The Utility of The Safe Surgery Organizational Readiness Tool Prior to Implementation of Trauma System Strengthening Interventions in Haiti

Injuries impact approximately 4.4 million people worldwide each year, accounting for nearly 8% of all deaths. Surprisingly, injury-related deaths surpass the rates of HIV/AIDS, Malaria, and Tuberculosis [1]. Unfortunately, 90% of these deaths occur in low- and middle-income countries (LMICs). In addition to fatalities, injuries lead to long-term consequences such as chronic pain, disability, and reduced quality of life [2,3]. Trauma systems are defined as coordinated efforts within a specific geographical area to provide comprehensive care for injured patients, integrated with the local public health system [4]. While high-income countries (HICs) have established trauma systems that effectively reduce morbidity and mortality, LMICs face numerous barriers, including limited training and education on quality trauma care, insufficient funding and resources, and a lack of political will and health system support [5-10].

Haiti, a country beset with persistent political, economic, and environmental instability, faces an increased burden of injury due to these adverse circumstances [11-16]. Unfortunately, Haiti’s trauma system is characterized by inadequate prehospital care, limited access to surgical services, and a lack of rehabilitation resources[17-19]. Most trauma patients in Haiti are treated at public hospitals, which often lack the necessary equipment, supplies, and staff to provide adequate care [20,21]. To improve Haiti’s trauma system, it is crucial to strengthen healthcare infrastructure. This includes developing trauma centers and providing sufficient resources for pre-hospital care. Achieving this will require collaboration among the government, international aid organizations, and private healthcare providers. Project Trauma Haiti (PROTRA Haiti) is a multistage initiative led by Haitian Medical Societies and the Program for Global Surgery and Social Change at Harvard Medical School. The goal is to enhance the quality and capacity of trauma care in Haiti by implementing a trauma care intervention package. This package includes primary trauma courses, trauma registries, and morbidity and mortality meetings [22].

The pre-implementation phase of PROTRA Haiti includes the use of the Safe Surgery Organizational Readiness Tool (SSORT) to assess stakeholder perceptions regarding readiness to implement quality improvement interventions. SSORT was developed to evaluate the readiness of surgical facilities in LMICs at the individual, team, and facility levels before implementing interventions. It originated from the Safe Surgery 2020, a multi-component intervention to strengthen health systems and surgical services in Ethiopia, Tanzania, and Cambodia. The qualitative component of this longitudinal study highlighted the importance of organizational readiness prior to health system strengthening interventions and assisted with developing several SSORT domains [23]. The SSORT is now a validated tool with a promising role in enhancing health systems by providing valuable insight to stakeholders [24].

Organizational readiness, as described in the literature, consists of three essential components: (a) motivation to implement an innovation, (b) general capacities of an organization, and (c) innovation-specific capacities required for a particular intervention [25]. Previous research emphasizes the poor organizational readiness of surgical facilities as a critical barrier to intervention implementation in LMICs. Culture has been found to play a pivotal role in successful and sustainable implementation of health innovations. This encompasses multiple dimensions, including organizational culture, incentive structures, and stakeholder attitudes toward innovation adoption [26]. In resource limited areas, issues related to support and engagement across various stakeholder levels, including government, hospital administration, clinicians, and data collectors has been noted as key barriers to trauma registry implementation [27-29].

By obtaining stakeholder perceptions, we can identify Haiti’s trauma system’s unique challenges and opportunities and develop tailored solutions for maximum effectiveness. This requires collaboration among healthcare providers, community leaders, and other stakeholders to ensure that the trauma system meets the needs of Haitian people. This study aimed to evaluate the perceptions of healthcare providers involved in trauma care regarding readiness to implement Primary Trauma Courses, Trauma Registries, and Morbidity & Mortality meetings at Hôpital de l’Université d’État d’Haïti (HUEH).

Study Design and Setting

The health system in Haiti is organized into three levels of care. Primary care is provided by approximately 800 health centers and 45 community reference hospitals. Secondary care is delivered by 10 departmental hospitals. Tertiary care is available at three specialized centers and five university hospitals [30]. HUEH, the largest public hospital in Haiti, houses 14 medical departments and serves as the primary educational hub for Haiti’s Faculty of Medicine and Pharmacy of the Haitian State University, underscoring its central role in the country’s healthcare infrastructure [31]. The hospital had undergone substantial reconstruction and renovation following the 2010 earthquake. However, in early 2025, an arson attack on HUEH significantly impacted health service delivery. Preparation for the reopening of HUEH, presents an opportunity for implementing robust trauma care training and delivery to serve the densely populated surrounding neighborhoods currently experiencing unprecedented volumes of violence-related trauma.

