Online Only ORIGINAL RESEARCH & CONTRIBUTIONS Special Report Leadership in Surgery for Public Sector Hospitals in Jamaica: Strategies for the Operating Room

Shamir O Cawich, MBBS, DM; Hyacinth E Harding, MBBS, DM; Ivor W Crandon, MBBS, FRCS; Clarence D McGaw, MBBS, DM; Alan T Barnett, MBBS, DM; Ingrid Tennant, MBBS, DM; Necia R Evans, BSc; Allie C Martin, MBBS, DM; Lindberg K Simpson, MBBS, DM; Peter Johnson, MBBS, DM Perm J 2013 Summer;17(3):e121-125

http://dx.doi.org/10.7812/TPP/12-117

Two public sector hospitals, Kingston Public Hospital and Abstract University Hospital of the West Indies, serve an estimated 826,880 The barriers to health care delivery in developing nations are persons residing in and around Kingston, the capital of Jamaica.7 many: underfunding, limited support services, scarce resources, These facilities also act as tertiary referral centers for the entire suboptimal health care worker attitudes, and deficient health island. Together, they have a combined capacity of 194 general care policies are some of the challenges. The literature contains surgical beds, 13 general operating theaters, and 24 multidisci- little information about health care leadership in developing plinary intensive care unit beds. However, this capacity is often nations. This discursive paper examines the impact of leadership unrealized because of many deficiencies in health care system on the delivery of operating room (OR) services in public sector funding, staffing, and management. hospitals in Jamaica. Delivery of OR services in Jamaica is hindered by many Health Care System Funding unique cultural, financial, political, and environmental barriers. According to the latest available figures from the government We identify six leadership goals adapted to this environment to of Jamaica, only 4% of the national budget is allocated to health achieve change. care.2 Apart from donations from nongovernmental organiza- Effective leadership must adapt to the environment. Delivery of tions, there is no source of financing for public sector health OR services in Jamaica may be improved by addressing leadership care. This creates many barriers to surgical care and optimal training, workplace safety, interpersonal communication, and functioning of ORs, including scarcity of monitoring equipment, work environment and by revising existing policies. Additionally, ventilators, operating tables, personal protective equipment, there should be regular practice audits and quality control surveys. drugs, surgical disposables, and hardware. Termination of the public sector health care system is not an Introduction option, because the majority of the population cannot access Several publications refer to differences in health care delivery private health care.1 Therefore, the public sector health care systems between developed countries and those that are still devel- delivery system continues to function, with impromptu solutions oping.1-6 Unique problems in the Caribbean have been explored, bypassing problems as they arise. This commonly results in can- particularly underfunding, limited support services, scarce resources, cellation of OR lists; postponement of treatment of major cases; suboptimal attitudes of health care workers (HCWs), and inadequate and HCWs working without personal protective equipment or health care policies. However, little has been published about health performing operations with insufficient high-dependency care, care leadership in developing nations. A deficiency in any of these intensive care unit backup, blood products, and support services. areas can cripple the delivery of surgical services; this is probably most evident in the daily function of the operating room (OR). Health Care System Staffing The University of the West Indies (UWI) offers undergraduate Operating Room Services In Jamaica and postgraduate medical education in the region.8 UWI trains Jamaica is the largest of the anglophone Caribbean islands, almost all categories of HCWs, gearing them for independent with a population of 2,709,281 persons.7 The government of practice in the anglophone regions of the Caribbean. A basic Jamaica offers free basic health care to residents through a net- degree from UWI is generally accepted as the minimal qualifica- work of public sector hospitals across the island.2 tion for licensure in these countries. Non-UWI medical graduates

Shamir O Cawich, MBBS, DM, is a Lecturer in Surgery at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Hyacinth E Harding, MBBS, DM, is a Lecturer in Anesthesia in Surgery at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Ivor W Crandon, MBBS, FRCS, is Professor of Surgery at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Clarence D McGaw, MBBS, DM, is a Lecturer in Anesthesia at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Alan T Barnett, MBBS, DM, is a Lecturer in Anesthesia at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Ingrid Tennant, MBBS, DM, is a Lecturer in Anesthesia at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Necia R Evans, BSc, is a Reader in Education in Kingston, Jamaica. E-mail: [email protected]. Allie C Martin, MBBS, DM, is a Lecturer in Surgery at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected]. Lindberg K Simpson, MBBS, DM, is an Associate Lecturer in Surgery at the Kingston Public Hospital in Jamaica. E-mail: [email protected]. Peter Johnson, MBBS, DM, is a Lecturer in Radiology at the University of the West Indies in Kingston, Jamaica. E-mail: [email protected].

