Quality Improvement Activities for Surgical Services at District Hospitals in Developing Countries and Perceived Barriers to Quality Improvement: Findings From Ghana and the Scientific Literature (original) (raw)
Related papers
2022
Background: Ghana Health Service has, as one of its major functions, the provision of accessible healthcare to the rural population with regards to surgical and other medical problems requiring hospital care. Methods: Data was obtained from ten district hospitals through interviews with health personnel, from theatre records and by the completion of a questionnaire before the visit of research team members, who then interviewed the person who completed the questionnaire. Results: None of the physicians working in these facilities had any formal surgical training beyond that obtained in medical school and during a six-month rotation each in surgery and obstetrics and gynaecology. They performed various emergency and elective surgical procedures such as caesarean sections, laparotomies for typhoid ileal perforation, herniorrhaphies, excision of lumps, among others. Outcome measures: Interim measures to expand the quantity and quality of emergency and essential surgical care at district hospitals include compulsory short-term surgical training for medical officers prior to assuming their responsibilities, making available opportunities for continuing short-term surgical education and additional surgical training for medical officers currently working in district hospitals, provision of financial and nonfinancial incentives to physicians with surgical training or surgical experience to entice them to occupy positions in such facilities and training of diplomates and non-physician clinicians to perform the most common emergency and essential surgical procedures. Conclusion: In the absence of surgical specialists in the District Hospitals, measures are needed to expand access to proper emergency and essential surgical service for the over 60% of the rural population.
2022
To the Editor: The authors set out to make proposals for improving access to, and quality of basic surgical care, based on assumptions of the current state of district hospital surgical care throughout the country. These arose from a survey conducted by the same investigators, presumably a few weeks earlier. The information came from a study of ten randomly selected district hospitals. The claim that the physical infrastructure and supply of surgical and anaesthesia equipment are reasonably good for a developing country (Ref. No. 4 in paper) is indeed surprising and runs counter to findings of surgeons and other specialists working on behalf of the Medical and Dental Council and the Ghana College of Physicians and Surgeons, in district hospitals earmarked for training of house officers and residents. Attainment of middle income status clearly has not yet been reflected on health care infrastructure. It is the daily experience of emergency personnel at the Korle-Bu Teaching Hospital that simple surgical emergencies (strangulated hernias, appendicitis, peritonitis from typhoid) are sent in from major district hospitals (and some regional centres) in the Greater Accra, Central and Eastern regions on account of deficiencies in supplies (especially anaesthesia) and inadequate theatre equipment. Having apparently established reasonable adequacy of infrastructure the authors go on to state that access and quality of surgical care can most readily be improved by fast-track professional training, additional to specialist outreach programmes, continuing professional development, surgical mentoring of young doctors and middle level manpower training. This reviewer is totally agreeable to these measures, much of which is already ongoing and could be enormously enhanced. This writer however regards the inclusion of nonphysician clinicians (NPCs) among middle level manpower, as far as surgical care is concerned, as a non sequitur. It is important to draw a distinction between medical officers undergoing a year to two year" s voc ational training and NPCs acquiring surgical skills on the job. The latter cannot be middle level manpower for surgical care. What of the problems of diagnosis in acute or elective cases, and the identification and management of post-operative complications? It would be more productive to channel resources into vocational training and support for medical officers to supervise surgical care than investment in NPCs being touted by this paper. Besides it would be unscientific to deploy NPCs as surgical middle level manpower just because it has been done successfully in Mozambique, Tanzania, Uganda, Malawi and Zaire. At least a well monitored pilot study is a prerequisite.
Surgical Training and Experience of Medical Officers in Ghanaʼs District Hospitals
Academic Medicine, 2011
Purpose To document the quality of training and experience of those who care for patients undergoing surgery and emergency obstetrical procedures at 10 government district hospitals in Ghana. Method A study team composed of Ghanaian and U.S. surgeons visited 10 district hospitals in 10 different regions of Ghana in August 2009. On-site interviews were conducted documenting the formal and informal training and the experience of the medical officers (MOs) performing in surgical facilities in these hospitals. Results Fourteen of the 17 MOs working at these facilities were available for interviews. All 14 had completed two years of housemanship, which is similar to a rotating internship. Only one had obtained any formal surgical training beyond the housemanship, although all were responsible for performing major surgical procedures. The formal training under qualified supervision during the housemanship was limited; the mean number of the most common major surgical procedures performed during training ranged from four to eight, depending on the procedure. Conclusions Even though formal general surgical residency training in Ghana is well developed, graduates of these programs are not working in the district hospitals surveyed. The majority of surgical services provided at the district hospital are provided by MOs, who would benefit from more comprehensive training and ongoing supervision. To help meet the challenge of a shortage of physicians working at district hospitals, the authors present alternative approaches to care described in the literature that involve nonphysician midlevel health providers. Emergencyandessentialsurgical services at district hospitals are a crucial component in the strengthening of health systems in low-and middle-income countries (LMICs), but these services are often underdeveloped, particularly in Africa. 1,2 District hospitals and their necessary surgical services are a key link in the health systems of developing countries 3 and function as the first level of referral care for emergency care patients, many of whom require surgery. District hospitals are more accessible than regional hospitals, particularly for the poor, who lack the funds and the transport to access higher-level facilities. LMICs bear a significant burden of the world's surgical and obstetrical conditions, which are estimated to account for 11% of the world's disabilityadjusted life years lost each year. 4 Yet, only 3.5% of the world's surgical procedures are performed in the poorest countries, which have one-third of the world's population. 5
BMJ Quality & Safety
BackgroundEvidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings.MethodsWe identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.ResultsPerformance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role o...
