title: Process redesign to improve first case surgical starts in an academic institution.
abstract: OBJECTIVE
  On time start of the first surgical case improves operating room (OR) utilization, physician, and patient satisfaction and decreases delays in subsequent cases. The goal of our study was to evaluate the effect of a multidisciplinary initiative to improve first patient in the room (FPIR) and first case on time start (FCOTS) metrics in a tertiary care setting.
  
  
  METHODS
  A multidisciplinary committee focused on first case start data collection. Reasons for both anesthesia and surgical delays were analyzed. Improvement efforts focused on the timely completion of surgical consent, a requirement of a surgical, anesthesia, and nurse team member presence at the patient's bedside by specific time, and parallel processing in the OR.
  
  
  RESULTS
  Over 65,100 OR cases were analyzed between 2007 and 2014. There was a statistically significant improvement in FPIR (82.80% versus 69.60%, p < .0001) and FCOTS (66.60% versus 55.90%, p < .0001). Surgical consent completion rate increased from 35% baseline to 68%-100%, depending on the surgical subspecialty. Improvements appeared sustainable several years following process implementation for both FPIR (84.60% versus 69.60%, p < .0001) and FCOTS (67.60% versus 55.90%, p < .0001).
  
  
  CONCLUSIONS
  Our study demonstrates a successful targeted, multidisciplinary initiative to improve first case surgical starts in an academic setting. Our approach was organizational rather than punitive or rewarding on an individual basis. Strategies included establishing concrete, time-specific goals and posting them visibly, empowering individuals to fulfill them, and ensuring no compromise in patient safety. In the complex environment of academic medicine including research protocols and teaching in the ORs, our organizational approach proved sustainable over several years.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Niharika
authors.initials: N
authors.lastname: Saw
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Vacanti
authors.forename: Xiaoxia
authors.initials: X
authors.lastname: Liu
authors.forename: Monica
authors.initials: M
authors.lastname: SaRego
authors.forename: Hugh
authors.initials: H
authors.lastname: Flanagan
authors.forename: Bhavani Shankar
authors.initials: BS
authors.lastname: Kodali
authors.forename: Richard D
authors.initials: RD
authors.lastname: Urman
mesh_terms: D000046:Academic Medical Centers; D001071:Appointments and Schedules; D032962:Consent Forms / Q000706:statistics & numerical data; D013502:General Surgery / Q000592:standards*; D006040:Goals; D006801:Humans; D033183:Interdisciplinary Communication; D009873:Operating Rooms / Q000592:standards*; D010348:Patient Care Team / Q000706:statistics & numerical data; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D013997:Time Factors
keywords: first case start; on time start; operating room efficiency; operating room management; surgery start