Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar

Close, Kristin L.; Baxter, Linden; Ravelojaona, Vaonandianina A; Rakotoarison, Hasiniaina N; Bruno, Emily; Herbert, Alison; Andean, Vanessa; Callahan, James M.; Andriamanjato, Hery Harimanitra; White, Michelle

doi:10.1136/bmjgh-2017-000430

Cited by 25 publications

(38 citation statements)

References 22 publications

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“…Indeed, wide variation in compliance rates (39–100 per cent) has been shown in England and New Zealand, and the present results showed a similar variation in individual checklist items and WHOBARS scores. These results are comparable to those of a previous study in Madagascar, which used the same 3‐day multidisciplinary training model for nationwide checklist implementation. This indicates that the present model of checklist scale‐up is transferable between countries.…”

Section: Discussionsupporting

confidence: 85%

“…The checklist course design embraced this construct as the implementation team ensured that each hospital kept the core components (the 6 basic safety steps) but adapted the other checklist items to suit the local environment. This flexibility is known to overcome implementation barriers.…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: Methodsmentioning

confidence: 99%

“…Focus groups used a previously reported discussion guide to provide qualitative data on checklist use as experienced by operating room staff.…”

Section: Methodsmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

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

White

Randall

Capo-Chichi

et al. 2019

British Journal of Surgery

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Background The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods This study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results At 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.

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Section: Discussionsupporting

confidence: 85%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…Focus groups used a previously reported discussion guide to provide qualitative data on checklist use as experienced by operating room staff.…”

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

White

Randall

Capo-Chichi

et al. 2019

British Journal of Surgery

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Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Collaborative¹

2019

British Journal of Surgery

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Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high‐HDI countries (risk difference −9·4 (95 per cent c.i. −11·9 to −6·9) per cent; P < 0·001), but the relationship was reversed in low‐HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30‐day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low‐ and middle‐HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low‐HDI countries was half that in high‐HDI countries.

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A Team‐Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

Hellar¹,

Tibyehabwa²,

Ernest³

et al. 2019

World j. surg.

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Introduction Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates. Methods We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018. Results During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p \ 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p \ 0.05). Conclusion and recommendationsOur findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania's National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

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Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar

Cited by 25 publications

References 22 publications

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

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

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

A Team‐Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

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