Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare

Abstract

ObjectiveThe COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled.MethodA multifunctional project team used the data-driven LSS process improvement methodology and followed the ‘DMAIC’ improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an ‘interrupted time series’ study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant.ResultsLast-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005).ConclusionThis study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.

Quality and process improvement of the multidisciplinary Heart Team meeting using Lean Six Sigma

“…This prevents cancellations due to suboptimal preparation or last-minute change of treatments. 11 In a hospital with 1000 CABG procedures annually and 15% last-minute cancellations, the amount equals about 150 CABGs per year. 11 Out of those, an estimated 20% (30 cases per year) could be prevented by a better HT and follow-up.…”

“… 11 In a hospital with 1000 CABG procedures annually and 15% last-minute cancellations, the amount equals about 150 CABGs per year. 11 Out of those, an estimated 20% (30 cases per year) could be prevented by a better HT and follow-up. An estimation of the average revenue per procedure of €12 000 would result in missed revenues of €360 000 annually.…”

“…This again could affect the entire care pathway, since suboptimal preparation of patients can lead to last-minute cancellations. 11 Due to the COVID-19 pandemic, the time to treatment is increased since resources and capacity are progressively limited. 12–15 Prolonged time to treatment for patients with severe CAD and valve pathology can plausibly lead to more adverse events (both prior the invasive procedure and perioperatively).…”

“…19 Lean Six Sigma (LSS) is a quality improvement (QI) methodology originated from the manufacturing industry that has the potential to create and implement improvements throughout the organisation by its data-driven, in-depth multidisciplinary approach to improve both process efficiency and quality of care. 11 20 21 The cardiac centre (cardiology and cardiothoracic surgery department) of the Amsterdam University Medical Centre (Amsterdam UMC), the Netherlands, initiated a QI project to optimise the HT with the aim of improving efficiency and quality of care. In 2019, the merger of two academic hospitals to Amsterdam UMC led to the lateralisation of the cardiac centre (cardiothoracic surgery and cardiology department) to one location with expected completion in 2024.…”

Outcomes and Disposition of Patients After Case Cancellation on Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective Cohort Analysis

“…20 In addition, past studies have noted differences in day-of-surgery case cancellations among varying surgical services. [21][22][23] Efforts to minimize late surgical case cancellation include the implementation of such techniques as comprehensive preoperative telephone screening by nurses, 24 the use of preoperative assessment clinics, [25][26][27][28] and the deployment of the Lean Six Sigma methodology 29 for continuous quality improvement. Nonetheless, some aggressive efforts to minimize case cancellation, such as onsite evaluation by an anesthesia resident for patients included in a Perioperative Surgical Home pathway, were not able to minimize these costly adverse events meaningfully.…”