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Hip and Knee


ABJHI’s internationally recognized work in raising the quality of care for hip and knee replacement patients began with designing a care path for Alberta based on the best evidence available worldwide. The new care path was designed in 2004 in collaboration with the Alberta Orthopaedic Society, representing the province’s orthopaedic surgeons, and with provincial health authorities.

The hip and knee care path set out the practices and protocols for treatment, beginning with referral by a family doctor to a specialist, and extending through:

  • Assessment by a specialist,
  • a treatment plan for non-surgical patients,
  • a plan to get surgical patients to their optimal readiness,
  • surgery,
  • recovery, and
  • rehabilitation in the community.

All services, other than family doctor and in-hospital, are provided in or through a hip and knee clinic. Care is fully integrated, provided by a multidisciplinary team, and coordinated by a case manager in the clinic.

The care path was tested in a provincial pilot in 2005-06, which was managed by ABJHI. Patients who followed the new care path had significantly greater improvement in general health, less pain after surgery, and greater ability to perform normal daily activities than those who received conventional care. Waiting times for consultation with a specialist and for surgery declined dramatically.

The hip and knee care path is now the standard across Alberta and has helped shape care in other areas of Canada.


Hip and knee care in Alberta is measured using a framework designed by ABJHI and built around the six essential dimensions of health care quality: safety, access, appropriateness, effectiveness, efficiency and acceptability.


You can’t improve what you don’t measure. That truism is behind a novel approach developed by ABJHI to stimulate continuous improvement in hip and knee replacement by surgeons and hospitals in Alberta.

ABJHI sifts through surgeon and hospital data to track performance against benchmarks in key areas of service and patient outcomes, such as:

  • how long patients waited for a consultation and for surgery,
  • how long the surgery took,
  • how long patients were in hospital after surgery,
  • how much patients improved in critical areas such as pain and physical function,
  • how many were readmitted to hospital because of complications,
  • how satisfied patients were with their treatment, and
  • how many had serious side-effects, such as infection, blood clot and heart attack.

ABJHI compiles and analyzes the data for each surgeon. The results are compared with provincial benchmarks and with the aggregated scores for the surgeon’s peer group after adjusting for the complexity of the cases. ABJHI presents the results in the form of a confidential Continuous Improvement Report to each surgeon every 6 months.

ABJHI also groups the surgeon reports by health care zone. This information is aggregated and de-identified to produce a Continuous Improvement Report for each of the five health zones in the province.

Alberta is the only jurisdiction in Canada where surgeons are receiving reports on the results of their work tied to benchmarks. Data from approximately 95% of the 10,000 hip and knee replacements performed annually in Alberta are included in the Continuous Improvement Reports.

In Brief

Alberta is the only jurisdiction in Canada where surgeons receive personal performance reports.

  • ABJHI tracks and reports surgeon performance against benchmarks in hip and knee replacements.
  • Critical areas of care measured – e.g. wait times, patient outcomes, health complications.
  • ABJHI also reports health zone performance.
  • The reports flag opportunities to improve care.
  • The reports help surgeons align personal performance targets with Alberta Health Services targets.


Evidence-based health care is, by definition, subject to change. Better drugs, more effective practices and safer protocols are being developed and introduced in health care with unprecedented rapidity. The best health care stays on top of these developments and takes advantage of them.

ABJHI set up a formal process in early 2007 to ensure its evidence-based care path for hip and knee replacements is truly evidence-based all the time. It struck a Clinical Committee, mandated by the Alberta Orthopaedic Society, which acts as an independent body of experts on patient care.

The committee comprises eight of Alberta’s top orthopaedic surgeons. The surgeons review new evidence related to hip and knee replacements. This evidence is gathered by ABJHI. It comes from research studies and scientific papers and directly from health care providers involved in patient care, including surgeons and other doctors, nurses and therapists.

