Surgical Checklists: Key Considerations for Optimising Design and Implementation in Today’s Practices

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As previously discussed, the success of checklists in surgery has led to the broadening of their application in healthcare [1]. Surgical checklists aim to reduce unnecessary deaths and complications in the operating room (OR) as well as reinforce accepted safety practices and improve communication between team members [2].

The use of the 2008 World Health Organization (WHO) Surgical Safety Checklist (SSC) gained prominence with the publication of a study in the New England Journal of Medicine that suggested efficacy for improving surgical outcomes [3]. The simplicity and brevity of its one-page design was not accidental; the format was intended to make it easy for local practices to adapt the SSC to their unique surgical settings [4]. Nevertheless, while simplicity may be a virtue in general, for the purpose of surgical checklist design and integration into existing practices [4], further complexity is warranted in some settings [5]. A recent report by The European Society of Thoracic Surgeons (ESTS) noted the need for a more a complex checklist design to accommodate the high-level requirements of thoracic surgical procedures [5]. Like the WHO SSC, the ESTS checklist is divided into three time points, but it places greater emphasis on the period prior to anaesthesia induction [5].

Many professional organisations now recommend the use of surgical checklists [6], and some government policies even mandate their adoption [7]. The WHO has reported that more than 4,000 institutions around the world have registered their interest in the SSC, and approximately 1,800 have used it [8]. In a study of Swiss hospitals, a surgical checklist was used in the majority (79.1%) of ORs, and use of a checklist entitled ‘The Swiss Patient Safety Foundation recommendations to avoid Wrong Site Surgery’ was the most prevalent (38.6%), followed by the WHO SSC (25.1%) and various others (15.1%) [9]. A large proportion of the doctors (84.1%) and nurses (79.9%) who reported using a checklist used it ‘almost all’ or ‘all’ of the time [9]. Other studies have demonstrated less common usage of surgical checklists. A survey study involving 6,269 medical professionals from 69 countries reported that the WHO SSC was used by only half of the respondents (57.5%) [10]. Those practising in high-income countries were more likely to apply the checklist than those in lower-income ones (83.5% vs 43.5%, respectively; p<0.001) [10]. Variation across countries was also demonstrated in a retrospective study examining surgical care of more than 45,000 patients in 28 European nations [11]. While the prevalence of surgical checklist use was 67.5% overall, the proportion varied widely between countries, from 0 to 99.6% [11].

Another important aspect of compliance is the need to complete the surgical checklist accurately and fully. A recent study of 18 centres in France suggested that although there was a relatively high mean compliance rate (90.2%), in regard to the use of surgical checklists, the mean rate of their full completion (all items ticked) was only 61% [12].

Barriers to the implementation of surgical checklists include those related to the design itself, as well as organisational factors that influence OR team processes and practice. A survey-based study in French surgical centres noted multiple barriers related to checklist design, such as the inclusion of items already reported through other means (16/18 centres), the length of time needed for completion (9/10 centres), and a lack of sense (9/18 centres) or ambiguity (8/18 centres) of the items listed [12]. Other barriers reported in the study related to the processes required for implementation, such as the challenges of effective communication between OR team members (10/18 centres) and of identifying the roles and responsibilities of staff (6/18 centres) [12]. A study of surgical checklist compliance at an Irish centre suggested that the need for signatures, the demands on time, and the lack of training and assertiveness of the OR team were particular deterrents [13]. Anaesthesiologists had a more negative attitude towards the adoption of checklists, compared with other members of the team, possibly because of their comparatively higher workload at the time of checklist implementation [13].

Based on evidence to date, valuable insights have been gained on how to improve the design and implementation of surgical checklists. Simplicity and brevity appear important for increasing uptake and compliance [2], unless the specific practice setting demands greater complexity in checklist design [5]. The design should reflect local routines and integrate appropriately into existing practice; for this, a pilot test in a limited setting should provide an important insight into the modifications needed [2]. Incorporation of surgical checklists into standard practice should involve strong leadership and full team involvement [2, 13–15], as well as enhanced communication and interaction between team members [2]. Dissemination of the checklist should be accompanied by relevant and sufficient education, as well as training, and the continued reinforcement of safety practices [13].
While further studies are needed to examine how best to optimise surgical checklist use, the results thus far suggest that applying rigour to the design and implementation process may translate to an improved culture of safety in institutions worldwide.

As previously discussed, the success of checklists in surgery has led to the broadening of their application in healthcare [1]. Surgical checklists aim to reduce unnecessary deaths and complications in the operating room (OR) as well as reinforce accepted safety practices and improve communication between team members [2].

The use of the 2008 World Health Organization (WHO) Surgical Safety Checklist (SSC) gained prominence with the publication of a study in the New England Journal of Medicine that suggested efficacy for improving surgical outcomes [3]. The simplicity and brevity of its one-page design was not accidental; the format was intended to make it easy for local practices to adapt the SSC to their unique surgical settings [4]. Nevertheless, while simplicity may be a virtue in general, for the purpose of surgical checklist design and integration into existing practices [4], further complexity is warranted in some settings [5]. A recent report by The European Society of Thoracic Surgeons (ESTS) noted the need for a more a complex checklist design to accommodate the high-level requirements of thoracic surgical procedures [5]. Like the WHO SSC, the ESTS checklist is divided into three time points, but it places greater emphasis on the period prior to anaesthesia induction [5].

