Annually, more than 300 million surgical procedures are performed worldwide (Weiser et al, 2016). Although the majority have the desired patient outcome with no adverse events, errors still occur. Surgery is associated with two thirds of in-hospital adverse events (de Vries et al, 2010). The Surgical Safety Checklist (SSC) was introduced by the World Health Organization (WHO) (2009) to address patient safety, ineffective communication and eliminate memory-dependent errors. Figure 1 outlines the key components of the SSC (WHO, 2009). The checklist, which has undergone minor revisions by the WHO, and has been adapted for use in England and Wales and is widely used in Ireland, is divided into three sections:
- Before induction of anaesthesia (also known as ‘sign in’)
- Before skin incision (also known as ‘time out’)
- Before patient leaves operating room (also known as ‘sign out’).
Checklists assist with the delivery of skilled care and can been seen as one of the greatest technical advances in surgical safety this century (Gillespie et al, 2018). Both early research and follow-up studies reported a reduction in mortality when the checklist was used effectively (Bergs et al, 2014; GlobalSurg Collaborative, 2016). The SSC has received worldwide acclaim and is currently used in 132 countries (Gillespie et al, 2018; NHS England, 2019). Safety checklists improve surgical safety through fostering better inter-professional teamwork and communication (Russ et al, 2013).
Background
Despite the SSC's worldwide acceptance and proven results, compliance challenges have emerged. The term ‘meaningful compliance’ refers to the frequency and completeness of checklist use on different items (Ziman et al, 2018). A study by Mahmood et al (2019) found 26% compliance for ‘sign in’, 59% for ‘time out’ and 42% for ‘sign out’. These findings concur with other studies that highlight that the checklist is not being undertaken in real time, team members do not stop to listen, and items are omitted (Saturno et al, 2014; Ambulkar et al, 2018). Even with mandatory checklist use, the NHS in the UK has reported 472 ‘never events’ including 226 wrong site surgeries and 101 retained foreign objects between April 2019 and March 2020 (NHS England/NHS Improvement, 2020). Similar incidents have also been reported in the Irish Health System (Health Service Executive, 2015). The SSC has been proven to reduce errors and improve patient outcomes; therefore, it is imperative that it is undertaken correctly and should be more than a tick-box exercise.
The aim of this review of the literature was to examine the published evidence on factors that enhance compliance with the SSC among surgical team members (Table 1). A PEO framework was used to identify and refine the research question. It formats the research question into three elements: patient, population or problem (P), exposure (E) and outcome (O).
Table 1. Search strategy
| Databases searched |
|---|
|
| Inclusion criteria |
|
| Exclusion criteria |
|
| Review question in PEO format |
|
A search string was created for each element. Boolean operators were used as conjunctions to combine or exclude keywords in a search. ‘OR’ was used to combine each element of the search string for population, then exposure, then outcome. Two elements were displayed in the outcome section, namely ‘enhance’ and ‘compliance’. Each search strings was then combined using the Boolean operator ‘AND’. The Boolean operator ‘NOT’ was not used. Synonyms, words and phrases that have the same or similar meaning were used in the search.
The search yielded 1340 published papers. The process of excluding duplicates, applying inclusion and exclusion criteria as well as primary and secondary filtering resulted in 17 papers included in this review.
Quality appraising
The Crowe Critical Appraisal Tool (CCAT) (Crowe et al, 2013), which is a reliable and valid tool for examining quantitative and qualitative studies, was used to critically appraise the quality of the 17 studies in this review. The tool consisted of eight categories (preliminaries, introduction, design, sampling, data collection, ethical matters, results and discussion), divided into 22 items, which were further subdivided into 98 item descriptors. The categories were scored on a 6-point scale of 0–5, with a maximum score of 40 and a minimum of 0. Scores were given for each item and converted into percentages in relation to the tool.
Findings
Thematic analysis was used to generate themes within the literature: ‘training and innovations’, ‘process adaptations’, and ‘team leadership’ were the themes identified and are presented in Table 2.
