Introduction

Injury is a major global public health problem. Each year, 5.8 million people die from injury, and many more are disabled [1, 2]. The burden is especially large in low and middle income countries (LMIC), where over 90 % of injury deaths occur [1, 3, 4]. To lower this unacceptable burden, a spectrum of actions is needed, including better surveillance and research, increased implementation of road safety and other forms of injury prevention, and strengthening of trauma care (care of the injured) [5].

Quality improvement (QI) programs have been shown to be valuable administrative tools with which to strengthen the care of severely injured patients in trauma centers and trauma systems in high income countries (HIC) [6]. They have also shown promise as a means of lowering trauma mortality in LMIC, at an affordable cost and in a sustainable fashion [6, 7]. However, beyond the activities of some local champions, very little is known about the status of current trauma QI activities or the challenges to improving the quality of trauma care in LMIC [8].

We therefore organized a two day meeting with senior and influential leaders directly involved with the organization of trauma services in both a clinical and administrative capacity from a range of LMIC across the Asia–Pacific region to explore opportunities to improve QI activities. The primary aim of the study was to review trauma QI practices in LMIC, identify gaps in existing practices, explore barriers to QI, and develop potential strategies by which to address these challenges.

Materials and methods

This study was conducted using a mixed methods methodology [9]. First, meeting participants were administered a pre-meeting survey [10]. Second, a facilitated meeting using open-ended questions was conducted and recorded for qualitative analysis [11]. Four specific questions pertaining to trauma QI in LMIC across the Asia–Pacific region were addressed:

  1. (1)

    What trauma QI practices are currently employed?

  2. (2)

    What are the perceived gaps in current trauma QI practices?

  3. (3)

    What are the perceived barriers to trauma QI?

  4. (4)

    What potential strategies could be implemented to address the perceived gaps and barriers to trauma QI?

Participants

Purposive sampling was employed to invite to participants who had demonstrated leadership in the delivery and/or improvement of trauma care, and who had diverse expertise and roles in countries within the World Health Organization’s (WHO) South-East Asia (SEAR) and Western Pacific Regions (WPR) [12, 13]. The SEAR and WPR regions were selected to limit the geographic scope of the meeting, facilitate participant travel in conjunction with the National Trauma Research Institute/Australasian Trauma Society’s annual scientific congress, Trauma 2010 [14], and to promote ongoing regional collaboration. It was anticipated that the participants would act as leaders, promoting trauma QI programs in their own countries and the region (Appendix 1).

Data collection

Data were collected in November 2010 by pre-meeting survey and recording of meeting observations and deliberations (written minutes and audiotape transcripts) [10, 11]. An electronic survey mailed to participants was designed to collect basic professional information, current injury care resources, and trauma QI activities, and to solicit information about gaps and barriers to trauma QI in LMIC [10] (Appendix 2). The survey instrument was developed from semi-structured interviews with injury and quality of care experts, and it was pre-tested to assess face validity, clarity, length, and completeness [10, 15].

The agenda for the two day meeting, facilitated by the investigators, included a presentation of background information collected from the survey and discussion of gaps and barriers to trauma QI and strategies to address these challenges [11, 16]. Participants were organized into small country-based groups in which they discussed meeting questions and then presented their ideas to the larger group [17]. Ideas contributed by participants were noted by the investigators; similar small group suggestions were collated and further discussed by the larger group [12]. Support staff who manually documented deliberations and decisions compared findings and resolved any differences. The audio tape recording of the meeting was transcribed verbatim.

Data analysis

Data analysis was performed in two phases: a descriptive summary of survey data followed by qualitative analysis of the meeting proceedings [10, 11, 18]. First, survey data were summarized using proportions. Statistical analyses were performed with a statistical software package (Stata version 10.0 StataCorp, College Station, TX). Second, two investigators (H.T.S., R.G.) independently (to increase reliability) analyzed the content of the meeting proceedings (minutes and transcripts) according to standard principles of qualitative research, drawing on inductive thematic analysis [11, 18]. Codes were grouped into categories. From the categories, concepts were developed to support a theory. The goal of the analyses was to identify gaps in existing trauma QI practices, explore barriers to QI, and identify potential strategies with which to address these challenges. Ethics approval was obtained from the University of Calgary’s Conjoint Ethics Review Committee. Workshop participants provided written consent.

