Background
Methods
Pre-project implementation | Project implementation phase | Post-project end | |
---|---|---|---|
UK SCI project team | 3 | 6 | 1 |
Borodar SCI project team | 4 | 5 | 5 |
Borodar OR staff | 15 | 19 | 8 |
Anaesthetic staff |
4
|
6
|
2
|
Surgeon & Obs-Gyn staff |
6
|
8
|
5
|
OR nurses |
5
|
6
|
5
|
Other OR staff | 4 | 4 | 1 |
Total | 22 | 30 | 14 |
Grand total | 66 |
Results
Project objectives | Proposed activities | Achievements |
---|---|---|
Overarching project objective: To improve access to the operating theatres for both surgical and obstetric patients in Borodar, by increasing the number of procedures and decreasing delays and periods of closure | Audits to assess: -Number of acute and elective procedures -Delays for acute obstetric emergencies -Amount of time ORs closed due to lack of functioning equipment or drugs | -None of the proposed audits were completed. -6-week audit of cancellations completed but not seen by all partners/project team members -No anecdotal evidence or reported observation of any improvement in through-put, delays or periods of closure |
To meet objectives and carry out activites through on-going collaboration between Borodar and Glennworth partners | -Ongoing support and dialogue between partners via email -One visit by Borodar OR committee members to UK -Two visits by two Glennworth OR professionals to run training workshops and support the OR management committee | -Efforts to maintain dialogue between partners enacted, but significant challenges and misunderstandings reported -Two visits by Borodar OR committee members to UK were undertaken, though later than scheduled -One visit by Glennworth OR professionals to Borodar, though later than scheduled and training workshops not held. |
To improve OR management through establishment of a functional, multi-disciplinary OR management team | -Identify and establish OR management team to include representatives of surgery, obstetrics, anaesthesia and nursing -Hold regular, minuted meetings. | -OR management committee members identified -Only two meetings held during 18-month project period |
To train all OR professionals in OR leadership and management skills | -Run four two-day workshops on leadership and management for all qualified staff using the operating theatres and recovery (about 60). | -Proposed workshops on leadership and management not held -Senior OR nurse provided some training in waste management to nurses |
To establish clinical record keeping and clinical audit in the operating theatres as routine management tools, and to monitor patient intra-operative morbidity and mortality | -Establish a reporting system to monitor adverse incidents, peri-operative morbidity (including infection rates) and mortality. -Establish a no-blame peri-operative morbidity and mortality review panel. -Establish 6-monthly clinical audit meetings -Create and use appropriate clinical records, including drug charts. -At least 1 completed audit in each 6-month period by each of the 4 professional groups in operating theatres and recovery. | -Reporting system not established -Morbidity and mortality review panel not established -6-monthly clinical audit meetings not held -New clinical records not created -1 audit of cancelled procedures completed by one of the professional groups; no other audits reported to be completed by other groups for the project (although some Masters students working in the OR completed audits for course requirements, separate to the SCI initiative) |
Project design: objectives, resources and strategies
Understanding of the project objectives
I think initially we thought it was more about, sort of, morbidity, mortality and improving any rates that there were, but it turned out to be more about more, sort of, basic and ground floor things [..]So I don’t know that it’s exactly what we set out to do (project team member, Glennworth)
I was disappointed that I was not involved in deciding on some of the things, and the other thing is that [the planned visit] was also not what I wanted to do (project team member, Borodar)
Mismatched resources, aims and activities
Partnership working
Exchange visits – logistical challenges
It seemed really likely to succeed because there was enthusiasm on both sides, but it hasn’t succeeded because there are a lot of external factors [..] the changes in the NHS meant there were delays in visits, changes meaning that visas are no longer reliably obtained by people from Ethiopia (project team member, Glennworth)
Communication
There is some communication failure also between us and [Glennworth partners],[..] sometimes decisions will come from the other side and I really don’t know anything about it[..] so that is also another big problem that I observed (project team member, Borodar)There was a great delay on both sides, but mainly on our side actually, on communications, so a month would go by and it doesn’t seem like very much, but then, you know, time, it just accumulates and it’s very frustrating for people waiting for a response. (project team member, Glennworth)
Project team roles, responsibilities and mutual understanding
I said to [another team member], you’re in charge of this bit, you and [another person] are the people who are leading it, but they wanted me to do it and I didn’t want to (project team member, Glennworth)
We didn’t do anything, because I thought they would come and give us some directions and things like that, that was my thinking (project team member, Borodar)It was discussed that we would go out there, but we were really keen they should come here first [..] I think it needs to be led by them. (project team member, Glennworth)
Local implementation context
Inter-disciplinary teamwork
They [surgeons] say, “with how many people should we have to fight? We fight with anaesthesia, then should we also have to fight with the nurses?” (OR nurse)
Engaging OR staff: hierarchy, resource scarcity and structural constraints
The relationship between workers here is the relationship of boss and servant. The relationship is mostly based on inferiority and superiority. No sprit of team work at all. (OR nurse)He [senior nurse] needs help from the physician’s side, but the doctors are a problem even for us, definitely there is, especially the senior doctors, they don’t cooperate. (project team member, Borodar)
Most of the things probably the surgeons don’t know about, I don’t know about this project [..] they did appoint some people, the improvement committee, […] they can discuss the problems and find a solution, but all those things are the responsibility of this OR improvement committee. (surgeon)
We don’t have simple gloves […] So how can people be happy to work? Whatever new policy, they don’t accept [..] unless you correct such very minor problems, how can you correct the big problems, how can you make people change? (surgeon)
I tried, I struggled so many times to establish an OR policy, but it was not an easy thing, because people were not cooperative (senior manager, project team member, Borodar)
You know, they are here because they don’t have any other choice, the amount of money that they get is very small and they are not really well motivated […]we don’t do anything from the higher office, because if you do it’s going to affect them so much (senior manager)
The OR, is a very very, hardworking place, and you have to work the whole day, the whole night, and then the next day, so [nurses] get exhausted, so after some time, they say “I’m leaving” (surgeon)
Discussion
Strengthening project design and partnership working
Tailoring implementation to context in resource-constrained settings
Conclusions
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□ The need for a funded lead-in phase to enable clarification and agreement on roles, responsibilities and the skills, support and resources needed by those charged with implementation; this should be participatory, and include plans for sustaining effective communication both within and between partnership teams;
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□ The need to explicitly incorporate adaptive, as well as technical, solutions, and strategies for engaging those not directly involved in the project; this includes allowing space for debate and challenge of the project goals and rationale, avoiding excess ambition and allowing for early, small wins;
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□ The importance of careful and transparent management of the allocation of resources and opportunities for professional development, and realistic evaluation of the additional resources needed to address technical and adaptive challenges;
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□ The need to identify and engage local leaders whose professional status and organisational position afford them authority and influence given local formal and informal structures of power and accountability;
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□ The importance of identifying and articulating links between project goals and wider organisational interests and priorities, while also recognising and agreeing the scope of the QI project.