To maintain standards of excellence and continuously improve their outcomes, specialized joint replacement centers must develop, implement, and sustain specific performance improvement activities. This article describes the activities at one. Midwestern healthcare system's joint replacement center related to three disease-specific performance improvement measures: fall prevention, preoperative education, and pain management. Specific steps in the process for each measure are described. These include current-state analyses, goals established, the use of Plan-Do-Study-Act (PDSA) methodology to identify and implement appropriate interventions, and the use of the Six Sources of Influence model to promote successful change. Outcomes, lessons learned, and suggestions for replication by other institutions are discussed.

... a method for outlining a plan of expected care providing a guide to recommended practice and outlining the likely outcomes of care. They (Clinical Practice Guidelines [CPGs]) provide a guide to best practice, a framework within which clinical decisions can be made, and are used as a benchmark against which clinical practice can be evaluated. Historically, CPGs were often developed by consensus of a group of expert clinicians without explicit reference to research evidence. Evidence-based CPG development (the development of CPGs) emphasizes the importance of linking recommendations to the scientific research that supports them, identified through a rigorous systematic identification and appraisal of all relevant research. (p. 2)

Spectrum Health, a not-for-profit health system with headquarters in Grand Rapids, MI, has incorporated the use of CPGs and other evidence-based performance improvement measures in its Center for Joint Replacement (CJR). Spectrum Health offers a full continuum of care through nine hospitals and more than 140 service sites. The organization has 16,000 employees, 1,500 medical staff members, and 2,000 volunteers. Within two of its Grand Rapids-based hospitals, there are six orthopaedic units with a total of 146 designated orthopaedic beds. Services are offered in general orthopaedics, joint replacement, spine, foot and ankle, hand, upper extremities, sports medicine, orthopaedic oncology, pediatric orthopaedics, and orthopaedic trauma care.

The orthopaedics practice has received the Blue Cross Blue Shield Blue Distinction Center of Excellence for Orthopaedics. It is also the only hospital in the region with Disease-Specific Certification in Hip and Knee Replacement from The Joint Commission, performing more than 2,800 surgeries per year.

Plan-Do-Study-Act and Six Sources of Influence

Plan-Do-Study-Act Process

Plan-Do-Study-Act is a well-known method for defining, tracking, and evaluating a change. Applied specifically to the healthcare arena, Deming's model for improvement is based on doing the right thing (evidence-based care) for every patient (equal care) every time (consistent, standardized care). The PDSA model includes the following steps:

* Plan. The problem is defined and current state identified. Data are collected about current performance, compared to chosen standards, and analyzed for variance.

* Do. Interventions are implemented and data are collected to determine the effectiveness of the improvement being trialed.

* Study. Tested interventions are evaluated. Results of the collected postintervention data are measured and analyzed.

* Act. The change is adopted, abandoned, or tested again under different conditions. Standardization is implemented after determining how to make the improvement part of the organization's culture.

Figure 1. Plan-Do-Study-Act (PDSA) cycle process form.

Six Sources of Influence

Table 1. Six Sources of Influence With Sample Questions

Project Objectives and Method

To identify and study performance improvement measures for its joint replacement practice, the CJR initiated a formal project in 2008 that has continued to the present. Three of the two hospitals' six orthopaedic units have been involved. To begin, the CJR's team chose to focus on three activities: (a) reduction of falls, (b) preoperative education participation, and (c) patients' perception of pain. For each of these three measures, the PDSA model was used. A current state analysis was conducted, a future state goal was identified, and a literature review of CPGs and/or evidence-based practices was performed. Specific process improvement activities and projected outcomes for the selected performance measures were identified.

Reduction of Falls

To begin the PDSA improvement process for this measure, a current state analysis of the CJR was conducted. The data indicated an unacceptably high rate of falls. Three to four falls per month were reported in 2007 and 2008, with a 1-month peak of seven falls and no notable improvement over time. Evaluating the data, a trend was identified related to femoral nerve blocks and toileting. A future state goal was then established: to have fewer falls than the National Database of Nursing Quality Indicators (NDNQI) median the majority of the time.

In reviewing CPGs, two applicable CPGs were selected for review: preventing falls in acute care and the prevention of falls and fall injuries in the older adult. The determination of which CPGs to use was based on topic, pertinence to clinical setting, relevance, and levels of evidence used to establish recommendations.

