Table 3

Implementation/operationalisation characteristics

Study	Checklist creation process (adoption or modification of existing checklist)	Expected outcomes of implementation process	Key attributes of checklist implementation process					Outcomes
Study		Expected outcomes of implementation process	Stakeholder engagement	Targeted education	Preimplementation ‘change management’	Use of ‘pilot’	Use of CQI methods (eg, PDSA cycles or simple feedback) to improve implementation	Outcomes	Documented sustainability
Avansino et al19	Use of baseline data and paediatric needs to revise WHO SSC	Compliance with checklist	Unclear	Yes	Education marketing and notifications: Newsletters, bulletins, posters in operating room Use of feedback	Yes	Compliance rates posted monthly during pilot	Improved compliance	Sustained compliance over 1 year
Gottumukkala et al31	Institution-modified WHO SSC and Universal Protocol	Adherence to Good Practice	Yes	None	No educational strategy outlined Use of feedback	No	Monthly audit of videotaped procedures Frontline teams use feedback to target lapses and create strategies to improve performance (PDSA)*	Improved compliance with process measures and decreased variability	Continual improvement sustained across multiple years
Jenkins et al20	Site-specific stakeholder involvement to modify WHO SSC	Decreased mortality Infection reduction Improved perioperative practice Improved teamwork and communication	Yes	Yes	Comprehensive education strategy Global aims: central organisation, support from NGOs Local implementation: Local checklist modification and implementation Translated materials Standardised ‘Practice Bundles’ and communication scripts Use of feedback	No	Annual benchmarking	Decreased mortality and decreased infections	Sustained benefits in mortality and morbidity reduction at 2 years
Khoshbin et al26	Institution developed Non-WHO SSC	Compliance with ‘huddles”and ‘time-outs’	Unclear	None	No educational strategy outlined Marketing and notifications: Announcements at departmental meetings Posters in operating rooms	No	No	Compliance excellent with time outs and good with huddles Nurses view SSC as important for safety Physicians view SSC as a tool for increasing efficiency	Sustainability not assessed
Levy et al24	Site-specific stakeholder involvement to modify WHO SSC	Compliance with checklist	Yes	Yes	Limited educational strategy Notifications: Posters in operating rooms	No	No	Poor compliance Poor implementation fidelity	Sustainability not assessed
Montgomery et al30	WHO ‘surgical pause’ Unclear if SSC modified	Compliance with checklist	Yes	None	No educational strategy outlined Use of feedback	Yes	Feedback presented at surgical team department meetings Feedback used to create posters to improve compliance	Improved Compliance	Sustainability not assessed
Norton27	Universal-Protocol-based checklist created by local champion and stakeholders	Compliance with checklist	Yes	Yes	Comprehensive education strategy Marketing and notifications: Marketing team CEO letter to practitioners Logo, flyers, posters, wearable button Stickers on charts Mandated education	No	Results posted	Excellent compliance throughout implementation	Sustained compliance over 14 months
Norton and Rangel29	Site-specific stakeholder involvement to modify WHO SSC	Compliance with checklist Process measure compliance Teamwork and communication measures	Yes	Yes	Education Marketing and notifications: Marketing team CEO letter to practitioners Posters in operating rooms Flyer in operating room sterile pack Screen savers on computers with SSC reminder, newsletter Mandated checklist use Local leadership Use of feedback	Yes	Feedback to staff monthly Feedback used to revise implementation strategy	Improved compliance	Continual improvement in compliance over 7 months
Putnam et al 201428	Use of baseline data and site-specific stakeholder involvement to modify WHO SSC	Compliance with checklist	Yes	Yes	Comprehensive education strategy Marketing and notifications: Distribution of web-based media Posters in operating room Local leadership Use of feedback	Yes	Feedback to staff Feedback from stakeholders and pilot testing used to revise implementation strategy	Improved compliance	None
Putnam et al 201528	Institutional checklist based on WHO SSC modified by stakeholders	Compliance with appropriate antibiotic administration	Yes	None	No educational strategy outlined Marketing and notifications: Notices on appropriate antibiotic use placed on anaesthetic carts Emails sent to staff regarding guideline changes Computer order entry system to facilitate correct antibiotic use	Yes	Unclear	No improvement in compliance with appropriate antibiotic use	None
Wyrick et al 2015 39	Stakeholder (surgeon) involvement to modify WHO SSC	Compliance with accurate SWC	Yes	Yes	Education Marketing and notifications: Bulletin boards near operating theatres	Yes	No	Improved accuracy of documented SWC	Sustainability not assessed

*Gottumukkala et al’s study did not specifically describe their implementation strategy as using the PDSA framework. However, given the fact that the elicited feedback from those using the checklists, collected and analysed this feedback and then used the feedback for checklist improvement, we have categorised this within the PDSA column.
CEO, chief executive officer; CQI, continuous quality improvement; NGO, non-governmental oranisation; PDSA, Plan-Do-Study-Act; SSC, safe surgery checklist; SWC, surgical wound classification.