• USAID Aaternal and Child FROM THE AMERICAN PEOPLE / Survival Program

South Africa End of Project Report June 2015–September 2019

Submitted on: September 30, 2019. Revision submitted January 10, 2020 Submitted to: United States Agency for International Development Cooperative Agreement #AID-OAA-A-14-00028 Submitted by: The Maternal and Child Survival Program

www.mcsprogram.org

The Maternal and Child Survival Program (MCSP) is a global, $560 million, 5-year cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support scale-up of high-impact health interventions among USAID’s 25 maternal and child health priority countries, as well as other countries. The program is focused on ensuring that all women, newborns and children most in need have equitable access to quality services to save lives. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment.

This report is made possible by the generous support of the American people through USAID under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of MCSP and do not necessarily reflect the views of USAID or the United States Government.

Table of Contents

Acknowledgments ...... v Acronyms and Abbreviations ...... vi Country Summary ...... vii Executive Summary ...... viii Introduction...... 1 Major Accomplishments ...... 3 Objective 1: Strengthen clinical leadership skills of newly appointed tertiary pediatric care nurses and other clinical care staff at the NMCH ...... 3 Objective 2: Support management to strengthen practice management and governance, including systems, processes, and protocols at the NMCH ...... 6 Objective 3: Coordinate the establishment of a network in the Southern Africa Development Community among USAID-supported implementing partners, national referral hospitals, and nursing associations ...... 11 Recommendations and Way Forward ...... 12

MCSP South Africa End of Project Report iii

iv MCSP South Africa End of Project Report Acknowledgments

The Maternal and Child Survival Program (MCSP) is grateful to the support of many collaborators in South Africa, most especially the Nelson Mandala Children’s Hospital executive and nursing teams, including Dr. Mandisa Maholwana, CEO, and Jayson Gopiechand, nursing director, as well as all nursing unit leaders and nursing staff. MCSP is also grateful to the support provided by the Nelson Mandela Children’s Hospital Trust in envisioning this partnership and assisting with activities in the early days prior to the opening of the hospital. MCSP also greatly appreciates the warm support from the entire Johns Hopkins Health System, which identified and provided a diverse range of expertise to support the program.

MCSP extends its thanks to USAID Southern Africa for its support of this project. The early assistance provided support to Nelson Mandela’s vision for ensuring that all children have access to the care they need, which is a guiding principal of the hospital and infused every aspect of this collaboration. MCSP also wishes to thank USAID Washington for their support and guidance during the life of the project.

MCSP South Africa End of Project Report v Acronyms and Abbreviations

ACH All Children’s Hospital CUSP Comprehensive unit-based safety program ECMO Extracorporeal membrane oxygenation JHCC Johns Hopkins Children’s Center JHI Johns Hopkins Medicine International MCSP Maternal and Child Survival Program NICU Neonatal intensive care unit NMCH Nelson Mandela Children’s Hospital NMCH Trust Nelson Mandela Children’s Hospital Trust PICU Pediatric intensive care unit USAID United States Agency for International Development

vi MCSP South Africa End of Project Report Country Summary

Geographic Implementation Areas Population Regions Country • Southern Africa, based in Johannesburg, • 56.72 Million South Africa Facilities MCSP -supported areas • Nelson Mandela Children’s Hospital (NMCH) • 13.2 Million Technical Areas: Child Health, Newborn Health, Health Systems Strengthening Program Dates Strategic Objectives Through the Life of Project June 2015–September 2019 • Strengthen clinical leadership skills of newly appointed tertiary pediatric care nurses and other clinical care staff at the NMCH • Cumulative Spending Support to strengthen practice management and Through Life of Project governance, including systems, processes and protocols at the NMCH • Coordinate the establishment of a network in the Southern Africa $2,250,000 Development Community among United States Agency for International Development-supported implementing partners, national referral hospitals, Demographic and Health and nursing associations Indicators Highlights Through the Life of Project Indicator # or % • Construction on the NMCH broke ground in 2014 Number of • In 2015, MCSP began working with the NMCH Trust to plan for the specialty development of a robust, highly skilled pediatric specialty nursing program, pediatric 4 with assistance from Johns Hopkins Medicine through the Johns Hopkins hospitals in Sub- Children’s Center and the Johns Hopkins All Children’s Hospital Saharan Africa • In December 2016, the hospital officially launched and the first outpatients 35 were received in June 2017 deaths • MCSP and its subpartner Johns Hopkins Medicine International provided Infant mortality per technical support to the nursing program throughout the planning and rate (South 1,000 opening of NMCH, including assisting with development of nursing policies, Africa)1 live standard operating procedures, interdisciplinary teams, and unit readiness births • MCSP assisted in the opening of each service unit through onsite training or skills-building exchanges for nurses, and remote follow-up • As the hospital scaled up its services, MCSP provided ongoing technical Under 5 assistance to the nurse managers to address quality, operational, and mortality rate management support needs (South Africa)1 • As of March 2019, NMCH had a nursing compliment of 91 professional nurses, 15 enrolled nurses, and 14 nursing assistants and had provided care to 1,999 outpatient clients and 1,354 inpatient clients

