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REVIEW • Rev. Bras. Enferm. 77 (2) • 2024 • https://doi.org/10.1590/0034-7167-2023-0431 copy

Lean and/or Six Sigma for process optimization in the perioperative period: an integrative review

Lean y/o Six Sigma para optimizar los procesos en el periodo perioperatorio: revisión integradora

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To analyze the evidence on the influence of Lean and/or Six Sigma for process optimization in the perioperative period.

Methods:

Integrative review carried out in the MEDLINE (PubMed), Web of Science, EMBASE, CINAHL, Scopus and LILACS databases on the use of Lean and/or Six Sigma to optimize perioperative processes. The studies included were analyzed in three thematic categories: flow of surgical patients, work process and length of stay.

Results:

The final sample consisted of ten studies, which covered all operative periods. Lean and/or Six Sigma make a significant contribution to optimizing perioperative processes.

Final considerations:

Lean and/or Six Sigma optimize perioperative processes to maximize the achievement of system stability indicators, making it possible to identify potential problems in order to recognize them and propose solutions that can enable the institution of patient-centered care.

Descriptors:
Surgicenters; Total Quality Management; Process Optimization; Perioperative Period; Health

Database	Search strategy
MEDLINE (PubMed)	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)
Web of Science	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)
EMBASE	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)
CINAHL	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)
SCOPUS	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)
LILACS	(“Total Quality Management” OR “Lean Healthcare” OR “Lean System” OR “Lean methodology” OR “Lean Six Sigma” OR “Six Sigmas” OR “Six Sigma”) AND (Surgicenter* OR “Surgery Department”)

Operative period	Author / Country	Methodology	Intervention	Results	Outcome: Have it optimized the processes?	Level of Evidence
Perioperative	Amato-Vealey et al., 2012(³⁷37 Amato-Vealey EJ, Fountain P, Coppola D. Perfecting Patient Flow in the Surgical Setting. AORN J. 2012;96(1):46-57. https://doi.org/10.1016/j.aorn.2012.03.013 https://doi.org/10.1016/j.aorn.2012.03.0... ) United States	Six Sigma	Tools: patient flow mapping, brainstorming, multidisciplinary visit. Population: not specified.	The implementation of Six Sigma resulted in improvement in the discharge process and ensured the ability to maintain a continuous flow of surgical patients without incurring financial costs.	Yes	VI*
	Montella et al., 2017(⁹9 Montella E, Cicco MVD, Ferraro A, Centobelli P, Raiola E, Triassi M, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-9. https://doi.org/10.1111/jep.12662 https://doi.org/10.1111/jep.12662... ) Italy	Lean Six Sigma	Tools: Define-Measure-Analyze-Improve-Control (DMAIC), process mapping, brainstorming and fishbone. Population: 20,000 patients.	The actions resulted in a significant reduction in the average number of hospitalization days (from 45 to 36 days). There was also a reduction in the percentage of patients colonized by sentinel bacteria (from 0.37% to 0.21%).	Yes	II*
	Ullah et al., 2020(³⁸38 Ullah MF, Fleming C, Fox C, Tewary T, Tormey S. Patient experience in a surgical assessment unit following a closed-loop audit using a Kaizen Lean system. Ir J Med Sci. 2020;189(2):641-7. https://doi.org/10.1007/s11845-019-02105-5 https://doi.org/10.1007/s11845-019-02105... ) Ireland	Lean Healthcare	Tools: 5s, Kaizen, pull and push systems and process mapping. Population: Phase 1: 100 patients and 20 employees (clerical, administrative and staff ) interviewed in order to understand their perspectives on the areas that required attention to improve service delivery and efficiency; Phase 2: 100 patients.	The results show the patient’s “perception” of waiting time. In phase 2, perception improved with 83% of patients compared to 67% in phase 1; perception of waiting time for medical review also improved significantly, with 26% of patients reviewed in phase 2 compared to 0% in phase 1. Only 7% of patients had a total stay of 6-8h in phase 2 compared to 33% in phase 1. There was satisfaction in different domains, perceptions of privacy and overall treatment was also improved.	It cannot be said that processes have been optimized.	VI*
Preoperative	Godinho Filho et al., 2015(³⁹39 Godinho Filho M, Boschi A, Rentes AF, Thurer M, Bertani TM. Improving hospital performance by use of lean techniques: an action research project in Brazil. Qual Engineering. 2015;27(2):196-211. https://doi.org/10.1080/08982112.2014.942039 https://doi.org/10.1080/08982112.2014.94... ) Brazil	Lean Healthcare	Tools: 5s e Single Minute Exchange of Dies (SMED). Population: quality manager (n=1), quality analyst (n=1), coordinator of the Materials and Sterilization Center (CME) (n=1), head nurse of the operating room (n=1), external consultants (unspecified), solution manager (n=1), consultant analysts (n=2).	A significant 94% reduction in the surgical delay rate due to a lack of materials in the Sterilization Materials Center (CME) was observed after the Kaizen event. Finally, a significant reduction in postoperative infection can be seen due to improved flow and standardized operating procedures, dropping from 1 to 1.5% to 0.21%.	Yes	VI*
Preoperative and Intraoperative	Iverson et al., 2021(⁴⁰40 Iverson KR, Roa L, Shu S, Wong M, Rubenstein S, Zavala P, et al. Quality improvement to address surgical burden of disease at a large tertiary public hospital in Peru. World J Surg. 2021;45:2357-69. https://doi.org/10.1007/s00268-021-06118-z https://doi.org/10.1007/s00268-021-06118... ) Peru	Lean Six Sigma	Tools: Plan-Do-Study-Act (PDSA), process mapping and fishbone. Population: 1- Pre-intervention: 75 patients (53 emergency and 22 elective). 2- Post-intervention: 109 patients (111 emergency and 31 elective).	Patients (87%) on the new waiting list had all relevant clinical data documented, a 13.3% improvement on the pre-existing list. The time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention.	Yes	II*
Intraoperatório	Amati et al., 2022(⁴¹41 Amati M, Valnegri A, Bressan A, Regina DL, Tassone C, Piccolo AL, et al. Reducing changeover time between surgeries through lean thinking: an action research project. Front Med. 2022;9:822964. https://doi.org/10.3389/fmed.2022.822964 https://doi.org/10.3389/fmed.2022.822964... ) Switzerland	Lean Healthcare	Tools: Gemba walks, process mapping, root cause analysis and Single Minute Exchange of Dies (SMED). Population: multidisciplinary team (a chair of anesthesia, a nurse anesthetist, a surgical technician, a housekeeper, an operating room administrative secretary, two surgeons and two head nurses, representing the gynecology and general surgery specialties).	The changeover time between operations was reduced by 17 minutes for gynecology and 15 minutes for general surgery (25% on average), with no changes in terms of infrastructure, technology or resources.	Yes	VI*
Intraoperatório	Leu et al., 2013(⁴²42 Leu JD, Ku HL, Chung K P. “Six sigma” as an effective process for reducing waiting time in surgery patients. Adv Mat Res. 2013;718-720:2533-8. https://doi.org/10.4028/www.scientific.net/AMR.718-720.2533 https://doi.org/10.4028/www.scientific.n... ) Taiwan	Six Sigma	Tools: process mapping. Population: Phase 1: 1246 patients. Phase 2: 1266 patients.	The reduction in waiting time for each study group was 0.54, 4.23 and 7.82 minutes, respectively. The average surgery turnover time also decreased significantly for each group (11.98, 16.4 and 19.72 minutes, respectively). The Six Sigma quality indicator changed from 3.35δ to 3.46δ, a difference of 0.11δ.	Yes	II*
Post-surgery	Blouin-Delisle et al., 2018(⁴³43 Blouin-Delisle CH, Drolet R, Gagnon S, Turcotte S, Boutet S, Coulombe M, et al. Improving flow in the OR: how Lean process studies can lead to shorter stays in the recovery ward. Int J Health Care Qual Assur. 2018;31(2):150-61. https://doi.org/10.1108/IJHCQA-01-2017-0014 https://doi.org/10.1108/IJHCQA-01-2017-0... ) Canada	Lean Healthcare	Tools: Define-Measure-Analyze-Improve-Control (DMAIC), Kaizen workshop, process mapping. Population: Project Care Unit professionals: head nurse (n=2), nurses (n=3), clerical assistant (n=1), head of admissions (n=1), head of surgical ward (n=1), agent responsible for implementing Lean concepts (n=1).	Hospital 1: The length of stay in the recovery ward was reduced by 62 minutes (68% reduction) and there was an increase of around 25% of all admissions made during the day after the project compared to the period before the project. Hospital 2: For the HEJ Lean project, time in the recovery ward was reduced by 6 minutes (29% reduction).	Yes	VI*
	Bouras, 2015(⁴⁴44 Bouras A. Quality tools to improve the communication level in the surgery department at a local hospital. Comput Human Behav. 2015;51(B):843-51. https://doi.org/10.1016/j.chb.2014.11.066 https://doi.org/10.1016/j.chb.2014.11.06... ) Saudi Arabia	Six Sigma	Tools: process mapping, fishbone, root cause analysis, cause and effect diagram, brainstorming. Population: not specified.	The results show a reduction in cycle time, impacting the reduction in the time needed to contact doctors; minimizing the time needed to carry out urgent cases and the patient referral process; reducing the delay time before starting the execution of the treatment plan.	Yes	IV^†
	McCulloch et al., 2010(⁴⁵45 McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. https://doi.org/10.1136/bmj.c5469 https://doi.org/10.1136/bmj.c5469... ) United Kingdom	Lean Healthcare	Tools: 5S, process mapping, visual management and Plan-Do-Check-Action (PDCA). Population: 1- Pre-intervention: 607 patients. 2- Post-intervention: 602 patients.	Focus on establishing safe processes and better results. The proportion of patients requiring transfer to other wards fell from 27% to 20%. Length of stay proved to be the most important risk factor for patient safety incidents.	It cannot be said that processes have been optimized.	IV*

