The Case for Quality Improvement in Pediatric Orthopedics

John Lovejoy, III is a POSNA member and a Pediatric Orthopedic Surgeon at Nemours Children’s Hospital (NCS) in Orlando, FL. The Nemours Foundation includes several healthcare facilities, providing multispecialty pediatric care. Nemours has separate Departments of Pediatric Orthopedics at A.I DuPont Hospital in Wilmington, DE, at NCS in Orlando, FL, in Jacksonville, FL, and in Pensacola, FL, all of which are involved in a quality improvement project related to supracondylar humerus fractures. John is the Director of Orthopedic Continuous improvement at NCS. I spoke with him about his involvement in this system-wide project. 


Hi, John. Tell me about your QI project.

Our project was for supracondylar humerus fractures. The project was designed to help standardize the treatment of this common pediatric elbow injury. We noticed that within our health system, there were several different algorithms regarding how these children received care. There was a lot of variation in the ways the injuries were documented, in details of the procedures, in the amounts of follow up, and what was done at those follow up visits. So, our objective was to standardize the treatment of these injuries to decrease this variation as much as possible. We wanted to maximize the quality of the patient experience, and to evaluate our processes from the patient’s perspective.

So why do we need these projects?

Decreasing unexplained clinical variance decreases your risk of complications. From a patient perspective, decreasing variation makes for a more predictable and pleasant experience (as much as treating an injury can be pleasant). When a patient comes to a hospital, and you have multiple different surgeons at the same institution managing the same problem with different methodologies, it can be confusing to the ancillary personnel who assist with the patients’ care, it can lead to mixed messages or incorrect expectations, and in some situations, it could potentially lead to a difference in the quality of the treatment that a patient gets.

Who do these projects benefit?

Hopefully, they benefit everybody involved in the healthcare process, including the surgeons. Part of our task was to look at these methodologies, and to see if there was literature that supported the variations. This was not intended to be majority rule. It’s possible that one surgeon was doing something new and innovative that other surgeons weren’t aware of yet, so learning from our peers was seen as a real benefit.

From the institution’s point of view, variation can be expensive. We saw variations in the type of draping used in the operating room, variations in the amount of time it took to do the procedures, variations in the number of follow up visits recommended. All of these can have direct cost implications for the institution. Decreasing that variation helps to provide the best quality at the lowest cost. And unquestionably, providing better quality at lower cost is beneficial to patients. It increases satisfaction, decreases complications, and provides better value.

Also, when you decrease variation, it makes it easier to study new variation. We wanted this to be a dynamic process. We wanted to let people know that if they wanted to do something other than what we had recommended for the group, it would be OK, but that we would then study it, and see if it’s making a real difference in terms of care and quality and cost. And if not, then maybe it would be better if they would try something different.

Are institutions required to do these projects for legal or regulatory reasons?

Not really with regard to this specific process. However, JACHO and other organizations that monitor hospital quality, such as infections rates, etc., certainly encourage these kinds of projects. Admittedly, it’s an opportunity for our institution to brag about a project that we’re doing, and it’s something we’re proud of that we think is good for patients, but it’s not one that’s specifically mandated. There are no specific reporting requirements, though we created research projects in conjunction with this QI project so that we could report results to our peers.

How did you identify an area of focus for this QI project?

We identified supracondylars because we wanted a high-volume problem so we could collect lots of data. We wanted something that would be relevant to all of the Nemours sites. We wanted an area that was also well-studied in the literature so we had some baseline research data.

What’s the best way to initiate a QI project?

Starting a project requires commitment on behalf of the participants. We committed to a weekly meeting. It was a video conference between all sites. If you were to do a project at a single site, I think a regularly scheduled meeting with protected time for all participants is an important first step that the institution needs to take.

What resources are needed for this type of project?

Other than protected time, you need someone to assist you with the data collection and evaluation of variances. Our institution is lucky to have a “Continuous Improvement” team, and they were central to helping us collect and process a lot of that data. People cost money, so you need support. To this point, there are not any other significant costs other than salaries associated with the time needed to produce the data. Looking at the research project portion of this, it will require a longer-term time commitment.
A key to evaluating the project is to have an audit mechanism. We came up with a mechanism, with help from our CI team, which will help us see how many of our providers are complying with recommendations, if certain recommendations have high or low compliance, what is being done instead, and if what is being done is better or worse than the current recommendations.

