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A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

  • Augustino HellarEmail author
  • Leopold Tibyehabwa
  • Edwin Ernest
  • John Varallo
  • Margaret Mary Betram
  • Laura Fitzgerald
  • Geofrey Giiti
  • Albert Kihundrwa
  • Ntuli Kapologwe
  • Mary Drake
  • Jeremie Zoungrana
  • Alena Troxel
  • Ruth Lemwayi
  • Shehnaz Alidina
  • Sarah Maongezi
  • Ahmad Makuwani
  • John Varallo
Surgery in Low and Middle Income Countries

Abstract

Introduction

Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates.

Methods

We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018.

Results

During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05).

Conclusion and recommendations

Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

Abbreviations

C-section

Cesarean section

FBO

Faith-based organization

NSOAP

National surgical, obstetric, and anesthesia plan

OR

Operating room

OT

Operating theater

WHO

World Health Organization

R/CHMT

Regional/Council Health Management Team

SSC

Surgical safety checklist

Notes

Acknowledgements

Safe Surgery 2020 is a unique multi-stakeholder partnership that transforms surgical systems through an ecosystem approach, implemented by Jhpiego, Dalberg, Assist International, Harvard Program on Global Surgery and Social Change (PGSSC), and other stakeholders in surgery, obstetric and anesthesia care. The work presented here involves the commitment and dedication of a multitude of health care workers including facility managers, surgical providers, anesthetists and nurses, as well as district and regional authorities in Kagera and Mara regions. We are grateful for the leadership and collaboration from the Ministry of Health Community Development Gender Elderly and Children and Presidents’ Office Regional Authorities and Local Governments. Adrienne Kols, Sharon Kibwana, Young-Mi Kim, Adam Katoto, Stella Mshana, and Dr Tigistu Adamu Ashengo are acknowledged immensely for their contribution to this work.

Authors’ contribution

AH, LT, and EE drafted the manuscript. EE managed the data, ran reports, and analyzed the data. JV, MB, LF, SM, GG, AK, NK, MD, JZ, AT, SA, RL, and AM provided inputs on the discussion and overall write-up. All authors read and reviewed the drafts of the manuscript.

