SummaryUnder the direction of an experienced nurse program coordinator, Hallmark Health System created a comprehensive initiative, known as the Bone & Joint Program, to provide clinical support and education to elective orthopedic surgical patients. The program includes monthly sessions in which a group of multidisciplinary providers educate patients and family members on the surgery and recovery process; preoperative screening and counseling sessions; clinical pathways and standardized electronic order sets; a dedicated orthopedic unit with specially trained staff; and proactive, coordinated planning for discharge and followup care. The program increased patient satisfaction and inpatient/outpatient volumes, reduced length of stay, achieved low surgical infection rates, and increased the percentage of patients who could be sent directly home after discharge (rather than to a rehabilitation facility).Moderate: The evidence consists of pre- and post-implementation comparisons of patient satisfaction, length of stay (LOS), inpatient and outpatient volumes, and the percentage of patients discharged directly home, along with post-implementation anecdotal reports from staff.
Developing OrganizationsHallmark Health System
Date First Implemented2007
Problem AddressedPatients undergoing elective orthopedic surgery represent a significant and increasing proportion of hospital admissions,1 particularly among older adults. Frequently, patients choose such surgical treatments without fully understanding the associated treatment and rehabilitative processes.
- Large, growing need for orthopedic surgery: In 2005, musculoskeletal procedures were performed in more than 3.4 million hospitalizations, representing approximately 9 percent of all hospital discharges. In nearly three-fourths of these admissions (2.5 million), musculoskeletal procedures represented the principal treatment performed, with these admissions being longer and more expensive than the typical hospitalization. From 1997 to 2005, the volume of musculoskeletal procedures grew by approximately 24 percent, from 2.7 to 3.5 million, with most musculoskeletal procedures being performed on older patients.1
- Patient knowledge deficits about surgical and postsurgery process: Findings from a recent study suggest that patient expectations with respect to knowledge about orthopedic surgery are not routinely being met,2 with patients feeling unprepared for the procedure and postdischarge process. Observations by surgical staff at Hallmark Health supported this finding, suggesting the need for more aggressive patient education before surgery.
Description of the Innovative ActivityUnder the direction of an experienced nurse program coordinator, Hallmark Health System created a comprehensive program to provide clinical support and education to elective orthopedic surgical patients. The program includes monthly sessions in which a group of multidisciplinary providers educate patients and family members on the surgery and recovery process; preoperative screening and counseling sessions; clinical pathways and standardized electronic order sets; a dedicated orthopedic unit with specially trained staff; and proactive, coordinated planning for discharge and follow up care. A more detailed description of the key elements follows:
- Monthly patient-provider sessions: Every month for approximately 2 hours, Hallmark Health hosts a "joint camp" for patients about to undergo surgery and their family members. These sessions include formal lectures and demonstrations, along with group discussions with a multidisciplinary team of providers (including surgeons, pharmacists, nurses, and physical/occupational therapists). During the sessions, patients and families learn about the surgical and recovery process and can get answers to any questions they may have. The sessions also provide an opportunity to develop supportive/networking relationships with the providers and other patients and family members. Patients receive a joint journal that describes the individualized care they will receive; the journal includes a section to write down questions or concerns. Patients take this journal to all pre-, intra-, and postoperative appointments, where providers review its contents to assess patient learning needs and develop care plans.
- Preoperative screening and counseling sessions: Patients meet with a preadmission testing nurse 1 week before surgery to ask questions. The nurse also performs any necessary preoperative testing, medication reconciliation, and physical assessments, including screening for methicillin-resistant Staphylococcus aureus.
- Standardized clinical pathways and order sets: Developed from recommended guidelines from the National Association of Orthopaedic Nurses, with input from a multidisciplinary team, standardized clinical pathways and corresponding computerized physician order sets specific to orthopedic patients are used to reduce variations in care. These pathways and order sets encompass all services, including nursing, anesthesia, follow up care, physical therapy, occupational therapy, pharmacy, nutrition, and case management. Pathways do not substitute for individualized care but rather provide a framework to direct care during hospitalization and after discharge.
