Clinical Orthopaedics and Related Research®

, Volume 472, Issue 5, pp 1619–1635 | Cite as

Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty

  • Aricca D. Van Citters
  • Cheryl Fahlman
  • Donald A. Goldmann
  • Jay R. Lieberman
  • Karl M. Koenig
  • Anthony M. DiGioiaIII
  • Beth O’Donnell
  • John Martin
  • Frank A. Federico
  • Richard A. Bankowitz
  • Eugene C. Nelson
  • Kevin J. Bozic
Clinical Research



Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.


The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.


We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9).


The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level.


We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation.

Level of Evidence

Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.


Care Pathway Total Joint Arthroplasties Family Engagement Care Period Author Opinion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Julia Rowe Taylor for assistance with project oversight; Jane Roessner and Val Weber for editorial assistance; Vanessa Chan for help with manuscript preparation; members of the 16 interdisciplinary care teams and two patients for their participation in semistructured interviews; and the 32 members of our multistakeholder panel for their work to refine and improve the care pathway. We also acknowledge that this work arose from efforts by the Dartmouth population health team and individuals at Dartmouth-Hitchcock Medical Center (ECN, KMK) to incorporate the Institute of Medicine’s quality aims into their care pathway development efforts. Dartmouth-Hitchcock’s GreenCare approach uses a similar conceptual framework, process flow diagrams to illustrate roles and tasks over the entire episode, integration of tasks into team roles and into the electronic medical record, and use of patient-reported outcomes. The current project offered the opportunity to adopt and extend Dartmouth’s approach to pathway development and to engage a diverse cross section of clinicians and health systems in developing a potentially generalizable care pathway.


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Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Aricca D. Van Citters
    • 1
  • Cheryl Fahlman
    • 3
  • Donald A. Goldmann
    • 4
  • Jay R. Lieberman
    • 6
  • Karl M. Koenig
    • 7
  • Anthony M. DiGioiaIII
    • 2
  • Beth O’Donnell
    • 4
  • John Martin
    • 3
  • Frank A. Federico
    • 4
  • Richard A. Bankowitz
    • 3
  • Eugene C. Nelson
    • 5
  • Kevin J. Bozic
    • 8
  1. 1.Institute for Healthcare ImprovementHanoverUSA
  2. 2.The Bone and Joint CenterMagee Women’s Hospital of UPMCPittsburghUSA
  3. 3.Premier Healthcare Solutions, IncWashingtonUSA
  4. 4.Institute for Healthcare ImprovementCambridgeUSA
  5. 5.Geisel School of MedicineThe Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA
  6. 6.Department of Orthopaedic SurgeryKeck School of Medicine of USCLos AngelesUSA
  7. 7.Department of Orthopaedic SurgeryDartmouth Hitchcock Medical CenterLebanonUSA
  8. 8.Department of Orthopaedic SurgeryUniversity of California, San FranciscoSan FranciscoUSA

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