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Overcoming resistance to a surgical safety checklist

Ariadne Labs
Aug 20, 2019 · 4 min read

By Bill Berry, MD, MPA, MPH

This is the second post in a series on implementation efforts at Ariadne Labs. Read the first installment by Sue Gullo, our director of Implementation.

Humans resist change. Maybe it’s a survival mechanism from our evolutionary past. When the world was uncertain, we stuck to what seemed to work. Such resistance can, however, prove problematic in health care, particularly when evidence suggests that change is beneficial, even lifesaving. What if we focus not on those who resist change, but try to talk directly with all of those being asked to change?

I thought about this while reading a Harvard Business Review article that focuses on the experience of anesthesiologist Michael Rose at McLeod Regional Health System in Florence, South Carolina. Dr. Rose helped to overcome resistance to instituting the World Health Organization (WHO) Surgical Safety Checklist that encourages preparation, communication, and adherence to important practices to reduce errors and help surgical teams work together better.

Rose has done an incredible job, but I understand his challenges. I was part of the team that developed the checklist, which was launched in 2008 and, according to the WHO, is now used in millions of surgeries. In 2012, when I became the chief medical officer of Ariadne Labs, encouraging the use of the checklist became our core program. So I was interested in Rose’s efforts.

According to the Harvard Business Review article, “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 was ultimately successful.

Research shows use of the Surgical Safety Checklist improves patient outcomes. After South Carolina established a voluntary, statewide program to implement the checklist, the state saw a 22 percent reduction in post-surgical deaths. Scotland saw a 36 percent reduction in post-surgical deaths since implementing the checklist as part of a national health safety program. Yet, physicians and even many scientists are experts at disagreeing with evidence that they don’t believe is true. Those seeking to institute a checklist in the operating room often encounter roadblocks, such as the attitude, “We have never done it that way.”

A while ago, I learned of a hospital in Delaware that had been successful in bringing the Surgical Safety Checklist into its operating rooms. So I decided to call them to find out just how they did it. I spoke to a nurse, who had been on their implementation team. She told me: “We just made appointments on all the doctors’ calendars at a convenient time for them. We took the checklist and we went to their office and spent half an hour eliciting their concerns and conveying to them how important it was for the operating room and that the whole hospital was committed to the implementation.”

In a bit of a twist, she added, “It was the nurses at our hospital who actually resisted the most because they were the ones whose processes had to change the most by bringing this into place.”

There are two critical elements for getting people — whether a CEO or housekeeper — to accept change. Tell them why and show them how.

In my experience, if you can get a resister to not be a resister any more, they become the most effective and most powerful enthusiasts for convincing other people. And I am absolutely convinced that talking one-on-one with people is the best approach.

I do get pushback about this — people say it takes too much time — but if you play this right and strategically you will find there are really enthusiastic people out there who as soon as you talk to them will “get it.” You give them guidance and maybe a script and you build your army of people who are going to spread the word.

Resistance is not limited to any one group. If you ask all the various people in various roles in an operating room who is really responsible for the safety of the patient, every one of them will say they are. This is a good thing because everybody’s so invested in the safety of the patient and they all think that the patient is their responsibility. But they also believe that they are often the only ones who care and that other surgical team members often work at cross-purposes. Getting team members from all disciplines talking with each other, understanding each other’s perspectives and involved in the modification of the checklist and in implementation activities is part of the magic.

Resistance is normal, should be anticipated, and can be overcome. Sometimes, I even wonder if I would have been initially resistant if someone told me I had to use a surgical checklist. Now, I would be hesitant to operate without one.

Bill Berry is co-founder of Ariadne Labs.

Illustration from iStock.com/Benjavisa

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Our mission is to create scalable health care solutions that deliver better care at the most critical moments in people's lives, everywhere.

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