QALA begins!

QALA participants (not seen: 'Me Nyenye, pharmacy director, 'Me Monki MSW, 'Me Tarr, nusring clinical supervisor) 'Me Maseru, manager of maternal-child health, 'Me Pholoana, ART nurse, HIV clinic, 'Me Ngwane, clinical instructor, School of Nursing, 'Me Mpholo, director of housekeeping and laundry, Ntate Tukula, officer, TB clinic, Ntate Mpitso, Lab representative, (back row), 'Me Tlelima, QI and infection control nurse, Ntate Neko, project manager, HIV, TB, social work and food security,  Dr. Julie Pua, medical staff representative.

On February 13, 2013, we held the first meeting of the Quality and Leadersip Academy (QALA) at Maluti Adventist Hospital.  The word qala means "begin" in Sesotho and made a useful acronym.  Eleven front-line managers attended the first meeting with a few more to join us next month.

QALA has three components. Each participant will:
1. carry out quality improvement projects within his or her department;
2. follow a topic or website on the internet; and
3. read sections from selected books on management and discuss them with the group.

For the opening session, I presented an overview of Quality Improvement (QI) projects, using the Institute for Healthcare Improvement Model for Improvement.  We discussed some potential projects that people would like to do and how improvement could be measured.

Then everyone took the survey developed by the Gallup Organization reported in the book First Break All the Rules: What the World's Greatest Managers Do Differently. I gave an overview of the first section of the book and the participants will give the survey to others in their departments.  Next month, thanks to the generous donations of many people, we will have a copy of the book for each participant to read and discuss, as well as new equipment to use for presenting the Powerpoints.

Thank you to the following donors to the Peace Corps Partnership Project who were willing to be publicly recognized: Anne-Marie Armstrong, Audrey Lew, Frankie Reece, Heidi Emam, Janis Droegkamp, Maurice Chabuz, Mike Veitenhans, Noel Howes, Patricia Boiko, Richard Gelb, Terry Cook and Virginia B. Meyer.  We are very grateful for your support!  The new equipment will make all of our future trainings much more efficient and effective as well as providing a dedicated computer for the QALA participants to use for their internet research.

Sending Lesotho sunshine your way!
Barbara

Stayin' Alive! Stayin' Alive! Pump, pump, pump, stayin' alive!

 Nurse Ntate Rakhoba grinned when I told him he would be the world's most famous Basic Life Support instructor when this photo was posted on the blog! 'Me Tlelima is demonstrating the use of bag and mask for ventilation of the "patient" who has had a cardiac arrest. The course slides are on the computer screen.

In December 2012, 16 key nurses were trained in Basic Life Support.  BLS is a daylong course that teaches CPR skills for all age patients as well as how to respond to choking in infants, children and adults. Training for the rest of the clinical staff is scheduled for 2013.

Barbara

Compliments of the New Year!

The view from our house.  Lesotho is very green this year! Last year we had drought.

Compliments of the New Year is the greeting that people give here in Lesotho when they see you for the first time in January.  Yesterday (January 24) a nurse very seriously assessed whether she and I had seen each other in the new year.  After careful reflection, the answer was no, so I (humbly) received the compliments and, of course, offered my compliments to her. I still find the phrase a bit mysterious, but go with the flow.

We want to thank Ginnie Meyer, Miriam Walden, Carol Meyer and Erin Nickeson for sending us wonderful packages for the holidays!  We also thank many people for sending holiday greetings through email and Facebook. It really helps us feel more connected to home.

With the onset of 2013, the realization that our Peace Corps service will end in seven months became much more real to us.  Terry and I have been reflecting on our accomplishments and our goals.  It is hard to acknowledge that some projects just won't get done, but exciting to see what we have been able to do.  The thought of seeing friends and family again is something that I am anticipating with great joy!

Peace Corps Projects: The Long and Winding Road

My first assignment after arriving at Maluti was to co-teach a "five week" course to third year nursing students on clinical research.  The five weeks stretched into six months as a few hours of research training were added here and there into the students' schedules.  The first five weeks were the didactic training, the other sessions involved helping them design research proposals.  I really enjoyed the students and the prolonged teaching schedule gave time for us to get to know each other better. My students have graduated from the RN program and are now taking a year of midwifery training, so I still see them around the hospital.

