In our imaginations and our memories of late days, ORs run off track as a result of a major disruption: a case that runs two hours over because of complications, an add-on emergency that reshuffles the schedule, a critical equipment issue, or a last-minute staffing gap.
But, more often, OR days simply drift off course case by case and turnover by turnover. A prep phase runs a few minutes long. A wrap-up stalls. Environmental services gets waylaid. A room sits idle while the team waits. Individually, each delay feels insignificant. But, throughout the course of the day, they compound, pushing cases later, backing up the schedule, and stretching teams thin.
This is true even for hospitals with strong first case on-time starts (FCOTS) performance. Even if OR days start on time, nearly half still end late. This gap tells us something important — the delays that derail an OR day aren’t necessarily happening at the start. They’re accumulating quietly throughout the day, in places most teams can’t see.
OR leaders and staff are working hard every day to keep things moving. So what’s preventing teams from managing these delays? The systems and data on which they rely have fundamental gaps that make real-time delay management nearly impossible. In practice, this breaks down into four key gaps:
- Delays aren’t visible early enough to act
- Teams can’t pinpoint where the delay is happening
- Teams don’t have a clear definition of what a delay is
- All relevant teams aren’t kept in the loop on when and where to act
Learn how Houston Methodist used Flagged Cases to cut late OR days in half.
Read the case study
1. Delays aren’t visible early enough to act
In most ORs, delays are recognized after they’ve already impacted the schedule. Teams rely on board checks, walking the floor, calling the OR, and periodic updates to track what’s happening across rooms. Even systems that label themselves as “real-time” often just show status, not whether something is off track.
Consider a common scenario: Case prep is running 10 minutes longer than usual. On the board, the case still shows that prep is in progress. But no one outside the room has any clear indication that prep is already trending late. By the time the delay is obvious, the next case is already affected.
What’s needed isn’t just visibility into the room, but visibility that a delay is happening.
2. Teams can’t pinpoint where the delay is happening
When a case is running late, the next question is: Why?
But most hospitals have visibility at the case, not phase level. They look at whether the overall case or turnover is running long, but they have no visibility into which part of the case or turnover is driving that delay.
The default assumption is that OR efficiency comes down to the procedure and the surgeon. But that’s only part of the story. Research published in The BMJ shows that roughly 67% of total OR time happens outside the procedure itself — in prep, wrap-up, and turnover. And, for the same procedure performed by different surgeons, variation in this non-procedure time ranges from 70 to 127 minutes.
That’s nearly an hour of fluctuation despite all cases being for the same type of surgery. What’s needed is phase-level visibility:
- Is it the prep phase? Are they waiting on positioning, draping, or a key team member to get started?
- Is it a stalled wrap-up? Is anesthesia emergence taking longer than expected? Or is PACU backed up?
- If it’s a long turnover, is it the cleanup or setup that’s causing extended times?
To fix a delay, teams need to know where it’s coming from.
3. Teams don’t have a clear definition of what a delay is
Even when something feels off, teams face a more fundamental question: Is this actually a delay?
There is no single standard. What’s normal for one case may be a delay for another, depending on the surgeon, procedure, room, time of day, or day of week. Even within the same surgical service line, preparation times can vary dramatically. What’s expected for a straightforward case may look completely different from a more complex procedure requiring additional equipment, staff coordination, or anesthesia setup. Without this context, it’s easy to mislabel natural variation as inefficiency when, in reality, each case follows its own timeline.
A 25-minute prep phase may be expected in one scenario, while a clear delay may be expected in another. The problem is that most hospitals rely on averages, general expectations, and relatively fixed mental models for delays — ones that don’t reflect real-world variation. As a result, delays are recognized only when they become obviously long or already affect downstream cases.
Teams need context-aware benchmarks to confidently determine if a delay is occurring and how to help.
4. All relevant teams aren’t kept in the loop on when and where to act
Even when a delay is recognized, acting on it requires coordination across multiple teams: charge nurses, anesthesia board runners, EVS, pre-op, and PACU.
But these teams often operate with different information and different timing. Without a shared, real-time view, it’s difficult to direct people to where they’re needed most in the moment — whether that’s getting EVS into the right room, knowing exactly when cleaning is finished so setup can begin, or ensuring float staff is supporting the room that will move the day forward fastest. As a result, effort gets spread unevenly, and the most impactful needs aren’t always addressed at the right time.
What early awareness changes
Keeping an OR day on track requires more than visibility. It requires the ability to:
- Detect issues early
- Understand where they’re occurring
- Determine whether they require action
- Coordinate a response across teams
In the next post, we’ll look at how real-time Delay Alerts address this gap by providing live, phase-level signals that help teams detect delays earlier, define what requires action, and coordinate more effectively to keep the day on track.
Learn how Houston Methodist used Flagged Cases to cut late OR days in half.
Read the case study