Improving Global Health through Leadership Development · 2018-10-24 · Hospital, East London and pharmacists Ya-Ying Wang and Sarisha Singh from Frere Hospital. The second was entitled

Improving Global Health through Leadership DevelopmentAnnual Report 2017/18

Developing people

for health and

healthcare

www.hee.nhs.uk

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Contents

04 Introduction

05 IGH Programme team

05 Key programme developments and achievements 2017/18

06 Dissemination of work

08 IGH Programme structure

09 IGH Programme description

10 IGH Programme summary – outcomes and outputs

12 Project summaries by partnership site

George, Western Cape, South Africa Project: Enhancing clinical effectiveness and reducing waste by improving

procurement and storage of stock across George Regional Hospital

13 Project: Developing patient information resources to improve patient education and safe discharge from hospital services

14 Project: Improving antimicrobial stewardship through system strengthening and staff development at George Hospital

15 Project: The implementation of a training management programme for George Hospital with focus on ssential Steps in Managing Obstetric Emergencies (ESMOE) training in Obstetrics and Gynecology

16 Project: Improving Patient Safety in the Emergency Centre

17 Project: A Positive Culture: Strengthening Antimicrobial Stewardship through Improved Communication at George Hospital

18 Samlout, Battambang Province, Cambodia Project: Maddox-Jolie-Pitt (MJP) Health Strategy

19 Project: The Happy Families Project

20 Project: PiImproving Management of Hypertension in the Samlout District

21 Yangon, Myanmar Project: Hip Fractures at Yangon Hospital (YGH) – a drive to coordinated care

22 Project: Baseline Evaluation of hand hygiene at Yangon Hospital (YGH)

23 Project: Improving Utilisation of Emergency Operating Theatres

24 Project: Quality Improvement around use of Point of Care Testing Devices in GP clinics; B. Development of GP Society website and GP database

25 Project: Introduction of the Integrated Care Package (ICP) for Fracture Neck of Femur (NOF) and improvements in pain’ management at Yangon Hospital (YGH)

26 Project: Raising awareness of Acute Kidney Injury (AKI) at New Yangon General Hospital (NYGH)

27 Project: Part 1. Quality Markers in General Practice (GP)- a pilot study Part 2. Quality Improvement of General Practice (GP) in Myanmar

28 Project: Improving and standardising pre-operative care in hip fracture patients’

“It is people, not policies who ultimately improve healthcare,

we should remember as partners to first focus on relationships

before diving into any project work”

29 Project: Developing soft skills within the General Practice Society (GPS)

30 Project: Group General Practice (GP)

31 East London, Eastern Cape, South Africa Project: Adverse Incident reporting and documentation

32 Project: Vital signs and outreach Project

33 Project: Improving Tuberculosis (TB) isolation in Cecilia Makiwane Hospital (CMH)

34 Project: Safe Antimicrobial Prescribing in Eastern Cape South Africa

35 Project: Improving patient documentation on Medical Wards at Cecilia Makiwane Hospital (CMH), Mdanstane, Eastern Cape, South Africa

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Introduction

The IGH programme has been in operation since 2008 and has gained recognition as an innovative and unique leadership development programme. Over this period, 189 IGH Fellows have been, or are on placement with an overseas partner; and have provided 965 months of work.

2017/18 has continued to be a busy and productive year. As well as continuing placements and partnerships the IGH programme has evaluated the programme’s impact and sustainability of work with our partner organisations in George, South Africa and Battambang, Cambodia.

• 27 IGH Fellows volunteered in four placement sites: Battambang, Cambodia; George, Western Cape, South Africa; East London, Eastern Cape, South Africa and Yangon, Myanmar

• 28 IGH Fellows were recruited onto the programme during this period

• 3 cohorts went through induction

• 2 Mentor CPD sessions were provided for 10 Mentors

• 20 Mentors were recruited from Alumni IGH Fellows

• In total IGH Fellows worked on 24 projects, trained 465 local staff and delivered 123 months of work during 2017/18

• 11 Alumni Fellows presented their work at conferences, 3 accepted for publication, and 1 gained new opportunities as a result of their Fellowship.

• 21 IGH Fellows presented at IGH Evening Events to local stakeholders, alumni, potential Fellows, Mentors and the IGH programme team

• IGH Fellows come from all professional backgrounds – including Doctors, Managers, Speech & Language Therapists, Dietitians, Clinical Scientists, Occupational Therapists and Radiographers.

This year the IGH programme was funded locally by Health Education England South, and so recruitment has also been from this geographic area.

The programme was shortlisted for an

HSJ ‘International Health Partnership’

Award in November 2017.

MYANMAR

TANZANIA

ZAMBIA

KENYA

SOUTH AFRICA

CAMBODIA

10overseas partnerships have been formed with organisations in Cambodia, Tanzania, Kenya, South Africa, Zambia and Myanmar.

Key programme developments and achievements 2017/18

• The IGH programme partnership with the MJP Foundation in Cambodia recommenced in March 2017 having been paused for six months while MJP reviewed all their programmes and external partnerships. Two IGH Fellows undertook a comprehensive review of heath work and current health gaps from which the MJP team developed their Health Strategy for the next 3-5 years. Two additional IGH Fellows have now started to implement this strategy.

• The IGH programme successfully bid for an HPS Knowledge Exchange and Sustainability Grant to evaluate the impact and sustainability of the programme’s quality improvement projects with two of its partners – the MJP Foundation in Battambang, Cambodia and the Western Cape Department of Health (Rural) in George, South Africa. Lees & Letouze (Consultants in Public Health) were appointed, following a recruitment process, to carry out the work. A small Steering Group was set up to direct this evaluation. The study found that there is

some evidence that the in-country project work carried out by IGH Fellows on the programme, had positive impacts on the health of the population, and that some of this is sustained over time. Ten themes associated with successful changes emerged from the analysis across all projects. These were further classified as four contexts and six mechanisms. Contexts included the physical environment; culture; strategic priorities; and systems. Mechanisms identified were the project; IGH Fellows; resources; supervision; relationships with stakeholders; and ownership. The recommendations for the study have been reviewed by the Operational Management Group and actioned accordingly during 2017/18.

• The IGH programme was shortlisted in the new International Health Partnership category of the Health Service Journal Awards in November 2017. The recognition of the programme by such a prestigious awards scheme was gratifying.

IGH programme team

Fleur and Deborah are employed and responsible for the day to day running of the IGH programme.

Partnership Link Leads

Partnership Link Leads provide a direct link between the UK programme team and their overseas partner organisations, with the aim of building and maintaining relationships. The Partnership Link Leads undertake a site visit once during each cohort of IGH Fellows placement and include meetings with the IGH Fellows to review their progress and wellbeing, and with local leads to review and help build the work programme. These are voluntary roles.

The value of the Partnership Link Lead role was confirmed during the evaluation work undertaken by Lees & LeTouze, into the impact and sustainability of the IGH programme’s quality improvement projects in Battambang, Cambodia and George, Western Cape, South Africa. This evaluation was funded by an HPS Knowledge Exchange and Sustainability Grant.

UK-based Senior Fellows

Vicki and Ann-Marie worked for the IGH team as UK-based Fellows for 2 years from April 2016 to March 2018.

Fleur Kitsell

IGH Programme Lead (0.2 wte)

Vicki Rowse

Education and Leadership

Dr Ian Kemp

Lead for The MJP Foundation, Cambodia and The Brighter Future Foundation, Myanmar

Deborah Watts

IGH Programme Manager (1.0 wte)

Ann-Marie Streeton

Monitoring and Evaluation

Dr Juanita Pascual

Lead for the Western Cape, South Africa

Dr Mick Nielsen

Lead for the Eastern Cape, South Africa

04 |

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1 IGH Fellow, Dr Lucy Frost, had a paper published in the African Journal of Primary Health Care and Family Medicine in April 2017 together with Louis Jenkins, George Hospital, Western Cape Government and Stellenbosch University, South Africa and Benjamin Emmink, George Hospital, Western Cape Government, South Africa. The paper was entitled ‘Improving access to health care in a rural regional hospital in South Africa’.

2 IGH Fellow, Dr Naina McCann, along with colleagues at the Western Cape Government Department of Health, presented a poster at the International Forum of Quality and Safety in Healthcare conference, 26-28 April 2017 in London, entitled ‘Evaluating and improving the effectiveness of clinical practice guidelines in the Western Cape, South Africa’.

3 IGH Fellow, Dr Joseph Freer, together with Dr Hassan Mahomed and Professor Anthony Westwood at the Western Cape Government Department of Health, presented a poster at the International Forum of Quality and Safety in Healthcare conference, 26-28 April 2017 in London, entitled ‘Prevention, management, and risk factors for diarrhoeal disease in under-5s in Cape Town, South Africa’.

4 IGH Fellow, Dr Lucy Maconick, presented a poster at the Royal College of Psychiatrists International Conference, 26-29 June 2017 in Edinburgh about the project she worked on whilst on placement, ‘Integrating mental health in primary care: an in-service training approach’

5 IGH Fellow, Dr Richard Francis, presented a poster at the International Forum on Quality and Safety in Health in Kuala Lumper, Malaysia, 24-25 August 2017, entitled ‘A review of Healthnet (Outpatient) transport within Eden, South Africa (Feb-July 2016)’.

