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Background A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource–constrained settings. Methods We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey ( n  = 25) and qualitative data through in-depth interviews ( n  = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes. Results All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention. Conclusion We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention’s success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Background: One key challenge in improving surgical care in resource-limited settings is the lack of high-quality and informative data. In Ethiopia, the Safe Surgery 2020 (SS2020) project developed surgical key performance indicators (KPIs) to evaluate surgical care within the country. New data collection methods were developed and piloted in 10 SS2020 intervention hospitals in the Amhara and Tigray regions of Ethiopia. Objective: To assess the feasibility of collecting and reporting new surgical indicators and measure the impact of a surgical Data Quality Intervention (DQI) in rural Ethiopian hospitals. Methods: An 8-week DQI was implemented to roll-out new data collection tools in SS2020 hospitals. The Kirkpatrick Method, a widely used mixed-method evaluation framework for training programs, was used to assess the impact of the DQI. Feedback surveys and focus groups at various timepoints evaluated the impact of the intervention on surgical data quality, the feasibility of a new data collection system, and the potential for national scale-up. Results: Results of the evaluation are largely positive and promising. DQI participants reported knowledge gain, behavior change, and improved surgical data quality, as well as greater teamwork, communication, leadership, and accountability among surgical staff. Barriers remained in collection of high-quality data, such as lack of adequate human resources and electronic data reporting infrastructure. Conclusions: Study results are largely positive and make evident that surgical data capture is feasible in low-resource settings and warrants more investment in global surgery efforts. This type of training and mentorship model can be successful in changing individual behavior and institutional culture regarding surgical data collection and reporting. Use of the Kirkpatrick Framework for evaluation of a surgical DQI is an innovative contribution to literature and can be easily adapted and expanded for use within global surgery.

Recognizing the unmet need for surgical care in Ethiopia, the Federal Ministry of Health (FMOH) has pioneered innovative methodologies for surgical system development with Saving Lives through Safe Surgery (SaLTS). SaLTS is a national flagship initiative designed to improve access to safe, essential and emergency surgical and anaesthesia care across all levels of the healthcare system. Sustained commitment from the FMOH and their recruitment of implementing partners has led to notable accomplishments across the breadth of the surgical system, including but not limited to: (1) Leadership, management and governance —a nationally scaled surgical leadership and mentorship programme, (2) Infrastructure —operating room construction and oxygen delivery plan, (3) Supplies and logistics —a national essential surgical procedure and equipment list, (4) Human resource development —a Surgical Workforce Expansion Plan and Anaesthesia National Roadmap, (5) Advocacy and partnership —strong FMOH partnership with international organizations, including GE Foundation’s SafeSurgery2020 initiative, (6) Innovation —facility-driven identification of problems and solutions, (7) Quality of surgical and anaesthesia care service delivery —a national peri-operative guideline and WHO Surgical Safety Checklist implementation, and (8) Monitoring and evaluation —a comprehensive plan for short-term and long-term assessment of surgical quality and capacity. As Ethiopia progresses with its commitment to prioritize surgery within its Health Sector Transformation Plan, disseminating the process and outcomes of the SaLTS initiative will inform other countries on successful national implementation strategies. The following article describes the process by which the Ethiopian FMOH established surgical system reform and the preliminary results of implementation across these eight pillars.

Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress. We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services. Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals. Significant improvements in quality of intrapartum care were detected from baseline (June-July 2015) to follow-up (February-March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (  < 0.001). The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.

