Fall Meeting

1

• Fall Meeting
• AAOS
• Orthopaedic Surgery Safety Update
• 2012
• William J Robb III MD
• Chair
• AAOS Orthopaedic Surgery Safety Summit
• AAOS Patient Safety Committee

2
Disclosure

• Consultant Blue Cross Blue Shield Association
• TJR - Centers of Distinction Program
• Consultant (Unpaid) - Smith and Nephew
• Investor emmi Solutions
• Chair AAOS Orthopaedic Surgery Safety Summit
• Chair AAOS Patient Safety Committee

3
Is there an Orthopaedic Surgery Safety Problem
2012?MediaABC News Report - Maryland 2012

• Report on Surgical Errors
• CMS - only 14 errors reported in hospitals
• Advised patients ask about checklists
• Report
• SSIs shoulder surgery
• Wrong site pediatric eye surgery

4
Is there an Orthopaedic Surgery Safety Problem
2012? HealthGrades - 2010

• gt350,000 patient safety errors/year 2006-2008
• Cost 9B
• 1/10 safety errors results deaths
• gt100,000 surgical error deaths/year
• Top 5 Hospitals only 43 reduction safety
  incidents
• Wrong Site Surgery (WSS) rates - 1/20,000
  surgeries
• Hospital SSI rates 2-3
• NO evidence safety/quality improvement 2000-2010

5
Is there an Orthopaedic Surgery Safety problem
2012?

• JC 2009-2010
• Wrong Site/Procedure/Patient Surgery (WSS)
• Mandatory State bsed WSS Reporting
• Minnesota (48 - WSS)
• Pennsylvania (58 - WSS)
• 35.4 WSS/wk. in US (estimated)

6
JC Sentinel Events Data Base 2007-2011 54
Orthopaedic WSS
7
Is there a Orthopaedic Surgery Safety Problem
2012?Hospital Data JC - 2011

• gt7 wrong site/side/level/implant/procedure/patient
  surgeries /day
• System errors NOT Surgeon errors
• Most frequent causes
• inadequate/missing surgical information
• scheduling discrepancies/errors
• irregularities in pre-op holding process
• inadequate/absent surgical site marking
• poor communication
• distractions in OR
• inadequate/absent OR process/time-out
• Mark Chassin MD, MPP, MPH

8
Is there an Orthopaedic Surgery Safety problem
2012?

• ABOS Certification/Recertification Data Base
  2011
• WSS Rate - 1/30,000 orthopaedic surgeries
• NO CHANGE 2000-2011

9
Surgical Safety/Quality/Value Timeline

• 1997 - AAOS - Sign Your Site Program - (safety)
• 1999 - IOM Report - To Error is Human Building a
  Safer
• Health System (safety)
• (44-88,00 deaths in hospitals/year from medical
  errors)
• 2001 - IOM Report Crossing the Quality Chasm A
  New
• Health System for the 21st Century (quality)
• 2003 - VA National Directive to reduce Risk WSS
  (safety)
• 2004 - JCAHO Universal Protocol
  (safety/quality)
• 2004 - SCOAP (safety/quality)
• voluntary hospital-based surgical safety/quality
  Washington

10
Surgical Safety/Quality/Value Timeline

• 2007 - SCIP (quality)
• mandated national surgical quality standards
• 2007 - WHO Safe Surgery-Saves Lives
  (safety/quality)
• 2009 - Checklist Manifesto Atul Gwande MD
  (safety and quality)
• 2010 - Berwick CMS Administrator
  (safety/quality/value)
• CMS payments - financial penalties for Never
  Events
• CMS/PQRS payments financial incentives for
  quality reporting
• 2012 CMS Public Quality Data Reporting Program
  (safety/quality/value)
• Hospital SSI Rates
• Surgical Re-admission Rates
• Surgical Care Outcome
  Assessment Program Washington State Hospital
  Association
• Surgical Care
  Improvement Program US Department of Health and
  Human Services
• Former President and
  CEO, Institute for Healthcare Improvement (IHI)

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Evidence Surgical Safety/Quality/Value Programs
are Effective

• 2006 Central Line Checklists Peter Pronovost
  MD
• Reduction central line infections - 40 to lt1
• 2008 WHO Safe Surgery - Saves Lives - Atul
  Gwande MD
• 50 reduction surgical mortality/complications
  (multi-nation study)
• 2010 Surgical Care Outcomes Assessment Program
  (SCOAP)
• Universal Protocol (UP) adopted in all Washington
  ORs
• lt Complications - appendectomy, colectomy,
  bariatric surgery
• lt Hospital Costs

