1

Background

In recent years, hospitals and health systems have encountered considerable financial pressure due to rising labor, pharmaceutical, and supply costs, exacerbated by persistent workforce issues, heightened administrative demands, and inflationary increases. . ^, Surgical treatment significantly impacts hospital systems’ financial viability, with the operating room (OR) accounting for approximately 40 % of total expenses while earning up to 70 % of total revenue. Understanding how to minimize waste and make economic decisions that enhance quality patient care and outcomes are crucial. Numerous variables influence success in OR workflow, making it difficult to pinpoint the moments and places of most failures. Without this information, devising effective action plans to improve efficiency is challenging, if not impossible, and the resulting OR delays can lead to significant financial consequences, including increased labor expenses and negative impacts on patient services. ^,

One of the most evaluated metrics indicating OR efficiency is the first case on-time starts (FCOTS), the first surgical procedure of the day starting on time as scheduled. ^, Any delay in FCOTS has a cascading effect, leading to delays in subsequent cases. Additionally, delays may cause dissatisfied healthcare workers and patients, high facility costs, reduced utilization, and decreased access to care. ^{, ,} Reducing delays in FCOTS enhances efficiency and improves financial performance, contributing to higher quality care and greater consumer confidence. ^, Mitigating the cascading second-order and third-order consequences linked to FCOTS delays will enhance the efficiency of the healthcare delivery system.

2

Introduction

Delayed OR starts are vulnerable across the preoperative and intraoperative phases of perioperative care. During the preoperative phase, factors contributing to delays include late patient arrivals, incomplete documentation (such as history and physical exams, surgical and anesthetic consents), and staffing shortages, all of which create workflow bottlenecks. In the intraoperative phase, FCOTS delay factors include prolonged team huddles, missing OR equipment, missing surgical supplies, and prolonged OR setup. To effectively manage these FCOTS delay factors, perioperative leaders must implement process improvement initiatives and collaborate across departments.

3

Description of the problem

In response to the growing demand for healthcare organizations to reduce costs by addressing non-value-added steps and inefficiency in care, this military ambulatory surgical center (ASC) recognized an opportunity for intervention within the perioperative surgical department. The ASC established a process improvement benchmark for the surgical department, aiming for FCOTS to occur 80 % of the time. However, this project was initiated when the ASC’s FCOTS fell below this benchmark, achieving an average of 14 % on-time starts for first cases in the last 4 months. This significant delay can cause a ripple effect, resulting in longer wait times, increased patient anxiety, and frustration among preoperative and surgical teams. Additionally, idle wait times during OR preparation for the first case lead to inefficient use of manpower, ultimately increasing labor and operational costs. ^{, , ,} These issues can limit surgical volume, negatively impacting hospital revenue and performance. ^{, ,}

4

Purpose

This case report outlines the workflow from surgical scheduling, preoperative processing, patient arrival, and when the patient enters the OR suite. The project setting is at an ASC in the mid-Atlantic region. The OR department maintains four ORs and performs over 2200 surgeries annually. Identifying variables influencing FCOTS has led to the development of modified patient processing procedures to enhance workflow efficiency. This project is designed to ensure the creation and adoption of new interventions across all departments, promoting transparency, efficiency, and deference to subject matter experts (SME).

5

Methods

Implementing process improvement methodologies such as Lean and Six Sigma produce the most effective results in identifying and analyzing non-value-added activities and enhancing operations across multiple interconnected departments. ^{, ,} Lean focuses on identifying and reducing waste, while Six Sigma aims to identify delays, reduce process variability, and minimize defects. ^{, ,} Combined, these approaches form Lean Six Sigma, which is particularly effective for addressing the multifaceted nature of delayed FCOTS. ^{, ,} By applying Lean Six Sigma techniques, perioperative leaders can identify causes of delays and inefficiencies in patient admission and FCOTS, ultimately reducing waste and process irregularities. Involvement from multidisciplinary representatives was essential for accurately identifying barriers to achieving FCOTS. The project leader, a perioperative registered nurse (RN), established the FCOTS committee, which comprised key stakeholders from each perioperative section. Committee members included the chief surgeon, two anesthesia providers, three OR RNs, one preoperative RN, and two surgical technologists. This multidisciplinary initiative was a joint effort to uncover inefficiencies and propose solutions. The five steps of the Lean Six Sigma methodology, define, measure, analyze, improve, and control (DMAIC), organized the framework for this project. The project commenced upon acquiring a non-research determination from the institutional review board. This initiative followed the Standards for Quality Improvement Reporting Excellence 2.0 Guidelines to ensure clear reporting of the design, implementation, and interpretation.

5.1

Define-measure-analyze-improve-control

5.1.1

Define

Fig. 1 illustrates the patient flow from the preoperative holding area to patient transport to the OR. In this perioperative surgical department, a late first case was operationally defined as the patient in the OR after 0730. For the purpose of this initiative, surgical case reviews excluded urgent and emergent cases, day of surgery add-ons, and canceled procedures, as well as patients with ASA 4 and ASA 5 classifications. Additionally, the committee convened weekly to initiate discussions that encompassed the problem, the establishment of goals, the delineation of roles and responsibilities, the method of accountability, and the development of a timeline.

The process begins at the patient’s arrival in the hospital and continues through the preoperative unit to the OR. The green boxes indicate patient care under the preoperative team. The purple boxes indicate patient care under the operative team.

5.1.2

Measure and analyze

The committee commenced the measurement phase by collecting baseline data and aggressively assessing OR workflow impacting FCOTS. A four-month retrospective chart analysis revealed the extent of the issue, including 180 first surgical cases of the day, of which 156 (86 %) experienced FCOTS delays. FCOTS was attained at a rate of 14 %, resulting in further delays for the remaining surgical cases. The committee identified 11 causes of delays ( Table 1 .). In response, they aimed to develop interventions to increase FCOTS at or above 80 % and determined that the department representatives in the committee, acting as SMEs, would be responsible for addressing each cause for delay.

Table 1

Causes of delays for first case on-time starts.

11 Causes of Delays
Preoperative
Miscommunication on case orders or patient arrival time Incomplete documentation, history, and physical exams Missing consents and orders Late patient arrivals Pending lab results Unmarked patient sites Reduced clinical care support
Operative
Late or missing surgical staff Prolonged time spent in team huddle Missing or incorrect surgical equipment and supplies Extended or delayed setup for operating room instruments and equipment

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