title: Kaizen method for esophagectomy patients: improved quality control, outcomes, and decreased costs.
abstract: BACKGROUND
  The majority of costs associated with esophagectomy are related to the initial 3 days of hospital stay requiring intensive care unit stays, ventilator support, and intraoperative time. Additional costs arise from hospital-based services. The major cost increases are related to complications associated with the procedure. We attempted to define these costs and identify expense management by streamlining care through strict adherence to patient care maps, operative standardization, and rapid discharge planning to reduce variability.
  
  
  METHODS
  Utilizing methods of Kaizen philosophy we evaluated all processes related to the entire experience of esophageal resection. This process has taken over 5 years to achieve, with quality and cost being tracked over this time period. Cost analysis included expenses related to intensive care unit, anesthesia, disposables, and hospital services. Quality improvement measures were related to intraoperative complications, in-hospital complications, and postoperative outcomes. The Institutional Review Board approved the use of anonymous data from standard clinical practice because no additional treatment was planned (observational study).
  
  
  RESULTS
  Utilizing a continuous process improvement methodology, a 43% reduction in cost per case has been achieved with a significant increase in contribution margin for esophagectomy. The length of stay has been reduced from 14 days to 5. With intraoperative and postoperative standardization the leak rate has dropped from 12% to less than 3% to no leaks in our current Kaizen modification of care in our last 64 patients.
  
  
  CONCLUSIONS
  Utilizing lean manufacturing techniques and continuous process evaluation we have attempted to eliminate variability, standardized the phases of care resulting in improved outcomes, decreased length of stay, and improved contribution margins. These Kaizen improvements require continuous interventions, strict adherence to care maps, and input from all levels for quality improvements.
authors.affiliation: Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242-1062, USA. markiannettoni@uiowa.edu
authors.forename: Mark D
authors.initials: MD
authors.lastname: Iannettoni
authors.forename: William R
authors.initials: WR
authors.lastname: Lynch
authors.forename: Kalpaj R
authors.initials: KR
authors.lastname: Parekh
authors.forename: Kelley A
authors.initials: KA
authors.lastname: McLaughlin
mesh_terms: D003365:Costs and Cost Analysis; D016629:Esophagectomy / Q000191:economics* / Q000379:methods* / Q000592:standards; D006801:Humans; D011182:Postoperative Care; D011183:Postoperative Complications / Q000209:etiology; D017410:Practice Guidelines as Topic; D011786:Quality Control; D011996:Records; D016896:Treatment Outcome