Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

Abstract

Objectives

To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning.

Design

We conducted a systematic literature review and narrative synthesis.

Setting

Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021.

Participants

MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched.

Intervention

We extracted data on intervention characteristics and how the intervention was delivered and evaluated.

Primary and secondary outcome measures

Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed.

Results

Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains.

Conclusions

There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected.

PROSPERO registration number

CRD42019125570

Correspondence to Mrs Nataliya Brima; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Our review includes hospital-based quality improvement interventional studies for anaesthesia and all surgical specialities in sub-Saharan Africa.

• Clinical, process and implementation outcomes are captured.

• An assessment of quality domains was undertaken.

• Our search was restricted to English-language articles only and it is possible that our findings have missed studies published from Francophone, Portuguese or German-speaking countries.

• It is possible that some studies were missed due to the diversity of the terms used in the literature.

Introduction

The ‘Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era’ report has highlighted that it will not be possible to reduce excess mortality and disability without addressing poor quality of healthcare in low-income and middle-income countries (LMICs).¹ In these settings, more than 5 million excess deaths per year are attributed to poor-quality care, leading to estimated economic welfare losses of $6 trillion.² In addition, two-thirds of the estimated 23 million disability-adjusted life-years lost each year due to in-hospital adverse events, reflective of poor quality, occur in LMICs, despite lower utilisation of healthcare facilities.³

In sub-Saharan Africa (SSA), an estimated 93% of the population do not have access to safe, affordable and timely surgical and anaesthesia care, when needed.⁴ Current evidence suggests that mortality in surgical patients in Africa is two times higher than the global average, despite patients being younger, having a lower-risk profile and developing fewer complications.⁵ Morbidity in surgical patients is also higher and the risk of surgical site infections (SSIs), the most common type of healthcare-associated infection in African surgical patients, is much higher than that reported in USA and Europe.^{5 6}

To achieve reduction in mortality and morbidity from surgical diseases, consistent delivery of high-quality evidenced-based surgical care is required.^{1 4 7 8} This need can be partly addressed through evidence-based hospital-level quality improvement (QI) interventions.⁸ However, health systems are complex and adaptive and can respond in predictable and unpredictable ways to interventions,^{8 9} and thus translating and implementing evidenced-based QI interventions into routine clinical practice within a particular context, in dynamic and diverging ‘real-world’ conditions that are influenced by human relationships and behaviours, remains challenging worldwide^{10 11} and is particularly challenging in the SSA context.^{10 12}

To support the implementation and sustainable integration of evidence-based QI interventions in novel settings within complex surgical care environments, the use of QI methods^13–16 and implementation science methods^{17 18} needs to be expanded. Improvement science is the scientific approach to achieving better patient experience and outcomes through changing provider behaviour and organisation, using systematic change methods and strategies. Implementation science is the scientific study of methods to promote the uptake of research findings into routine healthcare—practice or policy. Studying QI implementation will allow researchers to distinguish between failure occurring because the intervention was ineffective (intervention failure), from failure occurring because the implementation was ineffective (implementation failure). It will also ensure quality and rigour of the evaluation of implementation process.¹⁷ However, improvement and implementation science methods are rarely employed in LMIC settings, and other investigators have noted that QI methods should be used more widely.¹² In addition, implementation science frameworks¹⁸ should be applied, implementation strategies used¹⁹ and implementation outcomes measured²⁰ to assess the effectiveness of the implementation of any intervention.

Quality is a complex construct and challenging to define. The Institute of Medicine (IOM) defines quality of care as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’.²¹ In 2001, the IOM, defined the desirable characteristics of high-quality healthcare systems, through six domains of safe, timely, effective, efficient, equitable and patient centred care,²² expanding the Donabedian model that described quality of care across three domains—structures, processes and outcomes of care.²³ Evaluating the IOM quality domains can improve the evaluation of QI interventions, beyond that of clinical effectiveness.^{1 22}

To support the current research agenda for improving quality of surgical care in LMICs, we conducted a systematic review on hospital-based QI interventions in SSA, published from 2008 to 2021. The objectives of this review were to describe the state of QI research and programmatic initiatives in surgical and anaesthesia care, to understand the areas of intervention focus and the use of QI or implementation methodologies, to capture the outcomes studied and to identify the IOM quality domains that were addressed in the studies.

Methods

Design

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.²⁴ The study was registered with PROSPERO (CRD42019125570) and the protocol was published.²⁵

Eligibility criteria

The inclusion eligibility criteria as published in the protocol²⁵ are displayed in table 1.

Table 1

Inclusion and exclusion criteria

	Include	Exclude
Type of article	All peer-reviewed research articles Non-research reports from national or international health organisations, dissertations/theses, books/book chapters, conference abstracts and research in progress from grey literature	Unstructured reviews or overviews, theoretical papers, commentaries or opinion papers, Case studies, audits, editorials/ letters/comments, newspapers/trade journals, literature reviews Guidelines, strategies and policies from national or international health organisations
Type of conditions	Any surgical and anaesthesia care (operative or non-operative); type of presentation (elective or emergency); subspecialty surgical or anaesthesia care (including perioperative medicine and pain management)	*Trauma/injury care Studies on cosmetic and aesthetic surgical care and sports medicine
Type of population	Population with specific surgical diseases or conditions Adults, neonatal and children’s surgery	Non-human animals
Care setting	Hospital setting, within SSA countries	Studies that are not conducted in hospital-based settings. Studies that took place outside of SSA
Type of design	Interventional studies†98 that report an assessment of any outcomes relevant to quality improvement‡	Observational or descriptive studies Studies that report outcomes that are not relevant to quality improvement
Subject of study	Quality improvement of surgical care in following areas§ Service delivery Health Workforce Information Financing Leadership/governance	Studies that did not assess outcomes. Medical device production and new clinical technological devices Introduction of new procedures Medical products, vaccines and technologies

*Studies related to trauma/injury were excluded from this review, as there was another review undertaken at the same time looking specifically at trauma care in LMICs.

†Interventional studies are specifically tailored to evaluate direct impacts of treatment or preventive measures on disease and are those where the researcher intervenes at some point throughout the study.

‡Quality improvement is defined as any actions or strategies taken to improve the quality of healthcare delivery or patient outcomes that directly or indirectly involves care delivery to patients or by staff.

§WHO Health System building blocks related to the delivery processes of surgical care (‘Medical products, vaccines and technologies’ block was excluded as it is considered to be primarily related to the structural aspects of the health system as opposed to the healthcare service delivery processes).

LMICs, low-income and middle-income countries; SSA, sub-Saharan Africa.

Search strategy

The following databases were searched from 1 January 2008 to 31 December 2021²⁶: MEDLINE (Ovid), EMBASE (Ovid), Global Health (Ovid), CINAHL and Web of Science (Clarivate Analytics). The search strings for this review were as follows: (1) surgical and anaesthesia care, (2) QI hospital-based interventions and (3) SSA countries.²⁵ Our search was limited to studies published in English. The articles identified through all sources as described above, were collated and deduplicated in EndNote 20.²⁷

To identify grey literature QI interventions, the following sources were searched: (1) the Scopus (Elsevier’s) citation database, (2) first 50 hits from Google search, (3) documentation and reports of relevant national and international health organisations.^{25 28} In addition, a reference list of all included articles was handsearched and all relevant literature was included.

Study selection

To identify articles that specifically addressed the quality of surgical and anaesthesia care at the hospital level, we excluded articles that were primarily related to improving access to surgical care, rather than the quality of surgical care. For example, studies on increasing surgical volume or referral processes from community and primary care to secondary and tertiary care were excluded as they focus on improving access to care as opposed to quality of care provided. In addition, we excluded studies with a primary focus on delivery of educational/training programmes (basic surgical/anaesthesia skills, essential emergency care training) that were not part of a hospital-based QI intervention, and studies that did not explicitly relate to surgical patients.

