Global Surgery: Progress and Challenges in Surgical Quality and Patient Safety

  • Christopher Pettengell
  • Stephen Williams
  • Ara Darzi
Chapter

Abstract

Provision of high-quality surgical care is a prerequisite of all health systems worldwide. Although globally low- and middle-income countries (LMICs) bear the greatest burden of surgical disease, accessing high-quality surgical care in LMICs remains a major challenge due to severe limitations in infrastructure at multiple levels. Further challenges exist around issues of appropriate staffing, and a lack of funding which remains the largest hurdle for the majority of LMICs. Given these challenges, LMICs do not have the resources to implement international, well-validated programs and health care guidelines to ensure safe surgical care. The degree to which unsafe care is a problem for developing countries is not well known although the WHO estimates unsafe surgical care in LMICs are a leading cause of morbidity and mortality worldwide.

The engagement of international organizations has been a welcome boost for many patients in LMICs, but long-term sustainable strategies are required to meet spiralling health needs and generic efforts or guidelines have proven to be inadequate. Effective interventions in these resource-poor settings must be low-cost and targeted to local needs to improve capacity, infrastructure, and ability to access safe and high-quality surgical care in a timely and affordable way.

Keywords

Global surgery Surgical quality Patient safety Health care Low- and middle-income countries 

