In 1995, AAHS did approximately 200 Total Joint Replacements (TJR) with 8 surgeons. TJR was not profitable, inpatient care was inconsistent, patient satisfaction was merely "acceptable, and there was considerable out-migration to other hospitals in Baltimore and Washington, DC.

Led by Marshall Steele, MD, the hospital realized that the model of health care delivery had to shift from a linear model to a Continuum of Care. Thus, to initiate change, a leadership team (Dr. Marshall Steele, a nurse, and an administrator) was established. Other professionals were brought into the process: pharmacy, other surgeons, anesthesia, finance, public relations. The goal was to establish a "Destination Center of Superior Performance".

The Center contained the following elements of a Center of Superior Performance: a consistent message, coordination between the surgeons' offices and the hospital, standardized care plans, an identifiable orthopedic unit (physical space), a dedicated and involved staff, a high level of patient/family involvement, outcomes measurements, continuous quality improvements, cost containment benefits, and a leadership team to provide ongoing guidance.

They identified a new successful program for delivery that had many of the critical elements. There were educational materials for both the surgeon's offices and the hospital. Dr. Steele created expanded educational materials including surgical guidebooks for knees and hips, wall displays, and seminars. All of these materials improved quality and compliance, provided a consistent message, and saved time for the surgeons.

As a part of the program, the hospital established a 4-bed total joint unit to define the environment (now 20 beds), added a full-time coordinator, and dedicated staff to TJR. The surgeons developed standardized care processes for the entire length of stay, including discharge. This care plan was dramatically different.

The surgery schedule was reconfigured so that the patients had their surgery on one day-Monday. Busy surgeons were provided with two operating rooms simultaneously. To increase efficiency, the number of implant vendors was reduced from 8 to 2. This also increased efficiencies and reduced costs. The care was through a group process. (As the program grew, beds were added and additional surgical days were added to accommodate the tremendous growth in the program).

In addition, the patients were dressed early and out of bed on post-op day 1, spending their time in their recliner and/or participating in group physical therapy and activities. Walking was initiated on post-op day 1, stairs on post-op day 2. Families became "coaches" and were trained to assist the hospital staff. This reduced the need for additional staff. The philosophy has always been: "These are not sick patients - they are patients with a bad hip or bad knee. Expectations must be set so that they can participate in their own recovery."

The care and involvement continued after discharge from the hospital as every patient was surveyed by telephone at 3 weeks by the nursing staff, clinical outcomes were measured yearly, and all patients were invited to a monthly luncheon to solicit constructive criticism.

To assure quality, two monthly physician led conferences were established: a clinical case conference to discuss difficult surgical problems, and a multidisciplinary administrative conference to discuss issues.

The results have been spectacular. Patient satisfaction is in the 98%, most patients (80%) return home with outpatient therapy within 3 days, hospital costs and length of stay are the lowest in the region, TJR is the most profitable service line in the hospital. The volume is now over 1,000 cases per year, with growth rates of 21% per year. AAMC is of the top three providers of TJR surgery in Maryland.

Improvement and expansion continues. With minimally invasive surgery modifications have been developed to accommodate the shorter stay. Confidential report cards have been developed for individual surgeons.

The success of the program has been reproduced at AAMC by the spine surgeons (1998) and vascular surgeons (2002). Their results have mirrored those of the Joint Center. This has positive effects throughout the hospital. AAMC received #1 status for patient satisfaction by the Jackson Survey/2004 and "Top 100 Hospital" distinction by Solucient/2005.

This Center of Superior Performance model transferred to other hospitals as well. Over 200 hospitals have visited AAMC. Those that implemented the model have reported similar results, including 31 hospitals in Holland. Dr. Steele consults nationally and internationally on this hospital program as well as "The Effective Office" for surgeons.

Dr. Steele and his team truly believe that this model should be the standard for all orthopedic programs. This "healthcare model for the future" creates a culture that will ensure ongoing improvement.