OR Manager - February 2020 - 18

Enhanced Recovery After Surgery
SPECIAL SERIES
Enhanced Recovery After Surgery (ERAS) is a set of clinical
recommendations that, when combined, improve patient
outcomes while achieving cost savings. At Virginia Commonwealth
University Health System in Richmond, ERAS
implementation has presented an opportunity to review and
redesign the patient journey along the surgical continuum.
In this article, we will examine tools and tactics used to
examine a patient's surgical journey and identify opportunities
for improvement to ensure an efficient, standardized
workflow. This article is the fifth in a series that began with
the October 2019 issue of OR Manager.
Develop standard work for successful ERAS implementation
t Virginia Commonwealth University
(VCU) Health System
in Richmond, implementation
of Enhanced Recovery After Surgery
(ERAS) incorporates principles of Lean
thinking, a management methodology
that emphasizes " ...maximize[ing] customer
value while minimizing waste.
Simply, lean means creating more
value for customers with fewer resources, "
according to the Lean Enterprise
Institute.1
A
Several healthcare organizations
have used Lean methodologies to
streamline workflows, manage inventory,
or gain other efficiencies in the
perioperative environment. Lean keeps
the customer, ie, the patient, at the
center of process analysis, design,
and improvement. Lean implementation
has resulted in cost savings,
improved efficiencies, and enhanced
space utilization.2
To develop an end-to-end surgical
journey focused on adding value to
the patient, VCU Health formed a project
team with representatives from
all parts of the surgical pathway, including
schedulers, anesthesiologists,
pharmacists, therapists, surgeons,
nurses, and administrators. The team
participated in process redesign utilizing
tools and tactics from Lean and
other improvement methodologies.
Setting expectations
At the start of the process redesign,
the project team met with senior
leaders from ambulatory surgical
care, perioperative, and quality de18
OR
Manager | February 2020
partments to set expectations. They
emphasized the importance of integrating
ERAS principles with efficient,
standardized processes to ensure a
high-quality, consistent patient experience.
The goal was to improve
outcomes and processes across all
VCU Health clinics, ORs, and acute
care units, utilizing a systems approach
that transcends traditional
healthcare silos.
Mapping current state
To identify and eliminate waste in processes,
the first step is to understand
current state. We mapped the current
state workflows with the project team,
focusing on what actually happens,
as opposed to what is supposed to
happen. Mapping the current state is
necessary to establish a shared understanding
of the surgical continuum of
care. Team awareness of the baseline
Voice of the Customer responses
Healthcare providers at Virginia Commonwealth
University Health System in
Richmond use surveys, interviews, panel
discussions, and other tools to access
the " Voice of the Customer, " ie, identify
patients' needs.
Select patients were asked: From the
point of deciding to have surgery to when
you arrive at the hospital, what makes
you feel prepared for surgery? Their responses
helped the project team identify
value-add and non-value-add steps in
the process. Here are some of the responses
to the question:
➤ Having completed all paperwork,
preregistrations, and
knowing what my share of the
costs will be.
➤ Having heard from my doctor
about the benefits and risks of
the surgery. Having done my
own research about the medical
condition, other possible treatments,
and surgery outcomes
(usually check with Mayo, Cleveland
Clinic, and Johns Hopkins
websites). I expect to learn what
my recovery time will be and if
additional medical support services
like PT (physical therapy)
will be required.
➤ Getting information ahead of
time about the recovery process
made it easier for me to prepare
for when I came home. Also,
written instructions are a must!
Concrete, easy to follow, step by
step guidelines.
➤ Having a checklist provided by
the hospital of things I need to
do. Even if it's not directly related.
Not just no eating/drinking
past xyz time. Something like:
" Pack for 3-5 days post-surgery.
Request sick leave from employer
for at least x number of days. Update
emergency contacts. "
➤ Overall, no surprises or changes
in plans is very important.
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OR Manager - February 2020

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