References

  1. 1.
    Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy of Sciences; 1999.Google Scholar
  2. 2.
    American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). 2015. https://www.facs.org/quality-programs/acs-nsqip. Accessed 1 Nov 2015.
  3. 3.
    World Health Organization. World Alliance for Patient Saftey. 2015. http://www.who.int/patientsafety/about/en/index.html. Accessed 1 Nov 2015.
  4. 4.
    Darzi A. High quality care for all. NHS next stage review. Department of Health: Department of Health. 2008. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf. Accessed 1 Nov 2015.
  5. 5.
    Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;121:1145–50.Google Scholar
  6. 6.
    Gluck PA. Patient safety: some progress and many challenges. Obstet Gynecol. 2012;120(5):1149–59.PubMedGoogle Scholar
  7. 7.
    Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Framework for patient safety research and improvement. Circulation. 2009;119(2):330–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Gardner G, Gardner A, O’Connell J. Using the Donabedian framework to examine the quality and safety of nursing service innovation. J Clin Nurs. 2014;23(1-2):145–55.CrossRefPubMedGoogle Scholar
  9. 9.
    Lilford R, Chilton PJ, Hemming K, Brown C, Girling A, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010;341:c4413.Google Scholar
  10. 10.
    Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139–44.CrossRefPubMedGoogle Scholar
  11. 11.
    Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533–6.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624.CrossRefPubMedGoogle Scholar
  13. 13.
    Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316–23.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376(9746):1055–61.CrossRefPubMedGoogle Scholar
  15. 15.
    Dunser MW, Baelani I, Ganbold L. A review and analysis of intensive care medicine in the least developed countries. Crit Care Med. 2006;34(4):1234–42.CrossRefPubMedGoogle Scholar
  16. 16.
    Grimes CE, Bowman KG, Dodgion CM, Lavy CB. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg. 2011;35(5):941–50.CrossRefPubMedGoogle Scholar
  17. 17.
    O'Hara NN. Is safe surgery possible when resources are scarce? BMJ Qual Saf. 2015;24(7):432–4.CrossRefPubMedGoogle Scholar
  18. 18.
    Wall AE. Ethics in global surgery. World J Surg. 2014;38(7):1574–80.CrossRefPubMedGoogle Scholar
  19. 19.
    Kingham TP, Kamara TB, Cherian MN, Gosselin RA, Simkins M, Meissner C, et al. Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg. 2009;144(2):122–7. discussion 8.CrossRefPubMedGoogle Scholar
  20. 20.
    Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239(4):475–82.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Belle J, Cohen H, Shindo N, Lim M, Velazquez-Berumen A, Ndihokubwayo JB, et al. Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries. J Infect Dev Ctries. 2010;4(7):419–24.PubMedGoogle Scholar
  22. 22.
    Hoyler M, Finlayson SR, McClain CD, Meara JG, Hagander L. Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature. World J Surg. 2014;38(2):269–80.CrossRefPubMedGoogle Scholar
  23. 23.
    Stewart RM, Liao LF, West M, Sirinek KR. The general surgery workforce shortage is worse when assessed at county level. Am J Surg. 2013;206(6):1016–22. discussion 22-3.CrossRefPubMedGoogle Scholar
  24. 24.
    Daniels KM, Riesel JN, Meara JG. The scale-up of the surgical workforce. Lancet. 2015;385 Suppl 2:S41.Google Scholar
  25. 25.
    Gutnik LA, Yamey G, Dare AJ, Ramos MS, Riviello R, Meara JG, et al. Financial contribution to global surgery: an analysis of 160 international charitable organisations. Lancet. 2015;385 Suppl 2:S52.Google Scholar
  26. 26.
    Axt J, Nthumba PM, Mwanzia K, Hansen E, Tarpley MJ, Krishnaswami S, et al. Commentary: the role of global surgery electives during residency training: relevance, realities, and regulations. Surgery. 2013;153(3):327–32.CrossRefPubMedGoogle Scholar
  27. 27.
    Taira BR, Kelly McQueen KA, Burkle Jr FM. Burden of surgical disease: does the literature reflect the scope of the international crisis? World J Surg. 2009;33(5):893–8.CrossRefPubMedGoogle Scholar
  28. 28.
    McQueen KA, Hyder JA, Taira BR, Semer N, Burkle Jr FM, Casey KM. The provision of surgical care by international organizations in developing countries: a preliminary report. World J Surg. 2010;34(3):397–402.CrossRefPubMedGoogle Scholar
  29. 29.
    Veldhuis C. What borders MSF for surgery? Activity report 2006-7. Médecins Sans Frontières International. http://www.msf.org/msfinternational/invoke.cfm?component=article&objectid=C92B28F2-15C5-F00A-2554404A3400B0AE&method=full_html.
  30. 30.
    Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without borders: a brief history of surgery at Medecins Sans Frontieres. World J Surg. 2010;34(3):411–4.CrossRefPubMedGoogle Scholar
  31. 31.
    Farmer DL. The need for sustainability in contemporary global health efforts: missions vs mission. Arch Surg. 2010;145(8):752–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Marath A, Shepard S, Nesbit S, Henson S, Morla E, Barach P, Jacobs J. Creation of a Pediatric and Congenital Heart Surgery Outcomes Database for Developing Nations. Washington, DC: World Society for Pediatric and Congenital Heart Surgery; 2007.Google Scholar
  33. 33.
    Hakala T. Global surgery. Scand J Surg. 2015;104(2):59–60.CrossRefPubMedGoogle Scholar
  34. 34.
    Bickler SW, Spiegel D. Improving surgical care in low- and middle-income countries: a pivotal role for the World Health Organization. World J Surg. 2010;34(3):386–90.CrossRefPubMedGoogle Scholar
  35. 35.
    Integrated management of emergency and essential surgical care. World Health Organization. http://www.who.int/surgery/publications/imeesc/en/. Accessed 30 Nov 15.
  36. 36.
    World Health Organization. Surgical care at the district hospital. Geneva: World Health Organization; 2003.Google Scholar
  37. 37.
    Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia. World J Surg. 2012;36(10):2359–70.CrossRefPubMedGoogle Scholar
  38. 38.
    WHO. WHO global code of practice in the international recruitment of health personnel. Geneva: World Health Organization; 2010.Google Scholar
  39. 39.
    MacDonagh R, Jiddawi M, Parry V. Twinning: the future for sustainable collaboration. BJU Int. 2002;89 Suppl 1:13–7.Google Scholar
  40. 40.
    Gemici G. The metrics of the physician brain drain. N Engl J Med. 2006;354(5):528–30. author reply -30.CrossRefPubMedGoogle Scholar
  41. 41.
    Chandra A. The metrics of the physician brain drain. N Engl J Med. 2006;354(5):528–30. author reply -30.CrossRefPubMedGoogle Scholar
  42. 42.
    Govindarajan VTCTC, Trimble C. Reverse innovation: create far from home, win everywhere. Boston, USA: Harvard Business Review Press; 2012.Google Scholar
  43. 43.
    Crisp N. Mutual learning and reverse innovation—where next? Global Health. 2014;10:14.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Borraez OA. Manejo del Abdomen Séptico. Utilización del Polivinilo. In Avances en Cirugíae e Infección. (Presentations of the XV Congress). [Spanish]. Bogotá: Editorial Medica (Panamericana) Internacional, Columbia. 1989.Google Scholar
  45. 45.
    Kaplan M. Managing the open abdomen. Ostomy Wound Manage. 2004;50(1A Suppl):C2. 1–8, quiz 1p following 8.PubMedGoogle Scholar
  46. 46.
    Hakim S. Hydraulic and mechanical mis-matching of valve shunts used in the treatment of hydrocephalus: the need for a servo-valve shunt. Dev Med Child Neurol. 1973;15(5):646–53.CrossRefPubMedGoogle Scholar
  47. 47.
    Cotton M, Henry JA, Hasek L. Value innovation: an important aspect of global surgical care. Global Health. 2014;10:1.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8–26.Google Scholar
  49. 49.
    Louis R, Jouve JL, Borrione F. Anatomic factors in the femoral implantation of the Ilizarov external fixator. Surg Radiol Anat. 1987;9(1):5–11.CrossRefPubMedGoogle Scholar
  50. 50.
    Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, Jennings R, Marsh DR. Ilizarov principles of deformity correction. Ann R Coll Surg Engl. 2010;92(2):101–5.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
  52. 52.
    Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007;16(1):2–3.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    DelliFraine JL, Langabeer 2nd JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Qual Manag Health Care. 2010;19(3):211–25.CrossRefPubMedGoogle Scholar
  54. 54.
    Deming WE. Out of the crisis, vol. xiii. Cambridge: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1991. p. 507.Google Scholar
  55. 55.
    Johnson J, Barach P. Quality Improvement Methods to Study and Improve the Process and Outcomes of Pediatric Cardiac Surgery. Prog Pediatr Cardiol. 2011;32:147–53.Google Scholar
  56. 56.
    Goodney PP, Chang RW, Cronenwett JL. A percutaneous arterial closure protocol can decrease complications after endovascular interventions in vascular surgery patients. J Vasc Surg. 2008;48(6):1481–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Torkki PM, Alho AI, Peltokorpi AV, Torkki MI, Kallio PE. Managing urgent surgery as a process: case study of a trauma center. Int J Technol Assess Health Care. 2006;22(2):255–60.CrossRefPubMedGoogle Scholar
  58. 58.
    Shukla PJ, Barreto SG, Nadkarni MS. Application of Six Sigma towards improving surgical outcomes. Hepatogastroenterology. 2008;55(82-83):311–4.PubMedGoogle Scholar
  59. 59.
    Frankel HL, Crede WB, Topal JE, Roumanis SA, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg. 2005;201(3):349–58.CrossRefPubMedGoogle Scholar
  60. 60.
    Does RJMM, Vermaat TMB, Verver JPS, Bisgaard S, Van den Heuvel J. Reducing start time delays in operating rooms. J Qual Technol. 2009;41:95–109.Google Scholar
  61. 61.
    Adams R, Warner P, Hubbard B, Goulding T. Decreasing turnaround time between general surgery cases: a six sigma initiative. J Nurs Adm. 2004;34(3):140–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Krafcik JF. Triumph of the lean production system. Sloan Manage Rev. 1988;30:41–52.Google Scholar
  63. 63.
    Yousri TA, Khan Z, Chakrabarti D, Fernandes R, Wahab K. Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury. 2011;42(11):1234–7.CrossRefPubMedGoogle Scholar
  64. 64.
    Nicolay CR, Purkayastha S, Greenhalgh A, Benn J, Chaturvedi S, Phillips N, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. Br J Surg. 2012;99(3):324–35.CrossRefPubMedGoogle Scholar
  65. 65.
    Mason SE, Nicolay CR, Darzi A. The use of Lean and Six Sigma methodologies in surgery: a systematic review. Surgeon. 2015;13(2):91–100.CrossRefPubMedGoogle Scholar
  66. 66.
