Perioperative Care and the Importance of Continuous Quality Improvement—A Controlled Intervention Study in Three Tanzanian Hospitals

Introduction Surgical services are increasingly seen to reduce death and disability in Sub-Saharan Africa, where hospital-based mortality remains alarmingly high. This study explores two implementation approaches to improve the quality of perioperative care in a Tanzanian hospital. Effects were compared to a control group of two other hospitals in the region without intervention. Methods All hospitals conducted quality assessments with a Hospital Performance Assessment Tool. Changes in immediate outcome indicators after one and two years were compared to final outcome indicators such as Anaesthetic Complication Rate and Surgical Case Fatality Rate. Results Immediate outcome indicators for Preoperative Care in the intervention hospital improved (52.5% in 2009; 84.2% in 2011, p<0.001). Postoperative Inpatient Care initially improved to then decline again (63.3% in 2009; 70% in 2010; 58.6% in 2011). In the control group, preoperative care declined from 50.8% (2009) to 32.8% (2011, p <0.001), while postoperative care did not significantly change. Anaesthetic Complication Rate in the intervention hospital declined (1.89% before intervention; 0.96% after intervention, p = 0.006). Surgical Case Fatality Rate in the intervention hospital declined from 5.67% before intervention to 2.93% after intervention (p<0.0010). Surgical Case Fatality Rate in the control group was 4% before intervention and 3.8% after intervention (p = 0.411). Anaesthetic Complication Rate in the control group was not available. Discussion Immediate outcome indicators initially improved, while at the same time final outcome declined (Surgical Case Fatality, Anaesthetic Complication Rate). Compared to the control group, final outcome improved more in the intervention hospital, although the effect was not significant over the whole study period. Documentation of final outcome indicators seemed inconsistent. Immediate outcome indicators seem more helpful to steer the Continuous Quality Improvement program. Conclusion Specific interventions as part of Continuous Quality Improvement might lead to sustainable improvement of the quality of care, if embedded in a multi-faceted approach

Correction: Perioperative Care and the Importance of Continuous Quality Improvement-A Controlled Intervention Study in Three Tanzanian Hospitals.

[This corrects the article DOI: 10.1371/journal.pone.0136156.]

Surgical Case Fatality Rate for the intervention hospital and the control group before and after intervention.

<p>Figures were taken from the annual hospital reports, the annual regional reports and individual hospitals’ documentations. SCFR = Surgical Case Fatality Rate; before intervention = 2009; after intervention = 2010 or 2011, resp., as there was not always available in both years</p><p>Surgical Case Fatality Rate for the intervention hospital and the control group before and after intervention.</p

Structural quality in the intervention hospital 2009 to 2011.

<p>Significance was tested 2010 (t2) against 2009 (t1), 2011 (t3) against 2010 (t2) and 2011 (t3) against 2009 (t1).</p><p>Structural quality in the intervention hospital 2009 to 2011.</p

Individual hospital characteristics of the control group 2009 to 2011.

<p>Figures were taken from the annual hospital reports of the intervention hospital and the regional primary health care (PHC) reports (please see supplementary files: <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s001" target="_blank">S1 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s002" target="_blank">S2 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s003" target="_blank">S3 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s004" target="_blank">S4 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s005" target="_blank">S5 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s006" target="_blank">S6 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s007" target="_blank">S7 Table</a>)</p><p>*the number of health workers seems inconsistently documented (supplementary file: <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s001" target="_blank">S1 Table</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s002" target="_blank">S2 Table</a>)</p><p>** the number of medical doctors in the second control group hospital is missing in 2010, thus this number is likely to be underestimated (see supplementary file: <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.s005" target="_blank">S5 Table</a>).</p><p>Individual hospital characteristics of the control group 2009 to 2011.</p

Immediate outcome indicators for Postoperative Inpatient Care in the Control Group 2009 to 2011.

<p>Immediate outcome indicators from 2009, 2010, 2011. 2009 is the baseline assessment. Significance was tested 2010 (t2) against 2009 (t1), 2011 (t3) against 2010 (t2) and 2011 (t3) against 2009 (t1). Significant improvement is marked with *↑. Significant decline was marked *↓. Confidence interval is given for the differences of overall immediate outcome of the key procedure in 2009, 2010 and 2011.</p><p>Immediate outcome indicators for Postoperative Inpatient Care in the Control Group 2009 to 2011.</p

Immediate outcome indicators for Preoperative Care in the Control Group 2009 to 2011.

<p>Immediate outcome indicators from 2009, 2010, 2011. 2009 is the baseline assessment. Significance was tested 2010 (t2) against 2009 (t1), 2011 (t3) against 2010 (t2) and 2011 (t3) against 2009 (t1). Significant improvement is marked with *↑. Significant decline was marked *↓. Confidence interval is given for the differences of overall immediate outcome of the key procedure in 2009, 2010 and 2011.</p><p>Immediate outcome indicators for Preoperative Care in the Control Group 2009 to 2011.</p

Immediate outcome indicators for Preoperative Care in the intervention hospital 2009 to 2011.

<p>Immediate outcome indicators from 2009, 2010, 2011. 2009 is the baseline assessment. Significance was tested 2010 (t2) against 2009 (t1), 2011 (t3) against 2010 (t2) and 2011 (t3) against 2009 (t1). Significant improvement is marked with *↑. Significant decline was marked *↓. Confidence interval is given for the differences of overall immediate outcome of the key procedure in 2009, 2010 and 2011.</p><p>In the control group, the quality of Preoperative Care did significantly decrease over the whole study period (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0136156#pone.0136156.t005" target="_blank">Table 5</a>). Patients received anaesthetic visits the day before operation in less than 25% over the whole study period (7/32 in 2009, 0/28 in 2010 and 2011).</p><p>Immediate outcome indicators for Preoperative Care in the intervention hospital 2009 to 2011.</p

Immediate outcome indicators for Postoperative Inpatient Care in the intervention hospital 2009 to 2011.

<p>Immediate outcome indicators from 2009, 2010, 2011. 2009 is the baseline assessment. Significance was tested 2010 (t2) against 2009 (t1), 2011 (t3) against 2010 (t2) and 2011 (t3) against 2009 (t1). Significant improvement is marked with *↑. Significant decline was marked *↓. Confidence interval is given for the differences of overall immediate outcome of the key procedure in 2009, 2010 and 2011.</p><p>Immediate outcome indicators for Postoperative Inpatient Care in the intervention hospital 2009 to 2011.</p