Orthopedic center wins reimbursement in CMS pay-for-performance project

The surgical site infection rate at the Bone & Joint Hospital proves less than 1%. Others can get similar results.

In a recent pay-for-performance project, the Centers for Medicare and Medicaid Services ranked the Bone & Joint Hospital as the top participating center for hip and knee replacement care.

The Oklahoma-based center won $249,000 in the first year of the Premier Hospital Quality Incentive demonstration project, according to the Centers for Medicare and Medicaid Services (CMS). In 2004, the hospital had the third-highest rate of Medicare patient joint replacements. “At this point, our infection rates are well below 1%,” the executive vice president and chief operating officer of the Bone & Joint Hospital in Oklahoma City, Janet Farhood, told Orthopedics Today.

The hospital began aggressively improving the use of prophylactic antibiotics for hip and knee procedures in 1993. Hospital administrators cited literature that noted a 40% to 60% infection reduction when centers administer antibiotics at the appropriate time prior to the surgical incision. “We have continually moved the administration of antibiotics closer to the time of surgery,” Farhood said. “We used to administer antibiotics from the floor and then it was moved to the holding area in the surgery department. Now it's the responsibility of [the] anesthesia [team].”

Antibiotic timing

To ensure the appropriate selection and timing of antibiotics, staff members note the type and timing of medication on pre-printed pre- and post-surgical orders. Computer software, the Automated Infection Control Expert (ACE) database, connects to the OR systems allowing administrators to review system outliers and breaks in procedure as well as physician compliance. “When there are physicians who fall out of our guidelines, then we can work with them one-on-one to improve their ordering practices and, when a hospital process problem is identified, we improve it through our Continuous Quality Improvement approach,” Farhood said.

“It’s what I would call a combination of breakthrough improvement and continuous improvement,” she said. “We made some early changes to get breakthrough improvement and then we made slow, additional, incremental improvements through the years to get better, better and better at this.”

The hospital staff also learned valuable lessons through its involvement in the Oklahoma Foundation for Medical Quality’s infection prevention program. Farhood said that program stressed the following additional procedures to decrease infection:

clipping patients — not shaving them;
monitoring glucose levels; and
maintaining normothermia.

Farhood said that centers could increase physician and staff compliance with these procedures by implementing simple changes and making the connection to improved patient outcomes “transparent.”

“Make it easy for them to order the antibiotics, follow the protocol in an easy way and take responsibility for making sure it happens,” she said.

For more information:
Centers for Medicare and Medicaid Services Web site: cms.hhs.gov.