EARLY BIRDS Staff members at Carolinas Healthcare System are ready to go well before patients are brought back for surgery.

Several years ago, our first cases of the day rarely started on time. There was a lot of finger pointing. Nurses said the ORs weren't ready because the surgeons were always late. The surgeons didn't think showing up on time was a priority because the ORs were never ready. It was a vicious cycle. Today, 90% of our cases go back to surgery not only on time, but 10 minutes early. Here's how we changed the culture and expectations each morning so 90% of our cases go back to surgery not only on time, but 10 minutes early.

Before
Nurses and techs would filter in at odd times, fill their coffee mugs, talk in the lounge and they might or might not review their case assignments.

Now
Staff must be at their scheduled rooms at 6:30 a.m., 30 minutes before the scheduled case start time. We measure "on-time starts" as "wheels in the room," and we want patients in the OR at 7 a.m. Surgeon cut time is 10 to 30 minutes later, depending on how long it takes to position, prep and drape the patient.

When nurses arrive, they immediately visit the first patients of the day to confirm the correct procedure, determine if surgeons need to be consulted and resolve unexpected issues. They check for holes in supply wrappers, and ensure needed equipment and instruments are on hand. Basically, they now have time to make absolutely certain that the rooms are ready and issues are resolved.

Before
Surgeons noted cut times instead of "wheels in the room" times on their personal calendars. For example, they assumed surgery was scheduled to start at 7:30 a.m., and didn't know they should report earlier to complete pre-op visits with patients — that's why they were usually late.

Now
The day before surgery we print out the first cases and text in-room times to surgeons and what time they need to be finished with their patients in pre-op. For example, we text: Dr. Smith, your in-room time is 7 a.m., you need to be done in pre-op by 6:40 a.m. That small change has really helped get surgeons to their rooms when they need to be.

Before
We were often caught off guard when staff members called out sick, rooms weren't set up for complex cases or supplies weren't pulled the night before.

Now
A dedicated early-arrival team comprised of a nurse and surgical tech arrives at 6 a.m. They confirm that the correct supplies have been pulled and check that rooms scheduled for bigger procedures such as total shoulders are set up and ready to go. The team checks the big-picture items to ensure ORs are primed for the start of the day. They also serve as stopgaps for last-minute staff callouts.

Before
Changing the culture that led to delayed starts was one of the biggest challenges. No one knew the extent of the issues we faced or was able to see the big picture and understand why starting on time was so important.

Now
Once leadership decided to improve our on-time starts, we identified the issues that caused the delays and set out to correct them. We enlisted someone from each aspect of surgical care to share their views. They have ownership and input in the process. Having a champion within each department helps bring those people resistant to change along. Today, all departments are onboard and ready to go by 6:50 a.m.

Before
We didn't know where we stood with on-time starts and had no data to implement the changes we wanted to make.

Now
A nurse collects daily on-time start data, organizes it and presents it to leadership as objective facts (see "Meet the Bulldog"). Once the facts are known, no one can deny their ORs aren't starting on time. When dealing with challenging surgeons or anesthesiologists, we simply present the cold hard facts, which speak for themselves. We post each service line's on-time starts on a daily basis. That near real-time feedback makes managing start times easier; you can't talk about data from a month ago and expect to make real change happen. It also sparks some friendly competition among the surgical teams and surgeons, who don't want to be the ones bringing their service line's stats down.

Practice what you preach
We couldn't speak to our tardy surgeons unless our house was in order first. We made sure there were no setbacks in pre-op and in the OR before we said, We're ready, now it's your turn. If you want to maintain the momentum of change, one failure is one too many. If you're trying to improve the culture, it has to be done right every time.

PRE-OP PATROL
Meet the Bulldog

KILLER SMILE Shelley Smith, BSN, RN, CAPA, confronts tardy surgeons and staff.

Shelley Smith, RN, BSN, CAPA, patrols the pre-op area in the Carolinas Healthcare System in Charlotte looking for surgeons and staff members who aren't in their rooms by 7 a.m. — the time the first cases of the day are scheduled to start. It's a tough role to play, and Ms. Smith has the personality and guts to make it work. She also has a great working relationship with staff and surgeons. Perhaps that's why the "bulldog" nickname she's earned is more a term of endearment than it is an insult, at least by most who use it.

Notoriously tardy surgeons grew to respect her efforts and noticed how hard she was working to get the day's first cases started on time. After a while, they saw her coming and knew what to say: You're right, I'm sorry. Thanks for getting the team back there. Now, they're on time with no reminders.

— Daniel Cook