title: Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients.
abstract: BACKGROUND
  The goals of quality improvement are to partner with patients and loved ones to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste, yet few programs have successfully worked on of all these in concert.
  
  
  METHODS
  We evaluated implementation of a pathway designed to improve patient outcomes, value, and experience in colorectal surgery. The pathway expanded on pre-existing comprehensive unit-based safety program infrastructure and used trust-based accountability models at each level, from senior leaders (chief financial officer and senior vice president for patient safety and quality) to frontline staff. It included preoperative education, mechanical bowel preparation with oral antibiotics, chlorhexidine bathing, multimodal analgesia with thoracic epidurals or transversus abdominus plane blocks, a restricted intravenous fluids protocol, early mobilization, and resumption of oral intake. Eleven months of pre- and post-pathway outcomes, including length of stay (LOS), National Surgical Quality Improvement Program surgical site infection (SSI), venous thromboembolism, and urinary tract infection rates, patient experience, and variable direct costs were compared.
  
  
  RESULTS
  Three hundred ten patients underwent surgery in the baseline period, the mean LOS was 7 days, and the mean SSI rate was 18.8%. There were 330 patients who underwent surgery on the pathway, the LOS was 5 days, and the rate of SSI was 7.3%. Patient experience improved and variable direct costs decreased.
  
  
  CONCLUSIONS
  Our trust-based accountability model, which included both senior hospital leadership and frontline providers, provided an enabling structure to rapidly implement an integrated recovery pathway and quickly improve outcomes, value, and experience of patients undergoing colorectal surgery. The study findings have significant implications for spreading surgical quality improvement work.
authors.affiliation: Department of Surgery, Johns Hopkins University and School of Medicine, Baltimore, MD. Electronic address: Ewick1@jhmi.edu.
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Wick
authors.affiliation: Department of Surgery, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Galante
authors.affiliation: Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Hobson
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Andrew R
authors.initials: AR
authors.lastname: Benson
authors.affiliation: Armstrong Institute for Patient Safety and Quality, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: K H Ken
authors.initials: KH
authors.lastname: Lee
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University and School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Sean M
authors.initials: SM
authors.lastname: Berenholtz
authors.affiliation: Department of Surgery, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Efron
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University and School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University and School of Medicine, Baltimore, MD.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wu
mesh_terms: D003106:Colon / Q000601:surgery; D019091:Critical Pathways / Q000592:standards*; D013505:Digestive System Surgical Procedures; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015279:Organizational Culture; D009936:Organizational Innovation; D063868:Patient Outcome Assessment; D061214:Patient Safety; D019990:Perioperative Care / Q000592:standards*; D011183:Postoperative Complications / Q000517:prevention & control; D058996:Quality Improvement / Q000458:organization & administration*; D012007:Rectum / Q000601:surgery