Juba  Teaching  Hospital  Technology  in  Healthcare  Program  

Juba,  Republic  of  South  Sudan  

Project  Launch  Report  

 February  2014  

Real  Medicine  Foundation  11700  National  Blvd,  Suite  234  Los  Angeles,  CA  90064  (310)  820-­‐4502  

Table  of  Contents  

 

 

Program  Narrative  

Master  Trainers  

Training  Program  

Participant  Demographics  

Respectful  Healthcare  Training  

eLibrary/Omnio  Training  

Content  Feedback  

Device  Feedback  

Lessons  Learned  

Center  of  Excellence  Needs  Assessment  Progress  

Next  Steps  

 

 

 

 

 

 

 

 

 

 

Program  Narrative  

The  partnership  program  between  Health  eVillages  and  RMF  was  launched  this  month  at  Juba  Teaching  Hospital  (JTH).  After  several  weeks  of  laying  the  groundwork  for  this  exciting  program,  the  mobile  devices  generously  donated  by  Health  eVillages  finally  reached  the  hands  of  health  workers   at   the   nation’s   only   public   referral   and   teaching   hospital.   Participants   were   pre-­‐selected  based  on  their  literacy  in  English  (since  the  current  content  is  in  English),  known  level  of  responsibility  so  as  to  assure  safety  of  the  devices,  and  their  willingness  to  participate  in  the  program  and  give  ongoing  feedback.    

Before   the   training   took   place,   protocols   were   established   to  maintain   a   security   system   to  prevent   loss   and  breakage  of   devices.   This   involved   labeling   and  numbering   each  device   and  creating   a   registry   where   devices   are   checked   out   by   health   workers   and   checked   in   when  returned.   Further,   to   be   eligible   to   use   the  devices,   all   health  workers  must   have   completed  both  the  Respectful  Healthcare  and  the  eLibrary/Omnio  training  program.  They  also  must  have  signed  an  agreement  form  to  participate  in  the  program  (see  Appendix  A).  

 

 

Internet  installation  at  JTH  

 

 

Master  Trainers  

 

Two  South  Sudanese  Master  Trainers  were  recruited  for  this  project.  They  were  selected  based  on  knowledge  and  experience  with  the  RMF  Respectful  Health  Care  Training  Program,  advanced  command  of  both  English  and  Juba  Arabic,  extensive  clinical  experience,  and  their  knowledge  of  participants   as   past   staff   at   JTH   and   current   faculty   at   the   Juba   College   of   Nursing   and  Midwifery   (JCONAM).   A   collaboration   session  was   conducted  with   RMF   staff   and   the  Master  Trainers  to  finalize  best  methods  for  facilitating  tablet  use  among  JTH  staff,  data  collection,  and  the  creation  of  a  feedback  loop  between  participants  and  RMF.    

 

     

                                                   Sake  Jemelia  Bedu                  Siama  Abdallah  

 

 

 

 

 

Participant  Demographics  

The  first  round  of  training  consisted  of  14  staff  members  that  are  doctors,  midwives,  or  nurses  from  maternity,  antenatal,  and  pediatric  wards  at  Juba  Teaching  Hospital.  The  second  training  session  will  take  place  later  this  month  when  the  remainder  of  tablets  will  be  transported  from  Uganda  to  Juba  by  RMF  staff.    All  participants  were  asked  to  fill  out  a  demographic  survey  at  the  beginning  of  the  training.  

Table  1:  Demographic  Variables  

Demographic  Question   Result  Age   20-­‐25   3    

26-­‐30   7    31-­‐35   2    36-­‐40            0  41-­‐45   0    46-­‐50   2    51-­‐60+   0    I  prefer  not  to  answer    0    

Ethnicity   Bari   7    Dinka   1    Nuer                0  I  Prefer  not  to  answer   1    Other      4  (2  Maide,  1  Zande,  1  Muro)  Did  not  respond    1    

Language  Consideration  (preferred  language  to  read  medical  information)  

English    9  Arabic      2  Nuer            1  Did  not  answer      2  

Job  Title   Nurse   9    Midwife  4    Doctor        1  

Experience  Using    a  Tablet   Yes   5      No                      9  

Experience  Using  a  Smartphone   Yes     13      No                      1    

Experience  using  a  desktop  or  laptop  computer   Yes              14  No                0  

 

 

 

 