Cross-sectiona^l(34)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Total (Yes)
Amato-Vealey et al., 2012(³⁷37 Amato-Vealey EJ, Fountain P, Coppola D. Perfecting Patient Flow in the Surgical Setting. AORN J. 2012;96(1):46-57. https://doi.org/10.1016/j.aorn.2012.03.013 https://doi.org/10.1016/j.aorn.2012.03.0... )	N*	Y†	Y	Y	N	U‡	Y	U	-	-	-	4
Blouin-Delisle et al., 2018(⁴³43 Blouin-Delisle CH, Drolet R, Gagnon S, Turcotte S, Boutet S, Coulombe M, et al. Improving flow in the OR: how Lean process studies can lead to shorter stays in the recovery ward. Int J Health Care Qual Assur. 2018;31(2):150-61. https://doi.org/10.1108/IJHCQA-01-2017-0014 https://doi.org/10.1108/IJHCQA-01-2017-0... )	Y	Y	Y	Y	U	U	Y	Y	-	-	-	6
Bouras, 2015(⁴⁴44 Bouras A. Quality tools to improve the communication level in the surgery department at a local hospital. Comput Human Behav. 2015;51(B):843-51. https://doi.org/10.1016/j.chb.2014.11.066 https://doi.org/10.1016/j.chb.2014.11.06... )	N	U	Y	Y	N	N	Y	Y	-	-	-	4
Ullah et al., 2020(³⁸38 Ullah MF, Fleming C, Fox C, Tewary T, Tormey S. Patient experience in a surgical assessment unit following a closed-loop audit using a Kaizen Lean system. Ir J Med Sci. 2020;189(2):641-7. https://doi.org/10.1007/s11845-019-02105-5 https://doi.org/10.1007/s11845-019-02105... )	Y	Y	Y	Y	N	N	Y	Y	-	-	-	6
Qualitative (³⁶36 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, (eds). Adelaide: JBI; 2020. 1-6)
Amati et al., 2022(⁴¹41 Amati M, Valnegri A, Bressan A, Regina DL, Tassone C, Piccolo AL, et al. Reducing changeover time between surgeries through lean thinking: an action research project. Front Med. 2022;9:822964. https://doi.org/10.3389/fmed.2022.822964 https://doi.org/10.3389/fmed.2022.822964... )	Y	Y	Y	Y	Y	Y	U	NA^§	Y	Y	-	8
Godinho Filho et al., 2015(³⁹39 Godinho Filho M, Boschi A, Rentes AF, Thurer M, Bertani TM. Improving hospital performance by use of lean techniques: an action research project in Brazil. Qual Engineering. 2015;27(2):196-211. https://doi.org/10.1080/08982112.2014.942039 https://doi.org/10.1080/08982112.2014.94... )	Y	Y	Y	Y	Y	Y	U	U	N	Y	-	7
Quasi-experimental (³⁶36 Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, (eds). Adelaide: JBI; 2020. 1-6)
Iverson et al., 2021(⁴⁰40 Iverson KR, Roa L, Shu S, Wong M, Rubenstein S, Zavala P, et al. Quality improvement to address surgical burden of disease at a large tertiary public hospital in Peru. World J Surg. 2021;45:2357-69. https://doi.org/10.1007/s00268-021-06118-z https://doi.org/10.1007/s00268-021-06118... )	Y	Y	Y	N	Y	Y	Y	Y	Y	-	-	8
Leu et al., 2013(⁴²42 Leu JD, Ku HL, Chung K P. “Six sigma” as an effective process for reducing waiting time in surgery patients. Adv Mat Res. 2013;718-720:2533-8. https://doi.org/10.4028/www.scientific.net/AMR.718-720.2533 https://doi.org/10.4028/www.scientific.n... )	Y	Y	Y	N	Y	Y	Y	Y	Y	-	-	8
Montella et al., 2017(⁹9 Montella E, Cicco MVD, Ferraro A, Centobelli P, Raiola E, Triassi M, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-9. https://doi.org/10.1111/jep.12662 https://doi.org/10.1111/jep.12662... )	Y	Y	Y	N	N	Y	Y	Y	Y	-	-	7
Cohort (³³33 Aromataris E, Munn Z, (eds). JBI Manual for evidence synthesis [Internet]. Adelaide: Joanna Briggs Institute; 2020[cited 2021 Aug 15]. Available from: https://jbi.global/critical-appraisal-tools https://jbi.global/critical-appraisal-to... )
McCulloch et al., 2010(⁴⁵45 McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. https://doi.org/10.1136/bmj.c5469 https://doi.org/10.1136/bmj.c5469... )	Y	Y	Y	U	Y	Y	Y	Y	Y	NA	Y	9

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