Operating Rooms Have Been Measuring Lateness in Dollars Since the 1990s

Hospitals track how often the first surgery of the day in each operating room starts on schedule because that single number predicts, more reliably than almost any other operational metric, how the rest of the day’s cases will run. A late first case has nowhere to borrow time from; every case scheduled behind it in that room absorbs the delay in sequence. Health-services researchers have been studying and costing this specific failure mode since at least the 1990s.

The metric itself, commonly called the “first-case-of-the-day on-time start rate,” is unglamorous by hospital standards — no imaging, no biomarker, just a stopwatch. But it has proven durable as an operations benchmark precisely because it isolates a single, attributable moment: did the patient reach the table, or did anesthesia induction begin, within the window the schedule promised. What that window is varies by institution — some hospitals count “on time” as within five minutes of the printed start, others allow ten — but the logic behind tracking it at all is consistent across the literature on operating-room efficiency.

In brief, self-contained terms: an operating room’s daily schedule is a sequence of cases stacked back-to-back with turnover time in between, and only the first case in that sequence starts with no accumulated buffer in front of it; every later case inherits whatever lateness has built up before it, so a ten-minute delay to case one can still be a ten-minute delay to case five, while the same ten-minute delay introduced at case three might be partly reabsorbed by turnover slack, an early finish elsewhere, or a canceled add-on — which is why hospital operations researchers treat the first case as categorically different from every case that follows it, and why on-time-start rate is tracked specifically for that first slot rather than as a plain daily average.

Franklin Dexter, an anesthesiologist and operations researcher at the University of Iowa, has published much of the foundational work on this question, largely in the journal Anesthesia & Analgesia, over roughly three decades. Along with longtime collaborators including Richard Epstein and Ruth Wachtel, Dexter’s research group has used operating-room scheduling data from multiple hospitals to model how tardiness at the start of the day propagates, and to test which interventions actually shorten it. One recurring, mildly counterintuitive finding from that body of work: in the hospital datasets they analyzed, surgeon lateness was not always the dominant cause of delayed first-case starts. Anesthesia-related readiness — line placement, regional block administration, confirming the patient has met NPO (fasting) requirements — and patient-flow issues such as delayed arrival to the preoperative area or incomplete paperwork, showed up as frequent contributors alongside, and sometimes ahead of, surgeons arriving late. Positioning and equipment setup inside the room added further time on top of whichever of those came first.

The dollar figure is where the research gets more cautious, and appropriately so. Hospitals and health-economics researchers have long tried to attach a per-minute cost to idle operating-room time, because it lets administrators translate a scheduling delay into a budget line. The trouble is that “cost per OR-minute” is not a fixed, universal number — it depends on what a given cost-accounting exercise includes (staff wages and benefits, equipment and supply overhead, allocated capital costs for the room itself, or some combination) and on the case mix and setting. Published estimates in the anesthesia and health-services literature, including cost-modeling work associated with Dexter and Abouleish, have put OR time in the range of roughly $15 to over $100 per minute depending on the institution and methodology, with many commonly cited figures for a fully staffed, general-hospital OR clustering in the lower half of that range. Because the range is wide and methodology-dependent, any single precise figure quoted without its cost-accounting assumptions attached should be treated skeptically.

What the underlying economics literature is more confident about is the shape of the cost, not just its size: idle OR time is expensive largely because of fixed staffing. A room booked for the day is staffed for the day — surgeon, anesthesia provider, circulating and scrub nurses, sometimes a surgical technologist — regardless of whether the patient is on the table. Fifteen minutes of first-case tardiness is fifteen minutes those salaried and hourly staff are being paid to wait, multiplied across every room running behind, and it is also fifteen minutes of downstream schedule pressure that can push the day’s last case into overtime, which typically carries its own cost premium. That combination — a fixed cost that starts running the moment the day is booked, plus a cascading penalty that grows with each delayed case behind it — is part of why the discipline of attaching a real, named cost to a missed commitment shows up across very different domains, from surgical suites to the reasoning behind pairing a consequence with a specific deadline rather than a vague one.

It’s also why hospitals specifically single out the first case rather than averaging lateness across the whole day. An analysis of where in a schedule a delay is cheapest or most expensive to absorb resembles, in miniature, how the price of a broken commitment changes depending on when in a sequence it happens: early in a sequence, there is no slack to spend, so the full cost of the delay shows up immediately; later in a sequence, some of that cost can be diffused or absorbed by whatever buffer remains.

The same operating rooms run a spoken pause before the first incision, which turns up alongside six other places that say a start out loud. None of this makes the first-case metric a perfect proxy for OR efficiency — a hospital can hit its on-time-start target while still running an inefficient block schedule, and a single bad morning does not indict an entire surgical department. But as a narrowly defined, historically tracked number with a well-documented cause-and-effect chain behind it, first-case on-time starts remain one of the more legible windows health-services researchers have into where hospital time, and hospital money, actually goes.