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Turley N, Kogut K, Burian B, Moyal-Smith R, Etheridge J, Sonnay Y, Berry W, Merry A, Hannenberg A, Haynes AB, Dias RD, Hagen K, Molina G, Spruce L, Williams C, Brindle ME. Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol. ANNALS OF SURGERY OPEN 2024; 5:e436. [PMID: 38911631 PMCID: PMC11191993 DOI: 10.1097/as9.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
Objectives The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.
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Affiliation(s)
- Nathan Turley
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Karolina Kogut
- From the Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Barbara Burian
- NASA, Ames Research Center, Moffett Field, California, USA
| | - Rachel Moyal-Smith
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
| | - James Etheridge
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Yves Sonnay
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
| | - William Berry
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alan Merry
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Alexander Hannenberg
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alex B. Haynes
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas Austin, Austin, TX
| | - Roger D. Dias
- STRATUS Center for Medical Simulation, Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Kathryn Hagen
- Department of Anaesthesia and Peri-operative Medicine, Te Toka Tumai|Auckland City Hospital, Te Whātua Ora|Health New Zealand, New Zealand
| | - George Molina
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Lisa Spruce
- Sr. Director, Evidence-based Perioperative Practice at AORN, Denver, CO
| | | | - Mary E. Brindle
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, MA
- Professor of Surgery and Community Health Sciences, Cumming School of Medicine University of Calgary, Pediatric General Surgeon, Alberta Children’s Hospital, Calgary, AB
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Weller JM, Mahajan R, Fahey-Williams K, Webster CS. Teamwork matters: team situation awareness to build high-performing healthcare teams, a narrative review. Br J Anaesth 2024; 132:771-778. [PMID: 38310070 DOI: 10.1016/j.bja.2023.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 02/05/2024] Open
Abstract
Healthcare today is the prerogative of teams rather than of individuals. In acute care domains such as anaesthesia, intensive care, and emergency medicine, the work is complex and fast-paced, and the team members are diverse and interdependent. Three decades of research into the behaviours of high-performing teams provides us with clear guidance on team training, demonstrating positive effects on patient safety and staff wellbeing. Here we consider team performance through the lens of situation awareness. Maintaining situation awareness is an absolute requirement for safe and effective patient management. Situation awareness is a dynamic process of perceiving cues in the environment, understanding what they mean, and predicting how the situation may evolve. In the context of acute clinical care, situation awareness can be improved if the whole team actively contributes to monitoring the environment, processing information, and planning next steps. In this narrative review, we explore the concept of situation awareness at the level of the team, the conditions required to maintain team situation awareness, and the relationship between team situation awareness, shared mental models, and team performance. Our ultimate goal is to help clinicians create the conditions required for high-functioning teams, and ultimately improve the safety of clinical care.
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Affiliation(s)
- Jennifer M Weller
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand; Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.
| | - Ravi Mahajan
- Centre of Excellence in Critical Care, Apollo Hospitals Group, Chennai, India; Department of Anaesthesia and Intensive Care, University of Nottingham, Nottingham, UK
| | - Kathryn Fahey-Williams
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Craig S Webster
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand; Department of Anaesthesiology, School of Medicine, University of Auckland, Auckland, New Zealand
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Gillespie BM, Ziemba JB. Lost in translation: does measuring 'adherence' to the Surgical Safety Checklist indicate true implementation fidelity? BMJ Qual Saf 2024; 33:209-211. [PMID: 38191563 DOI: 10.1136/bmjqs-2023-016617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Brigid M Gillespie
- National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland & School of Nursing & Midwifery, Griffith University, Gold Coast, Queensland, Australia
- Gold Coast University Hospital, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Justin Bradley Ziemba
- Department of Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Moyal-Smith R, Etheridge JC, Turley N, Lim SR, Sonnay Y, Payne S, Smid-Nanninga H, Kothari R, Berry W, Havens J, Brindle ME. CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. BMJ Qual Saf 2024; 33:223-231. [PMID: 37734956 DOI: 10.1136/bmjqs-2023-016030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 09/02/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice. METHODS The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability. RESULTS The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23-28), checklist adherence was 7 (6-7), communication effectiveness was 6 (6-7), attitude was 6 (6-7) and engagement was 6 (5-7). CONCLUSIONS CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.
