Good afternoon. My name is Kate Siemieniewski
and I work in the Alumni Lifelong Learning at the
Wisconsin Alumni Association. Today I'd like to welcome you to
Global Hot Spots, a lecture series that takes you behind the
headlines with UW experts. Global Hot Spots is a
partnership between the Wisconsin Alumni Association and
the University of Wisconsin Department of International
Studies. Today's lecture, Improving the
Quality of Healthcare in Ethiopia, will be presented by
Lori DiPrete Brown, the Associate Director for Education
and Engagement at the newly established Global Health
Institute. Joining Lori today is a team of
UW staff and alumni. We have Ramon Aydiko Ayele,
Katherine Konkle, and Sweta Shrestha.
Please join me in welcoming our guest speakers.
[APPLAUSE]
Good morning, everyone, and thank you for
coming out to learn about our efforts in Ethiopia.
I have a lot to be thankful to Wisconsin Alumni for, and you'll
be hearing about that when I talk about some of our staff and
associates who are actually my former students who are young UW
alumna, but it just occurred to me now as I was coming out that
the reason I am most grateful to UW alumni is because they
produced a very important person, my husband, and I
literally owe them all the joys of my life.
So that's just kind of an aside. My role in the Global Health
Institute is as Associate Director for Education and
Engagement, and by engagement we are referring to engagements of
students, faculty, often alumni as well, in really making change
for global health and well-being.
So this involves education, it involves service learning, and
what we're going to describe today is a program where we're
really bringing some of the most talented and accomplished people
from the health sciences to partner with a hospital in
Ethiopia to make change. We're also engaging out students
in that. So we see it as a kind of nested
approach where we're joined to learning, and there's a lot of
mutual benefits. We learned so much from our
Ethiopian colleagues when we're here, they're also engaging with
our students to make change for global health and well-being.
So it's something that is very exciting to be a part of, and
you'll hear that from the whole team I think.
The Global Health Institute mission and vision is really,
these are the big ideas we're working with.
So we're wanting to really be about discovery and advancement,
discovery and change. We're looking at determinants
and root causes of health challenges and trying to
establish lasting solutions. And you'll see the emphasis on
empowerment and sustainability and how we're working in this
partnership with the Ethiopian professionals.
The three tenets of our program involve enhancing environmental
sustainability, improving the human condition, and carrying
that out with a focus on ethics and governance.
And the thing that I like about this project is even though it
starts with emergency services, which seems pretty narrow and
medical, it really does extend its tentacles out into these
areas, even the governance. And when you empower people by
showing them that change is possible, that has a spillover
impact into other parts of the program, and you'll see that in
what we describe here. So these are the big ideas that
have guided us, but what's really kind of wonderful about
Ethiopia is that while we're a new institute working out the
conceptual frameworks for all this, there's a wonderful
partnership in Ethiopia lead by Dr. Girma Tefera, who many of
you may know for different reasons.
He's an established clinician in the Madison area, leader in our
community, but also has wanted to work to strengthen systems in
his own home country of Ethiopia.
So he has really spearheaded this partnership which has
become a very fertile and emergent place for these ideas
to take root. Also, Dr. Cindy Haq, who was the
founding director of the Center for Global Health, which was
building block toward our institute, is engaged there in
family medicine. So we've had great, great
leadership from our deans and from our new Global Health
Institute director Dr. Jonathan Patz.
The Ethiopia partnership is sound, and it's sound for a
number of reasons. One is it meets critical needs.
We did not bring the agenda. The agenda emerged from the
setting. It also combines scientific
methodologies that you might have learned in your training at
UW with this concept of a twinning model where our
hospital is partnering with their hospital and working
together for change. So a lot of the us and them that
can sometimes get expressed in international collaboration
really is overcome by that relationship of what can we do
together. So it's not just our faculty
that go there. We bring them here for training,
for building relationships. So when I was asked to go do
this QI training in Ethiopia, I had already worked with the
fellows here. I had eight friends in the
country waiting for me to arrive.
I knew people by name. That's a very different model.
I worked with development agencies for many years before
joining UW. We also did great work, but this
model of having it be embedded in friendships and relationships
and Wisconsin style relationships really made it
great. Then UW Madison, this commitment
to partnership, again that long-term commitment makes it
very helpful. What I brought to it was the QI
methods and approaches. I've been involved in quality
improvement, which is a great change strategy that has so many
applications besides health, and that was something that we could
place within this context. I'm also going to be telling you
later about how this is just expanding in terms of some
wonderful opportunities, way more than we expected, partly
because when we use the twinning model people engage so much more
fully. We have people from our side
volunteering and just getting so excited about the environment
that other new projects are emerging.
You'll be really delighted when I show you what our students and
colleagues are doing. And then I just want to say the
UW alumni have been big contributors to, not just this
partnership, but really our institute.
I joined the institute eight years ago, and it as actually
through a generous alumni gift that we were able to even begin
our work, and now we have a very solid institute with a lot of
institutional support and funding.
So, anyway, besides that human resources that you'll see, we've
had alumni helping us out over the years.
Here's Ethiopia, for those of you who need a refresher on
where it is, in east Africa. 80 million people and it's 85%
rural and 15% urban. And that urban center is where
this Black Lion Hospital is where we're working.
And the Black Lion Hospital is a public hospital where all the
most serious cases will go. So it's a last stop for a
referral, and it is where most of the trauma patients would go.
Because it's a burgeoning urban center, they see a lot of
traffic accidents there, in particular, and Black Lion is
where they're seen. So when we think of our model
for GHI of looking at root causes, we even think about how
can we prevent accidents by doing some interventions at the
hot spots, if I can use that word, where the accidents are
occurring. But our project begins with
trying to improve emergency care.
And the need for emergency medicine, this is the waiting
room, familiar to all of us, we've spent time there, which is
an outdoor space. And this was taken by Pete
Rankin, one of the emergency medicine nurses from UW Hospital
who has been very, very, contributed so much to this
program. And here is the inside of the
emergency room. I did not see it like this
because by the time I got there, a lot of the interventions were
already made, and I was guided by a very proud colleague who
had implemented changes in infection control to what looked
like a very different place than this initial photo.
And also the pediatric ward that you'll hear about has been
redone. So the need for emergency
medicine, they used a systems approach which included learning
about pre-hospital and ambulatory care, triage systems,
communication, incorporating evidence-based practice, and QI,
quality improvement which is what we'll talk about today.
Here we have the background on the twinning partnership.
The Black Lion Hospital and the Addis Ababa University with UW
Madison Hospital and University Medical School, and another
great aspect of this program is the people to people connection.
This is a diaspora Ethiopian group that partners with us
which brings a lot of talent from people who've been outside
of their country for a number of years and, again, want to give
back and be involved in training.
So that's a really powerful combination.
Twinning partnership, just briefly, the principles include
volunteerism. Many, many of the work you'll
hear about people volunteering. And broad-based institutional
relationships, the mutuality of it and really a
relationship-based approach. I didn't really understand how
important it was until I went to the field and saw how that
twinning relationship made things go so much more smoothly.
There are some of our fellows that you'll be hearing more
about. Actually, I took them to visit,
they were here in the peak of the tulip bloom a few years ago,
and we broke out of class and went to visit the tulips in my
neighborhood because I just thought they can't go home
without seeing that. Quality improvement has five
components, and these five things together, very powerful.
Developing standards. There's a lot to that.
It's not just about having international standards but
adapting things that they make sense locally, and that's what
we're working with them on. Here's the evidence base, but
how do you take this to your local setting.
They would have an easy time staffing our emergency services
with the resources that we have. Their situation involves so much
kind of raw medical wisdom and that art of medicine and
improvising that we really need to sometimes adapt standards.
Then monitoring, introducing the idea of routine measurement and
acting on indicators. And then process improvement,
which is what we'll be talking about.
We did a lot of training on how to work in a team to improve
processes. Organizing for changing, having
some kind of structure and routines to it.
And then a culture of change, which it sounds so simple.
When we say that we can do it mentality or yes we can or
anything you want to say, but it isn't the case everywhere that
people think they can do it together.
Some of these settings are difficult.
When we worked in the hospital, Roman and I were working with a
great team, and they were so committed, and we became aware
that they didn't have sheets in the emergency room.
And so it's really hard to go and expect people to do quality
improvement work when the highest trained surgeon in the
country has to focus on hand washing and sheets.
But they do it because they want to make change and they know
what's needed. So we actually packed up 200
packs of sheets and brought them in our excess baggage, which was
appreciated. These are some of the tools that
you'll see used. We're teaching teams to use
these systematic problem-solving tools because it really helps
them understand what's really happening and what's going
wrong. These are some other kinds of
ways of organizing data. Again, things you've probably
seen in your work but they're relatively novel in terms of
using them as management tools in these settings, and they do
make a huge difference. This is where I kind of get sort
of spiritually engaged with the quality because on the one hand
you can do quality improvement, which I did for many years, to
the point, honestly, where I got tired of it.
It's different people, different problems, same method.
But then you start to see that in our own setting, quality
improvement, you get incremental change.
