10 Steps to Add Total Joint Replacements to a Surgery Center

Orthopedic and Sports Surgery Center in Appleton, Wis., opened in 2006 as an outpatient surgery center owned by seven orthopedic surgeons and one anesthesiologist. In March 2008, the center added partial knee replacements; today, the center performs 15-16 total joint replacements every month. Chris Washick, RN, CASC, director of operators for the surgery center, discusses how Orthopedic and Sports Surgery Center successfully added total joint replacements.   

1. Achieve physician buy-in. Ms. Washick says the process of adding total joints to Orthopedic and Sports Surgery Center started with enthusiasm from the center's physician-owners. "There was a trend of younger patients having joint replacements, and patients enjoyed coming to the surgery center and having a choice beside the hospital," she says. "The doctors decided to venture into exploring the possibility of doing total joints." The physician-owners — seven orthopedic surgeons and an anesthesiologist — joined the center's leadership team in researching other locations that performed total joints.

2. Start with partials. The physicians and ASC leaders visited a few locations that were planning similar transitions and decided to start with partial knee replacements in March 2008. To prepare the center for partial knee replacements, the leaders remodeled several parts of the existing recovery area to accommodate two patients for a 23-hour period. The center then kept partial joint patients overnight and sent them home with home healthcare. Implementing partial knees and partial joints at the center first was helpful in preparing the center for the eventual transition to totals, Ms. Washick says.

3. Plan for postoperative care. Total joint replacements in a surgery center require a significant amount of postoperative care, so ASCs must plan the patient's next steps after he or she leaves the surgery center. Ms. Washick says her ASC developed strong relationships with home healthcare agencies and skilled nursing facilities in the community to make sure the facilities were on the same page about the patients' needs. At first, the ASC kept partial joint patients overnight, but once the physicians saw that patients were recovering quickly in terms of pain control, they decided to let the patients go home the same day. Home health would then meet the patients at their houses to make sure they got home safely.

When the center added total knee and hip replacements, they partnered with a skilled nursing facility to take care of patients after surgery. "When we started doing total knees and total hips, we would keep those patients overnight here and then transport them to a skilled nursing facility, where they would stay an additional two days," she says. "We were able to accommodate more patients that way."

After the center and the skilled nursing facility had "worked out the kinks" of the transitions, the skilled nursing facility agreed to transfer 12 skilled rehab beds to a new "recovery inn" constructed on-site with the surgery center. "Now we can offer the same program minus the inconvenience," Ms. Washick says. "The building was designed and built with orthopedic rehab patients in mind."

4. Use experienced staff members to train other employees. Ms. Washick's surgery center staffed several surgical techs and operating room nurses who had come to the ASC from an inpatient setting and were very proficient with total joints. "They took the lead in training the rest of the staff with the help of the implant companies," she says. She says while every staff member was familiar with orthopedics, the presence of those "super techs" helped make every employee proficient on total joints as well.

5. Start with larger insurance companies before talking to smaller ones. Insurance companies may be hesitant to negotiate contracts for total joint replacements, so start with larger companies first and move to smaller payors, Ms. Washick says. "If these [procedures] aren't approved by Medicare, smaller companies may be [more hesitant]," she says. "Our finance director got some contracts in place with bigger payors, and as we did that, we would negotiate one-time contracts with the smaller ones."

At this point, she says most payors are happy to negotiate contracts with reimbursement for implants. She says surgery centers can succeed more easily in payor negotiations if they provide clear, thorough data on the center's outcomes. "It's also a better cost alternative for insurance companies and the patient, so the [payors] were pretty receptive to at least trying it."

6. Plan for larger capital purchases. Surgery centers adding total joint replacements will likely have to budget for several large purchases, Ms. Washick says. "As far as capital equipment, we required a couple of larger purchases, such as a portable x-ray because we only had c-arms on site," she says. "There are a couple of capital expenses involved, but [you can succeed] with planning and accurate projected volumes." She says vendors were accommodating about bringing in equipment so that the center did not have to front the capital expense. The center has since moved from performing 5-6 total joints every month to performing 15-16 a month.  

7. Screen and educate patients carefully. Not all patients will be appropriate for total joint procedures in a surgery center. To convince payors to negotiate contracts with your center, make sure you have a thorough screening process to catch patients with prohibitive co-morbidities. Before every surgery, the center's medical director "deep dives into the history of each patient" to determine whether the patient is a good candidate. This involves evaluating the patient's medical history, home environment, family support and personal motivation to recover.

Ms. Washick says patients should also be educated on the process of undergoing total joint replacement at an ambulatory surgery center. Her center's patient care coordinator is responsible for meeting with each patient and remaining his or her point of contact throughout the process.

8. Schedule total joints to allow room for recovery. Ms. Washick's schedulers try to schedule total joints in the morning so patients have more time to recovery after surgery. Fortunately, the addition of the recovery inn to the surgery center has allowed the schedulers to be more flexible. "Now that we have the recovery inn attached to the building and we don't have to keep patients for a 23-hour period, we can be more lenient as far as times go," she says. "But typically we try to start total joints by noon at the latest, because then we're not transferring patients at crazy times of night and keeping staff too long."

9. Track data on outcomes. Ms. Washick recommends surgery centers track data on their total joint outcomes to determine whether the ASC needs to make process changes. She says her center tracks data on patient satisfaction, pain management, nausea and vomiting, infection rates and other issues to make sure any problems are tackled as soon as they arise. "The benchmarking data does not mean we necessarily change whole processes, but we may change things such as medications or concentrations of pain pump medications so that patients are having better quad function in order to get up to therapy," she says. The center's total joint committee also meets on a weekly basis to review patients from the week before and the upcoming week.

10. Hold regular community outreach events.
Ms. Washick's ASC promotes its total joint program by holding regular events and inviting the center's physicians to speak on pertinent topics. "We have a big building off the highway, and lots of people probably drive by and wonder what we do here," she says. "So every month or so, one of our surgeons will host a community presentation on an orthopedic-related topic — arthritis or joint replacement, for example."

The ASC leaders invite the public to hear the talk and then try to incorporate tours of the ASC and recovery inn into the event. "That seems to be one of the best ways to get people educated on their choices," she says.

Related Articles on ASC Operations:
5 Reasons Physicians Should Partner With Hospitals on ASCs
7 Questions to Ask Before Adding a Specialty to a Single-Specialty ASC
New Procedures That Can Add Volume to Your ASC

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