Impact of workflow on the use of the Surgical Safety Checklist: a qualitative study

Abstract

Background Regardless of the benefits associated of the Surgical Safety Checklist, adherence across its three phases remains inconsistent. The aim of this study was to systematically identify issues around workflow that impact on surgical teams’ ability to use the Surgical Safety Checklist in a large tertiary facility in Queensland, Australia. Method Observational audit of 10 surgical teams and 33 semi‐structured interviews with 70 participants from nursing, medicine and the community were conducted. Data were collected during 2014–2015. Inductive and deductive approaches were used to analyse field observations and interview transcripts. Results The domain, impact of workflow on checklist utilization, was identified. Within this domain, seven categories illustrated the causal conditions which determined the ways in which workflow influenced checklist use. These categories included: ‘busy doing the task’; ‘clashing task priorities’; ‘being pressured, running out of time’; ‘adapting processes to work patterns’; ‘doubling up on work’; ‘a domino effect, leading to delays’ and ‘reality of the workflow’. Conclusions One of the greatest systemic challenges to checklist use in surgery is workflow. Process changes in the way that surgical safety checklists are used need to incorporate the temporal demands of the workflow. Any changes made must ensure the process is reliable, is easily embedded into existing work routines and is not disruptive.

Unlocking the “black box” of practice improvement strategies to implement surgical safety checklists: a process evaluation

“…Selection of KT strategies, that is, change champions/leaders, education, audit and feedback, and prompts and reminders, was data driven 15,31. Results of the observational audit indicated moderate consistency in implementation.…”

“…Most practice improvement interventions that rely on behavior change are implemented using pragmatic approaches, in response to emergent local needs rather than first identifying barriers and enablers to implementation within a theoretical framework. The approach to implementing these KT strategies, while responsive to the ever-changing contextual demands of the surgical environment, was informed by theory27,38 and empirical data, triangulated from a barrier analysis 15,31…”

“…Stakeholders considered that workflow had the greatest impact on their ability to be present and participate in all phases of the SSC. Consequently, workflow was systematically mapped with stakeholders 31. Findings indicated that the organization of work activities and the need to multitask during time-critical periods prevented team members from participating in various safety checks.…”

“…When checks were performed during “sign in,” they were not verbally confirmed with others in the surgical team because they were not present or were performing other priority tasks during that time. “Sign out” was not done at all as a team despite that most members were still present during wound closure 31. Enabling staff to better utilize the SSC required tailoring the SSC in relation to: 1) the person delegated to performing/leading the checks, and 2) the timing and confirmation of these checks with others.…”

Evaluation of a Brief Team Training Intervention in Surgery: A Mixed‐Methods Study

“…These everyday activities captured in the two video simulations are practices considered by many clinicians as routine. Environmental factors such as background noise, interruptions or distractions, cross conversations, and workflow influence team performance and therefore need to be managed 13,36,37 …”