Summary

Application of a Lean-based banyan board project management tool for arthroscopic shoulder tendon repair yielded statistically significant 20% less pain and 9% improved shoulder function at follow-up of two years after surgery compared to a global registry

Abstract

Purpose

Healthcare costs in the United States are rapidly increasing, with the OR serving as a hospital’s largest source of revenue and costly medical errors. Risk mitigation has passed on from insurers to healthcare delivery systems, emphasizing value-based care and bundled-payment models. This makes it essential to continuously refine system operations to improve patient outcomes and enhance overall value, defined as outcomes divided by costs. Lean is a data-driven quality improvement philosophy aimed to cut waste and increase value. Banyan boards are low cost outcome assessment tools that quantify processes into smaller, measurable steps with built-in inspection protocols. The goal of this tool is to combine easy implementation to the healthcare team with no additional burden to the patient resulting in less cost with improved outcomes, or increased value. Thus, the purpose of our study was to evaluate shoulder arthroscopy outcomes utilizing a Lean-based banyan board to optimize the surgical recovery period compared to global benchmarks.

Methods

We retrospectively reviewed prospectively collected outcome data for arthroscopically assisted tendon repair surgery for two attending shoulder surgeons from May 2017 to September 2019. We then benchmarked our outcomes to a global registry (Surgical Outcomes System). Inclusion criteria was undergoing an arthroscopic shoulder tendon repair. Independent variables addressed were age, sex, and ASA level. Dependent criteria were VAS, ASES, and VR-12 scores. Statistical analysis was by t-test and subgroup analysis via multiple linear regression.

Results

45 patients with a survey compliance rate of 82% and minimum follow-up of 2 years were prospectively case-controlled matched to 15,717 patients in a global registry with 58% compliance at two year follow-up. Case mean age was 49.8 +/- 12.8 years, mean ASA level was 2.2, and 64.4% of patients were female. Control mean age was 56.5 +/- 11.5 years and 40.5% of patients were female. Our primary objective identified a statistically significant improvement in delta VAS and delta ASES shoulder function and shoulder index scores in our Lean-based cohort compared to the global registry (p-values <0.001). Delta VR-12 physical and mental scores were also improved (p-values <0.001). 90 day re-operation rate for our case cohort was lower than what was reported in other studies. Our secondary objective did not identify any sub-group predictors of success. Shapiro-Wilk test of the case cohort confirmed a normal distribution (p-value = 0.3353). Post hoc power analysis yielded a power of 1.0.

Conclusions

Application of a Lean-based banyan board project management tool for arthroscopic shoulder tendon repair yielded statistically significant 20% less pain and 9% improved shoulder function at a minimum follow-up of two years after surgery compared to a global benchmark registry. Quality of life measures described by VR-12 scores improved by 13% for both physical and mental health. Physician workload and patient follow-up burden was reduced through the employment of athletic trainers to operate the banyan-board at a low cost and improve the surgical recovery period for shoulder arthroscopy patients.

Level of Evidence: Level III retrospective comparison of prospectively collected outcome data