Unlocking the "black box" of practice improvement strategies to implement surgical safety checklists: a process evaluation.

BACKGROUND: Compliance with surgical safety checklists (SSCs) has been associated with improvements in clinical processes such as antibiotic use, correct site marking, and overall safety processes. Yet, proper execution has been difficult to achieve.

OBJECTIVES: The objective of this study was to undertake a process evaluation of four knowledge translation (KT) strategies used to implement the Pass the Baton (PTB) intervention which was designed to improve utilization of the SSC.

METHODS: As part of the process evaluation, a logic model was generated to explain which KT strategies worked well (or less well) in the operating rooms of a tertiary referral hospital in Queensland, Australia. The KT strategies implemented included change champions/opinion leaders, education, audit and feedback, and reminders. In evaluating the implementation of these strategies, this study considered context, intervention and underpinning assumptions, implementation, and mechanism of impact. Observational and interview data were collected to assess implementation of the KT strategies relative to fidelity, feasibility, and acceptability.

RESULTS: Findings from 35 structured observations and 15 interviews with 96 intervention participants suggest that all of the KT strategies were consistently implemented. Of the 220 staff working in the department, that is, nurses, anesthetists, and surgeons, 160 (72.7%) knew about the PTB strategies. Qualitative analysis revealed that implementation was generally feasible and acceptable. A barrier to feasibility was physician engagement. An impediment to acceptability was participants' skepticism about the ability of the KT strategies to effect behavioral change.

CONCLUSION: Overall, results of this evaluation suggest that success of implementation was moderate. Given the probable impact of contextual factors, that is, team culture and the characteristics of participants, the KT strategies may need modification prior to widespread implementation.