title: Impact of Lean on surgical instrument reduction: Less is more.
abstract: OBJECTIVE
  To determine whether instrument sets that are frequently used by multiple surgeons can be substantially reduced in size with consensus.
  
  
  METHODS
  Prospective quality improvement study using Lean Six Sigma for purposeful and consensual reduction of non-value-added instruments in adenotonsillectomy instrument sets.
  
  
  METHODS
  Value stream mapping was utilized to determine instrumentation usage and reprocessing workflow. Preintervention instrument utilization surveys allowed consensual and intelligent set reduction. Non-value-added instruments were targeted for waste elimination by placement in a supplemental set. Times for pre- and postintervention instrument assembly, Mayo setup, and surgery were collected for adenotonsillectomies. Postintervention satisfaction surveys of surgeons and staff were conducted.
  
  
  RESULTS
  Adenotonsillectomy sets were reduced from 52 to 24 instruments. Median assembly times were significantly reduced from 8.4 to 4.7 minutes (P < .0001) with a set assembly cost reduction of 44%. Following natural log transformations, mean Mayo setup times were significantly reduced from 97.6 to 76.1 seconds (P < .0001), and mean operative times were not significantly affected (1,773 vs. 1,631 seconds, P > .05). The supplemental set was opened in only 3.6% of cases. Satisfaction was >90% regarding the intervention. Set build cost was reduced by $1,468.99 per set.
  
  
  CONCLUSIONS
  Lean Six Sigma improves efficiency and reduces waste by empowering team members to improve their environment. Instrument set reduction is ideal for waste elimination because of tool accumulation over time and instrument obsolescence as newer technologies are adopted. Similar interventions could easily be applied to larger sinus, mastoidectomy, and spine sets.
  
  
  METHODS
  NA.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.
authors.forename: Todd J
authors.initials: TJ
authors.lastname: Wannemuehler
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.
authors.forename: Alhasan N
authors.initials: AN
authors.lastname: Elghouche
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.|Aurora Health Care Medical Group, Milwaukee, Wisconsin, U.S.A.
authors.forename: Mimi S
authors.initials: MS
authors.lastname: Kokoska
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Deig
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A.
authors.forename: Bruce H
authors.initials: BH
authors.lastname: Matt
mesh_terms: D000233:Adenoidectomy / Q000295:instrumentation*; D004867:Equipment Design / Q000379:methods*; D006801:Humans; D011446:Prospective Studies; D058996:Quality Improvement; D013525:Surgical Instruments; D014068:Tonsillectomy / Q000295:instrumentation*; D017749:Total Quality Management / Q000379:methods*; D057188:Workflow
keywords: Lean; Six Sigma; adenotonsillectomy; assembly; instrument; quality