All articles were initially screened by a team of three reviewers (IOM-B, HS and VC) by title and abstract using Rayyan open web-based software.²⁹ All reviewers were trained by the first author (NB) on how to apply eligibility criteria and were asked to screen 30 articles using these criteria. These articles were reviewed by NB before the team (all three reviewers and NB) met to discuss and resolve any discrepancies identified. This process was repeated by reviewing a further set of 30 articles, until agreement over 85% was reached for all reviewers. All articles were then put back into the main pool and equally divided between reviewers who screened the articles by title and abstract independently. To maintain a high level of consistency, NB double screened at least 30% of all articles that were allocated to each reviewer throughout this screening stage. Articles proceeded to full-text screening if there was uncertainty between the reviewers about their inclusion based on title and abstract review. All articles selected for full text screening were reviewed in duplicate by NB and IOM-B. If there was disagreement between the two reviewers, the two senior coauthors (AJML and JD) were asked to discuss and reach consensus on inclusion or exclusion.

Data extraction

All information was extracted into a predeveloped data collection form, that was piloted and revised before entering the data.²⁵

Data extracted were:

• Basic characteristics—information on first author, the country or countries where studies took place, year of publication, information on study methodology, study design, sample size.

  Study methods were initially categorised as qualitative, quantitative or mixed methodology, and further as a randomised design (eg, randomised controlled trial (RCT)) or non-randomised design (quasi-experimental with time series design, quasi-experimental with control group before and after or quasi-experimental uncontrolled before–after study). The latter order represents the hierarchy of methodological strength.³⁰

• Intervention characteristics were as follows: study summary, intervention focus, intervention description, number of hospitals included in the study and hospital level (tertiary or district), whether QI or implementation science methods were used, IOM quality domains that the intervention intended to improve and defined as:

  • Safe: Care in healthcare facility should be safe as care in your home.

  • Timely: No waits or delays during care delivery.

  • Effective: Care should be science based and evidence based.

  • Efficient: Care that delivered and services provided should be cost-effective.

  • Equitable: There should be no disparities in care for different type of population (patient and staff).

  • Patient centred: Healthcare system should revolve around patients.

• Outcomes were captured as clinical, process, implementation and others. Clinical outcomes were in-hospital perioperative mortality within 30 days and morbidity (SSI, other infections); any additional clinical outcomes that did not fit in one of those categories were listed as ‘other’. Process outcomes were variables related to the delivery of care (eg, waiting times, length of hospital stay and blood availability). Implementation outcomes were the implementation outcomes described by Proctor et al²⁰ that determine the success of an implementation effort by assessment of several subjective and objective criteria including the following:

  • Acceptability: perception among stakeholders that the new intervention is agreeable.

  • Adoption: intention to apply new intervention.

  • Appropriateness: perceived relevance of the intervention for the setting and problem.

  • Feasibility: extent to which an intervention can be applied.

  • Fidelity: the proportion of management protocol components completed as intended.

  • Penetration: the proportion of eligible patients who actually receive the intervention.

  • Cost: costs of the intervention, including the delivery strategy.

  • Sustainability: extent to which a new intervention becomes routinely available/is maintained post introduction.

For the studies that defined mortality as the primary outcome, the assessment of the quality of evidence using GRADE criteria was planned (see the protocol for full details).²⁵

The quality of study conduct, trustworthiness of findings and the risk of bias assessment was not our primary aim.

Data synthesis and analysis

A descriptive and narrative synthesis of the data was undertaken.³¹ Meta-analysis was not possible, due to high heterogenicity of the data reported in the included studies. All data are reported as categorical variables, apart from brief description of the intervention that was given as a narrative summary. The number of studies reported over time was presented graphically. The results are described as the number of studies that were categorised under outcomes as described above.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination of our research.

Results

Study selection

After duplicate removal, we screened 1573 articles (figure 1). We included 49 articles in the final analysis. The 49 articles represent 39 studies as 4 studies^32–39 had 2 articles published and 2 studies^40–45 had 3 articles published. These articles reported different aspects or outcomes of the studies, therefore, were included as separate articles.

Figure 1. PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Basic characteristics

The studies were conducted in 17 out of 48 countries in sSA. All but one (16/17, 93.3%) were low-income-level or lower-middle-income-level countries (figure 2). Almost two-thirds of the studies were conducted in East Africa (31/49, 63.2%), mostly (24/31, 77.4%) in Ethiopia, Kenya, Tanzania and Uganda. A quarter of eligible articles were from West Africa (12/49, 24.5%) with 5/12 (41.7%) from Nigeria and 4/12 (33.3%) from Benin. The four articles in the Southern Africa region (4/49, 8.2%) were all conducted in South Africa. Only two studies were from the Central Africa region (2/49, 4.1%). There was a multicountry study which was conducted in four countries involving Kenya, Uganda, Zambia and Zimbabwe.⁴⁶

Figure 2. Sub-Saharan African countries featured in the systematic review.

Over time there was an increase in the number of published studies on QI. (figure 3)

Figure 3. Number of publications by year and linear trend over time with dates of seminal implementation science publications. 19 20 91-93

The majority of studies used quantitative methods (34/49, 69.4%) while over a quarter (15/49 30.6%) used a mixed-method analysis. Six out of 49 (12.2%) studies were RCTs and 43 (87.8%) studies used quasi-experimental designs.³⁰ Three out of 43 studies with quasi-experimental designs used time series quasi-experimental design (3/43, 7.0%). The majority of studies (40/43, 93.0%) used either uncontrolled or controlled before-and-after quasi-experimental design. Only 11 studies defined a sample size using statistical sample size calculation (11/49, 22.5%), the remaining (38/49, 77.6%) used a convenience sampling technique, with wide variability of sample sizes ranging from 31 to over 3000 patients. Eleven out of 49 studies (22.5 %) did not perform any formal statistical tests with many studies reporting descriptive findings as percentages only.

Intervention characteristics

The most common intervention foci were use of a surgical safety checklist (14/49, 28.6%) and reduction of SSI (12/49, 24.5%). Other intervention foci identified included: behaviour change, clinical decision making, some condition-specific areas, enhanced recovery after surgery, infection prevention control (IPC), quality of life (QoL) and pain management. More details and summary description of these interventions is presented in table 2. Most studies were conducted in a single hospital site (27/49, 55.1%) in a variety of tertiary (23/27, 85.2%) and district (4/27, 14.8%) hospital settings. Studies done in multiple hospitals (22/49, 44.9%) were conducted in tertiary (8/22, 36.4%), mixed (11/22, 50.0%) or not specified (3/22, 13.6%) hospital settings. Studies across multiple sites were conducted in 2–36 hospital sites, half (11/22) of which were performed in 10 or fewer hospitals and 5/22 (22.7%) were conducted in between 10 and 20 hospitals (>10 to ≤20) hospitals and the remaining 6/22 (27.3%) in over 20 hospitals (full distribution is presented in online supplemental appendix 1). Only eight articles mentioned the use of QI methods. Five of these studies used Plan–Do–Study–Act cycles,^{37 38 43 44 47} one used QI collaboratives,⁴⁸ and two used audit and feedback as the QI method.^{49 50} Use of implementation science frameworks was rare with only two studies using frameworks to support intervention implementation and the evaluation of implementation.^{51 52}