- Dedicated orthopedic unit with specially trained staff: Hallmark created a dedicated orthopedic unit with specially trained staff for all patients undergoing orthopedic surgeries. All nurses on the unit, including float pool staff, receive compulsory certification and competency training in orthopedics. The program coordinator also holds monthly educational meetings with unit nurses and participates in hourly bedside rounds with nursing staff. Previously, these patients were admitted to a combined medical/surgical unit staffed by nurses without specialized orthopedic training.
- Coordinated discharge and follow up services: Discharge planning begins during the joint camp session, with adjustments made as needed during the hospital stay. Discharge planners make follow up appointments before the patient's release and then call each patient after discharge to ensure that the followup plan is being executed appropriately. An outpatient liaison coordinates care between the hospital and rehabilitation facilities, including encouraging local rehabilitation facilities to follow the hospital's clinical pathways, thus ensuring a more seamless transition across care settings.
- Ongoing marketing and community outreach: The program coordinator periodically conducts community outreach designed to educate the public on the program, including free lectures at locations throughout the health system and presentations to charitable and community service organizations, including schools, senior centers, and community groups. These presentations provide general education about joint pain, preventive approaches, and treatment options, while also promoting the Hallmark Bone & Joint Program. The program coordinator also meets with partner rehabilitation centers to streamline and better coordinate discharge services.
Context of the InnovationHallmark Health System is a community-based, nonprofit hospital system located approximately 7 miles north of Boston, MA. In addition to providing medical, home health, and hospice services, the system includes two community hospitals with a combined 370 beds. Competing with larger academic medical centers in Boston, Hallmark Health's leaders sought opportunities to distinguish the organization within its service area. Informal discussions among staff members led to a realization that patients undergoing orthopedic surgery seemed to be inadequately prepared for the procedure and recovery process; a review of data also highlighted existing variations in orthopedic care. These observations stimulated interest in improving the care process for orthopedic patients. In 2006, a multidisciplinary task force charged with tackling this issue convened, ultimately leading to the development of the Bone & Joint Program, which was fully implemented in September 2007.
ResultsThe program increased patient satisfaction and inpatient/outpatient volumes, reduced length of stay (LOS), achieved low surgical infection rates, and increased the percentage of patients who could be sent directly home after discharge (rather than to a rehabilitation facility).
Moderate: The evidence consists of pre- and post-implementation comparisons of patient satisfaction, length of stay (LOS), inpatient and outpatient volumes, and the percentage of patients discharged directly home, along with post-implementation anecdotal reports from staff.
- Higher patient satisfaction and volumes: According to Press Ganey surveys, patient satisfaction among those undergoing elective orthopedic surgery increased from the 27th percentile in 2007 to the 99th percentile in 2009. Combined inpatient and outpatient orthopedic volume increased by 19 percent between 2007 and 2009.
- Lower LOS: The average LOS for elective orthopedic patients decreased from 5.1 days at baseline to 3.7 days in 2008.
- Few surgical infections: In 2007, only three orthopedic surgical patients had a surgery-related infection. There were no surgery-related infections in 2008 (the number of surgical infections before program implementation is not available).
- More patients ready to go directly home: In 2006, 90 percent of orthopedic surgical patients were discharged to short-term rehabilitation facilities, with only 10 percent going directly home. By 2008, 41 percent of patients went directly home after discharge.
- Anecdotal reports of better prepared patients: Informal staff reports suggest that patients are more knowledgeable about their condition and treatment, which, in turn, makes them more comfortable and less anxious during their hospital stay.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Formation of collaborative task force, appointment of program director: The system director of surgical services initiated the development of the aforementioned multidisciplinary task force, which included representatives from orthopedic medicine, nursing, case management, pharmacy, physical therapy, home care, plant management, and quality assurance. The task force developed a job description for a program coordinator and then nominated an individual to serve in this role.
