title: Decreasing the Preincision Time for Pulmonary Lobectomy: The Process of Lean and Value Stream Mapping.
abstract: BACKGROUND
  Our objective was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process).
  
  
  METHODS
  After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated.
  
  
  RESULTS
  One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p ≤ 0.001 for all). A protocol for the insertion of double-lumen endotracheal tubes was established and times decreased (mean, 14 minutes to 1 minute; p = 0.001). After all changes were made, the time between operating room entry and incision decreased from a mean of 64 minutes to 37 minutes (p < 0.001). Outcomes improved, mortality decreased from 3.2% to 0.26% (p = 0.015), and major morbidity decreased from 15.2% to 5.3% (p = 0.042).
  
  
  CONCLUSIONS
  Lean and value stream mapping can be safely applied to the clinical algorithms of high-risk patient care. We demonstrate that elimination of non-value-added steps can safely decrease preincision time without increasing patient risk in patients who undergo pulmonary lobectomy. Selected centers may be able to adopt some of these lean-driven protocols.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama. Electronic address: rcerfolio@uabmc.edu.
authors.forename: Robert James
authors.initials: RJ
authors.lastname: Cerfolio
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Brad L
authors.initials: BL
authors.lastname: Steenwyk
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Caroline
authors.initials: C
authors.lastname: Watson
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: James
authors.initials: J
authors.lastname: Sparrow
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Victoria
authors.initials: V
authors.lastname: Belopolsky
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Matthew
authors.initials: M
authors.lastname: Townsley
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Ralph
authors.initials: R
authors.lastname: Lyerly
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Michelle
authors.initials: M
authors.lastname: Downing
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Ayesha
authors.initials: A
authors.lastname: Bryant
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: William Quinton
authors.initials: WQ
authors.lastname: Gurley
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Colleen
authors.initials: C
authors.lastname: Henling
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Jack
authors.initials: J
authors.lastname: Crawford
authors.affiliation: Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Gayeski
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D017598:Efficiency, Organizational; D017558:Elective Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009873:Operating Rooms / Q000458:organization & administration*; D010348:Patient Care Team / Q000458:organization & administration; D056888:Patient Positioning; D011013:Pneumonectomy / Q000379:methods*; D011182:Postoperative Care / Q000379:methods; D057216:Propensity Score; D058996:Quality Improvement; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome