{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T03:08:26Z","timestamp":1788232106071,"version":"build-2803163510"},"reference-count":40,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2021,3,11]],"date-time":"2021-03-11T00:00:00Z","timestamp":1615420800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Surgical intervention within 48 h of hospital admission is the gold standard procedure for the management of elderly patients with femur fractures, since the increase in preoperative waiting time is correlated with the onset of complications and longer overall length of stay (LOS) in the hospital. However, national evidence demonstrates that there is still the need to provide timely intervention for this type of patient, especially in some regions of central southern Italy. Here we discuss the introduction of a diagnostic\u2013therapeutic assistance pathway (DTAP) to reduce the preoperative LOS for patients undergoing femur fracture surgery in a university hospital. A Lean Six Sigma methodology, based on the DMAIC cycle (Define, Measure, Analyze, Improve, Control), is implemented to evaluate the effectiveness of the DTAP. Data were retrospectively collected and analyzed from two groups of patients before and after the implementation of DTAP over a period of 10 years. The statistics of the process measured before the DTAP showed an average preoperative LOS of 5.6 days (standard deviation of 3.2), thus confirming the need for corrective actions to reduce the LOS in compliance with the national guidelines. The influence of demographic and anamnestic variables on the LOS was evaluated, and the impact of the DTAP was measured and discussed, demonstrating the effectiveness of the improvement actions implemented over the years and leading to a significant reduction in the preoperative LOS, which decreased to an average of 3.5 days (standard deviation of 3.60). The obtained reduction of 39% in the average LOS proved to be in good agreement with previously developed DTAPs for femur fracture available in the literature.<\/jats:p>","DOI":"10.3390\/ijerph18062843","type":"journal-article","created":{"date-parts":[[2021,3,11]],"date-time":"2021-03-11T04:46:53Z","timestamp":1615438013000},"page":"2843","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":89,"title":["Lean Six Sigma Approach for Reducing Length of Hospital Stay for Patients with Femur Fracture in a University Hospital"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9735-5227","authenticated-orcid":false,"given":"Arianna","family":"Scala","sequence":"first","affiliation":[{"name":"Department of Public Health, University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1346-515X","authenticated-orcid":false,"given":"Alfonso Maria","family":"Ponsiglione","sequence":"additional","affiliation":[{"name":"Department of Electrical Engineering and Information Technology, University of Naples \u201cFederico II\u201d, 80125 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4943-6780","authenticated-orcid":false,"given":"Ilaria","family":"Loperto","sequence":"additional","affiliation":[{"name":"Department of Public Health, University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Della Vecchia","sequence":"additional","affiliation":[{"name":"Hospital Directorate, \u201cSan Giovanni di Dio e Ruggi d\u2019Aragona\u201d University Hospital of Salerno, 84125 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Borrelli","sequence":"additional","affiliation":[{"name":"Hospital Directorate, \u201cSan Giovanni di Dio e Ruggi d\u2019Aragona\u201d University Hospital of Salerno, 84125 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Russo","sequence":"additional","affiliation":[{"name":"Hospital Directorate, National Hospital A.O.R.N. \u201cAntonio Cardarelli\u201d of Naples, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Triassi","sequence":"additional","affiliation":[{"name":"Department of Public Health, University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"},{"name":"Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9485-1687","authenticated-orcid":false,"given":"Giovanni","family":"Improta","sequence":"additional","affiliation":[{"name":"Department of Public Health, University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"},{"name":"Interdepartmental Center for Research in Healthcare Management and Innovation in Healthcare (CIRMIS), University of Naples \u201cFederico II\u201d, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,3,11]]},"reference":[{"key":"ref_1","first-page":"97","article-title":"Incidence and socioeconomic burden of hip fractures in Italy","volume":"57","author":"Rossini","year":"2005","journal-title":"Reumatismo"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2907","DOI":"10.1007\/s00264-018-3881-3","article-title":"Lateral Locked Plating for Distal Femur Fractures by Low-Energy Trauma: What Makes a Difference in Healing?","volume":"42","author":"Kim","year":"2018","journal-title":"Int. Orthop."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"S20","DOI":"10.1016\/S0002-9343(97)90023-1","article-title":"The Socioeconomic Burden of Fractures: Today and in the 21st Century","volume":"103","author":"Johnell","year":"1997","journal-title":"Am. J. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1007\/PL00004149","article-title":"Incidence and Direct Medical Costs of Hospitalizations Due to Osteoporotic Fractures in Switzerland","volume":"7","author":"Lippuner","year":"1997","journal-title":"Osteoporos. Int."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.bj.2018.04.001","article-title":"Risk Factors and Quality of Life for the Occurrence of Hip Fracture in Postmenopausal Women","volume":"41","author":"Chen","year":"2018","journal-title":"Biomed. J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.2106\/JBJS.O.00029","article-title":"Danish Fracture Database Collaborators. Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators","volume":"97","author":"Nyholm","year":"2015","journal-title":"J. Bone Joint Surg. Am."},{"key":"ref_7","unstructured":"Italian Ministry of Health (2020). National Agency for Regional Health Services (AGENAS). PNE Programma Nazionale Esiti\u2014Edizione 2020."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"253","DOI":"10.3934\/mbe.2021013","article-title":"Implementation and Validation of a New Method to Model Voluntary Departures from Emergency Departments","volume":"18","author":"Ricciardi","year":"2021","journal-title":"Math. Biosci. Eng."},{"key":"ref_9","unstructured":"Jarm, T., Cvetkoska, A., Mahni\u010d-Kalamiza, S., and Miklavcic, D. (2020\u20133, January 29). Multiple Regression Model to Predict Length of Hospital Stay for Patients Undergoing Femur Fracture Surgery at \u201cSan Giovanni Di Dio e Ruggi d\u2019Aragona\u201d University Hospital. Proceedings of the 8th European Medical and Biological Engineering Conference, 8th European Medical and Biological Engineering Conference, Portoro\u017e, Slovenia."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.ejor.2011.12.029","article-title":"SimLean: Utilising Simulation in the Implementation of Lean in Healthcare","volume":"219","author":"Robinson","year":"2012","journal-title":"Eur. J. Oper. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1177\/1062860613512863","article-title":"Incorporating Discrete Event Simulation Into Quality Improvement Efforts in Health Care Systems","volume":"30","author":"Rutberg","year":"2015","journal-title":"Am. J. Med. Qual."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.aorn.2011.05.021","article-title":"A Practical Guide to Applying Lean Tools and Management Principles to Health Care Improvement Projects","volume":"95","author":"Simon","year":"2012","journal-title":"AORN J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1108\/TQM-04-2013-0051","article-title":"Developing and Validating a Total Quality Management Model for Healthcare Organisations","volume":"27","author":"Mosadeghrad","year":"2015","journal-title":"TQM J."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Jarm, T., Cvetkoska, A., Mahni\u010d-Kalamiza, S., and Miklavcic, D. (2020\u20133, January 29). Evaluation of Medical Training Courses Satisfaction: Qualitative Analysis and Analytic Hierarchy Process. Proceedings of the 8th European Medical and Biological Engineering Conference, Portoro\u017e, Slovenia.","DOI":"10.1007\/978-3-030-64610-3"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1093\/intqhc\/mzm047","article-title":"Promoting Quality: The Health-Care Organization from a Management Perspective","volume":"19","author":"Glickman","year":"2007","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_16","unstructured":"Bevan, H. (2006). Lean Six Sigma: Some Basic Concepts, NHS Institute for Innovation and Improvement."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1093\/intqhc\/mzp038","article-title":"Some Challenges Facing Lean Thinking in Healthcare","volume":"21","author":"Young","year":"2009","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1093\/intqhc\/mzp036","article-title":"Application of Lean Thinking to Health Care: Issues and Observations","volume":"21","author":"Joosten","year":"2009","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Improta, G., Guizzi, G., Ricciardi, C., Giordano, V., Ponsiglione, A.M., Converso, G., and Triassi, M. (2020). Agile Six Sigma in Healthcare: Case Study at Santobono Pediatric Hospital. Int. J. Environ. Res. Public. Health, 17.","DOI":"10.3390\/ijerph17031052"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Jarm, T., Cvetkoska, A., Mahni\u010d-Kalamiza, S., and Miklavcic, D. (2020\u20133, January 29). Six Sigma Approach for a First Evaluation of a Pharmacological Therapy in Tongue Cancer. Proceedings of the 8th European Medical and Biological Engineering Conference, Portoro\u017e, Slovenia.","DOI":"10.1007\/978-3-030-64610-3"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1111\/jep.12844","article-title":"Reducing the Risk of Healthcare-Associated Infections through Lean Six Sigma: The Case of the Medicine Areas at the Federico II University Hospital in Naples (Italy)","volume":"24","author":"Improta","year":"2018","journal-title":"J. Eval. Clin. Pract."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1108\/LHS-09-2017-0055","article-title":"Can Lean Six Sigma Be Used to Reduce Medication Errors in the Health-Care Sector?","volume":"31","author":"Trakulsunti","year":"2018","journal-title":"Leadersh. Health Serv."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1108\/LHS-12-2018-0065","article-title":"An Exploratory Study into the Use of Lean Six Sigma to Reduce Medication Errors in the Norwegian Public Healthcare Context","volume":"32","author":"Antony","year":"2019","journal-title":"Leadersh. Health Serv. Bradf. Engl."