The Member States of the World Health Organization (WHO) are committed to achieve quality, equity and dignity for women, newborns and children as reflected in the four World Health Assembly Resolutions.1-4 These resolutions provide the foundation to reach the targets for maternal, newborn and child health and survival5 of the sustainable development goal on health, and universal health coverage. Although coverage of health services has increased, many women, newborns and children continue to die from poor care practices, even after reaching a health facility.6,7 Poor care practices are not limited to the medical aspects of care or resources needed to provide this care; research has demonstrated a disrespectful or neglectful treatment in the facilities that negatively impacts the care outcomes for women and newborns.8 Implementing an approach to improve quality of care at scale that is effective and sustainable is critical to further reduce mortality and improve health outcomes.9Recognizing the need for action, the national governments of Bangladesh, Côte d'Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Uganda and United Republic of Tanzania, together with WHO, the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), implementation partners and other stakeholders, have established the Network for Improving Quality of Care for Maternal Newborn and Child Health care.10 The network has agreed to pursue the ambitious goals of halving maternal and newborn deaths and stillbirths and improving experience of care in participating health facilities within five years of implementation. Under the leadership of the participating countries' health ministries, the network will support the implementation of national frameworks for quality improvement by pursuing four strategic objectives: (i) leadership by building and strengthening national institutions and processes for improving quality of care; (ii) action by accelerating and sustaining implementation of quality-of-care improvement packages through operationalizing a standards-based approach to quality improvement; (iii) learning by promoting joint learning and generating evidence on quality planning, improvement and control of health services; and (iv) accountability by developing, strengthening and sustaining institutions and mechanisms for accountability of quality maternal, neonatal and child health services that are equitable and dignified.

Approach We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intra partum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services. Approche Nous avons concu et teste une methode pour evaluer la qualite des soins dispenses aux meres et aux nouveau-nes, qui pourrait etre integree a une initiative nationale de gestion des performances de plus grande envergure. Grace a des observations directes et a l'examen des registres medicaux, notre outil a permis d'attribuer un score de qualite dans neuf domaines de soins intrapartum. Nous avons applique et teste notre outil dans le cadre de la visite des 18 hopitaux principaux ayant chacun la responsabilite de promouvoir et de coordonner les efforts d'amelioration de la qualite au sein d'un groupement d'hopitaux en Ethiopie. Entre les evaluations de depart et les evaluations ulterieures de suivi, le personnel d'une alliance nationale de collaboration pour la qualite a dispense des formations dans les hopitaux sur les services realises pendant le travail et l'accouchement.

BackgroundSince 2013, IHI has worked with the Ethiopian Federal Ministry of Health (FMoH) to leverage QI methodologies to accelerate progress of the FMoH in maternal newborn health (MNH), and build a culture of quality in the health system.ObjectivesUnderstand initial successes, challenges, and results of a multi-faceted strategy aimed at institutionalising QI and improving MNH outcomes in a resource-limited setting.MethodsThree collaboratives launched in three regions of Ethiopia April-September 2016. We report programmatic and core clinical indicators after LS1 (October 2016-June 2017). Monthly means of program process measures were extracted from routine monitoring tools. Control charts for core HMIS-derived indicators use baseline data (July 2015-August 2016) to set control limits and extend forward. Bundle implementation is displayed using run charts.ResultsCurrently, LS3 has been completed, and 57 health care workers have been trained in QI along with 83 manager-level staff. 20 QI teams have conducted 506 PDSA cycles. Sixteen (80%) teams have reported signals of improvement in bundle adherence by LS2. Aggregate control charts demonstrate initial improvement in data quality in 4-visit ANC, PNC within 48 hours of delivery, and skilled delivery as seen by an initial apparent performance drop. ANC coverage, PNC coverage, percent of women tested for syphilis during first ANC visit, and clinical bundles continued with signals of improved care quality with upward trend (see charts).ConclusionsInitial results are promising regarding program delivery and indicate high levels of facility-level QI activities, as well as initial signals of improved data and service quality in key maternal newborn health services.Abstract 865 Figure 14 visit ANCAbstract 865 Figure 2Postnatal care within 48 hoursAbstract 865 Figure 3Skilled birth attendanceAbstract 865 Figure 4Syphilis testing in ANCAbstract 865 Figure 5100% completion of ‘on admission’ bundleAbstract 865 Figure 6100% completion of ‘before pushing’ bundleAbstract 865 Figure 7100% completion of ‘soon after birth’ bundle