Fig. 3a Table showing Bone and Joint Institute performance metrics and 90-day rates of surgical site infections. The green squares show achievement of target rate of < 0.30 percent.

AAOS Now

Published 3/24/2021
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Theodore A. Blaine, MD, FAAOS, FAOA; John Grady-Benson, MD, FAAOS; Stacey Lombardi, MBA; Courtland Lewis, MD, FAAOS

The Success of Physician-hospital Co-management Agreements

Five-year update on performance of Hartford Healthcare’s Bone and Joint Institute

Consistent with the purpose and vision conceived by its founders, Hartford Healthcare’s Bone and Joint Institute (BJI) has achieved a successful model of musculoskeletal co-management agreements between physicians and hospital systems (“Co-management Agreements Prove to Be Viable Models for Physician Input,” AAOS Now, April 2019). BJI embarked on its journey in 2013 with the vision to “be the acknowledged regional leader in person-centered, innovative musculoskeletal health.” At the end of its fifth year of co-management and its third year of operation after opening an award-winning building, BJI has achieved many targets in key performance metrics set by the administrative team (Table 1).

Leadership and infrastructure

Bone and Joint Institute leadership: (from left) Courtland Lewis MD, FAAOS; Theodore Blaine MD, FAAOS; Stacey Lombardi, MBA; and John Grady-Benson MD, FAAOS
Table 1 Fifteen performance metrics established by the Bone and Joint Institute.(BJI). ACS, American Cancer Society; NSQIP, National Surgical Quality Improvement Program; HH, Hartford Healthcare; PACU, post-anesthesia care unit; DO, double occupancy; YOY, year over year; PROMs, patient-reported outcome measures; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems
Fig. 1 Grand Rounds speakers at the Bone and Joint Institute
Fig. 2a Theodore Blaine, MD, FAAOS, teaching a Center for Education, Simulation, and Innovation cadaveric training course in shoulder replacement surgery.
Fig. 2b Graham King, MD (London, Ontario, Canada) demonstrates a total elbow replacement to faculty and fellows at a Center for Education, Simulation, and Innovation cadaveric training course.
Fig. 3a Table showing Bone and Joint Institute performance metrics and 90-day rates of surgical site infections. The green squares show achievement of target rate of < 0.30 percent.
Fig. 3b Graph showing Bone and Joint Institute 90-day rates of surgical site infections.
Fig. 4 Bone and Joint Institute 30-day readmission rates with target goal of < 2.5 percent.
Fig. 5 Percent of patients using opioid pain medications 60 days after surgery.
Fig. 6 Bone and Joint Institute completed surgeries per year.
Fig. 7 Bone and Joint Institute OR turnover times by month, with target goal of < 30 minutes.
Fig. 8 Bone and Joint Institute length of time in post-anesthesia care unit for elective total knee and hip arthroplasty, with target goal of < 90 minutes
Fig. 9 Administration and staff celebrating with the Hartford Yard Goats Mascot in front of the Bone and Joint Institute.

BJI has a structured approach to management that is guided by shared physician and administrative leadership and supported by hospital infrastructure and resources. Working together with Jeff Flaks, chief executive officer of Hartford Healthcare, Courtland Lewis, MD, FAAOS, became the inaugural physician-in-chief (PIC) of BJI in 2013 and engineered the successful launch and early success of the enterprise. In January 2018, Theodore A. Blaine, MD, FAAOS, FAOA, was recruited from his former role as interim chair of the Yale University Department of Orthopaedics to become BJI PIC and vice president of musculoskeletal services at Hartford Healthcare together with Stacey Lombardi, MBA, also from Yale University, who assumed a role as vice president of business operations at BJI. John Grady-Benson, MD, FAAOS, assumed the lead role in October 2019, and he is now PIC of BJI, vice president of musculoskeletal services, and chair of the Department of Orthopaedic Surgery at Hartford Healthcare.