Table 2

Intervention characteristics, N=49

Characteristics	Grouping
Intervention focus	Intervention description	Counts, N=49
Behaviour change	Implementation of an interdisciplinary surgical non-technical skills training programme99	1
Clinical decision-making	Reduction of caesarean section rates59	1
Condition specific	Gastroschisis care protocol for neonatal surgery53 Gastrointestinal surgical critical care service for emergency patients100	2
Enhance recovery after surgery	Elective surgery101 Emergency surgery60	2
Hospital electronic record database	Surgical adverse events/surgical in-patient data recording61 62 Multicentre cloud-based perioperative register50	3
Hospital leadership	Continuous quality improvement/assurance programmes34 35	2
Infection Prevention Control	Equipment sterilising63 64perioperative antibiotic prophylaxis65	2 1
WHO Safe Surgery 2020	Multicomponent safe surgery intervention38	1
Pain management	Pain guideline48 Postoperative pain round66 Analgesic dosing67	3
Patient communication	Preoperative counselling102	1
Preoperative optimisation	Control of hypertension presurgery68	1
QoL	Patient education and physiotherapy to improve outcomes of obstetric fistula surgery36 37 47	3
Reduction of SSIs	Perioperative antibiotic prophylaxis32 69–72	5
	Surveillance of SSI33 45	2
	Surgical hand preparation73	1
	Multimodal intervention43 44 46 74	4
WHO Surgical Safety Checklist	Nationwide implementation40–42 51 52	5
	Multiple hospitals implementation75–77	3
	Single site hospital implementation49 78–81	5
	Surgical Safety Checklist Use and PostCaesarean Sepsis39	1
Setting	Hospital level
Single hospital site	Tertiary33 36 37 44 45 47–49 53 60–62 65 67 72 74 78–81 100–102	23 (46.9%)
	District32 66 71 73	4 (8.2%)
Multiple hospital site	Tertiary35 40–43 50 69 75	8 (16.3%)
	Mixed34 38 39 46 59 63 64 70 76 77 99	11 (22.2%)
	Not specified51 52 68	3 (7.0%)
Use of Implementation Science framework for implementation of the study	Yes51 52	2 (4.1%)
	No	47 (95.9%)
Use of quality improvement methods for delivery of the study	Yes34 35 43 44 48–50 81	8 (16.3%)
	No	41 (83.7%)
IOM quality domains addressed	Safe32–35 40–42 44–46 48 51–53 59–81	44 (89.8%)
	Timely40 64 74 76 79 100	6 (12.2%)
	Effective32 33 45 46 48 53 59 60 64–74 102	25 (51.0%)
	Efficient32 65	4 (8.2%)
	Equitable61 62	2 (4.1%)
	Patient-centred*35–37 47 48 60 66 67 102	9 (18.4%)

*QoL, patient perception to the fistula repair programme, patient feeling on receiving anaesthesia, pain score, collaborative relationships—relationship formed during consultation between patient and staff.

IOM, Institute of Medicine; QoL, quality of life; SSI, sub-Saharan Africa.

When assessing what IOM quality domains were intended to be improved by the QI interventions, 44/49 (89.8%) of studies focused on the safety quality domain. Effectiveness was the second most common quality domain (24/49, 49.0%), followed by studies on patient-centredness (9/49, 18.4%) and timeliness (6/49, 12.2%). Efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) were the least studied domains. Most studies assessed two domains (median 2, IQR (1–2), min-max (1–4)). Table 2 presents the detailed description of implementation characteristics.

Of the WHO Health System blocks, all articles presented at least three of the five Health System building blocks of interest-Governance and Leadership, Human Resources and Service Delivery. Health information and Finance were the least commonly addressed building blocks (15/49, 30.6% and 3/49, 6.1%, respectively).

Outcomes

All articles reported more than one category of outcomes. Clinical outcomes were reported in 29/49 (59.2%) studies. Perioperative mortality was reported in 13 out of 29 studies and only one study defined it as a primary outcome. Surgical complications were reported in 14/27 (51.6%) as SSI and in 17/29 (34.7%) as other complications. Seventeen studies reported other clinical outcomes (listed in table 3). All studies that reported on clinical outcomes reported more than one clinical outcome (table 3).

Table 3

Outcomes, N=49

Outcome category, n* of studies reported each category	Outcome subcategories according to the common themes identified	n*, (%)
Clinical, n=29 (59.2%) Broad categories of clinical outcomes reported	Perioperative mortality	13 (26.5%)
	SSI	14 (28.6%)
	Other surgical complications excluding SSI	17 (34.7%)
	Other clinical (adverse events, measure of pelvic floor muscles strength, pain score, quality of life)	17 (34.7%)
Process, n=34 (69.4%) Broad categories of process outcomes reported	Length of stay, waiting time, delays within facilities	8 (16.3%)
	Safety procedures	7 (14.3%)
	Adherence to a protocol	5 (10.2%)
	Other process (attendance, postoperative and preoperative care, number of inpatient admissions, no of follow-up visits, staff time, data quality recorded, number of therapy sessions for patients, dose frequency, surgery booking status, completeness and accuracy of electronic records)	14 (28.6%)
Implementation, n=35 (71.4%)	Acceptability	13 (26.5%)
	Adoption	20 (40.8%)
	Appropriateness	8 (16.3%)
	Feasibility	10 (20.4%)
	Fidelity	9 (18.4%)
	Cost	2 (4.1%)
	Penetration	18 (36.7%)
	Sustainability	9 (18.4%)
Other, 29 (59.2%)	Structural	24 (49.0%)
	Cost of treatment/materials†	4 (8.2%)
	Staff/patient satisfaction	4 (8.2%)
	Behaviour related‡	3 (6.1%)
	Training outcomes (change in knowledge, skills and attitude at assessment)	3 (6.1%)
	Collaborative relationship§	1 (2.0%)
	Interobserver agreement	1 (2.0%)
	Patient asked about side effects and feeling of receiving dose of ketamine	1 (2.0%)
Formal use of Evaluation Frameworks, n=7 (14.3 %)	Donabedian Model23	2 (4.1%)
	Kirkpatrick103	3 (6.1%)
	Implementation Outcome Taxonomy by Proctor et al20	2 (4.1%)

The reporting of study methods and results were suboptimal. Recommended reporting guidelines were rarely cited (7/49, 14.3%).

*The total in each type can exceed the total number of articles (N=49), due to studies reporting several outcomes from the same category and more than one category in the same study.

†Cost of a drug or a single item provided to make it possible for an intervention to take place. It contributes to the cost of implementation, however, it is not possible to calculate cost of implementation based on this data alone. Implementation cost is the cost impact of implementing effort and will depend on three components: the costs of the particular intervention, the implementation strategy used and the location of service delivery.²⁰

‡Relationship formed during consultation between patient and staff and assessed using a special proforma.

§Change in behaviour following training, behaviour change using WHO Behaviourally Anchored Rating Scale (WHOBARS), attitude.

SSI, Surgical Site Infection.

The process outcomes were reported in 34/49 (69.4%) studies. Most of those reporting process outcomes (29/34, 85.3%) reported multiple process outcomes, one collecting over a thousand variables to form a composite outcome measure.³⁴ We defined subcategories of process outcomes based on the themes that were identified from the extracted outcomes. All other outcomes were classified within the broad group due to the heterogeneity of the measures used in studies (see details in table 3).

Implementation outcomes were reported in 35/49 (71.4%) studies. The number of implementation outcomes reported per study varied from 0 to 6 (median 2). Adoption (20/35, 57.1%) and penetration (18/35, 51.4%) were reported most often, followed by acceptability (13/36, 26.5%), feasibility (10/35, 20.4%), fidelity (9/35, 18.4%), sustainability (9/35, 18.4%) and appropriateness (8/35, 16.3%). Cost of implementation was the least reported (2/35, 5.7%).