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Affiliation(s)
- Rachel Moyal-Smith
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James C Etheridge
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan Turley
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shu Rong Lim
- Health Services Research Department, Singapore General Hospital, Singapore
| | - Yves Sonnay
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah Payne
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Rishabh Kothari
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - William Berry
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joaquim Havens
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mary E Brindle
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Khalid SY, Sibghatullah QM, Abdullah MH, Farooq O, Ashraf S, Ahmed A, Arshad A, Nadeem A, Mumtaz H, Saqib M. Implementation of World Health Organization behaviorally anchored rating scale and checklist utilization: promising results for LMICs. Front Med (Lausanne) 2023; 10:1204213. [PMID: 37554500 PMCID: PMC10405729 DOI: 10.3389/fmed.2023.1204213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Operating teams can decrease the likelihood of patient risk by using the WHO Surgical Safety Checklist. To ascertain the impact of demographic factors on behaviorally anchored ratings and investigate operating room (OR) staff attitudes toward checklist administration, we set out to better understand how OR personnel use the checklist in a tertiary care hospital in Pakistan. MATERIALS AND METHODS A monocentric sequential mixed-methods study employing a quantitative approach of using World Health Organization Behaviorally Anchored Rating Scale (WHOBARS) assessments of surgical cases by OR personnel and two independent observers, who were certified surgeons having extensive experience in the rating of the WHOBARS scale for more than 1 year, followed by a qualitative approach of staff interviews were carried out in a tertiary care setting. In June and July 2022, over the period of 8 weeks, an intervention (training delivery) was implemented and evaluated. The information, skills, and behavior adjustments required to apply the checklist were taught in the course using lectures, videos, small group breakouts, participant feedback, and simulations. RESULTS After the introduction of WHOBARS, 50.81% of respondents reported always using the checklist, with another 30.81% using it in part. Participants' years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with always counting instruments (51.08%), patient identity (67.83%), difficult intubation risk (39.72%), the risk of blood loss (51.08%), prophylactic administration of an antibiotic (52.43%), and the use of pulse oximeter (46.75%). Interviewees felt that the checklist could promote teamwork and a safe culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. CONCLUSION The use of a multi-disciplinary course for checklist implementation resulted in 50.81% of participants always using the checklist and an increase in counting surgical instruments. Successful checklist implementation was not predicted by the participant's length of medical service, hospital size, or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.
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Affiliation(s)
- Syed Yousaf Khalid
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | | | - Muhammad Haroon Abdullah
- Department of Surgery, Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Pakistan
| | - Omer Farooq
- Department of Surgery, District Headquarter Hospital, Attock, Pakistan
| | - Sandal Ashraf
- Department of Surgery, Midland Regional Hospital Mullingar, Mullingar, Ireland
| | - Adeel Ahmed
- Department of Surgery, Gujranwala Medical College, Gujranwala, Pakistan
| | - Ashhar Arshad
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Abdullah Nadeem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Hassan Mumtaz
- Maroof International Hospital, Health Services Academy, Islamabad, Pakistan
| | - Muhammad Saqib
- Department of Emergency Medicine, Khyber Medical College, Peshawar, Pakistan