6 IGH Fellows, Dr Catriona Luce, Dr Ilsa Haeusler, Ms Viki Wadd and Dr Francis Collett-White together with Professor Andy Parrish, head of the Department of Internal Medicine at Cecilia Makiwane Hospital, East London, Eastern Cape, South Africa, presented at the Leaders in Healthcare conference in Liverpool, 30 October-1 November 2017. Their poster was entitled ‘Providing skills and motivation for healthcare staff to develop projects to improve patient care in the Eastern Cape, South Africa’.

7 IGH Fellows, Dr Catriona Luce, Dr Ilsa Haeusler, Ms Viki Wadd and Dr Francis Collett-White together with Professor Andy Parrish, head of the Department of Internal Medicine at Cecilia Makiwane Hospital, East London, Eastern Cape, South Africa,

presented a second poster at the Leaders in Healthcare conference in Liverpool, 30 October-1 November 2017. This was entitled ‘Is the NHS Healthcare Leadership Model relevant in South Africa’.

8 IGH Fellow, Dr Jennifer Joiner, who as a trainee with Health Education England – Wessex, was appointed to the RCGP’s ‘Chief Registrar’ scheme in August 2017 by the Postgraduate Dean, Dr Peter Hockey at Wessex PGMDE.

9 IGH Fellow, Dr Ilsa Haeusler, presented a poster at the THET (Tropical Health and Education Trust) Conference, 23-25 October 2017 in London, entitled ‘Improving TB infection control in a tertiary hospital in the Eastern Cape, South Africa’.

10 IGH Fellow, Dr Cate Luce, presented a poster at the THET (Tropical Health and Education Trust) Conference, 23-25 October 2017 in London, entitled ‘Increasing the capacity of healthcare staff to develop projects to improve patient care in the Eastern Cape, South Africa'.

11 IGH Fellow, Dr Dan Knights, presented a poster at the THET (Tropical Health and Education Trust) Conference, 23-25 October 2017 in London, entitled ‘An applied training programme to increase local capacity and motivation to improve healthcare quality in South Africa’.

12 IGH Fellow, Dr Ilsa Haeusler, presented a poster at the BMJ Leaders in Healthcare conference, 31 October-1 November 2017 in Liverpool, entitled ‘Improving TB infection control in a tertiary hospital in the Eastern Cape, South Africa’.

13 IGH Fellow, Dr Theeba Krishnamoorthy, presented on her project both orally and as a poster entitled ‘BEWARE AKI’ the beginning: Acute Kidney Injury Quality Improvement Project at New Yangon General Hospital in Myanmar’ at the 3rd Myanmar Nephro Urology Society Conference in Yangon, Myanmar on 4 and 5 November 2017.

14 IGH Fellow, Dr Francis-Collett-White was accepted to present 2 oral presentation at the FIDSSA Conference, Cape Town, 9-11 November 2017. The first was entitled ‘Antibiotic consumption after two years of antimicrobial stewardship ward rounds in the medicine department at a Tertiary Hospital in the Eastern Cape’ with Dr D Stead of Walter Sisulu University, Mthatha and Department of Medicine, Frere Hospital, East London and pharmacists Ya-Ying Wang and Sarisha Singh from Frere Hospital. The second was entitled ‘Assessing the impact of antimicrobial

stewardship ward rounds using an app-based data collection tool in two Public Hospitals in the Eastern Cape, South Africa’ again Dr David Stead, Ya-Ying Wang, Sarisha Singh and additionally Professor Andy Parrish, head of the Department of Internal Medicine at Cecilia Makiwane Hospital, East London, Eastern Cape, South Africa. Dr Stead and Ya-ying Wang made the presentations, Dr Collett-White was unable to travel to Cape Town at that time.

15 IGH Fellow, Ms Eloise Whitaker, together with Robert Yates, Project Director, UHC Policy Forum, Centre on Global Health Security and Tom Brookes, Programme Officer, The Elders published a research paper entitled ‘Hospital Detentions for Non-payment of Fees: A Denial of Rights and Dignity’ on 6 December 2017. There has been much interest internationally following publication of the paper from a number of news agencies.

16 IGH Fellow, Dr Elizabeth Junaid, was featured in the George Herald whilst on placement at George Hospital, Western Cape, South Africa. Dr Junaid had

organised a poster competition with a primary school there to promote hand hygiene.

17 IGH Fellow, Ms Marie Lonergan, gave an oral presentation at the Royal College of Occupational Therapists Roadshow at Brighton General Hospital on 14 March 2018, entitled ‘Leadership – working at the top of your game’.

18 IGH Fellow, Dr Theeba Krishnamoorthy, published a case study entitled ‘An Acute Kidney Injury (AKI) Quality Improvement Project at New Yangon General Hospital, Myanmar’ on the NHS Think Kidneys website in March 2018.

19 21 IGH Fellows presented over 4 IGH presentation evenings held April, September, December 2017 and February 2018 about their experiences whilst on placement, the projects they worked on and their leadership learnings.

Dissemination of work

“Always enjoys working with IGH fellows because we are so full of ideas”

“It was a pleasure and an honour to work with her and we will miss her!”

“That there are so many ways that he can share his love of medicine and learning”

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IGH programme structure

IGH Fellows do not provide direct clinical care whilst overseas, their role is that of a project coordinator and their remit is to help build local healthcare capacity and capability, through system-development and strengthening work.

While on placement IGH Fellows work in partnership with in-country health workers to plan and implement projects using improvement methodology and through this work develop their own leadership behaviours, using the NHS Healthcare Leadership Model (2013) domains. They are each allocated a mentor to support them throughout their Fellowship. Post placement they compete a detailed project report, reflect on their leadership development, and present their work and learning at an IGH evening meeting.

Finance

During this financial year, the IGH programme received funding from Health Education England South. The average direct costs for an IGH Fellow to be recruited to the programme and to complete a six-month placement with an overseas partner organisation is £10,000. When indirect costs are added, this comes to approximately £15,000. IGH Fellows receive a monthly stipend which reflects the cost of living in each overseas partner site and covers costs of accommodation, food, internet access, phone, travel related to the local office.

IGH programme description

Recruitment

All NHS staff groups are eligible to apply, which is done via a detailed application form and if shortlisted by an interview panel which includes IGH alumni.

Minimum eligibility criteria are:

• Employed within the NHS

• Doctors and dentists have successfully completed Foundation Year 2

• All others are working at Agenda for Change Band 6

• The support of their line-manager, training programme director or employer (as appropriate)

The programme has three phases: pre-placement, on placement and post placement.

1. PRE-PLACEMENT

Consists of 5 days of mandatory preparation. IGH Fellows are required to complete:

• A bespoke 2-day Induction Programme

• A 2-day personal Leadership Development Course

• The Edward Jenner programme foundation module

• A short on-line project management module

They also complete a Myers-Briggs Type Indicator Questionnaire and receive individual feedback.

Each Fellow is allocated a UK based Mentor and meet face to face with him/her before they depart on placement to discuss their personal leadership development goals and plans. These are identified though a self-assessment of their leadership behaviours using the NHS Healthcare Leadership Model (2013).

IGH Fellows also encouraged to meet their line manager to discuss the Fellowship and how they might use their leadership development on their return.

2. ON PLACEMENT

IGH Fellows do not provide direct clinical care. Their role is that of a project coordinator and their remit is to help build local healthcare capacity and capability, through system-development and strengthening work.

IGH Fellows are required to:

• Submit a project plan using Quality Improvement methodology at week 4, then midterm and final reports on their project

• Interview a member of the local team with whom they have worked closely and write this up as a brief case study illustrating what has been learned as a result of collaborating on the project

• Communicate regularly with their UK based mentor to support their leadership development

• Meet their local supervisor regularly

3. POST PLACEMENT

On their return to the UK, IGH Fellows:

• Complete the rest of the Edward Jenner programme

• Undertake a post placement leadership behaviour self-assessment using the NHS Leadership Model (2013)

• Write a reflective account of their personal leadership learning which is discussed with their Mentor during a final debrief meeting

• Present their work and learning at one of the regularly held IGH Presentation Evenings

In addition

• IGH Fellows are offered support to prepare an article for publication or a poster sharing their work and a small number (chosen through a competitive process) are supported to attend and share their work at a global health or QI conference.

• Receive a Certificate of Completion of the IGH Fellowship is awarded when evidence is received by the IGH Programme Lead that all assignments have been completed to a satisfactory standard.

Governance

The programme is led and managed by the IGH Programme Lead and IGH Programme Manager, supported by 2 UK-based Senior Fellows and 3 Partnership Link Leads.

An Operational Management Group meets quarterly, and the scheme is overseen by an Advisory Group which meets once a year.

The Partnership Link leads act as the link between the overseas partner and the UK programme team and oversee project work and wellbeing of Fellows while on placement. This includes carrying out support visits whist the IGH Fellows are overseas.

The UK-based senior Fellows roles are: Education and Leadership, and Evaluation and Monitoring, these roles are recruited from IGH Alumni for a 2-year term.

IGH Mentors are volunteers with experience of QI, NHS leadership and/or work in overseas healthcare, and many have been IGH Fellows. The Mentor provides individual personal support to the IGH Fellow before, during and after their placement, maintaining regular contact while the IGH Fellow is away.

All IGH Mentors are required to complete two days' training on coaching and mentoring skills. The IGH programme runs two CPD sessions per year and Mentors are required to attend one of these days every two years.

The IGH Programme has developed over the 9 years and it has been

running to ensure it is hasrobust process and governance.

The three equal aims of the IGH programme are:

To support the delivery of sustainable improvements in health and healthcare in

collaboration with our overseas partners in their community in resource-poor settings.

To provide an unparalleled personal and leadership development experience

for participants who are recruited as Volunteers (IGH Fellows) on the programme.

