Surgical provider-reported reasons for utilization of the World Health Organization’s Surgical Safety Checklist at a tertiary hospital in Ghana

Despite the established positive benefits, LMICs’ adoption of the WHO Surgical Safety Checklist (SSC) is inadequate, with as little as 20% use. This study assessed the utilization and beliefs that drive the non-utilization of the WHO SSC among surgical providers at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana. A cross-sectional study was conducted among 186 surgical providers at the KBTH in Ghana. Data collected included the category of personnel, awareness of the SSC, training received, previously identified barriers, and staff perceptions. Utilization and drivers associated with non-utilization of the SSC were assessed using bivariate log-binomial regression. Out of 190 surgical professionals invited, 186 gave their consent and participated in the survey, giving a response rate of 97.9%. Respondents comprised 69 (37%) surgeons, 66 (36%) anesthetists, and 51 (27%) nurses. Only 30.4% of surgical professionals always use the SSC, as advised by WHO. The majority (67.7%) of surgical professionals had received no formal training on using the WHO SSC. The proportion was highest among surgeons (81.2%) compared to anesthetists (66.7%) and nurses (51%). Surgeons were perceived by other professionals to be the least supportive of checklist use (87.6%), in contrast to nurses (96.1%) and anesthetists (93.9%). Significant drivers associated with checklist usage among surgical professionals included the SSC taking too long to complete, poor communication between anesthetist and surgeon, checklist not covering all perioperative risks, difficulty finding a coordinator, poor attitude of team members toward questions, surgical specialty/unit and training status of professionals. The checklist was always used by only a small (30%) proportion of surgical professionals at the KBTH. Improving checklist use will necessitate its careful application to all surgical operations and a cycle of periodic training that includes context-specific adjustments, checklist auditing, and feedback from local coordinators.

Introduction Treadwell et al. [19] classified barriers to utilization into four categories: confusion about how to use the checklist correctly; practical changes to efficient workflow; availability of resources; and individual staff perceptions and attitudes.
There is a paucity of evidence from LMICs, where this checklist may be more valuable and practical. Melekie & Getahun [35] for example, noted a lack of training and poor coordination among surgical team members as reasons for the infrequent use of WHO SSC in an Ethiopian study. In Ghana, a quality improvement study at the Cape Coast Teaching Hospital found that, although uptake of the SSC was high (93%) about a year after its implementation, its use was complete in only 21% of all cases [36]. As a result, to boost SSC uptake and sustain its effective use in LMICs, constraints to effective utilization that are specific to the local environment must be identified. The utilization and drivers of non-utilization of the WHO SSC among surgical employees at Korle Bu Teaching Hospital (KBTH), Ghana's largest tertiary health facility, were investigated in this study. KBTH is the foremost Teaching Hospital with a 2000-bed capacity, performing over 10,000 surgical procedures per year. It hosts the Centers of Excellence in Cardiothoracic and Plastic and Reconstructive Surgery, among other surgical specialties, and it is the main training center for over a third of the healthcare workers in Ghana, including surgeons, anesthetists, and perioperative nurses [37]. A successful implementation, therefore, may influence the acceptability and utilization of the SSC in regional and district hospitals if trained workers move and effect change in their new facilities. Identifying and removing barriers to utilization at this level may serve as a cornerstone to effectively implementing the checklist countrywide.