    Cassin B, Barach P. Balancing clinical team perceptions of the workplace: applying ‘work domain analysis’ to pediatric cardiac care. Prog Pediatr Cardiol. 2012;33(1):25–32. doi:  10.1016/j.ppedcard.2011.12.005.
  67. 67.
    Hesselink G, Zegers M, Vernooij-Dassen M, Barach P, Kalkman C, Flink M, Öhlen G, Olsson M, Bergenbrant S, Orrego C, Suñol R, Toccafondi G, Venneri F, Dudzik-Urbaniak E, Kutryba B, Schoonhoven L, Wollersheim H. European HANDOVER Research Collaborative. Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC Health Services Research. 2014;14:389. doi: 10.1186/1472-6963-14-389.
  68. 68.
    Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE, SQUIRE Development Group. Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project. BMJ. 2009;338:a3152.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Ruelas E, Gomez-Dantes O, Leatherman S, Fortune T, Gay-Molina JG. Strengthening the quality agenda in health care in low- and middle-income countries: questions to consider. Int J Qual Health Care. 2012;24(6):553–7.CrossRefPubMedGoogle Scholar
  70. 70.
    Stelfox HT, Joshipura M, Chadbunchachai W, Ellawala RN, O’Reilly G, Nguyen TS, et al. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg. 2012;36(8):1978–92.CrossRefPubMedGoogle Scholar
  71. 71.
    Stewart BT, Gyedu A, Quansah R, Addo WL, Afoko A, Agbenorku P, et al. District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries. Injury. 2015;47:211–9.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Baines RJ, Langelaan M, de Bruijne MC, Asscheman H, Spreeuwenberg P, van de Steeg L, et al. Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. BMJ Qual Saf. 2013;22(4):290–8.CrossRefPubMedGoogle Scholar
  73. 73.
    McCoy D, Kembhavi G, Patel J, Luintel A. The Bill & Melinda Gates Foundation’s grant-making programme for global health. Lancet. 2009;373(9675):1645–53.CrossRefPubMedGoogle Scholar
  74. 74.
    World Health Organization. Safe surgery saves lives. 2015. http://www.who.int/patientsafety/safesurgery/en/. Accessed 1 Nov 2015.
  75. 75.
    Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):365–70.CrossRefPubMedGoogle Scholar
  76. 76.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.CrossRefPubMedGoogle Scholar
  77. 77.
    Vivekanantham S, Ravindran RP, Shanmugarajah K, Maruthappu M, Shalhoub J. Surgical safety checklists in developing countries. Int J Surg. 2014;12(5):2–6.CrossRefPubMedGoogle Scholar
  78. 78.
    Kasatpibal N, Senaratana W, Chitreecheur J, Chotirosniramit N, Pakvipas P, Junthasopeepun P. Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand. Surg Infect (Larchmt). 2012;13(1):50–6.CrossRefGoogle Scholar
  79. 79.
    Lilaonitkul M, Kwikiriza A, Ttendo S, Kiwanuka J, Munyarungero E, Walker IA, 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(12):1345–55.CrossRefPubMedGoogle Scholar
  80. 80.
    Ibrahim GM, Cadotte DW, Bernstein M. A framework for the monitoring and evaluation of international surgical initiatives in low- and middle-income countries. PLoS One. 2015;10(3), e0120368.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Moss F, Garside P, Dawson S. Organisational change: the key to quality improvement. Qual Health Care. 1998;7 Suppl:S1–2.Google Scholar
  82. 82.
    Argyris C. The organisation: what makes it healthy? Harv Bus Rev. 1958;36(6):107–16.Google Scholar
  83. 83.
    Organisational Health: a new perspective on performance improvement? In: NHS Institute for Innovation and Improvement. 2009.Google Scholar
  84. 84.
    Hesselink G, Vernooij-Dassen M, Barach P, Pijnenborg L, Gademan P, Johnson JK, Schoonhoven, Wollersheim H. Organizational culture: an important context for addressing and improving hospital to community patient discharge. Medi Care. 2013;51(1):90–8. doi: 10.1097/MLR.0b013e31827632ec.
  85. 85.
    Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf. 2013;22(10):809–15.CrossRefPubMedGoogle Scholar
  86. 86.
    Barach P. Overcoming the barriers and political pressures to safety. Int J Relia Qual E-Healthcare. 2012;55–64. doi:  10.4018/ijrqeh.2012040105, ISSN: 2160-9551, EISSN: 2160-956X.
  87. 87.
    Neuhauser D. Ernest Amory Codman MD. Qual Saf Health Care. 2002;11(1):104–5.CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–6.CrossRefPubMedGoogle Scholar
  89. 89.
    World Health Organisation. WHO draft guidelines for adverse event reporting and learning systems. From information to action. Geneva: World Health Organisation; 2005.Google Scholar
  90. 90.
    Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15(7):470–7.CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003;18(1):61–7.CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    World Health Organisation. Assessing and tackling patient harm: a methodological guide for data-poor hospitals. Geneva: World Health Organisation; 2010.Google Scholar
  93. 93.
    Adhikari NK. Patient safety without borders: measuring the global burden of adverse events. BMJ Qual Saf. 2013;22(10):798–801.CrossRefPubMedGoogle Scholar
  94. 94.
    Baelani I, Jochberger S, Laimer T, Otieno D, Kabutu J, Wilson I, et al. Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers. Crit Care. 2011;15(1):R10.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Christopher Pettengell
    • 1
  • Stephen Williams
    • 1
  • Ara Darzi
    • 1
  1. 1.Imperial College Healthcare NHS Trust, Department of Surgery and CancerSt. Mary’s HospitalmLondonUK

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