Abstract
Increased life span and the aging "Baby Boomer" generation will soon result in an increased number of total joint replacements in the next 20 years. Limited financial resources warrant the need for the implementation of the best possible delivery system in total joint care. In 1995 Anne Arundel Medical Center Systems (AAMC), Televisual Communications (TVC), and Biomet (an orthopedic implant company) implemented a new delivery system at AAMC. Published data in 2000 has shown this system to provide superior patient satisfaction and profitability. Much effort has been expended to help other hospitals institute a similar system in their facility. In order to investigate the relative success of these efforts, one hundred and twenty four (124) questionnaires were sent out to hospitals that had either purchased a TVC program or visited AAMC. The forty-one (41) responding surveys were evaluated and scored. They were designed to measure the degree of program implementation completed by each hospital. The hospitals were then placed into one of four categories based on their score - centers of excellence model "COE", program model "TJP", services model "TJS", and no model "NM".

Based on the results, hospitals that more fully implemented this delivery system model reported higher profitability, greater patient satisfaction and fewer readmissions. However, successful completion was found to be difficult as only 14.6% of hospitals successfully implemented "centers of excellence." While all hospitals reported a number of barriers (4.56 on average), those hospitals with proper physician and administrative leadership were better able to overcome them. However, physician leadership did not by itself ensure success either. The presence of an experienced on-site administrator and physician for the first six months who serve to prepare, educate, and mentor the responsible staff and physician leadership may be necessary to improve results.

Introduction
Overall health improvements along with innovative medical treatments have led to longer life expectancy. Therefore, there are a greater number of older individuals experiencing the negative effects of degenerative joints, osteoarthritis, and other orthopedic conditions. These often result in the need for total joint replacements (TJR). As the "Baby Boomer" generation continues to age, resulting in a greater proportion of individuals over the age of 65, all estimates suggest that the volume of joint replacements will vastly increase in the near future. Some have suggested that by 2015, the "over 65" population in the world will double to 75 million, and the American Academy of Physical Medicine and Rehabilitation expects hip surgery to rise 60% in the next 30 years.

Clearly, the increased demand and need for joint replacements will put a strain on the healthcare system, requiring significant financial and personal resources. However, it is also a great opportunity for those healthcare systems that are prepared to be innovative in the use of these resources. In a time where customer service, friendly care, overall experience, and cost are valued with at least the same weight as the actual product or service, it is now not enough to "simply" perform an excellent surgery. Patients, health insurers, and employers demand value, which includes 1) excellent surgery, 2) premier physical therapy, 3) empathetic nurse care, 4) proper patient education, 5) quicker recovery times, and 6) affordable cost. The need to create innovative joint centers, that meet all these needs, is more relevant than ever. As minimally invasive surgery (MIS) becomes more of a practical reality, the decreasing patient length of stay (LOS) will shrink the available time necessary to educate the patients. The Joint Program's ideals of adequate patient education and preparation along with efficient systematization will become even more important with the rise of MIS. Patients will need to be placed in a culture with the most effective preparation and educational tools, along with highly precise standardization that will provide the consistency and efficiency needed for a successful outcome.

TVC, a marketing company, created the Joint Ventures program in 1995 that looked to improve the delivery system in the care of total joint patients. This program provides each hospital with the necessary tools to implement a program (wall displays, patient-educational tools, and further staff training at their Florida site). Anne Arundel Medial Center (AAMC), Annapolis, MD, also looked to improve its delivery system when it established a Joint Replacement Center ("Joint Camp") nearly 10 years ago that was similar to the Joint Ventures program. This center has been recognized for highly efficient practice methods and standardization of care. AAMC's Joint Camp, and others following a similar model, has become the prototype of patient-centered TJR programs. Dr. Marshall Steele's published data have shown that this system provides the consumer/patient an episode of care with the highest value, where value = quality plus service at low cost (JCOM , 2000).

Biomet an orthopedic implant company brought hospital administrators, physicians, and healthcare professionals throughout the United States and abroad to visit AAMC in order to observe the program and understand the elements, support, and personnel required to facilitate implementation of their own joint programs. TVC also provided site visits to their clients as well as the program tools and training. No comprehensive assessment was made of the hospitals before implementation. Some on site support was provided but it was not ongoing during the implementation phase. A measurement of the success of hospitals in program implementation as well as their overall results has not been previously reported.

The objectives of this study were:

1. To obtain an estimate the implementation success of hospitals attempting to implement a joint program
2. To evaluate whether this is a factor in results
3. To identify the most common barriers faced by these hospitals during implementation
4. To facilitate implementation of joint programs in hospitals

Methods
Contacts
In order to investigate the objective, 2 lists of hospitals were compiled.

