A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical...

ORIGINAL ARTICLE

A Qualitative Evaluation of the Barriers and Facilitators TowardImplementation of the WHO Surgical Safety Checklist Across

Hospitals in EnglandLessons From the “Surgical Checklist Implementation Project”

Stephanie J. Russ, PhD, Nick Sevdalis, PhD, Krishna Moorthy, MD, FRCS, Erik K. Mayer, PhD, FRCS,Shantanu Rout, MRCS, Jochem Caris, MD, Jenny Mansell, MSc, Rachel Davies, BA, Charles Vincent, PhD,

and Ara Darzi, MD, FACS

Objectives: To evaluate how the World Health Organization (WHO) surgicalsafety checklist was implemented across hospitals in England; to identifybarriers and facilitators toward implementation; and to draw out lessons forimplementing improvement initiatives in surgery/health care more generally.Background: The WHO checklist has been linked to improved surgical out-comes and teamwork, yet we know little about the factors affecting its suc-cessful uptake.Methods: A longitudinal interview study with operating room personnel wasconducted across a representative sample of 10 hospitals in England betweenMarch 2010 and March 2011. Interviews were audio recorded over the phone.Interviewees were asked about their experience of how the checklist wasintroduced and the factors that hindered or aided this process. Transcriptswere submitted to thematic analysis.Results: A total of 119 interviews were completed. Checklist implementationvaried greatly between and within hospitals, ranging from preplanned/phasedapproaches to the checklist simply “appearing” in operating rooms, or stafffeeling it had been imposed. Most barriers to implementation were specificto the checklist itself (eg, perceived design issues) but also included prob-lematic integration into preexisting processes. The most common barrier wasresistance from senior clinicians. The facilitators revealed some positive stepsthat can been taken to prevent/address these barriers, for example, modifyingthe checklist, providing education/training, feeding-back local data, fosteringstrong leadership (particularly at attending level), and instilling accountability.Conclusions: We identified common themes that have aided or hindered theintroduction of the WHO checklist in England and have translated these intorecommendations to guide the implementation of improvement initiatives insurgery and wider health care systems.

Keywords: WHO surgical safety checklist, implementation, barriers andfacilitators, patient safety, interview study, surgery, operating room, operatingtheatre

(Ann Surg 2014;00:1–11)

T he World Health Organization’s (WHO) surgical safety check-list was a key output of their 2007 “Safe Surgery Saves Lives”

campaign.1,2 The checklist comprises 3 components: “sign-in,”

From the Department of Surgery and Cancer, Imperial College London, UK.Disclosure: Supported by the National Institute for Health Research (NIHR), UK,

funds. The authors declare no conflicts of interest.The funders had no role in the design and conduct of the study; the collection,

management, analysis, and interpretation of the data; or the preparation, review,and approval of the manuscript.

Reprints: Stephanie Jane Russ, PhD, Department of Surgery and Cancer, ImperialCollege London, Room 504, 5th floor, Wright Fleming Building, Norfolk Place,London W2 1PG, United Kingdom. E-mail: [email protected].

Copyright C© 2014 by Lippincott Williams & WilkinsISSN: 0003-4932/14/00000-0001DOI: 10.1097/SLA.0000000000000793

“time-out,” and “sign-out,” which are carried out when the patientarrives into the operating room (OR) complex, just before the surgi-cal procedure starting and upon completion of the procedure, respec-tively. The purpose of this tool was to create a standardized frameworkto improve patient safety and reduce the morbidity and mortality as-sociated with potential deviations from best practice, for example,with regard to antibiotic and deep vein thrombosis prophylaxis, aswell as avoidable error in the surgical setting.3,4

The checklist was pilot-tested in a global study across 8 hos-pitals in the developed and developing world. The results were pub-lished in January 2009 and showed a significant reduction in mortalityand morbidity after checklist implementation.5 As a result of thesefindings, a modified version of the checklist was mandated by theUK’s Department of Health (through the then called “National Pa-tient Safety Agency,” NPSA) for use in all surgical procedures carriedout within the National Health Service (NHS) in England and Wales(including day surgery).6 Hospitals were given 12 months to fullyimplement the checklist (until January 2010). Some guidance regard-ing implementation, modification, and the correct use of the checklistwas made available online7 and the checklist was also highlightedas part of the “Patient Safety First” campaign, which was active be-tween June 2008 and March 2010 and aimed to promote patient safetyacross the NHS.8 To date, the WHO checklist, or a version of it, hasbeen introduced as best practice in several other countries, includingthe United States.9

To prospectively evaluate how the checklist was introducedand implemented within England, after the introduction of the WHOchecklist as national policy our research team set up the “SurgicalChecklist Implementation Project” in 2009. Here, we report longi-tudinal interview data collected between 2010 and 2011 on how thechecklist was received across a nationally representative sample ofhospitals in England. The following specific research questions wereaddressed:

1. How was the WHO checklist initially implemented within Englishhospitals?

2. What were the key barriers and facilitators to its implementation?3. What lessons can we extract for informing how to optimize the

diffusion and uptake of improvement initiatives in surgery andwider health care systems?

METHODSSetting and Participants

The Surgical Checklist Implementation Project was a multi-phase large research program. For this study, OR personnel weresampled from 10 English hospitals to take part in the interviews. The10 hospitals were selected to be nationally representative using thefollowing stratification criteria:

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Russ et al Annals of Surgery � Volume 00, Number 00, 2014

– Geographic spread: hospitals were selected to cover multiple re-gions. These were determined using the 10 (at the time of the study)health care administrative entities within England as provided bythe Department of Health.

– Type and size: the Department of Health has a hospital classifica-tion “clustering” system based on hospital type (eg, teaching vscommunity) and size (small vs medium vs large)—the latter basedon number of beds/admissions.

– Safety incident reporting levels: all English hospitals are linkedinto a national incident reporting system, termed the “NationalReporting and Learning System,” NRLS (www.nrls.npsa.nhs.uk).A database is maintained of the volume of incidents reported byeach hospital, which classifies them into low, medium, and highreporting hospitals. This criterion was used in light of the evidencethat shows that increased reporting to the NRLS is positively linkedto safety culture within hospitals,10 which can affect how a safetyintervention like the WHO checklist is implemented.

