Outcomes of a Multicomponent Safe Surgery Intervention in Tanzania’s Lake Zone: A Prospective, Longitudinal Study

Abstract Background Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. We evaluated the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) in Tanzania, hypothesizing it would (1) increase adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) reduce the incidence of maternal sepsis, postoperative sepsis, and surgical site infection. Methods We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania’s Lake Zone, across a three-month pre-intervention period in 2018 and three-month post-intervention period in 2019. Safe Surgery 2020 is a multicomponent intervention to support four surgical quality areas: 1) leadership and teamwork, 2) evidence-based surgery, anaesthesia, and equipment sterilization practices, 3) data completeness, and 4) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10,000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or caesarean delivery), postoperative sepsis, and surgical site infections prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. Results Safety practices improved significantly by an additional 20.5% (95% CI, 7.2%-33.7%; P=.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7%-60.8%; P=.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1%-1.9%; P=.02). Documentation completeness improved by 41.8% (95% CI, 27.4%-56.1%; P<.001) for sepsis and 22.3% (95% CI, 4.7%-39.8%; P=.01) for surgical site infections. Conclusion Our findings demonstrate the benefit of the Safe Surgery 2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

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Effectiveness of a multicomponent safe surgery intervention on improving surgical quality in Tanzania’s Lake Zone: protocol for a quasi-experimental study

BMJ Open ◽

10.1136/bmjopen-2019-031800 ◽

2019 ◽

Vol 9 (10) ◽

pp. e031800 ◽

Cited By ~ 2

Author(s):

Shehnaz Alidina ◽

Salome Kuchukhidze ◽

Gopal Menon ◽

Isabelle Citron ◽

Tenzing N Lama ◽

...

Keyword(s):

Experimental Study ◽

Data Quality ◽

Surgical Site Infections ◽

Postoperative Sepsis ◽

Surgical Quality ◽

Safe Surgery ◽

Lake Zone ◽

Quasi Experimental ◽

Maternal Sepsis ◽

Prospective Longitudinal

IntroductionEffective, scalable strategies for improving surgical quality are urgently needed in low-income and middle-income countries; however, there is a dearth of evidence about what strategies are most effective. This study aims to evaluate the effectiveness of Safe Surgery 2020, a multicomponent intervention focused on strengthening five areas: leadership and teamwork, safe surgical and anaesthesia practices, sterilisation, data quality and infrastructure to improve surgical quality in Tanzania. We hypothesise that Safe Surgery 2020 will (1) increase adherence to surgical quality processes around safety, teamwork and communication and data quality in the short term and (2) reduce complications from surgical site infections, postoperative sepsis and maternal sepsis in the medium term.Methods and analysisOur design is a prospective, longitudinal, quasi-experimental study with 10 intervention and 10 control facilities in Tanzania’s Lake Zone. Participants will be surgical providers, surgical patients and postnatal inpatients at study facilities. Trained Tanzanian medical data collectors will collect data over a 3-month preintervention and postintervention period. Adherence to safety as well as teamwork and communication processes will be measured through direct observation in the operating room. Surgical site infections, postoperative sepsis and maternal sepsis will be identified prospectively through daily surveillance and completeness of their patient files, retrospectively, through the chart review. We will use difference-in-differences to analyse the impact of the Safe Surgery 2020 intervention on surgical quality processes and complications. We will use interviews with leadership and surgical team members in intervention facilities to illuminate the factors that facilitate higher performance.Ethics and disseminationThe study has received ethical approval from Harvard Medical School and Tanzania’s National Institute for Medical Research. We will report results in peer-reviewed publications and conference presentations. If effective, the Safe Surgery 2020 intervention could be a promising approach to improve surgical quality in Tanzania’s Lake Zone region and other similar contexts.

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A multimodal mentorship intervention to improve surgical quality in Tanzania’s Lake Zone: a convergent, mixed methods assessment

Human Resources for Health ◽

10.1186/s12960-021-00652-6 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Shehnaz Alidina ◽

Leopold Tibyehabwa ◽

Sakshie Sanjay Alreja ◽

David Barash ◽

Danta Bien-Aime ◽

...

