1

Introduction

Operating room (OR) time accounts for significant expenditures for hospital systems and, accordingly, OR efficiency is a priority for most hospitals. ^, A factor that has been found to correlate with increased efficiency is the First Case On-Time Start (FCOTS) metric. This measurement analyzes a hospital’s success in starting the first day of the case punctually and is a good indicator of a system’s OR efficiency.

Efforts to maximize OR utilization must address FCOTS, turnover time between cases, and accurate predictions of lengths of cases. Improving FCOTS has proven among the most recalcitrant of these three efforts. In fact, literature abounds with efforts that have been attempted with modest, if any improvement, in FCOTS. ^{, ,}

Outside institutions have identified areas to improve on-time starts such as through preadmission testing of patients, preoperative meetings with anesthesia staff, and reassigning patient care roles to help create an efficient workflow. The principal etiologies for OR delays include issues with patient arrival times, unavailable team personnel, and lack of equipment or procedure trays ( Fig. 1 ).

Distribution of delay types for first case on time starts. Each delay type can be displayed with its frequency. “No Delay” was the listed cause for some of the late cases examined here. Though not in alignment with the FCOTS percentages shown, these “No Delay” cases were due to not being prompted to enter a reason for delay when a case was delayed.

The variability in staff preoperative arrival times is a major influence on the FCOTS. Prior to the project’s implementation, there was no standardized arrival time for the surgical, anesthesia and nursing teams. This led to a lack of communication and teamwork between interdisciplinary teams, resulting in siloed care for the patient. Various research and quality projects have reported that surgeons’ arrival times to surgery are a major impact in FCOTS delays. ^{, , ,} Some studies showed modest improvement when efforts were directed at simply ensuring the timeliness of surgeons. ^,

In our intervention, we implemented a designated preoperative stop and huddle 15 min before the scheduled start time to improve FCOTS. ^{, ,}

A workflow was designed that shifted the attention away from the 0730 ‘published’ case start time and moved the team’s focus to a compulsory meeting time (huddle) of 0715. All team members were required to be prepared for the case and present at the huddle at 0715. We hypothesized that adding mandatory 0715 huddle times and moving the team’s focus to the huddle would lead to improved FCOTS through prevention of late practitioner arrival.

The goal of this project was to increase the percentage of FCOTS throughout our healthcare system by standardizing a designated time of pre-operative bedside arrival for all OR staff through the implementation of a pre-operative stop and huddle 15 min prior to the scheduled OR arrival time.

2

Methods

The On-Time Start Committee was founded in 2017 to improve the systematic issue of a decreased percentage of on-time surgical starts compared to other local health care systems. The project was not initially successful, as project initiatives were not well received or implemented, and failed to yield the intended results. A bundle of new interventions was implemented simultaneously in May 2022. The first intervention was the introduction of a 0715 preoperative stop and huddle for the first surgical case of the day throughout the healthcare system. Staggered start times were abolished, and all ORs were mandated to start at 0730. The 15-minute lead time between huddle (0715) and FCOTS (0730) was felt to provide surgery, anesthesia, and nursing personnel ample time to address any pressing issues identified at the huddle. All preoperative preparations were expected to be completed before the huddle at 0715. That is, the surgeons were required to obtain consent, nurses were expected to set up room and complete counts, and anesthesia staff were expected to complete setup and consent patient in advance. The huddle was to be initiated at 0715 and the patient was to enter the OR by 0730.

In order to introduce and drive the preoperative stop and huddle initiative, as well as the FCOTS of 0730, a subcommittee called the On-Time Start Clipboard Committee was formed. Their purpose was to document the surgical team’s timing and preoperative “stop and huddle”. The On-Time Start Clipboard Committee was vital in improving FCOTS as the dedicated surgical staff that volunteered were tasked with documenting daily huddles and start times. This team enabled real-time accountability for a delay, if any, at the time of the preoperative huddle and verified data obtained electronically. The practitioners implicated in causing the delay were sent an email reminding them of the necessity for timeliness and opportunities for improvement. An example of this can be seen in Fig. 2 .

Email sent to tardy providers to encourage timeliness.

A six-step disciplinary action plan, staffed by Chairs and Directors of the surgical community, was ratified by the OR Committee. After three tardy arrivals to the huddle, a verbal warning and letter would be sent to the tardy provider, urging them to improve their practice. After their fourth tardiness, a formal meeting had to take place within one week consisting of the provider, their department chair, and the perioperative leadership team to discuss the necessity of their punctuality. Following their fifth tardiness, the provider was to meet with The Office for Professional Affairs, a memo was sent to the healthcare system executive leadership including the Chief Operating Officer and the Chief Medical Officer, the Executive Vice-President for Provider Enterprise and Academic Affairs, and to the department head of any contracted hospital that the team member may be associated with. If a sixth tardiness was noted, the provider would lose their privilege to first case starts for 90 days and was assigned a required online learning module about the importance of surgical staff timeliness. This disciplinary action plan applied to all staff of the health care team involved in patient care.

In addition to the escalating six-step disciplinary action plan, a member of the perioperative services management team issued a report each week collecting and analyzing the FCOTS delay data. The recorded data showed provider tardiness that caused a delay in FCOTS. This information was entered into the EHR under a specific flowsheet for the delay reason within that specific case, allowing all parties to view and acknowledge why the case was delayed. Providers were prompted to enter the reason for a case’s delay as a drop-down menu with preset options which can be seen in Fig. 1 . The perioperative management team member sent out a weekly email to tardy providers, denoting the reason for the delay and reminding them of the importance of their timeliness, while encouraging them to be punctual and timely going forward.

