title: Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction.
abstract: OBJECTIVE
  Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center.
  
  
  METHODS
  Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis.
  
  
  RESULTS
  Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11.
  
  
  CONCLUSIONS
  A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.
authors.affiliation: From the *Division of Plastic Surgery, University of North Carolina Health Care System, Chapel Hill, NC; and †Division of Plastic Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA.
authors.forename: Charles Scott
authors.initials: CS
authors.lastname: Hultman
authors.forename: Sendia
authors.initials: S
authors.lastname: Kim
authors.forename: Clara N
authors.initials: CN
authors.lastname: Lee
authors.forename: Cindy
authors.initials: C
authors.lastname: Wu
authors.forename: Becky
authors.initials: B
authors.lastname: Dodge
authors.forename: Chloe Elizabeth
authors.initials: CE
authors.lastname: Hultman
authors.forename: S Tanner
authors.initials: ST
authors.lastname: Roach
authors.forename: Eric G
authors.initials: EG
authors.lastname: Halvorson
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D004526:Efficiency; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000191:economics / Q000379:methods* / Q000592:standards; D008866:Microsurgery / Q000191:economics / Q000379:methods* / Q000592:standards; D008875:Middle Aged; D009657:North Carolina; D061646:Operative Time; D061525:Perforator Flap; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D057188:Workflow