Improving performances of the knee replacement surgery process by applying DMAIC principles
Open accessAbstract
Rationale, Aims, and Objectives: The work is a part of a project about the application of the Lean Six Sigma to improve health care processes. A previously published work regarding the hip replacement surgery has shown promising results. Here, we propose an application of the DMAIC (Define, Measure, Analyse, Improve, and Control) cycle to improve quality and reduce costs related to the prosthetic knee replacement surgery by decreasing patients' length of hospital stay (LOS) Methods: The DMAIC cycle has been adopted to decrease the patients' LOS. The University Hospital “Federico II” of Naples, one of the most important university hospitals in Southern Italy, participated in this study. Data on 148 patients who underwent prosthetic knee replacement between 2010 and 2013 were used. Process mapping, statistical measures, brainstorming activities, and comparative analysis were performed to identify factors influencing LOS and improvement strategies. Results: The study allowed the identification of variables influencing the prolongation of the LOS and the implementation of corrective actions to improve the process of care. The adopted actions reduced the LOS by 42%, from a mean value of 14.2 to 8.3 days (standard deviation also decreased from 5.2 to 2.3 days). Conclusions: The DMAIC approach has proven to be a helpful strategy ensuring a significant decreasing of the LOS. Furthermore, through its implementation, a significant reduction of the average costs of hospital stay can be achieved. Such a versatile approach could be applied to improve a wide range of health care processes.
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Economic benefits of lean healthcare include increase in revenue and costs reduction.
“there are effects of “increase in revenue” and “costs reduction” [21,38,48].”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [38]
The Discussion reports that applying DMAIC to the knee-replacement pathway reduced costs, with estimated annual savings of more than €260,000. Our copy does not report an increase in revenue, so it supports only the cost-reduction part of the claim. (LLM, conf=0.88)
Experimental — accuracy not yet measuredWith the use of DMAIC, the most prominent results were decreased lead time, reduced length of stay and decreased costs.
“with the use of DMAIC, the ones that stood out the most were decreased lead time, reduced length of stay and decreased costs [21,30,38,48,55].”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [38]
The Results report a 42% reduction in length of stay, and the Abstract Conclusions and Discussion describe reduced hospital-stay costs. The paper does not report a separate decrease in lead time; its measured time outcome is length of stay. Page numbers are unavailable in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measuredInterventions included review of work processes.
“review of work processes [38,46,47,48,49]”
From Lean Healthcare Tools for Processes Evaluation: An Integrative Review. (2021) · cites this paper as [38]
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Six Sigma in Health Literature, What Matters?
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Latessa, I., Ricciardi, C., Jacob, D., Jónsson, H., Gambacorta, M., Improta, G., & Gargiulo, P. (2021) · European Journal of Translational Myology · doi:10.4081/ejtm.2021.9651 · Cited by 17 · see citing works
Self-citationScala, A., Trunfio, T. A., Vecchia, A. D., Marra, A., & Borrelli, A. (2020) · World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany · doi:10.1007/978-3-030-64610-3_83 · Cited by 16 · see citing works
Profeta, M., Ponsiglione, A. M., Ponsiglione, C., Ferrucci, G., Giglio, C., & Borrelli, A. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503625 · Cited by 16 · see citing works
Self-citationPierce, A., Teeling, S. P., McNamara, M. S., O’Daly, B., & Daly, A. (2023) · Healthcare · doi:10.3390/healthcare11192626 · Cited by 15 · see citing works
Improta, G., Lauri, C. D., Vecchia, A. D., Borrelli, A., Russo, G., & Triassi, M. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503638 · Cited by 13 · see citing works
Self-citationIndustrial engineering into healthcare – A comprehensive review
Sharma, G. V. S. S., Prasad, C. L. V. R. S. V., & Rao, M. S. (2020) · International Journal of Healthcare Management · doi:10.1080/20479700.2020.1757874 · Cited by 13 · see citing works
