Imtiaz A. Munshi

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

IMPORTANCEnIn 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

Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital

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.nnnOBJECTIVEnTo determine the effectiveness of Lean Six Sigma process improvement methods applied in a VA hospital.nnnDESIGN, SETTING, AND PARTICIPANTSnPerioperative processes for patients undergoing total joint replacement were redesigned following the VA-TAMMCS model--the VAs 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.nnnMAIN OUTCOMES AND MEASURESnThe primary endpoint was length of stay; a secondary analysis considered non-VA care cost reductions.nnnRESULTSnLength 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

Age at Diagnosis as a Relative Contraindication for Intervention in Facial Nonmelanoma Skin Cancer

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.nnnCONCLUSIONS AND RELEVANCEnThe 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.

Helmet Use and Injury Patterns in Motorcycle-Related Trauma.

OBJECTIVESnTo implement an electronic laboratory utilization management system (laboratory expert system [LES]) to provide safe and effective reductions in unnecessary clinical laboratory testing.nnnMETHODSnThe LES is a set of frequency filter subroutines within the Veterans Affairs hospital and laboratory information system that was formulated by an interdisciplinary medical team.nnnRESULTSnSince implementing the LES, total test volume has decreased by a mean of 11.18% per year compared with our pre-LES test volume. This change was not attributable to fluctuations in outpatient visits or inpatient days of care. Laboratory cost savings were estimated at

Decreased Wait Times After Institution of Office-Based Hand Surgery in a Veterans Administration Setting

151,184 and

Ultrasonography-guided identification with methylene blue tattooing of the ilioinguinal nerve for neurectomy for chronic pain: A case series

163,751 for 2012 and 2013, respectively. A significant portion of these cost savings was attributable to reductions in high-volume, large panel testing. No adverse effects on patient care were reported, and mean length of stay for patients remained unchanged.nnnCONCLUSIONSnElectronic laboratory utilization systems can effectively reduce unnecessary laboratory testing without compromising patient care.

Comparison of Neurologic Trauma and Motorcycle Helmet Use in Drivers vs Passengers

Author Affiliations: Center for Colon and Rectal Surgery, Florida Hospital, Orlando (Lee, Monson); Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio (Dietz); Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York (Fleming); Department of Surgery, New York University Langone Medical Center, New York (Remzi); Department of Colorectal Surgery, Cleveland Clinic Florida, Weston (Wexner); Division of Research and Optimal Patient Care (Cancer), American College of Surgeons, Chicago, Illinois (Winchester).

Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System

Administrative, technical, or material support: Holcomb, Graham. Study supervision: Hawn. Conflict of Interest Disclosures: None reported. Funding/Support: This study is supported by a Department of Veterans Affairs Health Services Research and Development Grant (IIR 09-347). Dr Holcomb is supported by grant T32 HS013852-11 from the Agency for Healthcare Research and Quality. Dr Richman is supported by a Department of Veterans Affairs Career Development Award. Role of the Funder/Sponsor: The Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 3, 2015; Miami Beach, Florida. 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. 2. Iversen LH, Antonsen S, Laurberg S, Lautrup MD. Therapeutic delay reduces survival of rectal cancer but not of colonic cancer. Br J Surg. 2009;96(10):1183-1189. 3. Simunovic M, Rempel E, Thériault ME, et al. Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. Can J Surg. 2009;52(4):E79-E86. 4. Holcomb CN, Graham LA, Richman JS, Itani KM, Maddox TM, Hawn MT. The incremental risk of coronary stents on postoperative adverse events: a matched cohort study [published online April 17, 2015]. Ann Surg. doi:10.1097/SLA .0000000000001246. 5. Jackson GL, Melton LD, Abbott DH, et al. Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs. J Clin Oncol. 2010;28(19): 3176-3181. 6. Paulson EC, Fu X, Epstein AJ. Location and timing of care for colon cancer patients in the VA Health System. J Surg Res. 2013;183(2):639-644.

Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures

Carpal tunnel syndrome is a common peripheral nerve compression disorder causing symptoms of numbness, tingling, weakness, and muscle atrophy. Open carpal tunnel release (CTR) is a common treatment modality traditionally performed in the operating room with sedation or general anesthesia. It can also be performed in the surgeon’s office under local anesthesia only. 1 In our study, we examined the number of days from initial consultation and visit to operative intervention in a Veterans Administration (VA) setting. A significant decrease in wait time from initial consultation to operative intervention and from initial visit to operative intervention was hypothesized to occur with the transition to office-based hand surgery procedures, without an increase in complications. Methods | Institutional review board approval from the Richard L. Roudebush VA Medical Center was obtained to construct a database of recent surgical procedures performed for carpal tunnel syndrome by the plastic surgery service. Operations including CTR in conjunction with other procedures were excluded. The minor procedure room is located within the plastic surgery clinic, with a single nurse serving as a circulating nurse. The hand and forearm are prepped and draped, and both monopolar cautery and bipolar cautery are available. A more specific description to a similar configuration can be found in

Analysis of Cases in Which a Biopsy Specimen Is Positive and an Excised Lesion Is Negative for Nonmelanoma Skin Cancer

and 11-dehydro-thromboxane B2 (TXB2) excretion rates were measured as previously described.4 The study protocol was approved by the local ethics committee, and patients provided written informed consent. The effects of LAGB surgery were assessed using Friedman and Wilcoxon tests for paired samples. The Spearman rank correlation test and stepwise multiple linear regression analysis (using log-transformed data) were performed to assess variables associated with urinary 11-dehydro-TXB2 excretion rates. Two-sided P values of less than .05 were considered to be statistically significant.