Sources: 1. South Africa Demographic and Health Survey 2016

MCSP South Africa End of Project Report vii Executive Summary

From 2015 to 2019, the Maternal and Child Survival Program (MCSP) worked with the Nelson Mandela Children’s Hospital to develop clinical leadership and management skills of nurses with the goal of providing state-of-the-art, specialized pediatric care to children in South Africa and the Southern Africa region. Prior to the opening of the hospital in 2017, MCSP and its partner, Johns Hopkins Medicine International, assisted the Nelson Mandela Children’s Hospital Trust to outline recruitment, management, and onboarding plans for the nursing team. During the phased opening of the hospital, MCSP provided technical assistance to develop nursing policies and guidelines, assisted with readiness checks, and provided targeted hands-on training and mentoring for each unit prior to opening. MCSP also facilitated exchanges for newly hired nurse leaders to work with their counterparts in the US at the Johns Hopkins hospitals, and provided remote learning opportunities where feasible.

MCSP’s technical assistance focused on clinical skills for radiology, dialysis, pediatric/neonatal intensive care unit (PICU/NICU), cardiology, and surgical theaters, as well as the outpatient and day wards. A specific focus was placed on assisting the hospital to develop systems and practices around quality improvement, interdisciplinary teams, and ongoing learning, i.e., via simulations. The project culminated in a three-day pediatric nursing conference, the first such event hosted by NMCH and geared at building the role of the hospital’s nursing team within a network of pediatric specialty nurses in South Africa and the Southern Africa region. With the support of MCSP, NMCH was able to develop a vision for nursing excellence for this one- of-a-kind hospital, informed by international best practices, and to lay the groundwork for a nursing program defined by the highest standards of quality and patient safety.

viii MCSP South Africa End of Project Report Introduction

In 2014, construction on the Nelson Mandela Children’s Hospital (NMCH) began in Johannesburg, a legacy project of the former president who advocated strongly for better, more accessible health care for children in South Africa and throughout the Southern Africa region. The United States Agency for International Development (USAID) through the Development Credit Authority provided an 11 year, $15 million 50% portable guarantee to help the NMCH Trust to access much needed financing during the hospital’s development and start-up phase. This enabled the trust to secure state-of-the-art medical imaging equipment for use by the various sub-specialty clinical care units. In addition, USAID worked through American Schools and Hospitals Abroad program to construct the imaging center for the hospital.

The final part of USAID’s commitment focused on strengthening of human resources based at the hospital. To this end, USAID asked the Maternal and Child Survival Program (MCSP) to bring its expertise in human resource for health development and pediatric care to support the mentorship and training of the nursing staff at NMCH. In 2015, MCSP started working with the NMCH Trust to plan for the development of a pediatric specialty nursing workforce at the hospital, in partnership with Johns Hopkins Medicine International (JHI). NMCH occupies a unique position as one of only two dedicated children’s hospitals in South Africa, and one of only four in sub-Saharan Africa. It has a mission to help the sickest children in the region receive high-quality, state-of-the-art health care while advancing a teaching and learning program designed to build a wider nursing workforce for pediatric specialties.

Since the opening of the hospital in 2017, MCSP has led a series of exchanges and educational programming enabling nurses from NMCH to access world-class, hands-on training from the Johns Hopkins hospitals, enabling them to improve their skills, grow their leadership abilities, deepen their knowledge in processes of care, and build stronger interdisciplinary teams. South African pediatric nurse managers have taken part in observership visits to the Johns Hopkins All Children’s Hospital (ACH) in St. Petersburg, Florida, and the Johns Hopkins Children’s Center (JHCC) in Baltimore, Maryland, where they worked directly with their nursing counterparts, while nurses and clinical staff participated in trainings led by Hopkins nurses and specialists at NMCH in Johannesburg, to assist the hospital launch new services as it scaled up operations. These efforts contributed to a stronger pediatric health care workforce at NMCH, and better health outcomes for children with critical needs.

