Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist

Background The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low-income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods This study had a longitudinal embedded mixed-methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty-six hospitals received 3-day multidisciplinary training and 4-month follow-up. Seventeen hospitals were sampled purposively for evaluation at 12-18 months. The primary outcome was sustainability of checklist use at 12-18 months measured by questionnaire. Secondary outcomes were CFIR-derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results At 12-18 months, 86.0 per cent of participants (86 of 100) reported checklist use compared with 31.1 per cent (169 of 543) before training and 88.8 per cent (158 of 178) at 4 months. There was high-fidelity use (median WHOBARS score 5.0 of 7; use of basic safety processes ranged from 850 to 99.0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76.7, 81.1 and 82.2 per cent before, and at 4 and 12-18 months after training respectively; P < 0001). Acceptability, adoption, appropriateness and feasibility scored 9.6-9.8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.