Form 5 Site visits

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHRQ Safety Program for Improving Surgical Care and Recovery Site Visit Interview Guide

Public reporting burden for this collection of information is estimated to average 8 hours per visit, the estimated time required to complete the visit. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

Interview guide

*Questions in bold differ between groups

General questions to ask about program (or a survey that we hand participants to fill out):

Which of the following enhanced recovery pathway elements has your hospital implemented:

	Intervention component	Most of the time	Some of the time	About 50% of the time	Infrequently	Almost never
Preoperative
1	Patient Education					
Immediate Preoperative
2	Preoperative Mechanical Bowel Prep and Preoperative Oral Antibiotics					
3	Preoperative Bathing					
4	Reduced Fasting					
5	Carbohydrate Loading					
6	Multimodal Pre-Anesthesia Medication					
7	Mu Opioid Antagonists (Alvimopan)					
8	Glucose Control					
9	Normothermia					
Intraoperative
10	Prophylactic Antibiotics					
11	Preoperative VTE Prophylaxis					
12	Skin Preparation with an alcohol-containing agent					
13	Euvolemia  - Fluids/Goal-Directed Fluid Therapy					
14	Normothermia					
15	Avoid Drains/nasogastric tubes					
16	Use of Regional Anesthesia- Standard Intraoperative Anesthesia Pathway					
Postoperative
17	First Postoperative VTE Chemoprophylaxis Dose					
18	Standard Postoperative Multimodal Analgesic Regimen					
19	Early postoperative feeding					
20	Early postoperative day 1 mobilization					
21	Early Urinary Bladder Catheter Removal postoperative day 1					
22	Early IV Fluid Discontinuation postoperative day 1					

9. In the past nine months, how often did each of the following factors slow your team's progress in implementing the enhanced recovery pathway?

	Never/ Rarely	Occasionally	Frequently	Almost Always
Insufficient knowledge of evidence supporting interventions				
Leadership support issues
Not enough leadership support from executives				
Not enough leadership support from surgeons				
Not enough leadership support from anesthesiologists				
Not enough leadership support from nurses				
Insufficient autonomy/authority				
Team skills and cohesion issues
Lack of quality improvement skills				
Confusion about how to proceed with enhancing surgical care and recovery activities				
Lack of team member consensus regarding goals				
Inability of team members to work together				
Stakeholder push-back issues
Not enough buy-in from surgery staff				
Not enough buy-in from anesthesiology staff				
Not enough buy-in from nursing staff				
Not enough buy-in from other staff				
Workload and time issues
Not enough time				
Staff turnover on unit				
Data collection burden for staff				
Problems with data systems				
Competing priorities or distractions (e.g., new EMR, accreditation visit)				

Questions to potentially ask specific groups of people:

Senior Leadership

1. Can you describe how your hospital decided to implement the Improving Surgical Care and Recovery Program (ISCR)?

   1. Who was involved?

   2. How long did it take to arrive at this decision?

   3. What were the reasons given in favor of implementing the ISCR program?

   4. Was there any resistance against implementing ISCR? What were the reasons given?

      1. How did the project team deal with any resistance?

2. We’re interested in hearing about your experience with implementing ISCR.

   1. What has gone well?

   2. What has not gone well?

      1. Were you able overcome any of these challenges? How so?

   3. Did you have to add additional resources to implement ISCR?

      1. If so, what type of resources? 

      2. Did your implementation plan include funding for a dedicated nurse coordinator? If yes, for how long?

3. What do you foresee happening with the ISCR program in this hospital over the next year?

   1. Is the experience of implementing ISCR like other improvement efforts the hospital has undertaken, or different? How so?

4. What would you recommend to other hospitals trying to implement ISCR?

5. How has participating in the program affected your hospital?

6. Thank you for your time. Is there anything else about your enhanced surgical care and recovery efforts that you’d like to share?

Patient safety and quality staff

1. Can you describe how your hospital decided to implement the Improving Surgical Care and Recovery Program (ISCR)?

   1. Who was involved?

   2. How long did it take to arrive at this decision?

   3. What were the reasons given in favor of implementing the ISCR program?

   4. Was there any resistance against implementing ISCR? What were the reasons given?

      1. How did the project team deal with any resistance?

2. We’re interested in hearing about your experience with implementing ISCR.

   1. How many estimated hours did your team spend prepping for ISCR?

   2. What has gone well?

   3. What has not gone well?

      1. Were you able overcome any of these challenges? How so?

   4. Were there any process measures that you weren’t doing that you added once ISCR kicked off ? If so, what were they?

   5. Did you wait until the ACS registry data was ready to know about their process measures or did you attempt to collect them in real time?