The NMCH has aggressively recruited an array of nursing staff from the private and public sector across South Africa. While all nurses hold requisite degrees in nursing, many lack equivalent experience in a specialty pediatric setting. For example, some are pediatric nurses, but without advance training in specialized areas such as nephrology or neurology. Others have those specialized skills, but only have experience working with adults and need training on how to apply the specialization to pediatric patients. Regardless of educational background, NMCH is a new environment for all staff working there. Operational and protocol gaps have been experienced, as well as a steep learning curve in management of services in a new facility that is also designed differently from traditional hospitals (child-centered design).

NMCH has faced enormous pressure to accelerate its service provision, and concurrent with orienting staff and opening services, is striving to build strong nursing teams that bring together the wealth of diverse experiences of the nurses who have been hired. NMCH aims to be an example to other South African hospitals of how strong interdisciplinary nursing and medical teams can elevate the profession of specialty nursing, demonstrate nursing excellence and improve patient outcomes and experiences. In the process, the nursing team has embraced a vision that stresses patient quality and safety, highlights learning and teaching, and the routine use of data to drive decision-making. Against this backdrop, it is important to note that as a tertiary specialty hospital in an environment of enormous need, NMCH routinely receives patients requiring the most complex, advanced care. In the face of this, the new nurse managers are working to develop systems and mechanisms that ensure that patients receive all of the relevant services offered by the hospital. This includes clinical, physical, occupational, and other therapies, as well as tutoring services for school-aged children with long inpatient stays and accommodations for caregivers of children from out of town.

MCSP South Africa End of Project Report 1 To support the nursing program at NMCH, MCSP adopted the following conceptual framework (Fig. 1):

Figure 1. NMCH Nursing Support Conceptual Framework

INTERMEDIATE IDENTIFIED NEED STRATEGIES OUTCOMES IMPACT OUTCOMES Ensure that the Nelson • Hands on training Mandela Children’s around critical nursing Hospital is established as competencies (on-site Improved knowledge and a high level quality center and off-site at JHCC clinical skills of pediatric of excellence in and All Children’s nurses providing specialized pediatric care Hospital) specialized care to serve the needs of More children are • Needs-based training South Africa and the Improved management able to receive around nursing African continent by: and organization of advanced care and leadership and nursing for pediatric specialized services • Standardizing the management (hands Reductions in child centers of excellence clinical and on and remote) morbidity and management skills of mortality • Ongoing mentorship of Established continuous All children at the NMCH nursing nursing staff on nursing education system NMCH routinely staff clinical and at NMCH receive the highest Raising awareness of • management skills quality quarternary specialized needs of and tertiary and the Southern African region region African Southern and the

Stronger nursing systems Africa in South to children care pediatric specialized art, pediatric patients in • Technical assistance to - backed by robust policies pediatric care develop nursing the South Africa and SADC -

and standardized of • Supporting policies and systems - operating procedures coordination with • Training and mentoring SADC referral of clinical facilitators hospitals, nursing to support ongoing associations and

learning at NMCH state provide To partners

MONITORING &EVALUATION PARTNERSHIP & COLLABORATION NMCHT, NDOH, MCSP, JHCC, JHI SADC, Southern Africa Development Community, JHCC, Johns Hopkins Children’s Center; NMCH, Nelson Mandela Children’s Hospital; NMCHT, Nelson Mandela Children’s Hospital Trust; NDOH, National Department of Health; MCSP, Maternal and Child Survival Program; JHI, Johns Hopkins Medicine International

2 MCSP South Africa End of Project Report Major Accomplishments

MCSP adopted the following goals and objectives for the program in South Africa:

Goal: To provide state-of-the-art, specialized pediatric care to children in South Africa and the Southern Africa region.

• Objective 1: Strengthen clinical leadership skills of newly appointed tertiary pediatric care nurses and other clinical care staff at the NMCH • Objective 2: Support nursing management to strengthen practice management and governance, including systems, processes, and protocols at the NMCH • Objective 3: Coordinate the establishment of a network in the Southern Africa Development Community among USAID-supported implementing partners, national referral hospitals, and nursing associations

Objective 1: Strengthen clinical leadership skills of newly appointed tertiary pediatric care nurses and other clinical care staff at the NMCH Planning and development for nursing program In September 2016, MCSP and JHI conducted a of the NMCH, which included meetings with nursing and physician leadership teams from the NMCH Trust who were overseeing plans for completion and start-up of the hospital, and tours of the as-yet incomplete NMCH, potential referring hospitals, and a nursing college. The intended primary purpose of the visits was to observe and assess the organization and practice of nursing to help identify priorities for knowledge transfer and support for the NMCH nursing department. The assessment included a review of the nursing structure and management, plans for nursing practice, staffing models, personnel policies and procedures, and nursing staff competencies. The recommendations centered on developing an activity plan for supporting nurse mentoring, with a specific target on clinical facilitators (educators) and nursing management.

