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Quality, Safety, and Value

The Current AAOS Initiatives

Sanders, James O. MD

Journal of Pediatric Orthopaedics: July/August 2015 - Volume 35 - Issue - p S20–S23
doi: 10.1097/BPO.0000000000000538

The AAOS is committed to helping orthopaedists provide safe, effective, and high-quality care for their patients. There are a number of very active initiatives focused on patient safety, team performance, and evidence-based quality and value including clinical practice guidelines and appropriate use criteria. This article describes those initiatives.

Department of Orthopaedics and Rehabilitation, University of Rochester, Rochester, NY

No support was received for this article.

The author declares no conflicts of interest.

Reprints: James O. Sanders, MD, Department of Orthopaedics and Rehabilitation, University of Rochester, 601 Elmwood Avenue, Bo6 665, Rochester, NY 14642. E-mail:

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The AAOS recognizes that quality and safety are imperative to orthopaedists providing value to patients and society and has been a leader in the development of quality programs. In the 1990s, the AAOS embarked on an extensive program to develop patient-related outcome measures (PROMs), the MODEMS (Musculoskeletal Outcomes Data Evaluation and Management System) project, which has proven very effective over time with the development of well-regarded PROMS with nonpediatric instruments including the DASH and IKDC. For pediatric orthopaedics, the POSNA Pediatric Orthopedic Data Collection Instrument is a direct result of this program. Over time, the AAOS has expanded its work to include the support and development of evidence-based concepts in orthopaedics, quality and patient safety initiatives, and the understanding and improvement of value in orthopaedic care.

The AAOS established the Council on Research and Quality (CORQ) to oversee the main committees dealing with quality, safety, and value. The chair of this committee reports to the AAOS board. Within this council are the Committees specifically charged with quality and safety including the Evidence Based Quality and Value Committee, the Patient Safety Committee, and the Performance Measures Committee.

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Patient Safety Committee Initiatives

The goals of the patient safety committee are to improve orthopaedic care by changing orthopaedic surgeon/team behaviors and establishing a culture of safety. There is a strong recognition that many of the skills required for high-quality care are nontechnical, especially the ability to communicate well with patients and families, to develop and foster high performing team, to recognize the difficulties of high stress events, and how to create structures for optimum performance during these events.

The Patient Safety Committee has worked diligently to help orthopaedists overcome orthopaedists being “high tech-low touch” surgeons who regard patients more as body parts than individuals. To this end they have developed courses and mentoring in patient communication methods. Their website has a number of very helpful resources dealing with communication and safety. The Patient Safety Committee has invested a lot of effort in developing good methods of communication to prevent patient problems, and a number of their checklists are on the website. A major goal of the committee is to promote the Six C’s of Surgical Safety:

  • Communication: effective patient, surgeon, and surgical team communication.
  • Consistency: regular use of validated standardized surgical processes (checklists).
  • Collection: systematic surgical data accumulation/analysis.
  • Consent: accurate patient-centered surgical consent.
  • Confirmation: accurate surgical site marking and identification.
  • Concentration: focused/distraction-free OR environment.

The AAOS has endorsed TeamSTEPPS, a joint AHRQ and DOD project that is described in a separate article in this journal. Briefly, the program seeks to optimize the reliability of teams and improve their performance by using structured communications for improved communication clarity, minimizing distractions, and empowering members of the team with shared authority so the patient’s outcome is optimized.

The Evidence Based Quality and Value Committee was developed to assess, teach, and develop evidence-based medicine (EBM) in orthopaedics. They have developed several online courses in EBM available on The committee has evolved to develop other projects with the goal of using evidence to improve orthopaedic care and value.

The committee has followed the evidence cycle (Fig. 1) to create high-quality systematic reviews of select orthopaedic topics. The foundation of all the AAOS quality initiatives is a thorough systematic review with detailed meta-analysis of the important outcomes. The philosophy is that if physicians know the evidence and have it put into a readily available and usable format, then they will provide the highest quality of care possible. These topics are then used to create evidence-based clinical practice guidelines (CPGs) and all their derivative products including Appropriate Use Criteria (AUCs), Performance Measures, Patient Safety Checklists, and Shared Decision Making Tools. The CPGs and AUCs produced by the AAOS are listed in Table 1.





CPGs have been the basis of this because of their strong grounding in the evidence. Orthopaedics has been limited in the strength of its recommendations because of the limited strength of our literature. The CPGs have evolved and the process has continued to improve as we have learned from our past problems and successes. The AAOS is starting to tackle broader topics rather than subspecialty topics where there is likely to be very little literature. Examples include the treatment of hip fractures with the focus on the best course for the patient throughout their treatment course rather than whether fixing hip fractures works. Patient Safety Checklists and Shared Decision Making Tools have been developed for specific CPGs.

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Although the CPGs focus on what actually works and does not work, the AUC process focuses on in whom or when a procedure should be performed. For example, the CPG on anterior cruciate ligament (ACL) may indicate that ACL reconstruction maintains quality of life over nonoperative treatment. The AUC would focus on whom the ACL reconstruction should be performed, for example, a 24-year-old healthy athlete or a 73-year-old recreational tennis player with moderate osteoarthritis of the knee. The AAOS AUCs are available as an app at that can be accessed from any computer web browser, a tablet, or mobile device, has 3 sections. The first section provides a list of “assumptions” or considerations for ensuring that the user understands several important aspects about the patient and the application. The second section allows the user to select alternative to correctly describe the patient and their problem, and the third shows the results of the AUC panel’s decisions regarding the appropriateness of the various treatments using the example of a supracondylar humerus fracture (Fig. 2).



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These have become very important in federal policy discussions as ways to put quality into discrete measurements. The AAOS has started a new committee for the development of PMs. The committee will have interaction with the Physician Consortium for Performance Improvement (PCPI), National Quality Forum (NQF), National Committee for Quality Assurance (NCQA), and the CMS Physician Quality Reporting Committee (PQRS).

As both a final and future development is the recognition that improving both evidence and quality requires high-quality data. Other organizations such as the American College of Surgeons with their National Surgery Quality Improvement Project (NSQIP) have developed very effect data collection systems. The AAOS is investigating methods to help orthopaedists obtain useful data. As part of this, the CORQ Supports current the American Joint Replacement Registry (AJRR), but this only meets the needs of 1 segment of musculoskeletal care, and the area of data collection for evidence and quality is an important future direction for the AAOS.

In summary the AAOS is committed to helping orthopaedic surgeons provide the highest levels and improve the quality and value of the care they deliver. As this field evolves, the AAOS will continue to develop and implement the programs necessary for superb musculoskeletal care.


patient safety; clinical practice guidelines; appropriate use criteria; performance measures

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