Shorter hospital stays after surgery lead to fewer complications and better outcomes. Hospitals are places for people who are sick; home is where people can recover on their own turf, often with the care and comfort of loved ones, and get back to their daily lives as quickly as possible.
Building a faster pathway home requires every member of the health care team to work together with more efficient protocols and new approaches to care. Toward that end, Mayo Clinic’s colorectal surgery practice created an Enhanced Recovery Pathway (ERP) a decade ago, which achieved our goals while improving patient satisfaction and reducing costs. These process improvements then gained acceptance in many of Mayo Clinic’s other surgical departments. More recently, seven independent medical centers that are members of the Mayo Clinic Care Network also have adopted the ERP.
In this article, I will share how we got the buy-in from surgical clinicians at both Mayo Clinic and the independent medical centers.
ERP involves improved pain management practices, limitations on catheter use, early patient mobilization, advancing diet and patient education, and more. By streamlining the process and building in accountability, it has helped patients get home faster and has produced better outcomes. For example, ERP has enabled our colorectal surgery practice to cut in half the time patients spend in the hospital, with even more dramatic reductions in length of stay for patients with complex medical conditions.
This is also true in other surgical areas at Mayo Clinic where ERP has been implemented and at the Mayo Clinic Care Network medical centers.
Knocking Down the Silos
As chair of colorectal surgery at Mayo Clinic, I saw firsthand the need to make our post-surgery processes more efficient. Our practice is unusual in that we have 10 colorectal surgeons, more than most other U.S. medical centers, and as many as 12 people involved in the care of each hospital patient. Each of these care providers has his or her own view of what’s good and appropriate for each patient. If one person doesn’t know the details of the complete care plan and know them cold, the patient isn’t going to get the most effective care to speed recovery.
We started with a direction, not a destination, in planning to streamline the recovery process. In 2009, after months of research and preparation, we initiated ERP in my practice and that of a colleague in colorectal surgery. ERP calls for several pre-operative, intraoperative, and post-operative elements focusing on fluid, diet, and pain management.
We knew it would take a few early adopters who were slightly more risk-tolerant to embrace the changes. Health care tends to be very siloed, and this is true in the surgical culture at many institutions. We needed to knock those silos down. At first we focused on minimally invasive surgeries and personalized ERP elements based on the feedback of the two surgeons and the enlisted champions in Anesthesia, Pharmacy and Nursing. For example, in our colorectal surgical department, we have two floors of hospital beds, with 25 patients and about 50 nurses per floor. We identified the influencers and believers in change (five to 10 nurses) to lead the way. About a dozen pharmacists cover the two floors; we worked with two to three of them to champion changes in medication management.
We closely monitored results for length of stay in the hospital, as well as complications such as surgical-site infections, bleeding, abscesses, and readmissions, to name a few. We were reassured that we were on the right track, with results as well as compliance with ERP protocols. After six months, we began to implement ERP with all 10 surgeons. Again, we monitored the outcomes and refined processes to ensure adoption and success with the entire practice.
ERP became the standard of care for the entire colorectal practice in 2011. The surgeons in our practice handle up to 2,800 elective inpatient cases per year, about 40% of which involve cancer, so the plan has impacted thousands of patients in the past eight years, improving patient outcomes and satisfaction while reducing costs.
Since that time, the ERP principles have been incorporated into virtually every aspect of surgery and perioperative anesthetic care at Mayo Clinic. This has occurred naturally by observation, word of mouth, and individuals championing what we’re doing, as well as by diffusion through our department practice committees, electronic-health-record order sets, and a subcommittee (which I chair) that supports the redesign of practices throughout Mayo Clinic.
Collaboration Across Institutional Boundaries
The lessons learned in implementing this process change were put to use in 2015 and 2016, when we expanded the use of the Enhanced Recovery Pathway to interested members of the Mayo Clinic Care Network, a group of independent health care systems that pay an annual fee to access Mayo Clinic knowledge and resources.
Implementing the pathway within Mayo’s own colorectal division was one thing; to change well-established processes at other institutions was quite another. It took a different type of bridge building and collaboration, and significant buy-in and trust from the seven institutions that participated. They were of various sizes and from all parts of the country – from Pensacola, Florida, to Coeur d’Alene, Idaho. We used the “breakthrough” framework that was developed in the 1990s by the Institute for Healthcare Improvement and has been used in many areas of medical practice.
Teamwork across the multidisciplinary care teams was crucial. It was fairly simple to agree on metrics for assessing progress, for example, but data analytics and informatics was challenging since the institutions didn’t have common electronic medical records systems. Other barriers to be overcome, institutionally or within the care teams, included implementation of electronic new order sets and anesthesia protocols; new nursing monitoring and procedural protocols; and rigorous staff training.
Key steps in the nine-month process included a two-day meeting at Mayo Clinic in Rochester of the institutional teams (surgery, anesthesiology, nursing, and administrative) that were involved in making these changes happen. The meeting in September 2015 was to share clinical knowledge and best practices; it also attempted to build a relationship of trust to enable future workshops and communication to lead groups to a successful goal.
From September 2015 to March 2016, we conducted monthly 30-minute touch-point calls with each member institution, to talk about specific topical concerns with process, leadership and quality issues.
The ability of each institution to implement ERP exactly as we designed it varied, and there was no requirement that they do so. Having a well-defined standard was more important than having the same standard. Despite variations, all the teams were able to reduce the length of stay in hospital, which was the main clinical goal when the transition was completed in March 2016. Across all Mayo Clinic Care Network sites, the length of hospital stay was reduced by 33.9%. At one of the sites, length of stay was reduced by 48.7%. That same institution had the lowest surgical readmission rate in its home state after implementation.
As in most continuous improvement processes, there were benefits and lessons learned that we could not have anticipated. These included culture change, process issues, IT needs, and management-measurement challenges, as well as opportunities to innovate and adapt the ERP to local conditions. The Billings Clinic in Billings, Montana, for example, piloted a nurse navigator position during this program to provide patients with information and consistent support from pre-op through post-op. The teams were encouraged to share these local innovations as we went through the process, so we could learn from each other and celebrate success.
Peer-to-peer learning was especially important, as the Mayo Clinic Care Network sites had more in common with each other than with Mayo Clinic. A nurse in Pensacola, Florida, could share experiences that were more relevant to team members in Coeur d’Alene than may be true of the experiences at a much larger hospital such as Mayo Clinic Hospital in Rochester. Many of the teams quickly used lessons learned from the ERP process in other specialties at their medical centers, such as opioid reduction.
By the end of the process, it was clear that the learning had been multidirectional. The teams at the Mayo Clinic Care Network sites learned from Mayo Clinic but gained important insights from each other as well, and this also was certainly true of Mayo Clinic staff.
The results have been real, measurable, and replicated in other surgical areas and institutions. The ways in which we achieved this may offer a pathway for others to take.