British Journal of Anaesthesia, 120(1) 146e155 (2018)doi

British Journal of Anaesthesia, 120(1): 146e155 (2018)
doi: 10.1016/j.bja.2017.08.002
Advance Access Publication Date: 23 November 2017
Quality and Safety
Q U A L I T Y A N D S A F E T Y
The surgical safety checklist and patient outcomes
after surgery: a prospective observational cohort
study, systematic review and meta-analysis
T.E.F. Abbott1, T. Ahmad1, M.K. Phull2, A.J. Fowler3, R.
Hewson2,
B.M. Biccard4, M.S. Chew5, M. Gillies6 and R.M. Pearse1,*,
for the
International Surgical Outcomes Study (ISOS) groupa
1William Harvey Research Institute, Queen Mary University of
London, London EC1M 6BQ, UK, 2The Royal
London Hospital, Barts Health NHS Trust, London E1 1BB, UK,
3Guys and St. Thomas’s NHS Foundation
Trust, London SE1 7EH, UK, 4Department of Anaesthesia and
Perioperative Medicine, Groote Schuur
Hospital, Faculty of Health Sciences, University of Cape Town,

Cape Town, South Africa, 5Department of
Anaesthesia and Intensive Care, Faculty of Medicine and Health
Sciences, Link€oping University, 58185
Link€oping, Sweden and 6Department of Anaesthesia, Critical
Care and Pain Medicine, University of
Edinburgh, Edinburgh EH48 3DF, UK
*Corresponding author. E-mail: [email protected]
a Complete details for the collab authors are available in
Supplementary data.
Abstract
Background: The surgical safety checklist is widely used to
improve the quality of perioperative care. However, clinicians
continue to debate the clinical effectiveness of this tool.
Methods: Prospective analysis of data from the International
Surgical Outcomes Study (ISOS), an international obser-
vational study of elective in-patient surgery, accompanied by a
systematic review and meta-analysis of published
literature. The exposure was surgical safety checklist use. The
primary outcome was in-hospital mortality and the
secondary outcome was postoperative complications. In the
ISOS cohort, a multivariable multi-level generalized linear
model was used to test associations. To further contextualise
these findings, we included the results from the ISOS
cohort in a meta-analysis. Results are reported as odds ratios
(OR) with 95% confidence intervals.

Results: We included 44 814 patients from 497 hospitals in 27
countries in the ISOS analysis. There were 40 245 (89.8%)
patients exposed to the checklist, whilst 7508 (16.8%) sustained
�1 postoperative complications and 207 (0.5%) died
before hospital discharge. Checklist exposure was associated
with reduced mortality [odds ratio (OR) 0.49 (0.32e0.77);
P<0.01], but no difference in complication rates [OR 1.02
(0.88e1.19); P¼0.75]. In a systematic review, we screened 3732
records and identified 11 eligible studies of 453 292 patients
including the ISOS cohort. Checklist exposure was associated
with both reduced postoperative mortality [OR 0.75 (0.62e0.92);
P<0.01; I2¼87%] and reduced complication rates [OR 0.73
(0.61e0.88); P<0.01; I2¼89%).
Conclusions: Patients exposed to a surgical safety checklist
experience better postoperative outcomes, but this could
simply reflect wider quality of care in hospitals where checklist
use is routine.
Editorial decision: August 21, 2017; Accepted: September 18,
2017
© 2017 British Journal of Anaesthesia. Published by Elsevier
Ltd. All rights reserved.
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https://doi.org/10.1016/j.bja.2017.08.002
The surgical safety checklist and patient outcomes after surgery
- 147
Key words: cohort studies; operative/mortality; postoperative

care/methods; postoperative care/statistics and numerical
data; surgery; surgical procedures
Editor’s key points
� The surgical safety checklist is being promoted as an
effective tool to enhance patient safety
� This study provides outcome data from a large and
diverse collection of hospitals from around the world
� Surgical safety checklist use was associated with a
lower incidence of postoperative mortality, but not of
postoperative complications
� A pooled analysis of previous studies found that
checklist use was associated with a lower incidence of
both postoperative complications and death
More than 310 million surgical procedures are carried out
worldwide every year.1 Estimates of morbidity and mortality
vary.2e4 However, recent data suggest that approximately 75
million patients will experience a postoperative complication,
leading to two million deaths each year.5,6 An important cause
of avoidable harm is healthcare acquired illness or injury. In
the UK, perioperative adverse events account for one in six
patient safety incidents,7 and as many as half are potentially

avoidable.8 Preventable adverse events are costly in both hu-
man and financial terms. The UK Department of Health esti -
mates that iatrogenic harm costs the National Health Service
more than £1 billion each year,9 and other developed countries
are likely to be exposed to similar costs.
Checklists are a simple and reproducible way to stan-
dardize selected aspects of patient care. The World Health
Organisation (WHO) surgical safety checklist is the most
widely used surgical checklist, comprising 19 items in three
domains: before induction of anaesthesia, before surgical
incision, and before the patient leaves the operating theatre.
Actions include checks for a variety of items including patient
identity, introducing all team members, and antibiotic pro-
phylaxis.10 Since its inception, the checklist has been adopted
in >4000 hospitals worldwide,11 and is now considered a sur -
rogate marker for quality of patient care.12 However, there is
only limited evidence of any effect of checklist use on health
outcomes.12 A previous meta-analysis reported insufficient
high-quality evidence to draw robust conclusions, but there

have been further studies since this publication.12,13 Mean-
while, the clinical effectiveness of the surgical safety checklist
remains unclear and some clinicians object to its use.14,15
In the recent International Surgical Outcomes Study (ISOS)
we collected prospective data describing surgical safety
checklist use, along with patient outcomes following elective
in-patient surgery in 27 countries.6 Given the apparent wide-
spread and growing use of the surgical safety checklist and the
need for further evidence, we performed a prospective anal -
ysis of the effects of checklist exposure on postoperative pa-
tient outcomes. To contextualise the results of this analysis
and to describe the current evidence for this intervention, we
included these findings in a systematic review and meta-
analysis of the published literature.
Methods
This was a pre-planned secondary analysis of prospectively
collected data as part of ISOS. To complement this, we con-
ducted a systematic review of the existing literature and a

meta-analysis, in which we included the results of ISOS
analysis.
ISOS analysis: design, setting, and participants
ISOS was a 7-day international cohort study, the main results
of which have been reported previously.6 In the UK, the study
was approved by the Yorkshire and Humber Research Ethics
Committee (Reference: 13/YH/0371). In other countries, regu-
latory requirements varied with some requiring research
ethics approval and some requiring only data governance
approval. The inclusion criteria were all adult patients (age
�18 years) undergoing elective surgery with a planned over-
night stay in hospital. Each participating country selected a
single data collection week between April 2014 and August
2014. Patients undergoing emergency surgery, day-case sur-
gery, or radiological procedures were excluded. During the 1-
week study period, data were collected for consecutive pa-
tients until hospital discharge, using standardized paper case
record forms. Data included baseline demographic informa-
tion, details of the surgical procedure, postoperative care, and

in-hospital postoperative clinical outcomes. The use of the
surgical safety checklist was collected by study investigators
at each site as part of the core dataset. Data were censored at
30 days following surgery for patients who remained in hos-
pital. Data were anonymized and entered onto a purpose-built
secure internet database, which included automated checks
for plausibility, consistency, and completeness.
ISOS analysis: outcome measures
The primary outcome measure for the analysis of the ISOS
cohort was in-hospital mortality. The secondary outcome
measure was the presence of any postoperative in-hospital
complication assessed according to predefined criteria.6,16 A
patient with any of the following complications was deemed
to have met the secondary outcome: surgical site infection,
body cavity infection, pneumonia, urinary tract infection,
bloodstream infection, myocardial infarction, arrhythmia,
pulmonary oedema, pulmonary embolism, stroke, cardiac
arrest, gastro-intestinal bleed, acute kidney injury, post-

operative bleed, acute respiratory distress syndrome, anasto-
motic leak, or other un-categorized complications. The
severity of complications was graded as mild, moderate, or
severe.16
ISOS analysis: statistical methods
Data were included for hospitals returning valid data for �20
participants, and countries with at least 10 participating hos -
pitals. We dichotomized the sample according to the presence
Table 1 Baseline patient characteristics of patients included in
the analysis of the prospective observational cohort
(International
Surgical Outcomes Study). Data are presented as n (%) for
categorical variables and as mean with standard deviation (SD)
or median
with interquartile range (IQR) for continuous variables.
Univariable association with exposure to surgical safety
checklist presented as
odds ratios (OR) with 95% confidence interval (95% CI) and P-
value. ASA, American Society of Anesthesiologists physical
status score;
COPD, chronic obstructive pulmonary disease
Patients n (%) Checklist use (%) Did not use checklist (%) OR
(95% CI) P-value
n ¼ 44 814 n ¼ 40 245 n ¼ 4538 e e
Age, median (IQR) 57 (43e69) 57 (43e69) 56 (41e68) 1.04
(0.87e1.23) 0.70

