Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

Shehnaz Alidina, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Pritha Chatterjee, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA, Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
Noor Zanial, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Sakshie Sanjay Alreja, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Rebecca Balira, Department of Epidemiology, National Institute for Medical Research Mwanza Research Centre, Mwanza, Tanzania
David Barash, GE Foundation, Boston, Massachusetts, USA
Edwin Ernest, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Geofrey Charles Giiti, Depatment of Surgery, Bugando Consultant and Referral Hospital, Mwanza, Tanzania
Erastus Maina, Dalberg Implement, Dalberg Group, Nairobi, Kenya
Adelina Mazhiqi, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Rahma Mushi, Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
Cheri Reynolds, Department of Global Health, Assist International, Ripon, California, USA
Meaghan Sydlowski, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Florian Tinuga, Department of Health, Social Welfare and Nutrition Service, President’s Office – Regional Administration and Local Government, Dodoma, Tanzania
Sarah Maongezi, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
John G. Meara, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA, Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
Ntuli A. Kapologwe, Department of Health, Social Welfare and Nutrition Service, President’s Office – Regional Administration and Local Government, Dodoma, Tanzania
Erin Barringer, Dalberg Advisors, Dalberg Group, New York, New York, USA
Monica Cainer, Department of Global Health, Assist International, Ripon, California, USA
Isabelle Citron, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Amanda DiMeo, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Laura Fitzgerald, Safe Surgery 2020 Project, Jhpiego, Baltimore, Maryland, USA
Hiba Ghandour, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Magdalena Gruendl, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Augustino Hellar, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Desmond T. Jumbam, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Adam Katoto, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Lauren Kelly, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Steve Kisakye, Dalberg Implement, Dalberg Group, Dar es Salaam, Tanzania
Salome Kuchukhidze, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Tenzing N. Lama, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Gopal Menon, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Stella Mshana, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Chase Reynolds, Department of Global Health, Assist International, Ripon, California, USA
Hannington Segirinya, Department of Global Health, Assist International, Dar es Salaam, Tanzania
Dorcas Simba, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Victoria Smith, Department of Global Health, Assist International, Ripon, California, USA
Steven J. Staffa, Departments of Anesthesiology and Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
Christopher Strader, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
Leopold Tibyehabwa, Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
Alena Troxel, Safe Surgery 2020 Project, Jhpiego, Baltimore, Maryland, USA
John Varallo, Safe Surgery 2020 Project, Jhpiego, Baltimore, Maryland, USA
Taylor Wurdeman, Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
David Zurakowski, Departments of Anesthesiology and Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA

Document Type

Article

Publication Date

1-18-2021

Abstract

Background

Evidence on heterogeneity in outcomes of surgical quality interventions in low- income and middle- income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low- resource settings.

Methods

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

Results

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

Conclusion

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

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