The co-management agreement is designed to empower orthopaedic physicians in the operations of running BJI as well as driving quality standards. The co-managed service line agreement covers all aspects of planning and managing hospital-within-a-hospital services. The benefit to the physician in a co-management agreement is that he or she retains control and autonomy over his or her practice environment. The physician assumes little financial risk, does not have facility overhead, and is paid fair market value for his or her time and effort dedicated to managing the service line. Each physician is paid for documented hours of administrative work to manage daily operations and may receive incentive payments for reaching or exceeding agreed-upon quality metrics.

Key to the co-management infrastructure at BJI are the four nonphysician directors of nursing, perioperative services, inpatient services, and quality and safety. Providing clinical leadership and administration are the 13 MDs—one medical director and 12 service line leaders (spine, sports, hand, foot and ankle, physical medicine, rheumatology, anesthesia, shoulder and elbow, hip and knee, hip fracture, trauma, and perioperative medicine). These service line leaders hold monthly meetings to track service metrics, which also include the performance objectives that are collectively established by the orthopaedic physicians and BJI administration. The service line leaders are integral to engineering change and advancing patient-centered, high-quality care at BJI.

Academic mission: research and education

A key strategic focus of BJI has been building an academic infrastructure working together with BJI’s academic partner, the University of Connecticut (UConn). Orthopaedic residents from UConn rotate through BJI and are exposed to a high volume of clinical musculoskeletal care, especially on the trauma service. In 2019, a monthly grand rounds series was instituted, bringing in many national speakers from leading institutions, including the Rothman Orthopaedic Institute, Brown, Yale, Western University in Ontario, and UConn (Fig. 1, available in the online version).

Educational courses were also developed at Hartford Healthcare’s Center for Education, Simulation, and Innovation and included topics in arthroplasty, robotics, sports medicine, and rheumatology (Fig. 2, available in the online version). Working together with UConn, fellowship training programs were established in subspecialty areas including shoulder and elbow surgery, rheumatology, spine surgery, hand surgery, and regional anesthesia. Additional fellowship training programs are currently being planned and include foot and ankle and total joint arthroplasty.

An important part of the academic mission of BJI has been the initiation and performance of Institutional Review Board (IRB)-approved research studies. With this goal in mind, a robust research infrastructure was built with the support of Hartford Healthcare. Dedicated BJI staffing and analytics resources allow orthopaedic physicians to maintain a high level of clinical activity with appropriate support to move research queries and IRB submissions forward. Space was allocated in the new building to house the Clinical Research Division, which is now occupied by two clinical research coordinators, two research assistants, and a medical advisor for research and education. In addition, an information technology (IT) and business intelligence manager was hired to support the IT needs in research and data analytics. Finally, with the goal of providing comprehensive research opportunities for BJI physicians, partnerships were formed with UConn to perform basic science and biomechanics research.

All new studies are required to complete a research intake form, which is then reviewed and approved by the service line director, medical advisor for research, and vice president of business operations. Monthly research conferences are conducted to update and discuss all BJI research projects, with biweekly research conferences specific to each service. As a result of these research efforts, more than 18 new research projects were initiated over a 12-month period in 2019, with 12 new IRB approvals on a variety of topics. These approvals led to presentations by students, residents and fellows, nurses, and BJI physicians at a variety of national meetings, as well as several research publications. Further research expansion is in place for 2021 with scholarly medical writers who assist physicians with abstract and journal submissions.

Optimizing clinical care: quality and safety

Signature programs developed by the physicians at BJI have strengthened its missions of clinical care, research, and education and have helped to optimize patient care across the institution. An example is the PREPARE program, which ensures that patients are seen, evaluated, risk-assessed by anesthesiologists, medically optimized, and educated prior to elective surgery at BJI. Selected patients with modifiable risk factors, such as obesity and diabetes, are referred to the MODIFY program, which is designed to medically optimize such patients for surgery. Patients who have completed surgery are connected to the RECOVER program, where a variety of rehabilitation services are instituted to maximize their recovery after surgery.

