Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives

Abstract

Background: Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system. Methods: Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple's, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12. Results: Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines. Conclusions: Health care leaders have unique perspectives and approaches to support spread, scale and sustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.

Barriers to implementation of enhanced recovery after surgery (ERAS) by a multidisciplinary team in China: a multicentre qualitative study

“…Prominent themes were further explored in context through in-depth reading and refined until saturation was reached. 38 To ensure reliability, the research team met regularly to review the coded data, verify its relevance to main themes, discuss the interpretations and agree on any new theme which were required. Data collection ceased when no new codes or themes were identified, which meant data saturation.…”

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada

“…7 On the basis of this evidence, Alberta Health Services (AHS) expanded the scope of its ERAS program to multiple surgical pathways and hospital sites with continued engagement of leadership and health care practitioners. 8 Alberta Health Services is a publicly funded provincial health care system where approximately 288 000 operations are performed annually across 55 hospital sites. 9 Since the launch of ERAS for colorectal surgery in AHS in 2013, 2 ERAS practices have expanded across surgical disciplines and hospital sites throughout the province.…”

Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey

“…This strategy evolution started in 2017 in APHP will hopefully offer improvements for ERP in the future. This bottom-up approach will benefit from institutional support of APHP through support for ERP nurse appointment which appear determinant for implementation and sustainability of ERP (Gramlich et al 2020 ).…”