When Rebecca Urban became enterprise vice president for surgical services at Radnor, Pa.-based Main Line Health June 8, she inherited a perioperative team posting 78% first-case on-time starts and operating room turnaround times of about 42 minutes across its four hospitals.
By roughly the 90-day mark, first-case on-time starts had climbed to 92%, and enterprise turnaround time now averages about 33 minutes a month, Ms. Urban said. Main Line measures a first case as on time based on wheels-in, when the patient enters the OR, and applies that definition across all its sites.
Some of the biggest jumps came quickly. At Paoli Hospital, first-case on-time starts rose from 63% in late June to 85% by July 5 and have held in the 90s since Aug. 2, Ms. Urban said. Wynnewood, Pa.-based Lankenau Medical Center, the system’s flagship, went from 73% to 82% by July and has held in the 90s since August, she said.
The gains build on slower enterprise progress. Main Line averaged about 77% first-case on-time starts in 2021 and reached the low 80s by early 2026. Since June, the system has stayed above 85%, Ms. Urban said.
In mid-August, the four hospitals put together a run Ms. Urban said she had never seen in her career. On Saturday, Aug. 15, the previous day’s scorecards showed Bryn Mawr (Pa.) Hospital, Riddle Hospital in Media, Pa., and Paoli (Pa.) Hospital, one of the system’s trauma centers, at 100%, with Lankenau at 99%. She texted her team to ask whether the data was broken. Her team confirmed it was valid, and the run of near-perfect first-case on-time starts at all four sites continued for the next five days.
The gains did not come from adding cases. Speaking on the panel “Perioperative Flow 2030: Surgical Throughput in the Era of Command Centers” at Becker’s 2026 Perioperative Summit, Ms. Urban said surgical leaders need to look past the volume targets handed down from the C-suite.
“We live in a day and age where we are facing significant pressures to add more cases and increasing our volume to meet the needs of our community,” she said. “We have to think differently in the way we complete the work as our oranges have no more juice to squeeze.”
Instead, Ms. Urban said her focus is on growing service lines that fit Main Line’s community and delivering high-quality care close to home.
Ms. Urban spent most of her career at Cleveland Clinic as administrator for surgical operations and service lines and most recently worked at Philadelphia-based Jefferson Health. She said throughput depends on everything that happens around a surgical case. Here is how she is putting that into practice.
Measure how the work feels, not just how the room is used
Utilization and first-case on-time starts show how well an OR is being used, Ms. Urban said. “It does not tell you how that work is being experienced at the end of the day.”
A command center designed around nurses, techs and surgeons would track the friction staff run into while delivering care, she said, such as how often teams search for an instrument tray and how standardized those trays are. Most departmental spreadsheets, by contrast, focus on case counts and start times and say nothing about what teams go through to hit them.
At Cleveland Clinic, Ms. Urban’s team eliminated surgeon-specific special trays, standardized 3,653 trays and removed 51,000 instruments, saving about $5 million.
“I am still alive to tell the tale,” she joked. “That work mattered for our surgeons. It mattered for our nurses. It mattered for our SPD techs and scrub techs.”
She added that computer vision can show leaders when breaks are being missed, how workflows actually unfold and how teams recover from day-to-day surprises.
Main Line’s surgical command center today focuses largely on OR utilization, reactive cases and case cancellations. The team is working to become more proactive, using visibility into upcoming cases to open the right number of rooms and align anesthesia teams accordingly.
Next, Ms. Urban wants the command center to help place ambulatory cases in the right locations and make sure robotic rooms and robots are used at the same time. Robotics will be the department’s biggest focus in the coming year, she said, because health systems too often have a robot sitting idle in a robotic room.
Round on the ORs before huddle
As a new leader, Ms. Urban said she has prioritized frontline conversations, whether she is wearing scrubs or a suit, asking staff how their day is going and what is in their way. Food helps, too. “Pizza is not a swear word,” she said.
On her seventh day in the role, she changed how her nurse managers spend the first 20 minutes of each day. Before huddling, each manager now rounds on three ORs, Joint Commission-style, using a quick checklist and viewing each room from the perspective of the surgeon and the circulator. They check whether the room has the lead aprons it needs and whether carts are in the right spot.
The rounding gives managers an up-close look at the barriers physicians, anesthesia teams and frontline staff face, and provide an opportunity to fix them in the moment, Ms. Urban said. Daily scorecards then track the results and create accountability.
“The day-to-day scorecards allowed every leader at each site to proactively handle the variances and challenges the teams were facing,” she said. That beats waiting on end-of-month reports, which tend to be reactive.
The four sites are now competing on their on-time streaks.
“Your job as a leader is to get those barriers out of the way,” Ms. Urban said.
Take on lateness directly and make it visible
When one physician was consistently late, Ms. Urban took him to happy hour to talk through what was getting in his way. His concern was that he could not count on the team to be ready. She committed to being in the OR herself to make sure they were, and said she did not need to do so for many days.
Main Line Health also built a new daily scorecard in Tableau. Every executive leader, nurse manager and OR director receives a report each day showing who was late and why, and the list is posted in the OR for 24 hours, Ms. Urban said.
Within about three days, she said, physicians no longer wanted to appear on the list.
The response from surgeons has been largely positive, Ms. Urban said. Leaders reach out to anyone who appears on the list, and she has received emails from surgeons thanking her for paying attention to on-time starts. To them, the emails signal that the effort is more than lip service.
That buy-in also came from one-on-one meetings with physicians and surgeon forums explaining why the work matters, she said, along with recognizing wins through awards, plaques and emails.
Do the basics well before 2030
Looking toward 2030, Ms. Urban said perioperative leaders should right-size staffing models, keep matching the right case to the right location at the right time and get full use of physical assets such as surgical robots, which will only grow more expensive. Anesthesia shortages will persist, she added, making it critical to maximize those relationships and capacity.
None of that replaces the fundamentals. “It’s important that you do the basics really well,” she said. “Ensure that you have a strong turnaround. That makes all the difference when you’re trying to align your day.”
She also urged leaders to move on ambulatory strategy now and bring physicians into that planning. “It’s not tomorrow. It’s today,” she said. “Our physicians are such great leaders and great partners.”
Her advice for leaders heading back to their own ORs is simple: Walk through and ask staff what is in their way.
“That simple question is going to give you so many answers on where you need to focus,” Ms. Urban said.
