Demand for hip and knee arthroplasties was growing annually in Alberta while care protocols and practices were highly variable. In response, Alberta Orthopaedic Society, the professional body for orthopaedic surgeons, working with Alberta Bone and Joint Health Institute (ABJHI), developed a single integrated care path for the province.

ABJHI, a not-for-profit with expertise in implementing care paths and measuring their performance, also developed a Measurement Framework and continuous quality improvement (CQI) process. The care path and CQI are managed by Alberta Health Services and its Bone and Joint Health Strategic Clinical Network. Oversight is by a Provincial Hip & Knee Working Group.

The CQI process is robust and comprehensive involving the ongoing collection of data and analysis of key performance indicators (KPI) tied to critical areas of the care path and dimensions of quality. ABJHI collects patient data from surgeons and hospitals and produces a confidential CQI Report twice a year for each surgeon. The reports show surgeons their performance against evidence-based benchmarks in 17 KPIs. As surgeons strive for improvement in KPI results, their adherence to the care path is    strengthened, reducing variation in practice across Alberta.  A single report is produced for each of Alberta’s five health zones. Data for the reports are collected, stored and shared according to strict confidentiality protocols. Hospital orthopaedic units also have a CQI process using Balanced Scorecards with KPIs tied to the care path. Collectively, the reports analyze performance for 95% of the annual 10,000 elective hip and knee arthroplasties.

The integrated care path for hip and knee arthroplasties was designed to put patients at the center of their care and to make them active participants in their journey along the care continuum.  Central intake clinics serve as the hub for a streamlined process. Patients are assigned a multidisciplinary team based at the clinic, including a surgeon, physical therapists, and nurse case manager. The case manager guides patients along the continuum ensuring they see the right clinician at the right time and are taking steps to be at their optimal readiness for surgery; such as losing weight, stopping tobacco use and controlling blood sugar; which are specified in an agreement signed by patients. Using signed agreements to set out responsibilities provides a higher degree of patient participation in care.     Patients are also encouraged to bring family members and friends into their support circle.

Hip and knee arthroplasty care has been standardized in Alberta and care quality has improved. Among the gains: average hospital stay down to 3.8 days from 4.7 (estimated 50,400 bed days saved since 2009/10); blood transfusion rate down to 4.6% from 19.5%; patient mobilization on day of surgery 90% vs 43%. These improvements are valued at $52 million.

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Title:Hip and Knee Working Group Co-Lead; Executive Director

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