All outcomes that did not fit into clinical, process or implementation categories were coded as ‘others’ (29/49, 52.2%) and individual categories were made where possible. Although at the screening stage we excluded studies that aimed to only improve service structure, we found that many studies assessed structural outcomes as part of the baseline quality assessment of the surgical care services. Structural outcomes (eg, infrastructure, availability of equipment and resources, supply of medicines, materials, number of staff) formed one of the biggest categories in ‘other’ (24/49, 49.0%), this was followed by cost of treatment, staff/patient satisfaction, QoL, behaviour related and training evaluation. Use of evaluation frameworks was rare (7/49, 14.3%) (table 3).

As only one study defined mortality as the primary outcome,⁵³ the assessment of the quality of evidence using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria was not undertaken as planned in the protocol.

Discussion

We found fewer than 50 studies that focused on improving the quality of surgical and/or anaesthesia care in hospitals in SSA. The majority of these studies focused on the quality domains of safety and effectiveness of care, with little focus on efficiency, equitability, timeliness and patient-centredness. In addition, fewer than 10 studies used recognised QI or implementation science methods to support intervention implementation. However, a large proportion of studies used at least one implementation science method during assessment of findings. Studies were concentrated in a limited number of countries within SSA, despite the known challenges of poorer surgical outcomes across the continent compared with high-income settings.

The paucity of QI studies that we found aligns with the wider global health systems literature reporting that access to healthcare has been prioritised over the quality of healthcare delivery.¹ However, surgical and anaesthesia teams across the continent are, on a daily basis, striving to improve the quality of care within their own hospital environments outside the context of organised QI programmes or research studies. The ASOS 2 study is one of the best examples of QI research.⁵⁴ However, the enhanced postoperative surveillance for high-risk surgical patients in ASOS 2 failed to produce improved outcomes in this study. This may well have been due to local context—specifically the degree of buy-in from local teams.⁵⁵ We think that we need more QI studies and we need studies to embrace implementation science methods to maximise chance of improved surgical and anaesthesia outcomes.

Despite previous work suggesting that 5 billion people lack access to safe, effective and timely surgical care if required,⁴ recent modelling has suggested that poor quality care is now a bigger barrier to reducing mortality than insufficient access, including for surgical care.^{1 2} Indeed, a large epidemiological study of surgical patients in hospitals across SSA has shown perioperative mortality rates that are two times higher than the global average, despite patients being younger, having a lower-risk profile and developing fewer complications.⁵ Similar findings of worse outcomes after surgery in SSA have been seen in other studies of general or disease-specific surgery.^{5 6 56–58} Although the worse outcomes seen in these studies have a range of determinants including late presentation, the quality of care is a common theme which unites them.

Quality is a multidimensional concept and difficult to define. Donabedian was the first to address the issue of quality in healthcare. Later, at the turn of the century, the IOM report ‘To Err is Human’ highlighted the scale and impact of errors in healthcare, with a focus on safety in healthcare. Various institutions have produced quality frameworks with many embracing the domains of effective, efficient, timely, equitable, safe and patient-centred care. Quality, alongside access and financial risk protection are key aspects of universal health coverage as stated in SDG3.8. More recently, a quality health system framework from a Lancet Global Health Commission, included processes of care, health system foundations and quality impacts. We chose to analyse quality using the IOM domains which have a more clinical QI focus rather than a broader health system perspective on quality healthcare. Nevertheless, we acknowledge that in categorising quality, the interactions between individual categories are lost. Providing an analysis of the trade-offs and reinforcements between categories of the IoM framework is beyond the scope of our review.

We found that almost all the studies focused on either safety^{32–35 40–42 44–46 48 51–53 59–81} and/or effectiveness of care, with a lack of focus on other domains of quality. The prioritisation on safety was not surprising given the well-recognised magnitude of the patient safety problem²¹ and the resultant global movement to improve patient safety. The WHO is a global leader in establishing safety norms and standards and supporting country efforts in developing patient safety policies and practices. Two global patient safety reports relate specifically to safety in surgical care; one on the role of the surgical safety checklist,⁸² and the other on actions to reduce healthcare associated infections, paying particular attention to SSIs.^{57 83} It is clear that these WHO priorities are influencing the focus of hospital-based QI efforts; 14 of the studies which we found focused on the surgical safety checklist,^{40–42 49 51 52 75–81} 12 studies on SSI^{32 33 43–46 69–74} and 3 studies on Infection prevention and control (IPC)—2 on sterilisation^{63 64} and 1 on IPC policies.⁶⁵ However, despite the number of studies focussing on safety, the number of safety issues addressed were few. For instance, we found that none of the studies were based on postoperative ward based care, which is another safety quality issue that has recently been recognised as a problem.⁵

We also found that clinical effectiveness outcomes were not regularly assessed. We acknowledge that clinical outcomes are often complex to define and capture and can occur after discharge when patients in resource limited settings are often lost to follow-up. Process measures are easier to collect which may be why we found that these outcomes were more often collected than clinical outcomes, despite sometimes tenuous links between process and clinical outcomes.^{84 85}

Promoting safety and effectiveness are undoubtedly key factors for providing high-quality surgical care. However, improvements in the other IoM domains are needed to ensure the optimal use of resources in constrained settings and the delivery of services that are responsive to patient’s needs, which will help to engender trust in those services.²²

We found few studies using QI methods,^86–88 and few studies used implementation science methods^{10 12 17 89} which is of concern, as benefits of using these methods to support the delivery of evidence-based QI practices into routine healthcare, have been clearly demonstrated as critical to close the implementation gap. Indeed, there is wide acceptance that there is an implementation gap^{10 90} in scale up of evidenced based interventions into routine care in LMICs in general, and in surgical and anaesthesia care in particular.^{10 17 89 90} Over the last two decades there have been seminal publications on implementation science including the Consolidated Framework for Implementation Research, which was originally published in 2009,⁹¹ Proctor’s Implementation Outcomes in 2011²⁰ and the Expert Recommendations of Implementing Change in 2015.¹⁹ The Medical Research Council (MRC) guidance on process evaluation was also published in 2015.⁹² Finally, the Context and Implementation of Complex Interventions framework was published in 2017.⁹³ Our review covered publications from 2008 to the end of 2021 (figure 3) and only found two articles that mentioned any of the above methods.

Although there was no formal mention of formal implementation science frameworks in the majority of studies, we found that over two-thirds of studies reported at least one implementation outcome as defined by Proctor et al.²⁰ The most common reported implementation outcomes were adoption and penetration, with other outcomes being rarely reported, despite their well-recognised utility for assessing the likelihood that the intervention can be sustained, rolled out at scale or rolled out elsewhere.⁹⁴ The least assessed implementation outcome was implementation cost, whereas in any health system, and especially resource-constrained settings, costs of the intervention itself and cost of implementation of the intervention, are essential to inform uptake of interventions.⁹⁵

To address the implementation gap of successfully implementing and scaling up evidence-based interventions in ‘real-world’ conditions,⁹⁰ high-quality implementation research needs to remain high on the global health research agenda.¹² Implementation outcomes are of particular interest as they provide details on how and why the intervention implementation may need to change.

We also found that the quality of reporting of studies, in general, was not optimal. Many studies had issues of transparency and accurate reporting of basic parameters such as the follow-up period, type of population, study setting, study design, year when the study took place, length of follow-up and the names of statistical tests used. Several reporting guidelines exist that have been shown to be effective in improving reporting of research, limiting possibilities for information omission and helping the reader to understand and be able to replicate the study. We found that the use of recommended reporting guidelines were rarely reported in the papers.⁹⁶

This study has several limitations. Our search terms restricted the search to interventional studies related to surgical and anaesthesia care QI and we included many synonyms related to dimensions of quality. It is possible that we missed some studies that did not specifically mention quality or one of the synonyms we used. However, by choosing search terms related to ‘surg’, ‘quality’ and ‘hospital’, we believe all articles that framed their research as related to quality of surgical and anaesthesia care have been captured. Our search was restricted to English-language articles only and it is possible that our findings are regionally biased towards SSA Anglophone countries.