Keyword(s):

Mixed Methods ◽

Quantitative Data ◽

Resistance To Change ◽

Surgical Care ◽

Comparison Method ◽

Local Context ◽

African Countries ◽

Surgical Quality ◽

Safe Surgery ◽

Lake Zone

Abstract Background Safe, high-quality surgical care in many African countries is a critical need. Challenges include availability of surgical providers, improving quality of care, and building workforce capacity. Despite growing evidence that mentoring is effective in African healthcare settings, less is known about its role in surgery. We examined a multimodal approach to mentorship as part of a safe surgery intervention (Safe Surgery 2020) to improve surgical quality. Our goal was to distill lessons for policy makers, intervention designers, and practitioners on key elements of a successful surgical mentorship program. Methods We used a convergent, mixed-methods design to examine the experiences of mentees, mentors, and facility leaders with mentorship at 10 health facilities in Tanzania’s Lake Zone. A multidisciplinary team of mentors worked with surgical providers over 17 months using in-person mentorship, telementoring, and WhatsApp. We conducted surveys, in-depth interviews, and focus groups to capture data in four categories: (1) satisfaction with mentorship; (2) perceived impact; (3) elements of a successful mentoring program; and (4) challenges to implementing mentorship. We analyzed quantitative data using frequency analysis and qualitative data using the constant comparison method. Recurrent and unifying concepts were identified through merging the qualitative and quantitative data. Results Overall, 96% of mentees experienced the intervention as positive, 88% were satisfied, and 100% supported continuing the intervention in the future. Mentees, mentors, and facility leaders perceived improvements in surgical practice, the surgical ecosystem, and in reducing postsurgical infections. Several themes related to the intervention’s success emerged: (1) the intervention’s design, including its multimodality, side-by-side mentorship, and standardization of practices; (2) the mentee–mentor relationship, including a friendly, safe, non-hierarchical, team relationship, as well as mentors’ understanding of the local context; and (3) mentorship characteristics, including non-judgmental feedback, experience, and accessibility. Challenges included resistance to change, shortage of providers, mentorship dose, and logistics. Conclusions Our study suggests a multimodal mentorship approach is promising in building the capacity of surgical providers. By distilling the experiences of the mentees, mentors, and facility leaders, our lessons provide a foundation for future efforts to establish effective surgical mentorship programs that build provider capacity and ultimately improve surgical quality.

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In-Hospital Postoperative Mortality Rates for Selected Procedures in Tanzania’s Lake Zone

World Journal of Surgery ◽

10.1007/s00268-020-05802-w ◽

2020 ◽

Vol 45 (1) ◽

pp. 41-49 ◽

Cited By ~ 1

Author(s):

Taylor Wurdeman ◽

Christopher Strader ◽

Shehnaz Alidina ◽

David Barash ◽

Isabelle Citron ◽

...

Keyword(s):

Logistic Regression ◽

Mortality Rate ◽

Postoperative Mortality ◽

Mortality Rates ◽

Post Intervention ◽

Surgical Quality ◽

Safe Surgery ◽

Lake Zone ◽

District Hospitals ◽

The Impact

Abstract Background Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania’s Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months. Methods We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania’s Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality. Results The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention. Conclusions Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.

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

BMJ Quality & Safety ◽

10.1136/bmjqs-2020-011795 ◽

2021 ◽

pp. bmjqs-2020-011795

Author(s):

Shehnaz Alidina ◽

Pritha Chatterjee ◽

Noor Zanial ◽

Sakshie Sanjay Alreja ◽

Rebecca Balira ◽

...

Keyword(s):

Low Income ◽

Collective Learning ◽

Successful Implementation ◽

Theory Approach ◽

Cultural Changes ◽

Surgical Quality ◽

Middle Income ◽

Safety Practices ◽

Middle Income Countries ◽

Safe Surgery

BackgroundEvidence 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.MethodsWe 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.ResultsPerformance 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.ConclusionFuture 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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