Case Study: Improving Total Knee Replacement at Brigham and Women’s Hospital In
ID: 2762344 • Letter: C
Question
Case Study: Improving Total Knee Replacement at Brigham and Women’s Hospital
In 2007 John Wright gathered a group of people from all of the profes-sions involved in total knee replacement at Brigham and Women’s Hos-pital—surgery, anesthesia, nursing, physical therapy—to formulate a single standard way of doing knee replacements (Gawande 2012). The team carefully studied the medical literature, conducted some small-scale trials, worked together to develop a standard protocol, and tried to get everyone to follow suit. The new protocol involved changes in anesthesia, changes in the prostheses used, changes in medications, changes in postoperative activities for patients, and changes in physi-cal therapy. The new protocol reduced costs, improved pain control, improved the mobility of patients, and shortened length of stay. Lowe (2011) quotes Wright as saying, “Our primary goal is to improve the outcome and the process of care for the patient. Invariably when we pay attention to these concerns, we find that we achieve the secondary goals of efficiency and cost savings.” One of the most controversial changes involved limiting the prostheses that surgeons could use. Even minor differences in prostheses can result in changes to the operation, and surgeons have strong preferences about prostheses. But some prostheses cost far more than others, and little evidence indicated that the more expensive prostheses were better. The surgeons now use a single source for 75 percent of their prostheses, sharply improving the hospital’s bargaining power (Gawande 2012).
Discussion questions:
• Why would standardization reduce costs? How could it improve quality?
• How could the hospital reward physicians for helping standardize prostheses?
• How would this reward system help align incentives?
• Are any strategies less likely to cause problems with the Medicare Inspector General?
• Why would choosing a standard prosthesis improve the hospital’s bargaining position?
Explanation / Answer
1) Standardization of practice is an important goal because of the wide variation that exists in many areas of practice within surgery, etc. Variation in processes of care is problematic because it may lead to increased rates of error. Performing critical tasks the same way every time can reduce the kind of errors that all human beings are subject to, especially when fatigue is a factor and in stressful environments such as the labor and delivery suite or operating room. Elimination of variation in processes has been a cornerstone of improved performance and reliability over the past several decades in several segments and industry. A similar level of success can be achieved here also. For instance in the field of anesthesia, where adverse events can be significantly reduced through standardization of patient monitoring, dispensing of inhaled gases, and medication administration. Similarly, standardization of any process of care through the use of protocols and checklists can be expected to achieve a similar reduction in harmful events.
2) When standardized care is used, quality increases, variation decreases, and cost decrease. Hospitals can reward physicians depending on the quality of the service they provide, the feedback they receive, how effective they are implementing the standardized processes, etc. Physicians worry because they feel that their decision-making authority will be taken away from them in the process of "standardization"; but if one study the improvement efforts closely he will realize that the common thread is that doctors and frontline staff are integrally involved in the standardization efforts, without whom the efforts would surely fail. Once the team has determined, with a lot of careful input and thought process, that "one particular approach" makes sense for their organization in order to improve quality and reduce waste, individual physicians and staff would certainly be encouraged to implement that approach. Because of adoption of standarized process, cost also gets reducted and physicians should be suitable rewarded in monetary terms so that they would be encourgaed to follow and implement standard practices.
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