Hospitals in South Carolina that completed a voluntary, team-based surgical safety checklist had a significantly lower rate of 30-day post-operative mortality compared with hospitals that did not complete the program by the end of 2013, according to a population-based study.

The risk-adjusted 30-day mortality rates were 22 percent lower in hospitals that completed the program compared with those that did not complete the program.

Lead researcher Alex B. Haynes, MD, MPH, of Massachusetts General Hospital and Harvard T.H. Chan School of Public Health, and colleagues published their results online in the Annals of Surgery on April 17.

The checklist used in this study was based on the World Health Organization’s Surgical Safety Checklist and prior initiatives that emphasized multidisciplinary engagement, team alignment, and a culture of patient safety.

“That is a major reduction in post-surgical mortality and it demonstrates that when done right, the Surgical Safety Checklist can significantly improve patient safety at large scale,” Hayes said in a news release.

The program included a 12-part hospital implementation process and focused on securing resources and multidisciplinary participation, conducting formal assessment of patient safety culture, modifying the checklist based on feedback and providing teams with training. Ariadne Labs worked with the South Carolina Hospital Association to establish a state-wide hospital implementation.

The researchers examined 58 hospitals that performed inpatient surgery in South Carolina, including 14 that completed the program by December 2013. Hospitals that completed the program represented nearly 40 percent of the state’s inpatient operative volume.

The researchers found that hospitals that completed the program were significantly more likely to have participated in the complete webinar series, administer the baseline safety of surgical practice survey, formally designate a physician champion and attend one of the team training sessions.

Among the hospitals that completed the program, 22,514 adults in 2010 and 18,112 adults in the first 11 months of 2013 underwent nonobstetric, inpatient procedures. For hospitals that did not complete the program, 38,876 adults in 2010 and 30,218 adults in the first 11 months of 2013 underwent nonobstetric, inpatient procedures. The researchers noted that propensity-score adjustment showed there were no significant patient-level differences between years in either group of hospitals.

Among the hospitals that completed the program, the 30-day postoperative mortality rate was 3.38 percent in 2010 and 2.84 percent in 2013, which represented a significant reduction. However, the rates were not significantly different from 2010 to 2013 for hospitals that did not complete the program.

“We are honored to be a learning lab for the rest of the country,” Thomas Kirby, president and CEO of the South Carolina Hospital Association, said in a news release. “The study validates what we hoped and believed from the outset—if you change the operating room culture of how you communicate and coordinate your efforts, you can produce better outcomes.”

The researchers cited a few potential limitations of the study, including that they could not measure checklist use in the operating room. They also only focused in inpatient surgery, which they defined as having spent at least two midnights in the hospital following the procedure. In addition, they could not assess complications, patient quality of life or healthcare costs.

“Completion of a structured, voluntary implementation process appears capable of facilitating change in hospital-level surgical outcomes, paralleled with changes in patient safety culture, as have been previously reported,” the researchers wrote. “Our research suggests that the checklist serves as a catalyst for these changes, but that leaders and frontline clinicians, including surgeons, must engage in implementation to produce a meaningful clinical change. Further work in implementation science must focus on identifying factors and interventions that can support or inhibit hospitals’ ability to meaningfully employ patient safety innovations.”