Compliance Assessment to Enhanced Recovery Protocols: A Three-Tier Donabedian Framework-Based Approach.

Enhanced recovery pathways are multi-component perioperative care bundles that have been associated with reduced length of hospitalization, overall morbidity and hospital costs. The challenges faced with the implementation of enhanced recovery pathways in hepato-pancreato-biliary (HPB) surgery have been two-fold, namely, the inherent higher procedural complexity with an attendant risk of complications that may necessitate a case-by-case deviation from protocols, and the challenges of incomplete measurement of adherence, even when the pathways have been developed based on evidence. The counter argument is that the intended outcomes of enhanced recovery protocols were achieved despite low compliance to the protocol, a paradox that may be explained by partial adoption of high-impact components, limitations of how adherence is measured, and/or system-level program effects which includes audit/feedback, escalation behavior, and documentation quality. Data availability and analyzing compliance or the lack of it, thus, remains critical to understanding how or why enhanced recovery protocols may work in HPB surgery. Without proper data availability and subsequently reliable measurement of adherence, it is almost impossible to determine whether suboptimal outcomes reflect pathway failure, poor implementation, or clinically-justifiable deviations.