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CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity
  1. Rachel Moyal-Smith1,
  2. James C Etheridge1,2,
  3. Nathan Turley3,
  4. Shu Rong Lim4,
  5. Yves Sonnay1,
  6. Sarah Payne1,
  7. Henriette Smid-Nanninga5,
  8. Rishabh Kothari6,
  9. William Berry1,
  10. Joaquim Havens1,2,
  11. Mary E Brindle1,3
  1. 1 Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  2. 2 Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3 Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  4. 4 Health Services Research Department, Singapore General Hospital, Singapore
  5. 5 Scientific Institute, Martini Hospital, Groningen, Netherlands
  6. 6 Department of Surgery, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Rachel Moyal-Smith, Ariadne Labs, Boston, MA 02215, USA; rsmith{at}


Introduction The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice.

Methods The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability.

Results The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23–28), checklist adherence was 7 (6–7), communication effectiveness was 6 (6–7), attitude was 6 (6–7) and engagement was 6 (5–7).

Conclusions CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.

  • Quality improvement
  • Checklists
  • Patient safety
  • Surgery

Data availability statement

Data are available upon reasonable request. The data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. The data are available upon reasonable request.

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  • Contributors All authors contributed substantially to this work per Committee on Publication Ethics requirements, approved the final version and agree to be accountable for the accuracy and integrity of the data presented. RM-S is responsible for the overall content as the guarantor.

  • Funding This work was part of a larger study on device safety funded by Johnson & Johnson Medical Devices.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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