The Greenie Board

The enhanced recovery after surgery (ERAS) Greenie Board: a Navy-inspired quality improvement tool


This group of anaesthetists in Australia wanted to tackle the challenge of making changes to clinical practice – something difficult to achieve even when there is good evidence that it improves patient outcomes. They used an idea from the US Navy to encourage anaesthetists in their department to adhere to the enhanced recovery after surgery (ERAS) protocol. The “Greenie board” is a colour coded display used as a method of pubic feedback to their pilots –  each is given a colour code reflecting their performance during landing of each flight mission (green signifies an acceptable landing). It aims to improve performance by providing continues feedback, bench-marking with peers and encouraging competition between pilots.

For the first half of this one year study, the authors audited compliance to the seven anaesthesia-related intra-operative components of the ERAS protocol. Each case was given a score out of seven, according to the clinical records for each patient. After six months they introduced the Greenie board. At the time of its introduction they gave a departmental presentation, sent out emails and put up posters to encourage participation.

An anonymised “Greenie board” was used to display each anaesthetist’s compliance score for each case; this was updated monthly along with emails to the department suggesting areas for improvement, and individual data was emailed quarterly.

90 records were analysed in the first six months and 104 in the six months following the intervention. The authors found that overall compliance to the ERAS protocol increased significantly  following their intervention, with the percentage of cases with a score of six or more (out of seven) increasing from 33% to 72%. This peaked immediately following the introduction of the board, and also following the quarterly feedback emails.

They also performed a retrospective analysis to determine any impact on post-operative complications and found an improvement in only post-operative nausea and vomiting after introduction of the Greenie board. There was no link between ERAS compliance and complication rate.

This paper demonstrates a novel way of motivating clinicians to make changes to their practice when there are clear evidence based protocols. It highlights the importance of continuing to feedback or remind clinicians at regular intervals to maintain compliance, although this may be difficult to achieve when there are many different protocols and guidelines to follow. Their method was effective and was generally well received by the department, and could easily be replicated elsewhere.

Summary by Dr Jennifer Taylor

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