Appendix A. Facility Spreadsheet for One-on-One Conversations (Word File, 2.4 MB; Text Version)
This sample spreadsheet can help track who needs to have a one-on-one conversation and which member of the implementation team is responsible for talking about each problem.
Appendix B. Your First Checklist Meeting Guide (Word File, 2.4 MB; Text Version)
This is a sample agenda with topics you should consider discussing when your implementation team meets for the first time to discuss the checklist project.
Appendix C. Addressing Physician Concerns With the Checklist (Word File, 172 KB; Text Version)
This document contains common concerns you might hear from physicians about the checklist and examples of responses you can use to address these concerns.
Appendix D. Ambulatory Surgery Center Checklist Template (Word File, 2.4 MB; Text Version)
This checklist template is based on the World Health Organization Surgical Safety Checklist and has been modified for use in ambulatory surgery centers.
Appendix F. World Health Organization Checklist Goals Document (Word File, 2.4 MB; Text Version)
Review this document with your checklist implementation team to ensure that any changes to your checklist meet the goals of the original World Health Organization Surgical Safety Checklist.
Appendix G. Training Team Members on How to Use the Checklist (Word File, 2.4 MB; Text Version)
This sheet covers necessary things to consider when teaching staff how to use the checklist as well as unique ways to train team members.
Appendix H. Tabletop Simulation Videos
Tabletop simulations are used to do dry "run-throughs" before adopting full implementation of procedures.
Appendix I. Checklist Observation Tool (Word File, 2.4 MB; Text Version)
This tool allows you to collect information regarding the processes performed in the operating room or procedure room in order to improve surgical outcomes.
Appendix J. Coaching Tool Instructions and Observation Tool With Coaching Section (PDF, 219 KB; Text Version)
This tool can help you observe teams in your operating/procedure rooms and coach them on what they did well or what they can improve.
- Material Use Guide (Word File, 982 KB; Text Version)
- Study Elements (Word File, 183 KB; Text Version)
- Debrief Example
- Blank Template (PPTX, 1.3 MB; Text Version)
Appendixes N and O. A Clear View on Flexible Endoscope Processing
These two Webinar presentations discuss the standards of scope processing jointly released in April 2015 by the American National Standards Institute and the Association for the Advancement of Medical Instrumentation.
- Appendix N. Part 1—Transport, Leak Testing, Cleaning
- Appendix O. Part 2—Disinfection/Sterilization Record Keeping
- PowerPoint Slide Set (PPTX, 1.5 MB; Text Version)
- Audio (MP3, 16.3 MB)
- Audio Transcript/Facilitator Notes (Word, 183 KB; Text Version)