Orthopaedics Makes Widespread Changes to Advance Care Quality and Patient Safety

By Atul F. Kamath, MD

Improving patient outcomes in orthopaedics requires innovation, clinical prowess and foresight. But implementing sweeping changes and sustained improvement in orthopaedic care across a health system requires all that and more. Academic medical centers like Cleveland Clinic are using a “team of teams” approach — gathering various groups of caregivers dedicated to patient experience, quality and safety, clinical transformation and other broad-ranging efforts — to bring about cultural shifts in how patients receive care.

At Cleveland Clinic’s Orthopaedic & Rheumatologic Institute, we have begun to see the results of this advanced level of teamwork, results that are increasing patient safety, impacting the cost of care and improving patient experience overall.

Early efforts focused on helping prevent the abuse of opioids thanks to changes in our electronic health record (EHR) system. With new workflows and decision-support tools that better highlight patients’ risk of prolonged opioid use, orthopaedic and rheumatology providers now prescribe less opioid medication and more pain-relief alternatives. Morphine milligram equivalents prescribed across the institute decreased notably this year.

In addition, cross-team efforts in 2021 have led to better and more consistent plan-of-care visits, while implementing strategies to mitigate readmissions after joint replacement surgery and dramatically improving compliance with The Joint Commission’s Universal Protocol.

Better and more consistent plan-of-care visits

Plan-of-care visits are different than daily rounding. Rather than provider- or nurse-led care, plan-of-care visits involve the provider, nurse, patient and other caregivers in interactive decision-making, resulting in a collaborative treatment plan. For patients, the benefits include improved safety, satisfaction and health outcomes. For caregivers, the benefits include fewer questions regarding ongoing care plans, and often higher scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.

Before 2021, plan-of-care visits with hospitalized orthopaedic patients were completed at lower-than-benchmark rates. Thanks to the combined efforts of Patient Experience, Quality & Patient Safety, Continuous Improvement, Clinical Transformation, Nursing and Advanced Practice Provider teams, as of November 2021, Orthopaedics has boosted the completion rate to well above 90% at Cleveland Clinic’s main campus.

The first step in achieving this goal was a deep dive into metrics, with the help of custom-built dashboards to track which patients were having plan-of-care visits, their length of hospitalization and other data. Then, with support from the Office of Patient Experience, all orthopaedic providers (including residents and fellows) were trained in how to conduct a plan-of-care visit, from greeting the patient to documenting the visit in the EHR (Figure). Training involved didactic presentations as well as interactive practice and role-playing sessions.

Figure. This infographic is part of a suite of materials developed by Cleveland Clinic’s Office of Patient Experience to train orthopaedic caregivers in how to conduct plan-of-care visits.

Currently, we are designing predictive models based on patient demographics and procedures that may help identify patients who need more in-depth plan-of-care visits, even before hospitalization.

These efforts will spread to Cleveland Clinic’s regional hospitals in 2022.

Early results from main campus are favorable. Since beginning our new plan-of-care-visit protocol in late summer 2021, HCAHPS metrics have improved in doctor communication and in patient-perceived helpfulness of plan-of-care visits.

Fewer readmissions after joint replacement surgery

Another Quality & Patient Safety initiative aims to mitigate avoidable hospital readmissions following joint replacement surgery. A large portion of readmissions (within five to seven days after surgery) are for evaluation of potential infection. However, all red, hot, swollen joints do not indicate infection and may be attributable to routine postoperative healing. Quality & Patient Safety, Clinical Transformation, the Emergency Services Institute and other teams have collaborated to establish protocols and build point-of-care tools to help caregivers identify patients who may need to be readmitted versus those who can receive routine postoperative care.

These tools, currently being tested, incorporate evidence-based algorithms for evaluating and managing “hot joints.” Providers at any Cleveland Clinic site can follow a clinical pathway that indicates how to triage patients, which blood tests to order and when a joint aspiration may be required. Based on these evidence-based criteria, patients are admitted to a hospital, sent for an in-office evaluation, or sent home and scheduled for a follow-up appointment. Tools also provide talking points for communicating with patients as well as guidance for documentation in the EHR.

This effort, dubbed the “Hot Joints Initiative,” will help standardize best practices across our health system. Once established, we anticipate not only fewer readmissions after total hip and knee replacements but also fewer referrals to the ED for patient triage and reduced time spent in the ED.

Improved compliance with Universal Protocol

The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery has been top of mind at Cleveland Clinic in 2021 as well as at other U.S. medical centers. In our Orthopaedic & Rheumatologic Institute, we focused on improving Universal Protocol compliance for joint injections, among other office-based procedures.

Teams collaborated to incorporate a real-time review of a patient’s prior injections in the EHR. Records now display the type of medication and joint involved for all injections administered in the previous three months. It’s another way to ensure we’re giving the right injection to the right patient at the right time.

Also, order sets in the EHR now include best practice alerts (e.g., verify the correct procedure, verify the correct site) and confirmation of completion. Thanks to these changes, our institute is now approaching 100% compliance in Universal Protocol documentation of office-based procedures.

These initiatives are a small sample of the ongoing systemic changes we are making in the Orthopaedic & Rheumatologic Institute. They represent the widespread collaboration of Quality & Patient Safety, Patient Experience, Clinical Transformation and other teams needed to ensure the highest standard of care for orthopaedic patients.

Dr. Kamath is Director of the Center for Hip Preservation at Cleveland Clinic and Vice Chair of Quality & Patient Safety for Cleveland Clinic’s Orthopaedic & Rheumatologic Institute.