Cuyuna Regional Medical Center in Minnesota has developed a method to drastically cut surgical cancellations in rural settings. The hospital’s approach focuses on preoperative optimization for total joint arthroplasty patients. By embedding nursing workflows directly into the electronic health record, the team reduced same-day surgery cancellations from 9 percent to 2 percent over more than five years. This achievement earned the project a place among the 2026 Innovator Award winners, a recognition that highlights the value of practical informatics in resource-limited environments.
Shifting the Timeline of Patient Clearance
Traditional surgical preparation often leaves a gap in patient readiness. Adam English, CNP, the clinical director of orthopedics at CRMC, noted a significant delay in standard procedures. “Patients typically don’t get cleared by a primary care doctor until seven days before their surgery,” English said. Meanwhile, orthopedic clinics often see these patients months before the operation. “We often see patients in our orthopedic clinic six months before they have their actual surgery,” he added. The organization sought to utilize this extended window for better preparation rather than letting it sit idle.
The new protocol begins immediately upon scheduling. If a patient signs up for surgery, a registered nurse meets with them on that same day. They review all preoperative orthopedic algorithms together. This early interaction allows staff to identify clinical or social risks long before the scheduled date. In some cases, it becomes clear that a patient is not ready for surgery at all.
Early detection allows the medical center to reschedule procedures proactively. It prevents the disruption and wasted resources associated with last-minute cancellations.
Standardizing Care Through Digital Tools
Preoperative education nurses use a standardized SmartNote within the EHR. This tool relies on evidence-based protocols created through collaboration among multiple departments. The assessments cover medication reconciliation, laboratory validation, and infection risk screening. They also evaluate discharge readiness and potential barriers to recovery. If nurses identify risk factors that cannot be fully managed, they work with schedulers to move the surgery date. This step ensures that patients are medically and socially ready when they enter the operating room.
English emphasized the utility of this digital documentation. “Through this working SmartNote,” English emphasized, “we know to manage medications going in and out of surgery.” Furthermore, he said, “In the world of orthopedics, some you hold six weeks ahead of time, and some you resume a month after.” Finding this information sooner rather than later is key to reducing same-day cancellations. The standardized documentation improves communication among surgeons, anesthesia providers, nursing staff, and therapy teams. It reduces redundant data entry and allows for quick protocol updates without extensive retraining.
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This specific approach to preoperative optimization differs from broader hospital-wide quality initiatives often seen in large urban academic centers. Those programs frequently rely on significant capital investment or dedicated administrative staff. CRMC’s model, developed in a Critical Access Hospital, demonstrates that sustainable improvements are possible by leveraging existing nursing skills and internal EHR resources. The focus here is on workflow integration rather than adding new layers of bureaucracy.
Expanding Capacity and Patient Education
The impact on surgical volume has been substantial. One orthopedic surgeon at the facility was performing 10 surgeries a month initially. He is now the highest-volume orthopedic surgeon in the Midwest for a single private practice. This increase reflects the efficiency gained from fewer cancellations and better prepared patients. The system has also evolved to include prediction models built into the preoperative algorithm. These models help predict whether a patient will go home the same day, need to stay the night, or require an extended rehab stay.
CRMC also incorporated a Total Joint Care Pathway Guide into the process. Patients receive printed educational materials along with QR code-linked videos.
Collaboration Across Care Teams
Securing initial buy-in from primary care doctors was a notable challenge during implementation. Helping clinicians get comfortable with the technology also proved important. English described the process as a prime example of collaboration. “You can have a primary care doctor collaborating with a nurse in the orthopedic clinic, collaborating with orthopedic surgeons,” he said. The initiative extends beyond the hospital walls. It involves care managers, social workers, RNs, and physical and occupational therapists. This cross-functional approach ensures that social and clinical barriers are addressed holistically.
The initiative did not require significant capital or extra staff. By utilizing existing nursing skills and internal EHR resources, CRMC created a sustainable and scalable model. The data from over 3,500 patients supports the efficacy of this RN-led, EHR-embedded pathway.
