title: Redesigning a joint replacement program using Lean Six Sigma in a Veterans Affairs hospital.
abstract: OBJECTIVE
  In April 2009, an analysis of joint replacement surgical procedures at the Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, revealed that total hip and knee replacements incurred $1.4 million in non-Veterans Affairs (VA) care costs with an average length of stay of 6.1 days during fiscal year 2008. The Joint Replacement Program system redesign project was initiated following the Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS) model to increase efficiency, decrease length of stay, and reduce non-VA care costs.
  
  
  OBJECTIVE
  To determine the effectiveness of Lean Six Sigma process improvement methods applied in a VA hospital.
  
  
  METHODS
  Perioperative processes for patients undergoing total joint replacement were redesigned following the VA-TAMMCS model--the VA's official, branded method of Lean Six Sigma process improvement. A multidisciplinary team including the orthopedic surgeons, frontline staff, and executive management identified waste in the current processes and initiated changes to reduce waste and increase efficiency. Data collection included a 1-year baseline period and a 20-month sustainment period.
  
  
  METHODS
  The primary endpoint was length of stay; a secondary analysis considered non-VA care cost reductions.
  
  
  RESULTS
  Length of stay decreased 36% overall, decreasing from 5.3 days during the preproject period to 3.4 days during the 20-month sustainment period (P < .001). Non-VA care was completely eliminated for patients undergoing total hip and knee replacement at the Richard L. Roudebush Veterans Affairs Medical Center, producing an estimated return on investment of $1 million annually when compared with baseline cost and volumes. In addition, the volume of total joint replacements at this center increased during the data collection period.
  
  
  CONCLUSIONS
  The success of the Joint Replacement Program demonstrates that VA-TAMMCS is an effective tool for Lean and Six Sigma process improvement initiatives in a surgical practice, producing a 36% sustained reduction in length of stay and completely eliminating non-VA care for total hip and knee replacements while increasing total joint replacement volume at this medical center.
authors.affiliation: Department of Surgery, Indiana University School of Medicine, Indianapolis.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Gayed
authors.forename: Stephen
authors.initials: S
authors.lastname: Black
authors.forename: Joanne
authors.initials: J
authors.lastname: Daggy
authors.forename: Imtiaz A
authors.initials: IA
authors.lastname: Munshi
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D019091:Critical Pathways / Q000458:organization & administration*; D017598:Efficiency, Organizational; D005260:Female; D017048:Health Care Costs; D006787:Hospitals, Veterans; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*