Shorter hospital stays after surgery lead to fewer complications and better outcomes. But building a faster pathway home requires every member of the health care team to work together with more efficient protocols. That is why a decade ago Mayo Clinic’s colorectal surgery practice created an Enhanced Recovery Pathway, or ERP. The process improvements that were introduced as part of the initiative have increased patient satisfaction, have reduced costs and have since gained acceptance in many of Mayo Clinic’s other surgical departments.
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. As chair of colorectal surgery at Mayo Clinic, I was directly involved in the initiative.
In 2009, after months of research and preparation, a fellow surgeon in colorectal surgery and I initiated ERP in our practice, which counts a total of 10 surgeons. 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 our experience, as well as the feedback of a group of champions we enlisted from anesthesia, pharmacy and nursing. After six months, we began to implement ERP with all 10 surgeons in our 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 benefitted thousands of patients.
Over the past eight years, ERP principles have been incorporated into virtually every aspect of surgery and perioperative anesthetic care at Mayo Clinic. In 2015 and 2016, we expanded the use of ERP to 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. This required a different type of bridge-building and collaboration, and significant buy-in and trust from the seven participating institutions.
Teamwork across the multidisciplinary care teams was crucial. Barriers to overcome included implementation of electronic new order sets and anesthesia protocols; new nursing monitoring and procedural protocols; and rigorous staff training. Despite variations, all the teams were able to reduce the length of hospital stays, which was the main clinical goal. Across all Mayo Clinic Care Network sites, the length of hospital stay was reduced by 33.9%. At one site, length of stay was reduced by 48.7%.
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.
Copyright 2019 Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate.