National Total Joint Replacement Initiative: A Case Study for Accelerated Systemwide Spread and Learning

Abstracts from the Kaiser Permanente2018 National Quality Conference


Jeff Convissar, MD; Kate Koplan, MD; Ronald Navarro, MD;
Violeta Rabrenovich, MHA, CHIE

From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, Washington, Program Offices

Background: National Total Joint Replacement Initiative’s (NTJRI’s) approach balances safety, person centerness, effectiveness, efficiency, equity, and timeliness. NTJRI provides an opportunity for clinically appropriate patients to recover at home after surgery and to reduce any unnecessary time hospitalized in a facility, which can cut down on complications such as surgical infection and can allow patients to heal in a comfortable, safe environment by planning in advance for the support they will need after surgery. In addition, NTJRI provides a framework and a validated method to accelerate adoption of evidence-based practices and service improvement.
Methods: As the NTJRI work transitioned into a second year, NTJRI stakeholders recognized the importance of having a reliable methodology that evaluates performance on the basis of all aspects of Kaiser Permanente’s (KP’s) National Quality Strategy. The group developed an appropriate set of measures. Reports are issued quarterly, three months after the close of each quarter. Data for the previous three quarters are automatically updated and included in the charts in each report. In addition, we developed a process to set national and local targets, established a programwide directional target for each length of stay, and developed thresholds for monitoring of balancing measures and identified an appropriate set of benchmarks to compare our performance. The second-year regional gap analysis was conducted, demonstrating significant progress in the Regions.
Results: Each Region established its own length of stay targets that collectively combine to an overall KP programwide target of 22% 0-day and 57% 1-day surgeries. The NTJRI Quarter 3 2017 Report demonstrates an average length of stay (average of number of days past midnight between admission and discharge) decline during the past 12 months to 1.19, compared with 1.64 in Quarter 3 2016. At the national and local levels, quality and operational leaders monitor balancing measures to ensure safe and effective clinical care. Benchmarks have been set by the Total Joint Registry surgeon champions for return to Emergency Department and Urgent Care (ED/UC) within 7 days and hospital readmissions within 30 days. The benchmark for readmissions within 30 days is 3%. The benchmark for return to ED/UC within 7 days is 8%. According to NTJRI Quarter 3 2017 Report, our readmissions (2.7%) and return to ED/UC (7.1%) have remained stable.
Discussion: The learnings from NTJRI and the process can be transferred to other national and interregional initiatives. Collaborative efforts that support successful and reliable implementation of evidence-based practices require strong leadership and support of technical and operational leaders. Strategic alignment of national and regional improvement efforts enables accelerated improvements across the program. Strategically gathered and used patient input results in care delivery pathways that are embraced both by clinicians and patients.

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