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

Abstract

BackgroundCompliance with surgical safety checklists (SSCs) has been associated with improvements in clinical processes such as antibiotic use, correct site marking, and overall safety processes. Yet, proper execution has been difficult to achieve.ObjectivesThe objective of this study was to undertake a process evaluation of four knowledge translation (KT) strategies used to implement the Pass the Baton (PTB) intervention which was designed to improve utilization of the SSC.MethodsAs part of the process evaluation, a logic model was generated to explain which KT strategies worked well (or less well) in the operating rooms of a tertiary referral hospital in Queensland, Australia. The KT strategies implemented included change champions/opinion leaders, education, audit and feedback, and reminders. In evaluating the implementation of these strategies, this study considered context, intervention and underpinning assumptions, implementation, and mechanism of impact. Observational and interview data were collected to assess implementation of the KT strategies relative to fidelity, feasibility, and acceptability.ResultsFindings from 35 structured observations and 15 interviews with 96 intervention participants suggest that all of the KT strategies were consistently implemented. Of the 220 staff working in the department, that is, nurses, anesthetists, and surgeons, 160 (72.7%) knew about the PTB strategies. Qualitative analysis revealed that implementation was generally feasible and acceptable. A barrier to feasibility was physician engagement. An impediment to acceptability was participants’ skepticism about the ability of the KT strategies to effect behavioral change.ConclusionOverall, results of this evaluation suggest that success of implementation was moderate. Given the probable impact of contextual factors, that is, team culture and the characteristics of participants, the KT strategies may need modification prior to widespread implementation.

Using normalisation process theory to evaluate the implementation of a complex intervention to embed the surgical safety checklist

“…Therefore any intervention designed to improve consistency in checklist use, had to consider workflow. Clearly the complexity and workflow of surgery shapes the context in which individuals and teams work, and subsequently how health professionals interact with multifaceted interventions [ 8 , 30 ].…”

The lived experience of rescuing people who have driven into floodwater: Understanding challenges and identifying areas for providing support

“…Specifically, to reduce their risk of exacerbating the situation, requiring rescue themselves or adding further demands to the rescuers; these personnel require training in effectively managing the scene until flood rescue operators arrive, and to have effective protocols regarding participation in floodwater rescues only to the extent afforded by their training. Protocols are widely used by emergency and healthcare personnel and have been found to be effective in guiding decision‐making; however, review and revision of protocols is important for maintaining their utility . Clear role delineation is particularly important for effective collaboration between agencies, given the hierarchical structure that personnel are accustomed to within their own agency.…”

The impact of improved surgical safety checklist participation on OR efficiencies: A pretest-posttest analysis

“…Saving time (as a measure of efficiency) in the OR does not necessarily lead to increased efficiency 28 . PTB was implemented as a driver to enable change in practice and process when executing the checklist 14,24 . Yet strategies that target changes in practice (i.e.…”

“…Implementation of PTB aimed to simplify the checking process through addressing behavioural and contextual factors that contributed to limited use of the SSC 14,24 . Yet to achieve sustainable improvements in efficiencies, structural interventions such as parallel processing, physical layout of the OR and additional staffing should be considered.…”

“…Process strategies to promote behaviour changes in WHO SSC participation were delivered over four weeks and included audit and feedback, opinion leaders and change champions, reminders and prompts and formal and informal education. A process evaluation of these strategies is presented elsewhere 14 . The phases in which it was most difficult to maximise staff participation were the sign-in and sign-out phases.…”