Reducing First-Case Start Time Delays

Periop Today

By: AORN Staff

Published: 10/21/2025

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How one ASC team improved the rate of first-case on-time starts from 30% to 79% in 12 months.

Mornings can make or break a day in the OR. Nail the first-case on time start, and the rest of the day stays upright. Miss it, and you’re chasing delays the rest of your shift. Everyone feels it. Cases stack up. Teams scramble. Profits tighten as costs rise.

Preventing first-case delays is a challenge shared by some 11,000 inpatient and outpatient surgery centers across the U.S. First-case delays increase staff stress and can lead to longer work hours. Late starts also lead to higher procedure cancellation rates—and that’s a real dollars-and-cents reason to reduce delays.

A recent case study highlighted in AORN Journal details how one ambulatory surgery center (ASC) in the mid-Atlantic region dramatically turned around its challenges with first-case on-time starts (FCOTS). Over a span of four months, the ASC’s FCOTS rate dipped to 14%. Out of 180 first surgical cases of the day, 156 (86%) were late. The team knew it was time to act.

“As perioperative RNs, we recognized the vital role of identifying factors that impact first-case on-time starts,” said Christy V. Mitchell, DNP, APRN, AGCNS-BC, RNC-OB, CNOR, Maj, USAF, NC.

Mitchell is a contributor to the case study and an assistant professor at the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, and an adult-gerontology clinical nurse specialist.

Defining and Measuring the Problem

Mitchell and her fellow contributors explain how the ASC tackled its problem. First, they assembled a multidisciplinary team led by a perioperative RN and employed Lean Six Sigma to pinpoint causes and identify solutions. To tackle the problem, the team used the DMAIC template—define, measure, analyze, improve, and control.

Drawing a hard line, the team defined a late first case as anytime a patient reached the OR after 7:30 a.m.—though there were important exceptions. The project excluded emergent and urgent procedures, add-ons, canceled procedures, and patients with a severe life-threatening systemic disease and patients not expected to survive without surgery (ASA IV and ASA V).

Then, they mapped where time was leaking. “In the preoperative phase, delays were caused by miscommunication on case orders or patient arrival time,” Mitchell said. “Other causes included incomplete documentation—such as history and physical exams, missing or incomplete consents and orders, late patient arrivals, pending laboratory results, unmarked patient sites, and reduced clinical care support.”

They also saw operative-phase issues. This included late surgical staff, prolonged morning huddles, surgical equipment or supply issues, and delayed setup for OR instruments.

Introducing Practice Changes

They set out to change morning processes. “Among the changes introduced was the development and implementation of a preoperative checklist,” Mitchell said. “This tool aimed to reduce day-of-surgery issues by assigning clear, concise tasks to each perioperative team member. It also helped ensure that surgical scheduling across 10 separate clinics was executed with precision.”

The team reassigned key staff to first-case tasks—interviews, IV access, preoperative clipping, and OR setup. “OR team huddles were also assigned a designated start time to enhance punctuality and coordination among surgical staff to be ready to go,” Mitchell explained. Surgeons completed consents and medication orders the day before to avoid last-minute issues and minimize the risk of delays.

“We introduced early medication order entries,” Mitchell said. “This ensured that medications were available and delivered before the scheduled procedure, mitigating further delays.”

During end-of-the-day huddles, they shared FCOTS data with the periop team to keep everyone updated and engaged. Mitchell noted that these interventions contributed to a more streamlined perioperative workflow.

Major Turn Around

The FCOTS rate started trending in the right direction. After 12 months, the FCOTS rate improved from 30% to 79%. Overall, the project led to a 49% increase in first-case on-time starts.

After implementing the project:

  • Average delay dropped from 24 min and 18 s to 17 min and 32 s.
  • Annual delayed minutes fell from 119 h and 43 min to 63 h and 42 min.

The gains held more than a year. Over the course of a year, the project led to real cost savings, said Mitchell. “Applying a conservative rate of $62 per OR minute, this intervention could potentially save over $205,778 annually by reducing unutilized OR minutes,” she concluded.

Takeaway

With expenses rising faster than revenue at many hospitals and ASCs, financial pressures are unlikely to vanish anytime soon. Perioperative teams will continue to play an important role in minimizing waste by improving efficiencies and enhancing patient care and outcomes.

The bottom line is ORs generate approximately 60–70% of hospital revenue and account for 30–40% of costs. Efficiency gains like improving FCOTS have a big impact with cascading effects that can boost patient satisfaction, reduce unplanned cancellations, lower stress for periop staff, and increase an OR’s capacity for taking on elective surgeries.

Read more about this case study and find more solutions that have worked for other facilities and health systems:

Disclaimer

The opinions and assertions expressed by Christy V. Mitchell do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. Neither she nor her family members have a financial interest in any commercial product, service, or organization providing financial support for this research. References to non-Federal entities or products do not constitute or imply a Department of Defense or Uniformed Services University of the Health Sciences endorsement.

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