Table 1 Blue distinction criteria, points awarded, accommodations made to meet the criteria, and barriers to criteria’s implementation for general and structure criteria

General criteria for all blue distinction centers

Facility must be an inpatient acute care hospital that provides comprehensive inpatient care (e.g., Emergency Room, Intensive Care and other specified services)

Criterion met.

Full facility accreditation by a CMS-deemed national accreditation organization

Criterion not met.

Hospital is working to meet the Joint Commission’s accreditation criteria.

Facility participation in IHI with a commitment to patient safety, including formal commitment to at least 6 improvement campaigns (i.e., initiatives)

Criterion not applicable because IHI does not work in the Caribbean.

Program has engaged in quality improvement measures from IHI’s list of QI initiatives

IHI does not currently operate in the DR.

Facility publicly reports on the Leapfrog Web site via the Leapfrog Group Quality and Safety Hospital Survey

Criterion not applicable because Leapfrog does not work in D.R.

The Leapfrog Group does not evaluate international hospitals.

If facility does not report to Leapfrog, facility participates in other initiatives that encourage the sharing of best practices, incorporates data feedback for objective analysis, and promotes collaborative improvement

Criterion met.

Alternate initiatives will be reviewed on a case-by-case basis

Facility accepts the Association of American Medical Colleges (AAMC) principles for all clinical trials

Criterion met. Hospital participates in three multicenter trials, follows AAMC principles.

Facility uses a certified electronic medical record (EMR) certified by the Certification Commission for Healthcare Information Technology (CCHIT)

Criterion not met.

The hospital uses the LOLCLI 9000 EHR by LOLIMSA.

Facility uses an e-prescribing program to facilitate communication that meets the standards set forth in the 2003 Medicare Modernization Act (MMA)

Criterion not applicable.

Physicians e-prescribe using an electronic medical order sent directly to the hospital’s pharmacy. Prescriptions for outpatients must be made manually.

Medicare Modernization Act’s specifications relate to specific formularies that are not relevant in D.R.

Facility has a formal process of medication reconciliation that includes:

Criterion met.

--Verification

--Clarification

--Reconciliation

Facility is currently active in one of the following quality nursing excellence initiatives:

Criterion not applicable.

Hospital currently improving nursing quality, including evaluation of nurse performance, patient quality and safety education, and CME meetings

Magnet Award from ANCC requires compliance with U.S. Department of Labor and the Department of Health and Human Services (not applicable in the DR).

--Has earned the Magnet Recognition Award of the American Nurses Credentialing Center

--Reports to the American Nurses Association’s National Database of Nursing Quality Indicators (NDNQI)

Facility participates in HCAHPS survey and makes data publicly available on the Hospital Compare Web site for the most recent public reporting date

Criterion not applicable.

Op-Walk Boston’s research team collects data on satisfaction using surveys for patient satisfaction, and it uses this information to improve patient care.

HCAHPS is specific to U.S. hospitals.

Facility utilizes one of the following national quality improvement initiatives focused on surgical safety:

Criterion met. Op-Walk Boston uses WHO Surgical Safety Checklists.

--Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

--World Health Organization Surgical Safety Checklist

Facility participates in the Surgical Care Improvement Project (SCIP)

Criterion not met.

Hospital follows best practice guidelines but does not specifically follow SCIP. Working toward Joint Commission International (JCI) accreditation.

SCIP INF 1a: Prophylactic antibiotic received within one hour prior to surgical incision

Criterion met.

SCIP INF 2a: Prophylactic antibiotic selection for surgical patients

Criterion met. Medications and allergies are reviewed before selecting a prophylactic antibiotic.

SCIP INF 5: Postoperative wound infection diagnosed during index hospitalization (OUTCOME – facility tracks & internally reports data)

Criterion met.

SCIP VTE 1: Surgery patients with recommended venous thromboembolism prophylaxis ordered

Criterion met.

SCIP VTE 2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

Criterion met.

SCIP VTE 3: Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery (OUTCOME – facility tracks & internally reports data)

Criterion met.

SCIP VTE 4: Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery (OUTCOME – facility tracks & internally reports data)

Criterion met.

Facility’s SCIP database is able to produce procedure-specific performance reports

Criterion not met.

Op-Walk Boston’s research team evaluates each trip’s outcomes.

Facility has a policy on physician/surgeon conflict of interest

Criterion not met.

Facility publicly reports physician/surgeon conflict of interest related to financial relationships with pharmaceutical companies or device manufacturers

Criterion not met.

Facility discloses to patients prior to surgery exclusive relationships the facility has with device manufacturers or pharmaceutical companies

Criterion not met.

Facility has a written policy or process for selecting devices in the device formulary

Criterion not met.

Facility’s policy includes a mechanism for tracking FDA-recalled prosthesis and notifying patients who have received them

Criterion not met.

Facility reports incidences of device malfunction to the device manufacturer

Criterion met.

Facility has protocols for acute pain management in peri-operative surgical patients

Criterion met.

Pain management protocols are based on national guidelines:

Criterion met. Pain management protocols modeled after protocols followed in Boston-area teaching hospitals.

--American Society of Anesthesiologists’ Practice Guidelines for Acute Pain Management in the Peri-operative Setting

--Pain Management Standards of the facility’s accrediting agency (identified in question #8)

Facility has an interdisciplinary workgroup/committee/team in place for implementing pain management protocols and monitoring their effectiveness

Criterion met. Team of anesthesiologists, internists, nurses, PT’s, and orthopedists reviews pain mgmt. needs.