2.1

Statistical analysis

A comprehensive approach incorporating both qualitative and quantitative methods was employed to draw meaningful inferences from the data. Qualitatively, a collaborative decision-making process was initiated within the perioperative community at the forefront of this endeavor. This involved the creation of a fishbone diagram, as seen in Fig. 3 , where ambassadors from every portion of the perioperative community contributed their insights to identify potential factors contributing to the issue of delayed starts. Through iterative discussions and consensus-building, the decision was made to mandate an arrival time at patient bedside of 0715 – 15 min before the scheduled start time (0730). Using our healthcare system’s EHR, on-time start data was collected over several months, capturing timeframes prior to and following implementation of the initiative. Descriptive statistics were utilized to quantify the changes in on-time start rates, providing a clear overview of the improvement achieved. On the quantitative front, an interrupted time series analysis was used to model the observed trends before and after intervention at each site and system wide. Additionally, Student’s T-tests were used to identify significant differences between the observed data and the counterfactual at time of intervention and end of study based on these models. By integrating both qualitative insights and quantitative measurements, this dual-method approach offers a comprehensive understanding of the intervention’s impact on enhancing FCOTS within the perioperative environment.

Fishbone diagram reasons leading to delays in first case on-time starts (FCOTS).

The amalgamation of these interventions fostered a new expectation and responsibility for the perioperative team members to arrive promptly. Additionally, these changes helped motivate the perioperative staff, and held team members accountable to other surgical team colleagues. The direct observation by the On-Time Start Clipboard Committee capitalized on the Hawthorne effect, and further embedded the expectation for punctuality at the stop and huddle. As with any change in practice, there was a small adjustment period. Table 1 lists the interventions.

Table 1

List of Seven On-Time Improvement Interventions.

Intervention	Description
1. EHR Build and Reports	• Engaged dedicated technical staff to build tracking mechanisms and reports to track: ο Case start time ο Any staff member tardiness ο Reason for delay if case did not start by 0730
2. 0715 Huddle	• Implemented 0715 preoperative stop and huddle for the first case. • All preoperative preparation by surgery, anesthesiology, and nursing were to be completed by the 0715 huddle
3. 0730 FCOTS	• Implemented a mandatory 0730 start time for all first cases
4. Reason for Delay	• Surgical delay reason was added into the EHR for communication loop closure at the conclusion of the case.
5. Staff Tardiness Action Plan	• The progressive 6-tardiness disciplinary action plan was proposed to and accepted by the OR Committee to address staff tardiness issues.
6. Leadership Oversight	• Created On-Time Start Clipboard Committee. • This was formed to track first case on-time starts in real time and identify specific causes for not starting by 0730
7. Regular Reporting	• Distributed weekly emails to OR leadership regarding first case on-time starts. • Directly contacted any OR practitioners on their tardiness issues.

 

Baseline data was collected before implementation from January 2018 until May 2022. The hours of scheduled surgical cases within our healthcare system are Monday through Friday from 0730 to 1900. On weekends, the OR time is reserved only for surgical procedures that are deemed emergent. The arrival times of various surgical practitioners were observed and recorded for six weeks before the intervention. During this period, no standardized or designated time for each party of the surgical team to be present existed. Many practitioners called this phenomenon “herding cats”. After six weeks, a 0715 preoperative stop and huddle and a mandatory 0730 first case start time were implemented.

The percentage of FCOTS was measured using a comparison between In-Room Time and Scheduled Start Time, as denoted within the patient’s EHR. This In-Room Time is documented by a member of the nursing team when the patient enters the OR. This datapoint is checked against the Scheduled Start Time. If the In-Room Time was marked before Scheduled Start Time, the Boolean logic returned a result of “true”, indicating the OR was on-time. Utilizing this logic for every OR, the percentage of FCOTS was obtained. When there was a noted delay, the anesthesia provider was prompted for the delay reason which was later analyzed for commonalities ( Fig. 1 ). At the conclusion of each case, a time-out is standardly performed, and a surgical delay reason was added for communication loop closure. There were a variety of reasons for delays stemming from the surgeon, anesthesia provider, nursing staff, or the patient themselves and these reasons were used to determine the best course of action for the interventions.

This manuscript adheres to the SQUIRE (EQUATOR) guidelines for quality improvement studies.

3

Results

Fig. 1 displays the types of delays for cases that did not start on time. Of these cases, the most frequent causes for delay were Patient/Family, Surgeons, and Equipment. The category of No Delay accounted for several late cases shown. This category was selected when the system did not prompt the user to enter a reason for delay and making the provider select this option. Though marked as No Delay, these cases were still delayed.

Table 2 displays the number of surgical cases seen from the baseline data collection time period of January 2018 until January of 2024. In- and outpatient surgeries were recorded for each surgical center as well as numbers for adult and pediatric cases. Across that time period, the Main Campus reported significantly more cases (67,475), over double the number of cases as the next closest, West 150th (25,234) and still had more cases than the three other surgical centers combined with 53.38 % of the total cases. The Main Campus had 41,026 inpatient cases (60.8 %) and 26,449 outpatient cases (39.2 %). The West 150th center had 25,232 outpatient cases and only 2 inpatient cases. The Parma center had 808 inpatient cases (3.5 %) and 21,964 outpatient cases (96.5 %). The Brecksville center had only outpatient cases (10,913).

Table 2

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