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

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.