How the International Society of Orthopaedic Centers, a group of high-level orthopedic surgeons, is turning small meetings into global progress.
When Thomas P. Sculco, MD, was starting out, he spent months working in several European hospitals, something that was, and still is, pretty unusual for a young American doc. “I wanted to see how things were done in different environments so I could learn and bring those perspectives into my own practice,” says Sculco, who now is surgeon-in-chief at the Hospital for Special Surgery, a large academic- and research-focused orthopedics, rheumatology, and rehabilitation hospital in New York.
So it shouldn’t come as a surprise to find him as the driving force behind the creation of the International Society of Orthopaedic Centers. ISOC’s meetings bring together musculoskeletal specialists from the largest academic and research-focused orthopedic centers in the world to exchange ideas and cutting-edge practices, and to collaborate on finding ways to improve patient care, physician education, and research-based programs. The ultimate goal, he says, is to generate best practices that have been tested in these large facilities, and then share these benchmarks to improve orthopedic care worldwide.
Though the society is only four years old and the ink is still drying on its official nonprofit-status papers, the three meetings ISOC has already held have set it well on its way toward reaching that admittedly lofty goal.
REALLY, ANOTHER MEETING?
One thing that’s not in short supply is meetings for orthopedic surgeons. There’s the annual meeting of the American Academy of Orthopaedic Surgeons, which draws tens of thousands each year. Then there are the societies for those who specialize in spines, and hips, and knees, and hands, and shoulders. Do we really need yet another meeting?
Most definitely, says Claudio Mella, MD, current ISOC chairman and coordinator for international activities with the Clinica Alemana in Santiago, Chile. “The other meetings are for learning new treatments and scientific advances. ISOC does not provide specific instruction about, for example, how to put in a screw. It’s about developing strategies that will let us improve education and scientific activities.”
“We have different aims than other meetings,” says Beat Simmen, MD, PhD, chairman of upper extremity and hand surgery at the Schulthess Klinik in Zurich. “Of course, techniques are a part of it—when doctors get together, they will talk about what they do and how to do it better. But we focus on the larger picture: how politics and economics affect what we do, and how we can stay ahead of all that to improve the main things at the core of our daily work—education, patient care, and research.” Simmen, who is a past ISOC chairman, explains that because orthopedics is such a large and fast-growing segment of national health budgets, there is increasing pressure on orthopedic surgeons and orthopedic institutions around the world to document not only what they are doing but also the efficiency and efficacy (as measured in the cost of “quality life years”) of their work. There is a growing need to develop quality-management systems that can accomplish this, but the financial and manpower costs involved are high. Another key challenge in orthopedics today is the need to standardize processes and procedures within the orthopedic community. “These questions are at the core of ISOC,” says Simmen.
To tackle these strategic issues, ISOC keeps the meetings small and intimate (Sculco says the goal is to keep the number of participants to 60 or fewer, but definitely no more than 75). “The interaction is very different if you have 50 people in the room instead of 500,” says Sculco. “We wanted this to be a think tank where we could have open discussion and interaction between the different centers that would result in consensus on the best way to handle our various challenges.”
The format also is designed to foster idea generation and collaboration rather than simply to disseminate knowledge. Explains ISOC board member Fabio Catani, MD, professor of orthopedic surgery with the University of Bologna-Istituto Ortopedico Rizzoli, Bologna, Italy, “In the standard scientific symposium, most of the time is dedicated to lectures. At ISOC, discussion is the most important thing.” While each member center has the opportunity to present on what it is doing clinically, Mella says the lecture topics are chosen specifically for their ability to drive the creation of new projects and new clinical protocols and to stimulate larger discussions. Sculco, who serves as ISOC’s executive director, adds that what is presented at ISOC has to be “the most cutting-edge, the most traumatic, or the most exciting scientific or clinical research endeavors of each member institution.”
Sculco adds, “Here you have the biggest players [in orthopedic surgery] around the table, a group of very talented and very experienced people trying to resolve the issues we share and to learn from each other. It isn’t something you can do at the hip or knee society, because it’s bigger than hips or knees. It’s the entire field of orthopedics.”
CULTIVATING CULTURAL AWARENESS
This strategic approach also is why the meeting rotates to different member institutions around the world: The first was held in May 2007 at the Hospital for Special Surgery in New York City, the second was held in October 2008 at the Schulthess Klinik in Zurich, and the third was held this past May at the Istituto Ortopedico Rizzoli. The next meeting is scheduled to be held at the Clinica Alemana de Santiago in fall 2011. This rotation around the world allows participants to see firsthand how another member organization functions and what best practices it has instituted, says Sculco.