You go from 90 to 95 compliance, which is great for that 5%.
But in these low resource settings, you're talking about
dramatic change of systems where they think nothing is possible
and suddenly it's possible. So this is really a tool for not
only improved health outcomes but, even in terms of the
potential for advocacy for realization of human rights and
for improved governance, once you show people that they can
work together to make changes within their systems, it can
just mushroom. And that really is a very
practical tool for change. And that's why I get so excited
about doing this training. Here's a couple of graphs which
aren't looking that good in this lighting.
But one of them on the left shows the change in infection
control compliance. At the beginning you'll see it
was around 30, and we got it up to about 80s there.
This is hard to do in the low resource setting in Africa, and
it's really to the credit of our amazing colleagues that they
accomplished it. The one on the right shows
increases in compliance with the triage practices, and Roman is
going to tell you a lot more about that.
Again, these are two very, they went from having a triage system
that almost didn't work. So you've got a low resource
setting where every, really, every resource should be used to
help someone how really needs it, but that sorting isn't
happening maybe 10% of the time. And now it's happening like 95%
of the time. So when you think about that at
the largest urban hospital, it has an impact, it has a ripple
effect in the sense that people start to have more faith in the
whole health system when something like that starts to
work. And Roman worked with the team.
It's a laborious process to make those changes, and she'll tell
you about it. I'm just flashing, I'm doing the
easy part, flashing up the big impact.
So, that said, I'm going to now turn it over to Roman and Kate
and Sweta. These are people who I have
really enjoyed working with. Both Roman and Sweta are UW
alumni. They graduated both within the
last five years, both their undergrad and their MPHs here.
Another reason why I'm so proud of our institute and our growth
is because we can hire our own graduates, and it's really,
really exciting to see them go from being students who might
come for an advisory meeting to be colleagues that I can really
rely on for doing some great fieldwork.
I'm going to invite them each to tell you a bit more about
themselves, and Roman will be telling you about the fellows
program and her work on the triage.
Kate will be telling you about the process improvement
methodology. She's with the Population Health
Institute, does this kind of training all over Wisconsin,
brought that expertise to Ethiopia.
And then Sweta has been involved with me more recently.
We were invited to do a national training because they liked
this, and Sweta helped me with scaling this up, and she'll talk
more about what that national effort looked like.
So, with that, I will pass the wand to Ramon Aydiko.
Hi, everyone. Thank you, Lori, for that
introduction. My name is Ramon Aydiko Ayele.
I am a public health disease investigator/assistant
researcher for the Wisconsin Immunization Program right now.
I have done my undergraduate degree in biology and gender and
women's studies here at UW, and graduated in 2008.
And also continued on doing my master's in public health, and
graduated just this past May. I started working as an intern
in the quality improvement project with Lori.
And she took me in and mentored me and taught me everything I
need to know about quality improvement, and then I became
part of the trainers and the advisers for quality
improvement. And I started this as a graduate
student and continued working throughout my graduate program,
and it has been one of the most significant works that I have
done so far. Partly because, just the work is
exciting in itself and quality improvement is exciting, but
also having that connection with my home country, Ethiopia, you
can just imagine. It's really wonderful.
I'll just go into, today I will be talking about the Ethiopia
emergency department fellows training and what those
trainings consist of and how they're recruited and so on.
As Lori said earlier, the partnership is taking a systems
approach to address the entire continuum of emergency care.
There are three main objectives that the partnership is trying
to address, and these are providing leadership training
for individuals who would serve as the core leaders in the
emergency department at Black Lion Hospital.
So it as part of this leadership program that the quality
improvement training was developed.
And also, the second kind of objective is developing local
emergency medicine trainers, which ensured that all staff in
the emergency department and throughout the hospital would
have emergency medicine knowledge and skills and
awareness. And the third objective is
expanding local workforce and services.
For example, in 2010 emergency medicine training center was
opened where any kind of training related to, it could be
quality improvement, it could be clinical trainings that a lot of
the partnerships and the exchangeships happen in that
training center. So they have a place that they
can say this is our training center and build up on that.
So the quality improvement training we focus on, there were
four exchange trips that happened here at Madison.
There were four groups of fellows who traveled from
Ethiopia for four to six weeks here in Madison.
We had eight nurses and nine physicians so far, and they had
different kinds of training in emergency medicine and
leadership training, and one of the training was in quality
improvement. These physicians are selected
from pediatric and adult emergency medicine departments
with equal gender participation consideration and also with
different backgrounds. Their interest or background in
clinical work goes from intensive care unit nurses to
surgery to obstetrics and gynecologists and a variety of
fields so that when they come here they can be trained in
emergency medicine with the skill set they had previously.
So the specific training that the quality improvement training
that they received would be discussed, the methodology would
be discussed by Kate, but I just would like to go through some of
the trainings that we have done so far, specific ones.
While they are in Madison they receive 16 hours in instruction
taught by Lori and I. And they receive certificate of
completion at the end of each training.
And they also receive mentorship on independent quality
improvement projects that they would take back to Black Lion
Hospital where they implement those programs.
So far we had 15 quality improvement projects develop,
and I'll talk in depth about one of them and Sweta will cover the
different genres of quality improvement projects that were
undertaken. But there was quality
improvement training within the hospital where, in fall of 2010,
Lori and myself traveled there and conducted quality
improvement training for 50 senior staff from different
departments at the hospital, and the main theme of the training
was to alleviate demand of beds by the emergency department
through active inpatient bed management and improve bed
turnover by discharging patients on a timely manner.
And this was a huge issue because even though it was an
emergency department where patients are supposed to come in
and leave right away, it was a situation where patients stayed
in the emergency department for more than 30 days.
And another patient would come and there was just not enough
bed, and everyone in the emergency department was
frustrated so they communicated this frustration with other
departments through this quality improvement training and
designed and are implemented different methods as to how to
alleviate and coordinate those burdens that the emergency
department is receiving. And each department set its own
goals, but they also communicated those goals with
the emergency departments so that things go on smoothly.
This past fall, Lori, Kate, and Sweta traveled to Addis Ababa
with the aim of doing another quality improvement training
mostly for new leaders who were not part of the previous batch
that we trained in fall 2010. So they developed different aim
statements with these trainees included increased infection
prevention efforts in the pediatrics emergency department,
increasing emergency medication availability, and also increased
quality service at the hospital. So there are a lot of different
things that these trainings came about.
There was also an assessment of previous quality improvement
project that the fellows implemented that were assessed
and also monitored to figure out what's going on next and what's
the next step and so on. So this is the quality
improvement project that I was highly involved in.
I did my thesis for my MPH program in this area.
So the main project was taken by a physician named -- who said in
our emergency department, only about 10%-20% of our patients
are triaged, and we don't know what kinds of patients visit our
hospitals and what kinds of patients are seen, and we don't
know the demand so I would like to do this quality improvement
project. So, with the help and assistance
from Lori and myself, she designed and implemented that
program at Black Lion Hospital. And she did this through
redesigning the triage form because it was lengthy, and due
to crowding at the hospital, it was very difficult to fill this
form in. Redesigning, training the triage
nurses on the benefits of triaging, and also talking to
different stakeholders regarding the benefits and what the
challenges were. For example, a sheet of paper
was very difficult to find at the hospital sometimes.
They didn't have enough printed material so just simple things
like that. So she made sure that those
things were available and were included in the budget for next
year, and that the nurses and they physicians and the
residents knew the importance of triaging to decrease the
crowding at the hospital as well as respond well.
So after the implementation, patient triaging increased to
75% within the first three months of implementation.
Currently, 100% of the patients are triaged, and it wasn't easy
to get to that point but there was a lot of monitoring and
evaluation and follow-up and supportive supervision that she
did from the hospital and then Lori did from here from a
distance. And she said further evaluation
is needed because sometimes I noticed that some of the forms
the name is filled but the patient complaint is not
written, so I would like to study how the completion rate is
going. So we did another record review
to look at how complete the forms are and talk to the nurses
about these issues. And the goal was to improve the
quality of triage from completeness that was less than
50% to increase it up to 75%. And we saw a dramatic increase
where on average now there about 94% of the time the forms are
complete, which is a great progress for a triage where
there was only 10% completion rate.
This is after a year and a half of implementing the program, so
it shows that the program is sustainable and it's a
sustainable improvement and the nurses took ownership and
consider it as one of their tasks now.
I'll pass my mic to Kate so she can discuss about the
methodologies that we used.
Hi, everyone. Oh, I feel kind of tall which
doesn't often happen. So I am Kate Konkle.
I am a program manager and outreach specialist at the
University of Wisconsin Population Health Institute, and
I also a QI consultant with the Institute for Wisconsin's Health
Inc, which is another public health institute in Wisconsin,
and have done quality improvement training primarily
with local health departments and also the state Division of
Public Health all over Wisconsin.
So I was really excited about the opportunity to take that
skill set and take it to Addis Ababa and get to do some QI
training there. So, I am going to talk a little
bit more about the methodology and really what we did in our
week that we were in Addis. So the brief overview is we
didn't want to just go in and do a training with us being the
primary presenters, so we did do a three-day skill building
workshop, but we also did a nested train the trainer, and we
really wanted to build capacity for this training to continue
after we were gone and that there was capacity in country
and at these different institutions for this work to
continue. And then we also had a closing
symposium, and I will talk about each of these areas a little bit
more specifically. So our three-day workshop, our
goal was really to build QI skills and knowledge, again,
really giving people the tools and the understanding and
knowledge of how to do quality improvement broadly, but really
that process improvement that Lori talked about before.
How do they really get to the root of problems and work as a
team together to make these improvements to really improve
health outcomes in their community and at the hospital.
And then we also wanted participants to leave with a
tangible started project so that they weren't working on
something hypothetical or just an example project, but that
they were really applying these tools as they were learning them
to something that they had identified that was a real issue
that was important to them that they really wanted to address
and fix and that they could take that then back to the rest of
their group and have something started, hopefully building a
little bit momentum and a little bit enthusiasm and energy around
quality improvement and what it could really do for these issues
that they were looking at in the different departments that they
were from. And Sweta will talk more about
those specific projects that they worked on.
So it was really exciting to hear what was going on and what
they were struggling with and being able to help them and give
them some systematic tools to apply.
So the workshop consisted of, we provided that broad overview of
the quality improvement that Lori showed you the triangle,
the quality triangle and the broad strokes of quality
improvement and what that includes, but then really spent
a lot of time focusing on the tools and the skills needed to
do that process improvement and bringing a team together and
really digging deeper into the problem.
We also took some time to have a leadership discussion with them
recognizing that these were the individuals that were going to
go back and lead the QI efforts in their different departments
and that wanted to talk about what does that look like and how
do you get comfortable as a leader and are there different
ways to lead and what are the qualities of a good leader,
where did people feel like what qualities they individually
possessed as a leader and what they wanted to work on.
So we really wanted to make sure that we touched on that and
didn't just send them back without really thinking about
this might be a different role for them.
They might not be a supervisor in their department but that
this was an opportunity for them to step up in a different way
and really use this as an opportunity to do that, but
that's not always comfortable for people that aren't used to
that. So we really wanted to make sure
that we included that in our curriculum.
And then we finally gave them a lot of teamwork time.
Again, we wanted them to go back with this started project.
We wanted them to also come together as a team and figure
out what those dynamics look like and who was going to step
up and who could be a good leader, but really we wanted to
give them time to start a project.
And they were going to present this at the symposium at the end
so there was a lot of pressure on them to come up with
something as they were doing this work throughout the week.
We provided as much support as we could.
We also realized with the language barrier, Amharic is the
language that they were speaking during the training, and when
they sat with us they wanted to speak English and that kind of
inhibited sometimes the natural dialog.
So we often would just let them do their work and check in from
time to time and answer questions.
You'll see pictures as we go. This is a fish bone diagram
which is a root cause analysis tool that I'll talk about a
little bit. But lots of crazy pictures of
funny diagrams and process maps but some really good, hard work
that went on during that week. And it was really exciting to
see both their enthusiasm and the effort that they were
putting into really making some significant changes in the work
that they were doing. So now I'm going to walk
through. This was sort of the meat of our
training and what we really asked them to focus on and at
the end present on. And so we start with an aim
statement really asking them what does it look like, what
does success look like when you're finished?
What do you want to change? What do you want it to look like
when you're done with this project, and who should be
involved? QI is really about involving all
of the people who play a role in the process.
It's not just the leaders, it's not just the higher-ups, it's
the people that are doing the work.
So thinking about who needs to be part of this team and who
should you include and ask questions.
Sometimes that means janitorial staff, sometimes it means the
clerical staff. It's not just doctors.
There's lots of people that are involved in a lot of these
things. The cause and effect analysis is
really starting to dig deeper into the root of the problem and
figure out what's really going on, what's really driving the
problem that they're seeing. A lot of times we focus at that
sort of symptom level and we really want to dig a little
deeper. So we did fish bone diagrams,
and you'll see some pictures of those in there.
Some of them actually drew little fish with faces and
everything as well. We had lots of fun artists in
our group. And then we asked them to take a
look at the process. So what's currently happening
Again, this is about process improvements.
You have to know what the process looks like before you
can figure out where it's going wrong and how to make some
improvements. And then we talked about
indicators. Measuring is a huge part of
quality improvement. If you don't know where you
start and you don't know where you end, you don't know if you
made an improvement or not. We talk about it's really easy
to change things, it's hard to improve things.
