The use of Lean and Six Sigma methodologies in surgery: a systematic review

Implementing patient safety and quality improvement in dermatology. Part 2: Quality improvement science

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data.

Improving Time to Diagnostic Resolution in the Breast Imaging Service: A Tertiary Center's Experience and Process of Improvement

OBJECTIVE

Breast imaging services often experience a significant degree of variability in patient flow, leading to delay in time to diagnostic resolution, commonly referred to as time to resolution (TTR). This study applies Lean Six Sigma Methodology (LSSM) to reduce TTR and enhance patient outcomes.

METHODS

This study was IRB-approved. A baseline audit was done using cases of mammographic recalls (BI-RADS 0) to measure baseline TTR. Multidisciplinary meetings with all members of the breast imaging service, alongside a study of patient complaint data, were utilized to identify issues that were causing prolonged TTR. Following that, possible solutions were proposed and implemented. A post-implementation audit was conducted, and the resulting TTRs were compared. Significant differences in TTR between the pre- and post-solution implementation were assessed using the Mann-Whitney U test.

RESULTS

During the baseline audit of 8 months, 589 cases of mammographic recalls (BI-RADS 0) were identified, and the resulting average TTR was 86.3 days. During the post-implementation period of 3 months, 370 mammographic recalls (BI-RADS 0) occurred, with a resulting average TTR of 36.0 days. After applying LSSM, TTR was reduced by 58.3% (P < 0.01). Some changes implemented included training the coordinators, establishing a rapid diagnostic clinic using previously underutilized equipment, and having radiologists assigned full-time to the breast imaging service.

CONCLUSION

Our team has successfully managed to identify various causes behind the prolonged TTR using LSSM. Team collaboration was essential to study and decide on a more achievable TTR.

Streamlining and Consistency in Surgery: Lean Six Sigma to Improve Operating Room Efficiency

BACKGROUND

Improving perioperative efficiency helps reduce unnecessary surgical expenditure, increase operating room throughput, improve patient safety, and enhance staff and patient satisfaction. Lean Six Sigma (LSS) is a quality improvement model that has been successfully applied to eliminate inefficiencies in the business sector but has not yet been widely adopted in medicine. This study investigates the adaptation of LSS to improve operative efficiency for plastic surgery procedures.

METHODS

The authors followed the define, measure, analyze, improve, and control phases to implement LSS. The key outcome measures gathered were operative times, including the cut-to-close time, and the total time the patient spent in the operating room.

RESULTS

The study included a total of 181 patients who underwent immediate bilateral deep inferior epigastric perforator flap breast reconstruction between January of 2016 and December of 2019. The LSS interventions were associated with a decrease in total operative time from 636.36 minutes to 530.35 minutes, and a decrease in the time between incision to closure from 555.16 minutes to 458.85 minutes for a bilateral mastectomy with immediate deep inferior epigastric artery flap breast reconstruction.

CONCLUSIONS

This study demonstrates that LSS is useful to improve perioperative efficiency during complex plastic surgery procedures. The workflow of the procedure was improved by determining the optimal spatial positioning and distinct roles for each surgeon and preparing surgeon-specific surgical trays. Two process maps were developed to visualize the positioning of the surgeons during each stage of the procedure and depict the parallel workflow that helped improve intraoperative efficiency.

Six Sigma can significantly reduce costs of poor quality of the surgical instruments sterilization process and improve surgeon and operating room personnel satisfaction

Operating room (OR) management is a complex multidimensional activity combining clinical and managerial aspects. This longitudinal observational study aimed to assess the impact of Six-Sigma methodology to optimize surgical instrument sterilization processes. The project was conducted at the operating theatre of our tertiary regional hospital during the period from July 2021 to December 2022. The project was based on the surgical instrument supply chain analysis. We applied the Six Sigma lean methodology by conducting workshops and practical exercises and by improving the surgical instrument process chain, as well as checking stakeholders' satisfaction. The primary outcome was the analysis of Sigma improvement. Through this supply chain passed 314,552 instruments in 2022 and 22 OR processes were regularly assessed. The initial Sigma value was 4.79 ± 1.02σ, and the final one was 5.04 ± 0.85σ (SMD 0.60, 95%CI 0.16-1.04, p = 0.010). The observed improvement was estimated in approximately $19,729 of cost savings. Regarding personnel satisfaction, 150 questionnaires were answered, and the overall score improved from 6.6 ± 2.2 pts to 7.0 ± 1.9 pts (p = 0.013). In our experience the application of the Lean Six Sigma methodology to the process of handling the surgical instruments from/to the OR was cost-effective, significantly decreased the costs of poor quality and increased internal stakeholder satisfaction.

Methods and evaluation metrics for reducing material waste in the operating room: a scoping review

BACKGROUND

Operating rooms contribute up to 70% of total hospital waste. Although multiple studies have demonstrated reduced waste through targeted interventions, few examine processes. This scoping review highlights methods of study design, outcome assessment, and sustainability practices of operating room waste reduction strategies employed by surgeons.

METHODS

Embase, PubMed, and Web of Science were screened for operating room-specific waste-reduction interventions. Waste was defined as hazardous and non-hazardous disposable material and energy consumption. Study-specific elements were tabulated by study design, evaluation metrics, strengths, limitations, and barriers to implementation in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 38 articles were analyzed. Among them, 74% of studies had pre- versus postintervention designs, and 21% used quality improvement instruments. No studies used an implementation framework. The vast majority (92%) of studies measured cost as an outcome, whereas others included disposable waste by weight, hospital energy consumption, and stakeholder perspectives. The most common intervention was instrument tray optimization. Common barriers to implementation included lack of stakeholder buy-in, knowledge gaps, data capture, additional staff time, need for hospital or federal policies, and funding. Intervention sustainability was discussed in few studies (23%) and included regular waste audits, hospital policy change, and educational initiatives. Common methodologic limitations included limited outcome evaluation, narrow scope of intervention, and inability to capture indirect costs.

CONCLUSION

Appraisal of quality improvement and implementation methods are critical for developing sustainable interventions for reducing operating room waste. Universal evaluation metrics and methodologies may aid in both quantifying the impact of waste reduction initiatives and understanding their implementation in clinical practice.

