Standards were developed in each of these areas, and training modules developed. Eight workshops have been held to train key staff from each hospital, who return to their hospitals to introduce the standards to their medical and administrative staff. Each workshop produces a plan for implementing the standards according to the circumstances of each hospital. The training is incremental. For instance, rather than doing a one- to two-week workshop presenting all the training modules, two modules on standards (usually one clinical and one management area) are presented. Two new modules are presented quarterly thereafter, to prevent information overload, allow trainees to integrate what they have learned with real day-to-day management, and avoid the problem of hospitals being left without leadership for an extended period.
Mentoring
A skilled hospital management advisor visits the hospitals regularly so managers have the opportunity to work with a mentor to apply what they have learned to their hospitals. This practical experience involves applying principles to real-life situations with someone experienced enough to help overcome obstacles not anticipated in the workshops. Mentors from REACH and the Ministry of Public Health visit the provincial hospitals to discuss problems, review progress, talk about problems that prevented achievement of goals, and set goals for the next three-month period.
The first four provincial hospitals selected for this intervention are all in areas formerly controlled by the Taliban, and security issues have added other challenges to this program because of repeated terrorist attacks on non-governmental organizations and people employed by international organizations. The mentors involved must speak Pashto, the local language, and integrate into the culture so they do not attract attention or create local opposition. Mentoring is a necessary but dangerous activity for the success of the program.
Networking and Modeling
As more hospital managers and senior clinicians are trained through this program, networking becomes another important tool. The network uses meetings twice a year for two days in a participating hospital to provide an opportunity for hospital managers to discuss common issues and develop system-wide solutions. Between these meetings, hospital managers in the same region exchange visits to learn from each other. REACH facilitates this networking using e-mail (some of the provincial hospitals have Internet access, which has dramatically increased their participation in evidence-based approaches), dissemination of reports, and passing on requests for communication between hospitals. These formal meetings and informal exchanges permit hospital managers to interact about common problems and learn how other hospitals have solved those problems. This networking will slowly expand to cover more provincial hospitals and will assist in expanding the number of trainers and mentors.
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Modeling means trying new systems and methods generated by the trainees to address their self-identified problems. Improvements in five provincial hospitals (in Khost, Paktika, Paktia, Ghazni, and Badakhshan) will provide a model that demonstrates to the public that hospitals can be well run and serve the community. These hospitals can also be used as training grounds for other hospital managers from around the country as the initiative expands to more of the remaining 28 provincial hospitals. The goal is to develop optimism and creativity because one of the main barriers in training is that some managers have difficulty imagining things being different because they feel the system “has always been broken.” When trainees see that other hospitals have successfully tried new approaches, they will consider a broader range of possibilities for their own hospitals.
Resources
Along with the management improvements achieved through training, mentoring, and networking, additional resources are needed to improve hospital services. REACH has been the conduit for U.S. government funding, providing $2.6 million in critical resources to drive improvements in the five provincial hospitals. These funds are channeled through the contracted nongovernmental organizations, which hire staff and pay decent salaries.