Table 2 Re-implementing the World Health Organization (WHO) Surgical Safety Checklist

Intervention

 The WHO Surgical Safety Checklist is a tool to encourage team communication around critical tasks during the perioperative process through a series of conversation prompts and process checks [46, 47]. When used meaningfully, the checklist has reduced surgical morbidity and mortality and improved teamwork [48, 49]. During the initial implementation of the checklist, sites are encouraged to customize it to fit the local context, while not removing any core components or conversation prompts [47]

Context

 A large tertiary care hospital in Singapore initially implemented an adapted version of the WHO Surgical Safety Checklist over ten years ago. However, most conversation prompts had been removed and it was read by the nurse with no predefined roles for other surgical team members [50]. They had implemented a flawed intervention and gaps in team communication and culture persisted, contributing to several patient safety events

Re-implementation strategies

 We adapted the strategies from the established implementation guide [47]. Differences included:

  • Spending significantly more resources on a comprehensive multimodal evaluation, which included a survey on staff perceptions of the checklist [50]

  • Carefully balancing established routines around the checklist with best practices from the implementation guide when modifying the checklist. We conducted a series of observations and feedback sessions to understand the existing practice and surgical culture. We then built upon existing habits, for example, we minimized changes to the timing of when teams use the checklist

  • Devoting extra time to modifying and testing the checklist to ensure that stakeholders from all departments were involved and that changes fit the local practice. This was accompanied by frequent meetings with leaders of the surgical departments to collect feedback and address concerns about the updated checklist prior to launch

  • Developing training materials focused on the rationale for the changes to the checklist by connecting new items with patient safety events or staff feedback. This approach was designed to overcome resistance expressed by the staff that wished to keep the current checklist and differed from traditional checklist training, which focuses on the rationale for the checklist itself and how to use it [47]