View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
Knee and hip osteoarthritis, combined with the increased aging population, obesity, and other health-related risk factors, has led to a great need for joint replacement procedures. Joint replacement programs have been developed within hospitals to meet this demand. Joint replacement programs have been designed to provide an efficient and structured delivery of care. Facilities can demonstrate, to those seeking care, their quality programs by applying for and obtaining certification. Joint replacement certifications can guide facilities in providing a solid structure of improved care, quality, and superior outcomes. This article describes the steps that a community hospital took to attain the Blue Distinction Centers for Knee and Hip Replacement as well as The Joint Commission Disease-Specific Care Certification in Total Knee Replacement and Total Hip Replacement.
Knee and hip osteoarthritis is a major cause of pain, disability, and loss of quality of life (Robbins & Kulesa, 2012). Because of the ever-growing aging population, increase prevalence in obesity, and other health-related risk factors of osteoarthritis, the need for total joint replacements (TJR) and TJR programs is on the rise (American Academy of Orthopaedic Surgeons, 2008). By 2030, it is projected that 67 million U.S. adults will have some form of arthritis (Murphy & Helmick, 2012). One of the most common and effective orthopaedic operations for degenerative joint disease is the total knee replacement (TKR) and total hip replacement (THR) (Kurtz et al., 2005). Patients who undergo a TKR or THR can regain mobility and find an improved quality of life (St. Clair et al., 2006). Yearly in the United States, nearly 200,000 THRs and 400,000 TKRs are performed (Saenz de Tejada et al., 2009). From now until 2030, these procedures are estimated to increase by 174% and 673%, respectively (Kurtz, Ong, Lau, Mowat, & Halpern, 2007). Those who need a TJR will be seeking out a high-quality joint replacement facility to provide them with the best care. One way for facilities to demonstrate quality care is disease-specific certification.
Designation by a certifying body validates a facility as utilizing evidence-based practice and adhering to and upholding clinical practice standards. Certified facilities use advanced technologies, demonstrate efficiency in patient care, and have impetus and direction for their program. Although implementing certification standards is a time-intensive and lofty task, the benefits obtained are worth every effort. Certification means that an organization has demonstrated a commitment to providing quality care that benefits the organization and the patient. Certification demonstrates an organization's commitment to continuously seek to provide the best care (McWilliam-Ross, 2011).
To further develop the already-established TKR and THR center, the multidisciplinary Joint Center team of this northeastern Ohio hospital decided to seek out national certifications. The team wanted to demonstrate commitment to quality, safety, and patient-focused care to those seeking joint replacement. A clinical leadership team comprising a clinical nurse specialist (CNS), nursing manager, and an assistant nursing manager was assigned with the task of securing certification. The purpose of this article was to describe the process used by an acute care facility to achieve two distinct certifications for their TKR and THR center, the Blue Distinction Centers for Knee and Hip Replacement, and The Joint Commission Disease-Specific Care Certification for Joint Replacement Knee and Joint Replacement Hip.
The Joint Center is located inside a 150-bed community hospital. The hospital is certified by The Joint Commission as a primary stroke center and has been named a Thompsons Top 100 Hospitals for 3 years in a row (Thompson Reuters, 2012). The Joint Center has a mission to provide excellent, patient-focused, comprehensive joint replacement care. In 2011, the Joint Center performed 208 TKRs and 82 THRs.
Blue Distinction is a designation awarded by Blue Cross and Blue Shield to medical facilities that demonstrate a commitment to providing quality healthcare. To be awarded Blue Distinction, a facility must meet rigorous objective selection criteria and show that its practice is evidence-based. The criterion for selection was established by expert physicians and medical organizations (Blue Cross Blue Shield Association, 2011). Blue Cross Blue Shield publishes the Blue Distinction criteria for consumers to make informed healthcare decisions when deciding on what facility would best meet their medical needs. Facilities that receive certification are published on the Blue Cross Blue Shield website for patients seeking to find a joint center program that provides quality care consistent with evidence-based practices. Blue Distinction Designation is available in the areas of bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacements, spine surgery, and transplants. Through designation, providers improve the overall quality and delivery of care, which results in enhanced overall outcomes for the patients.
To begin the process of applying for Blue Distinction designation, a team was created to examine the application process, evaluate the Joint Center program compared with the required criteria, and collect appropriate information for the application. The established multidisciplinary leadership team consisted of a CNS, a nursing manager, and an assistant manager of the Joint Center, a physical and occupational therapist, 3 orthopaedic surgeons, a case manager, and a pharmacist. The team started with assessing the required criteria found on the Request for Information (RFI) and determined that no program changes were needed to meet the required standards (Knee and Hip Replacement Request for Information, 2009).
