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