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are required to pass licensing examinations before being granted This requires formal training in management. Effective leaders practicing privileges in the region. recognize that they cannot rely on business principles alone15 but Despite admission of more than 300 medical trainees at UWI’s must win cooperation from their staff through strong leadership.10 Mona Campus in Jamaica for the 2012 academic year,9 there is To do this, leaders must master their own personal interactions. still a shortage of trained personnel. This is because of the well- They must not rely on coercive power (influence through fear documented problem of emigration to developed nations.10-12 The or the ability to punish employees), which does not promote entire Caribbean is plagued by the brain drain phenomenon: it is desired actions.16 Instead, leaders should rely more on charisma reported that 70% to 90% of educated persons end up emigrating power (influence through force of character16). to North America.13-14 Plummer et al2 reported that the attrition Because of the small cadre of candidates in Jamaica, leaders rate for nurses from anglophone Caribbean was 8% per annum have been traditionally assigned to their roles on the basis and was primarily caused by emigration. But the phenomenon of experience, often without formal training in manage- affects all categories of HCWs, making it difficult to retain high- ment techniques. In addition, performance auditing is not quality staff within health care delivery systems. prioritized because of a combination of political influences, resource scarcity, and financial constraints that plagues most Health Care System Management developing Caribbean nations. Insufficient auditing is also Health care system management is a complex science that rationalized based on the need to channel scarce resources requires oversight of institutional resources and professional to address other well-documented inadequacies of health care groups to promote the health of the population. Jamaica’s delivery systems.1-5 public sector health care system has several managerial posi- Many steps could be taken at an institutional level to improve tions and titles. Individuals appointed to these positions are the current situation. First, leaders must be chosen on the basis of given control over institutional resources in order to direct their training in health care management instead of the traditional health care delivery. requisites of seniority, experience, or political affiliation. Other- One of the problems in small developing nations is that the wise, suboptimal leadership qualities are perpetuated. Instead of cadre of candidates is small. To compensate for this, experienced solving problems, ineffective leaders may erect further barriers, staff members are often selected to fill formal management posts from low morale among HCWs to flawed decision making. On- on the basis of seniority rather than formal training in manage- going development is critical; continuing education should be ment of health care systems. Because they lack formal training, mandatory for persons occupying formal leadership roles. And persons appointed to managerial positions are frequently un- auditing and evaluation of leadership roles is urgently needed. equipped to effectively steer ailing health care systems. Leaders must be held accountable for their performance. Institutions should also be familiar with their human resources Discussion so as to identify informal leaders10 who are not in official man- A unique combination of factors strains the public sector agement posts but use their own micro-organizational skills to health care delivery system in Jamaica, making it very differ- overcome existing barriers to service delivery. Informal leaders ent from those in developed nations. Although the good work should be identified and nurtured so that they maintain interest performed despite deficiencies is not to be discounted, there is in and contribute to the health care system. room to improve surgical care in this setting. A discussion of all barriers to surgical care delivery in public Commit to Policy Development sector hospitals in Jamaica is beyond the scope of this article. We Policy development is an important exercise that lays the have chosen to focus on an area that has not been addressed in foundation for successful functioning of ORs. Our leaders are the literature: attributes of good leadership that are needed in this charged with ensuring that OR policies and