Table 2. Study geographical location, methodology and themes
In undertaking the analysis, literature was coded, recorded, modified and the data collated into themes. Findings were grouped into thematic categories based on similar characteristics. Each article was read and re-read, generating codes which were reviewed and finalised into themes. Characteristics of studies such as the geographical location and methodology are also presented in Table 2.
Training and innovations
Two qualitative studies (Brindle et al, 2018; Schwendimann et al, 2019) reported training as an important component of enhancing compliance with the SSC. They reported on various training programmes with common threads running through each such as teamwork, communication and clinical leadership.
Eight quantitative studies showed increased compliance with different aspects of the SSC when training of all the surgical team was employed (Gillespie et al, 2017; Gillespie et al, 2018; Yu et al, 2017; McCulloch et al, 2017; Rakoff et al, 2018; Finch et al, 2019; Hellar et al, 2020; Röhsig et al, 2020). Yu et al (2017) used standardised education and training of staff to demonstrate an observed compliance increase of more than 30%. Similarly, structured validated reproducible training programmes were used in two studies (Gillespie et al, 2017; Gillespie et al, 2018) with favourable results. Furthermore, Rakoff et al (2018) compared a standardised training programme of WHO videos, didactic sessions and posters with a customised training of a locally designed department-specific video, posters and didactic sessions. Observations showed a significantly higher staff compliance with the customised training (87% versus 49%). McCulloch et al (2017) investigated compliance when a blend of work systems and processes in the operating room were altered. They found the combination of teamwork training and systems change improved compliance with the checklist more than isolated innovations. Hellar et al (2020) conducted 5-day leadership and a 5-day clinical training sessions, which resulted in increased compliance from 82% to 92.8% post-intervention.
Three studies introduced computerised checklists to replace paper checklists (Gitelis et al, 2017; Yu et al, 2017; Shear et al, 2018). Yu et al (2017) customised and computerised the checklist with the collaboration of key personnel. Gitelis et al (2017) compared the use of paper documentation versus a checklist that was embedded in a patient's electronic health record for compliance with sign in. Similarly, Shear et al (2018) compared paper versus electronic health records. They installed ‘surgical flight boards’ comprising a large flat screen monitor mounted at a central location in the room. This made the checklist visible to everybody in the operating room, resulting in significant improvements in the ‘time out’ phase of the checklist.
Dobbie et al (2019) used technology to enhance compliance with the checklist. Using video recorders and providing continued reinforcement and feedback contributed to the use of ‘time out’, increasing from 51% to 95%. Boillat et al (2019) used the most up-to-date technology to increase compliance. Surgeons navigated through the different aspects of the checklist by donning goggle glasses with a smart app that worked with an in-built checklist in the frames of the glasses. Using this technology increased compliance from 73% to 100%.
Process adaptations
Audit on the SSC by the department managers is a method of improving compliance (O'Brien et al, 2017; Gillespie et al, 2018; Georgiou et al, 2018). Gillespie et al (2018) and Dobbie et al (2019) suggested combining audit with feedback to improve compliance. Feedback consisted of advice from experts on items that were omitted. Gillespie et al (2018) used audit, feedback and reminders as part of a safety programme, resulting in significant improvements in compliance. In their study, Dobbie et al (2019) observed the surgical team remotely and provided feedback, which led to improvements with compliance.
Making checklist adaptations is a method of improving compliance. O'Brien et al (2017) reported that it should be adapted to suit the surgery. Rakoff et al (2018) and Röhsig et al (2020) adapted the checklist to suit the local needs of the department, which increased compliance. Yu at al (2017) reported that staff suggested that the checklist should be simplified and shortened. Some of the other adaptations to the checklist have been technological in nature. Gitelis et al (2017) cited positive outcomes when computerised systems replaced paper versions.
