Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study

Abstract

BackgroundIn low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.AimTo assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.MethodsA mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.Results53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.ConclusionsSurgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.

Evaluating the uptake and effect of Surgical Safety Checklist implementation in a rural hospital, Neno District, Malawi

“…The study showed that more than 90% of the theatre staff were familiar with the checklist with only one in four using it, indicating a gap between knowledge and practical implementation 25. Similar findings have been reported in studies done in other countries where knowledge of the SSC does not translate to practical implementation 26–28…”

“…Our study is one of the studies to examine the adoption of SSC in Malawi, and the second study to investigate SSC implementation in rural areas of the country 25 27. We found the median usage rate of SSC after 2-month implementation was 39.5%, with an overall rate of 37% over the study period.…”

“…There is still a paucity of literature regarding SSC implementation in Malawi with limited studies done in central hospitals which are located in urban settings and provide mainly specialist care 19. Only a few studies have been done in rural areas/facilities and none in the Neno District 27. Therefore, we aim to describe the pattern of surgical procedures conducted, the uptake of SSC, and measure the impact of SSC on surgical outcomes in rural hospitals in the Neno District.…”

Improving the management of open tibia fractures, Malawi

“…A systematic review of approaches to motivate physicians and nurses in low- and middle-income countries found that studies that primarily focused on financial compensation either showed no or negative effects; interventions with a supervisory component, on the other hand, had mostly positive effects. 38 Different supervision models for surgical care in low- and middle-income countries have been proposed, including managed surgical networks; 39 national accountability and monitoring programmes; 40 and regular in-person site visits by surgical specialists. 41 Both the training of orthopaedic specialists and orthopaedic clinical officers are cost-effective and are required to improve supervision.…”

Addressing quality in surgical services in sub-Saharan Africa: hospital context and data standardisation matter

“…The second article describes surgical service monitoring and quality control systems at district hospitals Malawi, Tanzania and Zambia. 8 The authors investigated surgical surveillance at a facility level and the types of quality processes and controls in place to assess Editorial service capacity, volume, outcomes and adherence to standards. After evaluating 75 district hospitals, the authors noted a number of major challenges, including that data registry and recording formats were not standardised; in fact, over half of hospitals surveyed had two or more systems in place.…”