Male, n (%) 20 458 (45.7) 18 317 (45.5) 2125 (46.8) 0.95
(0.89e1.01) 0.13
Females, n (%) 24 351 (54.3) 21 927 (54.5) 2413 (53.2) 1.05
(0.98e1.13) 0.13
Present smoker, n (%) 7931 (17.8) 6942 (17.3) 965 (12.2) 1.04
(0.89e1.22) 0.64
ASA physical status n (%)
I 11 227 (25.1) 9973 (24.8) 1246 (27.5) 0.97 (0.81e1.16) 0.72
II 22 265 (49.8) 20 300 (50.5) 1956 (43.2) 1.08 (0.94e1.24) 0.28
III 10 193 (22.8) 8991 (22.4) 1194 (26.4) 1.06 (0.92e1.23) 0.41
IV 1038 (2.3) 908 (2.3) 130 (2.9) 0.90 (0.66e1.23) 0.51
Grade of surgery, n (%)
Minor 8411 (18.8) 7448 (18.5) 960 (21.2) 0.69 (0.63e0.77)
<0.01
Intermediate 20 203 (45.1) 18 051 (44.9) 2137 (47.1) 0.93
(0.86e1.01) 0.11
Major 16 175 (36.1) 14 732 (36.6) 1438 (31.7) 1.54 (1.39e1.72)
<0.01
Surgical specialty, n (%)
Orthopaedic 9459 (21.1) 8683 (21.6) 771 (17.0) 1.18
(1.01e1.39) 0.04
Breast 1538 (3.4) 1393 (3.5) 145 (3.2) 0.86 (0.63e1.18) 0.34
Obstetrics and gynaecology 5674 (12.7) 5123 (12.7) 547 (12.1)
0.92 (0.75e1.12) 0.40
Urology and kidney 4871 (10.9) 4299 (10.7) 570 (12.6) 0.92
(0.76e1.11) 0.37
Upper gastrointestinal 1986 (4.4) 1776 (4.4) 208 (4.6) 1.31
(0.99e1.73) 0.06
Lower gastrointestinal 3073 (6.9) 2711 (6.7) 360 (7.9) 1.06
(0.84e1.33) 0.63
Hepato-biliary 2282 (5.1) 1959 (4.9) 322 (7.1) 1.18 (0.91e1.53)
0.22
Vascular 1599 (3.6) 1436 (3.6) 161 (3.6) 1.17 (0.85e1.61) 0.32
Head and neck 6510 (14.5) 5913 (14.7) 592 (13.1) 0.88
(0.74e1.03) 0.11
Plastic or cutaneous 1670 (3.7) 1386 (3.5) 284 (6.3) 1.01

(0.78e1.31) 0.94
Cardiac 1716 (3.8) 1557 (3.9) 159 (3.5) 0.54 (0.39e0.75) <0.01
Thoracic (lung and other) 1157 (2.6) 1086 (2.7) 69 (1.5) 1.44
(0.95e2.18) 0.08
Other 3270 (7.3) 2919 (7.3) 350 (7.7) 0.88 (0.72e1.09) 0.24
Laparoscopic surgery, n (%) 7087 (15.8) 6472 (16.1) 610 (13.5)
1.37 (1.10e1.69) <0.01
Comorbid disorder, n (%)
Coronary artery disease 4588 (10.3) 3952 (9.8) 632 (14.0) 1.17
(0.94e1.46) 0.16
Heart failure 1882 (4.2) 1594 (4.0) 287 (6.3) 0.93 (0.70e1.25)
0.65
Diabetes mellitus 5171 (11.6) 4596 (11.4) 571 (12.6) 0.85
(0.70e1.03) 0.10
Cirrhosis 342 (0.8) 311 (0.8) 31 (0.7) 1.15 (0.56e2.37) 0.70
Metastatic cancer 1706 (3.8) 1547 (3.9) 159 (3.5) 0.90
(0.67e1.21) 0.48
Stroke 1492 (3.3) 1333 (3.3) 158 (3.5) 1.00 (0.72e1.39) 0.99
COPD 4094 (9.2) 3790 (9.4) 303 (6.7) 1.07 (0.85e1.35) 0.55
Other 3269 (7.3) 16 552 (41.2) 2042 (45.1) 1.00 (0.87e1.16)
0.95
Had a complication 7508 (16.8) 6734 (16.7) 768 (16.9) 1.04
(0.87e1.23) 0.70
In-hospital mortality 207 (0.5) 163 (0.4) 44 (1.0) 0.79
(0.36e1.73) 0.55
148 - Abbott et al.
or absence of surgical safety checklist use and presented
baseline demographic and clinical characteristics. The out-
comes were considered as binary categorical variables. In the
primary analysis, we assessed for associations between
exposure to a surgical safety checklist and postoperative

mortality, compared to no exposure to a surgical safety
checklist, before and after adjustment for potential con-
founding factors. For the adjusted analysis, we used a hierar -
chical two-level generalized linear model, with patients at the
first level and hospitals at the second level; a three-level model
with countries at the third level did not converge. We included
the following pre-specified covariates to adjust for potential
confounding factors: age, gender, current smoker, American
Society of Anesthesiologists physical status score, grade of
surgery, surgical procedure category, and presence of co-
morbid disease (coronary artery disease, heart failure, dia-
betes mellitus, chronic obstructive pulmonary disease/
asthma, cirrhosis, metastatic cancer, stroke, and other un-
specified chronic disease). These covariates were selected
for clinical plausibility and evidence of association with
the exposure or outcomes in previous epidemiological
research.4,17e19 The results are presented as odds ratios (OR)
with 95% confidence intervals (CI) and associated Wald P-

values. The primary analysis was repeated for in-hospital
complications as the secondary outcome measure, consid-
ered as a binary categorical variable using a three-level
generalized linear model, with patients at the first level, hos -
pitals at the second, and countries at the third level. Normally
distributed continuous variables are presented as mean with
standard deviation (SD), and non-normally distributed
continuous variables are presented as median with inter-
quartile range (IQR), and proportions are presented as n (%).
We used STATA version 14 (StataCorp LP, College Station,
TX,
USA) for the statistical analysis.
Table 2 Results of the primary and secondary analyses of the
prospective International Surgical Outcomes Study (ISOS)
cohort.
Summary of two separate statistical models, where the
dependent variables were either mortality or any postoperative
complication
(excluding mortality). Generalized linear models, with results
presented as odds ratios with 95% confidence intervals and P-
values. All
variables were binary categorical unless otherwise stated, where
exposure to a variable was compared to non-exposure. ASA

physical
status and grade of surgery categorical variables where the
reference was the average effect across the whole cohort. ASA,
American
Society of Anesthesiologists; COPD, chronic obstructive
pulmonary disease
Any complication P-value Mortality P-value
Age (yr) 1.01 (1.00e1.01) <0.01 1.03 (1.02e1.04) <0.01
Male 1.05 (1.02e1.08) <0.01 1.03 (0.89e1.21) 0.67
Female 0.95 (0.93e0.98) <0.01 0.97 (0.83e1.13) 0.67
Present smoker 0.99 (0.92e1.07) 0.84 1.61 (1.12e2.31) 0.01
ASA physical status
I 0.54 (0.49e0.58) <0.01 0.09 (0.02e0.39) <0.01
II 0.71 (0.67e0.75) <0.01 0.69 (0.39e1.22) 0.20
III 1.21 (1.14e1.29) <0.01 2.20 (1.29e3.76) <0.01
IV 2.17 (1.92e2.46) <0.01 7.54 (4.18e13.63) <0.01
Grade of surgery
Minor 0.52 (0.49e0.56) <0.01 0.63 (0.43e0.93) 0.02
Intermediate 0.91 (0.87e0.96) <0.01 0.92 (0.71e1.21) 0.55
Major 2.10 (2.00e2.20) <0.01 1.72 (1.34e2.22) <0.01
Surgical specialty
Orthopaedic 0.89 (0.83e0.96) <0.01 0.64 (0.41e0.98) 0.04
Breast 0.59 (0.49e0.70) <0.01 0.65 (0.17e2.42) 0.52
Obstetrics and gynaecology 0.77 (0.69e0.85) <0.01 0.80
(0.36e1.76) 0.57
Urology and kidney 0.83 (0.76e0.91) <0.01 0.48 (0.26e0.89)
0.02
Upper Gastrointestinal 1.37 (1.23e1.53) <0.01 2.79 (1.85e4.22)
<0.01
Lower gastrointestinal 1.48 (1.34e1.62) <0.01 1.90 (1.27e2.84)
<0.01
Hepatobiliary 0.97 (0.86e1.10) 0.67 1.61 (0.93e2.78) 0.09
Vascular 1.05 (0.93e1.19) 0.42 0.96 (0.56e1.64) 0.87
Head and neck 0.67 (0.62e0.74) <0.01 0.63 (0.36e1.11) 0.11

