Partnership is primary in Kosovar projects
Your doctor is examining you in his office. Suddenly the door opens and another patient bursts into the room. No, there's no emergency. That's just the way people were accustomed to behaving at many health clinics in Kosova. Until recently, that is.
Dr. Donald Kollisch, a family physician at Dartmouth; project director Cristina Hammond; and nurse Ellen Thompson have been helping to address such problems and improve the way health care is delivered in family medicine clinics in Gjilan and Gjakova, Kosova. But this isn't a case of DMS experts marching in to tell personnel elsewhere what they're doing wrong. It was the Kosovar doctors and nurses themselves who asked for advice. They were frustrated by the constant interruptions, the noisy crowds in the clinic hallways, and other antiquated systems—like no waiting rooms, no receptionists, no appointments, no medical records, and nurses who weren't allowed to perform even simple clinical tasks like taking blood pressures. And they worried that these matters were interfering with their ability to give good care.
So Kosovar physician and nurse leaders teamed up with DMS on two primary-care projects funded by the American International Health Alliance and the United States Agency for International Development (USAID). The projects focused on instituting quality-improvement efforts at family medicine practices in the Gjilan Municipality (a program that ran from 2001 to 2004) and, later, in reproductive health services at family medicine centers in Gjakova (from 2004 to 2006).
Flow: First, the Kosovar team visited DMS family practice clinics to get ideas about things they might try in their own clinics. Then they collaborated with their DMS counterparts—Kollisch, Hammond, and Thompson—on developing a
workable infrastructure, establishing clinical practice guidelines, setting up appointment systems, creating patient flow plans, developing medical records systems, improving communications, and training staff.
In both projects, Kollisch explains, the DMS collaborators suggested using a "microsystems" approach—that is, examining every variable in a systematic way and then identifying what changes might help. In a medical office, the variables can include patient flow; who sees patients when; what services are provided; how supplies flow in, are inventoried, and distributed; how records are kept; and so on.
Records: It was no surprise that the clinics in Kosova didn't have the kinds of systems in place that are taken for granted in the United States. While the country was at war, "doctors and nurses
practiced out of their homes or wherever they could, but they didn't keep records," Hammond explains. After the war ended in 1999, the country tried to restructure its health system, but clinicians had no experience in implementing the necessary changes. Medical records, for instance, consisted of entries in a general logbook.
So the DMS team worked with their Kosovar partners to implement improvements in some health centers. "If systems could be improved throughout Kosova, we'd be saving lots of lives," says Kollisch. But making sustainable changes takes time, and funding is always easier to come by for starting than for continuing international health initiatives.
"Doing international health aid work," says Kollisch, "is a very unstable, unpredictable program." But clearly worthwhile.
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