To create a cadre of skilled clinical leaders with system-strengthening

skills who will be able to make a real difference to the NHS on their return to the UK.

IGH Fellows are recruited as NHS volunteers through a competitive interview process and undertake mandatory pre-placement preparation.

Currently the basic stipends are:

£1,000

East London, Eastern Cape, South Africa

£800

George, Western Cape, South Africa

£1,000

Yangon, Myanmar

£800

Battambang, Cambodia

plus £300 cost of living supplement to cover transport costs

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IGH programme summary

Over the course of the last year 27 IGH Fellows have

completed 21 projects and have started a further 3

Outcomes:

26 of the 27 (95%) of the IGH Fellows reported development in their personal leadership skills/behaviours by the end of their placement.

95%

16 of the 27 (61%) of the projects demonstrated leadership development of in-country healthcare workers.

61%

Of the 8 (30%) returned IGH Fellows who responded to a survey:

7 (87%) have taken on additional teaching/mentoring roles in the workplace on return to the NHS

6 (75%) felt the IGH programme has had a positive long-term impact on career direction or satisfaction within the NHS.

75% 87%

Outputs:

During the implementation of the 21 completed projects IGH Fellows have:

Worked in direct collaboration with 105 in-country doctors, 42 nurses and 55 managers/students/pharmacists and physiotherapists.

6 Projects led to the development of or improved use of clinical protocols

5 Projects led to the improved management of chronic disease

6 Projects led to improved patient safety and/or satisfaction

Delivered training to 465 in-country healthcare professionals105

5542

“It is people, not policies who ultimately improve healthcare,

we should remember as partners to first focus on relationships

before diving into any project work”

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Relevance to partners overall strategy

• George Regional Hospital (GRH) is a secondary level care hospital located in Eden district of the Western Cape province of South Africa, it provides primary care to the local population and receives referrals from other district hospitals across the region.

• GRH procures most materials (stock) needed for treating patients and running the hospital as ‘Store items’, which are reordered automatically.

• Procurement of stock is challenging due to national and regional constraints on suppliers and tendering, time-consuming national procurement protocols and the lack of adequate availability of medical supplies at national level.

Overseas Partners

Project Supervisor: Sharmane Janki, Deputy Director of Finance

Team Members: Michael Vonk, CEO, George Regional Hospital; Sister Elsa Sellers, Director of Nursing, George Regional Hospital; Sharmane Janki, Associate Director of Finance, George Regional Hospital; Leonie Jaars, Assistant Director of Revenue & Information, GRH; Justin Barnard, Manager.

Planned Outcomes

1 Strengthen relationships and improve communication between End Users, Supply Chain Management (SCM) and Buyers

2 Improve attitude towards stock management among staff across the system

3 Improve management of stock on wards at George Regional Hospital

4 Improve procurement processes in time for new financial year

Progress as of August 2017

This project was handed back to the overseas partner at the end of the 6-month period, progress at this point was as follows:

• A procurement folder was implemented for the stock management system to share files.

• A review of order quantities from financial years 2016/17 and 2015/16 was completed.

• A monthly ward clerk and procurement team forum for discussing and addressing any procurement issues was re-introduced.

• Of those who responded to a survey, six considered that procurement & stock management processes had improved during this programme, seven considered them unchanged, and three did not know.

• A significant reduction in time spent looking for items was seen on all pilot wards except lumbar puncture (LP) needles for which there was an increase of 4 seconds.

Overall Project Goal

Improve procurement and storage of stock across George Hospital resulting in enhanced clinical effectiveness.

Project summaries by partnership site

George, Western Cape, South Africa—Project Title: ‘Enhancing clinical effectiveness

and reducing waste by improving procurement and

storage of stock across George Regional Hospital’

Clíodhna Ní Ghuidhir: February 2017 – July 2017

Project Title: ‘Developing patient information resources

to improve patient education and safe discharge

from hospital services’

Carolyn Hunter: February 2017 – July 2017


• The Western Cape Government’s strategic framework for the future of health care states that the driving force behind the 2020 agenda is the need for a stronger patient-centered approach that focuses on improving the patient experience.

• Patient education is an essential component of health promotion, chronic disease management and fostering patient responsibility for their own health.

• Education should strive to go beyond information sharing through developing confidence in the patient to act on the knowledge shared.

• Studies demonstrate that patients recall and comprehend as little as 50% of what they have been told in a consultation and often less than this when they are an inpatient.

• When used effectively and appropriately, Patient Information Leaflets (PILs) can improve medication adherence and therapeutic outcome, reduce hospital readmissions and empower patients to more actively participate in medical decision making.

• There is currently no central database locally, regionally or nationally for PILs distribution/production.

• George is the Regional Hospital, therefore, many patients from outside George rely on hospital transport to attend for more specialist investigations or interventions. There are no PILs available to provide information about transportation services or the process of presenting and attending the Outpatient Department (OPD).

Overseas Partners

Project Supervisor: Zilla North, Medical Director, George Regional Hospital

Team Members: Francois Marais, student elective coordinator; Dr. Stark; Dr. Gould; Dr. North; Sister Pieteris; Nadia Ferreira, Communications Officer; Dr Ruth Cornick, Knowledge Translation; Nekemva Tom, Pharmacy Intern; Pieter Moolman, Quality Assurance Manager; Dr. Eastman, Director of Global Development for PACK; Dr. Rowse, Associate Professor, Faculty of Pharmacy, Rhodes University.

Planned Outcomes

1 Improved Health Literacy in patients with regards to their medical conditions, management plans and discharge follow-up

2 Re-prioritisation of patient engagement and education to ensure meaningful staff-patient interactions



• A qualitative questionnaire was completed by healthcare staff regarding barriers to adequate provision of patient information resources and consideration of addressing barriers.

• PILs were developed by staff in response to patient need.

• A database of currently available PILs with gaps identified was produced and made accessible on the hospital intranet. A feedback spreadsheet was made available for healthcare professionals to identify further patient needs.

• Nurse led development of operational inpatient and outpatient PILs was facilitated and made available in trial wards.

• A standard protocol was made available on hospital display notice boards and relevant information posters were produced.

Overall Project Goals

To develop and improve the distribution of patient education resources at George Regional Hospital in order to facilitate shared decision making between physicians and patients; improve patient engagement with hospital services and motivate and encourage self-management of chronic disease.

Phase 1: Co-ordinate a database of appropriate patient information resources and engage staff in identifying patient information needs and developing resources.Phase 2: Support staff in incorporating patient education opportunities into routine clinical practice.

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Project Title: ‘Improving antimicrobial stewardship through system

strengthening and staff development at George Hospital’

Jennifer Joiner: February 2017 – July 2017


• Antibiotic resistance (AMR) is one of the biggest threats facing human health today. The emergence over the last decade of multi-drug resistant (MDR) organisms such as MRSA and MDR-TB has been increasing on a global scale. It is estimated that by the year 2050, deaths from AMR will reach 10 million per year, if current trends continue.

• Attempts to tackle the problem of AMR by reducing antibiotic consumption have been increasing over the last decade, and many high- income countries have now managed to achieve a reduction in consumption. However, this is not the case for low and middle- income countries, where antibiotic usage has increased by up to 80%.

• A 2011 review of global antibiotic consumption, showed South Africa to have one of the highest rates in the world in terms of both absolute use and growth. In response to this the South Africa Antibiotic Stewardship Program (SAASP) was formed and a national framework to tackle AMR was developed.

Overseas Partners

Project Supervisor: Dr Trevor Gould, Internal Medicine Consultant

Team Members: Dr Hendre Swanepoel, consultant Microbiology; Sharnel Brits, pharmacist; Sister Jordaan

Planned Outcomes

1 Improved running of antibiotic stewardship ward rounds in order that they provide an effective platform for ensuring best practice in antibiotic use, diagnostic stewardship and ‘Infection Prevention and Control’ (IPC) practices.

2 Staff at George Hospital have an increased awareness of and improved attitudes to the importance of AS.

3 Reduction in antibiotic consumption.

4 Establish an effective Hospital Antimicrobial stewardship committee (HAMSC) which can identify areas of sub-optimal practice and knowledge gaps and produce an agenda for change.



• A HAMSC committee was set up. Committee members have been recruited and a terms-of-reference and standing agenda are complete.

• Data was collected on three key metrics– antibiotic consumption, antibiotic resistance and antibiotic prescribing practices.

• Performance based reports were produced for each clinical department on AS practices.

• An e-Learning module was produced, evaluated and released; it is now ready for use by the next intake of new medical staff.

• Baseline data on antibiotic consumption was produced.


To strengthen ‘Antimicrobial Stewardship’ (AS) practices and systems at George Hospital.


• The ‘Sustainable Development Goals’ 2030 outlines the requirement to substantially increase training for the healthcare workforce, particularly in developing countries

• The target for 2030 is less than 70 maternal deaths per 100,000. The 2015 annual report from the Western Cape Government puts maternal death rates at 71 per 100 000.

• Currently 81% of Obstetrics and Gynaecology staff receive no ESMOE training.

Overseas Partners

Project Supervisor: Dr Carl Firmin, Head of Obstetrics and Gynaecology

Key Team Members: Dr Carl Firmin, Head of Obstetrics and Gynaecology; Dr Juliana Van Jaarsveld; Sister Swanoepol, Operations Manager; Sister Meyer, Ward Manager; Sister Portland, ESMOE Champion.


To develop a training structure that provides George Hospital with a systematic approach to training. This will be piloted in Obstetrics and Gynaecology, focusing on ESMOE training.

