Implementation and evaluation of nationwide scale-up of the surgical safety checklist

Abstract

Background: The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low-income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods: This study had a longitudinal embedded mixed-methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty-six hospitals received 3-day multidisciplinary training and 4-month follow-up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR-derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results: At 12–18 months, 86⋅0 per cent of participants (86 of 100) reported checklist use compared with 31⋅1 per cent (169 of 543) before training and 88⋅8 per cent (158 of 178) at 4 months. There was high-fidelity use (median WHOBARS score 5⋅0 of 7; use of basic safety processes ranged from 85⋅0 to 99⋅0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76⋅7, 81⋅1 and 82⋅2 per cent before, and at 4 and 12–18 months after training respectively; P < 0⋅001). Acceptability, adoption, appropriateness and feasibility scored 9⋅6–9⋅8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion: This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.