Enhanced recovery pathways have worked well in individual trusts, but an innovative implementation approach is delivering results across an entire London sector, write Caroline Grace and colleagues.

Enhanced recovery pathways provide optimal care for patients having surgery. Patient centred pathways prioritise thorough preparation and high quality peri-operative care and post-operative rehabilitation, to help patients recover quicker. Fitter patients can be discharged sooner and resume normal life faster, saving resources.

Enhanced recovery is proven to deliver in individual trust specialties. However, this programme aims to optimise performance across north central London, where each one day reduction in mean length of stay would release more than £500,000 of capacity annually, assuming more than 2,000 orthopaedic and colorectal operations and a bed-day cost of £250.

The National Enhanced Recovery Partnership Programme supports strategic health authorities in implementing enhanced recovery and NHS London has encouraged implementation by a regional CQUIN tariff enhancement in 2009-10. But implementation has remained variable.

North central London mirrored the national situation with variable adoption in single specialties and little systematic implementation. This programme explored whether facilitated implementation could deliver rapid substantial improvement across a health sector.

The project aimed to ensure implementation in at least two surgical specialties, preferably orthopaedics and colorectal surgery, in each of the six acute trusts in the sector.

The six participating hospitals are Whittington Hospital Trust, Barnet and Chase Farm Hospital Trust, Royal National Orthopaedic Hospital Trust, Royal Free Hampstead Trust, North Middlesex University Hospital Trust and University College London Hospitals Foundation Trust.

Declaration of intent

Each participating project team signed an initial declaration of intent, which included:

  • Business case template agreeing commitment of trust and programme resources and expected return on investment
  • High level, realistic implementation plan to secure expectations of challenging deployment timescales.
  • Trust participation is conditional on initial demonstration of executive commitment

Lifting barriers

An ambitious time span of just one year was adopted to scope, engage, implement and evaluate. The programme was supported by an NHS London regional innovation fund award.

Attempts to implement change in the health service have included a number of tactics, including pamphlets, toolkits, website promotion, and collaborative workshops. Despite generating enthusiasm and debate these campaigns often fail to translate into substantial change in practice.

Implementation of innovation within NHS organisations can hit frustrating barriers, including weak change management capacity, departments budgeting in silos and non-committal executive sponsorship. 

The premise behind the north central London enhanced recovery programme was a novel three pronged approach to spread and adoption; namely to “sell” a well evidenced transferable product; aggressively drive delivery with change and clinical experts; and only start the project with a trust once robust executive sponsorship had been demonstrated.

The programme recruited a small, focused organising group of senior representatives from core stakeholders, including clinical leads, sector commissioners and the local cancer network. This group provided united leadership and ensured alignment between relevant agendas.

Stage 1: up front investment to secure buy-in and commitment of participating organisations

A launch event targeted communication at trust and primary care trust chief executive forums to promote the programme and flag the opportunity for trusts.

In parallel, programme and clinical leads worked with the trusts to produce a declaration of intent. This involved assessment of the trusts’ readiness to deliver, with acceptance in the programme dependent on signed off dedicated clinical and project facilitator resources.

Stage 2: aggressively driven delivery

The programme team had experience in implementation of change and clinical expertise.

We focused on securing change management capacity, with high calibre improvement experts within the trusts supported by external mentors to ambitiously drive implementation across multiple specialties within each hospital.

Although there was flexibility in how each trust established this capacity, commitment to appoint these internally funded lead roles was secured as part of the demonstration of intent.

A multidisciplinary team was established in each hospital to drive forward the project.

As a programme, the six teams formed a collaborative community of practice that was directed using the following methods:

Quarterly programme education events. Initially these focused on presenting examples of successful implementation, along with support and ideas, to ensure teams returned to their trusts with all the products they needed to facilitate prompt local implementation;

Mentoring opportunities and on-site learning from reference sites in London, to demonstrate enhanced recovery in operation;

Explicit direction and homework requests from the programme’s leadership so that trust teams knew what was required of them to prove delivery.

Stage 3: showcasing and rewarding

As the programme progressed, the sector-wide learning events focused less on external expertise and instead served as a platform for each trust team to present and showcase their achievements and also ask the community to offer solutions for issues they were facing.

This generated an environment of support and recognition for the efforts of the participating teams, along with a healthy element of competition.

Another important factor was the commitment of the sector commissioners, who mandated active participation in the project as essential to meet the enhanced recovery CQUIN requirements in the sector.

How the London implementation approach is different

  • Expert clinical and managerial leadership to drive change
  • Focus on spread and adoption of a tangible, proven product
  • Teams committed to start implementing change within weeks of project initiation
  • Mandatory data collection at the centre of the implementation process

Rapid results

All six participating trusts stayed fully engaged and delivered their projects in line with the expected timescales of the programme, achieving adoption across multiple specialties.

After six months of implementation the participating trusts have already reported significant improvements in outcomes.

The mean length of stay in 471 patients undergoing colorectal and orthopaedic operation between August 2010 and mid-February 2011, as reported by the trusts on the National Enhanced Recovery database, fell dramatically (see graph, previous page) and mean length of stay overall fell by five days.

These preliminary results are highly encouraging.

Patient experience:

“As a patient, the enhanced recovery programme is an excellent tool that helps make you aware of the technicalities of surgery and aftercare processes involved, but more importantly your role within it. It demonstrates how important it is to be a proactive and knowledgeable patient which ultimately enables you to recover faster.”

There are more than 2,000 colorectal and orthopaedic operations in north central London annually so each one day reduction in mean length of stay would release more than £500,000 of capacity annually, assuming £250 per bed day.

The programme requires each trust to measure patient experience and these reports are also strongly supportive; indeed one trust reported 100 per cent of patients would recommend the service to a friend.

With expert clinical and managerial support, commissioners can purchase and providers can rapidly implement high quality pathways, which can improve outcomes and release capacity across a health sector.

Lessons from the programme are informing London’s 2010-11 enhanced recovery CQUIN. Ultimately, the same principles could apply equally to other pathways.

Key success factors

  • Expert clinical and managerial facilitation
  • Engagement of senior representatives of key stakeholders
  • Executive sponsorship of participating teams secured up front
  • Aligning financial and clinical objectives
  • Examples of good practice and advice on implementation strategies
  • Emphasis on common sense with no overkill on particular improvement methodologies
  • Participants treated as adults, with devolved responsibility to plan local implementation
  • Progress driven by agreeing goals and deadlines with close monitoring of delivery
  • Mandatory data collection central to driving improvement
  • Regular showcasing by participating teams invaluable to support peer learning

The authors would like to acknowledge the project teams at the six participating hospitals;Nicki McNaney and Wendy Lewis of the National Enhanced Recovery Partnership Programme; and Siobhan Mythen, north central London enhanced recovery project coordinator.

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