The Four Pillars of Safe, Sustainable Cleft Surgery
Safe surgery depends on a trained workforce, essential equipment, resilient infrastructure, and reliable systems. Smile Train invests in all four to make cleft care safe, comprehensive, and sustainable worldwide.
In brief: Smile Train helps ensure safe cleft surgery by strengthening four connected pillars: workforce, equipment, infrastructure, and systems. We accomplish these goals in many ways, including training surgeons, anesthesia professionals, nurses, and other professionals; establishing rigorous safety protocols; supporting patient monitoring and other medical technology; maintaining accurate records; and investing in fit facilities for before, during, and after surgery.
Safe cleft surgery depends on more than one surgeon or technique. It requires professionals across multiple disciplines integrating safety into every stage of care.
What is a cleft?
- A cleft lip is an opening or separation in the upper lip.
- A cleft palate is an opening or separation in the roof of the mouth.
- A baby may be born with either a cleft lip, a cleft palate, or both.
- Clefts form around the twelfth week of pregnancy.
- About one in every 700 babies worldwide is born with a cleft, and almost five million people around the world have an untreated cleft.
- Clefts can affect feeding, nutrition, speech, hearing, oral health, self-esteem, and other parts of a person's wellbeing.
- Clefts are natural birth differences. They are never anyone’s fault.
How are clefts treated?
Clefts are treated through surgery and other comprehensive services such as nutrition, speech therapy, dental and orthodontic treatment, ear and hearing care, and psychosocial counseling, depending on each person’s needs.
Why does trust matter to patient safety?
Every part of the cleft journey depends on safety. The operating team must be trained in the proper surgical skills and in the best use of their equipment — and must be able to trust that their colleagues are the same. They must be able to trust that their patient records are accurate and that their equipment will function as it should and have reliable access to electricity. Families must likewise be able to trust that their medical teams are committed to their loved one’s health and safety.
These things may sound basic, but they are not in much of the world. Where reliable safety systems cannot be taken for granted, establishing those systems and demonstrating that they work is essential to earning families’ trust.
That is where Smile Train's locally led model comes in.
Instead of making care dependent on temporary visiting teams, Smile Train trains and equips local healthcare workers around the world. This makes treatment available every day of the year, from empowered local professionals who understand the communities, culture, and health systems of the places they work because they are a part of them. Being able to form a trust-based relationship with their healthcare teams empowers families to feel more comfortable asking questions, following their doctors’ instructions, and returning for follow-up care.
How does Smile Train support patient safety in cleft surgery?
Smile Train's Safety and Quality Protocol is foundational to our work. Based on the WHO-World Federation of Societies of Anaesthesiologists International Standards, it sets the required policies and procedures our partner treatment centers must follow to receive our support. These include minimum standards for patient record collection, preoperative assessments, anesthesia, operating-room practices, postoperative monitoring, professional credentials, team review, and responding to serious safety incidents.
It also reflects an important principle: Safety systems must be hard-wired into every stage of care. Safety cannot depend on individual clinicians remembering every step under pressure.
Consistent excellence reassures wary patients and families that our promises of safety are backed by clear practices, detailed accountability, and visible results.
Martha steps out of the shadows
Martha’s cleft turned her birth into a moment of panic for her mother, Mevis. Then the hospital staff came to her with reassuring news — there was a Smile Train partner five minutes from their house. Martha could receive cleft surgery for free. But Mevis didn’t take her. She didn’t trust it would be safe. Martha grew up underweight and mocked by her peers. Finally, when she was 12, Mevis agreed to take her for care. The surgery was a success, and now Martha dreams of becoming a doctor herself!
Who leads patient safety at Smile Train?
Dr. Elizabeth Igaga is an anesthesiologist and Smile Train's Senior Director, Program Safety, based in Uganda. Her guidance is key to our ability to support roughly 100,000 safe cleft surgeries across 75+ countries each year.
In 2023, Women in Global Health recognized her contributions to anesthesia, patient safety, health systems, mentorship, and advocacy by naming her a Heroine of Health, one of the most prestigious honors in the field.
It’s no coincidence that Smile Train hired an anesthesiologist to do this job. These specialists stand at the front lines of patient safety, responsible for assessing whether a patient is ready for surgery, planning anesthesia administration, monitoring vital functions during surgery, recognizing emerging problems, and supporting safe post-op recovery, among much else.
Of course, safety is also a shared responsibility. It requires technical excellence from surgical teams as much as the ability of every member to contribute to a culture where colleagues feel comfortable discussing concerns, learning from unexpected events, and improving systems without losing sight of the individual patient.
That is why Smile Train invests in safety measures that strengthen cleft teams as holistic units, including surgeons, nurses, nutritionists, anesthesiologists, and other specialists.
Interview with Dr. Elizabeth Igaga
We spoke with Dr. Igaga to learn more about her journey, the critical role of anesthesiologists in ensuring safe surgery, her vision for bringing the highest global standard of safe surgery to every Smile Train partner, and more.
