I remember when enough was enough. It was February 2005 when my general, urology and gyn surgical pod recorded 144 late starts. One- forty-four. That number jumps right off the page, doesn't it? It did to me. That's why I staked a permanent post outside the pod's 10 ORs each morning for a week. Staff was curious. "What's up?" they'd ask. "Bus leaves at 7:30 a.m.," I'd say, referring to when the first case of the day should start. "If you're not on board, it's going to leave without you."

Road to improvement
Changing the culture in my surgical pod began when I asked the circulating nurse in each OR for the actual start time of her day's first case. I'd write the percentage of on-time starts on a dry-erase board outside the ORs for all to see. I soon created a bulletin board, complete with buses (representing each OR) driving on a winding road. When an OR started its day on time, the room's bus was pinned to the bulletin board. The staff really took to the "Get On the Bus" concept and it soon became a rallying cry throughout the pod.

The next step involved drilling down to determine the causes for delayed starts. After talking to the front-line staff, we decided the following issues prevented on-time starts:

• Missing equipment. Instruments weren't in the ORs when they needed to be, or specialized devices — a table attachment, for example — were missing when the case was scheduled to start. We solved that problem by rearranging our personnel schedule to front-load the morning staffing levels. That let us assign point-of-service individuals to each OR. They're responsible for making sure equipment is processed and ready to go at the start of a case.
• Delivery of patients. Patients arriving from other hospital floors were showing up late because we had no holding area, which caused the surgical desk to call for patients only when the OR and clinical teams were ready to accept them. We remodeled our pre-op area to create space for additional patients; they're now in the pod well before their cases are scheduled to begin.
• Unsigned consent forms. Incomplete paperwork is one of the more common problems that delays the start of cases. It's also one of the easiest to fix. Surgeons now make sure consent forms are signed during patients' pre-op visits to their offices.
• Tardy surgeons. By far this is the biggest barrier to on-time starts in our hospital. To be fair, surgeons sometimes have to wait on a patient's arrival before a case can begin. That said, as the bus program began to gain momentum and as nurses and anesthesia providers jumped on board, the last piece of the on-time puzzle — the surgeons — proved a bit more challenging to put in place.

The most direct approach when trying to discover why surgeons are late is often the most effective. Just ask. That's what I did whenever a surgeon wasn't available at the start of a case. The answers were often typical: traffic, emergency cases elsewhere or running behind schedule when dropping their kids at daycare in the morning.

My response to their answers was not typical: I created a PowerPoint presentation about the "Get On the Bus" program to update those attending the hospital's monthly interdisciplinary meetings. One of the PowerPoint slides listed the "Top 5 Surgeon Excuses" for the month. Talk about peer pressure. Sometimes the truth in hard data is enough to spark change. The surgeons saw their reasons for being late as what they really were: excuses. For example, surgeons who had issues with getting to the hospital on time after dropping their kids off at daycare left their house 10 minutes earlier.

Driven to succeed
My "Get On the Bus" initiative was a success because I was passionate about starting our cases on time. My passion and commitment instilled the same feelings in the front-line staff — the ones who must be on board to generate any change in the culture of the ORs.

Also remember that bad habits are hard to break because they've become ingrained in the daily routine of your staff and surgeons. To enact change, you must dedicate yourself to making the actionable tips routine. That commitment may take weeks, months or even years.

Cases begin when they should because my program made our staff's commitment to on-time starts a part of the hospital's culture. The nurses began the movement and got the anesthesia team excited about the change. That excitement eventually influenced the surgeons' dedication to the program.

Our on-time success has been measured over three years. After the first year, 54 percent of my pod's cases started on time. Today, 91 percent of our cases begin when they should. After reviewing the success of the bus program, I decided to tackle another issue of concern.

Next up: All aboard the Turnover Train!