Solicit Institutional Support

Institutional support from hospital administrators is a necessary step for success, as for senior level buy-in sets the tone for the culture change with ERP implementation, and demonstrates to all staff that the institution supports dedicating the time and resources that are required to implement and maintain these pathways. Institutional support for ERP is necessary to identify where support can be offered, such as in the provision of an ERP facilitator, purchasing decisions, reallocation of staff and support services, education sessions in relation to ERPs, and the development of strategies to improve multidisciplinary buy-in and participation [11]. A recent study of SAGES members reported the single most important roadblock to successful ERP implementation was the lack of support from the hospital administration [12]. Thus, the visible top-down support of the institution and administration is key to drive the awareness and implementation of an ERP. As you put an ERP into practice, the next step after reviewing the evidence and building a clinical case is to present this evidence to the institutional administration to ensure high-level support of the initiative.

Defining Leaders and Creation of the Multidisciplinary Team

With support of the administration, the next step is to build the multidisciplinary team . A successful ERP requires active collaboration and participation from the entire healthcare provider team, to ensure that all involved stakeholders feel accountable for the implementation and maintenance processes [13]. It is essential to define leaders and assemble a multidisciplinary team, identifying champions from all involved specialties that will take the lead in organizing, implementing, and maintaining their specialty’s respective roles in the ERP . The team begins with defining a local clinical champion, who recognizes its benefits. This individual then forms a working group of similar-minded individuals from all involved parties into a steering committee, which should be able to effectively disseminate the clinical and economic benefits of the ERP approach to their colleagues, implement, and monitor changes. This steering committee should consist of representatives from the involved specialties, as well as allied health professionals that are essential for patient care. This multidisciplinary team is recommended to include surgeons, anesthesiologists, internists, nursing representatives from the preoperative center, postanesthesia care unit, surgical ward, physiotherapists, pharmacists, and nutritionists that meet on a regular schedule. Each of these individuals represents an essential component in the patient’s perioperative journey. The role of the surgeon and anesthesiologist is obvious; however other specialties and team members should also be recruited. For example, much of the preoperative testing and evaluation can be streamlined to minimize patient burden and resource utilization. In this regard, the inclusion of a representative of the medical specialty in charge of preoperative center is crucial. Operating room, perioperative care, and ward nursing representation are also critical, to ensure education, acceptance, and compliance with the ERP items during surgery and the patient’s stay in the postanesthesia recovery unit and inpatient floor. Similarly, allied health professionals that provide much of the care processes in the perioperative period should also be included. Pharmacists are an essential team member for agreement with medications included in the pathways and ease of future clinical trials. Nutrition, physical therapy, and wound ostomy care nurses are invaluable for input on managing high-risk and frail patients during the prehabilitation and postoperative periods. In most hospital systems, trainees are actively involved in patient care and may actually have the primary role of putting in orders and patient education. Thus, surgical resident involvement for ownership and buy-in of the care practices by the house staff is critical. For centers with the means or desire to publish, a librarian who can provide detailed literature searches on the best available evidence can also facilitate the dissemination process and pathway design. Once protocols have been developed and approved, the Information Technologies department can help streamline the implementation and audit processes, by integrating the pathways into the electronic medical record with automated order sets, back-end databases, and personalized queries on outcomes metrics. Finally, a dedicated ERP facilitator is one of the essential elements commonly overlooked. The facilitator is paramount for successful ERP implementation and subsequent audit processes [14, 15]. The ERP facilitator is mostly a nurse, nurse practitioner, or physician assistant (most common in the United States). Their responsibilities include reviewing the literature and evidence-based guidelines; shepherding the pathways through the approval process; maintaining momentum; creating patient education material; coordinating education sessions, meetings, and launch; and, finally, conducting postlaunch feedback and audit [15]. In cases where there is a dedicated colorectal unit, the facilitator could also be the nurse manager of the dedicated unit, helping to assure training and compliance with postoperative care principles. The ERP coordinator is a vital member of the team who is responsible for overseeing each of these key steps and coordinating among specialties.

