Implementation of Trauma Quality Improvement in Cameroon: A Qualitative Stakeholder Analysis

Trauma quality improvement (QI) is an integral part of trauma systems development but has had limited uptake in low- and middle-income countries. Stakeholder buy-in is critical to QI implementation. In 2019, a trauma QI program was implemented in four hospitals in Cameroon. Following program completion, participants were interviewed to understand the perceived value of QI, effects of project participation on care at their respective hospitals, and to identify facilitators and barriers to program success.

The initial program formed a multidisciplinary committee composed of 24 clinical staff and administrators who received training in QI methodology, then met regularly for 2 y to conduct root cause analyses of trauma-related morbidity and mortality. For this study, in-person semi-structured interviews were conducted in English or French with members regarding their views of the program, implementation barriers and facilitators, and changes in clinical practice they observed. Audio recordings were transcribed (and translated as necessary), coded for themes inductively, and analyzed by three independent coders.

A total of 16 committee members were interviewed. Perceived results of participation in the QI program included a heightened sense of professional responsibility and a deeper understanding of the overall health system. Patient care was felt to have improved through standardization of emergency care, reduced temporal delays, and better allocation of human resources. Reported improvements in clinical performance centered around vital signs collection and performance of the primary and secondary survey. Participants found discussions of cases from peer institutions especially valuable. However, systemic resource limitations were frequently cited as preventing full implementation of lessons learned through the QI process. Other challenges included negative perceptions of the program by nonparticipating hospital staff and occasional censorship of case reports by supervising clinicians involved in care under review. Strategies suggested to optimize future QI-related efforts included maintaining a nonpunitive culture within QI meetings, inviting a greater number of clinical/nonadministrative staff, and enhancing incentives for committee participation.

Despite implementation barriers, trauma QI was perceived by program participants as effective in strengthening workforce capacity and producing tangible care improvements at partner hospitals in Cameroon. Interviews identified key factors necessary for successful implementation of hospital-based QI programs in low- and middle-income countries, such as alignment of recommendations with local feasibility and prioritization of staff inclusiveness.