Despite these limitations, this review is the first to include hospital-based QI interventions for all fields of surgery (excluding trauma, as we have recently assessed this in a separate review) in SSA.⁹⁷ This is also the first systematic literature review to synthesise the information on surgical and anaesthesia quality of care using clinical, process and implementation outcomes that have been measured and assessed as part of QI interventions.

Conclusions

This systematic review has shown a paucity of QI studies on surgical and anaesthesia care, with the majority addressing the safety and effectiveness quality domains. In research settings, implementation and improvement methods are not adequately employed to address the current implementation gap for introduction of evidence-based interventions to improve the quality of surgical and anaesthesia care. To address the implementation gap of successfully implementing and scaling up evidence-based interventions in ‘real-world’ conditions,⁹⁰ high-quality implementation research needs to remain high on the global health research agenda.¹² Implementation outcomes are of particular interest as they provide details on what, how and why the intervention implementation may need to change.

The authors thank Hosni Khairy Salem (HS) who contributed to this work by reviewing articles by abstract and providing his expertise in the field during article review process.

Data availability statement

No addtional data avaialble.

Ethics statements

Patient consent for publication

Not applicable.

Footnote

Twitter @drjackoids

Contributors NB, JD and AJML conceived of the project and developed the study design. NB conducted the database search. NB, IOM-B, HS and VC conducted screening and data extraction. NB conducted the analysis and synthesis and wrote the first draft. All authors contributed to manuscript revisions and approved the final version. JD and AJML are the guarantors of this project.

Funding This systematic review is supported by the NIHR Global Health Research Unit on Health Systems Strengthening in Sub-Saharan Africa, King’s College London (GHRU 16/136/54).

Disclaimer The funding body had no input into the study design.

Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

References

¹ Kruk ME, Gage AD, Arsenault C, et al. High-Quality health systems in the sustainable development goals era: time for a revolution. Lancet Glob Health 2018; 6: e1196–252. doi:10.1016/S2214-109X(18)30386-3 http://www.ncbi.nlm.nih.gov/pubmed/30196093

² Kruk ME, Gage AD, Joseph NT, et al. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018; 392: 2203–12. doi:10.1016/S0140-6736(18)31668-4 http://www.ncbi.nlm.nih.gov/pubmed/30195398

³ Jha AK, Larizgoitia I, Audera-Lopez C, et al. The global burden of unsafe medical care: Analytic modelling of observational studies. BMJ Qual Saf 2013; 22: 809–15. doi:10.1136/bmjqs-2012-001748 http://www.ncbi.nlm.nih.gov/pubmed/24048616

⁴ Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386: 569–624. doi:10.1016/S0140-6736(15)60160-X http://www.ncbi.nlm.nih.gov/pubmed/25924834

⁵ Biccard BM, Madiba TE, Surgical Outcomes Study investigators ObehalfoftheSA. The South African surgical outcomes study: a 7-day prospective observational cohort study. S Afr Med J 2015; 105: 465–75. doi:10.7196/SAMJ.9435 http://www.ncbi.nlm.nih.gov/pubmed/26716164

⁶ Bagheri Nejad S, Allegranzi B, Syed SB, et al. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ 2011; 89: 757–65. doi:10.2471/BLT.11.088179 http://www.ncbi.nlm.nih.gov/pubmed/22084514

⁷ Weiser TG, Gawande A. Disease Control Priorities. In: Excess surgical mortality: strategies for improving quality of care, in essential surgery. 1. 3rd. Washington (DC, 2015.

⁸ World Health Organisation. Everybody’s Business. Strengthening Health Systems to Improve Health Outcomes. Geneva WHO: WHO’s Framework for Action, 2007.

⁹ Adam T, de Savigny D. Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan 2012; 27 Suppl 4: iv1–3. doi:10.1093/heapol/czs084 http://www.ncbi.nlm.nih.gov/pubmed/23014149

¹⁰ Peters DH, Adam T. Implementation research in health. A practical guide. who, 2013.

¹¹ Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med 2011; 104: 510–20. doi:10.1258/jrsm.2011.110180 http://www.ncbi.nlm.nih.gov/pubmed/22179294

¹² Ridde V. Need for more and better implementation science in global health. BMJ Glob Health 2016; 1: e000115. doi:10.1136/bmjgh-2016-000115 http://www.ncbi.nlm.nih.gov/pubmed/28588947

¹³ Boaden R. Quality improvement: theory and practice. British Journal of Healthcare Management 2009; 15: 12–16. doi:10.12968/bjhc.2009.15.1.37892

¹⁴ Taylor MJ, McNicholas C, Nicolay C, et al. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf 2014; 23: 290–8. doi:10.1136/bmjqs-2013-001862 http://www.ncbi.nlm.nih.gov/pubmed/24025320

¹⁵ Schouten LMT, Hulscher MEJL, van Everdingen JJE, et al. Evidence for the impact of quality improvement Collaboratives: systematic review. BMJ 2008; 336: 1491–4. doi:10.1136/bmj.39570.749884.BE http://www.ncbi.nlm.nih.gov/pubmed/18577559

¹⁶ Mauger B, Marbella A, Pines E, et al. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. Am J Infect Control 2014; 42: S274–83. doi:10.1016/j.ajic.2014.05.031 http://www.ncbi.nlm.nih.gov/pubmed/25239722

¹⁷ Ridde V, Pérez D, Robert E. Using implementation science theories and frameworks in global health. BMJ Glob Health 2020; 5: e002269. doi:10.1136/bmjgh-2019-002269 http://www.ncbi.nlm.nih.gov/pubmed/32377405

¹⁸ Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci 2015; 10: 53. doi:10.1186/s13012-015-0242-0 http://www.ncbi.nlm.nih.gov/pubmed/25895742

¹⁹ Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the expert recommendations for implementing change (ERIC) project. Implement Sci 2015; 10: 21. doi:10.1186/s13012-015-0209-1 http://www.ncbi.nlm.nih.gov/pubmed/25889199

²⁰ Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011; 38: 65–76. doi:10.1007/s10488-010-0319-7 http://www.ncbi.nlm.nih.gov/pubmed/20957426

²¹ Institute of Medicine Committee to Design a Strategy for Quality,. 1990, National Academies Press (US) Copyright ©. In: Lohr KN, ed. R. and M. Assurance in, in Medicare: A Strategy for Quality Assurance. 1. Washington DC: National Academy of Sciences, 1990.

²² Institute of Medicine. C.o.Q.H.C.i.A., Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press, 2001.

²³ Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44: 166–206. doi:10.2307/3348969

²⁴ Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010; 8: 336–41. doi:10.1016/j.ijsu.2010.02.007 http://www.ncbi.nlm.nih.gov/pubmed/20171303

²⁵ Brima N, Davies J, Leather AJ. Improving quality of surgical and anaesthesia care at hospital level in sub-Saharan Africa: a systematic review protocol of health system strengthening interventions. BMJ Open 2020; 10: e036615. doi:10.1136/bmjopen-2019-036615 http://www.ncbi.nlm.nih.gov/pubmed/32474430

²⁶ Bramer WM, Rethlefsen ML, Kleijnen J, et al. Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev 2017; 6: 245. doi:10.1186/s13643-017-0644-y http://www.ncbi.nlm.nih.gov/pubmed/29208034

²⁷ EndNote [program]. Endnote 20 version. Philadelphia, PA: Clarivate Analytics, 2013.

