IHP 435 Module 7 Project Two Example

Project Two: Getting the First Case Started on Time

[Student Name]

Southern New Hampshire University

IHP 435: Performance Improvement Measurement and Methodologies

Project Two

[Instructor Name]

[Date]

Project Two: Getting the First Case Started on Time

Cedar Point's six operating rooms book the day's opening cases for 7:30 each morning. Across the last quarter, only 54% started within five minutes of that time, and the median delay for late starts was eighteen minutes. A late first case pushes every later case back, extends overtime, frustrates surgeons and patients and sometimes causes cancellations at the end of the day. This project plans an improvement: it describes the problem and its causes, sets an aim, selects a method, lays out changes to test, addresses the context that will shape success and defines a complete set of measures.

Understanding the Causes

For one month, circulating nurses recorded a delay reason for every first case that started late, using a list of standard codes. Of 64 late starts, 22 involved a missing or incomplete consent or history and physical, 17 involved the surgeon arriving after 7:30, 11 involved the patient not being ready because preoperative tasks such as IV placement or lab results were incomplete, 8 involved anesthesia evaluation delays and 6 involved equipment or room issues. A Pareto chart showed that the first three causes accounted for about three quarters of delays. A process walk revealed why: consent forms were often signed in the surgeon's office but not scanned into the record, preoperative nurses started at 6:00 a.m. with too many patients arriving at once and there was no shared expectation that surgeons be present by 7:15 for the final check.

Aim

The aim is to increase the percentage of first cases starting within five minutes of schedule from 54% to 85% within six months, without increasing preoperative staff overtime or the rate of cases canceled on the day of surgery.

Choosing a Method

The causes are mainly problems of flow, preparation and coordination, the kinds of waste Lean is designed to remove: waiting for documents, batching of patient arrivals and unclear standard work. Surveying the Lean literature across health care, D'Andreamatteo et al. (2015) found that operating rooms and surgical services were among the settings where Lean was most often applied, with many studies reporting shorter delays and better use of time. They also noted that the evidence consisted largely of case studies and that success depended on moving beyond tools to organizational change. The project therefore uses Lean principles, standard work, flow and visual management, with each change tested through small PDSA cycles.

Changes to Test

Four changes target the main causes. First, a pre-surgery readiness check two business days before surgery, in which a scheduler confirms that consent and history and physical are in the record, escalating gaps to the surgeon's office. Second, staggered patient arrival times, with first-case patients arriving at 5:45 a.m. and others later, so preoperative nurses can prepare first cases fully. Third, a standard expectation, agreed by the surgery department, that surgeons arrive by 7:15 for the preoperative huddle, with arrival times posted. Fourth, a visual board in the preoperative area showing each first-case patient's readiness steps in real time. Each change will start with one or two rooms for two weeks before spreading.

Table 1. Changes, Causes, Owners and First Tests

Note. Each test is expanded only after its PDSA review.

The Context for Success

Kaplan et al. (2010) systematically reviewed research on the context of quality improvement and identified factors associated with success. Among the most consistent were leadership support from senior management, an organizational culture supportive of improvement, the maturity of data systems, physician involvement and the leadership and experience of the improvement team itself. They concluded that context can matter as much as the method.

The plan addresses these factors directly. The chief of surgery and the chief nursing officer co-sponsor the project and will attend monthly reviews. Two surgeons, one orthopedic and one general, serve on the team to lead peer conversations about arrival times. The quality department provides a daily automated report of first-case start times from the operating room system, so data do not depend on manual collection. And the team is led by the perioperative director, supported by a quality coach with Lean experience.

Measures

The main process measure, the share of first cases starting within five minutes of schedule, is tallied daily and charted weekly. Supporting process measures are the percentage of patients passing the two-day readiness check and median surgeon arrival time. The outcome measure is operating room overtime hours for scheduled staff, reflecting the day-long effect of on-time starts. A structure measure is the presence of the visual board and staggered schedule. Balancing measures are preoperative staff overtime and day-of-surgery cancellations, since early arrival times or stricter checks could shift burdens elsewhere.

Reading Progress Over Time

Perla et al. (2011) show how run charts, plotting data over time around a median with simple probability rules, help teams tell real improvement from chance. The team will plot weekly on-time start percentages beginning with twelve weeks of baseline and will annotate each chart when a change is introduced. A shift of six or more weeks above the baseline median after a change would indicate a real improvement. Balancing measures will be charted the same way so any unintended effects become visible early.

Timeline and Sustainability

Month one covers baseline data, team formation and the process walk. Months two and three test the readiness check and staggered arrivals. Months three and four test the surgeon arrival standard and visual board. Months five and six spread successful changes to all rooms and build them into standard work. Sustainability measures include adding the readiness check to scheduling job descriptions, reviewing on-time starts at the monthly surgical committee and keeping the visual board as part of daily routines.

Conclusion

First-case delays at Cedar Point come mainly from missing documents, preparation bottlenecks and late arrivals. Lean changes tested through PDSA, supported by leaders and surgeons and tracked with a full measure set on run charts, give the hospital a realistic path from 54% to 85% on-time starts.

References

D'Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209. https://doi.org/10.1016/j.healthpol.2015.02.002

Kaplan, H. C., Brady, P. W., Dritz, M. C., Hooper, D. K., Linam, W. M., Froehle, C. M., & Margolis, P. (2010). The influence of context on quality improvement success in health care: A systematic review of the literature. The Milbank Quarterly, 88(4), 500-559. https://doi.org/10.1111/j.1468-0009.2010.00611.x

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895