Reviewing Current Data

Once the team is created, it is important to provide clear goals for your ERP. The first step in this process is to review specific institutional practice patterns and outcomes. Determine what the current outcome and process measure data are at your institution. Process measures cover what the institution does to maintain or improve care; these measures typically reflect generally accepted recommendations for clinical practice . Examples include use of bowel prep, blood sugar control before surgery, and the delivery of timely prophylactic antibiotics to reduce surgical site infection. Outcome measures reflect the impact of interventions on the patient’s care and include metrics such as hospital length of stay, readmissions, and common complications. From these data, develop a specific needs assessment for change and initial goals for the ERP, such as reducing the rate of surgical site infections, reducing length of stay, or reducing opioid use. Provide the group with your institution’s current processes and outcomes, as well as the same metrics for other hospitals and national benchmarks to emphasize the need and help prove the need for the change. These are basics of patient improvement , financial benefits, and clinical outcomes , to give the team a sense of urgency and need to implement a protocol. Without these data, there may be resistance to change from healthcare providers that do not see any advantages of the ERP approach over their current practice or fear the process change will be cumbersome and expensive [12].

Creating an Education Program

With the current state of your institution and ERP goals defined, the next step involves education of these providers on current best practices and evidence-based recommendations and their potential improvements in clinical and financial outcomes. It is imperative to provide education for all staff at the appropriate levels, as well as to create a sense of urgency to drive change initiatives. This approach has been shown to be effective in a business setting, as well as in healthcare [11, 13]. Literature on the basic principles and successful outcomes of ERP can be sent for the team to review as pre-learning, prior to meeting in person. Suggested landmark background papers are seen in Box 7.1. Next, targeted education specific to each team member’s contribution is essential for the team to understand their role and essential contribution to the overall success of an ERP. Ideas for education include presenting the initiative at grand rounds for each department involved and trainees, staff meetings, designated education sessions, and ward “huddles” or sign-out sessions and creating handouts for the staff with the protocol and their main role highlighted. For the nursing and allied health staff, assure presentations occur at multiple periods to include staff that work on evening or weekend shifts. With education, acceptance of the culture change will come, followed by willing participation and then finally excitement for the new standard and identification of ERP champions. It is especially important to educate the primary caretakers, including nursing and other allied health professionals in the preoperative clinic, postanesthesia care unit, and postoperative surgical ward, as ERPs may require significant departures from long-standing practices. Specific changes like removing patient-controlled analgesia (PCAs) after surgery and removing the practice of preoperative fasting starting at midnight the night before surgery require changes across multiple providers, preoperative clinic, admitting office, preanesthesia clinic and anesthesiologists, and postoperative and ward nursing. These changes can be facilitated with the support of the champions, who can effectively set goals, disseminate the evidence and benefits underlying the proposed changes, and support the implementation [1].

Overcoming Barriers Through Culture Change

ERPs may represent a significant culture change – departures from long-standing clinical practices – and there may be initial resistance to change, especially if awareness of the benefits of the ERP is poor [14]. Resistance to change has been identified as one of the major barriers to ERP implementation, yet it is one that can be slowly broken down through enhanced multidisciplinary collaboration and communication, as well as support from hospital administration [16, 17]. Other potential barriers that are often encountered include lack of manpower, knowledge, hospital resources, buy-in, poor communication among team members, and patient factors [12]. There may also be specialty-specific barriers and concerns. From the nursing point of view, a potential lack of manpower and time is often viewed as potential barriers to ERP implementation, as nurses may be resistant to interventions that increased their workload and thus compound staffing shortages [16]. However, studies have reported decreased or unchanged nursing workload as a result of pathway implementation [18]. Surgeons often cite personal preferences, feeling little room for improvement from their current outcomes, lack of time to learn new methods, inconsistency with covering teams and partners, and comfort with long-standing practices as barriers to implementation [12]. Anesthesiologists were concerned about the surgeons’ willingness to cede control of perioperative elements traditionally under their control. One common theme across specialties is that they often saw other specialties as potential barriers, such as surgeon concerns about ward nursing not adopting many of the perioperative interventions. Many of these potential barriers can be overcome through improved organizational culture, communication, and education on everyone’s role in reaching the common goal of improved patient recovery. Another common barrier to adoption is the perceived additional costs and resources that these pathways require [16]. A review of the economic data (described in more detail below) will show that there are important cost savings associated with these pathways, and any initial resource investments can be recovered by the clinical and economic benefits [19, 20]. With the common barriers and obstacles to success identified, the steering committee can proactively develop action plans to overcome them and adjust the plans during regular meetings to address new issues that arise.

Overcoming Barriers by Building the Business Case for Enhanced Value with ERPs

One of the oft-stated barriers to ERP adoption is the perception that significant time, money, and resources are required. While certainly some investments in time and healthcare resources are necessary, especially when it comes to a dedicated ERP facilitator, these overall costs are often more than recovered based from the overall cost savings associated with ERPs. It is also important to frame the benefits of ERP through the “value” perspective. Value in healthcare is defined as the outcomes achieved per dollar spent [21]. Value is always defined around the customer, which is the surgical patient. Value depends on results, and it is important to realize that cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false “savings” and potentially ineffective care and poor outcomes. Conversely, when value improves, patients, payers, providers, and suppliers all benefit, and the economic sustainability of the healthcare system increases [21]. Improving the quality and cost-effectiveness of healthcare requires that we decrease or eliminate care that provides no benefit or offer interventions that provide good value for their cost [22]. ERPs eliminate surgical practices that are outdated, have no evidence-based benefit, and may be harmful – such as perioperative starvation and prolonged postoperative bedrest – and replace them with multiple evidence-based interventions within a single perioperative strategy that may reduce waste and variability and improve outcomes. There is a cost to set up an ERP, with much of the expense to cover salary of the ERP coordinator. However, these costs can be spread across a large number of patients, especially as ERP principles can be easily applied across different procedure groups, thus resulting in a negligible per patient cost. In addition, even including all input and maintenance costs, there is an overall cost benefit for the savings resulting from the accelerated recovery and use of resources during the hospital stay; these saving are furthered by the reduction of postdischarge healthcare resources, complications, and readmissions with ERP. Several studies have proven this overall cost benefit. In a cost-effectiveness analysis comparing ERP with conventional care in colorectal surgery, Lee and colleagues found the yearly cost of the ERP was $108,770 (2103 CAD); this cost was spread across multiple patients and specialties managed by ERPs, resulting in a mean overall cost of the multidisciplinary program to approximately $153 (2013 CAD) per patient [20] (Table 7.3). The authors found no shift in the burden of care to the outpatient setting, either resulting an overall significantly lower societal costs (productivity losses and caregiver burden) or total cost savings with ERP of $2985 ($373–$5753) per patient [20]. The available economic data generally support the cost-effectiveness of ERP, with lower total and direct costs [23–29]. At one institution, there was a per patient reduction of $7129 in direct costs, corresponding to a cost savings of $777,061 in the 6-month study period the ERP group [26]. The cost-effectiveness was generalizable to all patient populations, with the cost benefit for ERP expected to generate cost savings in at least 85% of unadjusted and 82% of adjusted cost samples [27]. Another study estimated that the implementation of ERP across an entire provincial hospital network in Alberta, Canada, reported that an upfront investment of $528,459 CAN over 2 years was required [30]. The “break-even point” – where the cost savings would be greater than the implementation costs – was estimated at 93 to 236 cancer resections or 38 to 80 noncancer resections. Based on these data, it was further estimated that every $1 invested would result in $3.8 (range 2.4–5.1) in return [31]. Data from an academic US center reported similar results (Table 7.4) [19]. All of these studies support the notion of higher value care with ERP, with provision of better outcomes at the same cost, identical outcomes at the same cost, or better outcomes at lower costs.

Table 7.3

Breakdown of McGill University Health Centre Surgical Recovery (SuRe) workgroup program costs over a 1-year period

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