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Received: 22 February 2024
-
Accepted: 7 May 2024
DOI: 10.1002/wjs.12216
ORIGINAL SCIENTIFIC REPORT
A novel global safe surgery mentorship program using a
multidisciplinary team approach
Samuel Negash
1,2
|Nichole Starr
2,3
|Samuel Mesfin
4
|Thomas G. Weiser
5
|
Tihitena Mammo Negussie
2,4
1
Menelik II Hospital, Addis Ababa, Ethiopia
2
Lifebox Foundation, Addis Ababa, Ethiopia
3
University of California San Francisco, San
Francisco, California, USA
4
Addis Ababa University, Addis Ababa,
Ethiopia
5
Stanford University, Stanford, California, USA
Correspondence
Samuel Negash, Addis Ababa, Ethiopia.
Email: negashsamie@gmail.com
Abstract
Background: The global surgery movement aims to provide equitable
surgical care in low‐and middle‐income countries (LMICs) and attempts to
address a wide range of issues around the lack of access and poor‐quality.
In response, the Lifebox McCaskey Safe Surgery Fellowship was estab-
lished in Ethiopia to train a multidisciplinary team of healthcare pro-
fessionals. We conducted this study to evaluate the outcome of this training
program.
Methods: A qualitative study was conducted to evaluate the implementa-
tions and outcomes of the first three cohorts of the McCaskey Fellowship.
Interviews with fellows, mentors, and program staff reveal valuable insights
into the program's strengths and challenges.
Results: Key findings include positive feedback on the program's curricu-
lum highlighting its multidisciplinary nature. Challenges were noted in
maintaining schedules, communication with healthcare facilities, and
budget constraints, suggesting the need for improved program manage-
ment. The fellowship's impact was evident in altering participants' percep-
tions of teamwork and enhancing their research and leadership skills.
Fellows initiated quality improvement projects impacting surgical practices
positively. However, challenges, such as hospital resistance and the
COVID‐19 pandemic, affected program implementation.
Conclusion: Despite various challenges, the program's unique approach
combining multidisciplinary training and local mentorship proves promising.
It fosters a culture of teamwork, equips participants with essential skills, and
encourages fellows to become advocates for safe surgery. As surgical
quality champions emerge from this fellowship, there is optimism for lasting
positive impacts on surgical care in LMICs.
KEYWORDS
global surgery, patient safety, rural, training
1
|
INTRODUCTION
Surgical diseases are now recognized as a significant
contributor to the global disease burden; in 2010, 16.9
million deaths were attributed to surgical conditions,
which accounts for around 30% of all deaths world-
wide.
1–4
This number is higher than the total mortality
from HIV/AIDS, tuberculosis, and malaria.
5
It is pre-
dicted that over the next 15 years, the worldwide
financial burden of surgical disease will reach US$20.7
© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).
World J Surg. 2024;1–7. wileyonlinelibrary.com/journal/wjs
-
1
trillion with low‐and middle‐income nations bearing the
majority of this expense.
6
To address the surgical need,
143 million additional operations must be performed
annually in low‐and middle‐income countries (LMICs);
to this day, five billion people still do not have access to
timely, affordable, and safe surgical care.
6,7
The Lancet
Commission on Global Surgery was established in
2014 in response to this significant global burden to
evaluate the current state of global surgery, examine its
effects on individuals and the economy, and develop
long‐term solutions.
8
In the past, global surgery was
frequently referred to as the “neglected stepchild of
surgery,” but currently, it is generally defined as
“placing priority on improving health outcomes and
achieving health equity for all people worldwide who are
affected by surgical conditions or have a need for sur-
gical care.”
9
Interventions offered by the global surgery commu-
nity have taken many different forms.
5
These include
the education and training of healthcare practi-
tioners,
10,11
the establishment of international partner-
ships and exchanges between HICs and LMICs, and
the support for infrastructure development among
others.
12
Designing programs that address the key is-
sues present in global surgery requires the establish-
ment of a multidisciplinary team consisting of surgeons,
nurses, anesthesiologists, public health experts, and
other stakeholders.
13–15
One of the means to address
these issues is facilitating local health worker's
engagement in research and quality improvement (QI)
endeavors.
16–19
The Lifebox McCaskey Safe Surgery fellowship is a
program focusing on this area. It was established in
2018 in collaboration with and funded by the McCaskey
Foundation. The program supports a multidisciplinary
team of professionals from within the surgical health
service system (nursing, anesthesia, obstetrics and
gynecology, and surgery) to develop their skills over the
course of 1 year. The program addresses one of the
core pillars of safe surgery: improving/strengthening
teamwork.
20
It also aims to provide fellows with the
relevant knowledge and skills on safe surgery prac-
tices. The goal was to create a cohort of champions to
contribute positively to the culture of surgical team
performance.
