AAOS Registry Program Blog

MountainView Regional Medical Center Leverages Registry Data to Earn Joint Commission's Gold Seal

Aug 8, 2018 12:00:00 PM

Dr. Sweetser from MountainView Regional Medical Center Helped Earn the Joint Commission's Gold Seal

This article was originally published in the August 2018 issue of AAOS Now, the American Academy of Orthopaedic Surgeons' (AAOS) monthly news magazine. The article concludes a three-part series illustrating practical aspects of AJRR participation through shared success stories from subscribing institutions. All three installments can be found at www.aaosnow.org.

MountainView Regional Medical Center (MVRM), located in Las Cruces, NM, has been an American Joint Replacement Registry (AJRR) subscriber since November 2014. Their AJRR participation helped MountainView’s Total Hip and Knee Replacement Center utilize Registry benefits to achieve and maintain the Joint Commission’s Gold Seal for core certification. Other health care institutions can learn from the Center’s checklist for choosing a registry capable of supporting a Joint Commission Certified Program.


Measures That Matter

The Joint Commission certification process provides MVRM with a framework to identify and measure areas for improvement. Because MVRM participates in an audited national data registry (the AJRR), they can systematically and consistently submit data, track progress, use benchmarks and see how their Total Hip and Knee Replacement Center’s certified program engages and/or improves various performance areas. Measures can include length of stay (LOS), discharge disposition, surgical site infections, comorbidities and other patient risk factors, revision rates, and complications data. These are measures that matter in the Joint Commission review process.

Beyond certification, registry data trending and benchmarking can provide insight into volume changes (Fig. 1), serve as an early warning in identifying safety issues, provide insights that influence surgeon and clinical staff behavior (Fig. 2), and decrease costs from excessive resource usage among other benefits.


Results That Matter

Examples of MVRM’s orthopaedic quality improvement results include the following:

  • 2016-2018 (last 1.5 years), LOS was reduced from 2.6 days to 1.3 days (Fig. 3)
  • 2013-2018 (last five years), LOS was reduced from four days to 1.3 days (Fig. 3)
  • 2016-2018 (last two years), patient discharge-to-home increased from 62 percent to 83 percent (Fig. 4)
  • Monitoring comorbidities prior to surgery has reduced surgery cancellations to near-zero among higher risk patients
    • Best Practice: Hemoglobin must be less than 7 g/dL to move forward with surgery
    • Best Practice: Body mass index must be below 40 kg/m² to move forward with surgery

 MVRM Procedural Volume

Fig. 1 MVRM’s Total Hip and Knee Replacement Center doubled its procedural volume between 2011 and 2017.


MVRM Blood Transfusions

Fig. 2 Monitoring hematocrit prior to surgery, ensuring that it is 34 or higher, and using tranexamic acid during surgery helped reduce the need for blood transfusions to near-zero levels.


MVRM 30-day Readmission Rate

Fig. 3 MVRM’s combined hip and knee surgery 30-day readmission rate was reduced from more than 5 percent of total volume in 2011 to less than 3 percent in 2017. 


MVRM Discharge-to-home Percentage

Fig. 4 In the last two years (2016 – 2018), MVRM’s combined hip and knee surgery discharge-to-home increased from 62 percent to 83 percent, allowing more patients to return home sooner.


First Steps in Achieving the Gold Seal

Joint Commission–accredited hospitals are eligible to apply for optional orthopaedic certification programs if they meet these minimum Joint Commission requirements:

  • program has served more than 10 patients;
  • use of standardized clinical care delivery based on evidence-based care and clinical practice guidelines; and,
  • use of a nationally audited registry or similar data collection tool to monitor data and measure outcomes for specified conditions and procedures.

“Our entry into AJRR has greatly enhanced our data collection, measurement, and analytical capabilities regarding various Joint Commission certification requirements,” said Edward Sweetser, MD, of MountainView Regional Medical Center.

