Clinical motivation and the surgical safety checklist

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist

Importance

Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety.

Objective

To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients.

Design, Setting, and Participants

This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff.

Intervention

The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021.

Main Outcomes and Measures

Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses.

Results

Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications.

Conclusions and Relevance

Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

Network prediction of surgical complication clusters: a prospective multicenter cohort study

Complicated relationships exist in both occurrence and progression of surgical complications, which are difficult to account for using a separate quantitative method such as prediction or grading. Data of 51,030 surgical inpatients were collected from four academic/teaching hospitals in a prospective cohort study in China. The relationship between preoperative factors, 22 common complications, and death was analyzed. With input from 54 senior clinicians and following a Bayesian network approach, a complication grading, cluster-visualization, and prediction (GCP) system was designed to model pathways between grades of complication and preoperative risk factor clusters. In the GCP system, there were 11 nodes representing six grades of complication and five preoperative risk factor clusters, and 32 arcs representing a direct association. Several critical targets were pinpointed on the pathway. Malnourished status was a fundamental cause widely associated (7/32 arcs) with other risk factor clusters and complications. American Society of Anesthesiologists (ASA) score ⩾3 was directly dependent on all other risk factor clusters and influenced all severe complications. Grade III complications (mainly pneumonia) were directly dependent on 4/5 risk factor clusters and affected all other grades of complication. Irrespective of grade, complication occurrence was more likely to increase the risk of other grades of complication than risk factor clusters.

Factors Causing Variation in World Health Organization Surgical Safety Checklist Effectiveness-A Rapid Scoping Review

INTRODUCTION

This review was conducted to determine what factors might be responsible for prejudicing the outcomes after the implementation of a World Health Organization Surgical Safety Checklist (WHO SSC), grouping them appropriately and proposing strategies that enable the SSC a more helpful and productive tool in the operating room.

METHODS

It was a rapid scoping review conducted as per Preferred Reporting Items for Systematic Review and Meta-analyses extension guidelines for scoping reviews (PRISMA-Scr). Comprehensive search on MEDLINE and Embase was carried out, to include all relevant studies published during last 5 years. Twenty-seven studies were included in analysis. The barriers to SSC implementation were classified into 5 main groups, with further subdivisions in each.

RESULTS

The results of review revealed that there are 5 major barriers to SSC at the following levels: organizational, checklist, individual, technical, and implementation. Each of these major barriers, on further evaluation, was found to have more than one contributing factors. All these factors were analyzed individually.

CONCLUSIONS

This rapid scoping review has consolidated data, which may pave the way for experts to further examine steps that might be taken locally or globally in order that the WHO SSC to successfully achieve all its desired goals.

Factors that enhance compliance with the Surgical Safety Checklist

BACKGROUND

The World Health Organization (WHO) has reported that its Surgical Safety Checklist (SSC) has resulted in significant reductions in morbidity and mortality. Despite its proven success, meaningful compliance with the Surgical Safety Checklist initiative has been low.

AIMS

The authors sought to identify and explore published research on factors that enhance compliance with the SSC within surgical team members.

METHODS

A review of the literature published between January 2017 and January 2021 was undertaken. Six databases were searched, and 1340 studies were screened for eligibility. The 17 studies included were critically appraised using the Crowe Critical Appraisal Tool.

FINDINGS

Three main themes were identified: training and innovations; process adaptations and team leadership.

CONCLUSION

This review of the literature draws attention to the complexities of checklist compliance and identifies the need for training, leadership and adaptation to new safety processes.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Surgical safety checklists for dental implant surgeries-a scoping review

OBJECTIVES

In both elective surgeries and aviation, a reduction of complications can be expected by paying attention to the so-called human factors. Checklists are a well-known way to overcome some of these problems. We aimed to evaluate the current evidence regarding the use of checklists in implant dentistry.

METHODS

An electronic literature search was conducted in the following databases: CINHAL, Medline, Web of Science, and Cochrane Library until March 2022. Based on the results and additional literature, a preliminary checklist for surgical implant therapy was designed.

RESULTS

Three publications dealing with dental implants and checklists were identified. One dealt with the use of a checklist in implant dentistry and was described as a quality assessment study. The remaining two studies offered suggestions for checklists based on literature research and expert opinion.

CONCLUSIONS

Based on our results, the evidence for the use of checklists in dental implantology is extremely low. Considering the great potential, it can be stated that there is a need to catch up. While creating a new implant checklist, we took care of meeting the criteria for high-quality checklists. Future controlled studies will help to place it on a broad foundation.

CLINICAL RELEVANCE

Checklists are a well-known way to prevent complications. They are especially established in aviation, but many surgical specialties and anesthesia adopt this successful concept. As implantology has become one of the fastest-growing areas of dentistry, it is imperative that checklists become an integral part of it.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis

OBJECTIVES

To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact.

BACKGROUND

The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood.

METHODS

We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034).

RESULTS

We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52).

CONCLUSIONS

The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Attitudes and compliance with the WHO surgical safety checklist: a survey among surgeons and operating room staff in 138 hospitals in China

Background

Ten years after the introduction of the Chinese Ministry of Health (MoH) version of Surgical Safety Checklist (SSC) we wished to assess the ongoing influence of the World Health Organisation (WHO) SSC by observing all three checklist components during elective surgical procedures in China, as well as survey operating room staff and surgeons more widely about the WHO SSC.

Methods

A questionnaire was designed to gain authentic views on the WHO SSC. We also conducted a prospective cross-sectional study at five level 3 hospitals. Local data collectors were trained to document specific item performance. Adverse events which delayed the operation were recorded as well as the individuals leading or participating in the three SSC components.

Results

A total of 846 operating room staff and surgeons from 138 hospitals representing every mainland province responded to the survey. There was widespread acceptance of the checklist and its value in improving patient safety.

860 operations were observed for SSC compliance. Overall compliance was 79.8%. Compliance in surgeon-dependent items of the ‘time-out’ component reduced when it was nurse-led (p < 0.0001). WHO SSC interventions which are omitted from the MoH SSC continued to be discussed over half the time. Overall adverse events rate was 2.7%. One site had near 100% compliance in association with a circulating inspection team which had power of sanction.

Conclusion

The WHO SSC remains a powerful tool for surgical patient safety in China. Cultural changes in nursing assertiveness and surgeon-led teamwork and checklist ownership are the key elements for improving compliance. Standardised audits are required to monitor and ensure checklist compliance.

Effects of a Perioperative Safety Checklist on Postoperative Complications Following Surgery for Gastric Cancer: A Single-Center Preliminary Study

Objective. A Perioperative Safety Checklist (PSC) for gastric cancer (GC) was established to evaluate the effects of PSC on the clinical outcomes of GC. Methods. This single-center preliminary observational study conducted at a tertiary referral hospital included patients with GC who underwent surgery from January 1, 2016, to June 30, 2016, treated without PSC (allocated to the control group) and those who underwent surgery between January 1, 2017, and June 30, 2017, managed according to the PSC designated as the PSCGC (Perioperative Safety Checklist for Gastric Cancer) group. Results. Overall, 1072 cases were enrolled, 556 cases in PSCGC group and 526 cases in control group. After matching, there were 474 patients in each group. PSC intervention led to significant reductions of the incidence of postoperative intestinal fistula formation ( P = .034), the incidence of unplanned secondary surgery ( P = 0.039), and the total hospitalization expenses ( P < .001). Total completion rate of all 14 checklists items was 79.1%. Intraoperative blood loss in the complete and partial implementation groups was significantly lower than the complete nonimplementation group ( P = .002), whereas hospitalization cost showed an opposite trend, which was significantly higher in the incomplete nonimplementation group ( P = .015). Conclusion. PSC implementation was associated with a decreased incidence of gastrointestinal fistula formation, unplanned secondary surgery, and hospitalization cost in patients with GC. However, it had no effect on the in-hospital mortality, the incidence of postoperative complications during hospitalization (ie, incision complications and lung infections), unplanned secondary admission, and the duration of postoperative hospital stay.

Effect Of Surgical Safety Checklists On Gastric Cancer Outcomes: A Single-Center Retrospective Study

Aims

Surgery is the primary treatment option for patients with gastric cancer, however the rate of postoperative complications are still high. The implementation of surgical safety checklists (SSCs) has been shown to reduce morbidity and mortality. This study aimed to evaluate the effect of SSCs on the clinical outcomes of gastric cancer.

Methods

A total of 881 gastric cancer patients who underwent D2 gastrectomy from May 2009 to April 2011 in a large teaching hospital in China were included in this retrospective study. Patients were matched and divided into the control group (SSC nonimplementation) and intervention group (SSC implementation). The outcomes including intraoperative condition, postoperative complications, and prognosis were then compared between the groups.