Plastic or cutaneous 1.01 (0.88e1.17) 0.85 0.94 (0.39e2.23) 0.88
Cardiac 2.49 (2.20e2.80) <0.01 1.47 (0.95e2.28) 0.09
Thoracic (lung and other) 1.25 (1.08e1.45) <0.01 1.19
(0.63e2.26) 0.59
Other 0.68 (0.60e0.77) <0.01 0.76 (0.37e1.58) 0.46
Comorbid disorder
Coronary artery disease 1.04 (0.95e1.13) 0.44 0.99 (0.70e1.40)
0.96
Heart failure 1.28 (1.13e1.44) <0.01 1.59 (1.08e2.32) 0.02
Diabetes mellitus 1.10 (1.01e1.19) 0.02 1.24 (0.89e1.73) 0.20
Cirrhosis 1.45 (1.11e1.88) <0.01 2.77 (1.34e5.72) <0.01
Metastatic cancer 1.45 (1.28e1.64) <0.01 3.41 (2.25e5.19) <0.01
Stroke 1.16 (1.01e1.32) 0.03 2.79 (1.88e4.14) <0.01
COPD 1.13 (1.04e1.24) <0.01 1.13 (0.78e1.64) 0.52
Other 1.23 (1.15e1.31) <0.01 1.47 (1.07e2.01) 0.02
Exposure to checklist 1.02 (0.88e1.19) 0.75 0.49 (0.32e0.77)
<0.01
- 149
ISOS analysis: sensitivity analyses
We were interested to assess whether countries with high
checklist usage, as a proportion of the total number of patients
(i.e. checklist compliance), were more likely to have lower risk
of in-hospital mortality or postoperative complications. We
calculated checklist compliance by country as the proportion
of patients in each country that were exposed to the checklist.
We ranked countries by compliance and divided the sample

into four similarly sized quartiles, with quartile one repre-
senting lowest compliance and quartile four representing
highest compliance. We repeated the primary analysis using
quartiles of checklist compliance as the exposure of interest,
using a deviation contrast where the mean compliance for the
whole cohort was treated as the reference category. Secondly,
to identify whether a relationship between checklist use and
postoperative complications or mortality differed according to
income status of the country of origin, we stratified the sample
by country income status (high income or low and middle
income), according to the World Bank definition and repeated
the analysis.20
Evidence synthesis: systematic review and meta-
analysis
We undertook a systematic review and meta-analysis of the
published literature describing the effects of surgical safety
checklist use on patient outcomes, including the results of the
ISOS study. We prospectively registered the systematic review
with PROSPERO (2016:CRD42016039878). The primary
outcome

was mortality, which we expected to be the most frequently
reported outcome measure. The secondary outcome was
postoperative complications. Definitions of complications for
included studies are presented in Supplementary Table 1. We
searched MEDLINE, The Cochrane Library, EMBASE, and
CINAHL for the years 2009e2017 using Healthcare Database
Advanced Search (hdas.nice.org.uk). We scanned the bibliog-
raphies of included studies and consulted experts to identify
studies that were missed by the search. Full details of the
search strategy are provided in Supplementary Table 2. We
extracted records to Mendeley (London, UK) to sort and
remove duplicates. Two investigators (M.P. and A.F.) inde-
pendently reviewed each record by title and abstract. Papers
Table 3 Compliance with surgical safety checklist by country
and postoperative outcomes. Summary of two separate
statistical
models, where the dependent variables were either mortality or
any postoperative complication (excluding mortality).
Generalized
linear models, with results presented as odds ratios with 95%

confidence intervals and P-values. All variables were binary
categorical
unless otherwise stated, where exposure to the variable was
compared to non-exposure. Checklist compliance, ASA score
and grade of
surgery categorical variables where the reference was the
average effect across the whole cohort. ASA, American Society
of Anes-
thesiologists; COPD, chronic obstructive pulmonary disease
Any complication P-value Mortality P-value
Age (yr) 1.01 (1.00e1.01) <0.01 1.03 (1.02e1.05) <0.01
Male 1.05 (1.02e1.08) <0.01 1.05 (0.90e1.22) 0.58
Female 0.95 (0.93e0.98) <0.01 0.96 (0.82e1.12) 0.58
Present smoker 0.99 (0.92e1.07) 0.84 1.58 (1.10e2.27) 0.01
ASA physical status
I 0.54 (0.49e0.58) <0.01 0.09 (0.02e0.40) <0.01
II 0.71 (0.67e0.75) <0.01 0.72 (0.41e1.26) 0.25
III 1.21 (1.14e1.29) <0.01 2.21 (1.29e3.78) <0.01
IV 2.17 (1.92e2.46) <0.01 7.02 (3.87e12.74) <0.01
Grade of surgery
Minor 0.52 (0.49e0.56) <0.01 0.64 (0.43e0.94) 0.02
Intermediate 0.91 (0.87e0.96) <0.01 0.91 (0.70e1.19) 0.5
Major 2.10 (2.00e2.20) <0.01 1.72 (1.33e2.22) <0.01
Surgical specialty
Orthopaedic 0.89 (0.83e0.96) <0.01 0.65 (0.42e0.99) 0.05
Breast 0.59 (0.49e0.70) <0.01 0.64 (0.17e2.40) 0.51
Obstetrics and gynaecology 0.77 (0.69e0.85) <0.01 0.83
(0.37e1.84) 0.65
Urology and kidney 0.83 (0.76e0.91) <0.01 0.49 (0.26e0.91)
0.02
Upper gastrointestinal 1.37 (1.23e1.53) <0.01 2.69 (1.78e4.08)
<0.01
Lower gastrointestinal 1.48 (1.35e1.62) <0.01 1.89 (1.26e2.83)
<0.01

Hepatobiliary 0.98 (0.86e1.10) 0.69 1.49 (0.86e2.58) 0.16
Vascular 1.05 (0.93e1.19) 0.45 0.97 (0.57e1.66) 0.92
Head and neck 0.67 (0.62e0.73) <0.01 0.62 (0.35e1.10) 0.11
Plastic or cutaneous 1.01 (0.88e1.17) 0.88 0.95 (0.40e2.26) 0.91
Cardiac 2.49 (2.20e2.81) <0.01 1.60 (1.03e2.49) 0.04
Thoracic (lung and other) 1.25 (1.08e1.45) <0.01 1.15
(0.61e2.19) 0.66
Other 0.68 (0.60e0.77) <0.01 0.74 (0.36e1.54) 0.43
Comorbid disorder
Coronary artery disease 1.03 (0.94e0.13) 0.48 0.98 (0.69e1.39)
0.91
Heart failure 1.27 (1.13e1.44) <0.01 1.47 (1.00e2.16) 0.05
Diabetes mellitus 1.10 (1.01e1.19) 0.03 1.26 (0.90e1.75) 0.18
Cirrhosis 1.45 (1.11e1.88) <0.01 2.72 (1.31e5.63) <0.01
Metastatic cancer 1.45 (1.28e1.64) <0.01 3.41 (2.24e5.19) <0.01
Stroke 1.15 (1.01e1.32) 0.03 2.80 (1.88e4.16) <0.01
COPD 1.13 (1.04e1.24) <0.01 1.18 (0.81e1.72) 0.38
Other 1.22 (1.15e1.31) <0.01 1.42 (1.03e1.94) 0.03
Checklist compliance
Quartile 1 (low) 1.07 (0.94e1.23) 0.32 1.80 (1.34e2.41) <0.01
Quartile 2 (medium) 1.17 (1.00e1.36) 0.04 1.02 (0.73e1.41)
0.93
Quartile 3 (high) 0.87 (0.75e1.02) 0.09 0.90 (0.61e1.32) 0.58
Quartile 4 (very high) 0.92 (0.81e1.03) 0.15 0.61 (0.45e0.83)
<0.01
150 - Abbott et al.
identified as potentially relevant were reviewed in full. Papers
were selected for inclusion if they described the use of the
WHO surgical safety checklist in adult patients (>18 years)
undergoing surgery, and reported either complications or
mortality as postoperative outcomes. We did not include

studies where the surgical safety checklist was tested with
another intervention or where the checklist was modified.21
Differences in opinion were resolved through discussion and
referred to a third investigator (M.G.). Data were extracted
from the selected papers by two independent investigators
(M.P. and A.F.) to a pre-formatted Excel worksheet (Microsoft,
Redmond, WA, USA). The meta-analysis was conducted using
Review Manager Version 5.3 (Cochrane Collaboration, Copen-
hagen, Denmark). Risk of bias was assessed using the
Cochrane tool for randomized controlled trials, the National
Institutes of Health ‘quality assessment of before-and-after
studies’ tool for before and after studies, and the Newcastle
Ottawa Scale for other non-randomized studies.22e24 Between
study heterogeneity was assessed with c2 test and I2 test using
P<0.1 as the pre-defined threshold for statistical significance.
A random effects model was used for all analyses. Results are
presented as OR with 95% CI, associated P-values, and forest
plots.
Results
Surgical safety checklist use in the ISOS cohort

We included 44 814 ISOS participants from 497 hospitals in 27
countries in this analysis (Supplementary Fig. 1). Eight coun-
tries, with 134 participating hospitals, were classed as low - or
middle-income nations.20 Participating hospitals had a me-
dian of 550 (329e850) beds and 21 (10e38) critical care unit
beds. Some 40 245/44 814 (89.8%) patients were exposed to the
surgical safety checklist, 7508/44 814 (16.8%) sustained at least
c
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ia
c
s
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rg
e
ry
;
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,
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p

