By Dieter Hartmann
In healthcare, we often speak of trimming the fat. To be lean is not about cutting off the fat, but rather about not spending energy on making the fat in the first place. With this analogy in mind, the delegates at the LEAN HEALTHCARE workshop at the PHASA conference 2014 explored how healthcare could be made less wasteful, and by so doing, deliver service better.
Lean is a philosophy that places the customer first, by ensuring that an organisation principally pursues value over waste, makes muscle, rather than fat. The elegance of Lean resides with the fact that interventions are of low cost and often free because Lean strives to use available resources more efficiently.
The applicability of Lean to healthcare is well established globally and desperately needed in South Africa. Our delegates learnt how to make muscle and how to recognise fat. We played interactive games in which delegates came to recognise that many of the things we do daily in our facilities are in fact wasteful acts and ultimately lower the quality and the speed of service delivery to patients.
Our case studies showed that even in the most ordinary of circumstances we can provide better service with shorter patient waiting times, more balanced loading of doctors and nurses, have better quality of care and improved health outcomes and all of this at reduced cost!
We believe that those who participated in this workshop have started their journey towards becoming agents of change in healthcare.
By Taryn Young
Evidence-informed health decision-making is an approach to that ensures that decision-making is informed by the best available research evidence. It is characterised by systematic and transparent approaches to access, appraise and use evidence as an input to the decision-making process.
Systematic reviews are well recognized sources of best evidence as it reduce bias by systematically identifying, appraising, synthesising, and, if relevant, statistically aggregating all relevant studies on a specific topic according to a predetermined and explicit method. During this workshop, facilitated by Taryn Young (Centre for Evidence-based Health Care, Stellenbosch University www.sun.ac.za/cebhc) and Elizabeth Pienaar (South African Cochrane Centre, South African Medical Research Council www.mrc.ac.za/cochrane), participants were introduced to systematic reviews and learnt how these differ from traditional narrative reviews. Participants gained the knowledge necessary to find (below), appraise, interpret and consider the applicability of findings of systematic reviews. Twenty participant attended and they found the workshop very useful. They especially liked the interactive nature.
Cochrane Reviews and Protocols of Relevance to Health Promotion and Public Health:
The Cochrane Library is published monthly and includes reviews and protocols relevant to health promotion and public health. Some of these will be published by the CPHG and some will be published by other Review Groups within the Collaboration, depending on topic scope. A list of protocols and reviews published specifically by the CPHG can be found here, and accessed within The Cochrane Library.
Websites for identifying other Systematic Reviews in Health Promotion and Public Health:
By Irwin Friedman
mHealth, a term used for the practice of medicine and public health supported by mobile devices, lies at the heart of one of the most exciting revolutions in the health sector. Most often this simply means using cell-phones, but it also includes using several kinds of other mobile communication devices, such as tablets, personal data assistants, netbooks and laptops in the health services by patients as well health workers, to provide information, build knowledge and skills, but also to affect emotional states.
The reason for its escalating importance is that there are more than 6 billion mobile phones worldwide, of which an incredibly 75% in developing countries. In South Africa, the impact could be just as important with more than 75% of low-income groups in the age group 15+ years owing a cell phone. There has been a strong growth in the number of "Mobile for Development" services launched in recent years. Services have mostly been developed for the most inexpensive basic phones. However, with the advent of cheaper smart phones, richer applications are becoming possible.
The mHealth workshop at the PHASA 2014 conference aimed to provide a deeper appreciation of the field and it comprised several participatory sessions.
A health systems strengthening perspective was provided by Cephas Chikanda and Christian Nyaundi of Anova Health, giving an overview of mHealth in public health in different countries, such as South Africa, India, Mexico and Bangladesh. Applications included use of call centres (Hello Doctor), social media (Mxit, Dr Sindi), providing help desks or sending out sms’s , offering information on topics related to maternal and child care (Mom Connect) or HIV (Cell Life) as well as educating and increasing awareness (Project Masiluleke, Hi4Life, Choma). Dr Sindi provided an interesting example of a health professional engaging mothers using different forums like Facebook, Twitter and Qooh.me, accessed by mobile phone. Text-to-Change in Uganda and 104 Advice in India provided hotlines for medical consultations serving mainly rural areas. More advanced health service programmes supported community health workers (CHWs) or managed health research (Mobenzi, Mezzanine, DiMagi). The advantages of mHealth were that it was less tedious than paper, quick, user friendly with data being immediately available, indirectly making employees accountable for their time. The disadvantage was that its success was dependent on stakeholder buy-in, ironing out teething issues and ensuring feedback.
The second session by Andi Friedman of Mobenzi covered the technology provider perspective on the basic technical elements of mHealth regarding data collection, workflow, integration and multi-channel communications. The first element was the dissemination of information and use of mHealth as a communication channel by stakeholders using several mobile channels. The second element was the electronic capture and transmission of data via mobile devices for census, disease surveillance, community interviews and activity reports. The third element was the use of longitudinal, relational data structures for the creation of electronic patient records and health worker profiles. And the fourth element was its use in scheduling, coordination and managing data flow, such as referrals and visit plans. A fifth element was the way data was aggregated, interpreted and visualised making the data useful to all stakeholders. A final innovative element was the use of mobile phones in point-of-care diagnostics using algorithms, software and hardware which enable real-time decision-support and disease diagnosis in the field.
The third session provided a case study of a research manager’s perspective in managing a large-scale longitudinal mHealth research project. Nobuntu Noveve and Natasha Titus from the South African Medical Research Council presented an overview of the mobile technology used for the National PMTCT evaluation 2010 to 2013 undertaken in collaboration with CDC, UNICEF, NoH and UWC. It reviewed the complex process which involved periodically measuring rates of early MTCT of HIV at 6 weeks and cumulative MTCT rates at 3, 6, 9, 12, 15 and 18 months postpartum. Mobenzi Researcher supported the data collection component of the project by facilitating mobile data capture, storage of raw data captured into surveys, enabling reporting on survey level data, communication via bulk sms’s, data cleaning, managing handset assignments to fieldworkers, exporting raw data to MS excel and troubleshooting field challenges.
