Fig. 1 Zero in on Zero Multimodal Problem Solving Targets. Ten adverse events in lower extremity arthroplasty best mitigated with simultaneously applied Integrated Clinical Pathways.
Courtesy of Mark A. Snyder, MD, FAOA


Published 3/1/2018
Mark A. Snyder, MD, FAOA

Eliminate Adverse Events with Integrated Clinical Pathways

Physician-led innovation maximizes value for patients and society
The current healthcare environment is forcing hospitals to face uncertain futures and chart new courses as they shift from volume- to value-based systems and business models. According to Ian Morrison, author of The Second Curve: Managing the Velocity of Change, the second curve is the future—new technologies, new consumers, and new markets—and traditional methods of change are not sufficient to enable companies, including healthcare organizations, to survive.

A proven, multimodal problem-solving innovation called Zero in on Zero (ZIOZ) can radically reduce adverse events and lead to rapid achievement of Second Curve status in hospitals where hip and knee arthroplasty surgeries are performed. At Good Samaritan Hospital, where I serve as medical director of the Orthopedic Center of Excellence, ZIOZ has been used to radically reduce rates of complications, readmissions, and revisions after primary hip and knee arthroplasties.

In 2011, we simultaneously enacted integrated clinical pathways (ICPs) for 10 adverse events (Fig. 1). Since then (through 2017), more than 2,000 consecutive primary hip and knee arthroplasties have been performed, with the following results:

  • no transfusions
  • no hospital falls with injury
  • no surgical site infections
  • less than 0.1 percent venous thromboembolism (VTE) readmissions
  • no serious 90-day opioid complications
  • no early primary total hip dislocations

As implemented at our hospital, ZIOZ is a straightforward, user-friendly approach that has resulted in a less than 2 percent combined all-cause 30- and 90-day readmission rate, as verified through a Level III registry and a peer-reviewed Institutional Review Board study. It's also resulted in a considerably lower cost of care.

In the Cincinnati Metropolitan Statistical Area—Bundled Payment Initiative for 2016 and 2017, the Medicare total episode spend for total hip arthroplasty (THA) and total knee arthroplasty (TKA) performed with full ZIOZ utilization was less than $18,000. This compares favorably (more than 20 percent lower) with the more than $23,000 mean spends for THA and TKA performed by all other surgeons in our health system's two major teaching hospitals.

The lower cost of care was driven by shortened length of stay, reduction of post-acute care inpatient stay, and minimal readmissions. It reflects the proven value concept proposed by Michael Porter and Tom Lee in 2013: achieving the best outcomes at the lowest cost.

How we did it
We used evidence-based, straightforward, and simultaneously enacted ICPs to address 10 adverse events. The major factors in the successful implementation of this process include multidisciplinary contributions, collaboration between health system employed and affiliated surgeons, and the triad leadership of a surgeon champion, high-ranking administrative leader, and the current program manager. We greatly appreciate the 7 years of support from the facility maintenance, clinical, and research staff, as well as from surgeons and hospital administrators.

In the process, we are also working toward the development and deployment of a perioperative surgical home. This requires broad and ongoing collaboration among anesthesiologists, clinical care navigators, surgeons, and nursing leaders, with support from the hospital's corporate suite. We are using the ZIOZ ICP process improvement as a foundational template for this perioperative orthopaedic surgical home.

The ZIOZ ICPs encompass the 120 days before, during, and after THA and TKA surgeries. We believe that this straightforward language is stronger and more easily understood than descriptions such as preoperative, intraoperative (acute stay), and postoperative, which are often used in other surgical home models. For each adverse event, we developed best practice recommendations based on levels of evidence support.

The tables accompanying this article show the best practice recommendations in each phase for transfusion prevention (Table 1), pain management (Table 2), and reducing VTE readmission. Bold text indicates widespread hospital implementation while italic text indicates physician-dependent choices. The level of evidence support is shown in parentheses following the recommendation—S for strong, M for moderate, and I for indeterminate.

Patient risk identification and risk reduction are best achieved through patient activation, and patient activities were built in as necessary for each adverse event. Health System LinkNet learning modules were built for continuing education credit. A higher percentage of clinical staff than surgeons accessed these modules.

Both employed and affiliated surgeons and health system hospitals were afforded early and free access to the ZIOZ ICPs. As predicted at the time of program inception, only those surgeons who were fully compliant with ZIOZ had the lowest rates of complications, readmissions, and cost reductions. However, the extensive implementation of ICPs by the hospital meant that all arthroplasty surgeons benefited.

Resistance by surgeons and health systems to the implementation of ICPs is well understood. But because implementing ICPs does not demean surgeon expertise and licensing, there is little reason for persistent fear, resentment, and disregard to block ICP utilization.

On a hospital level, the simultaneous implementation of ICPs to prevent several adverse events also yields greater synergy benefits. The ICPs are regularly vetted and refined, as evidence-based support becomes available. Large consensus efforts (such as those undertaken for periprosthetic joint infection), although strong in evidence assessment, are not formatted in a way that can be easily used for ICP efforts.

Turning the curve
ZIOZ is straightforward, data transparent, readily implemented, synergistically beneficial, Level III registry proven, and cost effective in primary THA and TKA surgeries. Our patients and families appreciate knowing about adverse event solutions and outcome-enhancing methods well in advance of arthroplasty surgery.

Second Curve hospitals must perform at supernormal levels to be successful in meeting risk contracts; they must also be clinically integrated to optimize the value in THA and TKA surgeries. Patient-access issues, such as current predictions that demand will exceed provider capacity before 2030, can only be mitigated if total joint surgeons and their respective hospitals maximize safe, high-value performance.

As demand for total joint surgeries increases, general orthopaedists will be required to supplement specialist care. Straightforward, easily understood ICPs for TKA and THA, if completely implemented, could reduce variation in adverse events and care episode costs, while increasing patient satisfaction and surgeon fulfillment. The success we experienced with ZIOZ ICPs in primary THA and TKA could eventually support large risk-sharing strategies like 90-day guarantees. Patients, payers, providers, programs, and places of service could all benefit.

Mark A. Snyder, MD, FAOA, is medical director of the Good Samaritan Hospital Orthopedic Center of Excellence in Cincinnati.


  1. Morrison I: The Second Curve: Managing the Velocity of Change. New York, Ballantine Books, 1996.
  2. Porter ME and Lee TH: The Strategy That Will Fix Health Care. Harvard Business Review 2013;91:10: 50–70.
  3. Manning BT, Callahan CD, Robinson BS, Adair D, Saleh, KJ: Overcoming Resistance to Implementation of Integrated Care Pathways in Orthopaedics J Bone Joint Surg 2013;95: p e100