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Quality Assurance Guidelines and Safety Measures for Outreach Cleft Missions: Overcoming Difficulties

  • May 20, 2016
  • Medical Outreach Exchange, Evaluation, Preparation

Usama Hamdan, M.D.

 F.I.C.S., President, Global Smile Foundation & Karen Daly, M.D., Program Director, Global Smile Foundation

There is an extreme need for comprehensive and multi-disciplinary cleft services throughout the world and outreach missions have become a necessary and extraordinary solution for many underserved areas. However, medical staff and volunteers who embark on such missions must deal with the realities inherent in providing healthcare services abroad and matching that with acceptable quality care.

Although some complications are not avoidable, based on our experience, many of the complications can be prevented with adequate planning. Global Smile Foundation (GSF) has drawn from the cumulative experiences of our founding members to implement a set of quality assurance and safety measures to ensure patient and team safety.

We have a rigorous protocol for evaluation and selection of potential mission sites, including site surveys of facilities coupled with a thorough documentation process. We strongly believe in networking with the onsite medical community and volunteers. In terms of trip preparation, we have created a staffing algorithm to assemble highly experienced cleft teams. Only experienced cleft surgeons who are currently performing these procedures in their base practices are able to join the GSF teams. Other team members include pediatric anesthesiologists, pediatric intensivists, PICU and pediatric PACU nurses, biomed engineers, speech therapists, pediatric and craniofacial dentists and psychosocial experts.

Leadership skills and a cohesive team are fundamental for any successful mission. In the perioperative phase, we implement a rigorous screening process with evidence-based inclusion criteria that allows us to develop an operative schedule based on capacity, level of deformity and urgency of care.

Strict and very vigorous patient safety protocols are in place based on the founders’ three decades of extensive experience in outreach cleft programs. Emergency drills are performed at the beginning of each mission to ensure the timely responsiveness of all team members. Onsite staff are invited to participate in these emergency drills to familiarize both teams with the time sensitive and life saving measures and enhance knowledge transfer.

No more than 3-4 OR cases are performed/OR/day to avoid team fatigue with a maximum of 2 airway cases/OR to ensure safe recovery of all patients and allowing enough rest time for the team. Airway cases are only performed at tertiary healthcare facilities or should be within 30 minutes to such facilities in case a patient has to be transferred to an intensive care. On call teams are available every night throughout the mission and are equipped with all needed communication devices and transport vehicles in case of an emergency.

By following these patient safety protocols, Global Smile Foundation has been able to provide high quality and safe cleft care throughout the world. Nonetheless, we are constantly evaluating and improving our operational systems to ensure maximum patient and team safety. GSF provides long term follow up care for our patients and many of them are now 20-25 years of age and volunteer on our missions.

Outreach missions are great opportunities to provide quality comprehensive care to underserved patients throughout the world, train onsite staff and provide an enriching experience for medical teams and volunteers. With the proper safety measures and help from AmeriCares Safe Surgery InitiativeGSF teams are continuously working on raising the quality of care in outreach settings.



Eberlin K, Zaleski K, Snyder D, Hamdan U. Quality Assurance Guidelines for Surgical Outreach Programs: A 20-Year Experience. Cleft Palate Craniofac J. 2008 May;45(3):246-55.

Patel K, Eberlin K, Vyas R, Hamdan U. Use of Safety Measures, Including the Modified World Health Organization Surgical Safety Checklist, During International Outreach Cleft Missions. Cleft Palate Craniofac J. 2014 Sep;51(5):597-604.

Vyas R, Eberlin K, Hamdan U Implementation of An Emergency Response Protocol for Overseas Surgical Outreach Initiatives. Plastic and Reconstructive Surgery, P: 631e-636e, April 2013