It is late afternoon. ORs are still running, but not for the patient who has been waiting on the add-on list for hours.
A patient arrived through the emergency department with a condition that clearly requires surgery. It is not immediately life-threatening, but it also cannot wait for a clinic visit or a scheduled slot several days later. She has been evaluated, stabilized, made NPO, and consented. Everything is ready, except access to the OR.
We often describe modern surgical care as patient centered. Yet, for a substantial group of patients, the experience is defined less by clinical urgency than by when the system can accommodate them.
In many respects, surgical systems perform remarkably well when patients fit established pathways. Elective patients follow a predictable course: They are scheduled in advance, prepared on arrival, treated by a ready team, and moved efficiently into recovery. Critically ill or injured patients follow a different but equally well-engineered pathway: When life-threatening hemorrhage or instability is present, teams mobilize and an OR opens within minutes.
But between these two groups lies another population: patients who are neither scheduled nor unstable. They require surgery, often within hours—not days—but they do not trigger the same urgency or access.
These patients do not move through a care pathway. They move through a gap.
A System that Works but Still Leaves Patients Waiting
This gap in OR access is not the result of inattention or a lack of commitment. It stems from how OR systems are structured and how performance is defined.
Most hospitals organize surgical access around two priorities: maintaining a full elective schedule during business hours and preserving the ability to respond to true emergencies at any time. Both priorities are appropriate, and both are measurable.
But another group of patients exists in the shadow of those priorities: patients who require surgery during their current hospitalization and cannot safely return home, yet do not meet the threshold for immediate operative access.
This conundrum does not exist outside the system. It is built into it.
The lack of access is not simply a matter of whether the OR is busy. At the core of the issue is how we define performance and whether that definition is broad enough to include patients whose waiting has become routine.
When Delay Is Not a Failure but a Feature
We often describe these situations as delays, implying that they result from breakdowns in an otherwise well-functioning system.
But in many cases, they are not breakdowns. They are the predictable consequence of design.
Daytime schedules are tightly allocated, while after-hours capacity is often constrained. Decision-making is distributed across services, each balancing its own priorities and challenges. Even when systems protect time for unscheduled cases, that capacity is often insufficient to absorb demand. Individual decisions—to defer a case to the next daytime slot, avoid displacing a scheduled case, or wait until morning—may be reasonable in isolation.
Collectively, however, these deferrals create a queue that no one owns, no one routinely reports, and for which no one is truly accountable.
Over time, this approach becomes normalized. Surgeons anticipate the barriers and adapt accordingly. Cases that might benefit from earlier intervention are deferred because timely access seems unlikely. The system appears to function because behavior has adjusted to its limits.
We speak easily about care without delay. Yet for many patients, the reality is care delivered within a structure that quietly normalizes delay.
Operational Blind Spot
One reason these delays persist is that they can be difficult to identify.
OR performance is typically measured using metrics that emphasize scheduled throughput, business-hours use, and responsiveness to emergencies. These are important benchmarks, but they do not capture the experience of the unscheduled, nonemergent patient.
Time to operation may be measured from the moment a case is posted or cleared rather than from when the patient enters the system. Delays may be attributed to clinical optimization or coordination without examining whether access itself is the constraint.
Part of the challenge lies in how incentives are structured. OR use during business hours is closely tracked and optimized. In contrast, care delivered after hours is often treated as a deviation to be minimized rather than as a component of timely care.
What Does “Timely” Actually Mean?
In an era of constrained staffing, limited margins, and pressure on throughput, hospitals have become highly attuned to efficiency within the scheduled day. But an important question remains: Can we afford not to provide these patients with timely surgical care?
The challenge, of course, is that “timely” is rarely defined for patients who are neither elective nor emergent.
For this group, timeliness is not about immediacy. It is about aligning clinical need with OR access without prolonged, nontherapeutic waiting. Once a patient has been admitted and a decision to operate has been made, time is no longer neutral. It becomes part of the care we deliver—or fail—to deliver.
Any definition of timely care in this context should be pragmatic. It must be ambitious enough to prevent routine delay from becoming acceptable, but realistic enough to account for staffing, competing priorities, and finite capacity. The goal is to aim high without pretending that constraints do not exist.
Without that balance, systems tend to oscillate between rigid targets that fail in practice and flexible approaches that quietly accept delay as inevitable.
For patients, prolonged preoperative waiting exposes them to pain, immobility, and the cumulative effects of hospitalization. In older adults, each additional hour may increase the risk of delirium, deconditioning, and loss of independence. For others, delay may allow disease to progress or make procedures more technically complex.
For surgeons practicing in this environment, clinical judgment is repeatedly constrained by access rather than need. Efficiency also suffers as inpatient length of stay increases and downstream capacity tightens.
For organizations, this is a throughput problem, a quality problem, and, increasingly, a financial problem. The costs of delay are dispersed across units, days, and services, making them easy to overlook. But they are not negligible.
Making the Invisible Visible
Addressing these delays does not begin with adding more ORs or staff, although these measures may eventually be part of the solution. Improving timely surgical care begins with making the problem visible.
1 The patient population must be recognized. Whether or not a formal label is used, identifying patients who are neither elective nor emergent, but remain time sensitive, is essential. Some healthcare professionals refer to this group as nonelective, nonemergent (NENE) patients. The label matters less than recognizing the distinct needs of the cohort.
2 Measurement must shift toward the patient’s experience. Tracking time from arrival or the decision to operate, rather than from administrative milestones, focuses attention on metrics that reflect what patients actually experience.
3 The OR queue must be visible to all stakeholders. A shared daily view of pending unscheduled cases transforms delay from an individual negotiation into a system responsibility.
4 Escalation pathways must be defined. Without clear thresholds for when wait times are no longer acceptable, decisions default to the path of least resistance.
5 Hospitals must confront the practical reality of capacity. Most organizations cannot easily expand the number of staffed ORs. Flexibility, therefore, may require extending hours and absorbing demand beyond the scheduled day. But this approach depends on alignment among surgeons and colleagues in anesthesia, nursing, sterile processing, transport, recovery, and inpatient units.
6 System leaders must acknowledge that decisions are often made from service-specific perspectives. What appears reasonable for one department may contribute to delay at the system level. Without a shared view of the patient journey, local optimization can undermine overall flow.
We have built highly reliable models for scheduled surgery and highly responsive models for life-threatening emergencies. But between those two domains lies a substantial portion of surgical care: patients who fit neither model, yet whose outcomes still depend on timely intervention.
Disclaimer
The thoughts and opinions expressed in this article are solely those of the author and do not necessarily reflect those of the ACS, HealthPartners, or the University of Minnesota.
Dr. Benoît Blondeau is the system chair of surgery at HealthPartners in the Twin Cities, Minnesota, and professor of surgery at the University of Minnesota in Minneapolis.
