Background: The purpose of this study was to reduce the length of stay of anterior cruciate ligament reconstruction patients within a private hospital in Ireland, reducing any non-value-added activity in the patient pathway, with the goal of increasing patient flow, bed capacity, and revenue generation within the hospital system, while maintaining patient satisfaction. Methods: We used a pre-/post-intervention design and Lean Six Sigma methods and tools to assess and improve the current process. Results: A reduction in inpatient length of stay by 57%, and a reduction in identified non-value-added activity by 88%, resulted in a new day-case surgery pathway for anterior cruciate ligament reconstruction patients. The pathway evidenced no re-admissions and demonstrated patient satisfaction. Conclusion: Six months post-project commencement, we had successfully achieved our goals of reducing our anterior cruciate ligament reconstruction patient’s length of stay. This study contributes to the growing body of published evidence which shows that adopting a Lean Six Sigma approach can be successfully employed to optimise care and surgical pathways in healthcare.

Esophageal adenocarcinoma (EAC) develops from within Barrett's esophagus (BE) concomitant with gastro-esophageal reflux disease (GERD). Wound healing processes and cellular transitions, such as epithelial-mesenchymal transitions, may contribute to the development of the BE and the eventual migratory escape of metastatic cancer cells. Herein, we attempt to identify the genes underlying esophageal cellular transitions and their potential regulation by the low pH environments observed in GERD and commonly encountered by escaping cancer cells. siRNA library screening and high content imaging analysis outlined changes in BE-HGD (High grade dysplasia) and EAC cell morphologies following gene silencing. Gene expression microarray (GEM) data and low pH exposures studies modelling GERD-associated pulses (pH4.0, 10 Mins) and tumour microenvironments (pH6.0, constant) were utilised. Statistical analysis of siRNA screening data defined 207 genes (Z-score>2.0), in 12 distinct morphological clusters, whose suppression significantly altered BE-HGD cell morphology. The most significant genes of this list included KIF11, RRM2, NUBP2, P66BETA, DUX1, UBE3A, ITGB8, GAS1, GPS1 and PRC1. Guided by GEM study data, both pulsatile and constant low pH exposures were observed to suppress the expression of GPS1 and RRM2 in a non-overlapping temporal manner in both BE-HGD and EAC cells, with no changes observed in squamous esophageal cells. Functional studies uncovered that GPS1 and RRM2 contributed to amoeboid and mesenchymal cellular transitions, respectively, as characterised by differential rates of cell motility, pseudopodia formation and altered expression of the mesenchymal markers vimentin and E-cadherin. Collectively we have demonstrated that low pH microenvironments associated with GERD, and tumour invasive edges, can modulate the expression of genes that triggered esophageal cellular transitions potentially critical to colonisation and invasion.

Person-centred cultures are increasingly recognised as essential to the delivery of compassionate, safe, and effective healthcare. While Lean Six Sigma (LSS) is widely adopted as a process improvement methodology, its application is often critiqued for lacking alignment with relational or values-based care. This study aimed to test the transferability of three previously developed Programme Theories (PTs), generated through realist inquiry in a public hospital setting, within a large private acute hospital. Realist-informed adjudication workshops were conducted with interdisciplinary staff who had completed university-accredited training in LSS. Structured workbooks, visual artefacts, and thematic synthesis were used to identify how context–mechanism–outcome configurations (CMOCs) held, shifted, or evolved in the new setting. All three PTs were confirmed, with six CMOCs refined, and eight new configurations generated. Key refinements included the role of strategic intent, informal improvement communities, and intrinsic motivation. These findings suggest that values-based mechanisms underpinning person-centred LSS are not confined to public systems and may be equally active in private settings. The study confirms the explanatory strength of the original PTs while contributing new insights into their adaptability. It offers practical guidance for healthcare leaders seeking to embed person-centred improvement approaches across diverse systems, regardless of sectoral funding or governance structures.