Four main areas were highlighted as focus points that NMCH should consider when developing their nursing plans and where MCSP could assist. These included (1) clinical facilitation and training, (2) nurse leadership development, (3) patient safety and quality, and (4) resource allocation. The first three topics continued to be recurring components of MCSP support throughout the life of the project. Throughout 2017, while construction on the hospital was completed, MCSP maintained frequent communication with the NMCH Trust to provide technical support to inform planning for the development of the nursing program, hiring, onboarding, and the development of nursing policies and standards. In mid-2017, the program underwent an informal reboot when the executive management team of the hospital was hired and MCSP support transitioned from the NMCH Trust to direct engagement with NMCH staff, including the nurse leaders. MCSP assisted in the development of the onboarding program for nursing staff and the prioritization of skills-development as the hospital initiated its plans for the phased opening of services in late 2017.

Training and mentorship visit In August 2017, MCSP conducted the first onsite training for newly hired NMCH nurses. Four nurse leaders and subject-matter experts from JHI led a two-week training and mentoring activity for clinical nurses and nurse leadership teams at NMCH in radiology, dialysis, perioperative care, cardiology services, age specific competencies, international patient safety goals, and leadership competencies. At the time of the visit, only outpatient radiology services were open, though it was anticipated that the day ward, dialysis, PICU and NICU services would open soon after. A total of 36 staff members attended all or part of the training sessions, including five nurse unit managers and seven radiographers and technicians.

MCSP South Africa End of Project Report 3 Overview of onsite training and mentoring program

The objectives of each training program were threefold: 1) assist the nursing teams to prepare for the opening of a new clinical service (following the phased plan for opening) by conducting readiness assessments and identifying specific actions for follow-up and strengthening; 2) building and broadening the knowledge and application of nursing leadership skills (communication, performance management, patient experience, high performing teams, recruitment and retention strategies, and an introduction to train-the-trainer concepts), and 3) supporting the development of clinical skills in target services—radiology nursing, peri- nursing, , and dialysis were the areas of clinical focus for the August 2017 training. Specific learning objectives were established for each training and structured around a mix of didactic and hands-on training, as follows: • Pre-and post-training preparation sessions with nursing leadership • Roughly 35 hours of classroom-based didactic training sessions, including discussion, case studies, and team building work designed around the learning objectives above • Most sessions were designed to be interdisciplinary, including nurses from different specialties and providing an overview of critical functions in other areas • Roughly 10 hours of simulations were conducted. These included “day in the life” scenarios, such as: • A patient having a CT scan who was prepped in the day ward, did not need anesthesia or sedation, and ended up having a severe reaction to contrast • Management of a patient requiring for a CT scan with sedation from arrival at the hospital and to the time of scanning • Most sessions were followed by quizzes (using Kahoot©) and evaluation forms were completed at the end of each week • Examples of learning activities during the radiology and day ward trainings included education on ionizing radiation safety and uses; MRI safety and uses; contrast administration, including safety and prevention and care of contrast administration complications; overview of ultrasound; management of nurse administered sedation with review of capnography and an overview of invasive procedure concepts, including biopsies, angiograms, tube and drain placement, and embolization • Airway maneuvers practice sessions were conducted utilizing an infant and pediatric resuscitation mannequin, nursing staff and operations managers practiced head tilt/chin lift, jaw thrust, bag/mask ventilation, and oral airway placement • Malignant hyperthermia simulation scenarios were conducted in the day ward with all available staff; pre- operative case study evaluated recognition and communication of suspicious family history for malignant hyperthermia risk.

