What’s Important: Moving Orthopaedic Patient Care Forward

Delivering consistently high-quality musculoskeletal patient care can be challenging, especially in tertiary and quaternary referral hospitals within integrated health-care delivery systems with seemingly countless stakeholders. Time and resources (e.g., financial and human capital) are limited, yet the demand for orthopaedic and complex medical care continues to grow. This creates added strain on hospitals and health-care systems, but most importantly leads to moral distress and professional frustration among caretakers (physicians, nurses, and others) who are trying their very best to focus on the patients they serve in suboptimal circumstances. While all stakeholders would love “quick fixes” that simultaneously address all of the issues, the reality is that incremental progress that focuses on 1 or 2 agreed upon “pain points” is likely the best approach. However, simply identifying such opportunities does not guarantee real change. One must have a structured process that is supported by leadership, management principles, and personal experience in order to drive the necessary changes collaboratively. This article highlights 8 tips that the senior author (T.V.L.) has learned throughout his career for successful systems improvement that can progress orthopaedic care. Tip 1: Surround Yourself with Game-Changers Whether in the operating room or elsewhere, trying to change how care is delivered requires a team effort. The likelihood of success increases when the identified stakeholders work collectively and are dedicated to common goals. Thus, even if you try to make a simple change independently, the likelihood of making it sustainable is quite limited. While the most successful teams are diverse in every sense of the word, each member of successful teams has an individual will to drive positive change; however, this is not sufficient. As Casciaro and Lobo noted in the Harvard Business Review, the individuals you should seek are the “lovable stars,” defined as those who not only have high competence but also have high likability1. You want these people not only on your team but also in your community to push everyone to be better each day. However, caution is warranted because it is critical to make sure that these people put the “we” ahead of the “I” when needed. Not all individuals are game-changers or people who find a way to routinely make progress on challenges. In fact, there is a wide range of individuals in any work setting, including health care. We propose a simple green-yellow-red framework, where individuals are either game-changers (i.e., green), demonstrate substantial potential but are not game-changers yet (i.e., yellow), or are toxic to progress (i.e., red) (Fig. 1). The goal is to build teams with as many game-changers as possible, while mentoring those with potential and ensuring that those who are toxic do not spread poor habits to their colleagues.Fig. 1: An illustration of the “rule of thirds” related to Tip 1 (i.e., “Surround yourself with game-changers”).Tip 2: Ensure Overarching Vision Alignment Across Stakeholders While it is critical to clearly articulate what you want to accomplish, there will be endless hurdles if your division, department, and/or institution do not understand the “need for change” and support the endeavor. However, it is important to note that support should not be an “all or nothing” expectation. In many cases, the overarching philosophy may be agreed upon, but how to design and implement the change will take negotiation and compromise in order to make a real, lasting difference. For example, time to surgery is an important modifiable factor to improve outcomes for geriatric patients who sustain a hip fracture. However, decreasing time to surgery is challenging; it requires algorithmic protocols and, most importantly, a well-aligned, multidisciplinary effort and overarching vision shared among orthopaedic surgeons, anesthesiologists, geriatricians, nurses, and physical therapists, among others. Therefore, we initiated a geriatric hip fracture working group with all of the stakeholders, who agreed on the broad vision to improve outcomes for our patients by decreasing the time to surgery. As a result, time to surgery improved dramatically, decreasing from 36 to 17 hours over a 2-year period (2021 to 2023); in-hospital length of stay also decreased (from 6.5 to 5.0 days). Importantly, if our team members had disagreed that time to surgery was an issue, it would have been much harder, if not impossible, to make the changes we desired. Tip 3: Pick Your Battles As part of routine patient care responsibilities, we witness the good and bad aspects of the systems in which we work. While there are an overwhelming number of positive aspects of what we accomplish each day, the frustrating shortcomings and disappointments become areas of focus, especially as part of systems improvement work. However, we must acknowledge that our time, as well as the time of our colleagues, and available financial resources are limited; thus, addressing all of the challenges is simply not possible. Further, there may be issues that some stakeholders feel are critical but others feel are less important. In fact, there may be issues that we appreciate but others simply do not feel are worthwhile to address or even recognize as problems. It is critical to remember that in such situations, we must compromise (as long as it does not harm our patients). We should never “burn bridges” regarding a singular frustration unless we are confident that it is absolutely pivotal for the safety of our patients or colleagues. Sometimes, the best battles are the ones you choose not to fight. Tip 4: If You’re Not Willing to Volunteer, Don’t Complain It is extremely easy to complain and identify areas that need improvement. It takes minimal effort, and while it may be cathartic, the positive feelings often evaporate quickly and are replaced by frustration, especially if an issue recurs frequently. Simply complaining does not fix the underlying issue and can often lead to animosity among care team members who may shift to blaming each other without searching for a solution to further enhance patient care. If you are not willing to volunteer to help fix a problem, you should not complain. For example, be the first to join the standing committee that is tasked with solving operating room issues or patient length-of-stay challenges. Additionally, if you are a decision-maker, when a major policy that may impact multiple individuals is shifted, make sure that it impacts you as well, if possible. Indeed, it is crucial to lead by example. However, it is important to note that this may not always be the case since you may be in a position to lead change that only impacts a subset of individuals. In such circumstances, it is important to be empathetic and an active listener, ensuring that you understand how a policy shift may affect key stakeholders and alleviating their concerns whenever possible. This may require changing proposed solutions and admitting your own fault or misunderstandings, which are key elements of leadership and should never get in the way of progress. Tip 5: Look in the Mirror Before Blaming Others Care teams are all busy, trying to accomplish many things simultaneously to move patient care forward. When issues arise, it is simple to say, “It’s not me, it’s them.” However, we must remember to be grounded and remain accountable for our actions, including the role we play in creating or worsening an issue. For example, it may be the orthopaedic surgery team, not the anesthesia or nursing teams as we often assume, that delays the start of a first case because of an incorrect consent or failure to mark a patient’s surgical site. When you are unsure of what is driving a problem, request the relevant data, and know that you likely are responsible for at least part of the issue. Do not come up with excuses when the data show that you are part of the problem; the data speak for themselves. Instead, embrace your role in the problem and seek to find a solution with the entire team. Tip 6: Think Twice Before You “CC” Someone’s Boss Building trust, good rapport, and mutual respect among team members who are working together to solve an issue is critical to success. However, this does not occur overnight. It takes time and transparency, as well as an understanding that disagreements and conflict are likely to occur but can be overcome. When disagreements occur between 2 team members, it is easy to quickly escalate an issue to another’s superior with the hope that they will side with you. Sometimes, such an approach even feels like the “right” thing to do. However, we strongly recommend against this approach. Instead, working collaboratively to address issues as well as possible should be the primary approach. A superior should be included in discussions only if you have determined that this is a “battle worth fighting” and after an extended time frame of trying to compromise and failing to do so. Importantly, informing a superior should not be done as a blind “CC” (i.e., “BCC”); you should alert the other party that you will be doing so and make it visible to all involved parties. This shows respect and does not “burn bridges” for future interactions and challenges that you are likely to face together. Tip 7: Focus on Change Locally Before Chasing Change Globally As orthopaedic surgeons, when we see an issue, we often want to fix it and then “move on.” When it comes to systems improvement, however, we must be willing to take a step back and be comfortable making and accepting incremental or local progress instead of broader or global change, at least to start. Our sphere of influence may be centered in a division, not a full department, hospital, or health-care system setting. By initially focusing more locally, achieved successes can then be leveraged to make broader changes instead of wasting time and limited resources trying to engage with those with whom you have no working or personal relationship. Ultimately, through dedicated education of different stakeholders regarding the issues at hand and their possible solutions, local change can occur; broader change may require research or data to support a shift in policy. For example, using the insights gained from our work with geriatric patients with hip fracture to reduce length of stay, work is now underway to improve this metric with other patients on a department-wide basis. Tip 8: Build and Foster Mentor-Mentee Relationships Mentorship matters. Success in health care, whether it be patient care, research, or business-related, is rarely accomplished by an individual but is rather a team effort. Throughout one’s career, there will always be “ups and downs,” and having a mentor in your corner for feedback and guidance can be invaluable, especially with systems improvement initiatives. The very best mentors are honest and provide frank advice and guidance that you may not want to hear but need to if you ultimately are to succeed. At times, these honest insights may come across as hurtful to the mentee, yet they are critical for continued educational, personal, and professional development. It is always important to remember that true mentors have a mentee’s best interest in mind. Further, mentors often see your “blind spots” and alert you to them. They cheer your successes and offer invaluable reflections on your shortcomings. They want you to succeed in a more expedited fashion than they did, often sharing their own experiences throughout the process. It is essential that mentors and mentees pick each other, as it is a 2-way relationship that requires continual maintenance2. You will likely be a mentor to some and a mentee to others. This dynamic leads to constant learning and an opportunity to grow personally and professionally since mentorship, especially in academic circles, often leads to sponsorship and professional advancement that otherwise may be tougher to accomplish. Final Thoughts As orthopaedic surgeons, we work in complex clinical settings with countless stakeholders. However, we must always remember that the patient is the primary stakeholder and the core reason that we should strive for systems improvement. While many care delivery processes work well, most have room for improvement. However, change is hard, even when it is known that a system is failing or falling short of its optimal outcome. By utilizing the 8 tips that the senior author has learned over his career, we believe that systems improvement initiatives can be more successful and enjoyable as diverse, collaborative teams are built and strong relationships are formed.