Doctor in Khayelitsha: committed change agent

On 27 January 2014, Dr Caroline Neumüller saw 26 patients. Four had duplicate folders, opened due to misplaced folders. Moreover, patients arrived at the clinic before 8am, but waited while reception staff tried finding their folders. She attended to them at 3pm.

In the past Dr Neumüller worked in the private sector and she would see patients who couldn’t afford private care but paid for it because the waiting times in public clinics were too long. Why did Neumüller choose to work in the public sector? Her reason: preference. In addition, “In a private clinic, simple treatments are expensive whereas at a public clinic I can attend to patients needing those same treatments for free,”  said Neumüller.

At present, Neumüller works at Matthew Goniwe clinic in Khayelitsha, Cape Town.  “I’ve worked at the clinic for six months and can’t take it anymore,” she said. The clinic’s disorganised filing system was compromising her patients’ timely health care.

Clinic-Reception-Disaster-Relief

When the facility manager gave the go ahead to start the file organising project, late in January, Neumüller created the Facebook open event, Clinic-Reception-Disaster-Relief. She reached out to all she knew, to volunteer, to help order patient folders, clean and label shelves- a process she and some of her colleagues had started in December 2013.

Helpfully, Tweeters in the health industry such as Health-e, Mogali Molatji from Clear Scan Medical and Laura Lopez Gonzales spread the call- for- help-posts by retweeting them.

One planned event turned into three separate sessions on 1, 8 and 15 February. Between five to eight volunteers attended each session. The duration of the sessions ranged between five and nine hours.

At the first session, Neumüller shared a clinic rumour: the clinic was selling patient folders to buyers who aimed to illegally apply for South African Social Security Agency grants, meanwhile the files were not being found.  She explained how to order the patient record folders. Each folder had a nine-digit clinic number. The last three numbers indicated the batch number. The volunteers had to file each batch of folders sequentially using the first three digits and then placing them back where the corresponding labelled batch number was on the shelves. Duplicate folders were collated. Volunteers worked while admin staff captured the folders they were unable to enter during the week. One clerk brought her daughter who worked as her volunteer assistant. The facility manager attended two sessions while clerks, cleaners and doctors also helped. “Cleaners sometimes help out in the reception area, leaving a backlog of cleaning work,” said Neumüller. As indicated by the staff’s gratitude, her hard work was appreciated and desperately needed. On their way home, they thanked the volunteers for their help.

Neumüller coordinated seamlessly showing volunteers how to set up the folders to ease the process. Simultaneously she worked at damage control as volunteer and supervisor. “Careful, don’t hurt your back,” she said to those who were arched in a self-injuring way while ordering folders. In addition to helping with filing, organising, cleaning of the office area and planning, organising, coordinating, controlling and directing volunteer teams, Neumüller donated a shelf and two step-chairs to reach files on high shelves, and provided volunteer refreshments.

Volunteer observations corroborated Neumüller‘s story. Volunteers compared each other’s highest total tally of folder-to-person ratio. The final tally was four folders. Additionally, the sooty files reflected a haphazard filing system and a clear backlog of cleaning in the reception area.

Positive results from the first volunteer session urged the clinic manager to approach the City of Cape Town’s Department of Health (DoH) to hire two filing clerks. The clerks’ primary focus was to organise the files. Together, Neumüller, the admin staff and manager worked with the hope of getting the job done by the end of February.

Doctor in Khayelitsha committed change agent

Before-and-after volunteer help pictures of Matthew Goniwe Clinic’s patient record folder shelves. Image provide by Dr Caroline Neumüller.

When questioned about the possibility of repeat disorderly files the following week, a composed Neumüller said, “That doesn’t mean it shouldn’t be done.” Although Neumüller achieved loads with her tireless, proactive volunteer sessions, unfiled and misfiled folders and boxes of laboratory results remained. Tough grind?  She doesn’t see it that way; she’s committed to ensuring the clinic operates smoothly with patients attended on time.

Feedback in March

In March, when checking in with Neumüller, the filing system was still unsystematic; backlogged and misfiled.