1. 85 hospitals that visited AAMC's Joint Camp
2. 97 hospitals that purchased TVC's Joint Ventures Program

Surveys
The tool utilized in this study was a survey that aimed to 1) identify which elements of the program each hospital actually implemented, 2) identify the barriers each hospital faced during implementation and 3) identify the results of their program. The survey contained 51 questions, and could be completed online or by mail.

Once completed and returned, each survey was scored based upon specific values to answers showing an aspect of the program. Questions were weighted with higher/lower values according to characteristics essential and inherent to the program. For example, group physical therapy is a key part of the program and, therefore received a higher weight. It was determined that group physical therapy contributes to an atmosphere of friendly competition and encouragement, maximizes the number of patients that can be seen by one therapist, provides excellent care, and reduces costs. This question received a maximum point assignment of 7 points, while a component of lesser importance, like the number of primary vendors used regularly by surgeons, had a maximum assessment of only 3 points.

The surveys were multiple-choice questions in order to simplify and standardize the questions for each hospital. If a question needed qualification or explanation, space was provided to offer an explanation when needed, or to explain comparable methods.

However, in order to reduce subjectivity in grading, the survey aimed to limit personal responses and maximize answers selected from a standard list. (While efforts were made to reduce subjectivity, the survey responses ultimately depended on the self-assessment of the individual completing the questionnaire, and thus may contain inaccuracy due to self bias.)

Key components of the Joint Program survey included:

1. Presence of a "Physician Champion", who leads the attempt to implement, lines up support at all levels, and maintains momentum and enthusiasm throughout the process.
2. The dedicated position of a "Program Coordinator," who manages the whole program including all pre-op education and post-op planning for the patient.
3. Dedicated unit/area devoted exclusively to joint patients, consisting of a specific number of beds that is sufficient to accommodate peak census.
4. Dedicated staff devoted exclusively to the joint program as first priority over other duties or units.
5. Group physical therapy.
6. Type and scope of pre-operative preparation/education for patients and family members.
7. Amenities (like massage therapy), which transform the atmosphere of the unit from one of sickness to one of healing and encouragement.
8. Blocked operating room schedules, where all joint surgery is done on specified day(s), so that patients can recover together as a group.
9. Standardized instruments/pre-op orders/discharge orders to provide consistent results.
10. Yearly assessments of outcomes to measure the clinical and financial performance of the center so that goals can be set and adequately measured.
11. The use of volunteer staff that assists in group therapy sessions.
12. The use of trained family members that act as coaches both during the patient's hospital stay and the ensuing recovery time.
13. Presence or absence of selection criteria to determine whether patients will be included in the program (For example, do not take the sicker patients - this would skew the data).

In order to compare the success of the differing programs, we also included questions that were designed to measure the results and statistics of each respective hospital. The following list displays those concepts, which were used to measure the success rate in terms of results, for each hospital:

1. Number of total joint (knees and hips) replacement surgeries performed/year.
2. Profitability of joint surgery.
3. Patient Satisfaction as measured by national standards (e.g. Jackson), as well as an appropriate way to gather constant feedback and criticism from the patients.
4. LOS (length of stay) and LTH numbers (average length to home duration, meaning average time a patient will be in the hospital before returning to their home, including time in hospital rehab center).
5. 30 day re-admission rates for total knee and total hip replacements

In order to obtain data concerning the difficulties that hospitals faced throughout implementation, several questions aimed to identify the largest barriers faced. The following list provides the potential barriers faced by hospitals:

1. Lack of leadership (Physician, Nursing, Administration)
2. Unwillingness to change (Physician, Nursing, Administration)
3. Politics (Physician, Nursing, Administration)
4. Disinterest (Physician, Nursing, Administration)
5. Other barriers (space provided for explanation)

Results
Out of 124 surveys that were sent to hospitals, we received 41 responses (33% return rate). Four groups of programs were determined. Below is the breakdown of the results:

The maximum and minimum scores possible ranged from 127 pts to zero. The actual range of scores was 0 pts - 116 pts, with an overall average of 67.9 pts, a median of 77, and a mode of 0 (5 programs).

