Excellence in Joint Replacement

UH joint replacement program controls costs while enhancing quality and value

Innovations in Orthopaedics - Winter 2019

Over the past four years, University Hospitals joint replacement surgeons have worked together to redesign how they provide care.

The redesign includes focusing on patient safety, quality and value, and ensuring that patients receive a uniform patient experience at all system hospitals. The benefits have been considerable in terms of reduced complications, readmissions and costs of care. As a result, UH system hospitals have been recognized as value leaders for joint replacement surgery. 

Matthew Kraay, MD Matthew Kraay, MD, MS

In June 2018, Walmart announced its selection of University Hospitals Cleveland Medical Center as a national Center of Excellence to provide joint replacement surgery for Walmart employees and their families. Several years ago, General Electric selected both UH Cleveland Medical Center and UH Conneaut Medical Center as national Centers of Excellence for joint replacement surgery.

Matthew Kraay, MD, MS, University Hospitals Joint Replacement and Rheumatology Institute Director, and Professor of Orthopaedics, Case Western Reserve University School of Medicine, says only five other hospitals in the United States serve as GE Centers of Excellence. Walmart has only 11 Centers of Excellence that serve about 1.5 million U.S. employees.

“We have seen a dramatic increase in patient volume since the start of this innovative program,” Dr. Kraay says. “We're estimating we will do 200 total joint replacement surgeries this calendar year for Walmart alone.”

Walmart Centers of Excellence have to meet high standards in patient care, patient experience and value. They're one of a growing number of self-insured companies choosing to contract directly with healthcare providers for employee health care. Employees receive enhanced benefits when choosing a Center of Excellence, while the employer receives better value for health services. 


The UH Joint Replacement Program’s commitment to high-quality, high-value care also led to recognition from several industry organizations. Healthrades gave UH Cleveland Medical Center a Joint Replacement Excellence Award in 2017 and five-star ratings for hip and knee replacement in 2018 and 2019, while UH Elyria Medical Center received this award in 2018 and 2019. This means these hospitals rate in the top five percent in the nation for risk-adjusted mortality and complication rates. 

Building on those accolades, Premier Inc., a healthcare improvement company, named UH its 2018 Richard A. Norling Premier Alliance Excellence Award winner. The Premier Alliance Excellence Award represents "the highest level of industry innovation and advancements in delivering high-quality, cost-effective care," according to Premier Inc. 

While this award recognizes UH's ongoing mission to provide innovative, patient-centric care, it also speaks to its focus on value. For example, three UH hospitals have participated in Medicare’s “Bundled Payment for Care Improvement” (BPCI) program for joint replacement since 2015. 

Both UH Cleveland Medical Center and UH Parma Medical Center received Premier Inc.'s “Premier Bundled Payment Collaborative BPCI Model Success Award.” Why? Each hospital shaved nearly half a million dollars off their joint replacement episode-of-care costs. 

“The comprehensive care redesign we undertook as a system-wide program prepared us very well for the challenges of delivering care under this alternative payment model that is being increasingly promoted by CMS,” Dr. Kraay says. “Success in this program requires shifting your focus to a 90-day episode-of-care rather than only the acute care hospital stay.

“We have to manage quality, reduce complications and readmissions and find more cost-effective and innovative ways to manage patients in all settings where they receive care. For example, we now send nearly 90 percent of our patients home after joint replacement instead of to skilled nursing facilities. Elimination of a still nursing facility stay reduces episode-of-care costs by about 30 to 40 percent, which promotes healthcare value.”

This approach emphasizes value while maintaining quality care. A 2017 study published in the Journal of the American Medical Association compared groups of total knee replacement patients who received either a hospital inpatient rehab program followed by a home-based program or a home-based program only. The authors found no difference in recovery or mobility. 

“UH has an extensive home care program,” Dr. Kraay says. “There are numerous benefits to providing physical therapy, nursing care and other healthcare services at home. It's more convenient and pleasant for the patient, promotes ‘wellness’ and is more cost effective.”

Medicare is expanding its bundled payment models to many other health conditions and surgical procedures. Dr. Kraay says nearly all UH hospitals will be participating in these programs in 2019. 

“The experience we have gained in the joint replacement bundled payment program will be very helpful for our UH colleagues in other areas of medicine,” he says. “Alternative payment models like BPCI are here to stay. We need to be involved, and we need to continue to focus on how we can deliver the highest quality, highest value care for our patients — and never stop innovating.”


To track efficiency and performance across all hospitals and for individual providers, a new Joint Replacement Outcomes Program has begun to collect key value metrics. Key Performance Indicators (KPIs) like length of stay, complications, readmissions, discharge to home versus skilled nursing, patient satisfaction and other variables are reviewed monthly as a part of a High Reliability Medicine (HRM) Initiative for joint replacement.

“In the future, joint replacement innovation and research will not likely focus on implants, but rather, new ways of delivering care to our patients," Dr. Kraay says. “Perhaps the most visible example of this is that we’re currently sending almost half our hip and knee replacements home on post-op day one, which was previously thought to be impossible.”

For more information on joint replacement or to refer a patient, call 216-844-7200.

1. Buhagiar MA, Naylor JM, Harris IA, et al. Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial. JAMA.2017;317(10):1037–1046. doi:10.1001/jama.2017.1224

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