ESMOE allows staff to practice common emergency scenarios in a ward-based setting using mannequins. Each ESMOE training session includes a practical demonstration, a short lecture and hands on experience (drill).

• Create and implement a Standard Operating Procedure (SOP) for training.

• Create standardised training registers, logbook and certificates.

• Empower training champions.

• Register with Health Professions Council of South Africa (HCPSA) for Continuing Professional Development (CPD) points.

Planned Outcomes

1 Produce a standardized and coordinated structure for in-service training at George Hospital including training attendance registers and an approach to reporting and tracking training at George Hospital.

2 Improved staff attendance to ESMOE training sessions to 50%.

3 Nurses to receive regular ESMOE training, improving their confidence and knowledge in emergency scenarios.

Progress as of end of January 2018

This project was handed back to overseas partner at the end of the 6-month period, progress at this point was as follows:

• A SOP was developed and implemented; attendance registers and the training database were reviewed and updated.

• Training attendance in 2017 increased from an average of 26% over the previous 9 months to 55% in October and 61% in November.

• Weekly training drills are now in practice.

• The master trainers undertook a refresher teaching course; 83% of staff stated confidence levels had increased.

• A champion for training was identified and enrolled.

• ESMOE training schedules as well as communication signs have been displayed on labor wards.

• ESMOE Logbooks have been implemented with training on how they are to be used.

• Nurses now receive CPD credits for attendance to ESMOE training sessions.

Project Title: ‘The implementation of a training management programme

for George Hospital with focus on Essential Steps in Managing Obstetric

Emergencies (ESMOE) training in Obstetrics and Gynecology’

Michaela Woodhouse: August 2017 – February 2018

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Project Title: ‘Improving Patient Safety

in the Emergency Centre’

Jenna Plank: August 2017 – January 2018


• The Emergency Centre (EC) at George Hospital provides urgent medical care to the surrounding population and is seen as the gate keeper to the rest of the hospital. Its efficient running is therefore paramount.

• Data has shown that ECs within the Western Cape are seeing an increase in the number of patients presenting to the EC by up to 5% per annum. This coupled with bed occupancy rates which are often over 100% means staff within the department are working in a frontline environment which is often very busy and crowded.

• Only 58% of patients seen in the EC within a week have complete data recorded. 15% of patients had no ICD-10 (clinical diagnosis) code assigned and 7% patients were not in the EC casualty book at all.

Overseas Partners

Project Supervisor: Dr Nellis Van Zyl Smi

Key Team Members: Purity Mncube, staff nurse, George EC. It was very difficult to single out other members of staff among the many who were involved including 28 doctors, 30 nurses (including those on short rotations) and 14 clerks

Planned Outcomes

1 Improved data collection of patient wait time, real-time analysis of EC workload and patient tracking through the EC.

2 Optimisation of patient flow through reduction in wait times.

3 Decrease in potential staff exposure to Tuberculosis (TB) and improved infection control measures.

Progress as of end of January 2018

This project was handed back to overseas partner at the end of the 6-month period, progress at this point was as follows:

• The Hospital Emergency Centre and Tracking Information System (HECTIS) was implemented at George Hospital.

• The new system provided instant access to patient numbers for each triage category (green, yellow, orange and red) allowing efficient resource allocation. It also allows easy and accurate data collection on a number of variables including waiting times.

• Patients cannot be discharged from HECTIS without a disposal destination and an ICD-10 code assigned. This means every patient now has complete data recorded and an assigned ICD-10 code.

• HECTIS was configured to facilitate electronic screening of patients attending the EC using the South African National Guidance on TB Screening. This is still at a very early stage and so not all patient attendees are being screened. Preliminary data shows that 8% of screened patients are positive for TB which implies that this form of TB screening could have a huge impact on patient care and also hospital infection control.

Relevance to Partners Overall Strategy

• Antimicrobial resistance is a growing problem worldwide.

• A global effort to preserve antimicrobials was commenced by the World Health Organisation (WHO) in 2015. The Global Action Plan on Antimicrobial Resistance was presented at the 2015 World Health Assembly with a focus on antimicrobial stewardship.

• South Africa is a country where infectious disease is still a significant problem with the greatest burden of deaths still being a result of infections and parasitic diseases. A national plan for antimicrobial stewardship in South Africa was developed.

Overseas Partners

Project Supervisor: Mr. Mike Vonk, CEO

Key team members: Dr Zilla North, Medical Manager; Dr Hendre Swanepoel, Microbiologist; Dr Trevor Gould, Internal Medicine; Sister Saria Van As, nurse; Sharnel Brits, Head of Pharmacy.

Planned Outcomes

1 Create communication platforms regarding antimicrobial stewardship which will be available to hospital staff and the public

2 Improved running of the antimicrobial stewardship ward round

3 Improved hand hygiene amongst patients and staff

4 Antimicrobial team to become empowered to educate on antimicrobial stewardship

5 Improved prescribing practices of antimicrobials

Progress at the end of Jan 2018

This project was handed over twice and so was run by three fellows over a period of 18 months. It was handed back to the overseas partner at the end of this 6-month period.

• Aug 2016- Jan 2017- Set-up antimicrobial prescribing surveillance in the form of a pharmacy chart audit, ward round efficiency via a checklist available in-patient notes, pharmacy training in antimicrobial stewardship and

established Hospital Antimicrobial Stewardship Committee Meetings (HAMSC). This project saw the introduction of the ‘4 pillar approach’ to antimicrobial stewardship ward rounds.

• Feb- Aug 2017- Ensured the continuation of the HAMSC meetings, the improved running of the antimicrobial stewardship ward round with compliance improving to 100% from 15% attendance at baseline, education to clinical staff via an online learning module and improved data collection on antimicrobial stewardship.

Progress at the point of project handover at the end of Jan 2018:

• Introduction of the antibiotic stewardship board resulted in 50% of those asked describing an increased awareness of antibiotic stewardship. 83% had an increased awareness due to emails and meetings.

• A full antibiotic stewardship ward round team was present on 29% of rounds in the first 2 weeks of the project which increased to 38% at the end.

• An Infection and Prevention Control (IPC) nurse has now been employed at George Hospital.

• A learning module produced by a previous fellow is now available on Enterprise Content Management (ECM) making it readily available to hospital staff.

Project Title: ‘A Positive Culture: Strengthening

Antimicrobial Stewardship through Improved

Communication at George Hospital’

Elizabeth Junaid: August 2017 – January 2018


To improve performance in antimicrobial stewardship and infection prevention and control through communication at George Hospital.


To improve patient safety through optimisation of timely care in the Emergency Centre (EC).

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• In the year 2000, 75 Cambodian children in every 1000 died before their fifth birthday – by 2015, the under-5 mortality rate had fallen to 42 in every 1000 live births. In 2000, life expectancy in Cambodia was 58. Today Cambodians live, on average, a decade longer.

• MJP has been an integral part of this health success. In MJP villages in Samlout district, Battambang province, Western Cambodia, malaria has fallen to one quarter of the levels seen in 2011, fewer children are undernourished than ever before and more than 99% of mothers are now delivering in MJP healthcare facilities with skilled birth attendants – well above the provincial, national and global average.

• Despite this considerable progress, old obstacles remain. Respiratory tract infections are still common in Samlout, caused by households burning polluting fuels like wood and charcoal.

• There are new challenges too. Cambodia now faces a dual burden of disease from both infections and chronic conditions. Heart disease is now the biggest killer of Cambodians, and diet is the number one risk factor for death and disability. Tobacco smoke, high blood pressure, high blood sugar and high cholesterol all feature in the top 10 risk factors.

• A fresh strategy is needed to face today’s health challenges, old and new.

• This project aims to produce a report that provides this new strategy.

Progress at the end of the project

This project was handed back to the in-country team at the end of the 6-month project period; two fellows worked together to complete the project in this time period.

By rigorously assessing the health of the population, taking an honest look at the programmes that work and those that don’t, and keeping an eye to the future, this project identified seven health priorities for MJP to focus on in the next five years:

1 Reducing diarrhoea

2 Ending undernutrition

3 Breathing clean air

4 Tackling noncommunicable disease

5 Improving maternal and reproductive health

6 Supporting mental health

7 Reducing infectious diseases

The report outlines how to approach these health themes and also the evidence for these approaches. It outlines how data should be reported, who should be in charge of this reporting and how frequently reports need to be produced. The report also discusses capacity building mainly directed towards education of staff, how to increase the availability of equipment and how to ensure that the work of IGH fellows is appropriately embedded into the MJP health strategy.

Samlout, Battambang Province, Cambodia—Project Title: ‘Maddox-Jolie-Pitt (MJP)

Health Strategy’

Emily Brown and Isaac Ghinai: March 2017 – September 2017


Write an MJP Health Strategy for 2017 – 2021

Project Title: ‘The Happy Families Project’

Fiona Thompson: September 2017 – February 2018


• Maddox-Jolie-Pitt (MJP) Health is a department within the Non-Profit Organisation (NGO) ‘MJP Foundation’ which was established in 2006. Its goal is to eradicate extreme rural poverty and promote sustainable rural economies that directly contribute to the health and vitality of communities, wildlife conservation, and effective natural resource management.

• Access to clean water and latrines is limited meaning diarrhoeal disease is common. There is also the growth of non-communicable disease (NCD), particularly hypertension and type-2 diabetes resulting in heart disease now being the biggest killer.

