Implementation of World Health Organization behaviorally anchored rating scale and checklist utilization: promising results for LMICs.

Background: Operating teams can decrease the likelihood of patient risk by using the WHO Surgical Safety Checklist. To ascertain the impact of demographic factors on behaviorally anchored ratings and investigate operating room (OR) staff attitudes toward checklist administration, we set out to better understand how OR personnel use the checklist in a tertiary care hospital in Pakistan. Materials and methods: A monocentric sequential mixed-methods study employing a quantitative approach of using World Health Organization Behaviorally Anchored Rating Scale (WHOBARS) assessments of surgical cases by OR personnel and two independent observers, who were certified surgeons having extensive experience in the rating of the WHOBARS scale for more than 1 year, followed by a qualitative approach of staff interviews were carried out in a tertiary care setting. In June and July 2022, over the period of 8 weeks, an intervention (training delivery) was implemented and evaluated. The information, skills, and behavior adjustments required to apply the checklist were taught in the course using lectures, videos, small group breakouts, participant feedback, and simulations. Results: After the introduction of WHOBARS, 50.81% of respondents reported always using the checklist, with another 30.81% using it in part. Participants' years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with always counting instruments (51.08%), patient identity (67.83%), difficult intubation risk (39.72%), the risk of blood loss (51.08%), prophylactic administration of an antibiotic (52.43%), and the use of pulse oximeter (46.75%). Interviewees felt that the checklist could promote teamwork and a safe culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. Conclusion: The use of a multi-disciplinary course for checklist implementation resulted in 50.81% of participants always using the checklist and an increase in counting surgical instruments. Successful checklist implementation was not predicted by the participant's length of medical service, hospital size, or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.