Systematic review on the involvement and engagement of patients as advisers for the organisation of organ transplantation services

OBJECTIVES

This systematic review aims to derive practical lessons from publications on patient involvement and engagement in the organisation of organ transplantation services.

DESIGN

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria for the analysis of publications in English cited in the databases PubMed and Web of Science until 6 December 2022 required that patients participated as advisers in the organisation of organ transplantation services. Quality assessment was performed using the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 small form and the Critical Appraisal Skills Programme (CASP) tool for the assessment of the risks of bias.

RESULTS

Deployed search strings identified 2263 records resulting in a total of 11 articles. The aims and strategies, deployed methods, observed effects, observed barriers and proposed improvements for the future varied vastly. All reported that well-developed programmes involving and engaging patients at an organisational level provide additional benefits for patients and foster patient-centred care. Lessons learnt include: (1) to empower patients, the information provided to them should be individualised to prioritise their needs; (2) financial as well as organisational resources are important to successfully implement patient involvement and engagement; (3) systematic feedback from patients in organisational structures to health providers is required to improve clinical workflows and (4) the consideration of ethical issues and the relationship between investigators and participating patients should be clarified and reported.

CONCLUSIONS

Actionable management recommendations could be derived. The quantitative impact on clinical outcome and economic clinical process improvements remains to be investigated. Study quality can be improved using the GRIPP 2 guidance and the CASP tool.

PROSPERO REGISTRATION NUMBER

CRD42022186467.

Operative Team Familiarity and Specialization at an Academic Medical Center

OBJECTIVE

To propose a framework for quantification of surgical team familiarity.

BACKGROUND

Operating room (OR) teamwork quality is associated with familiarity among team members and their individual specialization. We describe novel measures of OR team familiarity and specialty experience.

METHODS

Surgeon-scrub (SS) and surgeon-circulator (SC) teaming scores, defined as the pair's proportion of interactions relative to the surgeon's total cases in the preceding 6 months were calculated between 2017 and 2021 at an academic medical center. Nurse service-line (SL) experience scores were defined as the proportion of a nurse's cases performed within the given specialty. SS, SC, and nurse-SL scores were analyzed by specialty, case urgency, robotic approach, and surgeon academic rank. Two-sample Kolmogorov-Smirnov tests were used to determine heterogeneity between distributions.

RESULTS

A total of 37,364 operations involving 150 attending surgeons and 222 nurses were analyzed. Median SS and SC scores were 0.08 (interquartile range: 0.03-0.19) and 0.06 (interquartile range: 0.03-0.13), respectively. Higher margin SLs, senior faculty rank, elective, and robotic cases were associated with greater SS, SC, and nurse-SL scores ( P <0.001).

CONCLUSIONS

These novel measures of teaming and specialization illustrate the low levels of OR team familiarity and objectively highlight differences that necessitate a deliberate evaluation of current OR scheduling practices.

Assessment of Labor Practices in Healthcare Using an Innovatory Framework for Sustainability

Background and Objectives: The concept of sustainability in healthcare is poorly researched. There is a perceived need for new theoretical and empirical studies, as well as for new instruments to assess the implementation of new labor practices in the field. Such practices address unmet social needs and consolidate the sustainable development systems which promote health equity. The objective of the research is to design an innovative reference framework for sustainable development and health equity of healthcare facilities, and to provide a practical validation of this framework. Materials and Methods: The research methods consist of designing the elements of the new frame of reference, designing an indicator matrix, elaborating indicator content, and assessing the reference framework. For the assessment stage, we used sustainable medical practices reported in the scientific literature as well as a pilot reference framework that was implemented in healthcare practice. Results: The new reference framework suggested by the present study is composed of 57 indicators organized in five areas: environmental responsibility, economic performance, social responsibility, institutional capacity, and provision of sustainable healthcare services. These indicators were adapted and integrated into the seven basic topics of the social responsibility standard. The study presents the content of the indicators in the field of labor practices, as well as their evaluation grids. The innovative format of the evaluation grids aims to describe achievement degrees, both qualitatively and quantitatively. The theoretical model was validated in practice through its implementation at the Emergency Hospital in Targu Mures. Conclusions: The conclusions of the study reflect the usefulness of the new reference framework, which is compatible with the requirements in the healthcare field, but differs from other existing frameworks, considering its objective regarding the promotion of sustainable development. This objective facilitates the continuous quantification of the sustainability level, the promotion of sustainable development strategies, and sustainability-oriented approaches on the part of interested parties.

Distortions in the Balance Between Teaching and Efficiency in the Operating Room

INTRODUCTION

The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room.

METHODS

Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified.

RESULTS

Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue.

CONCLUSIONS

Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

Quality and process improvement of the multidisciplinary Heart Team meeting using Lean Six Sigma

INTRODUCTION

The Heart Team is a multidisciplinary meeting for shared decision-making in cardiology and cardiothoracic surgery. A quality improvement project to optimise the Heart Team was initiated after the merger of the cardiac centres of Amsterdam University Medical Centre.

METHODS

Lean Six Sigma was applied with the purpose of improving efficiency and quality of care. Qualitative and quantitative analyses supported the multidisciplinary team during quality improvement sessions. Lean Six Sigma tools included process mapping, gemba walks, root cause analysis, line balancing, first time right, standardised work and poka-yoke.

INTERVENTIONS

Seven areas of improvement were introduced. Key elements were the improvement of the patient referral process, introduction of a structured agenda, task division and balanced planning of patients, better exchange of information, improved availability of diagnostics and supportive tools and information technology. Work agreements were introduced to support a positive work culture and mutual respect.

RESULTS

Lean Six Sigma designed an optimised Heart Team to improve efficiency by better resource utilisation, first time right decision-making, patient selection, complete and better access to information and elimination of waste. It leads to higher quality of decision-making by involving physicians in a more structured preparation, attendance of an imaging cardiologist, meeting duration within limits, installation of standard operating procedures, increased involvement of the referring cardiologists and a better engaged team.