ABJHI updates the care path based on the Clinical Committee’s decisions. A measurement framework, which is used to track the hip and knee care path’s performance, and patient guides are also updated to reflect changes in the care path.

Both the revised care path and measurement framework are submitted to Alberta Health Services for approval and provincial implementation. ABJHI advises orthopaedic surgeons across the province of the changes and how to access the updated care path in a secure portal on its website.

In Brief

ABJHI ensures the hip and knee care path remains evidence-based.

  • Gathers new evidence and presents it to a committee of leading orthopaedic surgeons endorsed by the Alberta Orthopaedic Society.
  • Revises the care path based on committee decisions.
  • Seeks Alberta Health Services’ approval of care path changes and of implementing the changes.
  • Advises surgeons across Alberta of the care path changes.


Alberta has its first province-wide automated system for referring patients to a medical specialist. The new eReferral system was developed with the assistance of ABJHI and the Bone and Joint Health Strategic Clinical Network, a unit of Alberta Health Services (AHS).

eReferral is being used to refer patients for consultation with a specialist for hip and knee joint problems as well as for lung cancer and breast cancer. It simplifies the referral process by standardizing the information required to be submitted with the referral. The system informs the referring physicians of the waiting time to see the specialist before they transmit the referral. Referral status updates are available in real time, any time.

eReferral currently reports the time patients can expect to wait before their first assessment in a hip and knee central intake clinic. The reported wait times are current and available for each specialist.

eReferral eliminates errors by standardizing the information required on the electronic form. Missing referral information causes hours of extra work and adds as much as six weeks to the wait to see a specialist. Lost referrals will be a problem of the past as the transmission and exchange of paper are eliminated.

The eReferral system is integrated with Alberta Netcare, a secure and confidential health record database where all patient health information is integrated, stored and made available to authorized health care providers. Only physicians who have adopted Alberta Netcare can use eReferral. AHS is encouraging physicians to give up paper-based referrals and adopt eReferral and Netcare.

In Brief

An automated referral system that gives Alberta unprecedented opportunity to reduce wait times for hip and knee replacements.

  • A reliable snapshot of wait times in any area of the province – who is waiting, why and how long they have been waiting.
  • Quickly identifies wait time trends, identifies trouble spots.
  • Enables service planners to take targeted measures to counter delays.
  • Weeds out delays caused by patients for a true profile of health system performance.


A provincial project initiated by the BJH SCN and managed by ABJHI has saved tens of thousands of bed-days in Alberta hospitals valued at $52 million in the four years following its launch.

The project is helping to speed up access to hip and knee replacements in Alberta by freeing up bed space for patients waiting to have surgery.

A patient cannot have surgery if an acute-care hospital bed is not available. Research by ABJHI revealed that hip and knee patients were routinely staying in acute care beyond the four days specified in the province’s standardized care path. The most common reason: patients had not made arrangements for help with their recovery at home. Having support in place at home is a required step in Alberta’s standardized care path for hip and knee replacements.

ABJHI and the BJHSCN responded with a strategy to create multidisciplinary frontline teams in hospitals whose members would commit to following the care path, including applying the four-day length of stay. There are 13 hospitals in Alberta where hip and knee replacements are performed.

ABJHI estimates total savings of approximately 51,000 bed-days since 2010, when the project was launched. The bed-day savings have a value to Alberta’s public health care system of $52 million.

The project has become an important part of the measures being taken by the BJHSCN to meet annual wait time reduction targets for hip and knee replacements.

In Brief

Shorter stay in hospital for hip and knee replacement patients – a 4-day standard.

  • Freed up approximately 51,000 bed-days in Alberta hospitals since 2010.
  • Saved bed-days valued at $52 million.
  • Surgeons performing 45% more surgeries per year with 9% fewer hospital beds.
  • More surgeries mean shorter wait times for Albertans.
  • Patient Guides for different bone and joint surgery types, such as hip and knee replacements.



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