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Operating rooms (ORs) are an important source of hospital revenue, and utilization rate is a key determinant of OR efficiency. Multiple factors contribute to OR underutilization, and OR managers may have biased views about which factors contribute most to OR underutilization. We examined various factors leading to OR underutilization at one academic tertriary care center. Data were collected retrospectively from over a 12-month period. Contribution to OR underutilization was measured in terms of hours of OR underutilization. Statistical significance between categories and days was calculated using an unpaired t test. By comparing means of the various contributors to OR underutilization (patient in the room, turnover time, scheduling gaps, OR holds, closed rooms), we determined that mid/end-of-day gaps and closed rooms contributed the most hours (9 7% and 4.6%, respectively; P < .0001) to OR underutilization, whereas turnover time and "patient in the room" contributed the least (2.0% and 0.8%, respectively; P < .0001). The contributors to OR underutilization are complex, and many OR staff from physicians to nurses and OR administrators may have biased views about which factors contribute most predominantly to inefficiency. Awareness of how various factors contribute to OR underutilization can pave the way for goal-directed changes on a systems-based level to improve efficiency in the OR by decreasing underutilization. [ABSTRACT FROM AUTHOR]