Results

Twenty-two participants from seven LMIC (China, India, Malaysia, Philippines, Sri Lanka, Thailand, Vietnam—representing over 85 % of the population in the SEAR [1.5 billion people] and WPR [1.6 billion people]) attended the meeting, as did eight observers and facilitators from Australia and Canada (Appendix 1) [19]. Participants were surgeons (n = 13), emergency medicine physicians (n = 7), and nurses (n = 2) who worked in capital cities (n = 13) or regional centers (n = 9) and had experience in trauma QI (n = 13). Participants summarized their perceptions of existing trauma QI practices in their countries (Table 1). Practices varied between countries and the capital cities, regional centers, and rural areas within countries. Injury data collection and QI practices were reported to be most common in capital cities and regional centers. Morbidity and mortality conferences were the most frequently reported QI activity. A few participants reported the use of preventable death studies, quality of care audits, audit filters, and statistical analyses of injury morbidity and mortality.

Table 1 Participant reporting of trauma quality improvement practices in Asia–Pacific
Full size table

The results from our qualitative analyses are organized into three parts: description of perceived gaps in existing trauma QI practices (Table 2), identification of perceived barriers to trauma QI (Table 2), and presentation of potential strategies to improve trauma QI (Table 3).

Table 2 Trauma quality improvement gaps and barriers
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Table 3 Potential strategies to improve trauma quality improvement
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Gaps in existing trauma quality improvement practices

Paucity of reliable and valid injury data

Discussion about the challenges of obtaining reliable and valid injury data arose among the participants. Injury data collection varied between countries, with some having advanced systems of data collection and others working on implementing data collection. QI activities were reported to be limited by existing data, chiefly, a lack of data registries, limited data elements within registries, data collection errors, and limited documentation within medical records (e.g., adverse events). Existing organization of medical records and the absence of electronic tools (e.g., electronic patient lists) was felt to be an important limitation for data collection. Participants highlighted a lack of consensus about what kinds of data are required for QI and how data elements are defined. An important question for many participants was who should be responsible for data recording: health care providers, researchers, dedicated QI staff, or non-health care related organizations such as police or security organizations. Finally, some participants indicated that there was a lack of awareness about data such that existing data were sub-optimally incorporated into trauma QI.

“We need data. You say that you are providing good quality care, but how do you prove that? Thailand showed that their survival rates were quite high, but then further lowered their mortality and had data to show it.”

Lack of integrated trauma quality improvement activities

All participants indicated that trauma QI activities are being performed in their countries, but that there is room for improvement. Specifically, participants reported that many activities are performed in isolation by individual clinical departments, disciplines, or organizations with limited cooperation between stakeholders. For example, morbidity and mortality conferences are frequently performed within individual clinical departments, but without representation by other professionals who also participated in patient care. One explanation for a “silo” approach to QI was that groups were “protective of their turf.” As a result, actions taken to address quality concerns (“loop closure”) were reported to be suboptimal.

“Trauma quality improvement requires an integrated approach, but there is currently a lack of communication, preventing quality improvement across the spectrum … Each Department has its own morbidity and mortality conference … so you have the neurosurgeons [with] their own approach, [and] the general surgeons [with] their own approach, but they do not talk to each other.”

Absence of standards of care

Several participants raised the issue of a lack of standards of care. For them, the absence of quality of trauma care standards makes QI difficult and produces variation between individual clinicians and organizations. This gap was further complicated by a lack of perceived accountability for quality of care.

“What are [the] minimum acceptable standards of care? We don’t have any. Hospitals are unwilling to set quality of care standards and explore their weaknesses.”

Lack of training in quality improvement methods

Limited training and experience with QI was reported as another important gap in existing systems. Participants indicated that most clinicians are unfamiliar with QI, do not understand QI terminology, and may not even be aware of the role of QI in improving patient care. Education of clinicians in basic QI concepts and the role that QI programs can provide was perceived to be very important.