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li
ty
C
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m
p
li
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ti
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n
s
N
Y
N

Y
Y
Y
Y
N
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
- 151
one postoperative complication, and 207/44 814 (0.5%) died
before hospital discharge (Table 1). The results of regression
models for surgical safety checklist exposure against post-

operative mortality or complications in the ISOS cohort are
shown in Table 2. In the unadjusted analysis, exposure to the
surgical safety checklist was associated with a reduction in
mortality [OR 0.42 (0.33e0.58); P<0.01], which remained sta-
tistically significant after adjustment for confounding factors
[OR 0.49 (0.32e0.77); P<0.01]. Exposure to the checklist was
not
associated with a reduction in the incidence of postoperative
complications in either the unadjusted [OR 0.99 (0.91e1.07);
P¼0.74] or the adjusted analyses [OR 1.02 (0.88e1.19);
P¼0.75].
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4
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4
5
Sensitivity analyses of the ISOS cohort
When countries were ranked by compliance with the check-
list, the mean compliance in the lowest and highest quartiles
were 62.5% and 98.7%, respectively (Supplementary Table 3).
Low checklist use at a national level (quartile 1) was associated
with increased mortality [OR 1.80 (1.34e2.41); P<0.01] and
high
checklist use at a national level (quartile 4) was associated

with reduced mortality [OR 0.61 (0.45e0.83); P<0.01] (Table 3),
with the whole cohort as the reference category. National
rates of checklist use (quartile 1 and quartile 4) were not
associated with any effects on postoperative complication
rates. When we stratified the sample by income status of the
participating country and repeated the primary analysis, the
findings remained similar (Supplementary Tables 4 and 5). To
further explore the absence of association between checklist
use and reduced incidence of postoperative complications, we
conducted a post hoc sensitivity analysis to see if checklist use
was associated with reductions in the incidences of specific
severities of complications (either mild or moderate or severe).
However, we did not identify any such associations
(Supplementary Table 6).
T
a
b
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4
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4
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P
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rt
Systematic review and meta-analysis
Searches identified 3732 records. After removal of duplicates,
3554 abstracts were screened, 41 full-texts were reviewed, and
11 studies (including ISOS) were selected for inclusion
(Supplementary Fig. 2). Five studies included in previous sys -
tematic reviews were excluded because they did not meet our

inclusion criteria.12,13 A summary of the articles included is
provided in Table 4. A total of 419 799 patients were included
in
the meta-analysis for mortality. Some 2624/230 929 (1.1%) of
patients exposed to the checklist died, compared to 2466/188
870 (1.3%) not exposed to the checklist. In the random effects
meta-analysis, checklist exposure was associated with
reduced mortality [OR 0.75 (0.62e0.92); P<0.01; I2¼87%] (Fig.
1).
The definition of mortality was ‘in-hospital’ in two studies, in-
hospital restricted to 30 days in five studies, and in-hospital
restricted to 60 days in one study. In contrast, 12 054/161 858
(7.4%) of patients exposed to the checklist developed post-
operative complications, compared to 6043/123 329 (4.9%) of
patients not exposed to the checklist. In the random effects
meta-analysis, checklist exposure was associated with a
reduced incidence of postoperative complications [OR 0.73
(0.61e0.88); P<0.01; I2¼89%] (Fig. 2). The meta-analysis is
weighted according to effect size and the two biggest studies,
which account for 38.2% of patients showed no difference in

complication rates between exposed and unexposed patients.
The risk of bias was low in all included studies
(Supplementary Table 7) and visual assessment of funnel plots
Fig 1. Forest plot for meta-analysis of exposure to surgical
safety checklist and relative risk of postoperative mortality.
Fig 2. Forest plot for meta-analysis of exposure to surgical
safety checklist and relative risk of postoperative
complications.
152 - Abbott et al.
demonstrated no evidence of publication bias. Compliance
with checklist use was variable across studies with no pattern
of changing use over time (Supplementary Table 8). To account
for the possibility that some studies in the meta-analysis
included patients exposed to a modified checklist, we
repeated the meta-analysis including five studies of modified
surgical safety checklists that were excluded from the primary
meta-analysis.25e29 Our findings remained similar for both
mortality [OR 0.77 (0.64e0.91]; P<0.01; I2¼83%] and
complica-
tions [OR 0.71 (0.60e0.84); P<0.01, I2¼92%].
Discussion

The principal finding of this research was that patients
exposed to a surgical safety checklist had a lower incidence of
postoperative complications and death when compared to
patients who were not exposed to a checklist. These findings
may reflect a higher quality of care in hospitals where check-
list use is routine. While the data included in the meta-
analyses are primarily observational, this study adds to the
overall understanding of the surgical safety checklist, indi -
cating that checklists are widely used internationally, but that
in most healthcare settings it is not possible to randomly
assign patients to checklist use because of existing widespread
implementation. Therefore, in the absence of data from ran-
domized trials, our analyses may represent the highest
currently attainable level of evidence describing the effects of
surgical safety checklist use. Future randomized trials may not
be possible, but further research should be standardized for
individual compliance with the checklist. The findings of the
ISOS analysis, where checklist exposure was associated with

reduced mortality but not complications, contrasted with the
results of the meta-analysis. This is counterintuitive, but not
uncommon among meta-analyses, where the results of an
individual study may contrast with the overall weighted effect.
The results of this meta-analysis suggest that across a range of
studies at many hospitals, checklist use is associated with
fewer postoperative complications and deaths. However, it is
unlikely that it will ever be possible to prove the causality of
improved patient outcomes associated with checklist use.
Previous studies in mostly high-income countries have
demonstrated associations between checklist use and reduced
morbidity and mortality. The European Surgical Outcomes
Study, conducted in 426 European hospitals, suggested that
checklist exposure was associated with a 19% reduction in the
relative risk of in-hospital mortality, while a single centre
retrospective cohort study in Chile identified a 27% reduction
in mortality.14,30 However, there is less evidence to support
checklist use in low or middle-income countries.28 Our anal-

ysis of the ISOS is the largest study of which we are aware, to
include data from both low-, middle-/high-income countries.
Our results are therefore more widely generalizable and indi -
cate a need for research and quality improvement to ensure
safe and effective patient care in low- and middle-income
countries. Examples may include rapid response systems
and early warning scores.31e33 The largest study to evaluate
the surgical safety checklist to date was a cohort study of an
implementation project performed in acute care hospitals in
Canada.34 In contrast to our results, the authors did not
identify any benefit associated with checklist use, when
comparing the 3 months before and after implementation in
>200 000 patients. This may be attributable in part to pre-
existing high-quality care at these hospitals. We included
this study in our meta-analysis, which may explain, in part,
- 153
the smaller effect estimates than observed in a previous sys-
tematic review.12 Similarly, the findings of the ISOS analysis

contrast with the results of our meta-analysis, which identi-
fied a reduction in postoperative complications associated
with checklist exposure. This might be explained by the high
compliance with checklist use in the ISOS cohort (nine out of
10 patients), making it harder to detect a difference in out-
comes between exposed and non-exposed patients. Alterna-
tively, it may be attributable to bias or heterogeneity between
studies included in the meta-analysis (Supplementary
Table 6).
This work has several strengths. This was a prospective
analysis of the ISOS cohort and a prospective meta-analysis.
ISOS is one of the largest prospective international cohort
studies of surgical outcomes conducted to date, and in
contrast to many other studies, includes data from low -,
middle-, and high-income countries.6 Because of the large
number of patients enrolled, we were able to adjust the anal -
ysis for a variety of potential confounding factors. However, as
with any epidemiological study, we must acknowledge the

potential influence of unmeasured confounding. The meta-
analysis included more than 10 times as many patients as
the previous largest evidence synthesis, and the risk of bias
was lower than in previous work.12,13 Our study also has
several weaknesses. The ISOS investigators hoped to include a
mix of hospitals from each country. However, it is impossible
to say whether the results are representative of practice in any
one country. This is particularly pertinent to low- and middle-
income countries, where there was a bias towards university
hospitals and away from smaller district hospitals. In general,
we would expect hospitals that participate in research to offer
a better standard of care, since research active hospitals tend
to have superior clinical outcomes.35 There is likely to be
heterogeneity of surgical and perioperative care and admin-
istrative procedures across hospitals included in the ISOS
study, which may influence the results. For example, hospitals
in some countries may discharge patients at an earlier stage of
the postoperative pathway than others, which may influence

the rates of recorded in-hospital complications. This is further
illustrated by the variation in compliance with the checklist at
a country level, where three-quarters of countries used the
checklist in >89% of cases, in contrast to a wide variation in
checklist use among countries in the lowest quartile (27e85% ).
However, checklist complianceesimilar to the heterogeneity
of surgical care within and between countriese is unlikely to
be uniform across countries and the ISOS sample may not be
representative of country-wide practice. Furthermore, we did
collect data on individual components of the checklist, so it is
possible that some sections were completed more frequently
than others. The meta-analysis did not include studies of staff
training on the use of the surgical safety checklist and we did
not differentiate between different types of complications in
the analysis. The literature describing the checklist describes a
variety of methodologies including randomized trials, pro-
spective and retrospective cohort studies, implementation
studies, and natural trials. We performed a wide-ranging

systematic review and meta-analysis to reflect the breadth
of available knowledge. However, while we were able to in-
crease the precision of our effect size estimates compared to
previous studies, the population samples of included studies
may be different, and this is reflected in the between study
heterogeneity. An alternative approach is to undertake a
meta-analysis based on one methodology only, for example
randomized trials. This approach has been helpful, but is
limited by the number of available studies and therefore pa-
tients.13 Given the inclusion of three large studies in the meta-
analysis, there is the potential that the results may be skewed
towards findings of these studies. We were unable to adjust for
potential improvements in perioperative care over time or
differences in compliance with the checklist between or
within included studies.1,36,37 While several studies have re-
ported compliance rates greater than 90%, the findings of the
included studies do not suggest any trend to improved adop-
tion of the checklist over time.
Conclusions

