Adherence to known practice standards is a hallmark of high-quality health organizations; yet, similar to what is found in primary care and general practice settings, surgical delivery in HICs and LMICs alike frequently fails to follow standards of care, despite well-described strategies and techniques for improvement.
Surgical site infections in women and their association with clinical conditions
In addition to the risks during surgery, patients are at high risk during postoperative recovery. The two most common causes of complications within the first week of surgery are bleeding and infections. Additional causes of delayed morbidities include blood clots, heart attacks, pneumonia, and stroke. Anticipating potential complications, and either preventing them for example, by prophylaxis for venous thromboembolism or identifying the signs and symptoms and intervening early and aggressively, are essential to reduce these risks.
An important study established the prominent role of a mature system of postoperative care in managing complications and preventing them from resulting in death also known as failure to rescue. Ghaferi, Birkmeyer, and Dimick a , b found that although baseline complications rates were strikingly similar in institutions across the United States, mortality rates following these complications varied dramatically figure These findings confirm earlier research suggesting that the primary difference in outcomes among hospitals is not due to differences in complication rates but to differences in the rates of failure to rescue Silber and others Further research has demonstrated that higher-volume hospitals appear to have a better ability to recognize, intervene, and save patients undergoing high-risk procedures from death and complications following surgery Ghaferi, Birkmeyer, and Dimick Complications must be anticipated following high-risk procedures; the ability to recognize, diagnose, and treat complications separates the high performers from the poor performers.
The quality of communication and the systems of care, and the skills and capacity of ancillary services—such as availability of intensive care and the presence and experience of specialized services—appear to be important factors for improving outcomes following complications. Several effective strategies have been identified for improving surgical outcomes in LMICs.
These strategies include the adoption and use of basic technologies, the development of monitoring standards, and the use of surgical safety checklists. Organizational and management strategies also appear to be important. Essential to all of these interventions is a mandate to measure the delivery of care and its impact on health.
These low-cost interventions, which can dramatically lower postsurgical mortality rates, demand prioritization by health systems seeking to improve access and surgical service provision.
One of the most important contributions to improved surgical safety has been the development of basic standards of anesthetic monitoring. The Harvard monitoring standards for intraoperative anesthesia care formalized a set of medical standards of practice that have become de facto international standards endorsed by the World Federation of Societies of Anaesthesiologists Eichhorn and others ; WFSA The standards include the continuous presence of trained anesthesia providers and the uninterrupted monitoring of oxygenation, ventilation, and perfusion. Today, adherence to these standards in HICs is essentially universal; however, this was not the case a mere three decades ago, and it is far from standard practice in many LMICs.
In addition to continuous monitoring techniques, anesthesia delivery systems have been standardized, with safety engineered into the instruments themselves. Inhalational anesthetic machines are now engineered to be redundant; safety features, such as auto-lock mechanisms, prevent lethal hypoxic gas mixtures.
Despite the fold plunge in anesthetic-related mortality rates in HICs and UMICs during the past 40 years, anesthetic mortality in LMICs is a major problem due to lack of professional stature, training, and credentialing of anesthesia providers; deficiencies in basic monitoring equipment; and failure to adhere to strict standards of care. One critical mechanism for anesthesia monitoring is the use of pulse oximetry.
Although the continuous monitoring of blood oxygen levels using a pulse oximeter is considered an essential standard, more than 77, operating rooms worldwide do not have this basic monitoring device Funk and others Pulse oximetry can alert anesthesia personnel to drops in oxygenation before clinical signs become apparent, allowing for corrective actions before hemodynamic instability or lethal arrhythmias occur.
In Moldova, an implementation program supplying pulse oximetry equipment in conjunction with provider training on the use of a surgical safety checklist reduced postoperative deaths and complications Kwok and others Standardization of care is essential because of the tremendous magnitude of interactions and care processes that occur during even simple surgical procedures.
Complex patient characteristics, therapeutic options, technical demands, and team dynamics require specific strategies for organizing care protocols and service delivery. The effective use of checklists by teams during surgery has cut mortality rates by up to 50 percent. In , the WHO codified a set of basic surgical standards into guidelines for safe surgery. Researchers transformed these guidelines into a simple, item checklist to be used during the perioperative period and conducted a multicenter trial assessing the efficacy of this safety tool on postoperative morbidity and mortality figure In a pre- and postanalysis of nearly 8, surgical patients, use of this checklist nearly doubled adherence to basic perioperative safety standards, including confirmation of the procedure and operative site, administration of antibiotics, use of pulse oximetry for monitoring, objective airway assessment, and completion of instrument and sponge counts at the conclusion of the operation.
