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Last 2 Days at Hopital Ste. Croix

Our internet access has been more limited that we expected. As such, we update the blog only when we can. Our last 2 days at the hospital were Tuesday and Wednesday. These days were just as interesting as the first 3. We were very fortunate to be at the hospital when we were, considering the many new developments. Such developments have led us to conclude that the hospital is not sustainable past the near future. After the government repairs the canal that runs under the hospital, it is highly likely that a large majority of the first floor will be rendered useless, including 3 surgical suites, which are probably the nicest areas in the hospital. Furthermore, in order to get the hospital up and running, complete rework of the plumbing and electrical systems are necessary. Working on a strategic plan during all of these developments has required us to be extremely adaptive. As of now, we are considering re-opening only the second floor of the hospital, which will be protected from flooding and the methane gas from the canal. Along with the chairman of the board, we are exploring many options for the future of the hospital, most of which require a new location and facility. For now, the hospital will continue to operate outpatient clinics, lab, and radiology. The very least of our problems are the many operational inefficiencies of these services. Please feel free to comment on the latest developments.

On Wednesday afternoon, we traveled over the mountains to Jacmel, a city on the southern coast of Haiti. Wednesday and Thurday were filled with relaxation and contemplation. The chairman of the hospital board is expecting our final recommendations within the next couple weeks, so we're a bit stressed out with the situation. We'll try to post some pictures of the hospital as soon as we can.

Monday Meetings

Monday was quite the day. We were in meetings with various people the entire day. It was very productive, yet exhausting at the same time. We toured the hospital again, but realized we needed more information that required a translator. We met with Sister Judy and her summer intern Constantine. They came down from Fondwa to talk about our needs for an administrator and offer advice. Sister Judy seems to know everyone in Haiti that has anything to do with healthcare, and she's offered some great insight. She is an American nurse that has been working in Haiti for quite some time. Constantine recently graduate from NYU with a masters degree. The IT setup/internet seems to be working wonderfully in Fondwa, so we discussed sharing resources. Hopital Ste. Croix's Children's Nutrition Program has been extremely successful, so Sister Judy got some advice from the program director. Sister Judy had some suggestions for the hospital that were a little different than what we've heard from other people.

Hilda, the nursing school director in Leogane, also stopped by to visit. Her ideas for the hospital were vastly different from some of the other people we had spoken to. Hilda is a Haitian American nurse that has returned to Haiti to try and give back to the country she was born. She is really amazing and knows how to get things done. It was nice to speak with someone that can relate to both cultures.

Two days before our arrival in Leogane, the government tore through the wall protecting the hospital in order to clean out the sewer. The people witnessing this became very upset and stopped them out of loyalty to the hospital. Apparently, they plan to dig holes all along the sewer every 4 meters even if it is through homes and buildings. This is actually a result of money given to Haiti from the US government. So, we witnessed people packing up their homes before the government demolished them. We found out on Monday that the sewer line runs directly under the hospital, so the government plans to tear through the hospital and break through the foundation every 4 meters. Due to the flooding and waste issues in Haiti, this is actually a very good move for the country. But, it can destroy the hospital. So, the board had to quickly set up meetings with the Haitian government. Agreements were made to be careful not to destroy the hospital and keep it intact, but there will still be massive holes put into the foundation which will lead to many other issues. Luckily we had lots of great people at the hospital this week to mitigate this problem. They included Jimmy Hite, architect and board member, as well as Jim who is a contractor and Dick who is an electrician. All three of them have been committed to the hospital and its mission for many years.

There were many other meetings all of which led us down various paths in terms of strategy and future planning. Everyone had opposite views on the needs of the community and what the hospital can/should provide. There was also talk of another competing hospital being built and how can that become a symbiotic relationship. With the actions of the government, we began to wonder if we could keep this hospital where its at or if we need to consider relocating.

Even though everyone had differing opinions on the future of the hospital, several things became very clear.

1. The Leogane community that the hospital serves (200,000 people) desperately needs a hospital with inpatient care.
2. The Leogane community desperately needs emergency care.
3. The hospital must develop a sustainable funding model.
4. The hospital must prioritize infrastructure above everything.
5. The second priority must be to hire a competent administrator.
6. Management at all levels must be carried out well and communicated clearly.

