How hospital leaders implemented a safe surgery protocol in Australian hospitals.

OBJECTIVE To analyse the strategies used by hospital leaders to improve compliance with the 'ensuring correct patient, correct site and correct procedure protocol'. While following such a protocol saves lives according to an international study of the World Health Organization safe surgery checklist, promoting compliance in hospitals has proved to be a regulatory challenge. DESIGN SETTING AND PARTICIPANTS Using a qualitative research design and 'responsive regulation' theory, this study explored implementation strategies used by hospital leaders in 20 Australian public hospitals. Semi-structured interviews were conducted with 72 informants to analyse how front-line leaders improved compliance with the safe surgery protocol in their hospitals. INTERVENTIONS Implementation analysis of the safe surgery protocol. MAIN OUTCOME MEASURES The use of implementation strategies located on a 'responsive regulation' pyramid. RESULTS Informants identified many strategies used to improve protocol compliance typically beginning with persuasion. Supportive strategies were located on a regulatory pyramid beginning with softer interventions: persuade, enlist leaders, train, remind, relax protocol requirements, redesign hospital systems and reward compliance. In response to low and slow compliance, many hospital leaders switched to a pyramid of escalating sanctions: direct, delegate, monitor, publicly report, reprimand and penalize. CONCLUSIONS A multiplex problem requires graduated and multiplex regulation. Hospital leaders proved to be responsive regulators in applying both multiple supports and sanctions that improved compliance over 3 years. These experiences with protocol implementation illustrate the multifaceted challenge of health sector regulation and offer lessons for embedding future patient safety solutions.