Date of Award

Spring 6-7-2024

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Bomin Shim

Faculty Reader

Bomin Shim

Executive Summary

Executive Summary

Title: Improving Operating Room Efficiency by Ensuring a Timely Start of a First Operative Case

Background and Significance: Delays in the operating room significantly impact patient safety and satisfaction with care, provider job satisfaction, and hospital expenditures (Pashankar et al., 2020). First case on-time start (FCOTS) is a tool commonly utilized to predict operating room efficiency among medical centers (Saul et al., 2022). Ensuring timely start of the first operative case may help improve operating room efficiency by minimizing delays in subsequent surgeries. Previous research has shown that implementing various interventions, such as checklists, positive feedback systems, and specialized task force teams, can effectively enhance surgery FCOTS. However, there is a lack of studies focusing on interventions targeting the preoperative staff. Implementing interventions to streamline the preoperative process for nurses in the pre-surgery admission unit is a feasible approach to improve surgical FCOTS.

Problem and Purpose Statement: Surgical delays are often linked to patients not being adequately prepared for surgery in the preoperative unit. This quality improvement initiative targets the preoperative process, aiming to decrease delayed first case starts by introducing an intervention designed for the nursing staff in the presurgical department. A checklist has been implemented as part of the project to help nurses efficiently organize and oversee all tasks necessary for a safe and prompt transition of patients to the surgical suite.

Methods: This quality improvement project utilized a quasi-experimental pre-post intervention design to investigate a correlation between the introduction of a nursing task checklist and enhancements in the FCOTS. Data on the start times of the first operative cases was gathered for four weeks before and during the checklist implementation period. Subsequently, a comparative analysis of the data was conducted via dependent t-test to assess the effectiveness of the proposed intervention.

Results/Outcomes: During the 8-week period of pre and post implementation of the checklist, a significant difference in FCOTS was noted. Prior to the intervention, the percentage of on-time surgery starts averaged 84%, increasing to 91% following checklist implementation. While the observed increase did not reach statistical significance (p > 0.05), it is important to highlight the clinical significance and meaningful impact of this improvement on patient safety and health practices. The small sample size utilized in the study may have limited the statistical power to detect significant differences. Although the observed improvement in FCOTS was clinically significant, it is important to interpret the study findings cautiously due to the limitations imposed by the small sample size.

Sustainability: The leadership of the pre surgery admission unit gathers monthly FCOTS data for process improvement purposes. Hence, there is an opportunity to prolong the data collection over an extended period with the idea of the checklist being implemented over a longer period than four weeks. This would enable the attainment of a larger sample size, facilitating more comprehensive data comparisons. In regard to long-term sustainability, the project holds promise. It requires minimal to no financial involvement, poses no ethical risks, and demands little effort from the stakeholders during the implementation process.

Implications: The implementation of the checklist resulted in a noticeable increase in FCOTS, indicating a meaningful impact on patient safety. The checklist is adaptable and can be modified for use in surgery admission units among different specialties and organizations. Future efforts to enhance patient care, provider morale, and reduce hospital costs should focus on optimizing the preoperative process, with the involvement of nursing staff responsible for preparing patients for surgery.


Pashankar, D., Zhao, A., Bathrick, R., Taylor, C., Boules, H., Cowles, R., Grossman, M. (2020). A quality improvement project to improve first case on-time starts in the pediatric operating room. National Library of Medicine, 5(4), 305. DOI: 10.1097/pq9.0000000000000305

Phieffer, L., Hefner, J., Rahmanian, A., Swartz, J., Ellison, C., Harter, R., Lumbley, J., Moffatt-Bruce, S. (2017). Improving operating room efficiency: first case on-time start project. Journal of Healthcare Quality, 39(5), 70-78. DOI: 10.1097/JHQ.0000000000000018

Saul. B., Ketelaar, E., Yaish, A., Wagner, M., Comrie, R., Brannan, GD., Restini, C., Balancio, M. (2022). Assessing Root Causes of First Case On-time Start (FCOTS) Delay in the Orthopedic Department at a Busy Level II Community Teaching Hospital. Spartan Medical Research Journal 7(2), 1-6. 10.51894/001c.36719

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