The World Health Organization safe surgery checklist as a catalyst for system improvement

The World Health Organization (WHO) Safe Surgery Checklist was developed under the Safe Surgery Saves Lives initiative at the WHO, and originally published in 2008 1. Its contents reflect the ten essential objectives 2 identified for improving surgical outcomes that emerged from the project. Achieving these objectives was understood to require resources and infrastructure that was lacking in many of the settings in which the checklist may be used; in these environments, its contents could thus be described as aspirational. The checklist designers recognised this in the asterisked notice that modifications to fit local conditions were encouraged. Many of these modifications will reflect the well-documented shortcomings in resources, ranging from drugs, equipment, oxygen, blood, and electricity, to sufficient personnel 3, 4. Just as the oximetry item in the checklist is often deleted in high-resource settings because oximetry is universal, it may be omitted from checklists in low-resource settings because it is unobtainable. In this issue, Lilaonitkul et al. describe the introduction of the WHO Safe Surgery Checklist at Mbarara Regional Referral Hospital in Uganda, through an extensive, six-week program 5. This included baseline assessment interviews, inter-professional review and modification of the checklist, education, video demonstrations, coaching and ongoing monitoring and feedback. The uptake and use of the checklist following implementation was measured at an impressive 85% eight months after formal launch of the project. There is a compelling story found in the history of the Safe Surgery Checklist work at Mbarara, where a first attempt to introduce its use a year previously failed to produce sustained incorporation into practice. Nonetheless, the follow-up contained in this report establishes that two important processes of care called for in the checklist (oximetry and timely antibiotic prophylaxis) were successfully introduced and that these practices were sustained even when the use of the checklist was not. The ‘failed’ introduction of the checklist nonetheless drove improvement of processes of care, moving Mbarara closer to possessing the ten essential elements of safe surgery and addressing the resources needed to make at least two elements of the Safe Surgery Checklist relevant to that setting. Importantly, checklist introductions, whether nominally successful or not, often bring with them genuine improvements important to patients. In the Lilaonitkul report, the extensive consultation preceding introduction of the checklist into general practice in the operating theatres of Mbarara revealed that the instrument and swab count item of the Safe Surgery Checklist was considered unachievable. There were no standardised instrument kits in use, and no resources for documenting instrument and swab counts. The team went on to introduce standardised surgical kits for the first time so that counts could practically be done. This is an excellent illustration of how a Safe Surgery Checklist checkbox drives system improvement. Will standardised kits and counts be sustained practice in the way oximetry and antibiotic administration became a year earlier? Is Mbarara serially focusing on individual checklist elements that lead to higher quality care? Does each checklist-driven system improvement make the checklist itself more relevant and more likely embraced? If the answer to these questions is ‘yes’, the Safe Surgery Checklist can be viewed as a roadmap to improvements that save lives, with the consequent readiness of the facility for checklist adoption (itself a powerful safety tool) as a corollary benefit. This may seem a backwards view of the Safe Surgery Checklist, but it reflects the obvious need to recognise and address the gaps in practice highlighted by the checklist. Several of the leaders of the Safe Surgery Saves Lives campaign went on to target a specific gap knowingly highlighted in the checklist, namely the use of pulse oximetry 6, 7. It was recognised at the time of the checklist publication that a major gap in the availability of oximeters existed. It was subsequently estimated that more than 77 000 operating rooms worldwide 8 lacked a pulse oximeter, and that the Safe Surgery Checklist was thus that much less relevant in those settings. Indeed, the more the checklist calls for non-existent resources and processes, the less likely its sustained use. The Lifebox Foundation (www.lifebox.org) was created specifically to provide high-quality, low-cost pulse oximetry to the facilities in need worldwide, and has distributed more than 9000 devices in 90 nations since inception, with some notable success 9, 10. Lifebox has also recently launched an initiative to develop and test an intervention to overcome the barriers to surgical infection prevention in low-resource settings. This group is taking on the task of giving meaning, one by one, to the individual elements of the Safe Surgery Checklist. The implementation process described by Lilaonitkul et al. is typical of the most successful checklist introduction efforts 11. It was time consuming, deliberate, inter-professional and created a climate of collaboration and focus on improvement. These elements are often lacking in less successful implementations such as in Ontario 12, where the checklist was implemented under a government mandate and vanishingly few centers undertook any