CONCLUSIONS

Heart Teams are essential to make evidence-based, patient-centred treatment plans for optimal patient outcomes. However, clinical practice and experience showed that it is challenging to have an efficient and effective discussion with complete patient information and to bring together healthcare professionals. The application of Lean Six Sigma resulted in an optimised Heart Team and created a best practice design for patient-centred, evidence-based decision-making. After implementation and process stability, a postintervention analysis could clarify long-term success and sustainability.

Using a human-centered, mixed methods approach to understand the patient waiting experience and its impact on medically underserved Populations

PURPOSE

To use a mixed methods approach to investigate the patient waiting experience for a medically underserved population at an outpatient surgical clinic.

METHODS

We used lean methodology to perform 96 time-tracked observations of the patient journey in clinic, documenting the duration of activities from arrival to departure. We also used human-centered design (HCD) to perform and analyze 43 semi-structured interviews to understand patients' unmet needs.

RESULTS

Patients spent an average of 68.5% of their total clinic visit waiting to be seen. While the average visit was 95.8 minutes, over a quarter of visits (27%) were over 2 hours. Patients waited an average of 24.4 minutes in the waiting room and 41.2 minutes in the exam room; and only spent 19.7% of their visit with an attending provider and 11.8% with a medical assistant. Interviews revealed that patients arrive to their visit already frustrated due to difficulties related to scheduling and attending their appointment. This is exacerbated during the visit due to long wait times, perceived information opacity, and an uncomfortable waiting room, resulting in frustration and anxiety.

CONCLUSIONS

While time tracking demonstrated that patients spend a majority of their visit waiting to be seen, HCD revealed that patient frustrations span the waiting experience from accessing the appointment to visit completion. These combined findings are crucial for intervention design and implementation for medically underserved populations to improve the quality and experience with healthcare and also address system inefficiencies such as long wait times.

The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies

INTRODUCTION

Lean is largely applied to the health sector and on the healthcare-associated infections (HAI). However, a few results on the improvement of the outcome have been reported in literature. The purpose of this study is to analyze if the lean application can reduce the HAI rate.

METHODS

A comprehensive search was performed on PubMed/Medline, Scopus, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "lean" and "infection". Inclusion criteria were: 1) research articles with quantitative data and relevant information on lean methodology and its impact on healthcare infections; 2) prospective studies. The risk of bias and the study quality was independently assessed by two researchers using the "The National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group". The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines has been used. 22 studies were included in the present meta-analysis.

RESULTS

Lean application demonstrated a significant protective role on healthcare-associated infections rate (RR 0.50; 95% C.I.: 0.38-0.66) with significant impact on central line-associated bloodstream infections (CLABSIs) (RR 0.47; 95% C.I.: 0.28-0.82).

CONCLUSIONS

Lean has a positive impact on the decreasing of HAIs and on the improvement of compliance and satisfaction of the staff.

Cost and Quality Comparison of Hernia Surgery in Stationary, Day-Patient and Outpatient Care

BACKGROUND

Medical progress is increasingly enabling more and more stationary treatment to be provided in the outpatient sector. This development should be welcomed, as healthcare costs have been rising for years. The design of efficient processes and a needs-based infrastructure enable further savings. According to international recommendations (EHS/IEHS), outpatient treatment of unilateral inguinal hernias is recommended.

METHOD

Data from patients in GZO Hospital Wetzikon/Zurich between 2019 and 2021 for unilateral inguinal hernia repair was included in this study (n = 234). Any over- or under-coverage correlated with one of the three treatment groups: stationary, partially stationary and patients treated in outpatients clinic. Complications and 30-day readmissions were also monitored.

RESULTS

Final revenue for all patients is -95.36 CHF. For stationary treatments, the mean shifts down to -575.01 CHF, for partially stationary treatments the mean shifts up to -24.73 CHF, and for patients in outpatient clinic final revenue is 793.12 CHF. This result is also consistent with the operation times, which are lowest in the outpatient clinic with a mean of 36 min, significantly longer in the partially stationary setting with 58 min, and longest in the stationary setting with 76 min. The same applies to the anesthesia times and the relevant care times by the nurses as the most important cost factors in addition to the supply and allocation costs.

CONCLUSIONS

We show that cost-effective elective unilateral inguinal hernia care in the outpatient clinic with profit (mean 793.12 CHF) is possible. Stationary unilateral hernia care (mean -575.01 CHF) is loss-making. Crucial factors for cost efficiency are optimized processes in the operating room (anesthesia, surgical technique and quality, operating time), as well as optimized care processes with minimal preoperative services and care times for the patient. However, at the same time, these optimizations pose a challenge to surgical and anesthesiology training and structures with high levels of preoperative and Postoperative services and pay-as-you-go costs. The complication rate is 0.91% lower than in a comparable study. The readmission within 30 days post-operation results with a positive deviation of -3.53% (stationary) and with a negative deviation of +2.29% (outpatient clinic) compared to a comparative study.

Can Quality Improvement Methodologies Derived from Manufacturing Industry Improve Care in Cardiac Surgery? A Systematic Review

Objectives: Healthcare is required to be effectively organised to ensure that growing, aging and medically more complex populations have timely access to high-quality, affordable care. Cardiac surgery is no exception to this, especially due to the competition for and demand on hospital resources, such as operating rooms and intensive care capacity. This is challenged more since the COVID-19 pandemic led to postponed care and prolonged waiting lists. In other sectors, Quality Improvement Methodologies (QIM) derived from the manufacturing industry have proven effective in enabling more efficient utilisation of existing capacity and resources and in improving the quality of care. We performed a systematic review to evaluate the ability of such QIM to improve care in cardiac surgery. Methods: A literature search was performed in PubMed, Embase, Clarivate Analytics/Web of Science Core Collection and Wiley/the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. Results: Ten articles were identified. The following QIM were used: Lean, Toyota Production System, Six Sigma, Lean Six Sigma, Root Cause Analysis, Kaizen and Plan-Do-Study-Act. All reported one or more relevant improvements in patient-related (e.g., infection rates, ventilation time, mortality, adverse events, glycaemic control) and process-related outcomes (e.g., shorter waiting times, shorter transfer time and productivity). Elements to enhance the success included: multidisciplinary team engagement, a patient-oriented, data-driven approach, a sense of urgency and a focus on sustainability. Conclusions: In all ten papers describing the application of QIM initiatives to cardiac surgery, positive results, of varying magnitude, were reported. While the consistency of the available data is encouraging, the limited quantity and heterogenous quality of the evidence base highlights that more rigorous evaluation, including how best to employ manufacturing industry-derived QIM in cardiac surgery is warranted.

