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All That You Can’t Leave Behind: Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction
Charles S. Hultman, MD, MBA1, Sendia Kim, MD1, Clara N. Lee, MD, MPP1, Chloe E. Hultman, HSS1, Michelle C. Roughton, MD1, S Tanner Roach, HSS1, Eric G. Halvorson, MD2.
1University of North Carolina, Chapel Hill, NC, USA, 2Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Purpose:
Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six-Sigma (6σ) program on microsurgical breast reconstruction.
Methods:
Using methodologies developed by Motorola and GE, we applied critical pathway/workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Specific goals were to decrease operative times, length of stay, and complications, through reduced variability and improved efficiency. The project was divided into three phases: 1) Pre-6σ (24 months), 2) 6σ (10 months), 3) and Post-6σ (24 months). Groups were compared by Student’s T test, chi-square analysis.
Results:
Over a 5-year period, 112 patients underwent 168 perforator flap breast reconstructions, by fellowship-trained microsurgeons, at an AMC. Total operative time decreased from 714 to 607 minutes (p<0.01), with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (p<0.01). LOS decreased from 6.3 to 5.2 days (p=0.01). Complication and take-back rates remained similar, across the study. Physician revenue/minute increased from \.28 to \.59, while hospital revenue/minute increased from \.84 to \.11.
Conclusions:
A 6σ program in microsurgical breast reconstruction significantly improved operational and financial outcomes, without sacrificing quality or increasing complications. These incremental gains were maintained well into the control period, suggesting that reductions in operative time and variability were due to process improvements and not just “learning curve” phenomena.
Analysis of a Six Sigma Program in Microsurgical Breast Reconstruction
Nage
(years)
BMIOR time
(mins +/- SD)
Preop-to-cut time
(mins)
LOS
(days)
Partial or total flap lossUnplanned take backAll complications
Pre-6σ
24 months
3949.828.4714 +/- 168736.33%20.5%35.9%
6σ Period
10 months
2746.330.5652+/- 196655.611%20.7%33.3%
Post-6σ
24 months
4649.430.9607 +/- 146575.27%23.9%30%
P valueNSNS<0.01<0.01<0.01NSNSNS


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