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American Association of Plastic Surgeons
89th Annual Meeting Abstracts

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All That You Can Leave Behind: Implementation of a Six Sigma Program in Microsurgery to Reduce Variation, Increase Efficiency, and Improve Outcomes in Perforator Flap Breast Reconstruction
C Scott Hultman, MD, MBA, Eric G. Halvorson, MD, Sendia Kim, MD, Becky Dodge, RN, MBA, Ann Collins, PA, Clara N. Lee, MD, MPP, Kamil Erfanian, MD, Janet Chadwick, RN, MBA, Glen Spivak, MBA, Ronald WB Erickson, MSSBB.
University of North Carolina, Chapel Hill, NC, USA.

Purpose:
A successful program in microsurgery requires the complex coordination of diverse teams, resources, and processes, and as such, improvements in efficiency and performance can be difficult. Six Sigma (6σ) is a method for quality improvement and defect reduction that has been highly effective in manufacturing and business sectors, yet only recently have these principles been applied to healthcare systems. In fact, surgical disciplines have lagged far behind other specialties, such as anesthesia and neonatal intensive care. We hypothesized that implementation of a 6σ program in perforator flap breast reconstruction could improve operational, financial, and clinical outcomes, by reducing variation, improving quality and efficiency, and optimizing throughput.
Methods:
Using the DMAIC model (Define, Measure, Analyze, Improve, Control), we initiated a 6σ project to improve intra-operative efficiency, quality, and throughput in patients who underwent perforator flap breast reconstruction. Our team utilized the following methodologies: SIPOC analysis (suppliers, inputs, process, outputs, customers), VOC (voice of the customer) questionnaires and focus groups, stakeholder analysis, CTQ (critical to quality) and cause/effect trees, root cause analysis, workflow analysis, critical pathway analysis, lean manufacturing principles with parallel processing, and contingency planning. Our primary goal was to decrease operative times (preop-to-arrival in OR, arrival-to-cut, and cut-to-close), by reducing redundant anesthetic and surgical steps, eliminating non-essential nursing tasks, having consistent personnel with adequate training, frequent in-servicing of microscope and flap monitoring devices, rearrangement of OR bed and equipment, and creation of a microsurgery supply cart. We studied the impact of this project by comparing the operational, financial, and clinical outcomes of pre-6σ patients (n=39) with 6σ patients (n=27). Statistical significance for T tests and chi-square analysis was assigned to p values <0.05.
Results:
From 2006-2009, 66 patients (median age 48.4, BMI 29.3) underwent 98 breast reconstructions with DIEP and/or SIEA perforator flaps, by fellowship-trained microsurgeons at an academic medical center. Total OR time decreased from 714 to 652 minutes (p=0.08), with preop-to-cut time falling from 73 to 65 minutes (p=0.03). The greatest drop in total OR time came with unilateral cases (672 to 498 minutes, p=0.001), with less substantial gains noted in bilateral, immediate, or delayed cases. Length of stay (LOS) decreased from 6.3 to 5.6 days (p=0.05). Complication and take-back rates did not change, with only 1 total flap loss and 3 partial flap losses. Physician revenue increased modestly from $4,490 to $4,949 per case. More impressively, physician revenue/minute jumped from $6.28 to $7.59 (p=0.02). Hospital revenue increased minimally from $14,676 to $15,418 per case, but facility revenue/minute had more impressive gains, from $21.84 to $25.11. Contribution margin (revenue less variable costs) increased by $1,264 per case, due to reduction in OR time and LOS.
Conclusions:
A Six Sigma initiative in perforator flap breast reconstruction unequivocally improves operational, financial, and clinical outcomes, evidenced by decreased operative time, reduced length of stay, reduction in variable costs, improved physician revenue, and increased contribution margin to the healthcare system. Maintaining these gains in efficiency, defect reduction, and quality will be critical and may prove to be quite challenging.


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