Use of Lean and Six Sigma Methodology to Improve Operating Room Efficiency in a High-Volume Tertiary-Care Academic Medical Center Robert R Cima, MD, MA, FACS, Michael J Brown, MD, James R Hebl, MD, Robin Moore, MBA, James C Rogers, PMP, Anantha Kollengode, PhD, MBA, Gwendolyn J Amstutz, MHA, Cheryl A Weisbrod, RN, MS, Bradly J Narr, MD, Claude Deschamps, MD, FACS; on behalf of the Surgical Process Improvement Team, Mayo Clinic, Rochester BACKGROUND: Operating rooms (ORs) are resource-intense and costly hospital units. Maximizing OR effi- ciency is essential to maintaining an economically viable institution. OR efficiency projects often focus on a limited number of ORs or cases. Efforts across an entire OR suite have not been reported. Lean and Six Sigma methodologies were developed in the manufacturing industry to increase efficiency by eliminating non-value-added steps. We applied Lean and Six Sigma methodologies across an entire surgical suite to improve efficiency. STUDY DESIGN: A multidisciplinary surgical process improvement team constructed a value stream map of the entire surgical process from the decision for surgery to discharge. Each process step was analyzed in 3 domains, ie, personnel, information processed, and time. Multidisciplinary teams ad- dressed 5 work streams to increase value at each step: minimizing volume variation; streamlin- ing the preoperative process; reducing nonoperative time; eliminating redundant information; and promoting employee engagement. Process improvements were implemented sequentially in surgical specialties. Key performance metrics were collected before and after implementation. RESULTS: Across 3 surgical specialties, process redesign resulted in substantial improvements in on-time starts and reduction in number of cases past 5 PM. Substantial gains were achieved in nonoperative time, staff overtime, and ORs saved. These changes resulted in substantial increases in margin/OR/day. CONCLUSIONS: Use of Lean and Six Sigma methodologies increased OR efficiency and financial performance across an entire operating suite. Process mapping, leadership support, staff engagement, and sharing performance metrics are keys to enhancing OR efficiency. The performance gains were substantial, sustainable, positive financially, and transferrable to other specialties. (J Am Coll Surg 2011;213:83–94. © 2011 by the American College of Surgeons) Operating rooms (ORs) are often the largest contributors to a hospital’s financial success. However, ORs also repre- sent one of the most costly units within a hospital. As the health care economic environment becomes increasingly more challenging, increasing OR productivity represents a high priority. Efforts to increase OR productivity need to be counterbalanced against the impact on patient and staff satisfaction and, most importantly, patient and staff safety and ultimately patient outcomes. OR efficiency efforts that attempt to address many or all of these goals in a unified approach have not been widely reported. A number of authors have reported on factors and pro- cesses that contribute to OR inefficiencies. 1-4 Numerous factors constrain OR productivity and efficiency, including infrastructure, human resource management issues, sched- uling variation, process flow, technology issues, and infor- Disclosure Information: Nothing to disclose. Surgical Process Improvement Team, Mayo Clinic, Rochester: Timothy O Wilson, MD, W Richard Marsh, MD, David R Danielson, MD, Mark B Koch, MBA, Chad E Goetz, Sarah R Pool, RN, MS, Karen A Spaulding, RN, MS. Presented at the Western Surgical Association 118th Scientific Session, Chi- cago, IL, November 2010. Received January 3, 2011; Revised February 7, 2011; Accepted February 9, 2011. From the Departments of Surgery (Cima, Amstutz, Deschamps), Anesthesia (Brown, Hebl, Narr), and Nursing (Weisbrod), Mayo Clinic College of Med- icine and Research Administration (Kollengode), Systems and Procedures (Rogers), and Financial Analysis and Planning (Moore), Mayo Clinic, Roch- ester, MN. Correspondence address: Michael J Brown, MD, Department of Anesthesia, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. email: brown.michael3@mayo.edu 83 © 2011 by the American College of Surgeons ISSN 1072-7515/11/$36.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2011.02.009