19 - Implementing GEMBA Boards in an OR Setting to Improve First Case On-Time Starts

Description:

Introduction:
First case on-time starts (FCOTS) are a key performance indicator in the operating room (OR), directly impacting efficiency, patient safety, and satisfaction. In late 2022, Harris Health's perioperative team adopted the GEMBA board model- adapted from the Japanese concept of "Gemba," meaning "the real place" as part of a system-wide initiative aimed at process improvement. Prior to implementation, the OR's FCOTS rate averaged 75% in Q4 2022 below the institutional goal of 80%. Contributing factors included communication breakdowns, inconsistent processes, and unclear accountability.

Assessment:
To improve FCOTS by implementing a GEMBA board as a collaborative and visual tool for identifying and addressing practice gaps and workflow barriers in real time.

Implementation:
This quality improvement project took place in a high-volume, multi-specialty OR setting. A centrally located GEMBA board was introduced and updated daily by the OR leadership team. The board tracked key performance metrics and categorized delay reasons. Daily interdisciplinary huddles were held to review prior-day performance, resolve immediate concerns, and plan corrective actions. The prior-day performance metrics include case volume, timely first case starts, delays, patient safety issues, and facility issues.
Identified opportunities for improvement:
-Communication breakdown between inpatient units, OR and Pre-op departments regarding patient readiness for surgery, which includes pre-surgery checklists and surgical/anesthesia consents not being completed in a timely manner
-Competing demands for nursing attendants’ attention such as room turnovers and specimen lab delivery, leading to delays in surgical patient pickup and transport
In response, two targeted interventions were deployed:
1. Optimization Nurse Role: A designated OR nurse stationed in pre-op to verify consent completion and coordinate readiness with responsible departments.
2. Dedicated Inpatient OR Transport: Two full-time transport staff assigned solely to facilitate timely inpatient arrivals to the OR.
Data on FCOTS were collected for 2 years, comparing pre- and post-implementation performance.

Outcomes:
The GEMBA board served as a transparent, team-driven platform for ongoing feedback, accountability, and collaborative problem-solving. Staff engagement increased as demonstrated by increased attendance and participation rates, and ownership of processes was enhanced across roles.
Utilization of the GEMBA board during departmental huddles helped to identify several key areas for improvement such as the delay in obtaining complete and accurate consents from all members of the OR team Implementation of the GEMBA process revealed two key workflow gaps, which drove the OR team to implement two interventions that ultimately improved FCOTS. The implementation of the GEMBA board significantly improved FCOTS performance, with rates rising from 75% to a sustained 88% by Q1 2025.

Implementation:
Based on GEMBA Board findings, the Optimization Nurse role and the dedicated inpatient OR transporter were implemented to improve clinical workflow. This low-cost, high-impact strategy empowered perioperative teams and uncovered actionable gaps in practice. The model is scalable and can be adapted to other procedural areas to enhance operational efficiency and patient outcomes.