Fall Meeting
AAOS
Orthopaedic Surgery Safety Update
2012
William J Robb III MD
Chair
AAOS Orthopaedic Surgery Safety Summit
AAOS Patient Safety Committee
Disclosure





Consultant – Blue Cross Blue Shield Association
TJR - Centers of Distinction Program
Consultant (Unpaid) - Smith and Nephew
Investor – emmi Solutions
Chair – AAOS Orthopaedic Surgery Safety Summit
Chair – AAOS Patient Safety Committee
Is there an Orthopaedic Surgery Safety Problem
2012?
Media
ABC News Report - Maryland 2012

Report on Surgical Errors



CMS - only 14% errors reported in hospitals
Advised patients ask about checklists
Report


SSI’s shoulder surgery
Wrong site pediatric eye surgery
Is there an Orthopaedic Surgery Safety Problem
2012?
HealthGrades - 2010

>350,000 patient safety errors/year 2006-2008

Cost $9B

1/10 safety errors results deaths

>100,000 surgical error deaths/year

Top 5% Hospitals – only 43% reduction safety incidents

Wrong Site Surgery (WSS) rates - 1/20,000 surgeries

Hospital SSI rates 2-3%

NO evidence safety/quality improvement 2000-2010
Is there an Orthopaedic Surgery Safety problem
2012?
JC 2009-2010

Wrong Site/Procedure/Patient Surgery (WSS)

Mandatory State –bsed WSS Reporting



Minnesota (48 - WSS)
Pennsylvania (58 - WSS)
35.4 WSS/wk. in US (estimated)
JC Sentinel Events Data Base 2007-2011
54 Orthopaedic WSS
40
34
35
30
30
27
24
25
20
15
9
10
9
10
5
1
Wrong organ
Wrong patient
Wrong finger
Wrong side, other
Wrong side, knee
Other
Wrong side, ankle
Wrong level
Wrong side, hip
1
0
Is there a Orthopaedic Surgery Safety Problem
2012?
Hospital Data JC - 2011

>7 wrong site/side/level/implant/procedure/patient surgeries /day

System errors – NOT Surgeon errors

Most frequent causes:

inadequate/missing surgical information

scheduling discrepancies/errors

irregularities in pre-op holding process

inadequate/absent surgical site marking

poor communication

distractions in OR

inadequate/absent OR process/‘time-out’
Mark Chassin MD, MPP, MPH
Is there an Orthopaedic Surgery Safety problem
2012?

ABOS Certification/Recertification Data Base – 2011


WSS Rate - 1/30,000 orthopaedic surgeries
NO CHANGE 2000-2011
Surgical Safety/Quality/Value Timeline
1997 - AAOS - ‘Sign Your Site’ Program - (safety)
1999 - IOM Report - To Error is Human: Building a Safer
Health System – (safety)
(44-88,00 deaths in hospitals/year from medical errors)
2001 - IOM Report – Crossing the Quality Chasm: A New
Health System for the 21st Century (quality)
2003 - VA National Directive to reduce Risk WSS (safety)
2004 - JCAHO – ‘Universal Protocol’ (safety/quality)
2004 - SCOAP** (safety/quality)

voluntary hospital-based surgical safety/quality – Washington
Surgical Safety/Quality/Value Timeline
2007 - SCIP*

(quality)
mandated national surgical quality standards
2007 - WHO ‘Safe Surgery-Saves Lives’ (safety/quality)
2009 - Checklist Manifesto –Atul Gwande MD (safety and quality)
2010 - Berwick*** CMS Administrator (safety/quality/value)


CMS payments - financial penalties for Never Events
CMS/PQRS payments – financial incentives for ‘quality reporting’
2012 – CMS Public Quality Data Reporting Program
(safety/quality/value)


Hospital SSI Rates
Surgical Re-admission Rates
* Surgical Care Outcome Assessment Program – Washington State Hospital Association
** Surgical Care Improvement Program – US Department of Health and Human Services
*** Former President and CEO, Institute for Healthcare Improvement (IHI)
Evidence Surgical Safety/Quality/Value Programs
are Effective
2006 – Central Line Checklists – Peter Pronovost MD

Reduction central line infections - 40% to <1%
2008 – WHO ‘Safe Surgery - Saves Lives’ - Atul Gwande MD

