Starting first surgical cases on time is crucial for maintaining hospital operating room's schedule. Delay of first cases often leads to the rest of the scheduled cases to be delayed, resulting in costly overtime and decreased patient satisfaction. Lean techniques can be used to minimize first case delays and other forms of waste in the process. This research presents a case study on implementing Lean process improvement of first case starts in a tertiary hospital in Pennsylvania, USA. Several root causes for the first case delays were identified based on observations, analysis of historical data, time studies, and literature search. The root causes were then refined and validated using statistical analysis. To minimize the delay of first cases, several countermeasures were identified and prioritized. The operating room leadership selected the best countermeasures based on two main criteria: business impact and ease of implementation. The proposed strategies resulted in increasing the number of on-time first cases as well as reducing the amount of overtime and improving resource utilization. The value of the expected cost savings for the first year is $273,085.