Observership to dialysis unit, ACH An identified need during the first onsite training was additional support for the pediatric dialysis team. To assist the NMCH to develop their pediatric dialysis services, MCSP supported an exchange visit for two pediatric dialysis nurses and one dialysis technician to observe and work with nurses at the Johns Hopkins ACH in St Petersburg, FL. In South Africa, pediatric dialysis is not a nursing specialty and many of the newly hired nurses only had experience in managing adults on dialysis. The ACH has a dedicated service for pediatric dialysis that provided exposure of NMCH nurses to the specific operational requirements of a pediatric dialysis program and awareness on how pediatric dialysis nurses at Johns Hopkins are trained and assessed as competent. The nursing team had the opportunity to learn about the different dialysis modalities such as acute and chronic hemodialysis, peritoneal dialysis, transplantation, and MARS (liver dialysis), as well as to review procedures for reverse osmosis, dialysis machine disinfection, CRRT machine setup with the initiation of acute patients, management of chronic renal failure setup using AV Grafts and Tenckhoff catheter, and emergency preparedness simulations and mock codes. Following the opening of the renal unit, NMCH requested a follow-up observership by the nephrologist to ACH to assist in adoption of identified best practices and to promote the development of an interdisciplinary practice, which took place in March 2018.

4 MCSP South Africa End of Project Report Second training and mentoring visit A second onsite training and mentoring visit took place in February 2018, targeting NMCH’s clinical staff and leadership teams and covering dialysis, pediatric intensive care, neonatal intensive care, catheterization laboratory, and surgical theater nursing. Additional topics focused on nursing leadership and quality, and rapid cycle deliberate learning. The objectives of this training program were to build and broaden the knowledge and application of nursing leadership skills in building a quality infrastructure in dialysis, PICU, NICU, the operating theater, and the catheterization lab. As of the time of the training, a total of about 70 clinical staff (including nurse managers/unit heads, professional nurses, technologists, nursing assistants, and radiographers) had been hired at the hospital. The nursing staff were in attendance for the topics relevant to their area of employment. In coordination with the director of nursing, learning objectives were established for each subject area. Curriculum was developed in advance for each topic, including didactic and hands-on sessions, and shared with NMCH nurse leadership for feedback prior to the training. As the PICU and NICU services had not yet opened as planned at the time of the training, the JHI trainers instead focused on running simulations designed to prepare staff for emergency response on all units.

ECMO (extracorporeal membrane oxygenation) training Responding to an identified need at NMCH, MCSP and JHI provided a training in June/July 2018 for NMCH’s nursing and medical staff from the PICU, NICU, catheterization lab, and operating room. Reflecting the tremendous need for ECMO training, additional participants included attending physicians from Chris Hani Baragwanath Hospital. The objectives of this training visit were to build knowledge of the fundamentals of ECMO and the utilization of the ECMO equipment. These objectives were met over a four-day course that consisted of both lectures and skills lab session. The course was given over a two-week period in which the material was repeated the second week for a new cohort of nurses and physicians. This was the training facilitated by MCSP and JHI dedicated to a single topic, and it was a challenge to dedicate staff to a four-day, eight-hour-a-day program while operations need to continue. The training included the learning objectives geared around completing a readiness checklist for ECMO services and addressing gaps to assure safe opening of ECMO services; describing the primary functions of ECMO and identifying and explaining all components of the ECMO circuit; recognizing and troubleshooting alarms; and explaining weaning criteria.

A total of 31 staff participated. The participants were highly engaged and expressed a strong desire to gain more familiarity with how to successfully manage a patient on ECMO and to better understand how the machine works and give the best possible care to their ECMO patients. The course included classroom lectures (mornings) followed by hands-on skill sessions in the afternoon. Starting on day two, every day stated with a quiz, using Kahoot® to test comprehension of the lectures from the previous day. A skills checklist was used to sign off competencies during the skills sessions. The trainers were impressed with the trainees’ dedication and ease of understanding the complicated skills and knowledge needed to take care of these very complicated patients.

Observerships by nurse leaders to JHCC and ACH A subsequent observership to ACH took place in October 2018, including the deputy nursing director for clinical services and the nursing occupational health and safety manager. In addition to shadowing services, the participants took part in comprehensive unit-based safety program (CUSP) meetings, observed executive rounds, reviewed simulation programs, met with pharmacy teams, took part in disaster planning discussions, reviewed event reporting systems, learned about the nursing team’s role in the RISE (resiliency in stressful events) program, and collected examples of standard operating procedures and protocols to adapt for their services. In March 2019, a final nursing observership to Johns Hopkins Hospital in Baltimore, MD, took place. The nursing managers from the operating theater and the cardiology service worked with their nursing counterparts to study clinical, administrative, and management systems, including workflow processes, stock control management and billing, policies for their respective units, incident management systems, the electronic documentation systems, central sterile services department workflow processes, and infection

MCSP South Africa End of Project Report 5 control policies in practice. These were reviewed through paired observations of safety calls, procedures in the operating theater and cardiac catheterization lab, the central sterile services department, the intensive care units, outpatient services, and other wards, as well as participation in unit/ward meetings and subcommittee meetings (i.e., for CUSP, HERO, quality improvement). Following the observership, the two nurse managers made plans to strengthen and/or institute committees at NMCH to address service excellence and medication safety (inclusive of registered nurses, physician, pharmacy, RT, risk teams) and CUSP teams.