• Previous IGH fellows conducted a thorough piece of research which resulted in the production of a 5-year plan for MJP Health. One of the recommendations within this includes setting up a community outreach program called ‘Happy Families’ (HF) to improve access to healthcare and health education.

• Three barriers to accessing these community projects were identified: distance to travel, villagers unaware the project is running and villagers not feeling anything ‘useful happened during sessions’.

Overseas Partners

Project Supervisor: Dr. Loeur, MJP Health Officer

Key Team Members: Kunthea Run, Health Assistant

Planned Outcomes

1 Ensure HF projects run in line with government guidance for outreach.

2 Improve access by using transport links for remote areas.

Progress at the end of Feb 2018

This project has not yet been completed, it is anticipated that the project will be handed to another fellow at the end of the 6-month period. Progress at this point is as follows:

• Thirteen sites have been secured for HF delivery

• A timetable to include 2-monthly visits to each site was suggested and accepted.

• The budget for food packages has not yet been secured and so providing food packages for all children identified with malnutrition has not yet been achieved.

• The budget to help with improving transport has also not yet been approved.

• An engaging education package has been developed and delivery of this package has started.

• Educational posters and advertising resources have been created.

• There is now a dedicated play area with activities involving colouring, learning some English words and ball play.


• Increase attendance at Happy Families (HF) projects

• Increase accessibility – including providing transport to the more remote areas.

• Ensure the new HF project runs regularly in line with government recommendations.

• Advertise benefits of attending.

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• Non-communicable diseases (NCDs) are an increasing cause of morbidity and mortality around the globe causing an estimated 36 million deaths in 2008, primarily from cardiovascular disease, cancer, chronic respiratory diseases and diabetes.

• Cambodian data show over half of all deaths in 2012 were related to NCDs, predominantly cardiovascular disease.

• The main NCD risk factors are also common in Cambodia, with over 90% of the population having at least one risk factor such as tobacco smoking, excessive alcohol use or hypertension.

• The Maddox Jolie Pitt Foundation (MJP) has provided health support in Samlout district in the west of Cambodia since 2006, both through direct support to local health facilities and via community-based programs aimed at ending malnutrition, promoting safe birthing practices, encouraging the use of latrines, and reducing indoor air pollution.

• The MJP Health Strategy 2017-2021 identifies a need for robust data collection to monitor both individual and public health indicators. At present, limited data is collected and reported to the Provincial Health Department on a monthly basis.

Overseas Partners

Project Supervisor: Dr Loeur Choup, MJP Health Officer

Key Team Members: Mr. Chamrong Ly, MJP IT Consultant; Mr Roeng Keokosal, NCD and HIS Lead, Boeng Run Health Centre; Miss Kunthea Run, Health Assistant; Mr Choun Chum, Chief Boeng Run Health Centre; Miss Soekea Sieng, Hypertension Project Link.

Planned Outcomes

1 Better recognition of the burden of hypertension within the Samlout community

2 Improved monitoring of patients with hypertension to enable improved treatment

3 Reduced risk of complications from hypertension leading to improved health outcomes for patients

Progress as of March 2018

• Routine blood pressure (BP) screening has been introduced for patients over the age of 35 years attending the Outpatient Clinic at Boeng Run Health Centre (BRHC).

• As of late February 2018, 336 patients have been screened, with a further 49 patients screened at the ‘Happy Families’ community outreach sessions.

• 91 patients have been identified as having elevated BP and 38 of these are currently receiving treatment or being closely monitored.

• A BP record card and a disease register have been developed to encourage improved monitoring of these patients.

Project Title: ‘Improving Management

of Hypertension in the Samlout District’

Alison Malpass: September 2017 – February 2018


To improve the health of the community in Samlout District by reducing the burden of morbidity and mortality from non-communicable diseases.


• Within Asia, there is an expected 7.6-fold increase in the number of elderly people from 2000 to 2050; one of the most significant risk factors for osteoporosis.

• Osteoporosis is greatly under-diagnosed and under-treated in Asia yet by 2050 it is expected that more than 50% of the world’s fractures will occur within the continent.

• In Yangon, Myanmar, life expectancy is increasing and therefore it is inevitable that osteoporosis prevalence will also increase.

• ‘Capture-the-Fracture’ is a global campaign focusing on secondary prevention following incident osteoporotic fracture through the provision of a Fracture Liaison Service (FLS). It has an internationally endorsed best practice framework including 13-set standards, which can be used to set benchmarks whilst developing fracture prevention services.

Overseas Partners

Project Supervisor: Dr Thinn Hlaing

Key Team Members: Professor Zaw Wai Soe, Trauma and Orthopaedics; Professor Myint Thaung, Trauma and Orthopaedics; Professor Aung Myo Win, Trauma and Orthopaedics; Dr Hnin Yi Mon, Geriatric Medicine; Dr Aung Htet, Anaesthetics; Professor Khin Myo Hla, Physical Medicine and Rehabilitation; Professor Moe Wint Aung, Diabetes and Metabolic Medicine.

Planned Outcomes

1 To improve the referral system for both DEXA scanning and to fracture prevention clinic from General Medical Wards, Orthopaedic Wards and the Rehabilitation Unit at YGH.

2 Improved staff engagement and positivity regarding the osteoporosis referral system at YGH.

3 To motivate and engage senior nurses/ward doctors to monitor the quantity of referral forms on the ward and replenish these as necessary.

4 Improve the number of patients from high-risk areas that are evaluated for an osteoporosis risk assessment.

5 To evaluate the spectrum of bone disease seen in the fracture prevention clinic at YGH and to standardise investigation and management of osteoporosis within the fracture prevention clinic.

6 Improve the number of patients who need treatment for osteoporosis that are screened for secondary causes.

7 Improve the number of patients who are eligible for treatment for osteoporosis who are initiated on secondary prevention medication.

Progress at the end of October 2017

• A ‘Hip Fracture Registry’ was commenced in May 2017 (an expansion of some of the data that was already being collected). This was modelled from the UK ‘Fracture Fragility Network’ audit.

• Implementation of the ‘Integrated Care Pathway (ICP) for Hip Fracture Patients’ was not completed by the end of this project but the aim is for it to be launched by Jan 2018.

• Guidance for Venous Thromboembolism (VTE) prophylaxis prescribing was included in the ICP.

• A ‘Special Interest Group’ (SIG) comprising key stakeholder groups met regularly to work on the production of the ICP document.

• 1-2 champions were appointed from each of the stakeholder group who will be responsible for monitoring their section of the pathway.

• Updated guidelines from the Anaesthetic Department have been developed and implemented.

• Baseline data collection revealed that the average time for patients >65 years to become medically fit for surgery was 6 days.

• Orthogeriatrics liaison was set up 2 days a week.

Yangon, Myanmar—Project Title: ‘Hip Fractures at Yangon

Hospital (YGH) – a drive to coordinated care’

Emma Mitchell: November 2016 – October 2017


To ensure patients at YGH deemed to be at high-risk for osteoporosis are referred to the fracture prevention clinic

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• Patients requiring surgery from the General Surgery or Orthopaedic teams undergo this within the dedicated Yangon Hospital (YGH) Emergency Theatre complex. This consists of four operating theatres, staffed to provide an essentially 24/7 service.

• Demand for services is increasing markedly, so provision for future capacity requirements is essential.

• The high volume of emergency cases potentially confers an opportunity to significantly impact patient morbidity and mortality if peri-operative practices can be optimized.

Overseas Partners

Project Supervisor: Professor Mu Naing, Head of Anaesthetics

Key Team Members: Professor Moe Tin, Vice President of the Surgical Society of the MMA, and Head of the Department of Surgery at North Okkalapa General Hospital; Professor Aung Thein Htay, Orthopaedics; Prof Tin Mar, Yangon Specialty Hospital

Planned Outcomes

1 A reduction in unnecessary out-of-hours operations

2 Adoption of the World Health Organisation (WHO) Surgical Safety Checklist for all cases.

3 Timely patient flow through emergency theatres based on an agreed prioritisation guideline

4 Greater engagement in quality improvement across YGH surgical and orthopaedic teams.

Progress as of June 2017

This project was run by two previous fellows and so the whole project ran over an 18-month period.

• Dec 2015 to Jun 2016- An assessment of emergency theatre demand was conducted along with a study of patient flow through the emergency theatre department. The main findings were that the department was limited by staffing constraints which meant that 80% of procedures were completed out-of-hours. There was also an inconsistent system of case prioritization.

• Jun 2016 to Dec 2016- A study of the factors that caused delays in patients reaching theatre, along with the propensity for out of hours operating was conducted. A ‘steering committee’ of stakeholders was set up along with a surgical prioritisation guideline. Workforce planning was analysed and a proposal was submitted to the Ministry of Health asking for further nursing resources.

Progress over the course of this most recent 6-month project is as follows:

• A Myanmar WHO checklist was produced following discussion with the Patient Safety Team of the WHO in Geneva. Posters were displayed in each of the four emergency theatres.

• A workshop to introduce the concepts of clinical audit and quality improvement to junior doctors was developed; it unfortunately could not be implemented within the timescale of this project.

• Accurate peri-operative mortality figures were produced.


• Previous Improving Global Health (IGH) fellows identified that hand hygiene compliance was one area that was particularly poor at YGH.

• An international drive for improvements in hand hygiene is being headed by the World Health Organisation (WHO). The WHO First Global Patient Safety Challenge ‘Clean Care is Safer Care’ has developed recommendations, guidelines and tools to facilitate this improvement.

• There is overwhelming evidence that effective hand hygiene can reduce transmission and infection by drug resistant organisms in health-care settings.

