Safety in medicine has meant different things to different people; for surgeons, it typically invoked the skills a surgeon brings to bear in caring for patients on the table. However, our anesthetic colleagues are decades ahead of us when it comes to engineering safety into practice. From the early work of pioneers in Boston to the organizational structures put into place by professional societies, anesthesiologists have led the field.1,2 And yet, as we reflected on the task of providing a surgical perspective to the themes of safety in surgical care (for an anesthesiology audience, no less), we recognize that our role is in many ways unique. Our task as surgeons is to provide a voice to all disciplines that have a stake in surgical safety. We must promote the work the anesthesia community has engaged in, but we must also reach out to our obstetric and gynecological colleagues, our theater nurses, and the ancillary staff and other health professionals who labor behind the scenes to ensure that the tools, materials, and processes we rely on to deliver care are well resourced, organized, and supported by our hospital administration, our professional societies, our health ministries, and the people we stand ready to serve. Below, we have provided 3 personal perspectives of the directions that we see making a difference in the next decade.
FROM CHECKLIST TO REALITY AND BACK
In 2006, as I was finishing a Masters of Public Health (MPH) degree, Atul Gawande, a surgeon at Brigham and Women’s Hospital, agreed to lead the WHO (World Health Organization) Safe Surgery Saves Lives program. He hired me as a research fellow. I was taking time from my surgical training to pursue my MPH, something that was not particularly common for surgeons at the time, and I extended my research time to work on this project. Our first meeting occurred in his office, where we sat down and he announced to me and Bill Berry, a retired cardiac surgeon who was helping him with some of his other research work, that our goal was to improve the safety of surgery everywhere—in rich and poor countries, in all settings, anywhere and everywhere surgery might happen. Oh, and we had 2 years and a tiny budget. “So, what are we going to do?” he asked.
My first weeks were spent brainstorming and writing down every possible way I could think of to improve surgical outcomes: appropriate antibiotic use, postoperative walking, venous thromboembolism prophylaxis, improved equipment, advanced training, common standards for resources and infrastructure, anesthetic monitoring and routine use of pulse oximetry, sterile practices, improved surgical instruments and equipment, assurance of sterile glove availability, insurance schemes, and pay for performance; the list was extensive and diverse. Over the course of the first few months, some themes emerged, which clustered into 5 main categories: surgical infrastructure, infection control, anesthetic safety, surgical teamwork, and ongoing monitoring and evaluation. Because of our time limitations, we dismissed the idea of tackling surgical infrastructure. Besides, we knew that surgery was happening around the world, and that health facilities and systems were “making do” with the resources they had. Our goal became to ensure that the resources being consumed to provide surgical care were efficiently and appropriately used. In addition, our initial perception that we would be able to find 1 or 2 specific interventions was quickly dispelled; no one thing was going to address the major burden of unsafe surgery.
After discussing ideas with experts and talking with perioperative team members from surgery, nursing, anesthesia, sterile processing, and infection control, and conversing with patient advocates and safety experts from around the world, it became clear that no one thing would make a profound difference in surgical safety; surgical services were just too complicated. It was also clear that the most important element would always be the knowledge held by each person gathered around a patient at the time of surgery. We felt that if we could leverage this knowledge through some prompt that codified expectations and helped improve communication around the critical aspects of perioperative care, we would be able to avoid much surgical harm. And thus the checklist was born.
With the release of our pilot study on the effect of the checklist on surgical outcomes, we realized we had a powerful tool for improving surgical care.3 But we also recognized that the tool would be hard to implement and difficult to deploy. There would be resistance, and spreading the message would be an uphill battle. We wanted to avoid the lag time experienced by many “best practices,” in which behavior was glacially slow to follow evidence.4 Would it take a generation? Would I be a gray-haired surgeon whom residents would point out and say, “He used to operate without a checklist”? Would I even be so lucky as to have been a part of a radical cultural change in surgery? Do we really need to wait until 2030 and beyond to make this a reality?
In many ways, the question is being answered as this issue of Anesthesia &Analgesia is released. National surgical plans are focusing on both surgical capacity and safety, and they include safety tools such as the checklist as core components of their platforms. Countries from around the world have committed to using the checklist.5 And nongovernmental organizations involved in the delivery of surgical care have incorporated the checklist into their standard processes. It is encouraging to see such progress, and we have learned much about how to implement the checklist in rich and poor settings. I have seen the checklist flatten hierarchies, improve communication, and strengthen quality improvement programs. I have also seen it used to lobby for increased resources and materials, introduce improved perioperative protocols, and initiate new surgical outcomes surveillance programs. With each new experience, we improve our perioperative teams, develop our ability to communicate with each other and our colleagues from other disciplines, and bring knowledge and inclusivity that are so vital for surgical safety to the bedside. While we do this in the name of increased safety for our patients, it will endure because, frankly, it makes our own difficult and stressful lives just a little bit easier.