12
Evidence Safety/Quality/Value Programs are
Effective

• 2010 Northern New England Cardiovascular
  Disease Study
• Group
• improved Cardiovascular surgery outcomes -
  participating medical centers
• 2011 VA Surgical Safety Program
• reduced surgical errors 25 - 2006-2009

13
AAOS Orthopaedic Surgery Safety/Quality Survey
2011

• Survey Goals
• Assess safety/quality in orthopaedics
• Evaluate differences by
• sub-specialty
• length of practice
• practice type
• Evaluate orthopaedic leadership attitudes
  regarding safety/quality
• Assess orthopaedic safety practices/culture
  /errors
• Identify opportunities/barriers for change

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Survey Participants
15
Participating Practice Types
16
Participating Orthopaedic Sub-Specialties
17
Participant Surgical Settings
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ResultsPositive Findings

• gt90 use Universal Protocol (UP) in Hospital ORs
• 82 Believe UP Improves Surgical Safety/Quality
• No differences in utilization/understanding UP
  by
• Years in practice
• Sub-specialty

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Results Negative Findings

• Surgical errors reported ALL orthopaedic settings
• Most undereducated safety science
• lt50 UP use in surgi-centers - rare in
  office/procedure rooms
• Few surgeon safety leaders/champions
• Younger surgeons lt team communication knowledge

20
Model Safe Orthopaedic Surgical Care
21
HistoricalOrthopaedic Surgery Culture
22
ModelOrthopaedic Surgery Culture of Safety
23
DefinitionSafe Orthopaedic Surgical Care

• Safe surgical care is
• surgical care delivered with a highly reliable
  surgical system
• designed to reduce, with a goal of eliminating,
• preventable harm/s
• continuously monitored through safety data
  collection
• effectively integrating interfaces between
  surgical
• patient and family
• physicians, surgeons and staff
• suppliers and equipment
• and environments.
• Modified from Dev Raheja - Safer Hospital
  Care

24
Definition Quality Orthopaedic Surgical Care

• Quality Surgical Care is
• standardized surgical care based upon
• medical evidence and/or
• consensus-based best surgical practices
• continually improved through innovation
• validated through surgical quality data
  collection and analysis
• achieving optimal composite surgical outcomes

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Definition Value Orthopaedic Surgical Care

• Value in surgical care
• focused on patient-centered outcomes
• evaluated continually with surgical benchmarking
• supported by only essential resources ()
• effectively coordinated through the entire
  surgical care episode
• Modified from Michael Porter Redefining
  Healthcare

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RelationshipSafety, Quality and Value
27
What is needed to improve Orthopaedic Surgical
Safety?

• Change historical orthopaedic surgical behaviors
• Implement surgical safety science and behaviors
  into ALL orthopaedic settings
• Shift focus from surgeon to team performance
• Establish sustainable culture of surgical
  safety
• Build and maintain orthopaedic safety/quality
  data bases
• Validate safety programs in orthopaedic settings
• Collaboration with other safety stakeholder
  organizations

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Key Elements Orthopaedic Surgical Safety

• 6 Cs
• (1) Communication effective surgical team
  communication
• (2) Consent accurate timely informed consent
• (3) Confirmation proper surgical site
  marking/identification
• (4) Checklists use validated standardized
  processes
• (5) Concentration focused team without
  distraction
• (6) Collection systematic safety/quality data
  collection
• Submitted to CORR 10/2012 Kuo, Robb

29
AAOS Surgical Safety Program 2012

• 2011 Fall Board Workshop
• TeamSTEPPS
• 80 Hospital/Surgicenter training sites 2012-2014
• 2012 Spring Board Workshop
• Develop orthopaedic checklists
• Establish/collaborate orthopaedic safety data
  bases
• Surgical Safety Board Oversight Work Group
  2012-2014
• Chair - Dr. Fred Azar
• Orthopaedic Surgery Safety Summit
• Chicago 2012
• Orthopaedic Surgery Sub-Specialty Pilot Programs
• Validate Pilot Safety Programs 2012-2014

