The American College of Surgeons (ACS), in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, continues to support hospitals across the nation that are adopting enhanced recovery pathways. This enhanced recovery program—the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR)—launched in the fall of 2016, and is funded and guided by AHRQ.
This article looks at the rationale for starting ISCR, where the program has been, where it’s going, and the benefits of participation. It also summarizes the experience of three institutions that were early participants in the program, offering some lessons learned from the ISCR project leads.
The relevance of enhanced recovery programs
Enhanced recovery practices have gained a lot of traction in the surgical community. Not only do these practices offer an innovative approach to delivering standardized, evidence-based care, but the pathways have been associated with reducing surgical complications, improving the patient experience, and decreasing length of stay without increasing readmission rates.1-5 Given the strong interest and demonstrated improvements associated with these pathways, the goal of the AHRQ Safety Program for ISCR is to accelerate the journey toward improved surgical outcomes by offering support and disseminating information to U.S. hospitals that are seeking to implement enhanced recovery practices within the framework of the Comprehensive Unit-based Safety Program—a well-known model for sustainable safety improvement that has been associated with preventing harm in multiple areas.6-14
Since the start of the first cohort in July 2017, the ISCR program has actively supported participants in implementing evidence-based surgical care. The initial group focused on colorectal surgery. The second cohort launched in March 2018, expanding the work to include total joint replacement and hip fracture surgery. A third cohort is set to start in March 2019 with a focus on gynecologic surgery, but hospitals can still join and work on colorectal and total joint replacement and hip fracture pathways as well. The program is comprehensive and includes both the evidence and pathways together with implementation materials to help teams develop effective and sustainable programs.
Benefits of participation
Participants receive comprehensive evidence-based pathways that can be modified and adapted to individual hospitals, as well as succinct, up-to-date documents with the evidence supporting the pathways, access to educational materials on implementing the pathways, and support from national content experts and leaders in performance improvement and education who will help them troubleshoot as they implement. Furthermore, the program has developed a vibrant community of surgeons, nurses, and anesthesia providers committed to like-minded work that has become an outstanding resource.
Enrolled hospitals also have the opportunity to join monthly coaching calls and national leader webinars to learn from their colleagues and other experts in the field. Coaching calls are discussion-driven on topics such as patient and staff education; specific clinical practice area changes, such as bowel preparation or multimodal analgesia; and barriers to and facilitators of implementation, including such issues as identifying meeting times, communicating and working across units, surgeon engagement, or the electronic health record (EHR). National leader webinars take on a clinical focus with topics such as bowel prep versus oral antibiotics, preoperative lab testing, venous thromboembolism prophylaxis, building a culture of mobility, and delirium screening.
Additional support is provided by the ISCR team’s nurse consultant who has a wealth of knowledge and experience with adopting and implementing enhanced recovery practices. The program team also is available for clinical support and data collection efforts.
Collecting process and outcomes data to assess adherence to pathway elements and measure improvements in patient outcomes is a key component to gaining buy-in for this program, optimizing effectiveness, and sustaining the work. All participating hospitals have access to a registry that incorporates the lessons learned from the ACS Quality Programs and is focused on pathways and key outcomes. Support is available for hospitals’ data abstractors, and all hospitals have access to performance reports with benchmarking against other participating hospitals to help drive local conversations and engagement.
Patient experience reports
The patient’s experience is increasingly recognized as an important component of surgical care. Participating hospitals have the opportunity to measure their patients’ experience with practices that are compliant with the pathway. Hospitals receive feedback reports with comparative benchmarks that, from the patient perspective, identify areas that should be improved, as well as measure the impact of the work on patients.
What we have learned from the early participants
As part of understanding and optimizing the program, three participating sites allowed the program team to visit and spend the day with them to understand how the ISCR program helped them improve their colorectal surgery patient care. To help potential participant hospitals understand the myriad ways that the ISCR program can accelerate a perioperative quality improvement program, we have highlighted some of the findings from these visits.
We found that hospital-based ISCR teams organize their work around enhanced recovery pathways in different ways. At site one—a large, urban academic medical center—a longstanding team dedicated to improving quality for perioperative services took responsibility for folding an enhanced recovery pathway into their work. According to the ISCR project leader, the team’s goal was to create a “bundle of bundles” to align priorities and processes over a number of different initiatives. Given the lean staffing at this institution, the project lead used a top-down approach in which he served as a gatekeeper of information, disseminating only relevant information about the pathway to targeted staff.
Site two was a mid-sized, rural hospital. ISCR team meetings were incorporated into the department’s regular committee meetings on patient safety. Similar to site one, the ISCR project leads shared information in a segmented way, focusing separately on each phase of care (that is, preoperative, intraoperative, and postoperative). Although this approach was less effective at integrating information across the continuum of care, it allowed each sub-team to focus on the pathway elements that directly affected its workflow. Approximately six months into implementation, the team meetings about the pathway were phased out because of the low volume of enhanced recovery cases. In its place, the anesthesia team—led by a strong anesthesia champion—met immediately after each case to review intraoperative pathway measures.
In contrast to the first two sites, the ISCR project team at site three focused exclusively on implementing an enhanced recovery pathway. The leadership at site three—a mid-sized, suburban hospital—made the commitment to fund a dedicated enhanced recovery coordinator (a trained ACS National Surgical Quality Improvement Program surgical clinical registrar) who was responsible for coordinating meetings, abstracting data, and gaining buy-in from clinicians. According to the staff with whom we met, the enhanced recovery coordinator was able to effectively engage staff across the continuum of care through her energy and dynamism, data feedback, and use of ISCR program materials.
Despite different approaches to implementing the enhanced recovery pathway, the three sites shared several attributes. The first was the presence of strong champions. At site one, the project lead invested nearly one year in gaining buy-in from staff. The project lead at site three experienced a similar sense of “pounding the pavement,” meeting with each team member individually and distributing patient education booklets to surgeons’ offices in person. At site two, the two project leads included a highly engaged anesthesia champion, who served as an ambassador to different stakeholders, and the director of performance improvement, who was intimately involved in data abstraction and feedback.
A second shared characteristic was the hospitals’ participation in the ISCR program. Although the three sites used the program resources in different ways, all found a benefit to joining. For sites two and three, which were in the early phases of implementing an enhanced recovery pathway, the project leads and teams used the ISCR program materials extensively, from learning how to structure the project team, to evaluating current performance to identify areas for improvement. At site one, which was further along in its implementation journey, a more focused set of materials around EHR order sets and early mobility proved useful.
Challenges and overcoming them
In terms of implementation barriers, creating order sets within an EHR system proved to be a challenge for all. For example, at site one, developing a pathway in Epic took 10 months to complete after the workflows were in place. Another ubiquitous barrier was getting the project teams together to meet, as the schedules of large multidisciplinary teams are often difficult to coordinate. Other challenges included getting reports from the EHR that the project leads could use for feedback (site one), engaging with surgeons in private practice about the pathway (site two), and securing resources to scale the pathway to other surgical lines (site three).
For hospitals either considering, or already in the thick of implementing an enhanced recovery pathway, the sites had several insights and “best practices” to offer. The project lead at site one said that, at his rather large and complex institution, it is better to implement changes incrementally, not when everything is completely done, saying “things flow in waves…as we’re ready to make changes, we do.” An incremental approach to change was also evident at site two. In a hospital with little capacity for data collection, the anesthesia team built its own dashboard for intraoperative measures, which they could then review in real time after each case. At site three, in order to generate buy-in among surgeons, the ISCR team sent letters from the chief medical officer to surgeons that included benchmarking data. This strategy proved very effective in providing the “hard” data needed to motivate the need for change.
As evidenced by this small sample of sites, there are many different paths to accomplishing your enhanced recovery goals. To support your hospital’s implementation journey, the ISCR program is here to help.
How to enroll
ISCR is especially useful to hospitals that meet the following criteria:
- No prior enhanced recovery implementation experience
- Hospitals that have implemented enhanced recovery in one procedure area and are looking to expand to other areas
- Hospitals that have attempted to implement enhanced recovery pathways but did not experience significant improvements or were unable to sustain the program
The program team is now recruiting hospitals to participate in the third cohort, which will focus on gynecologic surgery, as well as the colorectal and the joint replacement and hip fracture cohorts. Hospitals are encouraged to begin enrollment now in order to participate in the 12-month program that starts March 2019.
If you are interested in joining or learning more about the program or participating in any of the three cohorts, e-mail ISCR@facs.org.
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