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.

Reducing the Risk of Delayed Colorectal Cancer Diagnoses Through an Ambulatory Safety Net Collaborative.

BACKGROUND: An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings. METHODS: A working group was convened to co-design implementation guidance, measures, and the collaborative model. Collaborative sites were recruited through a medical professional liability insurance program and chose to begin with developing an ASN for positive at-home CRC screening or overdue surveillance colonoscopy. The 18-month Breakthrough Series Collaborative ran from January 2022 to July 2023, with sites continuing to collect data while sustaining their ASNs. Data were collected from sites monthly on patients in the ASN, including the proportion that was successfully contacted, scheduled, and completed a follow-up colonoscopy. RESULTS: Six sites participated; four had an operational ASN at the end of the Breakthrough Series, with the remaining sites launching three months later. From October 2022 through February 2024, the Collaborative ASNs collectively identified 5,165 patients from the registry as needing outreach. Among patients needing outreach, 3,555 (68.8%) were successfully contacted, 2,060 (39.9%) were scheduled for a colonoscopy, and 1,504 (29.1%) completed their colonoscopy. CONCLUSION: The Collaborative successfully identified patients with previously abnormal CRC screening and facilitated completion of follow-up testing. The CRC ASN Implementation Guide offers a comprehensive road map for health care leaders interested in implementing CRC ASNs.

International Perspectives on Modifications to the Surgical Safety Checklist.

Importance: Modification of the World Health Organization's Surgical Safety Checklist (SSC) is a critical component of its implementation. To facilitate the SSC's use, it is important to know how surgical teams modify their SSCs, their reasons for making modifications, and the opportunities and challenges teams face in SSC tailoring. Objective: To study SSC modifications in high-income hospital settings in 5 countries: Australia, Canada, New Zealand, the United States, and the United Kingdom. Design, Setting, and Participants: This qualitative study used semistructured interviews based on the survey used in the quantitative study. Each interviewee was asked a core set of questions and various follow-up questions based on their survey responses. Interviews were conducted from July 2019 to February 2020 in person and online using teleconferencing software. Surgeons, anesthesiologists, nurses, and hospital administrators from the 5 countries were recruited through a survey and snowball sampling. Main Outcomes and Measures: Interviewees' attitudes and perceptions on SSC modifications and their perceived impact on operating rooms. Results: A total of 51 surgical team members and hospital administrators from the 5 countries were interviewed (37 [75%] with >10 years of service; 28 [55%] women). There were 15 (29%) surgeons, 13 (26%) nurses, 15 (29%) anesthesiologists, and 8 (16%) health administrators. Five themes emerged concerning the awareness and involvement in SSC modifications; reasons for modifications; types of modifications; the outcomes of modifications; and perceived barriers to SSC modifications. Based on the interviews, some SSCs may go many years without being revisited or modified. SSCs are modified to ensure they address local issues and standards of practice and that they are fit for purpose. Modifications are also made following adverse events to reduce the risk of reoccurrence. Interviewees described adding, moving, and removing elements from their SSCs, which increased their sense of ownership in their SSC and participation in its performance. Some barriers to modification included leadership and the SSC's inclusion in hospitals' electronic medical record. Conclusions and Relevance: In this qualitative study of surgical team members and administrators, interviewees described addressing contemporary surgical issues through various SSC modifications. The process of SSC modification may improve team cohesion and buy-in in addition to providing opportunities for teams to improve patient safety.

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey.

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use. Background: In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices. Methods: An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS. Results: A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%). Conclusions: While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.