The following chart displays the average score or the percentage of respondents for the four main groups as well as the overall numbers for a variety of statistics:

	Overall	COE	TJP	TJS	NM
Score on Survey	67.9	105.5	88.4	70.5	22.1
Joints Performed/year	414.2	561	526.6	222.9	304
% Profitable Programs	47.2%	66.7%	66.7%	25%	33.3%
% With 100-90% Patient Satisfaction Percentile	75%	100%	83.3%	66.7%	50%
% Re-admission rates <3%	66.7%	83.3%	66.7%	58.3%	66.7%
% Measure Outcomes (clinical/financial)	81%	100%	91.7%	75%	50%
LOS	3.55	3.46	3.35	3.80	3.50
LTH*	5.58	5.29	5.24	5.83	6.16
Barriers identified	4.56	4.33	5.54	3.92	5.00
% With Program Manager	86%	100%	91.7%	83.3%	33.3%
% Dedicated Staff	75%	100%	100%	58.3%	33.3%
% Dedicated Unit	75%	100%	91.7%	58.3%	50%
% With blocked Surgery	81%	100%	91.7%	75%	50%
% With No Selection Criteria	63.9%	100%	50%	66.7%	50%

*LTH stands for average length to home duration, meaning the average time a patient spends in the hospital before returning to their home (includes time in hospital rehab center).

Discussion
Contacts
One initial obstacle for the completion of this research was the identification of an appropriate contact person. Identification presented several difficulties and essentially limited the number of hospitals/centers that we could include in the survey. The older programs established several years ago, presented the largest hurdle in obtaining appropriate contact individuals.

When establishing a new program like a Joint Center, which involves patients, physicians, administration, OR scheduling, anesthesia, physical therapy, dietary, nursing, etc., time is required to mature and develop each aspect of the program. Because of this, newer centers usually provided little to no information, and the information provided was generally incomplete. Therefore, few newly founded centers were included in this study.

At the other end of the spectrum, if a program was purchased or developed and implemented several years ago, there was a greater chance that the original contact individual was no longer involved with the program or held the same position. Also, even if a proper Joint Program Coordinator (manages the whole program including all pre-op education and post-op planning for the patient) had been established, obtaining information about the implementation process was more difficult to ascertain. As with the new programs, these older programs represented a small proportion of completed surveys in the study.

The breakdown of hospital respondents and the established time of their programs are as follows:

Of those centers where a contact person could be reached, participation was extremely high, and the bulk of the surveys were provided by this category of hospitals.

Implementation Success
It is our assumption that those programs where an appropriate contact person could not be reached, or where they neglected to complete the questionnaire had too little or no program at all. If this is the case, then the following statistics represent the proportion of hospitals that were able to successfully implement the center:

While this assumption makes logical sense, it is a pretty liberal assumption and would positively skew the data. With that in mind, the statistics used in this study are represented by the hospitals that completed and returned the surveys. The hospital breakdown can therefore be represented by the following statistics:

In reality, the truth most likely resides somewhere in the middle of these two data sets, but due to the complexities of the research pool and also the somewhat inadequacy of the contact lists, it is difficult to estimate in full confidence.

It should also be noted that no significant differences were noted in both implementation success and program results between the two different lists of hospitals (AAMC list and TVC list) therefore they are being grouped together.

The following chart displays the implementation rates for the hospitals that only purchased a program from TVC, hospitals that only visited AAMC, and hospitals that both purchased and visited.

Length-of-Stay/Length-to-Home: LOS/LTH
The length-to-home statistic was designed to examine the true length of a patient's stay. Traditionally, the length-of-stay (LOS) statistic has been the measurement used, but upon further examination only represents the amount of time that a patient spends in the hospital. The LOS fails to calculate the length of time that patients spend in an institutional setting while incurring costs to the system. By taking a weighted average of original LOS, with the percentage of patients that are not directly sent home (along with the average duration of time in the rehab unit), the LTH statistic could be calculated.

By calculating the LTH figures, a more accurate picture of the institutional nature of the stay can be depicted. Based on the results, the average LOS calculated was 3.55 days, while the average LTH calculated was 5.58 days. This is a 65.6% increase in time spent in the healthcare system, which surely affects both the patient and the cost felt by the health care system. The following chart shows the LTH and LOS figures for each of the four groups.

The average LTH for each of the groups is as follows:

Selection Criteria
Out of all the participants in the survey, 46% of the hospitals had selection criteria that predetermined certain "non-ideal" patients (for example, sicker patients, revisions) as ineligible to participate in the program.

When comparing the hospitals, those possessing selection criteria had lower LTH and LOS numbers, while performing fewer joints on average than those without criteria. These findings are to be expected, as those programs, which filter out patients who will clearly have longer recovery times, will obviously have lower LOS/LTH figures. However, by selecting out the difficult patients, it appears that a program avoids testing its true capability to provide excellent care and lower hospital durations to all patients, ideal or non-ideal.

It should be noted that all of the "centers of excellence" did not use selection criteria, but still exhibited some of the lowest LOS and LTH numbers, while remaining profitable and in the highest patient satisfaction percentile.

