• Jeffrey Steven Raskin, Jesse Jia-Xin Liu, Ahmed M Raslan, Katherine Holste, and John Marquart.
• Neurosurgery. 2015 Aug 1;62 Suppl 1:212.

IntroductionDelivery of higher-value health care is an ultimate government and public goal. Improving efficiency in the operating room and standardization of surgical steps would improve patient outcome and reduce costs, and lead to higher-value health care. Lean principles have been applied to processes proceeding and following surgery and have improved timeliness; however, value stream mapping of surgery itself has not been performed; therefore, pure waste has not been targeted for improvement. We applied plan, do, study, act (PDSA) cycles to posterior instrumented fusion (PIF) in an attempt create a standard work flow, identify waste, and remove special cause variability among similar cases.MethodsAn evaluation PSDA cycle was performed as quality improvement by creation of value stream maps for 5 PIF procedures from a single faculty neurosurgeon. Plan = segment PIF, into basic components, Do = mapping and timing components, Study = analyzing results, and Act = identifying waste for elimination. Waste inventory, spaghetti diagram, and charting of time spent per step were performed. Common steps including exposure, decompression/discectomy, hardware placement, and closure were analyzed with box and whisker plots to evaluate the extent of variability.ResultsProcedural steps were defined, resulting in interchangeable modules, which could be studied despite the variability in PIF. Step duration for decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and defects accounted for 15% and 66%, respectively.ConclusionLean principles can be applied to neurosurgical procedure time, and can be used to standardize surgical workflow and identify waste; common to all procedures was waiting and defect waste from nonsurgical sources. These preliminary data were the basis of a quality improvement Kaizen event to decrease the causes of variability, improve efficiency, and decrease overall cost.

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