CERTIFIABLE Business is crisp at Ohio Specialty Surgical Suites, the first ASC in the nation to earn total joint certification from the Joint Commission.

The process for handling total joint patients used to be fairly simple at San Francisco's Presidio Surgery Center: Get them into the center, get their surgery done and get them home safely. Then one day, the Joint Commission called and everything changed. "They were trying to figure out standards [for their new total joint certification program] and wanted input from an ASC," says administrator Jessie Scott, MBA.

What followed was eye-opening, as Presidio began a journey that would lead to its becoming Joint Commission-certified for total joints, the second of only 3 such U.S. surgery centers to achieve this new designation meant to validate a surgical facility's ability to deliver excellent outcomes to every patient. The Joint Commission launched its "Advanced Certification for Total Hip and Total Knee Replacement" program in early 2016 for accredited hospitals, critical access hospitals and ASCs that perform both total hip and knee replacements.

"How you think about your responsibility toward patients changes as a result of the process," says Ms. Scott. "It's not just getting them into surgery. It's managing all these other things that go along with it."

That evolution began when a surgeon and a nurse, sent by the Joint Commission, arrived and began doing mock surveys and asking tough questions. How, for example, would the center handle an overnight patient who developed hyperglycemia or hypertension? (California patients can stay in ASCs for 23 hours and 59 minutes.)

"We said, well, we'd call the surgeon," Ms. Scott recalls with a laugh. "He pulled down his glasses and looked at me and said, 'I'm an orthopedic surgeon. I know we don't know what to do.' I knew he was right."

In September 2016, Ohio Specialty Surgical Suites in North Canton became the first surgery center to be certified. In so doing, they, too, had learned to expand their focus and immerse themselves in the entire episode of care. For example, the Joint Commission advised them to improve their collaboration with doctors' offices and everyone else involved in the process.

A CUT ABOVE? Standardization and evidence-based medicine are key elements of Joint Commission certification.

"We really learned how to take care of patients and their families from beginning to end," says patient educator Rosemary Kramer, RN, BSN.

The caretaking includes pre-op therapy. "Prehab" involves conditioning exercises and instructing patients on using a walker, going up and down stairs, and getting in and out of a vehicle and a bath tub, says Trish Smith, RN, also an educator and a PACU nurse. "We're coordinating with almost everybody in the building that has any access to the patient or the patient chart," she says.

It also includes providing mandatory classes for patients in the weeks leading up to surgery. As it turns out, the education has benefited more than just patients, says Angel Carlile, RN, the program coordinator at Ohio Specialty Surgical Suites.

"The Joint Commission is really big on lifestyle changes," she says. "Things like encouraging patients to quit smoking, maintaining a healthy weight, getting proper nutrition, making sure they exercise and blood clot prevention. They've actually made us more aware of the things that we're trying to educate patients on."

Show me the evidence
Both centers say they've also been enlightened by the Joint Commission's strong allegiance to evidence-based medicine, as opposed to what Ms. Scott calls the I-had-a-bad-experience-once, so-now-I-do-this approach.

"Myths get adopted in health care," she says. "But we've really changed our philosophy. Now when something is suggested, we say, let's consider it, where's the evidence, what's this based on?"

That doesn't mean everything is set in stone. But if you're proposing something new, "you have to be able to show that it's based on nationally accepted clinical practice guidelines and that it's evidence-based," says Ms. Scott. If you can, "they [the Joint Commission] are fine with it, but you're going to have to back it up.

"Our program elements are now very much standardized," she adds. "If a doctor wants to be in our program, he has to go along with standardized order sets." Fortunately, after some initial resistance, the philosophy has taken root, she says: "It was a hard battle, but it turned around. I hear doctors say it now: 'Where's the evidence?'"

Impressive distinction
Of course, one of the big benefits of certification is that it provides a strong promotional vehicle. As Ms. Scott puts it, "It's nice to have somebody besides you who thinks your program is good."

Ohio Specialty Surgical Suites is advertising its certification in newspapers, in pamphlets placed in surgeons' offices and on a billboard. The stamp of approval makes a difference, says Ms. Carlile. "A lot of patients are apprehensive at first. We're going to go home the first day? My friends are telling me you have to stay there 3 days. But when they see our program and the certification, it puts them at ease. People do seem to be impressed with the distinction."

And business is crisp in Ohio Surgical's 2 ORs. Among the customers are a significant number of out-of-towners who've driven 2 hours or more to get to North Canton. "January and February are usually our slow time because people didn't meet their deductibles," says Ms. Carlile. "But this year we're keeping up, doing 20 or 30 every month." "And," adds Ms. Kramer, "I'm sure when we get to October, November and December, we'll be doing 50 to 60 cases every month."

Business is good at Presidio, too, but Ms. Scott suspects there will be bigger rewards down the road.

"The big bang is going to come from the big payers when outpatient joints become more routine," she says. "They're going to have to build networks and figure out which are the right places to go. I'm expecting [certification] to help us there."

WE'RE NO. 1! A highway billboard makes sure the North Canton, Ohio, community gets the message.

An investment
At Presidio, the entire certification process took about a year, "but I'm slow," says Ms. Scott. "If you have a program up and going, and just need to tweak it, it would probably require less time."

There was a modest fee, she says, in part because 2 Joint Commission representatives were onsite for 2 days, including observation of a total joint procedure and the entire continuum of care. There are also some ongoing expenses on the staffing side. A pre-op nurse now spends more time as a patient care coordinator. And a data-entry person spends a few hours a week tracking data and entering it into the American Joint Replacement Registry and the Joint Commission website.

But it's been a good investment, says Ms. Scott. The key is having good surgeons and commitment from your team. Because it's work, she says. "People are going to have to change their practice. Everybody needs to understand what you're doing and why you're doing it, and they need to be bought in."

Part of that hard work was figuring out how to handle those potentially hyperglycemic or hypertensive overnight patients the Joint Commission surgeon asked about. Presidio contracts with an anesthesia provider to be the provider on the day of surgery and to be on call for that patient overnight. "If there's a hypertensive crisis or a diabetic crisis, we call the anesthesiologist in, not the surgeon," says Ms. Scott.

Improved communication and collaboration are leading to better outcomes at Ohio Surgical. For example, the screening of patients starts with a phone call, extends through the mandatory classes and continues right up until the day of surgery. Not much can fall through the cracks when the anesthesiologist, the pre-op education nurses and the surgeon each interviews the patient, says Ms. Kramer.

"I think every department has improved," says Ms. Carlile. "We've gotten to where we're continually hearing praise from patients who've had total joints done elsewhere and who then come here to have a second one done. They say their experience is much better here than it was in the hospital or in other facilities." OSM