We can do things differently, it doesn't mean
we're doing them better. So indicators can tell us
whether or not we're doing them better or if we're just doing
them in a different way. And then it's time to plan your
action. So once they kind of did all of
this work, they figured out what are some things that we could
do, some strategies we could take to make these improvements,
to improve the health outcome, to improve this process, to make
our group more efficient or to have better health outcomes.
And we asked them to put it all in a timeline.
So you want to make sure that you have a succinct time frame
in which this is going to happen so that you don't just have this
ongoing, never ending project. So, as you can see, that's a lot
of work to do in three days, and, actually, they were doing
it in about two and a half. So we asked a lot of them, and
they showed up, and they did an amazing job, and it was really
exciting and really energizing and exhausting, I think, to do
this work with them. Along with that, though, we
nested this train the trainer. Again, we didn't want to just go
in and build more skill and capacity in the participants,
but we wanted to make sure that there were some people who were
getting that leadership opportunity and could continue
this training even when we were finished.
So the goal really was to build the internal capacity and
leadership for quality improvement work for these
trainings to continue. We had a wonderful group of
facilitators who had either been part of the training here at UW
or had prior quality improvement work, and they did a really
great job coaching the teams, really giving their experience
and expertise in helping them through, and then also helping
us lead some of the sessions, doing examples or co-leading
some of these sessions so that they were really getting that
experience. That was a really fun group to
work with, and we did a preview and review every day with them
so that they really got an opportunity to ask questions and
know what was going on. I think that's the next slide.
Yes. So we did a pre-workshop
walk-through so that they knew what they were getting
themselves into and they knew what the workshop was going to
look like, and they were prepared for that and could ask
questions. We asked them to be presenters
and coaches and talked with them what that meant and what that
would look like, and then, again, these daily previews and
reviews. We started the day with do you
have questions about today, are there concerns, and then ended
the day with what went well, what could we do better which is
a great QI tool. Finally, we did a symposium on
Friday which was an opportunity for the group to really show off
the hard work that they had done, and we invited members
from the Black Lion CEO, which that's a picture of her there
talking. She was a really great supporter
of this. So she came, some individuals
from the Ministry of Health were there, from the International
American Health Alliance. We had a lot of good people that
were there and interested to hear about what was going on
with this project. There were some people that some
of the groups that had already done QI projects were from Debre
Berhan, which was one of the hospitals that attended, and
from Black Lion got to present their projects that were already
ongoing or had already taken place and been completed.
And then we asked our workshop participants to present the work
that they had done. And they just blew our
expectations away. They were really phenomenal.
We asked them to do this five by five model.
Five slides, five minutes to present all of that work we had
asked them to do, and they did such and incredible job.
And I think we were all blown away by both the amount work
they had done, the amount of really good thought they had put
into their projects and really excited to see where they were
going to go because I think they had a really good start and just
really put together some amazing presentations.
So Sweta, now, is going to tell you more about some of the work
that they did.
I do feel tall. Thank you so much for allowing
us to be here today. My name is Sweta Shrestha, and I
did my undergraduate degree here neurobiology and did my master's
in public health here too, and I found public health thanks to a
lot of great advisers. And it's great to be able to
work that I'm doing right now at the institute.
I serve as an adviser to the undergraduate and graduate
certificates in global health, so I get to hang around
undergrads and tell them all my wisdom and everything that I
have in the couple short years I've been working.
So I was really lucky to get the opportunity to go to Ethiopia
with Lori. I have experience working in
Uganda and in Nepal before. And I was part of the QI
training that went the summer before here in Madison.
So I'm just going to briefly talk about the projects.
I know Ramon talked about one, but I just wanted to kind of
give you an idea of the range of projects that they worked on,
and then talk a little bit more about the QI training that we
did this past fall/winter, fall. It was early December, late
November. And then just talk about the
projects that we did with them. So, the project started out, the
training started out focusing on adult emergency medicine and
then moved to pediatric emergency medicine, and then
with our group it was much broader than that.
So some of the projects that already mentioned was to
increase triage quality system, reduce decision making intervals
in trauma care, and effective and efficient patient registry
system. And a lot of this are things
that we take for granted here in our health systems that works
pretty well, but working with the fellows here and there, you
can really help them focus on what the problem is because we
don't know. Only through working
with the people there who do this on a daily basis can you
really focus on the root causes and actually make a difference.
And the year after, this is where the projects were more
about improving infection prevention and improving quality
of triage in pediatric emergency department.
So this is when we had a lot of our pediatric fellows here.