ISOC meetings also include a social and cultural component designed to foster informal communication, professional partnerships, and even friendships among the participants, as well as to provide the cultural backdrop and understanding of the forces that shape the environment in which that particular institution operates. At the 2007 meeting in New York, for example, participants got to know each other over dinner at the Knickerbocker Club on the first evening. The two days of scientific sessions, explorations of the structure and management of HSS, and roundtable discussions on academic training were broken up with lunch at the Museum of Modern Art and a ballet performance at the Metropolitan Opera House. When in Zurich at the Schulthess Klinik, cultural components included a trip to the Zurich Opera and a meal at a private art collection. In Italy, participants visited the Ferrari museum and enjoyed a piano concert.
“We were able to continue working to resolve what we talked about during the meetings in a more relaxed way, and we founded friendships. Many things are easier when you are friends,” says Simmen. “We are developing the networks that will help us accomplish our goals.” Adds Mella, “It can be difficult to pick up a phone and speak in my not-perfect English, but it’s quite different if I sit down at a table and Dr. Sculco says, ‘Hey, Claudio, can you tell us a bit about this?’ When you can speak more spontaneously, a lot of good ideas can arise.”
Also, Mella says, every medical system reflects the society in which it functions, so it is useful to see both how the institution itself is set up—you may find things that will help you organize your own institution a little better—and the societal framework of the host center.
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The first one was probably the hardest, as my obstetrician likes to say,” says Ilsa Klinghoffer, MPA, about the inaugural meeting. Klinghoffer is the administrative director of ISOC and director, International Learning and Training Center, Education Division, Hospital for Special Surgery. Despite small setbacks—like two members from China being waylaid because of a volcanic eruption near Japan that made it impossible to get to New York—participants walked away energized, and the excitement continues to grow, says Sculco.
That may be in part because participants are already beginning to see some results in the areas of education, clinical issues, and research from the meetings and the partnerships they built.
For example, the educational roundtable at the 2007 meeting resulted in an identification of challenges involved in teaching future surgeons, from issues around specialization, to how to introduce new surgical techniques, to balancing the economic need to use residents and fellows as working physicians with the educational need for teaching time. Participants also came up with a list of action items to improve training programs, including defining the appropriate length of time needed for specialty training and finding ways to increase research time. At the close of the second meeting, the group had written a position statement outlining the current research and education challenges facing large orthopedic hospitals, and some proposed solutions.
Another concrete result of ISOC meetings is an agreement to create a traveling ISOC fellowship, fully funded by the participating member centers, that would enable a fellow to conduct research on a specific topic while working in several member centers. He or she would write a paper on the research, both for presentation at a future ISOC meeting and for publication. And member organizations have begun to share their clinical protocols, and they are institutingvisits between member organizations.
One research challenge ISOC members have identified relates to how to determine which new tools and techniques they should use, given the plethora of innovations companies are trying to sell them. Of course, the innovations that improve the quality of care should rise to the top, but how do you measure the quality-of-life improvements resulting from orthopedic surgeries? ISOC is hoping to propose quality-measuring instruments and technologies that can measure, for example, a patient’s ability to walk after hip surgery, or how much function is gained after an upper extremity joint is replaced—a difficult question to answer, says Simmen. The leader of the outcomes and clinical studies task force, which was formed after the 2008 meeting in Switzerland, has visited several of the European and U.S.-based member centers to see which measures each is using as a first step in coming up with a universal way to record data, says Klinghoffer.
ISOC also is focusing on expanding implant retrieval registration and research. When an implant has to be removed due to infection, mechanical failure, or for other reasons, there is much to be learned by analyzing the extracted implant. However, says Simmen, all too often the removed implants end up in storage in a hospital’s basement. HSS has an implant registry already in place, and now that the Schulthess Klinik knows about it, it is sending its implants to HSS for registry in its system. The implants retrieval task force also is surveying member centers to find out if they are doing implant retrievals and, if they are, how they are handling collections.
While many of the ISOC projects are still in the early phases, the society’s Web site (isocweb .org), slated to go live this fall, is geared to help further facilitate collaboration between face-to-face meetings, says Klinghoffer.
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The group’s most recent meeting in Bologna incorporated a new level of strategic thinking—it brought in the centers’ CEOs for their own parallel meeting. With demand on the rise and healthcare costs under the microscope, it seemed like a good time to gather those leading the world’s largest orthopedic centers to discuss both the opportunities and the administrative challenges they face. But would the busy executives come to what thus far had been a meeting for clinicians and researchers? Louis Shapiro, FACHE, HSS’s president and CEO, says he and his colleagues weren’t certain it would be worth the time and money to travel to Italy for a CEO Summit.