Breast Surgery Cost Savings Through Surgical Tray Instrument Reduction

INTRODUCTION

Removing unnecessary instruments from surgical trays used in the operating room conserves resources and time. We aimed to assess the cost savings impact of breast surgical tray instrument reduction.

METHODS

Breast surgeons at a single institution reviewed the standard surgical tray used for lumpectomies and mastectomies and removed underutilized instruments to create a breast-specific tray. This tray was used for all breast surgeries performed throughout the 2019 calendar year. Data for breast-specific tray usage, instrument reprocessing costs, and instrument maintenance costs for inspection, sharpening, aligning, and lubricating were retrospectively obtained.

RESULTS

The breast-specific tray was reduced from 82 to 65 instruments. The cost of reprocessing each instrument is $1.69. After 30 tray sterilizations, each tray was sent for maintenance at a cost of $2.00 per instrument. With 10 breast-specific trays in circulation, the trays were used a total of 656 times during the calendar year. Each tray was sent for maintenance an average of two times during this time period. Thus, instrument reduction resulted in $18,847 in instrument reprocessing and $680.00 in maintenance savings, with total annual cost savings of $19,527.

CONCLUSIONS

Optimizing surgical trays by removing unused instruments yields significant cost savings and contributes to improved efficiency in the sterile processing department. As efforts to eliminate wasteful practices and reduce costs within the health care system continue, opportunities remain for standardization of trays across all surgical departments and institutions.

Improving Vitamin D Screening in a Pediatric Rheumatology Clinic Using Structured Quality Improvement Process

Introduction

Monitoring levels of 25-hydroxyvitamin D (25-OHD) is an integral part of bone health assessment in the general pediatric population, especially in at-risk populations such as children with juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (c-SLE), and juvenile dermatomyositis (JDM). However, only 38% of the patients with JIA, c-SLE, and JDM receiving care at Nationwide Children's Hospital Rheumatology clinic in 2016 had a 25-OHD level ordered in the preceding year. The objective of this project was to increase the percentage of 25-OHD levels ordered in patients with JIA, c-SLE, and JDM from 38% to 80% in 11 months and sustain it for 6 months.

Methods

A multidisciplinary team initiated a continuous improvement project utilizing the Lean Six Sigma methodology. The team diagrammed the clinical process and identified steps that needed improvement. In addition, the team completed a root cause analysis of the process and brainstormed subsequent countermeasures.

Results

The team did not meet the 80% target but did order a 25-OHD level on 61% of patients by the end of the study period compared to 38% at the start of the study (P value 0.001). The level was sustained after the study period, with 68% of these children having a 25-OHD level ordered.

Conclusion

The team successfully improved the screening processes for vitamin D deficiency in a busy subspecialty clinic setting using Lean Six Sigma methodology.

Environmental sustainability in orthopaedic surgery

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Methods

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.

Results

A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.

Conclusion

Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary.

Cite this article: Bone Jt Open 2022;3(8):628–640.

Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review

Despite the increasing utilization of lean practices and digital technologies (DTs) related to Industry 4.0, the impact of such dual interventions on healthcare services remains unclear. This study aims to assess the effects of those interventions and provide a comprehensive understanding of their dynamics in healthcare settings. The methodology comprised a systematic review following the PRISMA guidelines, searching for lean interventions supported by DTs. Previous studies reporting outcomes related to patient health, patient flow, quality of care, and efficiency were included. Results show that most of the improvement interventions relied on lean methodology followed by lean combined with Six Sigma. The main supporting technologies were simulation and automation, while emergency departments and laboratories were the main settings. Most interventions focus on patient flow outcomes, reporting positive effects on outcomes related to access to service and utilization of services, including reductions in turnaround time, length of stay, waiting time, and turnover time. Notably, we found scarce outcomes regarding patient health, staff wellbeing, resource use, and savings. This paper, the first to investigate the dual intervention of DTs with lean or lean–Six Sigma in healthcare, summarizes the technical and organizational challenges associated with similar interventions, encourages further research, and promotes practical applications.

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps

BACKGROUND

Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population.

METHODS

The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound.

RESULTS

The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort.

CONCLUSIONS

Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Lean six-sigma (LSS) applications in hospitals: a decade (2011–2020) bibliometric analysis

Purpose

This study examines the research landscape of Lean Six-Sigma (LSS) applications in hospitals for the period of the last decade (2011–2020) to derive answers to the research questions RQ 1: What are the current publication trends for the application of LSS in hospitals concerning document type, Journal (Source), active authors and country-wise publications and their comparison in the two most reputed scientific databases, i.e. Scopus and Web of Science (WoS), RQ2: What are the clusters based on the authors and keywords? RQ3: What are the research trends and author's productivity in LSS applications in Hospitals? RQ4: What are the future research areas?

Design/methodology/approach

This article compares these two databases (Scopus and WoS) based on publication pattern, document type, active authors and co-citation analysis. This article analyzes the core sources, author's productivity, globally cited articles, word growth analysis, thematic map and world collaboration map on the WoS and Scopus dataset. The software used are Vosviewer, Biblioshiny (R Package for Bibliometric) and M.S. Excel.

Findings

The application of LSS in hospitals is a niche theme. In the WoS database International Journal of Lean Six-Sigma and in Scopus database International Journal of Health Care Quality Assurance are the most relevant sources publishing research articles in this field. The USA has the highest scientific production in this field. Among the authors, Antony J is the most active author in this area, with the highest contribution over the years.

Originality/value

This study fills the literature gap by mapping the field of LSS in hospitals.