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Fridrich A, Imhof A, Staender S, Brenni M, Schwappach D. A Quality Improvement Initiative Using Peer Audit and Feedback to Improve Compliance with the Surgical Safety Checklist. Int J Qual Health Care 2022; 34:6622008. [PMID: 35770658 PMCID: PMC9290878 DOI: 10.1093/intqhc/mzac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/11/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background The Surgical Safety Checklist (SSC) published by the WHO in 2009 is used as standard in surgery worldwide to reduce perioperative patient mortality. However, compliance with the SSC and quality of its application are often not satisfactory. Internal audits and feedbacks seem promising for improving SSC application. Objective The purpose of this study is to investigate whether an intervention consisting of peer observation and immediate peer feedback can be implemented with high fidelity and acceptance. Method Data were obtained from a national pilot programme that was initiated in Switzerland in 2018 to measure and improve compliance with the SSC using peer audit and feedback. A total of 11 hospitals with 14 sites implemented the full intervention. Each hospital formed an interprofessional project team that should perform at least 30 observations with feedback on SSC application documented in an observation tool developed specifically for this programme. Since the SSCs of the study hospitals differ greatly regarding checklist items, for each of the three SSC sections standard items were defined: four at Sign In, five at Team Time Out and two at Sign Out. Frequency analyses were performed for initiation characteristics, SSC application at item level, feedback characteristics and programme evaluation. Results The 11 hospitals documented 715 valid observations, and feedback on SSC application was provided for 79% of the observations. In 61%, all team members stopped their work for the SSC application, and in 71%, the items were read off from the checklist (instead of recalled from memory). On average, 86% of the standard items were read out by the checklist coordinator, whilst the two items at Sign Out were read out only in 60% and 74%. Additional visual checks with another source (e.g. patient wristband) took place in only 41%, and verbal confirmation of the items (by someone else other than the checklist coordinator) was obtained on an average of 76% across all three checklist sections. The surgical teams reacted positively in 64% to the peer feedback. Conclusion Both implementation fidelity and acceptability of the intervention were high—the present intervention seems suitable for regular monitoring of the quality of SSC application with internal resources. Peer observation facilitated identifying weaknesses regarding the SSC process and application at item level. Across all hospitals, the Sign Out section in general, visual control for item checks and lack of work interruption of all team members during SSC application showed up as the main areas of improvement.
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Affiliation(s)
| | - Anita Imhof
- Swiss Patient Safety Foundation, Zurich, Switzerland
| | - Sven Staender
- Department of Anaesthesia & Intensive Care Medicine, Regional Hospital Maennedorf, Maennedorf, Switzerland
| | - Mirko Brenni
- Institute of Anesthesiology, Intensive Care Medicine, Emergency and Rescue Medicine, See-Spital, Horgen, Switzerland
| | - David Schwappach
- Swiss Patient Safety Foundation, Zurich, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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7
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The Impact of Behavioral Anchors in the Assessment of Fellowship Applicants: Reducing Rater Biases. Acad Pediatr 2022; 22:313-318. [PMID: 34864133 DOI: 10.1016/j.acap.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION No standardized evaluation tool for fellowship applicant assessment exists. Assessment tools are subject to biases and scoring tendencies which can skew scores and impact rankings. We aimed to develop and evaluate an objective assessment tool for fellowship applicants. METHODS We detected rater effects in our numerically scaled assessment tool (NST), which consisted of 10 domains rated from 0 to 9. We evaluated each domain, consolidated redundant categories, and removed subjective categories. For 7 remaining domains, we described each quality and developed a question with a behaviorally-anchored rating scale (BARS). Applicants were rated by 6 attendings. Ratings from the NST in 2018 were compared with the BARS from 2020 for distribution of data, skewness, and inter-rater reliability. RESULTS Thirty-four applicants were evaluated with the NST and 38 with the BARS. Demographics were similar between groups. The median score on the NST was 8 out of 9; scores <5 were used in less than 1% of all evaluations. Distribution of data was improved in the BARS tool. In the NST, scores from 6 of 10 domains demonstrated moderate skewness and 3 high skewness. Three of the 7 domains in the BARS showed moderate skewness and none had high skewness. Two of 10 domains in the NST vs 5 of 7 domains in the BARS achieved good inter-rater reliability. CONCLUSION Replacing a standard numeric scale with a BARS normalized the distribution of data, reduced skewness, and enhanced inter-rater reliability in our evaluation tool. This provides some validity evidence for improved applicant assessment and ranking.
