1102 - A Journey to Gold: Champion Driven Model

Learning Outcome: Learning Outcome: Attendees will report that this session increased their awareness, knowledge, and confidence on preparing for The Joint Commission Advanced Total Hip and Total Knee Replacement Certification Process.

Purpose: The aim of this podium/poster presentation is to provide a structured approach for other organizations seeking The Joint Commission’s Gold Seal of Approval for Advanced Total Hip and Knee Replacement. It serves to remind institutions they are not alone in their pursuit of expert patient care and excellent outcomes. We are here to help.

Overview/Abstract: Description of Team
Clinical nurses from the Operating Room (OR), Preoperative Unit (Preop), and Post Anesthesia Care Unit (PACU) played a vital role in preparing for The Joint Commission (TJC) Advanced Total Hip and Knee Certification Survey. The interdisciplinary team included champion clinical nurses, leadership, education, quality partners and orthopedic surgeons.

Preparation and Planning
In February 2024, perioperative teams began planning for upcoming TJC Advanced Total Hip and Knee Advanced Certification. A Nurse champion model was chosen to drive the initiative. Champion responsibilities included verifying competency, conducting literature review, assessing evidence-based practice, providing in-services, and creating and validating workflows. Nurse champions collaborated with physician champions, leadership, quality and education departments to ensure a comprehensive standardized approach.

Assessment
Competency validation verified documentation of skills, alignment to specialty standards, and the need to standardize individual practices among staff, physicians, anesthesiologists, and ancillary departments. While current standard of care was met, opportunities for improvement were identified to enhance best practices.

Implementation
Multiple preparation strategies were implemented during 2024. In the OR, all orthopedic general and service-specific competencies were reviewed, organized in a single server, categorized, and alphabetized for easy access. Four in-services were conducted for the orthopedic service team, including nurses and certified surgical technologists. A comprehensive four-page internal mock survey tool was created and utilized eleven surprise audits. Additionally, a list of potential TJC survey questions was developed.

In the Pre/Postoperative areas, documentation workflows were reviewed to ensure alignment with certification standards and to address practice variations. Communication was identified as a key driver of throughput and care quality. Postoperative nurses partnered with physical therapy to streamline evaluations for timely patient mobilization. Handoff practices were also enhanced, with the implementation of standardized, face-to-face RN-to-RN transitions from Preop to OR and OR to PACU to support safe, coordinated care.

Outcome
The TJC gold seal of approval for Advanced Total Hip and Knee Replacement Certification was successfully attained without findings. The champion model ensured peer accountability. One hundred percent of staff in the OR, Pre-op and PACU completed individualized education and demonstrated competency.

Implications for Perioperative Nursing
The certification journey, and the use of the champion model provided nurses with opportunities to assess individual practice, identify variations, and actively influence changes in practice and the clinical environment. Achieving this certification symbolizes a commitment to ongoing performance improvement and adherence to quality measures.

Description of Current State: Presence of none to a very limited public information on previously awarded organization's actual experience on the certification preparation journey. Difficulties in reaching out to other institutions and getting responses about preparation support were experienced. To provide structured support to other hospitals desiring to apply for The Joint Commission Advanced Total Hip and Knee Replacement Certification by doing this education session would be helpful.

Description of Desired/Achievable State: After attending the session, participants from other institutions seeking to apply for the TJC advanced Total Hip and Knee certification will gain knowledge and confidence on preparing for the certification. Participants will learn the structured approach to preparing for the certification survey.

Audience Engagement: Engagement from the attendees will be achieved through answering questions raised by the speakers. Attendees can share personal experiences related to the topic. At the end of the session, time will be provided for question-and-answer portion.

Additional Information: During the session, speakers will be supported by the presence of organization's Preop, Operating Room, and PACU leadership to help answer leadership and administrative related questions from the audience. A physician champion is also willing to join this session if necessary.

Speaker requirements:
Microphones for the speakers and the audience
Lapel microphones for the speakers
Lectern/podium for the speakers
PowerPoint slides projector
PowerPoint slides laser pointer
Presentation slides remote

Content/Topics: o Introduction
o Objectives
o Pre-op Preparation/Planning
Assessment
Education
Implementation
o OR Preparation/Planning
Assessment
Multidisciplinary Collaboration
Education
Timeline Goals
Implementation
Internal Mock Survey
o PACU Preparation/Planning
Assessment
Education
Implementation
o Day of Survey (Day 1 and 2)
o Certification Application Result
o Celebration
o Ever Ready State
o Question and Answer

References: This session is a journey of one organization regarding certification survey preparation. References are applicable to certain aspects only.

https://www.jointcommission.org/what-we-offer/certification/certifications-by-setting/hospital-certifications/orthopedic-certification/advanced-orthopedic/advanced-total-hip-and-total-knee-replacement/

AORN Guidelines for Perioperative Practice

Examination of Surgical Helmet and Surgical Hood Application Methods in Reducing Contamination in Arthroplasty Surgery - PMC (nih.gov)

Manufacturer's Instructions for Use