To participate in the ERAS^® Implementation Program (EIP), each participating unit is asked to form a multiprofessional and multidisciplinary team. They are also required to have an administrator sign an agreement to confirm that the team will have sufficient time away from their other duties to perform the tasks involved in the ERAS^® Implementation Program (see below).

Forming a team consisting of all the professionals involved in the entire patient journey is the key to successful implementation. That means that a surgeon, an anesthesiologist, PACU personnel and, importantly, nurses from each of the units involved in perioperative care form the basis for the local ERAS team. In addition, many units have very good dietitians and/or physiotherapists and they can also play an important part in an ERAS team.

The team will select a team leader, generally a physician, who will assume the overall medical responsibility for the group and the implementation process. They also select an ERAS coordinator, usually a nurse, who will be available about half time or longer, depending on the number of patients involved. The ERAS coordinator is reasonable for adapting provided material to produce local order sets, care paths, memos, slides, posters, and other information to support implementation. During the EIP, teams receive templates of these documents that conform with the ERAS^® Society guidelines and the Interactive Audit System (see below). The ERAS coordinator also prepares presentations to educate and provide information to the different units involved. Finally, but very importantly, the ERAS coordinator will be tasked with collecting data for the Interactive Audit that is used as part of the implementation process (see below). The team leader and the ERAS coordinator will also be the main contact persons with the EIP trainers and coaches.

The ERAS team should make time available for weekly or biweekly meetings during the process of implementation. They will also require time to ensure that everyone involved in the care of the patient is fully informed about the changes that will be made with the introduction of the ERAS protocol. Listening to the various professionals during this information process is important to understanding local barriers (see Chap. 18, “Overcoming Barriers to the implementation of an ERAS program”). They will also establish a system to provide continuous feedback to all units involved in the care process. For this to happen, it is essential that the leadership of the surgical and anesthesia/intensive care departments agree to make this program a priority. In order to resource the team appropriately, leadership should be informed of the evidence suggesting the significant clinical and economic benefits achieved with proper implementation of ERAS.

As reviewed in the first section of this manual, each of the interventions included in the ERAS protocols is supported by evidence. They are treatments in use worldwide and there is ample data supporting the safety and benefits of the approach. The “magic” of ERAS is to have best practices being used in as many patients as possible. That said, compliance with each element in an ERAS protocol does not need be 100 % to achieve results. There will be exceptions to the use of some of the elements for certain patients. But then again, many units reporting the use of ERAS actually comply with only around 50 % of the interventions when they start out, and an increase in overall adherence even to the 70 % range is associated with improved outcomes (faster recovery and fewer complications) [2] (Fig. 18.2).

The ERAS^® Implementation Program (EIP) brings together several units from different hospitals to a series of four workshops over a period of 8–10 months (Fig. 18.3). During these workshops a very standardized process of implementation is used, developed and tailored for ERAS from the Breakthrough methodology described by the Institute of Health Improvement [3]. A medical expert in ERAS and a Change management coach trained in ERAS Implementation run the program. They are both selected by the ERAS^® Society and have their own personal experience in ERAS implementation and ERAS care. The hospitals get the basic information on what ERAS care is about, the outline of the implementation program, how they are to work, and how to use Interactive Audit to have the team continuously review their practice and their outcomes.

Between workshops the teams have tailored coaching from the Trainers helping them resolve their specific issues. When coming back to work shops each team reports about their progress, problems and how they are tackling them, and the results; they also make their plans for the next work period.

From the clinical perspective, the evidence-based ERAS guidelines need to be translated into clinical routine of the respective hospitals; the considerable change from traditional practice is best achieved using institutional protocols and integrated clinical care pathways (Fig. 18.4). The teams are advised to spend ample time preparing for the changes by reviewing their actual care as captured by the Interactive Audit System. The work period between the first and second workshop is about 2 months during which time the teams gather the baseline data on their practice. The data collected during the first work period will be reviewed during Session 2. From then on the entire team will know where their practice needs to change based on real data.