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December 19, 2024
In the past two decades, Enhanced Recovery After Surgery (ERAS) has increasingly gained traction across North America. It is being recognized as a strategic tool that, with the right change management strategies, can improve outcomes, costs, and patient safety, while also keeping staff satisfaction high.
ERAS, where providers integrate evidence-based interventions into a coordinated, multidisciplinary care plan across the entire perioperative pathway, is leveraged by healthcare organizations to achieve early recovery for patients undergoing surgery. ERAS programs have proved to be increasingly effective at streamlining care, accelerating recovery, and reducing length of stay, surgical complications, and cost per encounter across organizations in the United States.
Many clinical quality improvement projects start and end as pilot projects, and the same is true for ERAS. The success of an ERAS program is arguably highly dependent on having efficient protocols in place that are followed across the pathway. However, the actual implementation process is just as crucial and often riddled with challenges, including resistance to change, lack of resources, and difficulties in motivating key stakeholders.
Here’s a look at how to secure initial organizational buy-in for an ERAS program.
Identify which surgery line and why
So you see the evidence-based benefits of an ERAS program and are keen to launch an ERAS program. But where do you start? For many healthcare systems and hospitals that are running successful ERAS programs across multiple pathways, the first step was being strategic about picking a pathway that can demonstrate increased ROI quickly for the organization.
Finding a high-volume specialty to launch to essentially get an early win – and building momentum from there on – is key. According to a 2021 study, the most commonly reported surgical service lines for ERAS in the USA were colorectal (87%), gynecology (51%), orthopedic (49%), surgical oncology (39%), and urology (35%).
For Brigham & Women's Hospital, a 793-bed teaching affiliate of Harvard Medical School, success in their Colorectal ERAS pathway paved the way for other service lines. Dr. Kevin Elias, President of the ERAS USA Society and Gynecology ERAS Leader at Brigham & Women's Hospital recently shared, “When you're implementing for the first time, you want a group that's at a fair amount of volume so you can figure out what's working, what's not working. So doing an ERAS implementation for a program that does four cases a month is really not going to be very helpful. It's going to take too long.”
Dr. Heather McFarland, Vice Chair Operations and Director at Anesthesia Value Network, University Hospitals (UH) echoes these sentiments. They too started at Colorectal before launching ERAS programs in their Gynecology and Cardiac surgical lines. “We had been focused a little bit on high-reliability medicine and Colorectal already had a high-reliability medicine team,” said Dr. McFarland. “So we wanted to pick a line that we could have success in and then bring the two others along for that first tier. We tiered our service lines as we rolled them out.”
Secondly, it is efficient to opt for a specialty that is not only high volume and has a shorter turnaround but is also one where you can measure immediate and impactful outcomes. As Dr. Elias says, “Colorectal surgery has some inherent risk associated with it as far as infection and anastomotic leak. So, it was a good opportunity to work in a field where you can measure big differences in outcomes.”
Finally, when launching the first ERAS pathway, it is helpful to identify one that has the most literature and information on it. For instance, Dr. Elias stated that “It didn't take as much convincing for them [stakeholders] because a lot of the original literature description came out of the Colorectal field. So they were pretty well versed in it already. Whereas some of our other disciplines like say neurosurgery, this was very foreign to them. It was not on their map at their meetings at that time.”
Find your champions
The next step is finding the key champions and motivating senior leadership. An ideal process that many leading healthcare organizations have seen success in when getting organizational buy-in, has been through finding engaged clinical stakeholders as well as executive and administration sponsors.
When introducing quality improvement initiatives, the common thread that healthcare systems see is the need for champions – experts in their field across medical and surgical departments, nursing, allied health, operations, or administration – to lead those projects. And this is true for ERAS as well. Finding leaders that see the benefits of ERAS can help rally the launch, motivate management buy-in, and help expand the program to sustain that momentum.
For many, this entails a top-down approach. It’s having someone in senior leadership, be it from the surgical department or the clinical informatics team, who is enthused about ERAS and understands how it can help elevate both patient care as well as clinical and cost outcomes for the organization. For University Hospital, this was Dr. Peter J. Pronovost, Chief Quality & Clinical Transformation Officer, who was already invested in the benefits of ERAS and had a vision for the health system. Dr. McFarland partnered with Dr. Pronovost to bring the recommendation to all senior leadership programs. The clinical teams were then brought in, and going into 2020, UH had already set up our operations team of three physician co-leads, a colorectal surgeon, two critical care anesthesiologists, including Dr. McFarland, and a project manager. The team was able to develop the protocols for ERAS and adapt those to their system.
For others, it could be a more bottom-up approach, wherein frontline clinicians who see the value proposition are engaged early on – champions from individual service lines that are passionate about implementing it in their specialties. As Dr. Elias mentions, for Brigham, it was “a couple of service lines that really decided to implement this in their specialties and then come to leadership and say, ‘Hey, look at what big differences we've made here. We can help our colleagues do better’.”
