Article Text

Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study
  1. Morgane Clarke1,
  2. Chiara Pittalis1,
  3. Eric Borgstein2,
  4. Leon Bijlmakers3,
  5. Mweene Cheelo4,
  6. Martilord Ifeanyichi3,
  7. Gerald Mwapasa2,
  8. Adinan Juma5,
  9. Henk Broekhuizen3,
  10. Grace Drury6,
  11. Chris Lavy6,
  12. John Kachimba4,
  13. Nyengo Mkandawire2,
  14. Kondo Chilonga7,
  15. Ruairí Brugha1,
  16. Jakub Gajewski1
  1. 1Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
  2. 2Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi
  3. 3Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
  4. 4Department of Surgery, Surgical Society of Zambia, University of Zambia University Teaching Hospital, Lusaka, Zambia
  5. 5East Central and Southern Africa Health Community, Arusha, United Republic of Tanzania
  6. 6Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  7. 7Department of Surgery, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
  1. Correspondence to Morgane Clarke, Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland; morganeclarke{at}rcsi.com

Abstract

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
  • surgery
  • quality measurement
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Statistics from Altmetric.com

Supplementary materials

Footnotes

  • Twitter @SURGAfrica

  • 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.

  • 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.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles