Planning, Building, and Maintaining a Successful Musculoskeletal Service Line

The Implementation of Lean Six Sigma Principles to Improve the Value of Care Delivery for Total Joint Arthroplasty Patients: The Perioperative Institute of Surgical Excellence Experience

BACKGROUND

With the projected increase in the volume of total joint arthroplasty (TJA), minimizing variations in surgery times, hospital length of stay (LOS), discharge dispositions, and inhospital complication rates would help reduce costs and improve the quality of care. As the move toward bundle payment models gains further traction, providers will be reimbursed based on the quality and cost associated with the surgical episode. As such, it remains critical to design and implement high-quality cost-effective perioperative delivery care models. Lean Six Sigma (LSS) methodology has been well described in the healthcare field as a superior strategy in designing processes aimed at reducing waste while minimizing error rates. We present an institutional experience with the design and implementation of a LSS quality improvement process specific to the TJA pathway, with a hypothesis of expected decrease in case cancellation rate, inhospital LOS, 30-day readmissions, and inpatient rehabilitation utilization after program implementation.

METHODS

In 2017, the Perioperative Institute of Surgical Excellence (PISE) program for lower limb TJA was designed and implemented at our institution over a 4-month duration. The program was designed following LSS principles as a low-cost easily adoptable model with a goal to reduce hospital LOS, case cancellation rate, 30-day readmissions, and inpatient rehabilitation utilization.

RESULTS

A total of 328 patients (128 total hip arthroplasty and 200 total knee arthroplasty) were included in PISE compared with a total of 255 patients (106 total hip arthroplasty and 149 total knee arthroplasty) for the preimplementation cohort. After implementation of the model, and compared with a similar 4-month preimplementation duration, the pilot results revealed an increase in monthly case load by 28.6%, decrease in the 30-day readmission rate by 1.16%, inpatient rehabilitation utilization by 60%, a reduction of the average LOS by 0.8 days, and a case cancellations decrease by 51%.

CONCLUSION

The implementation of the pilot protocol for PISE within our institution was successful in decreasing LOS, inpatient rehabilitation utilization, 30-day readmission, and case cancellation. Further assessment is needed to ascertain sustainability of the protocol over a longer duration and generalizability of the results at different institutions and surgeons.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

Economic Considerations of Acute Pain Medicine Programs

Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.

Gainsharing Strategies, Physician Champions, Getting Physician Buy In

As healthcare spending continues to outpace economic growth, legislators and healthcare economists have explored many processes aimed at improving efficiency and reducing waste. Gainsharing or the general concept that organizations and their employees can work together to continually improve outcomes at reduced expenditures in exchange for a portion of the savings has been shown to be effective within the healthcare system. Although gainsharing principles may be applicable to healthcare organizations and their physician partners, specific parameters should be followed when implementing these arrangements. This article will discuss 10 gainsharing strategies aimed at properly aligning healthcare organizations and physicians, which if followed will ensure the successful implementation of gainsharing initiatives.