Table 4 Summary of Constructs and Exemplary Quotes

Innovation

How evidence for and aspects of the program, policy, or intervention impact its uptake

“I think it could have been helpful to have a bit more – a little bit more formal training on it. Like maybe just – maybe more of the history, I would say, the background where it comes – and why it was introduced, why it’s thought to be important. And I think that helps, actually, people value it or get better buy-in to it.”—Anesthesiologist, CAN

“They think it’s as a replacement for good systems in general. It’s not. It’s that final check.”—Surgeon, NZ

“Well, the ultimate measure is lack of preventable adverse events. So, you know, anesthetizing a patient and then finding the prosthesis or a piece of equipment is not available means the checklist has failed. Certainly, wrong-site block or wrong-site surgery means that the checklist has failed, so a measure is the lack of adverse events.”—Anesthesiologist, AUS

“And to my knowledge I can only remember one case where anything was significantly picked up during the checklist. I remember one day we had a patient ready for a knee scope and he was all like in the positioning devices and stuff. And we said, “Okay is this Mr. Smith for a left knee scope” and we looked down and we had the right knee ready. So that was picked up on the checklist…”—Nurse, CAN

“…we don’t have good data on surgical site infection and its relationship to the checklist because we don’t get good data on surgical site infection.”—Health Administrator, UK

“That all those people talking to each other at the beginning. Whereas, you know, some of those surgical techs in the Navy, they’re brand-new in the Navy, young, much lower rank than say, the surgeons or anesthesia are. And to get them to speak up and say what they need to say about that patient’s care, is great.”—Nurse, USA

“Oh, that's the other thing too in EMR we made it a hard stop, we can't close or finalize our chart if we didn't do the elements of the timeout, like if we didn't do the fire risk because there's an entire segment about fire risk and this is a CMS requirement. So, we cannot close our chart if we didn't do the fire risk, if we didn't do the timeout. So those hard stops help in implementation, making sure that everybody does it.”—Nurse, USA

“…the logic behind just having something on the wall is that everyone stops … yes, it’s only done verbally and yes, there’s no, you know, documented … you know, documentation of every single point that’s been checked off, but people are actually engaged and actually listen.”—Surgeon, NZ

Recipient

The degree to which intended recipients, individually and collectively, influence the implementation of the innovation

“There's the resisters, the people that think — often surgeons, but people that think that the safety check list doesn't apply to them, and I just think that’s disrespectful of our patients. And when it was first introduced in 2009 or whatever, there were trainees in our department that would say oh, I don't need to do this. And I always found that disappointing that they would watch surgeons role modelling that sort of behaviour and think that that was acceptable.”—Surgeon, NZ

“I just think if the hospital wanted to implement that or wanted to make that a priority that they should have gone through the surgeons first because the nursing staff are more than willing to do these things but the problem is we get resistance from the surgeons.”—Nurse, CAN

“You see with the young-—I think in general there's pretty good uptake, especially with some of the younger guys, and it's a cultural change and it takes a while.”—Anesthesiologist, NZ

“I must say we had a number of adverse events with senior surgeons in a certain subspecialty and that changed immediately the practice in that unit; suddenly you realized that actually yes, we should be doing this because there’s someone who’s had effectively the wrong-site surgery with a senior surgeon involved and then all of a sudden overnight almost the checklist was adopted in that unit.”—Anesthesiologist, AUS

“… a few months after the publication we had a case of wrong kidney in a very well-publicized case in the UK where it went to the criminal courts and everyone got a little bit worried. And that was quite useful.”—Anesthesiologist, UK

“So, the way that I felt was the best way to make sure that everyone participated and listened and everything was to have me do it, since I would be the one actually starting the surgery, that I was the one who could kind of make the whole room stop and do the timeout effectively to make sure we had done everything. Because I know, I guess the WHO checklist recommends that like a nurse does it or something like that, but I just, I just didn't see that that was working. Umm, let's put it that way.”—Surgeon, USA

“My biggest concern when it was originally brought in was by giving the surgeons the overall control of the time out…there will be people who aren’t going to speak up now…And it’s still probably a slight concern of mine. That if you’ve got a surgeon who’s running through the time out really quickly, which does happen, and you’ve got a nursing student in the corner who’s seeing something going wrong they’re not going to speak up to that surgeon.”—Nurse, NZ

“Yes, so one thing that we really—I think that's been a major step forward for us is we made it very clear that the anesthesiologist should lead the sign in, the surgeon should lead the time out, and the nurse should lead the sign out. And that's improved ownership and it's improved sort of engagement from the team.”—Anesthesiologist, NZ

“I think it’s quite good the way we run it here where different teams take responsibilities for different aspects. It sort of encourages sort of the team spirit, the team responsibility. Also, shared leadership because we try to avoid being hierarchical. I think if there’s one person who’s leading the checklist, people think well, it’s all their responsibility. We become passive observers but actually, everybody has shared responsibilities for different aspects of it. So, I think there’s a lot to be said about shared leadership when it comes to aspects in safety. It shouldn’t just be on one person’s shoulders.”—Surgeon, UK

Context: Local

How the resources, structures, culture and leadership in the Operating Room support or discourage implementation of the innovation

