Orthopedic and Neurological Surgeon Quality Project

Collaborative engagement with providers increasing

One of L&I’s aims with this quality initiative is to engage in a more collaborative working relationship with orthopedic and neurological surgeons that have participated with L&I in other cooperative quality improvement efforts. An Interim Evaluation Report and Survey Report published independently in 2010 by the University of Washington (UW), as well as administrative data gathered by L&I’s project team, show that:

  • Engagement among qualified surgeons has increased during the project period.
    When the project began in July 2006, 34 surgeons from 8 clinics in the state of Washington enrolled. In the following years, enrollment increased gradually and, as of December 2013, 283 surgeons, from 42 clinics across Washington and 1 clinic in Oregon, are participating in the project. The UW Survey Report finds that most clinics in the project continued to treat the same number of workers’ compensation patients as before the project, and some clinics increased the number.
  • L&I attracted surgeons to the project who had lower costs and disability rates to begin with.
    Data from the UW Interim Evaluation Report shows that before the project began, when compared to other orthopedic and neurological surgeons treating similar injuries, project participants had a per claim average of $704 less in medical costs and 12 fewer days of timeloss.
  • Project participants want to continue working with L&I.
    In addition to maintaining or increasing the number of workers’ compensation patients they treat, the UW Survey Report reveals that 83% of providers said that improving their relationship with L&I was an important reason for continuing to participate in the project.

Success in implementing the quality indicators

Before we can find out if the project actually improves injured worker outcomes, it is critical that participating providers successfully implement the quality indicators in their day-to-day clinic practices. A good indication of successful implementation is that a surgeon has demonstrated 80-100% of the quality indicators on a consistent basis.

  • Most project surgeons are high performers.
    When the project began, L&I Management set a benchmark goal of at least 75% of participating surgeons implementing the quality indicators. During the first few years of the project, many providers struggled to do so. L&I’s project team worked closely with those providers to clarify expectations, and as of December 2013, 95% of participating surgeons have implemented the quality indicators successfully.
  • Most providers understand what they need to do to implement the quality indicators.
    The UW researchers reveal in the Survey Report that a clear majority of participating surgeons and their office staff reported that they consider the quality indicator and incentive tier system requirements of the project are clear, reasonable, and important for injured worker outcomes.
  • Room for improvement.
    Though almost all of the project surgeons have implemented the quality indicators, a few are still struggling to do so. The UW Survey Report reveals that L&I’s project team still has some work to do in terms of clarifying expectations about the quality indicators:
    • "...comments, especially the complaints about the time to surgery requirements, indicate that many of the respondents don’t know about available exceptions to the requirements."
    • "There were a number of comments about the APFs [Activity Prescription Forms] and confusion about when APFs are expected to be used, indicating more opportunities for training."

L&I’s project team continues to work closely with participating providers to make sure that expectations are as clear as possible.

Future goals

In the current phase of the project, we are focusing on:

  • Expanding the scope of the project by incorporating these four additional best practices:
    • Timely transition to surgical care at primary care provider’s request.
    • Pre-operatively documented return to work plans and goals.
    • Intervention of an integrated post-operative team when return to work goals aren’t met.
    • Timely transfer to next step in appropriate care at surgeon’s request.
  • Creating a new position of a Surgical Health Services Coordinator to help surgeons effectively use the four new best practices.
  • Working with providers to find more ways to reduce administrative burden.
  • Measuring and reporting on indicators of L&I’s quality and efficiency as a health insurer.
  • Continuing with a formal objective evaluation to answer (among other things):
    • What impact do the quality indicators have on clinical outcomes and timeloss?
    • What are the appropriate thresholds for incentives?
    • How much do generic drugs affect cost savings?
  • Communicating our best-practice findings to a broader health care community.

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