University Place 691 Global Hot Spots  Improving the Quality of Health Care in Ethiopia  Lori DiPrete Brown Feb. 17,2012  CC >> 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]