AAOS Bulletin - February, 2005

Board approves SOPs, patient safety projects, position statements

By Susan A. Nowicki, APR

The Boards of Directors (Board) of the American Academy of Orthopaedic Surgeons and the American Association of Orthopaedic Surgeons (AAOS) met Dec. 2-4, 2004, in Chicago and took the following actions:

Standards of Professionalism approved. The Board Project Team on the AAOS Expert Witness/Professional Compliance Program recommended, and the AAOS Board approved, three Standards of Professionalism (SOPs), as the basis of the AAOS Professional Compliance Program. The SOPs establish minimum standards of conduct in: 1) orthopaedic expert witness testimony, 2) professional relationships and 3) provision of musculoskeletal services to patients. They will be voted on by AAOS members during March and April 2005. An in-depth article on the development of the new SOPs begins on page 27.

Patient safety projects approved. Upon recommendation of the Patient Safety Committee, the AAOS Board approved two new patient safety educational projects. The AAOS Resident's Patient Safety Curriculum will help satisfy educational requirements in system-based practice and practice-based learning. Designed around six core competencies and presented in seven learning modules, the curriculum introduces patient safety concepts and critical terms, includes a review of the recent literature, provides tools and a template for utilization in Mortality and Morbidity (M&M) Conferences and discusses common orthopaedic topics that affect patient safety. The M&M template emphasizes systems investigation through root cause analysis.

Modules dealing with specific clinical problems and their treatments will be strictly evidence-based. Module topics include basic science of patient safety, morbidity and mortality, wrong-site surgery, communications, medication errors, surgical site infections and venous thromboembolism. The initial iteration will be Web-based and posted on the AAOS Patient Safety Web site to allow free access by orthopaedic residents and the public. The curriculum will also be distributed on CD-ROM to all orthopaedic residency program directors. All of the new patient safety curriculum modules will be completed by December 31, 2005.

A new educational video, “Medical Error: A Preventable Complication,” was also approved for distribution. The 18-minute DVD is directed primarily toward orthopaedic residents and medical students. It will also be of interest to health care professionals involved in procedures covered by the Joint Commission for the Accreditation of Healthcare Organizations’ Universal Protocol and Guidelines for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

Levels of Evidence and Grades of Recommendations approved. Upon recommendation of the Evidence-Based Practice Committee and the Council on Research and Scientific Affairs, the AAOS Board approved two research tools for measuring orthopaedic scientific evidence: “Levels of Evidence for Primary Research Questions” and “Grades of Recommendations for Summaries or Reviews of Orthopaedic Surgical Studies.” They were developed to provide a standardized, uniform system for classifying evidence that can be applied by various journals and organizations to orthopaedic evidence. The two measures can be obtained from the AAOS department of research and scientific affairs at (847) 384-4312.

Position Statement on new technologies approved. The new “Position Statement on Training for New Technologies” was approved by the AAOS Board at the recommendation of the Committee on Patient Safety. The position statement provides clarification on education, credentialing, certification, assessment and privileges. Technological advances in orthopaedics require surgeons to have appropriate training prior to using medical devices, biologics, drugs and combination products. Training should comprise both didactic and practical techniques including indications for use and specified surgical approaches. The statement reads, in part:

The American Academy of Orthopaedic Surgeons believes that surgeons must be adequately trained and assessed before performing new, complex procedures. Fellows should be apprised of manufacturer’s specific conditions of approval from the Food and Drug Administration, which may require extensive surgeon education and training. The orthopaedist should thoroughly examine his/her own training, skills and experience to determine the level of training necessary to perform such new procedures in a competent, safe manner. The AAOS recommends that Fellows trained in a new technology be assessed by a surgeon already trained and qualified in the procedure. Additionally, surgeons should work with hospital administration to ensure that all necessary equipment and appropriately trained staff are available for procedures.

The AAOS also believes that education should be provided by multiple sources and not solely by the product manufacturer. It also states that hospital medical staff must develop criteria for the delineation of clinical privileges for the use of new technologies.

