Module 24: Institutionalization of HCWM Organization, Training, Financing and Quality

UNDP GEF Project on Global Healthcare Waste

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MODULE 24: INSTITUTIONALIZATION OF HCWM – ORGANIZATION, TRAINING, FINANCING AND QUALITY IMPROVEMENT

Estimated Time  Lecture: 2 hour  Activity: 3 hours Module Overview  Describe the essential steps for institutionalizing a HCWM program  Describe how training is an essential piece which complements other activities for effective program implementation  Describe the costing tool to estimate capital, operating, and maintenance costs for HCWM  Describe the principles of continuous quality improvement (CQI) Learning Objectives  Define the key steps to institutionalize a HCWM program  Define who to train, when, and why  Use the costing tool to plan a budget for your HCWM program  Understand the role of monitoring and reporting in improving your HCWM program Target Audience  Administrative Personnel (this module will probably only be applicable to those in upper level management and administration).  Financial officer or treasurer of the facility, procurement officer  HCWM Coordinator and members of the HCWM Committee or Team  Training Coordinator if different from the HCWM Coordinator  Management staff and health professionals interested in HCWM planning and implementation  National and local staff in the Ministry of Health and in local governments involved in planning and budgeting Instructor Preparation  Make notes pages of PowerPoint slides to hand out to class  Make copies of class exercises and home work for distribution after PowerPoint presentation  There are no directly associated chapters from the Blue Book, but it may be used as a guide/reference for some information presented in the module

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 Look over any other materials included in the References  Make copies of any additional documents/readings that may be handed out to class, such as those included in the References  Prepare any additional notes to be discussed during the presentation  Prepare any additional discussion points or review questions  Learn how to conduct a SWOT analysis using the following link- Community Tool Box- http://ctb.ku.edu/en/tablecontents/sub_section_main_1049.aspx  Use the following links to identify model waste reduction and management strategies. All of it may not apply to your setting, but this will give you an idea of what you would like to discuss in class. http://infohouse.p2ric.org/ref/39/38649.pdf http://infohouse.p2ric.org/ref/39/38597.pdf http://www.sustainablehospitals.org/HTMLSrc/AuditTools.html  You may split this module into sub-sections and conduct them separately. Materials Needed  Projector  Student handouts: slides, exercise, homework  Flip chart and marker pens and/or board and chalk Student Preparation  Blue Book Chapter 13 for Training, Chapter 10 for Costing,  Think about the HCWM program at your facility and its institutionalization. Do you already have a program, or are you planning a program, or are you trying to improve your program?  Complete the homework Review Questions  How can you improve the effectiveness of your HCWM Committee?  Conduct a SWOT analysis of your facility’s training program.  Can you analyze your facility’s HCWM budget in relation to needs and projected expenditures?  What are other sources of funding to support HCWM in your facility?  How can you apply the principles of CQI to your HCWM system?

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PRESENTATION

Slide Number/Title Teacher’s Notes Slide 1: Title Slide This module covers four major subjects (organization, training, financing and quality improvement). The instructor could cover some or all of these topics depending on the needs and interests of the participants.

Slide 2: Module Overview Introduce the outline and major points of the presentation

Slide 3: Learning Objectives Describe what participants will learn at the end of this module.

Slide 4: Institutionalization? Define what institutionalization means in relation to a healthcare facility

Slide 5: Steps for Describe the major planning elements for institutionalization of a HCWM program: Institutionalizing a HCWM -determine the vision of a HCWM program Program -create a HCW management plan -estimate the required operating budget for the year after the project funding is spent -come up with 3-5 ways to sustain and institutionalize the program

Slide 6: Steps for -Establish a healthcare waste management plan and committee Institutionalizing a HCWM -Observe and report changes in practices related to HCW management across the facility Program -Ensure the availability of funds and their uses -Monitor injury reduction, waste minimization, recycling programs, employee awareness, management commitment

Slide 7: Waste Management Go over the philosophy of waste management. Philosophy The program should be site-specific and based on a number of factors. It should be developed in accordance with the specific philosophy, values, and beliefs of the institution.

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Slide 8: What is Your Vision? Ask participants what their vision is, or give them some of the pertinent questions to ask themselves when putting together a vision for the HCWM program.

Slide 9: HCWM Plan Ask the class participants some questions about their HCWM plans: Do you currently have a HCWM plan? Did you conduct an initial assessment of your facility? What areas does this plan cover? Are there any elements missing in your plan that you would like to add or think should be added?

You may go back to the slides in Module 2 and 3 to guide the participant.

Slide 10: Typical Waste Based on the country specific status, please focus on what structure works in your setting. Management Structure Many countries have one or two of these positions and people wearing multiple hats. This is an ideal team…..what works in your country should be encouraged.

Ask participants what the structure is in their facility?

Slide 11: Waste Management Team Slide 12: Waste Management Present the list of questions to participants regarding the HCWM team Team Slide 13: HCWM-related Ask participants to answer/think about whether their facility has the necessary resources Activities and equipment to: -segregate wastes -transport wastes -treat wastes -store waste on-site -respond in an emergency

Slide 14: HCWM-related Do you have meetings with staff in each ward or department on a regular basis?

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Activities Do you have a system for conducting surveys and walkthroughs of wards or floors?

What do you do when you observe a poor practice?

Slide 15: HCWM-related Do you have an OH&S committee? Activities Do you have a protocol in place for employees to report injuries or incidents?

Do you have a HCWM training program in your facility?

Do you think you have management commitment to implementing this HCWM program?

Slide 16: Common Obstacles Discuss barriers specific to the participants’ specific countries, regions, or facilities. For example, lack of awareness, budget, training, etc.

Slide 17: Training is Key Discuss the essential role of training in the successful implementation and sustainability of HCWM programs. A policy for the management of healthcare waste cannot be effective unless it is applied carefully, consistently, and universally. Training healthcare personnel in implementing the policy is critical if a waste management program is to be successful.

Slide 18: Why Train? Describe the major objectives of training. It should highlight the roles and responsibilities of healthcare personnel in the overall management programme. Health and safety at the workplace and environmental awareness are the responsibility of and in the interests of everyone.

Slide 19: Who Should Be Talk about who should be trained. Trained? All hospital personnel, including senior medical doctors, should be convinced of the need for a comprehensive health care waste management policy and the related training, and of its value for the health and safety of all. This should ensure their collaboration in the

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implementation of such a policy.

Since action is needed at the management level – by those producing the waste as well as by the waste handlers – training of all of these categories of personnel is equally important. Medical doctors may be educated through senior staff workshops and general hospital staff through formal seminars. The training of waste managers and regulators, however, could take place outside the hospitals, at public health schools or in university departments.

Slide 20: Basic Terminology and Principles of Training Slide 21: Considerations When Developing a Training Program Slide 22: Characteristics of a Successful Training Program Slide 23: Training Content The content of training will vary based upon the particular audience. One of the best ways of Should be Tailored to the learning is through practice, and hands-on training of small groups of personnel should be Audience considered where appropriate. Testing the participants at the end of the course, by means of simple true/false or multiple-choice questions, often provides an incentive for learning and allows the course organizers to assess the knowledge acquired by participants.

The instructors should have experience in teaching and training, and be familiar with the hazards and practices of health care waste management; ideally, they should also have experience in waste handling.

Slide 24: Targeted Audience Below are some points to cover in training programs targeted at specific audiences:

Healthcare personnel The training course should provide an overview of the waste management policy and underlying rationale and information on practices relevant to the targeted group of trainees. For personnel who provide healthcare, waste segregation is a key element in their training in waste management.

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Healthcare waste handlers The minimal training for waste management operators should include: -information on the risks associated with the handling of healthcare waste -procedures for dealing with spillages and other accidents -instructions on the use of protective clothing

Cleaning Staff Topics covered may include the waste management policy, health hazards, on-site transportation, storage, safety practices, and emergency response. Among staff members who routinely handle healthcare waste, awareness of the need for safety may decrease with time, which will increase the risk of injury. Periodic refresher training is therefore recommended.