practice guidelines environment. More specifically, because the OR is the area most are based on the best available evidence.17-20 Although most clini- affected in the delivery of surgical services, we focus on leadership cal data come from high-volume centers in developed nations, for the OR in public sector hospitals. In this context, we refer to leaders have the responsibility to analyze data and interpret them a leader as any person or group who has the vision and influ- in context to tailor policies for the environment of their ORs.21 ence to empower a group to work together for a common goal. Many authors have detailed the inadequacies of policies at Several authors have defined leadership goals that must be public sector hospitals in Jamaica. McGaw et al5 reviewed exist- observed in business settings.15-16 We review six leadership goals, ing OR guidelines at a tertiary referral hospital in Jamaica and modifying them to the context of health care delivery in the ORs noted that some practice guidelines were not evidence based. at public sector hospitals in Jamaica (see Sidebar: Leadership Specifically, they pointed to the requirement for routine face goals in the context of a Caribbean health care system). mask use and the requirement to change OR attire at each exit and reentry,5 despite evidence suggesting that these measures Mandate Leadership Training are not necessary.22-25 Health care management is a complex science. Physicians The most important example of failed policy is the failure to and nurses are not equipped for it on the basis of experience implement proven safety measures in the public sector ORs in alone. Coordinating the OR is particularly difficult because it Jamaica. Consider the universal regulatory standards developed must function with existing, usually outdated equipment; few by the Joint Commission on Accreditation of Healthcare Organiza- basic supplies; and limited financial resources. tions (JCAHO) and Centers for Medicare and Medicaid Services

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(CMS).26-27 To be accredited by the JCAHO/CMS, an institution Leadership goals in the context of a Caribbean health care system must comply with a three-tiered OR checklist that includes pre- operative verification of procedure and background information; Mandate leadership training marking of operation sites; and an official team meeting to confirm • Training in health care management should be a prerequisite for appointment to public sector hospital leadership roles patient identity and the planned procedure.26,27 A survey of public • Continuing education and development should be mandatory for leaders sector hospital ORs in Jamaica revealed that neither JCAHO/CMS • Frequent evaluation of leadership roles, via clinical audits and quality control protocols nor similar practices are routinely followed. surveys, is needed Another point to consider is that Jamaica’s health care delivery • Leaders should be made accountable for their performance based on goal system is grossly underfunded. Basic supplies that are taken for achievement granted in developed nations (eg, hand soap, personal protec- Commit to policy development tive equipment, OR scrubs, surgical aprons, surgical disposables, • Leaders must be made sensitive to the need to review and update existing puncture-resistant sharp disposal containers, consistent water policies to ensure that they are aligned with the goals supply, and uninterrupted electricity supply) are not routinely • When local policies are created, data must be considered in context—local data available at Jamaica’s public sector hospitals.1-6 After several de- should be used where available cades of constantly facing these barriers, OR staff have become • Make realistic policies, even if this means making unpopular decisions, such as used to functioning in a crisis mode. reimplementation of user fees for health care in public sector hospitals A critical leadership goal is to change this culture by devel- • Local studies should be regularly commissioned to provide data useful for oping well-thought-out policies that proactively steer surgical creating local policies services using existing resources while accounting for barriers to • A regional body should be established to oversee standards at health care facilities in the Caribbean implementation. Often, this requires making difficult decisions Prioritize workplace safety on the basis of the appropriate allocation of scarce resources. • Leaders should be made sensitive to the fact that workplace safety is