J. Lagoo2,3,6, R. Singal3,6, E. George3,6, J. Durney3,6, S. Lipsitz3,6, B. Neville3,6, B. Neal3,6, D. Schaps6, M. Miller4, M. Cook5, W. Berry2,3,6, A. Haynes1,3,6 1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,General Surgery,Boston, MA, USA 3Harvard T.H. Chan School Of Public Health,Boston, MA, USA 6Ariadne Labs,Boston, MA, USA 4Agency For Healthcare Research And Quality,Rockville, MARYLAND, USA 5American Hospital Association,Chicago, ILLINOIS, USA
Introduction: The World Health Organization Safe Surgery Checklist (SSC) has been shown to reduce morbidity and mortality with structured implementation in diverse settings worldwide. While published data has focused on hospitals, there is also interest in improving teamwork and communication through use of the SSC in ambulatory surgery centers (ASCs), where a high volume of procedures are performed. We hypothesize that ASCs must follow a sequential implementation pathway before sustainable use is achieved. Success in each step should predict success in the next, with higher baseline predicting greater likelihood of success in the program.
Methods: A national collaborative of stakeholders, supported by the Agency for Healthcare Research and Quality, aided in structured SSC implementation. Coaches facilitated implementation through a collection of baseline data, webinars, and one-on-one coaching for focused problem solving. A scoring system was created to evaluate stepwise completion of the SSC implementation program: baseline, preparation (initial roll-out), local ownership (individual site customization), expansion (institutional spread), and sustainability (continuous quality improvement). Partial correlation coefficients assessed the strength of the relationships between scores in our hypothesized implementation pathway, controlling for scores in prior steps on the pathway.
Results: Among the 180 ASCs with implementation data, the score ranges were: baseline (0.4, 11.3), preparation (0, 7), local ownership (0, 3), spread (0, 3), sustainability (0, 2), with higher scores meaning better performance on that step. Figure 1 displays all significant (p<0.05) partial correlations and shows that higher baseline score was positively correlated with preparation score (ρ=0.31, P<0.0001). In turn, higher preparation scores were positively correlated with local ownership (ρ=0.43, P<0.0001) and spread (ρ=0.25, P=0.04008). Higher local ownership scores were positively correlated with spread (ρ=0.43, P<0.0001) and sustainability (ρ=0.25, P<0.0009). Finally, improved spread scores were positively correlated with sustainability (ρ=0.35, P<0.0001).
Conclusion: Our data demonstrate that following a sequential implementation pathway including preparation, local ownership, spread in the facility, and focus on sustainability can lead to facility checklist adoption. Success in each step predicted success in the next and status of a facility at baseline predicted early success.