Respectful  Healthcare  Training  

As   the   foundation  of   all   programs  RMF  does,  we   facilitate  Respectful  Healthcare   (RHC)  Workshops   in  order  to  promote  the  values  of  compassion,  dignity  and  respect.  We  feel  that  this  not  only  improves  the  quality   of   care   patients   receive,   but   also   establishes   a   positive   work   environment   that   ensures   good  outcomes  not  only   in  our  programs,  but  also   sets   the   standard   for  maintaining  an   infrastructure  with  accountability,   sustainability,   and   independence   for   entire   communities.   This   aspect   of   our   programs  has  been  met  with  excellent  feedback  and  positive  outcomes.  The  core  components  of  the  program  are:  

� RMF   Concept   of   “Friends   Helping   Friends   Helping   Friends”:   welcoming   patients   and   their  families,  creating  rapport  and  trust,  concepts  of  body  language  and  respectful  communication  

� RMC   concept   of   “Building   Trust”:   Assessing   the   Patient,   Informed   Consent,   Privacy,  Confidentiality,  Human  Rights  

� RMF  Concept  of  “Compassionate  Care”:  Evidence-­‐Based  Care,  Collaborative  Practice  

� RMF  Concept  of  “Liberating  Human  Potential”:  Work  Relationships,  Accountability,  Stress  and  Burnout  Reduction    

As   part   of   this   training,   we   have   all   participants   complete   a   pre-­‐   and   post-­‐test   to   assess  knowledge  and  attitudes  (See  appendix  B)    

Pre-­‐test  #  correct   Post-­‐test  #  correct   Percent  Change  1. 8      9   +7.3%  2. 9    11   +14.3%  3. 13    14   +7.1%  4. 8    10   +14.4%  5. 8    13   +31.4%  

 

 

Respectful  Health  Care  Workshop  

eLibrary/Omnio  Training  

Training   for   the   use   of   the   tablets   was   collaboratively   done   with   RMF   staff   and   the  Master  Trainers   in   order   to   streamline   the   process.   All   subsequent   training   will   take   place  with   the  Master  Trainers.  There  were  4  components  of  the  training:  

1. Familiarity   with   the   devices:   turning   them   on   and   off,   navigation   to   use   apps   and  programs,  charging  devices,  and  other  general  mobile  device  orientation  

2. Omnio   functionality   and   use:   Drugs,   diseases,   calculators,   and   library   by   search,  browse,  and  additional  features,  use  of  reading  list  and  front  page  features  

3. Video   content:   review   of   Health   eVillages   promotional   videos,   navigation   and   use   of  Medical  Aid  Films,  and  use  of  camera  and  video  camera  for  recording  of  medical  cases  

4. Data  Collection:  digital  birth  log  and  potential  WelVU  applications  

 

Existing  Data  Collection  System:  These  are  photos  of  the  current  Department  of  Statistics  for  Juba  Teaching  Hospital  

 

 

Training  Photos    

 

 

 

 

 

 

Content  Feedback  

Participants  had  a   chance   to  give   feedback  both  during   the   training  and   in   the  days   following  as   they  began  to  use  devices  on  the  hospital  wards  and  RMF  staff  and  Master  Trainers  observed.  The  feedback  can  be  grouped  into  3  areas:  Content  feedback,  device  specific  feedback,  and  additional  suggestions.  

Content  Feedback   • The  infectious  disease  resources  should  be  more  extensive  and  more  specific  for  South  Sudan.  Examples  include  adding  both  video  and  literature  content  for:  ü Malaria  ü Cholera  ü Meningitis  ü Hepatitis  ü Polio  ü Typhoid  ü Tetanus  ü Management  of  Malnutrition  

• Specifically,  patient  education  videos  were  suggested  for  malaria  (especially  pediatric  resources),  and  cholera  

• A  video  on  medical  ethics/Respectful  Health  Care  was  suggested  

• A  video  on  family  planning  methods  was  requested  

Device  Specific  Feedback   • The  iPads  were  preferred  in  this  group  • The  GTabs  seemed  less  sturdy  and  the  

sensitivity  for  the  touch  screens  was  low.  It  seems  these  devices  may  not  withstand  a  heavy  usage  level  

• The  cameras  on  the  GTabs  were  very  pixilated  

• Devices  for  use  in  such  a  high  volume  setting  should  definitely  be  equipped  with  protective  cases  

Additional  Suggestions   • Development  of  eQuizzes  so  health  workers  can  test  themselves  on  content  

• Use  of  the  camera  to  document  abnormal  outcomes,  for  example  babies  born  with  anomalies    

• Predesigned  form  to  add  photos  of  cases  and  content  for  complex  cases/  peer  review  

• Use  of  the  video  to  record  procedures  for  teaching  purposes  

• The  pill  identifier  needs  to  be  localized  to  drugs  used  in  South  Sudan.    