Study site
In June 2019, a cross-sectional study was conducted at the Korle Bu Teaching Hospital (KBTH), Ghana's largest tertiary referral institution. In this study, surgical providers at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana, were asked about their use of the WHO SSC and the beliefs that prevent them from using it. The General Surgery, Neurosurgery, Urology and Pediatric Surgery units comprise the Surgical Department. Surgeons, anesthetists, and theatre nurses made up the surgical team. In total, there were 225 surgical employees comprising 85 surgeons, 77 anesthetists, and 63 nurses. Surgeons and anesthetists were divided into three categories based on their rank: consultant, specialist, and resident/medical officer. Consultant surgeons and anesthetists are the highest-ranked experts in their fields of endeavor appointed to take the overall responsibility for patients' care in the hospital, while Specialists are middle-level experts who work in conjunction with consultants and resident/medical officers in the care of patients. Residents are doctors under training to become specialists, while medical officers are doctors who have completed a mandatory two-year internship (houseman ship) period after medical school and are yet to start a residency. By convention, nurses are responsible for leading the application and completion of the WHO SSC. Locally, this is usually done by the circulating nurse but may be done by any team member who is not directly involved in the surgical procedure within the sterile field. Surgeons and anesthetists have varying roles in ensuring patients' safety, from induction of anesthesia to the completion of the surgery, including administering prophylactic antibiotics, addressing difficult airways, and minimizing blood loss. The study was open to all surgical employees in the department, provided they met the inclusion criteria.

Inclusion and exclusion criteria
Surgical professionals were eligible to participate in the study if they had worked or studied at the facility for at least six months, were available during the study period (June 2019), and provided written informed consent. Surgical professionals refer to surgeons, anesthetists, and nurses who perform specialized roles as part of a team operating on a patient in a designated theater space. In addition, consultant surgeons and anesthetists who worked in the surgical department of the University of Ghana Medical School solely for academic purposes and had not conducted procedures in theatre for more than two years were excluded from the study.

Data collection
The data was collected from June 3rd to June 28th, 2019. The study enlisted the participation of all surgical personnel who met the inclusion criteria. The study excluded 39 of the department's 225 surgical professionals (surgeons, anesthetists, and theatre nurses); 28 were not physically accessible (on yearly or study leave), and seven consultants were no longer active in theatre. The 30-item questionnaire (S1 Questionnaire) was self-administered by 190 eligible surgical providers at KBTH. The majority of the providers took the survey at weekly departmental clinical meetings. The rest took them in the operating theaters, surgical wards, and the out-patients department. In all, providers were given privacy and were not allowed to discuss the survey while taking it. On average, providers completed the paper-based questionnaire in 15 minutes. The survey collected data on the providers' socio-demographic factors (such as years of surgical experience, rank, and specialty), general information on checklist use (awareness, understanding of features, training, and use), and determinants of WHO SSC non-use. The questionnaire was based on Verwey and Gopalan's [38] set of questions adapted from Fourcade et al.'s [13] previously identified barriers to using the SSC. These were assessed on a 5-point Likert scale (strongly agree to strongly disagree).

Statistical analysis
The mean ± standard deviation (SD) for continuous variables and percentages for categorical variables were used to represent background characteristics, knowledge, and use of SSC. Where applicable, Pearson's Chi-square and Fisher's Exact Test were employed to look for differences between the groups. The variable frequency of usage was recategorized into a binary outcome variable, "always" and "not always," to determine whether the checklist was always used. Answers to questions about barriers and perceptions were coded as "yes" (agree) or "no" (disagree). The "cannot tell" responses were combined with the "no" responses. Categorization into binary outcomes was done to facilitate the determination of crude prevalence ratios and the proportion of providers that always use the SSC. Two observations were excluded from the analysis because they had more than half of their data missing. The Chi-square test was utilized to find variables that were linked to the use of the SSC. Crude prevalence ratio (PR) estimates were calculated with a 95% confidence interval using log-binomial regression.

Ethical considerations
The Institutional Review Board of Korle Bu Teaching Hospital granted ethical approval for the study (KBTH-IRB/00008/2019). The hospital administration was also contacted for permission. Informed consent was given verbally, and respondents were asked to sign a document indicating that they understood and agreed to all informed consent processes. This was done before enrolling in our research. All techniques followed the appropriate standards and regulations for conducting human population research.