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Alexander HC, McLaughlin SJ, Thomas RH, Merry AF. Checklists for image-guided interventions: a systematic review. Br J Radiol 2021; 94:20200980. [PMID: 33684307 DOI: 10.1259/bjr.20200980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Safety checklists have improved safety in patients undergoing surgery. Checklists have been designed specifically for use in image-guided interventions. This systematic review aimed to identify checklists designed for use in radiological interventions and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use. METHODS OVID, MEDLINE, CENTRAL and CINAHL were searched using terms for "interventional radiology" and "checklist". Studies were included if they described pre-procedural checklist use in vascular/body interventional radiology (IR), paediatric IR or interventional neuro-radiology (INR). Data on checklist design, implementation and outcomes were extracted. RESULTS Sixteen studies were included. Most studies (n = 14, 87.5%) focused on body IR. Two studies (12.5%) measured perioperative outcome after checklist implementation, but both had important limitations. Checklist use varied between 54 and 100% and completion of items on the checklists varied between 28 and 100%. Several barriers to checklist use were identified, including a lack of leadership and education and cultural challenges unique to radiology. CONCLUSIONS We found few reports of the use of checklists in image-guided interventions. Approaches to checklist implementation varied, and several barriers to their use were identified. Evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in radiological procedures. ADVANCES IN KNOWLEDGE There are few reports of the use of checklists in radiological interventions, those identified reported significant barriers to the effective use of checklists.
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Affiliation(s)
- Harry C Alexander
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Scott Jp McLaughlin
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Robert H Thomas
- Department of Interventional Radiology, Saint Mary's Hospital, London, UK
| | - Alan F Merry
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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9
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White MC, Daya L, Karel FKB, White G, Abid S, Fitzgerald A, Mballa GAE, Sevdalis N, Leather AJM. Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon. Anesth Analg 2020; 130:1425-1434. [PMID: 31856007 PMCID: PMC7147425 DOI: 10.1213/ane.0000000000004586] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention. METHODS A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist. RESULTS Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%. CONCLUSIONS This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.
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Affiliation(s)
- Michelle C White
- From the Centre for Global Health and Health Partnerships, King's College London, London, United Kingdom.,Department of Anaesthesia, Great Ormond Street Hospital, London, United Kingdom.,Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Leonid Daya
- Department of Anaesthesia and Intensive Care, Faculty of Medicine and Biomedical Sciences of Yaounde, Yaounde, Cameroon
| | | | - Graham White
- Department of Anaesthesia, Royal Alexandra Hospital, Paisley, United Kingdom.,Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Sonia Abid
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Imperial School of Anaesthesia, London, United Kingdom
| | - Aoife Fitzgerald
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Department of Intensive Care, Oxford University Hospitals, Oxford, United Kingdom
| | - G Alain Etoundi Mballa
- Ministry of Public Health, Cameroon.,Faculty of Medicine and Biomedical Sciences of Yaounde, Yaounde, Cameroon
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, United Kingdom
| | - Andrew J M Leather
- From the Centre for Global Health and Health Partnerships, King's College London, London, United Kingdom
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Weller J, Long JA, Beaver P, Cumin D, Frampton C, Garden AL, Moore M, Webster CS, Merry A. Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster-mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals. BMJ Open 2020; 10:e032997. [PMID: 32079573 PMCID: PMC7045010 DOI: 10.1136/bmjopen-2019-032997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals. METHODS AND ANALYSIS Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews. ETHICS AND DISSEMINATION We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143). TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.
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Affiliation(s)
- Jennifer Weller
- Centre for Medical and Health Sciences Education, The University of Auckland, Auckland, New Zealand
| | - Jennifer Anne Long
- Centre for Medical and Health Sciences Education, The University of Auckland, Auckland, New Zealand
| | - Peter Beaver
- Centre for Medical and Health Sciences Education, The University of Auckland, Auckland, New Zealand
| | - David Cumin
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Chris Frampton
- Department of Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand
| | - Alexander L Garden
- Anaesthesia, Wellington Hospital, Wellington, New Zealand
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Matthew Moore
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Craig S Webster
- Centre for Medical and Health Sciences Education, The University of Auckland, Auckland, New Zealand
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
| | - Alan Merry
- Department of Anaesthesiology, The University of Auckland, Auckland, New Zealand
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Patnaik R, Anton NE, Stefanidis D. A video anchored rating scale leads to high inter-rater reliability of inexperienced and expert raters in the absence of rater training. Am J Surg 2020; 219:221-226. [PMID: 31918843 PMCID: PMC10495932 DOI: 10.1016/j.amjsurg.2019.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/01/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our objective was to assess the impact of incorporating videos in a behaviorally anchored performance rating scale on the inter-rater reliability (IRR) of expert, intermediate and novice raters. METHODS The Intra-corporeal Suturing Assessment Tool (ISAT) was modified to include short video clips demonstrating poor, average, and expert performances. Blinded raters used this tool to assess videos of trainees performing suturing on a porcine model. Three attending surgeons, 4 residents, and 4 novice raters participated; no rater training was provided. The IRR was then compared among rater groups. RESULTS The IRR using the modified ISAT was high at 0.80 (p < 0.001). Ratings were significantly correlated with trainee objective suturing scores for all rater groups (experts: R = 0.84, residents: R = 0.81, and novices: R = 0.69; p < 0.001). CONCLUSIONS Incorporating video anchors (to define performance) in the ISAT led to high IRR and enabled novices to achieve similar consistency in their ratings as experts.
