title: How hospital leaders implemented a safe surgery protocol in Australian hospitals.
abstract: 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.
  
  
  METHODS
  
  
  
  METHODS
  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.
  
  
  METHODS
  Implementation analysis of the safe surgery protocol.
  
  
  METHODS
  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.
authors.affiliation: RegNet, Research School of Pacific and Asian Studies, Australian National University, Canberra, Australian Capital Territory 0200, Australia. judith.healy@anu.edu.au
authors.forename: Judith Mary
authors.initials: JM
authors.lastname: Healy
mesh_terms: D001291:Attitude of Health Personnel; D001315:Australia; D002985:Clinical Protocols; D019983:Guideline Adherence; D006739:Hospital Administration; D006801:Humans; D007318:Inservice Training; D007857:Leadership; D009042:Motivation; D015279:Organizational Culture; D061214:Patient Safety; D057766:Policy; D017410:Practice Guidelines as Topic; D017751:Safety Management / Q000458:organization & administration*; D013514:Surgical Procedures, Operative / Q000592:standards*