In the next step of the Plan phase, the following questions were asked: "Will it be possible to reduce falls in the total hip and knee populations?" "Are there additional interventions we have not applied that may accomplish our goal?" Potential fall-prevention interventions were discussed that had the likelihood of reducing patient falls.

Falls PDSA: Do

In the Do phase, the focus was on patient safety, with many of the interventions relating to femoral nerve blocks and toileting. They included the following:

* 4Ts during hourly rounds

* Falls action plan

* Manager/staff debriefing

* Unit falls committee

* Staff communication

* Falls-tracking board

* Falls electronic risk assessment

* Safety facts and tips sheet

* Information included in preoperative patient education

4Ts During Hourly Rounds

The first intervention involved rounds. All nurses conducted hourly rounds on their patients, with a focus on the 4Ts: toileting, tidying, tolerance of pain, and turning. Toileting was initially believed to have the greatest potential to influence falls. Patients were asked during each round if they needed to use the bathroom. Also, a toileting script was developed in which the nurse instructed the patient not to get up alone.

Falls Action Plan

An action plan was established, which outlined the criteria that would consistently be used when mobilizing a patient. This included a gait belt, two-person assistance, gripper socks, and remaining with the patient at all times while toileting. Bedside commodes and bed-exit alarms for those at high risk were also used. To keep falls prevention in the forefront, staff assignment sheets were modified to include a bright green sticker that listed the components of the falls action plan. Management rounding reinforced expected behaviors related to the falls action plan, allowing them to identify and address opportunities as they occurred.

Manager/Staff Debriefing

When a fall occurred, regardless of the time of day, the manager was called by the staff member who experienced the patient fall. They provided details and answered questions such as the following: "What could have prevented the fall?" "What could be done differently to prevent this patient from falling again?" This debriefing intervention was designed to be a learning opportunity rather than punitive. The information gleaned from this manager-staff interaction was communicated at Checkpoint, a time during each shift when all staff gather for brief communication. The staff then collectively discussed what could have prevented the fall.

Unit Falls Committee

A unit-level falls committee comprising staff, managers, educators, and clinical nurse specialists was established. This committee was responsible for reviewing CPGs, creating the falls action plan, and providing quarterly education for the unit staff. This education included falls-prevention case studies, online education and communication, and a femoral nerve block newsletter.

Staff Communication

Many forms of communication were utilized with the staff to repeatedly reinforce the interventions. Every opportunity to communicate was used, including posters, e-mail messages, notes in mailboxes, checkpoints, staff meetings, and one-on-one discussions. Also, all staff members were asked to sign a falls commitment statement. Basically, staff members were inundated with the topic.

Falls-Tracking Board

A falls-tracking board was created by the unit safety officer and posted by the time clock so that it could be viewed daily by all staff. This board displayed the number of days since the last fall occurred. Originally, a goal of 30 days without falls was set by the staff and manager. When this goal was met, staff were motivated to select and work toward a higher goal.

Falls Electronic Risk Assessment

The falls electronic risk assessment process was modified to automatically place any patient with a femoral nerve block in the high-risk category for falls. An individual falls risk plan of care was implemented when a patient met the high-risk criteria. The plan of care correlated directly with the risk factors for a specific patient. It included interventions such as falls risk signs on the patient's door and within the room, wrist bands that identified the patient as at risk for falls, and a falls brochure for patients and family members.

Safety Facts and Tips Sheet

A consultant from the hospital's Operational Improvement team and a consultant from the Department of Physical Therapy shadowed nurses on the unit to observe their current practices related to safety. The result was a professional facts and tips sheet that provided suggestions gleaned from the consultants' expertise.

Information Included in Preoperative Patient Education

The existing preoperative patient education class was enhanced to discuss the effects of femoral nerve blocks and emphasize the patients' heightened risk for falls. The content included education about decreased motor and sensory function associated with femoral nerve blocks and strategies for remaining safe until a nerve block resolves.

Falls PDSA: Study

In the Study phase, several outcomes became apparent. For falls reduction, changes related to toileting had the greatest effect overall. Two specific interventions that did not appear to affect falls reduction were telling the patient not to get up alone and the use of bed-exit alarms for all patients.

Patients, even though they would agree not to get up alone, still did, and then they fell. Therefore, this responsibility was shifted to the nurse with an understanding that it was the nurses' role to keep patients safe. Ultimately, checking with the patients during hourly rounds, offering assistance, and never leaving patients alone while toileting were successful interventions. While the patients' privacy was restricted, a new culture emerged in which "patient safety trumps privacy" became the mantra.

The bed-exit alarms became a patient dissatisfier because they did not alert the nurses accurately. There was a high frequency of alarms when patients had not actually gotten out of bed. Bed-exit alarms were found to be useful for some patient populations, but not as a routine intervention in the hip and knee replacement population.

Another important finding emerged from the physical therapy consultant's work. The quick screen used by physical therapists was not reliable for determining risk for falls in patients with femoral nerve blocks. Patients were able to perform the quick screen, yet their knee buckled with ambulation. Thus, it was suggested that patients lock their knee and their elbows when using a walker. In addition, it was recommended that nurses manually block the knee with their hands to prevent flexion.

Falls PDSA: Act

Figure 3. Total knee replacement patients-falls per procedures, January 2006-January 2011.

Preoperative Education Participation

To begin, the current state analysis of the CJR's program revealed that the overall rate of participation in preoperative education classes was 55% for primary joint replacements of the hip and knee. An analysis of physicians' expectations of patient participation in preoperative education showed wide variation. In fact, physicians were unaware of how many of their patients attended classes. Patients' participation in classes, sorted by individual physician, ranged from 0% to 100%, with a median participation rate of 56%. It was discovered that the CJR was relying on physicians' office staff to provide patients with information about class schedules, and physicians were unaware that their office staff were not delivering the correct messages to their patients. In light of these facts and the importance of preoperative patient education indicated by the literature review, the future state goal established was to have all primary joint replacement patients receive preoperative education.

During the Plan phase for this performance improvement measure, the following questions were asked: "How can we remove the barriers to increase preoperative education participation?" "Are there alternative methods for providing patient education?" Then, potential interventions were defined that were projected to increase primary joint replacement patients' participation in preoperative education. Ninety percent participation within 2 years was the initial goal.

Education PDSA: Do

The Do phase of the PDSA process included the following:

* Physician participation data

* Physician office staff visits

* Class registration simplification

* Barriers assessment and resolution

* Postoperative patient rounds

Physician Participation Data

This intervention began by collecting, evaluating, and sharing physician-specific data. The CJR's program coordinator met with each physician and his or her office staff to present aggregate and physician-specific patient class attendance data.

Physician Office Staff Visits

The program coordinator also visited physicians' offices and met with the office staff to identify specific barriers, provide information, and build relationships. Some of these visits confirmed the current state analysis data when it became apparent that not all patients received information about available classes and expectations for attendance. Office staff members were shown how to order the CJR's patient education handbook and they learned about class schedules, contact information, and the class registration process. Relationships were built as the program coordinator and office staff developed a mutual understanding of the actions needed and their respective roles in achieving patient education goals.

Class Registration Simplification

Patients scheduled for surgery had difficulty registering for classes because the registration process depended on a person answering the telephone, and it only functioned Monday-Friday, 8 AM-4:30 PM. The registration process was simplified. Patients were able to call one number to register for class, which was available 7 days a week from 7 AM to 6 PM. They were also able to leave a message on voice mail.

Barriers Assessment and Resolution

A questionnaire was sent to patients to assess the barriers they experienced in attending preoperative joint replacement class. Multiple barriers were identified, including distance, pain, impaired mobility, and conflicting work schedules. As a result, the number of preoperative classes was increased to include day, evening, and weekend classes. Hip and knee replacement classes were separated. For those unable to attend classes due to pain, impaired mobility, or conflicts, a phone education script was developed. A DVD was developed that provided education to patients who were unable to attend classes or preferred this method of education. A process was developed to proactively identify joint replacement patients who were not scheduled for classes, and phone contact was made.

Postoperative Patient Rounds

The joint replacement coordinator implemented rounding on postoperative patients. A script was developed asking the patients questions such as the following: "Did you find the class helpful?" "Is there anything that you didn't learn in class that you wish you had?" This recently developed intervention has yet to be evaluated.

Education PDSA: Study

Sharing specific physician participation data with physicians and their office staff members was a key factor in improving class attendance. Presenting these data increased physicians' awareness of the patient education process, changed office practices, and helped physicians get the correct messages to their patients. It also created an impetus for physicians to improve the percentage of their patients who participated in classes compared to their peers. After the interventions were conducted, physicians valued preoperative education more highly. Physician-specific data continue to be communicated quarterly.

