How can first case start times in the operating room (OR) be improved?

Improving First Case Start Times in the Operating Room

Implement a structured pre-operative checklist combined with staggered admission times and a dedicated OR facilitator to achieve sustained improvements in first-case on-time starts, which can reduce delays by up to 50% and save substantial OR time and costs.

Core Strategies for Improvement

Pre-Operative Checklist Implementation

• Deploy a standardized pre-operative checklist (often called a "Stop/Go" or "orange sheet" checklist) that verifies all required items are complete before patient rollback to the OR 1, 2.
• This checklist should confirm documentation completion, consent forms, H&P availability, and all necessary equipment/supplies are present 3, 1.
• The checklist approach reduced first-start delays from 10.07 per day to 4.95 per day (-49.2%) within 6 months in one academic center 1.

Dedicated Pre-Operative Facilitator

• Assign a dedicated OR facilitator whose sole responsibility is to intervene when any checklist items are missing or incomplete 1.
• This role proactively addresses barriers before they cause delays, rather than reacting after problems occur 1.
• The combination of checklist plus facilitator is more effective than either intervention alone 1.

Staggered Admission Times

• Group patient admissions into 2-4 time blocks (e.g., 07:00h, 10:00h, 12:00h, 15:00h) rather than admitting all patients simultaneously 4.
• This allows medical staff to review patients pre-operatively without creating bottlenecks, while minimizing patient waiting time 4.
• Patients should be admitted as close as possible to their surgery time to reduce unnecessary waiting 4.

Documentation-Related Interventions

Streamline Electronic Systems

• Implement automatic pre-operative orders to reduce manual documentation burden 3.
• Create dot phrases that allow rapid re-creation of unavailable consent forms 3.
• Improve H&P linking to the surgical encounter in the electronic medical record 3.
• These three documentation interventions improved on-time starts from 36.7% to 52.7% within 3 months, saving 55.63 hours of OR time and an estimated $121,834 over that period 3.

Process Control and Measurement

Real-Time Tracking and Feedback

• Establish real-time measurement systems that track first-case start times daily 2.
• Provide immediate feedback to all stakeholders about performance 2.
• Use statistical process control methodology to monitor whether improvements result from better process control versus simply starting earlier 5.

Performance Targets

• Set a realistic goal of 80-90% on-time starts as the daily mean target 2, 6.
• One institution achieved 95% on-time starts within 11 days of implementing a comprehensive program 2.
• Another improved from 15% to 72% on-time starts over several years using pre-OR timeouts and performance incentives 6.

Addressing Root Causes

Common Delay Categories to Target

The most persistent causes of first-case delays include:

• Late surgical attending arrival (19% of delays) 1
• Schedule changes (14% of delays) 1
• Anesthesia-related delays (initially 11%, but can be reduced to <1% with focused interventions) 1
• Documentation issues (consent forms, H&P availability) 3

Pre-Operative Preparation Optimization

• Conduct thorough pre-operative assessments in advance through nurse-run or consultant-led clinics 4.
• Use screening questionnaires with pre-set protocols to identify issues requiring resolution before surgery day 4.
• Provide written patient information in advance so patients arrive fully prepared 4.

Sustained Improvement Strategies

Process Control Over Earlier Starts

• Focus on bringing the process into better control rather than simply requiring staff to arrive earlier 5.
• Successful interventions reduced the inter-quartile range of start time variability from 13 minutes to 10 minutes, demonstrating improved process control 5.
• The median delay decreased from 5 minutes to 2 minutes without requiring preoperative staff to arrive earlier 5.

Financial Incentives

• Consider modest performance pay incentives for achieving >90% on-time start compliance 6.
• Combined with pre-OR timeouts, this approach saved an estimated $751,120 in one VA medical center by recovering 37,556 minutes of OR time 6.

Critical Implementation Considerations

Avoid the pitfall of focusing solely on one intervention—the evidence consistently shows that multi-component approaches (checklist + facilitator + documentation improvements + measurement) produce the most dramatic and sustained results 3, 1, 2.

Do not require staff to arrive earlier as a primary strategy; instead, improve process control and reduce variability in the existing workflow 5.

Ensure leadership commitment with a clinical lead (ideally a consultant anesthesiologist with management experience) responsible for developing policies and maintaining improvements 4.