An Innovative Framework for Sustainable Development in Healthcare: The Human Rights Assessment

Healthcare providers are investing considerable resources for the development of quality management systems in hospitals. Contrary to these efforts, the number of tools that allow the evaluation of implementation efforts and the results of quality, security and sustainable development is quite limited. The purpose of the study is to develop a reference framework for quality and sustainable development in healthcare, Sanitary-Quality (San-Q) at the micro system level, which is compatible with applicable national and international standards in the field. The research method consisted of the study of literature, identification and analysis of good sustainability practices in healthcare, which allowed identification of the areas of the new San-Q framework: quality, economic, environmental, social, institutional and healthcare. These areas are incorporated into the core topics of social responsibility mentioned by ISO26000. A total of 57 indicators have been defined that make up the new reference framework. The evaluation format of the indicators is innovative through a couple of values: completion degree–significance. In the experimental part of the research, a pilot implementation of the San-Q framework at an emergency hospital was performed, the results recorded in terms of responsibility for human rights being presented. The conclusions of the study reveal the innovative aspects of the framework that facilitate the development of a sustainability strategy promoted through performance indicators, the results obtained after evaluation being useful in establishing a reference level of sustainability but also in developing sustainability policies.

Lean six sigma in the healthcare sector: A systematic literature review

Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.

The Use of Lean Six Sigma Methodology in the Reduction of Patient Length of Stay Following Anterior Cruciate Ligament Reconstruction Surgery

Background: The purpose of this study was to reduce the length of stay of anterior cruciate ligament reconstruction patients within a private hospital in Ireland, reducing any non-value-added activity in the patient pathway, with the goal of increasing patient flow, bed capacity, and revenue generation within the hospital system, while maintaining patient satisfaction. Methods: We used a pre-/post-intervention design and Lean Six Sigma methods and tools to assess and improve the current process. Results: A reduction in inpatient length of stay by 57%, and a reduction in identified non-value-added activity by 88%, resulted in a new day-case surgery pathway for anterior cruciate ligament reconstruction patients. The pathway evidenced no re-admissions and demonstrated patient satisfaction. Conclusion: Six months post-project commencement, we had successfully achieved our goals of reducing our anterior cruciate ligament reconstruction patient's length of stay. This study contributes to the growing body of published evidence which shows that adopting a Lean Six Sigma approach can be successfully employed to optimise care and surgical pathways in healthcare.

Consecutive Surgeon and Anesthesia Team Improve Turnover Time in the Operating Room

Efficient management of the operating room (OR) contributes to much of today's healthcare expenditure and plays a critical role in generating revenue for most healthcare systems. Scheduling of OR cases with the same team and surgeon have been reported to improve turnover time between cases which in turn, improves efficiency and resource utilization. We aim to assess different operating room procedures within multiple subspecialties and explore the factors that positively and negatively influence turnover time (TOT) in the operating room. We conducted a retrospective review of cases that were completed on weekdays between 0600 and 2359 from July 2017 through March 2018. Cases between 0000 and 0559 were excluded from this study. Of the total 2,714 cases included in our study, transplant surgery had the highest mean TOT (71 ± 48 min) with orthopedic surgery cases without robots having the lowest mean TOT. OR cases in rooms with the same specialty had significantly less mean TOT compared to rooms switching between different subspecialties (70 vs. 117 min; p < 0.0001). Similarly, cases with the same surgeon and anesthesia team had a significant lower TOT (p < 0.0001). Consecutive specialty, surgeon, anesthesiologist, and prior procedure ending before 15:00 were all independent predictors of lower TOT (p < 0.0001). Our study shows scheduling cases with the same OR team for elective cases can decrease TOT and potentially increase operating room efficiency during the day. Further studies may be needed to assess the long-term effects of such variables affecting OR TOT on healthcare expenditure.

Lean six sigma and stroke in rural hospital - The case of Baruch Padeh Medical Center

PURPOSE

This case study aims to demonstrate the strengths of the Lean Six Sigma (LSS) methodology to improve the acute ischemic stroke (AIS) treatment rates and reduce process lead time at Baruch Padeh Medical Center (BPMC), a rural hospital in the Galilee region of Northern Israel. The LSS project redefined the BPMC stroke care pathway and increased its efficacy.

DESIGN/METHODOLOGY/APPROACH

The LSS methodology was implemented in September 2017 by integrating lean principles and the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control). Existing procedures, field observation, ad hoc measurement and in-depth interviews were utilized, and the GEMBA method was implemented to identify root cause and improve actions optimizing the stroke pathway.

FINDINGS

The presented case shows the usefulness of the LSS methodology in improving quality performance in a rural hospital. The intervention allowed the BPMC to improve the intravenous tissue plasminogen activator (IV-tPA) administration rate (+15.2%), reducing the process lead time. The lead time of door-to-computer tomography decreased from 52 to 26 min, and the door-to-needle time decreased from 94 to 75 min.

ORIGINALITY/VALUE

The present case study shows the implementation of the LSS methodology aimed to improve the IV-tPA administration rate and reduce the stroke pathway lead time in a rural hospital. The case demonstrates the potential for the LSS methodology to support the AIS pathway optimization and represents a guide for healthcare organizations located in rural areas.

The impact of routine post-anesthesia care unit extubation for pediatric surgical patients on safety and operating room efficiency

PURPOSE

Maximizing operating room (OR) efficiency is essential for hospital cost containment and effective patient throughput. Little data is available regarding the safety and efficacy of extubation of children in the post-anesthesia care unit (PACU) by a nurse rather than in the OR. We sought to evaluate the impact of a long-standing practice of PACU extubation upon airway complications and OR efficiency.

METHODS

The records of 1930 children who underwent inguinal hernia repair, laparoscopic appendectomy or pyloromyotomy at a children's hospital between July, 2018 and June, 2020 were reviewed. Extubations were performed in the OR only when the PACU was inadequately staffed or during the early months of the Covid-19 pandemic. Cases in which there was a deep extubation, a PACU hold was in effect or a patient went directly to an inpatient unit from the OR were excluded. Intra- and post-operative time metrics were recorded and emergency airway interventions were assessed.

