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A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project”

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

doi: 10.1097/SLA.0000000000000793
Original Articles

Objectives: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England; to identify barriers and facilitators toward implementation; and to draw out lessons for implementing improvement initiatives in surgery/health care more generally.

Background: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake.

Methods: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis.

Results: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply “appearing” in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability.

Conclusions: We identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated these into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.

The current study reports the first nationally representative evaluation of the implementation of the World Health Organization surgical safety checklist across National Health Service hospitals and the factors that facilitated or hindered this process. We have translated the findings into recommendations for the successful implementation of quality and safety improvements in surgery more generally.

From the Department of Surgery and Cancer, Imperial College London, United Kingdom.

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

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.

© 2015 by Lippincott Williams & Wilkins.