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The Bone & Joint Center is an independent, physician owned orthopedic surgical specialty clinic performing over 800 elective knee and hip replacement procedures annually.

CHI St. Alexius is designated as a Blue Distinction Center+ for knee and hip replacement. In April 2017, they received advanced certification for these two surgeries from the Joint Commission.

We spoke with Mark Johnson, CHI St Alexius’ total joint program coordinator, and Coleen Staloch, clinical joint coordinator at The Bone & Joint Center, to learn their responses to some of the questions people have as they consider applying for advanced certification:

What benefits have you seen after getting certified? Have you seen an increase in census and/or a decrease in complications?

Mark Johnson: It’s hard to say if we’ve had an increase in census or not. We have seen a slight increase in overall volume every year, but that could just be due to more ‘baby boomers’ getting to the age where joint replacements are more common.

When we started to implement the changes to meet Joint Commission advanced certification standards, we saw an improvement in outcomes. Infections, DVT, ER visits, readmissions, complications all improved. Another helpful tool was the patient satisfaction surveys conducted through Wellbe. Prior to that, we were relying on HCAHPS surveys, which did not really give up specific feedback on what we needed to improve on. With feedback from the Wellbe surveys, we were able to make the changes necessary to improve patient satisfaction and improve our HCAHPS score.

How did you go about getting the surgeons to agree to a standardized practice?

Coleen Staloch: This is an excellent question! If you cannot get your surgeons to standardize, you will only be a core knee and hip replacement candidate. Get to know your surgeons and their current practices, and choose a physician leader who is willing to take this on.

Keep in mind that the current and upcoming payment systems for orthopedic surgeons is likely to be based on outcomes and patient satisfaction. Our surgeons wanted to become a center of excellence—with marketing and market share being a driving force to obtain this. Most of our surgeons wanted to be perceived by the community as up-to-date; the minority who wanted to stay within their comfort zone went with the changes because of the push of the majority.

By using current practices and research, and adopting them into our program, everything fell into place and our data improved rapidly. Our LOS is 0.9 for knee and hip, patient satisfaction is over 90%, and pain control satisfaction is 90%. You will only be asking them to follow current evidence based practices for knee and hip surgery—they should have no problem with that. But get a feel for the surgeon’s view on this before spending time and resources toward advanced certification.

What were the reasons given for so many DSDF 1 citations — ‘practitioners are qualified and competent’?

MJ: It appears that in 2016 the Joint Commission found DSDF 1 out of compliance in 16% of the facilities surveyed. We did not get cited for this, but they met with our chief of staff physician to ask how we ensure every surgeon has the required credentials before performing surgery in our facility.

Importantly, the word ‘practitioner’ applies to all medical staff—nurses, PT/OT, RT, and so on. My advice is to start with your HR department and ensure all staff members are up to date on mandatory education—especially physicians.

Do you have a nurse specific to ortho patients that follows them in your BPCI program?

MJ: We are in the mandatory CJR bundled program. We have a part-time nurse navigator that assists me in following patients and making phone calls. We treat all patients the same whether they are a bundle patient or not. The nurse navigator pays closer attention to hip fractures – patients who receive a partial or total hip replacement secondary to a fracture. Most of these patients need SNF placement, but almost all our elective knee and hip patients return home from acute care.

Do you require your orthopedic surgeons to have any specific CME or education requirements?

CS: Joint Commission materials state that education specific to knee and hip surgery is required, but does not specify how to obtain it. Your hospital medical staff services keep track of provider CME and establishes requirements. The surveyor could request to review that, so we asked medical staff services to ensure the providers’ records were up to date, along with all licenses required.

Our ortho surgeons, clinic nursing staff, and ortho floor nurses routinely attend ortho conferences locally and nationally. For instance, your state likely has a state organization that presents an annual conference for which you can receive CME credit.

Do you use a risk assessment tool such as RAPT? If so, when?

CS: We use the preoperative ASA risk assessment tool only. Other tools were not mentioned by the surveyor as a consideration.

Is the inpatient unit a strictly orthopedic unit, free from infections?

CS: We do not have a dedicated orthopedic unit and the surveyor had no issue with this. Our infection rate is 1%.

Would you please share standard frequency and duration of PT for Home Care for both hip and knee replacements? Any outcomes available?

MJ: Thanks to our emphasis on pre-op education, the need for HHC and outpatient PT has decreased. The CJR bundle made us look at how those expenses would come out of our bundle payment.

Our ortho doctors have a standard script for six to eight PT visits for either HHC or outpatient PT. They will approve more but only if there is a documented reason for it. Our emphasis is a home-based rehab approach—we want patients to accept this as their responsibility as opposed to letting a therapist shoulder this burden.

Our TKA patients start outpatient PT at two weeks post-op and are usually followed for a few months as needed. A study came out that indicated THA patients with outpatient PT were no better off than patients who did not have PT in terms of functional outcomes, so our doctors removed the automatic referral. Outpatient PT is only for patients that really need it.

We use the HOOS/KOOS and Global promise health surveys pre-op and nine-months post-op. I don’t have the exact improvement percentage to quote from but what I have seen is there is a significant improvement in HOOS/KOOS post-op scores and minimal improvement in the Global promise health survey.

Learn more about The steps the Bone & Joint Center at CHI St. Alexius took to obtain certification in our free webinar.