• At the start of the project there was no forum, team, member of staff or program of work that was specifically dedicated to infection control at YGH. There was an Infection Control Committee but they had not met in at least 8 months.

Overseas Partners

Project Supervisor: Professor of Paediatrics at Yangon Children’s Hospital. Also made links with ‘the Reinvigoration of Yangon General Hospital project’.

Planned Outcomes

1 Reduced numbers of HCAIs each month at YGH.

2 Reduced mortality rates due to HCAI.

3 Reduced average length of stay across YGH.

4 To create a sense of urgency for change and improvement of hand hygiene at YGH.


This project was built on work completed by a previous fellow in the ‘Intensive Care Unit’ (ICU) at YGH. This project was handed back to the overseas partner at the end of the 6-month period, progress at this point was as follows:

• A report was produced on the current situation of hand hygiene at YGH. Surveys were conducted on hand hygiene compliance and the knowledge and perceptions of staff on hand hygiene and infrastructure.

• It was felt that YGH did not currently have the necessary resources or infrastructure in place to be able to implement a sustainable and effective program to improve hand hygiene across the hospital.

• Although there was no formal commitment to establish a group to take hand hygiene forward, there was a lot of discussion around each of the suggestions made which may lead to action in the future.

• A hand hygiene awareness event was held which was attended by over 100 members of staff from YGH

• A ‘Hand Hygiene Awareness Poster Campaign’ was run.

• The WHO Ward Infrastructure Survey was conducted of 6 wards.

Project Title: ‘Baseline Evaluation of hand hygiene

at Yangon Hospital (YGH)’

Chloe Donald: December 2016 – May 2017

Project Title: ‘Improving Utilisation of Emergency

Operating Theatres’

John Heathcote: December 2016 – May 2017


Reduce the number of healthcare associated infections (HCAI) at Yangon General Hospital (YGH)


This project aims to improve the safety and utilisation of the YGH emergency operating theatre complex.

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Project Title: ‘Quality Improvement around use of Point of Care Testing

Devices in GP clinics; B. Development of GP Society website and GP database’

Jessica Norton: December 2016 – May 2017


PART A

• Point of Care Testing (POCT) is a broad term that encompasses any test that can be carried out at the patient’s bedside and give a result at the time and place the patient is tested.

• Concerns were raised about the use of POCT in GP clinics as there was no understanding of the equipment, maintenance or validity of the results.

• A previous IGH fellow developed a model of care for non-communicable diseases which later evolved into a ‘Comprehensive Model of Care’ which emphasized the importance of strengthening and enhancing existing facilities.

• This project fits into the wider agenda of improving the quality of primary care as Myanmar moves towards universal health coverage (UHC).

PART B

• Historically family medicine in Myanmar has been provided by the private sector; there is no specific requirement nor regulation for General Practitioners (GPs).

• Myanmar GP Society (GPS) was formed in 1987 by GPs themselves, since they recognised the need to address some of the deficits in education and training, as well as to strive for improved quality in the practice of family medicine.

• GPs have recently developed a strategy which highlights their mission, values and long-term plans. One element of this is the communication and information sharing strategy.

Overseas Partners

Project Supervisor: Dr Myint Oo, Vice President at General Practitioners’ Society

Key Team Members: Dr Aung Pyi Soe, GPS member and Teacher at Hexagon Medical Education Centre; Dr U Tin Aye, GPS Patron and Myanmar Academy of Family Physicians President; Dr Than Soe, GPS member and project advisor; Dr Win Zaw, GPS member and project advisor.

Planned Outcomes

PART A

• Improved understanding of Quality Assurance practices around POCT.

• Increase in Quality Assurance Practice for POCT.

PART B

• Wider engagement of Myanmar GPS members beyond Yangon.

• Improved dissemination of information to GPs across Myanmar.

• Improved representation of Myanmar GPS members to both local and international partners.

• Improved documentation of GPs working in Myanmar



PART A

• GPS now runs several workshops on POCT and wider clinical care.

• Training was delivered in quality assurance in POCT to GPs with a post-training average quiz score of 95%

• A series of templates for risk assessment, equipment records and stock records with accompanying explanations was produced.

PART B

• It is now part of the official GPS strategy that communication will be key to achieving their goals and that both a website and a database could contribute to this.

• GPS is now working with Ministry partners, NGOs and local partners to look at ways to document GPs working in Myanmar.

• A map of all the international collaborators working with GPS was produced which highlighted the complete lack of a consensus It was decided that moving forward they should stick to a few key partnerships with clear expectations on both parts.

Project Title: ‘Introduction of the Integrated Care Package (ICP)

for Fracture Neck of Femur (NOF) and improvements in pain’

management at Yangon Hospital (YGH)’

Marie Lonergan: June – November 2017


• Due to an ageing population, it has been projected that over half of all hip fractures in the world will occur in Asia by 2050.

• In developing populations, particularly in Asia, the rates of osteoporotic fracture appear to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority amongst health measures considered by policy makers.

• The ‘National Institute of Clinical Excellence’ (NICE) Hip Fracture pathway recommends offering an assessment of patient pain immediately on admission and at intervals of 30-minutes and hourly until the patient is settled.

Overseas Partners

Key Team Members: Dr Thinn Hlaing; Dr Kyaw Min Soe, Consultant Orthopaedic Surgeon at Yangon Orthopaedic Hospital (YOH); Professor Christopher, Orthopaedics, YGH.

Planned Outcomes

1 Ensure clinicians are aware of the ICP for fractured NOFs and feel competent to complete it.

2 Increase referral to Fracture Prevention clinic (FPC) at YGH.

3 ICP document to be included in notes from the ED and transferred with patient to the wards.

4 Effective pain management pre and post operatively with all fractured NOF patients.

5 Clinicians feel more satisfied and confident with pain management in this patient group.

Progress as of November 2017

This project was run in conjunction with another IGH fellow who worked on the recognition and management of osteoporosis and also worked on the ICP document; at the end of the 6-month period the whole project was handed over to another IGH fellow:

• Train-the-trainer sessions were completed with all stake holder groups. Feedback obtained was positive and constructive.

• The format of the ICP document has been agreed by all the stakeholders although it has not yet been launched; this project will be completed by the next fellow.

• Nurses and nurse students were encouraged to complete work on pain management on the wards independently of the IGH fellow. This approach had variable success and so needs some further support from the next IGH fellow.

• Daily pain assessment using the ‘Wong Baker faces pain scale’ has been set up on one of the Orthopaedic wards.


• To introduce and implement a multidisciplinary ICP for use in patients with a fractured NOF from admission to an Orthopaedic ward via the Emergency Department (ED) through to discharge at YGH.

• Embed a culture of AE reporting and optimise processes so that learning from AE is reviewed and acted upon to improve patient care


PART A

To develop standardised quality assurance practices around POCT devices in GP clinics.

PART B

To improve communication, connectivity and information sharing between GPs across Myanmar via a GPS website and National GP database.

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Project Title: ‘Raising awareness of Acute Kidney Injury (AKI)

at New Yangon General Hospital (NYGH)’

Theeba Krishnamoorthy: June – November 2017


• AKI is a sudden reduction in kidney function and is associated with risk factors such as chronic kidney disease (CKD), advanced age/ cognitive impairment, generalised arteriopathy, previous AKI, sepsis, dehydration, nephrotoxic drugs and radiocontrast use.

• In Myanmar there is very little data on the burden of AKI on the country with the exception of the specialist centre in Yangon where the most severe cases of AKI are referred. Preliminary data collected by the Australian Sankebite Project from the hospital has shown that 68% of cases are due to snakebite with remaining cases being caused by predominantly sepsis, gastroenteritis and leptospirosis.

Overseas Partners

Project Supervisor: Prof U Zaw Lynn Aung, Dr Aye Myitzu.

Key Team Members: Dr Htet Htet Nyunt, Dr. Barani Bo, Dr, Nyo Paing and Dr. Htet Htet Nyunt

Planned Outcomes

1 All staff members engaged and keen to get involved in preventing and early recognition & management of AKI.

2 Fluid charts, National Early Warning Scale (NEWS) charts, AKI care bundle forms on each ward. Monitor usage of forms.

3 To ensure pathology department alert ward team of abnormal creatinine value.

4 Greater awareness & improved knowledge on AKI prevention, recognition and management.

Progress as of end of February 2017

This project was handed over to another IGH fellow at the end of the 6-month period who completed a further 2 months of work before handing it back to the in-country team. Progress at this point was as follows:

• An audit conducted at month three showed that 23 out of 25 of abnormal creatinine result reports had the ‘Beware AKI’ alert stamp on it.

• Fluid charts and NEWS charts were developed; an audit demonstrated they were being correctly used.

• 100% of patients with abnormal creatinine results triggering an ‘S-Alert’ had a fluid chart started and 100% of NEWS >3 have a fluid chart started on the High Dependency Unit (HDU).

• Teaching was delivered focusing on bedside monitoring such as NEWS, fluid charts and how this is linked to AKI.

• A ‘BewareAKI’ Facebook page was launched where team progress is uploaded through photos (919 followers).

• An AKI Care Bundle (CB) was developed but could not be introduced within the timescale of this project, this was handed back to the in-country team.

Project Title: ‘Part 1. Quality Markers in General Practice (GP)- a pilot study

Part 2. Quality Improvement of General Practice (GP) in Myanmar’

Sateesh Ganguli: June 2017 – May 2018


• Myanmar is experiencing a period of change. Following decades of political isolation and military rule, the country now appears to be on a path to industrial and economic progress.

