When done successfully, implementing enhanced recovery pathways (ERPs) can be an effective way to improve surgical patients’ clinical outcomes and experience. Yet wide variations in how well ERPs are put into practice speak to the many challenges that often undermine implementation efforts. Although many factors have the potential to support ERP implementation, which factors distinguish higher performing hospitals has remained elusive.  

Led by a team from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, a recent study published in the Annals of Surgery draws on diverse perspectives from across the perioperative continuum to explore which of the growing list of factors known to affect ERP implementation are most strongly associated with successful efforts. To do so, researchers used an implementation science framework to systematically categorize barriers and facilitators described by 168 people working in eight U.S. hospitals, which were diverse regarding structural characteristics including geography, teaching status and size. The degree of implementation success was assessed with nine process measures. Researchers then leveraged the differences to highlight key implementation factors that distinguished higher-performing hospitals. 

Hospitals that had the greatest improvement during the study period were distinguished by practitioners’ largely positive knowledge and beliefs about ERPs as well as leadership support at both the executive and clinical levels in making ERP implementation an institutional priority. Higher-performing hospitals were also more likely to have robust data collection and reporting infrastructures to fuel improvement efforts as well as a dedicated ERAS coordinator who could consistently devote time and attention to implementing a large scale project.  

Across all hospitals, factors that consistently had a positive influence on implementation included robust planning, engagement, and information-sharing infrastructure and processes. In contrast, the most common barriers across hospitals included the complexity of the ERP (which is comprised of more than 20 evidence-based practices), physician resistance and challenges with carrying out the implementation process according to plan (particularly in regard to making changes in electronic health record systems).   

"By analyzing a large, rich qualitative data set through the lens of a widely used implementation science framework, our study helps to shed light on the 'black box' of how to effectively put enhanced recovery pathways into practice,” says Christina Yuan, Associate Research Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health and Principal Faculty with the Johns Hopkins Armstrong Institute for Patient Safety and Quality. “We hope that these findings can help direct future implementation efforts towards factors perceived to be most impactful.” 

Researchers emphasize the importance for future ERP implementation analysis to include a broader sample size of participating hospitals so findings may apply to less high-functioning sites, and to analyze data collected after the COVID-19 pandemic to understand both short-term and long-term effects on ERP implementation efforts. 

“Implementing ERPs is challenging work, and it’s clear that organizations need new methods and tools to help them,” says Professor in the Department of Anesthesiology and Critical Care Medicine and Principal Faculty with the Johns Hopkins Armstrong Institute for Patient Safety and Quality. “This research has helped identify specific practices that work and a direction for future research and development.” 

Other researchers who worked on this study are JunBo Wu, Tasnuva M. Liu, Benjamin Eidman, Deborah Hobson, Elizabeth C. Wick, and Michael A. Rosen. 

No authors declared conflicts of interest under Johns Hopkins University School of Medicine policies. 

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