– Checklist implementation early response: after introduction of theWHO checklist as national policy in 2009, the Department ofHealth maintained a database of hospitals regarding where theywere on their implementation pathway (not acknowledged, ac-knowledged, ongoing, completed). Hospitals were required to havereached the stage of “completed” by February 2010.

To achieve representativeness of responses, the sampling tookplace in 2 stages. In the first stage a random set of hospitals acrossthe above criteria was generated by the NPSA. In the second stage,the research team cross-tabulated the criteria, identified hospitals thatfulfilled the cross-stratification as much as this was feasible (eg, therewere only 2 institutions that were listed as not having acknowledgedthe checklist policy, as should be expected), and then randomly se-lected within those. Hospitals were identified with a 3-letter acronymprovided by the Department of Health, to which the research teamwas kept blinded until after the final selection had been made.

Within the 10 selected hospitals, all OR personnel were identi-fied via the human resources department. All personnel subsequentlyreceived an electronic survey of their views on the WHO checklist(data not reported here). Participants who completed the survey hadthe option to provide their details so they could be interviewed regard-ing the checklist—that is, an “opt in” sampling strategy for this study.All of those who “opted in” were contacted for interview. Participat-ing personnel fell under the following professional groups: surgeons,anesthesiologists, OR nurses (including OR managers), operating de-partment practitioners (ODPs; they perform the role of an anestheticnurse or technician in English ORs), and radiographers.

Design and ProcedureInterviews were carried out longitudinally over the course of

1 year (March 2010–March 2011) to capture staff perceptions of thechecklist over time following its formal mandatory introduction intoEnglish ORs. All interviews were carried out over the phone by atrained interviewer from the market research company Ipsos MORI(www.ipsos.com). Interviews lasted approximately 30 minutes each,were audio-recorded, and later were transcribed verbatim for dataanalysis. Before data collection, the study was reviewed by the UK’sIntegrated Research Application System for health research and wasformally approved as a quality improvement study (September 28,2009).

Data Collection InstrumentA semistructured interview schedule was designed by our re-

search team, reviewed by Ipsos MORI experts, and subsequentlypiloted for feasibility at one of the study sites. The interviews com-prised a series of open-ended questions and prompts, which were

designed to capture detailed accounts of the following aspects ofchecklist implementation:

– how the checklist had been implemented within each hospital (eg,“How was the checklist introduced in your hospital?” “Did youreceive any training?”)

– barriers and/or facilitators toward its implementation (eg, “Whatwere your initial reactions upon hearing about the WHO check-list?” “Do you feel that staff are using the checklist as intended?Why/Why not?,” “Is it always possible to use the WHO checklist?,”“What sorts of things make it easier/more difficult to use?”).

The semistructured approach to the interviews was selectedas a method to allow exploration of interviewees’ full range of im-plementation experiences across the sample. An abridged version ofinterview schedule is available in the Appendix (a full version isavailable from the authors on request).

AnalysesAudio-recorded interviews were anonymized and responses

were transcribed verbatim. All transcripts were analyzed by a trainedpsychologist researcher (S.J.R.) using an inductive approach, evolv-ing an interpretive framework to fit the data. Thematic analysis wasundertaken, extracting specific themes from the transcripts regarding(1) how the checklist had been implemented and (2) the perceived bar-riers (factors that hinder uptake) and facilitators (factors that improveuptake) surrounding its implementation. Themes were extracted un-til the standard criterion for qualitative studies of “saturation” wasreached—that is, no further codes were needed to describe the partic-ipants’ views. A senior psychologist with expertise in surgical safety(N.S.) reviewed the analyses to control for bias in theme extraction.

To provide a framework for the coding of the interviews,themes representing barriers and facilitators were grouped accordingto whether they related to organizational, systems, team, or checklist-specific factors. These were based on the large evidence base onfactors affecting safety in surgery and were defined as follows:

– Organizational: Themes relating to financial resources and con-straints; organizational structure; policy, standards, and goals; strat-egy and planning; safety culture and priorities.11,12

– Systems: Themes relating to the integration of the checklistinto existing systems, protocols, and procedures (eg, efficiency,repetition).11–13

– Team: Themes relating to teamwork (eg, communication, cohe-sion), team structure/membership (eg, leadership), and team buy-inand ownership of the checklist.11–15

– Checklist-specific: Themes relating specifically to either checklistdesign, content, applicability or process, and/or the evidence basebehind the checklist.13,15

RESULTS

Participant Demographic InformationA total of 141 participants “opted in” to be interviewed, of

whom a final sample of 119 OR personnel across 10 NHS hospitalswere interviewed (response rate: 84.4%). Participants who were notinterviewed were unable to be contacted due to logistical problems—that is, holidays, lack of availability of time for the interview, orcancelation of interview due to clinical commitments. The 119 par-ticipants who were interviewed varied widely in their experience ofworking in ORs, ranging from 6 months to more than 30 years. Table1 displays respondent numbers according to professional group andhospital size. All hospitals had implemented the checklist 6 to 12months before data collection.


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http://www.nrls.npsa.nhs.uk

http://www.ipsos.com

Annals of Surgery � Volume 00, Number 00, 2014 Implementing Change in Health Care: The WHO Checklist

TABLE 1. Respondent Profiles

N = 119 N (% of Sample)

Professional groupSurgeon 37 (31)

Attending 19 (16)Other 18 (15)

Anesthesiologist 31 (26)Attending 18 (15)Other 13 (11)

Nurse 23 (19)Operating department practitioner (anesthetic

nurse/technician)18 (15)

Radiographer 10 (8)Trust size

Small 34 (29)Medium 27 (23)Large 25 (21)Acute teaching 33 (28)

How Was the WHO Checklist Initially Implemented?The manner in which the checklist was initially implemented

varied greatly, both between and within hospitals, and fell under 3broad themes:

1. Planned implementation approach2. Limited/no implementation approach3. Imposed implementation approach

Each of these themes is described in Table 2 with illustrativequotes.

