In November 2018, this column introduced readers to the ACS-COSECSA Surgical Training Collaborative, a joint initiative between the American College of Surgeons (ACS), the College of Surgeons of East, Central and Southern Africa (COSECSA), Hawassa University College of Medicine and Health Sciences, and 13 U.S. institutions that have surgical faculty engaged in global health.* In this month’s column, we describe the progress that has been made in pilot testing this program at Hawassa University in Ethiopia.
Background
As previously reported, the ACS Board of Regents approved an ACS global engagement strategy developed in 2017−2018. The Operation Giving Back (OGB) Committee on Global Engagement recommended a pilot project in collaboration with COSECSA to establish a centralized training hub where the quality of surgical training could be improved and the number of trainees could be scaled up.
The goal of this collaborative is to collectively develop a surgical training center of excellence that can better serve the region by providing opportunities to increase the surgical workforce, transfer knowledge and skills, and build the infrastructure for better patient care and research. This collaborative is based on the principles of twinning partnership, where shared goals are collectively developed, long-term institutional commitment is emphasized, responsibility is shared, and mutual benefit is acknowledged. This partnership was supported by policy leaders at the Ethiopian Ministry of Health and Hawassa University leadership.
After a series of exploratory trips, representatives of the ACS, Hawassa University, and the 13 partner institutions met in July 2018 at ACS headquarters in Chicago, IL, to discuss shared goals and to devise a workplan for the coming year. Four pillars of focus emerged: clinical care, quality, research, and education. Several strengths were identified, including the skills and hospitality of Hawassa faculty, willingness to collaborate, and knowledge base. Areas for improvement included operating room (OR) functionality and capacity, equipment/supplies availability and maintenance, and team-based learning to include other specialty areas, such as nursing and anesthesia.
Progress to date
The pilot ran from early January through the end of June 2019. Although the six-month pilot was intended to serve as a needs assessment process, several activities were implemented, including the introduction of morbidity and mortality (M&M) conferences, FAST (focused assessment with sonography in trauma) ultrasound training, intraoperative laparoscopic training, and improvement of basic infection protocols, among others. Details about these and other early achievements of this partnership in the four pillars of the program are as follows.
Clinical care
The Hawassa University department of surgery comprises seven general surgeons, one colorectal surgeon, and one pediatric surgeon. The U.S. faculty are involved in all aspects of clinical care, including providing services in the outpatient clinic, participating in inpatient rounds, as well as scrubbing in on OR care.
The first laparoscopic cholecystectomy at Hawassa was performed after one of the ACS volunteers, Marc De Moya, MD, FACS, Medical College of Wisconsin, Milwaukee, identified a functioning laparoscopic tower in the storage area. This procedure is now available with the help of our U.S. volunteers, and all the general surgeons at Hawassa University are being trained in the simulation lab in the fundamentals of laparoscopy.
Other first-time procedures include low anterior resection, extended neck dissection, and pancreatic resection. Principles of Advanced Trauma Life Support® also have been introduced to improve care for severely injured patients.
Quality
As surgeons, our core value is to promote a culture of quality in our institutions. Through this collaborative, the Hawassa University department of surgery has begun convening weekly M&M conferences. This initiative launched in February 2019 with support and mentoring from Abier Abdelnaby, MD, FACS, a faculty member from the University of Texas Southwestern, Dallas, who also is looking forward to implementing the principles outlined in the ACS Red Book, Optimal Resources for Surgical Quality and Safety.
Understanding that appropriate documentation is a fundamental component of ensuring quality of care, the local surgical faculty is adopting and customizing some of the U.S. operative report formats. The early foundations of quality assurance processes are being laid, as evidenced by the fact that baseline understanding of surgical infection rates and other complications are being documented to systematically address shortcomings.
Research
A research infrastructure is in development, starting with a basic research methodology course and assessment of the available research infrastructure. This initiative is supported by a taskforce led by Mary “Libby” Schroeder, MD, FACS, department of surgery, Rutgers New Jersey Medical School, Newark. The partnership has a collective goal of submitting five major manuscripts and publishing 10 case reports in this academic year. In addition, a trauma database is in development.
Education
The Education Workgroup, led by Edgar Rodas, MD, FACS, Virginia Commonwealth University, Richmond, has developed a detailed plan, which has led to the initiation of the following activities:
- Formation of a biweekly journal club, which launched in September 2019 and is led by the U.S. volunteers
- Biweekly didactic seminars scheduled to match the expertise of on-the-ground U.S. volunteers
- Simulation center standardization and training in Trauma Evaluation and Management, laparoscopy, basic surgical skills, and so on
- FAST ultrasound training for all surgical residents, which has significantly improved the assessment and care of surgical patients
- U.S. volunteer participation in a structured inpatient care and outpatient service
- Acute care surgeon participation in critical care services and education
In addition, we have established a philanthropy workgroup that has been hard at work identifying material support for this partnership. Under the leadership of Richard Caplan, MD, FACS, department of surgery, Houston Methodist, TX, hundreds of pounds of medical equipment have been delivered. The training center is seeking to build meaningful partnerships with industry and other nongovernmental organizations leading efforts to improve global health.
Moving forward
In the course of just one year, the ACS-COSECSA Surgical Training Collaborative has made great strides toward improving the training of surgical residents and the quality of care provided to surgical patients at Hawassa University. As Joseph Sakran, MD, MPA, MPH, FACS, faculty from Johns Hopkins University, Baltimore, MD, said, “With over 20 million Ethiopians receiving care at Hawassa, the ACS, along with other partners, has had the opportunity to begin transforming surgical care in this region. While the collaboration is at its infancy, what’s clear is the importance of the programmatic infrastructure being laid down that will ensure long-term sustainable interventions that will ensure capacity building within the region.”
Adding strong surgical services to any medical facility strengthens the whole system and guarantees sustainability. As the work at Hawassa University continues, plans are under way to establish a surgical training hub in other low-income regions. Our goal is to mitigate the negative health care consequences of living in under-resourced parts of the world for surgical patients and to expose U.S. surgeons and residents to techniques they can apply to improve value-based care at their home institutions. This initiative epitomizes how much good a small group of caring individuals can accomplish when they join forces to achieve a common goal. The ACS-OGB program is looking forward to working with other interested academic global surgery programs to develop additional collaboratives in other parts of the world.
If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.
*Hoyt DB. Looking forward. Bull Am Coll Surg. 2018;103(11):9-11. Available at: bulletin.facs.org/2018/11/looking-forward-november-2018/. Accessed January 6, 2020.