Lean six sigma in the public sector: overcoming persistent management challenges
Juliani, F., & de Oliveira, O. J. (2021) · Quality Management Journal · doi:10.1080/10686967.2021.1886022 · Cited by 12 · see citing works
Motivators to Application of DMAIC in Patient Care Processes
dos Reis, M. E. D. M., Viera, L. E. V., de Amaral, L. C., Filho, J. F., Teixeira, A., & Calado, R. D. (2021) · IFIP advances in information and communication technology · doi:10.1007/978-3-030-85902-2_29 · Cited by 12 · see citing works
Oyedeji, A. N., Obada, D. O., Dauda, M., Kuburi, L. S., Csáki, Š., & Veverka, J. (2022) · Polymer Bulletin · doi:10.1007/s00289-022-04541-3 · Cited by 12 · see citing works
Improving efficiency in neuroimaging research through application of Lean principles
Roy, A., Colpitts, J., Becker, K., Brewer, J. A., & van Lutterveld, R. (2018) · PLoS ONE · doi:10.1371/journal.pone.0205232 · Cited by 12 · see citing works
Linking practices to results: an analysis toward Lean Six Sigma deployment in the public sector
Juliani, F., & de Oliveira, O. J. (2020) · International Journal of Lean Six Sigma · doi:10.1108/ijlss-02-2020-0017 · Cited by 10 · see citing works
Analysis of voluntary departures from the Emergency Department of the hospital AORN “A. Cardarelli”
Ponsiglione, A. M., Majolo, M., Longo, G., Russo, G., Triassi, M., Raiola, E., & Improta, G. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503630 · Cited by 10 · see citing works
Self-citationChen, X., Li, X., Liu, Y. S., Yao, G., Yang, J., Li, J., & Qiu, F. (2020) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.13526 · Cited by 10 · see citing works
DMAIC Method of Quality Improvement of Ground Works Processes: Case Study
Nowotarski, P., Szymański, P., & Rzepecka, P. (2017) · IOP Conference Series Earth and Environmental Science · doi:10.1088/1755-1315/221/1/012002 · Cited by 10 · see citing works
Optimization for Sustainable Train Shunting Services Using DMAIC Cycle
Alshamlan, M., Alzahrani, A., BinYousef, M., Abdelhadi, A., Akkad, K., & Alyamani, R. (2022) · Sustainability · doi:10.3390/su14031719 · Cited by 9 · see citing works
Waste Reduction by Lean Construction - Office Building Case Study
Nowotarski, P., Pasławski, J., & Skwarek, J. (2019) · IOP Conference Series Materials Science and Engineering · doi:10.1088/1757-899x/603/4/042061 · Cited by 7 · see citing works
Luca, V. D., Birov, S., Beyhan, O., Robinson, S., Sanchez-Nanclares, G., Acuña, M. D. P. L., Fernandes, A., Hammerschmidt, R., Tramontano, G., Patalano, R., et al. (2020) · Communications in computer and information science · doi:10.1007/978-3-030-52677-1_1 · Cited by 7 · see citing works
Optimizing patient flow, capacity, and performance of COVID-19 vaccination clinics
Valladares, L., Nino, V., Martínez, K., Sobek, D. K., Claudio, D., & Moyce, S. C. (2022) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2022.2066740 · Cited by 6 · see citing works
Transformational Performance Improvement: Why Is Progress so Slow?
Hung, D. Y., Lee, J., & Rundall, T. G. (2022) · Emerald Group Publishing Limited eBooks · doi:10.1108/s1474-823120220000021002 · Cited by 6 · see citing works
Daniyan, I. A., Adeodu, A. O., Mpofu, K., Maladzhi, R. W., & Kanakana-Katumba, G. M. (2023) · Cogent Engineering · doi:10.1080/23311916.2022.2154004 · Cited by 6 · see citing works
Rebull, M. V. S., Niñerola, A. M., Ferrer-Rullan, R., & Hernández‐Lara, A. B. (2020) · International Journal of Occupational Safety and Ergonomics · doi:10.1080/10803548.2020.1829318 · Cited by 6 · see citing works
Kubala, M. E., Gardner, J. R., Criddle, J., Ward, A., & Richter, G. T. (2021) · International Journal of Pediatric Otorhinolaryngology · doi:10.1016/j.ijporl.2021.110779 · Cited by 6 · see citing works
Trunfio, T. A., Baviello, D., Perrone, A., Formisano, R., & Donisi, L. (2020) · World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany · doi:10.1007/978-3-030-64610-3_89 · Cited by 5 · see citing works
dos Reis, M. E. D. M., de Abreu, M. F., Campos, C. R., & de Souza, F. S. (2023) · Revista Meta Avaliação · doi:10.22347/2175-2753v0i0.4054 · Cited by 5 · see citing works
Koushki, A., Larti, N., Fakhri, M., & Fatahi, S. (2022) · Perioperative Care and Operating Room Management · doi:10.1016/j.pcorm.2022.100269 · Cited by 4 · see citing works
