Total joint replacement (TJR) surgeries have been steadily migrating from inpatient to outpatient settings in recent years, and that trend is building momentum even faster than previously anticipated. We believe that at least 70 percent of TJR surgery volume, perhaps more, can now be outpatient.
In 2018, research firm Sg2 projected 84 percent growth in knee and hip joint replacement surgery. The firm estimated that 57 percent of all non-fracture knee and hip replacements would be performed in an outpatient setting by 2028, with inpatient growth slowing due to factors like payer and patient price sensitivity, surgeon preference, and technology and pain management advances.
Outpatient joint replacement has been linked to overwhelmingly positive outcomes for patients, physicians, and healthcare facilities, including higher rates of patient satisfaction and lower costs. Studies show that joint replacement surgeries can be performed safely in an outpatient setting, with comparable complication rates to those of inpatient procedures, even for Medicare patients.
Five years ago, our organizations began working together to build an ASC in the Portland, Oregon, area focused on complex procedures, including TJR and spine disorders. Surgeons from six competing orthopedic practices in the area came together around a shared objective: forming a surgery center that offers the best high-acuity joint replacement and spine care in the state.
We have learned many lessons along the way. As the shift to outpatient surgery continues to gain momentum, we have outlined four considerations for center leaders interested in developing a total joint program or moving toward 70 percent outpatient TJR volume:
- Build a Successful Partnership
It is not always easy to gather a dozen joint replacement surgeons, all trained in different places and approaches, and reach any type of consensus. Our diverse backgrounds and perspectives were an asset in the long run, however.
We learned to check our egos at the door and listen to the experiences and ideas of other surgeons. Through open and honest dialogue, we made decisions as a team to standardize processes, encouraging and challenging each other to strive for the highest quality outcomes for our patients. We focused on creating a partnership that was collaborative and patient-centric above all.
- Adapt or Design the Right Facility
As joint replacement surgeries move to outpatient and technologies and patients evolve, operating rooms also must change. A standard 400-square-foot operating room does not make sense if you need adequate space for surgical robots and 10 or more trays for a knee or hip revision. We started by asking the surgeons: In a perfect world, what would you like to see in a surgery center? What do you want to accomplish, and what do you need to get there? What are the annoyances or problems from other places you have worked that you want to avoid?
Once we had answers to those questions, we brought them to our architectural firm and figured out how to incorporate them into the design plans. For the surgical team, it was an opportunity to create the ideal ASC environment, with features like spacious storage areas, operating rooms with backdoor exits into sub-sterile corridors, and private recovery suites. We were very progressive in planning the capacity of the surgery center. Five years ago, it felt bold to imagine up to 50 percent of our patients being eligible for outpatient surgery, but we pushed ourselves to plan for doubling our capacity or someday treating 90 percent of our patients in the center.
We also considered the patients’ and the family members’ experience in the design process. For example, we made sure the waiting room is a comfortable place to relax and work—with excellent broadband WiFi—so if the 45-year-old son of a 75-year-old patient needs to work from his laptop while looking after his mom, he can do both.
This consumer-focused approach has evolved from a trend to a mainstay, particularly in an outpatient environment when patients can decide where to go. Amenities and details matter not only to the patient, but to the family and caregivers.
- Build the Clinical Team
We were determined to have a patient-centric approach to surgery, and that meant assembling an experienced team of nurses, techs and anesthesiologists. Because our surgeons come from six separate groups that practice across every major hospital in the metropolitan area, we have recruited a strong team with diverse backgrounds, skill sets and perspectives.
One early surprise in staffing was discovering the necessity of hiring full-time orthopedic coordinators for the surgery center. These roles were not part of our original business plan, but they were so essential that we quickly reconfigured the budget to be able to hire more.
Orthopedic coordinators are nurses who act as the captains of the ship, keeping it on course and making sure we stay at the leading edge of providing outpatient joint services. We now have four full-time coordinators who develop preoperative education, teach classes and modify curriculum based on patient feedback and post-operative observations.
As surgery centers expand to include higher-acuity specialties, we expect the role of dedicated care coordinators will evolve and play a key role in outcomes and patient satisfaction.
- Continue to Refine the Clinical Pathway
From the beginning, we aimed to establish best-in-class clinical processes in our surgery center, but we recognized that we will always be learning, evolving and improving as we go. We never want to be complacent and get stuck in our ways, so we are constantly having conversations with implant vendors, payers, hospital systems and other important players in the orthopedic space to see how we can maintain good relationships, high patient satisfaction and high-quality ratings.
We are refining our clinical processes on an ongoing basis, focusing on optimizing key areas that include patient selection, preop management, day of surgery care, discharge and follow-up. For instance, we know that social determinants are the most important criteria for patient selection. Ideal candidates have a strong social network and a positive attitude and are willing to engage in the program and take direction. We train our entire clinical staff to reinforce this positive attitude from preop preparation through follow-up visits.
The growth potential of outpatient surgery is enormous. Forward-thinking surgeons, clinical teams and administrators will recognize the opportunities in this trend and look for ways to create safe, effective and patient-centric outpatient settings that meet the needs of the future.
We believe that at least 70 percent of TJR surgery volume, perhaps more, can now be outpatient.
– Chris Bishop and Christopher Nanson, MD.