So, the day was quite stressful. But, a lot got accomplished. Our knowledge and skills in healthcare administration were greatly appreciated. Many issues still needed to be resolved, so we slept on it. (There are ONLY 24 hours in a day)

Strategic Direction

Last night dancing was fun....to watch. None of us were bold enough to get shown up by the Haitians. We also don't know how to salsa. We did, however, meet the students from Duke. They are working on some interesting projects in Leogane. One student is mapping the healthcare facilities in the area using a GPS. Some of us also tried the local beer: Prestige, a typical pilsner.

We awoke this morning bright and early. The roosters here are extremely unintelligent, and therefore begin crowing at approx. 3am. After breakfast, we made our way over to the local church for their weekly service. We had no idea what was being said, as the service was in Creole. It was interesting to see that Haitians don't discriminate against animals in the church-a dog was perusing the aisles during the sermon. As the only "blancs" at the service, the pastor invited a member of our group to speak prior to the sermon. Jon went before the congregation to explain our purpose and the pastor translated for him. We still feel like celebrities everywhere we go, especially to children.

After church, we got right to work. We discussed the strategic direction of Hopital Ste. Croix with the chairman of the board, John Talbird. He answered many of our questions, but we're sure we'll have more. We believe that we have great ideas to offer, but need to put more time into thought and observation. The hospital is in a tight situation and will soon be experiencing the first competition in its history. Currently, the most obvious obstacle is an overall lack of resources. Our top priority is hiring qualified, experienced staff (which is much easier said than done). If you know of any expatriate hospital administrators interested in returning to Haiti, please let us know.

After several hours of discussion regarding strategy, we attended a party, at which they were celebrating the 15th anniversary of a local school. Several of the students performed songs and dances. In the late afternoon, we travelled to the beach, which was just outside of the Presbyterian mission we mentioned in yesterdays blog. It was great to relax and do some snorkeling. There was a coral reef just off the shore, so we saw quite a few small fish. Overall, it was a productive day.

Stay tuned for our next blog...

Arrival in Leogane

Jon, Jami, Kelsey, and Taylor arrived in Haiti this morning. Even the flight in was a bit of a culture shock. Most of the Haitians on the flight were illiterate, so we all spent a good portion of our flight time helping other people complete their customs documents. As soon as we walked into the airport, there was a band playing to greet everyone. Baggage claim was a mad dash. We though Taylor's bag got lost, but it turned out someone else grabbed it. Don't worry, Jami rescued it. While waiting for Jane (a retired pharmacist also volunteering in Leogane) at the airport, Jon met other Americans working in the area. H seems to be quite the networker in Haiti. It turns out that one of the people he met, Kathy, is a missionary working 5 miles away from us for a Presbyterian reforestation project. We are hoping to go visit her later this week to learn more. John Talbird, the chair of the hospital's board, and Blair met us outside the airport. There were people EVERYWHERE. Also at the airport were several UN vehicles (there presence here is appreciated) which were pretty interesting. BTW, it is really HOT here.

The drive from Port au Prince to Leogane was truly an eye-opening experience. The Haitians obviously are very creative and artful people. They put art wherever they can. The buses and tap-taps (taxis) are truly extraordinary works of art. We've never seen so many people anywhere. It's impossible to describe what the streets are like. People are selling everything you can think of (clothes, motor oil, TVs, mangoes, water, ice, chickens, pigs, goats, used Nikes). It is bothersome to see how much garbage is in the living areas of the city. There are people just setting up businesses on top of landfills. The streams are heavily polluted with trash. In areas without sanitation issues, the island is absolutely gorgeous. There are tons of "scents" throughout the drive. As we got further outside of Port au Prince, we could see livestock on leashes tied up to trees and poles. Apparently, that is the only way to establish ownership. There are no fences to define land ownership either. BTW, it is really, really HOT here.

We took a tour of the hospital. There are some beds, but there is very little equipment. The tour was a little overwhelming. There is so much to do, so w really need to decide on where to start. Jane has been going through the pharmacy and its inventory. Everyone at the guesthouse and on hospital grounds has been so amazing and willing to help us. BTW, it is really, really, really HOT here.