their For example, leaders could either lobby for the state to cease responsibility full funding of health care or introduce policy stating that the • Personal protective equipment should be made available public sector health care system will not provide modern services Optimize communication strategies such as laparoscopy, despite their proven benefits. Although • Constructive dialogue between policy makers and health care workers should be there is rationale for policy revision, these changes would be encouraged unpopular and might have negative repercussions for leaders • Form common interest groups, such as a theater-users committee who implement them. • Discuss all problems and any changes in policies/action before they are It may be time to establish a regional body to oversee stan- implemented dards at health care facilities in the Caribbean, similar to the • Involving stakeholders in decision making and policy changes is more effective function of the JCAHO. The regional body could commission than autocratic leadership styles local studies to provide good quality local or regional data that Nurture a healthy work environment would then be used to tailor policies. • Aim for fairness in the workplace • Nurture freedom of expression Prioritize Workplace Safety • Avoid any form of racial, class, or gender discrimination The government of Jamaica has legislation in place mandat- • Consider adopting a framework for interaction and communication, such as ing employers to ensure that workplace environments are safe the mandatory team briefing described in Joint Commission on Accreditation for employees.28 Safety is especially important in the OR, where of Healthcare Organizations and Centers for Medicare and Medicaid Services HCWs may be exposed to needlesticks, body fluid splashes, regulations blood, and dangerous infections. It is a reasonable expectation • Use organizational power to reward positive behavior with promotions or bonuses, where possible that employers ensure employee safety.29 • Increase the use of extrinsic motivators such as managerial praise, recognition Several breaches of this expectation occur in Jamaica. For ceremonies, and job-related autonomy example, personal protective equipment, such as waterproof • Invest in human resource development by providing scholarships for aprons, safety goggles, adequate sharps disposal systems, and supplemental training wherever possible properly fitting gloves, is not routinely available. Many times, • Show interest by organizing fellowships with partners in developed nations, HCWs simply endure without these in the interest of patient even in the absence of financial support care. This then creates the perception that such conditions are • Organize regular, in-house educational sessions for staff members, drawing on the norm, and the need for change is trivialized. In addition to local experts within the health care system placing HCWs at unnecessary risk, these circumstances create Regularly perform practice audits and quality-control surveys division between leaders and HCWs, who perceive a lack of • Prioritize the performance of clinical practice audits and quality-control surveys concern for their well-being. • Identify and partner with staff who are interested in research, motivating them to Leaders should be made sensitive to the fact that creating a carry out these activities safe workplace is one of their key responsibilities. Even though • Develop a research culture in the institution by emphasizing the importance of the system has traditionally worked without an emphasis on audits whenever possible • Form partnerships with academic institutions in the region that may have similar HCW safety, the time for change is here. Change must be a research interests priority. The appropriate resources should be allocated to make • Consistently hold leaders accountable for predefined goals protective equipment available.