A cross-sectional study design was used to assess organizational readiness at HUEH. Before the start of the study, ethical clearance for Haiti (Project Trauma Haiti) Study: Phase I was obtained from HUEH through IRB Protocol Number: IRB21-1479 to ensure compliance with established ethical standards and regulations for scientific research. Inclusion criteria consisted of healthcare workers directly involved in trauma care in Haiti, specifically those employed at participating healthcare facilities with willingness to participate and provide informed consent. Exclusion criteria encompassed healthcare workers not directly involved in trauma care, administrative staff without clinical responsibilities, temporary staff or volunteers with less than 3 months of service, and individuals unable to complete the assessment tools.

SSORT Survey and Sample

The SSORT is a validated psychometric assessment tool for measuring organizational readiness across nine domains and 28 items at the individual, team, and facility levels (Appendix). Survey takers rated each item on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”[24]. Domains assessed included appropriateness, resistance to change, team efficacy, team valence, team learning orientation, learning environment, communication about change, vision for sustainability, and facility capacity. Purposeful sampling was used to identify participants, including all surgical and anesthesia providers, quality improvement, and leadership staff at HUEH. Due to the prevailing socio-political climate, the Haitian Site investigators conducted the eligibility assessments of prospective participants. These preliminary discussions evaluated whether individuals satisfied the study requirements and gauged their interest in participating. In addition, email and WhatsApp were used to contact participants.

Data Collection

The data were collected between December 2021 and May 2022. Three local Haitian surgical residents were trained to administer the SSORT tool at HUEH. Standardized procedures for data collection and entry were provided to Haitian site investigators. Interviews were conducted by trained Haitian research staff who were fluent in English, Haitian Creole, and French. Survey instruments were available in formally translated Haitian Creole and French versions, which were reviewed by bilingual investigators for linguistic accuracy and cultural appropriateness prior to study initiation. To accommodate varying literacy levels, the questionnaire was read aloud to participants in their preferred language (English, Haitian Creole, or French). Consistency of translation and administration was ensured through investigator training, use of standardized scripts, and ongoing supervision by the study team. Demographic information, including age range, gender, role at the facility, tenure in that role, and tenure at the facility, was also collected. Given the socio-political instability in Haiti, Zoom interviews were provided as an alternative, along with in-person interviews in private rooms, allowing the interviewee to speak freely without interruption. Prior to commencement of the study, consent was obtained, confidentiality was assured, and no identifiers were collected. Incentives were not offered.

Data Analysis

Descriptive statistics (Mean and Interquartile Range) were calculated for each domain. One question with negative phrasing (opposite Likert scale to the remaining questions) was reverse coded prior to analysis. The domains were ranked according to the level of readiness for the trauma intervention, from highest to lowest, with scores of 3 or below identified as areas presenting opportunities to enhance readiness. This dichotomization of 3/5 mark represents the median point of the 5-point Likert scale, providing a boundary for domain categorization.

An exception was made for the “resistance to change” domain, wherein lower resistance-reflected by a lower score-corresponded to a higher level of readiness. The data were analyzed using Microsoft Excel (Version 16.82).

Respondent Characteristics

The respondents’ characteristics are summarized in Table 1. Survey respondents (n = 12) included surgical providers (n = 10, 83.3%), anesthesia providers (n=1, 8.3%), and surgical ward nurses (n = 1, 8.3%). Males made up 75% of the participants, (n=9) and 25% (n=3) were female. The majority (n=10, 83.3%) of the participants reported that they had worked at the facility for 1-5 years. As for time spent in current roles, 50% (n=6) reported 1-5 years, 41.6% (n=5) 10 years (Table 1).

SSORT Analysis

Higher Readiness

Using a 5-point Likert scale (5 = strongly agree), appropriateness (4.23/5), team valence (4.22), and team efficacy (4.00/5) demonstrated the highest levels of readiness and thus primary facilitators for implementation of the proposed intervention. Resistance to change, with a favorably low (inverse) score (1.52/5) indicated a low barrier to implementation of the trauma care package. Team learning orientation (3.98/5), learning environment (3.33/5), and vision of sustainability (3.17/5) revealed encouraging levels of readiness (Table 2) (Figure 1).

Lower Readiness

In contrast to the aforementioned domains which exhibited higher readiness, facility capacity (2.03/5) and communication about change (2.91/5), reflected lower readiness levels, signifying potential barriers to implementation.

Statement of Principal Findings

In preparation for trauma system-strengthening interventions, the SSORT identified areas of adequate readiness for implementation, as well as critical barriers requiring mitigation at HUEH. Encouragingly, individual trauma employees held strong beliefs that the proposed interventions were appropriate, a finding further reinforced by the low resistance to change demonstrated. At the team level, there was a strong consensus that the trauma team values the proposed changes and will execute the required tasks for implementation. However, the most significant barriers were raised as concerns about the facility’s learning environment and resource constraints-specifically funds, human resources, equipment, supplies, infrastructure, and information management.

Additionally, the evaluation results highlighted concerns regarding formal leadership support, communication, and sustainability of the proposal. Before implementation, a new focus will be placed on discussions with facility leadership to address concerns regarding sustainability, facility support, and resource needs. The proposed mitigation strategies include illustrating the value of the intervention regarding patient care and quality improvement metrics, ensuring that interventions will be as efficient as possible to minimize the time spent, and engaging stakeholders at various health system levels to ensure multilevel by-in.

Interpretation Within the Context of the Wider Literature

The findings of this study align with current literature on readiness for health intervention implementation in resource-limited settings. A study conducted in Rwanda utilizing an earlier iteration of the SSORT assessed organizational readiness and facility capacity for pediatric surgery in rural Rwandan district hospitals. The results showed similar high readiness scores in team valence, team efficacy, team learning orientation, learning environment, and vision of sustainability. Additionally, facilities also demonstrated low readiness in facility capacity while maintaining high readiness in resistance to change [32].

It has been found that organizational challenges  play a pivotal significant hurdles to mental health interventions in LMICs [33]. The implementation of Electronic Health Records (EHR) in Uganda for example stumbled due to inadequate organizational support and anticipated multilevel changes affecting various organizational aspects [34]. They emphasized the necessity for staff, both individually and collectively, to believe in the appropriateness of the intervention and the sufficiency of resources and organizational buy-in for successful implementation. Several impediments to scaling up health interventions in LMICs were identified through key informant interviews with 14 public health professionals [35]. These barriers include several organizational factors, including limited capacity, insufficient dissemination of implementation knowledge, financial constraints, and inadequate community readiness and engagement.

Implications For Policy, Practice and Research

Worldwide, concerted efforts have focused on improving surgical capacity and care delivery in LMICs [36].  Several tools are used globally to identify gaps in surgical care and guide interventions to improve surgical capacity, especially in LMICs [37-39].  Although these tools are useful, capacity-building intervention efforts can be complex and challenging to implement successfully, and one of the reasons why they may fail is the lack of prior evaluation of stakeholders’ beliefs and perceptions regarding the intervention [40-41].  While there are several tools available to assess organizational readiness specifically, it is important to note that most the tools have primarily been for high-income country settings or settings outside of healthcare and surgery. SSORT is a unique tool designed to consider the specific challenges and limitations faced by surgical facilities in resource-limited countries, providing a comprehensive assessment of readiness. The findings provide important groundwork for future research and intervention efforts in similar challenging settings.

Strengths and Limitations

Our study has several strengths. We adapted the survey to the Haitian context during a time of crisis and instability with the support of expert Haitian colleagues, many of whom had deep knowledge of the surgical context in the area. In addition, the survey was translated and administered in English, Haitian Creole, and French to improve comprehension and comfort with responding to questions. The evaluation of stakeholder beliefs and perceptions utilizing the SSORT made it possible to identify areas of concern or resistance and develop strategies to address these issues before they become major obstacles to the success of the intervention.  This can help ensure that the intervention is well-received by stakeholders and that it can achieve the desired outcomes. Unfortunately, given the persistent political and social instability in Haiti, this study was limited to a single institution HUEH, which restricted participant recruitment and resulted in a relatively small sample size. Although this was understandable in the context of the ongoing crisis, the limited sample may reduce the generalizability of our findings to other institutions and health system settings. The SSORT tool, as applied in this context, does not account for surgical capacity, resource availability, staffing levels, leadership structures, or interpersonal workplace dynamics that may influence implementation. Therefore, the use of complementary assessment tools is recommended to provide a more comprehensive evaluation prior to surgical system–strengthening interventions. The domain score cutoff constitutes a limitation of the study, as domains with scores near this boundary may not reflect meaningful differences in readiness and may be susceptible to misclassification. Accordingly, borderline scores were interpreted cautiously, and future studies may benefit from alternative or continuous analytic approaches. Potential social desirability bias was considered, as respondents may underreport undesirable attitudes or overreport favorable ones. Selection bias is also possible, as participants were identified by known local Haitian site coordinators based on availability and willingness to complete the SSORT.

There is a substantial disparity in the quality of trauma care between high-income countries and LMICs, leading to inferior outcomes and a higher burden of injuries. While ongoing efforts are being made to enhance trauma systems, it is crucial to tailor interventions to unique differences in baseline trauma care capacity, stakeholder perception, and facility readiness before implementation. This study underscores the ability of SSORT to evaluate stakeholder perceptions and surgical facility readiness before the implementation of health system strengthening interventions.

We would like to express our sincere gratitude to the Harvard Program for Global Surgery and Social Change and the Hôpital de l’Université d’État d’Haïti for their invaluable assistance and support in conducting this study.