Optimal Resources for Children's Surgery 2: Tiered Quality Improvement Recommendations for Children's Surgical Care Across Health System Levels

BACKGROUND: The previously published Optimal Resources for Children's Surgical Care (OReCS) addressed disparities in access to high-quality children's surgery in low- and middle-income countries (LMICs) with an emphasis on physical and human resources. Data from high-income countries (HICs) show a clear advantage in outcomes when there is an investment in quality improvement (QI) programs. In-hospital adverse events, many of which are avoidable through implementation of quality improvement programs, contribute disproportionately to morbidity in LMICs. The objective of this document is to make recommendations for quality improvement programming at the hospital level. METHODS: We performed a systematic review of the literature to identify quality improvement programming appropriate for a variety of healthcare settings. We then used an iterative Delphi like approach to rank specific quality improvement programs by hospital level according to the DCP3 and WHO classification systems. Participation was open to all members of the Global Initiative for Children's Surgery (GICS) with representation from 21 working groups and 50 LMICs and HICs. Final recommendations were made based on greater than 75% agreement by respondents and review by the GICS executive board. RESULTS: After three rounds of an iterative Delphi like approach, it is recommended that facilities of all levels, participate in a minimum of local data collection and review and establish an antibiotic stewardship program. Recommendations increased by the complexity of work done at each hospital level with the addition of surgical safety checklists, and protocols for multiple domains including the operating room, radiology, and transfusion medicine at first level hospitals. Surgical quality improvement committees and routine mortality and serious event review processes should be implemented at second level hospitals and above. At the National Children's Hospital level, program recommendations mirror those of most HICs, including continuous data collection and monitoring, multidisciplinary review boards, morbidity and mortality conferences and more. CONCLUSION: Quality improvement is defined in the literature as a systematic, data driven approach to improve outcomes and safety of healthcare delivery. Despite significant barriers in data collection, we recommend a minimum level of quality improvement programming and standardization of care for facilities of various levels.