Lasting impact: a qualitative study of perspectives on surgery by adult recipients of free mission-based surgical care in Benin.

OBJECTIVES: This study aimed to explore how adult patients who received free mission-based elective surgery experienced surgery and its outcomes, in order to provide recommendations for improved service delivery, measurement of impact and future quality initiatives for the humanitarian organisation Mercy Ships and other mission-based surgical platforms. SETTING: Data were collected in June 2017 in Cotonou, Benin, where the participants had previously received free mission-based elective surgery aboard the Africa Mercy, a non-governmental hospital ship. PARTICIPANTS: Sixteen patients (seven male, nine female, age range 22-71, mean age 43.25) who had previously received surgical care aboard the Africa Mercy hospital ship between September 2016 and May 2017 participated in the study. METHODS: Using a qualitative design, 16 individual semistructured interviews were conducted with the assistance of two interpreters. Participants were recruited using purposive sampling from the Mercy Ships patient database. Interview data were coded and organised into themes and subthemes using thematic content analysis in an interpretivist approach. FINDINGS: Analysis of interview data revealed three main themes: barriers to surgery, experiences with Mercy Ships and changes in perspectives of surgery after their experiences. Key findings included barriers to local surgical provision such as cost, a noteworthy amount of fear and distrust of local surgical teams, exceptional positive experiences with the care at Mercy Ships, and impactful surgery, resulting in high levels of trust in foreign surgical teams. CONCLUSIONS: While foreign surgical teams are meeting an immediate need for surgical care, the potential enduring legacy is one of trusting only foreigners for surgery. Patients are a critical component to a well-functioning surgical system, and mission-based surgical providers must formulate strategies to mitigate this legacy while strengthening the local surgical system.

A Mixed-Method Design Evaluation of the SAFE Obstetric Anaesthesia Course at 4 and 12-18 Months After Training in the Republic of Congo and Madagascar.

BACKGROUND: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12-18 months after SAFE-OB courses in Madagascar and the Republic of Congo. METHODS: We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12-18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12-18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12-18 months. RESULTS: At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12-18 months: neonatal resuscitation and airway management. At 12-18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12-18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12-18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change. CONCLUSIONS: Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12-18 months.

Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar.

BACKGROUND: The 2009 World Health Organisation (WHO) surgical safety checklist significantly reduces surgical mortality and morbidity (up to 47%). Yet in 2016, only 25% of East African anesthetists regularly use the checklist. Nationwide implementation of the checklist is reported in high-income countries, but in low- and middle-income countries (LMICs) reports of successful implementations are sparse, limited to single institutions and require intensive support. Since checklist use leads to the biggest improvements in outcomes in LMICs, methods of wide-scale implementation are needed. We hypothesized that, using a three-day course, successful wide-scale implementation of the checklist could be achieved, as measured by at least 50% compliance with six basic safety processes at three to four months. We also aimed to determine predictors for checklist utilization. MATERIALS AND METHODS: Using a blended educational implementation strategy based on prior pilot studies we designed a three-day dynamic educational course to facilitate widespread implementation of the WHO checklist. The course utilized lectures, film, small group breakouts, participant feedback and simulation to teach the knowledge, skills and behavior changes needed to implement the checklist. In collaboration with the Ministry of Health and local hospital leadership, the course was delivered to 427 multi-disciplinary staff at 21 hospitals located in 19 of 22 regions of Madagascar between September 2015 and March 2016. We evaluated implementation at three to four months using questionnaires (with a 5-point Likert scale) and focus groups. Multivariate linear regression was used to test predictors of checklist utilization. RESULTS: At three to four months, 65% of respondents reported always using the checklist, with another 13% using it in part. Participant's years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with counting instruments (p< 0.05), but not with verifying: patient identity, difficult intubation risk, risk of blood loss, prophylactic antibiotic administration, or counting needles and sponges. CONCLUSION: Use of a multi-disciplinary three-day course for checklist implementation resulted in 78% of participants using the checklist, at three months; and an increase in counting surgical instruments. Successful checklist implementation was not predicted by participant length of medical service, hospital size or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Overcoming challenges in implementing the WHO Surgical Safety Checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar.

