• Shehnaz Alidina, Noor Zanial, John G Meara, David Barash, Ladislaus Buberwa, Bwire Chirangi, Augustino Hellar, Steve Kisakye, Adelina Mazhiqi, William Mnyonyela, Meck P Nyanda, Cheri Reynolds, Florian Tinuga, Ntuli A Kapologwe, and Sarah Maongezi.
• Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School. Electronic address: Shehnaz_Alidina@hms.harvard.edu.
• J. Am. Coll. Surg. 2021 Aug 1; 233 (2): 177-191.e5.

BackgroundAccess to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality.MethodsWe used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method.ResultsIn the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period.ConclusionsExamining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.

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