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Yuan CT, Wu J, Cardell CP, Liu TM, Eidman B, Hobson D, Wick EC, Rosen MA. Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals. Ann Surg 2024; 279:789-795. [PMID: 38050723 DOI: 10.1097/sla.0000000000006165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success. BACKGROUND Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success. METHODS We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time. RESULTS Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives. CONCLUSION We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.
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Affiliation(s)
- Christina T Yuan
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - JunBo Wu
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chelsea P Cardell
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Tasnuva M Liu
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Eidman
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deborah Hobson
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael A Rosen
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Coeckelberghs E, Bislenghi G, Wolthuis A, Teunkens A, Dewinter G, Coppens S, Vanhaecht K, D'Hoore A. Quality indicators for ambulatory colectomy: literature search and expert consensus. Surg Endosc 2024; 38:1894-1901. [PMID: 38316661 PMCID: PMC10978605 DOI: 10.1007/s00464-023-10660-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Care for patients undergoing elective colectomy has become increasingly standardized using Enhanced Recovery Programs (ERP). ERP, encorporating minimally invasive surgery (MIS), decreased postoperative morbidity and length of stay (LOS). However, disruptive changes are needed to safely introduce colectomy in an ambulatory or same-day discharge (SDD) setting. Few research groups showed the feasibility of ambulatory colectomy. So far, no minimum standards for the quality of care of this procedure have been defined. This study aims to identify quality indicators (QIs) that assess the quality of care for ambulatory colectomy. METHODS A literature search was performed to identify recommendations for ambulatory colectomy. Based on that search, a set of QIs was identified and categorized into seven domains: preparation of the patient (pre-admission), anesthesia, surgery, in-hospital monitoring, home monitoring, feasibility, and clinical outcomes. This list was presented to a panel of international experts (surgeons and anesthesiologists) in a 1 round Delphi to assess the relevance of the proposed indicators. RESULTS Based on the literature search (2010-2021), 3841 results were screened on title and abstract for relevant information. Nine papers were withheld to identify the first set of QIs (n = 155). After excluding duplicates and outdated QIs, this longlist was narrowed down to 88 indicators. Afterward, consensus was reached in a 1 round Delphi on a final list of 32 QIs, aiming to be a comprehensive set to evaluate the quality of ambulatory colectomy care. CONCLUSION We propose a list of 32 QI to guide and evaluate the implementation of ambulatory colectomy.
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Affiliation(s)
- Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - An Teunkens
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Geertrui Dewinter
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Steve Coppens
- Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
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Wu J, Yuan CT, Moyal-Smith R, Wick EC, Rosen MA. Electronic health record-supported implementation of an evidence-based pathway for perioperative surgical care. J Am Med Inform Assoc 2024; 31:591-599. [PMID: 38078843 PMCID: PMC10873834 DOI: 10.1093/jamia/ocad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/30/2023] [Accepted: 11/25/2023] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Enhanced recovery pathways (ERPs) are evidence-based approaches to improving perioperative surgical care. However, the role of electronic health records (EHRs) in their implementation is unclear. We examine how EHRs facilitate or hinder ERP implementation. MATERIALS AND METHODS We conducted interviews with informaticians and clinicians from US hospitals participating in an ERP implementation collaborative. We used inductive thematic analysis to analyze transcripts and categorized hospitals into 3 groups based on process measure adherence. High performers exhibited a minimum 80% adherence to 6 of 9 metrics, high improvers demonstrated significantly better adherence over 12 months, and strivers included all others. We mapped interrelationships between themes using causal loop diagrams. RESULTS We interviewed 168 participants from 8 hospitals and found 3 thematic clusters: (1) "EHR difficulties" with the technology itself and contextual factors related to (2) "EHR enablers," and (3) "EHR barriers" in ERP implementation. Although all hospitals experienced issues, high performers and improvers successfully integrated ERPs into EHRs through a dedicated multidisciplinary team with informatics expertise. Strivers, while enacting some fixes, were unable to overcome individual resistance to EHR-supported ERPs. DISCUSSION AND CONCLUSION We add to the literature describing the limitations of EHRs' technological capabilities to facilitate clinical workflows. We illustrate how organizational strategies around engaging motivated clinical teams with informatics training and resources, especially with dedicated technical support, moderate the extent of EHRs' support to ERP implementation, causing downstream effects for hospitals to transform technological challenges into care-improving opportunities. Early and consistent involvement of informatics expertise with frontline EHR clinician users benefited the efficiency and effectiveness of ERP implementation and sustainability.
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Affiliation(s)
- JunBo Wu
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
| | - Christina T Yuan
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
| | - Rachel Moyal-Smith
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
- Ariadne Labs: A Joint Center of the Harvard School of Public Health and Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA 02215, United States
| | - Elizabeth C Wick
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143, United States
| | - Michael A Rosen
- Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States
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Lussiez A, Eton R, Anderson M, Valbuena V, Campbell D, Englesbe M, Howard R. Heterogeneity in Surgical Quality Improvement in Michigan. Ann Surg 2023; 277:612-618. [PMID: 35129495 DOI: 10.1097/sla.0000000000005282] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. SUMMARY BACKGROUND DATA Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. METHODS We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. RESULTS There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). CONCLUSIONS Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Ryan Eton
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Maia Anderson
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Valeria Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
| | - Darrell Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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Bamdad MC, Brown CS, Kamdar N, Weng W, Englesbe MJ, Lussiez A. Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy. J Am Coll Surg 2022; 234:300-309. [PMID: 35213493 PMCID: PMC10369366 DOI: 10.1097/xcs.0000000000000063] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy. STUDY DESIGN We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications. RESULTS A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication. CONCLUSIONS This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.
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Affiliation(s)
- Michaela C Bamdad
- From the Department of Surgery, University of Michigan, Ann Arbor, MI
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