Planned implementation refers to interviewees’ reports thatoutlined a clear, articulated strategy for introducing the checklistwith senior leadership and local facilitation—including producingearly modifications of the form, trialling implementation in 1 or 2ORs initially to allow troubleshooting, electing “checklist champions”who acted as local leaders and also a “go-to” person for frontlinepersonnel regarding queries, and providing education and trainingsessions around the importance and use of the checklist. In contrast,limited/no implementation emerged from interviewees’ reports thatemphasized a lack of awareness of any preplanned implementationstrategy and a perception that the checklist had simply “appeared” oneday in ORs. Some staff mentioned that they had received an e-mailor saw posters relating to the checklist’s introduction but that this wasnot formally consolidated by any further implementation exercises.Finally, imposed implementation refers to interviewees’ reports offeeling forced to use the checklist or of an overtly top-down approach(ie, from hospital senior management or the Department of Health)with no opportunity for frontline personnel feedback or involvement.Individuals within the same hospital often reported quite differentimplementation experiences, depending on what professional groupthey belonged to, or what shifts they worked. For example, certainspecialties may have provided some training and education aroundthe initiative during audit days whereas other specialties did not,and individuals working night shifts often reported missing relevantmeetings and education sessions.

Barriers and Facilitators to WHO ChecklistImplementation

A total of 11 themes were extracted that represented barriers tochecklist implementation and 9 themes that represented facilitators.These themes are presented in Tables 3 and 4 along with illustrativequotes. We found no apparent differences between the responsesof individuals who were interviewed at the start of the 1-year data

collection period compared with those interviewed at the end, nordid we find a difference between those who had implemented thechecklist earlier rather than later after the initial mandate.

BarriersOrganizational Barriers

Two themes reflected organizational barriers. The first, re-ported by 24% of the sample, related to the style in which the check-list was initially implemented within the hospital. When there was noplanned approach to implementation (eg, a lack of education or train-ing, a perceived lack of support from management, no customizationto the local context), or indeed an imposed approach, staff buy-into the tool was jeopardized because of a lack of ownership over theinitiative and because the local relevance of the tool had not beencommunicated. The second, reported by the same proportion of thesample (but not the same individual staff members), centered aroundthe culture within the hospital. Staff described a general resistance tothe introduction of change, whatever form it takes, particularly frommore senior members of staff. Some stated that this had resulted fromtoo many changes being made to recommended practice in England,and the feeling that “if it’s not broke, why fix it.”

Systems BarriersTwo further barriers related to problems integrating the check-

list into existing systems. Almost a third of the sample (29%) reportedthat the checklist took too long to complete, creating inefficiency inthe running of the operating list. And a quarter of the sample per-ceived the checklist to be directly repetitive of existing safety practicesalready in place, therefore failing to contribute anything “extra” interms of safety to the system (eg, where local checklists had alreadybeen developed and were not removed before the WHO checklist wasintroduced).

Team BarriersThe most common barrier to checklist implementation, re-

ported by 51% of the sample, was active resistance or passive non-compliance from individuals in the OR team, most frequently (84%of the time) from senior surgeons and/or anesthesiologists. This oftenmade it very challenging for the person leading the checks (often anurse) to complete them in the intended manner, or without feelingpersonally attacked.

Checklist-Specific BarriersThe majority of barriers that emerged were specific to the

checklist itself. A third of the sample (34%) reported design issueswith regard to the checklist’s content (eg, the awkward wording of cer-tain checks such as “are there any unexpected steps?”—intervieweescommented that if something is unexpected it follows it cannot beanticipated in advance), or physical structure/layout (eg, there beingno space to write answers to questions or to provide the date). Others(27%) perceived there to be issues with the timing at which certainchecks are carried out, for example, with the time-out often beingperceived as being too late to correct errors or disrupting staff at acritical time, and the sign-out suffering from staff leaving the ORbefore the end of the procedure. The checklist was also perceivedby 28% of the sample to be inappropriate for certain surgical pro-cedures; either specific surgical specialties (eg, ophthalmic surgery,obstetrics) or certain contexts (eg, time-pressured emergencies, rapidturnover day-cases). Similarly, some respondents (14%) were con-cerned about the reaction patients might have toward the checks. Forexample, some stated that patients often did not understand why theyhad to confirm their ID/procedure, etc, so many times during theirsurgical pathway, and others felt that specific questions around blood


C© 2014 Lippincott Williams & Wilkins www.annalsofsurgery.com | 3


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TAB

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Barr

iers

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Bar

rier

sN

(%)∗

Illu

stra

tive

Quo

tes

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the

chec

klis

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intr

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edpr

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buy-

inan

dcr

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dad

vers

ity.

28(2

4)T

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was

intr

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top

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edby

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ane

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shed

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oth

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ixed

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tabo

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told

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chec

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tis

com

ing,

this

isw

hati

tlo

oks

like

,and

you

wil

ldo

it.T

hatc

reat

edth

eim

pres

sion

that

itw

asju

stan

othe

rpi

ece

ofre

gula

tory

pape

rwor

k.A

tten

ding

Ane

sthe

siol

ogis

t,A

cute

Tea

chin

gH

ospi

tal

Lac

kof

cult

ure

for

chan

ge:

The

cult

ure

wit

hin

the

hosp

ital

isth

atof

age

nera

lre

sist

ance

toch

ange

and

new

prac

tice

.

28(2

4)A

loto

fpeo

ple

don’

tlik

ech

ange

and

they

don’

tlik

ene

wth

ings

,and

ifth

ey’v

ebe

endo

ing

itth

isw

ayfo

rth

ela

st20

year

san

dit

’sno

tbr

oken

why

fixit

?O

DP,

Lar

ge,H

ospi

tal

Just

pers

onal

inte

rest

and

refu

salt

och

ange

,una

ble

toad

apt.

Som

edo

ctor

sfe

elun

com

fort

able

whe

nyo

u’re

tryi

ngto

chan

ge.I

wil

lad

dth

eyar

ese

nior

mem

bers

ofth

eir

resp

ecti

vete

ams.

Att

endi

ngA

nest

hesi

olog

ist,

Med

ium

Hos

pita

l

Syst

ems

fact

ors

Tim

ew

asti

ng:

The

chec

klis

tcau

ses

unne

cess

ary

dela

yto

the

oper

atin

gli

st.

34(2

9)Ye

tmor

ede

lay!

Oh

gosh

,we’

rego

ing

toge

tles

sw

ork

done

for

the

pati

ents

.A

tten

ding

Surg

eon,

Acu

teT

each

ing

Hos

pita

l.T

hefir

stan

dse

cond

part

ofth

ech

eckl

istw

illd

elay

thin

gsbe

caus

eyo

u’re

dela

ying

star

ting

the

anes

thet

icro

oman

dyo

u’re

dela

ying

star

ting

onth

eop

erat

ing

tabl

e.A

tten

ding

Ane

sthe

siol

ogis

t,A

cute

Tea

chin

gH

ospi

tal

Rep

etit

ion:

The

chec

klis

tdup

lica

tes

exis

ting

safe

typr

oced

ures

,fai

ling

toad

dan

ythi

ngto

the

syst

em.

30(2

5)I

thin

kth

epr

oble

mis

that

,wit

hit

bein

ga

stan

dard

ized

chec

klis

t,is

that

hosp

ital

sha

veth

eir

own

chec

klis

tsas

wel

land

you

end

upha

ving

two

orth

ree

chec

klis

ts,a

llch

ecki

ngth

esa

me

sort

ofth

ing

soyo

uge

tsom

eov

erla

p.O

DP,

Med

ium

Hos

pita

lW

hen

itw

asin

trod

uced

,no

one

look

edat

wit

hdra

win

gw

hatt

hech

eckl

isti

sre

plac

ing.

Sost

affn

owfil

lin

the

chec

klis

tand

ever

ythi

ngel

seth

eyus

edto

filli

nas

wel

l.A

tten

ding

Ane

sthe

siol

ogis

t,A

cute

Tea

chin

gH

ospi

tal

Tea

mfa

ctor

sR

esis

tanc

ean

dno

ncom

plia

nce:

Cer

tain

indi

vidu

als

wit

hin

the

team

mak

eit

very

diffi

cult

toco

mpl

ete

the

chec

klis

twit

hout

conf

ront

atio

n,or

cert

ain

indi

vidu

als

are

note

ngag

edin

the

chec

ks.

61(5

1)T

hech

eckl

isti

tsel

fis

very

easy

.Get

ting

the

answ

erto

som

eof

the

ques

tion

sfr

omth

esu

rgeo

nsan

dth

ean

aest

heti

sts

isn’

t,an

dth

at’s

the

fall

dow

n.O

DP,

Lar

geH

ospi

tal

Whe

nth

esu

rgeo

nsw

eren

’ton

boar

dyo

uw

ere

told

to“

ohsh

utup

and

let’s

geto

nw

ith

it.”

Dur

ing

intr

oduc

tion

sw

eha

dsu

rgeo

nslo

okup

and

say

“oh

God

,I’m

soan

dso

,Pri

nce

ofD

arkn

ess,

ifyo

udo

n’tk

now

me

byno

wge

tout

ofm

yop

erat

ing

room

.”O

pera

ting

Roo

mN

urse

,Sm

allH

ospi

tal

(Con

tinu

ed)




TAB

LE3.

(Con

tinue

d)

Bar

rier

sN

(%)∗

Illu

stra

tive

Quo

tes

Too

l-sp

ecifi

cfa

ctor

s

Des

ign

prob

lem

s-co

nten

t/st

ruct

ure:

The

cont

enta

nd/o

rst

ruct

ure

ofth

ech

eckl

isti

sin

appr

opri

ate,

irre

leva

ntan

d/or

illo

gica

l.

40(3

4)It

asks

ques

tion

son

ther

ebu

twit

hout

any

defin

ite

answ

ers.

It’l

lask

abou

tthe

pati

ent’s

ASA

grad

e,so

you

just

tick

itan

dsa

yye

s.It

does

n’tm

enti

onw

hatt

heco

deis

orw

hatr

elev

ance

that

has

toan

ythi

ngor

anyt

hing

like

that

.So

it’s

abi

tbiz

arre

and

ther

e’s

ase

nse

of,I

’mno

tact

uall

ypr

ogre

ssin

gth

epa

tien

tcar

ew

ith

this

ques

tion

.O

DP,

Lar

geH

ospi

tal

Som

eof

the

ques

tion

sar

eli

kea

red-

rag

toa

bull

,lik

e“

are

you

expe

ctin

gth

eun

expe

cted

?”O

pera

ting

Roo

mN

urse

,Lar

geH

ospi

tal

The

reis

noco

lum

nfo

rth

eda

te—

Ith

ink

itre

quir

esda

tein

putb

ecau

seyo

uca

nha

veth

esa

me

pati

enth

avin

gre

peat

edsu

rger

y.O

DP,

Acu

teT

each

ing

Hos

pita

lN

otap

plic

able

toal

lsur

geri

es:

The

chec

klis

tis

nots

uita

ble

for

use

ince

rtai

nsp

ecia

ltie

san

d/or

cert

ain

type

sof

proc

edur

e(i

e,em

erge

ncie

s,da

y-ca

se).

33(2

8)W

here

peop

leha

veha

dpr

oble

ms

wit

hit

has

been

insp

ecia

ltie

sli

keop

htha

lmol

ogy.

Ikn

owpe

ople

have

said

itha

sbe

enov

erki

llfo

rth

em.

Att

endi

ngSu

rgeo

n,Sm

allH

ospi

tal

It’s

ali

ttle

too

rigi

dfo

rdi

ffere

ntki

nds

ofen

viro

nmen

t.Fo

rin

stan

ceda

ysu

rger

yit

was

ali

ttle

over

the

top

inth

atw

eou

ghtt

oha

veco

mbi

ned

som

eof

the

chec

ks,s

oth

ey’v

ew

alke

d50

yard

san

dth

enth

eyas

kth

emth

esa

me

ques

tion

sag

ain.

Att

endi

ngA

nest

hesi

olog

ist,

Acu

teT

each

ing

Hos

pita

lU

nsui

tabl

eti

min

gof

chec

ks:

Sec

tion

sof

the

chec

klis

tand

/or

indi

vidu

alit

ems

are

ill-

tim

ed.

