Managing the process of enhanced recovery

Enhanced recovery pathways are multi-step processes. There is not one single “magic step” and it is recognised widely in the literature that successful pathways are those which ensure every patient receives every step of the pathway as it was designed.

But how can you be sure that every patient receives every step of the pathway in the correct way? Process control and variance analysis is the answer and the above diagram shows it’s importance.

We associate 95% with excellence. If we achieved 95% in an exam at school we were top of the class, but is delivering each step of a pathway 95% of the time good enough? We don’t think so and will now explain why.

Typically an enhanced recovery pathway for surgical patients may consist of between 15-20 steps. For ease of illustration we have shown just 3 steps recommended by the DoH in their enhanced recovery guide.

The steps are not dependent on the each other and we show what happens if every step is completed 95% of the time. As you can see, only 85% of patients get the 3 steps delivered as intended and prescribed by the pathway. That means 15 patients did not get the full pathway.

If we had continued the drawing to include 10 steps, only 60% of patients would receive every step of the pathway in the correct way.

Therefore, process measures and variance analysis must be integral to any enhanced recovery pathway. Enhanced recovery is multi-modal, every step is as important as the next, therefore you must ensure that 100% of patients receive every step of the pathway.