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Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative

Haynes, Alex B. MD, MPH*; Edmondson, Lizabeth BA; Lipsitz, Stuart R. ScD; Molina, George MD, MPH*; Neville, Bridget A. MPH; Singer, Sara J. MBA, PhD*; Moonan, Aunyika T. PhD, CPHQ§; Childers, Ashley Kay PhD, CPHQ; Foster, Richard MD§; Gibbons, Lorri R. MSHL, RN, CPHQ§; Gawande, Atul A. MD, MPH; Berry, William R. MD, MPH

doi: 10.1097/SLA.0000000000002249

Objective: To determine whether completion of a voluntary, checklist-based surgical quality improvement program is associated with reduced 30-day postoperative mortality.

Background: Despite evidence of efficacy of team-based surgical safety checklists in improving perioperative outcomes in research trials, effective methods of population-based implementation have been lacking. The Safe Surgery 2015 South Carolina program was designed to foster state-wide engagement of hospitals in a voluntary, collaborative implementation of a checklist program.

Methods: We compared postoperative mortality rates after inpatient surgery in South Carolina utilizing state-wide all-payer discharge claims from 2008 to 2013, linked with state vital statistics, stratifying hospitals on the basis of completion of the checklist program. Changes in risk-adjusted 30-day mortality were compared between hospitals, using propensity score-adjusted difference-in-differences analysis.

Results: Fourteen hospitals completed the program by December 2013. Before program launch, there was no difference in mortality trends between the completion cohort and all others (P = 0.33), but postoperative mortality diverged thereafter (P = 0.021). Risk-adjusted 30-day mortality among completers was 3.38% in 2010 and 2.84% in 2013 (P < 0.00001), whereas mortality among other hospitals (n = 44) was 3.50% in 2010 and 3.71% in 2013 (P = 0.3281), reflecting a 22% difference between the groups on difference-in-differences analysis (P = 0.0021).

Conclusions: Despite similar pre-existing rates and trends of postoperative mortality, hospitals in South Carolina completing a voluntary checklist-based surgical quality improvement program had a reduction in deaths after inpatient surgery over the first 3 years of the collaborative compared with other hospitals in the state. This may indicate that effective large-scale implementation of a team-based surgical safety checklist is feasible.

*Ariadne Labs, Massachusetts General Hospital, Harvard T.H. Chan School of Public Health, Boston, MA

Ariadne Labs, Brigham and Women's Hospital, Boston, MA

South Carolina Hospital Association, Clemson University

§South Carolina Hospital Association, Columbia, SC.

Reprints: Alex B. Haynes, MD, MPH, Ariadne Labs, 401 Park Drive, 3rd Floor East, Boston, MA 02115. E-mail:

Funding: Branta and Rx Foundations, AHRQ (R18:HS019631).

The authors declare no conflict of interests.

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