Staff who transport waste Drivers and waste handlers should be aware of the nature and risks of the transported waste. In particular, transport staff should be trained in the procedures listed below. They should be able to carry out all procedures in accordance with the instructions, without help from others.

Treatment plant operators Qualified operators are needed for incinerators, autoclaves, microwave and other treatment facilities. If no qualified operators are available, healthcare establishments should arrange to train an adequate number of personnel.

Landfill operators The training of landfill operators is important for limiting the risks associated with buried healthcare waste, in relation to both scavenging and the quality of groundwater. Landfill operators should therefore be trained in these issues.

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Slide 25: Frequency of Discuss the frequency of training. Training Refresher trainings are organised at periodic intervals, say, every 6 months. Such refresher trainings are best carried out in-house by key trainers. Key trainers, in turn, should keep them updated with the latest developments in HCWM and other additional knowledge.

Slide 26: Different Modes of Go over some modes of delivery for training Delivery Slide 27: Trainers Trainers should be committed to the aims of the course and have expertise about the content

Slide 28: Ideal Characteristics for a Trainer Slide 29, 30, 31: Tips for Source: Train the Trainer: Basic Training Guidelines, Alameda County Public Health Trainers Department (www.acphd.org) http://www.psr.org/assets/pdfs/safety-curriculum-module- 2.pdf

http://www.csu.edu/TLMP/documents/TLMPTraining-the-TrainerManual2.pdf

Slide 32: Principles of Adult Source: http://www.nhi.fhwa.dot.gov/downloads/freebies/172/PR%20Pre-course Education %20Reading%20Assignment.pdf

Slide 33: Training Techniques Experiential training is an approach to individual and group learning that engages people, using action, reflection, application, and performance support. Minimal Approach

With the help of suitably developed IEC (information education & communication) material, half to 1 day training programmes can be carried out. Such training programmes can be designed separate for the waste handlers and the other middle & senior level health care functionaries.

Desirable enhancement for minimal & intermediate approaches.

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Enhancement for more advanced approaches

More advance approaches to training would mean the development of blended learning in health care waste management. To elaborate further, blended learning can take the form of a certified education & training programme through long distance learning as well as on-line programme, combined with a contact programme of about a week, in a identified health care facility

To summarize, field visits, informal discussions, action plan development, SWOT analysis have been found to be effective training tools. On the other hand only lecture followed by discussion is least effective. Further, attitude is the critical issue when it comes to Health care Waste Management.

Slide 34: Tools and Resources for Training Slide 35: Training of Trainers Source: Training of trainer Manual- http://www.csu.edu/TLMP/documents/TLMPTraining- (TOT) the-TrainerManual2.pdf

Slide 36: Framework for a TOT Program Slide 37: Financing HCWM The availability of resources plays a very important role in the establishment and sustained maintenance of a sound HCWM system.

Slide 38: Financing HCWM Describe WHO recommendations for sustaining HCWM costs by governments.

WHO recommends that donors and partners include a provision in their health program assistance to cover the costs of sound HCWM systems.

WHO recommends that non-governmental organizations (NGOs): include the promotion of sound HCWM in their advocacy and undertake programs and activities that contribute to

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sound HCWM.

Slide 39: Financing HCWM At the national level, once an initial assessment of the HCWM situation prevailing in the country has been carried out and an efficient management structure put in place, the following steps should be taken to ensure that the HCWM efforts have the required financial resources to be sustained on the long run: -Estimate required funds -Find funds -Set up a specific budget line -Calculate costs based on initial data -Ensure financial sustainability -Finance monitoring events -Promote coordinated regional approaches -Create financial incentives

Slide 40: General Cost Go over the estimation of capital costs and operating/maintenance costs for HCWM. Components for HCWM Slide 41: Specific Cost Items Go through the list of possible capital cost items for HCWM Slide 42: Specific Cost Items Operating (recurrent) costs items for HCWM Slide 43: Specific Cost Items Other costs items for HCWM Slide 44: Create and Analyze Create and analyze an annual budget for HCWM using available tools, incorporate HCWM an Annual Budget costs into the budget process, monitor budget variances, and adjust operating targets to meet the requirements of HCWM.

