RIGHT ON TIME Every facet of your facility benefits when the day's first cases start on time.

Nothing gets your day off on the wrong foot like failing to start the first case on time. Even a delay of 15 minutes can throw your schedule off track, frustrating patients as well as the entire OR team. If you're struggling to start the surgical day on schedule, follow these 3 steps to improve your rate of on-time first-case starts.

Define "on-time start"
There are many different ways to measure an on-time start: wheels-in time, induction time or cut time. Your staff and surgeons must work off a standardized definition of on-time starts so you can identify the issues that are causing delays and zero in on solutions. We define an on-time start as wheeling the patients into the OR on or before the scheduled start time. If surgery is scheduled to begin at 7:15 a.m., that's when the patient needs to be in the room. If a patient is wheeled in just 1 minute later, we consider the case delayed. However you measure an on-time start is fine, as long as everybody's watches are set for the same time.

Document the reasons for late starts
Create delay codes to help categorize the reason for start-time delays. Was the surgeon late arriving at the facility? Was the anesthesia provider held up with another patient? Did the patient fail to show up at the required time? Was the IV difficult to start? Were instruments not ready? You want to gather accurate data and reduce the amount of entries coded as "other," so consult with your frontline staff to determine which codes would capture the issues they face in getting cases started on time. Create a spreadsheet, dashboard or some other communication tool so staff can quickly note the reason for a delayed start. Track the delay codes over a couple months to identify patterns of problem areas. Update your team on the results of the code tracking during staff meetings, through e-mail reminders or when you walk the floor.

ON THE CLOCK Members of the surgical team meet with the pre-op staff 10 minutes before a case starts.

Fix what's broken
Make changes based on the results of your findings. When we determined that some delays were the result of anesthesia providers getting caught up caring for a patient in another OR, we staggered our first-case start times. Surgery is scheduled to start at 7:15 a.m. in 4 ORs and at 7:30 a.m. in the 17 other rooms. This tweak lets our anesthesia providers focus on getting patients ready for earlier starts in a few dedicated rooms and frees them up to move to the other ORs when they're finished.

We also implemented the "10-minute rule," which requires all members of the surgical team to meet at the patient's bedside in pre-op 10 minutes before the scheduled start time. During the handoff, the OR team discusses the patient's clinical status and care needs with the pre-op staff, as is typically done. If the case won't start on time, staff agree on the reason for the delay, which the circulating nurse notes on the communication tool and enters into the patient's electronic medical record. The 10-minute rule increases the likelihood that surgeries will begin on time, because all of the important stakeholders are required to be present and accountable before the scheduled start time. It also lets us capture accurate delay data that we can use to change our processes or address specific issues.

Proven results
In 2013, 40% of our first cases were delayed an average of 9 minutes. If each OR minute costs $62, those delays cost our organization nearly $1 million. The 10-minute rule lowered our late-start percentage to 30% and the average delay to 8 minutes. That 10% decrease in delays equates to annual savings of about $100,000 based on the cost of an OR minute.

A late first-case start can delay the rest of the day's cases. That might cause surgical team members to feel rushed and pressured into taking shortcuts to make up time. Staff may also feel that delays contribute to a decrease in the quality of care they provide. Leadership, meanwhile, views delays as non-productive time that increases staffing expenses. More frequent on-time first-case starts changed perceptions of inefficiency and rushed patient care in our surgical services department. It's also improved the satisfaction levels of our surgeons and patients — we've definitely received fewer complaints from both. The face-to-face handoff mandated by the "10-minute rule" also improved communication among staff involved in the care of the patient. We're still not satisfied, though. Our surgical managers continue to monitor on-time first-case start percentages and delay codes on a monthly basis to look for trends and determine what adjustments we should make moving forward. OSM