Adaptation of the World Health Organization (WHO) Safe Surgery Checklist for Use With Cesarean Sections: Implementation and Outcomes With the Safe Cesarean Section Checklist.

Introduction The World Health Organization (WHO) Safe Surgery Checklist significantly decreases morbidity and mortality in regular operating room cases. However, significant differences in workflow and processes exist between regular operating room cases and cesarean sections performed on the labor and delivery unit. The aim of this study is to adapt the WHO Safe Surgery Checklist for the labor and delivery unit and cesarean sections to improve communication and patient safety. Methods A multidisciplinary team consisting of all major stakeholders reviewed and revised the WHO Safe Surgery Checklist making it more applicable to cesarean section operations. The new Safe Cesarean Section Checklist was tested and then integrated into the electronic medical record and utilized on the labor and delivery unit. A specific cesarean section safety attitudes questionnaire was developed, validated, and administered prior to and one year after implementation. Results Usage of the Safe Cesarean Section Checklist was greater than 95% after initial implementation. Significant improvements were reported by the staff on the cesarean section attitudes questionnaire for several key areas including the feeling that all necessary information was available at the beginning of the procedure, decreases in communication breakdowns and delays, and fewer issues related to not knowing who was in charge during the procedure. Discussion Implementation of the Safe Cesarean Section Checklist was successfully adopted by the staff, and improvements in staff perceptions of several key safety issues on our unit were demonstrated. Additional studies should be undertaken to determine if clinical outcomes from this intervention are comparable to those seen with the use of the WHO Safe Surgery Checklist.

Implementation of the TALK© clinical self-debriefing tool in operating theatres: a single-centre interventional study.

BACKGROUND: Debriefing in operating theatre environments leads to benefits in mortality, efficiency, productivity, and safety culture; however, it is still not regularly performed. TALK© is a simple and widely applicable team self-debriefing method to collaboratively learn and improve. METHODS: An interventional study introducing TALK© for voluntary clinical debriefing was carried out in operating theatre environments in a UK National Health Service hospital over 18 months. It explored compliance with the Five Steps to Safer Surgery and changes in behaviour in surgical teams regarding consideration and completion of debriefing. RESULTS: Team briefing and compliance with the WHO surgical safety checklist were performed consistently (>95% and >98%, respectively) throughout the study, which included 460 surgical lists. Consideration of debriefing increased at all data collection periods after intervention, from 35.6% to 60.3-97.4% (P≤0.003). Performance of debriefing, which was 23.3% at baseline, reached 39% at 6 months (P=0.039). Team planning of actions for improvement during debriefing also increased (P<0.001). A decline in performance of debriefing and subsequent improvement actions was observed after 6 months, albeit rates were above baseline at 18 months. The most reported reason not to carry out a debriefing was 'lack of issues'. After implementation, nurses and allied healthcare professionals increased their contribution to initiating and leading debriefing. Reported barriers were <18% at baseline, and decreased after intervention. CONCLUSIONS: A simple intervention introducing TALK© for voluntary debriefing in theatres prompted significant changes in team behaviour and sustained growth regarding consideration and performance of debriefing, especially in the first 6 months.

Optimizing Teamwork in the Operating Room: A Scoping Review of Actionable Teamwork Strategies.

Suboptimal teamwork in the operating room (OR) is a contributing factor in a significant proportion of preventable complications for surgical patients. Specifying behaviour is fundamental to closing evidence-practice gaps in healthcare. Current teamwork interventions, however, have yet to be synthesized in this way. This scoping review aimed to identify actionable strategies for use during surgery by mapping the existing literature according to the Action, Actor, Context, Target, Time (AACTT) framework. The databases MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Cochrane, Scopus, and PsycINFO were searched from inception to April 5, 2022. Screening and data extraction were conducted in duplicate by pairs of independent reviewers. The search identified 9,289 references after the removal of duplicates. Across 249 studies deemed eligible for inclusion, eight types of teamwork interventions could be mapped according to the AACTT framework: bundle/checklists, protocols, audit and feedback, clinical practice guidelines, environmental change, cognitive aid, education, and other), yet many were ambiguous regarding the actors and actions involved. The 101 included protocol interventions appeared to be among the most actionable for the OR based on the clear specification of ACCTT elements, and their effectiveness should be evaluated and compared in future work.

