Improving on-time surgical starts through a perioperative stop and huddle

General Information

Institution Name: The MetroHealth System

Author Name and Title: Faria Nisar, Jonathan A. Alter, Alexander Estright, Michael Platten, David C. Kaelber, Michael D. Leeds, Hannah Hill, Samantha E. Pope, Luis E. Tollinche

Name of Case Study: Improving on-time surgical starts through a perioperative stop and huddle

Identification of Local Problem

Operating room (OR) time represents a massive expenditure for hospital systems, making overall OR efficiency an institutional priority. At this center, the First Case On-Time Start (FCOTS) metric, a key indicator of overarching systemic efficiency, was plagued by recurring punctuality failures. These first-case delays were highly variable and frequently missed the target due to fragmented pre-operative timelines (e.g., late practitioner arrivals, unfinalized consents, and delayed room setups).

Fig. 1. Distribution of delay types for first case on time starts. Each delay type can be displayed with its frequency. “No Delay” was the listed cause for some of the late cases examined here. Though not in alignment with the FCOTS percentages shown, these “No Delay” cases were due to not being prompted to enter a reason for delay when a case was delayed.

Context of the QI Activity

Prior to the initiative, the surgical teams focused heavily on the published 07:30 AM case start time. However, this led to fragmented preparation timelines where essential pre-operative steps (such as finalized surgical consents, room setups, counts, and anesthesia evaluations) bled past the target window. The project was launched across a multi-site system to foster a culture of accountability and systematically shift behaviors across all perioperative stakeholder departments.

Interventions

The core strategy involved moving the team’s mental focus away from the 07:30 AM-start time toward a strict, pre-surgical "stop and huddle":

The 07:15 AM Compulsory Huddle: A mandatory meeting initiated precisely at 07:15 AM. All pre-operative tasks (nursing room setup/counts, anesthesia consent, surgeon documentation) were required to be completed before this huddle.
Perioperative Checklist & Visual Boards: A standardized tracker deployed to trace active readiness milestones leading directly up to the RFI ("ready for induction") target.
Granular Data Feedback: Compiling individual surgeon tardiness and performance metrics to share transparently with departmental leadership.

Implementation Strategy

The team combined Lean Six Sigma methodologies with a collaborative, multi-tiered approach:

Qualitative Root-Cause Mapping: Frontline staff and ambassadors from every branch of the perioperative community created a fishbone diagram to isolate the primary operational bottlenecks.
The On-Time Start Clipboard Committee: A dedicated subcommittee of volunteer staff was created to track daily compliance, manually verifying electronic timestamps, and auditing huddle participation in real-time.
Leadership Transparency: Implemented automated tracking workflows alongside weekly operational emails detailing FCOTS success rates to maintain accountability.

Fig. 2. Email sent to tardy providers to encourage timeliness.

Fig. 3. Fishbone diagram reasons leading to delays in first case on-time starts (FCOTS).

Costs and Funding Sources

This quality improvement project was supported in part by the Clinical and Translational Science Collaborative (CTSC) of Cleveland via funding from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS) under a Clinical and Translational Science Award (CTSA) grant.

Overall Results and Analysis

An interrupted time series analysis demonstrated that shifting to the mandatory 07:15 AM lead-time huddle successfully improved systemic FCOTS percentages. Shifting the teams' operational focus away from the 07:30 AM wheel-in time to a mandatory 07:15 AM preparation deadline created a reliable 15-minute buffer to resolve unexpected, last-minute clinical or administrative snags before the 07:30 AM wheel-in time. This structural change resulted in sustained efficiency gains and a statistically significant upward shift in FCOTS percentages by successfully absorbing minor workflow variations before they could trigger cascading delays.

Fig. 4. Overall Interrupted Time Series Analysis of FCOTS metric. The blue line depicts the factual (observed) data with intervention.

Fig. 5. Interrupted Time Series Analysis of FCOTS metric by facility with datapoints. The blue line depicts the factual (observed) data with intervention. The pink line depicts the counterfactual (unobserved) data that would be expected given previous trends in increased FCOTS continued and no intervention was performed. The Main Campus (A) houses twenty operating rooms; the three other sites, Brecksville (B), Parma (C), and West 150th (D), are Ambulatory Surgical Centers.

Limitations

Missing Delay Accountability: Quantitative tracking occasionally encountered "No Delay" labels on delayed cases due to software gaps where providers weren't properly prompted to input the actual delay cause, requiring manual verification by the clipboard committee.
System Customization: Because the checklist tracking relies heavily on localized electronic health record (EHR) configurations, external sites would need to modify the data capture fields to match their specific digital workflows.

Lessons Learned

Buffer Windows Foster Resilience: Requiring 100% preparation readiness 15 minutes prior to target start times provides a vital operational buffer to absorb minor workflow shocks.
Data-Driven Culture Changes Behavior: Combining real-time documentation from an objective committee with the delivery of granular, surgeon-specific metrics directly to leadership creates a robust loop of shared responsibility across surgery, anesthesia, and nursing teams.