Go to the resources page of the Healthcare Waste Management website to download documents about the Costing Analysis Tool (CAT) and the Expanded Cost Analysis Tool (mentioned on next slide) http://www.healthcarewaste.org/resources/documents/

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Slide 45: Costing Analysis Tool (CAT) Slide 46: Expanded Cost The Expanded Cost Analysis Tool (ECAT) is a modified version of the CAT that provides more Analysis Tool (ECAT) options and approaches. Check the resources section of the HCWM site to find out more about it- http://www.healthcarewaste.org/resources/documents/

Slide 47: Key Elements of the ECAT Slide 48 Demonstration of the Develop this slide with an example of the ECAT tool and its key entries. ECAT Use the following source for some notes on the costing tool. http://siteresources.worldbank.org/INTUSWM/Resources/463617- 1210023020779/Topic6healthcarewm.pdf

Slide 49: Strategies for Finding funds for both the initial capital investments (training, purchase of equipment, etc.) Financing HCWM and long term recurrent costs requires investigating and lobbying the different sources of funding available, both external (international and non-governmental organizations) and internal (governmental and private).

Slide 50: Strategies for List what could be financed externally by immunization partners (using the “polluter pays” Financing HCWM principle program would be required to contribute a per-syringe fee to the country’s medical waste management system).

See how Inter-agency Coordination Committees might help to mobilize external funds.

Discuss with class what internal mechanisms could be used to cover HCWM costs, such as additional charges on medical supplies for waste disposal.

Slide 51: Strategies for Public funds are generally insufficient to pay for initial capital investments. Financing HCWM Two additional options: 1) Private Funding

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2) Support from NGOs/international organizations, either in the form of a loan or donation Slide 52: Strategies for Financing HCWM Slide 53: Continuous Quality Discuss continuous quality improvement in the remaining slides Improvement (CQI) Slide 54: Continuous Quality A major aspect of continuous improvement is the updating of goals of the HCWM program. Improvement Data should be periodically analyzed. Remember: plan, do, check, and act (PDCA).

Slide 55: Steps in Continuous The diagram shows the interrelated nature of the steps in CQI. Quality Improvement Slide 56: Applying CQI to A continuous process of monitoring and quality improvement is required for your HCWM HCWM program to work effectively.

Slide 57: Applying CQI to Here are some important items in the application of CQI to HCWM: HCWM -Record waste production and disposal. -Report injuries and accidents. -Report spills. -Report equipment performance.

Slide 58: Applying CQI to It is important to continually monitor the quality of the processes and procedures of the HCWM HCWM program.

Slide 59: Applying CQI to HCWM Slide 60: Discussion Generate a class discussion with these questions

References (in order as they Blue Book Chapter 13 for Training, Chapter 10 for Costing, appear in slides) Starting healthcare waste management in a medical institution: http://www.healthcarewaste.org/fileadmin/user_upload/resources/HCW_practicalInfo1.pdf

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Train the Trainer: Basic Training Guidelines, Alameda County Public Health Department (www.acphd.org) http://www.psr.org/assets/pdfs/safety-curriculum-module-2.pdf

Training the trainer Manual- http://www.csu.edu/TLMP/documents/TLMPTraining-the- TrainerManual2.pdf

Principles of adult learning: http://www.nhi.fhwa.dot.gov/downloads/freebies/172/PR %20Pre-course%20Reading%20Assignment.pdf

Better healthcare waste management: http://www.who.int/water_sanitation_health/medicalwaste/bhcwmeng3.pdf

WHO, Healthcare Waste Management: Resources. http://www.healthcarewaste.org/resources/documents/

Sadat International, Inc., Engineering and Environmental Services: Notes on WHO Costing Tools for Health-Care Waste Management. http://siteresources.worldbank.org/INTUSWM/Resources/463617- 1210023020779/Topic6healthcarewm.pdf

Community Tool Box- How to conduct a SWOT analysis? http://ctb.ku.edu/en/tablecontents/sub_section_main_1049.aspx

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ACTIVITY: MODULE 24: EXERCISE A (45 MINUTES)

The purpose of this activity is for the HCWM coordinators to identify organizational barriers to an effective HCWM program in their facility and create strategies to overcome them. This exercise is important for members of HCWM Committees or Teams.

