- What does an ideal culture look like?
- In what areas can we improve?
- What does "better" look like?
- How can we prioritize the areas in which we want to improve? – How many areas will we choose to focus on? – Which specific areas are most important to us right now?
- Where will we share these results?
- Which questions do we want to share, and with which audiences?
- Which way is the best way to present the results for each audience?
- Can we identify specific results that we want to highlight in our one-on-one conversations with physicians and staff? – What will resonate with nurses (e.g., comfort in speaking up)? – What will resonate with surgeons (e.g., how people see them as leaders)?
Recruit Your Implementation Team
The implementation team is a multidisciplinary group of people responsible for planning and executing the checklist initiative. Each member of the team will share responsibility for successful implementation and use of the surgical safety checklist in your facility. The team should include representatives from each role on the surgical team. If possible, the team should include an administrator or representative from your quality improvement program. Team members need to be enthusiastic, respected, and committed. Use one-on-one conversations to recruit people for your team (Appendix A). Consider using Your First Checklist Meeting Guide (Appendix B) as a sample agenda for your first meeting. Once your team is in place, meet regularly every 2 weeks, even if certain members are unable to attend. Meetings may be less frequent after the initial planning and once the checklist has been expanded in operating/procedure rooms.
Engaging Physicians
It is important to find a physician and an anesthesia professional who can participate on the team and will champion the checklist work with their peers. Try to find physicians who already emulate some of the desired behavior in the operating/procedure room (e.g., may already be sharing an operative plan or leading a debrief). When initiating the checklist conversation with your physician, use the Addressing Physician Concerns tool (Appendix C). The active participation of a physician champion is a key indicator for implementation success. The support of "formal" leadership is necessary, but those leaders are often not the ones who should guide this effort directly because their availability is limited, and their formal position may influence the interactions of the team.
Phase 2: Own
Ideas for change that come from outside an organization are often treated as suspect (not relevant, unproven, too cumbersome, not "for us," etc.)—which makes those ideas easy to ignore or dismiss. Because health care facilities are subject to so many mandates from accrediting bodies, government regulators, and payers, fatigue or even outright hostility to outside ideas can be a real barrier to improvement. In the Own phase, you address this tendency by making sure your checklist initiative is driven from within your facility and by your teams, and supported by your leadership. Work with members of your team to customize the checklist to fit the needs of your patients and facility (Appendix D, Appendix E, and Appendix F).
Observe, Modify, and Test
Some facilities feel pressure to put the checklist into their operating/procedure rooms immediately, but rushing the process invites serious risks. If you ask surgical teams to use the checklist in an operating/procedure room before they are ready, you can undermine the teams' confidence in the checklist as an effective communication and safety tool and can undermine their confidence in your implementation team. We recommend that you test your checklist in a simulation prior to implementing it throughout your facility. This gives your team an opportunity to practice it, reflect on what went well and what needs to change, and make modifications to the checklist if needed (Appendix G, and Appendix I).
Plan for Expansion
Have conversations, publicize the changes you are planning to make, and engage all team members. Start training team members on how to use the checklist (Appendix G), and work with team members to perform a tabletop simulation of checklist use before bringing it into the operating or procedure room. Next, start monitoring checklist use. Performing observations can often reveal weaknesses in checklist performance that might otherwise go unnoticed. The Checklist Observation Tool (Appendix I) allows you to collect information regarding the processes performed in the operating room or procedure room in order to improve surgical outcomes.
Phase 3: Expand
The Expand phase encompasses steps for actually putting your checklist into use in operating/procedure rooms throughout your facility. When done well, expansion is a slowly building process that is carefully managed so that each member of every surgical team is properly trained, each team receives supportive coaching, and feedback from team members is incorporated. This is when the preparation and planning you have done in earlier steps pays off.
Watch and Coach
Coaching is part of a learning progression that begins with a one-on-one conversation and continues with hands-on training. It is a vital part of every successful implementation because it helps lead individuals and teams to better performance and helps sustain effective checklist use over time. In this step, your goal is to coach all teams at least once shortly after they begin using the checklist in real cases and to coach them multiple times whenever possible. Coaching starts with an observation of a team in the operating/procedure room. The coach/observer pays close attention to what is going on: watching the team and how they perform the items on the checklist and listening to their conversations and questions (Appendix J).
Phase 4: Continually Expand
At this point, your team has put a great deal of effort into telling people about the checklist, raising its profile, talking to people individually, and training and coaching them on proper checklist use. Throughout the implementation period, the checklist has received a great deal of attention. You now face a different challenge: how to sustain the work and improve it over time. As you turn to the next problem to be addressed in the operating/procedure room, whether it's redosing of antibiotics or updating the skin prep to the latest protocol, your attention shifts, and the checklist work might start to slide a bit. This step encompasses the variety of tasks that need to continue in your facility so that, over time, people feel that using the checklist effectively "is just the way that we do the work here."
Over time, your team will continue to—
- Identify areas for improvement that additional training can address
- Talk with people individually about checklist use, and thank them for their checklist use and efforts to improve surgical safety.
- Watch and coach (randomly, across the full range of surgical practices in your facility).
- Collect and share stories about checklist successes.
- Engage, train, and coach new physicians and staff.
- Administer an annual culture survey to surgical team members.
- Periodically evaluate and update the checklist content to reflect any changing needs.
- Periodically bring new people onto your implementation team to add energy and fresh perspectives.
Tools
One-on-one conversations are used to engage surgical team members in enhancing their use of the surgical safety checklist or can be used in a quality improvement effort to engage physicians and staff. This example spreadsheet can be used when having one-on-one conversations with everyone who works in your facility. The spreadsheet can help track who needs to receive a one-on-one conversation and which member of the implementation team is responsible for talking about each problem.
This is a sample agenda with topics you should consider discussing when your implementation team meets for the first time to discuss the checklist project.
It is important to have one-on-one conversations with physicians about implementing the checklist in your facility. This document contains common concerns you may hear from physicians about the checklist and some examples of responses you can use to address these concerns.
This checklist template is based on the World Health Organization (WHO) Surgical Safety Checklist and has been modified for use in ambulatory surgery centers. It is recommended that you use this template and modify it to fit with the workflow in your facility.
This checklist template is intended to be used in endoscopy centers. We recommend you use this template and modify it to fit with the workflow in your facility.
When making modifications to your checklist, review this document with your checklist implementation team to ensure that your checklist meets the goals of the original WHO Surgical Safety Checklist.
This sheet is helpful to read before expanding checklist use in your facility. It covers necessary things to consider when teaching staff how to use the checklist as well as unique ways to train team members.
Appendix H. Tabletop Simulation Videos
Tabletop simulations are used to do dry "run-throughs" before adopting full implementation of procedures.
Monitoring checklist use is an extremely important part of this project. Performing observations can often reveal weaknesses in checklist performance that may otherwise go unnoticed. This tool allows you to collect information regarding the processes performed in the operating room or procedure room to improve surgical outcomes.
This tool can help you observe teams in your operating/procedure rooms and coach them on what they did well or what they can improve. It is similar to the observation tool, with the difference being that you will now be asked to make some notes and coach teams based on what you watched in the operating/procedure room using the three-part question.
These documents were created to assist the completion of a quality improvement study for the purposes of an accreditation survey. The quality improvement framework document includes an example of implementing one component of the surgical safety checklist, but can be used for any quality improvement project.
- Material Use Guide.
- Study Elements.
- Debrief Example (slides, facilitator notes & audio).
- Blank Template.