The WHO Surgical Safety Checklist was launched in 2009, and appropriate use reduces mortality, surgical site infections and complications after surgery by up to 50%. Implementation across low-income and middle-income countries has been slow; published evidence is restricted to reports from a few single institutions, and significant challenges to successful implementation have been identified and presented. The Mercy Ships Medical Capacity Building team developed a multidisciplinary 3-day Surgical Safety Checklist training programme designed for rapid wide-scale implementation in all regional referral hospitals in Madagascar. Particular attention was given to addressing previously reported challenges to implementation. We taught 427 participants in 21 hospitals; at 3-4 months postcourse, we collected surveys from 183 participants in 20 hospitals and conducted one focus group per hospital. We used a concurrent embedded approach in this mixed-methods design to evaluate participants' experiences and behavioural change as a result of the training programme. Quantitative and qualitative data were analysed using descriptive statistics and inductive thematic analysis, respectively. This analysis paper describes our field experiences and aims to report participants' responses to the training course, identify further challenges to implementation and describe the lessons learnt. Recommendations are given for stakeholders seeking widespread rapid scale up of quality improvement initiatives to promote surgical safety worldwide.

Interval follow up of a 4-day pilot program to implement the WHO surgical safety checklist at a Congolese hospital.

BACKGROUND: The World Health Organisation Surgical Safety Checklist (SSC) improves surgical outcomes and the research question is no longer 'does the SSC work?' but, 'how to make the SSC work?' Evidence for implementation strategies in low-income countries is sparse and existing strategies are heavily based on long-term external support. Short but effective implementation programs are required if widespread scale up is to be achieved. We designed and delivered a four-day pilot SSC training course at a single hospital centre in the Republic of Congo, and evaluated the implementation after one year. We hypothesised that participants would still be using the checklist over 50% of the time. METHOD: We taught the four-day SSC training course at Dolisie hospital in February 2014, and undertook a mixed methods impact evaluation based on the Kirkpatrick model in May 2015. SSC implementation was evaluated using self-reported questionnaire with a 3 point Likert scale to assess six key process measures. Learning, behaviour, organisational change and facilitators and inhibitors to change were evaluated with questionnaires, interviews and focus group discussion. RESULTS: Seventeen individuals participated in the training and seven (40%) were available for impact evaluation at 15 months. No participant had used the SSC prior to training. Over half the participants were following the six processes measures always or most of the time: confirmation of patient identity and the surgical procedure (57%), assessment of difficult intubation risk (72%), assessment of the risk of major blood loss (86%), antibiotic prophylaxis given before skin incision (86%), use of a pulse oximeter (86%), and counting sponges and instruments (71%). All participants reported positive improvements in teamwork, organisation and safe anesthesia. Most participants reported they worked in helpful, supportive and respectful atmosphere; and could speak up if they saw something that might harm a patient. However, less than half felt able to challenge those in authority. CONCLUSION: Our study demonstrates that a 4-day pilot course for SSC implementation resulted in over 50% of participants using the SSC at 15 months, positive changes in learning, behaviour and organisational change, but less impact on hierarchical culture. The next step is to test our novel implementation strategy in a larger hospital setting.

An Observational Assessment of Anesthesia Capacity in Madagascar as a Prerequisite to the Development of a National Surgical Plan.

BACKGROUND: The global lack of anesthesia capacity is well described, but country-specific data are needed to provide country-specific solutions. We aimed to assess anesthesia capacity in Madagascar as part of the development of a Ministry of Health national surgical plan. METHODS: As part of a nationwide surgical safety quality improvement project, we surveyed 19 of 22 regional hospitals, representing surgical facilities caring for 75% of the total population. The assessment was divided into 3 areas: anesthesia workforce density, infrastructure and equipment, and medications. Data were obtained by semistructured interviews with Ministry of Health officials, hospital directors, technical directors, statisticians, pharmacists, and anesthesia providers and through on-site observations. Interview questions were adapted from the World Health Organization Situational Analysis Tool and the World Federation of Societies of Anaesthesiologists International Standards for Safe Practice of Anaesthesia. Additional data on workforce density were collected from the 3 remaining regions so that workforce density data are representative of all 22 regions. RESULTS: Anesthesia physician workforce density is 0.26 per 100,000 population and 0.19 per 100,000 outside of the capital region. Less than 50% of hospitals surveyed reported having a reliable electricity and oxygen supply. The majority of anesthesia providers work without pulse oximetry (52%) or a functioning vaporizer (52%). All the hospitals surveyed had very basic pediatric supplies, and none had a pediatric pulse oximetry probe. Ketamine is universally available but more than 50% of hospitals lack access to opioids. None of the 19 regional hospitals surveyed was able to completely meet the World Federation of Societies of Anaesthesiologists' standards for monitoring. CONCLUSIONS: Improving anesthesia care is complex. Capacity assessment is a first step that would enable progress to be tracked against specific targets. In Madagascar, scale-up of the anesthesia workforce, investment in infrastructure and equipment, and improvement in medication supply-chain management are needed to attain minimal international standards. Data from this study were presented to the Ministry of Health for inclusion in the development of a national surgical plan, together with recommendations for the needed improvements in the delivery of anesthesia.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. METHOD: Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. RESULTS: In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. CONCLUSION: Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.