The next step was to decide on the time frame from which data would be gathered to meet all standards. According to the RFI, data submitted had to be for a 12-month period starting no earlier than January 2009. The team began working on the RFI in September 2010; the chosen time frame for the RFI was September 2009 through August 2010. The goal was to submit the completed RFI in November 2010. The CNS, the manager, and the assistant manager divided up the 37 RFI categories and began collecting data. Examples of the various RFI categories include health information technologies, nursing excellence, hospital consumer assessment of healthcare providers and systems, and national quality improvement initiatives. To address each RFI category, specific questions are asked. Data were gathered electronically to answer each specific question and then brought back to weekly meetings. Each RFI category has specific criteria that must be met to obtain all the possible points assigned to that category. All the required standards plus a total of 60 points are required for Blue Distinction consideration. A spreadsheet was created that included RFI category, RFI number, criteria description, points achievable, points attained, the evidence to support meeting that criterion, a to-do list, and date completed. Included in Table 1 is a sample of how the spreadsheet was set up. Data were recorded on the spreadsheet to keep track of progress and organize workflow to maintain timelines. Progress toward completion was reported to the multidisciplinary Joint Center team at monthly meetings.
Blue Distinction certification requires multidisciplinary care for the patients throughout the entire continuum of care. Many resources were utilized by the group to gather the data needed to ensure that the maximum number of points was obtained. Information systems ran reports on total numbers of joint replacement surgeries, the number of joint replacement revisions, readmission rates, and length of stay. Information systems assisted with patient satisfaction reports. The surgeon's office manager assisted with the surgeon's credentials, numbers of surgeries performed, and preoperative screening information. Postdischarge patient data were obtained from the surgeon's office. The Quality Department assisted with information from the Surgical Care Improvement Project. Physical and occupational therapy were able to provide information regarding functional postoperative assessments. Many of the questions were to analyze the program from a multidisciplinary approach. As with many certifying applications, the RFI included questions regarding outcome data of the Joint Center.
Once all data were gathered, the Joint Center team, along with the surgeons, met to review the final application and verify whether all the information was correct. The group had the chief executive officer sign the attestation. The RFI survey, along with the scanned signed attestation and supporting letter for acceptance, was submitted to the Blue Distinction Center's Administration in November 2010. In March 2011, a notice was received stating that the Joint Center did not meet the selection criteria to be eligible for designation. After reviewing the RFI feedback, the team determined that the question regarding availability of physiatry was misinterpreted and answered incorrectly. The question should have been answered as not applicable because our facility does not have a physiatrist on staff. A corrected RFI survey, along with a written appeal request, was submitted to the Blue Distinction Center's Administration within 10 business days from the date of the determination letter. The appeal was granted, and the Joint Center was awarded Blue Distinction for Knee and Hip Replacement. The hospital's designation as a Blue Distinction Center for Knee and Hip Replacement began June 1, 2011, and remained in effect until December 31, 2011. Currently, the Joint Center team is seeking renewal, which will be in effect for a 1-year term.
Overall, most of the time spent was on data collection. The Joint Center had the required criteria already in place, but networking with the right people to address the other standards proved to be a challenge at times. Although many hours were spent, the designation was worth every effort. The Blue Distinction designation validates that the Joint Center is following all the appropriate guidelines when providing care to TJR patients and giving patients the best quality of care possible using a multidisciplinary approach.
After completing the Blue Distinction application process, and before designation was granted, the CNS, the nursing manager, and the assistant manger decided to move forward with applying for The Joint Commission Disease-Specific Care Certification (The Joint Commission, 2011). The Joint Commission's Disease-Specific Care Certification program, implemented in 2002, is intended to provide healthcare providers a process for implementing quality improvement principles into their care pathways.
The Joint Commission's standards were modeled after Dr. Edward Wagner's Chronic Care Model (Potter, 2004). Wagner's model is patient-centered, focusing on the delivery of care and the patient and healthcare provider relationship. Furthermore, with expert guidance from 25 healthcare organizations and the use of a 21-member Certification Advisory Committee partly composed of the National Chronic Care Consortium, the Disease Management Association of America, and the Disease Management of Purchasing Consortium, The Joint Commission was developed.