• Historically poor funding has led to a health system that lacks the infrastructure and resources required to provide effective care.

• The National Health Plan (NHP) identifies that within primary care, “the quality of care shows great variations”. Efforts must therefore be made to ensure that all services and interventions meet the same minimum standards of care.

• This project will build upon previous work conducted by the General Practice Society (GPS) in developing and defining appropriate quality markers.

Overseas Partners

Project Supervisor: Dr Myint Oo, Vice President of GPS and NHS IGH In-country Supervisor

Key Team Members: Dr U Tin Aye, Patron of GPS and President of MAFP; Dr Aung Pyi Soe, Member of GPS, Hexagon Medical Education Centre; Dr Than Soe, Member of GPS; Dr Aye Aye Thein; Dr Kyaw Thu, Dr Zay Yar Aung; Dr Vijay Kumar, Executive Committee member of GPS, Quality Committee member; Dr Wut Hmone Hlaing, Executive Committee member of GPS, Quality Committee member, Hexagon Medical Education Centre


PART 1

To promote the standardisation and quality of primary care in Yangon, Myanmar

Phase 1: To build upon previous work by the GPS in developing relevant and appropriate quality markers, and then auditing chosen voluntary GP clinics against these.

Phase 2: To support the clinics in producing strategies to achieve any unmet quality markers

PART 2

To improve quality in two previously identified key areas of General Practice in Myanmar: infection control and medical record keeping.

Planned Outcomes

PART 1

1 Improve the standardisation of primary care in Yangon, Myanmar

2 Create awareness and engagement in Quality Improvement (QI) practices amongst GPs in Yangon, Myanmar

PART 2

3 To improve hand hygiene compliance in GP clinics

4 Introduction of sustainable infection control training program for GPs

5 To encourage the use of disease registers in GP clinics

6 To promote a culture of clinical governance amongst GPs, including skills in aspects such as record keeping, clinical audit and quality assurance.


This whole project will be run over a 12-month period by the same fellow, it is divided into two parts of 6 months each. It is anticipated that the project will be handed back to the local team at the end of the 12-months.

PART 1

• The pilot developed 10-quality indicators. These were used to assess the standards of quality in 34 GP clinics, in 5 different regions of Myanmar (this was extended beyond the original 10 that was planned).

• The study highlighted several fundamental gaps in quality and recommended that quality improvement should be focused on priority areas.

• Infection control: 1 in 5 clinics did not have access to both a sink with soap and alcohol gel, and less than half of the GPs reported that they washed their hands in between patient contact.

• Medical Records: Just 6% of clinics had an electronic medical record (EMS) system in place, and less than half of the clinics had access to paper records stored at the clinic.


To prevent hospital acquired AKI, to improve recognition and to initiate early management of community and hospital acquired AKI.

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Project Title: ‘Improving and standardising pre-operative

care in hip fracture patients’

Amit Parekh: December 2017 – May 2018


This project was taken over from a previous fellow and has already been running for 12 months. This part of the project was started by conducting interviews with consultants from different departments involved in the last 12-months of the project. The following came to light:

• The Emergency Department (ED) has its own dedicated clerking proforma already which negated the need for a dedicated ED clerking in the Integrated Care Pathway (ICP) document.

• The Orthopedic department saw the ICP as a data collection tool only.

• The ortho-geriatric ward rounds were no longer taking place; the geriatric department feel they do not have the resources to re-instigate this.

• It was unclear how the ICP document fits with the current system of medical review at YGH which appears to work well.

• Feedback from training sessions revealed a feeling that the ICP was too long.

Overseas Partners

Project Supervisor: Professor Aung Htet

Planned Outcomes

1 Improved geriatric review of patients over the age of 65 admitted with hip fracture.

2 Improved adherence to the DVT prophylaxis guidelines.

3 Improved adherence to osteoporosis treatment guidelines by geriatricians performing falls assessments.

Progress as of February 2018

This project is due to be completed at the end of April 2018, progress as of February 2018 is as follows:

• A hip fracture pathway document was finalised and implemented, the next stage of the project will involve evaluating its use.

• The hip fracture pathway document asks if DVT prophylaxis was prescribed and administered, if the patient was reviewed by a geriatrician and also if an osteoporosis risk assessment was performed.

Project Title: ‘Developing soft skills within the

General Practice Society (GPS)’

Usmaan Rhaman: December 2017 – May 2018


• The Myanmar health system faces many challenges. One of these is the challenge of human resources which is caused by shortages in numbers, an inappropriate balance and mix of skills and inequitable distribution and difficulties in rural retention.

• The vision of the GPS is to ‘Deliver compassionate, inclusive, comprehensive and high quality primary health care to the people of Myanmar for a better and healthier life’.

Overseas Partners

Project Supervisor: Dr Myint Oo, Vice President of GPS.

Key Team Members: Dr Khine Soe Win, President of GPS (Central); Dr Aung Pyi Soe, Member of GPS (Yangon); Dr Nay Win, President of GPS (Mandalay); Dr Thaung Myint, President of GPS (Mawlamyine); Dr Khin Soe, Member of GPS (Meiktila); Dr Nu Nu Hlaing, President of GPS (Pathein)

Planned Outcomes

1 Identification of soft skill requirements for primary care

2 Improvement in understanding and awareness of soft skills


This project will be handed back to the overseas partner at the end of the 6-month period, it is due to be completed at the end of April 2018. Progress as of the end of February 2018 is as follows:

• 100% All GPs (over 50) who were provided with a questionnaire completed it.

• Workshops have been developed and will be run in April/May 2018 looking at 2-3 of the most important soft skills to GPs.


Improved preoperative clinical care in patients with hip fractures.


Improvement and awareness of soft skills in primary care.

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• Primary care in Myanmar is currently a private service; it is not recognized as a speciality in its own right and as such there is no official training program. This leads to a vast difference in the quality of care provided to patients.

• Groups of GPs working together may be able to provide peer support, facilitate educational opportunities and together provide better patient care.

• The GP Society (GPS) would like to run a pilot of a GP group clinic in Yangon. This would be a ‘quality standard’ clinic providing care of a standard that other practices would strive to achieve.

Overseas Partners

Project Supervisors: Dr. Myint OO, Dr. Than Soe and Dr. Aung Pyie Soe

Planned Outcomes

1 Increased knowledge of current models of general practice being in Yangon


This project is due to be completed at the end of April 2018, progress as of the end of February 2018 is as follows:

• A skeleton proposal document has been created and is being assessed by GPS.

• A questionnaire has been developed and 4 GPs have completed it so far.

• A plan has been drawn up which will be discussed with the GPS Vice President which transforms the idea of group GP into reality.

Project Title: ‘Group General Practice (GP)’

Clare Doherty: December 2017 – May 2018


Take the first steps towards developing a new model for primary care delivery in Myanmar by gathering baseline information and helping to develop a clear business case for a pilot quality group in general practice.


• The National Core Standards state that there should be an adverse event reporting system in place. This is the case at Cecilia Makiwane Hospital (CMH) but it appears that there is further work to do to embed the approach and ensure that the learning cycle is completed following Adverse Event (AE) reporting. The situation at Frere Hospital (FH) is as yet unclear.

• AE reporting should be a key element of a continuous quality improvement program. International studies have indicated that 10% of hospital admissions are associated with an adverse event and that between 35 - 50% are preventable.

Overseas Partners

Project Supervisor: Professor Parrish, Head of Department Internal Medicine

Key team members: Dr Sane Matole, Medical Officer, Medicine; Candice Johannes, Physio; Shelly Seby, Physio; Vishaal George, Physio; Dr Q Salie, Medical Officer, Surgery; Dr Jay, Head of Department, Surgery.

Planned Outcomes

1 A reduction in the number of AE happening

2 A reduction in litigation for such events. This is likely to take 18 months - 2 years

3 A reduction in the number of complaints as a result of learning from AE


This project was handed back to the in-country team on completion, progress at this point was as follows:

• A survey of new interns was completed to determine the issues with existing documentation.

• A new shorter admission form was introduced.

• A new post-take form was introduced in April 2017.

• A new Multi-Disciplinary Team (MDT) discharge form was developed.

• New nil by mouth signs were designed, printed, laminated and displayed.

• A survey was conducted of all theatre staff to better understand reasons for surgical delays.

East London, Eastern Cape, South Africa—Project Title: ‘Adverse Incident reporting

and documentation’

Viki Wadd: January 2017 – June 2017


• Improving the quality and organization of inpatient documentation

• Reducing surgical delays

• Embed a culture of AE reporting and optimise processes so that learning from AE is reviewed and acted upon to improve patient care

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PART A

• Providing equal and sufficient health care in rural areas is a challenge for many countries. In the Eastern Cape 65% of the population live in the rural areas.

• Access to healthcare is difficult as patients must travel long distances without sufficient transport and there is often a shortage of health care workers and resources.

• The rural population within the Eastern Cape face a difficult socioeconomic environment. The average wage is well below the poverty line and significantly lower compared to the urban areas.

PART B

• Abnormal vital signs are associated with increase morbidity and mortality as it reflects abnormal physiology. This can indicate a disease process and highlight a deteriorating patient.

• A problem of the recognition and communication of patients’ abnormal vital signs has been identified.

• This has led to poor morbidity and mortality.

Overseas Partners

Project Supervisor: Professor Parrish, Head of Internal Medicine

Key Team Members: Dr Jenny Nash, General Practitioner in District Clinical Specialist Team; Dr Stacy Rossouw, Consultant Neurologist; Sister Xuba Z.G; Mrs Pona, Area Matron for Internal Medicine, CMH; Sister Spenekop, Operational Manager; Mrs Tschangana, Head of Quality Assurance, CMH; Mrs Silinga, Head of Quality Assurance; Mrs Pona, Matron of Internal Medicine.

Planned Outcomes

PART A

1 Improved team-working via better communication both within and between hospitals.

2 A supportive working environment by the development of a regional network.

3 Enhance clinical skills.

4 Local hospitals able to recognise and express the support that is required to improve patient outcomes.

PART B

5 Improve the recording of vital signs by the nurses on the medical wards.

6 Improve engagement of staff in learning the importance of recording and recognising abnormal vital signs.

7 Improve the communication of abnormal vital signs to the doctors.

8 Increase the percentage of patients being managed in the correct level of care.



PART A

• 5 support visits were conducted by Professor Parrish (Internal Medicine Consultant) to three rural hospitals.

• Clinical and quality improvement teaching was delivered to a total of 12 doctors and 6 nurses.

• An outreach program with objectives and goals was agreed by the stakeholders

• Quality Improvement teaching material was developed which includes a 12-week training program (development of audio/video material being created)

• A staff feedback questionnaire highlighted that communication between the rural hospitals and Cecilia Makiwane Hospital (CMH) improved after the support visits had been conducted.

• Doctors feedback shows that they are now following the guidelines for management of hypertension and epilepsy thereby reducing polypharmacy following the support visits.

• Currently developing direct phonelines to specialists in the tertiary hospitals.

PART B

• In-service teaching was delivered to nurses in different departments at CMH on how and why we take vital signs.

• The new chart was implemented on all medical wards. All vital signs are now recorded on one chart which requires saturations and their conscious level using the AVPU scale to be recorded. It also introduces an Early Warning Scoring (EWS) system.

• Ward-based training on vital signs and the use of the new charts was delivered to 40 nurses and 15 student nurses

Project Title: ‘Vital signs and outreach Project’

Cate Luce: February 2017 – July 2017

Project Title: ‘Improving Tuberculosis (TB) isolation in

Cecilia Makiwane Hospital (CMH)’

Ilsa Haeusler: February 2017 – July 2017


• TB is the most common cause of death in the Eastern Cape.

• A high proportion of inpatients and outpatient attendees in CMH have active TB disease, of which active pulmonary TB is infectious to contacts.

• Interventions that have been adopted on an international level to reduce nosocomial TB infection include isolating patients with suspected or confirmed TB and applying surgical face masks to patients with suspected or confirmed TB.

• At CMH, patients with TB or suspected of having TB are often nursed on the open ward, rather than in isolation, risking infecting other patients and members of staff.

• This project was started by a previous fellow, who facilitated change to improve isolation of TB patients and other infection control measures on the four medical wards in CMH.

• Interventions to date include a TB Awareness Week held in January 2017, which included in-service training, mask fitting training, departmental competitions and an information stall with games.

Overseas Partners

Project Supervisor: Professor Andy Parrish, Head of Internal Medicine, CMH

Key Team Members: Dr David Stead, Consultant in infectious disease, CMH); Sister Tshaka, lead infection control nurse, CMH; Sister Yolisa Nqaphela, TB infection control nurse, CMH; Mr Vishaal George, Physiotherapist, CMH; Ms Eden Smith, Physiotherapist, CMH.

Planned Outcomes

1 A reduction in the number of TB infections acquired by staff working in CMH.

2 Increased number of patients correctly isolated in wards.

3 Increased number of patients suspected or diagnosed with TB wearing surgical masks.

4 Increased number of airborne precaution signs placed above beds of patients with suspected or diagnosed TB.


This project was started in October 2016 and so has been run over a total of 12 months (2 fellows), it is now ready to be handed back to the overseas partner, progress at this point was as follows:

• A TB Awareness Month was run in March 2017 culminating with World TB day; the team organized a series of highly successful events including a series of speeches by senior influencers.

• ‘Fishing’ games were run each Friday morning throughout March. This involved setting up a stall at CMH where members of staff were engaged with a game designed to improve understanding of TB infection control measures.

• Engagement with local radio stations. The team worked with the District Health Promotion team to secure a 20-minute slot.

• An hour-long in-service training session was delivered to the nursing staff at CMH by Dr Ilsa Haeusler.

• A TB nurse was appointed and mentored at CMH over a period of three months, she has been left responsible for the management of TB in the hospital and is being supported by a deputy nurse. The TB nurse was trained in how to use the TB audit tool for routine data collection.


• To increase the knowledge of staff members across all wards and departments in CMH with regards to TB and TB infection control.

• Embedding TB infection precautions into the routine work of the Infection Prevention and Control team and have this documented in a Standard Operating Procedure.

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Project Title: ‘Safe Antimicrobial Prescribing in

Eastern Cape South Africa’

Francis Collett-White: February 2017 – July 2017


• Infectious bacterial diseases remain the most common cause of death in South Africa and are a common cause for presentation to healthcare facilities in the Eastern Cape, South Africa. Due to the high rate of antibiotic prescribing, guidelines have been produced within the Essential Medicines List (EML) to aid antimicrobial stewardship.

• Antimicrobial resistance is a significant problem in South Africa leading to increasing difficulty managing previously treatable conditions.

Overseas Partners

Project Supervisor: Professor Andy Parrish and Dr David Stead

Key Team Members: Dr. Estian, Intern in Internal Medicine, CMH; Seshnee, Clinical Pharmacist, CMH; Jako, Clinical Pharmacist, CMH; Ya- Ying, Clinical Pharmacist, Frere Hospital (FH); Sarisha, Clinical Pharmacist, FH; Luniswa Tshaka, Lead in Infection Control; Ncumisa, Pharmacy Intern, CMH; Deon Oothuizen, Software Engineer; Cherise Sims, Physiotherapist; Sr Lindiswa Tshaka, Nurse

Planned Outcomes

1 Improved compliance with antibiotic guidelines in CMH

2 Staff aware of antibiotic guidelines and motivated to improve practice

3 Improved staff communication of inappropriate antibiotic prescriptions


This project was started in October 2016 and so has been run over a total of 12 months (2 fellows), it is now ready to be handed back to the overseas partner, progress at this point was as follows:

• The Anti-Microbial Stewardship (AMS) ward round was introduced; it is run by pharmacists once a week during medical and surgical ward rounds.

• Compliance with medical guidelines is now being audited using data from these ward rounds.

• The results of a 3-year surveillance of antibiotic use in the medical wards of FH showed that since introduction of the Anti-Microbial Stewardship (AMS) ward rounds total antibiotic use has fallen significantly.

• A hand hygiene audit was conducted using a nationally proposed audit tool.

• Hand hygiene education sessions were run.


• Work from previous IGH fellows found that the quality and organization of patients’ medical records was poor and inconsistent.

• This was found to not meet the ‘National Core standard’ and has been linked to time wasting, compromised patient safety, adverse events and a negative reputational impact.

• A new admission form was introduced by previous IGH fellows; it was audited in four medical wards in order to ensure it had become sufficiently embedded.

• Recurring error themes were found in admission documentation.

• Work was therefore started on a new admission document. The implementation was very successful.

• As the project progressed it became clear that there was a much greater need to focus on improving the prescription and administration of iv fluids; and therefore, the project changed direction.

Overseas Partners

Project Supervisor: Prof. Andy Parrish, Head of Internal Medicine

Key Team Members: Dr Matole, Medical Officer, Internal Medicine, CMH; Mrs Vara, Head of Human Resources Department, CMH.

Planned Outcomes

1 Increased percentage of patient medical records containing all relevant documents

2 Increased percentage of documents completed fully

3 Increased percentage of patients asked for consent for treatment at admission (documented)

4 Improved staff satisfaction towards documentation.

5 Reduction of time spent looking for information in a folder

6 A reduction of adverse events related to poor documentation and a reduction of claims should be observed

Progress at the end of January 2018

This project was handed back to the in-country team at the end of the project, progress at this point was as follows:

• A detailed root cause analysis was conducted of the current state of patient documentation.

• Seven Quality Improvement (QI) sessions were run with Internal Medicine Interns

• Sessions on problem solving and organization of the workplace were delivered to frontline staff.

• An auditing tool was created for i.v fluid prescribing.

• An admissions folder was created in casualty which contains admission forms, medication charts, IV fluids prescription and administration forms, glucose control forms and referral forms.

• By project handover it was found that: 100% of patients admitted by internal medicine had the new admission document completed, there was an increase in the number of i.v fluid prescriptions that had been signed and all wards including casualty had a consistent supply of blank documents available for use.

Project Title: ‘Improving patient documentation on

Medical Wards at Cecilia Makiwane Hospital (CMH),

Mdanstane, Eastern Cape, South Africa’

Laura Bottini: August 2017 – January 2018


Improve patient care and staff satisfaction by improving the quality of medical record keeping.


Improve antibiotic stewardship the Eastern Cape, South Africa.

Improving Global Health through Leadership Development Annual Report 2017/18

http://www.tvwleadershipacademy.nhs.uk/improving-global-health-igh-through-leadership-development-programme

Huge thanks to the Partnership Link Leads,

Mentors, Operational Management Group and

Advisory Group, all of whom give of their

time on a voluntary basis.

Documents

Improving Global Health through Leadership Development · 2018-10-24 · Hospital, East London and pharmacists Ya-Ying Wang and Sarisha Singh from Frere Hospital. The second was entitled