Webinars and remote follow-up To continue to build on key topics identified during the training visits, during the early start-up and expansion of services at the hospital, MCSP, and JHI also facilitated a series of webinars with NMCH nurses and manages to continue discussions around topics such as managing transition and change, the science of patient safety, pediatric early warning signs, RISE and second victim initiatives, and more broadly how Hopkins’ systems incorporate learning and evidence-based practice in their systems of care. The webinars were led by various subject matter experts throughout the Johns Hopkins Health System and were incorporated into onboarding and ongoing learning programs for the nurses.

Summary From inception to the opening of services, MCSP assisted the newly formed nursing teams to develop clinical policies and standard operating procedures, organize their readiness plans, and provided hands-on skills building for nursing teams (and interdisciplinary teams where appropriate) in the dialysis, radiology, NICU, PICU, cardiac, surgical, and day wards. MCSP focused on building inter-professional ties with nursing teams in the Hopkins’ health system to promote ongoing exchange and learning, and facilitate the sharing of best practices. As the hospital opened, MCSP responded to specific needs for clinical skills building, such as for ECMO. The experience of simulated practice used by JHI trainers will hopefully be continued and expanded at NMCH, building on the example of the structured simulation program at ACH, once the clinical facilitation program is initiated.

Objective 2: Support nursing management to strengthen practice management and governance, including systems, processes, and protocols at the NMCH Patient safety certificate program Building on requests for support to develop quality and safety platforms at NMCH, hospital nursing staff took part in a patient safety certificate program, led by the Armstrong Institute at Johns Hopkins Medicine. The five-day program took place in March 2018 and consisted of 24 modules covering topics such as patient safety culture, patient-centered care, safe design principles, and interdisciplinary teamwork and communication. Participants included the nursing director, the newly appointed deputy nursing director for clinical practice and education (a post which covers occupational health and infection control) and the infection control focal point. The certificate course was paired with a week-long observership at Johns Hopkins Children Center, tailored to include relevant clinical, administrative, and management topics.

Executive exchange to Johns Hopkins Hospital In November 2018, the CEO and nursing director of NMCH undertook a week-long observership to Johns Hopkins, including four days at the ACH and one day at Johns Hopkins Hospital in Baltimore. In addition to observing operations in a high-volume children’s hospital, the visit was an opportunity to meet with executives in both hospitals to learn about planning, management, growth strategies, and systems for ensuring excellence and learning. Among the topics reviewed and discussed during the visit were:

6 MCSP South Africa End of Project Report • Hospital risk management processes, including sentinel events strategies. Of great interest were the integration of incident management systems that allow the hospital to log, organize, communicate, and follow-through on incidents that may arise. The visitors observed the incident management tools the hospitals use to improve processes, reduce costs, and prevent incidents from happening in the future by facilitating lessons learned through education. • The visitors toured the state-of-the-art simulation lab at ACH, which includes a simulated home-based environment for training parents. The director of the hospital simulation program, Dr. Jen Arnold, described the process for developing an integrated simulation program and goals of the simulation program, which is coordinated with all services around the hospital to plan and develop simulation curriculum for staff, patients, and parents. This includes the use of the simulation lab as well as unit and service-based simulation programs. • A variety of meetings with clinical and management teams discussed the hospital’s nursing strategy, including: • Transformational leadership • Shared governance bi-laws • Clinical ladder (Ladder for Excellence and Advancement in Patient Care Services—LEAP program) • Reward and recognition • Volunteer programs • Clinical development • Retention • The Daisy program (recognizing excellence in nursing) • ELITE preceptor program • Exemplary professional practice

In addition, the NMCH team learned about the process ACH has undertaken to achieve magnet accreditation. Visits with the emergency medicine and oncology services assisted the maternal and child health leadership team to learn more about how these units are run and discuss their vision for developing these services in the future. For emergency medicine services, intra- and inter-hospital patient transfer is an important aspect of patient care, which NMCH seeks to further develop, with a systematic platform with emphasis on patient safety and communication.

