Scaling up of safety and quality improvement interventions in perioperative care in low and middle income countries: a systematic scoping review of strategies and effectiveness of implementation.

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Abstract

Background
Globally 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high income countries implementing them in low- and middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

Methods
Systematic scoping review of perioperative QI interventions in LMICs from 1960-2020. Studies were identified through Medline, EMBASE and Google Scholar. Data was extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for: implementation strategies and scale-up frameworks used; and implementation outcomes reported.

Results
We screened 45,128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31/137 (23%) articles reported scale-up with the commonest intervention being the WHO surgical safety checklist. The commonest implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

Conclusion
Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.



Original languageEnglish
JournalBMJ Global Health
Publication statusAccepted/In press - 16 Sept 2022

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