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The reduction of costs has a more and more relevant role in the healthcare context, therefore, a large effort is done by health providers to this aim, for example, by reducing the length of hospital stay (LOS) of patients undergoing surgery. Fast track surgery fits perfectly this issue and was applied to patients undergoing knee replacement surgery due to Osteoarthritis, one of the most common diseases of aged population. The paper aims to discuss these issues.

Lean six sigma was applied to analyze the implementation of fast track surgery through the define, measure, analyze, improve, control roadmap, used as a typical problem-solving approach. It is characterized by five operational phases, which make possible the achievement of fixed goals through a rigorous process of defining, measuring, analyzing, improving and controlling business problems.

The corrective action, consisting in the application of fast track surgery, improved both effectiveness and efficiency of the process of care. The average length of hospital stay (LOS) was reduced from 8.34 to 6.68 days (–19.9 percent) and its standard deviation from 2.41 to 1.99 days (–17.1 percent). The statistical significance of this decrease was verified by means of proper tests. Moreover, some variables influencing the LOS were identified.

The follow up and the satisfaction of patients were not analyzed and could be a future development of this study.

Patients will experience a faster recovery while the hospital will benefit from a rise of available beds. The effect is a general improvement of hospital management.

The introduction of fast track surgery for patients undergoing knee replacement surgery made significantly reduce LOS and, consequently, costs’ with a money saving of more than 50,000 euro per year.

Head and neck cancers are multi-factorial diseases that can affect many sides of people's life and are due to a lot of risk factors. According to their characteristics, the treatment can be surgical, use of radiation or chemotherapy. The use of a surgical treatment can lead to surgical infections that are a main theme in medicine. At the University hospital of Naples “Federico II”, two antibiotics were employed to tackle the issue of the infections and they are compared in this paper to find which one implies the lowest length of hospital stay (LOS) and the reduction of infections.

The Six Sigma methodology and its problem-solving strategy DMAIC (define, measure, analyse, improve, control), already employed in the healthcare sector, were used as a tool of a health technology assessment between two drugs. In this paper the DMAIC roadmap is used to compare the Ceftriaxone (administered to a group of 48 patients) and the association of Cefazolin plus Clindamycin (administered to a group of 45 patients).

The results show that the LOS of patients treated with Ceftriaxone is lower than those who were treated with the association of Cefazolin plus Clindamycin, the difference is about 41%. Moreover, a lower number of complications and infections was found in patients who received Ceftriaxone. Finally, a greater number of antibiotic shifts was needed by patients treated with Cefazolin plus Clindamycin.

While the paper enhances clearly the advantages for patients' outcomes regarding the LOS and the number of complications, it did not analyse the costs of the two antibiotics.

Employing the Ceftriaxone would allow the Department of Maxillofacial Surgery to obtain lower LOS and a limited number of complications/infections for recovered patients, consequently reducing the hospitalization costs.

There is a double value in this paper: first of all, the comparison between the two antibiotics gives an answer to one of the main issues in medicine that is the reduction of hospital-acquired infections; secondly, the Six Sigma through its DMAIC cycle can be employed also to compare two biomedical technologies as a tool of health technology assessment studies.

This paper aims to present a systematic review of the latest scientific literature, in the context of pediatric orthopedics, on the development by additive manufacturing of anatomical models, orthoses, surgical guides and prostheses and their clinical applications.

Following the current guidelines for systematic reviews, three databases (Elsevier Scopus^®, Clarivate Web of Science^TM and USA National Library of Medicine PubMed^®) were screened using a representative query to find pertinent documents within the timeframe 2016–2023. Among the information, collected across the reviewed documents, the work focused on the 3D printing workflow involving acquisition, elaboration and fabrication stages.

Following the inclusion and exclusion criteria, the authors found 20 studies that fitted the defined criteria. The reviewed studies mostly highlighted the positive impact of additive manufacturing in pediatric orthopedic surgery, particularly in orthotic applications where lightweight, ventilated and cost-effective 3D-printed devices demonstrate efficacy comparable to traditional methods, but also underlined the limitations such as printing errors and high printing times. Among the reviewed studies, material extrusion was the most chosen 3D printing technology to manufacture the typical device, particularly with acrylonitrile butadiene styrene.

To the best of the authors’ knowledge, this is the first systematic review which annotates, from a more engineering point of view, the latest literature on the admittance of the clinical application of additive manufacturing (and its effects) within typical pediatric orthopedic treatments workflows.

Since healthcare spending accounts for approximately 6.6 per cent of the gross domestic product, reducing waste in health facilities is necessary to generate significant cost savings. After previous work concerning the application of Lean Six Sigma (LSS) to hip surgery, the purpose of this paper is to use LSS as the correct methodology to analyse a clinical pathway. Fast track surgery was introduced to the Complex Operative Unit of Orthopaedic and Traumatology of the University Hospital “Federico II” to improve quality and further reduce costs associated with prosthetic hip replacement surgery.

The DMAIC (Define, measure, analyse, improve, control) roadmap was used as the typical problem-solving approach of the LSS methodology. A rigorous process of defining, measuring, analysing, improving and controlling business problems can be used to reach fixed goals. The paper was written following the Standards for Quality Improvement Reporting Excellence (SQUIRES Guidelines).

In this work, the authors found that multiple variables could influence the length of hospital stay (LOS) for inpatient treatment, thereby increasing patient management costs due to longer periods of hospitalisation. Therefore, LSS analysis of the implemented corrective actions demonstrated the efficacy and efficiency of the novel protocol. The average LOS was reduced from 10.66 to 7.8 days (−26.8 per cent).

The introduction of fast track surgery was validated through a rigorous LSS analysis, which demonstrated that the new protocol benefitted both patients and the hospital.

The rise of the mean age incremented the occurrence of femur fractures with respect to the past, leading thus to serious consequences, as regards morbidity and socio-economic impact. The direction of the A.O.R.N. Cardarelli of Naples has introduced a DTAP whose aim was the reduction of LOS. The paper aims to discuss this issue.

The aim of this paper is to analyze the introduction of DTAP, employing Lean Thinking and Six Sigma methodology based on the DMAIC cycle. To evaluate the effectiveness of DTAP, two groups of patients have been observed for 14 months (before and after the implementation of DTAP).

Statistical tests were performed on the groups and graphics were provided to visualize the decrease of LOS (29.9 per cent). The overall population was also divided in subgroups according to six variables potentially influencing LOS.

Authors considered six variables of influences; yet, others could be taken into account in the future.

The decrease of costs due to the management of elderly patients with femur fracture, the optimization of care processes in hospitals and a faster recovery for patients is the tangible contribute of DTAP.

The implementation of DTAP allowed the hospital to obtain a significant reduction of LOS with a consequently decrease of costs alleviating the hospital and the society from the socio-economic burden and the morbidity of this pathology.

The best treatment for femur fractures is the surgical one within 48 h from the admission to the hospital. These fractures have serious consequences, both in terms of morbidity and socio-economic impact. In the hospital A.O.R.N. Cardarelli of Naples in Italy, the mean pre-operative length of hospital stay (LOS) was nine days and just 4 per cent of patients was operated within the suggested time. Therefore, a diagnostic-therapeutic-assistance path (DTAP) was implemented to improve the process.

This paper analyzes two groups of patients (534 and 562, respectively) before and after the introduction of DTAP, through six sigma (SS) based on define, measure, analyze, improve and control cycle. Age, gender, American Society of Anaesthesiologists (ASA) score, cardiovascular diseases, diabetes and allergies were used as independent subgrouping variables. The t-tests and chi-square were performed to compare the groups, tools of SS were used.

The analyses were conducted considering overall patients and some subgroups. The overall reduction in LOS was about 54 per cent, patients without cardiovascular diseases and with a low ASA score had the highest reduction, more than 60 per cent. All the p-values proved a high statistically significant difference between the two groups.

The influence of the Italian health-care system is a minor limitation while, unfortunately, the lack of a follow-up did not allow quantifying the real gain in health of patients. A lean thinking analysis would suit this context.

