ARTICLE: What went right? Ten Lessons in successful project implementation from the surgical world

An article1 published in the New England Journal of Medicine shows how a simple, inexpensive tool – a checklist – can reduce errors and can lead to improvements in health outcomes in any operating room, in any country. The article describes a study conducted by the World Health Organization’s (WHO) Safe Surgery Saves Lives program and concludes that the use of a simple, 19-point checklist in the operating room can significantly reduce complications and deaths from surgery. Especially noteworthy about the study is that it was conducted at sites in eight countries - Jordan, India, the US, Tanzania, the Philippines, Canada, England, and New Zealand - with diverse populations of patients and under a range of economic circumstances. The study not only describes “best practices” to improve surgical outcomes, it also provides important project implementation “best practices” that can be adapted to other types of projects, such as implementing standard operating procedures, introducing a new process, or making large changes in an organization.

This article looks at what the research team did to ensure that their checklist was implemented, and describes how the lessons learned from this study can be applied to ensure the success of other projects.

(1) Get support from the top.
The WHO researchers sought – and obtained – support for the study from the administration of each of the participating hospitals. Having support for the project from the top builds support for the project within the organization, unifies the team, and prevents the project from being suspended or derailed mid-way through. Obtaining this support is a necessary first step for any successful project.

(2) Understand the existing situation before you start.
At the outset, the researchers carefully analysed the surgical safety policies and practices in place at the hospitals enrolled in the study and identified areas of deficiency. Doing this allowed them to determine what needed to be changed and where to focus their efforts, and helped them anticipate challenges that might arise. The rationale for this step is pretty obvious: before you decide where you might go, or what route you might take, you have to know where you are starting from. In other words, before implementing any project, you need to thoroughly research and understand the existing situation.

(3) Identify and work with project champions.
In the WHO study, a local investigator was selected at each of the participating hospitals to lead the surgical project and to take responsibility for implementing the checklist. The champion was there to help inform others about the project, to build enthusiasm in the organization, to identify challenges, and to work with those who might be resistant to change. This study demonstrates that you need a dedicated champion – someone inside the organization or the team – who is fully committed to ensuring the project moves ahead.

(4) Ensure that the project is communicated – in multiple ways – to everyone involved.
To educate the local project teams, the WHO researchers used a variety of communication methods including recorded videos, teleconference calls, and site visits. To introduce the checklist to operating-room staff, the team used lectures, written materials, and direct guidance. The WHO team took great care to ensure that everyone involved in the project, at every level, was informed about the project and educated about their role. Using multiple modes of communication helps ensure that everyone understands the requirements and their roles, and increases the likelihood of buy-in and success.

(5) Use the power of a team to reinforce the change.
The study organizers deliberately introduced steps in the checklist to help the surgical staff in the operating room come together as a team.  These steps included introducing a pause in the operating room proceedings for the surgical team members to introduce themselves to each other, and having team briefings before and after the surgery. This created opportunities for team members to communicate directly with one another, which ultimately helped strengthen implementation of the checklist and led to better surgical outcomes for the patients. The lesson here is clear: creating opportunities for team members to communicate directly helps build a team and the power of a team will strengthen your implementation.

(6) Be flexible and be prepared to adapt if necessary.
The study researchers adapted to local situations by translating the checklist into the local language when appropriate, and by adapting the checklist to accommodate the process of care at each hospital. In addition, when insufficient amounts of data were collected at some sites, the duration of the study was extended at these three sites to allow enough data to be collected. The success of this study serves as a reminder that projects may need to be adapted to different sites and different people, and may have to be modified to accommodate unanticipated situations.

(7) Measure whether the project is being implemented.
To ensure the new processes were being followed, the WHO researchers required hospitals to record the results of six safety measures that were conducted for each patient. To verify this, the hospitals had to document their results and the WHO team monitored the information.  This verification process was critical, because implementation often requires both systemic and behavioral changes. By monitoring whether implementation is being done as planned, problems with implementation can be identified and rectified, for example by providing additional training, adapting the study, or providing extra support.

(8) Determine what success looks like and how you will measure it.
You not only need to determine the expected outcome, you need to consider how you will measure it.  At the outset, the WHO research team determined that “success” would be a significant improvement in surgical outcomes and to establish this they measured the number of complications after surgery. They needed to collect enough data from each site to ensure that the results of the study would be statistically significant. They collected data on 3,733 patients before implementation and 3,955 after the checklist was implemented, so that they could determine whether improvement was made as a result of implementation of the checklist. The impact of your findings and conclusions will be greater if you measure what you want to change and you make sure your metrics are significant.

(9) Anticipate different potential outcomes and plan accordingly.
The WHO researchers worked through a wide variety of “what ifs” by defining exactly what was meant by a “surgical complication” and by creating a process for determining what they would do if other, unanticipated, events happened. Though you may not be able to anticipate all potential problems and outcomes, you need to have a way of dealing with the challenges or changes that may arise once the study is in progress.

(10) Communicate the outcomes.
Because the results of this study were published in a prestigious medical journal, others will learn and benefit from the WHO team’s experience and success. Though the details of your project might not get such wide coverage, it’s important that you make sure your findings and conclusions are communicated, at least to the team or the organization, if not to a wider audience. Communication acknowledges the participation and hard work of all involved and helps reinforce the changes that were made.

Just as the WHO team’s surgical checklist is likely to be seen as a best practice for operating rooms everywhere, this article is written in the hopes that the lessons set out here will become part of your project management “best practices”, and will ensure that your future initiatives “go right”.

By Chrystal Palaty, PhD

1 Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population, by Haynes AB, Weiser TG, Berry WB, et al, New England Journal of Medicine. 2009 Jan 14; 360 (3): 491-499.
http://content.nejm.org/cgi/content/full/NEJMsa0810119