World Journal of Surgery

, Volume 43, Issue 1, pp 16–23 | Cite as

Safety Culture and Perioperative Quality at the Volta River Authority Hospital in Akosombo, Ghana

  • Katherine Smiley
  • Love Ofori
  • Cindy Spangler
  • Rebecca Acquaah-Arhin
  • Deborah Deh
  • Juliana Enos
  • Stephen Manortey
  • Frank Baiden
  • Samuel Finlayson
  • Raymond Price
  • Marta McCrumEmail author
Original Scientific Report



The Volta River Authority Hospital (VRAH) is a district hospital associated with a large public works project in Akosombo, Ghana, that has developed a reputation for high-quality care. We hypothesized that this stems from a culture of safety and standardized processes typical of high-risk engineering environments. To investigate this, we evaluated staff and patient perceptions of safety and quality, as well as perioperative process variability.

Materials and methods

The Safety Attitudes Questionnaire (SAQ) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to evaluate staff and patient perceptions of safety. Perioperative general surgery and obstetrical procedure observations generated process maps, which were analyzed for variability and waste.


Thirty-one SAQs were administered. 83% of workers held a positive perception of teamwork, and 77.4% held a positive perception of safety culture. Fifteen HCAHPS surveys of surgical inpatients showed a median hospital rating of 10 [IQR 8.5–10] on a ten-point scale. 90% gave maximal scores for pain management and 84.4% for nurse communication. Ten general surgery and obstetrical procedures were observed for which process map analysis was notable for no consistent waste steps and 100% adherence to the World Health Organization Safe Surgery Checklist.


Surveys suggest an institutional commitment to safety with strong teamwork culture and patient communication. Perioperative process mapping supports this culture, with low levels of variability and waste, and is useful for evaluating standardization of care. VRAH demonstrates the feasibility of delivering high standards of perioperative care in a low-resource setting.



The authors would like to acknowledge Clinical Investigators Dr. Charles Arhinful and Dr. Tarus Valmont who provided and cared for study patients and were instrumental in accessing surgical facilities at the Volta River Authority Hospital. We would also like to acknowledge Jill Rhead Bednarik for her assistance in preparing the process mapping figures for the manuscript. There are no external funding sources or conflicts of interest to report for any author.


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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Katherine Smiley
    • 1
  • Love Ofori
    • 2
  • Cindy Spangler
    • 1
  • Rebecca Acquaah-Arhin
    • 2
  • Deborah Deh
    • 3
  • Juliana Enos
    • 3
  • Stephen Manortey
    • 3
  • Frank Baiden
    • 4
  • Samuel Finlayson
    • 1
  • Raymond Price
    • 1
  • Marta McCrum
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of Utah Center for Global SurgerySalt Lake CityUSA
  2. 2.Electro Volta HouseVolta River Authority HospitalAccraGhana
  3. 3.Ensign College of Public HealthAkosomboGhana
  4. 4.Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK

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