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Affiliation(s)
- Ronit Patnaik
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr. Emerson Hall, Indianapolis, IN, 46202, USA.
| | - Nicholas E Anton
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr. Emerson Hall, Indianapolis, IN, 46202, USA.
| | - Dimitrios Stefanidis
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr. Emerson Hall, Indianapolis, IN, 46202, USA.
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Tomczyk S, Aghdassi S, Storr J, Hansen S, Stewardson AJ, Bischoff P, Gastmeier P, Allegranzi B. Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level. J Hosp Infect 2019; 105:83-90. [PMID: 31870887 DOI: 10.1016/j.jhin.2019.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Monitoring and evaluation are an essential part of infection prevention and control (IPC) implementation. The authors developed an IPC assessment framework (IPCAF) to support implementation of the World Health Organization (WHO) guidelines on core components of IPC programmes in acute healthcare facilities. AIM To evaluate the usability and reliability of the IPCAF tool for global use. METHODS The IPCAF is a questionnaire with a scoring system to measure the level of IPC implementation according to the eight WHO core components. The tool was pre-tested qualitatively, revised and translated selectively. A convenience sample of hospitals was invited to participate in the final testing. At least two IPC professionals from each hospital independently completed the IPCAF and a usability questionnaire online. The tool's internal consistency and interobserver reliability or intraclass correlation coefficient (ICC) were assessed, and usability questions were summarized descriptively. FINDINGS In total, 46 countries, 181 hospitals and 324 individuals participated; 52 (16%) and 55 (17%) individual respondents came from low- and lower-middle income countries, respectively. Fifty-two percent of respondents took less than 1 h to complete the IPCAF. Overall, there was adequate internal consistency and a high ICC (0.92, 95% confidence interval 0.89-0.94). Ten individual questions had poor reliability (ICC <0.4); these were considered for revision according to usability feedback and expert opinion. CONCLUSIONS The WHO IPCAF was tested using a robust global study and revised as necessary. It is now an effective tool for IPC improvement in healthcare facilities.
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Affiliation(s)
- S Tomczyk
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland; Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - S Aghdassi
- Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; National Reference Centre for Surveillance of Nosocomial Infections, Berlin, Germany
| | - J Storr
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - S Hansen
- Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; National Reference Centre for Surveillance of Nosocomial Infections, Berlin, Germany
| | - A J Stewardson
- Department of Infectious Diseases, The Alfred and Central Clinical School, Monash University, Melbourne, Australia
| | - P Bischoff
- Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; National Reference Centre for Surveillance of Nosocomial Infections, Berlin, Germany
| | - P Gastmeier
- Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; National Reference Centre for Surveillance of Nosocomial Infections, Berlin, Germany
| | - B Allegranzi
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland; Institute of Global Health, University of Geneva, Geneva, Switzerland.
