Fifty-Nine Percent of First Cases Start Late: Problem Statement, Setting and Questions for a Capstone on Operating Room Start Times
Student Name
American College of Education
HLTH5693: Capstone Experience for Healthcare Administration
Module 1 Assignment
Instructor Name
January 8, 2029
The Problem
The composite 196-bed community hospital in this capstone runs eight operating rooms, performing about 8,400 surgical cases a year. Each weekday, the first case in each room is scheduled to start at 7:30 a.m. The hospital defines a first case as on time when the patient enters the operating room at or before the scheduled start. Over the six months from April through September 2028, the surgical information system recorded 1,008 first cases on weekdays. Of these, 413, or 41 percent, started on time. The other 595 were late: half by more than 14 minutes, with an average delay of 19 minutes, and 112 started more than 30 minutes late.
Late first cases affect more than the first hour. Staff are scheduled from 7:00 a.m., so minutes lost at the start are paid for whether or not they are used, and delays can push the last case of the day past the end of the scheduled shift, producing overtime. Surgeons named late starts as their leading complaint in the most recent medical staff survey, and two have moved some elective cases to an ambulatory surgery center across town. A late first case is the one delay in the operating room that everyone sees, because it happens at the same time every morning.
The Setting and Its Stakeholders
The hospital's surgical department includes a preoperative area with 14 bays, the eight operating rooms and a 12-bay recovery unit. It serves general surgery, orthopedics, gynecology, urology, otolaryngology and ophthalmology, with 31 surgeons holding regular block time. Anesthesia is provided by a contracted group of anesthesiologists and nurse anesthetists. Perioperative nurses, surgical technologists and preoperative nurses are hospital employees. The perioperative services director reports to the chief nursing officer, and an operating room committee of surgeons, anesthesiologists and nursing leaders sets policy.
Each group experiences the problem differently and has a different view of its cause. Surgeons tend to see delays in preoperative preparation; preoperative nurses point to patients arriving late and missing paperwork; anesthesia points to incomplete histories and physicals; and nurses in the operating rooms point to surgeons arriving after 7:30. The capstone must answer with data, because every stakeholder already has an answer.
Why This Problem, and Why Now
Several problems competed for this capstone, and this one was chosen for three reasons. First, it matters to the hospital's strategy. The hospital's three-year plan depends on growing elective surgical volume, and surgeons choosing where to operate weigh reliable start times heavily; the two surgeons who have moved cases to the ambulatory surgery center cited late starts in their exit conversations with the chief medical officer. Second, it is measurable with data the hospital already records, so the capstone can analyze it rather than rely on opinions. Third, it is within the hospital's control. Unlike reimbursement or the regional labor market, the causes of late starts lie mostly inside the hospital's own processes, among people who report to its leaders or work under its policies.
The problem also affects patients in ways the financial analysis will not capture. Patients scheduled for 7:30 a.m. have usually fasted since midnight and arrived by 5:30 a.m.; each minute of delay extends their fast and their anxiety. Late first cases also tend to push later patients' surgeries back, and patients scheduled for the afternoon wait longest of all. The capstone will not measure patient experience directly, since the hospital's survey data are not detailed enough by time of day, but its recommendations will consider patients as well as costs. Perioperative overtime cost the hospital about $412,000 in the last fiscal year, a figure the capstone will examine rather than attribute entirely to late starts.
What the Evidence Suggests Before Analysis
The problem is common and has been studied. Halim et al. (2018), in a systematic review of 14 studies of interventions to improve operating room start times, found that financial incentives, educational approaches, system-based changes, communication improvements and schemes such as the golden patient initiative, in which the first patient is confirmed ready the day before, had all been shown to improve start times, but that it remained uncertain which was most effective, how long effects lasted and whether results transfer between settings. That uncertainty is a reason to diagnose this hospital's causes before choosing a remedy.