Education PDSA: Act

The remaining barriers are more challenging to remove. The current preoperative education participation processes are undergoing another evaluation and revision. A new process for mandatory presurgical education participation is currently being explored. Preoperative education will be one component of the plan, which includes a preoperative history, physical evaluation, and clearance for surgery. Changing to this new mandatory process is intended to reduce complications, improve patient outcomes, and individualize the plan for each patient.

Patients' Perception of Pain

A current state analysis revealed that the CJR's joint replacement patient pain management satisfaction scores did not meet expectations. An internal survey of patient satisfaction performed by Press Ganey (postdischarge) asked questions such as the following: "How well was your pain controlled?" It showed that the CJR was in the 40th percentile. In addition, an examination of data obtained during the course of hospital stays revealed that patients rated their pain management as "acceptable" only 65% of the time.

Thus, the future state goal established was to have all patients perceive pain management as acceptable throughout their hospital stay. This definition included pain being acceptable at rest and with all activities required during their recovery. Potential CPGs were evaluated on the basis of strength of evidence, currency of the literature, and applicability to the environment and population of patients for which the guidelines would be used. The CPGs were then selected and used to guide interventions. They included methods for effective treatment related to the physiological mechanisms of pain and providing comprehensive evidence-based nursing care. The CPG recommendations were then translated into an action plan.

In the Plan phase, the primary question asked was, "Will it be possible to achieve improved patient perceptions of postoperative pain management?" It was predicted that pain management strategies could be implemented, which would result in increased acceptable postoperative pain ratings.

Pain PDSA: Do

The Do phase included a number of interventions:

* Pain quality improvement committee

* Patient education

* Missoula Demonstration Project Pain Scale (MDPPS) tool

* Staff education

* White board and night pain plan

* Hourly rounds

* Management and staff audits

* Physician order sets

Pain Quality Improvement Committee

The first step was to establish a staff-based pain quality improvement committee composed of staff nurses, clinical nurse specialists, a patient educator, the unit manager, and ad hoc members including pharmacists, surgeons, physician assistants, anesthetists, and rehabilitation specialists. The committee was designed to analyze the selected CPGs and develop and implement strategies that would positively affect pain management.

Patient Education

Multiple interventions were focused on patient education. Pain management information and explanations of postoperative expectations were enhanced in the patient handbook and preoperative joint replacement classes. Patients were informed that pain is expected at an intensity that allows them to rest and move about. They were encouraged to use medication as appropriate around the clock using a mutually established pain plan.

MDPPS Tool

The MDPPS is the tool selected to standardize the communication language regarding patients' pain intensity at rest and with activity. The choice of this tool was based on ease of use (i.e., patient preference), visual appeal, and the applicability of descriptors to the postoperative orthopaedic population. The MDPPS combines the FACES pain scale, a verbal descriptor pain scale, and a numeric pain scale. Permission was granted to use and copy the MDPPS from the primary investigator for the Missoula Demonstration Project. Nurses were trained in how to use the tool as a means for patient communication about pain. A laminated copy of the MDPPS was posted in each patient room and in the physical therapy gymnasium.

Staff Education

Staff education, an important intervention, included three efforts. First, a pain response algorithm reference card was developed by the pain quality improvement committee to guide nursing practice, based on each patient's pain score. The purpose of this card was to communicate the next step that should be taken when the patient was still in pain. It also communicated the need to continue intervening when the patient was not comfortable.

Second, a pain resource folder was created for the nursing staff. The folder contained in-depth information about nerve blocks, a reference to the orthopaedic core curriculum on pain, and additional articles about pain. Staff members were encouraged to use this folder as a reference tool and as a foundation upon which to build their knowledge about pain.

Finally, additional online education addressing The Joint Commission standards related to pain assessment and reassessment was a requirement for all staff.

White Board and Night Pain Plan

Another focus of attention was the development and use of white boards. The white board was located in direct view of the patient in each room. It contained the pain goal mutually established each shift between the patient and the registered nurse. Documented on the white board were the patient's "last medication given" and "next medication due." There was also a note at the bottom urging patients to call the nurse if their pain remained unrelieved.

The white boards were also used to support a night pain plan. The night pain plan was designed to proactively identify a process for pain management during the sleeping hours, with the goal being to provide a steady state of comfort. Education was provided to each patient regarding the importance of around-the-clock medication without prolonged gaps. Then the nurse established with the patient if they wanted to be awakened for night pain medication. This was documented on the white board and the nurse provided the patient with medication as agreed. The utilization of the white board with the night pain plan eventually evolved into a 24-hour pain plan.

