How One Health System Overcame Resistance to a Surgical Checklist

How One Health System Overcame Resistance to a Surgical Checklist 1

How One Health System Overcame Resistance to a Surgical Checklist 2
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During a time when health care is undergoing the most sweeping change ever, health systems, not surprisingly, are struggling to overcome resistance to change. The natural reaction by leaders at all levels charged with implementing change is to fight the resisters. But research and the experiences of some organizations suggest that embracing those who resist change the most — empathizing with them, identifying the sources of their resistance, and helping them see change as positive — is far more effective.

The experience of Michael Rose and his supporters in overcoming resistance from surgical teams at McLeod Regional Health System in Florence, South Carolina, to employing a checklist aimed at reducing errors and improving outcomes illustrates the benefits of this positive approach.

The story ends well. Surgical teams at McLeod now use the checklist for 100% of surgical cases. Since implementing the checklist, McLeod’s 30-day surgical mortality rate has dropped by nearly one-third; surgical teams’ productivity has increased (by 7.5 hours per case), saving more than $4 million annually; and a greater volume of surgical cases, combined with the higher operating room throughput, has generated more than $3 million in additional revenue annually. Surgical team members also report that their job satisfaction has risen and there’s a stronger culture of safety in which everyone, regardless of their position, feels they can speak up to call attention to and take action as safety issues arise.

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Yet, the story begins as most change efforts do: with resistance. For 18 months between 2009 and 2010, Rose, an anesthesiologist who was then vice president of surgical services at McLeod, worked with surgical teams to implement the checklist — an evidence-based best practice for safe surgery. Similar to a flight safety checklist in the aviation industry, the surgical safety checklist ensures that the patient is the correct person, the surgery that’s about to be performed is the correct surgery, and surgical teams are prepared for emergent complications. The benefits of the checklist are clear: It takes only a few moments to conduct, improves patient outcomes, and saves lives.

Even with this evidence — and a national mandate from hospital accreditation agencies to use the checklist — adoption rates flagged. Some surgical teams never used it; others tried and abandoned it. In fact, in hospitals across the world, surgeons and surgical teams were resisting it.

This isn’t surprising; resistance is a normal psychological response to change. Neurologically, the emotional brain first feels something negative about the change and then the rational brain kicks in and thinks of reasons to defend that feeling. Resistance can take many forms: apathy, doubt, hopelessness, rejection. A more subtle (but all too familiar) form of resistance, especially in compliance-based settings like health care, is publicly acting in accordance while privately disagreeing.

And resistance can come from anyone: from senior leaders who drag their feet in providing the resources needed for change to occur to frontline staff who don’t want to alter their behavior. It often shows up under the guise of “competing priorities” or “not enough time.”

In his efforts to get surgical teams to adopt the surgical safety checklist, Rose experienced many of these forms of resistance. For 18 months, he shared the checklist’s virtues, instituted training to teach teams how to use it, marketed its benefits, persuaded or cajoled colleagues, and mandated its use. Despite all of these efforts, adoption rates stalled at 30%.

Then Rose tried a different approach: embracing three essential measures to address people’s psychological reactions to change.

Don’t fight the resisters. Rose fought the temptation to view resistance from surgical team members as a problem, obstacle, personal attack, or source of frustration. Instead, he focused on understanding and addressing its root cause, especially fear. He leaned in to the resistance and drew people in. He invited them to identify how they felt about the checklist — what was workable and what they saw as barriers to progress.

As described in the Institute for Healthcare Improvement’s Psychology of Change Framework, Rose “activated people’s agency” — their ability to choose to act with purpose. By inviting people to share their own views of what worked and what didn’t, he enlisted team members in the effort to move the checklist forward — he made them feel like they had power. And by surfacing and addressing their fears, he helped team members have the courage to overcome them.

Stop telling people what changes to make. Rather than asking, “How can I get this group of people to do what I want them to do?,” Rose made a critical pivot to listen and ask, “How can I get this group of people to do what they want to do?”

Rose invited surgical team members to think about how the checklist connected to their personal values and motivations — and he offered to be the first to share. He relayed the responsibility he felt for the well-being of thousands of patients. Despite his desire to control the factors and people in play, he had come to terms that it was not a personal weakness but a strength to join with others to accomplish something seemingly out of reach. Team members then shared their vulnerabilities, including stories of loved ones who had experienced harm in hospitals and staff who had made a difference. They shared universal moments of loss and grief, of professionals who had helped them through profoundly uncertain moments — and how those people and moments transformed them as human beings and as health care professionals.

Rose also sought to unearth team members’ interests in the change being asked of them — What do they stand to gain and lose by implementing the surgical checklist? — revealing the power dynamics at play. Not everyone’s interests are met all the time; some people experience (or perceive) real loss with change. For example, some surgeons felt they were solely responsible for the patient. Because they perceived a loss of control when the surgical team employed the checklist together, some surgeons asserted their authority and rejected its use. However, as surgical teams (including other surgeons) began to use the checklist, this dynamic shifted, creating new pressure on the initially resistant surgeons.

In addition, by activating more and more surgical staff to test and improve the checklist, Rose elicited “ownership” and avoided the trap of “buy-in” (i.e., they took real responsibility for ongoing improvement instead of committing to rote action). This generated a shared understanding and reinforced people’s mastery of skill, sense of purpose, and autonomy. The result: meaningful (rather than suboptimal) use of the checklist.

Focus on the people who already are committed to change. By starting with those who were committed to the surgical safety checklist, Rose engaged leadership across disciplines and levels. Nurses and technicians joined with surgeons, anesthesiologists, and senior leaders to advance the adoption of the checklist. Together they built a commitment-based network on top of a compliance-based hierarchy, or what John Kotter calls a “dual operating system.” Both were necessary to the safe delivery of care.

Results followed. As Rose sees it, the surgical team members not only saved others’ lives by adopting the checklist, they also improved the staff’s well-being and renewed their spirits.

Unless organizational leaders adequately address people’s psychology toward change, any given improvement effort will remain stuck in second gear. These mind shifts are not nice to have; they are essential.

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