Picture two operating rooms on a typical day. In one OR, the first case of the day begins 15 minutes late. Yet, somehow, the operating room still manages to end the day on time.
In the second OR, the first case starts right on schedule. But, by mid-afternoon, that operating room is running two hours behind. Patients are upset. Clinical staff extend their already-demanding shifts. Hospitals face the financial burden of overtime pay or canceled cases that impact revenue and access to care. By the end of the day, the entire team is running on fumes.
Which scenario deserves more scrutiny? When aiming to improve OR efficiency, is it more effective to focus on FCOTS, or to dig deeper into the cascading factors that derail an entire day? If your FCOTS rates look good and delays still pile up, it’s time for a new approach — and new metrics.
The appeal of FCOTS
First-case on-time starts (FCOTS) have long been treated as one of the go-to benchmarks for measuring OR efficiency across health systems. The metric’s appeal lies in its simplicity. It’s easy to define, simple to measure, and widely understood. In a perioperative environment, where data is often fragmented or difficult to understand, FCOTS stand out as clear and digestible data. Either the first case started on time, or it didn’t. That clarity makes it especially attractive to hospital leadership.
FCOTS also easily integrate into performance tracking and executive dashboards and are simple to benchmark, track over time, and compare across providers, departments, and facilities. Many systems tie FCOTS performance to financial or operational incentives to drive accountability. In short, FCOTS offer quick, quantifiable snapshots of how well teams are coordinating to start the day, a powerful tool for many healthcare leaders.
Check out our case study on How Houston Methodist Used Precision Data to Prioritize OR Efficiency and scheduled 50% more cases at least one day per week.
The limitations of FCOTS
FCOTS capture just one moment in a complex surgical day: whether the first case starts on time. While useful, it offers a narrow view.
FCOTS can lead to misplaced focus and frustration
A laser focus on morning start times can create unintended consequences. Surgeons often find themselves in the hot seat when it comes to delays, bearing the brunt of criticism for late starts, even when those delays stem from factors beyond their control, like pre-op delays, anesthesia issues, or long turnovers. While they’re held responsible for being just five minutes late, other contributors to inefficiency rarely face the same scrutiny. This uneven accountability creates frustration and often leads to increased tension and finger-pointing among the team.
FCOTS don’t tell the whole story
Would you judge a runner just by their start? A perfect FCOTS rate might look good on paper, but it doesn’t mean the OR runs smoothly. One late-running case can snowball delays. You could start on time and still fall hours behind, yet FCOTS would still say 100%.
FCOTS can mask the source of delays
Focusing on first-case starts can create the assumption that morning delays drive all schedule disruptions. In reality:
- Morning cases tend to run closer to schedule than afternoon cases
- Delays often originate during mid-day transitions
- Case duration accuracy varies dramatically by surgical specialty
By focusing too narrowly on FCOTS, leaders often over-invest in early-morning process improvements while overlooking more actionable and impactful areas for change.
FCOTS lack actionable insights
FCOTS data alone does not provide the necessary insights to pinpoint and resolve the sources of OR inefficiency. To drive meaningful improvements, OR leaders need answers that help identify the root cause of delays like:
- Is Dr. Smith’s total joint replacement consistently taking 30 minutes longer than scheduled?
- Are your trauma ORs experiencing equipment delays during afternoon cases?
- Do certain anesthesiologists take longer for inductions on specific procedure types?
Without more granular metrics throughout the day, OR managers and leadership teams lack the specific insights needed to implement targeted improvements.
Looking Beyond First Case Starts
Although FCOTS provide a helpful baseline for whether the average day starts on time, hospitals need a more comprehensive approach to OR efficiency. In the next post of this series, we’ll outline which additional metrics matter and how tracking them can drive more meaningful improvements.
Check out our case study on How Houston Methodist Used Precision Data to Prioritize OR Efficiency and scheduled 50% more cases at least one day per week.