Date: 09/01/2015

Orthopaedic surgeon David Cohen and his colleague in neurosurgery, Jean-Paul Wolinsky, could not ignore what was in front of them. They had put together a working group to compare how their respective departments performed surgeries and delivered postoperative care. What they found was a pattern of disparities, both between departments and within them, even for the same procedures, such as anterior cervical discectomy and fusion and lumbar fusion.

That working group was the genesis for the Spine Clinical Community, formed in January 2014 to bring together spine surgeons based in orthopaedics and neurosurgery from Johns Hopkins’ Baltimore- and Washington-area hospitals. Its goal, like that of the other 18 clinical communities, is to improve patient outcomes while reducing costs. Since 2011, the Armstrong Institute for Patient Safety and Quality has chartered the communities and provided them with project management, analytics and administrative support.

Standardizing Practices

Clinical communities are charged with standardizing care protocols and order sets and reassessing all costs associated with care delivery. They have formed around such issues as blood management, care in the neonatal intensive care unit and maternity services.

Each community, which meets one to two hours per month, includes 15 to 20 members representing the five Baltimore- and Washington-area hospitals and different departments within them. The Spine Clinical Community includes physicians from anesthesia and from physical medicine and rehabilitation, in addition to orthopaedics and neurosurgery. It also includes nurses, operating room staff and department administrators, as well as membership from supply chain and quality. Community members establish safety and quality priorities and set measurable goals, such as reducing patients’ complication rates or length of stay.

The Spine Clinical Community decided to focus on anterior cervical discectomy and fusion (ACDF) surgery, in which a herniated cervical disk is removed via the front of the throat, and then the spine fused. “The community agreed: If you are going to have ACDF surgery under the Johns Hopkins brand, it should be consistent among the Baltimore- and Washington-area hospitals,” says Lisa Ishii, chief quality officer for clinical best practices in the Johns Hopkins Health System and medical director of clinical integration in the Office of Johns Hopkins Physicians. “We should provide the best care, with the best outcomes, wherever we perform this procedure."

Toward that end, says Joshua Ammerman, a neurosurgeon from Sibley Memorial Hospital, the Spine Clinical Community gathered baseline data about complication rates and length of stay for the units represented in the community. “After we finish and apply the clinical pathways we are developing, do we see that every unit’s complication rate and length of stay go down to the levels seen in those with the lowest rates? If not, what’s going on at those specific institutions?”

Making Change Happen

Because standardizing care processes requires physicians to alter their practice patterns, getting them to believe in the process is critical. “Our physicians tend to think they’re already using best practices,” says David Chin, a Distinguished Scholar with appointments in the Bloomberg School of Public Health and the school of medicine. But when they come together and look at the data, they recognize that unnecessary variation compromises quality, he says. “Clinical communities are very data-driven, which physicians respect, and they take advantage of the fact that our physicians want to do the best job they can for their patients.”

Their effectiveness, says Ishii, resides in how they allow physicians to develop solutions themselves, rather than leadership saying, “This is what you’re going to do.”

Finally, physicians’ desire to be respected by their peers motivates them to change, explains Peter Pronovost, director of the Armstrong Institute, as does “peer norming”: As they see colleagues adopt new practice patterns, they become more likely to do so themselves.

Integrating for High-Value Care

The communities’ ultimate goal is superior care delivered efficiently. They partner with finance to look at costs and supply chain issues. Standardizing practices among all the hospitals and agreeing to use, for instance, a narrower selection of artificial joints allows for better pricing on those joints, saving the health system money.

One clinical community led by orthopaedic surgeons Paul Khanuja, chief of hip and knee replacement in Johns Hopkins’ Department of Orthopaedic Surgery, and Anthony Unger at Sibley Memorial worked closely with supply chain staff to implement a capitated price program for total joint implants that saved $1.5 million in a year. Physicians must approve medical devices and medical equipment—along with ways of standardizing care—before any agreements are final. Pronovost says, “This is the clear and simple philosophy we present to clinicians: They will make decisions about supplies, but they should be mindful of their cost and consider the potential cost savings of using something else."

For information about participating in clinical communities, contact senior project administrators Lois Gould, at [email protected], Patricia Wachter at [email protected] or project administrator Lauren Stearns at [email protected].