A. Mattingly1, N. Starr2,3, S. Bitew3, J. A. Forrester3,5, S. Bereknyei Merrell6, T. Mammo7, T. G. Weiser3,5 1Stanford University,Palo Alto, CA, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 3Lifebox Foundation,Boston, MA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Stanford University,Department Of Surgery, S-SPIRE,Palo Alto, CA, USA 7Addis Ababa University,Department Of Pediatrics Surgery,Addis Ababa, Ethiopia
Introduction: Clean Cut is a quality improvement intervention focusing on key perioperative infection prevention standards currently being implemented in Ethiopia. Developed by Lifebox, a non-profit dedicated to improving surgical safety, Clean Cut engages surgeons, nurses and anesthesia providers to identify and improve perioperative processes. In order to refine the implementation framework, we interviewed providers to better understand the benefits and challenges of implementing this program.
Methods: We conducted a qualitative study using semi-structured interviews of staff perspectives on hospitals’ baseline performance, implementation barriers and facilitators, process improvement strategies, and sustainability. After obtaining consent, 20 Clean Cut team members (surgeons, nurses, anesthetists and managers) were interviewed. Audio recordings were transcribed, coded for themes, and analyzed using Dedoose software. Stanford University IRB approved the study.
Results: Major themes across all sites were the ability to enact perioperative process changes, enumeration of barriers to implementation, and strategies for improving adherence to surgical safety standards. Process changes focused on improving the appropriate use of the Surgical Safety Checklist (SSC), routine use of sterility indicators, discarding faulty gowns and drapes, and improved timing of prophylactic antibiotic administration. Challenges included lack of material resources such as computers and paper for data entry, functional autoclaves, sterile indicators, alcohol hand rub, and consistent running water. Payment for data collection affected motivation and incentives; non Clean Cut staff associated SSC completion and follow up as the responsibility of those who were being paid, rather than an inheret part of the job. Checklist completion led to increased perceived accountability that had both negative (fear of punishment) and positive (feelings of reassurance) effects. Benefits of implementation included perceived permanent changes in surgical practices: participants expressed improved self-reported patient satisfaction, incorporation of SSI education at discharge and increased training for staff on infection rates. Strategies for successful implementation included incorporating checklist interventions into routine OR behavior through evidence-based training and one-on-one conversations to overcome resistors.
Conclusion: Despite major barriers to implementation including lack of materials and staff resistance, Clean Cut was effective at producing changes in perioperative infection prevention practices. Expansion must consider an individualized approach to change longstanding surgical practices and motivate staff with evidence-based trainings. We identified a need for increased education to disseminate quantitative findings beyond Clean Cut participants, and a need for a new strategy of efficient data collection that minimizes payment conflicts.