Medical optimization before surgery has led to fewer complications; the overall surgical site infection rate was as high as 1.6 percent in 2018 and was reduced to the goal of less than 0.3 percent in 2019 (Figs. 3a and 3b, available in the online version). Thirty-day readmission rates were also reduced to less than 2.5 percent (Fig. 4, available in the online version). Part of this success has been ensuring the message of “call your doctor/treatment team before you go to the emergency department” as part of the preoperative communication in the physician offices. Opioid use, another measure of both the PREPARE and RECOVER programs, has also seen significant reductions to less than 5 percent of patients using opioid pain medications at 60 days postoperatively (Fig. 5, available in the online version).

Finance and operations: volume and revenue

Consistent with its objectives, BJI has seen steady growth in patient volume and revenue. Surgical volumes increased by 8 percent over two years to 5,493 completed cases in 2019 (Fig. 6, available in the online version).

With many performance metrics focused on operating efficiencies, BJI made significant improvements in its operations, from central sterile processing to the ORs and patient care facilities. In the ORs, on-time starts improved from 60 percent to nearly 90 percent in one year. Turnover times between surgeries decreased from 40 minutes to 33 minutes (target of 30 minutes) (Fig. 7, available in the online version). In addition, post-anesthesia care unit (PACU) times decreased from 128 minutes to 88 minutes (Fig. 8), allowing more patients to be transferred from the PACU to inpatient rooms and increasing throughput efficiencies.

Data transparency and physician collaboration on standardized patient care protocols have been instrumental in achieving clinical quality-performance metrics. Open reporting and discussion of patient outcomes and adverse events occur at all monthly service line meetings. The data-reporting structure identifies each surgeon by name. Substantial work to adjudicate data sources and improve data accuracy has engendered physician trust and allowed for process improvements, as well as individual behavioral change to meet benchmarking standards. The cultural norm is to review all outcomes and adverse events in a spirit of cooperation, without “blame or shame.”

Patient and employee satisfaction

One of the key determinants of BJI’s success has been its focus on patient and employee satisfaction. Hospital Consumer Assessment of Healthcare Providers and Systems scores lead the institution, with patient satisfaction rates consistently over 90 percent. In addition to the focus on operations, central sterile processing, and perioperative services, an emphasis on inpatient services led by service line directors, the medical director, and the PIC, with collaboration with the nursing director and manager, has contributed to high levels of patient satisfaction. The Patient Family Advisory Council, which gives patients a voice in how their care is delivered at BJI, has also contributed to this success.

The BJI Advisory Council, composed of representative members of the staff, administration, and physicians, has allowed employees an opportunity to make suggestions and improvements. Initiatives have included “Winter Wellness Wednesdays,” when an exercise class was offered in the morning to all staff pre-pandemic, followed by a staff lunch where healthy food was prepared in the demonstration kitchen on site at BJI. There was also a quarterly staff breakfast with the PIC and administration. All of these improvements have led to high employee satisfaction scores and low rates of staff turnover (Fig. 9, available in the online version).

Conclusion

Overall, the Hartford Healthcare BJI has been a successful example of physician-hospital co-management in its first five years of operation. Anchored by its missions of clinical care, research, education, and people, BJI has achieved success in the majority of performance metrics that were established by its leadership. Physicians, hospital administration, and staff remain engaged and focused on the continuing success of the institute. Financial and operational performance have been strong, while clinical care has been “top box” and has been driven by improvements in quality and safety. A focus on research and education has advanced the academic mission of BJI, which has also improved employee and physician engagement. This five-year performance is a strong endorsement of the co-management model and bodes well for future partnerships among physicians, healthcare workers, and large hospital organizations.

Theodore A. Blaine, MD, FAAOS, FAOA, is from the Hospital for Special Surgery and is professor of orthopaedic surgery at Weill Cornell Medical College.

John Grady-Benson, MD, FAAOS, is from Orthopedic Associates of Hartford PC.

Stacey Lombardi, MBA, is from Hartford Healthcare.

Courtland Lewis, MD, FAAOS, is from Hartford Healthcare.