Use of the checklist reduced deaths by more than 47 percent and cut complication rates by 35 percent Haynes and others This beneficial effect was maintained in a subanalysis of urgent and emergency cases Weiser, Haynes, Dziekan, and others Several other large, well-designed studies have confirmed the substantial enhancements to surgical safety that checklists provide. Following the introduction of a comprehensive perioperative checklist in six hospitals in the Netherlands, postoperative complications and deaths dropped by 30 percent and 47 percent, respectively; in five control hospitals, no improvements were noted during the same period de Vries and others A second study in the Netherlands virtually repeated the original multinational WHO investigation, demonstrating improvements in postoperative mortality that strongly correlated with checklist compliance van Klei and others These processes are particularly important in the complex and multidisciplinary environment of surgery.
Checklists are often a critical part of crew resource management, a method of team training that promotes shared mental models for care and conduct that has been implemented in many organizations and sectors in which high reliability and fidelity are paramount, such as aviation and nuclear power. This method has been extended to surgical teams; it has been observed, for example, that cardiac surgery teams that consistently work together are more efficient and have better outcomes than those with rotating members Carthey, de Leval, and Reason ; de Leval and others Because this method is often not possible in urgent circumstances or when human resources are limited, checklists can play an essential role in promoting consistent processes of care.
A study conducted at 74 Veterans Administration hospitals in the United States demonstrated significant improvements in mortality compared to controls following a full-day team training program that included implementation and training in the use of checklist-guided briefings and debriefings Neily and others Checklists have become an established standard of surgical care globally Birkmeyer Their effectiveness has demonstrated the accuracy of previous estimates suggesting that at least 50 percent of existing surgical mortality is preventable.
Checklists are most effective when they are implemented, not as a tickbox exercise, but as a means to reinforce communication, prompt genuine dialogue and discussion of critical information, and facilitate prospective feedback and quality improvement Weiser, Haynes, Lashoher, and others Large-scale regulatory mandates alone appear not to be effective in fostering effective adoption Urbach and others Implementation has been found to require local champions from all disciplines, support from leadership, monitoring of progress, and involvement of frontline clinicians such as through team training and not just administrators.
Such an approach has been followed in Scotland, leading to a statistically significant drop in inpatient surgical death rates from after three years of flat mortality rates. The Scottish government has documented more than 9, lives saved Leitch The challenge of conducting multidisciplinary implementation programs in LMICs raises legitimate concerns about ability to scale up such programs globally.
However, a follow-up WHO study in Honduras, Moldova, and Zambia confirms the ability to implement and replicate large improvements in safety and outcomes Kim and others Effective and efficient management strategies are an essential component in the smooth functioning of health facilities. Numerous econometric studies have looked at management practices in industry and business and identified characteristics that affect productivity.
Two economists from Stanford University and the London School of Economics conducted a series of interviews with midlevel managers from a range of medium-sized manufacturing firms in France, Germany, the United Kingdom, and the United States, using a survey to assess four domains of management: operations, monitoring, targets, and incentives Bloom and van Reenen High scores in these domains were strongly related to higher productivity and profitability, as well as to the longevity of the company.
In LMICs, however, multiple factors affect the performance of industry, particularly for the worse. Management practices are suboptimal for various reasons, including lack of knowledge of optimal management practices, reduced competition, high proportion of family ownership, lack of delegation of decision making because of fear or mistrust, reduced incentives, and poorly allocated financing. Bloom and van Reenen and Bloom and others note that similarly sized local firms in LMICs were severely lacking in management practices, with correspondingly lower overall productivity.
Although economic environments and organizational factors played a role Bloom, Sadun, and van Reenen , introducing management practices through an intensive consulting process resulted in massive improvements in efficiency and productivity Bloom and others ; Bloom and others In health care, the management practices evaluated by Bloom and van Reenen roughly translate to operations management, quality evaluation, goal-setting, and talent management.
Their scoring mechanism has been used to evaluate hospital management practices and its subsequent correlation with patient outcomes across Brazil, Europe, India, and the United States. They find tremendous variability in management practices within countries, as well as a particularly large proportion of poorly managed hospitals in LMICs.
Although there is a paucity of research in the area of hospital management in LMICs, it is reasonable to infer that management practices affect the organizational structure, efficiency, and even safety of the health system. In one of the first studies of this kind, Funk and others suggest that more robust management practices are associated with enhanced surgical productivity.
Unfortunately, many first-level rural and urban referral hospitals in LMICS are likely to be plagued by poor management practices similar to their business and manufacturing counterparts. Such problems lead to waste and poor resource allocation, and potentially even to fraud and abuse. It remains to be seen whether improvements in management translate into improved surgical productivity in these settings and, if so, the mechanisms by which such improvements occur. One essential mechanism that management uses to enhance the quality of care is the implementation of surveillance and evaluation practices, allowing quality improvement QI programs to be targeted to identified weaknesses.
