National pilot program «progress!»

COM-Check – Safe Surgery: Safety by self-evaluation and feedback

A high degree of compliance with the surgical checklist contributes significantly to ensuring that no patient suffers avoidable harm. The national progress! program COM-Check - Safe Surgery aimed to investigate and sustainably improve this compliance. Several hospitals participated in the pilot program, which was concluded on 30 September 2021. The final communication will take place with the 5+ series of publications and a training film in German, Italian and French in January 2022.

The checklist alone is not enough, because
Checking is more than just ticking off!

The surgical checklist is an important element of patient safety. While the progress! programme Safe Surgery (2013-2015) introduced the surgical checklist throughout Switzerland, the program COM-Check - Safe Surgery (2018-2021) aims to review and improve its application in Switzerland.

COM-Check stands for compliance with the surgical checklist. Strong compliance means that it is applied consistently and correctly by the entire surgical team. The focus is on safety-relevant team and communication processes. In the program programme, compliance with the checklist was tested by the hospitals themselves and improved through observation and feedback. Progress measurements are intended to keep this at a high level in the long term.

The Swiss Patient Safety Foundation supported the pilot hospitals in setting up internal structures and competencies for surveying compliance with the surgical checklist and in initiating improvement processes. The specially developed observation tool was made available to the hospitals and the project teams were trained in observation and in giving feedback.

progress! COM-Check – Safe Chirurgie

17 pilot hospitals in 20 sites signed the program agreement and attended the kick-off event in January 2020. All had already experienced with the surgical checklist and intended to improve its use and the associated safety culture. Five pilot sites dropped out of the program during the course due to the coronavirus pandemic and other reasons.

In the COM-Check program, compliance was systematically assessed as part of internal quality management, improved through feedback and monitored during the course. The quality of the checklist process was assessed by an internal observation team. Surgical and anesthesia managers as well as OR or anesthesia nursing managers observed the use of the checklist and gave the OR team - their colleagues - direct feedback that promoted learning.

To avoid blind spots and promote mutual learning, the observation team also observed those parts of the checklist that were the responsibility of another professional group. At the end of a measurement period, the project team analyzed the compliance data and, if necessary, initiated further improvement measures, such as an adaptation of the currently used checklist or the associated guidelines, training for checklist coordination or for new OR staff, development of structural aids, such as a pocket card, and planning of the next progress measurement.

Compliance with the checklist in Switzerland

The surgical checklist has been introduced in most Swiss hospitals today and is accepted in principle. This is shown by interviews (>>> Link), conducted by Patient Safety Switzerland from January to March 2019 with checklist managers in surgery, anesthesia, OR nursing and OR management from different hospitals and outpatient surgical practices.
However, of the 16 healthcare facilities interviewed, only one hospital continuously and systematically surveyed compliance with the surgical checklist. But all interviewees estimate the frequency with which the checklist is used in their hospital at over 90 percent of operations. Their assessment of the quality of implementation is more critical. Even with a successfully introduced checklist, carelessness creeps in with routine. For example, not all checklist items are processed with the same consistency, attention decreases or concerns are not voiced under time pressure. These experiences confirm national studies that show gaps in compliance and in recording it (Cullati et al. 2013; Schwendimann et al. 2019; Seppey, Oesch, and Viehl 2019).

progress! Safe Chirurgie

The national progress! program COM-Check - Safe Surgery is a follow-up program to progress! Safe Surgery, which was implemented from 2013 to 2015. The core of the earlier program was the WHO Surgical Safety Checklist, which was specifically adapted for Switzerland with the aim of reducing the number of surgical incidents. The basic principles developed in the first national pilot program, such as the Publication No. 5, the checklist of Safe Surgery, the tool box with tools for implementing as well as the e-learning program for training staff, are still available to institutions practicing surgery.

Surgical Checklist

The Surgical Checklist published by the World Health Organization (WHO) in 2009 was adapted for Switzerland by the Swiss Patient Safety Foundation (2012) and implemented as part of the progress! program  Safe Surgery  (2013 - 2015). Thechecklist aims to avoid unnecessary complications during operations. However, the checklist only fulfils its purpose if it is applied consistently, completely and correctly by the entire surgical team.

The surgical checklist consists of three parts that are applied at three different, clearly defined points in the surgical process. The first part - the Sign In - is performed before the induction of anaesthesia, the second part - the Team Time Out - before the incision and the third part - the Sign Out - at the end of surgery. The checklist includes two types of checklist items. One requires a check such as verifying patient identity, the other is for sharing information within the surgical team. This includes the exchange of information about the planned surgical procedure and possible risks.

The checklist aims to avoid unnecessary complications during operations. However, its only fulfils its purpose if it is applied consistently, completely and correctly by the entire surgical team. In the COM-Check programme, a monitoring system is introduced in which compliance with the surgical checklist is regularly measured and improved or maintained at a high level through direct feedback to the surgical team that promotes learning.

Who supports the programme

The program is widely supported by professionals. The following associations and organizations support the program ideally:

  • FMCH Foederatio Medicorum Chirurgicorum Helvetica
  • FMH Association of Swiss Doctors
  • SBV TOA Swiss Professional Association of Surgical Technicians (HF)
  • LOPS Association for Senior Operating Theatre Staff and Management
  • SIGA/FSIA Swiss Interest Group for Anesthesia Care
  • H+ The Hospitals of Switzerland

progress! COM-Check - Safe Surgery was financially supported by the FOPH.

Anita Imhof MSc
Program manager

+41 43 244 14 97