title: Lean principles optimize on-time vascular surgery operating room starts and decrease resident work hours.
abstract: OBJECTIVE
  Lean process improvement techniques are used in industry to improve efficiency and quality while controlling costs. These techniques are less commonly applied in health care. This study assessed the effectiveness of Lean principles on first case on-time operating room starts and quantified effects on resident work hours.
  
  
  METHODS
  Standard process improvement techniques (DMAIC methodology: define, measure, analyze, improve, control) were used to identify causes of delayed vascular surgery first case starts. Value stream maps and process flow diagrams were created. Process data were analyzed with Pareto and control charts. High-yield changes were identified and simulated in computer and live settings prior to implementation. The primary outcome measure was the proportion of on-time first case starts; secondary outcomes included hospital costs, resident rounding time, and work hours. Data were compared with existing benchmarks.
  
  
  RESULTS
  Prior to implementation, 39% of first cases started on time. Process mapping identified late resident arrival in preoperative holding as a cause of delayed first case starts. Resident rounding process inefficiencies were identified and changed through the use of checklists, standardization, and elimination of nonvalue-added activity. Following implementation of process improvements, first case on-time starts improved to 71% at 6 weeks (P = .002). Improvement was sustained with an 86% on-time rate at 1 year (P < .001). Resident rounding time was reduced by 33% (from 70 to 47 minutes). At 9 weeks following implementation, these changes generated an opportunity cost potential of $12,582.
  
  
  CONCLUSIONS
  Use of Lean principles allowed rapid identification and implementation of perioperative process changes that improved efficiency and resulted in significant cost savings. This improvement was sustained at 1 year. Downstream effects included improved resident efficiency with decreased work hours.
authors.affiliation: Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address: Courtney.J.Warner@hitchcock.org.
authors.forename: Courtney J
authors.initials: CJ
authors.lastname: Warner
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Walsh
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Horvath
authors.forename: Teri R
authors.initials: TR
authors.lastname: Walsh
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Herrick
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Prentiss
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Powell
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D004503:Education, Medical, Graduate / Q000191:economics / Q000458:organization & administration; D017598:Efficiency, Organizational; D017721:Hospital Costs; D006801:Humans; D007396:Internship and Residency / Q000191:economics / Q000458:organization & administration; D007587:Job Description; D009873:Operating Rooms / Q000191:economics / Q000458:organization & administration; D010561:Personnel Staffing and Scheduling / Q000191:economics / Q000458:organization & administration; D017064:Process Assessment, Health Care / Q000191:economics / Q000458:organization & administration; D013997:Time Factors; D013996:Time and Motion Studies; D014656:Vascular Surgical Procedures / Q000191:economics / Q000193:education* / Q000458:organization & administration; D057188:Workflow; D000078329:Workforce; D016526:Workload