Collaboration aims to lower costs, improve outcomes for knee and hip replacements

November 15, 2014


The Connecticut Joint Replacement Institute at Saint Francis Hospital and Medical Center in Hartford is one of three project leaders on a collaborative organized by Harvard Business School faculty and staff and the Institute for Healthcare Improvement to improve the value of care by reducing costs and improving outcomes for knee and hip replacement procedures.

The collaborative, called the Joint Replacement Learning Community, runs throughout 2014. Harvard Business School faculty taught about 30 participating organizations how to use time-driven, activity-based costing methodology to map each step and cost involved with knee and hip replacements. Then, Institute for Healthcare Improvement faculty worked with the same organizations on ways to make improvements to their systems to enhance quality and reduce costs, and how to better measure both clinical and patient-reported outcomes.

Such focus on bettering cost and outcomes is intended to lay the groundwork for more bundled payment contracts for joint replacements, in which providers or hospitals receive a single payment covering surgery and postsurgical care. According to a website about the collaborative, members paid $24,500 per participating hospital and its affiliated orthopedic surgeons to take part in the learning community. Members have met in person twice, with one more group meeting planned this month; took part in webinars and group phone calls and communicated through email.

Serving as a project leader for the learning community was a natural extension of the Connecticut Joint Replacement Institute's efforts to standardize joint replacement surgeries and let data drive decisions related to patient care and the business of medicine. Its surgeons have performed more than 17,000 knee and hip procedures since Saint Francis formed the institute in the summer of 2006.


Dr. Steven Schutzer, surgeon and medical director of the Connecticut Joint Replacement Institute, took Robert S. Kaplan and Michael E. Porter's "Value Measurement for Health Care" Harvard Business School executive education course in 2012 because the education aligned with the joint institute's goal of offering dependable surgical outcomes while containing costs. Kaplan, in turn, was interested in the joint institute's experience in improving health care value. The organizations began a collaboration, and that led to the Connecticut Joint Replacement Institute being a project leader for the learning community.

"We've had a great year. We've learned as much as we've taught others. … Every entity has something to bring to the table where we say: Hey, why didn't we think of that?" Schutzer said.


Derek Haas, a fellow and project director of value-based health care delivery at Harvard Business School who works with the learning community members, said clinicians and financial staff at each participating organization tracked the patient care cycle from the time the decision for a surgery was made through post-discharge care. Clinicians and financial analysts recorded what care was delivered, by what level of staff member, at what cost, how much time was spent on care and the supplies and materials used as part of the care.

At a face-to-face meeting in Massachusetts in May, participants learned how their organization compared with other surgery groups in the collaborative. Haas said, "We're very careful and very sensitive to make sure we're not disclosing identified cost information."

From there, the learning community addressed categories where members of the collaborative could reduce costs, such as trying to improve efficiencies to shorten a patient's length of stay in a hospital and the time and costs in the operating room. Discussions explored how hospitals could proactively plan to ensure as many patients as possible could safely be discharged to home and receive outpatient therapy, which carries lower cost than discharging patients to an inpatient rehabilitation program or a skilled nursing facility.

Participants also considered supply costs and learned strategies for negotiating better prices.

Schutzer said when the Connecticut Joint Replacement Institute formed, it gained an advantage in negotiations with joint implant suppliers by inserting a surgeon into price and purchasing talks. "Because of the volume we do, all of them want our business. We've been very successful, when we have a seat at the table, of driving the price point down."


The Connecticut Joint Replacement Institute also did a lot of work in the years before the learning community began to adjust job responsibilities so that staff were working at their highest clinical level, and it has advised other learning community members on similar efficiency efforts. Maureen Geary, program manager at the Connecticut Joint Replacement Institute, said, "For instance, does a physical therapist need to walk a patient down the hall? Can that be a mobility tech or a physical therapist assistant?" While organizational change can be difficult, Geary said she thinks it's a "staff satisfier if you have them working at their highest clinical level."

The learning community also shared clinical outcomes and how to gather and assess patient-reported outcomes. While there's not yet full standardization on patient-reported outcomes, it's a way for a hospital or facility to gauge if a patient reports less pain than he or she had before an implant procedure, and if the patient is able to return to the activities or sports the person enjoyed before needing a hip or knee replacement.

Schutzer said employers who are paying for health care want more data, such as how quickly patients can return to work and how soon they'll be able to return to the physical tasks of a job following joint replacement surgery.

And he said patients, some of whom face higher deductibles than they have in past, are seeking more information about costs and clinical outcomes. He said, "They want to know: Hey, are you any better than anyone else?"


Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2014 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.