The outcomes from the visit included: • Potential future research collaborations: In discussion with Dr. Tina Cheng, the director of the JHCC, it was noted that JHCC often seeks to identify additional representative patient population for their trials. Given NMCH’s intention to develop a research platform in the future, there could be a possibility of networking and engaging in collaborative research efforts. • Development of leadership systems: following the visit, Dr. Mandisa Maholwana, CEO, implemented a leadership forum at NMCH, effective December 2019. • Patient navigator role: NMCH bought into this role as important value add to further enhance customer experience at NMCH. The hospital aimed to adopt this position in 2019. • Development of support IT systems for patient management, safety and quality assurance: the visit further highlighted the need for incorporation of patient surveys and incident management platforms.

MCSP South Africa End of Project Report 7 Support for nursing standard operating procedures, policies, and management infrastructure Wherever feasible, MCSP provided support to NMCH to develop its nursing systems through technical support and advise on the development and roll-out of critical policies and guidelines, including assisting to ensure nursing policies reflect international best practices. MCSP also provided technical and financial support to develop a supportive infrastructure for successful patient management, including facilitating the dissemination of policies and guidelines via nurse managers by ensuring that managers in the first wave of services had laptops to allow them to access and utilize standard operating procedures, checklists, data reporting tools, and policies. Following the observership visit by the NMCH CEO and chief nursing officer to ACH in November 2018, a specific request was made for MCSP to assist NMCH to incorporate online patient safety and patient feedback platforms that are standard practice in advanced pediatric care settings. Subsequently, MCSP assisted NMCH to source, subscribe, and install online incident management and patient feedback platforms. It was intended for the two platforms to be fully live by May 2019, however, an extended period of feedback and modifications were required to adapt and customize the platforms. Figure 2 provides an overview of reported incidents by month. The dashboard format is designed to present actionable information to unit heads and hospital management. Figure 3 provides a summary of patient feedback received and escalation pathways. The introduction of the online patient feedback mechanism has allowed unit leaders to identify areas where improvements were needed, such as communication (i.e., health education on medication), feedback on clinical processes, such as discharge and admission processes.

Figure 2. NMCH incident management platform dashboard, by month

Management Platform

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Pediatric nursing practice and education conference In May of 2019, MCSP collaborated with NMCH to host its first pediatric nursing conference, bringing together clinical experts, nurse leaders, and educators to share information and build networks around development of nursing pediatric specialties. This conference served as a closing event for MCSP’s role in NMCH, building on MCSP’s relationships and leveraging our international networks to help launch NMCH’s position as a leader of pediatric nursing education in the region.

The overall theme of the conference was “Strengthening coordination and collaboration to improve health outcomes of children.” The topics and presenters were identified around the following conference objectives: • Embracing a shared goal to urgently reduce and then eliminate serious harm for the children being cared for in our facilities

MCSP South Africa End of Project Report 9 • Bringing together leading minds to reflect on the state of specialty pediatric care in South Arica, look to the future and build on the platform embodied by the NMCH • Reflecting on and sharing lessons on specific advancements in pediatric nursing • Improving communication and coordination between nursing experts • Discussing strategies to increase the pediatric nursing workforce • Raising awareness among students of nursing, medical, and allied services about opportunities for working in pediatrics

An indirect, but centrally important aim of the conference was to further establish NMCH as a leader in pediatric nursing in South Africa and demonstrate its potential role as a convener for academic, clinical, and policy learning. Less than two years after it first started serving clients, NMCH has learned important lessons and begun to demonstrate the possibilities for expanding access to high-quality, state-of-the-art care for children with complex health needs, but has not yet developed its role as a teaching and learning hospital, including building on networks with local universities in Gauteng and Western Cape to advance specialty pediatric nursing disciplines. The conference was designed to kick start a discussion on how NMCH can more systematically collaborate with these institutions to improve clinical learning and develop the pediatric specialty nursing workforce. Similarly, as an informal “capstone” event for MCSP, the conference provided an opportunity to cement networks between NMCH and the international community, including pediatric hospitals in the US and Canada, which will continue beyond the life of project and hopefully provide opportunities for research, learning, and professional development for the nursing teams at NMCH.

The conference included 25 interactive presentations over three days, with two engaging panel discussions (see the conference trip report included as an annex). Speakers came from a wide range of backgrounds from throughout South Africa, along with international speakers from Lesotho, the US, and Canada. The conference drew a total of 147 participants over three days, representing over 20 universities, hospitals, professional associations, government agencies, and the private sector, including: • National Department of Health • USAID • Chris Hani Baragwanath Academic Hospital • University of KwaZulu Natal • Sefako Makgatho Health Sciences University • Netcare Limited • The Organisation for Paediatric Support in South Africa • Johns Hopkins Hospital and Johns Hopkins ACH • Jhpiego • Hospital for Sick Children (SickKids)

Though aimed primarily at nurses, the conference drew medical doctors, researchers, hospital departmental managers, nutritionists, and public health professionals, creating a diverse and multidisciplinary space to share best practices in pediatric care, and how best to capacitate pediatric nurses. The conference was a great success, with NMCH establishing itself as an institution committed to building the capacity of the nursing workforce in South Africa and providing opportunities for education and professional development within the pediatric health care sector.