Role of the WHO Surgical Safety Checklist in Reducing Morbidity and Mortality Among Obstetrics and Gynecology Patients Undergoing Surgery: A Prospective Comparative Study.

BACKGROUND: As surgery is an essential aspect of healthcare around the globe, it is necessary to consider complications related to it. Therefore, this study was conducted to evaluate the impact of the World Health Organization Surgical Safety Checklist (WHO SSC) on reducing the incidence of postoperative complications Methods: This single-center, prospective, comparative study was conducted at the Department of Gynecology and Obstetrics in a government hospital in Patna, Bihar. To assess the efficacy of the WHO SSC, the patients were divided into two groups, in which one group undergoing surgery was assessed with the checklist, and the other group was not. The rates of surgery-related complications were then compared in both groups. RESULTS: Our results showed a reduction in surgery-related complications in patients assessed with the WHO SSC. No statistically significant difference in duration of surgery was found between the groups. However, a statistically significant difference was observed in the rates of surgery-related complications between groups, especially in sepsis (p=0.0009), hemorrhage (p<0.0001), and infection at the site of surgery (p<0.0001). Mortality rates were not affected by the use of the SSC. CONCLUSION: The WHO SSC is a simple yet effective tool for reducing postoperative complications by improving communication between the various team members working in the operation theatre, although it has no effect on reducing mortality. Further research is needed to enhance its successful implementation and ensure its sustained use.

Guidelines in Practice: Team Communication.

The perioperative setting is a complex environment requiring interdisciplinary team collaboration to avoid adverse events. To protect the safety of patients and perioperative team members, communication among personnel should be clear and effective. The recently updated AORN "Guideline for team communication" provides perioperative nurses with recommendations on the topic. To promote effective communication in perioperative areas, all personnel should value and commit to a culture of safety. This article discusses recommendations for supporting a culture of safety, developing and implementing an effective hand-off process and surgical safety checklist, and developing education strategies for team communication. It also includes a scenario describing the implementation of a standardized, electronic surgical safety checklist in the OR. Perioperative nurses should review the guideline in its entirety and apply the recommendations for team communication in their working environments.

Does the WHO Surgical Safety Checklist Need Modification for Orthopaedic Surgery Practices? A Cross-Sectional Survey Among Indian Orthopaedic Surgeons.

Background: It is well known that the implementation of the WHO surgical safety checklist (SSC) leads to improved operating room team coordination and reduced perioperative complication and mortality rates. Although it is proven to be beneficial worldwide, its awareness and usage need to be evaluated in a diverse country like India. As orthopaedic surgeries involve implants and tourniquet usage, it is important to evaluate the applicability of WHO SSC specifically to orthopaedic surgeries, and whether any modifications are needed. Materials and Methods: A web-based cross-sectional survey was conducted among Indian Orthopaedic Surgeons with a pre-defined questionnaire regarding awareness, usage and suggestions to modify the existing WHO SSC (2009) for orthopaedic surgeries. Results: 513 responses were included for final analysis. 90.3% of surgeons were aware of the surgical safety checklist; however, only 55.8% used it routinely in their practice. The awareness of SSC availability was 1.85 times more among younger surgeons (< 20 years of experience) than among those with > 20 years of experience. 17% of surgeons thought the usage of SSC was time-consuming and 52.4% of participants felt a need to modify the existing WHO SSC (2009) for orthopaedic surgeries. 34.5% recommended the inclusion of the patient blood group in the "Sign-in" section, 62.77% proposed the inclusion of details about the tourniquet, whereas only 6.63% suggested adding about surgical implant readiness in the "Time-out" section and 72.7% suggested including a check to make sure the tourniquet was deflated, removed and also recording of the total usage time during the "Sign-out" section. Conclusion: Despite high (90%) awareness among Indian Orthopaedic surgeons, they have limited usage of the WHO SSC in their practice. Identifying barriers and considering modifications for orthopaedic surgeries, like details about tourniquet usage during the "Time-out" section and a check to ensure it was removed during the "Sign-out" section, will improve patient safety and outcomes. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01096-5.

