Assessing Root Causes of First Case On-time Start (FCOTS) Delay in the Orthopedic Department at a Busy Level II Community Teaching Hospital

INTRODUCTION: Due to the high cost of operating room time, hospitals have been under increasing pressure to optimize operating room (OR) efficiency. One parameter that has been used to predict OR efficiency is First Case On-Time Start (FCOTS). In this brief report, the authors describe results from a quality improvement project designed to identify the rates and primary causes of first case delay for elective procedures within the orthopedic department at their suburban community hospital. METHODS: This was a retrospective, quality improvement project. The authors reviewed information from their anesthesia group to identify the rate and causes for delayed FCOTS, as well as observations and employee interviews to map contributing factors of delay. RESULTS: Surgery data on 159 days reviewed indicated that 107 (67.3%) days had first case delays. Of the 398 total first cases during this period, 156 (39.2%) were found to be delayed. The authors identified surgeon practices, with 74 (56.5%) as the main contributor to delay, followed by pre-operative processes, with 24 (18.3%), and room-related causes, 17 (13.0%). The anesthesia department and the patient were minor causes of delay, with 9 (6.9%) and 7 (5.3%) of case delays respectively. DISCUSSION: Results were similar to other studies, indicating surgeons and pre-operative as main cause for delay. A fishbone diagram revealed patient factors, inefficiency in the pre-operative process, and staff tardiness as some of the causes. CONCLUSIONS: During this project, surgeon practices and preoperative processes were the main factors contributing to OR inefficiency within the community-based hospital. Future strategies to improve daily OR flow within similar institutions should target surgeon on-time arrival and streamlining of the pre-operative process to effectively reduce FCOTS delays.