“They’re refusing to comply, now what do we do?” That was the first thing I heard from one of our facility Chief Medical Officers (CMO) after implementing an Enhanced Recovery After Surgery (ERAS) Program for bowel surgery across our system. ERAS programs were well established in the literature, so I did not anticipate this response from our surgeons. The CMO pointed out they were not against ERAS, so much as against being told how to manage their patients by corporate. To them, this appeared to be just another one of the endless stream of corporate directives handed down from the system.
They were a single group, at one of our system’s hospitals, and this group did all of the bowel surgery cases at that hospital. Their resolve was strong and they asked me what I planned to do about it. I asked them if the group was united in their agreement to not support the system’s approach to the clinical practice. They said they were. I also asked them if their goal was to produce the best outcomes for their patients. They agreed that was their intention. I told them I would support them. There was stunned silence. One of the surgeons finally said, “Did you just say, you would support us?”. Yes, I said. “Why would you do that?”, he asked. “You’re the physician lead for the ERAS Program and you wrote up the clinical practice we just told you we wouldn’t support.” My answer was, “Since your group has committed to maintaining the same clinical practice, then we will have a comparison group for the system. If what you are doing produces better results, then we should implement what you do as the system clinical practice. On the other hand, if the system outperforms your practice, then you will need to re-evaluate your approach to getting the best outcomes for your patients.” On this they also agreed.
There were two process measures for the clinical practice. One was early alimentation (drinking liquids) and the other was early ambulation. True to their word, for the first couple of months after we implemented the practice change, they did not change their practice. Between the 3rd and 4th month, something changed. They were now using the clinical practice on a regular basis and were leading the system in its use. I asked the CMO what happened. He said, they were so committed to beating the system’s outcomes with their own program, they naturally gravitated toward the underlying clinical practices of the ERAS program. By focusing them on their goal of producing excellent patient outcomes they changed their own behavior. We did not resort to disciplinary measures, corrective action or threats because none of this was necessary. What was necessary was trusting in them to achieve the patient outcomes we agreed was our shared goal. This led to a 28% reduction in complications, 17.5% reduction in readmissions across the system and was ultimately published in the Journal for Healthcare Quality. Trust can be a powerful motivator.
