Edward Sweetser, MD, MountainView Regional Medical Center


Published 8/1/2018
Karen Metropulos, MBA

MountainView Regional Medical Center Leverages Registry Data to Earn Joint Commission’s Gold Seal

MountainView Regional Medical Center (MVRM), located in Las Cruces, N.M., has been an American Joint Replacement Registry (AJRR) subscriber since November 2014. AJRR participation helped Mountainview’s Total Hip and Knee Replacement Center utilize registry benefits to achieve and maintain The Joint Commission’s Gold Seal certification. Other healthcare institutions can learn from the center’s experience in choosing a registry capable of supporting a Joint Commission–certified program.

Measures that matter

The Joint Commission certification process provides MVRM with a framework to identify and measure areas for improvement. Because MVRM participates in an audited national data registry (AJRR), it can systematically and consistently submit data, track progress, use benchmarks, and see how its Total Hip and Knee Replacement Center’s certified program engages and/or improves various performance areas. Measures can include length of stay (LOS), discharge disposition, surgical site infections, comorbidities and other patient risk factors, revision rates, and complications data. These are measures that matter in The Joint Commission review process.

Beyond certification, registry data trending and benchmarking can provide insight into volume changes (Fig. 1), serve as an early warning of safety issues, provide insights that influence surgeon and clinical staff behavior (Fig. 2), and decrease costs from excessive resource usage, among other benefits.

Results that matter

Examples of MVRM’s orthopaedic quality-improvement results include the following:

  • 2016–2018: LOS was reduced from 2.6 days to 1.3 days
    (Fig. 3).
  • 2013–2018: LOS was reduced from four days to 1.3 days
    (Fig. 3).
  • 2016–2018: Patient discharge to home increased from 62 percent to 83 percent (Fig. 4).
  • Monitoring comorbidities prior to surgery has reduced surgery cancellations to near zero among higher-risk patients.
    • Best practice: Hemoglobin must be less than 7 g/dL to move forward with surgery.
    • Best practice: Body mass index must be below 40 kg/m2 to move forward with surgery.

First steps in achieving the Gold Seal

Edward Sweetser, MD, MountainView Regional Medical Center
Fig. 1 MVRM’s Total Hip and Knee Replacement Center doubled its procedural volume between 2011 and 2017.
Courtesy of MVRM and Edward Sweetser, MD
Fig. 2 Monitoring hematocrit prior to surgery, ensuring that it is 34 or higher, and using tranexamic acid during surgery helped reduce the need for blood transfusions to near-zero levels.
Courtesy of MVRM and Edward Sweetser, MD
Fig. 3 MVRM’s combined hip and knee surgery 30-day readmission rate was reduced from more than 5 percent of total volume in 2011 to less than 3 percent in 2017.
Courtesy of MVRM and Edward Sweetser, MD
Fig. 4 In the past two years (2016–2018), MVRM’s combined hip and knee surgery discharge-to-home rate increased from 62 percent to 83 percent, allowing more patients to return home sooner.
Courtesy of MVRM and Edward Sweetser, MD

Joint Commission–accredited hospitals are eligible to apply for optional orthopaedic certification programs if they meet these minimum Joint Commission requirements:

  • Joint Commission–accredited organization
  • program has served more than 10 patients
  • use of standardized clinical care delivery based on evidence-based care and clinical practice guidelines
  • use of a nationally audited registry or similar data-collection tool to monitor data and measure outcomes for specified conditions and procedures

“Our entry into AJRR has greatly enhanced our data-collection, measurement, and analytical capabilities regarding various Joint Commission certification requirements,” said Edward Sweetser, MD, of MVRM.

Daniel J. Berry, MD, chair of the AAOS Registry Oversight Committee, added, “Quality-improvement efforts, like Joint Commission–certified orthopaedic programs and others, benefit from three levels of AJRR data. New Level II risk-adjusted data support better-informed surgical decisions. New Level III data provide patient-reported outcomes, creating a more comprehensive picture of patient care. In this way, AJRR continues to evolve to meet our participants’ needs and their continuous focus on improving patient care.”

MVRM checklist for choosing a registry

MVRM’s experience suggests that facilities should look for the following features when choosing a data registry to support their Joint Commission–certified programs, as well as other quality-improvement initiatives:

  • access to national registry database participation
  • Qualified Clinical Data Registry designation from the Centers for Medicare & Medicaid Services
  • established electronic health record data capture and analysis
  • network of national database users to allow further investigation of findings at local and national levels and identify best practices
  • proprietary data dashboards aligned to the facility’s certification program
  • national comparative dashboards to assess quality and create performance benchmarks

Dr. Sweetser concluded, “As a national registry, AJRR is able to provide the mostLO accurate and complete picture of the arthroplasty experience in the United States. By [AJRR] providing benchmarking and monitoring outcomes of arthroplasty, we can further advance the efforts of patient safety and quality of care. Implementation of a certified orthopaedic program and national registry participation provides clinicians with an efficient framework to improve patient outcomes at the hospital and surgeon levels.”

Editor’s note: This article concludes a three-part series illustrating practical aspects of AJRR participation through shared success stories from subscribing institutions. All three installments can be found at www.aaosnow.org.

Karen Metropulos, MBA, is a content writer and blog editor at AJRR, part of AAOS’ Registry Program.