Improving implementation of the World Health Organization surgical safety checklist in high-income contexts

BACKGROUND: The World Health Organization’s Surgical Safety Checklist (SSC) is used in over 130 countries to improve patient safety by reducing preventable surgical complications. Previous studies have demonstrated that there is significant variation in adherence to and implementation of the SSC in high-income contexts, which impacts its effectiveness and puts thousands of patients at risk for adverse outcomes. A mixed methods study of multiple high-income contexts was conducted to 1) identify barriers and facilitators to SSC implementation, 2) develop recommendations to improve the likelihood of implementation success, and 3) identify a framework to guide future implementation efforts for the SSC and similar interventions. METHODS: Survey (n=2,032) and interview (n=51) data collected from health care administrators and surgical team members practicing in five high-income countries were analyzed. Descriptive statistics, Chi-squared tests, Fisher’s exact tests, and McNemar’s tests were used to explore and compare differences in survey responses. Thematic content analysis of interview data was used to assess implementation barriers and facilitators and checklist processes both within and across study countries. Predominant themes that emerged across study countries were mapped to the i-PARIHS framework to identify common gaps in current implementation practices. RESULTS: Study participants cited use of well-liked and well-respected peer champions, receiving education on the background and rationale for the SSC, and use of a shared leadership model for performing checklist processes as facilitators to successful implementation. However, time pressures in the operating room, reported disconnects between SSC patient safety goals and organizational priorities, and lack of local evidence of checklist effectiveness were cited as barriers to implementation. Key findings mapped well to the i-PARIHS framework, which facilitated the identification of specific areas of improvement for current implementation efforts. CONCLUSION: Informal leadership, better alignment of SSC use with organizational priorities, and use of relevant performance metrics appear to be a key factors in the success of SSC implementation. Implementers should consider using abbreviated network and stakeholder analyses to identify highly influential SSC champions, utilize patient safety metrics to develop local evidence of checklist effectiveness, and use the i-PARIHS framework to assess their context and develop a tailored implementation plan.2023-09-10T00:00:00