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

Making tacit knowledge explicit through objects: a qualitative study of the translation of resilience into practice

IntroductionIt is common practice to use objects to bridge disciplines and develop shared understanding across knowledge boundaries. Objects for knowledge mediation provide a point of reference which allows for the translation of abstract concepts into more externalized representations. This study reports from an intervention that introduced an unfamiliar resilience perspective in healthcare, through the use of a resilience in healthcare (RiH) learning tool. The aim of this paper is to explore how a RiH learning tool may be used as an object for introduction and translation of a new perspective across different healthcare settings.MethodsThis study is based on empirical observational data, collected throughout an intervention to test a RiH learning tool, developed as part of the Resilience in Healthcare (RiH) program. The intervention took place between September 2022 and January 2023. The intervention was tested in 20 different healthcare units, including hospitals, nursing homes and home care services. A total of 15 workshops were carried out, including 39-41 participants in each workshop round. Throughout the intervention, data was gathered in all 15 workshops at the different organizational sites. Observation notes from each workshop make up the data set for this study. The data was analyzed using an inductive thematic analysis approach.Results and conclusionThe RiH learning tool served as different forms of objects during the introduction of the unfamiliar resilience perspective for healthcare professionals. It provided a means to develop shared reflection, understanding, focus, and language for the different disciplines and settings involved. The resilience tool acted as a boundary object for the development of shared understanding and language, as an epistemic object for the development of shared focus and as an activity object within the shared reflection sessions. Enabling factors for the internalization of the unfamiliar resilience perspective were to provide active facilitation of the workshops, repeated explanation of unfamiliar concepts, provide relatedness to own context, and promote psychological safety in the workshops. Overall, observations from the testing of the RiH learning tool showed how these different objects were crucial in making tacit knowledge explicit, which is key to improve service quality and promote learning processes in healthcare

Feasibility of implementing a surgical patient safety checklist: prospective cross-sectional evaluation

Background The World Health Organization’s Global Patient Safety Action Plan 2021–2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients’ involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients’ completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial. Methods This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis. Results Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway. Conclusions Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety.publishedVersio

Development and validation of patients' surgical safety checklist

Background Poor uptake and understanding of critical perioperative information represent a major safety risk for surgical patients. Implementing a patient-driven surgical safety checklist might enhance the way critical information is given and increase patient involvement in their own safety throughout the surgical pathway. The aim of this study was to develop and validate a Surgical Patient Safety Checklist (PASC) for use by surgical patients. Method This was a prospective study, involving patient representatives, multidisciplinary healthcare professionals and elective surgical patients to develop and validate PASC using consensus-building techniques in two Norwegian hospitals. A set of items intended for PASC were rated by patients and then submitted to Content Validation Index (CVI) analyses. Items of low CVI went through a Healthcare Failure Mode and Effect Analysis (HFMEA) Hazard Scoring process, as well as a consensus process before they were either kept or discarded. Reliability of patients’ PASC ratings was assessed using Intraclass Correlation Coefficient analysis. Lastly, the face validity of PASC was investigated through focus group interviews with postoperative patients. Results Initial development of PASC resulted in a checklist consisting of two parts, one before (32 items) and one after surgery (26 items). After achieving consensus on the PASC content, 215 surgical patients from six surgical wards rated the items for the CVI analysis on a 1-4 scale and mostly agreed on the content. Five items were removed from the checklist, and six items were redesigned to improve PASCs’ user-friendliness. The total Scale-level index/Average (S-CVI/Ave) before revision was 0.83 and 0.86 for pre- and post-operative PASC items, respectively. Following revision, these increased to 0.86 and 0.93, respectively. The PASC items reliability score was 0.97 (95% confidence interval 0.96 to 0.98). The qualitative assessment identified that patients who used PASC felt more in control of their situation; this was achieved when PASC was given to them at what they felt was the right time and healthcare professionals took part in its usage. Conclusion Multidisciplinary perioperative care staff and surgical patients agreed upon PASC content, the checklist ratings were reliable, and qualitative assessment suggested good face validity. PASC appears to be a usable and valid checklist for elective surgical patients across specialties.publishedVersio

Влияние изменений климата на геоэкологические риски нефтегазовой отрасли в районах вечной мерзлоты

Objective: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications. Background: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement. Methods: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ 2 test and binary logistic regression. Results: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38–0.72) for intervention procedures, 0.54 (95% CI: 0.37–0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11–0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC. Conclusions: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SCC implementation and improved care processes led to better patient outcomes

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

Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room

Background: Even though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO’s Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators. Methods: Grounded theory was used in gathering and analyzing data from observations of the checklist used in the operating room, in conjunction with single and focus group interviews. A purposeful sample of 14 nurse-anesthetists and operating room nurses as surgical team members in a tertiary teaching hospital participated in the study. Results: The nurses’ main concern regarding checklist utilization was identified as “how to obtain professional and social acceptance within the team”. The emergent grounded theory of “adjusting team involvement” consisted of three strategies; distancing, moderating and engaging team involvement. The use of these strategies explains how they resolved their challenges. Each strategy had corresponding conditions and consequences, determining checklist compliance, and how the checklist was used. Conclusion: Even though nurses seem to have a loyal attitude towards the WHO’s checklist regarding their task work, they adjusted their surgical team involvement according to practical, social and professional conditions in their work environment. This might have resulted in the incomplete use of the checklist and therefore a low compliance rate. Findings also emphasized the importance of: a) management support when implementing WHO’s Safe Surgical Checklist, and b) interprofessional education approach to local adaptation of the checklists use

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties

Background The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffʼs perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored – yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies. Methods An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis. Results We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSCʼs practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded. Conclusion When the SSC is not integrated within existing risk management strategies, but perceived as an “add on”, its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.publishedVersio

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties

Background The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffʼs perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored – yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies. Methods An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis. Results We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSCʼs practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded. Conclusion When the SSC is not integrated within existing risk management strategies, but perceived as an “add on”, its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation