Week 3 – 28th June 2015
So week three has been and gone and I am writing this with just one week to go! Week three was all about action. We did more physical organising, built things and changed things this week and I met other members of the health centre team, who were also keen to make changes in their areas along the lines of what we are doing in the maternity unit.
Monday was intended to be about the stock system but after doing some initial work putting together overall stock lists there was a power cut that stopped us using the PC for several hours. Power cuts are relatively common, very often lasting only a few minutes but this one lasted a long time. The staff and patients handle it because they have to but with no fans working inside it did get very hot. I was also conscious that some of the key equipment in the department, such as the oxygen concentrator used with new babies, couldn’t be operating whilst the power was off. To make the most of the time though, one of the doctors, Gemma, and I decided to tackle a store cupboard that I had found on an earlier survey. I had hoped that we might be able to make some usable space in the cupboard to enable stock from the ‘donation container’ to be brought into the department in greater quantities than they had room for on the main labour ward, saving time and reducing the frequency of restocking. It was a successful exercise, with things like hundreds of pounds worth of surgical instruments being found and put back into service, allowing some older, less effective kit to be disposed of and a large area of shelving released for useful materials to be stored.
One Tuesday I met the Officer in Charge of the Health Centre to try and understand a bit more about the organisational context that the maternity unit is operating in and also to explain my work and what I was hoping to achieve whilst I was there. He was very supportive of both the maternity unit and the idea of doing continuous improvement work and even offered a small amount of funding to pay for some of the things that we wanted to do in the sterilisation and staff areas.
Wednesday was back to stock – there are lots of different sources of stock from the local government pharmacy to a private pharmacy and then the large container on site that holds donations sent by charities and private individuals. One of the doctors, Alice, along with the departmental manager, Omar, spent time with me working through each consumable item that they order, capturing the specification, funding source and stock source into a single list so that we could use that to create things like stock check and ordering forms.
In the afternoon I attended the first Management Team meeting of the Maternity Unit since I had been there. It was interesting to learn that many of the challenges that the team face are very similar to those that we discuss in the equivalent meetings back home such as introducing new procedures and ensuring the right resource and scheduling of staff. One thing that we agreed to experiment with was having a single list of all the actions that the team needed to follow up on, to make it more dynamic and to enable updates between meetings. Colleagues back at work might smile at this, I am known for being a big believer in ‘action trackers’ as useful tools for teams to stay organised. Back there we use Excel on a server, but with no such server at the health centre, we found an internet based application that members of the team could download onto their phones and the office PC. Even the Officer in Charge joined us in setting up to use it!
Thursday we started the physical work on the sterilisation area. Having already spent time with Gemma, dismantling some unused and awkwardly placed shelves and attachments to the trolleys in the area, I spent time with the maintenance officer working out what options we had to improve the storage facilities. One thing we realised is that we had quite a large area of unused space because one of the trolleys had no shelves despite being quite high. He suggested that we approach a local welder to see if they could fabricate something for us. They did and the trolley came back with two very useful shelves. A couple of coats of paint and it was ready to be put back into service.
Friday brought another reminder of why the work of the team in the maternity unit is so important. When Gemma, Alice and I arrived in the ward in the morning for handover I could see that the board where all the patients are recorded looked full. The team quickly but clearly handed over and then Alice and Gemma got to work. One lady was very sick and suffering from a ‘PPH’ (post-partum haemorrhage). This meant that she was losing a lot of blood and needed fresh blood quickly. Unfortunately the blood bank didn’t have any of the right type so Gemma and I went over to see if there were any local donors that could help. After a short conversation about how critically ill the patient was two members of staff stepped forward and donated. For one it was his first ever donation and he said that he was doing it because next time it might be a member of his family and he would like someone to step in for them. It is a sentiment that I have heard a lot here. The two units of fresh blood helped to stabilise the patient who was then transferred to the hospital in the capital. Once again I was struck by how quickly the team coordinated their efforts to save this patient, all very calm and professional, despite the fast moving situation. I also saw that some of the procedures that Alice and Gemma have implemented since arriving here, such as having an specialist ‘PPH’ box with all the kit and medicines required to respond in an emergency, made a difference to how easy it was for the team to work together.
The weekend isn’t necessarily time off for the doctors out here, who work one in three days for 24 hours. On Saturday I joined the team and we spent some time in the ‘donation’ container, trying to create an area of known stock items to make it easier to pull from. This work needed to be done early in the morning, due to it getting very hot by midday. Two of the team volunteered to work with me and we had a very good organising session, finding lots of materials in larger quantities than we realised we had.
We also found a number of walking frames and when the team saw them they thought that one might be suitable for use as a ‘suturing’ chair – something for the midwives to sit on when they are carrying out stitching to save them straining their backs. We dusted one down and tested it out with a few of the team (of different heights!) and were pleased to see that it worked. It is not easy, or affordable to buy purpose built equipment for all the needs the team have and, as there were several of these walkers for regular use, repurposing one for this use was a simple way of making the work a bit easier for the team.
Sunday was a day away from the maternity unit and we were fortunate to receive an invitation to visit another centre that was thinking of referring patients to Brikama. It was about an hour away and the three of us took a taxi. This journey was the first time that I had travelled through police checkpoints and there were several along the route. When we arrived we were greeted with lunch and shown around the grounds. The centre has a lot of lovely vibrant pink and red flowers growing, common in Gambia, that make for a pretty backdrop for the cream and white buildings.
After lunch we were invited to visit a local village that is supported by this centre. It is difficult to do justice to how I felt at that village. The people were lovely, welcoming and inquisitive about where we were from and happy to show us how they live and work. I was very conscious that, in travelling only an hour from where I was working, I had reached a place with no running water in the houses and no electricity at all. The village is set not far from the river that runs through the centre of Gambia and the people depend a good deal on fishing oysters from it. When the rains come (which they should have by now – they are quite late) they also farm peanuts and cashews, common crops in Gambia. One of the guides that took us there explained that if the harvest is bad they see the effects of it a few months later with undernourished children visiting the centre. It was a sobering experience.
On the way back we talked about everything that we had worked on so far and where the most important places were to focus in my last week. The team were feeling motivated, we had done a lot of sorting and organising, finding and testing together. This was to be the week when we finished things off.