Can a process improvement methodology most famously applied to the auto industry help spinal cord surgeons provide better care for their patients?

Lean Six Sigma tools and techniques can be applied to improve any process, as spinal surgeons recently discovered after implementing the methodology in a way that is patterned after how Lean is used by the Toyota Production System.

Toyota is one of the most famous examples of applying Lean Six Sigma to make operations more efficient while creating products that better meet consumer demands.

Cut Waste, Improve Services

The primary goal in Lean Six Sigma is to cut waste and add value to the customer. Every step in a process is assessed based on these two main ideas, with anything that doesn’t add value to the customer eliminated.

When it comes to spinal surgery, there is a large operation involved. Patients will go to a single hospital for the work, but successful completion of their treatment and surgery involves departments such as radiology, pathology, pharmacy and rehabilitation, in addition to surgery.

As pointed out by spinal surgeons in the Oxford University Press, each of these areas have “individual processes, inefficiencies and errors.”

In a larger context, spinal surgery – like all healthcare delivery in the United States – is currently under pressure to reduce costs and improve services. This is a tall order. But it’s also the result Lean Six Sigma was designed to produce.

Mapping Out Success

In writing about their application of Lean Six Sigma to spinal surgery procedures for the Oxford University Press, three neurosurgeons – two with the Oregon Health and Science University in Portland and one from Indiana University – wrote that they decided to focus on low-back spinal fusion surgeries.

They chose this procedure because it is common in the United States. From 2001 to 2011, the number of spinal fusion surgeries per year increased from 288,000 to 488,000, according to data from the Healthcare Cost and Utilization Project.

The surgeons also noted that operating rooms are a “natural target” for process improvement that leads to better value of care. They wrote: “The operating room is a system within itself; nurses, students, technicians, anesthetists and surgeons all work together to provide the best care they can. Despite best intentions, every system has inefficiencies which can be improved upon to lower cost.”

In implementing Lean, the three decided to use PDSA – Plan, Do, Study, Act. This approach was created from the original PDCA – Plan, Do, Check, Act – technique developed by Dr. W. Edwards Deming. The two are very similar. Essentially, PDSA – with “study” instead of “check” – puts an emphasis on going beyond checking to make sure new procedures are followed to studying the results of the changes.

The four phases of PDSA are:

  • Plan: Define the process to improve, find changes that might be useful, agree on how to measure results of changes
  • Do: Analyze the process to find both wasteful and useful steps
  • Study: Study the results of the analysis to find areas where improvements can be made
  • Act: Implement changes to improve upon the results, start the cycle again

Application to Spinal Fusion

The three surgeons applied PDSA in the spinal fusion surgery process for patients.

In the Plan phase, they focused on areas such as surgical exposure, (discectomy/decompression, which involves removing the intervertebral disc or parts of the bone which cause symptomatic compression of nerves), hardware placement and surgical closure.

In the Do phase, they tracked wasted time and effort in each of those modular events. They analyzed those results in the Study phase and implemented changes in the Act phase.

In the detailed report on their findings, the doctors were able to identify the areas where the most time was wasted. The longest amount of time spent on the surgical procedure was during the initial “exposure of the spinal area.” Contributing factors included surgeons with “variable efficiency and familiarity” to perform the majority of exposure, the fact that spine surgery is performed on difficult anatomy, and that incomplete initial exposure requiring later returning to this first step.

They reported that “operating time is inversely proportional to a surgeon’s level of experience.” They noted that having attending surgeons oversee residents in certain phases of the procedure where they are the least comfortable could lead to more efficiency.

Another area they identified was time wasted while surgeons wait in the operating room for certain instruments to arrive or the necessary personnel to be on-hand. They wrote that anticipating each need before it arrives would lead to more efficiency and suggested that a written plan available for all to see before the surgery begins could help in this area.

The three praised Lean Six Sigma for offering a straightforward approach for tackling complex operational problems.

In the Oxford University Press article, the three wrote: “There is no simple answer to blunt the rising cost of U.S. healthcare, but by focusing on small parts of this complex system, we can create meaningful change.”