Many professional organisations now recommend the use of surgical checklists [6], and some government policies even mandate their adoption [7]. The WHO has reported that more than 4,000 institutions around the world have registered their interest in the SSC, and approximately 1,800 have used it [8]. In a study of Swiss hospitals, a surgical checklist was used in the majority (79.1%) of ORs, and use of a checklist entitled ‘The Swiss Patient Safety Foundation recommendations to avoid Wrong Site Surgery’ was the most prevalent (38.6%), followed by the WHO SSC (25.1%) and various others (15.1%) [9]. A large proportion of the doctors (84.1%) and nurses (79.9%) who reported using a checklist used it ‘almost all’ or ‘all’ of the time [9]. Other studies have demonstrated less common usage of surgical checklists. A survey study involving 6,269 medical professionals from 69 countries reported that the WHO SSC was used by only half of the respondents (57.5%) [10]. Those practising in high-income countries were more likely to apply the checklist than those in lower-income ones (83.5% vs 43.5%, respectively; p<0.001) [10]. Variation across countries was also demonstrated in a retrospective study examining surgical care of more than 45,000 patients in 28 European nations [11]. While the prevalence of surgical checklist use was 67.5% overall, the proportion varied widely between countries, from 0 to 99.6% [11].

Another important aspect of compliance is the need to complete the surgical checklist accurately and fully. A recent study of 18 centres in France suggested that although there was a relatively high mean compliance rate (90.2%), in regard to the use of surgical checklists, the mean rate of their full completion (all items ticked) was only 61% [12].

Barriers to the implementation of surgical checklists include those related to the design itself, as well as organisational factors that influence OR team processes and practice. A survey-based study in French surgical centres noted multiple barriers related to checklist design, such as the inclusion of items already reported through other means (16/18 centres), the length of time needed for completion (9/10 centres), and a lack of sense (9/18 centres) or ambiguity (8/18 centres) of the items listed [12]. Other barriers reported in the study related to the processes required for implementation, such as the challenges of effective communication between OR team members (10/18 centres) and of identifying the roles and responsibilities of staff (6/18 centres) [12]. A study of surgical checklist compliance at an Irish centre suggested that the need for signatures, the demands on time, and the lack of training and assertiveness of the OR team were particular deterrents [13]. Anaesthesiologists had a more negative attitude towards the adoption of checklists, compared with other members of the team, possibly because of their comparatively higher workload at the time of checklist implementation [13].

Based on evidence to date, valuable insights have been gained on how to improve the design and implementation of surgical checklists. Simplicity and brevity appear important for increasing uptake and compliance [2], unless the specific practice setting demands greater complexity in checklist design [5]. The design should reflect local routines and integrate appropriately into existing practice; for this, a pilot test in a limited setting should provide an important insight into the modifications needed [2]. Incorporation of surgical checklists into standard practice should involve strong leadership and full team involvement [2, 13–15], as well as enhanced communication and interaction between team members [2]. Dissemination of the checklist should be accompanied by relevant and sufficient education, as well as training, and the continued reinforcement of safety practices [13].
While further studies are needed to examine how best to optimise surgical checklist use, the results thus far suggest that applying rigour to the design and implementation process may translate to an improved culture of safety in institutions worldwide.

References

  1. The WHO Surgical Safety Checklist: Its Relevance and Application to Different Perioperative Settings. J Periop Med. 4: 3–4
  2. World Health Organization. WHO Guidelines for Safe Surgery: Safe Surgery Saves Lives. 2009. Available from: http://apps.who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf. Accessed May 2016
  3. Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491–499
  4. World Health Organization. WHO Surgical Safety Checklist. 2009. Available from: http://www.who.int/patientsafety/safesurgery/checklist/en/. Accessed May 2016
  5. Novoa NM. Patient safety in thoracic surgery and European Society of Thoracic Surgeons checklist. J Thorac Dis 2015; 7(Suppl 2): S145–S151
  6. Treadwell JR et al. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014; 23(4): 299–318.
  7. Urbach DR et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370(1S): 1029–1038
  8. World Health Organization. Patient safety: surgical safety web map. Available from: http://maps.cga.harvard.edu/surgical_safety/ and http://maps.cga.harvard.edu/surgical_safety/info.html. Accessed May 2016
  9. Mascherek AC et al. Frequency of use and knowledge of the WHO-surgical checklist in Swiss hospitals: a cross-sectional online survey. Patient Saf Surg 2013; 7(1): 36
  10. Vohra RS et al. Attitudes towards the surgical safety checklist and factors associated with its use: A global survey of frontline medical professionals. Ann Med Surg (Lond) 2015; 4(2): 119–123
  11. Jammer I et al. Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. Br J Anaesth 2015; 114(5): 801–807
  12. Fourcade A et al. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf 2012; 21(3): 191–197
  13. O’Connor P et al. Surgical checklists: the human factor. Patient Saf Surg 2013; 7(1): 14
  14. Walker IA et al. Surgical safety checklists: do they improve outcomes? Br J Anaesth 2012; 109(1): 47–54
  15. Sendlhofer G et al. Implementation of a surgical safety checklist: interventions to optimize the process and hints to increase compliance. PLoS One 2015; 10(2): e0116926

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