After the hospital tour, all five of us took a walk around Leogane. Everywhere we went, people were calling out, "blanc, blanc, blanc." We felt like celebrities. W could overhear people talking about Hopital Ste. Croix as we walked by, so we knew that they understood why we are here. Everyone was very happy to see us. We took a walk along a trail that went behind the some houses. Little kids from everywhere were yelling, "blanc, blanc, blanc." They could hear us coming down the trail. All the little kids wanted to come out and see us. It reminded Jami of The Wizard of Oz when Dorothy first arrived in Munchkinland. All eyes were on us, and there seemed to be a following. BTW, it is really, really, really, really HOT here.

Back at the hospital, Jon started talking with some of the Haitian students that are studying English. Eventually, the rest of us joined in. It was really fun to connect with people. We all exchanged email addresses, so we are excited to continue our conversations with them. Dinner at the guesthouse was amazing. Again, the people here at the hospital are amazing.

Tonight is disco night, so we're off to salsa dancing. There are supposed to be other students from Notre Dame and Duke at the disco, so it will be great to connect with them.

Key Management Issues at Hopital Ste. Croix

With the hospital currently “closed,” it is an excellent opportunity to put proper management systems into place in the hospital so that it can be administered correctly. Various systems that need to be established include, but are not limited to: leadership, human resources management, patient flow and medical records management, nursing standards and practice, infection prevention policies, pharmacy inventory and supply chain management, cost-based budgeting and financial management. Also, there is a need to try and develop an information management system that links archival records that come from community health outreach with the hospital’s out- and in-patient records. It is necessary to prioritize the development of these management functions and make sure that they are implemented in a consistent and complementary way.

It is my understanding that there has been a revolving door of physician administrators at the hospital in the last decade or two. More recently, it was discovered that many paychecks were being distributed to non-existent personnel. Further, the hospital has had minimally trained administrators who apparently weren’t aware of how to implement proper management systems. Thus, the first priority of the hospital should be to hire an administrator. A job description for this position should include the usual requirements: experience, proper values, strategic planning, communication, empowerment and relationship building. However, there are other responsibilities for the position at Hopital Ste. Croix and these are described among the various management issues that are described below.

1. Human Resources Management. Human resources management is the key issue for Hopital Ste. Croix today. An administrator needs to be hired and an executive team needs to be put into place to implement the management systems which will keep the hospital operational in coming years. The administrator’s position needs to be spelled out in terms of responsibilities, authority and lines of communication. Also, health professional recruitment, performance management, and compensation and benefits systems and policies have to be established. Further, the hiring of health professionals needs to be linked with the hospital’s strategic plan about which services it will not offer or offer and develop in the future. Overall, key elements of HRM that need to be developed include job descriptions, an organization chart of authority and lines of communication, performance appraisal and management, employee motivation and job satisfaction, employee training and development, employment records, compensation and benefits, a scheduling system, and personnel policies.

2. Financial Management and Budgeting. The hospital relies almost exclusively on cashiering. What needs to be developed is a cost accounting system by department and functional area. Cost accounting will allow the hospital’s management team and advisory board to strategically manage the hospital and oversee and fix problems. For example, if the hospital is making higher profits in one service area than another, a decision might be made to further develop and expand the more profitable service at the hospital. Likewise, if is discovered that private pharmacies in Leogone have an unusually high amount of business, it might be necessary to talk with the hospital’s physicians about what drugs they are prescribing and why. It sounds as though the hospital was losing business as physicians only prescribed higher cost drugs through the hospital’s pharmacy.

3. Developing an Executive Team to Manage the Hospital. It will be quite a task to find a hospital administrator for Hopital Ste. Croix who can perform all the necessary functions of a hospital while starting up many hospital operations and working with a new hospital advisory board. As such, I strongly suggest that the administrator’s job description be focused on strategic planning, implementation of new management systems and facilities management , leaving other operational aspects of the hospital to a new executive team. As shown in Attachment 1, the executive team for Hopital Ste. Croix should probably include the following positions: community relations, medical staff director, nursing/pharmacy/lab director, budgeting/finance director, and human resources manage/IT director.