Background characteristics
A response rate of 97.9% was achieved, with 186 of the 190 questionnaires received being returned. Not every surgical provider answered every query. Table 1 lists the backgrounds and personal traits of the surgical professionals. Respondents were relatively evenly distributed across the different cadre of surgical professionals; surgeons (37%), anesthetists (36%), and theatre nurses (27%). Most providers (50%) were between the ages of 27 and 34. Surgeons had the highest percentage (16.2%) of responders between the ages of 45 and 64 years, while nurses had the lowest percentage (2.0%). A total of 97 respondents (52.7%) were men. The majority of anesthetists (59.1%) and nurses (80%) were female, but the majority of surgeons (88.2%) were male.
The educational background of the surgical professionals varied, with most anesthetists having a bachelor's degree (51.5%). In comparison, most surgeons (54.4%) had a postgraduate degree. However, among nurses, a diploma degree was the most frequently mentioned educational achievement (52%). Bachelor's degree refers to a university degree in nursing or medicine; a postgraduate degree refers to any qualification obtained after a Bachelor's degree, while a diploma refers to qualifications obtained from the Nursing Training College or equivalent institution other than the University. The general surgery unit employed around 36% of the responders, while the neurosurgery, pediatric surgery, and urology units employed about 13%, 9%, and 6%. Anesthetists working in the anesthesia division who were not affiliated with a particular surgical unit made up 35.9% of the workforce. Anesthetists comprised 51.5% of residents and medical officers, while 19.7% and 28.8% were specialists and consultants. Among surgeons, 47.1% were residents, 23.5% were specialists, and 29.4% were consultants. The average (SD) number of years spent working or studying at the hospital was 7.1 years (5.5), with anesthetists having the highest average of 7.6 years (6.0) and nurses having the lowest average of 6.4 years (4.2).

Checklist utilization
All surgical professionals who were interviewed knew about and had ever used the WHO SSC. Nearly a third (30.4%) of surgical providers reported always utilizing the checklist for all surgical cases, as the WHO recommends. Compared to anesthetists (27.3%) and surgeons (26.5%), more nurses (40.0%) used the SSC always. On the other hand, surgeons made up around 43% of the staff who did not always use the SSC. About two-thirds (67.7%) of our respondents said that since the SSC's implementation, they had not received any training on its use. The highest percentage of non-trained individuals were surgeons (80.9%), followed by anesthetists (66.7%) and nurses (50.0%). Self-reported knowledge of the checklist was highest among anesthetists (33.3%) than among nurses (32.0%) and surgeons (23.5%). The level of awareness, utilization, training, and expertise of surgical workers is shown in Table 2.   The results also demonstrate that the majority of respondents agreed with the claim that surgical professionals support the use of the checklist. Nurses (96.1%) and surgeons (87.6%) were rated as the most and least supportive of the SSC, respectively, among the categories of surgical professionals. Table 4 displays the findings of factors that influence surgical professionals' use of the checklist. In the bivariate analysis, utilization of the checklist was significantly associated with the following perceptions: it is difficult to find a coordinator for the checklist; there is poor communication between the anesthetist and surgeon; I know whose responsibility it is to initiate the checklist; team members believe that the SSC takes too long to complete; and the SSC does not cover all risks, such as skin preparation and postoperative pain. For instance, surgical professionals were less likely to consistently use the SSC if they felt that the checklist was too time-consuming to complete, that it did not account for all perioperative hazards, or that it was challenging to find a coordinator for the checklist. However, surgical professionals who concurred that they knew who was responsible for initiating the checklist were more inclined to use it in every circumstance. The use of checklists was also significantly associated with the personnel specialty unit and training on SSC use. Compared to employees at the Neurosurgery unit, those working in General Surgery, Urology, and Pediatric Surgery units were less likely to use the SSC constantly. Compared to employees who received no training, those who received SSC training were more likely to use the checklist consistently.