The Joint Commission has developed disease-specific care certification programs for a number of disease processes such as primary stroke, heart failure, and chronic obstructive pulmonary disease (The Joint Commission, 2011). The disease-specific care certification is voluntary; however, some payers have started to require certification, such as with ventricular assist devices, as a way to ensure quality patient services (Potter, 2004). The Joint Commission Certification demonstrates a public commitment to quality, safety, and evaluation of patient care. Joint replacement programs seek out certification to demonstrate a commitment to a higher standard of service. According to The Joint Commission (2011), the certification process can help to infuse a solid structure and framework into the program. Building a solid structure instills standardization of care, greater efficiency, and improved outcomes. Certification can provide a competitive edge in the marketplace for consumers and can enhance staff recruitment and development for the organization (The Joint Commission, 2011).
To be eligible for certification through The Joint Commission, facilities must provide either clinical care directly to participants or clinical support and direct interaction with participants by telephone or through online services or other electronic resources (Mooney & Potter, 2002). Once eligibility is determined, the certification has three basic requirements. The first is compliance with consensus-based national standards. The second is to consistently use effective and appropriate evidence-based clinical practice guidelines for the knee and hip replacement population. Last, joint replacement programs must collect and analyze four performance measures that are specific to the knee and hip replacement patient population. Once these compliance measures are met, certification is awarded for a 2-year period (The Joint Commission, 2011).
As with the Blue Distinction certification process, our first step was to create a team. Since the CNS, nursing manager, and the assistant manager had already worked together for the first certification, the Joint Center team elected the same people to move forward with The Joint Commission certification.
In moving forward, the leadership team completed a gap analysis to assess how well the Joint Center was complying with the specific certification requirements. The first step was to review The Joint Commission's 2011 Disease Specific Care Certification Manual (The Joint Commission, 2012). This manual provided an insight on the eligibility requirements to apply for any disease-specific certification. After reviewing the requirements and determining that the Joint Center was eligible, the team moved toward the certification process. From here the team reviewed the standards and elements of performance that must be met by all facilities, regardless of which certification they are applying for. Ensuring that all the standards and elements of performance were met, the leadership team applied for certification.
Applying for certification was completed online through The Joint Commission website. The application process is divided into two steps, completing the Certification Measure Information Process (CMIP) and setting a date for the on-site visit. An account executive from The Joint Commission was established to help guide the team in completing the steps of the application. The CMIP was by far the most lengthy and time-consuming process of the application. The CMIP consists of a performance improvement plan that includes four performance measurements (PMs), two of which must be clinical measures. The CMIP requests that clinical practice guidelines are used by the program. Two CMIP forms are required to be completed, one for TKR certification and one for THR certification. The team submitted the clinical practice guidelines first. Choosing the clinical practice guidelines proved to be difficult, because there is no standard guideline for joint replacement unlike stroke or diabetes. All guidelines chosen were supported by The National Guidelines Clearinghouse (2011) or the American Association of Orthopaedic Surgeons (2011). Clinical practice guidelines chosen were as follows: (1) antibiotic prophylaxis in surgery, (2) perioperative protocol, (3) prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty, (4) assessment and management of pain, and (5) guideline for prevention of catheter-associated urinary tract infections. These clinical practice guidelines were chosen because they were currently being used to care for the Joint Center patients.
The performance improvement plan and the four PMs were tackled next. The PMs were created on the basis of the facility needs during the application process. The same PMs were used for both knee and hip. The four PMs chosen for the application were (1) prophylactic antibiotic received within 1 hour prior to surgical incision, (2) appropriate prophylactic antibiotic selection for surgical patients, (3) prophylactic antibiotic discontinued within 24 hours after surgery end time, and (4) patient satisfaction with nursing care. Each measure required rationale for use and the method used to collect the data. Once the electronic application was complete, the date for the on-site survey were set. The team was notified of the on-site visit date 30 days in advance.
During the application process and the 30-day advanced notification window, the team developed a plan to prepare the staff for the on-site survey. The first step was to create a bulletin board in the Joint Center staff lounge to remind the staff of the PMs, measures being taken to improve those PMs, and the expected outcomes. The bulletin board was changed weekly to provide new information and keep the staff engaged in the certification process. Staff was encouraged to provide input and be involved in the certification process. To keep all staff up-to-date on how the certification process was progressing, the CNS attended monthly staff meetings in other key areas such as ambulatory care and the postanesthesia unit. Education was provided to all Joint Center staff members with a read and sign article regarding the certification process and a PowerPoint presentation provided through electronic media. The PowerPoint presentation included 36 slides and addressed the specific clinical practice guidelines, PMs, current activities to meet PMs, and evaluation of outcomes. Other measures taken to prepare staff included mock surveys where staff members were asked possible surveyor questions. Constant positive feedback was provided to the staff regarding The Joint Commission survey and the care they provide at the Joint Center. Overall staff were prepared for the survey and confident in their care.