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Wewiorski NJ, Gorman JA, Ellison ML, Hunt MG, Evans L, Charns MP. A site visit protocol for assessing recovery promotion at the program level: An example from the Veterans Health Administration. Psychiatr Rehabil J 2019; 42:323-328. [PMID: 31233322 PMCID: PMC6741775 DOI: 10.1037/prj0000369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A site visit protocol was developed to assess recovery promotion in the organizational climate and culture of programs for veterans with serious mental illnesses. METHOD The protocol was pilot-tested in 4 programs: 2 that had scored high on the pilot version of a staff survey measure of program-level recovery promotion and 2 that had scored low. Two-person teams conducted onsite visits and assigned global and organizational domain ratings. Interrater agreement was assessed by examining adjacent agreement and computing weighted kappa. RESULTS The on-site protocol had good interrater agreement and discriminated between sites that scored high and low on the staff survey. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE This site visit protocol and procedure shows promise for evaluating recovery promotion in milieu-based programs. After further refinement of this tool, adaptations could be developed for accreditation protocols or for program self-assessment and quality improvement efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Nancy J Wewiorski
- Center for Healthcare Organization and Implementation Research (CHOIR)
| | - Jay A Gorman
- Social and Community Reintegration Research Program (SoCRR), Bedford VA Medical Center
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Banguti PR, Mvukiyehe JP, Durieux ME. The World Health Organization Surgical Safety Checklist: Happy 10th Birthday! Anesth Analg 2019; 127:1283-1284. [PMID: 30433916 DOI: 10.1213/ane.0000000000003732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Paulin R Banguti
- From the Department of Anesthesiology, University of Rwanda, Kigali, Rwanda
| | | | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Higham H, Greig PR, Rutherford J, Vincent L, Young D, Vincent C. Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review. BMJ Qual Saf 2019; 28:672-686. [DOI: 10.1136/bmjqs-2018-008565] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 12/18/2022]
Abstract
BackgroundOver the past three decades multiple tools have been developed for the assessment of non-technical skills (NTS) in healthcare. This study was designed primarily to analyse how they have been designed and tested but also to consider guidance on how to select them.ObjectivesTo analyse the context of use, method of development, evidence of validity (including reliability) and usability of tools for the observer-based assessment of NTS in healthcare.DesignSystematic review.Data sourcesSearch of electronic resources, including PubMed, Embase, CINAHL, ERIC, PsycNet, Scopus, Google Scholar and Web of Science. Additional records identified through searching grey literature (OpenGrey, ProQuest, AHRQ, King’s Fund, Health Foundation).Study selectionStudies of observer-based tools for NTS assessment in healthcare professionals (or undergraduates) were included if they: were available in English; published between January 1990 and March 2018; assessed two or more NTS; were designed for simulated or real clinical settings and had provided evidence of validity plus or minus usability. 11,101 articles were identified. After limits were applied, 576 were retrieved for evaluation and 118 articles included in this review.ResultsOne hundred and eighteen studies describing 76 tools for assessment of NTS in healthcare met the eligibility criteria. There was substantial variation in the method of design of the tools and the extent of validity, and usability testing. There was considerable overlap in the skills assessed, and the contexts of use of the tools.ConclusionThis study suggests a need for rationalisation and standardisation of the way we assess NTS in healthcare and greater consistency in how tools are developed and deployed.
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White MC, Randall K, Capo-Chichi NFE, Sodogas F, Quenum S, Wright K, Close KL, Russ S, Sevdalis N, Leather AJM. Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist. Br J Surg 2019; 106:e91-e102. [PMID: 30620076 PMCID: PMC6519364 DOI: 10.1002/bjs.11034] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 01/19/2023]
Abstract
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. Implementation works
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Affiliation(s)
- M C White
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.,Centre for Global Health and Health Partnerships, King's College London, London, UK.,Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - K Randall
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - N F E Capo-Chichi
- Department of Paediatric Surgery, Centre National Hospitalier Universitaire Hubert Koutoukou Manga, Cotonou, Benin
| | - F Sodogas
- Faculté des Sciences de la Santé de Cotonou, Université d'Abomey Calavi, Cotonou, Benin
| | - S Quenum
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - K Wright
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - K L Close
- Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - S Russ
- Centre for Implementation Science, King's College London, London, UK
| | - N Sevdalis
- Centre for Implementation Science, King's College London, London, UK
| | - A J M Leather
- Centre for Global Health and Health Partnerships, King's College London, London, UK
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Abstract
INTRODUCTION Teamwork is a critical aspect of patient care and is especially salient in response to multiple patient casualties. Effective training and measurement improve team performance. However, the literature currently lacks a scientifically developed measure of team performance within multiple causality scenarios, making training and feedback efforts difficult. The present effort addresses this gap by integrating the input of subject matter experts and the science of multicasualty teams and training to (1) identify overarching teamwork processes and corresponding behaviors necessary for team performance and (2) develop a behavioral observation tool to optimize teamwork in multicasualty training efforts. METHOD A search of articles including team performance frameworks associated with team training was conducted, leading to the identification of a total of 14 articles. Trained coders extracted teamwork processes and the corresponding team behaviors indicative of effective performance from these articles. Five subject matter experts were interviewed using the critical incident technique to identify additional behaviors. RESULTS Team situation awareness, team leadership, coordination, and information exchange emerged as the four core team processes required for team performance in scenarios with multiple patient casualties. Relevant behaviors and subbehaviors within these overarching processes were identified to inform a pilot behavioral framework of team performance. CONCLUSIONS The processes and associated behaviors identified within this effort serve as scientifically grounded behaviors of team performance in the case of multiple patient casualties simulated training scenarios. Future work can use and further refine these results to ensure that measures of team performance are grounded in specific, observable, and scientifically delineated behaviors.