Often, the effectiveness of these efforts could be increased by simple measures, such as better recording of problems discussed, more purposeful enactment of corrective action, and monitoring of the outcome of the corrective action. A WHO review of the effectiveness of QI programs for trauma care identifies 36 studies, 34 of which report improvements in patient outcomes including mortality or process of care after a new QI program or method is introduced Juillard and others Two articles report no change, and no articles report a worsening of any outcome; five articles also report cost savings.
Most of the articles were from HICs; two were from Thailand. A summary of the model QI program in Thailand is provided in chapter 3 on trauma care in this volume.
The WHO has outlined a multimodal approach to QI processes for trauma systems through the use of morbidity and mortality, preventable death panel reviews, audit filters, and the establishment of trauma data bases and surveillance systems WHO a. The measurement of outcomes of intervention, regardless of the service provided, is essential to ensure that the effects of care are aligned with intent and that resources are used efficiently, effectively, and with the least harm to patients.
Practitioners, facilities, and health systems require information on surgical capacity, throughput, and results to determine how such service lines perform. Other notable public health successes, such as improvements in maternal and neonatal health, HIV care, and control of poliomyelitis and malaria, have been dependent on surveillance Ceesay and others ; Ronsmans and Graham ; WHO , , Surveillance is equally essential in optimizing access to and the safety of surgical care; the absence of data on surgical delivery and outcomes perpetuates the neglect such therapy receives in resource-constrained settings Weiser and others , The WHO has proposed a set of standardized metrics for surgical surveillance at the national level that have been tested and validated WHO d , and is included in annex 16B.
These metrics include the number of operating rooms in each country, the numbers of trained surgeons and trained anesthetists in each country, the number of procedures performed in operating rooms in each country, the number of deaths on the day of surgery, and the number of in-hospital deaths after surgery Weiser and others table Although each of these metrics has important weaknesses that must be acknowledged, all can be obtained and reported in a straightforward manner. National-level metrics nonetheless require the interest, investment, and commitment of the central government or agency responsible for collecting, analyzing, and disseminating such information.
Local efforts at QI should not be limited to crude, population-level data collected to measure health system performance. Several basic metrics must be adopted by facilities and health systems to improve the quality and delivery of care table These could include the following:. One of the issues of greatest concern is the misuse of such metrics to deny care to the most frail and vulnerable populations. Health systems that manipulate their outcomes by increasing inappropriate services, failing to intervene, and underreporting mortality succumb to perverse, negative incentives that divert essential resources and inhibit care for the sickest patients.
Under ideal circumstances, surgical statistics should help health systems improve the delivery and safety of surgical care by creating benchmarks for improvement rather than being used for punishment or comparison across fundamentally different organizations, environments, and populations WHO b. Attempts at comparisons across systems, countries, and health settings ignore variations in patient condition and complexity of procedure. Hospitals and health systems that wish to evaluate differences between facilities and practitioners must account for the characteristics of the patients, case mix, and urgency—all of which require robust and sophisticated data collection that is frequently beyond the capacity of overworked or underfinanced health systems.
Services on Demand
Any complete discussion of quality clearly encompasses more than simple measures of mortality and complications. Important outcomes also include, among others, the nuanced measures of functional recovery, control of pain, and satisfaction with care. While meaningful, these issues are beyond the scope of this chapter, as are the potentially important strategies for improving surgical capacity through the use of physician extenders and task sharing, and the aggregation and centralization of cases to take advantage of volume-outcome relationships.
Much work is needed to strengthen surgical systems of care, and the investments are likely to be considerable.
Given the barriers to access and delivery of needed surgical services, investments are necessary at the facility and institutional level, as well as for the progressive financing of health protection and communication and transportation infrastructure. Improving anesthetic monitoring and safety, implementing surgical checklists, refining management practices, and instituting measurement and surveillance techniques could dramatically improve care within existing health systems. However, designing, implementing, and scaling these interventions in LMICs will take considerable resources because each strategy for improvement requires training, infrastructure, an information management system, and political will.
Even though little is currently known about the actual investment and recurrent costs of introducing and scaling up these strategies, they are likely to be highly cost-effective. To avoid premature death, disability, and suffering from the time of birth through adulthood, most human beings require surgical care at some point in their lives. Strategies to increase access to surgical care, however, must also increase the safety and quality of care.
Profound consequences, including massively high rates of disability and death, ensue when health systems neglect to use strategies known to improve surgical safety.