Sure, it would be great to meet others who have similar jobs (“We don’t have a big peer group in our local markets, or even in our countries,” says Shapiro.) But peer interaction alone, while valuable, wasn’t enough to make it worthwhile to travel around the world to meet, he says.
Shapiro surveyed the member center CEOs ahead of time to determine their major challenges and opportunities, which he laid out on a grid. Despite the fact that they worked in healthcare systems that run the gamut from public to private to government-run, he found a fair amount of overlap. Among the common needs were finding ways to increase efficiencies to meet capacity demands, maintaining high quality and service during periods of rapid growth, and overcoming constraints to physical expansion by identifying opportunities in other geographic areas.
“The deep dive into topics we had in common was very useful,” says Shapiro, though finding solutions that work across the board is a little more complex for CEOs than it is for the surgeons.
“If you tear your ACL, there’s science behind how you repair it, whether you’re in Germany, or China, or the U.S.,” says Shapiro. “It’s different for us because we’re dealing with different regulatory, competitive, and governmental environments. While we may have many problems in common, the solutions are unique to the center’s location, in many cases.”
But not in all. For example, the member centers are in different stages of implementing Lean Manufacturing practices, and Shapiro says it was useful to share how they’re using that process to shape business strategies. Another common problem was coping with today’s demand for orthopedics, which is exceeding capacity at every center at the table. “While our healthcare systems are different, the efforts associated with improving quality, reducing costs, improving outcomes, and using electronic medical records all transcend what’s unique about a country,” says Shapiro.
The surgeons also found it useful to have the CEOs join the rest of the group for the social and cultural activities. “We now have more fluid contact with our own CEOs, which gives us a new way to develop educational and scientific projects,” says Mella. The Istituto Ortopedico Rizzoli’s Catani, who hosted the first CEO summit, says, “Having the CEOs there was a step forward in creating a synergy between surgeons, researchers, and CEOs. Instead of following our separate pathways, we were able to work together.”
The CEOs decided to take on an interim project to identify best practices for collecting data around performance measurement, both clinically and operationally. “We’re working on an IT-related solution so we can identify and share the information and analyze it efficiently.” It’s a simple, straightforward project, says Shapiro, but it’s also one that the CEOs can build upon.
While it is unclear whether or not the CEO summit will become a permanent piece of the ISOC meetings, it will be part of the 2011 meeting. While the CEOs decided unanimously that the summit was worth the time and energy, “What wasn’t clear is whether it always would be worth it, which is why we decided to do an interim project,” says Shapiro. “We’ll test that theory when we meet in Chile. Time is very valuable, and we don’t want to meet for the sake of meeting. We’ll let you know how it goes.”
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Sidebar: ISOC STRUCTURE AND MEMBERSHIP
Because the exclusivity of its membership and the intimate nature of its meetings are key drivers of its success, the International Society of Orthopaedic Centers limits the number of member organizations it will accept. It originally was limited to just 10 centers from the U.S., Chile, China, Germany, Italy, Mexico, Switzerland, and the United Kingdom. After the first meeting, the group decided to expand to 14, with the additions coming from the U.S., the Netherlands, and Sweden. The plan now is to add two or three more member centers—the membership committee is reviewing the credentials of centers in South Africa, Australia, and Canada.
“We want to keep it small so we retain the ability to communicate and develop relationships,” says Ilsa Klinghoffer, ISOC’s administrative director. The board of directors does want to get as broad a representation of different cultures as possible, which is why it is considering expanding the membership beyond the current 14 centers.
ISOC’s criteria for membership are rigorous. Member organizations must be specialty orthopedic hospitals or large orthopedic departments in general hospitals that function within an academic center. The centers have to perform a minimum of 5,000 orthopedic surgeries each year; have at least 20 orthopedic surgeons who do research and training; employ fellows and residents; and have an active research arm. “We wanted to have the collaboration stretch across not just clinical, but also research and educational, boundaries,” says ISOC Executive Director Thomas P. Sculco, MD.
The society holds its meetings every 18 months at a different member center. It also holds a meeting of its executive board annually in conjunction with the American Academy of Orthopaedic Surgeons’ annual meeting. After the second meeting in Switzerland, the society created task forces to focus the work in its key areas: education and fellowship, outcomes and studies, implants and retrieval, and Web site and information exchange. ISOC chairmanship rotates every 18 months, with the chairman being the lead person in the member center that will be hosting the next meeting.
All membership and meetings costs are covered by the participating member centers, says Klinghoffer. There is no commercial support involved, and no CME credits are offered for participating in the educational activities.
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