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Protocol for process evaluation of evidence-based care pathways: the case of colorectal cancer surgery. INT J EVID-BASED HEA 2019; 16:145-153. [PMID: 30095534 DOI: 10.1097/xeb.0000000000000149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting. METHODS The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews. DISCUSSION To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.
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Medvedev ON, Merry AF, Skilton C, Gargiulo DA, Mitchell SJ, Weller JM. Examining reliability of WHOBARS: a tool to measure the quality of administration of WHO surgical safety checklist using generalisability theory with surgical teams from three New Zealand hospitals. BMJ Open 2019; 9:e022625. [PMID: 30782682 PMCID: PMC6340010 DOI: 10.1136/bmjopen-2018-022625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To extend reliability of WHO Behaviourally Anchored Rating Scale (WHOBARS) to measure the quality of WHO Surgical Safety Checklist administration using generalisability theory. In this context, extending reliability refers to establishing generalisability of the tool scores across populations of teams and raters by accounting for the relevant sources of measurement errors. DESIGN Cross-sectional random effect measurement design assessing surgical teams by the five items on the three Checklist phases, and at three sites by two trained raters simultaneously. SETTING The data were collected in three tertiary hospitals in Auckland, New Zealand in 2016 and included 60 teams observed in 60 different cases with an equal number of teams (n=20) per site. All elective and acute cases (adults and children) involving surgery under general anaesthesia during normal working hours were eligible. PARTICIPANTS The study included 243 surgical staff members, 138 (50.12%) women. MAIN OUTCOME MEASURE Absolute generalisability coefficient that accounts for variance due to items, phases, sites and raters for the WHOBARS measure of the quality of WHO Surgical Safety Checklist administration. RESULTS The WHOBARS in its present form has demonstrated good generalisability of scores across teams and raters (G absolute=0.83). The largest source of measurement error was the interaction between the surgical team and the rater, accounting for 16.7% (95% CI 16.4 to 16.9) of the total variance in the data. Removing any items from the WHOBARS led to a decrease in the overall reliability of the instrument. CONCLUSIONS Assessing checklist administration quality is important for promoting improvement in its use, and WHOBARS offers a reliable approach for doing this.