What are the four pillars of safe surgery?
Smile Train’s patient-safety work aligns with the Lancet Commission on Global Surgery’s four pillars of safe, affordable surgery:
- Workforce: The professionals who assess, treat, monitor, and support each patient
- Equipment: The medical technology and supplies teams need to monitor patients and provide appropriate treatment
- Infrastructure: The operating rooms, recovery areas, dependable power, and centers that allow care to continue safely
- Systems: The protocols, records, checklists, governance, and learning processes that make safe care repeatable
These foundations reinforce one another. Equipment is only useful when professionals know how to use it. Training has limited impact if a hospital lacks reliable systems or power. A checklist is effective only when everyone on the team has the time, authority, and resources to act on its findings.
How does workforce training make cleft surgery safer?
Safe surgery begins with a skilled local workforce.
Smile Train supports training in surgery, anesthesia, nursing, and all other aspects of comprehensive cleft care. Because our partner professionals live and work in the communities they serve, they can share their knowledge with colleagues and be available for future patients. We call it our “teach a person to fish” model.
How surgical simulation makes cleft surgery safer
Hands-on surgical simulation gives trainees the opportunity to practice difficult techniques without placing patients at risk.
Through Simulare Medical, Smile Train has become the global leader in producing anatomically precise, three-dimensional cleft surgery simulators. These models allow trainees to practice key steps, receive feedback, and refine their technique under expert supervision before applying their skills in a real operating room.
Smile Train also offers advanced digital training tools. Our award-winning Virtual Surgery Simulator combines interactive anatomy, surgical footage, text, and narration for self-directed learning. Our Virtual Reality Operating Room is an immersive Metasphere environment where professionals can practice individually or learn with an instructor and other trainees around the world. These tools are built to complement, not replace, supervised clinical education.
Why safe cleft surgery requires nurses and anesthesia professionals
Smile Train has made the American Heart Association's Basic Life Support curriculum available to our partners. While it is the gold standard for training in the US, it was largely out-of-reach to healthcare professionals in the places Smile Train works, until we put it in their hands.
Nurses are essential to all stages of safe surgery. Smile Train developed the Nursing Care Saves Lives curriculum to strengthen their skills at every stage of our patients’ cleft care journeys — and made it available in multiple languages.
Likewise, through our partnership with the World Federation of Societies of Anaesthesiologists, we support pediatric anesthesia education, professional development, specialist fellowships, and wider access to essential patient-monitoring tools. The partnership also includes courses tailored to pediatric and cleft anesthesia.
Together, these programs demonstrate that workforce development is not simply about adding more professionals. It is about giving each member of the care team the skills, opportunities, and support they need to continuously improve.
Dr. Sithole Makes History
Dr. Tsitsi Sithole fell in love with pediatric anesthesiology in medical school. But living in Zimbabwe, there was no avenue for her to pursue it — until she learned about a Smile Train-supported fellowship in Kenya. Today, she is back home living her dream, treating local kids as her country’s first female pediatric anesthesiologist.
Why is appropriate equipment essential to safe surgery?
Even the most highly trained team cannot provide safe care without the right tools for assessing, monitoring, and treating patients.
Pulse oximeters and capnographs are two of the most basic components of safe surgery, yet they are often missing from operating rooms outside of high-income countries.
Smile Train and the global surgery NGO Lifebox have been working together for over a decade to make these vital monitors readily available at all of our partner centers.
Pulse oximeters rapidly measure the oxygen level in a patient's blood. Through a multi-year initiative, we developed a durable, affordable version designed specifically for use in low-resource settings.
Capnography helps anesthesia professionals monitor a patient's ventilation during surgery. We likewise put these lifesaving units in thousands of operating rooms around the world.
Children have different clinical and equipment needs from adults during surgery. The NGO Kids Operating Room recognizes this, and is dedicated to building modern, child-friendly operating rooms across Africa. We are proud to partner with them to create modern, well-equipped surgical spaces designed with children’s needs in mind to help our partners across the continent provide the best care for our patients.
High-quality equipment also supports the wider comprehensive care journey. Smile Train is working with Dentsply Sirona to empower local oral health professionals with clinical education and digital imaging, scanning, treatment-planning, and other technologies. These resources are improving how teams assess patients, coordinate treatment, and plan long-term oral healthcare around the world every day.
With all of these initiatives, the goal is not to place technology in a hospital and move on; it is to help our partners master it. We complement each new device with the training, maintenance planning, and clinical standards our partners need to ensure they and their colleagues can use it to its fullest benefit.
Smile Train and Dentsply Sirona Bring Latest X-ray Innovation To the Philippines
How does infrastructure protect surgical patients?
To facilitate safe surgery, an operating room needs appropriate space, infection-prevention processes, oxygen and monitoring equipment, a separate recovery area, reliable electricity, and staff who know how to use the facility's resources. A weakness in any one of these areas can compromise the whole system.