We have provided evidence to show that patients exposed to a
surgical safety checklist experience better postoperative out-
comes. However, it remains uncertain whether these associ-
ations are a direct causal effect, or if this simply reflects wider
quality of care in hospitals where checklist use is routine.
Authors’ contributions
Study design/plan: T.E.F.A., R.P.
Study draft: T.E.F.A., T.A., A.F., M.G., R.P.
Patient recruitment and data collection: members of the ISOS
study group (see supplementary file).
Analysis of ISOS data: T.A., T.E.F.A.
Systematic review: A.F., M.P., M.G.
Meta-analysis: A.F., T.E.F.A., M.G.
Writing paper: T.E.F.A., A.F., R.P.
Revised paper: all authors.
Acknowledgements
The ISOS study was funded through an unrestricted research
grant from Nestle Health Sciences. T.E.F.A. is supported by a
Medical Research Council/British Journal of Anaesthesia clin-

ical research training fellowship. B.B. is funded by a National
Research Foundation rating grant and an MRC (SA) self-
initiated research grant. M.G. is a Chief Scientist Office (Scot-
land) NHS Research Scheme Clinician. R.P. is a UK National
Institute for Health Research Professor.
Declaration of interest
R.P. holds research grants, and has given lectures and/or per -
formed consultancy work for Nestle Health Sciences, BBraun,
Medtronic, Glaxo SmithKline, and Edwards Lifesciences, and is
a member of the Associate Editorial Board of the British Jour-
nal of Anaesthesia. M.S.C. has received unrestricted research
grants, and has given lectures and/or performed consultancy
work for Thermofisher Scientific, Pulsion Medical Systems,
and Edwards Lifesciences, and is a member of the Associate
Editorial Board of the European Journal of Anaesthesiology. All
other authors declare they have no conflicts of interest.
Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.bja.2017.08.002.
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http://www.who.int/patientsafety/safesurgery/checklist/en/
http://www.who.int/patientsafety/safesurgery/checklist/en/

https://datahelpdesk.worldbank.org/knowledgebase/articles/906
519-world-bank-country-and-lending-groups
https://datahelpdesk.worldbank.org/knowledgebase/articles/906
519-world-bank-country-and-lending-groups
https://http://www.nhlbi.nih.gov/health-pro/guidelines/in-

develop/cardiovascular-risk-reduction/tools/before-after
http://refhub.elsevier.com/ S0007-0912(17)53945-8/sref29

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37. Kahan BC, Koulenti D, Arvaniti K, et al. Critical care
admission following elective surgery was not associated
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countries. Intensive Care Med 2017; 43: 971e9
38. Askarian M, Kouchak F, Palenik CJ. Effect of surgical

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outcomes support implementation of a surgical safety
checklist. J Am Coll Surg 2012; 215: 766e76
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population. N Engl J Med 2009; 360: 491e9
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preventable complication-related reoperations.
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ness of the surgical safety checklist in a high standard
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Handling editor: P.S. Myles

http://refhub.elsevier.com/S0007-0912(17)53945-8/sref44The
surgical safety checklist and patient outcomes after surgery: a
prospective observational cohort study, systematic revi
...Editor's key pointsMethodsISOS analysis: design, setting, and
participantsISOS analysis: outcome measuresISOS analysis:
statistical methodsISOS analysis: sensitivity analysesEvidence
synthesis: systematic review and meta-analysisResultsSurgical
safety checklist use in the ISOS cohortSensitivity analyses of
the ISOS cohortSystematic review and meta-
analysisDiscussionConclusionsAuthors'
contributionsAcknowledgementsDeclaration of
interestSupplementary dataReferences
Outline A - ORAGANIZATIONAL CHANGE AND
WORKFORCE MANAGEMENT

I. Organization Development
A. Workplace Communication
1. Effective communication is a key element of organizational
success
2. An active communications approach will guide the employee
to organizational outcomes and goals
3. Employees gain understanding and commitment
4. Trust between management and employees
B. Motivation
1. Motivating employees is important to any business
2. Understand what motivates the employees
3. Employee incentive programs
C. Leadership
1. Exceptional Leaders:
a. State the Future
b. Show Up
c. Inspire Employees
d. Direct Appreciation
e. Celebrate Successes
2. Different roles of a successful leader
D. Employee Stress
1. When is workplace stress too much
2. Signs of stress to look for
3. Managements role in reducing stress
E. Decision Making
1. Decision-making outlines for day-to-day execution.
2. Rank several priorities at once
3. Calculate the decision-making approach
F. Conflict Management
1. The nature of conflict
2. Steps to Conflict Resolution
3. Organizational Impact
4. Personal impact
5. The cost of not managing conflict
G. Team building and group dynamics
1. A philosophy of teamwork involves trust, collaboration, and

accountability.
2. The impact of team building on the organization
H. Embracing change and change management
1. Employee involvement
2. Resistance and Comfort
3. Managing Change
4. Reinforcing Change
II. Human Resources
A. Organizational and human resource systems.
1. Human Resource Management (HRM) is to increase the
performance of the organization
2. Measurement of the HRM system
3. HRM practices and workforce characteristics
B. The steps and decisions involved in recruitment, selection,
and retention of staff
1. Major steps and decisions involved in designing and
implementing a recruitment effort
2. Recruitment Sources
3. Job Requirements and Selection Tools
4. Retention of current future staff
C. Compensation and performance systems
1. Performance measures with objective performance measures
2. Bonuses with pay for performance
3. Performance measurement plans with balanced plans
D. Training and development
1. Training and Development and its Process
2. Importance of Training and Development in an
Organizational Development Training and career
3. Identification of Training and Development Needs
E. Relationship of organized labor and management in
healthcare
1. Maintaining an unorganized employee base
2. Prepare the leaders
3. Engage the employees
F. The resources, key staff/roles, and steps required to develop

a safe workplace
1. A system of safety management practices
2. Safe work procedures
3. Safety training
4. Communication
5. Managers and supervisors take a proactive role
Reference
Anderson, B. (2014). Motivating Employees to Achieve the
Strategic Plan. Retrieved from http:// /wp-
content/uploads/2014/02/MotivatingEmployees.pdf
Becker, E. (2015, April). Team Building and Group Dynamics.
Retrieved from
https://www.td.org/Publications/Magazines/TD/TD-
Archive/2015/04/Team-Building- and-Group-Dynamics
Dillard, J. (2016). Strategic Planning Steps for Better Overall
Decision Making. Retrieved from /382182/4-Strategic-
Planning-Steps-For-Better-Overall-Decision-Making
Eisenhauer, T. (2016). Improve Workplace Communication.
Retrieved from
https://axerosolutions.com/blogs/timeisenhauer/pulse/210/i
mprove-workplace- communication
Fried, B. (2015). RECRUITMENT, SELECTION, AND
RETENTION. Retrieved from
http://www.ache.org/mbership/BOGEXAMOT_V3/fried/ch
apter8.pdf
Green, H. (2014). Why Engaging Your Employees Is The
Answer To Strategic Planning. Retrieved from https://
forbes.com/sites/work-in-progress//why-engaging-your-
employees-is-the-answer-to-strategic-planning
Heskett, J. (2017). How Should Pay Be Linked to Performance.
Retrieved from http://hbswk.hbs.edu/item/how-should-pay-
be-linked-to-performance
Higashide, J. (2014). Summary of Change Management: The
People Side of Change. Retrieved from business/process-
improvement/assets/people-side-ofchange/summary-of-change-

management-the-people-side-of-change
Jensen, M. (2014). It’s Not How Much You Pay, But How.
Retrieved from
https://hbr.org/2014/05/ceo-incentives-its-not-how-much-you-
pay-but-how
Keddy, J. (2014). Managing Conflict at Work. Retrieved from
/library/view/managing-conflict- at/9780749459529/.xhtml
Lepak, D.P. , Liao, H. , Chung, Y. and Harden, E.E. (2016), “A
conceptual review of human resource management systems in
strategic human resource management research”, Research in
Personnel and Human Resources Management , Vol. 25 No. 1,
pp. 217-271
Lotich, P. (2015, July 22). Effective Communication in the
Workplace. Retrieved from
http://thethrivingsmallbusiness.com/effective-
communication-in-the-workplace/
Morse, S. (2015). As unions grow, healthcare execs need to
know how to handle them. Retrieved from
http://www.healthcarefinancenews.com/news/unions-grow-
healthcare-execs-need- know-how-handle-them
Nyberg, A.J. Moliterno, T.P. Hale, D. Jr and Lepak, D.P.
(2014), “Resource-based perspectives on unit-level human
capital: a review and integration”, Journal of Management,
Vol. 40 No. 1, pp. 316-346.
Punke, H. (2014). How Hospitals and Unions Can Bridge Their
Gaps. Retrieved from
http://www.beckershospitalreview.com/human-capital-and-
risk/how-hospitals-and- unions-can-bridge-their-gaps.html
Segal, J. (2017, April). Stress in the Workplace What
Employers can do. Retrieved from
https://www.helpguide.org/articles/stress/stress-in-the-
workplace.htm
Scholar, D.N. (2014). Role of Training & Development in an
Organizational Development. Retrieved from International
Journal of Management and International Business Studies.
ISSN 2277-3177 Volume 4, Number 2 (2014), pp. 213-220