²⁸ Godin K, Stapleton J, Kirkpatrick SI, et al. Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada. Syst Rev 2015; 4: 138. doi:10.1186/s13643-015-0125-0 http://www.ncbi.nlm.nih.gov/pubmed/26494010

²⁹ Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan-a web and mobile APP for systematic reviews. Syst Rev 2016; 5: 210. doi:10.1186/s13643-016-0384-4 http://www.ncbi.nlm.nih.gov/pubmed/27919275

³⁰ Harris AD, McGregor JC, Perencevich EN, et al. The use and interpretation of quasi-experimental studies in medical informatics. J Am Med Inform Assoc 2006; 13: 16–23. doi:10.1197/jamia.M1749 http://www.ncbi.nlm.nih.gov/pubmed/16221933

³¹ Snilstveit B, Oliver S, Vojtkova M. Narrative approaches to systematic review and synthesis of evidence for international development policy and practice. J Dev Effect 2012; 4: 409–29. doi:10.1080/19439342.2012.710641

³² Aiken AM, Wanyoro AK, Mwangi J, et al. Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design. PLoS One 2013; 8: e78942. doi:10.1371/journal.pone.0078942 http://www.ncbi.nlm.nih.gov/pubmed/24244390

³³ Aiken AM, Wanyoro AK, Mwangi J, et al. Evaluation of surveillance for surgical site infections in Thika Hospital, Kenya. J Hosp Infect 2013; 83: 140–5. doi:10.1016/j.jhin.2012.11.003 http://www.ncbi.nlm.nih.gov/pubmed/23332563

³⁴ Bosse G, Abels W, Mtatifikolo F, et al. Perioperative Care and the Importance of Continuous Quality Improvement--A Controlled Intervention Study in Three Tanzanian Hospitals. PLoS One 2015; 10: e0136156. doi:10.1371/journal.pone.0136156 http://www.ncbi.nlm.nih.gov/pubmed/26327392

³⁵ Bosse G, Mtatifikolo F, Abels W, et al. Immediate outcome indicators in perioperative care: a controlled intervention study on quality improvement in hospitals in Tanzania. PLoS One 2013; 8: e65428. doi:10.1371/journal.pone.0065428 http://www.ncbi.nlm.nih.gov/pubmed/23776482

³⁶ Castille Y-J, Avocetien C, Zaongo D, et al. Impact of a program of physiotherapy and health education on the outcome of obstetric fistula surgery. Int J Gynaecol Obstet 2014; 124):: 77–80. doi:10.1016/j.ijgo.2013.06.032 http://www.ncbi.nlm.nih.gov/pubmed/24094998

³⁷ Castille Y-J, Avocetien C, Zaongo D, et al. One-Year follow-up of women who participated in a physiotherapy and health education program before and after obstetric fistula surgery. Int J Gynaecol Obstet 2015; 128: 264–6. doi:10.1016/j.ijgo.2014.09.028 http://www.ncbi.nlm.nih.gov/pubmed/25497882

³⁸ Alidina S, Menon G, Staffa SJ, et al. Outcomes of a multicomponent safe surgery intervention in Tanzania's lake zone: a prospective, longitudinal study. Int J Qual Health Care 2021; 33. doi: doi:10.1093/intqhc/mzab087. [Epub ahead of print: 29 Jun 2021 ]. http://www.ncbi.nlm.nih.gov/pubmed/34057187

³⁹ Wurdeman T, Staffa SJ, Barash D, et al. Surgical safety checklist use and Post-Caesarean sepsis in the lake zone of Tanzania: results from safe surgery 2020. World J Surg 2022; 46: 303–9. doi:10.1007/s00268-021-06338-3 http://www.ncbi.nlm.nih.gov/pubmed/34799791

⁴⁰ White MC, Randall K, Ravelojaona VA, et al. Sustainability of using the who surgical safety checklist: a mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Health 2018; 3: e001104. doi:10.1136/bmjgh-2018-001104 http://www.ncbi.nlm.nih.gov/pubmed/30622746

⁴¹ White MC, Baxter LS, Close KL, et al. Evaluation of a countrywide implementation of the world health organisation surgical safety checklist in Madagascar. PLoS One 2018; 13: e0191849. doi:10.1371/journal.pone.0191849 http://www.ncbi.nlm.nih.gov/pubmed/29401465

⁴² Close KL, Baxter LS, Ravelojaona VA, et al. Overcoming challenges in implementing the who surgical safety checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar. BMJ Glob Health 2017; 2: e000430. doi:10.1136/bmjgh-2017-000430 http://www.ncbi.nlm.nih.gov/pubmed/29225958

⁴³ Forrester JA, Starr N, Negussie T, et al. Clean cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study. Br J Surg 2021; 108: e144–34. doi:10.1093/bjs/znaa166 http://www.ncbi.nlm.nih.gov/pubmed/34157086

⁴⁴ Forrester JA, Koritsanszky LA, Amenu D, et al. Developing process maps as a tool for a surgical infection prevention quality improvement initiative in resource-constrained settings. J Am Coll Surg 2018; 226: 1103–16. doi:10.1016/j.jamcollsurg.2018.03.020 http://www.ncbi.nlm.nih.gov/pubmed/29574175

⁴⁵ Forrester JA, Koritsanszky L, Parsons BD, et al. Development of a surgical infection surveillance program at a tertiary hospital in Ethiopia: lessons learned from two surveillance strategies. Surg Infect 2018; 19: 25–32. doi:10.1089/sur.2017.136 http://www.ncbi.nlm.nih.gov/pubmed/29135348

⁴⁶ Allegranzi B, Aiken AM, Zeynep Kubilay N, et al. A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa: a multicentre, before-after, cohort study. Lancet Infect Dis 2018; 18: 507–15. doi:10.1016/S1473-3099(18)30107-5 http://www.ncbi.nlm.nih.gov/pubmed/29519766

⁴⁷ Keyser L, McKinney J, Salmon C, et al. Analysis of a pilot program to implement physical therapy for women with gynecologic fistula in the Democratic Republic of Congo. Int J Gynaecol Obstet 2014; 127: 127–31. doi:10.1016/j.ijgo.2014.05.009 http://www.ncbi.nlm.nih.gov/pubmed/25022342

⁴⁸ Tequare MH, Huntzicker JJ, Gidey Mhretu H, et al. Pain management and its possible implementation research in North Ethiopia: a before and after study. Adv Med. 2020; 2020: 5317352. 2020. doi:10.1155/2020/5317352 http://www.ncbi.nlm.nih.gov/pubmed/32566691

⁴⁹ Ngonzi J, Bebell LM, Boatin AA, et al. Impact of an educational intervention on who surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda. Int J Qual Health Care 2021; 33. doi: doi:10.1093/intqhc/mzab089. [Epub ahead of print: 13 Aug 2021 ]. http://www.ncbi.nlm.nih.gov/pubmed/34390247

⁵⁰ Network for Peri-operative Critical care (N4PCc)*. Addressing priorities for surgical research in Africa: implementation of a multicentre cloud-based peri-operative registry in Ethiopia. Anaesthesia 2021; 76: 933–9. doi:10.1111/anae.15394 http://www.ncbi.nlm.nih.gov/pubmed/33492690

⁵¹ White MC, Randall K, Capo-Chichi NFE, et al. Implementation and evaluation of nationwide scale-up of the surgical safety checklist. Br J Surg 2019; 106: e91–102. doi:10.1002/bjs.11034 http://www.ncbi.nlm.nih.gov/pubmed/30620076

⁵² White MC, Daya L, Karel FKB, et al. Using the knowledge to action framework to describe a nationwide implementation of the who surgical safety checklist in Cameroon. Anesth Analg 2020; 130: 1425–34. doi:10.1213/ANE.0000000000004586 http://www.ncbi.nlm.nih.gov/pubmed/31856007

⁵³ Wesonga A, Situma M, Lakhoo K. Reducing gastroschisis mortality: a quality improvement initiative at a Ugandan pediatric surgery unit. World J Surg 2020; 44: 1395–9. doi:10.1007/s00268-020-05373-w http://www.ncbi.nlm.nih.gov/pubmed/31965276