Smile Train's Cleft Leadership Centers are regional hubs for treatment, education, training, and research. They are designed to facilitate coordinated, team-based care and serve as resources for other cleft centers in their regions.
Smile Train's work with Kids Operating Room is also addressing one of the most fundamental infrastructure risks facing our partners: unreliable power grids. Consistent electricity is not optional in an operating room. It supports anesthesia machines, lighting, suction, monitoring equipment, sterilization, communication, and so much else. Our work strengthening power resilience by outfitting operating rooms with solar panels is, therefore, protecting not only children and families seeking cleft treatment, but everyone else receiving care at these partner centers.
Healthier Together: A path to a better world
Smile Train is proud to present "Healthier Together: A path to a better world." This video, featuring one of our most innovative — and impactful — safe surgery initiatives, was produced for us and Kids Operating Room by BBC StoryWorks Commercial Productions in consultation with the WHO Foundation.
How do clinical systems turn safety into daily practice?
Developing strong systems helps ensure that good practices become standard across teams, patients, and facilities.
Smile Train’s rigorous global standards are informed by regional expertise
Smile Train's Global Medical Advisory Board includes some of the world’s top experts from multiple cleft care disciplines. It works with regional Medical Advisory Councils to establish the safety and quality standards all Smile Train partners and programs are expected to meet.
These local Councils matter because clinical standards must be both rigorous and workable in the contexts where care is delivered. Rather than making every decision from the top down, Smile Train collaborates with professionals in every region who understand regional medical practices, available resources, referral pathways, and patient needs best.
Checklists make safety systemic
Smile Train's cleft surgical safety checklist guides teams through critical checks at three stages: before anesthesia begins, before the incision, and before the patient leaves the operating room.
The checklist covers subjects such as patient identity and consent, equipment readiness, allergies, airway concerns, anticipated blood loss, team roles, sterility, critical steps in the procedure, instrument and material counts, and postoperative plans.
The checklist is not meant to replace professional judgment. Its value is in giving the whole team a shared moment to confirm essential information and identify a problem before it reaches the patient.
Safety continues after the operation
Safe surgery also means helping families understand what to do after discharge and how to seek support if they have concerns.
Smile Train developed the postoperative discharge checklist to help teams provide families with essential recovery information before their child leaves the hospital. It includes care instructions, warning signs, contact information, follow-up expectations, and next steps in the patient’s cleft treatment journey.
Digital records support accountability and continuity
Our proprietary treatment database, Smile Train Express, is the world’s largest record of cleft cases. It is also an essential tool for ensuring consistent safety across our global network, as it allows us to review results, offer feedback, and spot patterns quickly.
Accurate recordkeeping also helps local teams understand what care a patient has received, coordinate future treatment, and examine outcomes over time.
To this end, Smile Train and our partners FDI World Dental Federation and Dentsply Sirona developed global protocols and educational resources for digital cleft care that describe digital workflows across different stages of oral healthcare, including patient data collection, treatment planning, remote monitoring, and technology-assisted treatment.
Takeaways
High technology and intimate team building. International systems and individualized local protocols. Smile Train’s investments in workforce, systems, equipment, and infrastructure are helping our local partners in 75+ countries turn patient safety from a promise into a repeatable practice.
By making cleft surgery safer, we are making all surgeries safer. And we are committed to always using every method, tool, and technology available to ensure all of our medical partners meet the highest global standards of patient safety, no matter where they are.
Frequently asked questions about safe cleft surgery
What makes cleft surgery safe?
Safe cleft surgery requires a properly trained team, careful patient assessment, safe anesthesia, appropriate equipment, infection-prevention practices, clear communication, accurate records, postoperative monitoring, and follow-up care. No single tool or professional can provide all of these elements alone.
How does Smile Train support patient safety?
Smile Train supports patient safety by establishing required safety and quality standards, partnering with local medical professionals, funding training and equipment, providing best-practice resources, supporting digital patient records, and investing in facilities and infrastructure.
Why are anesthesia professionals important to safe surgery?
Anesthesia professionals help evaluate patients before surgery, plan and administer anesthesia, monitor vital functions, recognize emerging risks, and support recovery. Their role is central to patient safety.
What is a surgical safety checklist?
A surgical safety checklist is a structured communication tool used by the operating team at key stages of each procedure. It helps the team confirm the patient, procedure, equipment, clinical risks, team responsibilities, and postoperative plan.
How does surgical simulation support safer care?
Simulation lets professionals practice techniques repeatedly, receive feedback, and prepare for difficult procedures before applying those skills to real-life patients. Physical, digital, and virtual-reality simulation can only complement supervised clinical training, however; it cannot replace it.
Do Smile Train's safety investments benefit patients without clefts?
Yes. The training programs, operating-room equipment, reliable power sources, recovery facilities, and safety systems Smile Train provides may be used across a hospital's surgical services.