SaLTS: THE ETHIOPIAN NATIONAL SURGICAL PLAN
Over the past 2 decades, the Ethiopian Federal Ministry of Health (FMOH) has sought to improve its public health system by implementing 4 strategic health sector development plans for its population of more than 90 million people. Before 2014, maternal, newborn and child health, nutrition, and infectious disease were often the focus of its health policy. However, the current strategic plan, called the Health Sector Transformation Plan, emphasizes an agenda for change specific to essential and emergency surgical and anesthesia care, and embeds it within its quality initiative. Ethiopia is one of the first low-income countries to prioritize surgical system reform within its national health agenda.
Before the World Health Assembly (WHA) resolution 68.15 on emergency and essential surgical and anesthesia care, FMOH had identified the lack of adequate and equitable surgical services, the scarce surgical workforce, and insufficient infrastructure as issues of major importance.6 Although it is estimated that more than 5 million surgical interventions are needed in Ethiopia each year to adequately serve the needs of the population, estimates show that no more than 300,000–400,000 operations are actually performed annually.7 Patients seeking surgical care may experience waiting times as long as 1 or 2 years in some instances, and the lack of access to quality care is further exacerbated by a shortage of qualified surgical and anesthesia providers.
Since the adoption of the WHA resolution in 2015, Ethiopia has emerged as a pioneer among low-income countries with respect to a national surgical plan. Cognizant of the fact that fulfilling the aims of the Lancet Commission on Global Surgery and the WHA resolution requires strong political and government led commitment, FMOH launched the Saving Lives Through Safe Surgery (SaLTS) initiative, a 5-year (2015–2020) strategy designed to be implemented across all levels of the health care system, from first-level to tertiary hospitals.8 SaLTS is designed to address quality and equitable health system reform, 1 of 4 transformation agendas of the FMOH National Health Sector Transformation Plan. It is built on the already existing Ethiopian Hospitals Alliance for Quality platform created by FMOH to foster collaboration and self-reliance among clusters of hospitals in a specific region.
Despite recommendation of the Lancet Commission for countries to develop a national surgical plan, global experience demonstrates that the articulation of a “plan” is not enough to improve access to safe, affordable, surgery, and anesthesia care. The Ethiopian initiative is exemplary because the plans were translated into actions within a few months of its approval by the government.
The targets of the initiative are founded on 8 major pillars of excellence, and since inauguration of the program in 2016, a number of major accomplishments have been achieved:
- Excellence in Leadership, Management, and Governance: A national SaLTS Project team along with regional SaLTS leadership structures have been formed, along with a comprehensive 5-year plan that includes training on SaLTS provided to regions and hospital in the country through a cluster hub-and-spoke model. Furthermore, Jhpiego, an international nonprofit health organization affiliated with the Johns Hopkins University, has, through its Ethiopia team, provided leadership training and mentoring in the Amhara and Tigrai regions in partnership with the GE Foundation. It has plans to bring this next to the Oromia and Southern Nations, Nationalities, and Peoples Region.
- Excellence in Infrastructure Development: FMOH allocated monies for the construction of 370 additional theater blocks in 2 phases; 80 new theater blocks have been completed, and 290 more are underway.
- Excellence in Supplies and Logistics Management: Theater equipment worth $25 million has already been procured and is being distributed to hospitals throughout the country. This included the development of a more detailed plan for essential anesthesia equipment and supplies, although the final plan is still pending approval.
- Excellence in Human Resource for Surgery Development: A general surgery human resources National Roadmap has been developed and approved. This was based on an assessment of the regional availability and need for a specialized surgical workforce. Regions and hospitals are being supported to commence training of the surgical workforce at the regional level. An anesthesia human resources National Roadmap has also been developed, but is still pending approval.
- Excellence in Partnership and Advocacy: In February 2017, Addis Ababa hosted an International Safe Surgery Conference in partnership with the African Union, the College of Surgeons of Eastern, Central, and Southern Africa, and the Pan African Academy of Christian Surgeons. There has been ongoing collaboration to improve surgical and anesthetic safety and capacity with international partnership including the College of Surgeons of Eastern, Central, and Southern Africa, the American College of Surgeons, Lifebox, and the Lancet Commission. Within the country, the program is promoted through periodic newspaper articles, radio, and television programs to inform the public.
- Excellence in Quality and Safety: FMOH, in conjunction with the Society of Surgeons of Ethiopia, have approved a list of National Essential Surgical Procedures along with national perioperative guidelines. These guidelines are now being supported by country-specific projects such as the Lifebox Clean Cut program, a surgical safety checklist–based intervention to reduce surgical site infections, widespread implementation of the WHO Surgical Safety Checklist, and improved safety and quality training for hospital managers and leadership.9
- Excellence in Innovation: An innovative oxygen delivery system is being implemented at selected hospitals in the Amhara region. Approval for construction of an oxygen plant has also been completed.
- Excellence in Monitoring and Evaluation: Monitoring and evaluation tools and indicators have already been developed. Full implementation of a monitoring and evaluation surveillance system is underway.
With these pillars, an action plan, government commitment, and leadership from the professional societies in Ethiopia, we hope to make the ideals of the resolution on Safe Surgery and Anesthesia For All a reality.
