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Table 2 Description of the content of the implementation activities in the IMPROVE standard and additional packages

From: Improving the implementation of perioperative safety guidelines using a multifaceted intervention approach: protocol of the IMPROVE study, a stepped wedge cluster randomized trial

Implementation activities


Standard package


Small-scale educational meetings

Workshop or skills training for perioperative key disciplines including assignments, role playing, own presentations, patient stories or discussion, and problem solving of hypothetical patient situations/case studies. Provided by an opinion leader within the field of patient safety or a highly respected colleague. Based on active participation in small groups: multi- or mono-disciplinary groups (i.e., per discipline, e.g., surgeons and recovery nurses separately). The content is based on the key constraints and the most important obstacles in applying the guidelines for a hospital (based on the results of the audit) and a brainstorming session during the training or pre-handed topics participants find important to discuss.

Audit and feedback

Feedback is based on the indicator measurement(s), structural observation, barrier analysis, and the TCI and HSOPS questionnaires. The feedback consists of a local paper report with the hospital’s own results, benchmarked, and presented in relation to all nine participating hospitals. The hospitals in the intervention phase receive this report shortly after a measurement period. The feedback report is presented and discussed with the key professionals in a meeting.

Structural observation

Observation by a trained expert of the pre-, per-, and postoperative trajectory of one surgical patient (on the ward, operation room, and recovery ward) based on a structured observation list. Feedback is based on the completed observation list. The hospitals receive the feedback immediately afterwards. Also, the structured observation list used is then made available to the hospital. In this way, the hospital is able to perform its own observations of the perioperative process.

Local embedding of the guidelines

Concrete and visible integration into and/or completion of a local protocol and/or checklist, for example, the adaptation of the guidelines in a local protocol; conducting audits (indicator measurements), structural observations, and visitation to monitor the implementation of the guidelines; the use of reminder systems (completing existing checklists based on the guidelines, if possible, new digital checklist may be installed in electronic patient records); decision support and feedback on the implementation of the protocol (using ICT); and incorporation of the guidelines in the clinical pathway, e.g., resignation letter to the general practitioner.

Patient safety cards

Two patient safety cards (each with six cartoons on the front and explanations on the back) based on the perioperative guidelines, entitled “Help us with your safe surgery” and “Discharge from the hospital” are sent to the patients with an accompanying letter in preparation of the preoperative screening or admission to the hospital.


Both patient safety cards are offered again to the patients on the preoperative outpatient clinic and on the nursing ward, respectively.


Medical specialist and nurses discuss the patient safety cards with the patient in order to explicitly invite patients to ask questions and to attend caregivers on parts of the cards during their health-care process.

Additional package


Personal information letter in the mailbox

Personal information letter to all key disciplines about the (use of the) guidelines.

Exchange platform

This is a platform for the hospitals within a group to exchange their best practices, ideas, and experiences with implementing the guidelines.

Scan of the total perioperative process

A practice scan consisting of five parts:


-Hospital staff complete an online questionnaire about the perioperative process (via e-mail with a login code)


-Interviews with hospital staff for more background information (based on remarkable answers in the questionnaire)


-Structured observation on side


-Paper report by post (the report contains the findings, a top five of strengths and weaknesses, and recommendations)


-Feedback meeting to discuss the report

Electronic reminder message

Catchy quote on behalf of an opinion leader within the perioperative process of a hospital. The content is based on the audit results; a recommendation comes in the spotlight which proves to be a bottleneck for the hospital.


Visual representation of e.g., the stop moments and the perioperative trajectory of the patient, shown as a subway line.

Multi-professional team training

The IMPROVE team facilitates contacts between the participating hospitals and organizations which provide trainings aimed at improving team culture, like crew resource management.