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Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar
  1. Kristin L Close1,2,
  2. Linden S Baxter2,3,
  3. Vaonandianina A Ravelojaona2,
  4. Hasiniaina N Rakotoarison2,
  5. Emily Bruno2,4,
  6. Alison Herbert2,
  7. Vanessa Andean2,5,
  8. James Callahan2,
  9. Hery H Andriamanjato6,
  10. Michelle C White1,2,7
  1. 1 Department of Medical Capacity Building, Mercy Ships, Cotonou, Benin
  2. 2 Department of Medical Capacity Building, Mercy Ships, Toamasina, Madagascar
  3. 3 Nuffield Department of Anesthesia, John Radcliffe Hospital, Oxford, Oxfordshire, UK
  4. 4 Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  5. 5 Department of Anaesthesia, The Austin Hospital, Melbourne, Australia
  6. 6 Ministère de la Santé Publique, Antananarivo, Madagascar
  7. 7 Department of Anaesthesia, Great Ormond Street Hospital, London, UK
  1. Correspondence to Dr. Michelle C White; doctormcw{at}


The WHO Surgical Safety Checklist was launched in 2009, and appropriate use reduces mortality, surgical site infections and complications after surgery by up to 50%. Implementation across low-income and middle-income countries has been slow; published evidence is restricted to reports from a few single institutions, and significant challenges to successful implementation have been identified and presented. The Mercy Ships Medical Capacity Building team developed a multidisciplinary 3-day Surgical Safety Checklist training programme designed for rapid wide-scale implementation in all regional referral hospitals in Madagascar. Particular attention was given to addressing previously reported challenges to implementation. We taught 427 participants in 21 hospitals; at 3–4 months postcourse, we collected surveys from 183 participants in 20 hospitals and conducted one focus group per hospital. We used a concurrent embedded approach in this mixed-methods design to evaluate participants’ experiences and behavioural change as a result of the training programme. Quantitative and qualitative data were analysed using descriptive statistics and inductive thematic analysis, respectively. This analysis paper describes our field experiences and aims to report participants’ responses to the training course, identify further challenges to implementation and describe the lessons learnt. Recommendations are given for stakeholders seeking widespread rapid scale up of quality improvement initiatives to promote surgical safety worldwide.

  • health education and promotion
  • health systems evaluation
  • surgery
  • qualitative study

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Handling editor Valery Ridde

  • Contributors KLC and MCW conceived and designed the study. All authors were involved in data acquisition. KLC, LSB and MCW contributed to data interpretation and analysis. KLC wrote the first draft of the manuscript. All authors were involved in the critical revision of the article and approved the final version for publication.

  • Funding EB received funding for international travel from the Boston Children’s Hospital, Boston, Massachusetts, USA, and from Mark Allen McConkey, MD, Medical Student Public Service Fund. LSB received a travel and education grant from the National Institute for Academic Anaesthesia, UK.

  • Competing interests None declared.

  • Patient consent The requirement for individual written consent for every participant in the training program was waived by the IRB and the Ministry of Health

  • Ethics approval Mercy Ships Institutional Review Board and the Ministry of Health, Madagascar.

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

  • Data sharing statement There are no additional data.

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