Transitioning from Episodic Cardiac Missions to Sustainable National Cardiac Surgery Services in Papua New Guinea: A Mixed-Methods Programme Evaluation

Study design

A mixed‑methods programme evaluation was conducted during the March 2026 Singapore–PNG cardiac surgery mission at Port Moresby General Hospital. This study was conducted as a programme evaluation. Institutional approval was obtained from National Heart Centre Singapore, and the requirement for formal ethical review was waived as no patient‑level data were collected and all responses were anonymised.

This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [6]. Qualitative components were reported in line with recognised standards for qualitative research reporting.

Participants

A total of 28 participants across multidisciplinary roles (surgeons, anaesthetists, perfusionists, nurses, cardiologists and physiotherapists) completed the evaluation, with representation from both Singapore and PNG teams.

Quantitative data

Quantitative data were collected using Likert‑scale questionnaires (1‑5), where higher scores indicated more favourable responses. Survey domains included overall experience, pre‑mission planning, intraoperative workflow, post‑operative care, education and sustainability.

Descriptive statistics were used to summarise responses. Likert‑scale data were treated as ordinal variables but summarised using means and standard deviations (mean ± SD) to facilitate domain‑level comparison. Results were interpreted cautiously, with emphasis placed on trends rather than precise numerical differences.

No inferential statistical testing was performed, given the exploratory nature of the study and the relatively small sample size (n = 28). Subgroup comparisons (e.g. between Singapore and Papua New Guinea participants or across professional roles) were not conducted due to limited statistical power.

All analyses were performed using Microsoft Excel (Microsoft Corp., Redmond, WA, USA).

Qualitative data

Open‑ended responses were analysed using thematic analysis to identify key strengths, challenges and system‑level issues.

Participant characteristics

Of the 28 respondents, 18 were from PNG and 10 from Singapore. Participants represented a wide range of clinical roles, with the largest groups comprising surgeons (n = 12), anaesthesia providers (n = 6) and nurses (n = 6) (Figure 1).

Figure 1

Quantitative findings

The overall quantitative findings are summarised in Table 1.

Pre‑mission planning domains were generally well rated, including case selection (4.39 ± 1.03) and logistics (4.14 ± 1.04). However, patient information (3.89 ± 1.17) and equipment planning (3.93 ± 1.05) scored lower. Intraoperative performance was rated positively, particularly for collaborative decision‑making (4.32 ± 0.94) and patient safety (4.32 ± 0.98), although operating theatre flow was less consistent (3.86 ± 1.11). Post‑operative care domains were consistently lower, particularly protocol clarity (2.86 ± 1.33), intensive care unit (ICU) staffing (3.43 ± 1.29) and complication management (3.46 ± 1.07). Education and collaboration domains were highly rated, including teaching opportunities (4.14 ± 0.93) and collegiality (4.43 ± 0.92). Participants also reported strong alignment with long‑term goals (4.57 ± 0.96), although perceptions of sustainability were more moderate (3.86 ± 1.01).

Qualitative findings

Strengthening non‑physician workforce development

Addressing this gap requires a structured and programmatic approach to non‑physician education.

Pre‑mission education should be expanded to include targeted training for nursing and allied health staff, focusing on core competencies such as haemodynamic monitoring, post‑operative pathways and early recognition of complications. Delivering such training prior to missions may improve baseline readiness. During missions, bedside teaching should be formalised with clearly defined learning objectives. Training should be aligned with task‑specific competencies, enabling staff to develop practical skills relevant to their roles. Post‑mission continuity is equally important. Virtual teaching sessions, case discussions and shared educational materials may help sustain learning between missions.

Standardised protocols and checklists can further support non‑physician staff by reducing variability and providing clear guidance for routine cases. Finally, future missions should incorporate dedicated non‑physician educators, such as senior ICU nurses and perfusion trainers, to facilitate targeted capacity building.

Pragmatic strategies to improve service delivery

Rather than proposing large‑scale system transformation, our findings highlight practical strategies that can be implemented within existing constraints.

First, strengthening post‑operative care pathways is critical. The low rating for protocol clarity underscores the need for standardised ICU management frameworks. Practical interventions include the development of locally adapted post‑operative protocols, structured ICU handover templates and pre‑mission education sessions to align expectations regarding post‑operative care.

Second, communication processes can be improved through relatively simple interventions. Expanding multidisciplinary discussions to include all hands‑on team members—including ICU nurses and junior staff—may enhance shared understanding of patient management plans. The use of structured communication tools, such as standardised handover formats and shared messaging platforms (e.g. WhatsApp groups), may further improve coordination and responsiveness to clinical changes.

Third, workflow efficiency may be improved through better preoperative planning and clearer allocation of resources. Early confirmation of patient lists, improved coordination of equipment availability (e.g. echocardiography machines), and structured preoperative briefings involving all relevant disciplines may reduce intraoperative delays and improve utilisation of limited resources.

Fourth, resource constraints should be explicitly incorporated into planning processes. Limited ICU capacity, for example, should inform patient selection and scheduling. While supply chain limitations may not be immediately modifiable, improved pre‑mission inventory planning and communication can mitigate disruptions.

Finally, addressing workforce limitations requires targeted and context‑sensitive approaches. Short‑term strategies may include expanding the composition of visiting teams to include key specialities such as intensivists, cardiologists and physiotherapists. In parallel, mission design should account for local manpower constraints, ensuring that care delivery and teaching activities are aligned with available staffing capacity.

A summary of identified challenges and corresponding pragmatic solutions is provided in the supplementary material (Table 1).

What is already known on this topic

• Cardiac surgery access in LMICs is extremely limited and often dependent on short‑term missions.

• Episodic mission models provide immediate care but rarely achieve long‑term sustainability.

What this study adds

• Demonstrates how a mentorship‑based cardiac mission can transition towards local clinical ownership.

• Identifies post‑operative care, supply chain and workforce gaps as primary system bottlenecks.

• Provides a pragmatic, system‑level strategies to improve cardiac surgical delivery within constrained settings

How this study might affect research, practice or policy

• Supports policy shifts from mission‑based care towards system‑oriented service delivery models.

• Highlights actionable improvements in ICU care, workflow and communication.

• Offers transferable insights for LMICs developing cardiac surgical capacity.