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Effective and efficient joint replacement programs need constant review and renewal of processes

Issue: June 2012

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Recent efforts in total joint care have focused on the patient and the processes in the delivery of patient care. This is consistent with the nursing efforts at patient- and family-focused care models in hospitals. A strong team with a surgeon leader is essential to a successful joint replacement program. Part of the joint replacement program is about consistently educating and setting expectations for the patient and then delivering. This is an elective procedure, and we need be able to deliver consistent outstanding care.

In this Orthopedic Today Round Table session, the panelists discuss the creation of consistent preoperative and perioperative processes for total joint replacements (TJR). What happens in the preoperative component for a TJR patient sets the stage for success in the entire episode of care. There is little chance of building a successful TJR program without proper patient selection, preoperative testing and education. The perioperative component of the program is a time when efficiency is critical to both the surgeon and hospital. Effective perioperative processes can significantly assist patients by increasing their safety, decreasing complications and reducing their stress levels during a critical time in their lives. The immediate postoperative period is when consistency in pathways and order sets are critical to allow for effective nursing care and rehabilitation. Having processes hard-wired allows for safe patient discharge. This consistency of care will translate into a better patient experience.

Richard W. Cohen, MD
Moderator

Richard W. Cohen, MD: What key issues in health care drive the need for efficiency in TJR and care?

Joe Tomaro, PhD: Two key concepts drive the need for creating effective joint replacement programs. The first is the demand for joint replacement surgeries vs. supply. In most market areas, the growth of total joint replacement patients averages around 3% per year. This is due to the baby boomer population coming of age when they will need TJRs, an increase in obesity, and thus, an increased rate of joint arthritis, and the benefit of TJR surgery in patients younger than 65 years old.

Many studies have projected that this demand will not be met in the future because fewer orthopedic surgeons are choosing to focus on TJRs. In 2009, 39% of the joint replacement fellowship positions in the United States went unfilled. Therefore, surgeons who do perform TJRs will need to be efficient to meet the population demands.

The second issue is the flat or decreasing Medicare reimbursement for hospitals in the diagnosis-related group (DRGs) for TJRs, and other payers are following this lead. This flat or decreasing reimbursement for both the hospital and the surgeon should be a driving force in creating a collaborative environment for both to develop joint replacement efficiencies and programs.

Jeffery Pierson, MD: An underappreciated benefit of efficiency in joint replacement is its powerful effect on improving quality. The path to efficiency should be through reduction of variability (standardization). Reduction of variability almost always leads to improvements in quality in medicine and many other disciplines. For example, reducing the time spent in the operating room (OR) on a TJR is not achieved by hurrying. Rather, the goal is to reduce the time in between the steps of the operation. This is accomplished by standardization of the procedure, a consistent OR team and anticipation of the next step in the procedure. In a similar way, reduction of variability throughout the care continuum improves quality and creates value.

Cohen: One of the most critical components to a successful outcome is to identify and educate the correct patient for the procedure. What key criteria do you use in patient selection?

Pierson: TJR continues to be one of the most effective interventions in all of health care. However, this is not true if the details are not managed well. The surgeon and office team need to evaluate three major patient-specific considerations. For me, the best candidate for a TJR has advanced stages of hip/knee arthritis, can undergo the procedure without major health risks and has realistic expectations about the outcome of the procedure. The last consideration is particularly important because marketing by the industry, surgeons and hospitals has increased patient expectations considerably.

In many cases, the patient’s expectations are unrealistic and the patient may be dissatisfied with the outcome even with the best results. Our approach is to avoid surgery on these patients unless we can modify their expectations with preoperative education. My office nurses are usually more intuitive about the patients’ expectations, and surgeons should rely on their perceptions. Finally, the preoperative education program should manage the expectations of the patients and their families regarding length of stay and discharge disposition. Our experience is that patients will live up to the expectations the surgical team sets if they are well-communicated.

Cohen: If patients are well informed and understand their role in recovery, then they will have a significantly better and more assured outcome, with greater satisfaction in the process and the care they will receive. It is important that we create an atmosphere for the patient to succeed. We try to treat our patients as we would an athlete who is rehabilitating from an injury, rather than a patient who is ill in the hospital. They are up the day of surgery, in gym clothes the first morning and on their way to a rapid recovery.

Cohen: What key processes need to be in place for effective preoperative testing and patient education?

Thomas S. Muzzonigro, MD: The best place to start patient and family education is in your office during the first visit. It is important to develop a team approach in your office setting that encourages all caregivers to reinforce your protocols and to reassure patients and their “coaches.” I also find it helpful to provide information explaining the diagnosis, treatment options, upcoming procedure, expectations and preoperative testing. Having a collegial, working relationship with your medical colleagues and educating them and their staff can minimize delays in clearance. Some communities welcome physicians who specialize in perioperative evaluations and clearance as a successful model to increase preoperative efficiencies.

Developing a dedicated multispecialty taskforce is ultimately the most effective means of implementing, promoting and monitoring effective preoperative testing. It is imperative to include preoperative assessment testing on the team as it will offer unique insights and will have important suggestions for improving patient flow and testing. Formalized patient and coach education is best accomplished by developing a required formal “joint camp” where education and testing are combined in a one-stop shopping experience. At my institution, we are currently trialing a web-based, interactive patient support program. Early feedback is promising and has given insights into strengthening our standard program.

Cohen: In an effort to bridge between the office, joint class, preoperative room and OR, we have developed a “Thursday conference.” These multidisciplinary team efforts last 15 minutes, and go through every case for the coming week. We want to illuminate all surprises. We set next week’s schedule based on this conference, and our protocol for scheduling our OR cases is not based on patient or physician wishes and favors. This has significantly improved our OR flow, patient care and outcomes.

Cohen: Why is it important to have a consistent well-trained team working with you in the OR when performing TJR surgery?

Pierson: The operating room can be a stressful environment in many hospitals. In our experience, this is avoidable for high volume procedures, such as TJRs. The most common cause of stress in the operating room occurs when the surgeon or OR staff are placed in situations in which they are inadequately trained or experienced to succeed. Using variable people with variable skill sets to perform variable processes and procedures almost always creates high stress, inefficiencies and variable outcomes.

In contrast, developing a consistent TJR OR team with a standardized operation results in low stress, higher efficiency and a higher quality outcome. In these ORs, the emphasis is on skill development, anticipation and team building. It makes no more sense to regularly rotate OR staff for high volume procedures than it does to have a pool of executive assistants rotate daily among the hospital administration C-suite leaders. Despite the obvious logic to this, OR staffing at many hospitals is driven by other considerations that have been given higher priority. As a result, high levels of stress, reduced productivity and highly variable outcomes persist. It is the 80-20 rule in reverse.

Sandra L. Nettrour, PA-C: I would like to emphasize the need for the inclusion of staff outside of the OR itself. A dedicated team can have tremendous insight, so we have monthly operational team meetings to discuss and create action items that resolve efficiency issues. The operations team includes anesthesia and all perioperative departments that could affect the timeline. We also have weekly case review to anticipate patient issues that could delay start time. Central sterile should be a part of streamlining surgical trays to improve throughput and turnover time. The OR management has been integral in creating staff schedules to maximize the dedicated team concept.

Cohen: What critical processes can be used to ensure an efficient and effective perioperative flow?

Muzzonigro: I think my surgical day should be the most fun and rewarding day of my work week. The key to a smooth and efficient surgical day starts with a dedicated orthopedic team. The goal of the team is to provide outstanding surgical care to our patients. The orthopedic service line meets monthly, and key members meet weekly to review and plan for efficient OR days. Preadmission registration is stressful for patients on the day of surgery and should be done ahead of time; i.e., at a joint camp. Perioperative order sets and protocols are initiated at the time of surgical scheduling to decrease paperwork and stress. The surgical schedule is generated and optimized by working together with anesthesia based on operating room flow and efficiency. The surgeon plays a key role by arriving in the OR early, checking in with the team and product representative, and reassuring patients and their families while confirming and marking laterality. Nothing should be done on the day of surgery that could have been done previously. Now you are ready to have great surgical day.

Nettrour: Team members should have a clear understanding of how their duties facilitate the process, and then need to be empowered to initiate their roles without prompting. Find tasks that can be performed concurrently. Operating rooms tend to record huge amounts of data, such as arrival times and procedure times. This is a resource to diminish wait times throughout the timeline. For example, if it takes 30 minutes to block, prep and drape, then the patient should be in the OR room at 7:00 am for a 7:30 am surgical start. Utilization of “turnover teams” to decrease turnover time will improve productivity.