RESULTS

1747 operations were evaluated. Time from the end of the procedure to leaving the OR ranged from 4.1 to 4.8 min when extubation was done in the PACU and was 6-9 min less than with OR extubation. (see table). There were 23 airway events (1.5% of all cases) after PACU extubation that necessitated only brief bag-mask ventilation. There were no cases of re-intubation.

CONCLUSIONS

In a large population of children undergoing diverse surgical procedures, post-anesthesia care unit extubation was safe and resulted in rapid transfer of patients from the operating room after completion of their operation. Time saved because of shorter operating room times reduces hospital costs and can allow for increased throughput. Extubation in the post-anesthesia care unit may not only be as safe as operating room extubation, but may result in fewer serious airway events as patients may be less likely to have their endotracheal tube removed prematurely.

LEVEL OF EVIDENCE

Treatment Study, Level III.

Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents.

BACKGROUND

There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery.

METHODS

We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully.

RESULTS

There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting.

CONCLUSIONS

The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.

Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

AIMS

To utilize lean six sigma (LSS) and failure model and effect analysis (FMEA) to prevent dispensing errors in a Chinese teaching hospital.

METHODS

Medication errors (MEs) reported to the China Core Group of the international network for the rational use of drugs (INRUD) by pharmacists at the hospital were collected. Following LSS methodology, the data analysis was structured according to define, measure, analyse, improve, and control (DMAIC) phases, and typical LSS tools (Pareto diagrams, brainstorming sessions) were used to determine the risk factors leading to dispensing errors. FMEA was applied to generate the risk priority numbers (RPNs) of MEs events, and key medications targeted for error prevention strategies were identified through quantitative analysis of the impacts of failure. Finally, corrective measures to prevent MEs were implemented and monitored for efficacy.

RESULTS

Before the implementation of this programme, a total of 603 cases of dispensing errors were reported from the Year 1 to Year 6, reaching an average rate of incidence of 0.33 cases per 10 000 medication orders delivered, and no difference was found between these years (P = .9424). There was also no difference as location, error type, contributing factors, cause classification were considered. We then determined the real cause behind dispensing errors, and a total of 67 medications were targeted for specific error prevention strategies. One year after intervention, progress had been achieved in the following aspects: the incidence rate of dispensing errors was significantly decreased compared with the previous years (0.19, P = .007). Simultaneously, the incidence rate of dispensing errors occurred in outpatient pharmacy (0.04, P = .0008), with junior pharmacists (0.15, P = .0258), with LASA medications (0.06, P = .0319), as well as with memory-based errors were significantly decreased (0.03, P = .0191).

CONCLUSION

The combination of LSS and the FMEA tool can be an efficient approach for helping reduce MEs in pharmacy dispensing.

The Power Law in Operating Room Management

The Acute Care Surgery model has been implemented by many hospitals in the United States. As complex adaptive systems, healthcare systems are composed of many interacting elements that respond to intrinsic and extrinsic inputs. Systems level analysis may reveal the underlying organizational structure of tactical block allocations like the Acute Care Surgery model. The purpose of this study is to demonstrate one method to identify a key characteristic of complex adaptive systems in the perioperative services. Start and end times for all surgeries performed at the University of Vermont Medical Center OR1 were extracted for two years prior to the transition to an Acute Care Surgery service and two years following the transition. Histograms were plotted for the inter-event times calculated from the difference between surgical cases. A power law distribution was fit to the post-transition histogram. The Kolmogorov-Smirnov test for goodness-of-fit at 95% level of significance shows the histogram plotted from post-transition inter-event times follows a power law distribution (K-S = 0.088, p = 0.068), indicating a Complex Adaptive System. Our analysis demonstrates that the strategic decision to create an Acute Care Surgery service has direct implications on tactical and operational processes in the perioperative services. Elements of complex adaptive systems can be represented by a power law distributions and similar methods may be applied to identify other processes that operate as complex adaptive systems in perioperative care. To make sustained improvements in the perioperative services, focus on manufacturing-based interventions such as Lean Six Sigma should instead be shifted towards the complex interventions that modify system-specific behaviors described by complex adaptive system principles when power law relationships are present.

Aligning implementation science with improvement practice: a call to action

Background

In several recent articles, authors have called for aligning the fields of implementation and improvement science. In this paper, we call for implementation science to also align with improvement practice. Multiple implementation scholars have highlighted the importance of designing implementation strategies to fit the existing culture, infrastructure, and practice of a healthcare system. Worldwide, healthcare systems are adopting improvement models as their primary approach to improving healthcare delivery and outcomes. The prevalence of improvement models raises the question of how implementation scientists might best align their efforts with healthcare systems’ existing improvement infrastructure and practice.

Main body

We describe three challenges and five benefits to aligning implementation science and improvement practice. Challenges include (1) use of different models, terminology, and methods, (2) a focus on generalizable versus local knowledge, and (3) limited evidence in support of the effectiveness of improvement tools and methods. We contend that implementation science needs to move beyond these challenges and work toward greater alignment with improvement practice. Aligning with improvement practice would benefit implementation science by (1) strengthening research/practice partnerships, (2) fostering local ownership of implementation, (3) generating practice-based evidence, (4) developing context-specific implementation strategies, and (5) building practice-level capacity to implement interventions and improve care. Each of these potential benefits is illustrated in a case study from the Centers for Disease Control and Prevention’s Cancer Prevention and Control Research Network.

Conclusion

To effectively integrate evidence-based interventions into routine practice, implementation scientists need to align their efforts with the improvement culture and practice that is driving change within healthcare systems worldwide. This paper provides concrete examples of how researchers have aligned implementation science with improvement practice across five implementation projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00201-1.

The Length of Gomco Clamp Timing and Its Effect on Bleeding

BACKGROUND

Bleeding is the most common complication of circumcisions in newborns. Gomco clamps are used to perform neonatal circumcisions. Although a clamp time of 5 minutes is recommended, there is no evidence to support this recommendation.

METHODS

Circumcisions performed by attending physicians from the Division of Pediatric Hospital Medicine at an academic children's hospital were split into 2 groups. Group 1 had a clamp time of 5 minutes. Group 2 did not have a clamp time minimum. Nursing staff examined for bleeding at intervals of 15- and 30-minutes' postprocedure. Bleeding was determined to be significant if pressure and/or a microfibrillar collagen hemostat agent was applied.