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Affiliation(s)
- Oleg N Medvedev
- Center for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Carmen Skilton
- Center for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Derryn A Gargiulo
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Simon J Mitchell
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Jennifer M Weller
- Center for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
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White MC, Randall K, Ravelojaona VA, Andriamanjato HH, Andean V, Callahan J, Shrime MG, Russ S, Leather AJM, Sevdalis N. Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Health 2018; 3:e001104. [PMID: 30622746 PMCID: PMC6307586 DOI: 10.1136/bmjgh-2018-001104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/24/2018] [Accepted: 10/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background The WHO Surgical Safety Checklist reduces postoperative complications by up to 50% with the biggest gains in low-income and middle-income countries (LMICs). However in LMICs, checklist use is sporadic and widespread implementation has hitherto been unsuccessful. In 2015/2016, we partnered with the Madagascar Ministry of Health to undertake nationwide implementation of the checklist. We report a longitudinal evaluation of checklist use at 12-18 months postimplementation. Methods Hospitals were identified from the original cohort using purposive sampling. Using a concurrent triangulation mixed-methods design, the primary outcome was self-reported checklist use. Secondary outcomes included use of basic safety processes, assessment of team behaviour, predictors of checklist use, impact on individuals and organisational culture and identification of barriers. Data were collected during 1-day hospital visits using validated questionnaires, WHO Behaviourally Adjusted Rating Scale (WHOBARS) assessment tool and focus groups and analysed using descriptive statistics, multivariate linear regression and thematic analysis. Results 175 individuals from 14 hospitals participated. 74% reported sustained checklist use after 15 months. Mean WHOBARS scores were high, indicating good team engagement. Sustained checklist use was associated with an improved overall understanding of patient safety but not with WHOBARS, hospital size or surgical volume. 87% reported improved understanding of patient safety and 83% increased job satisfaction. Thematic analysis identified improvements in hospital culture (teamwork and communication, preparation and organisation, trust and confidence) and hospital practice (pulse oximetry, timing of antibiotic prophylaxis, introduction of a surgical count). Lack of time in an emergency and obstructive leadership were the greatest implementation barriers. Conclusion 74% of participants reported sustained checklist use 12-18 months following nationwide implementation in Madagascar, with associated improvements in job satisfaction, culture and compliance with safety procedures. Further work is required to examine this implementation model in other countries.
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Affiliation(s)
- Michelle C White
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Kirsten Randall
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | | | - Hery H Andriamanjato
- Directeur du Partenariat, Ministère de la Santé Publique, Antananarivo, Madagascar
| | - Vanessa Andean
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - James Callahan
- Department of Medical Capcity Building, Mercy Ships Africa Bureau, Cotonou, Benin
| | - Mark G Shrime
- Centre for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Stephanie Russ
- Centre for Implementation Science, King’s College London, London, UK
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, King’s College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King’s College London, London, UK
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Weller JM, Jowsey T, Skilton C, Gargiulo DA, Medvedev ON, Civil I, Hannam JA, Mitchell SJ, Torrie J, Merry AF. Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals. BMJ Open 2018; 8:e022882. [PMID: 30559155 PMCID: PMC6303739 DOI: 10.1136/bmjopen-2018-022882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration. DESIGN Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews. PARTICIPANTS OR staff in three New Zealand hospitals. OUTCOME MEASURES Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration. RESULTS Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. CONCLUSIONS The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.
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Affiliation(s)
- Jennifer M Weller
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Tanisha Jowsey
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Carmen Skilton
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Derryn A Gargiulo
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Oleg N Medvedev
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
| | - Ian Civil
- Division of Surgery, Auckland City Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Simon J Mitchell
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Jane Torrie
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Crisis Resource Management in the Delivery Room: Development of Behavioral Markers for Team Performance in Emergency Simulation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15030439. [PMID: 29510491 PMCID: PMC5876984 DOI: 10.3390/ijerph15030439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 11/28/2022]
Abstract
Human factors are the most relevant issues contributing to adverse events in obstetrics. Specific training of Crisis Resource Management (CRM) skills (i.e., problem solving and team management, resource allocation, awareness of environment, and dynamic decision-making) is now widespread and is often based on High Fidelity Simulation. In order to be used as a guideline in simulated scenarios, CRM skills need to be mapped to specific and observable behavioral markers. For this purpose, we developed a set of observable behaviors related to the main elements of CRM in the delivery room. The observational tool was then adopted in a two-days seminar on obstetric hemorrhage where teams working in obstetric wards of six Italian hospitals took part in simulations. The tool was used as a guide for the debriefing and as a peer-to-peer feedback. It was then rated for its usefulness in facilitating the reflection upon one’s own behavior, its ease of use, and its usefulness for the peer-to-peer feedback. The ratings were positive, with a median of 4 on a 5-point scale. The CRM observational tool has therefore been well-received and presents a promising level of inter-rater agreement. We believe the tool could have value in facilitating debriefing and in the peer-to-peer feedback.
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