“People do not know what quality improvement is. I represent the best of the hospital[s] in my country, but before I came here, if you would have asked me what quality improvement is, I did not know what I would discuss.”

Limited organizational cultures of quality and safety

Participants from different countries and regions within countries described a diversity of health care cultures. However, a common theme was that quality and safety of patient care were generally not important components of the culture. Some participants described their health care cultures using terms such as “hierarchical,” “reactive,” or “punitive.” Some organizations were reported to be unwilling to explore controversies or deficiencies in the care provided to injured patients, fearing criticism or legal rebuke. These factors contributed in some countries to suspicion of QI and an unwillingness to accept recommendations for QI.

“I have worked in different parts of the [country] throughout my career and I have not seen a single place where [trauma QI] is positively oriented… It leads [to] hierarchical traditions especially in surgeons. When the senior consultant talks it is the end of the story. This is how the system exists.”

Barriers to trauma quality improvement

Limited engagement of leaders

Participants indicated that QI was a low priority in most countries. They indicated that clinical and organizational leaders provided varying degrees of support for the concept, but were primarily focused on other health care issues. Limited ability to engage leaders in trauma QI makes it difficult to obtain commitment from health ministries, to encourage administrations to participate in QI, or to foster communication, coordination, and networking of clinical groups.

Organizational diversity

Participants noted that considerable diversity in QI and clinical care existed between countries and between organizations within countries. Infrastructure, funding, and organization of both clinical work and QI were noted to vary. This was complicated by large differences in patient populations and clinical workload. Furthermore, in many countries central coordination of trauma care was reported to be limited. Participants highlighted that patient care should be adapted to local circumstances, but that the absence of uniform policies, guidelines, and protocols impairs communication among centers and creates a barrier to effective trauma QI. Without a common approach, QI is very difficult.

Limited resources

Resource limitations were universally described as an important barrier to trauma QI and included limited funding, lack of trained clinical and QI personnel, limited facilities and equipment, and in some cases a lack of dedicated trauma services. Some participants noted that resource limitations placed important time constraints on QI activities. Others reported that QI was simply not feasible given the resources available. Limited infrastructure presents challenges in establishing mechanisms for the development and maintenance of trauma registries, even to the point that there are no personnel for data entry. Participants highlighted the challenges of prioritizing the use of limited resources to provide patient care versus improving the quality of patient care.

“In a country where there’s no money, I am sure that the ministry will not spend their money [on QI]. Where do you want to spend the money, in patient care or data care?”

Heavy clinical workload

Participants described large volumes of clinical work as an important barrier to effective QI. Some indicated that their institutions were responsible for providing care for large populations of patients relative to the number of available providers. This severely restricts available time for activities other than direct patient care. To complicate matters, financial reimbursement schedules discourage QI. Participants perceived that other clinical activities were reimbursed at higher levels than providing trauma care, and that QI activities are reimbursed at even lower levels, if at all. As a result, key clinicians are infrequently available to review deaths or adverse events, or to address other quality of care concerns, let alone to develop new QI strategies.

“All cases cannot be discussed [at morbidity and mortality conference] because of the volume… If we had two or three patients that is fine, but we have 30–40 deaths in a month, and if we do a meeting once in 3 months for 3 h how many patients can you discuss? It is just impossible.”

Medico-legal concerns

A minority of participants identified medico-legal worries as an important barrier to QI. They indicated that concerns about legal discovery limited the scope of QI activities in an important way. For example, in some institutions morbidity and mortality findings were restricted to departmental members, never shared outside of the department. Similarly, in other organizations QI activities, including morbidity and mortality conferences, were purposefully “not documented” to protect participants from discovery.

“The most common excuse for not documenting these [morbidity and mortality conferences] is access of data for [litigation] purposes.”