Instructor: Divide the participants into groups of 3 to 4 people. Participants will complete the activity in groups and record their answers. Instructor should record participant/group responses on a wipe board, flip chart, or transparency, categorize their responses. Instructor will go over the responses, once again, during the de-brief.

MODULE 24 -EXERCISE A: INSTITUTIONALIZING AND SUSTAINING HEALTHCARE WASTE MANAGEMENT

Instructor should describe the module overview and objectives and then ask participants to 1. Discuss strategies for institutionalizing and sustaining a HCWM program in your facility 2. Present their organizational structures and describe the duties they currently perform 3. Describe current or potential organizational barriers.

De-brief

Instructor and participants will then discuss strategies to overcome barriers.

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ACTIVITY: MODULE 24: EXERCISE B (45 MINUTES) The purpose of this activity is for HCWM coordinators/administrators to create an outline of a training plan for one particular audience in your facility. This exercise is important for managers and staff involved in training.

MODULE 24 -EXERCISE B: TRAINING Instructor should describe the module overview and objectives and then ask participants to:

1. Identify current HCWM training programs in their facility.

2. Discuss the limitations, barriers and need for additional training.

3. Select one particular audience in their facility and outline a training program

a. what content may be needed,

b. how do they plan to deliver the training,

c. frequency of training

d. how will they evaluate the impact of this training

De-brief

Instructor and participants will then discuss strategies for cost effective training in their facilities.

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ACTIVITY: MODULE 24: EXERCISE C AND HOME WORK (1 HOUR)

The purpose of this activity is to discuss budgeting strategies for a HCWM program using the Costing Analysis Tool (CAT) and the Expanded Cost Analysis Tool provided in the resources section of the WHO HCWM website- http://www.healthcarewaste.org/resources/documents/

This exercise is important for facility administrative personnel and national or local planners involved in health systems planning and budgeting.

Instructor: Divide the participants into groups of 3 to 4 people, or individual facilities may complete their own budget. Participants will need to complete the homework prior to the session. The other option is for the instructor to work with the participants in the class and teach them how to use the costing tool. Instructor should record participant/group responses on a wipe board, flip chart, or transparency, categorize their responses, or use the costing tool excel sheet. Instructor will go over the responses, once again, during the de-brief

Module 24 -Home work for Exercise C: Estimate the cost and develop the first draft of an annual budget for HCWM in your facility. Highlight the cost items that need to be verified in the future.

MODULE 24 -EXERCISE C: HEALTH CARE WASTE MANAGEMENT BUDGETING Instructor should describe the module overview and objectives and then ask participants to:

1. Discuss the budget process in their facility

2. Identify key items required in a HCWM budget

3. How can they incorporate HCWM into the budget process? What are the current barriers?

4. How can they raise additional funds?

5. Can they complete the costing tool?

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De-brief

Instructor and participants will then discuss the costing tool and budgeting strategies.

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ACTIVITY: MODULE 24: EXERCISE D (1 HOUR)

The purpose of the exercise is to enable participants to develop a monitoring and improvement process for any one location in the facility.

Instructor: Divide the participants into groups of 3 to 4 people. Instructor should record participant/group responses on a wipe board, flip chart, or transparency, categorize their responses. Instructor will go over the responses, once again, during the de-brief

MODULE 24 –EXERCISE D: CONTINUOUS QUALITY IMPROVEMENT

Instructor should describe the module overview and objectives and then ask participants to:

1. Identify one location or process of their facility and outline: a monitoring plan (survey, walkthrough, audit, inspection)

2. Identify key questions they want to answer?

3. How will they gather and analyze the data?

4. Next steps?

De-brief

Instructor and participants will then discuss the monitoring plans