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Optimize Communication Strategies recognition (corresponding to the ego-status need identified Several groups work in the OR to complete procedures that by Maslow34) and a sense of achievement, satisfaction, and ultimately benefit patients. Communication, the main tool to self-fulfillment based on one’s contributions (similar to the self- achieve this goal, is made difficult in any OR where tenuous actualization need Maslow identified34). personal relationships, poor communication, human conflict, or There are several ways to satisfy HCWs’ ego-status needs. flawed decision making exist.30,31 These problems are magnified Leadership theories discuss organizational reward power, in Jamaica, where public sector health care delivery systems where leaders have administrative control over institutional are perpetually in crisis mode and staff must constantly adapt resources that allow them to reward good service.16 Jamaica their routines. does not have the financial resources to allow promotions or Previous surveys in Jamaica identified inappropriate com- bonuses as reward power, but leaders can still use extrinsic munication (lack of communication and autocratic leadership motivators as simple as managerial praise, recognition cer- styles) between leaders and HCWs as one of the main causes of emonies, or even increased autonomy on the job. Leaders workplace contention.5 Autocratic leadership styles undermine should harness these subtle institutional reward powers to OR function by creating animosity between leaders and HCWs, improve staff motivation. by fostering negative attitudes, and by reducing productivity.5 We can empower HCWs with a sense of self-worth (self- This is compounded if HCWs disagree with policy, lack confi- actualization) through continuing medical education. McGaw dence in policy developers, or expect poor outcomes.15,19,32,33 All et al5 reported that 20% of Jamaican HCWs felt inadequate in these issues can be resolved with dialogue. their knowledge of OR safety practices. Formal scholarships Autocratic leadership styles are no longer appropriate in or financial aid may not be feasible in the current economic modern health care systems. Leaders must engage HCWs in climate, but there are several other ways to promote continu- constructive dialogue, relying on charisma power more than ing medical education. By simply tapping into existing hu- coercive power. This may be achieved by forming common man resources (organizing the large cadre of OR specialists interest groups, for example a theater-users committee that to host regular teaching sessions, for example), leaders could incorporates HCWs, giving them a stake in the organization. contribute to staff education and development. Alternately, Regular meetings can give leaders and HCWs a forum to discuss by taking the initiative to approach existing partners in devel- problems and propose solutions. oped nations about arranging fellowships or observer periods, leaders could help increase HCW motivation, self-worth, and Nurture a Healthy Work Environment workplace satisfaction. Success of the public sector health care system hinges on retaining trained, competent, and motivated staff. Unfortunately, Regularly Perform Clinical Practice Audits the majority of educated persons emigrate from Jamaica.13,14 Regular clinical audits are important instruments of qual- Questionnaire surveys in the public sector health care systems ity control. Audits identify ongoing problems in the OR and have revealed that dissatisfaction with the workplace is the main are prerequisites for solving them. Without these exercises, reason HCWs consider emigration from Jamaica, followed by it is difficult to ensure that acceptable care standards are insufficient work-related rewards.5 maintained. This is a multifactorial issue, but it lends itself to analysis Public sector hospital ORs in Jamaica do not have effective with Abraham Maslow’s hierarchy of needs theory.34 After an auditing systems to generate good-quality data and objectively individual’s most basic physiologic and safety needs are met, evaluate the ORs.5 This is partly caused by the lack of electronic the next to be satisfied is belonging (the human desire to be databases in public sector hospitals in Jamaica,2 a lack of em- accepted and appreciated by others). This becomes important phasis on auditing, failure to appreciate the importance of local in the OR, where personnel from many disciplines (eg, nurses, data, and low expectations for outcomes from auditing. Leaders scrub technicians, anesthetists, and surgeons) and at different must appreciate the importance of these activities and encourage training levels (eg, house officers, residents, and consultants) them because in their absence, systemic inadequacies persist. interact on a daily basis. Tenuous personal relationships, poor Resource limitations may not allow the use of sophisticated communication, and human conflict can produce hostile environ- electronic monitoring systems, but clinical audits can still be ments30,31 not conducive to workplace satisfaction. performed using paper-based systems. Identifying these problems