Impact of the WHO Surgical Safety Checklist implementation on perioperative work and risk perceptions : A process evaluation by use of quantitative and qualitative methods

Background: Human performance deficiencies account for a large proportion of adverse surgical events. The World Health Organization (WHO) Surgical Safety Checklist (SSC) was launched to improve teamwork and patient outcome. Its introduction in hospitals worldwide has been associated with beneficial impacts on a range of patient and team outcomes. However, both the implementation quality and the comprehensive inclusion of all parts of the checklist is reported to differ among hospitals, surgical specialties and surgical staff members. To understand and engage with these differences, studies were warranted to investigate both perioperative work processes and process indicators associated with positive SSC outcomes. Aims: To investigate the impact of WHO SSC implementation on perioperative care processes and patient outcome. To explore perioperative work processes in the provision of surgical antibiotic prophylaxis (SAP) following the SSC implementation. To explore how the WHO SSC fits with existing perioperative risk management strategies among the multidisciplinary team members. Methods: A combination of quantitative and qualitative methods was used in the studies for this thesis, including data from patients, healthcare personnel and perioperative teamwork observations. In Study 1, we performed a secondary analysis of a WHO SSC stepped wedge cluster randomised control trial. A total of 3,708 surgical procedures were analysed from three surgical units (neurosurgery, cardiothoracic, and orthopaedic) from Haukeland University Hospital. We examined how the SSC implementation quality affected perioperative work processes and patient outcome. In Study 2 and Study 3, we used a prospective ethnographic design, combining 40 hours of observations and 22 single face-to-face interviews of key informants, conducted at Haraldsplass Deaconess Hospital, Førde Central Hospital and Haukeland University Hospital. We explored perioperative work processes in relation to SSC utilisation. In Study 2, we outlined the provision of surgical antibiotic prophylaxis, and in Study 3, we analysed the integration of the SSC in local and professional perioperative risk management. Results: In Study 1, the results showed that high-quality SSC implementation, i.e., all 3 checklist parts used, was significantly associated with improved perioperative work processes (preoperative site marking, normothermia protection, and timely provision of SAP pre-incision) and reduction of complications (surgical infections, wound rupture, perioperative bleeding, and cardiac and respiratory complications). In Study 2, we identified that the provision of SAP was a complex process and outlined the linked perioperative work processes. This involved several interacting factors related to preparation and administration, prescription accuracy and systems, patient specific conditions and changes in the operating theatre schedules. The timeframe of 60 minutes described in the SSC was a prominent mechanism in facilitating administration of SAP before incision. In Study 3, we identified three dominant strategies: “assessing utility”, “customising SSC implementation”, and “interactive micro-team communication”. Each of these reflected on how the SSC was integrated into risk management strategies in daily surgical practice. Each strategy had corresponding categories describing how SSC utility assessment was carried out and how performance of SSC was customized, mainly according to actual presence of team members and barriers of performance. The strategy of “interactive micro-team communication” included formal and informal micro-team formations where detailed, and specific risk assessments unfolded. Conclusion: Utilisation of all 3 parts of the SSC was significantly associated with improved processes and outcomes of care. Overall improvement of SAP administration is likely to have been influenced by the SSC timeframe of “60 minutes prior to incision”, either as a cognitive “reminder” of timely administration and /or as an educational intervention. Although the SSC use has made significant impact on specific perioperative work processes, identified norms of behaviour and communication indicate that the SSC seemed not to be fully integrated into existing perioperative risk management strategies on a daily basis among the multidisciplinary team members