Discussion
Despite being well-documented as a high-impact safety measure, usage of the WHO SSC since its implementation continues to vary across different economic settings [32]. This study aimed to assess surgical professionals' use of the WHO SSC and identify variables that contribute to its non-use so that recommendations may be tailored to promote its use in Ghana. Even though all respondents in our study were aware of the WHO SSC, only 30.4% said they always used it as intended. This finding is similar to one found in an Indian study, in which the majority of respondents praised the SSC's positive effects (>96%) but observed a compliance rate of 40% among operating employees [39]. This self-reporting of low compliance to the WHO SSC supports the notion that even a massively positive attitude among employees does not imply compliance. According to Rogers and Shoemaker, the transmission of innovation, even when it has evident benefits, can be difficult and take a long time to spread [40]. As a result, the unique challenge for stakeholders has been to discover a mechanism to accelerate the rate of innovation diffusion. Other factors, other than recognition of the checklist's merits, appear to affect its non-use in the operating room. Time-related concerns were revealed as a significant factor of checklist non-use in our study. Although nearly all employees (98.9%) agreed that using the SSC was necessary, about a fifth of them, especially anesthetists (21.2%) and nurses (20.8%) thought the checklist took too long to complete. Surgical professionals who believed the checklist took too long to complete were 80 percent less likely to use it all of the time. One of the primary barriers to checklist compliance found by Fourcade et al. [13] and reinforced by Kariyo et al. [41] in their research of African countries was the feeling that the checklist took too long to complete. Although time was a significant determinant of SSC non-use among respondents, the majority of surgical staff (81.8%) did not believe the SSC takes too long to complete. It is worth noting the similarities between this discovery and that of Verwey & Gopalan [38], who acknowledged the difficulties in interpreting a comparable observation in their South African study. We reason that, while the SSC is designed to be quick, the extra few seconds spent outside of surgical personnel's everyday routines at various stages during the procedure can be viewed as an "additional" task, which is sufficient to encourage non-use. The fact that substantially more nurses than surgeons and anesthetists acknowledged difficulty incorporating the SSC into their perioperative practice supports this conclusion. Nurses were about 16 times more likely than surgeons and anesthetists to have difficulty incorporating the SSC into their practice. According to the WHO SSC's default design and suggested use, nurses have a greater role in completing the checklist, as they are responsible for reading out the items on the checklist and filling it out. This could explain why nurses had more difficulty incorporating the checklist into their daily routine than surgeons and anesthetists.
Most surgical professionals (84.3%) believe the SSC does not address all hazards, such as skin preparation and postoperative pain. In our study participants, this was a significant factor of non-utilization. Personnel who thought the SSC's risk coverage was insufficient were 54% less likely to use the checklist. Furthermore, almost one-third of respondents (31.3%) said finding a coordinator for the checklist was difficult. Personnel who cited difficulty locating a coordinator were 78% less likely to use the SSC regularly than those who did not. These findings align with Fourcade et al.'s [13] study, which found that both impressions are essential. In their investigation, Verwey and Gopalan [38] did not find both characteristics as important impediments. When it comes to the obstacle of the checklist's insufficient coverage, adjusting the content and application for varied situations is one area where intervention can help enhance compliance. Studies indicate that when the checklist is contextualized to the hospital's operations, use improves [13]. In a multi-center study that looked at the interacting elements that influence WHO SSC use, it was discovered that a minor tweak to the checklist in the context of local hospital operating procedures could help enhance its use and make it easier to accept the checklist [42]. Few doctors in the study even advised creating a checklist that can be easily customized to match different surgical procedures to boost utilization. Furthermore, contextualizing a checklist to represent local operating room dynamics allows for consideration of aspects such as time, checklist integration into personnel routine, and duplication of existing procedures.