Shaw, J.D. , Gupta, N. and Delery, J.E. (2015), “Pay dispersion
and workforce performance: moderating effects of incentives
and interdependence”, Strategic Management Journal , Vol. 23
No. 6, pp. 491-512.
Solomon, L. (2016). Designing a Compensation Program
That Motivates and Produces a Profit-Driven Workplace.
Retrieved from http://aubreydaniels.com/pmezine/designing-
compensation-system-motivates
Watcher, J. (2014). Accident Analysis & Prevention. Retrieved
from Accident Analysis & Prevention Volume 68, July
2014, Pages 117-130
Outline B Option #1: Memorial’s Healthcare System:
Organizational Change and Workforce Management
1. Organizational Development Defined
1. Implementing Organizational Development
4. Workplace Communication
0. Consequences of poor communication at the senior and
departmental level
0. Benefits of an effective communication structure
0. Implementing and maintaining effective communication.
Zaumane, I. (2016). The Internal Communication Crisis and its
Impact on an Organization’s Performance. Journal of Business
Management, (12), 24-33.
Turaga, R. (2016). Organizational Models of Effective
Communication. IUP Journal of Soft Skills, 10(2), 56-65.
4. Motivation
1. Who needs motivated and when?
1. Best motivation techniques and how to implement
1. Motivated employees impact on quality of care and
efficiency.
Jyothi, J. (2016). Non-Monetary Benefits & Its Effectiveness in

Motivating Employees. CLEAR International Journal Of
Research In Commerce & Management, 7(5), 45-48.
Mohebbifar, R., Zakaria Kiaei, M., Khosravizadeh, O., &
Mohseni, M. (2014). Comparing the Perspectives of Managers
and Employees of Teaching Hospitals about Job
Motivation. Global Journal of Health Science, 6(6), 112-118.
doi:10.5539/gjhs.v6n6p112
4. Leadership
2. “Tone at the Top”
2. Communication in Leadership
Argenti, P. A. (2017). Strategic Communication in the C-
Suite. International Journal of Business Communication, 54(2),
146-160. doi:10.1177/2329488416687053
Gokce, B., Guney, S., & Katrinli, A. (2014). Does Doctors’
Perception of Hospitals Leadership Style and Organizational
Culture Influence Their Organizational Commitment? Social
Behavior & Personality: An International Journal, 42(9), 1549-
1561.
4. Employee Stress
3. Signs of Employee Stress
3. Impacts of stress on workplace, patient care, turnover
3. Preventing & combating stress in employees
Khamisa, N., Oldenburg, B., Peltzer, K. and Ilic, D. (2015)
Work Related Stress, Burnout, Job Satisfaction and General
Health of Nurses. International Journal of Environme ntal
Research and Public Health, 12(1): 652-666.
Kim Holton, M., Barry, A. E., & Don Chaney, J. (2016).
Employee stress management: An Examination of Adaptive and
Maladaptive Coping Strategies on Employee
Health. Work, 53(2), 299-305. doi:10.3233/WOR-152145
4. Decision Making
4. Importance of decision-making style

Harden, H., & Fulop, L. (2015). The Challenges of a Relational
Leadership and the Implications for Efficacious Decision-
Making in Healthcare. Asia Pacific Journal of Health
Management, 10(3), SI51-SI62.
Borkowski, N. (2016). Organizational behavior in health care
(3rd ed.). Burlington, MA: Jones & Bartlett Learning.
4. Conflict Management
5. Dealing with Conflict in the workplace
5. Consistent conflict resolution
5. Organizational Impact (morale)
5. Personnel impact of conflicts (turnover)
Khan, K., Iqbal, Y., & Hussainy, S. K. (2016). Causes, Effects,
and Remedies in Conflict Management. South East Asian
Journal of Management, 10(2), 152-172.
Patton, C. M. (2014). Conflict in Health Care: A Literature
Review. Internet Journal of Healthcare Administration, 9(1), 1.
4. Team building and group dynamics
6. Group dynamics in healthcare
6. Organization wide team building
6. Improving patient centered care with team building
Dwyer, K. P., Osher, D., Maughan, E. D., Tuck, C., & Patrick,
K. (2015). Team Crisis: School Psychologist and Nurses
Working Together. Psychology in the Schools, 52(7), 702-713.
Purohit, B. (2015). A Case Study on Processes in Team
Building and Performance Improvement at Government Health
Centers in Rajasthan, India. International Journal of Medicine &
Public Health, 5(4), 372-377. doi:10.4103/2230-8598.165985
4. Embracing change and change management
7. Change in an organization
7. Effectively implementing changes
1. Communication
1. Consistency
1. Support
7. Culture of change
Eamranond, P., Joshi, M., Haque, I., Scarry, A., Geary, S., &
Collins, B. (2017). A System-Wide Movement to Improve

Patient Care and Reduce Unnecessary Laboratory
Testing. MLO: Medical Laboratory Observer, 49(4), 46-47.
Larsen, T., & Eskerod, P. (2015). Using Change Management
Principles in Projects - An Exploratory Case Study. Journal of
Management & Change, 34/35(1/2), 44-59.
1. Human Resources
5. Organizational and human resource systems.
0. Human Resource Management
Trebble, T. M., Heyworth, N., Clarke, N., Powell, T., &
Hockey, P. M. (2014). Managing Hospital Doctors and Their
Practice: What Can We Learn About Human Resource
Management from Non-Healthcare Organizations? BMC Health
Services Research, 14(1), 566-588. doi:10.1186/s12913-014-
0566-5
5. The steps and decisions involved in recruitment, selection,
and retention of staff
1. Retaining top talent in the organization
1. Recruiting and selecting top talent
Ackerman, J. (2016). Recruiting and Retaining Talent. CPA
Journal, 86(8), 14.
Buchan J: What Differences does ("good") HRM Make? Human
Resources for Health. 2004, 2: 6-10.1186/1478-4491-2-6.
5. Performance Management Systems
2. Types of performance management systems
5. Compensation and Reward Systems
3. Types of compensation and reward systems
5. Training and Development Processes and their Contribution
to the Organizations Bottom Line
4. Importance of training and development of staff (S&W costs)
4. Execution of an effective employee development program
5. Relationship of organized labor and management in
healthcare
5. The resources, key staff/roles, and steps required to develop a
safe workplace

6. Importance of a formalized compliance and safety program
6. Reporting mechanism for employees
6. Training and education of program
6. Practice of program procedures
6. Leadership involvement in the compliance and safety
programs
Scott, B. C. (2015). Hospital Boards – Why Quality and Safety
Matter. Physician Leadership Journal, 2(1), 62-64.
Burchill, C. (2015). Development of the Personal Workplace
Safety Instrument for Emergency Nurses. Work, 51(1), 61-66.
doi:10.3233AVOR-141889
Loeppke RR, Hohn T, Baase C, et al. (2015) Integrating Health
and Safety in the Workplace: How Closely Aligning Health and
Safety Strategies can Yield Measurable Benefits. JOEM, 57(5),
585–597.
1. Conclusion
6. Review of key steps in implementing change to
organizational culture
6. Review steps needed to generate sustainable change
References
Ackerman, J. (2016). Recruiting and Retaining Talent. CPA
Journal, 86(8), 14.
Argenti, P. A. (2017). Strategic Communication in the C-
Suite. International Journal of Business Communication, 54(2),
146-160. doi:10.1177/2329488416687053
Borkowski, N. (2016). Organizational behavior in health care

