Summary
Enhanced Recovery Pathways (ERPs) are proven to improve outcomes and experiences for surgical patients, yet many hospitals struggle to implement them reliably. This qualitative study examined why some hospitals made far more progress than others and found a practical truth leaders see everywhere: execution is rarely blocked by evidence. It is blocked by belief, bandwidth, and the systems that make improvement visible. Hospitals that improved the most paired strong executive and clinical leadership support with credible local champions, robust data feedback loops, and dedicated coordination, turning a complex, multi-step change into an institutional priority instead of a “project.”
Most organizations don’t fail because they choose the wrong strategy. They fail because they can’t translate a good strategy into consistent behavior at scale.
Enhanced Recovery Pathways are a perfect example. On paper, ERPs look like a straightforward upgrade: a set of evidence-based practices that, when followed, reduce complications, accelerate recovery, and improve the patient experience. In practice, ERPs demand coordination across professional boundaries, specialties, workflows, and digital systems. They require clinicians to change habits under time pressure, teams to align on what “the pathway” means, and leaders to make room for disciplined follow-through amid competing priorities.
That’s why ERPs function as more than a clinical protocol. They are a stress test of leadership, teaming, and organizational design.
Getting to the source of the problem
The researchers set out to answer a deceptively simple question: What distinguishes hospitals that implement enhanced recovery pathways successfully from those that struggle?
This matters well beyond healthcare because it challenges a familiar assumption: that implementation success is mainly about having the right roadmap. Many change efforts are built around the logic of “If we train people and publish the protocol, adoption will follow.” But complex interventions rarely work that way. They require sustained coordination, reinforcement, and the ability to learn quickly when the system pushes back.
To understand what separates higher-performing hospitals, Christina Yuan, PhD, MPH, CIL Affiliate and Associate Research Professor at the Johns Hopkins Bloomberg School of Public Health, and her colleagues interviewed 168 people across eight U.S. hospitals involved in a national surgical recovery improvement program, capturing perspectives from leaders, clinicians, and staff across the perioperative continuum. They analyzed these accounts using an implementation science framework to surface the barriers and facilitators most tied to real-world progress.
New findings with Implications for Implementation and Team Performance
Across hospitals, a few factors consistently helped implementation: strong information-sharing practices and the “front-end” work of planning and engaging people early. When teams had routines to communicate, coordinate, and problem-solve together, they were better able to translate intention into action. But the study also highlighted why even well-supported initiatives can stall. Barriers weren’t just resistance or lack of knowledge. They were structural and operational:
- The pathway itself was complex, involving more than 20 evidence-based practices, making reliability hard without tight coordination.
- Execution broke down in predictable places, especially where teams had to change enabling infrastructure, such as electronic health record workflows.
- And hospitals varied in whether they had the capacity to run improvement like a discipline, not a side job.
What most clearly distinguished the hospitals that improved the most was not a single tactic, but a reinforcing set of conditions:
- In higher-performing hospitals, clinicians largely believed in the value of the pathways, and leaders at both the executive and clinical levels made ERP implementation a visible institutional priority.
- They were more likely to have robust data collection and reporting infrastructure that could fuel learning and improvement rather than leaving teams to guess whether changes were working.
And they were more likely to have a dedicated ERAS/ERP coordinator with protected time, providing the steady attention that complex change requires.
In other words, the difference wasn’t that high performers “wanted it more.” The difference was that they built the conditions that made follow-through possible.
What this means for leaders
This study offers leaders a practical reframing: implementation is a leadership system, not a rollout plan. If you want complex change to stick, the work is not only persuading people that the change is evidence-based. It is building an environment where belief, coordination, and measurement reinforce each other.
Leaders can take several behavior-shifting lessons from these findings:
- Treat clinician (or frontline) belief as a strategic asset. The hospitals that improved most were distinguished by positive knowledge and beliefs about the pathways. That suggests that local credibility and shared conviction are not “soft” factors; they are the fuel that keeps change moving when friction appears.
- Make support visible at multiple levels. Executive sponsorship mattered, but so did clinical leadership support. Complex change needs vertical alignment: senior leaders to prioritize and protect resources, and respected practitioners to translate the “why” into daily practice.
- Invest in the feedback loop, not just the kickoff. Higher-performing hospitals were more likely to have robust data and reporting infrastructures. Leaders often underestimate how demoralizing it is to work hard on change while flying blind. When teams can see progress (and gaps) clearly, improvement becomes learnable instead of political.
- Stop pretending complex implementation is “extra.” The presence of a dedicated coordinator with time and attention is a reminder that many initiatives fail for a simple reason: nobody truly owns the connective tissue of execution. Coordination is real work, and in high-performing systems, it is staffed accordingly.
Enhanced Recovery Pathways are about improving surgical care, but the leadership lesson is broader: the challenge is rarely deciding what good looks like. The challenge is building an organization that can deliver “good” consistently.
For leaders facing any complex implementation, this study points to a clear question worth revisiting: Have we designed our change effort to succeed in the real system we operate, or only in the plan we wish were true? When belief is cultivated, priorities are reinforced across levels, progress is made visible through data, and coordination is resourced, execution becomes less heroic and more reliable.
Access the full research paper here: Yuan, C.T., Wu, J., Cardell, C.P., Liu, T.M., Eidman, B., Hobson, D., Wick, E.C., Rosen, M.A. (2024). Implementing enhanced recovery pathways: A qualitative study of factors that distinguished higher-performing hospitals. Annals of Surgery, 279(5), 789-795. https://doi.org/10.1097/SLA.0000000000006165