30
Orthopaedic Safety Summit Goals

• Unify orthopaedics regarding safety
• Reduce errors/ preventable harm/s
• wrong site/side/level/procedure/implant/patient
  surgery
• surgical complications
• readmissions
• Establish surgical safety as a specialty priority
• Improve orthopaedic outcomes
• Collaborate with other surgical safety
  stakeholder organizations

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Participating/Presenting Organizations

• 1. American College of Surgeons (ACS)
• 2. Surgical Care Outcomes Assessment Program
  (SCOAP)
• 3. Centers for Disease Control and Prevention
  (CDC)
• 4. Centers for Medicare and Medicaid Services
  (CMS)
• 5. Agency for Healthcare Research and Quality
  (AHRQ)
• 6. The Joint Commission (TJC)
• 7. Ambulatory Surgical Center Association (ASCA)
• 8. Accreditation Association for Ambulatory
  Healthcare (AAAH)
• 9. Association of Operating Room Nurses (AORN)
• 10. Webster Healthcare Consulting
• 11. Pascal Metrics

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Participating Orthopaedic Organizations

• 1. American Academy of Orthopaedic Surgeons
  (AAOS)
• 2. American Association for Hand Surgery (AAHS)
• 3. American Orthopaedic Foot and Ankle Society
  (AOFAS)
• 4. American Association of Hip and Knee Surgery
  (AAHKS)
• 5. American Orthopaedic Society for Sports
  Medicine (AOSSM)
• 6. American Shoulder and Elbow Society (ASES)
• 7. American Society for Surgery of the Hand
  (ASSH)
• 8. American Spinal Injury Association (ASIA)
• 9. Arthroscopy Association of North America
  (AANA)
• 10. Cervical Spine Research Society (CSRS)
• 11. Hip Society (HS)
• 12. Knee Society (KS)

33
Participating Orthopaedic Organizations

• 13. Limb Lengthening and Reconstruction Society
  (LLRS)
• 14. Musculoskeletal Tumor Society (MSTS)
• 15. North American Spine Society (NASS)
• 16. Orthopaedic Trauma Association (OTA)
• 17. Pediatric Orthopaedic Society of North
  America (POSNA)
• 18. Scoliosis Research Society (SRS)
• 19. Society of Military Orthopaedic Surgeons
  (SMOS)
• 20. American Academy of Orthopaedic Surgeons
  (AAOS)
• Board of Directors (BOD)
• Board of Specialty Societies (BOS)
• Board of Councilors (BOC)
• Council on Research and Quality (CoRQ)
• Patient Safety Committee (PSC)

34
Summit Work Group Safety Projects

• Hand/Foot Ankle Opioid Abuse
• Hip/Knee/Tumor SSI Prevention Bundle
• Pediatrics Peds Patient/ Family Checklist
• Spine Wrong Level Spine Surgery
• Sports UP in Surgicenters
• Trauma Hip Fracture

35
Patient Safety Summit

• Next Steps
• Develop Pilot Projects
• Explore data relationships
• ACS, SCOAP
• Explore Global SSI Prevention Program
• CDC, AHRQ, AAOS
• Unified Orthopaedic Safety Information Statement
• Explore BOS Safety role

36
Safety Barriers

• Surgeon resistance to change
• Inadequate surgeon knowledge
• Limited utilization of surgical team safety
  science
• Limited surgeon data contribution and
  benchmarking
• Inadequate surgeon leadership

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Orthopaedic Surgical Safety Journey

• Safety is no Accident
• AAOS Sign Your Site Program 1997

38
(No Transcript)
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Paradigm Shifts Orthopaedic Safety Programs
Education

• Orthopaedic education programs
• New focus/balance safety, quality and value
  science in all
• orthopaedic education programs/products
• Orthopaedic Quality Institute
• Safety Summit
• Standardization system-based focus vs.
  implant/surgical technique focus

40
Paradigm Shifts Orthopaedic Safety Programs
Data

• New safety/quality data programs
• CMS Public Reporting (PACA)
• national benchmarking
• regional benchmarking (by state)
• HVHC - Dartmouth Institute private
  benchmarking collaborative
• System performance vs. surgeon performance
• System focus prevention harm vs. good results
  
• Deming count bad light bulbs not good light
  bulbs
• Patient outcomes vs. surgeon outcomes reporting
• Multi-center vs. single center trials reporting

41
Paradigm Shifts Orthopaedic Safety Programs
Clinical

• New standardized system-based interdisciplinary
  surgical
• care programs
• Geisinger ProvenCare
• Patient contract
• Intermountain Health System
• ACOs
• Bundled Care products
• NorthShore University HealthSystem
• Care reliability (LOS, Costs)
• Complication prevention
• Readmission management

42
AAOS Orthopaedic Surgery Safety Summit Chicago,
2012

• 6 Ortho Sub-Specialty Work Groups
• Conference Calls. April - July
• Safety Webinar
• Tuesday, July 31
• Safety Summit
• Sunday, August 5 - Monday, August 6

43
Hand Foot/Ankle Work Group

• Opioid misuse/abuse
• Orthopaedic prescribing practices
• Orthopaedic education
• Build consensus standards
• Collaboration national organizations/federal
  government/advocacy

44
Is there an Orthopaedic Surgery Safety Problem
2012? Orthopaedic Evidence

• Orthopaedic surgical outcomes highly variable -
  by surgeon/hospital/healthcare system/region
• Limited local, regional, national orthopaedic
  safety/quality data
• Slow adoption Safety/Quality communication and
  process
• Few recognized surgeon safety leaders/champions

45
Hip, Knee, Tumor Work Group

• SSI Prevention bundle
• Pre-op checklist
• Diabetic optimization
• smoking cessation
• OR checklist
• Skin Prep
• Antibiotic optimization
• Post-op checklist
• Wound care optimization
• PIM/OKO modules
• Collaboration AHRQ, AAHKS, HS, KS, MSTS, CMS,
  AORN

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Pediatric Work Group

• Patient/Family Checklist
• 10-15 elective procedures
• Focus patient safety, quality, value
• Collaboration POSNA, SRS, Peds Hospitals
• Pilot Study

47
Spine Work Group

• Wrong-level Surgery Prevention
• Sign Mark and X-ray
• (SMaX)
• OR Checklist
• Confirmation with imaging
• Pilot Study
• Develop PIM
• Collaboration - NASS
• Educate

48
Sports Work Group

• Universal Protocol (UP)- Surgicenters Offices
• Pilot Project
• Scheduling
• Pre-op Holding
• OR
• Patient focus
• Collaboration AOSSM,
• AANA, JC

49
Trauma Work Group

• Hip FX Quality Pathway
• Checklists/order-sets
• Pilot Study
• SSI Prevention
• New SSI Quality bundle
• Pilot study
• Hip FX PIM/s
• Collaboration - CDC, AHRQ, OTA, AGS

50
AAOSSafe Orthopaedic Surgical Programs

• Surgical Team Communication
• effective patient and surgical team communication
• TeamSTEPPS
• human factors supporting a Culture of Safety
• distraction-free/focused OR environment
• Standardized Surgical Processes
• accurate timely patient-centered informed consent
• proper marking and confirmation of
• site - side - level - implant - procedure -
  patient
• regular use standardized surgical checklists
• Surgical Data
• Systematic surgical data collection and analysis

51
Orthopaedic Safety Summit Ortho Sub-Specialty
Work Groups

• Hand/Foot-Ankle David Ring MD
• Hip/Knee/Tumor Mark Froimson MD
• Pediatrics Kit Song MD
• Spine Paul Huddleston MD
• Sports Laurence Higgins MD
• Trauma Steve Olson MD

52
CMS NorthShore THR/TKR All-Cause Readmissions

• consensus building among surgeons
• collaboration hospital administration
• surgical team communication
• patient-centered care with optimized outcomes
• reducing/controlling unnecessary costs
• validate innovation improvements
• surgeon self reporting - safety/quality/value
  data

53

• Thanks

54
Historical Unsafe Surgical Behaviors

• Process - surgical techniques/care plans - highly
  variable
• surgeon-unique
• Data -surgical care experience-based
• little/no surgical data collection/analysis
• Communication - surgical authority hierarchal
• surgeon top down to surgical team

55
Model Needed forSafe Surgical Behaviors

• Process - surgical techniques/care plans
  standardized and evidence/consensus-based best
  practices
• consistent/reliable
• Data - surgical data systemically collected and
  analyzed
• improvements data/active management driven
• Communication - Surgeon authority shared in team
  model
• surgeon as leader supporting transparency and
  authority
• delegation

56
Model Orthopaedic Surgical Safety
57
How?

• Introduce OR behaviors benefitting entire
  surgical team
• Embrace safety science in orthopaedic practices
• Own orthopaedic surgical safety data and errors
• Shift focus surgeon to surgical care system
  improvement
• Celebrate improvements
• Partner with patient, stakeholder and safety
  organizations