And also to increase compliance in the pediatric emergency
department with protocols of hand hygienes and really
improving it to 75%. And in 2011, they focused on
reducing orthopedic trauma patient stay in the ER,
increasing emergency drug and material accessibility in the
pediatric ER, and reducing length of stay in the emergency
patients for radiology workup. A lot of the pediatric emergency
medicine quality improvement work has been on hold.
You'll see they were building a new ER for the pediatric
department, and I have a picture of that, and it's quite amazing
all the work that they have done and are continuing doing.
So, Kate talked a little bit about the work that we did, and
I just wanted to point out that while the previous workshops
focused on Black Lion Hospital and the doctors and nurses and
pharmacists, this opened it up to more of the regional partners
through AIHA and the CDC and the twinning partnership.
Really, we had people from Tanzania who were working in
HIV/AIDS control and social workers.
So we had a broader audience for this workshop.
And one of the groups chose to focus on reducing the percent of
patients staying more than 24 hours in the ER from the
currently 41% to 20% within the first three months of
implementation by making appropriate and timely decision.
So really streamlining the process, and they were the ones
who knew best what were the holdups and what was preventing
them from reaching the 20%. So the quality improvement
workshop we did really gave them the tools that the fish bone
diagram to help them really map out what were the challenges
that we're facing. Another project that one of the
groups focused on, this was a group of pharmacists in Addis
Ababa University, is to increase the availability of emergency
medicine from 28% to 75% within 12 months through application of
proper drug supply management system.
And this is from the essential drug list from the WHO.
And really trying to get more of those drugs that the WHO deems
important to have in every ER available.
And what was great about this team was as they were talking
and debating back and forth, they were a really lively team,
a couple of the members said, well, it's not possible.
We will never get all of these meds in our hospitals.
And a few members of the team said, well, this country that we
just visited a few years ago or a few months ago, I think they
had just gone to Zambia, they said they have it, why can't we?
And that is so key because that it's never going to happen here,
we're never going to deal with the problems, is just
everywhere. So to hear them say of course we
can do it, they're doing it and saying it to their own
colleagues was just great for me to see.
And another team that were present at this workshop was
from Debre Berhan and that is a rural hospital a few hours away
from Addis Ababa, and they came and really wanted to work on
improving the waiting time. And they wanted to reduce the
outpatient waiting time to one hour within three months by
building one extra window for cashiers and really improving
the communication with physicians.
And while they were there, they were a really great group to
work with, they mapped out where the patients were waiting and
what was going on, trying to figure out what was causing this
hours and hours of wait, and they figured out that the same
cashier was dealing with and the patients were coming for the
first time paying for their medication.
So as simple as building another window was, hopefully, going to
work out, and this was something that they're working on right
now. And also improving
communication, really making sure that the physicians are on
time. They know why the other patients
are late. So all of that is being worked
on right now. And another thing I wanted to
point out in this picture is the nurse that you can see in the
right side of the picture, she was the one who gave the
presentation on the last day, the symposium, and a lot of
times, even here, I think nurses don't really have the respect
that other health professionals do, and she was really quiet
through the whole workshop and really starting to get her voice
on the last day. And for her to stand up in this
large group where there were people, representatives from the
CDC, from the Ministry of Health, and give a presentation
in five minutes about what they wanted to do was incredible.
And just what Lori talked about, the transformational aspects of
quality improvement, it's not just about little things about
reducing the time from 20 minutes to 15.
It's about really empowering people to really believe, as I
do, that quality can happen and that they can do it with
whatever they have, and the greatest asset that these people
have are themselves and their talent.
And another team that I had the privilege of working with was
from Tanzania, and they were two doctors, and they wanted to
really improve the utilization of the skills lab that had been
built around Tanzania but aren't being used.
So really, through the workshop, we sat down and talked about why
as these skills labs not used. So they're going to focus on
trying to develop manuals so that 27 nursing schools, there
are actually schools all over the country so you can imagine
the magnitude of this project when it's actually implemented
could have. So that's a project that,
hopefully, we'll have a chance to work on more in the future,
which I'm excited about. And this is a picture of the
new pediatric triage area. They built a new pediatric
emergency department, and it's great to see the color, the
light, and the cleanliness. If you walk through the old
pediatric ER, it's a windowless room where all of these kids
are. And when I was walking through
here, I just think about our children's hospital that we have
here and a lot of times take for granted.
Just having this color and this open, bright space for kids to
be when they're sick is so amazing, and I'm really, really
happy that this is in place so that they can really go ahead
with implementation of all these other pediatric projects to give
them the best care possible. And then one of the other groups
that were there were focused on HIV testing and counseling, and
they really wanted to make sure that as the services are being
implemented that they were doing everything they can to make it
as appropriate as possible. So that's another thing that
we're following up, and then Lori will touch base on as we
go. Thank you.