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals.

Patient harm, patient safety and their governance have been ongoing concerns for policymakers, care providers and the public. In response to high rates of adverse events/medical errors, the World Health Organisation (WHO) advocated the use of surgical safety checklists (SSC) to improve safety in surgical care. Canadian health authorities subsequently made SSC use a mandatory organisational practice, with public reporting of safety indicators for compliance tied to pre-existing legislation and to reimbursements for surgical procedures. Perceived as the antidote for socio-technical issues in operating rooms (ORs), much of the SSC-related research has focused on assessing clinical and economic effectiveness, worker perceptions, attitudes and barriers to implementation. Suboptimal outcomes are attributed to implementations that ignored contexts. Using ethnographic data from a study of SSC at an urban teaching hospital (C&C), a critical lens and the concepts of ritual and ceremony, we examine how it is used, and theorise the nature and implications of that use. Two rituals, one improvised and one scripted, comprised C&C's SSC ceremony. Improvised performances produced dislocations that were ameliorated by scripted verification practices. This ceremony produced causally opaque links to patient safety goals and reproduced OR/medical culture. We discuss the theoretical contributions of the study and the implications for patient safety.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist.

BACKGROUND: The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices. METHODS: Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them. RESULTS: Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory. CONCLUSION: Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

It's not the arrow, it's the archer: the role of the surgeon leader in a safety driven-era.

BACKGROUND: In an era where team communication and patient safety are paramount, standardized tools have been deemed critical to safe, efficient practice. In some cases-perhaps most notably in the surgical safety checklist (SSC)-these tools have been elevated as the key to safe patient care. However, effects of the SSC on patient safety in practice remain mixed. We explore the role and impact of the surgeon leader in the use of structured communication tools to understand how surgeon engagement impacts intraoperative teamwork. METHODS: Using a constructivist grounded theory approach, OR staff members (surgeons, anesthetists, nurses and perfusionists) were recruited to participate in a one-on-one semi-structured interview. The interview explored participant experiences working in the OR, focusing on the role and impact of the surgeon as leader. RESULTS: Engaged use of the surgical safety checklist by the attending surgeon had the potential to improve teamwork in the operating room. Surgeons who used the checklist to engage with their team and facilitate group discussion were able to avoid tensions later in the operation typically arising from lack of situation awareness and familiarity with team member experience levels. Surgeons who engaged with the SSC as more than a memory aid were able to foster a better team environment. CONCLUSIONS: Surgeons can harness their role as leader in the operating room by engaging with structured communication tools such as the SSC to foster improved teamwork.

The use of the World Health Organization Surgical Safety Checklist in operating theatres.

Background: There is a global concern over intraoperative patient safety, as adverse events are on the rise. When the World Health Organization Surgical Safety Checklist (WHO SSC) is used correctly, it has the potential to prevent such events. Unfortunately, the intraoperative team in the designated hospital lacked the cooperation to successfully use the checklist. Aim: This study, therefore, aimed to explore and describe the factors that affect the use of the checklist in the operating theatres in a designated hospital. Methods: A qualitative research approach together with an implementation science strategy structured according to the Consolidated Framework for Implementation Research was used. Individual interviews with nine surgeons and focus group interviews with six operating theatre professional nurses provided sufficient data for inductive and deductive analysis. Results: A deeper understanding of the contextual and interventional factors that affect the use of the WHO SSC is provided by the findings. A high demand for surgery, the hierarchy in the surgical team, their uncertainty about hospital policies and reluctance to adjust to change contributed to the poor use of the checklist. Conclusion: A sustainable implementation process is crucial and should be embraced and promoted by the intraoperative team. Contribution: The article contributes a description of the factors that address the use of a checklist for intraoperative patient safety. It recommends that the factors that hinder the use of the checklist be timeously addressed.

The Role of an Assistant Nurse in Implementing the WHO Surgical Safety Checklist: Perception and Perspectives.

Introduction The World Health Organization (WHO) Surgical Safety Checklist is a tool developed by the WHO to promote safer surgical practices and reduce the incidence of surgical errors and complications. This study aims to describe the role of assistant nurses in the implementation of this checklist by surgical teams. Materials and methods This descriptive study utilized a questionnaire-based survey conducted between September 2018 and March 2019 among 196 healthcare professionals at two surgical units in a university hospital in Sweden. The questionnaire covered demographic information such as age, gender, and occupation, as well as details about their workplace, experience, education/training on using the WHO checklist, the adaptation of the checklist to their department, their responsibilities in implementing and using the checklist, the frequency of use in emergency situations, and the impact on patient safety. Results The results of the study showed that assistant nurses, despite having the lowest level of education among healthcare professionals, were highly trusted and valued by other members of the surgical team. Most healthcare professionals were unsure who was responsible for using the WHO checklist but believed it was the assistant nurse's responsibility to ensure its implementation. Assistant nurses reported little to no training on using the checklist but noted that it had been adapted to the department's needs. Almost half (48.8%) of assistant nurses believed that the checklist was often used in emergency surgery, and most believed that it improved patient safety. Conclusions Improved understanding of the significance of assistant nurses in implementing the WHO Surgical Safety Checklist may enhance adherence to the checklist and potentially improve patient safety, as they were the most valued and trusted healthcare professionals in the surgical team according to the study's findings.

Feasibility of implementing a surgical patient safety checklist: prospective cross-sectional evaluation.

BACKGROUND: The World Health Organization's Global Patient Safety Action Plan 2021-2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients' involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients' completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial. METHODS: This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis. RESULTS: Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway. CONCLUSIONS: Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03105713. Registered 10.04.2017.

Compliance With and Barriers to Implementing the Surgical Safety Checklist: A Mixed-Methods Study.

This mixed-methods study aimed to determine nurses' views on the use of the Turkish version of the World Health Organization's Surgical Safety Checklist (SSC). Phase 1 of the study consisted of a survey of perioperative and surgical nursing unit nurses' perceptions on the use of the SSC. The results showed that personnel believed that every step of the checklist was not always applied and that an increased workload and the lack of team cooperation negatively affected the use of the checklist. Phase 2 of the study involved RN circulator interviews and focused on their experiences using the SSC, the obstacles to SSC implementation, and ways to increase compliance. We interviewed 126 nurses during phase 1 and 20 nurses during phase 2. We analyzed the interviews and identified three themes: the importance of using the SSC, barriers to using the checklist, and compliance with the checklist and applicability.

Creating a high-performance surgical safety checklist: A multimodal evaluation plan to reinvigorate the checklist.

RATIONALE, AIMS, AND OBJECTIVES: The WHO Surgical Safety Checklist is a communication tool designed to improve surgical safety processes and enhance teamwork. It has been widely adopted since its introduction over ten years ago. As surgical safety needs evolve, organizations should periodically review and update their checklists. A holistic evaluation of the checklist in the context of an organization is the first step to making informed updates. In this article, we describe a comprehensive but feasible strategy for checklist evaluation which we developed and implemented as part of a surgical safety initiative in a high-performing center. METHODS: A three-part evaluation plan was developed and carried out by a multidisciplinary team. The evaluation included assessment of 1. Quality of care through a review of surgical safety events; 2. Safety culture through a validated survey and informal feedback; and 3. Checklist performance through direct observations and a staff survey. To prepare for re-implementation the current institutional checklist was critically evaluated and a context assessment survey was administered to surgical staff. RESULTS: The evaluation revealed challenges in communication and teamwork, with surgical staff often perceived to be working in silos. The quality of care assessment indicated room for improvement in safety processes. Deficiencies in the safety culture measures of communication and feedback shed light on an overall lack of engagement with the checklist. Checklist performance demonstrated good adherence to the items on the checklist but limited engagement by the surgical team and minimal communication between subteams. These findings informed our revisions to the checklist and its implementation processes. CONCLUSIONS: We developed and implemented a comprehensive, scalable approach to checklist evaluation which directly informed improvements to the checklist that were tailored to the organization's current context. Organizations can apply this framework to breathe new life into their checklist and transform their safety culture.