Hourly Rounds

Hourly rounds, with a focus on the patients' tolerance of pain, were used as a means to shift the culture on the unit from waiting for patients to ask for pain medication to proactively giving medication when due. The nursing staff took ownership in ensuring their patients' comfort. This hourly, continual reassessment of the patients' level of pain kept this topic in the forefront of nursing practice.

Management and Staff Audits

In an effort to standardize staff behavior, auditing was used by both management and staff to ensure complete documentation of the white boards and pain assessment and reassessment practices. Leadership rounded daily, reviewing completion of the white boards and assessing patients' perception of pain via interviews. If anything was found to be incomplete, one-on-one feedback was given. Exemplary behavior was recognized and publicly acknowledged as a method for role modeling and reinforcing expected behavior.

The documentation of pain reassessment was reviewed each shift by the oncoming nurse during shift report. If any opportunities were identified, they were discussed between the two nurses at that time. In addition, an audit tool of the reassessments was given to the nurse manager for review. Auditing for documentation on the patient's white board, the patient's pain goal, the time the last medication was given, and the time the next medication was due began as a daily event. As success was achieved, auditing became less frequent.

Finally, the CJR's safety officer performed chart audits on the documentation of the registered nurses. Again, success was shared with the staff members individually and as a group, and recognition was provided to the role models.

Physician Order Sets

Physician orders were developed with categories for opioid-naive, opioid-exposed, and opioid-tolerant patients. The purpose of these order sets was to customize care for each patient's needs. The order sets were created by a team of physicians, pharmacists, anesthetists, clinical nurse specialists, and staff nurses. Each order set was further divided into mild, moderate, and severe categories to help caregivers effectively address each patient's pain.

Pain PDSA: Study

All interventions were assessed during the Study phase. A specific gap identified during the current state analysis was pain reassessment. Through the use of hourly rounding, staff education, and sharing unit data, the importance of intentionally reassessing the patients' pain and auditing documentation became clear. These also positively affected the patients' perception of pain management.

In relation to staff education efforts, the nursing staff often reported that when they actually gave the patient everything ordered, it was sufficient for pain control. Perhaps of greater importance, there was a culture shift in thinking; it became unacceptable to leave a patient in pain.

Members of the pain quality improvement committee were invited to present information to the Patient and Family Advisory Council, which explores and addresses issues that affect every aspect of the patient experience. This council includes current and former patients and family members. They work closely with health system's leadership, physicians, and staff-offering ideas, insights, perspectives, and recommendations to help the organization better understand and improve patient care and the family experience. Council members, when asked to participate as consultants in improving pain control, positively reinforced the use of white boards in pain control.

Pain PDSA: Act

With each intervention, expectations were incorporated using a supportive strategy termed "the love and learn stage," when the expectations were taught with patience. The "coaching and mentoring" stage followed, when expectations were enforced in an effort to help individuals achieve success. This was done respectfully by incorporating rewards and mentoring into the overall process. In the "sustainability" stage, hardwiring the behaviors was the key focus. Continual celebrating, teaching, and auditing ensured that the culture changed.

Conclusion: Lessons Learned

Multiple interventions supported each of these three performance measures. No single "magic bullet" offered a solution. Instead, success resulted from an accumulation of interventions that caused an upward shift in the data.

Effective communication was the first step required to sustain the changes. Ensuring that everyone understood the process and the goals-and each individual's role in the process-was vital to success. It required engaging all of the key stakeholders within the interdisciplinary teams.

Creating a new culture and changing behavior require accountability and persistence in addition to implementing the correct process. It is important to ensure that these interventions are part of every day, every shift, and every person until and after the culture has changed. This leads to embedded behaviors and sustained change.

It is important to establish achievable goals, communicate progress, and celebrate publicly and often. Setting small but achievable goals creates an environment of enthusiasm, determination, and pride.

Finally, once success has been achieved, it needs to be shared with other teams so the concepts and processes can be applied to other projects. This, ultimately, will lead to an overall improvement in patient satisfaction, quality care, and safety.

Acknowledgments

The authors thank Theresa M. Peliotes, MSN, RN, CNRN, quality improvement specialist in the Spectrum Health Quality Department, for her assistance with organizing and analyzing the date included in this article.

We also gratefully thank Beyond Words, Inc., for the editorial assistance in the preparation of this article. Although Beyond Words supplied paid professional editing services, this does not indicate its endorsement of, agreement with, or responsibility for the content of the article. No funding was requested or received by any of the authors in relation to this article.

References