Published 11/2/2017

Could lean processes revolutionize the delivery of bone and joint health care?

Enhancing safety and value in spine surgery

ROSEMONT, Ill. (November 2, 2017)—The lean transformation model continuously improves customer value-driven purpose, process and people. It has helped manufacturing and service industries maximize customer value and efficiency and create consistency in products and services. But, could lean processes adapted to health care also increase patient outcomes and optimize the value of patient care services, eliminate waste, and reduce complications? Rajiv K. Sethi, MD, an orthopaedic surgeon specializing in spine surgery and health services research and executive director of Virginia Mason Neuroscience Institute’s Complex Spine Surgery and Spine Center of Excellence Programs, explains his findings in a review published in the November issue of the Journal of the American Academy of Orthopaedic Surgeons.
A lean organization’s goal is to provide value to the customer through a process with zero waste. The methods revolutionized manufacturing in Japan in the late 20th century, and soon after prominent U.S.-based manufacturing and service industry companies also began adopting lean processes.
“Consider the aviation industry, which has embraced lean processes and a culture of safety. When flying an aircraft from New York to Seattle, there is minimal pilot variability in how the plane takes off and lands because of automation and standard, checklist-based processes that are universal among pilots of all types,” explains Dr. Sethi.
“Simple things like less waiting, getting the right care at the right time, reducing overutilization of drugs and procedures that don’t help patients and a more predictable hospital stay after a procedure” are examples of the patient experience that Dr. Sethi and his co-authors say the lean process improvement can enhance. “Variability in health care creates waste and errors. Lean process improvement standardizes processes and algorithms to remove these barriers, decrease medical errors, enhance patient safety and enhance outcomes,” says Dr. Sethi. The authors’ findings suggest lean process improvement can be used in any process in which there is major variability and waste across the medical landscape to enhance cost-effectiveness and the patient experience.
The Virginia Mason Medical Center (VMMC) in Seattle, Wash., was one of the first health care institutions to implement the lean methods. Their initial work reduced the incidences of ventilator-associated pneumonia at VMMC from 34 cases with five deaths in 2002 to four cases with one death in 2004. VMMC’s usage of lean processes later extended into orthopaedic surgery and spine surgery—known as the Seattle Spine Team approach. Key service providers (i.e., the spine care team) helped define the customer (i.e., the patient) value, driving them to deliver the safest and most effective complex spine surgery at the lowest cost. The processes reduced avoidable complications in complex environments with known extensive risks and the need for unplanned secondary surgeries.
According to the review, hospital groups that implemented lean processes reported striking findings:
  • VMMC’s Seattle Spine Team approach significantly reduced overall complex spine surgery complication rates by 36 percent—from 52 percent to 16 percent.
    • The hospital successfully sustained the lower complication rate over a seven-year period through continuous pre-, intra- and postoperative process improvements. Due to this sustained continuous improvement, the hospital now receives preferred contracts from large private employers bringing spine and total joint patients to Seattle from all over the United States. 
    • Dr. Sethi’s group recently published findings in Spine demonstrating that 60 percent of patients offered spinal fusions in community hospitals were offered non-surgical options by the Virginia Mason multidisciplinary panel, which equally empowers surgeons and other spine providers such as physiatrists and psychologists in the decision-making process.
    • Optimizing preoperative communications also included managing important patient factors such as obesity, smoking and suboptimal bone density before surgery.
  • The Pittsburgh Regional Health Initiative reduced central line infections by up to 90 percent within one year of implementation; and,
  • ThedaCare, a Wisconsin-based hospital group, reduced inefficiencies and waste, and created $3.3 million in institutional savings in 2004.
“Success is a continuous improvement process,” says Dr. Sethi. “It depends on the adoption of culture that everyone is empowered to examine the process, and involved in creating and supporting the culture of change within the organization.” When successfully implemented and supported, lean process has demonstrated that it can help orthopaedic surgical teams and institutions effectively enhance safety and the value of orthopaedic care.
# # #
More information about the AAOS
Follow the AAOS on Facebook, Twitter and Instagram
Follow the conversation about JAAOS on Twitter

From the Neuroscience Institute, Virginia Mason Medical Center, Seattle, WA (Dr. Sethi and Dr. Yanamadala), the Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS (Dr. Burton), and the Denver International Spine Center, Denver, CO (Dr. Bess). Dr. Sethi or an immediate family member serves as a paid consultant to K2M, NuVasive, and Orthofix; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from K2M; and serves as a board member, owner, officer, or committee member of the Scoliosis Research Society and the Washington State Orthopaedic Association. Dr. Burton or an immediate family member has received royalties from and serves as a paid consultant to DePuy Synthes; has received research or institutional support from Bioventus, DePuy Synthes, and Pfizer; and serves as a board member, owner, officer, or committee member of the Scoliosis Research Society. Dr. Bess or an immediate family member has received royalties from K2M and RTI Surgical; is a member of a speakers’ bureau or has made paid presentations on behalf of and serves as a paid consultant to K2M; has received research or institutional support from DePuy Synthes, K2M, Medtronic Sofamor Danek, NuVasive, Stryker, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the North American Spine Society and the Scoliosis Research Society. Neither Dr. Yanamadala nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.
J Am Acad Orthop Surg 2017;25: e244-e250. DOI: 10.5435/JAAOS-D-17-00030

Contact AAOS Media Relations 

Deanna Killackey 


Lauren Riley