Along with preparing staff for the on-site review, the CNS, the nursing manager, and the assistant manager prepared the required materials. An overview of the program was created in a PowerPoint presentation. This presentation included the Joint Center's organizational structure, leadership team members, mission, goals, objectives, and an overall view of the Joint Center's concepts. The PowerPoint included the clinical practice guidelines and the PMs. Next, the team created binders to house all the required information that was needed during the on-site survey. Documents included in the binders were Plan Do Study Act sheets for each of the PMs, PM outcome data, organizational charts, our nursing practice model, doctor credentials, patient and nursing education, care plans, Surgical Care Improvement Project measures, and various statistics on the Joint Center. The leadership team met at least weekly in the 30 days prior to the survey to discuss readiness for the survey. The last step in the preparation process was to structure a timeline of the agenda activity for the on-site review (see Table 2). Along with the timeline, the CNS secured appropriate meeting rooms and meals and invited appropriate personal applicable to the agenda activities.
On the day of the survey, the opening session included key stakeholders of the Joint Center including the chief executive officer of the facility. The PowerPoint presentation of the Joint Center was given by the CNS, and questions were answered. Following the presentation, the remainder of the morning consisted of individual tracer activities. The surveyor traced four current patients, two TKRs and two THRs. An electronic health record was used to research the care given to those four patients. These patients, as well as the nurses caring for them, were interviewed privately by the surveyor. After lunch, a review process of the clinical measures and clinical practice guidelines was completed. The afternoon session included discussion of staff and physician competence assessments and credentialing. The day ended with the exit conference led by the surveyor. Comments about the program were shared, questions were answered, and the facility was verbally awarded certification. The surveyor suggested changing the PMs because all were being met. Consequently, the PMs were changed to (1) incidence of postoperative nausea, (2) mean pain score 16 hours postoperatively, (3) incentive spirometry volume documentation every 12 hours, and (4) reduced length of stay to 2.5 days. With the new PMs and the excitement of the certification, the team gained momentum again to move forward in making the Joint Center a true center of excellence.
Maintaining and sustaining a certified Joint Replacement program takes commitment from all staff and a strong commitment from hospital administration. Quality measure data are collected weekly and reported to The Joint Commission monthly by the CNS, the nursing manager, and the assistant manager. The PMs are continually assessed and discussed at Joint Center meetings. Discussion includes setting goals and expected outcomes on those PMs needing improvement and celebrating reached outcome goals.
Patient surveys and follow-up phone calls are completed by staff nurses to assess patient experiences in the Joint Center. The patient survey and phone call follow-up data are shared in staff and Joint Center meetings. Staff participated in a nursing orthopaedic certification study group. The group comprised four nurses whose goal was to obtain orthopaedic certification. The group met monthly to review material and study questions for the Orthopaedic Nurses Certification examination. Orthopaedic certification allows nurses to demonstrate personal commitment to patients and the nursing profession. Like disease-specific certification, orthopaedic certification for nurses certifies their excellence in orthopaedic care (Orthopaedic Nurses Certification Board, 2011). Currently two nurses have received their orthopaedic certification and two nurses have applied to sit for the examination.
During both certification processes, roadblocks were battled and lessons were learned (see Table 3). Both application processes can be overwhelming and seem insurmountable. Breaking down the applications into small objective driven steps helped the team create timelines and reasonable goals for each step. The Blue Distinction application required networking and participation from many hospital departments, doctor's offices, and surgeons. The Joint Commission Disease-Specific Care Certification application required dedication and a commitment from all staff involved to have a successful on-site survey.
The process of obtaining The Joint Commission Disease-Specific Care Certification and Blue Distinction from Blue Cross Blue Shield for our program has brought about many positive outcomes. Throughout the process, the Joint Center has successfully implemented a process for assessing Joint Center patient's satisfaction, improved the postsurgical teaching documentation from 40% complete to 80% complete at discharge, and increased the presurgical class attendance from 77% to 86%. Certification has provided the Joint Center with national recognition as being a center that uses evidence-based practice to give quality care that produces optimal outcomes.
A future goal to move the Joint Center forward is to apply for the UnitedHealth Premium Total Joint Replacement Hospital recognition. The UnitedHealth Premium program is designed to help consumers make a more informed choice in selecting the finest facility for their surgery. By receiving the recognition, the Joint Center would be designated as a facility that provides quality and cost-efficient care (UnitedHealth Premium, 2011). UnitedHealth Premium designation is unique from other certification recognition programs because it incorporates a cost-efficiency component. Designation required that criteria include facility characteristics, volume requirements, staff experience, program components, data reporting, and cost-efficiency (UnitedHealth Premium, 2011).
