• Sara J Singer, George Molina, Zhonghe Li, Wei Jiang, Suliat Nurudeen, Julia G Kite, Lizabeth Edmondson, Richard Foster, Alex B Haynes, and William R Berry.
• Harvard TH Chan School of Public Health, Boston, MA; Harvard Medical School, Mongan Institute for Health Policy, Boston, MA; Massachusetts General Hospital, Boston, MA. Electronic address: ssinger@hsph.harvard.edu.
• J. Am. Coll. Surg. 2016 Oct 1; 223 (4): 568-580.e2.

BackgroundStudies show that using surgical safety checklists (SSCs) reduces complications. Many believe SSCs accomplish this by enhancing teamwork, but evidence is limited. Our study sought to relate teamwork to checklist performance, understand how they relate, and determine conditions that affect this relationship.Study DesignUsing 2 validated tools for observing and coaching operating room teams, we evaluated the association between checklist performance with surgeon buy-in and 4 domains of surgical teamwork: clinical leadership, communication, coordination, and respect. Hospital staff in 10 South Carolina hospitals observed 207 procedures between April 2011 and January 2013. We calculated levels of checklist performance, buy-in, and measures of teamwork, and evaluated their relationship, controlling for patient and case characteristics.ResultsFew teams completed most or all SSC items. Teams more often completed items considered procedural "checks" than conversation "prompts." Surgeon buy-in, clinical leadership, communication, a summary measure of teamwork overall, and observers' teamwork ratings positively related to overall checklist completion (multivariable model estimates from 0.04, p < 0.05 for communication to 0.17, p < 0.01 for surgeon buy-in). All measures of teamwork and surgeon buy-in related positively to completing more conversation prompts; none related significantly to procedural checks (estimates from 0.10, p < 0.01 for communication to 0.27, p < 0.001 for surgeon buy-in). Patient age was significantly associated with completing the checklist and prompts (p < 0.05); only case duration was positively associated with performing more checks (p < 0.10).ConclusionsSurgeon buy-in and surgical teamwork characterized by shared clinical leadership, open communication, active coordination, and mutual respect were critical in prompting case-related conversations, but not in completing procedural checks. Findings highlight the importance of surgeon engagement and high-quality, consistent teamwork for promoting checklist use and ensuring a safe surgical environment.Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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