Quality assurance in surgery: surgical audit in the developing world.

Surgical audit is an essential component of quality assurance in surgery, particularly in the developing world, where resources and skills are limited. The structure, process and outcome of care can be measured. With regard to structure, in developing countries the delivery of care is influenced by lack of resources and access to surgical skills. The number of operations not being done needs to be estimated as well as the throughput of surgery. With regard to process, ward rounds and writing in case-notes are daily activities which affect the process of care. The use of investigations, particularly ones which are expensive or have risks, should be audited to ensure there is maximum cost-benefit to both the patient and the health care system. Surveys of patient perception of quality are also important. With regard to outcome, surgeons measure quality by auditing complications and mortality. Audit and mortality meetings should be held to discuss problems and how they can be avoided. The factors responsible for 34 deaths at Port Moresby General Hospital are presented. To be reliable, mortality audits should grade illness severity, for example, by using the Glasgow Coma Scale to grade the severity of a head injury. Where mortality rates are low, for example, in patients with fractures, long-term follow-up of disability may be a more appropriate measure of outcome and quality than mortality rates.