The principal purpose of an assistance program is not to perform, but to teach by working side-by-side with the local teams, while performing. There is no theoretical or classroom-style teaching stronger than hands-on exercise. The establishment of a patient discussion conference is the first step in accomplishing this goal. All patients selected for intervention/surgery during the 2-week visit periods are open for discussion, and relevant information is equally shared. We believe it is during this process of sharing the information available and the experiences of the most senior leaders of our teams that the hosting team benefits the most. While in occidental societies, we believe that the opportunity to openly discuss and question the decision-making process is fundamental for the good outcome of the patients and is not an exercise commonly carried out in other cultures. The agreement to question leadership and decisions is a learned habit that promotes good leadership skills while fostering change, keystones to the development of modern cardiac surgery centers.

Equally important is the shared experience in the operating room or catheterization suite. Our programmatic approach to the sharing/educating experience permits the transition of leadership roles over a variable period of time, from the visiting to the local team. Our expectations are that while at the beginning of the program assistance implementation, the visiting team (us) will lead and partake in most if not all of the interventions/surgeries, and over time the local surgeon(s) and interventional cardiologist will share a larger proportion of responsibility in the decision making and the actual doing of the procedure. Using the Kharkiv experience, the proportion of locally led surgeries during international assistance trips significantly increased from 0 % in 2008 to 76.2 % in 2010, finalizing with 100 % locally led surgeries in 2015. Likewise, surgical milestones made by the local team with international team assistance include first times as primary surgeon for a tetralogy of Fallot full repair (2009), complete AV canal repair (2011), and the arterial switch operation (2012). Since 2010, a second local pediatric heart surgeon has also begun training as lead surgeon.

It is important to consider that the volume and complexity of cases is kept up during the periods when we are not visiting and assisting, demonstrating a solid movement toward self-sustainability.

The role of formal education should not be underestimated. Fundamental concepts must be mastered in the safe environment a classroom provides before put to practice. We believe the introduction of nurses and perfusionist to the most updated concepts to be of essential importance. Constant improvement, a concept ligated to high-reliability organizations (HROs) (organizations such as airlines and nuclear power plants that cannot afford the occurrence of even a single unwanted event) depends greatly on education and insight. Using this concept to develop a cardiac surgery center implies a trend toward zero tolerance for mishaps. Unwanted events are to be avoided by planning ahead rather than coping with them by relying on multiple safety mechanisms.

At the core of high–reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed (Hines et al. 2008):

These thought processes should be implemented from the beginning and kept in play as case mix complexity grows and a new personnel is incorporated.

Pediatric cardiac care is heavily reliant upon equipment in order to safely carry out the procedures and care of children during and after intervention. The level of technological sophistication that has been achieved in today’s equipment provides us with safeguards previously unavailable. However these features also come with significant costs, which few LMIC can afford. Moreover, although much of the improvement in hardware was healthcare professional driven, it is not essential in order to provide safe cardiac care to children. Adequate equipment which has been refurbished and certified for human use can be acquired at a fraction of the cost of the new one, and in many cases as developed country hospitals upgrade their equipment one can obtain the replaced equipment for shipping costs alone.

Our approach has been to provide critical pieces of needed equipment which has been refurbished but which is not so outdated that replacement parts or entire pieces cannot be found readily. The equipment is tested before it is shipped from the United States, and an experienced biomedical engineer travels with the team’s first trip into each country annually. Repairs are made on this first trip; equipment in need of replacement is identified and sought for between trips. We have used point-of-care testing as a means to bypass local laboratory deficiencies or inefficiencies. We routinely bring two handheld point-of-care devices and supply of necessary cartridges on all trips where we are knowledgeable of local laboratory shortcomings.