Cohen: What key changes in health care drive the need for coordinated postoperative and post-discharge care?

Tomaro: Most payers, including Medicare, are adapting pay-for-performance measures that will impact between 1% to 2% of the hospital’s reimbursement. Included in these performance measures are process of care measurements, such as Surgical Care Improvement Project (SCIP) measures, patient experience ratings and re-admission rates. While this appears to be only an issue for hospital reimbursement, surgeons should work collaboratively with their hospitals to define, track and improve measures, because ultimately, surgeons are tied to these measures in any public reporting and will also face these pay-for-performance issues in the future.

Another area influencing TJRs is that more payers, including Medicare, are piloting bundled payment models. In a bundled payment model, the payer pays the hospital and the surgeon one combined flat fee to cover the episode of care for the TJR patient. These new payment models are being piloted and will drive hospitals and surgeons to develop processes to address a wider episode of care beyond the hospital stay.

Cohen: What have you done to continue refining your postoperative protocols, order sets and pathways?

Pierson: Postoperative order sets, pathways and protocols need to be reviewed at least once a year and modifications made based upon either new evidence or ideas generated from your team. Second, remember that pathways and protocols are not a substitute for having dedicated team members caring for the patient. The combination of a dedicated TJR team (floor nurses, therapists, discharge planners, etc.) with well-designed pathways is the ultimate goal. Many hospitals make the mistake of thinking that pathways are a substitute for expertise among their staff. Well-intended, but poorly informed, providers commonly contribute to poor patient experiences, even with good pathways. Third, as your team matures and successes are achieved, continue to strive toward further reductions in the variability of order sets and pathways. For example, getting multiple surgeons to agree to a standardized set of orders on the first attempt is unrealistic. However, as the benefits of standardization to the patients and providers are realized, there is more openness to continued efforts at reducing further the variability.

April Mount, RN, BSN, RNC: We have initiated a few additional opportunities, such as all joint surgeries go to a unified order set for preoperative and postoperative orders. This was a best practice initiative and was reviewed and driven by the physicians in our total joint program. We incorporate SCIP measures within the order sets to assist in compliance.

We provide our patients with gym clothes to replace their hospital gowns on the morning after surgery. This has changed our patients’ mindsets to one of being in “rehab” vs. “you are sick.” The clothes are provided at the preoperative joint class.

Cohen: What key processes should be put into place to allow for effective and efficient patient discharge?

Mount: The creation of an interdisciplinary team that includes the physician, total joint educator, staff physical therapist and registered nurse, and the discharge/care coordinator is the core element to our process and success. The primary attribute of the team is communication. The physician is the one who sets patients’ expectations for the rehabilitation of their total joint and discharge.

We found that the preoperative total joint class reinforces the physician’s expectations for the patient’s rehabilitation and discharge. Our weekly total joint meetings review the entire plan of care for each patient. This allows us to identify any barriers in the patient’s needs for discharge and allows us to act proactively. The inpatient team is vital to keep the patient on tract toward discharge. We have developed a step-by-step scorecard for patients that informs them of their daily expectations through to discharge. Part of daily physician rounding with the team is the assessment of the patient’s needs for discharge to home. More than 80% of our patients go home, many with home health services. This high rate of discharge to home is due to the interdisciplinary team approach.

Lastly, we are developing a “discharge class” for our patients prior to discharge and feel this will lead to a more effective discharge process.

Muzzonigro: The surgeon and his office staff must initially set the length of stay expectation when scheduling the procedure. Establishing a functional orthopedic service line will help implement effective discharge processes. It is critically important to educate your medical colleagues and hospitalists about the total joint program and its goals. Having a “boots on the ground” team member, such as a physician’s assistant or certified registered nurse anesthetist, available on day of discharge is helpful and effective. Communication and collegiality are key to a successful program.

Cohen: What other elements of teamwork need to be in place to have a successful joint replacement program?

Pierson: The benefits of a consistent OR team are difficult to overestimate. However, this alone is insufficient. Recognizing this, the concept of a dedicated team should be more generalized. Having a consistent team in the preoperative area, OR turnover help, central sterile supply and the post-anesthesia care unit (PACU) enhance efficiency, productivity and quality.

As we know, there is a long list of people and processes that can create inefficiencies in the hospital. In most cases, this inefficiency is facilitated by many different “silos” of care. To eliminate these, it is important to bring all of these areas onto a common team. This eliminates the silo effect and creates the possibility for processes that are efficient and satisfying to the patient and surgeon. High volume procedures should utilize dedicated teams from start to finish.

Muzzonigro: Dr. Pierson’s concept of working with consistent teams cannot be overemphasized. I believe orthopedic surgeons and their patients benefit from consistency in both the office setting, perioperative and in the OR. Personally, I love the idea of having technical and nursing leads in all settings who understand and buy into our total joint program. We typically assign an orthopedic technical and nursing lead to each surgeon in our office, which cuts down on stress on wild and wooly office days. Similarly, routinely working with the same nurses and aides in preoperative, PACU and on the floor is reassuring to me.

Cohen: What do you foresee for the future of total joint care? What should orthopedic surgeons do now to prepare?

Muzzonigro: Due to changing patient demographics, health care reform and novel economic realities, we are likely to see increased surgical volumes and decreased health care resources in the near future. Delivering outstanding surgical care to our patients will thus require real teamwork, and safe and efficient treatment. To best prepare for upcoming change, it is imperative orthopedic surgeons develop service lines that can improve patient care and surgical outcomes in a fiscally sound fashion. Similarly, I believe it is important to try to partner with your local hospital/health system and the implant industry. It is in everyone’s interest to try to improve the quality of care while increasing volumes and decreasing inefficiencies.

Pierson: The anticipated costs of health care in the United States are one of the single biggest contributors to our nation’s debt. Successful programs realize that they will need to create more value. The benefits of TJRs are great, but we must reduce inefficiencies of our care. These changes usually take many years to accomplish, so my best advice is to start now. The next horizon will include eliminating inefficiencies in post-hospital discharge care. Bundled pricing will include the entire episode of care. To do this, we will need to increase the number of patients going home, reduce re-admissions and minimize services that do not improve outcomes.

Tomaro: The good news is that the number of TJR patients will continue to increase. The bad news is that the overall cost of TJRs to payers, including Medicare, will continue to drive them to push most cost-effective treatment. I believe a key to future success with the payers will be to show a long-term improvement in the functional ability of TJRs and quality of life with a cost-effective treatment program. Whoever is able to do this will be the winners in the future health care environment.

Cohen: Setting patient expectations early about their hospital length of stay and discharge destination will be critical to successful postoperative care. The concepts presented here require discipline to consistently implement them. The surgeon leader and team are critical to achieving this consistency. Orthopedic surgeons need to constantly review and renew processes to maintain an effective and efficient program. It is critical to survival in the current and future health care environments.

I want to thank the panelists for their participation. They have created successful joint replacement programs and continue to work toward bettering their programs. The process never stops.

For more information:

• Richard W. Cohen, MD, can be reached at Wellstar Health Systems, 805 Sandy Plains Rd., Marietta, GA 30066; 404-217-0000; fax: 770-792-1490; email: rwcm@mindspring.com.
• April Mount, RN, BS, RNC, can be reached at 770-793-6782; email: april.mount@wellstar.org.
• Thomas S. Muzzonigro, MD, can be reached at Tri Rivers Surgical Associates Inc., 142 Clearview Circle, Butler, PA 16001; 724-283-5233; email: muzzy@tririversortho.com.
• Sandra L. Nettrour, PA-C, can be reached at Butler Health System, One Hospital Way, Butler, PA 16001, 724-284-4128; email: sandra.nettrour@butlerhealthsystem.org.
• Jeffery Pierson, MD, can be reached at 317-706-2361; email: jefferypierson@hotmail.com.
• Joe Tomaro, PhD can be reached at Accelero Health Partners, 380 Southpointe Blvd., Plaza II, Suite 400, Canonsburg, PA 15317; 724-743-3760; fax: 724-743-3762; email: joe.tomaro@accelerohealth.com.
• Disclosures: Cohen, Mount, Muzzonigro and Nettrour have no relevant financial disclosures; Pierson is a consultant to Accelerohealth, Zimmer, Biomet and Exactech; Tomaro is an employee of Acclero Health Partners, which is a part of Zimmer.