Case Study: Improving Total Knee Replacement at Brigham and Women’s Hospital

In 2007 John Wright gathered a group of people from all of the profes-sions involved in total knee replacement at Brigham and Women’s Hos-pital—surgery, anesthesia, nursing, physical therapy—to formulate a single standard way of doing knee replacements (Gawande 2012). The team carefully studied the medical literature, conducted some small-scale trials, worked together to develop a standard protocol, and tried to get everyone to follow suit. The new protocol involved changes in anesthesia, changes in the prostheses used, changes in medications, changes in postoperative activities for patients, and changes in physi-cal therapy. The new protocol reduced costs, improved pain control, improved the mobility of patients, and shortened length of stay. Lowe (2011) quotes Wright as saying, “Our primary goal is to improve the outcome and the process of care for the patient. Invariably when we pay attention to these concerns, we find that we achieve the secondary goals of efficiency and cost savings.” One of the most controversial changes involved limiting the prostheses that surgeons could use. Even minor differences in prostheses can result in changes to the operation, and surgeons have strong preferences about prostheses. But some prostheses cost far more than others, and little evidence indicated that the more expensive prostheses were better. The surgeons now use a single source for 75 percent of their prostheses, sharply improving the hospital’s bargaining power (Gawande 2012).

Discussion questions:

• Why would standardization reduce costs? How could it improve quality?

• How could the hospital reward physicians for helping standardize prostheses?

• How would this reward system help align incentives?

• Are any strategies less likely to cause problems with the Medicare Inspector General?

• Why would choosing a standard prosthesis improve the hospital’s bargaining position?