How do you obtain buy-in from key stakeholders (especially physicians) to participate?

It’s challenging, but doable. You want to be as transparent as possible about the process. You want to be as inclusive as possible. We also emphasized that we were putting together guidelines, not rules. Although we requested everyone’s participation, and were hoping for 100% compliance, we did allow the option to deviate from recommendations with the caveat that we would study the variances.
You also have to have strong management and leadership at each site. If the leaders haven’t bought into the project, it is unlikely that you’ll have strong participation from the other surgeons.
Physicians, in general, are scientific and data driven, since that’s the way we’re traditionally trained. It’s much easier to convince somebody to consider a change to their normal protocol when they see objective data. Gathering objective data, rather than subjective opinions about best practices, is really a key.

What is a reasonable time frame to complete a QI project?

I’m sure it depends on the intended breadth of the project. For our project, we had hoped to have it completed within a year, and the reality was that it took about a year and a half. It may depend some on the experience of the participants. In our case, we were new to CI initiatives, so we had a steep learning curve at the beginning to understand the process. I think in the future projects will benefit from that initial training, and will be more efficient. Of course, it also depends on the amount of support you have. Generally, the more support you have, the more potential there is for efficiency.
The timeline needs to include incremental goals. You need to have deadlines. Your colleagues must understand that in order to accomplish this in a reasonable amount of time, you only have so many opportunities to participate or interject.

More important than the time frame is laying out the project in an organized fashion. Have an initial meeting, get your stakeholders together, find out what resources are available, develop the framework for the project, and then consider an appropriate timeline.

How does a QI project differ from clinical research?

QI projects that are purely for continuous improvement of your practice are generally exempt from the IRB process, a least at our institution. That exemption does come with some caveats. If your intent is to publically publish data in the future, then you are likely going to need IRB approval. QI projects can look exactly like clinical research, but they can also be completely different. For example, we were trying to make some immediate changes to improve standardization, such as getting providers to use similar progress notes for documentation. That wouldn’t qualify as clinical research. However, we had another arm of the project, for which we did get IRB approval, to look at the actual data that was collected in the progress notes, and to publish our findings. It really comes down to “intent”. If one could argue that you intend to publish the data, it’s best to get IRB approval first.

What resources do you suggest to physicians wanting to learn more about QI projects?

There’s a book called Lean Doctors, by Aneesh Suneja that focuses on these approaches. Of course there’s the classic LEAN books about Toyota management principles, including The Toyota Way by Jeffrey Liker and The Machine that Changed the World by James Womack and Daniel Jones.

What else do you want young Pediatric Orthopedic Surgeons to know about QI initiatives?

I think that for young surgeons, things are changing rapidly. This is not unexpected, since every generation has had some type of change and growth during their practice careers. The current change is that there is much more emphasis on quality, safety, the patient perspective, and cost effectiveness. This may change how we practice more than in previous generations where things like development of technologies, development of institutions, and establishment of the third party payer reimbursement system predominated.

I often hear young pediatric orthopedic surgeons reflect upon a frustration of having to work within an institutional environment, because I think the private practice model is dying, at least for our subspecialty. More and more pediatric orthopedic surgeons will be employees. The interesting thing about the QI process is that once an institution goes “all in”, it can be a great outlet for young surgeons to promote and achieve change to improve the quality of care that they provide to their patients. It can also make you more cost-effective and valuable to your institution. If you can provide higher quality care, at a lower cost, with higher patient satisfaction, you are going to become very valuable to your institution, and also valuable to your peers, because they will want to know what you’re doing so well. I see it as a real opportunity. Identifying time to meet with your departments and identify barriers to quality, cost-effective care, and to identify opportunities, gives you an outlet and a venue to advocate for change, rather than being frustrated with the status quo. So, I would really encourage young pediatric orthopedic surgeons to look at quality improvement as something that can not only benefit their patients and their institution, but that can also benefit them personally as well.
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