Franco-Alucano, I., Tortorella, G. L., Aguilar-Duque, J., Flores, D., Limón-Romero, J., Báez-López, Y., & Tlapa, D. (2025) · IEEE Access · doi:10.1109/access.2025.3640970 · Cited by 3 · see citing works
Profeta, M., Cesarelli, G., Giglio, C., Ferrucci, G., Borrelli, A., & Amato, F. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503652 · Cited by 3 · see citing works
Pendekatan Berbasis DMAIC untuk Perbaikan Proses Suplai Bahan Baku
Baldah, N., & Safitri, W. (2024) · Jurnal INTECH Teknik Industri Universitas Serang Raya · doi:10.30656/intech.v10i1.7761 · Cited by 3 · see citing works
Iverson, K. R., Roa, L., Shu, S. B., Wong, M., Rubenstein, S., Zavala, P., Caddell, L., Graham, C. E., Colina, J., León, S. R., et al. (2021) · World Journal of Surgery · doi:10.1007/s00268-021-06118-z · Cited by 3 · see citing works
Ponsiglione, A. M., Trunfio, T. A., Rossi, G., Borrelli, A., & Romano, M. (2021) · International Conference on Bioinformatics and Biomedical Science (ICBBS) · doi:10.1145/3498731.3498748 · Cited by 3 · see citing works
Self-citationOvercrowding in emergency department: a comparison between indexes
Improta, G., Colella, Y., Vecchia, A. D., Borrelli, A., Russo, G., & Triassi, M. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503643 · Cited by 3 · see citing works
Self-citationPonsiglione, C., Trunfio, T. A., Bruno, F., & Borrelli, A. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503616 · Cited by 3 · see citing works
Quality and Safety in Healthcare, Part XCIV: Six Sigma and Lean Six Sigma in Health Care.
Harolds, J. A. (2023) · PubMed · doi:10.1097/rlu.0000000000004059 · Cited by 2 · see citing works
Mitigation strategies for waste elimination and cost reduction in the manufacture of Bowden cables
Koch, L., Silva, F. J. G., Campilho, R. D. S. G., Sá, J. C., Lucas, R. R., & Sales-Contini, R. C. M. (2025) · The International Journal of Advanced Manufacturing Technology · doi:10.1007/s00170-025-15367-4 · Cited by 2 · see citing works
Mapping the DMAIC Tool in the Public Sector
da Silva, M. C., & Santiago, S. B. (2021) · International Journal for Innovation Education and Research · doi:10.31686/ijier.vol9.iss10.3469 · Cited by 2 · see citing works
DMAIC Application in an Emergency Care Unit
dos Reis, M. E. D. M., de Abreu, M. F., Neto, O. D. O. B., Costa, H. G., & Viera, L. E. V. (2022) · Advances in healthcare information systems and administration book series · doi:10.4018/978-1-6684-5185-4.ch003 · Cited by 2 · see citing works
Barari, N., & Sethi, D. (2023) · Journal of Datta Meghe Institute of Medical Sciences University · doi:10.4103/jdmimsu.jdmimsu_487_22 · Cited by 2 · see citing works
Efficiency through a Lean Healthcare Implementation in a Public HospitalPreprint
Rosas-Hernández, L., Tlapa, D., Baez-Lopez, Y. A., Limón-Romero, J., & Pérez-Sánchez, A. (2019) · Preprints.org · doi:10.20944/preprints201912.0230.v1 · Cited by 2 · see citing works
Chen, Y., Chen, S.-C., & Liu, Y.-S. (2023) · Health Informatics Journal · doi:10.1177/14604582231203757 · Cited by 1 · see citing works
Order Fulfillment Process Improvement in E-Commerce Warehouse: A DMAIC Approach for PT XYZ
Putra, A. D. E., & Basri, S. T. D. E. M. H. (2024) · International Journal of Current Science Research and Review · doi:10.47191/ijcsrr/v7-i7-101 · Cited by 1 · see citing works
Material waste and cost reduction in the manufacture of Bowden cables using DMAIC cycle
Silva, F. J. G., Campilho, R. D. S. G., Brito, M. F., Sebbe, N. P. V., Pereira, M. T. R., & Sá, J. C. (2026) · The International Journal of Advanced Manufacturing Technology · doi:10.1007/s00170-026-17489-9 · Cited by 1 · see citing works
Montella, E., Marino, M. R., Majolo, M., Raiola, E., Russo, G., Longo, G., Sparano, M., Borrelli, A., & Triassi, M. (2022) · International Conference on Medical and Health Informatics (ICMHI) · doi:10.1145/3545729.3545779 · Cited by 1 · see citing works
Self-citationImpact of diagnostic techniques on the length of stay in emergency medicine
Profeta, M., Cesarelli, G., Giglio, C., Rossi, G., Borrelli, A., Amato, F., & Romano, M. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503653 · Cited by 1 · see citing works
Self-citationSantalucia, I., Marino, M. R., Raiola, E., Majolo, M., Russo, G., Longo, G., Ferrucci, G., Borrelli, A., & Triassi, M. (2022) · International Conference on Medical and Health Informatics (ICMHI) · doi:10.1145/3545729.3545770 · Cited by 1 · see citing works
Self-citationQuality and Safety in Healthcare, Part XCII: Introduction to Six Sigma.
