NR 631 Week 4 Evidence Review Example

Evidence Review: First-Case Start Changes Grouped by What Was Actually Put In, What Each Took to Run and Whether It Held

Student Name

College of Nursing, Chamberlain University

NR 631: Nurse Executive Concluding Graduate Experience I

Instructor Name

Month Day, Year

Evidence Review: First-Case Start Changes Grouped by What Was Actually Put In, What Each Took to Run and Whether It Held

How the Review Is Arranged

The sources are grouped by the kind of change made, not by author or year, because the director will be choosing between kinds of change. Each group begins with what went in, then gives the facts a leader needs before believing it would transfer: who ran it, what it took, where the site started and how long results were followed.

Group 1: Changes Inside Preoperative Holding

What went in. At a large public safety-net hospital, a lean redesign changed the workflow for elective first cases in the preoperative holding area (Coffey et al., 2018). At a regional hospital, a nurse-driven plan set target times for each preoperative step and used an observer with an audit form to record which steps were met and why delays happened (Blair et al., 2024).

What it took. The safety-net project was multidisciplinary, with surgery, anesthesia, emergency medicine and nursing authors, and ran a 35-day implementation period. The nurse-driven plan was led by surgical services leaders and an operating room nurse, with research consultants, and needed an observer for each audited case.

Starting position. The safety-net hospital began at a weekly mean of 23.5% on time; after the change the mean was 73.0%, measured over 294 operating days. The nurse-driven study was a posttest-only design with 99 patients, 31 of whom were late, so it describes causes rather than proving an effect.

Fit for this hospital. Both worked where nursing controls the morning. Neither moved the readiness check to the afternoon before, which is this project's idea; that remains untested in these sources.

Group 2: Documentation Fixes

What went in. At an academic center, three changes targeted documentation-related delays: automatic preoperative orders, a quick way to re-create unavailable consent forms and better linking of the history and physical to the surgical encounter (Singh et al., 2023).

What it took. Electronic record build time from informatics staff, which is the scarce resource at this hospital.

Starting position and follow-up. The rate rose from an average of 36.7% to 52.7% in the first three months. Three months is short; the review cannot tell whether the gain held.

Fit for this hospital. Two of the four readiness codes here, missing histories and consents, are documentation problems. A record-build change cannot be made during the information systems change freeze in November, so this group informs a later phase rather than the first.

Group 3: Measurement, Feedback and Governance

What went in. An academic center with 26 operating rooms used an interdisciplinary committee and Six Sigma tools, combining problem mapping, readiness changes, informatics support and continuous measurement with feedback (Phieffer et al., 2017). Another hospital changed the definition of on time to incision with no grace period and built a nine-month plan around it, with engaged physician leaders (Allen et al., 2019).

What it took. Embedded improvement staff and published data, in the first case; a redefinition agreed by physician leaders, in the second.

Starting position and follow-up. The academic center started at 49%, peaked at 92% by June 2013 and fell to 78% through 2014. That fall is part of the finding: the peak did not hold, though the later level stayed well above baseline. The incision-time hospital reached 73.6% under its stricter definition and estimated 1,343 hours of operating room time saved a year.

Fit for this hospital. The hospital already reports the measure monthly, which is the starting point for this group. Redefining the measure is the OR Executive Committee's decision and outside a nursing project.

Group 4: How Improvement Happens

A secondary analysis of almost 29,000 first cases asked why an initiative worked (Tiwari et al., 2018). Delays narrowed because the process came under better control, not because preoperative work started earlier, and staff did not need to arrive earlier. That matters here, where earlier start times for preoperative nurses would need agreement the project cannot obtain.

The Source That Disagrees

Work on schedule tardiness argues that small interventions touching few cases do little to overall lateness, and that adjusting the published schedule to account for known first-case lateness and case duration bias reduced tardiness far more (Wachtel & Dexter, 2009). That is a fair challenge to a four-room readiness project: even if it works, the effect on the whole suite's day may be small. The review keeps this source rather than dropping it, and the project's aim is limited to first cases in four rooms for that reason.

Sources Beyond the Journals

The hospital's own OR Executive Committee minutes from 2024 record an earlier attempt: a reminder email to surgeons' offices about histories and physicals, sent for two months. No follow-up figures were kept. Its lesson is that a reminder without someone assigned to check readiness was not enough, and that a measure needs to be agreed before the change starts.

What the Sources Do Not Address

None of the sources studied a community hospital where surgeons' offices are independent practices, which is the arrangement here and the main reason the afternoon call depends on goodwill. None reported patients' views of an extra call. And none separated the effect of the readiness change from the effect of being watched; in every case the measure became more visible at the same time. These gaps do not argue against the project. They argue for measuring the share of calls returned and the day-of-surgery cancellations alongside the on-time rate, and for reporting results after enough weeks that a single good week is not mistaken for a change. A run chart of weekly figures does that more honestly than a single before-and-after comparison.

Summary for the Director

What the Review Supports

A nursing-led readiness change is the closest match to the evidence that this hospital can try first without a record build. The size of any effect is uncertain, the effect on the rest of the day may be small and sustaining it needs continued measurement.

References

Allen, R. W., Taaffe, K. M., Neilley, V., & Busby, E. (2019). First case on-time starts measured by incision on-time and no grace period: A case study of operating room management. Journal of Healthcare Management, 64(2), 111-121. https://doi.org/10.1097/JHM-D-17-00203

Blair, K., Mijatovic, O., Thompson, M., Monroe, M., & Davies, C. C. (2024). A nurse-driven plan to diminish first-case operating room delays. The Journal of Nursing Administration, 54(9), 503-506. https://doi.org/10.1097/NNA.0000000000001467

Coffey, C., Jr., Cho, E. S., Wei, E., Luu, A., Ho, M., Amaya, R., Pecson, M., Dalton, F. V., Kahaku, D., Spellberg, B., & Sener, S. F. (2018). Lean methods to improve operating room elective first case on-time starts in a large, urban, safety net medical center. The American Journal of Surgery, 216(2), 194-201. https://doi.org/10.1016/j.amjsurg.2018.05.002

Phieffer, L., Hefner, J. L., Rahmanian, A., Swartz, J., Ellison, C. E., Harter, R., Lumbley, J., & Moffatt-Bruce, S. D. (2017). Improving operating room efficiency: First case on-time start project. Journal for Healthcare Quality, 39(5), e70-e78. https://doi.org/10.1097/JHQ.0000000000000018

Singh, D., Cai, L., Watt, D., Scoggins, E., Wald, S., & Nazerali, R. (2023). Improving operating room efficiency through reducing first start delays in an academic center. Journal for Healthcare Quality, 45(5), 308-313. https://doi.org/10.1097/JHQ.0000000000000398

Tiwari, V., Ehrenfeld, J. M., & Sandberg, W. S. (2018). Does a first-case on-time-start initiative achieve its goal by starting the entire process earlier or by tightening the distribution of start times? British Journal of Anaesthesia, 121(5), 1148-1155. https://doi.org/10.1016/j.bja.2018.05.043

Wachtel, R. E., & Dexter, F. (2009). Reducing tardiness from scheduled start times by making adjustments to the operating room schedule. Anesthesia & Analgesia, 108(6), 1902-1909. https://doi.org/10.1213/ane.0b013e31819f9fd2