How to Salvage a Useful Process That Isn’t Working Anymore

In health care and many other settings, innovation is a relentless pursuit. But what should organizations do when a promising innovative process fails to live up to expectations or a once-fresh innovation languishes over the years and eventually loses its effectiveness? A solution is reimplementation: rethinking an innovative process within an organization’s context, making the necessary changes, and then reintroducing it. A team at Ariadne Labs assisted in an successful effort to do just that at Singapore General Hospital (SGH). The process in question was the application of its surgical safety checklist. The three of us were involved in that effort. In this article, we share the lessons we learned. A Faltering Performance The SGH surgical safety checklist, like most checklists used in operating rooms, was instituted during the wave of global adoption of the World Health Organization (WHO) Surgical Safety Checklist. First introduced in 2009, the WHO Surgical Safety Checklist is a communication tool that reduces surgical complications. Initially, it was a star of the improvement scene, even inspiring Atul Gawande’s best-selling book, The Checklist Manifesto. Over the years, however, many hospitals like SGH that had adopted a checklist found that its performance waned, and its potential benefits risked being lost entirely. After SGH had used the checklist for more than a decade, however, its safety audits showed that despite the fact that checklists were being completed for most surgeries, there were still significant challenges. Often, the checklist was adhered to in form but not in spirit, indicating the lack of an embedded culture of safety. The challenges ranged from issues with staff engagement and communication to instances of preventable harm and “near-miss events,” which are potentially serious mistakes in patient care that are caught before they can cause harm. These events, though isolated, underscored systemic vulnerabilities and highlighted a crucial need to improve communication and surgical-safety processes. The Reimplementation Effort SGH recognized that an overhaul of its checklist approach was needed to address underlying issues. Committed to fostering a culture of safety and open communication across surgical teams, it partnered with a team at Ariadne Labs to help redesign and reimplement its checklist. Johnson & Johnson funded the project. Ariadne Labs was founded by Atul Gawande and Bill Berry, both of whom were original developers of the Surgical Safety Checklist. We brought to the partnership our expertise in human-centered design, implementation, and over a decade of stewarding the checklist. Our work together was successful: There were significant gains in team performance. Using a validated observation scale to assess leadership, teamwork, problem-solving, and situational awareness among surgical teams, we observed teams improving by over four points, advancing from “standard” to “excellent” across all categories. Following reimplementation, SGH’s culture around patient safety showed improvement in nine out of 12 areas, and there were notable reductions in surgical safety events, serious complications, and mortality rates. Through our partnership with the SGH implementation team, we gleaned four principles that are key to making reimplementation efforts succeed. 1. Match organizational challenges with existing innovations. Identify your organization’s most pressing problems, then use those as a lens through which to view existing innovations with fresh eyes. By examining safety trends, SGH leaders noticed that the checklist had become a routine process focused on tasks instead of encouraging intentional communication about safety. They recognized that some of the preventable harm they saw could have been avoided if the checklist had been used to its fullest potential. But instead of embarking on a new organizational initiative that would add yet another layer of process for the surgical teams, SGH leaders chose to invest in reimplementing the checklist in a way that would address the challenges. 2. Reimagine what is possible. The reimplementation process is about reimagining what exists. By rethinking assumptions, expectations, and current systems, reimplementation can transform an innovation that’s become stale. Looking at the culture of surgery at SGH, it became clear that communication was strained by team hierarchy: Nurses handled administrative tasks and surgeons commanded the operating room, allowing little communication between roles. SGH envisioned a future in which every team member prioritized and took ownership of the checklist and shared speaking opportunities. To this end, the new checklist included conversation prompts for teams about key activities, and every member of the team was assigned a portion of the checklist to lead, bolding their title on the checklist itself. The reimplementation of this new checklist helped lead the transformation of the local safety culture at SGH, prompting team members to talk to each other and empowering everyone to voice concerns and be leaders in patient safety. 3. Build momentum to overcome routine habits. Reimplementation requires a concerted effort to create a groundswell of support. It entails relentlessly engaging staff, compelling messaging, and repetition. A sense of urgency must be instilled in staff. Rapid cycles of testing and adaptation are critical to build momentum. However, the habits created by the “old way” of doing things can be major obstacles. Therefore, the reimplementation process must include identifying and eliminating problematic behaviors. This should not be stretched out. There must be an unmistakable shift that creates a clear “before” and “after” so people do not slip back into old behaviors. For example, we helped SGH create training videos to demonstrate how the new checklist should be used, providing a frame of reference for what active team participation and communication looked like. Also, instead of having a nurse read the checklist from a paper, we transformed the checklist into a poster that took up considerable real estate on the walls of the operating room. It became a visual cue and focal point for teams, with vibrant green and purple headings and bold black lettering. We created a tool for SGH to monitor how teams used the checklist over the long term, so if individuals fell into their old behaviors, they could intervene quickly, through remediation and coaching on the proper use of the checklist. 4. Embrace vulnerability. Reimplementation is an inherently vulnerable process. Leaders must be willing to expose problems and confront failures. Staff may resist reimplementation, not wanting to change something with which they are familiar and consider good enough. Indeed, members of the SGH surgical staff openly questioned why the checklist was being changed, were skeptical that it would actually make a difference in team communication, and worried that it would take too much time, adding more work to their already-packed days in the operating room. One important reason SGH’s reimplementation succeeded was the strong support provided by its surgical leaders, who were transparent about where they saw opportunities for improvement, adopted its use enthusiastically, and championed the initiative with staff. For example, the surgeon who led the SGH implementation team held meetings with every surgical department, where she explained the reason for reimplementation, outlined how adverse events could have been prevented by optimizing their checklist, and shared the results of a staff survey on culture. Another important champion was a respected surgical leader, who agreed to be one of the first people to test the new checklist and played a role in the training videos. The ability of such leaders to keep a focus on the need for the reimplementation and to communicate their vision and commitment generated support for the new checklist across the surgical teams. • • • The success of process innovations can fade over time. Consequently, it is crucial for organizations to periodically check them so they can identify declines in performance early. Once leaders uncover such a deterioration, they should determine the cause instead of immediately trying to force people to “get with the program.” With this knowledge, they can then redesign and reimplement the process and enable it to once again to deliver on its promise.

How to Salvage a Useful Process That Isn’t Working Anymore

Summary.

Partner Center