Training delivery included soft skills workshops as
well as didactic lectures presented both in‐person and
virtually from experts abroad. Additionally, local men-
tors were involved to guide the fellows conduct a QI
project over the course of the fellowship. The fellowship
was open to Ethiopian nationals and so far, it has had
three cohorts with 26 fellows selected from different
teaching hospitals in the country. We conducted this
study to assess the implementation process and out-
comes of the first three cohorts of the McCaskey
fellowship program.
2
|
METHODS
This was a qualitative study performed by interviewing
the McCaskey program fellows, mentors, and Lifebox
staff. The convenience sampling method was applied to
select sample from each discipline for those who con-
sented to participate in the study. Lifebox staff were
selected based on their involvement in the fellowship
program in areas of program development, selection, or
implementation. In‐depth and key informant interviews
were conducted with semi‐structured interview guides
by trained final‐year medical students (Appendix A).
Priori codes were used to determine the number of in-
terviewees. The interview was conducted from June 14,
2021, to June 25, 2021; no findings from any prior
interview were used to shape subsequent interviews.
The interview was recorded and then transcribed to
ease data analysis. Interviews were manually coded.
Categories, themes, and codes identified. Five major
themes were selected: structure, activities, output, us-
age, and impact and presented separately below
(Figure 1).
3
|
RESULTS
In this review, a total of 18 fellows, eight mentors, and
four representatives from the program staff were inter-
viewed (Table 1).
3.1
|
Structure
The study participants generally had favorable views of
the program's curriculum and objectives. However,
some of them did observe that the fellowship did not
always follow the curriculum. They remarked that it was
challenging to plan because some sessions were
skipped and the schedules were rearranged. Regarding
partnerships, nearly all of the fellows, mentors, and staff
members acknowledged that Lifebox did not commu-
nicate adequately with healthcare facilities and fellows
acknowledged that this affected how their QI projects
were carried out. The majority of respondents did not
express concern about funding; however, the third
cohort had a smaller budget and was behind schedule
for data collection, which led to data collectors losing
interest and affecting the accuracy of the data collected.
Therefore, they suggested improving the incentive
program.
3.2
|
Activities
Some fellows were unaware of the details of the
application and selection process; however, they all
2
-
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FIGURE 1 Major Themes explored in the study.
TABLE 1Participants demographics: roles, hospitals, and departments.
Role Country Hospital (N) Department (N) Cohort Count
Fellows Ethiopia AaBET
1
GP, quality improvement office 3rd 1
St. Paul
1
GP, OBGYN 2nd 1
TASH
12
Surgery
4
1st 1
2nd 2
3rd 1
Anesthesiology
3
1st 1
2nd 1
3rd 1
Anesthetist
2
1st 1
2nd 1
Nurse
3
2nd 2
3rd 1
Gandhi
1
GP, quality improvement office 3rd
1
1
St. Peter
2
GP, quality improvement office 2nd 2
GP, OR manager
Yekatit
1
GP, quality improvement office 3rd
1
1
Mentors Ethiopia AHRI
1
Researcher 3rd
1
1
St. Paul
1
OBGYN 2nd
1
1
TASH
4
Anesthesiologist 1st
1
1
Nurse 2nd
1
1
Surgery
2
1st
1
1
2nd
1
1
Gandhi
1
Anesthesiologist 3rd
1
1
St. Peter
1
GP, quality improvement 3rd
1
1
Staff Ethiopia
2
Program
1
1
Clinical
1
1
UK/US
2
Program
1
1
Clinical
1
1
Total 30
Abbreviations: AHRI, Armauer Hansen Research Institute; GP, general practitionaire; OBGYN, obstetrics and gynecology; TASH, Tikur Anbessa Specialized
Hospital.
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remarked that by selecting candidates from a variety of
academic backgrounds, the process considered the
team's multidisciplinary nature. It was also suggested
that a more rigorous screening procedure be utilized to
choose fellows who have the drive, commitment, and
fortitude to design and conduct QI projects by using
interviews, reference letters, or recommendation let-
ters. Fellows mentioned that additional promotion of the
program was needed to attract a more qualified appli-
cant. Professionals outside Addis Ababa University are
largely unaware of the fellowship program unless they
have worked with Lifebox in the past.
The fellows appreciated the mentoring and said
their meetings with their mentors were highly produc-
tive. However, the majority claimed that they had little
time for contact with their mentors due to scheduling
conflicts; regular schedules either did not exist or were
not followed, and the frequent mentor changes during
the fellowship period hampered the fellows' ability to
make consistent development. Each fellow valued the
training. They praised the delivery strategy and appre-
ciated the idea of including all surgical teams. They also
remarked that they learned a lot from highly qualified
teachers. The program, it turned out, lacked a formal
monitoring and evaluation framework.
