Background
Prior to the development of SJI in 2012, the many entities that contributed
to a successful, positive patient experience were not aligned. These entities
included physicians offices, nurses, therapists, patients, families, and
outpatient therapy. Through collaboration between RCH and its orthopedic
physicians, SJI was envisioned. The vision of shared decision making,
standardized care, enhanced patient education and increased physician and
nurse satisfaction lead to the creation of SJI. The SJI Unit was developed to
provide patients with specialized care, with staff specifically trained to care
for this population. The ultimate goal was to shift focus from treating illness
to promoting health and enhancing quality of life in the elective surgical
patient. This focus on health and not illness subsequently, would decrease
hospital-acquired infection rates, fall rates, and greatly improve the safety
and wellbeing of this patient population as well as influence the HCAHPS
scores.
SJI Unit: Commitment to Improving the
Patient Experience
Quiet Environment Bundling cares Shared responsibility for cleanliness Hotel-like atmosphere Rapid call light response Cookies and popcorn provided to patients and family to encourage
activity outside of the room. Encourage family assistance, supporting 24-hour visiting hours SJI Shirts and shorts provided to patients; no patient gowns Flowers provided to each patients by their surgeon Multimodal Pain Management Standardized antibiotic and DVT prophylaxis Standardized discharge information as well as patient and coach
education Routine follow up call
SJI Program Objectives
1. Implement evidence-based patient selection criteria to optimize the patient
health status prior to surgery, enhance recovery time, and improve
outcomes.
2. Collaborate with physician offices to create a “one stop shop” experience for
the patient.
3. Implement the “Coach role” in order to build in a support system, and
develop patient and family engagement.
4. Implement Pre-Operative education by offering specialized classes,
preparing patients and their Coaches for the recovery journey.
5. Provide Patient Navigation Pre and Post Operatively for individualized case
management.
6. Providing social support and guidance to encourage a healthy recovery for
all patients served; identifying limiting factors prior to surgery and pre-
planning to eliminate barriers at discharge.
7. Promote a proactive physical therapy program for early ambulation and
mobilization within 1-4 hours post-operatively.
8. Utilize standardized order sets that improve safety, efficiency, and
communication.
9. Provide hotel-like atmosphere for patients and families.
10. Implement early daily interdisciplinary rounding with MD, Physical
Therapy, Patient, Family/Coach, and Nursing.
11. Promote multimodal pain management and alternative pain
management therapies tailored to meet each patient’s individualized needs.
12. Improve post operative nausea/vomiting rates through individualized
anesthesia administration and management.
13. Utilize standardized clinical pathways to ensure that all patients meet their
goals and are safely discharged home.
14. Provide a supportive, engaged, motivating environment by staff specially
trained in orthopedics and customer service.
15. Collect accurate data for continuous improvement and
alignment among all team members.
Implementation
1.Hospital Commitment: Involve all stakeholders in decision making.
2. Establish Effective and Efficient Leadership: Create a formalized process for sharing input.
3. Define Goals: Perform Baseline Assessment of patient population.
4. Evidence-based Selection Criteria: Develop standard parameters for specialty program
5. Standardize program: Utilize clear clinical pathways and standardized order sets.
6. Establish clearly defined expectations: Develop common script with all parties.
7. Training: Develop program to train specialty staff
8. Gather accurate data: Establish metrics and develop tools to capture important functions as guided by
Best Practice parameters.
9. Transparency: Shared data with the team throughout the entire continuum of care.
10. Celebrate success: Include all team members.
Introduction
The Spine and Joint Institute (SJI) was established through the collaboration of
Redlands Community Hospital (RCH) and its Orthopedic Partners. The mission
of both Redlands Hospital and the Spine and Joint Institute is to promote high
quality care, as well as create an exceptional hospital experience. This shared
vision lead to a partnership that has resulted in improved nurse, physician, and
patient engagement and satisfaction.
Results By joining forces with all who interact with our patients, we have
succeeded in dramatically decreasing our hospital length of stay and
readmission rates, as well as curb our SNF transfers. By utilizing
evidence-based research and standardized program objectives, we
have been able to markedly improve patent outcomes and improve
physician, nurse and patient satisfaction scores. This endeavor has
ultimately helped us achieve superior clinical outcomes, and deliver
high quality cost effective care. This partnership created between our
hospital administration and front line staff (surgeons, therapists,
nurses) has resulted in achieving U.S. News Best Hospitals 2019-2020
High Performing ranking in Hip and Knee Replacement.
Continuous Process Improvement: Our future
performance improvement project will include the implementation
of an enhanced recovery program. Pre-Operative Clear
Carbohydrates will be administered to our patients, and post
operative nausea and vomiting data points will be collected.
References:
Beck, A. (2007). Nurse-led preoperative assessment for elective surgical patients. Nursing Standard, 21(51), 35-38.
