PT - JOURNAL ARTICLE AU - Shehnaz Alidina AU - Pritha Chatterjee AU - Noor Zanial AU - Sakshie Sanjay Alreja AU - Rebecca Balira AU - David Barash AU - Edwin Ernest AU - Geofrey Charles Giiti AU - Erastus Maina AU - Adelina Mazhiqi AU - Rahma Mushi AU - Cheri Reynolds AU - Meaghan Sydlowski AU - Florian Tinuga AU - Sarah Maongezi AU - John G Meara AU - Ntuli A Kapologwe AU - Erin Barringer AU - Monica Cainer AU - Isabelle Citron AU - Amanda DiMeo AU - Laura Fitzgerald AU - Hiba Ghandour AU - Magdalena Gruendl AU - Augustino Hellar AU - Desmond T Jumbam AU - Adam Katoto AU - Lauren Kelly AU - Steve Kisakye AU - Salome Kuchukhidze AU - Tenzing N Lama AU - Gopal Menon AU - Stella Mshana AU - Chase Reynolds AU - Hannington Segirinya AU - Dorcas Simba AU - Victoria Smith AU - Steven J Staffa AU - Christopher Strader AU - Leopold Tibyehabwa AU - Alena Troxel AU - John Varallo AU - Taylor Wurdeman AU - David Zurakowski TI - Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others? AID - 10.1136/bmjqs-2020-011795 DP - 2021 Feb 04 TA - BMJ Quality & Safety PG - bmjqs-2020-011795 4099 - http://qualitysafety.bmj.com/content/early/2021/02/04/bmjqs-2020-011795.short 4100 - http://qualitysafety.bmj.com/content/early/2021/02/04/bmjqs-2020-011795.full AB - 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’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.