WHO Safety Protocols and Process Excellence

Synopsis

Surgery requires orchestration of numerous components, including requirements for satisfactory operating space; a clean, safe environment; working sterile equipment; and qualified anesthesia, nursing, and theater personnel. Also essential are factors outside of direct perioperative control. Guaranteeing that all of these pieces come together in the correct sequence, with the right timing, for every case is difficult under the best of circumstances. In austere operating environments, achieving these goals can be difficult at best. To facilitate a systematic approach to these myriad issues with the goal of improved safety and desirable outcomes, perioperative personnel including surgeons, anesthesiologists, and nurses rely increasingly on a variety of processes and protocols to help drive the proper and safe completion of these tasks. The most prominent of these to date is the World Health Organization (WHO) Safe Surgery Checklist, but other checklists are used increasingly.

Measuring Quality

The measure of quality in medicine in general and surgery specifically is a relatively new field. The importance of measuring quality is generally first attributed to Donabedian. First published in 1966, the concept emphasized the importance of quality, which he divided into structure, process, and outcome measures. Though modified by several researchers over the decades, these three foundations still serve as a framework for approaching myriad issues that continue to stand in the way of delivering high-quality, safe surgical procedures. More recently, research in high-income countries has shown that medical errors contribute to a significant number of poor patient outcomes. The incidence of errors in poorly resourced environments is less well known, but may be presumed to be high as well, if not higher. These poor outcomes and the errors that lead to them occur despite the presence of altruistic health care providers who often work in sub-optimal environments. In highly resourced countries, these errors and the subsequent outcomes have driven many changes in the way health care is delivered. Though grounded in a quest for improved patient safety, these initiatives have a large financial component as well, because health care is reimbursed by both federal and private entities. The possibility of a reduction of errors, and the concomitant financial savings, is a large driver for the quest to improve quality and reduce patient errors. This chapter will explore ways to assess quality, methods that have been used to date to improve upon problem areas, and approaches to applying these solutions to the delivery of surgical care in more poorly resourced environments.

Structural Issues Affecting Quality

Multiple structural issues affect the quality of care delivered in the perioperative arena, in part because surgery is so resource intensive. These issues include the soundness of the facility itself and infrastructure issues such as the availability of clean operating theaters with working lights, a functional operating table, adequate suction, and a reliable oxygen source. Often, a backup generator is required due to the unreliability of supplied power. Sterilizing equipment, surgical instruments in good condition, and working anesthetizing equipment must all be available for an operation to proceed. In addition, proper instruments that are in good repair must be assembled for a specific case (case cart) and be available in a timely fashion. Personnel requirements contribute to structural requirements for quality as well, from availability of a surgeon to the presence of a qualified scrub tech for the passing of instruments. Indeed, a complete team is necessary for all but the most rudimentary of surgical procedures. Other structural components outside of the theater but equally important include the availability of a working, staffed recovery area, a bed for the patient to move to after immediate post-operative recovery, and ancillary services that may be required, such as a blood bank, an x-ray machine, ventilator, or intensive care unit. Ensuring that all of these structural quality measures are in place is a major, expensive undertaking in the best of circumstances; in a limited environment, a deficiency in any one of these can be the contributor to a poor outcome.

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