Team leadership
There is some disagreement in the literature as to who is best placed to lead the team to provide best outcomes with compliance (Yu et al, 2017; O'Brien et al, 2017; Gillespie et al, 2018; Brindle et al, 2018; Georgiou et al, 2018; Boillat et al, 2019). Yu et al (2017) suggested that anaesthetists were best placed to instigate the checklist, as they are a fixed team member and exhibit stronger leadership skills than nurses. Brindle et al (2018) and Georgiou et al (2018) acknowledged a hierarchical issue with regard to nurses and felt they received the least amount of respect from other colleagues, and were least likely to speak up in the operating room. O'Brien et al (2017) suggested that it was an initiative enforced on nurses and strong confident people are required to lead it to ensure success. Röhsig et al (2020) acknowledged this when they trained their nursing team, empowering them in the use of the SSC, with favourable results. Sharing of the SSC components among key personnel was favoured by two studies (Gitelis et al, 2017; Gillespie et al, 2018). One study identified senior nurses in the perioperative setting as change champions and leaders. The surgeon led the ‘time out’ portion with the anaesthetic/circulating nurse leading the other two elements. Good initial results were found but these decreased during the ‘sign out’ element after 12 months (Gillespie et al, 2018).
Team participation was suggested as a factor in the success of the checklist. Korkiakangas's (2017) video study observed that, when patients were transferred on to the operating table, all staff were usually present, deducing that if the checklist was undertaken at this stage there would be more engagement with the process. Furthermore, they highlighted the importance of the checklist ‘call’ to address compliance with everyone in the room. Shear et al (2018) looked at a surgeon-led ‘flight board’ (visible team interactive board) to promote team participation. Increased compliance was noted following use of the ‘flight board’. Yu et al (2017) suggested a poster to help with workflow to improve team participation, which aided compliance.
Brindle et al (2018) and Schwendimann et al (2019) concurred that participation from all members of the surgical team in the execution of the SSC is a factor in its success. Brindle et al (2018) mentioned open communication as a process facilitated by surgeons to allow everyone in the room to feel empowered to speak and contribute to the accurate execution of the ‘sign out’ (debrief). Schwendimann et al (2019) suggested that collaboration between expert staff and an atmosphere that allowed whole-team participation, including a quiet environment, was crucial. Acceptance of the value of the SSC by the surgical team was reported as an enhancer of compliance (O'Brien et al, 2017; Georgiou et al, 2018; Schwendimann et al, 2019). O'Brien et al (2017) suggested that the belief in the value of the checklist developed over time.
Discussion
Bringing staff together is a key principle of the WHO's vision of the checklist's potential success (WHO, 2009). Group team training is a consistent type of effective training reported in the studies reviewed. The use of training DVDs (Gillespie et al, 2017), clinical skills training (Gillespie et al, 2018; Hellar et al, 2020), coaching and group meetings (McCulloch et al, 2017; Gillespie et al, 2018; Finch et al, 2019) and simulation (Rakoff et al, 2018) are frequently used training methods. Although some team training was successful (Hellar et al, 2020), time constraints and difficulties with bringing the team together for training made the process challenging (Gillespie et al, 2017). Yu et al (2017) highlighted the importance of training, and identified an opportunity to capture medical staff during medical grand rounds and department learning sessions. Finch et al (2019) provided a solution to these issues, which included ‘checklist coaches’ in the operating room. This intervention does not require off-site training, with minimal delays occurring. Any nonconformity could be relayed back to staff and opportunities for improvement identified. This initiative could be extended to incorporate all aspects of the checklist and into the daily routine of the perioperative environment.
Long-term planning and the investment of money for technology and resources requires consideration. Boillat et al (2019) introduced smart glasses to the operating room as a means of increasing compliance. However, a limitation of this technology was the isolating of the surgeon from the rest of the team. Although compliance did increase, it contradicts the philosophy of the checklist, which is to bring the team together. Additionally, the estimated cost of one pair of smart glasses would be approximately $1500 (£1300), excluding cleaning and updating of software. Furthermore, nurses cited difficulties in the operation of this technology (Finch et al, 2019).