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"182","DOI":"10.5530\/ijopp.11.4.38","article-title":"Application of Six Sigma DMAIC Methodology to Reduce Medication Errors in a Major Trauma Care Centre in India","volume":"11","author":"George","year":"2018","journal-title":"Indian J. Pharm. Pract."},{"key":"ref_25","first-page":"309","article-title":"Reduction of Patient Wait Time at a Multi-Specialty Hospital Using DMAIC Methodology and Factor Analysis","volume":"7","author":"Mahesh","year":"2018","journal-title":"Int. J. Eng. Technol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"881","DOI":"10.5435\/JAAOS-D-16-00947","article-title":"Implementation of a Hip Fracture Care Pathway Using Lean Six Sigma Methodology in a Level I Trauma Center","volume":"26","author":"Sayeed","year":"2018","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1108\/TQM-06-2019-0159","article-title":"Fast Track Surgery for Knee Replacement Surgery: A Lean Six Sigma Approach","volume":"32","author":"Ricciardi","year":"2020","journal-title":"TQM J."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1401","DOI":"10.1111\/jep.12810","article-title":"Improving Performances of the Knee Replacement Surgery Process by Applying DMAIC Principles","volume":"23","author":"Improta","year":"2017","journal-title":"J. Eval. Clin. Pract."},{"key":"ref_29","first-page":"70","article-title":"Use of Lean Principals to Improve Flow of Patients with Fractured Neck of Femur--the HOPE Study","volume":"107","author":"McNamara","year":"2014","journal-title":"Ir. Med. J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1108\/IJLSS-02-2019-0014","article-title":"The Application of Six Sigma to Reduce the Pre-Operative Length of Hospital Stay at the Hospital Antonio Cardarelli","volume":"11","author":"Improta","year":"2019","journal-title":"Int. J. Lean Six Sigma"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1108\/TQM-02-2019-0065","article-title":"Lean Six Sigma Approach to Reduce LOS through a Diagnostic-Therapeutic-Assistance Path at A.O.R.N. A. Cardarelli","volume":"31","author":"Ricciardi","year":"2019","journal-title":"TQM J."},{"key":"ref_32","unstructured":"Jarm, T., Cvetkoska, A., Mahni\u010d-Kalamiza, S., and Miklavcic, D. (2020\u20133, January 29). Lean Six Sigma Approach to Implement a Femur Fracture Care Pathway at \u201cSan Giovanni Di Dio e Ruggi d\u2019Aragona\u201d University Hospital. Proceedings of the 8th European Medical and Biological Engineering Conference, Portoro\u017e, Slovenia."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1111\/imj.14280","article-title":"Hip Fractures in Patients with Chronic Kidney Disease Admitted to Victorian Hospitals","volume":"49","author":"Rao","year":"2019","journal-title":"Intern. Med. J."},{"key":"ref_34","first-page":"226","article-title":"Early-Stage Chronic Kidney Disease and Hip Fracture Mortality","volume":"27","author":"Frisch","year":"2018","journal-title":"J. Surg. Orthop. Adv."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1906","DOI":"10.3346\/jkms.2017.32.12.1906","article-title":"Hip Fracture in Chronic Kidney Disease Patients: Necessity of Multidisciplinary Approach","volume":"32","author":"Yoon","year":"2017","journal-title":"J. Korean Med. Sci."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Dong, C., Wang, Y., Wang, Z., Wang, Y., Wu, S., Du, Q., and Wang, A. (2016). Damage Control Orthopedics Management as Vital Procedure in Elderly Patients with Femoral Neck Fractures Complicated with Chronic Renal Failure: A Retrospective Cohort Study. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0154906"},{"key":"ref_37","unstructured":"Decree of the Italian Ministry of Health (DM 12 Marzo 2019) (2019). Nuovo Sistema Di Garanzia per Il Monitoraggio Dell\u2019assistenza Sanitaria."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Vanhaecht, K., Sermeus, W., Peers, J., Lodewijckx, C., Deneckere, S., Leigheb, F., Boonen, S., Sermon, A., Boto, P., and Mendes, R.V. (2012). The Impact of Care Pathways for Patients with Proximal Femur Fracture: Rationale and Design of a Cluster-Randomized Controlled Trial. BMC Health Serv. Res., 12.","DOI":"10.1186\/1472-6963-12-124"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1111\/j.1945-1474.1994.tb00705.x","article-title":"Applying Quality Improvement Tools to Quality Planning: Pediatric Femur Fracture Clinical Path Development","volume":"16","author":"Gallagher","year":"1994","journal-title":"J. Healthc. Qual."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1007\/s10195-013-0240-4","article-title":"Fractured Neck of Femur Patient Care Improved by Simulated Fast-Track System","volume":"14","author":"Kosy","year":"2013","journal-title":"J. Orthop. Traumatol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/6\/2843\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:33:50Z","timestamp":1760160830000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/6\/2843"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,11]]},"references-count":40,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,3]]}},"alternative-id":["ijerph18062843"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18062843","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,11]]}}}