Systems-based Quality Improvement as a tool to implement the Surgical Safety Checklist in Rwanda

Objective: Effective strategies for implementation of the World Health Organization’s Surgical Safety Checklist (SSCL) are not well characterized in resource-limited settings. Our objective was to utilize a systems-based quality improvement (QI) approach to initially implement a single, high-priority item from the SSCL.
Setting: Butaro Hospital, a rural district hospital in northern Rwanda.
Methods: A surgical service QI team was formed and trained with support of local leadership and expatriate staff trained in QI methodology. The team identifid perioperative antibiotic administration as the fist SSCL area for improvement. Baseline performance was measured by sampled chart review of Cesarean sections. Using systems-based QI methods and the Model for Improvement, a protocol for choice and timing of perioperative antibiotics was identifid as the necessary intervention, developed, and then implemented. The impact on performance and spread of QI was measured.
Results: At baseline, only 5.2% of Cesarean section patients received both correct choice and timing of a prophylactic antibiotic agent. After development of the protocol, appropriate choice and timing of antibiotic was observed in 61.7% of cases (p < 0.001). This initial QI initiative stimulated additional projects to implement other components of the SSCL and to improve quality of surgical and anesthetic care.
Conclusions: Implementing one component of the SSCL using QI methodology focused on stakeholder engagement, measurement, and team-based development of iterative systems of improvements facilitated a cultural change at Butaro Hospital. Training and support in QI methods can create an environment in which the SSCL and other efforts for quality in surgical and anesthetic care can be more readily implemented.

Keywords
Antibiotic Prophylaxis; Checklist; Surgical Procedures; Quality of Health Care; Developing Countries