title: Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences.
abstract: BACKGROUND
  Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change.
  
  
  METHODS
  A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit.
  
  
  RESULTS
  Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support.
  
  
  CONCLUSIONS
  Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.
authors.affiliation: Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Room K3W-28, Toronto, ON, M4N 3M5, Canada. lesley.gotlibconn@sunnybrook.ca.
authors.forename: Lesley
authors.initials: L
authors.lastname: Gotlib Conn
authors.affiliation: Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. mmckenzie@mtsinai.on.ca.
authors.forename: Marg
authors.initials: M
authors.lastname: McKenzie
authors.affiliation: Department of Surgery, Mount Sinai Hospital Joseph and Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. epearsall@mtsinai.on.ca.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Pearsall
authors.affiliation: Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 1P5, Canada. robin.mcleod@cancercare.on.ca.
authors.forename: Robin S
authors.initials: RS
authors.lastname: McLeod
mesh_terms: D003106:Colon / Q000601:surgery; D003107:Colorectal Surgery / Q000379:methods*; D017558:Elective Surgical Procedures; D006801:Humans; D011182:Postoperative Care / Q000379:methods; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement; D012007:Rectum / Q000601:surgery