In 2009, strict adherence to the WHO Surgical Safety Checklist, an inexpensive and easy-to-use tool, was found to reduce 30-day mortality from 1.5% to 0.8% and overall complications from 11% to 7% in eight diverse hospitals from Tanzania to the United States. Since then, the Checklist has been adopted by 3,200 hospitals in 93 countries. The benefits of the Checklist, however, depend upon the individual hospitals'ability to implement it effectively. Implementation is the process by which adopting organizations introduce innovations and encourages their use. Implementation may or may not be effective at producing consistent, high-quality utilization of a target innovation. The proposed study will examine implementation processes in a large group of US and international hospitals and will identify factors supportive of effective implementation. The study will also examine the relationship of effective implementation to teamwork, as an explanation for how the Checklist improves outcomes. In order to achieve these aims, data will be collected from 75 surgical units. Data on Checklist implementation processes will be obtained from implementation leaders and surgeons using a survey developed by drawing on prior instruments and preliminary research. Data on implementation effectiveness, teamwork, and Checklist outcomes will be obtained by direct nurse manager, patient safety officer and circulating nurse observations of surgical procedures. Cross-sectional and longitudinal comparisons will relate implementation processes to effective implementation and effective implementation to teamwork and Checklist outcomes. This study will make significant theoretical, methodological, practical and contributions to the field of implementation science. We will contribute to theory about innovation implementation and teamwork by demonstrating that effective Checklist implementation can lead to a virtuous cycle, affecting team dynamics in ways that can continuously improve implementation effectiveness and thus the benefits of the innovation. We will employ novel evaluation tools and training methods that can be applied broadly to increase the likelihood of effective implementation of the Checklist and in future studies of the implementation of similar innovations. For practical purposes, we will identify specific contextual factors and activities that lead to effective Checklist implementation, which can be emulated by other organizations implementing the Checklist and similar innovations.

Public Health Relevance

A simple Surgical Safety Checklist has been shown to reduce complications and death from surgery by more than 30 percent. However, its impact will spread to the more than 200 million operations performed each year only if used consistently and correctly. This study will investigate how hospitals implement the Checklist and how differences in their implementation processes lead to differences in teamwork and, ultimately, the safety of surgical care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Health Care Quality and Effectiveness Research (HQER)
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Opstal, Marcy
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Harvard University
Public Health & Prev Medicine
Schools of Public Health
United States
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Molina, George; Berry, William R; Lipsitz, Stuart R et al. (2017) Perception of Safety of Surgical Practice Among Operating Room Personnel From Survey Data Is Associated With All-cause 30-day Postoperative Death Rate in South Carolina. Ann Surg 266:658-666
Haynes, Alex B; Edmondson, Lizabeth; Lipsitz, Stuart R et al. (2017) Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Ann Surg 266:923-929
Molina, George; Jiang, Wei; Edmondson, Lizabeth et al. (2016) Implementation of the Surgical Safety Checklist in South Carolina Hospitals Is Associated with Improvement in Perceived Perioperative Safety. J Am Coll Surg 222:725-736.e5
Singer, Sara J; Jiang, Wei; Huang, Lyen C et al. (2015) Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals. Med Care Res Rev 72:298-323
Huang, Lyen C; Conley, Dante; Lipsitz, Stu et al. (2014) The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability. BMJ Qual Saf 23:639-50