It is surgery's chicken-or-the-egg question: How do you define an on-time start? How you set the clocks at your facility goes a long way in determining whether your cases go off as scheduled throughout the day or if you're always playing a harried game of catch-up. Which are you on?

• Arrive time. When the patient's wheeled into the OR.
• Anesthetize time. When the patient's on the table and ready for anesthesia.
• Incise time. When the surgeon makes the first cut.

Arrive, anesthetize, incise. How many minutes separate each of these 3 events? You're really scrambling if you and your surgeons are working in 2 different time zones — your surgeons going by incision time and the rest of your team working on patient-in-room time.

"Our policy defines surgery time as incision time," says Dianne Appleby, RN, MBA, administrator of the Menomonee Falls (Wisc.) Ambulatory Surgery Center. "We put this into our policy for the very purpose of having a unified understanding of the parameters."

Ms. Appleby is in the minority. Our online poll last month of 230 readers found that 70% of you define on-time start as the time the patient is wheeled into the OR, 24% as time of incision and 3% as when anesthesia is started. The 2% that don't measure on-time starts might realize that the problem with being on time is that there's nobody there to appreciate it. And 1% tell time by some other method.

"We use patient-in-room time due to the variables of anesthesia and prep," says Steve Lickar, RN, nurse manager of the Puget Sound Surgical Center in Edmonds, Wash. "Some patients are difficult to intubate, and others require special prep and positioning. Using the admit time into the OR as the start time helps us with our scheduling and puts the onus on the surgeon to get into the OR when we call him. One of my surgeons was pushing for the 8 a.m. start to be incision time. The reason for that is he wanted to wait for the last minute to enter the OR suite."

The trouble with equating an on-time start with incision time is that incision time doesn't account for the many critical activities that take place — and take time — in the OR before and after the incision: the timeout, anesthesia time, positioning, prepping and draping, and then turnover time.

If your scheduled time for surgery is patient-in-room time, your surgeons should arrive 10 to 15 minutes before the scheduled time. "If the case is scheduled for 8 a.m., the surgeon should be in the room with the patient at 7:45, draped and ready to go at 8," says Karen Murphy, RN, MSN, director of the Northeast Regional Surgery Center in Plains, Pa.

Robert Lerma, MBA, CASC, chief operating officer of the Special Surgery Center of Houston (Texas), sets his patient-in-room clocks back an hour. "The patient is expected to be signed in and admitted into pre-op 1 hour before the scheduled time," he says. "If there is a block, then we ask the patient to come in 1 ? hours before the scheduled time."