3.3
|
Output, usage, and impact
The fellows stated that they had altered their perspec-
tive on the value of teamwork in the surgical environ-
ment. They also mentioned that the fellowship had
developed their knowledge and abilities in terms of
research methodologies such as literature review,
presentations, the use of supporting data in working
situations, and publishing research. Along with aware-
ness of the difficulties and successes of QI work in
resource‐constrained and complex care settings,
QI projects were recognized as one of the fundamental
competencies obtained through the fellowship together
with leadership skills and soft skills.
3.4
|
Challenges
The most important challenge was the lack of motiva-
tion/commitment of fellows as most of the activities
require teamwork. The other challenge was regarding
QI projects; some of the participants faced resistance
from the hospitals that were chosen to carry out the QI
project. The availability of mentors, time management,
and some of the fellows' English proficiency were
additional issues. The third cohort of fellows likewise
encountered challenges because of the COVID‐19
pandemic. These include fewer procedures performed
and the fellows specifically emphasized the need for in‐
person gatherings to brainstorm ideas because they
found virtual meetings to be less productive. Regarding
the sustainability of the program, it was suggested to
recognize the fellows so they remain motivated and
continue their support. Participants also suggested that
an alumni network after graduation needs to be
established to facilitate regular meetings where fellows
from all cohorts can meet and exchange ideas regu-
larly. In addition, the promotion of the program, main-
taining a record of achievements, continued funding,
and involvement of the government were also stated to
be essential to ensure the sustainability of the
fellowship.
4
|
DISCUSSION
The global surgery movement aims to provide equitable
surgical care in LMICs.
9
One of the ways to improve the
outcome of surgical patients is by increasing the com-
petency of the OR team as well as improving working
conditions through teamwork and communication.
However, there are currently very few surgical QI
training programs for LMIC participants.
21
Existing
training also focuses only on professionals from one
discipline mainly surgeons or anesthetists.
22,23
Training
also tends to focus on a single area such as curricular
content or nontechnical skills.
24,25
The Lifebox program is unique because it combines
a multidisciplinary team of professionals working in the
operating room, in addition to integrating academic with
nontechnical skills such as leadership, teamwork,
communication, and decision‐making skills. Our quali-
tative study found that this mode of training delivery
was appreciated by the participants with some calling it
their best experience. The program also catalyzed
changes in behavior as many fellows have started
promoting the principles of Safe Surgery in their day‐to‐
day activities. For example, one alumnus working in a
university hospital has started incorporating Safe Sur-
gery teachings into his lectures for anesthesia trainees.
Additionally, as QI initiatives are a core component
of the program, fellows generate solutions tailored to
their environment. Fellows have initiated interventions
to improve OR efficiency, WHO Surgical Safety
Checklist utilization, preoperative prophylactic antibiotic
use, and postoperative pain management in their hos-
pitals. An added advantage is that the projects can
easily be replicated in other LMIC facilities because of
the similarity in the systems.
Furthermore, we see long‐term impact as fellows
are making changes to their hospitals even after the
fellowship has ended. Several fellows continue to work
with the Ministry of Health and multilateral organiza-
tions to improve care and refine their own skill sets in
global surgery. The ultimate goal of the fellowship is to
develop surgical quality champions who will eventually
hold leadership positions in their departments, facilities,
4
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and even in the Ministry of Health but it is too early to
assess this impact.
Although the program had many accomplishments,
there were many challenges faced during imple-
mentation. The most notable was resistance from the
hospitals to implementing QI projects. The introduction
of such programs needs to consider strengthening
partnerships with hospital administration and man-
agement and building support within the Ministry of
Health.
Looking forward to the expansion of the program,
another barrier may be acquiring funds. Most partici-
pants suggested that maintaining a record of achieve-
ments and promoting the program more broadly might
help identify other sources of financial support. It will
also make the program more visible to ministries of
health, and if deemed of high value, might be a program
the ministry itself would fund. An additional challenge to
disseminating the program to other countries is its
mode of delivery and the recruitment of mentors. We
have seen during the COVID‐19 pandemic that it is
difficult to deliver all aspects of the training online. En-
glish proficiency and internet connectivity are further
limitations which caused some difficulties. Therefore,
the program must identify capable mentors from each
local environment who can guide fellows based on their
country‐specific circumstances.
5
|
CONCLUSION
We found promising results from the novel multidisci-
plinary training and mentorship approach implemented
in Ethiopia. Training cadres of surgical teams together
cultivates a culture of teamwork, which is an essential
pillar of safe surgery. Recruiting local mentors makes
the program low cost and sustainable, and fosters
mentorship experience among local professionals as
well. This fellowship exemplifies such training models
can be successful in enhancing knowledge, skill,
behavior, and culture regarding safe surgical practices.