50% reduction surgical mortality/complications (multi-nation study)
2010 – Surgical Care Outcomes Assessment Program (SCOAP)
 Universal Protocol (UP) adopted in all Washington OR’s

< Complications - appendectomy, colectomy, bariatric surgery

< Hospital Costs
Evidence Safety/Quality/Value Programs are
Effective
2010 – Northern New England Cardiovascular Disease Study
Group

improved Cardiovascular surgery outcomes - participating medical
centers
2011 – VA Surgical Safety Program

reduced surgical errors 25% - 2006-2009
AAOS Orthopaedic Surgery Safety/Quality Survey 2011

Survey Goals

Assess safety/quality in orthopaedics

Evaluate differences by:



sub-specialty
length of practice
practice type

Evaluate orthopaedic leadership attitudes regarding
safety/quality

Assess orthopaedic safety practices/culture /errors

Identify opportunities/barriers for change
Survey Participants
Participating Practice Types
Participating Orthopaedic Sub-Specialties
Participant Surgical Settings
Results
Positive Findings

>90% use Universal Protocol (UP) in Hospital OR’s

82% Believe UP Improves Surgical Safety/Quality

No differences in utilization/understanding UP by:


Years in practice
Sub-specialty
Results
Negative Findings

Surgical errors reported ALL orthopaedic settings

Most ‘undereducated’ safety science

<50% UP use in surgi-centers - rare in office/procedure rooms

Few surgeon safety leaders/champions

Younger surgeons < team communication knowledge
Model
Safe Orthopaedic Surgical Care
Historical
Orthopaedic Surgery Culture
Surgical
Processes
• Highly variable
surgical
techniques
• Surgeon specific
care plans
• Surgeon-centric
care
Data
• Experience/
Memory driven
• Limited
systematic data
collection
Communication
• ‘Top-down’
surgical hierarchy
• Limited shared
decision making
Model
Orthopaedic Surgery ‘Culture of Safety’
Surgical
Processes
• Standardized
techniques
• Reliable evidence/
consensus-based
care plans
• System-centric
care
Data
• Systematic data
collection and
analysis
• Active data
management
demonstrating
improvement/s
Communication
• Shared authority
‘team model’
• Delegated
responsibilities
• Transparency
Definition
Safe
Orthopaedic Surgical Care

Safe surgical care is:




surgical care delivered with a highly reliable surgical system
designed to reduce, with a goal of eliminating,
preventable harm/s
continuously monitored through safety data collection
effectively integrating interfaces between surgical:




patient and family
physicians, surgeons and staff
suppliers and equipment
and environments.*
* Modified from Dev Raheja - Safer Hospital Care
Definition
Quality
Orthopaedic Surgical Care

Quality Surgical Care is:

standardized surgical care based upon





medical evidence and/or
consensus-based ‘best’ surgical practices
continually improved through innovation
validated through surgical quality data collection and analysis
achieving optimal composite surgical outcomes
Definition
Value
Orthopaedic Surgical Care

Value in surgical care:




focused on patient-centered outcomes
evaluated continually with surgical benchmarking
supported by only essential resources ($$$)
effectively coordinated through the entire surgical care episode*
* Modified from Michael Porter – Redefining Healthcare
Relationship
Safety, Quality and Value
Value
Optimal Outcomes
with ONLY
Essential
Resources
Quality
Reliable Care
Improvement
Systems
Safety
Organized Error
Elimination
What is needed to improve
Orthopaedic Surgical Safety?





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
Change historical orthopaedic surgical behaviors
Implement surgical safety science and behaviors into ALL
orthopaedic settings
Shift focus from ‘surgeon’ to ‘team’ performance
Establish sustainable ‘culture’ of surgical safety
Build and maintain orthopaedic safety/quality data bases
Validate safety programs in orthopaedic settings
Collaboration with other safety stakeholder organizations
Key Elements Orthopaedic Surgical Safety

6 C’s
 (1) Communication – effective surgical team communication
 (2) Consent – accurate timely informed consent
 (3) Confirmation – proper surgical site marking/identification
 (4) Checklists – use validated standardized processes
 (5) Concentration – focused team without distraction
 (6) Collection – systematic safety/quality data collection
Submitted to CORR 10/2012 – Kuo, Robb
AAOS Surgical Safety Program 2012





