Using i-PARIHS to assess implementation of the Surgical Safety Checklist: an international qualitative study

Abstract

Background Strategies selected to implement the WHO’s Surgical Safety Checklist (SSC) are key factors in its ability to improve patient safety. Underutilization of implementation frameworks for informing implementation processes hinders our understanding of the checklists’ varying effectiveness in different contexts. This study explored the extent to which SSC implementation practices could be assessed through the i-PARIHS framework and examined how it could support development of targeted recommendations to improve SSC implementation in high-income settings. Methods This qualitative study utilized interviews with surgical team members and health administrators from five high-income countries to understand the key elements necessary for successful implementation of the SSC. Using thematic analysis, we identified within and across-case themes that were mapped to the i-PARIHS framework constructs. Gaps in current implementation strategies were identified, and the utility of i-PARIHS to guide future efforts was assessed. Results Fifty-one multi-disciplinary clinicians and health administrators completed interviews. We identified themes that impacted SSC implementation in each of the four i-PARIHS constructs and several that spanned multiple constructs. Within innovation, a disconnect between the clinical outcomes-focused evidence in the literature and interviewees’ patient-safety focus on observable results reduced the SSC’s perceived relevance. Within recipients, existing surgical team hierarchies impacted checklist engagement, but this could be addressed through a shared leadership model. Within context, organizational priorities resulting in time pressures on surgical teams were at odds with SSC patient safety goals and reduced fidelity. At a health system level, employing surgical team members through the state or health region resulted in significant challenges in enforcing checklist use in private vs public hospitals. Within its facilitation construct, i-PARIHS includes limited definitions of facilitation processes. We identified using multiple interdisciplinary champions; establishing checklist performance feedback mechanisms; and modifying checklist processes, such as implementing a full-team huddle, as facilitators of successful SSC implementation. Conclusion The i-PARIHS framework enabled a comprehensive assessment of current implementation strategies, identifying key gaps and allowed for recommending targeted improvements. i-PARIHS could serve as a guide for planning future SSC implementation efforts, however, further clarification of facilitation processes would improve the framework’s utility. Trial registration No health care intervention was performed.

Barriers and facilitators associated with the implementation of surgical safety checklists: A qualitative systematic review

“…Of the 1912 publications retrieved from the database searches, a total of 34 studies were included (Figure 1) (Page et al, 2021). The studies were conducted in a range of countries: Jordon 1 (Albsoul et al, 2022), Turkey 1 (Aydin Akbuga et al, 2023), Brazil 1 (De Oliveira Junior & De Magalhães, 2017), France 1 (Fourcade et al, 2012), Cyprus 1 (Georgiou et al, 2018), Thailand 1 (Kasatpibal et al, 2018), Sweden 3 (Krupic et al, 2020; Nordström & Wihlborg, 2019; Rönnberg & Nilsson, 2015), Saudi Arabia 1 (Manamela et al, 2022), Zambia 1 (Munthali et al, 2022), Spain 1 (Peñataro‐Pintado et al, 2021), Switzerland 1 (Schwendimann et al, 2019), New Zealand 1 (Weller et al, 2018) and Madagascar 1 (White et al, 2018), USA 2 (Alidina et al, 2017; Conley et al, 2011), multiple countries 2 (Aveling et al, 2013; Elam et al, 2022), Norway 3 (Haugen et al, 2015; Høyland et al, 2014; Wæhle et al, 2012), UK 3 (O'brien et al, 2017; Robertson‐Smith, 2016; Russ et al, 2015), Australia 4 (Braaf et al, 2013; Gillespie, Marshall, et al, 2016; Gillespie, Withers, et al, 2016; Rogers et al, 2020) and Canada 6 (Dharampal et al, 2016; Gagliardi et al, 2014; Mahmood et al, 2019; Mobilio et al, 2022; Spence et al, 2011; Ziman et al, 2018). The sample sizes ranged from 8 to 196 participants and represented the total number of all members of the perioperative MDT: surgeons, anaesthesiologists, operating room nurses, medical students, nurse anaesthetists, surgical trainees, theatre support workers, radiographers, nursing students, administrative staff, management and consumers (see Table 1).…”

“…Specific surgical specialties were reported as barriers because the culture inherent within individual specialties impacted compliance rates and engagement in the MDT (Elam et al, 2022;Munthali et al, 2022;Peñataro-Pintado et al, 2021;Rogers et al, 2020;Schwendimann et al, 2019;Weller et al, 2018;Ziman et al, 2018). The culture of professional independence or disciplines working in 'professional silos' in operating theatres was a barrier to team communication and successful checklist processes (Alidina et al, 2017;Braaf et al, 2013;Fourcade et al, 2012;.…”

“…Organizational issues, which include staffing levels, management support and existing organizational policy, were reported to create barriers to checklist compliance (Elam et al, 2022; Mobilio et al, 2022; Munthali et al, 2022). Staffing issues including complexities of high staff turnover, prolonged shifts and staff shortages in combination with existing time pressures create difficulties in completing the checklist prior to surgery commencement (Alidina et al, 2017; Aveling et al, 2013; Fourcade et al, 2012; Kasatpibal et al, 2018).…”

“…Specific surgical specialties were reported as barriers because the culture inherent within individual specialties impacted compliance rates and engagement in the MDT (Elam et al, 2022; Munthali et al, 2022; Peñataro‐Pintado et al, 2021; Rogers et al, 2020; Schwendimann et al, 2019; Weller et al, 2018; Ziman et al, 2018).…”

“…Management support, education and training, audits and clear policy were four main organizational considerations that facilitated the surgical safety checklist use. Support from management and perioperative leaders who provided clear policy documents, offered rewards for compliance and encouraged a safety culture by implementing disciplinary action for non‐compliance was important enabler and impacted patient safety and outcomes (Alidina et al, 2017; Aydin Akbuga et al, 2023; Elam et al, 2022; Gagliardi et al, 2014; Kasatpibal et al, 2018; Manamela et al, 2022; Munthali et al, 2022; Russ et al, 2015; Schwendimann et al, 2019). Organizations that implemented regular audits and constructive feedback to MDT teams demonstrated effective uptake and completion of the checklist (Aveling et al, 2013; Dharampal et al, 2016; Gagliardi et al, 2014; Kasatpibal et al, 2018).…”