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Published 6/1/2010
John J. Callaghan, MD

All aboard the quality train!

As many of you know, I’ve identified “quality” as the focus of my AAOS presidency. I understand that every member of the AAOS believes that he or she delivers quality care to his or her patients. At the end of the day, however, I think most of us realize there is always room for improvement.

The perception that quality problems exist is widespread. Within orthopaedics, we must sort out which of these perceived problems are real—and how those real problems can be addressed (minimized or improved). The issues of wide variations in the use of healthcare services—such as the underuse of some services, overuse of other services, and misuse of services, including an unacceptable level of errors—are reflected in the following examples of perceived quality problems in healthcare delivery:

  • According to the Dartmouth Atlas Project, wide variations in the rates of hip, knee, and shoulder replacement can be found in different geographic areas and by race.
  • A recent report from the U.S. Department of Health and Human Services found that, of five major types of serious hospital-related infections, rates of illnesses increased for three, declined for one, and remained level for another.
  • Recent studies among orthopaedic surgeons have found that the practice of “signing your site” is still not universal, and in one study, was performed after the incision or not at all in 30 percent of cases!

Is it any wonder, then, that the recently passed healthcare reform bill includes more than 50 original provisions and amendments that deal directly with quality? These include the linking of payment to quality outcomes in Medicare under the Physician Quality Reporting Initiative (PQRI), the establishment of a “Patient-Centered Outcomes Research Institute” to conduct comparative effectiveness research on treatments, and the creation of voluntary “accountable care organizations.”

Do not believe—not for a moment—that these provisions will go away or that the emphasis on quality will dissipate. The “Quality Train” has left the station and is barreling down the track. If you’re not on board, you’re liable to be run over. During the course of the next year, I will try to keep you informed of the many quality issues that will affect our practices.

The consequences of not leading
Delaying or debating the merits of the current push on quality does not help us or our patients. We must get on board the quality train—better yet, we must become drivers of quality.

If physicians do not lead the process, we may find that nonphysicians are monitoring our performance. If orthopaedic surgeons do not participate in shaping quality measures, we may find ourselves judged more on process than on outcomes. If we do not continuously examine and adopt “best practices,” we may find ourselves under scrutiny for the services we perform.

In these days of high healthcare costs, many regulators are equating quality with value. The United States spends more per capita on health care than any other industrialized economy, but the overall performance of the U.S. healthcare system is ranked only 37th in the world, according to the World Health Organization. This gives the appearance that patients in the United States are not getting good value for all the money that is spent on health care.

Orthopaedic surgeons know, for example, that the measurement of patient-centered outcomes to determine “value” in medicine is essential. We cannot just look at direct costs, but must also look at the impact that procedures (such as total hip arthroplasty in my case) have on productivity and quality of life for our patients.

We can drive this train
I believe that the best way to respond to the focus on quality is to embrace it, to make it our goal, and to begin to drive the initiatives. In this way, we can ensure that quality measures are real and verifiable, that they will make a difference in outcomes for our patients, and that they do not place unrealistic or unaffordable burdens on physicians. The AAOS Board of Directors has been working diligently, particularly during two recent workshops, to understand the landscape of these quality initiatives in medicine so that we can lead our profession in developing appropriate measures of quality.

The AAOS is already taking steps to ensure that orthopaedic surgeons are seen as providers of high-quality musculoskeletal care. Quality initiatives at the AAOS include the development of evidence-based clinical practice guidelines, the establishment and support of the American Joint Replacement Registry, and the fostering and communication of well-developed quality measures.

In addition, the Access to America’s Orthopaedic Services (AAOS) Act (HR 1021/S 1548) addresses the fundamental need to educate Congress and the public on the burden of musculoskeletal diseases and conditions and aims to identify and analyze healthcare disparities within orthopaedics.

At our most recent Board workshop, Michael J. Goldberg, MD, vice chair of the AAOS Guidelines and Technology Oversight Committee, reviewed the 20-year history of quality initiatives at the AAOS. The Academy’s record is indeed impressive and proves that we have the skills, dedication, and ability to develop the outcome tools as well as the efficiency and other quality measures to be a major player in this growing and developing field.

The AAOS mission statement is to “serve the profession, champion the interests of patients, and advance the highest quality musculoskeletal health.” Our patients expect quality, the government is demanding it, and we must be able to present evidence that we deliver quality if we are to succeed. By emphasizing quality and our quality initiatives in all aspects of our governance (education, research, advocacy, and communication), we will be true to our mission.

Do you have a quality tip?
Across the country, orthopaedic surgeons are taking the lead in implementing quality practices in their hospitals, their offices, and their interactions with patients, as the following examples show:

  • The orthopaedic surgeons at an ambulatory surgical center implement a system of time-outs and checklists to ensure that all patients receive appropriate care.
  • The orthopaedic department in a hospital champions the use of waterless alcohol hand sanitizers outside every patient room to facilitate routine hand washing by staff and visitors.
  • An orthopaedic practice regularly conducts patient surveys and adapts its practices to improve care coordination and shared decision-making.

If you have a quality tip, I encourage you to share it with me—and I will share a “Quality Tip of the Month” with the fellowship through the AAOS Web site and the pages of AAOS Now.