Quality Improvement and Patient Safety in Orthopaedic Surgery

Preface
Contents
Contributors
1: Quality Improvement Principles and Models
Quality Improvement Principles
Quality Improvement Models
Model for Improvement/Institute for Healthcare Improvement (IHI)
Root Cause and Common Cause Analysis
5 Whys Methodology
Pareto Charts
Cause and Effect (Fishbone) Diagram
Plan, Do, Study, Act (PDSA) Cycle
Key Driver Diagrams
Six Sigma and DMAIC
Lean Management
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)
Conclusion
References
2: Concepts of Patient Safety
Introduction
Teamwork
Communication
Black Box Thinking
Multiple Layers of Defense
Putting It All Together
Suggested Reading
3: TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety
Background
Planning
Execution
Review and Modify
Conclusion
References
Select Additional Articles
Books
4: Shifting from Volume to Value
References
5: Quality Improvement: Using Care Pathways in EMR
Introduction
How to Create a Care Pathway within an EMR
There Are 4 Stages to Development of a Care Pathway
Stage One: Creation of Care Map
Stage Two: Creation of Care Pathway into the EMR
Stage Three: Implementation and Compliance
Stage Four: Quality Improvement
Case Example
References
6: Pre-op Optimization Checklists
Introduction
Medical Comorbidities: Modifiable Risk Factors
Smoking
Morbid Obesity
Diabetes and Glycemic Control
Hypertension
Anemia
Nutrition
Medical Comorbidities: Non-Modifiable Risk Factors
Metabolic Syndrome
Hypothyroidism
Inflammatory Conditions
Opioid Use/Tolerance
Osteoporosis/Fragility
Obstructive Sleep Apnea and CPAP Use
Bladder Function
Depression
Frailty
Surgical Considerations
Risk for Venous Thromboembolism
Antibiotic Prophylaxis
Methicillin-Resistant Staphylococcus Aureus
The Hospitalist-Anesthesiologist Preoperative Visit
References
Suggested Reading
7: Surgical Site Infection Risk Reduction
Introduction
Preoperative Risk Factors
Methicillin Sensitive Staphylococcus Aureus (MSSA)/Methicillin Resistant Staphylococcus Aureus (MRSA)
Obesity
Diabetes Mellitus and Hyperglycemia
Diabetes Mellitus
Hyperglycemia
Diabetes Screening
Rheumatoid Arthritis
Anemia
Malnutrition
Tobacco Use
Alcohol Consumption
Depression and Anxiety
Cardiovascular Disease
Renal Failure and Dialysis
Conclusion
References
8: Reduction of Wrong Site Surgery
Introduction
Scope of the Problem
Timeline
Financial and Legal Ramifications
Patient and Family Considerations
Causes of Wrong Site Surgery
Techniques for Preventing Wrong Site Surgery
Conclusion
References
9: Learning from Mistakes
The Word “Mistake”
Definition
Good Surgeons Make Mistakes
System Defenses to Protect Patients from Mistakes While We Learn and Improve
Opportunities to Learn
Individual Learning
Black Box Thinking, Why Most People Never Learn from Their Mistakes: But Some Do by Matthew Syed, Portfolio/Penguin; 2015
The Checklist Manifesto, How to Get Things Right by Atul Gawande, Metropolitan Books, Henry Holt and Company, LLC, 2009
How Doctors Think by Jerome Groopman, First Mariner Books, 2008
Zero Harm, How to Achieve Patient and Workforce Safety in Healthcare, Craig Clapper, James Merlino, Carole Stockmeier, Editors, Press Ganey Associates, Inc., 2019
Group Learning
Organizational Learning
Informal Learning
Formal Learning
Some Organizational Learning Opportunities to Be Leveraged
Simulation
Video and Virtual Reality Learning
Incident Reporting Systems—Detecting Mistakes and Harm That Does Occur
Chart and Case Reviews
Patient Claims and Complaints
Prospective Risk Analyses
Orthopedic Surgeons as Leaders
In Conclusion
References
10: Use of Registries and Prospective Cohorts to Improve Care
Joint Replacement
Trauma
Sports Medicine
Spine
The Future of Registry and Prospective Cohorts
Conclusion
References
11: Clinical Practice Guidelines and Appropriate Use Criteria to Guide Care
Introduction
Evidence-Based Quality and Value Committee
Clinical Practice Guidelines
Work Group Defined Criteria
Standard Criteria for all CPGs
Appropriate Use Criteria
Incorporating Clinical Practice Guidelines into Clinical Practice
Future Work
Conclusions
References
12: Performance Measures
Structural
Process
Outcome
Patient Experience
Suggested Reading
13: Interpreting and Implementing Evidence for Quality Research
Interpreting Evidence
“Macro” Influences on Research Integrity
Sensationalism
Distortion
Inaccessibility
“Micro” Influences on Research Integrity
Study Prioritization
Study Design
Study Conduct
Data Interpretation
Implementing Evidence
The Evidentiary Base in Clinical Research
Implications of Poor-Quality Research
Stewarding Evidence-Based Research
References
14: Biologics, Implants, and Patient Safety
Introduction
Quality
Mechanism
Intended Indications and Actual Use
Efficacy
Safety
Assessing Risks and Benefits
Surgeon Self-Reflection
Developing a Patient-Centered Plan
Evaluating Outcomes and Promoting a Culture of Scrutiny
Value
Conclusion
References
15: The Cyclical Process of Medical Device Realization: Development, Implementation, and Quality Control
Design/Development
Paradigm for Evaluation
Implementation
Identifying Risk
Design Validation
Design Review
Design Transfer
Manufacturing
Regulatory Approval
Post-Market Surveillance
When a Device “Fails”
Reporting
Device Company
User Facility
Complaint Investigation
Conclusion
Suggested Reading
16: Variation, Costs, and Physician Behavior
Introduction
Cost
Variation
Physician Behavior
Cost Reduction Strategies
Summary
References
17: Development of Care Maps for Complex Conditions
Introduction
Designing a Care Pathway (See Table 17.1)
Components of a Care Pathway (See Fig. 17.2)
Implementation of a Care Pathway (See Fig. 17.2)
Evaluation of a Care Pathway (See Fig. 17.2)
Important Considerations for Pathway Design
References
18: Communication Strategies to Minimize Harm and Improve Care in Orthopedic Surgery
Introduction
Why Communication Matters
Defining Communication
Communication in the Perioperative Setting
Standardized Communication Tools
CUS
SBAR
Briefings
Intraoperative Briefings and Checklists
Pre-Induction Pause
Pre-Incision Pause
Postoperative Briefing
Communication with Patients
Conclusion
References
19: Integration of Physician Management into Supply Chain Optimization
Evolution of Supply Chain from the Basement to the Boardroom
Goals of a Physician and The Value Proposition
Standardization—What It Is and What It Is Not
What Is It
Opportunities
Missteps
Case Studies
The Case for Savings Via Supply Chain Management
How Not to Save Costs on Implants
Standardization: “How Many Different ACL Grafts Do We Need?”
As a Member to a Chair: Value Analysis Committee
Your Role as a Stakeholder and Partner
Takeaways
Suggested Reading
20: Organizational Response to Error
References
21: Using Simulation to Decrease Patient Harm
References
22: Safe and Effective Alleviation of Pain and Optimal Opioid Stewardship
Introduction
Pain Alleviation Based on Evidence in the Biopsychosocial Paradigm
Pain Alleviation after Planned/Discretionary Surgery
Pain After Unplanned Surgery
Strategies for Safe and Effective Postoperative Pain Management
Opioids
Non-opioid Medications
Physical Interventions
Proper Disposal of Unused Opioids
Conclusions
References
23: Diversity and Cultural Competence to Enhance Quality and Safety
References
24: Radiation Safety
Science of Radiation Health
The Risk of Exposure
Reducing the Exposure
The ALARA Principle
Alternative Imaging
Operating Room
Education
Physical Barriers
Conclusion
References
25: Physician and Clinician Well-Being
Introduction
Prevalence of Physician Burnout
Implications for Patient Safety and Quality Care
The Cost Case to Promote Clinician Well-Being
Organizational Strategies to Promote Physician Well-Being
Conclusions
References
26: Advocacy to Promote Quality Musculoskeletal Care
AAOS and Advocacy
Regulations and Agencies
Specific Agencies Issues
Advisory Committees and Task Forces
27: The Role of the Board in Driving Performance Improvement
Introduction
Are We Discussing Quality or Value Improvement? Or Something Else?
Quality as a Fiduciary Responsibility of the Board
Why Is the Board Important in PI Efforts?
A Tale of Two Organizations’ Performance Improvement Efforts
The Importance of the Board’s Role
Four Key Roles for Boards to Support PI
Staying Anchored on True North
Start Focused, Stay Focused
Commit to a Reliable and Supportive Cadence of Accountability
The Board’s Role in the Accountability System
Mentoring
Summary
28: Innovation and Value
Introduction
Defining Value
Weighting Value
Value-Based Reimbursement
Hospital Value Committees
Payer Value Committees
Needs Finding, Value, and Innovation
Identification
Invention
Implementation
Conclusion
29: The Modern Orthopedic Morbidity and Mortality Conference: An Instrument for Education and System-Wide Quality Improvement
Introduction
History of the M&M Conference
The Fundamentals of an Improved Orthopedic M&M Conference Process
Inter-Disciplinary, Inter-Professional Participation
Application of Standard Methodology
Root Cause Analysis
Error Classification
Identify Areas of Systems Improvement
Summary
References
30: Telehealth and Quality Care
Introduction
Example of a Telehealth Quality Improvement Experience
Plan
Do
Study
Act
Key Takeaways
Discussion
Telehealth and Patient Satisfaction
Telehealth and Clinician Satisfaction
Telehealth Value-based Considerations
Barriers to Telehealth
Future Directions
Conclusion
References
31: Using Quality Improvement to Enhance Geriatric Fracture Care
Introduction
Gaps in the Continuum of Care
Acute Phase
Long-Term Management and Prevention
Examples of Quality Improvement in Geriatric Orthopedic Fracture Care
Keys to Success
Conclusion
References
32: Orthopedic Surgeons as Managers and Leaders: Developing the Right Culture
What Is the Definition of Leadership?
What Is the Definition of Organizational Culture?
Is There a Difference Between Managing People and Leading People?
Leadership Is About Selecting and Aligning People, Then Motivating and Inspiring Them
Know Thyself
Know Your People
Define the Why or Purpose of the Group
On Competition Versus Collaboration in Medicine
Leaders Understand the Basic Needs of the People That They Work with Including the Need for Income, Stable Job, Housing, Health Care, and Ability to Take Care of Their Families
Be A Contrarian
Work for Those Who Work for You
Promote Innovation, Improvement, and a Focus on Getting Better Every Day by Using Peer Review
Value Diversity
Conclusion—Developing the Right Culture
References
Index