This case study, produced by Health Innovation Forum in collaboration with orthopaedic surgeon Dr. Ken Hughes and project manager Cindy Roberts, examines how the Richmond Hospital staggers surgeries in a dedicated hip and knee unit to improve efficiency. — Produced as part of the 2008 program of the MUHC-ISAI .

The problem

The effort to reduce wait times for surgical procedures and clear the backlog for hip and knee replacement surgery in British Columbia involves initiatives at all stages, from first patient referral, to effective triaging, to completion, to postoperative rehabilitation. The goal cannot, however, be reached without a considerable increase in the number of surgeries performed.

The program

In 2004, the Richmond Hospital, a community hospital in the Vancouver Coastal Health Authority, created a high-quality, high-volume, low-cost model of “best practice” dedicated to hip and knee surgery. The Richmond Hospital’s multidisciplinary team looked for efficiencies in the use of operating room resources, the standardization of equipment, prostheses and supplies, the adequate preparation of patients, and the coordination of patient flow post surgery.

Increased surgical efficiency started by staggering operation start times and schedules between two rooms, so surgeons could “swing” between rooms as their patients were ready. This, in addition to coordination with surgical units post-op, allowed operating teams to complete eight joint replacements or reconstructions per day instead of three. Surgical procedures and clinical practices were standardized, using one single type of prosthetic device, which made work smoother for nurses and allowed the hospital to negotiate better deals on bulk purchases. Together, these measures were able to increase operating room efficiency by 25% and enabled a 136% increase in completed cases. This contributed to bringing wait times for surgery down by 75%, from 20 months to five months. The two Richmond operating rooms are able to capitalize on the efficiencies that come with specialization similar to private surgical centres.

Patients who do not meet the criteria for the eight joint operating days are accommodated on other days when longer surgery times can be scheduled. This is also true for patients who require a different model of prosthesis than that which is available during an eight joint day.

Dedicated funding of $1.3 million from the provincial government, Provincial Health Services, the Vancouver Coastal Health Authority and the Richmond Hospital Foundation bought the project a full-time manager, equipment, research and evaluation tools, a newly-renovated operating room and new operating suite equipment.


While some of the ideas for efficiencies adopted by the Richmond Hospital were already in use at specialized orthopedic sites, the Richmond experiment demonstrates that they can be adapted to a community hospital. The model is now an entrenched part of the Richmond Hospital. The Richmond group distilled the innovations at their hospital into a toolkit called The Arthroplasty Plan (TAP) model. The toolkit is available to other surgical centres seeking to make more efficient use of existing resources.

The model was adopted by the University of British Columbia’s Centre for Surgical Innovation (CSI), which has a mandate and $25 million in provincial funding to help clear the province’s backlog in hip and knee replacement surgery by fast-tracking low-risk patients from across the province who have been on a waiting list for more than 26 weeks. The CSI has four dedicated operating rooms and 38 inpatient beds, and aims to perform 1,600 surgeries a year. About 25 orthopedic surgeons provide service at the centre.

Potential for expansion

Reduced wait times cannot be achieved through operating room efficiencies alone. A complementary project, the Osteoarthritis Service Integration System (OASIS), has been initiated by Vancouver Coastal Health to fill some of the important gaps in care for patients with osteoarthritis by better coordinating primary care, community care, home care and hospital care. From the time the decision to proceed with surgery is made, a multidisciplinary team becomes involved in preparing the patients and planning for postoperative rehabilitation. One important aim is to reduce declines in health among patients waiting for surgery and those who are not surgical candidates.

Many of the efficiencies realized in this project translated to and benefited other surgical services, who also saw faster turnover times as efficiencies in case cart turnover, porter availability, OR cleaning and other functions were addressed. By addressing bottlenecks in the patient flow process, delays in preparing patients for the OR or transferring them from the OR to the PACU unit to the surgical floor were reduced.