Background: Surgical site infections (SSIs) are a burden on healthcare systems worldwide, particularly in low-income countries. The Lifebox Clean Cut program prevents SSI through strengthening adherence to infection prevention and control (IPC) measures. We aimed to identify and classify key gaps in IPC within hospitals where the Clean Cut program was implemented. 

Methods: We used the Burke-Litwin Causal Model of Organizational Performance and Change to identify and classify gaps in IPC measures identified through a retrospective review of program materials such as surveys, field notes, process maps and action plans. This model was chosen because it allows analysis of both system-level leadership and day-to-day operational gaps. Data were included from 35 hospitals across 11 countries where Clean Cut had been implemented. We compared hospitals by type: referral (n=25) vs. district (n=10), General Clean Cut (n=22) vs. Cesarean Section (n=9) vs. Long Bone Fracture (n=3) vs. Cleft Lip & Palate (n=1), compliance rates, and whether gaps needed financial support to be addressed. An example of a gap that did not need financial support to be addressed is lack of knowledge in the benefit of using surgical safety checklist, while an example of a gap that needs financial support to be addressed is the desired antibiotics not being available.

Results: Referral hospitals showed greater deficiencies in surgical instrument reprocessing (P=0.021), and organizational culture (P=0.049) compared to district hospitals. When comparing hospitals with compliance rates to Clean Cut’s quality improvement program against ones with low compliance rates, there were no statistically significant differences found within the modified Burke-Litwin framework. There was no significant association between the degree of compliance with Clean Cut and prevalence of gaps requiring financial support to be addressed.  

Conclusions: Bolstering leadership, focused training and education programs, and strengthened infrastructure can reduce SSI rates within low-resource settings. Our findings help inform policy advancements at the hospital, national and international levels.