• Jared A Forrester, Luca A Koritsanszky, Demisew Amenu, Alex B Haynes, William R Berry, Seifu Alemu, Fekadu Jiru, and Thomas G Weiser.
• Department of Surgery, Stanford University, Stanford, CA; Lifebox Foundation, Ariadne Labs, Brigham. Electronic address: jaredf2@stanford.edu.
• J. Am. Coll. Surg. 2018 Jun 1; 226 (6): 1103-1116.e3.

BackgroundSurgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety.Study DesignWe introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements.ResultsProcess mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals.ConclusionsEnumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs.Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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