BMC health services research, 2016
Access to safe surgical care represents a critical gap in healthcare delivery and development in many low- and middle-income countries, including Ethiopia. Quality improvement (QI) initiatives at hospital level may contribute to closing this gap. Many such quality improvement initiatives are carried out through international health partnerships. Better understanding of how to optimise quality improvement in low-income settings is needed, including through partnership-based approaches. Drawing on a process evaluation of an intervention to improve surgical services in an Ethiopian hospital, this paper offers lessons to help meet this need. We conducted a qualitative process evaluation of a quality improvement project which aimed to improve access to surgical services in an Ethiopian referral hospital through better management. Data was collected longitudinally and included: 66 in-depth interviews with surgical staff and project team members; observation (135 h) in the surgery departme...
Journal of Surgical Research, 2011
Background. For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. Materials and Methods. After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. Results. A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. Conclusions. The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.
Where there is no specialist: surgical care in a secondary health facility in a developing country
Background A major deterrent to providing qualitative surgical care in developing countries is the lack of adequate facilities and severe shortage of human resources. Therefore, most of the surgical workforce in rural areas and urban slums predominantly includes general practitioners with little formal training in providing surgical care. There is a need for constant review of patients’ care in this setting with the aim of improving service delivery and conforming to the internationally acceptable standard of practice. Materials and methods A 5-year descriptive retrospective study, from January 2007 to December 2011, of general surgery cases at State Specialist Hospital Ikere-Ekiti (Nigeria) was carried out. Results A total of 80 patients underwent 85 surgical operations. Most of them (86.2%) had ward admission for a mean duration of 4.6±1.4 days. The most frequent elective operation was hernia repair [66 (77.7%)]; whereas that of emergency was appendectomy [seven (8.2%)]. Other operations included lumpectomy [three (3.5%)], hydrocelectomy [two (2.4%)] and orchidectomy and laparotomy [three (3.5%) each]. All patients received postoperative antibiotics, with 71.3% receiving two or more antibiotics. Fifteen (18.8%) patients had surgically excised specimens with no histopathological evaluation. Only four (5%) patients were followed up beyond 4 weeks. No mortality was recorded. Conclusion Surgical volume was grossly low and there is a need for the government to equip secondary healthcare centres with basic facilities and strengthen surgical capacity for maximum utilization and improved quality of care. Periodic training programmes for general practitioners to ensure strict adherence to the international best practices will be helpful. In addition, health education should be available for everyone to reduce sociocultural-related problems.
Challenges faced by Hospital in providing surgical care and handling surgical needs in Zambia
Medical journal of Zambia, 2012
Objectives: To determine challenges faced by hospitals in providing surgical care and handling surgical needs in Zambia. Specifically looking at staffing levels, skills and training, equipment and infrastructure in hospitals relating to surgical care. Design: The authors carried out a non-intervention cross sectional study. The study further looked, post operative care, proportion of male to female patient, surgical cases not catered for, number of operations done, and availability of anaesthetic drugs. The design was both quantitative and qualitative. For quantitative data collection the questionnaire was used to determine the outcome of certain variables. While for qualitative the questionnaire and information audit was done from the theatre register. Results: In all the hospitals surveyed, staff raised a number of challenges that hinder them in offering adequate surgical services to their clients. The problems include; lack of briefings about surgical services (9.1%), lack of training (11.7%), and low staffing levels (9.1%), lack of specialized equipment (15.7%) was also a major problem cited by most of the staff and lastly but not the least the lack of drugs required to conduct a successful operation was named as a big hindering factor (3.9%). Conclusions: The challenges faced by hospitals may be higher than explained because things like funding, accommodation, and training among others were not discussed in this study. However the major challenges have been highlighted which seem to support the literature review. The findings such as critical shortage of essential surgical staff, inadequate funding, poor state of health facilities and equipment, inadequate development of social support systems for fostering health programmes, insufficient empowerment of communities to improve their health, poor geographical access, especially rural areas, and inadequate systematic research in alternative and traditional medicines.
PLOS Medicine, 2010
Background: Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub-Saharan African countries.