“But surgeons and how they come across because of their position of leadership, their attitude to the safe list is very pervasive on the team and if they are dismissive then, you know, why should everybody else buy into it, do you know what I mean?”—Surgeon, NZ

“I have a very, very powerful, strong, effective, sensible CEO at my hospital. And he takes no prisoners. And he recently threw out the biggest financial earner in the hospital because of a problem. And a lot of CEOs would not have done that

And I think that's the other thing that it needs. It needs a proper management who will stand up to maintaining standards, as opposed to, well we need the money.”—Anesthesiologist, UK

“Because I do think that the sign in, or amalgamating the sign in and the timeout has some risks involved with it. My impression also is that all over the happiness with the process is rather low, which I believe is for various reasons because there's been recurrent changes and it sounds like there's a bit of change fatigue in terms of the surgical checklist.”—Anesthesiologist, AUS

“…probably 15 to 20 min of that pathway between leaving the ward and hitting the operating table is completion of checklists… I think the number of checklists and the number of points could be reduced.”—Surgeon, UK

Context: Organizational

How the resources, structures, culture, and leadership in the hospital or surgical center impact the implementation of the innovation

“That's always—the hospital is concerned about how quickly we're turning over these cases because that's what generates income for the hospital so it can stay open, right? So, a lot of pressure with time is put on that, the critical safeguard's checklist such that it plays a big role in the success of it.”—Nurse, USA

“There’s always a theatre efficiency time pressure to get the job done and I feel that the time pressure often goes against the Surgical Safety Checklist and people instead of paying attention to the items, it turns into, ‘Ah we just need to tick all the boxes and then we can proceed’.”—Anesthesiologist, AUS

“I don’t think you can look at the checklist in isolation without also addressing the safety culture. It’s a tool to help change safety culture but if it’s used on its own it won’t change anything; you have to look at the whole safety culture of the department and hospital in order to affect real change,”—Health Administrator, UK

“I think it just has – it has to be a culturally, not just acceptable, but a culturally desirable practice. And I'm not sure that we've cultivated that yet. We've got champions that do it, but those champions don't have opportunity to interact with other surgeons.”—Health Administrator, CAN

“…one of the things that made it not spread as fast as it could is a culture of let’s not talk about our mistakes, let’s not talk about that fact that we caught that patient from having the hernia instead of their teeth. Instead of sharing it as a wonderful example of a save.”—Anesthesiologist, NZ

“It’s mandatory, like there’s no – it’s not an option and we, every month we get a report back to say if there isn’t any that are complete and we do an investigation and we talk to the team and we find out what the barriers are or what happened. But it’s mandatory, it’s not an option.”—Health Administrator, CAN

“I'm sure there's a policy that we have to do it but no one enforces that. Like there's no way to evaluate how well we're doing the checklist. It's just a yes or no whether it was done in our charting…”—Nurse, CAN

Context: External Health System

How the resources, structures, culture, and policies of the broader health system impact the implementation of the innovation

“The problem is we’re very isolated, we each work, we’re in a private hospital, so everyone works independently. So, there's no departmental or group policy. Private medicine here is different to a University Hospital, where there's a rule, we’re just pretty well do what we want. And that's where it may fall down in our hospital, where I don't know what the guy next door is doing.”—Surgeon, AUS

“The private system looks at surgeons as being the customer. So, the surgeon’s the customer and the customer brings their patient. So, it’s a different way of looking at it and therefore they’re here running their business on our premises. So, we’re not in a position necessarily to say doctor, will you stop and listen, please. We try. But it shouldn’t be driven by the nursing staff. I really believe that it works – it’s far more successful if it’s driven by the medical staff.”—Nurse, AUS

Facilitation

Processes

The active process that utilizes both facilitators and facilitation processes to integrate elements of the other three constructs

“…our hospital CEO has been very visible in supporting the safety huddle that we do and through that the prioritization of safety.”—Health Administrator, UK

“Our CEO does regular rounds of our hospital, so there’s leadership rounds, so certainly part of that is visiting the theatre and – So all it takes for his interest to know and ask about it…”—Surgeon, NZ

“…you need to get buy-in from people in every area. So, if you have anaesthetists and surgeons and nurses and non-medical…you want all of them on board, you have to get a couple of champions from my point of view for all of those areas to push it through their colleagues…”—Health Administrator, UK

“The feedback from the audits? Immediate feedback coaching, kind of, you know, during that audit. And then there’s the scorecard, you know, how well each team did. Because we used to be divided up like you were the ortho team. You were the neuro team and kind of competition type thing. Like how well did you do? You know, peer pressure. That can accomplish a lot.”—Nurse, USA

“For us getting over the implementation it took feedback – how many of the theatres are actually doing a checklist and which theatres are not doing a checklist, and so on.”—Surgeon, NZ

“And it’s a team of probably 20 people that are going to be drifting in and out the whole day but they’re all there at the beginning and we go through everyone’s names, what everyone does and then we go through each case and discuss the needs for all various equipment. That’s a really good huddle.”—Anesthesiologist, AUS

“That’s the time that you specifically think, “Okay, for my third operation I’m going to need – oh yeah, I’m going to need something different. I’m going to need X.” Then the nurses have two operations beforehand to prepare the actual instrument you need…”—Surgeon, NZ