In October 2011, I began to focus on the issue of hand hygiene because many of the wards here lack sinks.  If someone had told me prior to my arrival in Lesotho that I would become an "expert" and nagger-in-chief on the subject of hand hygiene, I would have said, "No way!" My regular readers may recall the saga of hand sanitizer acquisition from previous blog posts. After six months of searching, we found and purchased an affordable product. 'Me Nyenye, the pharmacy director, and I had tried to get materials and ingredients to make it according to the World Health Organization formula--no luck. The approved government medication provider offered to make it for us, but at a higher cost. So we made forays across the border to South Africa to buy hand sanitizer from a local pharmacy chain.  Just a few weeks ago, I asked the pharmacist how we were doing with our supply.  She showed me a five liter bottle from the government supplier for 93 maloti--half the cost of the product we are using now!  Somehow, when I wasn't looking, they decided to make the WHO formula and lower the price! Whoohoo!

In December, 'Me Tom,  a nurse on holiday from advanced training in South Africa, walked around the wards with me to do a self-assessment of hand hygiene using a WHO assessment tool. The hospital had improved over one year's time from about 40 points (because sinks are lacking and gloves are used instead) to 132, moving us into the "Basic" category. Our goal is to get above 250 in the next few months, which would mean that we not only have the infrastructure and training that we need, but also institutional commitment, a budget for supplies and evaluation through direct observation--a pretty sophisticated level in a low resource country.

My counterpart, 'Me Tlelima, has looked at the list of projects we are working on together and realized that she needs help when I leave. Thus, I now have 'Me Halahala, young energetic nurse, working with me on the hand hygiene project. She is gung-ho to recruit some "hand hygiene champions" (who will also be our trained observers) and wisely noted that sometimes it is good to give a disgruntled colleague a project to get them more engaged in work.  We will also ask our champions to assist with training and to help us keep the dispensers supplied with soap, towels and hand sanitizer by letting the right person know when they are empty.

Maluti Adventist Hospital campus seen from a nearby hill. The building under construction is for the School of Nursing. The hospital has several wings that are seen behind it. We live in a part of a house hidden by trees down the hill from the church.

Two weeks ago, 'Me Tlelima and I walked around this 160 bed hospital and all of the outpatient departments counting the number of sinks and dispensers we need-the minimum we consider necessary and the maximum that would fulfill our dreams.  The answers surprised us: 14 sinks, 53 soap dispensers, 78 towel dispensers and 130 to 225 handrub dispensers. Wow! Further checking showed that the 1970's model soap and towel dispensers do not work so well, so it will be around 85 soap and towel dispensers. The business office manager has assigned me the job of figuring out the best deal on the dispensers--one more thing my medical school education did not fully prepare me for!  I will write about some of my other projects next month.

Life is not all work, no play.  We are enjoying the lovely summer weather by taking walks and hikes and trips to the camptowns when we can. On Sunday, six hospital volunteers went to visit a retired doctor who lives in a beautiful mountain setting in a nearby district. Terry took the adventure hike, which included wading through a river in waist deep water. I opted for the short tour of the river which involved mostly admiring the beautiful rapids and the mountains all around, then going inside for snacks.

Terry admiring the view of Mount Mahlatsa on our New Year's hike. We hiked with other volunteers to the top of Mt. Mahlatsa in April 2012 and saw all of our district below us.

On our hike, we met this woman wearing a Basotho hat for sun protection.

We think of all of you back home frequently and look forward to seeing you again this year. We're excited that Terry's son Chris and his wife Rhonda will be visiting in a few weeks. Should be interesting to hear their impressions!

Love to all,
Barbara

View of the hospital campus and adjacent village from across the valley

Building a Culture of Patient Safety

My counterpart, 'Me Matumelo Tlelima, RN, is a passionate advocate for quality improvement and patient safety. Though she is a soft spoken person, her drive for excellence is powerful.  She lives the paradox of a limited resource setting, simultaneously sizzling with impatience and stoically waiting out delays due to lack of materials, staff or equipment. She wears many hats, one day orienting a new nurse, another day starting pediatric IVs and later running a meeting to teach healthcare waste management. She is the lone paid staff member responsible for the quality improvement and infection control program for a hospital and five clinics serving 200,000 people and staffed by 250 employees. She will celebrate the one year anniversary of the creation of her position next week.

