In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a ‘portfolio’ approach to safety improvement in four broad categories: prioritizing critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognized as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organizations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

‘In many clinical settings in LRS, it may be simply not feasible to follow all professional guidelines, so decisions must be made about what is a ‘must do’ and what is ‘do if possible’ among a huge number of potential things to do.’

This last observation is hugely important. One of the key characteristics of useful healthcare information is that it should be actionable. Ideally, clinical guidelines should be implementable with the resources available in the setting where they are used. I would be interested to hear people’s experience in this regard. On the one hand, there is a real problem if the guidance is written with the assumption that the health facility is well resourced. There is also the clinical challenge of what to do in fluctuating settings, for example where there is a stock-out of the antibiotic that is indicated for a case of sepsis, or where there is no oxygen available for a patient with severe COVID-19.

Should there be more emphasis on guideline development for low-resource settings? Should guidance routinely say, “If X is not available, do Y”? Clinical judgement in these settings requires a high degree of expertise – how can health workers be better supported in such decision-making?…more