Application of lean principles to neurosurgical procedures: The case of lumbar spinal fusion surgery, a literature review and pilot series

Jesse J. Liu, Jeffrey S. Raskin, Fran Hardaway, Katherine Holste, Sarah Brown, Ahmed M. Raslan*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


BACKGROUND: Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed. OBJECTIVE: To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases. METHODS: Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability. RESULTS: Temporal variabilities in duration of 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 instrument defects accounted for 15% and 66% of all waste, respectively. CONCLUSION: This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.

Original languageEnglish (US)
Pages (from-to)332-340
Number of pages9
JournalOperative Neurosurgery
Issue number3
StatePublished - Sep 1 2018
Externally publishedYes


  • Healthcare
  • Lumbar posterior instrumented fusion
  • Plan/Do/Study/Act cycles
  • Value

ASJC Scopus subject areas

  • General Medicine


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