Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar

Abstract

BackgroundThe 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support. Since checklist use leads to the biggest improvements in outcomes in LMICs, methods of wide-scale implementation are needed. We hypothesized that, using a three-day course, successful wide-scale implementation of the checklist could be achieved, as measured by at least 50% compliance with six basic safety processes at three to four months. We also aimed to determine predictors for checklist utilization.Materials and methodsUsing a blended educational implementation strategy based on prior pilot studies we designed a three-day dynamic educational course to facilitate widespread implementation of the WHO checklist. The course utilized lectures, film, small group breakouts, participant feedback and simulation to teach the knowledge, skills and behavior changes needed to implement the checklist. In collaboration with the Ministry of Health and local hospital leadership, the course was delivered to 427 multi-disciplinary staff at 21 hospitals located in 19 of 22 regions of Madagascar between September 2015 and March 2016. We evaluated implementation at three to four months using questionnaires (with a 5-point Likert scale) and focus groups. Multivariate linear regression was used to test predictors of checklist utilization.ResultsAt three to four months, 65% of respondents reported always using the checklist, with another 13% using it in part. Participant’s years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with counting instruments (p< 0.05), but not with verifying: patient identity, difficult intubation risk, risk of blood loss, prophylactic antibiotic administration, or counting needles and sponges.ConclusionUse of a multi-disciplinary three-day course for checklist implementation resulted in 78% of participants using the checklist, at three months; and an increase in counting surgical instruments. Successful checklist implementation was not predicted by participant length of medical service, hospital size or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist

“…At the end of the course, the hospital‐specific checklist, including surgical counting tool, is given to the surgical team and presented to the hospital director. A more detailed course description and timetable has been published previously.…”

“…The primary outcome was sustained checklist use at 12–18 months measured by self‐reported validated questionnaire.…”

“…Four specific measurement tools were used as well as focus groups. Questionnaire 1 uses a validated five‐point Likert scale response format to measure checklist use and adherence to six basic safety processes. Questionnaire 2 uses a visual analogue scale ranging from 1 to 10 to measure the participant's immediate reaction to the training course, based on the Kirkpatrick model of evaluating training courses.…”

“…Implementation research is a form of health policy and systems research that can be used to study and support the scale‐up of quality improvement interventions into health systems at the national level. Recent research in Madagascar has shown that nationwide checklist implementation is feasible and results in high‐fidelity checklist use.…”

“…This study used implementation science principles to evaluate nationwide checklist implementation in Benin. Based on studies in Madagascar and England, the hypothesis was that sustained checklist use would be reported by at least 50 per cent of participants at 12–18 months after introduction. The aim was to measure the sustainability of checklist use; and to evaluate the acceptability, adoption, appropriateness, feasibility and fidelity of nationwide checklist implementation, including penetration of the checklist into operating room culture and its impact on individual staff.…”