There are practical advantages for both hospital and patients: the hospital will have an increase in admissions and more beds available, while patients will benefit of a faster intervention and a shorter wait.

This is the first analysis through SS of DTAP showing its positive influences in terms of both socio-economic impact and patients’ outcome. Policy leaders could use this study as an example to evaluate the introduction of the same clinical pathway in other health facilities.

Despite an increasing body of research on value co-creation through social media, service organizations still face difficulties in leveraging the potential of social media communication to facilitate value co-creation with multiple stakeholders. This article addresses this challenge by adopting a multistakeholder, communication perspective.

This article uses a conceptual approach and builds upon concepts widely recognized in the public relations (PR) literature to assess communication in multistakeholder social media-mediated exchanges.

This article discusses the role of social media communication in enabling value co-creation as well as the communicative challenges that come along with it. Moreover, applying PR academic insights to the service innovation and service recovery research fields, it advances theoretical propositions that predict how service organizations can successfully build upon the social media communication fundamentals – namely dialogue, engagement, social presence and conversational human voice – to trigger value co-creation with and among multiple stakeholders.

This article introduces selected relevant theoretical concepts from the PR field and develops novel theoretical propositions that are likely to make unique contributions to the service management field. The article also advances future research avenues that will help service and communication scholars together move the field forward.

Transport is the main enabler of tourism, but also one of its main sources of environmental impact. This paradoxical condition is even more controversial if considering the reluctancy of policymakers to introduce traffic management strategies, as they fear possible drops in tourism demand. This chapter addresses the ‘tourism-traffic paradox’ as a wicked problem and explores adequate and efficient policy interventions to foster sustainable mobility in Alpine destinations, minimising rebound effects in tourism demand. The chapter is focussed on the exemplary case of the Dolomites World Heritage Site (WHS), as this Italian area has experienced a long-lasting process of evidence-informed decision-making in transport, with two pilot actions for traffic calming in 2017 and 2018. The main goal of those actions was to shift the modal choices of tourists, to optimise the traffic network use and to minimise environmental impacts. The policy interventions were rooted in a sustainability governance approach, that is, they were creating a government-led network of stakeholders, including several academic experts, involved in the transport planning and monitoring phase. Advantages and disadvantages of this government-led network to solve the tourism-traffic paradox are discussed in the chapter.

This article aims to investigate evaluative framing of global plastic pollution as discursively performed by two opposed categories of social actors, namely corporations versus environmental movements.

The article builds on the literature related to framing, issue arenas and moral evaluations to unravel how evaluative framing and counterframing are implemented in multimodal digital spaces and how social practices get legitimized or delegitimized according to different communicative purposes. It presents a longitudinal critical discourse analysis of the issue-related webpages and press releases of PepsiCo, one of the worst global plastic polluters, and of the global environmental movement #breakfreefromplastic.

Findings suggest that the systematic recurrence of specific evaluative strategies has a double macro-function: (a) organizing discourses strategically through its presence or absence; (b) signalling the moral significance of recontextualized social practices by conferring legitimacy to remedial actions and/or illegitimacy to deviant actions.

This study contributes to increasing accountable environmental action and trustful communication for overcoming global sustainability issues.

The article offers a nuanced understanding of the role of evaluative framing in communicating global sustainability issues. Methodologically, it extends existing categories of moral evaluations and articulates a framework for future studies.

This paper aims to explore the role of employee engagement for competitiveness. In particular, the role of employee communication to create engaging workplaces.

Two field surveys were conducted to assess, which are the most relevant leverages that contribute to create engaging (or disengaging) workplaces in Italy: the first one on a statistical sample of large companies, the second one on a snowball sample of employees.

Italian companies often miss the opportunity to create engaging workplaces and to exploit the potential of employee communication to foster employee engagement.

Further research could focus on a survey on a sample of managers and employees belonging to the same company.

Companies should pursue an inclusive relational approach, using employee communication appropriately.

The study develops and tests a model showing the linkages among managerial approaches and engaging workplace contexts and examines the role of employee communication to foster employee engagement.