4. Public relations and Political Sensitivity – Community relations should range from working with community groups, partnering with the government, and developing a plan to bring about an image of the “new hospital” as a high quality institution and an employer of choice throughout the area. Further, there has to be a concerted effort to work with the Ministry on health planning for the area. For example, we have discovered that a Duke University team has gained support from religious groups and others in North Carolina and elsewhere to build a hospital in Leogone. The hospital is supposed to start as a maternity center, but they appear to be aiming for many if not all services in that they have or will soon break ground for a 100,000 square foot facility.

5. Development of the Hospital’s Community Health Outreach Program and Network. The nutrition and community health reach programs have continued in recent years and, to some extent, have held up the hospital’s positive image as a center of health in the area. I’m not sure what else needs to be done by the hospital to support these programs, however, such a conversation should take place. Further, efforts should begin to link community health outreach workers records from their catchment areas to the hospitals out- and in-patient records to ensure continuity of care and care coverage.

6. Recruiting Health Professionals. Having physicians brought in from Port au Prince to work from 10am to 4pm, as has been done in previous years, is a strategy that is geared more toward the physcians’ interests for extra income than the hospitals’ needs for patient care and clinical availability. Working with the local pediatrician (his name escapes me) to gain his loyalty toward the hospital is a good starting point toward gaining a locally-based physician workforce for the hospital. However, further efforts for health professional (physicians, nurses, lab tech, IT, etc.) recruitment and retention need to be made.

7. Gaining the Loyalty of Health Professionals. A key problem that needs to be addressed is the need for physician loyalty to the hospital. There are a variety of strategies that could be used to gain and maintain the loyalty of health professionals. For example, the hospital should implement an incentive system that augments physicians’ monthly salaries. For example, if physicians are going to get paid the equivalent of $1,000US/month, it would be helpful to lower this (e.g., $900US/month) allowing for a monthly bonus based on productivity and quality management. Productivity could be measured in terms of patients seen, willingness to work off hours (on call in the evenings and weekends, etc.). Another strategy to consider implementing is to put physicians, and possibly other health personnel, on annual, renewable contracts. This will minimize the costs of unproductive physicians as well as severance arrangements that are built into employment policy in Haiti. Having the above performance and quality management systems in place will go a long way toward administrative oversight and developing needed loyalties from the health professionals on staff.

8. Developing Current and Additional Revenue Sources. The hospital is torn between cutting costs and increasing productivity while providing a variety of care services. Instead of seeing the budget as a given, the hospital needs to consider new sources of revenue which will allow the hospital to grow in capacity and its ability to serve all populations, including the poorest of the poor. One strategy to gain revenues, while increasing physician loyalty, is to open up a private wing in the hospital. For example, the 2nd floor of the pediatric ward provides an excellent opportunity for this. It is a large space that won’t get wet (during floods), it has a reception area, is generally private and away from most other hospital operations, and it could be spruced up to meet the higher expectations of private-care seeking patients.

9. The Development of the Hospital as a Training Facility. To enhance its reputation as a referral hospital, Hopital Ste. Croix needs to build physician and nurse training into its operations. The hospital should serve as a training ground for the new nursing school in Leogone and it should begin to welcome physician residents for training. To enhance a continual learning environment, all health professionals should be required to participate in a “grand rounds” meeting a couple days per week at the hospital. Grand Rounds is the place to discuss unique cases and learn about new procedures and techniques. It also indirectly serves to develop a colleagial among staff and between staff and administration at the hospital.

10. Putting Management Monitoring and Evaluation Systems into Place. The hospital needs to put management systems into place to track patient flows/registrations, quality management, cost centers and expenses, employee productivity, compensation and benefits, etcetera. For example, quality management can be measured in terms of patient care (infection rates, re-admissions, patient satisfaction). Key to putting a quality management and other systems into place is getting a good computer system and network and maybe even a computer server. This will also require a dedicated IT person for installation and maintenance of the system.

11. Inspiring Employees to Work Harder and Smarter. Communication is key to excellent hospital administration. Administrators need to gather information about the hospitals operations and they need to communicate the results of this information to key staff (physicians) and their advisory board. However, communication should not just be limited to operational support. Administrators also need to develop supportive, collegial and personal relations with all employees and staff. Administrators that get to know their employees and staff on a more personal level have a much higher probability of job success than administrators who are merely operationally focused.