THE REALIST IN MUMBAI SPEAKS TRUTH TO POWER
The concept of high-, middle-, and low-income countries is being replaced by an understanding of the wider disparities within countries. In fact, these disparities are perhaps greater determinants of surgical outcomes than national-level metrics of surgical safety would suggest. Although a national perioperative mortality rate is a recommended metric articulated by the World Health Organization and the Lancet Commission on Global Surgery, its capture, when such a thing actually occurs, reflects only a part of the picture. In low- and middle-income countries, mortality frequently occurs outside the hospital during transfer or at home. Furthermore, participation in surgical safety audits propagates a selection bias of better-performing hospitals. These are usually the university public hospitals, which can afford to undertake such surveillance, and also have incentives to report their outcomes as they treat complex patients and are under tighter regulatory control. However, the majority of the health care in India occurs in unregulated private facilities and through private fee-for-service providers.
Thus, one surgical safety standard cannot do justice within a single country such as India because the intracountry context may be both resource-rich and resource-poor. In this situation, patient safety is often confused with resources, and resources are more often than not blamed for failure of surgical safety. Blaming poor resources rather than poor behaviors runs the risk of increasing costs of surgical care by making mandatory the use of expensive medical devices (like end-tidal CO2) that are contextually inappropriate and currently unaffordable.10 It will be a disservice to the patient safety agenda if such purchases, disguised as patient safety measures, contribute to the catastrophic expenditure faced by an already vulnerable population.
The Indian Society of Anaesthesiologists has failed to rise to the challenge of providing anesthesia services in the rural areas of India. Yet it has also prevented medical officers trained in providing “Life-saving Anaesthesia Services” from functioning as task-shifted anesthetists in physician-shortage areas by using patient safety as a justification. Anesthesia, in these circumstances, regresses into the hands of untrained providers who use open-ether and ketamine with no monitoring devices to fill the unmet need for anesthesia for the critical bellwether procedures. Numerous examples of task sharing, as recommended by the Lancet Commission, exist that help extend the reach of anesthesia and surgery in areas where such providers either cannot or will not serve.11 Canada and Australia address this issue by providing certified extra training for general practitioners going to work in rural areas.12 Tanzania and other countries have long histories of task sharing cesarean delivery and hernia repair, and their results have been demonstrably comparable to physician providers when they are well trained and supervised, and their roles and responsibilities are clear.13,14 Many European and North American facilities hire nurse anesthetists who work under the supervision of anesthesiologists. It is vital that the Indian Society of Anaesthesiologists involve itself and become a leader in helping the government address this issue.
Solutions include using low-cost interventions for patient safety. The WHO trauma care checklist and the childbirth checklist are classic examples for promoting safe behaviors and improving compliance with best practices. The provision of anesthesia in many of the poorest settings is best done in a task-shared model, in which medical officers trained in anesthesia are provided oversight by a fully trained anesthesiologist. Task-shifting has been only partially successful in low- and middle-income countries, and although proven to be safe in routine surgical cases in terms of competency, the legal responsibility, when faced with complications after care, remains unresolved. For the global surgery agenda for 2030, the task of providing safe anesthesia is more difficult than providing safe surgery because the unmet need of anesthesia manpower, equipment, blood, and critical care is far greater.
Name: Thomas G. Weiser, MD, MPH, FACS.
Contribution: This author helped organize the study and write the introduction and the section, “From Checklist to Reality and Back,” review the study, and edit the content.
Conflicts of Interest: T. G. Weiser is currently working with Lifebox to improve surgical safety. T. G. Weiser is a trustee of Lifebox.
Name: Abebe Bekele, MD, FCS (ECSA).
Contribution: This author helped write the section, “SaLTS: The Ethiopian National Surgical Plan,” review the study, and edit the content.
Conflicts of Interest: A. Bekele is currently working with Lifebox to improve surgical safety.
Name: Nobhojit Roy, MD, PhD.
Contribution: This author helped write the section, “The Realist in Mumbai Speaks Truth to Power,” review the study, and edit the content.
Conflicts of Interest: N. Roy is currently working with Lifebox to improve surgical safety.
This manuscript was handled by: Angela Enright, MB, FRCPC.
1. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256:1017–1020.
2. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth. 2010;57:1027–1034.
3. Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.
4. Gawande A. Slow ideas: some innovations spread fast. How do you speed the ones that don’t? New Yorker. July 29, 2013.
6. World Health Organization. WHA68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage 2015.Geneva: WHO World Health Assembly.
7. Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016;94:201F–209F.
10. McQueen K, Coonan T, Ottaway A, et al. The bare minimum: the reality of global anaesthesia and patient safety. World J Surg. 2015;39:2153–2160.
11. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
12. Lipnick MS, Bulamba F, Ttendo S, Gelb AW. The need for a global perspective on task-sharing in anesthesia. Anesth Analg. 2017;125:1049–1052.
13. Beard JH, Oresanya LB, Akoko L, Mwanga A, Mkony CA, Dicker RA. Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World J Surg. 2014;38:1398–1404.
14. Pereira C, Mbaruku G, Nzabuhakwa C, Bergström S, McCord C. Emergency obstetric surgery by non-physician clinicians in Tanzania. Int J Gynaecol Obstet. 2011;114:180–183.