@article {Alidinabmjqs-2020-011795, author = {Shehnaz Alidina and Pritha Chatterjee and Noor Zanial and Sakshie Sanjay Alreja and Rebecca Balira and David Barash and Edwin Ernest and Geofrey Charles Giiti and Erastus Maina and Adelina Mazhiqi and Rahma Mushi and Cheri Reynolds and Meaghan Sydlowski and Florian Tinuga and Sarah Maongezi and John G Meara and Ntuli A Kapologwe and Erin Barringer and Monica Cainer and Isabelle Citron and Amanda DiMeo and Laura Fitzgerald and Hiba Ghandour and Magdalena Gruendl and Augustino Hellar and Desmond T Jumbam and Adam Katoto and Lauren Kelly and Steve Kisakye and Salome Kuchukhidze and Tenzing N Lama and Gopal Menon and Stella Mshana and Chase Reynolds and Hannington Segirinya and Dorcas Simba and Victoria Smith and Steven J Staffa and Christopher Strader and Leopold Tibyehabwa and Alena Troxel and John Varallo and Taylor Wurdeman and David Zurakowski}, title = {Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?}, elocation-id = {bmjqs-2020-011795}, year = {2021}, doi = {10.1136/bmjqs-2020-011795}, publisher = {BMJ Publishing Group Ltd}, abstract = {Background Evidence 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{\textquoteright}s Lake Zone to distil implementation lessons for low-resource settings.Methods We 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.Results Performance 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 of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.Conclusion Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.}, issn = {2044-5415}, URL = {https://qualitysafety.bmj.com/content/early/2021/02/04/bmjqs-2020-011795}, eprint = {https://qualitysafety.bmj.com/content/early/2021/02/04/bmjqs-2020-011795.full.pdf}, journal = {BMJ Quality \& Safety} }