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Original Investigation
August 15, 2019

Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
  • 2University of Kansas Hospital, Kansas City
JAMA Otolaryngol Head Neck Surg. 2019;145(10):926-930. doi:10.1001/jamaoto.2019.2250
Key Points

Question  Can using Lean methodology improve operative efficiency for head and neck free flap reconstruction?

Findings  In this cohort study of 210 patients, a single intervention, the free flap plan of the day, was created using Lean methodology. Use of the plan of the day was associated with a clinically meaningful decrease in operating room times.

Meaning  The free flap plan of the day may improve operating room efficiency for head and neck free flap reconstruction.

Abstract

Importance  Inefficiency in the operating room (OR) is detrimental to the patient, the hospital, and the surgeon. Head and neck procedures requiring microvascular reconstruction are complex, lengthy operations in which prolonged operative time is associated with higher complication rates and increased costs.

Objective  To use Lean methodology to identify potential OR efficiency improvement opportunities for head and neck surgical cases involving free tissue transfer, to implement an intervention, the free flap plan of the day, and to evaluate OR times after implementation.

Design, Setting, and Participants  Phase 1: In 2015, with the assistance of the Lean Promotion Office at our institution, a tertiary academic medical center, we identified efficiency-improvement opportunities for 10 patients undergoing free flap reconstruction. Phase 2: A single intervention, the free flap plan of the day, was implemented on February 1, 2016. A retrospective medical record review of head and neck free flap reconstructions beginning 2 years before the implementation of the intervention and ending 2 years after the intervention was performed from February 1, 2014 until February 1, 2018 to analyze OR times, cost, and complications. Mean OR times were compared using the t test.

Main Outcomes and Measures  In-room-to-incision time and total OR time.

Results  Phase 1: The surgical procedures of 10 patients undergoing free flap reconstruction were observed by Lean specialists, and a time study with a process map was completed. Using this framework, major opportunities for decreasing intraoperative time waste were identified. Multiple communication breakdowns were seen to drive intraoperative time waste; therefore, a free flap plan of the day was created to improve communication between team members. Phase 2: 200 patients were included in the study and were categorized into 2 groups, no plan group (n = 104) and plan group (n = 96), based on whether the plan of the day was used or not. The age and sex distributions of the study participants were not collected. Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group (difference, 7.1 minutes; 95% CI, 3.8-10.4 minutes). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group (difference, 56.7 minutes; 95% CI, 23.6-89.6 minutes).

Conclusions and Relevance  Lean methodology was used to identify efficiency-improvement opportunities for head and neck free flap reconstruction procedures and to design a focused intervention. A free flap plan of the day was used in this study to improve communication between the OR team and was found to improve efficiency and be associated with reduced OR times.

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