Abstract
BackgroundEnhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.MethodsA qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.ResultsFifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions’ belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.ConclusionsSuccessful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project’s organization-level visibility as important to ERAS uptake and sustainability.
Highlights
Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery [1, 2]
We did a follow-up series of lunch and learns as well as breakfasts where we presented the data to the different areas because it’s been about a year and a half or so that we’ve been involved in ERAS so we presented some of the data from the report that we got back. (Nurse)
Using the Normalization Process Theory (NPT), we have identified a number of implementation enablers: the belief of project champions in the value of the programme, the fit and cohesion of champions and champion teams, a bottom-up approach to stakeholder engagement targeting relationship building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice
Summary
Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery [1, 2]. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The strategy included: identification and support of local champions in surgery, nursing, and anaesthesia; development of a community of practice [29]; audit and feedback on clinical performance [30]; development of pre-printed orders, staff reminders, and patient education materials; facilitation of communication, networking, and sharing best practices among disciplines and centres; and, support from hospital administration. It included hiring a site coordinator for each participating hospital whose role was primarily clinical data collection. The full details of our knowledge translation and implementation strategy have been previously published [9]
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