(3rd ed.). Burlington, MA: Jones & Bartlett Learning.
Buchan J: What Differences Does ("good") HRM Make? Human
Resources for Health. 2004, 2: 6-10.1186/1478-4491-2-6.
Burchill, C. (2015). Development of the Personal Workplace
Safety Instrument for Emergency Nurses. Work, 51(1), 61-66.
doi:10.3233AVOR-141889
Dwyer, K. P., Osher, D., Maughan, E. D., Tuck, C., & Patrick,
K. (2015). Team Crisis: School Psychologist and Nurses
Working Together. Psychology in the Schools, 52(7), 702-713.
Eamranond, P., Joshi, M., Haque, I., Scarry, A., Geary, S., &
Collins, B. (2017). A System-Wide Movement to Improve
Patient Care and Reduce Unnecessary Laboratory
Testing. MLO: Medical Laboratory Observer, 49(4), 46-47.
Gokce, B., Guney, S., & Katrinli, A. (2014). Does Doctors’
Perception of Hospitals Leadership Style and Organizational
Culture Influence Their Organizational Commitment? Social
Behavior & Personality: An International Journal, 42(9), 1549-
1561.
Harden, H., & Fulop, L. (2015). The Challenges of a Relational
Leadership and the Implications for Efficacious Decision-
Making in Healthcare. Asia Pacific Journal of Health
Management, 10(3), SI51-SI62.
Jyothi, J. (2016). Non-Monetary Benefits & Its Effectiveness in
Motivating Employees. CLEAR International Journal Of
Research In Commerce & Management, 7(5), 45-48.
Khamisa, N., Oldenburg, B., Peltzer, K. and Ilic, D. (2015)
Work Related Stress, Burnout, Job Satisfaction and General
Health of Nurses. International Journal of Environmental
Research and Public Health, 12(1):652-666.
Khan, K., Iqbal, Y., & Hussainy, S. K. (2016). Causes, Effects,
and Remedies in Conflict Management. South East Asian
Journal of Management, 10(2), 152-172.
Kim Holton, M., Barry, A. E., & Don Chaney, J. (2016).
Employee stress management: An Examination of Adaptive and
Maladaptive Coping Strategies on Employee
Health. Work, 53(2), 299-305. doi:10.3233/WOR-152145

Larsen, T., & Eskerod, P. (2015). Using Change Management
Principles in Projects - An Exploratory Case Study. Journal of
Management & Change, 34/35(1/2), 44-59.
Loeppke RR, Hohn T, Baase C, et al. (2015) Integrating Health
and Safety in the Workplace: How Closely Aligning Health and
Safety Strategies can Yield Measurable Benefits. JOEM, 57(5),
585–597.
Mohebbifar, R., Zakaria Kiaei, M., Khosravizadeh, O., &
Mohseni, M. (2014). Comparing the Perspectives of Managers
and Employees of Teaching Hospitals about Job
Motivation. Global Journal of Health Science, 6(6), 112-118.
doi:10.5539/gjhs.v6n6p112
Patton, C. M. (2014). Conflict in Health Care: A Literature
Review. Internet Journal of Healthcare Administration, 9(1), 1.
Purohit, B. (2015). A Case Study on Processes in Team
Building and Performance Improvement at Government Health
Centers in Rajasthan, India. International Journal of Medicine &
Public Health, 5(4), 372-377. doi:10.4103/2230-8598.165985
Scott, B. C. (2015). Hospital Boards – Why Quality and Safety
Matter. Physician Leadership Journal, 2(1), 62-64.
Trebble, T. M., Heyworth, N., Clarke, N., Powell, T., &
Hockey, P. M. (2014). Managing Hospital Doctors and Their
Practice: What Can We Learn About Human Resource
Management from Non-Healthcare Organizations? BMC Health
Services Research, 14(1), 566-588. doi:10.1186/s12913-014-
0566-5
Turaga, R. (2016). Organizational Models of Effective
Communication. IUP Journal of Soft Skills, 10(2), 56-65.
Zaumane, I. (2016). The Internal Communication Crisis and its
Impact on an Organization’s Performance. Journal of Business
Management, (12), 24-33.
Outline C - Organizational Behavior Human Resources in

Healthcare: Spring17-C-8-HCM502-2
Portfolio Milestone
Outline
A: Introduction
B: Women in Healthcare CEO positions
a: Percentage of Women CEO’s
[email protected] Staff (2016) Cracking the Glass (Hospital)
Ceiling: Gender Diversity in Healthcare. Retrieved from
https://mha.gwu.edu/blog/healthcare-gender-diversity/
b: Percentage of minority women CEO’s
ACHE (2015) Increasing and Sustaining Racial/Ethnic Diversity
in Healthcare Management. Retrieved from
https://www.ache.org/policy/minority.cfm
C: Opportunity for Advancement
a: What can they do to advance?
b: What is in their way?
c: Do women really want top positions?
Waller., N., & Lublin. J., S. (2015) What’s Holding Women
Back in the Workplace? Retrieved from
https://www/wjs.com/articles/whats-holding-women-back-in-
the-workplace-1443600242
D: Technology
a: Why is the Technology workforce mainly white or Asian
males?
b: Are women not qualified enough to hold a top position?
Marcus. B. (2015) The Lack of Diversity in Tech is a Cultural
Issue. Retrieved from
https://www.forbes.com/sites/bonniemarcus/2015/08/12/the-
lack-of-diversity-in-tech-is-a-cultural-issue/
E: Promotion and Professional Development
a: “Numerous researchers have looked into whether government
equal opportunity programs have positive effect on professional
development of women.” (andric,2013)
b: What has HRM contributed to the professional development
of women?
Andric. M., M. (2013) The Role of Human Resource

Management in Professional Development and Promotion of
Women: Journal of Engineering Management and
Competitiveness (JEMC) Vol. 3, No 1,2013,22-26
F: Cultural Bias
a: Why are 85% of executive’s men?
b: Are women and minorities really penalized within our
system?
Johnson. S.K., & Hekman., D. R., (2016) Women and Minorities
are Penalized for Promoting diversity. Retrieved from
https://hbr.org/2016/03/women-and-minorities-penalized-for-
promoting-diversity
Johns. M., L., (2013) Breaking the Glass Ceiling: Structural,
Cultural, and Organizational Barriers Preventing Women from
Achieving Senior and Executive Positions. Retrieved from
https://www.ahima.org/breaking-the-glass-ceiling-structural-
cultural-and-organizational-barriers-preventing-women-from-
achieving-senior-and-executive-positions
1. Outline D - How to make organizational change successful
(Al-Haddad & Kotnour, 2015)
1. Organizational Development
1. Workplace communication
0. Develop a clear and attainable plan (Longenecker et al.,
2014)
0. Transformational Leadership supporting communication
(Bell, Powell & Sykes, 2015)
1. Motivation
1. How cynicism can mediate between role stressor and turn

over (Nazir et al., 2016)
1. Three methods to motivate change (Lister, n.d.)
1. Leadership
2. The discrepancies of leaders self-rating and their followers
rating (Aarons et al., 2017)
2. Middle managers impact on organizational performance
(Johansen & Hawes, 2016)
1. Employee Stress
3. Benefits and costs of work friendships (Burkus, 2017)
3. Digesting Workplace stress (Workplace, 2014)
1. Decision Making
4. Virtual simulation to build critical thinking (Williams-Bell et
al., 2015)
4. Clinical practice guidelines to guide policy (Kredo, 2016)
1. Conflict management
5. How to resolve (Lytle, 2015)
1. Team building and group dynamics
6. Multigenerational team building to improve outcomes
(Moore, Everly & Bauer, 2016)
1. Embracing change and change management
7. 10 principles of change management (Aguirre & Alpern,
2014)
1. Human resources
2. Organizational and human resource systems
0. How HR influence job attitudes and operational efficiency
(Cogin, Ng & Lee, 2016)
2. Recruitment and retention
1. Hospitals are changing the HR approach (How Hospitals,
2017)
2. Performance management systems
2. In healthcare organizations HR practice and performance
links (Petros, 2014)
2. Compensation and reward systems
3. HR and employee well-being to improve performance (Guest,
2017)
2. Training and developments contribution to the bottom-line

4. Improve your organizations collaborative culture (Wallace,
2016)
2. Organized labor’s relationship with management
5. How to work with unions (Morse, 2015)
2. Resources, key staff/roles, and steps to create a safe
workplace
6. Four strategies to create a safe and healthy workplace
(Walden, 2014)
1. Conclusion
3. Integrating organizational and human resources into a
strategic change plan to affect the culture
3. Identify steps for sustainable change
References
Aarons, G. A., Ehrhart, M. G., Torres, E. M., Finn, N. K., &
Beidas, R. S. (2017, February). The humble leader: Association
of discrepancies in leader and follower ratings of
implementation leadership with organizational climate in mental
health. Psychiatric Services, 68(2), 115-122. Retrieved from
//csuglobal.idm.oclc.org/login?url=https://search-proquest-
com.csuglobal.idm.oclc.org/docview/1866473552?acco untid=38
569
Aguirre, D., & Alpern, M. (2014). 10 Principles of leading
change management. Retrieved from https://www.strategy-
business.com/article/00255?gko=9d35b
Al-Haddad, S., & Kotnour, T. (2015). Integrating the
organization change literature: a mode for successful change.
Journal of Organizational Change Management, 28(2), 234-262.
http://dx.doi.org/https://doi.org/10.1108/JOCM-11-2013-0215
Bell, N., Powell, C., & Sykes, P. (2015, Apr). Transformational
Leadership. The Safety & Health Practitioner, 33(4), 30-32.
Retrieved from
com.csuglobal.idm.oclc.org/docview/1678624879?accountid=38
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Burkus, D. (2017). Work friends make us more productive
(Except when they stress us out). Retrieved from