⁵⁴ Biccard, B.M, ASOS-2 Investigators. Enhanced postoperative surveillance versus standard of care to reduce mortality among adult surgical patients in Africa (ASOS-2): a cluster-randomised controlled trial. Lancet Glob Health 2021; 9: e1391–401. doi:10.1016/S2214-109X(21)00291-6 http://www.ncbi.nlm.nih.gov/pubmed/34418380

⁵⁵ Chu KM, Weiser TG. Real-World implementation challenges in low-resource settings. Lancet Glob Health 2021; 9: e1341–2. doi:10.1016/S2214-109X(21)00310-7 http://www.ncbi.nlm.nih.gov/pubmed/34418381

⁵⁶ GlobalSurg Collaborative. Mortality of emergency abdominal surgery in high-, middle- and low-income countries. Br J Surg 2016; 103: 971–88. doi:10.1002/bjs.10151 http://www.ncbi.nlm.nih.gov/pubmed/27145169

⁵⁷ GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study. BMJ Glob Health 2020; 5: e003429. doi:10.1136/bmjgh-2020-003429 http://www.ncbi.nlm.nih.gov/pubmed/33272940

⁵⁸ GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis 2018; 18: 516–25. doi:10.1016/S1473-3099(18)30101-4 http://www.ncbi.nlm.nih.gov/pubmed/29452941

⁵⁹ Kaboré C, Ridde V, Chaillet N, et al. Decide: a cluster-randomized controlled trial to reduce unnecessary caesarean deliveries in Burkina Faso. BMC Med 2019; 17: 87. doi:10.1186/s12916-019-1320-y http://www.ncbi.nlm.nih.gov/pubmed/31046752

⁶⁰ Baluku M, Bajunirwe F, Ngonzi J, et al. A randomized controlled trial of enhanced recovery after surgery versus standard of care recovery for emergency cesarean deliveries at Mbarara Hospital, Uganda. Anesth Analg 2020; 130: 769–76. doi:10.1213/ANE.0000000000004495 http://www.ncbi.nlm.nih.gov/pubmed/31663962

⁶¹ Laing G, Bruce J, Skinner D, et al. Using a hybrid electronic medical record system for the surveillance of adverse surgical events and human error in a developing world surgical service. World J Surg 2015; 39: 70–9. doi:10.1007/s00268-014-2766-x http://www.ncbi.nlm.nih.gov/pubmed/25167900

⁶² Anderson GA, Ilcisin L, Ngonzi J, et al. Validation of an Electronic Surgical Outcomes Database at Mbarara Regional Referral Hospital, Uganda. World J Surg 2018; 42: 54–60. doi:10.1007/s00268-017-4172-7 http://www.ncbi.nlm.nih.gov/pubmed/28785840

⁶³ Fast OM, Gebremedhin Teka H, Alemayehu/Gebreselassie M, et al. The impact of a short-term training program on workers' sterile processing knowledge and practices in 12 Ethiopian hospitals: A mixed methods study. PLoS One 2019; 14: e0215643. doi:10.1371/journal.pone.0215643 http://www.ncbi.nlm.nih.gov/pubmed/31042774

⁶⁴ Fast O, Fast C, Fast D, et al. Mixed methods evaluation of the impact of a short term training program on sterile processing knowledge, practice, and attitude in three hospitals in Benin. Antimicrob Resist Infect Control 2018; 7: 20. doi:10.1186/s13756-018-0312-6 http://www.ncbi.nlm.nih.gov/pubmed/29456840

⁶⁵ Alekwe LO, Kuti O, Orji EO, et al. Comparison of ceftriaxone versus triple drug regimen in the prevention of cesarean section infectious morbidities. J Matern Fetal Neonatal Med 2008; 21: 638–42. doi:10.1080/14767050802220490 http://www.ncbi.nlm.nih.gov/pubmed/18828055

⁶⁶ Sund GS, Morriss WM, Ikeda KI, et al. Essential pain management at a rural district hospital in Burundi. Southern African Journal of Anaesthesia and Analgesia 2020; 26: 250–5. doi:10.36303/SAJAA.2020.26.5.2395

⁶⁷ Tuchscherer J, McKay WP, Twagirumugabe T. Low-Dose subcutaneous ketamine for postoperative pain management in Rwanda: a dose-finding study. Can J Anaesth 2017; 64: 928–34. doi:10.1007/s12630-017-0914-0 http://www.ncbi.nlm.nih.gov/pubmed/28631150

⁶⁸ Pfister C-L, Govender S, Dyer RA, et al. A multicenter, cross-sectional quality improvement project: the perioperative implementation of a hypertension protocol by Anesthesiologists. Anesth Analg 2020; 131: 1401–8. doi:10.1213/ANE.0000000000004966 http://www.ncbi.nlm.nih.gov/pubmed/33079862

⁶⁹ Abubakar U, Syed Sulaiman SA, Adesiyun AG. Impact of pharmacist-led antibiotic stewardship interventions on compliance with surgical antibiotic prophylaxis in obstetric and gynecologic surgeries in Nigeria. PLoS One 2019; 14: e0213395. doi:10.1371/journal.pone.0213395 http://www.ncbi.nlm.nih.gov/pubmed/30845240

⁷⁰ Brink AJ, Messina AP, Feldman C, et al. From guidelines to practice: a pharmacist-driven prospective audit and feedback improvement model for peri-operative antibiotic prophylaxis in 34 South African hospitals. J Antimicrob Chemother 2017; 72: 1227–34. doi:10.1093/jac/dkw523 http://www.ncbi.nlm.nih.gov/pubmed/27999061

⁷¹ Saxer F, Widmer A, Fehr J, et al. Benefit of a single preoperative dose of antibiotics in a sub-Saharan district Hospital: minimal input, massive impact. Ann Surg 2009; 249: 322–6. doi:10.1097/SLA.0b013e31819782fd http://www.ncbi.nlm.nih.gov/pubmed/19212189

⁷² Usang UE, Sowande OA, Adejuyigbe O, et al. The role of preoperative antibiotics in the prevention of wound infection after day case surgery for inguinal hernia in children in Ile Ife, Nigeria. Pediatr Surg Int 2008; 24: 1181–5. doi:10.1007/s00383-008-2241-6 http://www.ncbi.nlm.nih.gov/pubmed/18726104

⁷³ Nthumba PM, Stepita-Poenaru E, Poenaru D, et al. Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 2010; 97: 1621–8. doi:10.1002/bjs.7213 http://www.ncbi.nlm.nih.gov/pubmed/20878941

⁷⁴ Brisibe SF-A, Ordinioha B, Gbeneolol PK. The effect of hospital infection control policy on the prevalence of surgical site infection in a tertiary hospital in South-South Nigeria. Niger Med J 2015; 56: 194–8. doi:10.4103/0300-1652.160393 http://www.ncbi.nlm.nih.gov/pubmed/26229228

⁷⁵ Igaga EN, Sendagire C, Kizito S, et al. World Health organization surgical safety checklist: compliance and associated surgical outcomes in Uganda's referral hospitals. Anesth Analg 2018; 127: 1427–33. doi:10.1213/ANE.0000000000003672 http://www.ncbi.nlm.nih.gov/pubmed/30059396

⁷⁶ Hellar A, Tibyehabwa L, Ernest E, et al. A team-based approach to introduce and sustain the use of the who surgical safety checklist in Tanzania. World J Surg 2020; 44: 689–95. doi:10.1007/s00268-019-05292-5 http://www.ncbi.nlm.nih.gov/pubmed/31741072