The fourth session presented by Tumelo Mampe of Health Systems Trust offered an NGO perspective of health system strengthening of the North West CHW Programme in supporting Ward-Based Outreach Teams. This programme provided a case study of the Mobenzi Outreach system which enabled CHWs to profile/register households, enrol and track under five children, antenatal and post natal women, treatment adherence and general clients. It also provided for mutual referrals systems between CHWs and facilities. It offered much improved supervision and support and an automated way of exporting reports to the District Health System.
By Annette Gerritsen
This workshop focused on the uses of epidemiology in general (natural history, describing population health status, finding causes, evaluating interventions), and in public health.
The different study designs were discussed, including examples of their use. I covered in detail the differentiation between a randomised controlled trial, non-randomised study, in terms of experimental designs, as well as the various observational designs. These include: cross-sectional studies, case-control studies and cohort studies. The technical details, advantages and disadvantages of all study designs were discussed.
I also went into detail on the different frequency measures, used to quantify the occurrence of disease in a population: prevalence, incidence rate and cumulative incidence. Measuring the occurrence of disease is only the beginning of the epidemiological process. The next step is the comparison of occurrence in two or more groups of people whose exposures have differed. The relative risk (used in cohort studies) and the odds ratio (used in case control studies) were presented, explained and illustrated by examples.
Throughout the workshop attendees completed exercises and case studies were discussed in order to enhance the learning of the participants.
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By John Capati
The American International Health Alliance (AIHA) conducted a workshop titled “The Impact of Mid-Level Workers on South Africa’s Health System” at the 10th PHASA Conference in Polokwane on September 3 from 13:30-16:30. Over 30 conference attendees representing government, academia, the NGO community and other stakeholders participated in the workshop focusing on three mid-level worker cadres which have been supported by AIHA: clinical associates, pharmacy technicians and paramedics. This support is made possible through the generous support of the American people with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR) and CDC/South Africa. Activities are managed by AIHA’s HIV/AIDS Twinning Center, which is funded by the US Department of Health and Human Services, Health Resources and Services Administration (HRSA).
After welcoming remarks by James P. Smith, AIHA Executive Director and overview of Twinning Center support for the mid-level professions by AIHA Country Director John Capati, the workshop began with an overview of the clinical associate, pharmacy technician and paramedic professions. Dr. Audrey Gibbs, coordinator of the clinical associates program at the University of the Witwatersrand (Wits), provided background on the development of the new mid-level medical professional, described the three-year training program offered by three universities which results in the award of a Bachelor’s degree in Clinical Medical Practice (BCMP), and noted challenges for the new profession such as the finalization of the scope of practice. Highlighting the need to upgrade the knowledge and skills of the current mid-level workers in pharmacy, Shirley-Anne Boschmans, Head of the Pharmacy Department at Nelson Mandela Metropolitan University (NMMU), described the development of the new pharmacy technician training program offered at NMMU. Nicole De Montille, Training Officer at ER24, outlined the various qualifications in emergency care, stressing the need to organize and convert tertiary training to develop well-trained emergency care assistants, technicians and practitioners.
Workshop participants then learned about some of the innovations being utilized in the training of mid-level workers in South Africa. Dr. Mukund Khatry-Chhetry, coordinator of the clinical associates program at Walter Sisulu University (WSU), discussed inter-professional education and how clinical associate students at WSU are training side-by-side and at bedside with medical and nursing students. Ameera Hamid shared how Wits is utilizing tablet devices to manage the placement of clinical associates at hospital sites to ensure students receive the practical training they need. Michael Gogwane, Program Coordinator at AIHA, described the impact of mentors who provide capacity-building assistance to university faculty in the training of clinical associates and pharmacy technicians. The US experts provide their expertise on a pro-bono basis, with the placements facilitated through the Volunteer Healthcare Corps (VHC) mechanism of the AIHA Twinning Center program. Nicole De Montille explained how problem based learning is a core aspect of all emergency medicine training, with simulation allowing students to learn the skills needed to manage increasingly complex cases while properly using the necessary equipment to provide care.
The workshop concluded with a series of presentations focusing on the impact of and challenges facing the mid-level professions. While there are challenges facing newly qualified clinical associates such as the need for a doctor’s countersignature on prescriptions, lack of understanding of their job description, and insufficient supervision; Dr. Martin Bac from the Family Medicine Department at the University of Pretoria shared results of a study demonstrating that clinical associates are contributing to patient care and have more time for patients, reducing waiting times in the hospitals where they practice. Shirley-Anne Boschmanns described the practice analysis conducted by NMMU for the pharmacy professions to inform the training of pharmacy technicians to ensure they meet the needs of the workplace. The new Professional Association of Clinical Associates in South Africa (PACASA) is representing the interests of the young profession. Edwin Leballo, clinical associate and PACASA Chairperson, described how PACASA is supporting the young profession through advocacy, representation with governmental and other stakeholders, networking with crucial partners, and support for professional growth and career path development. Loveness Satande, AIHA Program Coordinator, shared results from data collection pilot studies demonstrating the impact of clinical associates on general patient care and HIV/AIDS service delivery in the Eastern Cape and KwaZulu-Natal.
Based on the questions/answers and discussions at the end of each group of presentations, there is great interest in the role mid-level workers can play to enhance South Africa’s healthcare system. Public health practitioners have an important role to play in conducting research which further informs the training and deployment of these crucial human resources for health.
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