Background In 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.
Aim To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.
Methods A 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.
Results 53% (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.
Conclusions Surgical 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.
- health services research
- quality measurement
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Contributors MCl: this author helped conceive the original idea and study design; helped with data acquisition, analysis and interpretation and helped review the literature, write the first draft of the manuscript and approve the final manuscript. CP: this author helped conceive the original idea and study design; helped with data acquisition, analysis and interpretation and helped critically appraise and approve the final manuscript. LB, MI, HB: these authors helped with data interpretation and critically appraise and approve the final manuscript. MCh, GM, AJ, GL: these authors helped with data acquisition and critically appraise and approve the final manuscript. EB, CL, JK, NM, KC, RB, JG: these authors helped conceive the original idea and study design and critically appraise and approve the final manuscript.
Funding This study was funded by Horizon 2020 Framework Programme (Grant number: 733391).
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Ethical approval was granted by Research Ethics Committee of the Royal College of Surgeons in Ireland: REC 1417; College of Medicine Research Ethics Committee in Malawi: No. P.05/17/2179; University of Zambia Biomedical Research Ethics Committee: No. 005-05-17; Kilimanjaro Christian Medical College Research Ethics (No. CRERC 2026) and National Institute for Medical Research in Tanzania (No. NIMR/HQ/R.8a/Vol. IX/2600). All Ministries of Health approved the DH data collection. Informed audio-recorded consent was obtained from the study participants.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data (deidentified participant data) are available on reasonable request from the corresponding author.
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