Potential strategies to improve trauma quality improvement

Support network for trauma quality improvement

Participants identified the value of meeting with colleagues from different centers and countries as a mechanism for improving trauma QI. Specifically, they noted that establishing a support network would improve trauma QI through several mechanisms: (1) alleviate what many perceived as working in isolation with limited support from local colleagues or organizations, (2) provide opportunities for learning from the experiences of other participants, (3) motivate participants to improve local QI programs, (4) provide opportunities for coordinating QI activities so as to explore economies of scale (e.g., data management software) or potential for implementing standard policies (e.g., guideline implementation), (5) facilitate QI education and continuing medical education through workshops or courses, (6) help participants explore approaches for supporting local QI activities, and (7) promote a better understanding of QI in the field of trauma. Participants concluded the meeting by establishing the Asia–Pacific Trauma Quality Improvement Network (APTQIN).

Engage leadership

Participants identified the importance of engaging institutional leadership to promote high quality trauma care. Suggestions to accomplish this included adding trauma to the scope of existing non-trauma QI activities (e.g., hospital quality and safety teams), establishing infrastructure (e.g., multidisciplinary trauma committee) to attract participants in QI, identifying and targeting key administrators or clinicians as potential leaders in the effort, identifying local and national organizations with relevant interests that may provide guidance or support the goals of QI, and gathering people with a mutual interest in QI. A response to these suggestions would allow for the establishment of critical masses of like-minded individuals to work toward improving the quality and safety of trauma care.

“We also agreed that we should identify key [people] when we go back there and that is not exclusive to surgeons… critical mass is not the number, it is the personality that is involved…”

Education

Participants identified the importance of advancing trauma QI through educational efforts, particularly by increasing awareness of QI among health providers. Participants identified three specific education goals: (i) Recruit and educate individuals for specific QI activities to improve the quantity and quality of personnel working in QI. This should include instruction in how to analyze and use data for understanding injury patterns and advocacy, and should lead to establishment of QI administration programs. (ii) Work on changing the culture of organizations through promoting greater awareness of QI among staff. Such an effort would foster a culture of safety and quality. (iii) Train future champions and leaders of trauma QI using a two pronged strategy: (1) incorporate QI training into frequently held trauma conferences through workshops or pre-conference courses, and (2) introduce QI into undergraduate and specialist medical education so as to familiarize clinicians with basic terminology and concepts.

Standardize injury data

Establishing standardized injury data was identified as a key strategy. Meeting participants outlined that agreement on a reliable and valid data systems was paramount for trauma QI. Specifically, this would include decision on a minimal data set, key performance indicators, identification of appropriate low cost software options, development of standardized and simple data collection forms, electronic recording of data if possible, establishment of local and central trauma registries with dedicated data entry personnel, and data quality checks and training and awareness around data utilization, including benchmarking. In addition, participants highlighted the need for updating existing measures of quality of care.

“Integrating injury surveillance data collection with trauma quality improvement data collection is an important way to get quality improvement. We need to establish trauma registry minimum data requirements, develop registries and get assistance on how to use the data.”

Pilot projects

Participants identified the importance of establishing pilot QI projects that could serve as tests and demonstrations for QI. Finding small sums of money to support pilot projects was thought to be more feasible than targeting larger more expensive QI activities. Furthermore, successful projects that were shown to be feasible and associated with improved care could plausibly attract additional resources. Participants highlighted the work of Dr. Chadbunchachai from Thailand as an excellent example of how to build trauma QI in small incremental steps from the ground up [7, 20, 21].

“A small fund in the beginning allowed us to provide documents and help train personnel and hospital clinicians. … We had a group of only two doctors and a couple of nurses. We started a small simple project to establish an information system … we were able to get some skill [and obtain] a second period of support for inter-hospital triage process improvement. This was the beginning.”

Discussion

Principal findings

This article provides the first description of perceived gaps and barriers to trauma QI and potential strategies to address these challenges in LMIC of the Asia–Pacific region. The results are derived from both quantitative (pre-meeting survey) and qualitative (thematic analysis of meeting transcripts) analyses of a meeting of senior and influential leaders to explore opportunities to improve trauma QI activities in LMIC of the Asia–Pacific region. Participants reported that trauma QI activities are currently performed to varying degrees in different countries and different institutions and organizations within countries. Trauma QI gaps and barriers identified included limited injury data, lack of training in QI methods, heavy clinical workloads, and organizational cultures focused on medico-legal worries. Opportunities to improve and expand existing trauma QI activities were identified and included collection of reliable and valid injury data, training providers in QI methods, development of integrated QI programs, and encouraging organizational cultures of quality and safety. A regional trauma QI network was identified as a potential tool to support local and regional activities, and participants agreed to establish the APTQIN.

