reduction in neurosurgical turnover times
savings opportunity from 10-minute TOT reduction
savings identified from targeted delay reductions
Background
Across healthcare systems, operating time is one of the most valuable (and limited) resources a hospital manages. Nowhere is this more acute than in neurosurgery, where complex procedures and a heavy reliance on specialized equipment mean that even small delays escalate quickly, disrupting schedules, frustrating staff, and driving up costs.
Salford Royal, part of the Northern Care Alliance NHS Foundation Trust, is a large university teaching hospital in Northwest England and home to one of the UK’s largest and most advanced neurosurgery departments. With 23 consultant (attending) neurosurgeons and sub-specialty expertise across vascular, spinal, skull base, pituitary, oncology, and functional neurosurgery, the department serves as a key tertiary referral center for the North West and beyond. To support this high-complexity environment, Salford Royal launched a major initiative with Incision to improve surgical team efficiency and reduce operating room (or operating theatre) delays.
The collaboration focused on practical, team-led improvements to daily preparation and workflows, using Incision Assist to organize and share detailed surgical workflows and surgeon preferences across teams. Rather than taking a top-down approach, the partnership centered on identifying actionable insights in day-to-day case preparation—driving incremental improvements that influence how neurosurgical lists run, while supporting teams to build on their existing structures and workflows. Here, we describe some of the early results of the collaboration and trial.
“As one of the biggest and most specialized neurosurgical centers in the UK, reducing delays is a major priority for us. With over 20 consultant neurosurgeons—each with their own specific way of working—every case adds a layer of complexity for the team. How we prepare for each procedure is key to both successful outcomes and day-to-day efficiency, and that’s exactly what we recognized in Incision and the Assist platform.”
– Lee Bennett, Associate Director Perioperative Care, Northern Care Alliance NHS Foundation Trust
Understanding Workfloor Challenges
This high volume of surgeons performing a wide range of complex procedures creates a fast-paced environment with frequent opportunities for delay. Each case demands precise, surgeon-specific preparation. Teams must coordinate a large array of instruments, devices, and setups—often involving intraoperative navigation and radiological support.
With varying experience levels across staff, quick access to accurate, usable information is essential for maintaining high-quality care. For new or temporary staff in particular, being able to quickly locate critical details helps them integrate into the team and adapt to surgeon-specific workflows.
From a management standpoint, reducing surgical delays had long been a strategic priority. Initiatives such as the "golden patient" approach and efforts to reduce cancellations and bed blocking had already laid strong foundations. Still, the ongoing challenge of balancing operational efficiency with uninterrupted, high-quality care led leadership to look more closely at daily workflows—recognizing the surgical team as a central driver of sustainable improvement.
Figure 1: Categories of Neurosurgical Case Delays (Jan–Dec 2024)
Undercovering Drivers of Delay
To better understand the scale and root causes of delays, Incision conducted a 12-month analysis using process mapping and operational data extracted from the hospital’s electronic health record (EHR) system. A total of 861 delays recorded for neurosurgical procedures in 2024 were identified, categorized, and reviewed, reflecting a complex mix of operational, clinical, and staffing-related challenges (Figure 1).
To better understand the scale and root causes of delays, Incision conducted a comprehensive 12-month analysis using process mapping and operational data extracted from the hospital’s electronic health record (EHR). A total of 861 delays recorded for neurosurgical procedures in 2024 were identified, categorized, and reviewed—reflecting a mix of operational, clinical, and staffing-related challenges. As seen in many retrospective EHR-based reviews, the largest single category was "unknown," reflecting incomplete or missing documentation [1]. Among identified causes, patient-related delays (17.7%), staffing-related delays (13.1%), and surgeon-related delays (12.6%) form a significant burden, representing complex realities such as rota gaps and conflicting clinical priorities.
Within the identified categories, equipment-related delays offered the clearest opportunity for action, accounting for 14.4% of total delay time. These ranged from instruments not ready at the start of a case to competition for shared resources such as microscopes. Notably, equipment-related delays were among the longest delay types, with an average duration of 54 minutes.
In total, equipment-related delays amounted to 94 hours and 7 minutes of lost operating time—equivalent to nearly 12 full working days (based on 8-hour shifts). Applying the NHS reference cost of £1,200 per OR/theatre hour, this translates to an annual opportunity cost of £112,940. This is likely a very conservative estimate, as it’s based on 2019 NHS benchmarks [2].
“We identified equipment-related issues as low-hanging fruit to improve our theatre utilization. It’s a key area where we could make measurable improvements quickly—and where our teams needed support the most. Our partnership with Incision directly enables us to do this, with case-specific equipment and materials information forming a key part of the Assist platform.”
– Senior Scrub Practitioner, Neurosurgery, Salford Royal NHS Hospital
Improving Turnover in High-Acuity Lists
Neurosurgical procedures often involve long case durations with only one or two turnovers per list, making transitions between cases relatively fewer but by no means less critical. Even small delays can have significant downstream effects, pushing second- and third-case patients beyond their scheduled starts or into costly overtime, and frustrating staff and patients alike. Previous research by Incision has shown significant improvements in turnover times with the use of Assist, particularly in high-volume surgical settings; one large-scale study demonstrated a 15% average reduction in turnover times across all surgical specialties at a medium-sized hospital [3]. But how does this translate to high-complexity, lower-volume environments like neurosurgery?
To evaluate early impact, average turnover times in the neurosurgical department were compared before and six months after introducing Assist. Despite being in the early stages of implementation, turnover times fell by more than 13%—far exceeding the 2.2% reduction observed across other specialties during the same period (Figure 2). These align closely with Incision’s broader research findings.
Using the same conservative NHS benchmark of £1,200 per hour, a 10-minute reduction in turnover equates to a £200 saving per case. For a hospital performing approximately 7,000 neurosurgical procedures per year, this represents an annual opportunity cost saving of around £1.4 million.
While time saved during turnover does not directly translate into space for extra cases, especially in lower-volume lists, it remains a critical marker of process efficiency. Eliminating avoidable delays frees up valuable time for other clinical priorities, helps limit overtime, and reduces frustration for surgeons and teams.
Figure 2: Comparison of Pre- and Post-Assist Turnover Times
Shifting the Performance Paradigm: A Team-First Approach
While major advancements have been made in improving operational performance in surgical care (for example, in scheduling and block time optimization), a critical element is often overlooked: frontline support for the teams who deliver that care.
Incision Assist empowers frontline staff with clear, visual, case-specific guidance—strengthening performance in key daily workflows. By helping standardize preparation, reduce variation, and minimize avoidable delays, Assist enables teams to deliver care more efficiently and consistently. In addition, teams using Assist consistently report improvements in team dynamics, increased confidence, better preparedness, and reduced stress [4].
As surgical services worldwide face increasing pressure to do more with less, Assist offers a practical, scalable, and human-centered path to sustainable performance improvement. By enhancing—not replacing—existing systems, it supports frontline teams to work confidently and efficiently, saving time and improving outcomes, as reflected in these early results at Salford. At the time of writing, the organization is in a trial period and is investigating funding for formal implementation.