modification process whatsoever. Leape 13 cited the consequences of short-changing checklist implementation in undermining effective checklist use associated with improvement in patient outcomes. Indeed, this may be the most plausible discriminant between checklist successes and failures. However, we have a reminder here that a perfunctory or absent review and modification effort not only diminishes the likelihood of sustained use of the checklist but also sacrifices the benefit of many eyes examining how the Safe Surgery Checklist could work locally and the incidental system improvements, like standardised kits, oximetry and antibiotic protocols, arising from that process. This dynamic is not unique to the WHO Safe Surgery Checklist 14. An earlier safety intervention built around a checklist shares many of these characteristics. In 2006, Pronovost and colleagues reported on the results of the Keystone collaborative in 108 intensive care units across Michigan designed to reduce the frequency of central venous catheter infections 15. A short checklist was introduced to reinforce the performance of evidence-based steps in the line insertion procedure. The introduction of the checklist and aseptic protocol was, like Liliantokul's, pain-staking, collaborative and extensive. At the end, across a variety of settings, these infections were virtually eradicated and the improvement sustained over time. As implementation scientists looking at the Keystone project have noted 16, it was not so much the checklist itself, but what happened all around the checklist, that led to the improvements. Social and hierarchical adjustments and system improvements create the environment in which a checklist is a handy tool. In Keystone, chain-of-command was turned upside down by empowering nurses to halt the central line procedure for protocol violations. Local modification and training on the Keystone checklists uncovered wasted effort needed to gather up the supplies for the procedure and a specific equipment trolley was introduced 17. Chlorhexidine was acquired in the facilities lacking it. Incidental system improvements like these and cultural changes made the checklist more practical, more likely to be followed and more likely to produce results in a way that is analogous to the collaterals of the Safe Surgery Checklist introduction in Mbarara. The Safe Surgery Checklist is meant to foster teamwork and communication through its daily use – the team member introductions called for in the checklist are meant to promote this environment. An inclusive implementation process can be a powerful force in building the foundation for this teamwork from the beginning. In many settings, the review and modification process may be the first time that individuals across the peri-operative disciplines have any kind of meaningful, interactive collaboration and the first time an initiative to address safety is launched. This process draws out the observations and perspectives of nurses, technicians, anesthetists and surgeons, breaking through established hierarchy at the institutional level. All of these features are key ingredients in building a culture of safety. The challenge of overcoming the barriers to effective teamwork arising from rank and hierarchy are not unique to low resource settings, as the leaders of Keystone recognized and as Fourcade and colleagues noted in studying the use of the Safe Surgery Checklist in France: “Verbal communication between health professionals (surgeons, anaesthetists and nurses) has to be egalitarian for checklist use to be effective but the findings suggest that operating room staff practices are rooted in a time-honoured hierarchy, at least in France” 18. At Mbarara Regional Referral Hospital in Uganda, a remarkable educational fringe benefit of the checklist introduction work is also notable. The anesthetic registrar at Mbarara took the responsibility for presenting reports on compliance with the checklist and its component activities to each of the surgical departments. These reports were presented as statistical run charts, a relatively sophisticated quality improvement tool. Thus, the Safe Surgery Checklist implementation work there has incidentally produced a new physician skilled in the tools of quality improvement. While American residency programs are beginning to incorporate formal training in such techniques, it is quite remarkable that this education is appearing in a tiny training program in the heart of Uganda. Where so much needs to be done to advance quality and safety, propagating a corps of trained leaders of this work can enhance the momentum of many improvements across the health system. The message in Lilaonitkul et al's report from Mbarara is that a robust implementation program for the WHO Safe Surgery Checklist yields important benefits to clinical care even before the checklist's first use in practice. An multi-disciplinary process to modify, introduce and train for the use of the checklist develops a collaborative culture, finds and fixes system deficiencies, and grooms improvement leaders. All of these collateral benefits of the implementation work have great value of their own and may bring a facility to the point at which the checklist becomes less and less aspirational, more and more relevant and more likely to be embraced in practice. The author is a trustee of the Lifebox US foundation. No external funding and no conflicts of interest declared.

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