Surgical safety checklist: an element of work organization in the operating theater / Lista de verificação de segurança cirúrgica: um elemento de organização do trabalho no bloco cirúrgico

Objectives: the surgical safety checklist (SSC) is a document that is intended to increase patient safety in the operating theater by eliminating avoidable errors. The original document has been published in English by the WHO which recommends its obligatory use. The document's name is often distorted when translated into European languages, for instance into the "surgical control list". This article aims to assess the consequences of the distortion of the originally intended meaning for the completion of SSC in the operating theater. Methods: we compared the exactness of the meaning of translation in 29 European languages based on Google translator. Particular attention was paid to the presence of essential words such as "checklist" and "safety" in the translation. Results: we found that in 15 out of the 29 languages, the translation of these two words was incorrect, particularly in Slavic languages. The most often mistranslation was the "control card" or "control list", which was a misnomer. Conclusions: the translation of the SSC name into native languages is inadequate in about one-half of the cases, which may jeopardize its proper use by team members of the operating theater, and thus the patient perioperative safety.

Objetivo: a lista de verificação de segurança cirúrgica (SSC) é um documento que visa aumentar a segurança do paciente no centro cirúrgico, eliminando possíveis erros. O documento original foi publicado em inglês pela OMS que recomenda seu uso obrigatório. O nome do documento é frequentemente distorcido quando traduzido para idiomas europeus, por exemplo, na "lista de controle cirúrgico". Este artigo visa avaliar as consequências da distorção do significado originalmente pretendido para a realização do SSC na sala de cirurgia. Métodos: para isso, comparamos a exatidão do significado da tradução em 29 idiomas europeus com base no tradutor do Google. Atenção especial foi dada para a presença de palavras essenciais como "lista de verificação" e "segurança" na tradução. Resultados: descobrimos que em 15 dos 29 idiomas, a tradução dessas duas palavras estava incorreta, principalmente em idiomas eslavos. A tradução incorreta mais frequente era o "cartão de controle" ou "lista de controle", o que era um equívoco. Conclusão: a tradução do nome do SSC para as línguas nativas é inadequada em cerca de metade dos casos, o que pode comprometer seu uso adequado pelos membros da equipe de centro cirúrgico e, portanto, a segurança perioperatória do paciente.

Surgical Burden of Disease in Women.

Globally, an inequitable surgical burden exists. Greater than 90% of people in low- and middle-income countries (LMICs) lack access to safe, affordable surgical care. Also, patients undergoing surgery in LMICs suffer much higher rates of perioperative complications and death. In many LMICs, cesarean section is both underused and overused, and frequently performed unsafely. Obstetric fistula and women's cancers contribute to the surgical burden of women in LMICs. Surgical team nontechnical skills (eg, teamwork and communication) and use of tools such as the WHO Surgical Safety Checklist and Enhanced Recovery after Surgery program have the potential to greatly improve surgical outcomes.

Factors that enhance compliance with the Surgical Safety Checklist.

BACKGROUND: The World Health Organization (WHO) has reported that its Surgical Safety Checklist (SSC) has resulted in significant reductions in morbidity and mortality. Despite its proven success, meaningful compliance with the Surgical Safety Checklist initiative has been low. AIMS: The authors sought to identify and explore published research on factors that enhance compliance with the SSC within surgical team members. METHODS: A review of the literature published between January 2017 and January 2021 was undertaken. Six databases were searched, and 1340 studies were screened for eligibility. The 17 studies included were critically appraised using the Crowe Critical Appraisal Tool. FINDINGS: Three main themes were identified: training and innovations; process adaptations and team leadership. CONCLUSION: This review of the literature draws attention to the complexities of checklist compliance and identifies the need for training, leadership and adaptation to new safety processes.

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

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.