32(2

7)A

ndit

’sdo

neto

ola

te.O

nce

that

pati

ent’s

onth

eta

ble,

anes

thet

ized

,and

then

you

find

that

you

have

n’tg

otth

epr

osth

esis

,or

the

bloo

ds,o

rth

eri

ghte

quip

men

t,it

’sto

ola

teis

n’ti

t?O

DP,

Med

ium

Hos

pita

lW

efin

dth

em

ostd

iffic

ultp

artt

oco

mpl

ete

isth

efin

alpa

rtof

it.T

hetr

ansf

erfr

omO

Rs

tore

cove

ry,l

ike

the

sign

-out

part

,bec

ause

that

’sa

very

very

busy

tim

e.O

pera

ting

room

nurs

e,M

ediu

mH

ospi

tal

Uni

nten

ded

nega

tive

effe

cts:

The

chec

klis

tca

nha

veun

inte

nded

nega

tive

effe

cts

onsu

rgic

alsa

fety

ifus

edas

ati

ck-b

oxex

erci

seor

ifit

crea

tes

fric

tion

wit

hin

the

team

20(1

7)In

som

eca

ses,

beca

use

ofth

eco

nflic

titc

reat

es,i

tsac

tual

lybe

enco

unte

rpro

duct

ive.

Att

endi

ngA

nest

hesi

olog

ist,

Smal

lHos

pita

lW

here

the

answ

erto

chec

ksis

in99

9ou

tof1

000

case

sa

“no

”or

“no

tapp

lica

ble,

”th

ete

amm

ight

beco

me

com

plac

enta

bout

the

chec

ksan

dus

eth

eto

olas

ati

ck-b

oxex

erci

se,f

aili

ngto

pick

upth

eon

eca

sew

here

the

answ

erw

asa

“ye

s.”

Thi

sis

harm

ful

beca

use

itde

-sen

siti

zes

staf

fand

aner

ror

can

occu

r.A

nest

hesi

olog

ist,

Reg

istr

ar,S

mal

lHos

pita

l.P

atie

ntpe

rcep

tion

s:To

om

any

chec

ksin

gene

ralm

ake

pati

ents

conc

erne

dth

atth

esy

stem

isn’

tsaf

e,an

dso

me

ofth

esp

ecifi

cch

ecks

are

anxi

ety

prov

okin

g.

17(1

4)O

neof

the

thin

gsth

atth

epa

tien

tsdo

n’tl

ike,

and

we’

veha

dth

isfr

omth

epa

tien

tsur

veys

we’

vedo

ne,i

sbe

ing

bom

bard

edw

ith

ques

tion

afte

rqu

esti

on,a

ndth

enha

veth

esa

me

ones

aske

dag

ain.

OD

P,L

arge

Hos

pita

lT

hetw

om

ain

area

sth

atal

way

sca

used

rais

edey

ebro

ws

wit

hpa

tien

tsar

edi

scus

sion

ofbl

ood

loss

,esp

ecia

lly

for

oper

atio

nsw

here

the

pati

entd

idn’

texp

ectt

obl

eed.

All

ofa

sudd

enth

eir

sim

ple

eye

oper

atio

nw

astu

rnin

gin

toa

pote

ntia

lblo

odba

than

da

thre

atto

thei

rli

fe,a

nddi

scus

sion

ofdi

fficu

ltai

rway

.T

rain

eeA

nest

hesi

olog

ist,

Acu

teT

each

ing

Hos

pita

lSc

epti

cism

rega

rdin

gth

eev

iden

ceba

se:

The

evid

ence

base

behi

ndth

ech

eckl

isti

sw

eak

and/

orno

tapp

lica

ble

toth

ecu

rren

tco

ntex

t.

13(1

1)I

thin

kit

’sa

knee

jerk

reac

tion

toth

epr

oble

man

dI’

mno

tsur

eth

ere’

sa

huge

amou

ntof

evid

ence

that

,wit

hin

the

cont

exto

fho

spit

als

inde

velo

ped

coun

trie

s,th

atit

wil

ldo

very

muc

h.A

tten

ding

Surg

eon,

Med

ium

Hos

pita

lIt

seem

sto

conc

entr

ate

enti

rely

onth

ings

for

whi

chth

ere

ispr

etty

dodg

yev

iden

ce.I

t’sse

lect

ive

inth

atth

ere

are

othe

rth

ings

todo

wit

hpr

even

ting

surg

ical

site

infe

ctio

ns,f

orw

hich

ther

eis

bett

erev

iden

ce,w

hich

are

nota

ddre

ssed

.A

tten

ding

Ane

sthe

siol

ogis

t,A

cute

Tea

chin

gH

ospi

tal

∗ N(%

)of

sam

ple

repo

rtin

gth

eba

rrie

r.



Annals of Surgery � Volume 00, Number 00, 2014 Implementing Change in Health Care: The WHO ChecklistTA

BLE

4.Fa

cilit

ator

sto

Che

cklis

tIm

ple

men

tatio

n

Faci

litat

ors

N(%

)∗Il

lust

rati

veQ

uote

s

Org

aniz

atio

nalf

acto

rs

1.E

duca

tion

/tra

inin

g:S

taff

buy-

inan

dow

ners

hip

ofth

ech

eckl

isti

sim

prov

edby

educ

atio

nan

dtr

aini

ngar

ound

its

evid

ence

base

,its

loca

lrel

evan

cean

dbe

stpr

acti

ce.

40(3

4)E

duca

tion

’spr

obab

lyth

em

osti

mpo

rtan

tthi

ng.E

duca

tion

prog

ram

sto

ever

ybod

y,no

tjus

tmed

ical

staf

f,bu

tope

rati

ngro

omst

affa

sw

ell.

Itne

eds

tobe

inco

rpor

ated

into

clin

ical

gove

rnan

ceda

ysor

som

ethi

ng,a

bout

why

you’

redo

ing

the

chec

klis

t,an

dw

hat

impr

ovem

ents

itha

sm

ade.

Ane

sthe

siol

ogis

t,C

T1–

3,Sm

allH

ospi

tal.

We

shou

ldha

veal

lhad

trai

ning

init

,exp

lain

ing

wha

tthe

yw

ant,

why

itw

asim

port

ant,

why

they

wan

ted

usto

doit

,and

how

tode

alw

ith

resi

stan

ttea

mm

embe

rs.

Ope

rati

ngR

oom

Nur

se,L

arge

Hos

pita

l2.

Feed

back

onlo

cald

ata:

Reg

ular

feed

back

oflo

cald

ata

and

anec

dota

lev

iden

cesu

ppor

ting

abe

nefi

cial

impa

ctof

the

chec

klis

trei

nfor

ces

that

itis

notj

usta

tick

-box

exer

cise

.

36(3

0)I

thin

kth

atif

you

coul

dpr

oduc

eda

tato

show

that

unto

war

dev

ents

are

bein

gre

duce

dlo

call

y,ev

enin

the

rela

tive

lysh

ortt

ime

it’s

been

roll

edou

t,I

thin

kth

atw

ould

galv

anis

epe

ople

into

usin

git

.A

tten

ding

Surg

eon,

Med

ium

Hos

pita

lW

hatI

’mst

arti

ngto

dono

wis

ask

peop

leto

reco

rdw

hen

itfla

gsso

met

hing

up,s

oI

can

stan

dup

ata

staf

fmee

ting

once

am

onth

and

say

the

surg

ical

safe

tych

eckl

istt

his

mon

thha

spr

even

ted

16ne

arm

isse

s-

this

wou

ldpr

omot

eit

sus

eev

enm

ore.

Ope

rati

ngR

oom

Man

ager

(Nur

se),

Med

ium

Hos

pita

l3.

Acc

ount

abili

tyfo

rno

n-co

mpl

ianc

e:R

amifi

cati

ons

for

activ

eno

ncom

plia

nce

wit

hth

ech

eckl

ista

rede

sire

dan

dth

ough

tto

impr

ove

effe

ctiv

enes

sof

the

tool

.

18(1

5)A

noth

erth

ing

that

coul

dbe

done

isth

ehi

gher

man

agem

entc

ould

star

tto

have

teet

h,if

you

like

,sta

rtto

take

peop

leas

ide

and

say,

you

doth

is,o

rel

se,b

utyo

udo

find

inm

edic

alpr

ofes

sion

sth

atdo

esn’

thap

pen

muc

h.A

tten

ding

Ane

sthe

siol

ogis

t,M

ediu

mH

ospi

tal

The

orga

niza

tion

now

have

puto

utth

atif

the

WH

OC

heck

list

isn’

tdon

ean

dth

ere’

spe

ople

resi

stin

g,th

esu

rgeo

nsan

dth

est

affc

ange

trep

orte

dto

thei

rre

gist

ered

bodi

es.I

t’sa

thre

at,b

utit

wor

ks.

Ope

rati

ngR

oom

Man

ager

(Nur

se),

Med

ium

Hos

pita

l4.

Supp

ort

from

hosp

ital

man

agem

ent:

Vis

ible

,flex

ible

and

activ

esu

ppor

tfro

mho

spit

alm

anag

emen

tdur

ing

impl

emen

tati

onan

dbe

yond

rein

forc

esth

eim

port

ance

ofus

ing

the

chec

klis

t.

9(8

)M

anag

emen

thav

eto

play

ali

ttle

,man

agem

entm

eans

the

man

ager

s,no

tthe

doct

ors,

they

have

tosh

owcl

inic

ians

allo

ver

the

hosp

ital

that

this

isno

tjus

tthe

irjo

b,bu

tour

job

toge

ther

.A

tten

ding

Ane

sthe

siol

ogis

t,A

cute

Tea

chin

gH

ospi

tal

It’s

afe

wdi

nosa

urs

that

we

have

,but

the

chie

fexe

cuti

veat

this

hosp

ital

istr

ying

toau

ditn

owth

roug

hou

rop

erat

ing

room

man

agem

ents

yste

mso

that

she

can

try

and

addr

ess

it.

Ope

rati

ngR

oom

Man

ager

(Nur

se),

Smal

lHos

pita

l

Syst

ems

fact

ors

5.In

tegr

atio

nw

ith

exis

ting

proc

esse

s:T

hech

eckl

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loss and difficult airway (part of the sign-in checks) would be anxietyprovoking for certain patients (this was a particular concern if thepatient was undergoing a local anesthetic procedure and thereforewitnessed all of the checks). Some also felt that the evidence basebehind the checklist was not robust enough, either in general or withregard to the English health care system specifically (eg, several in-terviewees mentioned that English hospitals were noncomparable tothe developing world hospitals that showed the largest improvementin outcomes after introduction of the checklist in the pilot study).5

Finally, 20% of the sample raised the issue that when not used inthe intended manner the checklist could have unintended negativeeffects on care, making it paradoxically less safe for the patient. Forexample, if used as a tick-box exercise with limited buy-in from staff,the checklist could create a false sense of security and, over time,result in complacency—inadvertently causing diminished levels ofteam vigilance in the OR. In addition, staff might be distracted fromtheir routine safety processes if the checklist was initiated at an inap-propriate time, or indeed resistant individuals might cause animosityamong team members having a negative impact on teamworking andteam cohesion.

Facilitators

Organizational FacilitatorsFour of the 9 facilitators to checklist implementation repre-

sented organizational factors. A third of the sample reported that theprovision of education and training around the checklist would be apowerful facilitator to its successful implementation. Many expresseda desire to be provided with information about the background to itsdevelopment, the evidence supporting its efficacy and why it wasrelevant to the context of their local OR. Similarly, training sessionsteaching best practice in use of the tool and/or how to deal with re-sistant team members when carrying out the checks were suggested.A comparable proportion of respondents felt that the regular provi-sion of data and feedback (eg, at audit days) regarding benefits thatthe checklist was achieving locally (eg, reductions in complicationsand incidents, improved outcomes, anecdotal clinical stories of nearmisses prevented by the checklist) would significantly increase buy-in to the tool, particularly for those doubting its relevance to EnglishORs. Next, 15% of the sample expressed the desire for there to beconsequences for noncompliance with the checklist such that resis-tant individuals are held accountable at a management level for theiractions. However, it was also mentioned that this kind of enforcedaccountability was rare in the medical profession (although it wasmore applicable to OR nurses). Finally, and related to this, 15% ofstaff mentioned that there being visible support and alignment fromhospital management around the checklist during implementationand beyond was critical to gaining buy-in from frontline staff, be-cause it emphasized that the initiative was a priority throughout theorganization.

Systems FacilitatorsA number of respondents (16%) reported that use of the check-

list could be facilitated by integrating it with existing paperwork andprocesses (eg, integrating it into the patient care plan to avoid lots ofloose pieces of paper and removing existing checks that the checklistwas replicating)—acting to reduce the feeling of too much repetitionand extra workload.