2011 Fall Board Workshop
 TeamSTEPPS
 80 Hospital/Surgicenter training sites 2012-2014
2012 Spring Board Workshop
 Develop orthopaedic checklists
 Establish/collaborate orthopaedic safety data bases
Surgical Safety Board Oversight Work Group 2012-2014
 Chair - Dr. Fred Azar
Orthopaedic Surgery Safety Summit
 Chicago – 2012
Orthopaedic Surgery Sub-Specialty Pilot Programs
 Validate Pilot Safety Programs 2012-2014
Orthopaedic Safety Summit
Goals





Unify orthopaedics regarding safety
Reduce errors/ ‘preventable harm/s’
 wrong site/side/level/procedure/implant/patient surgery
 surgical complications
 readmissions
Establish surgical safety as a specialty priority
Improve orthopaedic outcomes
Collaborate with other surgical safety stakeholder organizations
Participating/Presenting Organizations
1. American College of Surgeons (ACS)
2. Surgical Care Outcomes Assessment Program (SCOAP)
3. Centers for Disease Control and Prevention (CDC)
4. Centers for Medicare and Medicaid Services (CMS)
5. Agency for Healthcare Research and Quality (AHRQ)
6. The Joint Commission (TJC)
7. Ambulatory Surgical Center Association (ASCA)
8. Accreditation Association for Ambulatory Healthcare (AAAH)
9. Association of Operating Room Nurses (AORN)
10. Webster Healthcare Consulting
11. Pascal Metrics
Participating Orthopaedic Organizations
1. American Academy of Orthopaedic Surgeons (AAOS)
2. American Association for Hand Surgery (AAHS)
3. American Orthopaedic Foot and Ankle Society (AOFAS)
4. American Association of Hip and Knee Surgery (AAHKS)
5. American Orthopaedic Society for Sports Medicine (AOSSM)
6. American Shoulder and Elbow Society (ASES)
7. American Society for Surgery of the Hand (ASSH)
8. American Spinal Injury Association (ASIA)
9. Arthroscopy Association of North America (AANA)
10. Cervical Spine Research Society (CSRS)
11. Hip Society (HS)
12. Knee Society (KS)
Participating Orthopaedic Organizations
13. Limb Lengthening and Reconstruction Society (LLRS)
14. Musculoskeletal Tumor Society (MSTS)
15. North American Spine Society (NASS)
16. Orthopaedic Trauma Association (OTA)
17. Pediatric Orthopaedic Society of North America (POSNA)
18. Scoliosis Research Society (SRS)
19. Society of Military Orthopaedic Surgeons (SMOS)
20. American Academy of Orthopaedic Surgeons (AAOS)
Board of Directors (BOD)
Board of Specialty Societies (BOS)
Board of Councilors (BOC)
Council on Research and Quality (CoRQ)
Patient Safety Committee (PSC)
Summit Work Group Safety Projects






Hand/Foot Ankle – Opioid Abuse
Hip/Knee/Tumor – SSI Prevention ‘Bundle’
Pediatrics – Peds Patient/ Family Checklist
Spine – Wrong Level Spine Surgery
Sports – ‘UP’ in Surgicenters
Trauma – Hip Fracture
Patient Safety Summit

Next Steps





Develop Pilot Projects
Explore data relationships
 ACS, SCOAP
Explore Global SSI Prevention Program
 CDC, AHRQ, AAOS
Unified Orthopaedic Safety Information Statement
Explore BOS Safety role
Safety
Barriers

Surgeon resistance to change

Inadequate surgeon knowledge

Limited utilization of surgical team safety science
Limited surgeon data contribution and benchmarking
Inadequate surgeon leadership


Orthopaedic Surgical Safety
Journey
Safety is no Accident
AAOS Sign Your Site Program 1997
Paradigm Shifts
Orthopaedic Safety Programs
Education

Orthopaedic education programs


New focus/balance safety, quality and value science in all
orthopaedic education programs/products
• Orthopaedic Quality Institute
• Safety Summit
Standardization system-based focus vs. implant/surgical technique
focus
Paradigm Shifts
Orthopaedic Safety Programs
Data