⁷⁷ Yuan CT, Walsh D, Tomarken JL, et al. Incorporating the world Health organization surgical safety checklist into practice at two hospitals in Liberia. Jt Comm J Qual Patient Saf 2012; 38: 254–AP2. doi:10.1016/S1553-7250(12)38032-X http://www.ncbi.nlm.nih.gov/pubmed/22737776

⁷⁸ Bashford T, Reshamwalla S, McAuley J, et al. Implementation of the who surgical safety checklist in an Ethiopian referral hospital. Patient Saf Surg 2014; 8: 16. doi:10.1186/1754-9493-8-16 http://www.ncbi.nlm.nih.gov/pubmed/24678854

⁷⁹ White MC, Peterschmidt J, Callahan J, et al. Interval follow up of a 4-day pilot program to implement the who surgical safety checklist at a Congolese Hospital. Global Health 2017; 13: 42. doi:10.1186/s12992-017-0266-0 http://www.ncbi.nlm.nih.gov/pubmed/28662709

⁸⁰ Ellis R, Izzuddin Mohamad Nor A, Pimentil I, et al. Improving Surgical and Anaesthesia Practice: Review of the Use of the WHO Safe Surgery Checklist in Felege Hiwot Referral Hospital, Ethiopia. BMJ Qual Improv Rep 2017; 6. doi: doi:10.1136/bmjquality.u207104.w6251. [Epub ahead of print: 01 03 2017 ]. http://www.ncbi.nlm.nih.gov/pubmed/28321296

⁸¹ Lilaonitkul M, Kwikiriza A, Ttendo S, et al. Implementation of the WHO Surgical Safety Checklist and surgical swab and instrument counts at a regional referral hospital in Uganda - a quality improvement project. Anaesthesia 2015; 70: 1345–55. doi:10.1111/anae.13226 http://www.ncbi.nlm.nih.gov/pubmed/26558855

⁸² Patient Safety & World Health Organization. WHO guidelines for safe surgery 2009: safe surgery saves lives. World Health Organization, 2009.

⁸³ Pittet D, Allegranzi B, Storr J, et al. 'Clean care is safer care': the global patient safety challenge 2005-2006. Int J Infect Dis 2006; 10: 419–24. doi:10.1016/j.ijid.2006.06.001 http://www.ncbi.nlm.nih.gov/pubmed/16914344

⁸⁴ Davies JI, Reddiar SK, Hirschhorn LR, et al. Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: a multicountry analysis of survey data. PLoS Med 2020; 17: e1003268. doi:10.1371/journal.pmed.1003268 http://www.ncbi.nlm.nih.gov/pubmed/33170842

⁸⁵ Leslie HH, Sun Z, Kruk ME. Association between infrastructure and observed quality of care in 4 healthcare services: a cross-sectional study of 4,300 facilities in 8 countries. PLoS Med 2017; 14: e1002464. doi:10.1371/journal.pmed.1002464 http://www.ncbi.nlm.nih.gov/pubmed/29232377

⁸⁶ Fereday S. A guide to quality improvement methods. Healthcare Quality Improvement Partnership Ltd (HQIP, 2015.

⁸⁷ Shojania KG, Grimshaw JM. Evidence-Based quality improvement: the state of the science. Health Aff 2005; 24: 138–50. doi:10.1377/hlthaff.24.1.138 http://www.ncbi.nlm.nih.gov/pubmed/15647225

⁸⁸ Peters DHE-S, Siadat B, Janovsky K. World Bank ISBN-13: 978-0-8213-7888-5. In: Improving Health Service Delivery in Developing Countries: From Evidence to Action. Washington D.C., USA, 2009: 364.

⁸⁹ Beyranvand T, Aryankhesal A, Aghaei Hashjin A. Quality improvement in hospitals' surgery-related processes: a systematic review. Med J Islam Repub Iran 2019; 33: 129. doi:10.47176/mjiri.33.129 http://www.ncbi.nlm.nih.gov/pubmed/32280635

⁹⁰ Alonge O, Rodriguez DC, Brandes N, et al. How is implementation research applied to advance health in low-income and middle-income countries? BMJ Glob Health 2019; 4: e001257. doi:10.1136/bmjgh-2018-001257 http://www.ncbi.nlm.nih.gov/pubmed/30997169

⁹¹ Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50. doi:10.1186/1748-5908-4-50 http://www.ncbi.nlm.nih.gov/pubmed/19664226

⁹² Moore GF, Audrey S, Barker M, et al. Process evaluation of complex interventions: medical Research Council guidance. BMJ 2015; 350: h1258. doi:10.1136/bmj.h1258 http://www.ncbi.nlm.nih.gov/pubmed/25791983

⁹³ Pfadenhauer LM, Gerhardus A, Mozygemba K, et al. Making sense of complexity in context and implementation: the context and implementation of complex interventions (CICI) framework. Implement Sci 2017; 12: 21. doi:10.1186/s13012-017-0552-5 http://www.ncbi.nlm.nih.gov/pubmed/28202031

⁹⁴ Proctor E, Luke D, Calhoun A, et al. Sustainability of evidence-based healthcare: research agenda, methodological advances, and infrastructure support. Implement Sci 2015; 10: 88. doi:10.1186/s13012-015-0274-5 http://www.ncbi.nlm.nih.gov/pubmed/26062907

⁹⁵ ESSENCE on Health Research. Research-costingpractices:towards bridging the gaps in research funding in low- and middle-incomecountries; 2012.

⁹⁶ Pandis N, Fedorowicz Z. The International EQUATOR network: enhancing the quality and transparency of health care research. J Appl Oral Sci 2011; 19. doi:10.1590/S1678-77572011000500001 http://www.ncbi.nlm.nih.gov/pubmed/21986662

⁹⁷ Whitaker J, O'Donohoe N, Denning M, et al. Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the three delays framework to injury health system assessments. BMJ Glob Health 2021; 6: e004324. doi:10.1136/bmjgh-2020-004324 http://www.ncbi.nlm.nih.gov/pubmed/33975885

⁹⁸ Thiese MS. Observational and interventional study design types; an overview. Biochem Med 2014; 24: 199–210. doi:10.11613/BM.2014.022 http://www.ncbi.nlm.nih.gov/pubmed/24969913

⁹⁹ Abahuje E, Bartuska A, Koch R, et al. Understanding barriers and facilitators to behavior change after implementation of an interdisciplinary surgical non-technical skills training program in Rwanda. J Surg Educ 2021; 78: 1618–28. doi:10.1016/j.jsurg.2021.01.011 http://www.ncbi.nlm.nih.gov/pubmed/33516750

¹⁰⁰ Many HR, Otoki K, Parker AS, et al. Implementation of a surgical critical care service reduces failure to rescue in emergency gastrointestinal surgery in rural Kenya: interrupted time-series analysis. Ann Surg 2021. doi: doi:10.1097/SLA.0000000000005215. [Epub ahead of print: 13 Sep 2021 ]. http://www.ncbi.nlm.nih.gov/pubmed/34520427

¹⁰¹ Loots E, Sartorius B, Paruk IM, et al. The successful implementation of a modified enhanced recovery after surgery (ERAS) program for bariatric surgery in a South African teaching hospital. Surg Laparosc Endosc Percutan Tech 2018; 28: 26–9. doi:10.1097/SLE.0000000000000488 http://www.ncbi.nlm.nih.gov/pubmed/29064879

¹⁰² Abdull MM, McCambridge J, Evans J, et al. Can adapted motivational interviewing improve uptake of surgical or laser treatment for glaucoma in Nigeria: randomized controlled trial. J Glaucoma 2017; 26: 822–8. doi:10.1097/IJG.0000000000000729 http://www.ncbi.nlm.nih.gov/pubmed/28857945

¹⁰³ Kirkpatrick D KJ. Evaluating training programs. San Francisco: Berrett-Koehler, 2009.