Role play as part of TeamSTEPPS

The Quality Improvement Committee that she chairs (and I support) began meeting monthly in January 2012.  One of our first mandates was to provide teamwork training to the staff.  We were fortunate to discover TeamSTEPPS, an evidence based program available free on the web from the US Agency for Healthcare Research and Quality.  The primary goal of TeamSTEPPS (Team Strategies to Enhance Performance and Patient Safety) is to improve patient safety by training staff to work together as a team.

'Me Tlelima, center, and Ntate Neko, standing, give instructions for the ice breaker at the beginning of a TeamSTEPPS training at Maluti Adventist Hospital, Mapoteng, Lesotho

20 members of the hospital staff have been trained as instructor/coaches.  They have taken over all of the course planning and teaching for the eight module clinical training program. The TeamSTEPPS program has seven modules: Introduction, Team Structure, Leadership, Situation Monitoring, Mutual Support, Communication and Summary.  We have also added a module on clinical teaching, The One Minute Preceptor, since all of the staff assist in teaching the student nurses from the Maluti School of Nursing.

'Me Ramoqopo, RN, teaches the Leadership module.

We have now trained about 100 members of the clinical staff at the hospital, in groups of about 15 at a time. The reviews from participants have been great!  We are also hearing some stories about the impact on daily life.  One nurse said that she volunteered to work an extra four hours to accompany a patient to the capital city in the ambulance, "Because of TeamSTEPPS." A doctor was asked to help with a task that a nurse was having trouble with: "TeamSTEPPS, Dr. Pua, TeamSTEPPS!" Keeping the needs of the patient central to our work is a day by day, minute by minute task. The instructor/coaches choose one or two skills each month to re-inforce to help the culture of patient safety take root.

 Can you help us acquire some equipment for training?  One thing you will notice is that we use a projector, laptop and speakers to give the training. ( The video vignettes that are part of the training require good speakers so that they are loud enough to be heard.) We have to beg or borrow equipment each time we give a training, which can be time consuming.  Our goal is to train one hundred staff members who work at the five outlying clinics early in 2013. We have an appeal for funds to purchase dedicated equipment for the Quality Improvement department on the Peace Corps website.  Go to www.peacecorps.gov/donate.  Search by country (Lesotho) or volunteer name (Meyer).  The project is called "Improving Health Care Quality".  The funds will also support a new project called Quality and Leadership Academy (QALA).  QALA will provide management training for front-line managers through a monthly meeting.  At the QALA meeting, we will plan and share quality improvement projects, seek best practice information from internet sites (e.g. World Health Organization and Institute for Healthcare Improvement) and discuss selected books about management.
QALA should be fun!  Here is the direct link to the project website:

https://donate.peacecorps.gov/index.cfm?shell=donate.contribute.projDetail&projdesc=632-124

Kea leboha, thank you, for all of your support!

Barbara

Tanzania

In September, we took a couple of weeks vacation to Tanzania with fellow Peace Corps volunteer Rusty Delucia.  Here are some of the pictures from our safari, a glimpse of Mount Kilimanjaro and beautiful Zanzibar!  We enjoyed the warm weather and wonderful food as we were just emerging from winter in Lesotho. We also pondered the eruption that caused Ngorongoro Crater 4 million years ago.  A crater 19 kilometers across impresses us, coming from volcano country!

Baobab Tree at Tarangire

Rusty Delucia and our guide Edgar

Secretary bird

Hippo pool--dozens of hippos!

Zebra crossing

Wildebeests

Jackals at Ngorongoro Crater

Wildebeest and storks near salt flat, Ngorongoro

Warthog. Tusks, OK. What are the other knobs for?

Green bananas transported on bikes are a regular sight on the streets of Northern Tanzania

Mount Kilimanjaro, Africa's highest peak

Stone Town, Zanzibar

Stone Town

After the Snow Fall

Hello, back again, now that the snow has subsided. Here are a few photos from Cape Town.

Table Mountain on the right, Devil's Peak on the left. Terry's race took him around and three quarters of the way up Devil's Peak.

Terry before the race.

Terry and others after the finish of the 22K trail race.

Two Oceans Marathon finish line 

You know that you're not in Lesotho when the University Fitness Centre offers Beach Volleyball!

