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The Devil Is in the Details: Sustaining First-Case On-Time Starts at a Quaternary Care Center
Background:
First case on time start is an increasingly important surgical operations metric. First case on time start delay is multifactorial, and institutional improvement requires an iterative, efficiency-centered approach.
Methods:
An institution-specific Lean Six Sigma Approach was taken to identify causes for case start delay and modify processes to improve "ready for induction" (RFI) times. A perioperative checklist was developed to track active steps to on-time start. Emphasis was placed on a visual management board, daily perioperative huddles, shared responsibility across all stakeholder departments, and the sharing of granular surgeon data with department leadership.
Results:
This study took place at a nonprofit multispecialty quaternary care academic medical center. From April 2024 to July 2025, RFI on-time improved from 52% to 77%. "In OR" time reduced by 6 minutes, RFI time by 7 minutes, and incision time by 7 minutes. After intervention, median skin incision time was 20 minutes earlier for comparable on-time starts, and these cases ended 47 minutes earlier. Delays were most often related to surgical team (19.6%).
Conclusions:
This sustained quality improvement initiative demonstrated successful application of a perioperative checklist and focused behavior modification.
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