Med peds noon conference dec 2010


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  • Stress the “success” of being approached by the gov’t for collaboration – this slide should really just be “a few months after opening the clinic, we were approached by the government and local community, and offered to join in a public-private partnership to re-open the Bayalpata Hospital
  • Stress the importance of our philosophy in how we approach our work
  • 50,000 patients to date
  • Make the point that even tho we have these problems, relative to other regional facilities, we are actually totally in line with the standards (Jason says he thinks we’re even in line with WHO guidelines, but likely better not to cite it cuz you might get into an argument re policy details), and that when (for example) you spoke w/mark zimmerman (NSI/PH) about this, he said that they were doing the exact same thing. It’s not that you were doing a bad job relative to what everyone said you were supposed to be doing, it’s that the standards are simply too low and thus, we needed to move outside the regional area for intl expertise on how to push the envelope forward, setting new precedents
  • - This slide should be used to summarize Nyaya’s goals and highlight our next steps (which are key fundraising initiatives).
  • Med peds noon conference dec 2010

    1. 1. Implementation Gaps and Quality Chasms: Building Health Systems in Rural Nepal<br />Duncan Maru, MD, PHDCo-Founder| Nyaya Health<br />Med-Peds Noon Conference, December 16, 2010<br />
    2. 2. Learning Objective<br />Think critically about healthcare delivery and quality in resource-poor areas<br />1<br />
    3. 3. Where We Work: Nepal – Achham District, Far Western Region<br />
    4. 4. Achham District, Far Western Region, Nepal<br />
    5. 5. Achham District, Far Western Region, Nepal<br />
    6. 6. Achham District, Far Western Region, Nepal<br />
    7. 7. Achham District, Far Western Region, Nepal<br />
    8. 8. Achham District, Far Western Region, Nepal<br />
    9. 9. Achham, Nepal<br />250,000<br />population of Achham<br />0<br />number of allopathic doctors in Achham before Nyaya<br />6+<br />hours in bus to reach the nearest operating room<br />14<br />hours in bus to reach the nearest intensive care unit<br />6% & 54%<br />Female and male literacy rates, respectively<br />1 in 125<br />deliveries results in the mother’s death<br />64<br />number of stillborns for every 1,000 live births<br />>80%<br />of men migrate to India for work; over 7% return with HIV<br />99.5%<br />of babies are born in homes and cattle sheds<br />50¢<br />average daily per capita income in Achham<br />60%<br />60%<br />of children are chronically malnourished<br />8<br />
    10. 10. NyayaHealth Snapshot<br />Social justice-oriented mission: <br /><ul><li>To provide free community-based healthcare in rural Nepal that strengthens the Nepali Ministry of Health’s public sector
    11. 11. To develop scalable models of healthcare delivery in resource-poor settings throughout the world
    12. 12. Founded in 2006; public-private partnership with Nepali Ministry of Health & Population in 2009
    13. 13. Managed by a volunteer Board of Directors and 27 full-time employed Nepali staff
    14. 14. Over 99% of all funds used directly in Nepal</li></ul>9<br />
    15. 15. SanfeBagar Primary Health Center<br />Sanfe Bagar Health Center: After<br />Sanfe Bagar Health Center: Before<br />10<br />
    16. 16. BayalpataHospital<br />11<br />
    17. 17. BayalpataHospital<br />
    18. 18. Bayalpata Hospital<br />Infrastructure development and capacity building, not care provision alone<br />Government collaboration: Government partnership contract for 5 years signed June 2009 – June 2014<br />Currently one of the highest levels of clinical care in the Far West (2 million people)<br />50,000 patients seen to date<br />
    19. 19. BayalpataHospital<br /><ul><li>All health care services free of charge:
    20. 20. Inpatient & Outpatient services
    21. 21. 24-hour emergency and obstetric services
    22. 22. Laboratory & Pharmacy
    23. 23. Radiology: X-Ray & Ultrasound
    24. 24. HIV, TB treatment programs
    25. 25. Malnutrition treatment (RUTF)
    26. 26. Ambulance services
    27. 27. Community Health Worker (CHWs) services
    28. 28. 2011 Expansion Plans:
    29. 29. Comprehensive surgical suite
    30. 30. Solar energy
    31. 31. Expanded CHW network
    32. 32. Teaching hospital status</li></li></ul><li>Challenges<br />But doing things and doing things well are two different things…<br />15<br />