New safety/quality data programs






CMS Public Reporting (PACA)
• national benchmarking
• regional benchmarking (by state)
HVHC - Dartmouth Institute – private benchmarking collaborative
System performance vs. surgeon performance
System focus ‘prevention harm’ vs. ‘good results’
• Deming – count bad light bulbs not good light bulbs
Patient outcomes vs. surgeon outcomes reporting
Multi-center vs. single center trials reporting
Paradigm Shifts
Orthopaedic Safety Programs
Clinical

New standardized system-based interdisciplinary surgical
care programs
 Geisinger ProvenCare
• Patient contract
 Intermountain Health System
 ACO’s
 ‘Bundled Care’ products
 NorthShore University HealthSystem
• Care reliability (LOS, Costs)
• Complication prevention
• Readmission management
AAOS Orthopaedic Surgery
Safety Summit
Chicago, 2012

6 Ortho Sub-Specialty Work Groups


Safety Webinar


Conference Calls. April - July
Tuesday, July 31
Safety Summit

Sunday, August 5 - Monday, August 6
Hand – Foot/Ankle
Work Group

Opioid misuse/abuse




Orthopaedic prescribing practices
Orthopaedic education
Build consensus standards
Collaboration – national organizations/federal
government/advocacy
Is there an Orthopaedic Surgery Safety Problem
2012?
Orthopaedic Evidence

Orthopaedic surgical outcomes highly variable - by
surgeon/hospital/healthcare system/region

Limited local, regional, national orthopaedic safety/quality data

Slow adoption Safety/Quality communication and process

Few recognized surgeon safety leaders/champions
Hip, Knee, Tumor
Work Group

SSI Prevention ‘bundle’

Pre-op checklist
• Diabetic optimization
• smoking cessation

OR checklist
• Skin Prep
• Antibiotic optimization

Post-op checklist
• Wound care optimization


PIM/OKO modules
Collaboration – AHRQ, AAHKS, HS, KS, MSTS, CMS, AORN
Pediatric Work Group

Patient/Family Checklist




10-15 elective procedures
Focus – patient safety, quality, value
Collaboration – POSNA, SRS, Peds Hospitals
Pilot Study
Spine Work Group


Wrong-level Surgery Prevention
Sign Mark and X-ray
(SMaX)






OR Checklist
Confirmation with imaging
Pilot Study
Develop PIM
Collaboration - NASS
Educate
Sports Work Group


Universal Protocol (UP)- Surgicenters & Offices
Pilot Project





Scheduling
Pre-op Holding
OR
Patient focus
Collaboration – AOSSM,
AANA, JC
Trauma Work Group

Hip FX Quality Pathway



SSI Prevention




Checklists/order-sets
Pilot Study
New SSI Quality ‘bundle’
Pilot study
Hip FX PIM/s
Collaboration - CDC, AHRQ, OTA, AGS
AAOS
Safe Orthopaedic Surgical Programs

Surgical Team Communication




effective patient and surgical team communication
 TeamSTEPPS
human factors supporting a Culture of Safety
distraction-free/focused OR environment
Standardized Surgical Processes


accurate timely patient-centered informed consent
proper marking and confirmation of:



site - side - level - implant - procedure - patient
regular use standardized surgical checklists
Surgical Data

Systematic surgical data collection and analysis
Orthopaedic Safety Summit
Ortho Sub-Specialty Work Groups
Hand/Foot-Ankle
Hip/Knee/Tumor
Pediatrics
Spine
Sports
Trauma
David Ring MD
Mark Froimson MD
Kit Song MD
Paul Huddleston MD
Laurence Higgins MD
Steve Olson MD
CMS NorthShore THR/TKR All-Cause Readmissions

consensus building among surgeons

collaboration hospital administration

surgical team communication

patient-centered care with optimized outcomes

reducing/controlling unnecessary costs

validate innovation improvements

surgeon self reporting - safety/quality/value data
Thanks
Historical
‘Unsafe’
Surgical Behaviors



Process - surgical techniques/care plans - highly variable
 surgeon-unique
Data -surgical care experience-based
 little/no surgical data collection/analysis
Communication - surgical authority hierarchal
 surgeon ‘top down’ to surgical team
Model Needed for
‘Safe’
Surgical Behaviors



Process - surgical techniques/care plans standardized and
evidence/consensus-based ‘best’ practices
 consistent/reliable
Data - surgical data systemically collected and analyzed
 improvements data/active management driven
Communication - Surgeon authority shared in ‘team model’
 surgeon as leader supporting transparency and authority
delegation
Model
Orthopaedic Surgical Safety
How?