and promoting healthy relation- An important task of good leaders is to identify the ships among OR staff and between leaders and subordinates is strengths and weaknesses of their staff. Leaders can identify an important leadership responsibility. Leaders should strive for staff members who are interested in research and motivate fairness in the workplace and nurture freedom of expression them to spearhead this type of work and eventually develop while avoiding racial, class, and gender discrimination. The a research culture in the workplace. Partnering with existing JCAHO/CMS universal regulatory standards26 may be good poli- educational institutions is another approach to promoting a cies to adopt. The official team briefing could be a framework research-oriented workplace. for structured, healthy personal interactions that foster a team Simply implementing quality-control surveys and clinical approach and a positive environment. audits is not sufficient. There must be overt consequences. Fredrick Herzberg adapted Maslow’s theory to the workplace35 Quality-control data should be used to hold leaders account- and suggested that employee motivation depends on reward/ able when pre-set performance goals are not met and to reward

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them when appropriate. This may work at several levels. For 13. Dugger CW. Developing lands hit hardest by ‘brain drain’ [monograph on the Internet]. New York, NY: The New York Times; 2005 Oct 25 example, awareness of ongoing monitoring may be sufficient [cited 2013 Apr 17]. Available from: www.nytimes.com/2005/10/25/ in itself to bring about positive behavior modification by HCWs, international/25brain.html?_r=0. even without the immediate threat of penalties.36 14. Negrón R. Personal networks and migration decision: the case of Jamaican brain drain. Journal of Identity and Migration Studies 2012 Mar;6(1):43-63. 15. Dexter F, Ledolter J, Wachtel RE. Tactical decision making for selec- Conclusion tive expansion of operating room resources incorporating financial Several unique cultural, financial, political, and environ- criteria and uncertainty in subspecialties’ future workloads. Anesth Analg 2005 May;100(5):1425-32. DOI: http://dx.doi.org/10.1213/01. mental factors influence the delivery of surgical services in ANE.0000149898.45044.3D Jamaica; this context is different from that of developing 16. Montana PJ, Charnov BH. Leadership: theory and practice. In: Montana countries. Effective leadership must adapt to its environment. PJ, Charnov BH, editors. Management (Barron’s Business Review). 3rd ed. The delivery of surgical care in this environment may be im- Hauppauge, NY: Barron’s Educational Series, Inc; 2000. p 254-75. 17. McCrae N. Evidence-based practice: for better or worse. Int J Nurs proved by attention to leadership training, workplace safety, Stud 2012 Sep;49(9):1051-3. DOI: http://dx.doi.org/10.1016/j. communication, work environment enrichment, and revision ijnurstu.2012.08.010 of existing policies. Practice audits and quality control surveys 18. Rincon TA. Integration of evidence-based knowledge management in microsystems: a tele-ICU experience. Crit Care Nurs Q 2012 Oct- should be conducted regularly. v Dec;35(4):335-40. DOI: http://dx.doi.org/10.1097/CNQ.0b013e318266bfd1 19. Pierson DJ. Translating evidence into practice. Respir Care 2009 Disclosure Statement Oct;54(10):1386-401. The author(s) have no conflicts of interest to disclose. 20. What do we mean by appropriate health care? Report of a working group prepared for the Director of Research and Development of the NHS Man- agement Executive. Qual Health Care 1993 Jun;2(2):117-23. Acknowledgment 21. Thomas S, Mooney G, Mbatsha S. The MESH approach: strengthening Leslie Parker, ELS, provided editorial assistance. public health systems for the MDGs. Health Policy 2007 Oct;83(2-3):180-5. DOI: http://dx.doi.org/10.1016/j.healthpol.2007.01.002 22. Lipp A, Edwards P. Disposable surgical face masks: a systematic review. Can References Oper Room Nurs J 2005 Sep;23(3):20-1, 24-5, 33-8. 1. Ward E, Fox K, Ricketts L, et al. A review of hospital care in Jamaica: 23. Skinner MW, Sutton BA. Do anaesthetists need to wear surgical masks in morbidity and mortality patterns, resource allocation and cost of care. the operating theatre? A literature review with evidence-based recommen- [Abstract]. West Indian Med J 2001;50(S2):21. dations. Anaesth Intensive Care 2001 Aug;29(4):331-8. 