Daniel J. Berry, MD - chair of the AAOS Registry Oversight Committee - added, “Quality improvement efforts, like Joint Commission–certified orthopaedic programs and others benefit from three levels of AJRR data. New Level II risk-adjusted data supports better informed surgical decisions. New Level III data provides patient-reported outcomes, creating a more comprehensive picture of patient care. In this way, AJRR continues to evolve to meet our participants’ needs and their continuous focus on improving patient care.”


MVRM Checklist for Choosing a Registry

MVRM’s experience suggests that facilities look for the following features when choosing a data registry to support their Joint Commission–certified program, as well as other quality improvement initiatives:

  • access to national registry database participation;
  • Qualified Clinical Data Registry designation from the Center for Medicare & Medicaid Services;
  • established electronic health record data capture and analysis;
  • network of national database users to allow further investigation of findings at local and national levels and identify best practices;
  • proprietary data dashboards aligned to the certification program; and,
  • national comparative dashboards to assess quality and create performance benchmarks.

Dr. Sweetser concluded, “As a national registry, AJRR is able to provide the most accurate and complete picture of the arthroplasty experience in the United States. By [AJRR] providing benchmarking and monitoring outcomes of arthroplasty, we can further advance the efforts of patient safety and quality of care. Implementation of a certified orthopaedic program and national registry participation provides clinicians with an efficient framework to improve patient outcomes at the hospital and surgeon levels.”


Karen Metropulos, MBA, is a content writer and blog editor at the AJRR, part of the AAOS Registry Program.



For information about the AJRR RegistryInsights™ platform, speak with a Registry Engagement Associate at (847) 292-0530 or Request A Demo today!


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Topics: Case Studies

A Message for Our Readers

This blog was created by the American Joint Replacement Registry (AJRR), part of the American Academy of Orthopaedic Surgeons (AAOS) Registry Program. The blog is part of our commitment to improve orthopaedic care through the collection, analysis, and reporting of actionable hip and knee arthroplasty data. Our purpose is to communicate with others in the orthopaedic field who share the same commitment. Watch for weekly news alerts, quick tips, actionable checklists, best practices, and research findings posted to this blog. It will be information you can use each week!

The more interactive you are, the greater the value shared. Visit us at www.aaos.org/ajrr, speak with a Registry Engagement Associate at 847-292-0530, or follow us on Twitter.

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This Week's Blog

  • Wednesday, August 8, 2018 - MountainView Regional Medical Center Leverages Registry Data to Earn Joint Commission's Gold Seal 

This Week’s References

Joint Commission Core Orthopaedic Certification Options 

Core orthopaedic certification options provide structure for programs, often in hospital settings, to improve their patient outcomes and reduce patient risk through clinically proven evidence-based care. Orthopaedic certification options are evaluated under the Joint Commission's Disease-Specific Care Certification Manual and have three components: standards, clinical practice guidelines, and performance measurement. MountainView Regional Medical Center has achieved this certification.

Joint Commission Advanced Certification for Total HIP and Total Knee Replacement (THKR)

The THKR advanced certification program must meet core standards plus additional, clinically relevant requirements and expectations. See page 7 of Comparative Joint Commission Table - Advanced vs. Core: What's the Difference

Joint Commission Orthopaedic Certification for Ambulatory Surgical Centers (ASCs)

Four orthopaedic certification options are available to Joint Commission accredited ASCs. ASCs seeking one or more of the core or advanced certification options must meet core standards under the Disease-Specific Care Certification Manual. Read Total Hip / Total Knee Replacement Certification Raises Bar for Orthopedic ASCs



AJRR RegistryInsights™

As a health care provider of orthopaedic services, you can access information about joining AJRR and RegistryInsights by visiting www.aaos.org/ajrr or speaking with a Registry Engagement Associate at (847) 292-0530.  New Call-to-action

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AJRR Staff Writers

AJRR Blog posts are researched and created by AJRR staff writers: Karen Metropulos, Erik Michalesko, and Lori Boukas. If you would like to contact the writing staff, email us at AJRRinfo@aaos.org


This blog shares health care information from a variety of independent expert sources. Some sources offer opinions that may be of interest to other professionals facing similar challenges. Our approach helps ensure diverse, well-rounded presentation of important, often complex health care content. Shared content does not necessarily represent AJRR or AAOS findings and practices.