We believe the fellowship program can easily be
adapted and expanded for use in other low‐income
settings.
AUTHOR CONTRIBUTIONS
Samuel Negash: Conceptualization, data curation,
formal analysis, investigation, methodology, project
administration, supervision, visualization, writing –
original draft, writing – review & editing. Nichole Starr:
Conceptualization, data curation, methodology, project
administration, visualization, writing – original draft,
writing – review & editing. Samuel Mesfin: Formal
analysis, investigation, writing – review &
editing. Thomas G. Weiser: Conceptualization,
methodology, project administration, supervision,
writing – review & editing. Tihitena Mammo Negussie:
Conceptualization, methodology, project administra-
tion, supervision, writing – review & editing.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of
Alex Haynex, Kris Torgeson, Miliard Derbew, Katie
Fernandez, Senait Bitew, Milena Abreha, Natnael
Gebeyehu, and Assefa Tesfaye.
CONFLICT OF INTEREST STATEMENT
No conflicts of interest or disclosures.
DATA AVAILABILITY STATEMENT
The qualitative data generated from in‐depth interviews
in this study are not publicly available to ensure confi-
dentiality and privacy of the participants. However, ex-
cerpts or anonymized portions of the transcripts may be
available upon reasonable request. Requests should
be directed to the corresponding author.
ETHICS STATEMENT
Ethical approval was obtained from the college of
health sciences at Addis Ababa University Ethiopia.
Participants were provided informed consent, and
measures were taken to uphold confidentiality.
ORCID
Samuel Negash
https://orcid.org/0000-0001-7660-
6912
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AUTHOR BIOGRAPHIES
Samuel Negash is a pediatric surgeon at Menelik II
hospital, Addis Ababa, Ethiopia. He is a former
fellow with Lifebox and University of California cen-
ter for health equity in surgery and anesthesia.
Nichole Starr is a Trauma and Surgical critical care
Fellow at the University of California, San Francisco
and Zuckerberg San Francisco General Hospital.
She is a former safe surgeryfellow with Lifebox and
NIH/Fogarty Fellow. She currently serves as Surgi-
cal Advisory for Lifebox.
Samuel Mesfin is a medical graduate from Addis
Ababa University. He is a global surgery enthusiast
currently serving as the co‐president of the Global
Cardiac Surgery Initiative (GCSI).
Thomas G. Weiser is a clinical professor in the
department of surgery at Stanford University. He is a
member of the Board for Lifebox, a charity dedicated
to improving surgical safety worldwide. He is
currently the program director for Welcome Leap
where he leads the SAVE program (Surgery: Ac-
cess/Validate/Expand).
Tihitena Mammo Negussie is an Associate pro-
fessor of pediatric surgery at Addis Ababa Univer-
sity. She is also the global clinical director at Lifebox
foundation and the president of the Association of
Ethiopian Pediatric Surgeons (AEPS).
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APPENDIX A: IN‐DEPTH INTERVIEW GUIDE
1. How was your experience during the application
and screening process for this fellowship? How
better could the selection process be? Please
explain in detail.
2. Was there a challenge in program delivery that
could be done better in the future? Please explain
in detail.
3. What were the challenges and lessons learned
in relation to the McCaskey Safe Surgery
Fellowship approaches/strategies? (In areas
like contributing to measurable improvement in
the safety and quality of surgery and anesthesia
in a low‐resource setting? Please explain in
detail.)
4. Did the fellowship effectively partner with stake-
holders from health facilities and the government?
How better could the fellowship program engage
them? Please explain in detail.
5. How was the team dynamics of the fellows? Did
you face any challenges?
6. Would you please explain any best practices and
lessons learned in relation to the fellowship's
design and implementation approaches?
7. What are the key factors that require attention to
ensure the sustainability of the McCaskey Safe
Surgery Fellowship initiatives?
8. What were the key challenges that you faced dur-
ing the implementation of the McCaskey Safe
Surgery Fellowship? Please explain any best
practices and the lessons learned regarding how
you dealt with the challenges.
9. How do you rate the capacity‐building program of
the fellowship? Both regarding soft skills and other
science lessons?
10. How effective was the fellowship in addressing the
needs of fellows? Please explain in detail.
11. How was the mentorship process?
12. How often did you meet with your mentors? How
helpful were they? Give examples.
13. Did you face any challenges with the mentors?
How do you think it can be corrected for the future?
14. How satisfied are you with the fellowship program?
Please explain in detail.
15. How better could the program improve its mode/
strategy of implementation and delivery? Please
explain in detail.
16. What changes would make similar fellowship pro-
grams more efficient? Please explain in detail.
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