10 MCSP South Africa End of Project Report Summary MCSP worked first with the NMCH Trust, then with the newly created hospital management team to identify key areas for support to guide the effective development of nursing leadership and management systems. Responding to the hospital’s stated goal of building strong systems for quality and patient safety, MCSP helped share best practices and build the skills of nurse leaders through course work and exchanges with Johns Hopkins’ hospitals, as well as assistance to create online platforms to better enable the hospital to track and respond to quality and safety concerns. MCSP also built networks between the leadership teams at NMCH and the Johns Hopkins hospitals, to share experiences around planning and management of a specialty children’s hospital.

Objective 3: Coordinate the establishment of a network in the Southern Africa Development Community among USAID- supported implementing partners, national referral hospitals, and nursing associations Due to the evolution of plans during implementation, the transition in management from the NMCH Trust to the hospital executive team, and the delays in opening the hospital, MCSP’s design evolved to focus on other objectives and outcomes, which NMCH deemed were important to its success. Thus, MCSP did not support the development of a regional referral network for critical pediatric cases from other Southern Africa Development Community countries.

MCSP South Africa End of Project Report 11 Recommendations and Way Forward

By the end of July 2019, NMCH had served more than 2,900 patients, including 663 cardiac patients, 242 NICU patients, and 216 PICU patients, as well as 4,739 radiology patients (predominantly outpatients). The hospital has received referrals from public hospitals in five provinces, including Gauteng, as well as a variety of private hospitals. The hospital has come a long way since it opened, but is not yet operating at full capacity and has not opened all its planned services (oncology, for example, is not yet open as the hospital continues to discuss plans for the purchase of drugs). MCSP continued to work with NMCH up to the end of the project to develop plans for capacitating personnel and developing a system for the nursing clinical facilitators (who have responsibility for continued professional development), who, unfortunately, had not been hired by the end of the project. Given the lack of preservice training for pediatric nursing specialties (and the general need for additional qualified nurses), this is a critical focus area for the future. In discussion with NMCH, MCSP recommends that this include a two-track approach that focuses both on building the system at the hospital for learning and professional development and developing networks with academic institutions (Witwatersrand University and University of Cape Town for example) to include NMCH as a teaching hospital for nursing specialty courses.

For the in-service learning portion, MCSP recommends that NMCH adopt and learn from best practices developed in other specialty hospitals to ensure that clinical facilitators have well defined roles and are mandated and equipped to assist teams at the hospital to incorporate ongoing learning. One recommendation based on the trainings that have been conducted to date and learning exchanges to the Johns Hopkins hospitals is to continue to incorporate structured simulation in clinical practice, including both competency-based learning for individual staff members and team practice. NMCH has a skills lab that, although not designed with nursing teams in mind, provides a platform from which to grow a simulation program. NMCH has also displayed a strong interest in building its use of data for decision-making, learning, and research and in developing its capacity to take part in research opportunities. Given its unique positon as a specialty pediatric hospital, NMCH has a great platform to contribute to building further knowledge of clinical practices for children in resource-poor settings.

In South Africa, clinical facilitators have a similar role to nurse educators in the US and much discussion was undertaken about how to conceptualize this role, how to support and train the clinical educators when they were hired, and how to adopt lessons learned and best practices from the Johns Hopkins Health System around integration of ongoing learning for nurses and incorporation of hospital-wide and unit-based learning programs. The clinical facilitation program was seen as a natural focus of MCSP assistance, as it offered the most sustainable opportunity to support ongoing development of clinical and management skills for nurses. Multiple plans were made during the course of the project for training or other kinds of assistance for the clinical facilitators, which never came to fruition as the timeline for hiring the facilitators continued to be pushed back due to funding constraints and challenges in finding suitably qualified personnel. The lack of clinical facilitators was strongly felt both by the program as well as the nursing team at NMCH, as it places additional burden on nurse managers to plan and oversee professional development and continuing education efforts. The project and nursing team tried to counter this in various ways, mostly by discussing plans for subject-matter “champions” or “super-users,” which was also constrained by the volume of day-to-day work, especially for highly motivated nurses.

12 MCSP South Africa End of Project Report