October 17, 2019

After colorectal surgeons at Mayo Clinic successfully piloted a program to get patients home more quickly, the clinic expanded the practice to other Mayo surgical departments and eventually to seven independent medical centers throughout the country, David Larson, Mayo's chair of colon and rectal surgery, writes for Harvard Business Review.

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How Mayo's protocol works

In 2009, Mayo Clinic's colorectal surgery practice developed a clinical protocol, called Enhanced Recovery Pathway (ERP), to reduce the amount of time patients have to spend in the hospital, away from home. The protocol "involves improved pain management practices, limitations on catheter use, early patient mobilization, advancing diet and patient education, and more," Larson, who helped lead the project, explains.

A handful of surgeons in the colorectal team piloted the protocol and found that the process boosted patient satisfaction, reduced costs, and improved outcomes. For instance, the colorectal team found ERP reduced colorectal surgery patients' length of stay by about 50%, according to Larson, and patients with more complex medical conditions saw an even greater reduction in length of stay.

The practice eventually caught on with other surgical departments at Mayo, which have seen similar success, Larson notes.

How Mayo colorectal surgeons implemented ERP

To implement and share ERP successfully, its proponents in the colorectal surgery practice knew they "needed to knock down" the silos common in health care, and in surgical culture in particular, Larson writes. So according to Larson, the team at the onset "focused on minimally invasive surgeries and personalized ERP elements based on the feedback of the two [pilot program] surgeons"—Larson and one of his colleagues—as well as feedback from "the enlisted champions in Anesthesia, Pharmacy and Nursing," including five to 10 nurses and two or three pharmacists identified as "influencers and believers in change."  

The team "closely monitored results for length of stay in the hospital" along with complications, such as abscesses, bleeding, surgical site infections, readmissions, and others, according to Larson. The results "reassured" the team that they "were on the right track," Larson writes, and six months later, all 10 surgeons in the colorectal department adopted the ERP protocol.  After continued monitoring, the protocolbecame standard of care in 2011 for the colorectal practice, Larson writes—and in the last eight years, the program "has impacted thousands of patients … improving patient outcomes and satisfaction while reducing costs."

Since 2011, ERP has spread throughout Mayo, thanks to "observation, word of mouth, and individuals championing [the process], as well as by diffusion through our department practice committees, [EHR] order sets, and a subcommittee" that Larson chairs "that supports the redesign of practices throughout Mayo Clinic," he writes.

Implementing ERP across the Mayo network

According to Larson, Mayo in 2015 and 2016 put to use the "lessons learned in implementing this process change" to spread ERP to its Mayo Clinic Care Network, a group of independent health systems that pay to share Mayo's knowledge and assets.

However, while "[i]mplementing the pathway within Mayo's own colorectal division was one thing; to change well-established processes at other institutions was quite another," Larson notes. It took significantly more buy-in and trust from the seven independent health care systems that opted to participate in the project.

"Teamwork across the multidisciplinary care teams was crucial," Larson notes. While "[i]t was fairly simple to agree on metrics for assessing progress, … data analytics and informatics was challenging since the institutions didn't have common [EHR] systems," Larson writes.

There were a few "[k]ey steps" during the implementation process, which lasted nine months. One was a two-day meeting in 2015 at Mayo's Rochester, Minnesota, campus, where representatives from the Care Network sites "met the institutional teams (surgery, anesthesiology, nursing, and administrative) that were involved in making these changes happen," Larson writes. The meeting allowed for the sharing of clinical knowledge and best practices as well as relationship and trust building, according to Larson.

In addition, for each month between September 2015 and March 2016, Laron's team had a 30-minute "touch-point" call with each institution to discuss specific concerns. And while "[t]he ability of each institution to implement ERP exactly as we designed it varied," Larson writes, "[h]aving a well-defined standard was more important than having the same standard." The transition wrapped up in March 2016.

In the end, all of the networks successfully reduced length of stay, according to Larson. Across the Mayo Clinic Care Network sites, length of stay fell by 33.9%. At one site, it fell by 48.7%, and that facility went on to have the lowest rate of surgical readmission in its home state, Larson notes (Larson, Harvard Business Review, 10/15).

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