One useful way to approach this, and what tends to separate stronger answers, is to split root causes between factors inside the OR system's direct control and those that depend on external parties.

Internal factors (within the hospital's direct control):

• Room Readiness: setup not completed before patient arrival; sterilization delays from the prior day carrying over into morning starts
• Staffing Gaps: OR team not fully in position at shift start
• Anesthesia Readiness: pre-op assessment not completed until morning of surgery; anesthesia team not at wheels-in position on time

External factors (dependent on parties outside the OR team):

• Patient Prep: late arrivals to pre-op holding; missing labs, unsigned consent forms, or NPO (nil per os, meaning nothing by mouth after a set time before surgery) violations requiring cancellation or delay
• Surgeon Behavior: late arrivals; incomplete pre-operative notes; last-minute schedule changes or add-on requests the morning of surgery

Recommended interventions include a 24-hour patient confirmation call with a structured prep checklist, mandatory anesthesia pre-op assessments completed the prior day for all elective cases, OR charge nurses empowered to escalate room readiness issues at least 30 minutes before scheduled start, and surgeon-level on-time start scorecards shared with department chairs. A 54% rate is also a cultural signal, and lasting improvement requires visible accountability from leadership alongside process changes.