Introduce OR behaviors benefitting entire surgical team
Embrace safety science in orthopaedic practices
Own orthopaedic surgical safety data and errors
Shift focus surgeon to surgical care system improvement
Celebrate improvements
Partner with patient, stakeholder and safety organizations
Safety Summit

No!
cultural change resistance
 other industries safety change > decade
Options





embrace change – improve care
resist change – accept regulatory mandates/financial penalties
Safety Summit designed to



expand safety practices introduced by AAOS in 1997
build new orthopaedic specific safety ‘tools’
affirm orthopaedic leadership/commitment
Safety Summit
Summary Overview




Participant Recognition: Prioritize Safety for ALL orthopaedic settings
6 sub-specialty work groups : PILOT new orthopaedic safety programs
Safety collaboration - CMS, AHRQ, JCAHO, ACS, SCOAP
Unify Orthopaedic community :
 UNIFIED Orthopaedic Safety Information Statement
 BOS and AAOS collaboration new safety programs /products
Summit Safety
Outcomes Summary






Unified Position Statement on Orthopaedic Surgical Safety
Develop funding support for Work Group pilot safety programs
Continue communication CMS, JCAHO, AHRQ
Explore partnering with ACS/SCOAP for surgical safety data
Explore ongoing support and coordination of the Orthopaedic Safety
programs
 ? new BOS Safety Committee
Collaborate with AAOS Surgical Safety TeamSTEPPS
Communication Program (80 Centers/3 years)
Safety Recommendations
Trauma Work Group


Recommend to AAOS - SSI Prevention Guideline
Develop SSI Prevention Checklist (Bundle)




Antibiotic management
Surgical warming (>35c.)
Smoking Cessation
HbA1C/Hypergylcemia Management
Albumin/Nutritional management
Blood manageent
Pilot a Standardized Hip Fracture Patient Care Pathway

Standardized Order Sets



Pre-op
Post-op
Discharge

Hip Fracture PIM

Goals: decreased LOS, decreased costs and improved Fx outcomes

Safety Recommendations
Sports Work Group

Develop a Surgical Safety Program for Ambulatory Surgery Centers

Collaborate with JCAHO, ASCA
Develop training modules
Collaborate with AAOS TeamSTEPPS training program

Currently only 50% of orthopaedic surgicenters use Universal Protocol


Safety Recommendations
Spine Work Group


Recommend to AAOS - SSI Infection Prevention Guideline
Pilot - Wrong Level Spine Surgery Checklist



Define imaging requirements
Define ‘wrong level’ surgery
Define exception/outlier management – obesity, retained implants
Safety Recommendations
Pediatric Work Group

Pilot a Family/Patient Focused Peri-operative Checklist

Pre-op




Surgical



Care plan review
Discharge


Post-op surgeon review
Post-op


Care team review
Consent,
Team huddle
Follow-up appointment
10-15 pilot centers identified
Potential funding sources identified
Safety Recommendations
Hip/Knee/Tumor Work Group


Recommend to AAOS - SSI Prevention Guideline
Develop SSI Prevention education products



OKO
PIM
With AHRQ pilot Pre-op Optimization SSI Prevention
Checklist (Bundle):




Obesity (BMI>40 counseling)
Smoking Cessation (Pre-op counseling/cessation)
Diabetic Management (Optimize Pre-op HbA1C <7)
Anemia Assessment (for pre-op Hb<10)
Results
Wrong Site/Procedure Errors


2010-11 - Wrong Site/Procedure Surgeries

Hospital OR’s - 0.4/yr.

Surgi-Center OR’s - 0.25/yr.

Office Procedure Rooms – 0.05/yr.
Career - Wrong Site/Procedure Surgeries

Hospital OR’s – estimated -1/20,000 surgeries

Surgi-Center OR’s – estimated -1/80,000 surgeries

Office Procedure Rooms – insufficient data (rare)
Safety Recommendations
Hand/Foot-Ankle Work Group

Develop an comprehensive opioid drug misuse/abuse
management and education program to:





decrease peri-operative opioid drug events,
improve orthopaedic outcome satisfaction
reduce opioid dependency/abuse
80% of worlds opioid drugs consumed in US
Opioids - #1 cause of accidental death in young adults in US