One wonderful thing about Fall is that we have been eating great food out of the garden. Terry planted all kinds of great vegetables, so dinner has included fresh food nearly every night. Here's one example:

I am working with the Quality and Infection Control nurse, 'Me Tlelima (pronounced May Tlaydeemah) on several projects. Our latest big project is teamwork improvement using a program called TeamSTEPPS.  TeamSTEPPS was developed in the US and is being implemented by hospitals throughout the United States.  We were able to download all of the materials except the video vignettes at no cost and received the videos for a very reasonable price. Thank you, Mother, Virginia B. Meyer, for mailing us the 100 pocket guides 10 DVD's as well as sending a generous donation to the hospital to help support the program!  We trained 20 instructors and coaches on May 22-23.  Now they will be coaching colleagues and teaching the material to the rest of the hospital staff.

Our supervisor, Robert Neko, discussing team structure.

Maluti Adventist Hospital TeamSTEPPS Instructors and Coaches Training May 2012

Dr. Leslie Bhebhe, staff physican from Zimbabwe, presented information on Mutual Support, including respectful ways to question those with more status if they seem to be making an error.

'Me Faith Pulumo makes a point at TeamSTEPPS Training of Trainers.
From the left, 'Me Tlelima, Quality and Infection Control nurse, 'Me Pulumo, Midwifery Tutor, Ntate Rakhoba, nurse, 'Me Nyenye, Director of Pharmacy, Dr. Londa, Dr. Kabeya, 'Me Monki, MSW, Social Worker

Fall in southern Africa: TB, Trails,Table and Teams

Hello, friends and family!
Terry and I have been quite busy since our last post.  It is Fall here and today the weather is cloudy and cool. Other volunteers at higher elevations have already experienced snow--astounding their friends who do not expect to find snow and Africa in the same sentence. We fired up the woodstove in the last few days and appreciate the pleasant warmth it provides. We use scrap wood from some trees that were cut down to make way for construction. We also have an electric heating panel near the bed and best of all, an electric plug-in mattress warmer!  We sleep well, though we feel a little like we're cheating on the Peace Corps experience.

Bottles of hand sanitizer in our storage closet!

Yes, friends, we have hand sanitizer! Shortly after the last post, we began to get a regular supply from the Clicks pharmacy chain in South Africa. We now even have extra stored in the cupboard. With a plentiful supply, the next challenge is to encourage staff to use it regularly.  It is a new practice that is not yet a habit.  Mostly people are using gloves when the sink is not handy. Even in the US, encouraging proper hand hygiene is an ongoing struggle for most hospitals. At least we now have the resources we need to conduct that campaign!

Cave paintings near Malealea

Peace Corps Volunteer (PCV) Lisa Dold joined us on our pony trek to the cave paintings

Terry led the warm up for the race at Senekane

Lesotho PCV's Brandon Delise, Terry Ellard, Grant Comstock and Amy Jo Carson hold a finish line conference

During March, we were busy visiting with other volunteers on most of our weekends. I gave a presentation at the World TB Day PCV gathering at the Malealea Lodge. Most of our training group and some of the other Lesotho volunteers gathered to discuss TB, celebrate the birthdays of two volunteers and do some pony trekking. Terry and I rode Basotho ponies with Lisa Dold to see some cave paintings. The following week, we assisted PCV Amy Jo Carson with a running event for a secondary school. In mid-April, we gathered in the historic town of Morija with our Country Director Kathy Jacquart Dill and the other "Older Than Average" volunteers to discuss the older volunteer experience. The owner of the Morija Guest House was so warm and welcoming that our 24 hours there felt like a much longer vacation.

Lesotho "Older" PCV's Barbara Meyer, Rusty Delucia, Maggie Day, Amy Jo Carson, Nancy Feraco, Terry Ellard

 In the first week of April, we travelled to Cape Town, South Africa so that Terry could run the Two Oceans Trail Half Marathon. It was wonderful to see the magical city that I've dreamed of visiting for years! We stayed at a nice bed and breakfast near the University of Cape Town so that we could walk to the start and finish of the races. Altogether, more than 20,000 runners from all over the world participated in the races held that weekend, 800 of them in the trail races. Terry's race wound around Devil's Peak for 14 miles, in one place so steep that ropes were provided to assist the runners in getting down! He loved the run due to the amazing beauty--up close views of Table Mountain with the ocean in the distance.

Street market in Cape Town

We were able to watch these children performing traditional dances while eating a fine Kurdish lunch on the balcony above. We enjoyed the wide variety of food available in Cape Town.

Market square with a glimpse of table mountain in the background.

June 9, 2012: It just started to snow!  And our internet connection slowed way down, so....
To be continued!