Team FacilitatorsThree facilitators were associated with the OR team and how

they drove use of the checklist. First, participants (22%) reportedthat the checks were completed best when the person leading themhad strong leadership skills and an assertive presence in the OR.




This meant that any resistance could be overturned and the entireteam was more likely to engage and listen rather than the checkssimply “happening” in the background. “Checklist champions” (pas-sionate individuals who promoted the tool on the ground and actedas a “go-to” point for queries) were also described as powerful fa-cilitators to uptake. Second, and related to this, an optimal conditionaccording to approximately a quarter of the sample, was if seniorclinicians (ie, surgeons and anesthetists at Attending level) showedvisible leadership of the checklist. In particular, if Attending surgeonsand anesthesiologists led the checks themselves or actively drove useof the checklist, it was said to foster engagement from the team as awhole and impress on everyone the significance of the tool. Finally,although senior clinical leadership was thought to be a key, inclusiveinput around the introduction and customization of the checklist fromthe entire multidisciplinary team was also reported to be important.

Checklist-Specific FacilitatorsThe most commonly reported facilitator to implementation of

the checklist (by 56% of the sample) was modification of the tool tosuit the specific surgical context and/or to make it more user-friendly.A number of respondents reported that the checklist had been suc-cessfully adapted to suit a particular surgical specialty (either throughlocal customization or by adopting one of the modified versions madeavailable by the NPSA), and others outlined more general customiza-tions that had been made to the tool, for example, displaying thechecklist on the OR wall rather than using the paper form (which wasperceived to make it less of a tick-box exercise and more of a safetydiscussion).

What Lessons Can We Extract for Informing How toOptimize the Diffusion and Uptake of ImprovementInitiatives in Surgery/Health Care?

On the basis of the themes extracted from OR personnels’ com-ments, a set of guidelines have been put together that apply broadlyto the implementation of improvement within health care systemsand indicate the strategies that should be considered during the earlyphases of introducing an improvement initiative (Box 1).

Box 1. Lessons for Implementing Change inHealth Care

A plan for implementation should be devised before in-troduction of the initiative, which is tailored toward all relevantstakeholders (aligning all levels of the organization) and takesinto account unusual shift patterns etc. Practical steps that shouldbe considered when formulating this plan are as follows:

� Modification of the initiative to suit the local context is veryimportant (2 or more different versions of the tool or processmay be required). Modifications should focus on how best tointegrate the initiative within existing processes to streamlineand remove repetition. The focus should be making the initia-tive user-friendly. Frontline staff involvement in the processof modification is key for optimizing buy-in.

� Education around the evidence base for the improvement ini-tiative is critical. This education should be tailored to reach allstakeholders and be should hold relevance to the local teamsand organization. Education should include an emphasis ofthe reasons why there is a need for the improvement in thefirst place.

� Training on the practical application of the improvementshould be included. This should focus both on the optimalday to day use of the initiative as well as how to deal with re-sistant members of staff or other potential barriers that mightemerge. Training should be multidisciplinary, rather than be-ing delivered to different professional groups independently.

� Data highlighting the local impact of the initiative should befed-back to staff periodically. This will reinforce the personalrelevance of the initiative for local teams. Anecdotal staffstories highlighting the benefits of the initiative are particu-larly powerful and should be shared within multidisciplinaryforums.

� Champions or early adopters should be identified, elected,and nurtured to promote uptake of the initiative on the groundand to act as a “go to” point for queries around implemen-tation. Social forums or communication channels by whichthese individuals might influence others should be supported.

� Buy-in from senior clinical staff should be sort at the veryearly stages of implementation. Senior staff members are par-ticularly powerful advocates for the introduction of changeand should be harnessed wherever possible to communicateto others their commitment to the new initiative, setting theexample from the top.

� Management should be seen to be involved and support-ive of frontline staff during introduction of the initiative andbeyond, such that it is seen as an organizational priority fromthe outset and all levels of the organization are aligned on acommon goal.

� A system that holds people accountable for improper be-havior or use of the initiative should be considered.

� Auditing of the initiative should be carefully thoughtthrough such that the “how” it is being used can be capturedas well as the “if.” Observations of the use of the initiative inpractice are strongly encouraged. This will inform on specificlocal barriers and facilitators surrounding its use, whether it isbeing used in the intended manner and whether there are anyunintended consequences of its introduction. It will also aidthe provision of comprehensive feedback to team membersfor quality improvement.

DISCUSSIONThis study was part of a national evaluation of the imple-

mentation of the WHO surgical safety checklist across England (theSurgical Checklist Implementation Project). To our knowledge, thisqualitative study is the first of its kind and size to be reported, coveringa representative sample of English hospitals. It aims to understand thebehaviors and strategies that have led to successful implementationof the checklist, and those that have hindered it. Thus, it aims to in-form practical steps that hospitals might take to better embed the toolinto practice and to extract lessons to reduce current variation andbetter inform the implementation and uptake of quality improvementinitiatives more generally.16–18

Key FindingsThere was large variation in how the checklist was initially

implemented, both between and within hospitals. This ranged fromapparently very well-orchestrated strategies in some hospitals, to




others, where the checklist simply appeared without prior warning,or staff felt like it was being imposed upon them. Although there wasguidance available for implementing the initiative (from the NPSA),not all hospitals utilized this effectively. This is important becausea poor implementation strategy was identified as an important or-ganizational barrier to effective uptake of the checklist. For safetyand quality interventions to realize their potential benefit, a concrete,multiphased implementation plan needs to be developed before theirintroduction.

Numerous additional barriers and facilitators to checklist im-plementation emerged from the interviews, which included organi-zational and system-, team-, and checklist-specific factors. The ma-jority of the barriers concerned the checklist itself (eg, perceiveddesign issues and doubts surrounding the evidence), but duplicationof processes and difficulties in integrating the checklist with existingsystems were also reported. The most common barrier was resistanceor noncompliance from individual members of the OR team (particu-larly at Attending level), which in many cases prevented the checklistfrom being used in the manner it was intended. This supports recentobservational data, which demonstrates poor compliance with thechecklist in practice.19 The checklist is essentially an aid to enhanceteam performance, communication, and vigilance; however, here ithas been demonstrated that when poorly or improperly used withoutadequate buy-in it can adversely affect the OR team.20

The facilitators that emerged demonstrate the positive andproactive strategies that have been developed to mitigate the vari-ous barriers and greatly increase the chances of proper use of thechecklist and of full implementation. These centered around modify-ing the tool to suit the local context to complement existing systems;conveying the relevance and importance of the tool to local teams andindividuals (through education/training and feedback of local data);identifying strong leaders and advocates for the initiative (particularlyat Attending level); considering methods of instilling accountability;and aligning strategic priorities across the hospital (from frontline per-sonnel to hospitals’ executive boards). These steps are evidenced byquotations from the sample and are in line with previous literature.14

They form the basis of our recommendations (Box 1) and should beincorporated into local efforts to aid implementation of the checklistand other surgical safety initiatives.