One of the WHO SSC's primary goals is to improve communication among surgical team members [23]. In our study, anesthetists and nurses were 2.4 and 2.9 times more likely than surgeons to believe there was inadequate communication between anesthetists and surgeons, respectively. Additionally, the overwhelming majority of surgical professionals believed that the SSC was supported by nurses (96.1%), anesthetists (93.9%), and management (92.7%). In contrast, the perception of surgeons' support for the use of the checklist had a lower majority (87.6%) and was significantly different among the groups of surgical professionals. These findings are in keeping with other studies and indicate an area for intervention [13,39,43], in contrast to Tostes & Galvao [44] who identified a lack of administrative and management support as one of the barriers to the use of the SSC. Educating surgical personnel on using the SSC offers a viable modality of intervention that can address communication issues and the disparate perspectives among surgical personnel [45].
Only a third (32.3%) of all respondents in our study had formal training in using the SSC. Among the various types of surgical workers, this was lowest among surgeons (19.8%), who were also the least supportive of the SSC. The low level of training on SSC use among personnel (32.3%) highlights an area of concern similar to that observed in a South African study among theatre staff [38]. Anwer et al.'s [46] review of surgical procedures in Pakistan also indicated a positive correlation between compliance and the training period, implying that training surgical professionals may be a crucial intervention to promote compliance. Interestingly, despite ongoing training, research in Ethiopia found that SSC compliance decreased by 65% over eight months following introduction [47]. This shows that training alone may not be sufficient to solve the problem of low compliance. Nearly all of our group (98.4%) believed that surgical staff needed to be trained, even though most (77.4%) said they knew the checklist either well or very well. It is possible that this finding indicates surgical professionals' awareness of a problem with the sustainability and implementation of SSC use, which they believe can be addressed through training. Nonetheless, the results of our study appear to support a beneficial relationship between training and checklist use. The likelihood that surgical providers will always utilize the SSC was twice higher after training on checklist use (PR, 95% CI; 2.07, 1.35-3.16).
Additionally, we observed a strong relationship between surgical specialty and the use of the SSC. For example, professionals in the General Surgery and Pediatric Surgery units were 63% and 55% less likely to always use the checklist compared to the Neurosurgery unit. This is in line with research that evaluated how different subspecialties complied with the surgical checklist and was conducted across ten hospitals in Colorado [48]. The observed variation in SSC use among the specialties may further emphasize the need for context-specific checklist modifications and surgical professional-oriented interventions.
A few limitations may apply to our study. First is the use of convenience sampling in selecting our study population from a single public tertiary facility. Although this approach enhanced our total sample size, our findings may be center-specific and not generalizable to non-public or non-tertiary facilities. Second is the use of data from self-administered questionnaires, which were completed individually by the different categories of providers. This meant that we could not parse out the conflicting or reinforcing perceptions of checklist use amongst providers who work together as a team. Lastly, we cannot exclude social desirability bias in our study population and may have overestimated checklist awareness and utilization.

Conclusion
Despite surgical personnel's widespread knowledge of and familiarity with the WHO SSC, its intended use was inadequate, putting surgical patients at risk. The hurdles linked to the time required to complete the checklist, the inexhaustive coverage of risks, and the confusion in designating a checklist coordinator were the key drivers that caused the checklist's non-use in our setting. Significant differences in perception between the two groups of surgical personnel suggest poor team communication, difficulty incorporating the SSC into a perioperative routine, and surgeons' lack of support for using the SSC are areas of concern that could benefit from differential intervention. Overall, the determinants of non-use in our study environment are similar to those observed in other settings. As a result, there is a need to address socio-cultural hurdles unique to various settings that affect the checklist's adoption and long-term viability. In this population, we advocate targeted and ongoing SSC training. Training should focus on adapting the checklist to the local environment and enhancing the overall performance of the various workers in the operation room as a team. With a focus on surgeons, training should also address communication, support, and role-playing deficiencies. Local coordinators should be recruited and assigned the task of championing the WHO SS checklist and regularly auditing and evaluating its use. This procedure will also reveal emergent concerns that can be addressed through more training or feedback.