## 3 The Application of Lean Six Sigma to Surgical Pathways
### Surgery  
Flow, the efficient and smooth coordination of tasks and processes [39; 40], is of paramount importance in the operating room (OR). The OR is a complex and high-stakes environment where collaborative teams of surgeons, anaestrists, and nurses work together with other healthcare professionals and support staff to provide safe and effective patient care [33]. Achieving optimal flow in the OR is critical for patient safety, surgical outcomes, and team efficiency [32; 33; 50]. Lean Six Sigma has demonstrated its effectiveness as an improvement methodology when applied to the following in the OR:  
* Patient Safety. Flow in the OR is essential for ensuring patient safety. An organized and streamlined workflow minimizes the risk of errors, such as wrong-site surgery [51] or medication mistakes [52], which can have serious consequences for patients. The use of Lean Six Sigma in designing patient safety protocols and operating procedures has been shown to improve OR efficiency and quality of care [53] and also helps to prevent delays in surgical start times, which can reduce the risk of peri-operative complications and infections.
* Surgical set-up times. Where Lean Six Sigma has been used to reduce the time required in the preparation of consumables, equipment and instrumentation for surgery, there is a corresponding positive impact on both OR turnaround times and on the time available for nurses to spend on direct patient care [32; 33].
* Surgical Outcomes. A well-coordinated OR ensures that surgical teams have the necessary resources, instruments, and equipment readily available, allowing them to perform procedures efficiently and effectively [32; 33]. The use of Lean Six Sigma to identify and streamline key steps can lead to significantly improved surgical outcomes for patients, including reduced operative times [33] that ultimately enhance patient safety and the quality of surgical care provided [54].
* Team Efficiency. Teamwork in the OR is an important component of OR efficiency, quality of care, and patient safety [55]. Efficient flow in the OR enhances teamwork and collaboration among surgical team members. It helps to establish clear roles and responsibilities, promotes effective communication, and optimizes the utilization of resources [53]. Lean Six Sigma facilitates the understanding of roles and responsibilities through its promotion of cross-functional teams of healthcare staff, co-designing to enable sustainable solutions, and focusing on staffs' as well as patients' experiences of care [21; 25]. A smoothly running OR that demonstrates 'flow' reduces unnecessary distractions and interruptions, allowing surgical teams to focus on their tasks and work together cohesively. This can enhance team morale, staff satisfaction [55; 56], and overall OR performance.
* Time and Cost Savings. Flow in the OR can also result in time and cost savings. Efficient workflow reduces both delays to surgery and scheduled surgery cancellations, which can help to optimize OR utilization and increase patient throughput [32; 33]. This can result in cost savings by minimizing overtime shifts [32], reducing peri-operative resource wastage [32; 33], and maximizing revenue generation from increased surgical volumes [31].
* Organizational reputation and patient experience. The flow in the OR also impacts the reputation of the healthcare facility and the overall patient experience. Patients and their families expect timely and well-coordinated care [57], and efficient OR flow contributes to a positive patient experience. A good reputation for efficient and safe surgical care can enhance patient and staff satisfaction, staff retention [58], increase patient referrals, and boost the overall reputation of the healthcare facility.  
In summary, the use of Lean Six Sigma enhances OR efficiency, allowing flow that ensures patient safety, optimizes surgical outcomes, improves team efficiency, saves time and costs, and enhances patient and staff experiences of care.