    33. 33. Case 1: Nosocomial Tuberculosis<br />27yo M lab tech from BH presenting with cough x3wks and hemoptysis<br />Considered high-risk for TB exposure (3-4 sputa examinations per day)<br />
    34. 34. Case 2: Infant Pneumonia<br />An 8-month-old boy with severe respiratory distress and five-day history of pneumonia presented to the BayalpataHospital. Previously, the boy had been seen by untrained private “clinicians” in the community three times over four days. At presentation, the child was seen by one of Nyaya's mid-level practitioners who provided an initial course of antibiotics. Despite the child's ill appearance, supportive treatment including intravenous fluids and supplemental oxygen was not provided until discussion with the Medical Director three hours later. That evening, the hospital lost power – the public electricity grid shut off for its usual daily blackout, and the hospital generator had been improperly maintenanced and broken several days prior – so the electric nebulizer did not work. The oxygen canister was missing its regulator and therefore no oxygen could be provided during the power outage, nor could the patient be transferred via ambulance without oxygen. Additionally, due to the high costs of other regional health facilities the family refused transfer (our facility provides free services). That evening, after not being examined for some time by on-call staff, the child was found unresponsive with a thready pulse. CPR was not initiated for over ten minutes as the midwife managing the ward did not know the procedure and the AMBU bag was not at bedside. Following fifteen minutes of unsuccessful resuscitation, the child was declared dead. <br />
    35. 35. Key Challenges<br />Human resources<br />Supply chain management<br />Energy systems<br />Telecommunications<br />Community relationships, outreach<br />Public sector relationships<br />
    36. 36. Achieving Excellence in Healthcare Delivery…<br />InstitutionalizeReflectiveDialogue: Mortality and MorbidityReviews<br />InstitutionalizeTransparency in Reporting: Data Program<br />
    37. 37. M&M Review: Nosocomial tuberculosis<br /><ul><li>Issue 1: Lab Ventilation
    38. 38. Lack of local and regional infection control; BH met standards!
    39. 39. Director of Medicine at foremost teaching hospital in Nepal: “never seen a safety hood in Kathmandu”
    40. 40. Solution 1a: Collaboration with international partners via GHDonline to design newly-constructed TB-specific lab space with negative pressure
    41. 41. Solution 1b: Collaboration with MOH & District to conduct infection control trainings
    42. 42. Issue 2: Personnel Safety
    43. 43. Solution 2: Procurement of N95s, and trainings</li></li></ul><li>M&M Review: Infant Pneumonia<br /><ul><li> Oxygen in ambulance
    44. 44. Oxygen protocol for ER
    45. 45. Dedicated ambu bag
    46. 46. CPR training for staff
    47. 47. ER crash trolley</li></li></ul><li>Nyaya Data Program: Local System <br /><ul><li>Open-Source Access Database, Gnucash
    48. 48. Challenges in electricity, human resources, retention</li></li></ul><li>Nyaya Data Program: Wiki<br /><ul><li>Wiki is a searchable repository of:
    49. 49. Management policies
    50. 50. Financial data
    51. 51. Clinical protocols
    52. 52. De-identified clinical data
    53. 53. All pages viewable to the public
    54. 54. A forum to share lessons-learned from Achham with organizations in similar settings around the world
    55. 55. Opportunity for critical feedback and collaboration</li></ul><br />
    56. 56. Concluding Thoughts and Next Steps<br />Summary<br />Supporting public sector builds sustainable healthcare systems<br /> Quality healthcare relies on energy, telecommunications, logistical systems—management innovations are needed in both the clinical and non-clinical realms<br /> Commitment to place can drive global insights<br />Nyaya’sNext Steps: <br />Larger community health worker network<br />Surgical capacity<br />Solar energy systems<br />Implementation Research<br />
    57. 57. My Personal Vision for Bayalpata Hospital<br />
    58. 58. Acknowledgements<br /><ul><li>The staff of Bayalpata Hospital & the people of Achham, Nepal
    59. 59. The volunteers and individual donors of Nyaya Health
    60. 60. The Nepali Ministry of Health & Achham District Health officials: Dr. Deepak Gaylal, Mr. SailendraShrestha, Mr. JhanakDhungana
    61. 61. Institutional Supporters: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Frederick Lovejoy Foundation, Google Grants, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Yale University</li>