RESULTS

The study sample contained 23 physicians who saw a total of 1252 patients: 13 physicians (647 patients) in group 1 and 10 physicians (605 patients) in group 2. The average clamp time in group 2 was 2 minutes, 5 seconds. The estimated percentage of circumcisions that required microfibrillar collagen hemostat application was 5.1% (95% confidence interval [CI], 3.1-8.1) for group 1 and 5.6% (95% CI: 3.5-8.8]) for group 2. Circumcisions that had pressure applied were estimated to be 0.6% (95% CI: 0.2-1.7) for group 1 and 1.3% (95% CI: 0.5-3.1) for group 2. The difference between groups, in both categories, was not statistically significant.

CONCLUSIONS

In this prospective study we evaluated clamp time duration and bleeding outcomes for neonatal circumcision. Clamp time does not appear to have an association with bleeding risk. Providers need not maintain a 5-minute clamp time to decrease postprocedural bleeding.

Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare

OBJECTIVE

The COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled.

METHOD

A multifunctional project team used the data-driven LSS process improvement methodology and followed the 'DMAIC' improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an 'interrupted time series' study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant.

RESULTS

Last-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005).

CONCLUSION

This study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice

OBJECTIVES

Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service.

METHODS

First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation.

RESULTS

57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders.

CONCLUSIONS

Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

The Utilization of an Opioid-Free Anesthetic for Pediatric Circumcision in an Ambulatory Surgery Center

Circumcision is one of the most common urologic procedures performed at pediatric ambulatory centers. Emerging data on the short- and long-term effects of perioperative opioid administration has highlighted the importance of an opioid-free anesthetic regimen. We sought to evaluate the effectiveness of an opioid-free anesthetic in pediatric circumcision and its correlation with ambulatory surgery center efficiency. Patients, 3 years of age and younger, who underwent circumcision or circumcision revision by two surgeons pre and post introduction of an opioid-free anesthetic fast-track regimen at an outpatient surgical center were included. There were 100 patients included in this analysis, with 50 patients in each cohort. On univariate analysis, fast-tracking was associated with a decrease in median combined in-room and post-anesthesia care unit times (102.5 vs. 129.0 min, p-value < 0.001). This difference continued after multivariable analysis with an adjusted median combined in-room and post-anesthesia care unit time difference of -15.6 min (95% CI -34.2 to -12.7 min, p-value 0.018). In addition, the fast-track cohort received less intraoperative morphine equivalents without an increase in post-operative analgesic administration or change in postoperative questionnaire score. This demonstrates that opioid-free anesthesia may be used effectively in pediatric circumcision while also allowing for significant time savings for surgical centers.

A Standardized Framework for Evaluating Surgical Enhanced Recovery Pathways: A Recommendations Statement from the TDABC in Health-care Consortium

Background: Innovative methodologies to redesign care delivery are being applied to increase value in health care, including the creation of enhanced recovery pathways (ERPs) for surgical patients. However, there is a lack of standardized methods to evaluate ERP implementation costs. Objectives: This Recommendations Statement aims to introduce a standardized framework to guide the economic evaluation of ERP care-design initiatives, using the Time-Driven Activity-Based Costing (TDABC) methodology. Methods: We provide recommendations on using the proposed framework to support the decision-making processes that incorporate ERPs. Since ERPs are usually composed of activities distributed throughout the patient care pathway, the framework can demonstrate how the TDABC may be a valuable method to evaluate the incremental costs of protocol implementation. Our recommendations are based on the review of available literature and expert opinions of the members of the TDABC in Healthcare Consortium. Results: The ERP framework, composed of 11 steps, was created describing how the techniques and methods can be applied to evaluate the economic impact of an ERP and guide health-care leaders to optimize the decision-making process of incorporating ERPs into health-care settings. Finally, six recommendations are introduced to demonstrate that using the suggested framework could increase value in ERP care-design initiatives by reducing variability in care delivery, educating multidisciplinary teams about value in health, and increasing transparency when managing surgical pathways. Conclusions: Our proposed standardized framework can guide decisions and support measuring improvements in value achieved by incorporating the perioperative redesign protocols.

Standardization of Procedures to Contain Cost and Reduce Variability of Care After the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our private and professional routine. In particular, the lockdowns have severely affected the entire healthcare system and hospital activities, forcing it to rethink the protocols in force. We suggest that this scenario, in spite of the new challenges involving so far complex healthcare providers, may lead to the unique opportunity to rethink pathways and management of patients. Indeed, having to resume institutional activity after a long interruption that has completely canceled the previously existing schemes, healthcare providers have the unique opportunity to overcome obsolete and “we have always done in this way” model on the wave of the general desire to resume a normal life. Furthermore, the pandemic has highlighted some flaws in our health system, highlighting those critical issues that most need to be addressed. This article is a review of pre-pandemic literature addressing the use of Lean Six Sigma (LSS) and standardization processes in thoracic surgery to improve efficiency. Our goal is to identify the main issues that could be successfully improved along the entire pathway of a patient from the first referral to diagnosis, hospitalization, and surgical operation up to convalescence. Furthermore, we aim to identify the standardization processes that have been implemented to achieve significant improvements in patient outcomes while reducing costs. The methods and goals that could be used in the near future to modernize our healthcare systems are drawn up from a careful reading and interpretation in light of the pandemic of the most significant review articles in the literature.

Quality Improvement to Address Surgical Burden of Disease at a Large Tertiary Public Hospital in Peru

BACKGROUND

In resource-limited settings, there is a unique opportunity for using process improvement strategies to address the lack of access to surgical care. By implementing organizational changes in the surgical admission process, we aimed to decrease wait times, increase surgical volume, and improve patient satisfaction for elective general surgery procedures at a public tertiary hospital in Lima, Peru.

METHODS

During the first phase of the intervention, Plan-Do-Study-Act (PDSA) cycles were performed to ensure the surgery waitlist included up-to-date clinical information. In the second phase, Lean Six Sigma methodology was used to adapt the admission and scheduling process for elective general surgery patients. After six months, outcomes were compared to baseline data using Wilcoxon rank-sum test.