I want to make sure we have time for questions, so I'll just
wrap up really briefly with the way these programs are just kind
of exploding into some new initiatives.
So, in addition to working at the hospital level, we've been
invited to work at the national level with the other twinning
partnerships, there are seven, in Ethiopia.
And more recently, we just were engaged by the American
International Health Alliance to do an Africa region program also
on quality. We'll be Zambia in April working
with their partners, and then in Tanzania in the fall.
So it's really taking off, and we're hoping that we can build a
joint learning network among those countries so that those
shared lessons can happen. So really one small project can
just be a catalyst for so much more.
In the spirit of our global health institute approach, we
have a lot of other things going on of different scales, but just
because people kind of come engaging with their whole heart
as well as their UW trained minds, we've been able to
identify a master's thesis related to climate change that
our institute is funding. First one of its kind in
Ethiopia. We presented our work at the
16th annual conference on AIDS and STDs in Africa which was
10,000 people there, and we got to have a UW presence.
We have student projects. Sweta and I lead a freshman
honors class in global health. They became interested in the
Hamlin Fistula Hospital, which is a whole other topic for a
whole other day, but at their insistence we visited the
hospital and we've come up with a project where our students can
make blankets that they hand out to the women when they arrive
there to get treatment for this highly stigmatizing condition
that is, for the most part, curable.
We are also looking, Roman and Dr. Andrew Muriuki and I are
involved in evaluation of programs for AIDS orphans and
vulnerable children in Ethiopia, again using QI approaches for
policy development and system strengthening.
And we're hoping to have service learning programs.
We have service learning programs in a number of
countries, again topic for another day, but we're
developing one with Save the Children in Ethiopia, hopefully.
So a lot of opportunities for professionals and students to
engage in Ethiopia. Lots of relationships building
on each other, again, hoping to create change and to learn with
these really amazing partners that we have.
We're really, really grateful to you for coming.
As I said, so much of this wouldn't be possible without
alumni support. Even just being our audience and
giving us an opportunity to tell this story is a real gift to us
because it's hard work and it's nice to share.
So thank you very much and look forward to questions for any of
us. We would welcome them.
Thank you. >> Thank you, everyone.
[APPLAUSE] I'll bring the
microphone around now for questions.
Anyone have any questions? >> How many hospitals are there
in Ethiopia? Are you aware of the number?
I don't know the exact number of hospitals in Ethiopia.
There are none other of this size.
There are a number of urban hospitals.
There's a system of public hospitals and private hospitals
just like here. Each region would have a major
hospital. So in terms of this level of
care, probably it's at the regional level.
We are in conversations with the Ministry about working with a
network of hospitals. >> How many beds are there in
this particular hospital? >> No, in the hospitals.
It's an 800-bed hospital. It was designed for, like, 200,
and it's just exploded over the last 20 years.
How are the participants in the training chosen?
Are they self-selected or how do you get the people?
Again, this is a benefit of the twinning partnership.
The leadership there is very engaged in figuring out who
would be the right people, who would really take advantage of
the training and do it. There was some self-selection
because, frankly, with all these trainings that occur in these
settings, people just don't come if they're not motivated.
But there was coordination, particularly the leadership of
the hospital decides who gets trained.
In some of the cases, they wanted to train everyone.
So anybody who was a nurse supervisor above, like for the
active bed management almost every department was represented
at that level. >> Are there any other
questions? >> How do you handle politicians
and budgets and all kind of things?
Well, Ethiopia, at the Ministry of Health level, is
fortunate because they have a Minister of Health who really
has a great reputation nationally for being progressive
and wanting to follow WHO strategies for building blocks
for better systems. There's a lot of political,
administrative even, constraints in this situation.
So some of the things, it is this incremental change idea.
Some of the things that really hamper these projects have to do
with the way procurement is done, and it takes eight months
to get soap dispensers because of how procurement works.
So some of those things are constraints that we work around
because quality improvement isn't a tool for everything, but
one can hope that those systems are going to be concurrently
improving. We haven't had any political
opposition to what we're doing. It benefits everybody to improve
emergency services. You can imagine other things
where you might, and again, the network is strong and very well
trained, very enlightened, and they do have an enlightened
Minister of Health. So we've been fortunate at that
level. The larger country politics are
a separate item that we haven't had a lot of interaction with.
Okay, well, if there are no more questions, I just want to
congratulate you on the new Global Health Institute.
Thank you. >> And, ladies, thank you very
much for joining us today, and we hope to hear more from you in
the future. Thank you.
[APPLAUSE]