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Lean methods to improve operating room

elective first case on-time starts

BITS Pilani
Hyderabad Campus

First case on-time start rate:

Percentage of patients having elective procedures and leaving the pre-
operative holding area at or before the listed start time.

Los Angeles County + University of Southern California Medical Center

• 25 ORs and annual surgical total volume of 14,000 procedures

• 23.5 % first-case start rate prior to lean implementation

BITS Pilani, Hyderabad Campus


Problems caused due to low start rate:

• Cancellations of cases scheduled later in the day

• Long surgical queues and high hospital censuses

• Low morale amongst residents, fellows, attending physicians,

nurses, and other OR staff members

• Low patient satisfaction due to long wait times and last-minute


Creation of a Pre-operative lean team to stage efforts to improve

first-case starts

BITS Pilani, Hyderabad Campus


1. Lean thinking and identification of goals

• Creation of a multidisciplinary pre-operative Lean Team.

• A goal was set to achieve 80% on-time starts for elective first cases

• Performed numerous observations and walk-throughs of the operating

room and pre-operative areas through the patients' eyes

• Value stream mapping, spaghetti diagrams, value and waste

identification, root cause analysis using the 5 Why's

BITS Pilani, Hyderabad Campus

• Workgroups were created to address the following:
• Patient Registration and Scheduling
• Multi-disciplinary Team Communications
• Nerve Blocks
• Last-minute Schedule and Equipment Changes
• Team Communications in the pre-operative holding area

• Pre-operative lean team implemented an improvement bundle

consisting of three key components:
• improving the patient arrival process
• improving the operative team communication
• multi-disciplinary team debriefing that reviewed and improved performance on a
daily basis

BITS Pilani, Hyderabad Campus


• Clear map of hospital, specific parking spots for patients, new hospital signage

• Greeters met the patients at the hospital entrance and escorted them to the OR
check-in desk.

• Piloted multiple Plan-Do-Check-Act cycles on the check-in process to

incorporate staggered arrivals, expedited registration, and direct-to-bed upon
completion of check-in.

• Huddles were expected to occur at the patient's bedside 10 min prior to the
scheduled time.

• Visual “huddle ready” signs posted at the end of patient beds,

• All members of the operating team participated in the huddle

BITS Pilani, Hyderabad Campus

Process Improvement Map (Before Lean

BITS Pilani, Hyderabad Campus

Process Improvement Map (After Lean

BITS Pilani, Hyderabad Campus


BITS Pilani, Hyderabad Campus