Strengths and LimitationsThe current study has certain limitations. The number of hos-

pitals from which participants were sampled is small compared tothe overall number of English hospitals, thereby potentially limitinggeneralizability. Furthermore, the opt-in sampling strategy may meanthat we have captured the individuals with the strongest views (eitherpositive or negative) around the checklist and who are most passionateabout sharing them, meaning that we may have missed some valuablefeedback from those who are more impartial. In addition, for practi-cal reasons, data collection took place over the period of 1 year afterthe official national deadline for implementing the checklist, whichmeans that some respondents will have been using the checklist forlonger than others at the time of interview; this could have influ-enced some of the responses we collected. We did, however, examinethe themes extracted from earlier versus later interviews and fromearlier versus later implementers and found no apparent patterns ordifferences distinguishing these groups. We therefore conclude thatfactors associated with the timeline of the study are not likely to haveaffected our dataset. Finally, we have captured the views of OR per-sonnel only, and while this is important it might also be instructive tocapture the views of managerial staff and the views of those from thewider regulatory bodies who were involved in implementation of thechecklist, such as the Department of Health. This would provide apotentially fuller picture of the challenges and enablers encountered

throughout the process of implementation. The current research alsohas some notable strengths. First, to the best of our knowledge, thisis the first nationally representative evaluation of the checklist witha multicenter hospital sample and therefore these findings are gener-alizable to a certain level. The themes revealed by this study likelyrepresent the barriers and facilitators at play during the implemen-tation of many change initiatives in health care and hence present avaluable learning opportunity. Second, the qualitative approach un-dertaken allowed for a detailed analysis of the barriers and facilitatorstoward implementation of the checklist, which would not have beenpossible using a broader survey approach. The accounts generatedfrom the interviews were detailed, and reaching saturation in the the-matic extraction of these interviews suggests that the analysis wasexhaustive. Finally, theme extraction was reviewed and checked by2 psychologists with expertise in both the methodology and patientsafety research, to ensure accuracy and control of bias in the analysis.

Future DirectionsSimilar barriers and facilitators to the implementation of the

checklist have been previously identified as factors influencing theimplementation of change in health care and also in other industries,and as such have been translated into recommendations for imple-mentation already.21–23 This presents the difficult question—why aresome institutions failing to take advantage of existing knowledge andguidelines about how to introduce an intervention successfully? Thecentralized structure of the English health care system should allowthe introduction of improvement initiatives, with the potential to pos-itively influence the care of millions of patients, but interventionsoften struggle to achieve full implementation.24 Further systematicresearch can shed light on what differentiates teams and organizationsthat employ an effective implementation strategy from those who failor struggle.

In addition, although getting the implementation strategy rightis key in order for an initiative such as the checklist to fulfil its poten-tial (or conversely to avoid unintended negative impacts on safety),ultimately it must be demonstrated that this variation in implemen-tation has tangible and sustained impacts on patient care at the locallevel. This means that continuous evaluation of an intervention shouldbe part of its implementation (and not an afterthought). Locally col-lected data are more personally relevant and more persuasive to clin-ical teams—and indeed if we are to shift to a culture of intelligentdata usage aimed at continuous quality and safety improvement, wetake the view that data ought to be collected, fed-back, and discussedregularly. This study clearly demonstrates that not doing so ultimatelyjeopardizes buy-in, which we believe applies not just to the checklistbut to any such intervention. It is therefore important to focus ef-forts on developing methods by which the impact of the checklist ondaily, case-by-case team performance can be captured and fed-backto teams. Routinely collected data, observations as well as anecdotalexamples, and clinical stories relating to the benefits brought aboutby the checklist all have a role to play.

CONCLUSIONSThe WHO surgical safety checklist was a high profile and

mandatory safety improvement initiative that was required to be im-plemented throughout English ORs. This nationally representativestudy has identified a large degree of variation in the approach takento introduce the checklist and a number of factors representing bar-riers and facilitators to the success of the implementation across 10hospitals. We have translated these findings into a number of lessonsthat should be considered when implementing change in surgery andhealth care more broadly. Implementation guidance should includeexplicit attention to barriers and facilitators and the developmentof a proactive implementation strategy at a local level. Local data




collection and feedback in relation to how initiatives like the check-list work in practice will also be necessary to engage clinical teamsand to highlight areas where further intervention or training is needed.

ACKNOWLEDGMENTSThe authors thank the following individuals who formed the

advisory board for the project: Mr Kevin Cleary, National PatientSafety Agency, UK; Mr Graham Copeland, Warrington and HaltonNHS Trust, UK; Mr Mark Emerton, Leeds Teaching Hospitals NHSTrust, UK; Mr Derek Fawcett, The British Association of UrologicalSurgeons; Professor Atul Gawande, Harvard Medical School, US;Alan Glanz, Department of Health, UK; Professor Michael Horrocks,Association of Surgeons of Great Britain and Ireland; Dr Judith Hulf,Royal College of Anaesthetists, UK; Sir Bruce Keogh, Medical Di-rector, National Health Service, UK; Professor Ravi Mahajan, RoyalCollege of Anaesthetists, UK; Miss Clare Marx, Royal College ofSurgeons of England; Claudia Mcmonagle, Patient Representative,UK; Professor Peter Pronovost, Johns Hopkins Medicine, US; Pro-fessor James Reason, University of Manchester, UK; and ProfessorJane Reid, The International Federation of Perioperative Nurses.

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http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

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http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-news/current/WHOSafeSurgeryChecklist/

http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-news/current/WHOSafeSurgeryChecklist/

http://www.jointcommission.org/standards_information/up.aspx

http://www.jointcommission.org/standards_information/up.aspx

A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical...

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