Secure executive buy-in
The value proposition to senior executives and management is often very different from that to frontline clinicians. The key is often being strategic about how to align the value of ERAS with the ongoing challenges within the industry at the time, such as capacity, resources, clinical outcomes, or staff shortages.
Healthcare organizations that have garnered high buy-in for ERAS, have seen how clinical evidence of success, improved patient outcomes that they get audited for (eg: reduced length of stay, lower readmission rates, and fewer complications), and cost efficiencies associated with the program go a long way in motivating senior leadership.
At UH, surgical lines with ERAS saw a 50% decrease in the length of stay. As Dr. McFarland says, “In this day and age, when you're dealing with a hospital capacity that is probably reduced secondary to a nursing shortage, you are able to move those patients through more quickly, …which is very clinician driven and I think satisfying to them. But then when you talk about decreasing the length of stay by 50%, you're almost increasing your capacity by 50% because that can be filled again. Those two things have caught our senior leadership's attention.”
At Brigham, Dr. Elias’ team was trying to move the needle on fewer surgical site infections and fewer (readmissions. They also saw a huge increase in their patient satisfaction scores, which motivated the leadership. “I think length of stay is more motivating for the individual clinicians because we like not having huge services on the inpatient side,” shared Dr. Elias. “But I think from the hospital's point of view, it's really the cost efficiency, the patient satisfaction, and avoiding some of those complications that we get audited on a lot.”
Finally, emerging patient care issues, and participating in being a solution to a public health crisis instead of necessarily contributing to it, is another key factor for executive leadership teams. For instance, the CDC recently reported over 100,000 deaths from overdose in the USA. At University Hospital, Dr. McFarland’s team had seen over a 50% reduction in discharge narcotics for their ERAS patients, which caught the leadership team’s attention as the need for narcotics monitoring and reduction continues to be a challenge.
Communicate the plan
Provide additional information on the benefits and the processes of the ERAS program. The first ERAS guidelines for colorectal surgery, published in 2005, had 16 elements and since then, the ERAS Society has released 12 surgical subspecialty guidelines with up to 25 components. With the increasing complexity of ERAS protocols, it is essential to have the evidence and implementation plan ready to persuade both executive leadership and clinical teams.
The good news is that with the increasing uptake in ERAS programs across the United States, there is a lot of literature outlining the value of ERAS. In the face of rising healthcare costs, the true value of ERAS lies in its ability to improve outcomes, reduce complications, and decrease hospital length of stay, leading to a reduction in healthcare costs without taking away from patient experience and an efficient recovery journey. Several health economic studies have proven the cost reductions associated with successful ERAS implementation and technology to streamline ERAS workflows continue to rise as well.
For instance, Dr. McFarland mentions the numerous presentations they had to make for senior leadership talking about ERAS and the benefits, even though they had buy-in from their chief clinical informatics officer. “In the beginning, you don't necessarily have your ROI for your hospital, but there is enough information out there that you can show the benefits,” said Dr. McFarland. “A lot of that comes from Europe and shows the benefits that other organizations have had. And so presenting that information along with just really being in those meetings and talking about the benefits of ERAS to the patients” is key to having high executive buy-in.
And once the outcome and cost audit results come in, it is a clearer route to scaling. With the success that UH saw in its colorectal program, more service lines became interested in understanding how the ERAS program can be generalized across the hospital.
For Brigham, it was a similar trajectory. Once their Colorectal, Gynecologic Oncology, and Urology ERAS pathways showed a marked improvement in outcomes, the team received a lot of interest across the hospital and expanded to other surgical disciplines. Dr. Elias shares, “Now, we have 20 different ERAS service lines going at the hospital and for most of our specialties, it's considered the default plan of care. So you really have to opt somebody out of ERAS; otherwise assume that most patients are going to be on an ERAS pathway.”
In the last few years, there has been a huge shift towards providers either implementing ERAS for the first time or expanding across multiple pathways. Every healthcare system has its unique perspectives, goals, and resources, and a successful ERAS implementation requires motivated health professionals and leadership teams to be the catalyst, all driven by the foremost goal to improve outcomes and the quality of care.
As ERAS becomes the standard of care, digital tools to help further amplify the implementation, standardization, outcomes measurement, and patient experience are gaining ground. Patient engagement technology is a recommended component in some ERAS guidelines. A recent study published by UAB evaluating the impact of a patient engagement platform on postoperative outcomes among gynecologic oncology patients undergoing surgery on an enhanced recovery protocol (ERP) cited a 50% reduction in readmissions and 19% reduction in length of stay.
To hear more insights from Dr. Elias and Dr McFarland watch our on-demand webinar Best Practices for Deploying an Enhanced Recovery After Surgery Program. Or join us for an interactive discussion with ERAS leaders from WakeMed, Providence Anesthesiology Associates, and Baylor Scott & White Health focused on Leveling Up Your ERAS Program: How to Effectively Optimize and Scale Across Pathways.
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