Advances to minimally invasive surgical techniques, blood loss management, and anesthetics have led to a rise in total joint arthroplasties (TJA) being performed at ambulatory surgery centers (ASCs). Orthopaedic specialists and patients nationwide are increasingly well-served with the same-day model, in which patients receive their total joint replacement and return home for recovery within 24 hours, typically on the same day as surgery. Many orthopaedic-focused and multidisciplinary ASCs are preparing to offer a same-day TJA program, if they do not already. For ASCs working to initiate a credible total joint program, there are key clinical, business, and marketing elements of a well-developed program to consider.
Five questions ASC board members and investors will want to ask before approving a TJA program follow.
1. How does the ASC determine TJA patient selection criteria?
Well-formed patient selection criteria are important components of a successful TJA program. Key stakeholders will likely query, is there a national standard for outpatient TJA patient selection criteria? Unfortunately, the current answer is no. Outpatient total joints do not have as much history as that of outpatient surgery in general. And few professional societies have yet to publish specific criteria for outpatient total joint replacements. However, publications from institutions doing TJA successfully on an outpatient basis are available.
To form a TJA patient selection criteria that is safe for your patients, lean on your clinical leaders. This includes your clinical nurse manager and head anesthesiologist. Begin with your center’s current patient selection criteria for all patients. Then, consider American College of Surgeons National Surgical Quality Improvement Program (NSQIP) standards and American Society of Anesthesiologists (ASA) standards. Do this before reviewing accepted standards from peer-reviewed publications and other ASCs with successful TJA programs.
2. What is the ASC’s clinical plan for performing total joints?
A thorough clinical plan includes patient selection criteria, pre-operative screening protocols, anesthesia plans (pre-operative, intra-operative, and post-operative), clinical guidelines, discharge guidelines/criteria, and follow-up guidelines. Once again, rely on your clinical leaders to formulate the guidelines. If you are having trouble determining some of the clinical plan components, contact a qualified total joint program consultant and/or your ASC association. You can also perform an internet search to look at what other ASCs are doing. Finally, the clinical plan should also incorporate physical therapy, which many ASCs are arranging for patients to complete at the ASC both pre-operatively and post-operatively on the day of surgery.
3. Is the ASC’s nursing staff prepared for the first TJA case?
The beauty of working with skilled nurses in an ASC is their wide-ranging experience. Their experience often includes total and partial joint surgeries at hospitals and other surgery centers. Still, you will want to work with your Clinical Nurse Manager to prepare your ASC’s nursing staff for the TJA program. Identify individuals on your team with the most experience in orthopaedic surgery and in performing total joint surgeries. If you are lucky, you may even have nurses on staff who have worked on TJA cases with the physicians who will be performing them at your center. Rely on these individuals to serve as your skilled TJA nurses and teachers for the other nurses.
In advance of your first patients, prepare your operating room nurses. Arrange for a TJA walk-through with your device representatives. Prepare your pre-op/PACU recovery nurses by arranging for a lesson with a physical therapist who can teach them safe post-surgery movement and ambulation techniques that will prepare TJA patients for discharge. If overnight patient stays are part of your clinical plan, ensure nursing staff members understand patient care expectations during this extended recovery time.
4. What will be the fiscal impact on the ASC?
If you are projecting a certain number of total joint cases in your first year, identify the market and physicians who you expect will deliver these cases. For example, is there a patient population you are not treating because an outpatient total joint program isn’t currently in place? Or, will your physicians be moving a sector of their current patient population to your ASC? Is there another way to capture market share? Combine projected case counts with information on reimbursements and costs to identify the potential fiscal impact on your ASC.
5. What is the marketing strategy and plan for your TJA program?
To answer this question, one must first gain direction from the ASC’s governing body. Determine their interest in working collaboratively with key stakeholders such as the hospital partner to market a comprehensive total joint program. In some cases, collaborative marketing may be a strong desire of your board. Regardless, it will behoove you to create a marketing plan that divides marketing efforts into consecutive stages.
For example, the initial stage might aim to maintain the current customer base. This can include efforts like marketing to referral sources and direct-to-consumers through patient education, media/public relations, and website enhancements. The next stage could then focus on expanding the customer base by exploring new market areas and referral sources. At each stage, marketing efforts and metrics should be evaluated to determine if program goals are being met. This analysis will help determine future growth opportunities and identify further initiatives for enhancing the TJA program.
One of the key components of a successful outpatient total joint replacement program is early preparation. Completing a clear and concise clinical, business, and marketing plan will not only demonstrate to surgery center board members the ASC is ready for total joint approval, it will also deliver a safe environment for total joint replacements performed in your facility.
Jack Mast – Physician Liaison