Results

The control group comprised 414 patients (47.0%), and the intervention group included 467 patients (53.0%). Patients in the intervention group had a significantly shorter length of postoperative stay (P < 0.001). Operation time, blood loss, blood transfusion, and hospital charges were comparable between the two groups (all P > 0.05). SSC was not associated with postoperative complications (all P > 0.05). Overall survival was also comparable between patients in the two groups (P > 0.05).

Conclusion

The implementation of an SSC was associated with a decreased length of postoperative stay in gastric cancer patients following D2 gastrectomy but did not significantly affect the other outcomes.

Effect of a risk-stratified intervention strategy on surgical complications: experience from a multicentre prospective study in China

OBJECTIVES

To develop a risk-stratified intervention strategy and evaluate its effect on reducing surgical complications.

DESIGN

A multicentre prospective study with preintervention and postintervention stages: period I (January to June 2015) to develop the intervention strategy and period II (January to June 2016) to evaluate its effectiveness.

SETTING

Four academic/teaching hospitals representing major Chinese administrative and economic regions.

PARTICIPANTS

All surgical (elective and emergent) inpatients aged ≥14 years with a minimum hospital stay of 24 hours, who underwent a surgical procedure requiring an anesthesiologist.

INTERVENTIONS

Targeted complications were grouped into three categories (common, specific, serious) according to their incidence pattern, severity and preventability. The corresponding expert consensus-generated interventions, which focused on both regulating medical practices and managing inherent patient-related risks, were implemented in a patient-tailored way via an electronic checklist system.

PRIMARY AND SECONDARY OUTCOMES

Primary outcomes were (1) in-hospital death/confirmed death within 30 days after discharge and (2) complications during hospitalisation. Secondary outcome was length of stay (LOS).

RESULTS

We included 51 030 patients in this analysis (eligibility rate 87.7%): 23 413 during period I, 27 617 during period II. Patients' characteristics were comparable during the two periods. After adjustment, the mean number of overall complications per 100 patients decreased from 8.84 to 7.56 (relative change 14.5%; P<0.0001). Specifically, complication rates decreased from 3.96 to 3.65 (7.8%) for common complications (P=0.0677), from 0.50 to 0.36 (28.0%) for specific complications (P=0.0153) and from 3.64 to 2.88 (20.9%) for serious complications (P<0.0001). From period I to period II, there was a decreasing trend for mortality (from 0.64 to 0.53; P=0.1031) and median LOS (by 1 day; P=0.8293), without statistical significance.

CONCLUSIONS

Implementing a risk-stratified intervention strategy may be a target-sensitive, convenient means to improve surgical outcomes.

Use of the WHO surgical safety checklist in low and middle income countries: A review of the literature

A wealth of research now exists surrounding use of the WHO surgical safety checklist. This paper reviews the literature regarding checklist use in developing countries. Results identify a lack of available literature specific to developing countries despite this potentially being where the greatest impact could be observed. Unique challenges of checklist use are discussed and opportunities for future research focusing on use of the checklist in developing countries suggested.

Protocol for a multicentre, multistage, prospective study in China using system-based approaches for consistent improvement in surgical safety

INTRODUCTION

Surgical safety has emerged as a crucial global health issue in the past two decades. Although several safety-enhancing tools are available, the pace of large-scale improvement remains slow, especially in developing countries such as China. The present project (Modern Surgery and Anesthesia Safety Management System Construction and Promotion) aims to develop and validate system-based integrated approaches for reducing perioperative deaths and complications using a multicentre, multistage design.

METHODS AND ANALYSIS

The project involves collection of clinical and outcome information for 1 20 000 surgical inpatients at four regionally representative academic/teaching general hospitals in China during three sequential stages: preparation and development, effectiveness validation and improvement of implementation for promotion. These big data will provide the evidence base for the formulation, validation and improvement processes of a system-based stratified safety intervention package covering the entire surgical pathway. Attention will be directed to managing inherent patient risks and regulating medical safety behaviour. Information technology will facilitate data collection and intervention implementation, provide supervision mechanisms and guarantee transfer of key patient safety messages between departments and personnel. Changes in rates of deaths, surgical complications during hospitalisation, length of stay, system adoption and implementation rates will be analysed to evaluate effectiveness and efficiency.

ETHICS AND DISSEMINATION

This study was approved by the institutional review boards of Peking Union Medical College Hospital, First Hospital of China Medical University, Qinghai Provincial People's Hospital, Xiangya Hospital Central South University and the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences. Study findings will be disseminated via peer-reviewed journals, conference presentations and patent papers.