Position Statement on definition of musculoskeletal disorders approved. At the recommendation of the Occupational Health and Workers Compensation Committee and the Council on Health Care Policy and Practice, the AAOS Board approved a new “Position Statement Defining Musculoskeletal Disorders in the Workplace.” The term musculoskeletal disorder (MSD) is commonly used as a catchall phrase to refer to a variety of diseases or injuries to bones, muscles, tendons, joints, nerves and blood vessels but grouping these divergent pathologies into a single term can create confusion and muddle thinking among employers, employees, health care providers, insurers and policymakers who must address workers’ compensation and ergonomic issues. Other vague catchall terms include: cumulative trauma disorder, repetitive stress disorder, repetitive stress injury and work-related disorder. Use of these unclear terms can lead to erroneous assumptions and conclusions about pathologies that may occur in the workplace. In part, the statement says:

The American Academy of Orthopaedic Surgeons (AAOS) believes “musculoskeletal disorder” and other non-specific phrases should not be used as a clinical diagnosis because these terms are vague and confusing and do not appropriately describe diseases and injuries that may occur in the workplace. The AAOS believes ICD diagnosis codes should be used instead of “musculoskeletal disorder” and other non-specific terms when describing and reporting pathologies that may occur in the workplace.

Position Statement on physician-owned physical therapy services approved. Upon recommendation of the Academic Advocacy Committee, the AAOS Board approved a new “Position Statement on Physician-Owned Physical Therapy Services.” Physical therapists have become an integral part of musculoskeletal health care teams. Models for the collaborative delivery of physical therapy include free-standing physical therapy centers, physical therapists acting as independent contractors within physicians’ office and physical therapists working as employees of physicians providing physical therapy as an in-office ancillary service.

Recently, some groups have tried to add language to state-level physical therapy practice legislation, as well as interpret existing statutory language to prohibit physical therapists from working for physicians and physician group practices. These activities seem to be motivated more by financial considerations than the patient’s best interests. This approach may also result in the fragmentation of patient care. The position statement says that:

The American Association of Orthopaedic Surgeons (AAOS) believes that patients should have access to quality, comprehensive and non-fragmented care. Doctors, nurses, physician’s assistants, physical therapists and other health practitioners work together, often in the same office, to provide comprehensive care to patients. Separation of these services would only serve to disrupt a patient’s treatment and further inconvenience them.

The statement also says that physician-owned physical therapy services should continue to be an alternative for patients.

Patients should be given the ability to choose the site of care. Physicians employing physical therapists should communicate to the patient their financial interest in any physical therapy practice prior to referring the patient to the site. The physician should also discuss possible alternate sites for physical therapy services. In all instances, the AAOS believes that the best interest of the patient should be foremost when referring a patient for physical therapy services.

Position Statement on specialty hospitals approved. At the recommendation of the Health Care Delivery Committee and the Council on Health Care Policy and Practice, the AAOS Board approved a new “Position Statement on Specialty Hospitals.” Specialty hospitals offer focused services rather than the broad range of services provided by community hospitals. Physician owners in specialty hospitals have greater control over the facility and the quality and efficiency of care. Furthermore, these facilities tend to have greater patient satisfaction, reduced costs and improved infection rates.

As specialty hospitals have risen in popularity, they have been accused of attracting only the healthiest and the most financially rewarding patients. Many community hospitals contend that physicians with ownership interests in specialty hospitals may be providing unnecessary services and that lower revenues in community hospitals can be attributed, in part, to competition from specialty hospitals. The statement reads, in part:

The American Association of Orthopaedic Surgeons (AAOS) supports the rights of all patients to receive high quality, efficient health care. Specialty hospitals provide high quality services in the communities in which they are established. Several ownership models exist and all are successful at adding quality care to the community. The AAOS supports the development of specialty hospitals and encourages physicians and non-physicians to invest in the continued quality improvement of health care in their community.

The AAOS believes that specialty hospitals treat patients in a safe, high quality and efficient setting. Physicians should always consider the best interests of the patient in making the determination as to the facility in which the care is provided. The provision of services to the patient should not be based on medical criteria and facility capabilities.

In addition, the AAOS also believes that Certificate of Need laws should be repealed to foster health competition among all health care facilities, including specialty hospitals. Such competition will result in improved patient access and quality of care.

Advisory opinions adopted. At the recommendation of the Board of Councilors (BOC), the AAOS Board adopted an “Advisory Position on Medical Staff-Governance,” which supports medical self-governance as one of the primary protections for physician oversight of quality patient care in the hospital setting. The BOC also recommended an advisory opinion on support for military medicine, which the Board adopted. This opinion affirms and applauds “the superlative efforts of military orthopaedists in rendering responsible orthopaedic care to wounded victims of the Iraqi conflict.”

The full text of all approved position statements and advisory opinions is on the AAOS Web site at www.aaos.org; click on “Library and Archives,” then on “Policies,” then on “Position Statements” or “Advisory Opinions.”

New representative to Arthritis Foundation appointed. The Board approved the appointment of outgoing AAOS President Robert W. Bucholz, MD, as the new AAOS representative to the Arthritis Foundation, effective with the 2005 Annual Meeting.

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