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