Description: A delay in On-Time First Case Starts has a negative effect in the operating room. These delays cost money, time, and overall dissatisfaction. Our operating rooms were tasked with improving on-time first case starts and our current practice was slacking with an average of 59%. While observing the operating rooms several issues were identified. Nurses were pacing between departments, Surgeons were arriving late, orders were omitted, and lack of communication amongst the entire team was delaying entry into the OR. Therefore, the idea emerged to construct a one-directional, efficient workflow. This evolved from basic human anatomy of the heart. Blood flow in the heart is one-directional. If there are any impairments with the heart valves the outcome can lead to congestive heart failure in other words, “backup.” Thus, the notion was to create a new process with this theory of preventing “backup” in mind. In order to create a successful workflow Surgeons, Anesthesia, Nurses, Scrub techs, PNAs, and the unit secretary were involved. A detailed outline was designed with precise time frames to complete each task. The time frames were given in 10-15 minute increments to complete pre-op work, nurse interview, anesthesia interview, and surgeon identification. Anesthesia was also given the task to be the team that rolled the patient to the operating room. This, in turn, gave the circulating nurse time in the OR to set-up, count, and be ready for the patient’s arrival. In order to enhance the process, the unit secretary announced overhead once a surgeon had identified his/her patient. Circulating Nurses were provided with workstations in the hallway leading to pre-op in order to review patient’s chart in turn deterring them from pacing between departments. Lastly, a checklist was created and placed on each patient’s pre-op door that was to be completed prior to proceeding to the OR. The checklist was to be signed by the Nurse, Anesthesia, and Surgeon once their interviews and documentation were complete. Additionally, if laterality was involved it was to be verified by the circulating RN. Once the checklist was completed Anesthesia was then allowed to safely proceed with the patient to surgery. This checklist has served as an excellent communication and safety tool amongst the entire perioperative team. After commencement of this process in September 2018 our on-time first case starts increased by 10% with an end of year average of 68%. So far in 2019 the process continues to evolve and our current average on-time starts is 76%. This new practice has become part of our routine and was also adopted by the Urology OR. The Urology OR has also demonstrated improvement in their on-time first case starts with this method. Our original goal of 80% on-time starts is promising for the end of 2019.