When McLeod Regional Health System in South Carolina sought to implement a surgical checklist, it took time and a three-strategy approach to get surgical staff on board and achieve 100% adoption of a protocol that saves them $4 million annually, Kate Hilton and Alex Anderson write for the Harvard Business Review.

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Initial resistance to the checklist

Surgical checklists are modeled on those used by pilots in the aviation industry and have been proven to improve patient outcomes and save lives, Hilton, a faculty member at the Institute for Healthcare Improvement, and Anderson, a research associate at the Institute, write.

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They note that the checklist aims to ensure that:

• A patient is who they're supposed to be;
• The surgery about to be performed is correct; and
• The surgical teams are prepared for an emergency.

Yet despite evidence that the checklist can save patient lives and a national mandate from hospital accreditation agencies to adopt it, surgeons nationwide—including those at McLeod—have resisted it, according to Hilton and Anderson.

"This isn't surprising; resistance is a normal psychological response to change," Hilton and Anderson write. "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."

Michael Rose, an anesthesiologist who at the time was VP of surgical services at McLeod, encountered several of these kinds of resistance when he sought to implement a surgical checklist at the hospital, Hilton and Anderson note.

After 18 months of working with surgical teams in 2009 and 2010, McLeod only had a 30% adoption rate.

How McLeod overcame resistance

At that point, Rose decided it was time to try a different approach, which involved "embracing three essential measures to address people's psychological reactions to change," Hilton and Anderson write.

1. Don't fight the resisters: Instead of seeing those resisting the checklist as a problem, Rose focused on addressing the root cause of the resistance by talking with surgeons about their feelings toward the checklist, Hilton and Anderson write. This allowed team members to have agency in the effort and voice their views on what worked and what didn't.
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3. Don't tell people what changes to make: Rose chose to stop asking, "How can I get this group of people to do what I want them to do?" and instead ask, "How can I get this group of people to do what they want to do?" Hilton and Anderson write. To do this, Rose invited surgical team members to think about how the checklist connected with their own motivations and values. He also sought out feedback about what team members felt they had to gain and lose by adopting the checklist. By doing this, Rose was able to generate "a shared understanding and reinforc[e] people's mastery of skill, sense of purpose, and autonomy," Hilton and Anderson write.
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5. Focus on those who are already committed to changing: Rose started working with the people already committed to the surgical checklist, Hilton and Anderson write. This ultimately led him to engage senior leaders across various disciplines, who helped bring nurses, technicians, surgeons, and anesthesiologists on board.

Thanks to these strategies, McLeod now uses the checklist for 100% of surgical cases, Hilton and Anderson write. Since McLeod implanted the checklist, it has seen an almost one-third drop in its 30-day surgical mortality rate and an increase in surgical team productivity by 7.5 hours per case, which has saved over $4 million annually, Hilton and Anderson write.

Further, the increase in volume of surgical cases along with the higher OR throughput has led to more than $3 million in additional annual revenue for McLeod, Hilton and Anderson write. The surgical teams have also reported better job satisfaction and a stronger culture of safety, where everyone feels they have the ability to speak up to call attention to safety issues as they arise.

"Unless organizational leaders adequately address people's psychology toward change, any given improvement effort will remain stuck in second gear," Hilton and Anderson write. "These mind shifts are not nice to have; they are essential" (Hilton/Anderson, Harvard Business Review, 5/20).

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