https://hbr.org/2017/05/work-friends-make-us-more-productive-
except-when-they-stress-us-out
Cogin, J. A., Ng, J. L., & Lee, I. (2016, September 20).
Controlling healthcare professionals: how human resource
management influences job attitudes and operational efficiency.
Human Resources for Health. http://dx.doi.org/DOI:
10.1186/s12960-016-0149-0
Guest, D. E. (2017). Human resource management and employee
well-being: towards a new analytic framework. Human Resource
Management Journal, 27(1), 22-38. http://dx.doi.org/doi:
10.1111/1748-8583.12139
How hospitals are reinventing HR approaches. (2017).
Retrieved from http://www.hhnmag.com/articles/8101-how-
hospitals-are-reinventing-hr-approaches
Johansen, M., & Hawes, D. P. (2016, Fall). The effect of the
tasks middle managers perform on organizational performance.
Public Administration Quarterly, 40(3), 589-616. Retrieved
from //csuglobal.idm.oclc.org/login?url=https://search-proquest-
569
Kredo, T., Berhhardsson, S., Machingaidze, S., Young, T.,
Louww, Q., Ochodo, E., & Grimmer, K. (2016, Feb 28). Guide
to clinical practice guidelines: the current state of play.
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Page 1
Research Summary Checklist
Before you begin
Tip: Ensure summary is relevant and useful to your target
audience
It is important to have a clear understanding of your target
audience before you begin writing a
summary. Your target audience will have specific professional
needs and you will want to
consider why and how reading your research summary will help
your target audience meet
their needs. Knowing your target audience will help you

determine which research articles you
should prioritize for summary - for example, you may want to
summarize research articles that
are directly relevant and useful to your target audience first –
and will also help you clarify what
you should include in the “How you can use this research
summary” (see p. 4 below).
Tip: Save time
Summaries will take between 4-6 hours (or longer) to write. To
ensure time is not wasted, it is
useful to skim and scan each research article before writing,
particularly the Abstract, Findings
and Conclusion sections. This will help you determine whether
the research study is relevant
and useful to your target audience.
Further, depending on the needs of your target audience, you
may not choose to summarize
the literature review section of the research article. For this
reason, a summary writer may not
need to read this section in great depth.
Tip: Length
Summaries can vary in length and an appropriate balance needs
to be found between providing
concise information in a brief summary without over
simplifying the research and
compromising the quality of the summary. Generally, 2 to 4
pages are enough to capture the
key elements of an article.
Tip: Visuals
Include visuals whenever possible, as visuals are capable of
summarizing a great deal of
information in a small space, and grab the reader’s attention.

Make sure the visuals are easy to
read/understand, though. Poor or overly complex visuals may
detract readers.
This summary writing checklist was developed by the OERE
(http://oere.oise.utoronto.ca/) in order to increase the
efficiency of our summary writing process and the quality of
our research summaries. The checklist was written by
Shasta Carr-Harris, Project Manager of the OERE, in
consultation with the 2012 OERE summary writing team. It has
also been informed by an unpublished writing guide developed
by the Centre for Addiction and Metal Health (CAMH)
(http://www.camh.ca/en/hospital/Pages/home.aspx), a Research
Snapshot Template developed by the Research
Impact program at York University
(http://www.researchimpact.ca/researchsearch/), which provides
the basic structure
of all OERE summaries, and has been informed by Amara,
Ouimet, & Landry (2004) and Nutley, Walter, & Davies
(2007) (see references below). For more information, please
contact Shasta Carr-Harris at
[email protected] or via twitter @ShastaCH
http://oere.oise.utoronto.ca/
http://www.camh.ca/en/hospital/Pages/home.aspx
http://www.researchimpact.ca/researchsearch/
https://twitter.com/ShastaCH
Page 2

Headline
This is the “hook” that grabs the interest of the potential reader
and entices them to read the
Snapshot. The headline can be a question which the Snapshot
answers:
“Are girls really better readers?”
Or, it can be a simplified version of the article’s title:
“The Relationship between Student Self-Efficacy and Ability in
Reading and Writing”
Tip: write the Headline near the end when you have a complete
picture of the article and your
summary in mind.
What is this research about? (3-5 sentences)
Key things to include:
Highlight the purpose of the study
Include the research question (rewritten in plain language)

Define any terms necessary
What did the researchers do? (5-10 sentences)
This section is based on the methods/methodology section of the
article.
Things to include:
How did the researchers collect data?
If the researchers administered a survey, provide details: online
or paper
survey? Open-ended or close-ended questions used?
Provide examples of key questions asked (2-4 examples)
Page 3
Provide examples of answers participants had to choose from
(2-3
examples to give the reader a sense of how participants could

respond)
If interviews were conducted were these: in person, over the
phone,
etc.? What were the key questions asked? Provide examples of
questions.
Note: the description of the questions asked in a survey or
interview should match the purpose
of the study, as you have described it in the “What is this
research about” section of the
summary.
Number of people sampled?
How were participants selected (inclusion/exclusion criteria)?
Final number of people who participated in the study?
Demographics (or other key characteristics) of the final
participants in the
study?
Note: Importance of including sample size and participant
characteristics
The number of participants included in the study and the
characteristics of the final participants
are both critical pieces of information as they suggest how
“generalizable” the findings from
this study are. That said, you may not find that every study
includes this information. In this
case, you may want to contact the researcher for this

information or you may want to draw
your audience’s attention to this in the summary by noting that
this information is missing and
therefore the reader should be cautious when generalizing the
findings.
What did the researchers find? (5-10 sentences)
Things to include:
Key findings from the study, rather than every finding from the
study.
When describing findings make sure to make these as clear as
possible by giving
specific details:
Numbers: how many people reported X? How many test results
were
found to be X? etc;
Page 4

Provide a few examples whenever possible.
Instead of:
The researchers found that a majority of teachers had a positive
view of the after school
literacy program.
Be specific:
The researchers found that the majority of teachers surveyed (35
out of 40) had a
positive view of the after school literacy program. Specifically,
teachers reported that it
was easy to deliver as it did not require a lot of pre-planning or
extra resources.
Tip: Bulleted lists
The nature of the results will determine the layout of this
section. For a study with 3 or more
results it may be best to use a bulleted list, which can make the
information more organized
and simpler to digest visually. Also, remember to be as specific
as possible when presenting key
findings as this will help practitioners understand how this
study is relevant to their practice.
How can you use this research? (3-7 sentences)
Identify who would be interested in the findings from this study
(remember to focus on

your target audience). For example, if your target audience is
educational practitioners
in schools you may want to include different ways that teachers,
principals, vice
principals, and/or educational assistants can use the research.
Provide suggestions as to how this research can be used by
practitioners. This section
may invite practitioners to use research conceptually or
instrumentally. In either case,
any recommendations about how to use the research should
follow logically from the
findings of the research study:
Conceptual use: research is used to shed light on situations and
problems in one’s field of work
(Amara, Ouimet, Landry, 2004).
The research could help practitioners:
o Identify or understand issues/problems better or from
different perspectives;
o Understand why action is required;
o Know which stakeholder can or should be consulted when
addressing
issues/problems;

o Understand the programs/policies/practices that can be used to
address
issues/problems and in which context different
programs/policies/practices are
most effective;
o Understand the different methods available to implement
programs/policies/practices, etc.;
(Adapted from Nutley, Walter, Davies, 2007)
Instrumental use: research has a direct impact on policy and/or
practice decisions (Amara,
Ouimet, Landry, 2004).
The research may help practitioners take action to:
o Learn and implement evidence-based methods;
o Implement organizational programs/policies/practices based
on research
evidence that can be used to address issues/problems;

o Consult with stakeholders to develop
policies/programs/practices founded in
research evidence;
o Provide staff training that help practitioners learn evidence -
based methods;
o Etc…
What you need to know (3-4 sentences):
This section is a very brief overview of the summary - what the
study is about and an overview
of the findings. This section can be put into a highlighted box
on the top right hand side of the
first page, so that practitioners can quickly decide whether this
research summary will be useful
to them.
Example:
This study examined the factors that impact a young person’s
decision to pursue
university education in Canada. The researchers found that
family income and level of
parental education were important factors. The researchers also
found an increasing

gender gap between male and female participation, with more
young women attending
university than young men.
Page 6
Things to include:
1 sentence description of the study;
1-2 sentence general description of finding;
Original research article
You will want to provide readers with a citation and link to the
full research article whenever
possible.
About the researchers
In this section, you can include a very brief bio (1-2 sentences)
on each of the researchers.

References
Include any other references cited in article, if applicable.
Keywords
If you are adding your summaries to an online database, it is
important to include key words
with which to “tag” each summary. Then, when practitioners
search the database using these
key terms, their search will lead to the summary.
Tip: It is best to tag the summary with all relevant keywords to
give your audience the greatest
chance of finding the summary when searching an online
database.
About this summary
In this section you can include a very brief description of the
team that developed the summary
and a link to your website.

References
Amara, N., Ouimet, M., & Landry, R. (2004). New evidence on
instrumental, conceptual,
and symbolic utilization of university research in government
agencies. Science
Communication, 26(1), 75-106.
Nutley, S. M., Walter, I., & Davies, H. T. (2007). Using
evidence: How research can inform public
services. The Policy Press.

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