2. Plummer JM, Roberts PO, Leake PA, Mitchell DI. Surgical care in Jamaica in 24. Roxburgh M, Gall P, Lee K. A cover up? Potential risks of wearing theatre the laparoendoscopic era: challenges and future prospects for developing clothing outside theatre. J Perioper Pract 2006 Jan;16(1):30-3, 35-41. nations. Perm J 2011 Winter;15(1):57-61. DOI: http://dx.doi.org/10.7812/ 25. Woodhead K, Taylor EW, Bannister G, Chesworth T, Hoffman P, Humphreys TPP/10-096 H. Behaviours and rituals in the operating theatre. A report from the Hospi- 3. Cawich SO, Cherian CJ, Wilson C, Baker A, Lloyd C, Thomas C. Challenges tal Infection Society Working Party on Infection Control in Operating The- against the advancement of minimally invasive surgery in Jamaica: a atres. J Hosp Infect 2002 Aug;51(4):241-55. DOI: http://dx.doi.org/10.1053/ national hospital survey. [Abstract]. West Indian Med J 2012;61(S4):54. jhin.2002.1220 4. Dan D, Nararynsingh V, Cawich S, Jonnalagadda R. The history of 26. Facts about the Universal Protocol. The Joint Commission; 2013 Jan 3 [cited laparoscopic general surgery in the Caribbean. West Indian Med J 2012 2013 Apr]. Available from: www.jointcommission.org/assets/1/18/Univer- Jul;61(4):467-71. sal_Protocol_1_3_13.pdf 5. McGaw CD, Tennant I, Harding HE, Cawich SO, Crandon IW, Walters CA. 27. Joint Commission Center for Transforming Healthcare launches second Healthcare workers’ attitudes to and compliance with infection control targeted solutions tool. Tool focuses on reducing the risk of wrong site guidelines in the operating department at the university hospital of the surgery. Jt Comm Perspect 2012 Mar;32(3):1,15. West Indies, Jamaica. International Journal of Infection Control [serial on 28. The Factories Regulations: Safety, Health & Welfare, and Duties. Parts II-IV the Internet]. 2012 [cited 2013 Apr 17];8(3):[about 9 p]. Available from: (1961). [Jamaica]. www.ijic.info/article/download/10411/7403. DOI: http://dx.doi.org/10.3396/ 29. Pronovost PJ, Rosenstein BJ, Paine L, et al. Paying the piper: investing ijic.v8i3.023.12 in infrastructure for patient safety. Jt Comm J Qual Patient Saf 2008 6. Regional Global Patient Safety Challenge Workshop—PAHO [Web page Jun;34(6):342-8. on the Internet]. Geneva, Switzerland: World Health Organization; 30. Macario A. Are your hospital operating rooms “efficient”? A scoring system 2007 [cited 2013 Apr 17]. Available from: www.who.int/patientsafety/ with eight performance indicators. Anesthesiology 2006 Aug;105(2):237- events/07/05_03_2007/en/index.html. 40. DOI: http://dx.doi.org/10.1097/00000542-200608000-00004 7. Population census 2001 facts [Web page on the Internet]. Kingston, 31. Strum DP, Vargas LG, May JH, Bashein G. Surgical suite utilization and Jamaica: Statistical Institute of Jamaica; updated 2013 Apr 15 [cited 2013 capacity planning: a minimal cost analysis model. J Med Syst 1997 Apr 17]. Available from: http://statinja.gov.jm/Census/PopCensus/TotalPopu- Oct;21(5):309-22. lationbyBroadAgeGroupsandParish.aspx. 32. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clini- 8. The Faculty of Medical Sciences [Web page on the Internet]. Mona, cal practice guidelines? A framework for improvement. JAMA 1999 Oct Jamaica: The University of the West Indies; [cited 2013 April 18]. Available 20;282(15):1458-65. DOI: http://dx.doi.org/10.1001/jama.282.15.1458 from: www.mona.uwi.edu/postgrad/pdf/Programmes/Faculty_of_Medi- cal_Sciences.pdf. 33. Kahn JM. Disseminating clinical trial results in critical care. Crit Care Med 2009 Jan;37(1 Suppl):S147-53. DOI: http://dx.doi.org/10.1097/ 9. The Faculty of Medical Sciences [Web page on the Internet]. Mona, Ja- CCM.0b013e3181920fa3 maica: The University of the West Indies; c2004-2013 [cited 2012 Dec 20]. Available from: www.mona.uwi.edu/fms/about.php. 34. Maslow AH. A theory of human motivation. Psychol Rev 1943 Jul;50(4):370-96. DOI: http://dx.doi.org/10.1037/h0054346 10. Strategies for addressing the evolving nursing crisis. Jt Comm J Qual Saf 2003 Jan;29(1):41-50. 35. Herzberg F. One more time: how do you motivate employees? 1968. Harv Bus Rev 2003 Jan;81(1):87-96. 11. Hauff HM. Where has all the staff gone? Strategies to recruit and retain quality staff. Prog Transplant 2007 Jun;17(2):89-93. 36. Heath C, Luff P, Svensson MS. Overseeing organizations: configuring action and its environment. Br J Sociol 2002 Jun;53(2):181-201. DOI: http://dx.doi. 12. Johnson N. Analysis and assessment of the “brain drain” phenomenon and org/10.1080/00071310220133296 its effects on Caribbean countries. Florida Atlantic Comparative Studies Journal 2008-2009;11(1):1-16.

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