Brueilly, K.E., Pabian, P.S., Straut, L.C.,Freve, L.A., & Kolber, M.J. (2012). Factors contributing to rehabilitation outcomes following hip arthroplasty. Physical Therapy Reviews, 17(5), 301-
310.
Chen, S.R., Chen, C.S., & Lin, P.C. (2014). The effect of educational intervention on the pain and rehabilitation performance of patients who undergo a total knee replacement. Journal
of Clinical Nursing, 23, 279-287. Doi: 10.1111/jocn.12466
Guerra, M.L., Singh P.J., & Taylor, N.F. (2014). Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review.
Clinical Rehabilitation, 29(9), 844-854. doi:10.1177/0269215514558641
Hass. S., Jaekel, C., & Nesbitt, B. (2015). Nursing strategies to reduce length of stay for persons undergoing total knee replacement: integrative review of key variables.
Journal of Nursing Care Quality 30(3), 283-288. Doi:10.1097NCQ0000000000000104
Jennifer Nol, RN, MSN; Denise McGinty, RN, BSN; Sara Long, RN, MSN; Debi Bernard, RN, ASN; Eric Ayawaila, RN, ASN; Heidi Bontjes, LVN; Jennifer Burroughs, RN, BSN; April Colquitt, RN, BSN; Elena Cortez, RN, BSN; Delisa Dimpudus, RN, MSN;
Cassi Keller, RN, BSN; Ricki Leonard, RN, BSN; Victory Mailangkay, RN, BSN; Claudia Munguia, RN, BSN; Noel Nario, RN, ASN; Natasha Ramirez, RN, BSN; Julie Sanchez, RN, ASN; Haley Seah, RN, BSN; Karen Zirkle, PT, MSHSA.
Innovative Orthopedic Program leads to Improved
Quality and Safety for Orthopedic Patients.
PACU Time
2012 2013 2014 2015 2016 2017
1.68 1.67 1.42 1.29 1.33 1.65
1.42 1.41 1.47
1.61
1.50
1.51
1.38
0.00
1.00
2.00
3.00
2018 Jan Feb Mar Apr May Jun
Ave
rage
Hou
rs
YTD June 2019PACU Time
Goal: 1.50 HoursAveraging 1.48 Hours
Average Length of Stay
2012 2013 2014 2015 2016 2017
Joint Spine Joint Spine Joint Spine Joint Spine Joint Spine Joint Spine
2.3 1.6 2.1 1.5 1.9 1.4 1.7 1.4 1.5 1.3 1.5 1.3
1.3
1.3 1.3
1.5
1.3 1.3 1.31.3
1.41.3
1.1
1.31.4
1.2
1.0
2.0
3.0
2018 Jan Feb Mar Apr May Jun
Day
s
YTD June 2019
Average Length of StayGoal: 2.0 Days
Averaging: 1.3 Days
Joint
Spine
Post-Op Nausea –
Joints/Spine Breakdown
2014 2015 2016 2017
Joints 18% 19% 12% 11%
Spine 22% 21% 9% 14%
11%
15%
14% 23%
19%
20%
15%16% 16%
12%
34%
8%
35%
12%
0%
10%
20%
30%
40%
2018 Jan Feb Mar Apr May Jun
% o
f Pat
ient
s w
ith N
ause
a
YTD June 2019Averaging 18% Joints, 18% Spine
Joints
Spine
Percentage of Patients Seeing Physical
Therapy on Day of Surgery & the Causes
of Outliers
88%
9%
June
Saw PT Day of Surgery (141)
PACU Stay Past 7:30 PM (14)
Nausea/Vomiting (4)
Spinal Numbness (1)
Patient Refusal (1)
85%
12%
YTD June 2019
Saw PT Day of Surgery (790)
PACU Stay Past 7:30 PM (113)
Nausea/Vomiting (12)
Spinal Numbness (5)
Patient Refusal (3)
Pain (2)
Blood Pressure (1)
Achievements
Healthgrades America’s 100 Best Hospitals for Orthopedic Surgery 2012 - 2017
Healthgrades America’s 100 Best Hospitals for Joint Replacement 2012 - 2015
Healthgrades America’s 100 Best Hospitals for Spine Surgery 2012 - 2013, 2015 - 2017
Healthgrades Spine Surgery Excellence Award 2012 - 2013, 2015 - 2017
Healthgrades Outstanding Patient Experience Award 2016
Healthgrades Patient Safety Excellence Award 2016
Healthgrades Orthopedic Surgery Excellence Award 2012 - 2017
Healthgrades Joint Replacement Excellence Award 2011- 2016
Blues Distinction Center : Knee and Hip Replacement 2019
Patients Transferring to SNF/TCU
48%
9%6% 6% 6% 5%
2% 3% 2%
0%
10%
20%
30%
40%
50%
60%
Pre-SJI 2012 2013 2014 2015 2016 2017 2018 YTD June2019
Per
cent
of P
atie
nts