Risk-Adjusted Discharge Rate (95% CI*) to Skilled Nursing
Facility after Hip Replacement, (2/2013–1/2014)
*CI = Confidence Interval
Improvement Team and Interventions (Phase 1)
A multidisciplinary team (see “Initial Team Members”) was
formed and its initial focus was on reducing SNF LOS for joint
replacement patients from 27 to 14 days (~50%). They identified a SNF in the community as a pilot site for this work. The
project team developed two interventions: (1) a “SNF Expectations Document”; and (2) a post-discharge care pathway for
patients discharged to a SNF after a total joint replacement.
The “SNF Expectations Document” was developed after they
recognized that the orthopaedic surgeons and health system
physical and occupational therapists had never explicitly
communicated post-discharge care expectations to the SNFs.
The document listed a standard post-discharge care bundle,
including 20 steps for total joint replacement patients who were
discharged to a SNF. Topics included beginning therapy on day
zero, pain management, and proper leg elevation. These expectations were also incorporated into patient education materials
so that everyone involved would have a shared understanding
of how a SNF stay post-surgery should progress.
The project team also worked with the SNF physicians and
staff to develop a care pathway for patients discharged from
a SNF to home after a total joint replacement. A care pathway
serves as a guide through clinical care and recovery expectations for clinical staff, patients, and families. That post-SNF
discharge pathway included functional goals, educational
goals, and care transition goals.
After introducing the expectations document and the clinical
care pathway, the health system saw a 37% decrease in LOS
from 27 days to 17 days. While this did not reach the desired
goal, it was felt to be a successful first step.
The next area targeted was to reduce the number of patients
sent to a SNF to the state average of 23% and to decrease
hospital LOS after a total joint replacement. The project was
moved from the Population Health Office to the health system’s Clinical Design and Innovation team (CDI), which uses
Lean principles to create a standard approach to measure
and improve value for an episode of care. The project team
was reorganized to reflect the shift in focus (see “Reorganized
Team Members”). The new team conducted a root cause analysis (RCA) to determine why the health system sent such a
large percentage of patients to SNFs after surgery.
The process began years earlier, when the hospital had
high occupancy levels, and orthopaedics offered to discharge
patients to SNFs for rehabilitation to open hospital beds.
Based on several gemba walks (gemba means “the real place”
in Japanese, and is a Lean principle that involves going to the
site where care is delivered and observing and asking questions), the team also identified that a lack of inpatient and
outpatient care pathways led to patient uncertainty regarding
post-surgical care. This feeling of uncertainty led to higher
SNF admissions and longer hospital LOS prior to discharge.
The project team also met with patients and learned that
going to a SNF had become a community expectation. This
was partially due to a shared understanding held by patients
who had witnessed friends and family undergo joint replacement surgery followed by a SNF stay, and partially due to
unintentional expectations set by the orthopaedic surgeons.
In the pre-surgical class attended by all joint replacement
OC TOBER 2018