Barriers Encountered
Upon closer inspection of the barriers identified in the surveys by each hospital and each of the four groups of hospitals, several assertions can be made. First, regardless of the strength of the program, every hospital attempting to implement a program collided with barriers. Even the "COE" identified an average of 4.33 barriers, which is just slightly under the overall average of 4.56 barriers identified. Additionally, unwillingness to change (64% of the programs identified this as a barrier) and politics (55% identified this as a barrier) were the most common barriers to implementing the program. This does not come as a shock as change is rarely an easy process, especially with the degree of complexity with regard to the coordination of a great number of departments and professionals involved in establishing a joint program. In addition, 39% of the hospitals reported both lack of leadership and disinterest as major barriers they encountered during implementation.

Overcoming barriers was successful in some hospitals and clearly unsuccessful in others. It should be noted that the top programs, when compared to the others, had the strongest core leadership during implementation. For example, 100% of these top programs reported a physician champion leading the way and uniting their efforts. Also, out of all the respondents, hospitals from this top group accounted for only 5% of those who identified lack of leadership as a barrier, and only 16.7% of these top hospitals stated they had any leadership barriers. Additionally, 100% of these hospitals not only possessed: 1) a leadership team (consisting of devoted members that serve to unite and standardize everything, but also 2) a task force (consisting of members from various departments to ensure cooperation from their respective departments). In these hospitals, each of these two leadership bodies was meeting on at least a monthly basis. The following chart displays the leadership statistics for each respective group:

	COE	TJP	TJS	NM
% With Physician Champion	100%	83%	58%	50%
% With monthly meetings of task force/dedicated staff	100%	50%	50%	16%
% With Leadership barriers	16.7%	50%	25%	66.7%

This chart shows a large discrepancy between the "centers of excellence" and the others, including the "program models", in terms of leadership characteristics. The complete programs simply had better leadership that meet on a regular and consistent basis.

Conclusion
Successful implementation has been shown to be a difficult process, as only 14.6 % of the responding hospitals established "centers of excellence" and 26.8% failed completely with the rest somewhere in between. In reality, it is likely that the percent with "no model" would be much higher since we could not include hospitals that did not respond to the survey. These statistics suggest that visits to well-established programs or the purchasing of implementation toolkits and training do not necessarily result in successful completion of the program. It appears that the use of an on site and experienced consultants who first does an assessment of the hospital, customizes the program, mentors the leadership team and participates in the implementation process may be more effective. This method, utilized in Holland, appears to have consistent and successful rates of complete implementation, although no official study has been conducted.

Based on the results of this study, successful implementation is highly correlated with the strength of leadership (dedicated and serious leaders who can spearhead the process, line up support on all levels, hurdle barriers, persuade opponents, and minimize disinterest by keeping the project moving towards completion).

Just as proper educational tools and mentoring is essential to sufficiently educate a patient, perhaps proper educational tools and mentoring are equally essential to thoroughly and effectively educate and enable leaders. Physician leaders, nursing leadership, and administrative leadership must understand "frequently encountered barriers" (FEB's) and be prepared to implement proven solutions to overcome these barriers. The following is an example of a FEB list:

1. Lack of leadership (Physician, Nurse, Administration, Physical Therapy, Anesthesia, Operating room)
2. Unwillingness to change (Physician, Nurse, Administration, Physical Therapy, Anesthesia, Operating room)
3. Politics (Physician, Nurse, Administration, Physical Therapy, Anesthesia, Operating room)
4. Disinterest (Physician, Nurse, Administration, Physical Therapy, Anesthesia, Operating room)
5. Physician competition
6. Lack of physician collaboration
7. Staff too busy to implement changes
8. Insufficient funding
9. Failure of hospital to "Buy In" to Joint Program concept
10. Staffing shortages
11. Difficulty in standardizing protocols
12. OR schedule blocking conflicts
13. Agreeability amongst surgeons
14. Lack of accountability
15. Inability to dedicate staff/beds
16. Mistrust
17. Inconsistent vision
18. Difficulty in holding beds
19. Constraints of physical location.

As reimbursements continue to be squeezed, costs rise, and patients become more knowledgeable, it is essential for hospitals to become more efficient, profitable, cost effective, and patient friendly if they are to remain competitive. The successful implementation of an innovative joint delivery system has been shown to accomplish these goals. The results as measured by patient satisfaction, profitability, speedy recovery to home, and decreased readmissions improve with more successful program completion. Implementation is usually unsuccessful unless leadership is empowered and mentored. Every hospital serious about providing total joint surgery would be well advised to implement a complete joint program in their institution.

If you have questions concerning this study or are in need of further assistance please call Dr. Marshall Steele or Kyle Prickett at (410) 268-8862.