12. Working with an Advisory Board. Although it is good to hear that an excellent board has been developed in the U.S. for Hopital Ste. Croix, the new board’s capacity to govern will be very limited if it has to rely on anecdotal evidence of hospital operations. What is needed to move the hospital forward in terms of governance and administration at the hospital is the development of management systems which provide weekly, monthly and quarterly reports which can monitored and evaluated for good and bed trends.

13. Facilities Development and Management. Admittedly, I do not know much about facilities management, but it is clear that there is a need to get a hospital architect to consider how the hospital should be renovated to make it a quality environment. For example, the ventilation and fan system in the out-patient ward is situated in such a way that the tuberculosis consulting room will put physicians, patients and others at risk of catching this deadly air borne disease. This system needs to be restructured and consideration should be made to putting TB consults in an isolated area of the hospital. Also, the hospital sites in a low lying area and flood waters drain onto the land. What can be done to lessen standing water around the hospital (mosquito breeding grounds) and lessening the likelihood of flooding of the first floor of the hospital during the rainy season? Is there away to divert rain waters away from the hospital and toward a less-used area of the community? Further, consideration should be given to developing the second floor of the large peditrics unit. This space is likely to be under-utilized even if the hospital were full services operational today. As described above, the second floor of the pediatrics unit could be used for revenue generation through the care of private patients.

Big Picture/Vision

Our team will be gathering tomorrow in Port au Prince and heading down to Leogane and Hopital Ste. Croix. After that, we'll be posting our day to day efforts/issues/problems, etc. However, before we get into the nitty gritty of our project, let's put the project in a bigger context.

Today, the health administration profession is well developed and present at hospitals throughout industrialized nations, but is almost totally lacking in developing nations and transitional nations. That is, there 4billion people are not receiving the benefits that professional health administrators can bring to health services locally.

The typical scenario for hospital administration in most of the world today remains as one clinicians rotate through the administrator’s office on an annual basis. These physician/administrators generally have minimal administrative skills and still see patients for fifty percent of their time.

The dearth of health administration professionals in the developing world is now being met with outreach efforts by American university programs. For example, the U. of Minnesota health administration program started a health administration program at the U. of Hong Kong last year, and Yale University has started their “global health initiative” by focusing on training of hospital administrators in Africa (Ethiopia, Liberia and So. Africa). New efforts at health administration training outreach by American universities is welcome news, but I believe it only goes half way toward what is needed in developing nations.

Much of what we teach in health administration in America is top heavy relative to developing world hospitals and, in some cases, isn’t even relevant. For example, it would make no sense for a U.S.-based health finance/accounting professor to teach about techniques for third-party insurance billing and accounts receivable in a developing nation. Most developing nations don’t have insurance products and hospital payments are made up front prior to the delivery of services so accounts receivable are minimal.

Hopital Ste. Croix provides an opportunity for the U. of Colorado Denver Health Administration program to immerse ourselves in a project and work with a real live case study. Such an experience will allow us to reflect on what we are and should be teaching in regards to health administration for hospitals and clinics in developing nations.

Do you think the development of an international health administration profession is a worthwhile endeavor? What are some of the potential pitfalls that we should be considering in this development?

Re-Building a Hospital in Haiti

We are a small group of U. of Colorado Denver folks (one faculty, two grad students) who will be assisting with bringing Hopital Ste. Croix in Leogane, Haiti back into operations. This large, referrral hospital (120 beds) was closed on the in-patient side a few years back due to a variety of problems. We'll be trying to bring a new administrator to the hospital soon and putting management systems in place (HRM, infection control, quality management, pharmacy, etc.) to enhance accountability, record keeping and over sight of the hospital in future years. This is an especially critical situation given the dire health and economic conditions (e.g., 70% unemployment in Haiti).

Key players in this venture include Jami Craig (MBA/Health student, employed at Catholic Health Initative in Denver, IT expert), Jon Moller (recent grad of the MBA/Health program and a finance/budget expert), and Blair Gifford (professor of international health management at UCDenver - Business, Public Health). Minor players include Blair's children, Kelsey (19) and Taylor (18).

Thanks to Father John Talbird, Board Chair and Father Frances Cole, Interim Adminstrator of Hopital Ste. Croix for giving the U. of Colorado Denver the opportunity to assist in this venture.

We'll be sending out daily updates with pictures. Hope you enjoy this story.