Rounds Coverage

Joe Cantlupe, for HealthLeaders Media , May 13, 2011
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The MemorialCare Health System was moving forward with its orthopedic care program, anticipating growth with an aging baby boomer population, but the program seemed to be missing something. The care team wasn’t united under a common philosophy. The process didn’t appear to be patient-centered. The result: a lack of focus and defined outcomes.

Within two years, the orthopedic program was revamped, with a team-driven approach directed toward patients instead of clinical processes, and had vast ROI improvements within a joint-replacement center. The patient-centered approach in orthopedic care was the focus of a discussion at a HealthLeaders Media Rounds event, “Orthopedic Leadership Strategies: Engage, Measure, and Perform,” held at the Orange Coast Memorial Hospital in Fountain Valley, CA.

Orthopedics is an appropriate service line for Lean approaches to improve patient care because of the complexity of patient flow, the high cost, and significant volume, says Pamela Chevreaux, vice president of ambulatory services for the Long Beach Memorial Medical Center.

Using Lean principles, the MemorialCare Health System also developed patient-education coaching for orthopedics patients while improving physician leadership strategies for better alignment and engagement, says Chevreaux. Within a specific plan, Chevreaux says MemorialCare was able to improve care for patients prior to surgery and streamline patient interaction with staff. Establishing a family- and patient-selected “coach” through the process made for successful education strategies. Patients also were assigned a joint center coordinator to review their procedures, Chevreaux says.

Previously, a lack of focus was reflected in the system’s postoperative goals, which were “clinician-centric not patient-centric,” says Douglas Garland, MD, medical director of the Joint Replacement Center and cochair of the orthopedics, neuroscience, and rehabilitation units at Long Beach Memorial Medical Center. “We needed to create meaningful metrics and standards, with the patients engaged throughout the process,” says Garland. 

The continued process improvements included a new daily management system, a dedicated team for standardized postop protocols and data-driven decision-making, Garland says. “We had to develop a common vision for the patient and caretaker, a physician-hospital collaboration with a performance improvement team,” Garland says.

The joint-replacement center focuses on patients in need of hip and knee replacements, and patients usually have hospital stays of only two or three days. The center features private rooms, a group room for therapy, education programs, and group lunches. Patients and families, volunteers, and staff work together as the patient starts a “cruising to recovery” program at the cruise ship–themed center. A “walking board” tracks the number of steps a patient takes each day, representing a symbolic journey around the world. Patients receive guidebooks as part of their education process, not only for their hospital stay, but also to help them understand what to expect when they go home. As family members or friends participate as coaches, they attend therapy and educational sessions.

According to Chevreaux and Garland, under the previous system, patients who had orthopedic surgery would not get out of bed until the day after surgery, stay in the hospital for at least four days, and probably be off work for three months. It would take them at least six weeks to get into a car and drive. In addition, they say there was uncertainty for the patient about when to begin physical therapy after leaving the hospital.

The larger educational component for the patient has reduced “fear and confusion,” Garland says.

Improved collaboration between physician and staff has reduced the potential for turf wars, he adds.

The joint-replacement procedure changes have resulted in significant improvements to patient care as well as ROI, Chevreaux says.

For instance, she says, the system has seen decreased length of stays for patients, from 4.35 to 2.96 days, plus improved distances that the patients are walking and improvements in overall recovery. The number of patients sent directly home increased from 21% to 81%. As for costs, implant expenses were reduced to lower than the national average, and the number of private pay patients increased 31%, she says. 

The different manner of care is also reflected in the clothes worn by patients; previously they had to wear hospital gowns, but now they wear street clothes, Chevreaux says. “The focus is on health and wellness; we are addressing independence [for the patient] from the moment the physician meets the patient to the transition home.”

Hospital collaboration is especially important with IPAs and the MemorialCare Physician Society, which consists of more than 2,000 physicians, says Marcia Manker, CEO of the Orange Coast Memorial Medical Center. “It’s the foundation of our physician alignment that is critical to meet the needs of our doctors and the changing face of our delivery system,” Manker says. “The physician society teams up with our employees to drive clinical standards in performance resulting in exceptional outcomes.”

California’s restrictions on ownership of medical practices and systems does allow the medical foundation model for “greater alignment and shared efficiencies,” Manker says. The MemorialCare Health System also includes the Long Beach Memorial Medical Center, Miller Children’s Hospital, and the Saddleback Memorial Medical Centers in Laguna Hills and San Clemente.

In partnering with physicians, it is important for health systems to reduce waste in orthopedic care and “benchmark against best practices,” says Marshall K. Steele, MD, of Marshall Steele & Associates. Steele was founder of a 16-surgeon subspecialty musculoskeletal center. With economic constraints and healthcare reform, hospital systems are virtually required to improve quality, Steele says. Hospital systems and physicians are being to be asked to be more accountable “to prove that the interventions that they perform are successful, and the only way to do that is to collect patient-reported outcomes.”

James D. Holstine, DO, an orthopedic surgeon at PeaceHealth St. Joseph Medical Center in Bellingham, WA, says hospital systems should evaluate their culture to establish better standards. “Culture trumps process for a world-class patient experience,” he says, referring to changes implemented by the MemorialCare system designed to improve patient care. “You put the patient first,” he says.


Joe Cantlupe is senior editor for physicians and service lines. He may be contacted at

Reprint HLR0511-12

Joe Cantlupe is a senior editor with HealthLeaders Media Online.

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