58
Safety Summit

• No!
• cultural change resistance
• other industries safety change gt decade
• Options
• embrace change improve care
• resist change accept regulatory
  mandates/financial penalties
• Safety Summit designed to
• expand safety practices introduced by AAOS in
  1997
• build new orthopaedic specific safety tools
• affirm orthopaedic leadership/commitment

59
Safety Summit Summary Overview

• Participant Recognition Prioritize Safety for
  ALL orthopaedic settings
• 6 sub-specialty work groups PILOT new
  orthopaedic safety programs
• Safety collaboration - CMS, AHRQ, JCAHO, ACS,
  SCOAP
• Unify Orthopaedic community
• UNIFIED Orthopaedic Safety Information Statement
  
• BOS and AAOS collaboration new safety programs
  /products

60
Summit SafetyOutcomes Summary

• Unified Position Statement on Orthopaedic
  Surgical Safety
• Develop funding support for Work Group pilot
  safety programs
• Continue communication CMS, JCAHO, AHRQ
• Explore partnering with ACS/SCOAP for surgical
  safety data
• Explore ongoing support and coordination of the
  Orthopaedic Safety programs
• ? new BOS Safety Committee
• Collaborate with AAOS Surgical Safety TeamSTEPPS
  Communication Program (80 Centers/3 years)

61
Safety Recommendations Trauma Work Group

• Recommend to AAOS - SSI Prevention Guideline
• Develop SSI Prevention Checklist (Bundle)
• Antibiotic management HbA1C/Hypergylcemia
  Management
• Surgical warming (gt35c.) Albumin/Nutritional
  management
• Smoking Cessation Blood manageent
• Pilot a Standardized Hip Fracture Patient Care
  Pathway
• Standardized Order Sets
• Pre-op
• Post-op
• Discharge
• Hip Fracture PIM
• Goals decreased LOS, decreased costs and
  improved Fx outcomes

62
Safety Recommendations Sports Work Group

• Develop a Surgical Safety Program for Ambulatory
  Surgery Centers
• Collaborate with JCAHO, ASCA
• Develop training modules
• Collaborate with AAOS TeamSTEPPS training program
• Currently only 50 of orthopaedic surgicenters
  use Universal Protocol

63
Safety Recommendations Spine Work Group

• Recommend to AAOS - SSI Infection Prevention
  Guideline
• Pilot - Wrong Level Spine Surgery Checklist
• Define imaging requirements
• Define wrong level surgery
• Define exception/outlier management obesity,
  retained implants

64
Safety Recommendations Pediatric Work Group

• Pilot a Family/Patient Focused Peri-operative
  Checklist
• Pre-op
• Care team review
• Consent,
• Team huddle
• Surgical
• Post-op surgeon review
• Post-op
• Care plan review
• Discharge
• Follow-up appointment
• 10-15 pilot centers identified
• Potential funding sources identified

65
Safety Recommendations Hip/Knee/Tumor Work Group

• Recommend to AAOS - SSI Prevention Guideline
• Develop SSI Prevention education products
• OKO
• PIM
• With AHRQ pilot Pre-op Optimization SSI
  Prevention
• Checklist (Bundle)
• Obesity (BMIgt40 counseling)
• Smoking Cessation (Pre-op counseling/cessation)
• Diabetic Management (Optimize Pre-op HbA1C lt7)
• Anemia Assessment (for pre-op Hblt10)

66
Results Wrong Site/Procedure Errors

• 2010-11 - Wrong Site/Procedure Surgeries
• Hospital ORs - 0.4/yr.
• Surgi-Center ORs - 0.25/yr.
• Office Procedure Rooms 0.05/yr.
• Career - Wrong Site/Procedure Surgeries
• Hospital ORs estimated -1/20,000 surgeries
• Surgi-Center ORs estimated -1/80,000 surgeries
• Office Procedure Rooms insufficient data (rare)

67
Safety Recommendations Hand/Foot-Ankle Work
Group

• Develop an comprehensive opioid drug misuse/abuse
  
• management and education program to
• decrease peri-operative opioid drug events,
• improve orthopaedic outcome satisfaction
• reduce opioid dependency/abuse
• 80 of worlds opioid drugs consumed in US
• Opioids - 1 cause of accidental death in young
  adults in US