Service development: prehabiltation

DEVELOPING A PREOPERATIVE SERVICE: PREHABILITATION AT UCLH

| Lorna Starsmore | John Whittle |

The implementation of perioperative healthcare services can be challenging and requires sustained enthusiasm. The prehabilitation service at University College London Hospitals (UCLH) was opened in November 2021 and has received over 115 referrals from six surgical specialities to date. Although several barriers were encountered, the service continues to expand and was recently awarded the UCLH Celebrating Excellence award. We hope to offer some insight into how this perioperative service was developed and introduced using Kotter’s eight stage model of transformational change as a framework1 .

Cultivating a Climate for Change

Create Urgency Generating interest and creating sense of urgency will help prioritise your project. Utilise supporting evidence in the literature, or best practice at centres of excellence, and compare this to local data. Patient stories can be very powerful and may garner emotional engagement.2

Prehabilitation is supported by the Centre of Perioperative Care3 as a strategy for transforming surgical wait lists into active preparation times and successful programmes

Figure 1. Key goals of the UCLH prehabilitation service

have been established around the UK (e.g. in Wessex4 and Greater Manchester5). There is increasing interest in the growing success of prehabilitation at trust and departmental level, underlined by emerging evidence suggesting that rehabilitation can halve postoperative complications after major abdominal surgery6 , lead to faster recovery7,8 and be emotionally beneficial to patients9 . Engagement with colleagues will also allow you to identify those who share your enthusiasm and may wish to collaborate.

Assemble Your Coalition Perioperative medicine is truly a multidisciplinary team (MDT) endeavour, and it is essential to find colleagues who share your passion in the project. An enthusiastic team will create drive, find innovative solutions to challenges and allow networking within a wide range of stakeholders.

The clinical lead of the prehabilitation service at UCLH is a consultant anaesthetist and intensivist with a research background in exercise physiology. The team consists of physiotherapists, a dietician, exercise physiologists, perioperative medicine fellows, a consultant anaesthetist with a specialist interest in coaching, engaged surgical colleagues and administrative support.

Regular communication is promoted with a weekly meeting dedicated to non-clinical aspects of the service.

Develop a Vision and Strategy ✦ Develop a vision with: Project aims

Determine your project’s goals as a team and identify those which are essential and aspirational, focusing initial resources on the services’ key principles. Flexibility will be needed to embed your service into existing pathways but clear goals help prevent project drift.

Key goals of the UCLH prehabilitation service are outlined in Figure 1.

With the core goals identified it is then possible to develop specific, measurable, attainable, realistic and time related (SMART)10 aims. This allows ongoing service improvement and can demonstrate measurable success to stakeholders and funders. Embedding quality improvement methodology from the outset allows challenges to be addressed using structured methodology.

✦ Develop the vision: Outcomes

Outcomes measures will quantify success and should be carefully considered from the inception of the service. Some required metrics will defined by your SMART aim but they can also align your project with research or funding interests.

We use a secure database in order to collect basic service information including the number of patients being referred to the service. Data is also collected on pre- and post-prehabilitation physiological parameters and qualitative feedback from patients. Outcome metrics including length of stay and morbidity help align the service with those trust priorities focused on tackling surgical waiting times and may help secure future funding.

✦ Develop the strategy: Pathway Mapping

A patient’s perioperative pathway is often complex, involving multiple teams and appointments, and frequently varies between surgical specialities. Mapping patient pathways allows visualisation of how your service may integrate into existing structures. Considering each stage of a process can highlight barriers and those external stakeholders needed to implement your project. The prehabilitation patient pathway is illustrated in figure 2.

Engage and enable the whole organisation

Communicate the Vision Whilst your close coalition will be enthusiastic about the project there are likely to be many other stakeholders who need to be engaged to embed your service.

✦ Referrers

Key surgeons, anaesthetists, specialist nurses and oncologists were identified as being proponents of prehabilitation. Collaboration with these early adopters allowed wider distribution of the prehabilitation ‘vision’ from proposed patient benefits to the practicalities of making referrals. Communication also relies on listening to those using your service and working with stakeholders to minimise additional work and disruption on their part.

✦ Patients

Arguably the key stakeholder in all perioperative services are the patients that those initiatives are designed to serve. Including patients in service design and feedback can provide an insider perspective and provide solutions to issues e.g. poor patient engagement. All patients have been asked to provide feedback on the prehabilitation service and a number have agreed to help with a mentoring service, for future patients, which is in development.

✦ Wider Organisation

Those stakeholders funding your service will need a clear business plan alongside the vision for your service.

Empower Action Establishing overall service goals and setting aims empowers all members of the team to drive new services forward. Assigning smaller projects, based on specific aims, and regular meetings to discuss progress allows individuals to work independently but within a supportive team environment.

Celebrate Quick Wins Some project outcomes may take months or years to become apparent, for example changes in length of stay or mortality. It is therefore important to consider what demonstrates success in the short term. This could be as simple as receiving the first referrals and interacting with the first patient cohort.

An early ‘win’ experienced by the UCLH team was the first quantifiable improvement in CPET results seen in a patient who had completed the programme. The sense of achievement helped unite and motivate the team. Conviction in the service was further compounded by patient feedback which was often shared at the team Tuesday meeting.

Celebrating wins within the team is vital in maintaining drive and enthusiasm but should also be widely shared to sustain change.

Leverage and Sustaining Change

Leverage Wins to Drive Change The prehabilitation service successes have been presented in forums ranging from local presentations to international meetings. Demonstrating value increases credibility and creates leverage when redesigning aspects of your service or when persuading other teams to engage.

Celebrating achievements maintains drive, encourages others to adopt practices and is one step towards embedding the process in culture so that engagement becomes the norm rather than the exception.

Embed in Culture Sustaining change can be just as challenging as implementing a new service. Projects which rely on a single individual or have unintended adverse consequences are especially vulnerable. The UCLH prehabilitation service benefits from having a team of motivated colleagues such that when individuals are not available the service continues to run. Planning future developments can also help maintain momentum and widen the network of influence your service has. We have recently expanded into two new surgical pathways, including maxillofacial surgery, developed an online

Figure 2. UCLH prehabilitation clinical pathway

training programme and have plans to launch a wearables component of the service.

Summary

Implementing and sustaining perioperative healthcare services can be challenging. Creating a robust plan, generating enthusiasm and gathering a supportive coalition are all essential. Embrace challenges as an opportunity to develop the service and celebrate the wins. Sustainability is as important as establishing a project and requires ongoing commitment and demonstration of financial value.

Link to references