Using the WHO Surgical Safety Checklist to Direct Perioperative Quality Improvement at a Surgical Hospital in Cambodia: The Importance of Objective Confirmation of Process Completion

Abstract

Background: The WHO surgical safety checklist (SSC) is known to prevent postoperative complications; however, strategies for effective implementation are unclear. In addition to cultural and organizational barriers faced by high-income countries, resource-constrained settings face scarcity of durable and consumable goods. We used the SSC to better understand barriers to improvement at a trauma hospital in Battambang, Cambodia.

Methods: We introduced the SSC and trained data collectors to observe surgical staff performing the checklist. Members of the research team observed cases and data collection. After 3 months, we modified the data collection tool to focus on infection prevention and elicit more accurate responses.

Results: Over 16 months we recorded data on 695 operations (304 cases using the first tool and 391 cases with the modified tool). The first tool identified five items as being in high compliance, which were then excluded from further assessment. Two items-instrument sterility confirmation and sponge counting-were identified as being misinterpreted by the data collectors' tool. These items were reworded to capture objective assessment of task completion. Confirmation of instrument sterility was initially never performed but rectified to >95% compliance; sponge counting and prophylactic antibiotic administration were consistently underperformed.

Conclusions: Staff complied with communication elements of the SSC and quickly adopted process improvements. The wording of our data collection tool affected interpretation of compliance with standards. Material resources are not the primary barrier to checklist implementation in this setting, and future work should focus on clarification of protocols and objective confirmation of tasks.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Fig. 1

The original data collection tool, tool 1, was modified by removing those items with near 100% compliance or found to be contextually unnecessary, rewording unclear questions with a focus on objectivity, and adding more infection prevention focused items

Fig. 2

Percent of cases with documentation of imaging available in room and post-procedure sponge counting. During weeks 1–11, a paper tool was used, and at week 12 (arrow), an electronic tool was introduced

Fig. 3

Percent of cases with documented confirmation of instrument sterility. During weeks 1–11, a paper tool was used, and at week 12 (arrow), an electronic tool was introduced, and a surrogate sterile indicator was developed

Fig. 4

Percent of cases with post-procedure sponge count as assessed using the second tool, which required input of number of sponges counted if data collector indicated a count had been performed

Fig. 5

Percent of clean cases with prophylactic antibiotics administered within 60 min of skin incision