Joint replacement programs that successfully demonstrate compliance in all three areas are awarded certification for a two-year period. At the end of the first year, the organization is required to attest to its continued compliance with standards and provide evidence of performance improvement activities. To maintain certification, the cycle repeats with an on-site review conducted every two years and a bi-annual submission of an acceptable assessment of compliance by the organization.
“With this national certification, UNMH is held to a higher standard of performance for our patients throughout the entire joint replacement process – from diagnosis, to patient education, to hospital admission and discharge, and through follow-up therapies,” asserts Rachel Landavazo, MS, PA-C, program director, UNMH Total Joint Replacement Program. “The bottom line is that this certification confirms the quality of care provided to our patients.”
Ongoing Analyses
Certified programs must demonstrate a systematic approach to care delivery and a commitment to performance improvement through ongoing data collection and analyses. Included in the process is a multi-day, onsite review to identify areas of program strength and/or improvement. During the visit, the reviewer assesses how clinical outcomes and other performance measurements are used to improve care; leadership's commitment to improvements; how patients are educated with respect to self-management and guidelines that are pertinent to them; and that evidence-based guidelines are incorporated into daily clinical practices. Certified programs are required to regularly submit data to The Joint Commission.
The Joint Commission is governed by a 32-member Board of Commissioners that includes physicians, administrators, nurses, employers, a labor representative, quality experts, a consumer advocate and educators. The Board of Commissioners brings to The Joint Commission diverse experience in health care, business and public policy.
Team Effort
In 2011, UNM Hospitals’ joint replacement teams replaced 95 hips and 185 knees. In 2012, those numbers rose to 131 hips and 208 knees. Teams include physicians, nurses, rehabilitation therapists, pharmacists, unit-based educators, social work, case managers, analysts, and hospital and physician leadership. These teams are fully integrated to reduce surgical complications, improve patient safety and quality of care, educate patients in all aspects of joint replacement prior to surgery through courses and materials, train staff regarding protocols, evaluate and adapt the program based on current research and best practices.
“With this national certification, UNMH is held to a higher standard of performance for our patients throughout the entire joint replacement process – from diagnosis, to patient education, to hospital admission and discharge, and through follow-up therapies,” asserts Rachel Landavazo, MS, PA-C, program director, UNMH Total Joint Replacement Program. “The bottom line is that this certification confirms the quality of care provided to our patients."
