The first step is to decide whether to develop an ERP from scratch, or adopt a preexisting one. There are many published examples of ERP for various types of procedures [14, 15, 20, 21], in addition to ERAS Society best practice guidelines for perioperative care [22–25]. However, the local practice environment, organizational culture, and availability of resources must be taken into consideration as they may influence specific pathway elements. Guidelines for perioperative care may include more than 20 different elements, and implementation of a pathway that is not feasible within a local setting is likely to fail. The necessity and feasibility of each pathway elements should be evaluated for local settings. Nevertheless, existing pathways may serve as a starting point. An example of the bowel surgery ERP at our institution is shown in Table 27.1. It is at this point that consensus must be obtained from all of the relevant stakeholders for what will be included in the pathway and how these elements will be operationalized. Potential barriers to implementation must also be identified, and the appropriate actions taken to remedy them.

Prior to undertaking an ERP, an audit strategy should be discussed and baseline data should be collected for benchmarking. This is continued throughout the development and implementation periods to provide information to the steering committee. There is nothing like reliable data to motivate quality improvement projects. An outcome of interest to all stakeholders should be selected. Length of stay and readmissions are convenient intra-institutional markers that correlate with organ recovery, complications, and cost and are easy to collect. Ideally, adherence to process measures, occurrence of common complications (ileus, SSI, nausea/vomiting, UTI), time to be medically fit for discharge, and patient-reported outcomes would also be collected [26].

Once the ERP elements are decided, specific ERP material must also be created. This includes procedure-specific patient education material (see Fig. 26.​3), pathway order sets, and dedicated nursing documentation (Fig. 27.2a, b). In particular, efforts should be made to create clear patient education material. It is important that these educational materials be written in a manner that can be easily understood by patients. At our institution, booklets were created for each ERP, in consultation with the hospital Patient Education Office, and were written to target a low health literacy level [27]. These booklets are generously illustrated, and contained procedure descriptions, preoperative optimization to be undertaken by the patient, detailed day-by-day expectations and goals, and post-discharge instructions.

Once the development of a suitable pathway is complete, the implementation phase involves educating the involved stakeholders of the new ERP management strategies, including preoperative clinic, operating room, post-anaesthesia care unit, and ward nurses, as well as allied health professionals. These education efforts should include a brief introduction to the key principles of ERP, and outline the entire perioperative pathway, rather than just specific portions. Significant changes should be highlighted and evidence for the change provided. Each stakeholder group should be made aware of their contributions to the ERP, and how it affects the total care of the patient. All of the relevant documents must also be at hand, so that frontline staff may familiarize themselves with the new changes. There should be no surprises once the ERP is formally introduced. It is important to also include other personnel that do not provide direct patient care, but may affect patient care indirectly. For example, the admitting personnel had to be educated to no longer inform patients to begin nil per os as of midnight before their surgery, as this was contradictory to the ERP education material and had been causing confusion amongst patients. These education efforts should be spearheaded by the steering group, in particular the clinical leaders in each specialty and the ERP coordinator. Having institutional data available to highlight areas for improvement is invaluable, as people tend to have an inaccurate picture of how current care differs from best practice or outcomes.

A clear timeline for the implementation process should also be laid out, including a firm launch date for which the ERP is put into practice. We recommend this approach over piecemeal integration of several pathway elements at a time, as this may engender frustration amongst users over a perceived lack of improved outcomes [28]. Process measures and outcome data should be collected for a cohort of patients prior to formal ERP introduction.