Harolds, J. A. (2023) · PubMed · doi:10.1097/rlu.0000000000003943
Advances in Cell-based Therapeutic Process Development
Gretzinger, S. (2020) · Repository KITopen (Karlsruhe Institute of Technology) · doi:10.5445/ir/1000105111
DMAIC Approach to Reduce LOS in Patients Undergoing Oral Cancer Surgery
Latessa, I., Picone, I., Fiorillo, A., Sorrentino, A., Orabona, G. D., & Valente, A. S. (2020) · World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany · doi:10.1007/978-3-030-64610-3_49
Trend of the LOS for patients suffering from different kidney injuries
Cesarelli, G., Profeta, M., Giglio, C., Ferrucci, G., Borrelli, A., Romano, M., & Amato, F. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503645
Self-citationMontella, E., Loperto, I., Pietrantonio, M., Colucci, V., Triassi, M., & Ponsiglione, A. M. (2021) · International Symposium on Biomedical Engineering and Computational Biology (BECB) · doi:10.1145/3502060.3503649
Self-citationQUALITY MANAGEMENT OF HOSPITALIZATION PROCESSES
Baśkiewicz, N., Daroń, M., Pachura, A., & SANOJCA, A. (2023) · Scientific Papers of Silesian University of Technology Organization and Management Series · doi:10.29119/1641-3466.2023.181.1
DMAIC-v2: A Novel Guide to the Improvement of Industrial Processes
Nsekuye, J. B., Erramli, O., Elouadi, A., Gretete, D., & Mushirabwoba, B. (2024) · Smart and Sustainable Manufacturing Systems · doi:10.1520/ssms20220037
- Authors
- Improta, G., Balato, G., Romano, M., Ponsiglione, A. M., Raiola, E., Russo, M. A., Cuccaro, P., Santillo, L. C., & Cesarelli, M.
- Affiliations
- University of Naples Federico II (IT)
- Magna Graecia University (IT)
- Federico II University Hospital (IT)
- Fondazione Salvatore Maugeri (IT)
- Corresponding author
- Improta, Giovanni
- ORCID
- Venue
- Journal of Evaluation in Clinical Practice
- Publisher
- Wiley
- Published
- 2017-09-26
- Volume
- 23
- Issue
- 6
- Pages
- 1401-1407
- ISSN
- 1356-1294 (ISSN-L)
- 1365-2753
- PMC
- PMC6585639
- OpenAlex
- W2758975722
- Cited by
- 105
- References
- 31
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 5 · 2023: 9 · 2022: 14 · 2021: 36 · 2020: 22 · 2019: 10 · 2018: 3 · 2017: 2
- FWCI
- 13.89
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Evaluation in Clinical Practice (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Health Sciences › Health Professions › Emergency Medical Services › Healthcare Operations and Scheduling Optimization
- Social Sciences › Business, Management and Accounting › Management Information Systems › Quality and Supply Management
- Keywords
- knee arthroplasty, length of hospital stay, DMAIC, Lean Six Sigma, process improvement, hospital costs, surgical process, process mapping, healthcare quality improvement
- MeSH terms
- Aged, Aged, 80 and over, Cost-Benefit Analysis, Female, Humans, Interprofessional Relations, Italy, Length of Stay, Male, Middle Aged, Patient Care Team, Efficiency, Organizational, Total Quality Management, Arthroplasty, Replacement, Knee, Quality Improvement
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