Using the WHO Surgical Safety Checklist to Direct Perioperative Quality Improvement at a Surgical Hospital in Cambodia: The Importance of Objective Confirmation of Process Completion

Abstract

BackgroundThe WHO surgical safety checklist (SSC) is known to prevent postoperative complications; however, strategies for effective implementation are unclear. In addition to cultural and organizational barriers faced by high-income countries, resource-constrained settings face scarcity of durable and consumable goods. We used the SSC to better understand barriers to improvement at a trauma hospital in Battambang, Cambodia.MethodsWe introduced the SSC and trained data collectors to observe surgical staff performing the checklist. Members of the research team observed cases and data collection. After 3 months, we modified the data collection tool to focus on infection prevention and elicit more accurate responses.ResultsOver 16 months we recorded data on 695 operations (304 cases using the first tool and 391 cases with the modified tool). The first tool identified five items as being in high compliance, which were then excluded from further assessment. Two items—instrument sterility confirmation and sponge counting—were identified as being misinterpreted by the data collectors’ tool. These items were reworded to capture objective assessment of task completion. Confirmation of instrument sterility was initially never performed but rectified to >95% compliance; sponge counting and prophylactic antibiotic administration were consistently underperformed.ConclusionsStaff complied with communication elements of the SSC and quickly adopted process improvements. The wording of our data collection tool affected interpretation of compliance with standards. Material resources are not the primary barrier to checklist implementation in this setting, and future work should focus on clarification of protocols and objective confirmation of tasks.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries

“…We screened 1562 citations and included 47 papers reporting 42 unique studies in the final analysis 8,22–67 . Details of the selection process are shown in Figure 1.…”

Barriers and enablers to utilisation of the WHO surgical safety checklist at the university teaching hospital in Lusaka, Zambia: a qualitative study

“…Other studies highlighted that improvements in hospital practice and resources increased the use of the SSC [ 21 , 28 – 30 ]. However, findings from studies in Cambodia and Moldova [ 29 , 31 ] reported that material resources were not the primary barrier to checklist implementation in these settings, and a good level of SSC implementation was achieved despite limitations in resources. This suggests potential contextual differences across geographical regions.…”

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia–Pacific Region

“…Implementation of the WHO checklist has also been evaluated in several APAC countries, including Thailand, India, Cambodia, Pakistan and Indonesia. Variability in awareness and compliance has been highlighted, as well as differences in subjective clinical decision making and cultural norms [51,[55][56][57][58].…”