Lessons  Learned  

Qualitative  feedback  from  participants:  

“We   want   to   thank   RMF   and   Health   eVillages   for   this   gift.   We   are   being   given   the   gift   of  knowledge  and  this  is  more  important  than  anything  else  we  could  be  given.  As  those  who  work  in  the  hospital,  it  is  like  a  lifeline.”  

“I   like  the  videos  a  lot.  When  you  are  busy  with  so  many  patients,   I  am  thinking  that  showing  the   videos   in   the  waiting   area   somehow  with   a   projector   would   give   education  without  me  having  to  do  it  one  on  one  with  each  woman.  The  warning  signs  of  pregnancy  one  is  especially  useful.”    

“We  could  use  the  camera  to  take  photos  of  anomalies  on  babies  born  so  we  can  present  cases.  We  don’t  have  a  system  of  peer  review  at  all  and  this  is  a  big  problem.  Maybe  we  can  make  a  digital   form   that   you   insert  he  photo  and  answer  put   information  about   the  case   so  you  can  email  it  to  others  or  present  it  at  a  meeting.”  

“We  really  need  the  data  collection  to  be  digital.  An  electronic  health  record  would  prevent  so  many  mistakes.  My  cousin  died  of  anaphylaxis  when  she  came  to  have  her  baby.  The  doctor  did  not  know  she  was  allergic  to  cephalosporin  because  there  was  no  chart  to  show  the  nurse  had  asked  her  this.  It  could  have  been  avoided  if  we  did  things  on  these  tablets  instead  of  paper.  I  also  look  at  the  interaction  feature  on  Omnio  and  feel  this  will  save  lives.”  

“I  can’t  believe  all  those  textbooks  fit  on  this  small  device!  It  is  like  a  miracle.  I  dream  that  one  day  everyone  who  works  in  healthcare  in  the  world  can  have  this.  It  really  makes  me  see  how  many  things  we  can  do  to  improve  the  hospital.  It  is  very  very  exciting  and  I  will  use  this  every  day.”  

“Birth  in  the  Squatting  Position!  Yes!  The  video  from  the  Respectful  Maternity  Care  Training!  I  will  show  this  to  all  the  students  and  the  staff  in  maternity  because  nobody  believed  me  about  this.  Since  you  showed  it  to  me  last  year  I  have  been  letting  women  deliver  in  any  position  they  want  and  now  with  this   tablet   I  can  show  my  colleagues  and  the  women  that   I  am  correct   in  advising  such  a  thing.”  

 

 

 

 

Center  of  Excellence  Needs  Assessment  Progress  

The   architectural   assessment   of   JTH   began   with   general   assessments   by   the   engineer   and  photographic  documentation  of  the  current  status  of  the  buildings.  

 

Women  often  have  to  share  beds  in  labor  or  labor  on  the  floor.  There  is  no  privacy  or  room  for  labor  support  from  partners/family  due  to  space  constraints.  

 

This  woman  walked  from  deep  in  the  bush  and  was  in  labor  for  3  days.  When  she  arrived  she  was  dehydrated  and  had  maternal  exhaustion.  With  the  help  of  the  midwives,  she  delivered  surprise  twins;  one  boy  and  one  girl  both  healthy  and  over  3  kg.  She  did  not  even  have  a  

blanket  so  had  to  borrow  some  from  another  patient.  

 

 

A  new  mother  and  a  woman  in  early  labor  sharing  a  bed          The  main  entrance  of  the  maternity  ward  

 

Updates  and  Next  Steps  

Ø Training  of  the  remaining  health  workers  when  the  final  20  devices  arrive  from  Uganda  will  occur  in  the  3rd  week  of  this  month.  

Ø Patient  Satisfaction   Interviews  will  be  conducted  by  the  Master  Trainers  and  compiled  for   the   monthly   reports.   These   will   reflect   Respectful   Healthcare   values   as   well   as  whether   a   health   worker   used   a   mobile   advice   at   the   bedside   as   part   of   their   care  and/or  health  education.  

Ø Monthly   participant   feedback   surveys   will   be   collected;   qualitative   feedback   and  suggestions  will  be  ongoing  using  a  formal  data  collection  tool  designed  by  RMF.  

Ø Maternal  Mortality  Data  Collection  Analysis  will  be  done:  Meetings  with  the  Ministry  of  Health,  Administration  of  the  Department  of  OB/Gyn  at  JTH,  and  the  JTH  department  of  statistics  were  done.  New  data  has  been  compiled  on  maternal  mortality  within  JTH  and  nationwide  that  will  be  used  as  the  baseline  for  this  program.    

Ø Architectural   Needs   Assessment   has   been   initiated   and   will   be   completed   in  collaboration  with  the  Ministry  of  Health  and  JTH  administration.  

Ø Monthly  reporting  will  be  submitted  to  stakeholders.  Ø Photographic  documentation  of  the  program  will  be  ongoing.  Ø Site  visits  by  any  donors/stakeholders  are  welcome  at  any  time.  

 

 

 

 

 

Appendix  A              

Healthy  eVillages/Real  Medicine  Foundation  electronic  device  agreement  

 

Name:________________________________  

 

1) I  understand  that  I  have  been  chosen  to  participate  in  a  pilot  study  with  the  goal  to  see  if   bringing  medical   reference   information   to  health  workers   at   Juba  Teaching  Hospital  would  be  a  useful  tool  for  improving  patient  care.  

2) As  part  of  this  program,  I  have  attended  training  to  learn  how  to  use  the  devices.  3) I  will  keep  the  device  for  a  period  of  3  months.  4) I   agree   to   use   the   device   when   I   think   it   is   necessary   for   medical   reference,   patient  

education,  or  other  purposes  as  a  clinician.  5) I  agree  to  give  monthly   feedback  to   the  RMF  staff  as  needed  on  the  program  and  the  

use  of  technology  in  healthcare  at  Juba  Teaching  Hospital.  6) I  agree  to  return  the  device  at  the  end  of  3  months.  7) I  will  be  responsible  for  any  loss,  theft,  or  breakage  of  the  device  during  the  3  months  

that  I  have  it.  8) I   am   aware   of   how   to   reach   an   RMF   staff  member   if   I   have   questions,   problems,   or  

would  like  to  return  the  device  early.  9) I  understand  that  the  device  needs  to  regularly  be  charged  to  maintain  enough  battery  

for  use.  10) I  will  not  leave  the  devices  in  patient  areas,  offices,  or  other  places  that  might  increase  

the  chance  of  theft.  11) Lost  or  broken  devices  will   cost  $200  USD   to   replace  and   I  will  be   responsible   for   the  

cost.  

 

I  agree  to  all  of  the  above  statements  (sign  name)__________________________________________  

 

 

Appendix  B  

Respectful  Health  Care  (RHC)  Pre  and  Post  Test  

1. Implementing  Respectful  Health  Care  in  a  hospital  can  lead  to:  a) Lower  morbidity  and  mortality  b) Higher  patient  satisfaction  c) Less  stress  for  health  workers  d) B  and  C  only  e) All  of  the  above                                                                                                                                                                                                                                                        

   2. When  patients  enter  a  health  facility,  they  usually  feel:  

a) Confident  b) Angry  c) Afraid    d) Excited  

3. You  can  build  trust  with  patients  by:  

a) Introducing  yourself  and  smiling  b) Not  explaining  their  medical  problem  if  you  think  it  will  be  too  confusing  for  them  to  understand  c) Discussing  their  case  in  an  open  and  public  place  d) All  of  the  above  

4. What  a  core  parts  of  Respectful  Health  Care  (RHC):  

a) Providing  Informed  Consent  for  all  procedures  b) Using  Evidence-­‐Based  Practice  c) Allowing  Patients  to  bring  a  family  member  or  support  person  with  them  d) Maintaining  Privacy  and  Confidentiality  at  all  times  e) All  of  the  above  

5. What  should  you  do  if  a  patient  or  the  family  members  refuse  a  medical  treatment  or  procedure  that  you  recommend?  

a) Explain  to  them  that  because  of  your  training,  you  know  better  and  they  should  listen  to  you  b) Tell  them  they  will  get  more  sick  or  die  if  they  do  not  take  your  advice  c) Explain  the  risks  and  benefits  of  your  recommendation  as  well  as  all  the  other  options  and  their  

risks  and  benefits  d) Have  another  staff  member  try  and  talk  to  them  and  help  convince  them  to  change  their  mind