Funding

This project was funded under grant number 5R18HS024235-02 from the GE Foundation and Grant Number 17-F0012 from ELMA Philanthropies. The contents are the responsibility of the authors and do not necessarily reflect the views of the GE Foundation or ELMA. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Treadwell JR, Lucas S, Tsou AY (2014) Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 23(4):299–318.  https://doi.org/10.1136/bmjqs-2012-001797 CrossRefPubMedGoogle Scholar
  2. 2.
    Nyberger K, Jumbam D, Dahm J et al (2018) The situation of safe surgery and anaesthesia in Tanzania: a systematic review. World J Surg.  https://doi.org/10.1007/s00268-018-4767-7 CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Walker IA, Reshamwalla S, Wilson IH (2012) Surgical safety checklists: Do they improve outcomes? Br J Anaesth 109(1):47–54.  https://doi.org/10.1093/bja/aes175 CrossRefPubMedGoogle Scholar
  4. 4.
    Pugel A, Simianu V, Flum RD et al (2015) Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health.  https://doi.org/10.1016/j.jiph.2015.01.001 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491–499CrossRefGoogle Scholar
  6. 6.
    Global Surgery Collaborative (2019) Pooled analysis of WHO surgical safety checklist use and mortality after emergency laparotomy. Br J Surg 106(2):e103–e112.  https://doi.org/10.1002/bjs.11051 CrossRefGoogle Scholar
  7. 7.
    Close KL, Baxter LS, Ravelojaona VA, Rakotoarison HN et al (2017) Overcoming challenges in implementing the WHO surgical safety checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar. BMJ Glob Health 2(Suppl 4):e000430.  https://doi.org/10.1136/bmjgh-2017-000430 CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Gillespie B, Marshall A (2015) Implementation of safety checklists in surgery: a realist synthesis of evidence. Implement Sci. 10:137.  https://doi.org/10.1186/s13012-015-0319-9 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Russ S, Sevdalis N, Leather AJM (2019) Implementation and evaluation of nationwide scale-up of the surgical safety checklist. Br J Surg 106(2):e91–e102.  https://doi.org/10.1002/bjs.11034 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Gagliardi AR, Straus SE, Shojania KG et al (2014) Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. PLoS ONE 9(9):e108585.  https://doi.org/10.1371/journal.pone.0108585 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    White MC, Randall K, Capo-Chichi NFE (2019) Implementation and evaluation of nationwide scale-up of the surgical safety checklist. BJS 106:e91–e102.  https://doi.org/10.1002/bjs.11034 CrossRefGoogle Scholar
  12. 12.
    Aveling E, McCulloch P, Dixon-Woods M (2013) A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ open 3:e003039.  https://doi.org/10.1136/bmjopen-2013-003039 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Rakoff D, Akella K, Guruvegowda C et al (2018) Improved compliance and comprehension of a surgical safety checklist with customized versus standard training: a randomized trial. J Patient Saf 14(3):138–142CrossRefGoogle Scholar
  14. 14.
    Alidina S, Goldhaber-Fiebert SN, Hannenberg AA et al (2018) Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implement Sci IS 13(1):50.  https://doi.org/10.1186/s13012-018-0739-4 CrossRefPubMedGoogle Scholar
  15. 15.
    World Health Organization (WHO) (2012) Safe surgery saves lives: the second global patient safety challenge. https://www.who.int/patientsafety/safesurgery/en/. Accessed 21 June 2019
  16. 16.
    Mahmood T, Mylopoulos M, Bagli D et al (2019) A mixed methods study of challenges in the implementation and use of the surgical safety checklist. Surgery 165(4):832–837.  https://doi.org/10.1016/j.surg.2018.09.012 CrossRefPubMedGoogle Scholar
  17. 17.
    Melekie TB, Getahun GM (2015) Compliance with surgical safety checklist completion in the operating room of University of Gondar Hospital. Northwest Ethiopia. BMC Res Notes 8:361.  https://doi.org/10.1186/s13104-015-1338-y CrossRefPubMedGoogle Scholar
  18. 18.
    Biccard BM, Madiba TE, Kluyts HL et al (2018) African surgical outcomes study (ASOS) investigators: perioperative patient outcomes in the African surgical outcomes study: a 7-day prospective observational cohort study. Lancet 391(10130):1589–1598.  https://doi.org/10.1016/S0140-6736(18)30001-1 CrossRefPubMedGoogle Scholar
  19. 19.
    Kariyo PC, Hightower J, Ndihokubwayo JB et al (2013) Challenges facing the introduction of the WHO surgical safety checklist: a short experience in African countries. Afr Health Monit 16:36–39Google Scholar
  20. 20.
    Mayer EK, Sevdalis N, Rout S et al (2016) Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Ann Surg 263(1):58–63.  https://doi.org/10.1097/SLA.0000000000001185 CrossRefPubMedGoogle Scholar
  21. 21.
    Kumar S, Yadav V, Balasubramaniam S, Jain Y et al (2016) Effectiveness of the WHO SCC on improving adherence to essential practices during childbirth, in resource constrained settings. BMC Pregnancy Childbirth 16(1):345CrossRefGoogle Scholar
  22. 22.
    Sendlhofer G, Mosbacher N, Karina L et al (2015) Implementation of a surgical safety checklist: interventions to optimize the process and hints to increase compliance. PLoS ONE 10(2):e0116926.  https://doi.org/10.1371/journal.pone.0116926 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Babu A, Levison A (2012) Effective implementation of WHO surgical safety checklist. British J Anaesth 108(2):ii33–ii34Google Scholar
  24. 24.
    Aveling EL, Dixon-Woods M, Mc Culloch P et al (2015). Optimising Surgical Safety Checklist implementation: key lessons for practitioners and partners. University of Leicester. https://hdl.handle.net/2381/32366. ISBN 978–0–9933380–0–7
  25. 25.
    Danso-Bamfo S, Su B (2016) Improving the use of a surgical safety checklist. Ann Glob Health 82(3):348CrossRefGoogle Scholar
  26. 26.
    White MC, Randall K, Ravelojaona VA et al (2018) Sustainability of using the WHO surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Health 3:e001104. https://doi.org/10.1136/ bmjgh-2018-001104CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Augustino Hellar
    • 1
    Email author
  • Leopold Tibyehabwa
    • 1
  • Edwin Ernest
    • 1
  • John Varallo
    • 2
  • Margaret Mary Betram
    • 2
  • Laura Fitzgerald
    • 2
  • Geofrey Giiti
    • 3
  • Albert Kihundrwa
    • 4
  • Ntuli Kapologwe
    • 5
  • Mary Drake
    • 1
  • Jeremie Zoungrana
    • 1
  • Alena Troxel
    • 2
  • Ruth Lemwayi
    • 1
  • Shehnaz Alidina
    • 6
  • Sarah Maongezi
    • 7
  • Ahmad Makuwani
    • 7
  • John Varallo
    • 2
  1. 1.Jhpiego TanzaniaDar-es-SalaamTanzania
  2. 2.JhpiegoBaltimoreUSA
  3. 3.Department of SurgeryCatholic University of Health and Allied Sciences, Weill-BugandoMwanzaTanzania
  4. 4.Department of Obstetrics and GynaecologyBugando Medical CenterMwanzaTanzania
  5. 5.President’s Office Regional Authority and Local GovernmentDodomaTanzania
  6. 6.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  7. 7.Ministry of Health Community Development, Gender, Elderly and ChildrenDodomaTanzania

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