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Original Investigation | Association of VA Surgeons

Redesigning a Joint Replacement Program Using Lean Six Sigma in a Veterans Affairs Hospital

Benjamin Gayed, MD1; Stephen Black, PT2; Joanne Daggy, PhD2,3; Imtiaz A. Munshi, MD, MBA1,2
[+] Author Affiliations
1Department of Surgery, Indiana University School of Medicine, Indianapolis
2Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
3Department of Biostatistics, Indiana University School of Medicine, Indianapolis
JAMA Surg. 2013;148(11):1050-1056. doi:10.1001/jamasurg.2013.3598.
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Importance  In April 2009, an analysis of joint replacement surgical procedures at the Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, revealed that total hip and knee replacements incurred $1.4 million in non–Veterans Affairs (VA) care costs with an average length of stay of 6.1 days during fiscal year 2008. The Joint Replacement Program system redesign project was initiated following the Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain (VA-TAMMCS) model to increase efficiency, decrease length of stay, and reduce non-VA care costs.

Objective  To determine the effectiveness of Lean Six Sigma process improvement methods applied in a VA hospital.

Design, Setting, and Participants  Perioperative processes for patients undergoing total joint replacement were redesigned following the VA-TAMMCS model—the VA’s official, branded method of Lean Six Sigma process improvement. A multidisciplinary team including the orthopedic surgeons, frontline staff, and executive management identified waste in the current processes and initiated changes to reduce waste and increase efficiency. Data collection included a 1-year baseline period and a 20-month sustainment period.

Main Outcomes and Measures  The primary endpoint was length of stay; a secondary analysis considered non-VA care cost reductions.

Results  Length of stay decreased 36% overall, decreasing from 5.3 days during the preproject period to 3.4 days during the 20-month sustainment period (P < .001). Non-VA care was completely eliminated for patients undergoing total hip and knee replacement at the Richard L. Roudebush Veterans Affairs Medical Center, producing an estimated return on investment of $1 million annually when compared with baseline cost and volumes. In addition, the volume of total joint replacements at this center increased during the data collection period.

Conclusions and Relevance  The success of the Joint Replacement Program demonstrates that VA-TAMMCS is an effective tool for Lean and Six Sigma process improvement initiatives in a surgical practice, producing a 36% sustained reduction in length of stay and completely eliminating non-VA care for total hip and knee replacements while increasing total joint replacement volume at this medical center.

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Figures

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Figure 1.
Summary of Events and Changes

BID indicates twice daily; DC, discharge; PT, physical therapy; and SW, social work.

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Figure 2.
Monthly Length of Stay Average Control Chart

The shaded area represents the project implementation period. The mean length of stay (LOS) (after adjusting for covariates) for the preproject, project, and sustainment periods are displayed above the chart (P < .001). CL indicates center line; LCL, lower control limit; and UCL, upper control limit.

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Figure 3.
Non–Veterans Affairs Care Costs

The non–Veterans Affairs care costs for total hip arthroplasty and total knee arthroplasty are shown for fiscal years 2008 through 2012.

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Figure 4.
Veterans Affairs and Non–Veterans Affairs Care for Total Joint Replacement Cases per Year

The number of cases of total hip arthroplasty and total knee arthroplasty in Veterans Affairs (VA) and non-VA care are shown for fiscal years 2008 through 2012. The proportion of patients using non-VA care showed a statistically significant decrease each year (P < .05).

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