One of the most common and effective orthopaedic operations for degenerative joint disease is the TKR and THR (Kurtz et al., 2005). Patients who undergo a TKR or THR can regain mobility and find an improved quality of life (St. Clair et al., 2006). One way to ensure that these patient outcomes are achieved is to develop a center of excellence in joint replacements. A dedicated team and staff were instrumental in developing a Joint Center that has become known for its service and high quality of care. A CNS, the nursing manager, and the assistant manager were assigned the task of obtaining certification. This team started with the Blue Distinction Certification, moved onto The Joint Commission Disease-Specific Care Certification, and then continued on to looking at the criteria to qualify for the UnitedHealth Premium specialty center. Through the certification process, the Joint Center team, along with staff, was able to increase presurgical class attendance, assess patient satisfaction, improve on postoperative documentation, and develop a study group for nursing orthopaedic certification. Certification provided the Joint Center with impetus and direction to keep the program and staff focused on constant performance improvement. Through these efforts, patients are achieving their desired postoperative outcomes and the Joint Center has become known as a center of excellence.
American Academy of Orthopaedic Surgeons. (2008). Arthritis and joint pain. In The burden of musculoskeletal disease in the United States-prevalence, societal and economic cost. Retrieved May 8, 2012, from http://www.boneandjointburden.org/[Context Link]
American Association of Orthopaedic Surgeons. (2011). Clinical practice guidelines. Retrieved March 12, 2011, from http://www.aaos.org/research/guidelines/guide.asp[Context Link]
Blue Cross Blue Shield Association. (2011). Blue distinction. Retrieved October 7, 2011, from http://www.bcbs.com/why-bcbs/blue-distinction/[Context Link]
Knee and Hip Replacement Request for Information. (2009). Blue distinction. Retrieved February 7, 2012, from http://www.bcbs.com/why-bcbs/blue-distinction/BDC_Spine_Knee_Hip_Replacement_RFI[Context Link]
Kurtz S., Mowat F., Ong K., Chan N., Lau E., Halpern M. (2005). Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. The Journal of Bone and Joint Surgery, 87-A(7), 1487-1497. [Context Link]
Kurtz S., Ong K., Lau E., Mowat F., Halpern M. (2007). Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of Bone and Joint Surgery, 89(4), 780-785. doi:10.2106/JBJS.F.00222 [Context Link]
McWilliam-Ross K. (2011). A clinical nurse specialist led journey to The Joint Commission disease-specific certification in hip fractures. Orthopaedic Nursing, 30(2), 89-95. [Context Link]
Mooney C., Potter M. (2002). What's behind disease-specific care certification? Nursing Management, 33(11), 16-17. [Context Link]
Murphy L., Helmick C. (2012). The impact of osteoarthritis in the United States: A population health perspective. American Journal of Nursing, 112(3), 13-19. [Context Link]
Orthopaedic Nurses Certification Board. (2011). Certifying excellence in orthopaedic nursing. Retrieved December 20, 2011 from http://oncb.org/[Context Link]
Potter M. (2004). Disease specific care certification. Disease Management, 7(2), 89-92. [Context Link]
Robbins L., Kulesa M. (2012). The state of the science in the prevention and management of osteoarthritis. Orthopaedic Nursing, 31(2), 74-81. [Context Link]
Saenz de Tejada M., Escobar A., Herrera C., Garcia L., Aizpuru F., Sarasqueta C. (2010). Patient expectations and health related quality of life outcomes following total joint replacement. Value in Health, 13(4), 447-454.
St. Clair F., Higuera C., Krebs V., Tadross N., Dumpe J., Barsoum W. (2006). Hip and knee arthroplasty in the geriatric population. Clinics in Geriatric Medicine, 22, 515-533. [Context Link]
The Joint Commission. (2011). Orthopedic joint replacement. Retrieved October 13, 2011, from http://www.jointcommission.org/certification/orthopedic_joint_replacement.aspx[Context Link]
The Joint Commission. (2012, ). Disease-specific care certification manual. Oakbrook Terrace, IL: Joint Commission Resources. [Context Link]
The National Guidelines Clearinghouse. (2011). Guidelines by topic. Retrieved March 15, 2011, from http://www.guideline.gov/index.aspx[Context Link]
Thompson Reuters. (2012). 100 top hospitals. Retrieved February 7, 2012, from http://www.100tophospitals.com/[Context Link]
UnitedHealth Premium. (2011). UnitedHealth Premium total joint replacement specialty centers methodology. Retrieved December 20, 2011, from https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/Pr[Context Link]
For 12 additional continuing nursing education articles on quality improvement topics, go to http://nursingcenter.com/ce.
Back to Top