Consistent audit activity helps to generate a culture of quality improvement in the clinical setting (Jones, 2019). In their analysis of audit of the SSC, Woodman and Walker (2016) stated that data is a powerful way to initiate change, an important element of any quality improvement project. Georgiou et al (2018) and O'Brien et al (2017) reported on the value that nurses place on auditing, which encourages the identification of the need for change and improvements.
Brindle et al (2018) noted ‘feedback’ after the debrief or ‘time out’ as a factor in their compliance with the process. Feedback enabled staff to get timely responses on specific issues mentioned in the debrief, leading to increased engagement by the surgical team as issues were addressed. Finch et al (2019) also found this, suggesting that the debrief brought closure to issues affecting workflow and patient safety, and this therefore could be viewed as an effective risk-management strategy. Hicks et al (2014) suggested that improved efficiency, acceptability and sustainability is realised when the ‘feedback loop’ is closed. These initiatives can be incorporated easily and inexpensively into organisational processes in the management of an operating theatre.
Cautious adaptation of the checklist is encouraged to better fit the needs and processes of care in specific areas to ensure crucial elements are not omitted (WHO, 2008). The WHO SSC template was never intended to be all-inclusive and needs to be modified with surgical teams customising the checklist to meet specialty needs (Dabholkar, 2018). Input from nurses, anaesthetists, surgeons and others is imperative in creating a sense of ownership that is fundamental in practice change. Yu et al (2017) involved key stakeholders in their adaptations to their checklist, which showed lasting results relating to compliance levels.
The importance of leadership in cultivating effective use and compliance with the SSC is essential, The leader needs to be confident (O'Brien et al, 2017) and have the ability to initiate and co-ordinate the checklist (Korkiakangas, 2017). However, evidence highlights that this leadership role is provided by different professionals in the operating room, including the anaesthetist (Yu et al, 2017) and the nurse (Brindle et al, 2018).
Several studies mentioned the surgeon as a factor in the success or failure of the checklist (O'Brien et al, 2017Brindle et al, 2018; Georgiou et al, 2018). Ironically, the surgeon must deal with the implications of an error when the checklist is not executed correctly. Georgiou et al (2018) suggested that younger surgeons are more compliant because they have been taught to use the checklist during their education. Brindle et al (2018) suggested linking the use of the checklist with surgical privileges and promotions. Staff who have a belief in the value of the checklist have better compliance levels.
Conclusion
The importance of using the SSC appropriately has been acknowledged (GlobalSurg Collaborative, 2016). Verwey and Gopalan (2018) identified challenges such as stress, time pressures and ineffective communication among the surgical team that can negatively impact on the effective use of the SSC. Having a comprehensive understanding of the factors that enhance compliance with the SSC is important in addressing the complexities with the implementation of the checklist and ensuring patient safety.
This literature review has demonstrated a range of interventions that could improve compliance with the SSC. The involvement of all the surgical team in undertaking and completing the SSC will continue to create a culture of safety in the perioperative setting. Fostering a culture of good communication and teamwork is essential in this setting. This review highlights the importance of training, effective leadership and adapting to new safety processes as a means of nurturing effective use and compliance with the safety checklist.
KEY POINTS
- Compliance with the Surgical Safety Checklist (SSC) provides a safe, positive, and collaborative environment for the surgical team, minimises risk and supports positive patient outcomes
- The importance of incorporating continuous education and training needs to be accepted and acted upon to maintain compliance
- Fostering strong nurse leadership within the perioperative setting will assist with increasing compliance
- Technological developments have provided more strategies to enhance compliance with the SSC
CPD reflective questions
- Are you aware of your hospital's policy regarding the Surgical Safety Checklist (SSC)?
- Why it is important to adhere to best practice with regard to the SSC?
- Why do you think surgical team members might not engage meaningfully with this initiative?
- Reflect on your practice as part of the perioperative team leading the SSC and consider how you might improve it