The results of our study need to be considered within the context of the existing literature. Previous studies have demonstrated that there are large discrepancies in injury outcomes between countries of different economic levels. For example, Mock et al. [22] reported overall mortality rates among severely injured patients (defined as injury severity score ≥9) of 35 % in the United States (high-income), 55 % in Mexico (middle-income), and 63 % in Ghana (low income). Similarly, in a study of patients with injury severity scores 15–24, mortality was six times higher for patients in low income locations than in high income locations [23]. Improvements in injury control have significantly lowered rates of injury-related deaths in many HIC [24, 25]. These have been achieved across the spectrum of injury control, ranging from surveillance and primary prevention to medical management from the moment of injury to the time of recovery. Larger opportunities for improvement exist in LMIC, where injury rates are far higher than in HIC, and where most of the world’s people live and only limited injury control activities have been undertaken.

Our study adds to the existing literature by highlighting opportunities to improve trauma care in LMCI through trauma QI practices (many of which could also be applied in HIC). First, standardizing injury data is a first step in improving injury care. Injury control activities cannot be effectively conducted without adequate assessments of their impact [25]. Development of reliable and valid minimal data sets that include key performance indicators are essential for effective injury surveillance, targeting interventions, and assessing their success or failure. Implementation of simple and standardized data collection forms and basic software programs need not be expensive. Second, increasing awareness and understanding of QI among health providers and organizational leaders is important for effective QI. For example, the essential trauma care project is an effort to set low-cost minimum standards for trauma care services worldwide [26]. Education could encourage local implementation of QI efforts, evaluation of their effectiveness (and modification for local needs), and it could also engender a culture of safety and quality in injury care within local resource constraints. Third, engaging people in leadership roles to understand the importance of injury-associated morbidity and mortality is likely to promote better quality of care and greater injury control efforts. Organizational leadership that understands the ramifications of injury are more likely to drive QI efforts and demonstrate interest in prevention strategies [25]. Fourth, although QI efforts need to be locally responsive, there is tremendous opportunity for capacity-building through strategic alliances at national and regional levels. The APTQIN aims to support local QI efforts by providing a forum for knowledge and experience exchange, increasing QI capacity through workshops and training and coordinating the development and dissemination of trauma QI tools.

Limitations of the method

There are several limitations to this study. First, participants were from capital cities and regional centers in LMIC of the Asia–Pacific region, and thus the findings may not be generalizable to other settings. Second, some people may question whether sampling 22 participants from seven countries reflects the views of health care providers in the countries of Asia–Pacific. However, purposive sampling of participants was employed to ensure representation of diverse expertise, roles, and organizations. Furthermore, saturation of themes occurred during analysis of the meeting proceedings, suggesting that it is unlikely that important concepts were missed [11, 18]. Third, our study only included physicians and nurses, although they are key front line health providers of trauma care. Fourth, research studies employing mixed methods have not been frequently reported in the trauma literature and may be unfamiliar to readers. Nevertheless, these reliable and valid methodologies [9, 11, 18] have been used successfully in health services research [27–29].

Conclusions

Around the world, countries are faced with a quietly growing injury epidemic [1, 2]. Yet remarkably, little is known about trauma QI programs in LMIC. Our mixed methods study involved a landmark meeting of multiple key stakeholders from seven countries across the Asia–Pacific region and achieved a record of gaps, barriers, and strategies for trauma QI. Participants agreed to build on current trauma QI activities in their own institutions, and to provide leadership in the spread of trauma QI program development across the region by establishing the APTQIN. The network will focus on expanding QI activities using a region-wide approach tailored to local settings by assisting members in disseminating trauma QI materials, promoting collaborations, and facilitating linkages with participants, institutions and organizations, and countries not represented at the meeting as an important step toward reducing the burden of injury in LMIC.