Perceiving the hard work had gone to waste, one of Neumüller’s doctor colleagues, who initially assisted with the Clinic-Reception-Disaster-Relief became disheartened and told her she had lost interest. Furthermore, in the past, in meetings where Neumüller was present with doctors from other Khayelitsha clinics, doctors admitted to similar problems related to muddled or lack of filing

The back-story is that Neumüller arrived at the Goniwe clinic to a chaotic filing system, where patients experienced excessive waiting times because of it. With a provincial day hospital's tool belt- that helped patients receive health care on time- strapped to her side, Neumüller shared her filing system knowledge to promote prompt patient care. She changed the system from having Chronic Disease; HIV/AIDS related, Diabetes, Hypertension, Paediatric and Acute categories, labelled club on the folders, to a system where all the files were categorised numerically. Previously devised club categories were meant to facilitate clerks to filing and finding folders but the new system is aimed at efficient retrieval. She admits to being a fixer and the clinic is something she can help fix. “The staff doesn’t see that if they follow this system, their work will become easier,” said Neumüller.

According to Neumüller, half of the reception was sorted when the staff gave up, not realising the amount of time it would save them in the end. “I think some of the clerks did support the idea of a new system, just that it took a long time to be implemented and resulted in a large backlog that they eventually felt they had to give up on it,” said Neumüller. 

Neumüller said she thought the project had failed to be implemented properly. Firstly, it took longer than the staff had anticipated. Secondly, the reception staff didn’t see the benefit of committing to the project. Thirdly, ‘the implementation wasn't managed properly: better management would never have allowed the hard work that had been done to go to waste.’

In a meeting Neumüller had with a manager, it was decided, for now, not to push sorting the filing system but instead to set daily goals for the reception clerks. Things have improved. “They are capturing the folders and filing but for me the issue is that we have three extra people helping out, and the clerks have been going to work on the weekend to keep everything sorted- which of course is not sustainable,” said Neumüller.

What national reports say

In the 2013 South African National, Health and Nutrition Examination Survey (SANHANES)  (1), indicated that 24.4% of respondents said that the waiting time was bad or very bad in the public sector compared to only 4.5% in the private sector.

Prior to the 2013 SANHANES survey, the 2012/2013 South African Health Review (SAHR) (2), reported the DOH’s establishment of facility improvement teams (FITs) trained in addressing problems at the worst performing facilities- as found in the last national audit. To start, the FITs teams began their work within the NHI pilots.

The FITs teams identified ‘quick fix’ and ‘best practice’ solutions in the Sedibeng district where waiting times were questionable. Arranging triage by a professional nurse, reorganising the waiting area; having fast queues for emergencies, family planning, children and pregnant women were among the solutions. In addition, a booking system was developed for chronic diseases and vital sign patients and dispensing done by the primary health nurse in each consulting room. ‘Quality circles’ would discuss performance every day.

Although 1 000 facilities have been serviced, the SAHR reports that there’s ‘a need now to systematically scale up the initiative, whilst evaluating and learning from the current experiences and successes’.

It seems, quick fix and best practices are ineffective in the absence of a well run filing system. One could improve waiting times by opening additional folders but that begs the question: how do you treat patients accurately without knowing their full patient history? According to the SAHR report, ‘Some problems are more systemic and require longer-term strategies to improve leadership and culture.’

To this end, Neumüller has stepped back from the patient record filing system to self-preserve, reboot and let the manager, admin staff and stocks manager supervise. However, in her personal time, she has filed and sorted approximately 3000 X-rays and continues to do so. “Change takes time,” she said.

Neumüller’s diabetes project

In the meantime, Neumüller focuses on her Diabetes project. When Neumüller started working at the clinic, diabetes patients didn’t have the means to monitor their blood glucose levels. She telephoned Roche, who supplied her with free of charge Accuchek blood glucose monitors. Now, 80 patients have monitors and patients can take better care of themselves. At this point there aren’t enough monitors for everyone, but those who don’t have (130 people) are put on a waiting list. Neumüller is in the process of collating statistics on her diabetes course project. “I have plans for this clinic,” she said. Lastly, a doctor friend in the private sector says, “She’s like a dog with a bone, once she has her mind set on something there’s no stopping her.”

If anyone would like to sponsor blood glucose monitors, Neumüller’s work e-mail address is diabetes.helper.cpt@gmail.com.

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