   6. Did you have a Senior Executive that helped support you through ISCR implementation? What was his/her involvement like? Can you give me an example of how s/he helped in the implementation? How were you able to get him/her involved?

   7. Did you have to add additional resources to implement ISCR?

      1. If so, what type of resources? 

      2. How were you able to obtain these resources?

      3. Did your implementation plan include funding for a dedicated nurse coordinator? Do you think such a role is important for sustained use of ISCR?

3. What do you foresee happening with the ISCR program in this hospital over the next year?

   1. Is the experience of implementing ISCR like other improvement efforts the hospital has undertaken, or different? How so?

4. What would you recommend to other hospitals trying to implement ISCR?

5. How has participating in the program affected your hospital?

6. Thank you for your time. Is there anything else about your enhanced surgical care and recovery efforts that you’d like to share?

Perioperative leadership (Pre-op, OR, PACU, step down, inpatient, discharge, etc.)

1. Can you describe how your hospital decided to implement the Improving Surgical Care and Recovery Program (ISCR)?

   1. Who was involved?

   2. How long did it take to arrive at this decision?

   3. What were the reasons given in favor of implementing the ISCR program?

   4. Was there any resistance against implementing ISCR? What were the reasons given?

      1. How did the project team deal with any resistance?

2. We’re interested in hearing about your experience with implementing ISCR.

   1. How many estimated hours did your team spend prepping for ISCR?

   2. What has gone well?

   3. What has not gone well?

      1. Were you able overcome any of these challenges? How so?

   4. Were there any process measures that you weren’t doing that you added once ISCR kicked off ? If so, what were they?

   5. Did you wait until the ACS registry data was ready to know about their process measures or did you attempt to collect them in real time?

   6. Did you have a Senior Executive that helped support you through ISCR implementation? What was his/her involvement like? Can you give me an example of how s/he helped in the implementation? How were you able to get him/her involved?

   7. Did you have to add additional resources to implement ISCR?

      1. If so, what type of resources? 

      2. How were you able to obtain these resources?

      3. Did your implementation plan include funding for a dedicated nurse coordinator? Do you think such a role is important for sustained use of ISCR?

3. What is the structure of your operating room? Do you have designated teams?

4. How is your pre-op education done? Does it include language about ISCR? Do you educate your patients about early mobility, early discharge, etc. as part of the pre-op education? If so, how do you educate them (e.g., website, brochures, nurse educator, etc.)

5. What do you foresee happening with the ISCR program in this hospital over the next year?

   1. Is the experience of implementing ISCR like other improvement efforts the hospital has undertaken, or different? How so?

6. What would you recommend to other hospitals trying to implement ISCR?

7. How has participating in the program affected your hospital?

8. Thank you for your time. Is there anything else about your enhanced surgical care and recovery efforts that you’d like to share?

Perioperative frontline staff (Pre-op, OR, PACU, step down, inpatient, discharge, etc.)

1. We’re interested in hearing about your experience with implementing the ISCR program.

   1. What has gone well with the implementation process?

   2. What has not gone well?

      1. Were you able overcome any of these challenges? How so?

      2. Were any of these challenges concentrated in any part(s) of the continuum of care (pre-operative, intra-operative, post-operative)?

   3. In thinking about the different people with whom you need to interact when caring for enhanced recovery patients, what is it like to work with them?

      1. Have those interactions changed since starting a formal ISCR program?

   4. Did you have a Senior Executive that helped support you through ISCR implementation? What was his/her involvement like? Can you give me an example of how s/he helped in the implementation? How were you able to get him/her involved?

   5. Did you have to add additional resources to implement ISCR?

      1. If so, what type of resources? 

      2. How were you able to obtain these resources?

      3. Did your implementation plan include funding for a dedicated nurse coordinator? Do you think such a role is important for sustained use of ISCR?

2. What is the structure of your operating room? Do you have designated teams?

3. How is your pre-op education done? Does it include language about ISCR? Do you educate your patients about early mobility, early discharge, etc. as part of the pre-op education? If so, how do you educate them (e.g., website, brochures, nurse educator, etc.)

4. In the current literature about enhanced recovery practices for surgical patients, some frontline staff have expressed confusion about when to deviate from the enhanced recovery practices protocol (for example, if a patient has nausea or poor pain control)? Has anyone experienced a similar sense of confusion? Or noticed that the protocol is not being consistently applied? Have there been any efforts to resolve these issues?

5. What do you foresee happening with the ISCR program in this hospital over the next year?

   1. Is the experience of implementing ISCR like other improvement efforts the hospital has undertaken, or different? How so?

6. What would you recommend to other hospitals trying to implement ISCR?

7. How has participating in the program affected your hospital?

8. Thank you for your time. Is there anything else about your enhanced surgical care and recovery efforts that you’d like to share?