- Site visit to learn best practices: In conjunction with Stryker Orthopaedics, the hospital system sponsored a site visit to Piedmont Hospital, a Center of Excellence in Joint Replacement, in Georgia. While touring this facility, staff learned about coordinated, multidisciplinary approaches to patient education and about clinical pathways for ensuring quality patient care.
- Development of pathways and order sets: The task force held biweekly meetings to gather input from pharmacy, rehabilitation, nurses, and orthopedic surgeons; these meetings focused on creating and integrating standardized clinical pathways and corresponding electronic physician order sets that would allow for collaboration and the sharing of information across disciplines.
- Nurse training and education: With the support of nursing leaders (including the chief nursing officer, unit director, and others), nurses on the newly created orthopedic unit received paid time off from their regular duties to complete mandatory training in orthopedics. The task force also created and distributed poster presentations and educational packets designed to promote the continued education of nurses on the unit.
Resources Used and Skills Needed
- Staffing: This program required no additional staff, as the program coordinator's job was integrated into her existing surgical staff position, and nurses on the new unit were transferred from other units within the system.
- Costs: Program costs are minimal, consisting primarily of the program coordinator's salary and benefits. Other minor expenses include the costs to develop and distribute marketing materials and hold the monthly Joint Camp sessions, including buying the joint journals.
Funding SourcesHallmark Health System held a golf tournament that raised $70,000 to support program development and implementation.
Tools and Other ResourcesInformation on credentialing and clinical pathways through the National Association of Orthopaedic Nurses is available at http://www.orthonurse.org/.
General resources on orthopedic care are available through the American Academy of Orthopaedic Surgeons at http://www.aaos.org/.
Getting Started with This Innovation
- Ensure multidisciplinary collaboration in program development: Involve physicians, nurses, pharmacists, rehabilitation staff, and others in the creation and execution of the program, as this collaborative input helps to secure stakeholder buy-in and ensure a comprehensive approach to patient education and care.
- Recruit champions: Recruiting multidisciplinary champions increases the likelihood of successful program implementation, as these champions can foster a sense of commitment at the outset that should continue as the program grows and evolves.
- Standardize processes: Use of standardized clinical pathways, order sets, and certification requirements can help to establish uniform expectations among care providers and ensure that each patient receives the highest level of care.
Sustaining This Innovation
- Remain passionate and committed: The program coordinator and other providers should strongly believe in the merits of the program and demonstrate ongoing commitment to it on a daily basis.
- Continue community outreach efforts: Community education and outreach increases awareness of orthopedic services and options among patients and potential sources of referrals.
- Regularly assess improvement strategies: Collect and analyze data on the program's effectiveness, and refine the program as appropriate to improve patient care and outcomes.
Contact the InnovatorDeborah L. Cronin-Waelde, RN, MSN, NEA-BC, ONC
System Director, Emergency Services
Hallmark Health System
585 Lebanon Street
Melrose, MA 02176
Phone: (781) 979-3358
Fax: (781) 979-3018
Innovator DisclosuresMs. Cronin-Waelde has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesCronin-Waelde D. Building a bone & joint program: nursing leads the way in developing a cost-effective, quality-driven program in a community hospital setting. Orthop Nurs. 2009;28(2):64-7. [PubMed]
Hallmark Health. Joint Camp at Hallmark Health, MA, prepares joint-replacement patients for life pre- and postop. 2008. Available at: http://www.hallmarkhealth.org
Hallmark Health. Bone & Joint Program at Hallmark Health. Available at: http://www.hallmarkhealth.org/hallmark-health-bone-and-joint-program.html.
Heikkinen K, Leino-Kilpi H, Hiltunen A, et al. Ambulatory orthopaedic surgery patients' knowledge expectations and perceptions of received knowledge. J Adv Nurs. 2007;60(3):270-8. [PubMed]
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Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 14, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.