Department of Medical Capacity Building, Mercy Ships Africa Bureau, Cotonou, Benin.
Centre for Global Health and Health Partnerships, King's College London, London, UK.
Br J Surg. 2019 Jan;106(2):e91-e102. doi: 10.1002/bjs.11034.
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.
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.
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 85·0 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 < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6-9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully.
This study shows successfully sustained nationwide checklist implementation using a validated implementation framework.
世界卫生组织手术安全检查表可改善手术效果，但在低收入国家成功实施的证据和理论框架仍有所欠缺。基于马达加斯加的前期研究，贝宁全国范围内实施了该检查表，并进行了纵向评估。
本研究采用纵向嵌入式混合方法设计。经充分验证的实施研究综合框架（CFIR）被用于构建方法并评估实施情况。36 家医院接受了为期 3 天的多学科培训和 4 个月的随访。17 家医院被有针对性地抽取用于 12-18 个月的评估。主要结局是通过问卷调查评估 12-18 个月时检查表使用的可持续性。次要结局是使用世卫组织行为锚定评定量表（WHOBARS）、安全性问卷和焦点小组评估 CFIR 得出的实施结局。
在 12-18 个月时，86.0%（100 人中的 86 人）的参与者报告了检查表的使用情况，而培训前为 31.1%（543 人中的 169 人），培训后 4 个月为 88.8%（178 人中的 158 人）。实施过程具有高保真度（中位 WHOBARS 评分为 7 分中的 5.0 分；基本安全流程的使用率为 85.0%-99.0%），医院安全文化显著改善，表明实施过程渗透度高（经过培训前后分别为 76.7%、81.1%和 82.2%的适应人类因素态度问卷评分；P<0.001）。接受度、采纳度、适宜度和可行性评分分别为 10 分中的 9.6-9.8 分。该方法成功地整合了 36 个 CFIR 实施结构中的 31 个。
本研究采用经验证的实施框架，成功地持续开展了全国范围内的检查表实施。
