Barriers to the Implementation of Best Practice Benchmarks

Hans J. Kreder, M.D., FRCSC
Toronto, ON

In 2002 the Canadian Orthopaedic Association formed the National Standards Committee with a mandate to formulate evidence-based policy recommendations with respect to acceptable national standards related to the practice of orthopaedic surgery. This work led to reports that highlighted the need for more operating time and other institutional and human resources to meet the musculoskeletal care needs of the Canadian population.


The committee's suggested benchmarks for time to treatment were adopted widely by Provincial Health Ministries for total hip and total knee replacement surgery. However, the incremental resources that were meant to accompany these benchmarks were inadequate and those that were made available were inconsistently distributed across the country. Moreover, accountability for adherence to suggested benchmarks was generally delegated to hospital CEO's with the result that orthopaedic clinical practice patterns and recruitment was in some cases determined by hospital leadership anxious to participate in government financial incentive total joint quota‐based programs, with little or no input from the orthopaedic surgeons.

In 2008 the Bone and Joint Health Network was created in Ontario through the Ministry of Health and Long-term Care. Led by a panel that includes orthopaedic surgeon representatives, the mandate of this Network was to operationalize efforts to improve the orthopaedic care of the population through implementation of evidence-based guidelines. One of the issues tackled by the Network involved optimizing the care of hip fracture patients. The panel recommended that all patients with hip fractures should undergo surgery within 48 hours16. Toolkits were developed to assist in the implementation of best practice regarding patient optimization for surgery (e.g. how to manage patients on Plavix or anticoagulants), best surgical practice to allow immediate weight-bearing as tolerated, rehabilitation strategies, and the prevention and management of delirium, depression and dementia.

Hospitals throughout the province have been monitored regarding implementation of the 48 hour access to surgery benchmark. However strategies to implement this benchmark have varied widely across the province. In some hospitals, hip fracture patients have been assigned more urgent surgical status (type 1B) to ensure that they will be done within the recommended timeline. Where resources for urgent cases are available outside of orthopaedic scheduled surgical time, this has allowed patients with hip fractures to access these resources in competition with other urgent surgical cases (i.e. urgent neurosurgical, general surgery and other cases). In some cases, hospitals have recently created incremental type 1B operating resources to process these urgent cases including hip fractures. Unfortunately, it appears that in other institutions, the orthopaedic surgeons are being asked to implement the 48 hour hip fracture benchmark by displacing scheduled orthopaedic cases, without being given access to any additional resources. This latter strategy obviously pits the welfare of unquestionably deserving patients with hip fracture against those of scheduled patients displaced by the implementation of the guideline. The problem is not the evidence-based benchmark but the implementation of this benchmark within a given institution or even a local community or LHIN. In fact the LHINs as initially conceived would have been the ideal vehicle for the implementation of these benchmarks by working with the local community to ensure the appropriate distribution or redistribution of resources to meet the needs of the population being served. This might involve regionalizing care of certain groups of patients such as those with hip fractures into one or more LHIN institutions that were appropriately resourced to comprehensively address the surgical, rehabilitation, and secondary prevention needs of this patient group. Unfortunately this never did materialize and this LHIN function has been devolved to individual hospital leadership. Consequently, broad system changes such as regionalization and policies regarding resource allocation remain fragmented and inconsistent.

Ideally, resource allocation of beds, operating time, human resource requirements and subspecialty training mix should all be determined by the needs of the population. I believe it is the duty of the orthopaedic community to continue to work on generating the evidence that forms the basis of decisions with respect to the national and local needs for human and other resources, acceptable times for access to care, optimal treatment and the development of new and better health care models and systems. Using this information to generate evidence-based benchmarks or guidelines for maximum wait times seems a logical strategy that would be expected to improve patient outcomes through timely access to care (although I know of no systematic research that compares benchmarking to other potential strategies in terms of achieving the goal of improved access to care and patient outcomes).

Given that, in this country, we as orthopaedic surgeons do not directly control most of the resources required to deal with the MSK needs of Canadians, we must continue to partner with others. We need to involve the public to advocate for their MSK needs using the information that we provide. We need to continue working with the provincial ministries of health to educate them regarding the resources, and the policies that they need to enact to achieve our vision of a healthy population with lifelong mobility. To succeed, our message must be clearly focused on patients and their needs. Finally, within our own communities and institutions, orthopaedic surgeons must continue to provide leadership regarding the ultimate allocation and distribution of resources.


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  2. Pickett W., Hartling, L., Brison, R.J.: A population based study of hospitalized injuries in Kingston,Ontario, identified via the Canadian Hospitals injury Reporting and Prevention Program. Chron. Dis. Can. 1997;18:61-9.
  3. Adunsky, A., Fleissig, Y., Levenkrohn, S., et al: A comparative study of mini-mental test, clock drawing task and cognitive-FIM in evaluating functional outcome of elderly hip fracture patients. Clin. Rehabil. 2002;16:414-419.
  4. Hoenig, H., Rubenstein, L.V., Sloane, E., et al. What is the role of timing in the surgical and rehabilitation care of community-dwelling older persons with acute hip fracture? Arch. Phys. Med. 1997;157:513-520.
  5. Zuckerman, J.D., Skovron, M.L., Koval, K.J., et al: Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J. Bone Joint Surg Am. 1995;77:1551--‐1556.
  6. Scottish Intercollegiate Guidelines Network (SIGN): Prevention and management of hip fracture in older people: A national clinical guideline. 2002;56.

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