This retrospective cohort study was approved by the institutional review board at Duke University Medical Center. The requirement for informed consent was waived by the institutional review board. For most retrospective studies, our institutional review board will waive the requirement for informed consent so long as the only risk to patients relates to the use of patient health information and there is an appropriate plan for protecting that patient health information in place. Institutional ACS-NSQIP data files were used to identify a sample group of patients undergoing major CRS at Duke University Medical Center between January 1, 2008, and December 31, 2012. These procedures included low anterior resection, abdominoperineal resection, partial or total abdominal colectomy with or without proctectomy, proctectomy, pelvic exenteration, or Hartmann-type procedure (including Current Procedural Terminology codes 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, 44210, 44155, 44156, 44157, 44158, 44211, 44212, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45160, 45395, 45397, 45402, and 45550). Both open and laparoscopic cases were included. The bundle was designed for and by colorectal surgeons (J.K.M.T. and C.R.M.) who used it in all of their cases from the implementation date (July 1, 2011) forward. Therefore, only procedures performed by 1 of 3 board-certified colorectal surgeons at our institution were considered throughout the study period. Emergent cases or cases that occurred more than 1 day from the date of admission were excluded. Patient demographics, preoperative comorbidities, intraoperative factors, and 30-day outcomes were determined using the ACS-NSQIP institutional data. The ACS-NSQIP data relate to a systematically sampled set of surgical procedures and are collected by a trained surgical-clinical reviewer (M.W.), ensuring an accurate data set.28,29 In addition to the ACS-NSQIP data, the variable direct costs (VDCs) for the index admission were obtained from Duke University Hospital Finance. The VDCs account for costs incurred during a hospital stay related to care provided to the patient but exclude physician fees. Examples of VDCs include operating room time and equipment use, pharmaceutical agents, and nursing, laboratory, radiological, and other services.