PT  - JOURNAL ARTICLE
AU  - Alidina, Shehnaz
AU  - Chatterjee, Pritha
AU  - Zanial, Noor
AU  - Alreja, Sakshie Sanjay
AU  - Balira, Rebecca
AU  - Barash, David
AU  - Ernest, Edwin
AU  - Giiti, Geofrey Charles
AU  - Maina, Erastus
AU  - Mazhiqi, Adelina
AU  - Mushi, Rahma
AU  - Reynolds, Cheri
AU  - Sydlowski, Meaghan
AU  - Tinuga, Florian
AU  - Maongezi, Sarah
AU  - Meara, John G
AU  - Kapologwe, Ntuli A
AU  - Barringer, Erin
AU  - Cainer, Monica
AU  - Citron, Isabelle
AU  - DiMeo, Amanda
AU  - Fitzgerald, Laura
AU  - Ghandour, Hiba
AU  - Gruendl, Magdalena
AU  - Hellar, Augustino
AU  - Jumbam, Desmond T
AU  - Katoto, Adam
AU  - Kelly, Lauren
AU  - Kisakye, Steve
AU  - Kuchukhidze, Salome
AU  - Lama, Tenzing N
AU  - Menon, Gopal
AU  - Mshana, Stella
AU  - Reynolds, Chase
AU  - Segirinya, Hannington
AU  - Simba, Dorcas
AU  - Smith, Victoria
AU  - Staffa, Steven J
AU  - Strader, Christopher
AU  - Tibyehabwa, Leopold
AU  - Troxel, Alena
AU  - Varallo, John
AU  - Wurdeman, Taylor
AU  - Zurakowski, David
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 Dec 01
TA  - BMJ Quality & Safety
PG  - 937--949
VI  - 30
IP  - 12
4099  - http://qualitysafety.bmj.com/content/30/12/937.short
4100  - http://qualitysafety.bmj.com/content/30/12/937.full
SO  - BMJ Qual Saf2021 Dec 01; 30
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.De-identified data are available upon reasonable request and approval by the Tanzania Ministry of Health officials per the data sharing agreement.