Structure

Program is currently and has been actively performing knee and hip replacement surgery since July 1, 2009 or for at least the immediately previous 12 uninterrupted months

Criterion met.

Program has a formal CQI program in place for knee and hip replacement services with the following components:

All subcategories of this criterion are met.

--Collection of quality indicator data

--Analysis of collected data

--Identification of issues

--Development of improvement goals

--implementation of changes

--Demonstration that the implemented changes improve the quality of clinical care that patients receive

--Ongoing requirements for physician/surgeon learning and improvement and/or regularly scheduled educational conferences

Program maintains an internal registry or database to track knee and hip replacement patients’ treatment and outcome data

Criterion met. Research team tracks outcomes with standardized surveys.

Program has a process in place to track complications in the context of a program-wide quality improvement process

Criterion met. Complications reviewed at the end of each trip and corrective actions are taken to minimize future complications.

Program has a process in place to track primary knee and hip replacement patients who return to the facility for revision of their primary procedure

Criterion met. Op-Walk Boston’s colleagues in the D.R. monitoring patients’ ongoing needs (including revision).

Program obtains and evaluates patient satisfaction specific to knee and hip replacement services with results reported back to program staff

Criterion met.

Program has a protocol in place to contact patients (or primary physicians) for follow-up and status information post-discharge

Criterion not met.

The hospital lacks a protocol for contacting patients. Follow-up consultations are scheduled by the individual doctors.

Able to contact patients, but communicating with PCPs is challenging.

Program reports to a multi-center registry or database that tracks knee and hip replacement surgery

Criterion met. Op-Walk Boston keeps a database that is shared between HGPS and the Brigham and Women's Hospital.

Program reports to at least one of the following registries or database:

Criterion not applicable.

Op-Walk Boston’s research team tracks surgical quality.

Organizations are primarily focused on US hospitals. Require expensive membership fees or purchasing other goods.

--National Surgical Quality Improvement Program (NSQIP)

--University HealthSystem Consortium (UHC)

--Premier Clinical Advisor

Program plans to participate in a comprehensive national knee and hip replacement registry once one is developed

Criterion met.

Op-Walk Boston uses a database to track all knee and hip replacement outcomes.

No TJR registries exist in the DR and there are no ongoing plans to establish one.

Facility has an inpatient unit dedicated to the care of orthopedic patients

Criterion met. During the mission trip, Op-Walk Boston has an entire hospital ward dedicated exclusively to its patients and team members.

Program utilizes multi-disciplinary clinical pathways/protocols for the care of knee and hip replacement patients that include the following features:

Criteria met for all subcategories.

--Treatment goals

--Sequence and timing of interventions

--Active participation of a multi-disciplinary team

--Daily milestones

--Coordination of discharge, patient education and other patient needs

Multi-disciplinary pathways/protocols address the full continuum of care across inpatient and outpatient settings

Criterion met.

Multi-disciplinary pathways/protocols generate standardized pre- and post- operative order sets

Criterion met. Clinical teams follow pre- and post-operative standardized work flows.

Electronic medical systems within the host hospital do not allow for automated, electronic order sets.

Program has standing orders that are utilized for the care of knee and hip replacement patients

Criterion met.

Each procedure has defined protocols. These procedures are documented in the patients’ chart.

Pathways/protocols or standing orders are placed in the medical record for daily use by all care providers

Criterion met.

Specific physician orders are required to deviate from the pathways/protocols or standing order set

Criterion met. Deviations discussed in the context of an interdisciplinary team.

Program consults resources to develop facility’s pathways/protocols or standing orders (e.g., clinical guidelines, national standards)

Criterion met. Op-Walk Boston strives to replicate the TJR process followed by the MGH and Brigham and Women's Hospital

In addition to orthopedic surgery and/or neurosurgery, other dedicated members of the multi-disciplinary care team for knee and hip replacement include:

Most criteria met. Op-Walk Boston lacks psychiatrists and psychologists, pain management specialists, and dedicated case managers.

Anesthesia team has experience in pain management, so they function as pain management specialists.

Case managers would require additional resources.

x  Anesthesiology

x  Psychiatry/Psychology

x  Pain Management Specialist

x  Clinician focused on peri-operative medical management

x  Nursing

x  Physical Therapy/Occupational Therapy (PT/OT)

x  Physiatrist/Physical Medicine and Rehabilitation

x  Dedicated case managers as care coordinators for complex patients

Program identifies departments that have at least one identified clinician who provides as-needed consultation to the knee and hip replacement team:

Criterion met.

x  Cardiology

x  Endocrinology

x  Pulmonology

x  Nutrition

x  Social Services

Program has pain management specialist(s) with subspecialty certification in Pain Medicine

Criterion not met.

Op-Walk Boston’s anesthesiologists provide all needed pain care.

Program identifies subspecialty certification(s) held by nurses on the care team:

Criterion met, although not all nurses have one of these certifications.

x  Surgical nursing

x  Orthopedic nursing

x  Rehabilitation nursing

Physical therapists on the care team maintain the American Physical Therapy Association (APTA) certification in orthopedic care

Criterion met.

Knee and hip replacement team holds multi-disciplinary team meetings or case management conferences at least monthly

Criterion met.

Surgeons performing knee and hip replacement surgery are certified or eligible for certification by the American Board of Medical Specialties, the Royal College of Physicians and Surgeons Board, or the American Osteopathic Board of Orthopedic Surgery

Requirement met.

50% of knee and hip replacement surgeons have ACGME fellowship training in Adult Reconstructive Orthopedics

All surgeons are fellowship trained in Reconstructive Orthopedics.

Surgeon participation in American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC)

Criterion met.