The financial case also needs testing rather than assuming. Operating room time is expensive: an analysis of California hospitals estimated a mean cost of about $58 per minute in fiscal year 2022 (Ashrafi et al., 2026). Yet a closer analysis by Dexter and Epstein (2009) showed that the savings from reducing first-case tardiness depend on whether rooms run long enough for the saved minutes to reduce paid time; in their data, each minute of reduced tardiness reduced staffed time by about 1.1 minutes, but only in rooms with more than eight hours of cases. Multiplying late minutes by the cost per minute would overstate what the hospital can save.
Scope
The capstone studies weekday first cases of the day in the eight main operating rooms. It excludes emergency and add-on cases, which have different causes; turnover time between later cases, which the operating room committee is addressing separately; the block scheduling system, which is governed by a policy under renegotiation with the surgeons; and the obstetric operating room in labor and delivery, which is staffed and scheduled separately. These exclusions keep the capstone focused on a problem that can be analyzed and addressed in the time available.
The Questions
The capstone will answer five questions. First, how often, by how much and in which rooms, services and days do first cases start late, measured consistently? Second, what causes the delays, measured in minutes attributed to each cause rather than in anecdotes? Third, what interventions does the evidence support for the causes found here? Fourth, what financial value would a realistic improvement produce, given how the hospital staffs its rooms? Fifth, what would implementing the recommended changes require in cost, staffing and compliance with rules on preoperative documentation and consent?
The order is deliberate, since every question leans on the answer to the previous one. The second cannot be answered without the first's consistent measure; the third depends on the causes found; the fourth depends on which improvements are realistic; and the fifth turns recommendations into a plan. A capstone question is worth answering when the organization would make a different decision depending on the answer.
Data Needed and Access
The first two questions depend on data the hospital already holds. The surgical information system records scheduled start, patient in room and the time each preoperative step is completed. The perioperative services director has approved access to de-identified extracts for the six-month baseline. Delay reason codes are entered by circulating nurses but are incomplete, so the capstone will add two weeks of direct observation in the preoperative area, with the operating room committee's approval. Cost data, including staffing schedules and overtime, will come from the finance department. The capstone will not use identifiable patient information, and no surgeon or staff member will be identified in any finding.
References
Ashrafi, A., Maggard-Gibbons, M., & Childers, C. P. (2026). Costs, charges, and revenue of hospital operating rooms in California. JAMA Surgery, 161(9), 901-907. https://doi.org/10.1001/jamasurg.2026.2355
Dexter, F., & Epstein, R. H. (2009). Typical savings from each minute reduction in tardy first case of the day starts. Anesthesia & Analgesia, 108(4), 1262-1267. https://doi.org/10.1213/ane.0b013e31819775cd
Halim, U. A., Khan, M. A., & Ali, A. M. (2018). Strategies to improve start time in the operating theatre: A systematic review. Journal of Medical Systems, 42(9), Article 160. https://doi.org/10.1007/s10916-018-1015-5
How this HLTH 5693 Module 1 example is structured
HLTH 5693 Module 1 often fixes the problem statement, the setting and the questions worth answering; your classroom's instructions decide the format and whether a site approval is required. This example states the problem with its definition and baseline, then describes the setting and the people affected. The scope section says what the capstone will not study, and the questions section explains why each question is worth answering. A final section lists the data the capstone will need, because a question without accessible data cannot be answered in the time available.
HLTH5693 Module 1 questions, answered
What does HLTH5693 Module 1 usually ask for?
HLTH5693 Module 1 often asks students to define the problem their capstone will address, describe the organizational setting and state the questions the capstone will answer. Many sections also expect a scope and a note on data access. Your classroom's instructions decide the format and whether site approval is needed.
How do I write a strong capstone problem statement?
Define the problem with a clear measure, a baseline period and numbers, describe its consequences specifically and avoid building the cause or solution into the statement. A problem stated as a measured fact is easier to analyze than one stated as an opinion.
How many research questions should a capstone have?
Enough to reach a decision and few enough to answer well, often three to five. Order them so each builds on the one before, and make sure the data needed for each is accessible within the course timeline.
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