RESULTS

At the conclusion of phase one, 87.0% (488/561) of patients on the new waitlist had all relevant clinical data documented, improved from 13.3% (2/15) for the pre-existing list. Time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention. Median wait times from admission to operation for elective surgeries were unchanged at 4 days (p=0.076) pre- and post-intervention. There was a trend toward increased weekly elective surgical volume from a median of 9 to 13 cases (p=0.24) and increased patient satisfaction rates for elective surgery from 80.5 to 83.8% (p=0.62), although these were not statistically significant.

CONCLUSION

The process for scheduling and admitting elective surgical patients became more efficient after our intervention. Time from admission to discharge for all surgical patients improved significantly. Other measured outcomes improved, though not with statistical significance. Main challenges included gaining buy-in from all participants and disruptions in surgical services from bed shortages.

Safe and effective protocol for discharge 3 days after cardiac surgery

The Enhanced Recovery After Surgery (ERAS) protocol affected traditional cardiac surgery processes and COVID-19 is expected to accelerate its scalability. The aim of this study was to assess the impact of an ERAS-based protocol on the length of hospital stay after cardiac surgery. From January 2019 to June 2020, 664 patients underwent consecutive cardiac surgery at a Latin American center. Here, 46 patients were prepared for a rapid recovery through a multidisciplinary institutional protocol based on the ERAS concept, the “TotalCor protocol”. After the propensity score matching, 46 patients from the entire population were adjusted for 12 variables. Patients operated on the TotalCor protocol had reduced intensive care unit time (P < 0.025), postoperative stay (P ≤ 0.001) and length of hospital stay (P ≤ 0.001). In addition, there were no significant differences in the occurrence of complications and death between the two groups. Of the 10-central metrics of TotalCor protocol, 6 had > 70% adherences. In conclusion, the TotalCor protocol was safe and effective for a 3-day discharge after cardiac surgery. Postoperative atrial fibrillation and renal failure were predictors of postoperative stay > 5 days.

Effects of Lean Thinking and Emerging Technologies on Breast Cancer Patients' Therapeutic Process During COVID-19 Pandemic: A Case-Control Matched Study

Introduction: The advent of the COVID-19 pandemic has led to the sudden disruption of routine medical care, and the subsequent reorganization of hospital structures and therapeutic algorithms, aiming at protecting patients and health professionals. This was inevitably bound to affect our Breast Unit, dilating both pre- and post-operative times. The aim of this study was to evaluate the effect on patients' flow of organizational and logistic changes (key interventions) based on lean thinking implemented after the COVID-19 outbreak.

Materials and Methods: Clinical and demographic data were retrospectively collected from patients undergoing sentinel lymph node biopsy for breast cancer at the Verona University Hospital from January 2018 to June 2020. Patients enrolled (n = 341) were divided into two groups according to date of admission: before (Group A; n = 294) and after (Group B; n = 47) the implementation of key interventions. Each case in Group B was subsequently matched 1:1 by means of case-control matching with cases from Group A for age, comorbidities, and type of surgery (Subgroup A1; N = 47). Pre-admission time (T0) and length of stay (T1) were compared between the three groups.

Results: Median T0 was 312 h, whereas median T1 was 24 h. Patients in Group B had a higher frequency of comorbidities (57.4 vs. 25.2%, p = 0.001) and underwent mastectomy more often than patients in Group A (61.7 vs. 36.7%, p = 0.001). Both median T0 and T1 were higher in group B than in group A (384 vs. 300 h, p = 0.001, 48 vs. 24 h, p = 0.001, respectively). Median T0 and T1 did not significantly differ between Group B and Subgroup A1 (all p > 0.05).

Conclusions: Lean thinking and new technologies could prove useful to the optimization of preoperative and postoperative times during the current pandemic, minimizing healthcare personnel and patients' exposure to SARS-CoV-2, and promoting a rational use of limited resources, while complying with oncological principles.

Safety Profile, Surgical Technique, and Early Clinical Results for Simultaneous Lateral Lumbar Interbody Fusion and Anterior Lumbar Interbody Fusion in a Lateral Position

STUDY DESIGN

Description of surgical technique and retrospective review.

OBJECTIVE

To describe a novel surgical technique for multilevel lumbar fusion and describe early clinical results.

SUMMARY OF BACKGROUND DATA

Patients with multilevel lumbar spinal stenosis and adult degenerative scoliosis often require multilevel interbody placement to achieve indirect decompression and lordosis. We describe a case series of patients treated with simultaneous lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF) at L5-S1.

METHODS

We retrospectively reviewed a consecutive series of patients treated for multilevel lumbar spinal stenosis with simultaneous ALIF and LLIF with at least 3-month follow-up. All patients received supplemental percutaneous bilateral pedicle screw placement as well. We measured on preoperative radiographs their lumbar lordosis, pelvic incidence, and L5-S1 lordosis. Intraoperative factors such as operative time, estimated blood loss, fluids provided, number of levels fused, and whether a trainee was present during the procedure were all recorded.

RESULTS

There were 15 patients included within our case series (69.5, 4 F). There were no reported intraoperative vascular or neurological complications in 15 cases. The operative time for the cases ranged from 2.7 to 8.4 hours (average=5.2±1.9 h). The average lordosis gained at L5-S1 was 8.6±3.0 degrees and the average lumbar lordosis gained was 14.7±6.4 degrees. The average PI-LL mismatch went from 22.4±13.3 degrees preoperative to 7.8±10.2 degrees postoperative. One patient had a postoperative complication of a sacral fracture requiring placement of a pelvic screw for a L2-pelvis fusion. There were 8 patients with 4+ levels of fusion. For this cohort of patients, the average lumbar lordosis gained was 16.0±7.5 degrees and the average PI-LL mismatch went from 24.7±16.3 degrees preoperative to 8.8±12.9 degrees postoperative. For the patients with 4+ levels of fusion, the average operative time was 5.9±1.8 hours.

CONCLUSIONS

We have described our early positive results with simultaneous LLIF/ALIF surgery for treatment of lumbar degenerative conditions.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is 'good' in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability.