Teamwork for Eye Care M Babar Qureshi Director: Neglected Tropical Diseases, CBM and Chair: ICO Committee on Training Teams, Cambridge, UK

Community Eye Health

JOURNALVOLUME 27 | ISSUE 86 | 2014 Teamwork for eye care M Babar Qureshi Director: Neglected Tropical Diseases, CBM and Chair: ICO committee on training teams, Cambridge, UK. Hillary Rono [email protected] Human resource development (HRD) – the development of the people who deliver health care – has been identified as one of the key pillars of eye health delivery. HRD is one of the essential building blocks of the World Health Organization (WHO) Global Action Plan: 'Towards universal eye health'. The importance of HRD is also recognised beyond eye care, as can be seen in the WHO Health Systems approach. Historically, eye care delivery was mainly the responsibility of ophthalmologists. It soon became clear, however, that in order to effectively reduce avoidable blindness, other types of health care workers would need to be developed, trained and deployed to work with and support ophthalmologists. A team A ophthalmic clinical officer observes a community health worker examining a approach would therefore be essential. patient's eyes so that he can offer helpful feedback and support, if needed In recent years, eye care team development has become an important tional committees on HRD, and IAPB has in a way that supports the development part of the advocacy and action plans also formed regional HRD committees. of the eye care team as a whole. of most global eye health agencies and One of their key tasks has been to The composition of an eye care team regional bodies. The International identify gaps and plan HRD for individual varies from region to region and country Agency for the Prevention of Blindness groups of eye health providers – including to country, and it will also differ depending (IAPB) and the International Council of ophthalmic nurses, ophthalmic clinical on whether the team is working in a Ophthalmology (ICO) both have interna- officers, and optometrists/refractionists – Continues overleaf ➤

ABOUT THIS ISSUE Elmien Wolvaardt Ellison experience: low vision and rehabilitation when people are undergoing training. We Editor: Community Eye Health workers, teachers, community health focus on good leadership, which is Journal. workers, equipment technicians, recep- needed to keep team members focused tionists, cleaners, drivers, and outreach This issue is about teamwork for eye on what is important, on the goals the care, and about how eye teams can workers – to name but a few. team wants to achieve, and on good function more effectively to address A good indicator of a team that is planning and management, all of which blindness and improve eye health in the functioning well is that people are helps to support and facilitate teamwork. communities where the need is greatest. enjoying working together. What can be There is advice on how to function within Our authors look at the various people better than doing worthwhile work with a team and improve the effectiveness of involved: ophthalmic nurses, ophthalmic people you respect and appreciate, and the team. Other articles look at various clinical officers, ophthalmologists, who each bring unique skills, perspectives groups of eye health workers, the optometrists, the surgical team, and and energy to the team? challenges they face, and how these are managers. But there are many more But great teamwork does not always being addressed to improve teamwork. people whose enthusiastic and skilled come naturally. This issue therefore looks We hope you will enjoy this issue and participation is essential for both good at the importance of establishing a that you will be inspired to make positive clinical outcomes and a good patient culture of teamwork right at the start, changes where you work.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 21 EDITORIAL Continued In this issue 21 Teamwork for eye care national eye care programme or in a rural • being willing to listen to others eye clinic. The goal is the same, however: • making decisions based on a collective 24 Don’t drop the patient: to provide high quality eye care to the and evidence-based approach (rather teamwork for cataract surgery satisfaction of the patient. than for personal gain) 26 Building the eye care team • treating people fairly, whatever their Leadership: a crucial cultural background, gender, sexual 28 Training, certifi cation and component of teamwork orientation or health/disability. accreditation for eye teams Teams need leaders who are knowl- By being fair, available, and communi- edgeable, skilled, highly motivated, and 29 A team approach to providing cative, the team leader can ensure that who aim to offer high quality, sustainable refractive error services there is good communication among the eye care services. A good leader will rest of the team and that working relation- 30 Non-clinical managers: consult with the team, take their opinions ships are positive. the key to a successful eye on board, and create a vision and goals Leaders also have a facilitative role: programme that are genuinely shared by everyone; ensuring that the team has everything they this means that the team members will need to achieve their goals, such as appro- 32 Ophthalmic nursing services feel personally motivated to achieve these priate (and functioning) equipment, a in Botswana shared goals. Good leaders are able to reliable supply of medicines and consum- champion the team’s vision and goals 33 Case study: Encouraging ables, good systems and protocols, and a with energy and enthusiasm, inspiring nurses in Indonesia to develop clean and safe environment in which to their team members to keep going during skills and confi dence work. Managers (see page 30) can difficult times. She or he will share credit support the team leader in this role. 34 Ophtalmic clinical offi cers: and be able to manage the negative A good leader also keeps the profes- developments in Uganda fall-out if things go wrong. sional growth of the team in mind by The team leader sets the tone for the 36 CLINICAL SKILLS Red reﬂ ex proactively seeking career development team and is responsible for maintaining for the team and ensuring that everyone 37 EQUIPMENT CARE AND the team’s values and the ‘team culture’, has a clear job description, detailing their MAINTENANCE Understanding i.e. what behaviour is acceptable and roles and responsibilities. Team members your operating microscope’s what is not. The team leader can and should understand where their job fi ts into assistant scope and should model the correct attitudes and the health system and what their opportu- beamsplitter behaviour for the rest of the team. For nities for career progression are. example: 38 TRACHOMA UPDATE • showing professional respect for the Being a good team member 39 CPD QUIZ skills and limitations of each member of The team needs to be able to support the 40 NEWS AND NOTICES the eye team leader in achieving high performance and • demonstrating professional dilligence quality of service, delivered to the satis-

Community Eye Health Editor CEHJ online Address for subscriptions Elmien Wolvaardt Ellison Visit the Community Eye Health Journal Anita Shah, International Centre for Eye

JOURNALVOLUME 27 | ISSUE 86 | 2014 [email protected] online. All back issues are available as Health, London School of Hygiene and Teamwork for eye care M Babar Qureshi Director: Neglected Tropical Diseases, CBM and Chair: ICO committee on HTML and PDF. Visit Tropical Medicine, Keppel Street, London training teams, Cambridge, UK. Hillary Rono [email protected] Editorial committee Human resource development (HRD) – the development of the people who deliver health care – has been identified WC1E 7HT, UK. as one of the key pillars of eye health www.cehjournal.org delivery. HRD is one of the essential building blocks of the World Health Allen Foster Organization (WHO) Global Action Plan: 'Towards universal eye health'. The importance of HRD is also recognised Tel +44 (0)207 958 8336/8346 beyond eye care, as can be seen in the WHO Health Systems approach. Historically, eye care delivery was Clare Gilbert Online edition and newsletter mainly the responsibility of ophthalmologists. It soon became clear, however, that in order to effectively reduce avoidable Fax +44 (0)207 927 2739 blindness, other types of health care workers would need to be developed, trained and deployed to work with and Nick Astbury Sally Parsley: [email protected] support ophthalmologists. A team A ophthalmic clinical officer observes a community health worker examining a approach would therefore be essential. patient's eyes so that he can offer helpful feedback and support, if needed In recent years, eye care team Email [email protected] development has become an important tional committees on HRD, and IAPB has in a way that supports the development part of the advocacy and action plans also formed regional HRD committees. of the eye care team as a whole. of most global eye health agencies and One of their key tasks has been to The composition of an eye care team Daksha Patel regional bodies. The International identify gaps and plan HRD for individual varies from region to region and country Agency for the Prevention of Blindness groups of eye health providers – including to country, and it will also differ depending (IAPB) and the International Council of ophthalmic nurses, ophthalmic clinical on whether the team is working in a Consulting editors for Issue 86 Ophthalmology (ICO) both have interna- officers, and optometrists/refractionists – Continues overleaf ➤

ABOUT THIS ISSUE Richard Wormald Exchange articles Elmien Wolvaardt Ellison experience: low vision and rehabilitation when people are undergoing training. We Editor: Community Eye Health workers, teachers, community health focus on good leadership, which is Journal. workers, equipment technicians, recep- needed to keep team members focused Sally Crook, Daksha Patel, Babar Qureshi tionists, cleaners, drivers, and outreach This issue is about teamwork for eye on what is important, on the goals the care, and about how eye teams can workers – to name but a few. team wants to achieve, and on good Peter Ackland We accept submissions of 400 or 800 function more effectively to address A good indicator of a team that is planning and management, all of which blindness and improve eye health in the functioning well is that people are helps to support and facilitate teamwork. communities where the need is greatest. enjoying working together. What can be There is advice on how to function within Our authors look at the various people better than doing worthwhile work with a team and improve the effectiveness of involved: ophthalmic nurses, ophthalmic people you respect and appreciate, and the team. Other articles look at various clinical officers, ophthalmologists, who each bring unique skills, perspectives groups of eye health workers, the Janet Marsden words about readers' experiences. Contact: optometrists, the surgical team, and and energy to the team? challenges they face, and how these are managers. But there are many more But great teamwork does not always being addressed to improve teamwork. people whose enthusiastic and skilled come naturally. This issue therefore looks We hope you will enjoy this issue and Please support us participation is essential for both good at the importance of establishing a that you will be inspired to make positive clinical outcomes and a good patient culture of teamwork right at the start, changes where you work. Catherine Cross Anita Shah: [email protected] COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 21 David Yorston We rely on donations from charities and Serge Resnikoff generous individuals to carry out our work. © International Centre for Eye Health, London. Articles Volume 27 | Issue 86 We need your help. Subscriptions in may be photocopied, reproduced or translated provided Supporting Regional consultants high-income countries cost UK £30 per these are not used for commercial or personal profi t. Hugh Taylor (WPR) Acknowledgements should be made to the author(s) VISION 2020: annum. Please support us by adding a and to Community Eye Health Journal. Woodcut-style The Right to Sight Leshan Tan (WPR) donation: £15 will send the journal to a graphics by Victoria Francis and Teresa Dodgson. GVS Murthy (SEAR) front-line eye care worker in a low- or ISSN 0953-6833 R Thulsiraj (SEAR) middle-income country for 1 year. Contact Disclaimer Babar Qureshi (EMR) Anita Shah ([email protected]) Signed articles are the responsibility of the named Mansur Rabiu (EMR) or visit the journal website: authors alone and do not necessarily reflect the Hannah Faal (AFR) www.cehjournal.org/donate views of the London School of Hygiene & Tropical Kovin Naidoo (AFR) Medicine (the School). Although every effort is made to ensure accuracy, the School does not warrant that Ian Murdoch (EUR) Subscriptions the information contained in this publication is Janos Nemeth (EUR) complete and correct and shall not be liable for any Readers in low- and middle-income Van Lansingh (AMR) damages incurred as a result of its use. countries get the journal free of charge. Andrea Zin (AMR) The mention of specific companies or of certain Send your name, occupation, and manufacturers’ products does not imply that they are Editorial assistant Anita Shah postal address to the address opposite. endorsed or recommended by the School in preference Design Lance Bellers French, Spanish, and Chinese editions to others of a similar nature that are not mentioned. The School does not endorse or recommend products Proofreading Jane Tricker are available. To subscribe online, visit or services for which you may view advertisements in Printing Newman Thomson www.cehjournal.org/subscribe this Journal.

22 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 faction of the patients they serve. Team the example set by leaders during practical community health staff and teachers members must be professionally training). Changing the curriculum is who now are being actively involved in competent in their field of work, diligent always a challenge, but this can be primary eye care, screening and referral and committed, and should view their overcome through advocacy and sharing of eye patients, and must be included in leaders as mentors and facilitators. succesful examples of a curriculum the defi nition of the eye care team. It makes sense to develop the focused on the team. attitudes and skills needed for successful Focusing on our patients teamwork from the outset, during training Task shifting The concept of teamwork has been (see page 28). A curriculum geared To enhance the quantity and quality of an perfected by successful manufacturing towards teamwork will encourage and eye service, task shifting has been used companies, where people with different train eye care workers to: with a lot of success. Task shifting means skills come together to make a car or delegation of tasks within the team to other product which is then marketed, • identify themselves as team members complement one another. This can take sold, and supported with after-sales • communicate clearly and respectfully place informally (at the level of the insti- service. Teams in health care may face • develop critical thinking and problem tution) or formally (i.e. at ministry of many additional challenges, including solving skills health level, with the creation of a new funding and wider health systems issues. • make decisions and respect the role such as that of cataract surgeon). We deal with human beings and their decisions of others One of the best examples of task sight; therefore we should do our best to • support and complement the work of shifting has been the use of mid-level provide not just great service, but also to others personnel, optometrists and nurses to offer a positive experience to our • trust other members of the team undertake many of the tasks which the patients. For many of them, there is no • give clear and prompt feedback ophthalmologist used to do in the past, second chance, so we must ensure that • motivate themselves and others thereby giving the ophthalmologist more a high quality service is delivered the first • keep learning. time for specialised tasks or surgery that time. Teamwork can help by enhancing These ideas and skills should be included only she or he is qualifi ed to perform. the efficiency and quality of our work, in the curriculum and taught both explicitly Mid-level eye care workers are also task both of which are essential to improve (during course work) and implicitly (through shifting their previous activities to the vision and quality of life of our patients. Commonwealth Eye Health Consortium

Research ellowships are o ered at PhD and post-doctoral levels to strengthen eye research capacity and address questions o ophthalmic public health importance. Fellows will develop, conduct and analyse research. Application in ormation is available rom: http://cehc.lshtm.ac.uk/research- ellows/ The Commonwealth Eye Health Consortium (CEHC) is a group Open educational resources will provide reely available o eye health organisations working together to strengthen online learning materials that cover: (i) epidemiology o eye health services and the quality o eye health care across blinding eye diseases, (ii) principles o research in eye care the Commonwealth. Brought together through unding rom and (iii) health development and The Queen Elizabeth Diamond eye care programmes. Jubilee Trust and coordinated by the International Centre or Eye The Diabetic Retinopathy Team Health, the consortium is delivering Training Network, based on an exciting, integrated, ive-year VISION 2020 LINKS in A rica and programme o ellowships, the Caribbean, will work together research and technology aimed to build a South-South network at eye health workers based in and help plan and develop national low- and middle-income diabetic retinopathy services. Commonwealth countries. OpenEyes is an open source Masters scholarships in Public electronic patient record system Health or Eye Care are o ered that is particularly suited to low or study at the University o and middle-income country Cape Town or the London School PEEK settings. Support is available to o Hygiene & Tropical Medicine in order to equip implement the system in multiple locations. Application ophthalmologists and eye care managers to implement in ormation is available rom: http://cehc.lshtm.ac.uk/openeyes/ e ective, sustainable strategies to prevent and treat Peek is a multi unctional smartphone system that empowers blindness. Application in ormation can be obtained rom: eye health workers to diagnose eye diseases using a low-cost http://cehc.lshtm.ac.uk/msc-scholars/ device in remote settings. Clinical ellowships will support both long and short-term Please re er to the CEHC website http://cehc.lshtm.ac.uk or sub-specialty training or ophthalmologists to gain the ull details. knowledge and skills to more e ectively relieve the burden o blindness in their own countries. Application in ormation can be obtained rom: http://cehc.lshtm.ac.uk/clinical- ellows/

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 23 article distributed under the Creative Commons Attribution Non-Commercial License. THE PATIENT'S JOURNEY Don’t drop the patient: teamwork for cataract surgery

Daksha Patel E-learning Director: International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK. [email protected]

Sally Crook Programme Manager: Seeing is Believing,

London, UK. [email protected] Adriane Ohanesian/Sightsavers

The purpose of a team is to work together towards a common goal. On an athletics track, relay race teams run with a baton that is passed from one team member to another, without breaking the pace. If the baton is dropped, the team is disqualified. The journey of the baton is a good analogy for the journey of someone who is visually impaired from cataract. Everyone has to work together within the health system to ensure that the patient is not ‘dropped’. In other words, the eye team must ensure that an informed patient, who is relaxed and mentally prepared for the next level of treatment, gets to a Everyone within the health system has to work together to ensure that a patient surgical centre and back home again. with cataract will receive the best possible care from start to finish The patient's journey begins when cataract is detected and the patient is operative care, including detection of bigger ‘eye team’. As an example, high- informed about the possibility of treatment. complications and referral back to the volume cataract surgical centres, such as This is done at the community level by surgical centre if needed. This ‘return those based in India, work closely with their health workers – such as primary health loop’ is important, both for the post- referral networks to ensure uptake of care workers and community health operative management of the patient and surgery is not hindered due to delays in the workers – who then refer the patient to an for the process of assessing outcomes pathways or at the point of treatment. ophthalmic clinician for assessment and/ (for quality control and auditing, and or surgery. This stage of the journey has to feedback to the surgical team). Improving teamwork be managed with sensitivity and reassurance The patient's journey is completed only There is much the team working at the for blind or vision-impaired patients, as when the patient has been followed up eye unit can do to improve teamwork with they are likely to be afraid of surgery. and is satisfied with the services and the their colleagues in the community. There is also a return journey: a outcome. If not, then any issues must be Strengthen communication cataract patient must come back to the addressed or resolved and constructive In order to successfully refer patients for community for follow-up and post- and helpful feedback should be given to surgery, there has to be good communi- the appropriate team members. cation and information sharing between Low vision and rehabilitation the workers at community level and the Good working relationships team at the surgical centre. Staff at the Some patients may not achieve good – whose responsibility? community/primary level should be vision after cataract surgery. This may In order for health workers at the confident that the information they are be due to surgical problems, post- community level to successfully refer giving patients is correct and up to date. operative complications, or underlying patients, there has to be a good working New communication technologies, such eye diseases such as glaucoma. relationship – involving regular and as SMS (text messages), instant messaging These patients may benefit from pro-active communication, information (e.g. WhatsApp or BBM) and email have rehabilitation or low vision services, sharing and feedback – between them made it possible to be in immediate contact which range from learning to use and the team at the surgical centre. with colleagues out in the community. It assistive devices (e.g. magnifiers) to We would like to suggest that much of may require some effort to gather every- being taught new skills to improve the responsibility for good teamwork rests one’s contact details and set up the employment opportunities. These with the team at the surgical centre or eye communications system. But once set up, services can maximise quality of life unit, who rely on the health workers in the such a system can be used to keep in for people with vision impairments, community to identify and refer patients for regular contact with health workers in the and it is therefore important to include surgery and to care for them once they community, provide them with feedback on low vision or rehabilitation experts return to the community. The staff in the successful (and unsuccessful) referrals, and within your eye care team and to refer eye unit must consider and think about the inform them about any changes, for example patients to them if needed. staff delivering eye care in the community if there is a change in the clinic dates or much, much more, and bring them into a times. Both community and surgical

24 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 centre workers should be trained in the example by SMS or via instant messaging) communications system and motivated so that they can inform patients. Any staff to use it. All of the above will help to shortages or service issues, such as ensure that workers in the community Heiko Philippin broken down equipment or a shortage of are not isolated or unsupported. consumables, should be urgently addressed.

Establish referral protocols Practice good teamwork within the It is important to acknowledge the surgical eye unit challenges patients face when they are At the surgical centre, the manager must referred for cataract surgery. The indirect establish good information flow between costs of cataract surgery can be high and team members within the eye unit and include transport costs and the lost wages between them and the health workers in of the patient and the accompanying the community. Recognising the various person. It is therefore crucial that referrals Regular communication and careful roles within the team (including finance, are done carefully. If a patient arrives on a planning supports the patient's journey administration, reception, stores, day when the clinic is closed or surgery is equipment maintenance, cleaning and cancelled, they may not have the Offer support, supervision, and pharmacy) will also help to ensure the resources to come a second time. feedback smooth functioning of the unit. The result A process for referral, using a protocol, The important role played by health workers – regular procurement of medicines and would provide clear and consistent steps at community level is strengthened if they instruments, good patient flow into to follow. For example: are provided with regular feedback about theatre and aseptic functioning in their performance by the district or second- 1 Explain to the patient what has been operating theaters – will boost both the ary level team. Workers need to know who found and that their sight can be number of operations and their quality. to ask for help with complicated and restored. Good working relationships between unusual cases, and must be given the team at the eye unit and the health 2 Tell the patient what to expect: what the acknowledgement when they are doing treatment involves, its safety, possible workers in the community can lead to well. Pre- and post-operative counselling more effective service delivery, as steps outcomes and the benefits of of patients is essential and health workers treatment. can be taken to ensure neither group is should be supported with clear, consistent overburdened or under-used. Regular 3 Ask about, and address, any fears or practice guidelines and information. concerns the patient may have. communication (ideally between named individuals) and clear, well-understood 4 Inform the patient about where to go Ensure reliable services protocols will provide a framework for daily next, in enough detail (e.g. date, time, Surgical centres must establish a regular interactions. cost) to ensure that the patient can work plan or schedule that is shared with Teamwork can be further strengthened make the journey successfully and everyone at community level and updated by training, mentoring and active support receive the care she or he needs. regularly. Colleagues at community level for workers in the community. All of the Communication should be consistent and must be informed of any changes or above will ensure that the patient receives repeated as often as needed. Establishing unexpected gaps in services (e.g. staff timely and high-quality service in an a rapport with the patient – and under- shortages) as quickly as possible (for effi cient and user-friendly style. standing their concerns – will help with the acceptance of treatment. People Time to reﬂ ect working at community level who refer patients should have visited the surgical Do you have the following in place? to look out for, what to do, and unit at least once, so they can tell the where to go). cataract patient exactly what to expect. 1 A registration system that links 6 Communication pathways, both There must also be a referral protocol different services (e.g. refractive within the eye unit and out to back to the community so that people can services or the diabetes clinic) to health workers in the community. be followed up and any complications the eye department and keeps This includes having the names managed after surgery. patient records together. and contact details of key Informing patients about post- 2 Agreed referral protocols, people within the hospital, and operative complications – what to look including referral to low vision arranging regular opportunities out for and what they should do (including and rehabilitation services. for the team at the surgical where they should go) – should be built 3 An arrangement for workers at centre to meet the health into the post-operative protocol or referral community level to observe workers who form part of their pathway. One example is thickening of the cataract surgery so they can referral network in the community. posterior capsule, which is a common inform patients about the 7 Good inventory management complication of cataract surgery. It procedure and about the hospital. and procurement protocols. involves gradual deterioration of vision and 4 Pre-operative counselling at 8 Human resource mechanisms can be easily remedied. For patients, the community level to address the to ensure that posts are filled and visual improvement after surgery is always fears of people who are older, that people are in place to do a remarkable experience. If vision deterio- blind or vision impaired. the work of those who are on leave. rates due to this complication, and 5 Post-operative follow-up and 9 A system for recording patient patients don't know why, they could lose reassurance for the patient, and satisfaction, taking any needed faith in the eye care system and not information about the possibility action, and giving feedback return for help, which is one way of of complications (including what to staff. 'dropping' the patient.

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 25 article distributed under the Creative Commons Attribution Non-Commercial License. TEAM MANAGEMENT Building the eye care team

Thulasiraj Ravilla Executive Director: Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System, Madurai, India Gnanasekaran Chinnathambi HR manager: Aravind Eye Care System,

Madurai, India. [email protected] Aravind Eye Care System

Eye care services are people intensive. They require the right people (competence), in the right numbers (capacity), in the right mix (team) with the right resources and processes (enabling conditions) to ensure effective and sustainable delivery of patient care. To be effective, the team should have the right mix of ophthalmologists, ophthalmic assistants, administrative staff and support staff. It is important for each team member to be clear about Operating theatre nurses are given an orientation session in the use of IOL injectors what is expected of them and how their tasks relate to the overall purpose of the undergo a well-designed orientation constraints relating to the availability of organisation that employs them. Building (induction) to help her or him to become trained eye care professionals and an effective workforce is a continuous familiar with the new surroundings. This supplies, should also be taken into journey. Inadequate staff numbers, lack should be led by the newcomer’s desig- account. of competency, and low motivation and nated line manager. The orientation Employee empowerment. Team productivity are common challenges. In should aim to deepen the new employee's meetings should have a clear agenda and our experience, however, systematically understanding of the organisation and foster an open and democratic environment addressing all of the following areas cover its aims, history, key members, that encourages members to jointly contributes to success. operating model and values. It should address any difficulties, such as a also clarify the person’s roles and respon- Recruitment and selection. In some temporary shortage of a particular sibilities and how these relate to the settings, particularly in government consumable. Employees should also be programmes, there may be organisation’s mission and vision. The encouraged to initiate new projects and little choice in the selection orientation lays the share their ideas about how to improve of staff. However, where the ‘The recruitment foundation for working patient care. Having a say in operational eye care service has the process should together as a team. level decisions enhances people's flexibility to manage its own Enabling environment. engagement in their work and creates a recruitment, there are two ensure the The hospital has to create culture of ownership among employees. distinct steps. First, in an enabling environment Performance assessment and order to get a pool of right fit for the for its employees by feedback (appraisal). There should be a suitable candidates, each ensuring that they have formal system for each employee and her post should have a clear job organisation’s the required resources or his line manager regularly to discuss description and be adver- values’ (patients, equipment, the employee’s performance (at least tised appropriately with supplies and support staff) once a year). This discussion should be enough time for the candi- and also the under- held in an open and non-threatening way, dates to respond. The selection process standing and authority they need to take and should be recorded on a standard should probe not just the candidate’s decisions and accomplish their tasks. For form. It should provide constructive competency but also his or her motivation. instance, the nurse in charge of the feedback on performance and on any The reality is that technical skills can be operating rooms should have the concerns. Together, the employee and developed and improved over time, but it authority to requisition supplies as line manager must draw up an action plan is much more challenging to change required, and the person in charge of to upgrade skills and/or improve fundamental beliefs, attitudes and transportation should have the authority behaviour. The plan should include how behaviour. Thus the recruitment and to hire vehicles as needed. Such opera- best the organisation can support this selection process should ensure both tional decisions should not require the process. competency and the right fit for the approval of the medical director. If an employee has serious problems of organisation’s values, but with a greater Responsibilities can be made clear competence or behaviour, mentoring may emphasis on the values (which are through sharing all job descriptions with be considered. An experienced staff reflected in the organisation’s mission members of the team, and be reinforced member could be assigned to help the and vision). through regular team meetings – ideally employee resolve problems relating to Orientation (induction). On joining the once a week. Trends in eye care technology, work life, or to provide support when there hospital, the new employee should changing patient expectations, as well as are problems in her or his personal life.

26 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 Career development and training. FROM THE FIELD When employees show motivation and ability, they should be given Retaining the eye team: top tips additional responsibilities (with appropriate training) if possible. This could from Kenya be an opportunity to lead a new activity and improve their leadership skills. The 1 Kitale District • Performance targets are set at the organisation should endeavour to have Hospital Eye Unit beginning of every year by the whole a well-defined career path for all types eye care team. These targets form the Hillary Rono: Ophthalmologist of employees, as this builds people's basis of performance assessment aspirations towards the next level in their • At our hospital, eye care workers and feedback (appraisals). career. When an employee shows ability undergo regular refresher training in • Keeping staff motivated over a long and a desire to move to a new position surgical and clinical skills, instrument period of time is a challenge, as the within the organisation, it is good to be care and good ‘customer’ relations. needs of individuals change over time. supportive to the extent it is practical. This is done through attachments at Within the eye unit, we offer supportive This could both help the employee (self- high-volume hospitals, an annual supervision (a respectful and development) and retain her/his skills. workshop on instrument care and a non-authoritarian approach that The organisation should periodically programme in which they are involves joint problem solving1) and conduct training needs assessments for mentored by an ophthalmologist. In appraise staff every quarter (i.e. we all employees and design training the mentorship programme, existing assess their performance and provide programmes based on the needs identified. talents and skills are identified and feedback). We also offer opportunities Pay and benefits. This is one of the most developed and staff are encouraged to participate in outreach programmes sensitive aspect of employment. To an to acquire new skills. This ensures and in quality improvement employee, the salary is the indicator of that high quality service is programmes (based on feedback from how they are valued in the organisation. maintained. cataract surgical outcome monitoring). More often than not, dissatisfaction with • Personnel are given on-the-job We encourage and support staff to pay is the reason people leave an organi- training in other tasks. Support attend relevant continuous sation. Where possible, try to ensure that workers (with no clinical background, professional development workshops salaries are competitive (compared to e.g. people who provide clerical, and training, and to collaborate on those offered by similar organisations) cleaning, equipment maintenance research projects with other and represent fair market rate. Internally, and financial services) are trained to institutions. The annual appraisal of employees' pay and benefits should be test visual acuity, dilate eyes and to the eye unit performance within the comparable to that of others within the assist in theatre. Skilled eye care hospital also helps to motivate staff. workers (ophthalmologists, clinical organisation doing similar jobs. If pay rates Further reading are set externally, however, whether by the officers and ophthalmic nurses) are familiarised with operations 1 World Health Organization. Supportive supervision government or other bodies (e.g churches), (training module). Visit www.who.int/immunization/ it may not be possible to do very much. management and bookkeeping. documents/MLM_module4.pdf Retention and welfare. Employee retention should be a major concern 2 Kwale District encourages a sense of responsibility. for any organisation. Individuals, once Eye Centre • Staff have regular tea breaks. We well trained and effective, may opt to have found that it is more difficult for move for better prospects. In that case, Helen Roberts: Medical Director tired, thirsty staff to give good the line manager or leadership team customer care. may try to convince the employee to • At our hospital, staff • We acknowledge and talk about stay by offering a new challenge, such as are encouraged to teamwork and emphasise its additional responsibilities which carry take the leave they importance at meetings and in general. extra benefits. If the employee is deter- are entitled to. • Although meetings take time, they are mined to leave, a formal exit interview is • There is a sensible sickness policy important for communication and useful to inform management about her and staff are well looked after if sick. motivation. It helps to know that we or his experiences within the organisation • Punctuality is respected, both on are aware of each other's challenges and what might be improved. arrival to work and completing the and share responsibility for addressing The organisation has to be concerned day. Our staff register is kept in an them. As medical director, I check the about employees’ physical, mental, open plan office, so staff sign in and minutes of each department's regular social and spiritual wellbeing. Health out in my presence. This is a good meetings to ensure they are taking place. insurance, scholarships for career devel- opportunity to meet and greet each • Moving people around departments opment or child care are some of the staff member and to discuss the day isn't always comfortable, but it helps welfare measures that can motivate ahead, or the day past, or to simply our team members to understand people to stay. Social events and compe- acknowledge them. how the other departments work. If it titions to demonstrate talent can also • Staff have a nice uniform and clearly is not appropriate for someone to encourage creativity and foster team spirit. written name badges. Once a name work in a department, we make sure The performance of a hospital is a badge is in place, everyone knows they visit (e.g. the adminstators refl ection of the quality of the people who who they are and what their job is. visiting outreach activities). work there. It is therefore essential to Any visitor can pinpoint a staff • We have an informal social event for recruit and retain employees with the member as having served them, so it the team at least once a year. right attitude, competence and potential.

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 27 article distributed under the Creative Commons Attribution Non-Commercial License. TEAM DEVELOPMENT Training, certification and accreditation for eye teams

Karl Golnick Certification usually includes a President: Joint Commission on Allied standardised test of an individual’s Health Personnel in Ophthalmology; competence. Some countries Director for Education: International already have certification processes Council of Ophthalmology. for most eye care team members Lynn Anderson but many do not. The International CEO: Joint Commission on Allied Aravind Eye Care System Health Personnel in Ophthalmology. Council of Ophthalmology (ICO) has [email protected] international examinations to certify ophthalmology residents. The Joint Recent data suggests there may Commission on Allied Health Care in never be enough ophthalmologists Ophthalmology (JCAHPO) currently to meet the needs of global eye care.1 certifies several levels of allied health One way to lessen the impact of the care in 29 countries. National and/or shortage is to increase the efficiency Eye care training programmes can be accredited to international certification should be and effectiveness of each ophthal- ensure they meet quality standards developed for all eye care team mologist by putting together a team members in so that their competence doctors, residents, nursing staff, allied of well trained personnel to support them. can be assured. health providers and the patient’s primary This increases both the availability and Accreditation is a process designed care team, all of whom need to coordinate quality of eye care. to ensure that training programmes meet with each other. In an outpatient setting, The ophthalmologist-led eye care team quality standards. The accreditation the team may consist only of a doctor and can include optometrists, nurses, mid- process assesses the training programme mid-level ophthalmic personnel. Whatever level ophthalmic personnel (ophthalmic based on standardised guidelines. the setting, team members should be assistants/technicians/medical technolo- Typically, the programme completes a performing their agreed-upon roles, gists), refractionists, orthoptists, contact self-assessment document that is then allowing each team member to complete lens fitters, opticians, ophthalmic photog- evaluated by the accrediting organisation. their assigned tasks, prevent duplication raphers, community health workers, low This is followed by a site visit in which an of effort, and maximise each team vision and rehabilitation specialists, and outside observer verifies compliance with member's skills. This results in the ophthal- may include other community workers accreditation guidelines. Some countries, mologist being able to care for the maximum (e.g. teachers) who screen and refer but not all, have mechanisms in place to number of patients by focusing her or his potential eye patients. accredit eye care training programmes. expertise on diagnosis and treatment. Eye care teams may be large or small, Recently, international guidelines for Teamwork is a complex process but there depending on their goals and needs. In a ophthalmic allied health training are best practice principles for forming and teaching hospital, there will be teams of programmes have been established by using a team approach to improve access the International Joint Commission on and quality of patient care. The team Allied Health Care in Ophthalmology Strategies for team training approach should be more than simply (IJCAHPO).3 India, Pakistan and assembling the various team members Cross training. For example, residents Singapore have IJCAHPO-accredited required. It is crucial to define roles, respon- can be asked to teach the nursing staff programmes. sibilities, job descriptions and sub-teams, and mid-level ophthalmic personnel In summary, the high-performing eye and to promote team member cooperation.2 about diseases and new treatments. care team is widely recognised as a Good team communication is essential and Nurses can be asked to show residents fundamental tool for constructing a more should result in mutually agreed upon roles. how to maximise the skills of a nurse patient-centred, coordinated, effective Exact descriptions of these roles should be or an ophthalmic surgical assistant in and high quality eye care delivery system. known and understood by all team the operating theater. Ophthalmic Having health care teams with well- members. The team should work together to assistants or technicians can capably defined roles and proof of competence is make decisions and formulate goals. This and effectively train residents in the essential to meet global eye care needs. approach will foster a sense of common fundamentals of refraction and help A well functioning ophthalmologist-led purpose, create shared responsibility for them to refine their refraction skills. eye care team should increase efficiency team actions, and increase teamwork to Grand rounds. 'Grand rounds' and availability of care in a cost-effective achieve team goals. Cross-training (see sessions are case-based discussions manner and improve the health systems panel) will improve the adaptability and and include all members of the team. in a country. They are designed to illustrate flexibility of team members and ultimately individual roles and responsibilities in improve team effectiveness. Finally, a well- References functioning team will provide mechanisms 1 Resnikoff S, Felch W, Gauthier TM, Spivey B. The providing efficient, effective patient number of ophthalmologists in practice and training care. A regular, internal training for interactive conflict resolution. worldwide: a growing gap despite more than 200,000 system using a 'grand rounds' method The ability of each team member to practitioners. Br J Ophthalmol 2012;86:716-722. perform her or his required function is 2 Mitchell P, Wynia M, Golden R, et al. 2012. Core can effectively address the key principles & values of effective team-based health care. knowledge and skills (or 'core compe- essential to the team’s success. Discussion Paper, Institute of Medicine, Washington, tencies') needed by the eye care team. Professional development, through DC. www.iom.edu/tbc. individual certification and programme 3 International Accreditation Standards & Guidelines. This can positively impact patient Ophthalmic Medical Personnel Education and Training outcomes on an ongoing basis. accreditation, aims to ensure that team Programs. Available at: http://www.ijcahpo.org/pdfs/ members are competent in their roles. IJCAHPOAccreditationStandards_June2013.pdf.

28 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. TEAMS FOR REFRACTIVE ERROR A team approach to providing refractive error services

Kovin Naidoo knowledge and skills. For example, as Global Programmes Director: optometry is increasingly being integrated Brien Holden Vision Institute, Durban, at regional and district hospitals, there is South Africa. Heiko Philippin an opportunity to shift tasks like Pirindha Govender refraction, low vision, ocular disease Global Programmes Associate: Brien Holden Vision Institute, Durban, screening, pre-operative assessment and South Africa. post-operative follow-up examinations to Worldwide, there are over 640 million optometrists (or to ophthalmic techni- people who are vision impaired, simply cians or ophthalmic nurses, where they because they do not have access to a are available). This will free ophthalmologists to focus on surgery and the simple eye examination and a pair of Pinhole testing can be carried out by spectacles.1 With 43% of vision impair- nurses or other primary health care management of disease. ment being due to uncorrected refractive workers to detect patients who need Some aspects of refractive services may error,1 it is no wonder that there have refractive error care be ‘task shifted’ to others, e.g. nurses screening for myopia, hyperopia and been increased efforts to improve service refractive error or ocular disease. At the presbyopia. Prescribing presbyopia delivery in this area. However, a recipe for secondary level, comprehensive spectacles for individuals who have good successfully and predictably ‘scaling up’ refractive examinations should be distance vision and no obvious pathology (expanding) programmes to provide eye provided by optometrists, ophthalmic could take place at this level, and appro- examinations and spectacles to everyone clinical offi cers and other mid-level priate referral protocols should be defi ned. in need has thus far remained elusive. personnel trained for this purpose. A team approach and task shifting There have been different confi gura- Ophthalmologists should be deployed at requires the eye care system to provide tions used when expanding refractive error this level in cases where they are the the appropriate training required by services, some of which have seen optom- primary refractive personnel in the etrists and refractionists integrated as country. At the tertiary level, pre- and different health workers so that a good core members of the eye care team, and post-operative refraction of patients, quality service can be provided at all others in which they have worked outside management of conditions such as levels, and more patients can be seen. this team. Regardless of the confi guration, keratoconus, and other medical-related One example of a fl exible training we believe that a team approach to contact lens fi tting can be provided by approach is provided by the Regional School refractive error care will create a collabo- optometrists in a co-management of Optometry in Malawi, set up by a rative and enabling environment which will agreement with ophthalmologists. These partnership comprising the Brien Holden ultimately benefi t patients. personnel will also work closely with Vision Institute, SightSavers and Optometry In a team approach (Figure 1), personnel specialised clinics such as advanced low Giving Sight. It consists of two programmes: at the community level – such as community vision services or rehabilitation services. • a conventional four-year BSc optometry health workers – can conduct health A team approach to refractive error care degree that trains individuals for public promotion and screening activities to ensures that eye health workers all identify and private sector deployment. encourage individuals to seek eye exami- themselves as part of a team. Each team • an optometric training diploma which is nations for refractive error. It will also member’s role must be clearly defi ned by delivered over 3 years and allows detect those who need to be referred. At the needs of the health system within graduates to provide refractive services the primary level (eye clinic), personnel which they work, while maintaining their and eye care in the public sector, where such as nurses can screen and separate primary professional role. Consideration the need is greatest. refractive from non-refractive patients must be given to the complementary (the pinhole is particularly useful in this nature of the job of each member and Graduates of the diploma programme respect), and provide presbyopic their inter-dependency in the team.1 have the opportunity to upskill and correction for those whose vision Adopting a team approach to eye care progress to the four-year degree, thereby impairment is not caused by distance helps to optimise staff experience, Continues overleaf ➤ Figure 1. One example of how members of a refractive error team could work together COMMUNITY LEVEL Public awareness PRIMARY LEVEL and case finding SECONDARY LEVEL Vision screening Community health workers TERTIARY LEVEL Primary health care workers Diagnosis and and/or ophthalmic nurses management Advanced disease Optometrists, ophthalmic management, clinical officers and/or rehabilitation ophthalmologists and surgery Ophthalmologists, optometrists, orthoptists and/or vision rehabilitation specialists, etc.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 29 TEAMS FOR REFRACTIVE ERROR Continued MANAGING EYE PROGRAMMES Non-clinical managers: the key to a successful eye programme meeting both the professional needs of the person and the needs of society. Although each setting is different, a managers to be accountable and will make team approach rooted in the local human it easier for them to work with other resources for eye health strategy and Edson Mwaipopo hospital staff members, e.g. accountants, health policies will help to make services Deputy director: Kilimanjaro Centre for store keepers, the hospital administrator more sustainable. Ideally, decisions Community Ophthalmology Tanzania LTD. and the matron, all of whom play an should be informed by evidence-based, E-mail: [email protected] important role in the success of the eye context-specific research to determine The importance of management in an eye programme or eye department. feasibility and impact. One example is the care programme should not be under- ‘Giving Sight to KZN’ project supported by estimated. It is hard to imagine how a busy Training and capacity building Standard Chartered Bank. This involved ophthalmologist could attend to her or his After recruitment, it is important that the the integration of refractive error services patients, as well as doing all of the tasks new manager learns as much as possible into the district health system in KwaZulu- needed to manage a successful eye about eye care, which can be done at the Natal, South Africa.2 department, eye hospital or hospital- eye department. The new manager needs Whatever the situation, we should not based VISION 2020 eye programme. to understand how the departmental compromise on a team approach and Some of these tasks are set out below. systems work internally as well as within should instead actively seek integration the wider health system. • Planning and organising clinic-based and with other components of the health It may be helpful to assign one clinical outreach activities. system. The very success of our efforts staff member to assist the new manager in • Receiving and issuing supplies, including depends on this. the learning process. There are easy-to- for operating theatre, the outpatient understand reading materials available on References department, and refractive error services. 1 Faal H. Reaching into the district: strengthening the eye eye health, leading causes of blindness • Making regular inventory reports and care team. Community Eye Health Journal 2004; 17: 36–37. and their management. The Community 2 Naidoo KS, Naidoo K, Maharaj YI, Ramson P, Wallace reordering when necessary to ensure Eye Health Journal is recommended! DB, Dabideen R. Scaling up the delivery of refractive that supplies are in stock. error services within a district health system: the The manager must also learn about KwaZulu-Natal South Africa experience. BMC Health • Keeping track of accounting for the international and World Health Services Research 2013; 13: 361–368. hospital or overall eye care programme Organization (WHO)-led actions such as and producing reports, including a cost VISION 2020 and the Global Action Plan Professional competition recovery report. for Universal Eye Health 2014–19. Eye • Preparing and submitting reports to The public health challenges in low- care service delivery planning, leadership donors and partner organisations. and middle-income countries, where skills, team building, partnership building, • Ensuring that the programme vehicle is the eye care needs are greatest, the basics of financial and human maintained properly. demand of us a collaborative and resources management, and bridging • Identifying and liaising with potential donors/ partnership approach. strategies to connect hospitals and sponsors who can support the hospital Professional competition within communities are all essential for the task and/or VISION 2020 activities in the region refractive error service delivery may be of management. Some training is • Managing human resource issues, positive. Appropriately trained cadres available: courses covering these subjects including recruitment, annual leave/ who are supported with continuing are run by KCCO International, LAICO/ vacations and deployment. professional development are able to Aravind, the University of Cape Town, the increase the professional standard of It makes sense to employ a programme London School of Hygiene and Tropical the services they provide. Over time, manager to carry out the above tasks. If Medicine, and others (see page 40). better and more professional services there is a good manager in the team, the It should be noted that the learning and increase community expectation, driving ophthalmologist can meet regularly with capacity building process must be ongoing. a need for increasing professional her or him to review reports and agree The manager needs to learn every day, competency among practitioners in a budgets. The ophthalmologist can even after being fully employed. It will take given geographic area. We cannot, dedicate the rest of her or his time to some time before the new manager will however, allow the professional battles examining and treating patients. understand all the aspects of her or his job. that sometimes occur in high-income countries to intrude upon our work in Finding a good manager Mentoring low- and middle-income countries, or There is no specific academic background This involves someone with experience in allow the narrow interests of profes- needed, but it is preferable to recruit someone eye care management keeping in contact sionals to dominate the service with some management and adminis- with a new manager to assist and advise delivery landscape. trative training. It is not recommended to her or him. Mentoring is a training and The roles of different eye service train and recruit clinical staff to this post. capacity building process, and new providers (ophthalmologists, optome- This is a full time job and there is a very managers are lucky if they can take trists, ophthalmic nurses, ophthalmic limited number of trained clinical staff in advantage of this. Mentoring is ongoing, clinical officers, and other allied personnel) low- and middle-income countries; they with more frequent contacts and commu- should be defined by a collective evalu- should not be taken away from their nications at the beginning and fewer being ation of the needs of a particular eye clinical duties. It is easier and more needed as the manager gains the confi- health system, the distribution and economical to train a non-clinical staff dence and skills to work independently. availability of the different types of provider member as a programme manager. A manager can make a big difference in and the potential to task shift at all levels. It is ideal if programme managers are an eye care programme, especially one There are enough poor people to recruited and employed by the central that reaches proactively into the community reach in our world; it is unnecessary for us to trip over each other to serve them. hospital, rather than independently (by the to provide services to those who would not eye department alone). This will help come to hospital on their own. The

30 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. MANAGING EYE PROGRAMMES Non-clinical managers: the key to a successful eye programme

manager is very dedicated, hard working View from a manager and, above all, honest. Having very good interpersonal skills is also important. Organising outreach activities is one of the most important How do you divide your responsibilities? responsibilities of He does the narrative and financial reporting, Winston Mbao, the Aravind Eye Care System supervises support staff, and communi- non-clinical manager at Kitwe Central cates with our partners. I look after the Hospital. Here he explains how its clinical side of things and come up with outreach programme has helped to new ideas which he will implement after increase the cataract surgical output at discussing them with the rest of the team. the hospital. How do you ensure a good working Before I was appointed in 2003, the relationship? hospital performed around 500 cataract Frequent and good communication, at operations per year. The current output is least three times per day. There is a strong 2,500 per year, mainly due to outreach. When an eye programme has a non- sense of teamwork and shared responsi- Zambia is sparsely populated and clinical manager, organising outreach bility. When one of us is unable do a task, people often cannot afford transport to an activities will become one of his or her the other takes it up. We regularly review eye health facility. We visit a different main responsibilities. our activities and know who is responsible community every week to screen people for what. and then bring those who need surgery enjoyment of the clinical staff when they to our hospital. We also provide return are free to do what they do best, with lots What were the biggest challenges for transport. of patients, in an efficiently run system, is you both? Eight times a year one of our surgical also a large bonus for an eye programme! There is no government recognition for managers in eye care, so there is no career teams will also go and ‘camp’ at another View from an ophthalmologist path. Finding money is therefore challenging district hospital. They screen people at different local health centres, transport Asiwome Seneadza is head of and at the moment our manager’s salary those who need surgery to the hospital, Kitwe Central Hospital’s eye is partly dependent on NGO funding. and take them back afterwards. This involves department in Zambia. The What are the benefits of having a a lot of planning! As a manager, one of my hospital is run by the manager? Would you recommend it to most important responsibilities is to government and is a tertiary referral centre others? organise these outreach activities, so for the northern part of Zambia, with its First of all, it is impossible to do all the services reach where the need is greatest. population of 4.7 million. Currently, it is necessary administrative work and remain the only centre in Zambia offering a clinician. Clinicians can be leaders but For more information, please contact paediatric and retinal services. not managers. Managers are crucial for Winston Mbao at Kitwe Central Hospital. any programme to run successfully! Email: [email protected] Why did you employ a manager? I realised early on that my performance would be affected if I had to take on both Case study: Madagascar the clinical and administrative responsibil- The Antsinanana VISION 2020 Initially, there were no managers – ities involved in managing the eye programme was established in June 2010 either for the regional eye care department. Although I still have adminis- and is a joint effort between the programme or the two hospitals. The trative responsibilities, my key focus is the Madagascan Ministry of Health, ophthalmic staff had to perform all clinical clinical excellence of our department. Kilimanjaro Centre for Community and non-clinical duties. Although both What were you hoping the manager Ophthalmology (KCCO), Swiss Lions and hospitals had basic equipment to enable would do for the eye department? Lions Sight First Madagascar. them to perform surgery, the two centres First and foremost, I wanted the manager The region has two facilities providing performed only 481 cataract operations to have a sense of ownership! Fortunately, secondary eye care services: the Atsinanana per year (in 2010). Services were limited he acquired this early, partly because we set Regional Hospital in Toamasina and the to those patients who could pay for their targets together – at that time it was targets Vatomandry District Hospital. own transport to the two facilities. for cataract surgery. He looked into how The subsequent employment of a we could improve our finances, conduct full-time non-clinical manager gave the outreach, place orders, and write reports. clinical staff more time to do clinical work. Staff members enjoyed this How did you find a good manager? change and were able double the What did you look for? number of cataract operations to 1,068 Initially, the key focus for me was improving in 2011, while in 2013 they performed a our financial accounting. As we didn’t have total of 1,728 cataract operations. funding at the time, I selected a very good Due to strong advocacy by the accountant from the central hospital to manager there is now also more Ministry help us part time. Fortunately he picked up of Health involvement. Reports are most of the eye work very fast! He also prepared and submitted on time and the attended a 6-week management course at role of each staff member has been Aravind in India, and has recently attended A planning meeting

Edson Mwaipopo carefully spelled out. a refresher course. I think the ideal

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 31 article distributed under the Creative Commons Attribution Non-Commercial License. CASE STUDIES Ophthalmic nursing services in Botswana

Chatawana Molao Head of Advanced Ophthalmic Nursing: also the main contacts to whom primary • The fact that inexperienced ophthalmic Molepolole Institute of Health Sciences, health care workers refer patients. nurses (most of whom are newly Molepolole, Botswana. However, Botswana does not have a well- qualified) are sent to work in primary [email protected] structured referral pathway for all health care settings where they are isolated Ophthalmic nurses make up 90% of all eye teams, particularly between the private and lack supervision. workers in Botswana’s public sector, and and public sector. The absence of strong • A lack of incentives to attract nurses they are the only eye professionals being referral pathways from primary or district and retain them in remote settings. trained inside the country. level to tertiary level means that eye • Limited career pathways and In 2010, there were 88 ophthalmic patients who are referred for specialist professional development options. nurses working in the public sector. The eye care locally and externally cannot be • A lack of prevention of blindness policy majority (74) were in primary and easily traced in order to track their guidelines, which means there is no secondary care settings where they progress and monitor their condition governance or coordination of work done functioned independently under the closely. As a result of poor contact and in the varied ophthalmic care settings. supervision of general (non-ophthalmic) communication, patients who are referred • A lack of well defined or harmonised facility and department managers. Some to centralised tertiary facilities do not take deployment and distribution of received remote supervision and support up these referrals. In some cases, ophthalmic nurses in the public sector. from ophthalmologists based at tertiary patients who do take up referrals do not hospitals, but this was minimal. Fourteen get to see the ophthalmologist they have Addressing the challenges nurses worked in tertiary hospitals under been referred to. This is due to irregular The Botswana Ministry of Health’s the direct supervision of an ophthalmol- opening times which are not communi- prevention of blindness unit has estab- ogist; they also scrubbed for minor and cated to patients. Another issue is the lished two tertiary centres of excellence major ophthalmic surgical procedures. large proportion of ophthalmologists who and a VISION 2020 LINKS partnership with Overall, most ophthalmic nurses (81%) resign or move on, due to the fact that a UK institution (Addenbrookes Abroad, worked in the urban or semi-urban areas they are usually employed on a contract Cambridge) in an effort to improve eye care inhabited by 61% of Botswana’s approxi- basis. services in Botswana. Capacity building mately 2 million people. The 39% of This breakdown – or lack – of connection workshops have been organised through people who live in the remote and isolated weakens the contact between the the partnership in order to enhance rural parts of the country were served by ophthalmic nurses, the ophthalmologists continuing professional development for only 16 ophthalmic nurses (18%). Eye and the community. ophthalmic nurses. Since 2013, about 17 services remain a challenge in rural areas ophthalmic nurses have been trained in due to difficult terrain and limited financial Challenges basic refraction, 15 in diabetic retinopathy and material resources. However, in many A recent study1 identified several challenges. screening and 13 in children’s vision cases, ophthalmic nurses have built screening. The training has strengthened • Working without the direct supervision strong teams and share resources, such networking among the ophthalmic nurses. of a specialist. as transport, to extend services to all They communicate quite often using • The absence of a well documented catchment areas within the district. communications technologies such as scope of practice, professional WhatsApp (an instant messaging appli- Supervision and support registration and job description for cation used on cell phones) and Facebook ophthalmic nurses, which results in their In all primary and district hospitals, the eye (a social networking platform) to share being assigned to do general nursing. unit forms part of the outpatient department. work experiences and support one another. The ophthalmic nurses are mostly managed The ophthalmic nursing training and supervised by the head of the outpatient programme at the Institute of Health department or facility. In some units, this Sciences (IHS) in Molepolole is currently setup has caused conflict because reviewing its curriculum in an effort to non-ophthalmic managers are not aware Chatawana Molao upgrade the advanced diploma programme of the importance of eye care services or to an honours degree, and to increase have not fully understood the role and enrolment from 12 to 15 candidates (every job description of the ophthalmic nurses. 2 years). It is also anticipated that the Integration of ophthalmic services curriculum will include training in planning within mainstream health services is and managing eye care services. minimal, and efforts have begun to train Plans and advocacy to develop policy general nurses and community-based guidelines on the deployment and scope health care assistants in primary eye care of practice of ophthalmic nurses are in order to strengthen collaborations and ongoing, and draft job descriptions have been developed to spell out their roles. increase the availability of eye services. This will mean that ophthalmic nurses will Referral pathways be better recognised and supported in their role within the broader health system. Ophthalmic nurses form a central referral link for optometry services in both urban Reference 1 Molao, C, 2010. Situational Analysis of Ophthalmic Nursing and rural settings, as they are the main Ophthalmic nurses are involved in Services in Botswana. MSc Public Health for Eye Care. public sector eye care providers. They are school health screening in Botswana London: London School of Hygiene and Tropical Medicine.

32 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. Case study: Encouraging nurses to develop skills and confi dence in Indonesia Widya Prasetyanti tells the not traditionally included in planning or story of Henny Nurjanah, a team meetings. As a result, nurses can general nurse who has been remain under-valued and their consid- working with Helen Keller erable skills and experiences can International at Balai Kesehatan Mata remain under-utilised. 2 Building a team requires clear planning

Masyarakat, a community eye health ©HKI/Widya Prasetyanti centre in East Java, Indonesia, since 2010. and direction – or key players could be omitted, as they will not put themselves As part of Henny's training in her new job, forward. she was invited to take part in a training 3 With correct training and support, nurses module on the early detection of eye Henny Nurjanah uses Lea symbols to are more confident and are valuable disorders among children. Initially, she assess a child's vision staff members who can deliver key work. lacked confidence as she had never sat 4 Involving all staff in training materials together with doctors and eye health making friends, she also gained the trust development not only improves the experts before. She also felt she did not of her supervisor and colleagues in dealing quality of the materials (because have experience outside of her daily with patients, particularly children. “If the everyone brings additional experience duties as a nurse. However, she later intention is good, everything will go well, and expertise), it can also help to attended a meeting of the module organ- the main point is that I am happy working improve self-confidence, create isers where she gave input about how the with children and collaborating with HKI”, ownership and develop teams. module could be improved and her ideas she says. 5 Individual confidence is built up over were accepted, which pleased her. several events or training sessions – Following an internship on a paediatric Commentary do not expect staff to gain confidence ward, she was invited to help develop a This case study highlights some after one initial training event. module on how to train others to screen important issues around involving nurses 6 Given opportunities, most staff children’s eyes. The development team in the eye team, particularly when it members will develop and grow. consisted of ophthalmologists, refrac- comes to their professional development. However, nurses in particular may tionists, opticians/optometrists, nurses need to be encouraged by their and trainers from the provincial, city and 1 Nurses do not or automatically put managers and colleagues until their regency departments of health, and was themselves forward – they often lack own confidence develops sufficiently. supported by child eye health specialists. confidence, perhaps because they are Written by Sally Crook After several meetings, the team of 'master trainers' had to present the FROM THE FIELD modules that they had developed. She had never expected to take the Surgical nurses: key members of role of a master trainer. However, with encouragement from other members the operating theatre team of the team, Henny presented a session to the others, who gave her Heather Machin is an Throughout my career, I have had to feedback on how to improve her ophthalmic and ambulatory speak out, sometimes in disagreement presentation skills. surgery registered nurse who has worked with others, to ensure policy and patient in international development since 2007, and Although she only had fi ve people safety are adhered to at all times. attending her fi rst training session for is a consultant with the Fred Hollows Foundation in New Zealand. When I have a concern about other trainers, she felt very nervous. Over equipment, procedures, timetabling, time, however, her confi dence has grown. By working together as members of a competence or the needs of the She has found that her experience – as functional and mutually supportive eye patient, I have a professional duty to an eye nurse who deals with children care team, we can provide high quality, speak out and inform others in the every day – strengthens her teaching, as patient-focused eye care. Nowhere is health care team. it provides her with many practical this more important than in the operating This is also an essential component examples of eye disorders she can share. theatre, where the patient's life is in the of the World Health Organization’s Safe When she was asked if there were hands of the health care providers. Site Surgery processes where major changes in herself after becoming Nurses are trained to focus on the individuals in the team are checking a trainer of trainers, Henny said: “The fi rst needs and wellbeing of the patient. If their environment, equipment, time I delivered a training session, I they are valued and respected by the themselves and each other to ensure prayed that none of the participants other members of the surgical team, that patient care proceeds safely and would ask questions. But now, it is me they will be able to speak out when they as planned. who prompts, ‘Is there anything you want notice something that will put the patient’s Nurses also have a personal respon- to ask?’.” Her dealings with patients have health or safety at risk. Not only will sibility to ensure they are reviewing their also changed. “Now, my delivery and tone patient safety improve, but so too will own work area, that they take part in of voice are a bit different. I am more the outcomes and patient satisfaction. any improvements, that they are patient and more detailed when As an advocate for patient care, I am participating in their own continual explaining something’’, she said. acutely aware that my role is to protect professional development and that they Henny has gained a lot by working at the patient from harm and to ensure a safe are maintaining knowledge of current the eye health clinic for children. In environment for the patient and colleagues. policy at their workplace. addition to increasing her knowledge and

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 33 article distributed under the Creative Commons Attribution Non-Commercial License. EXCHANGE Ophthalmic clinical officers: developments in Uganda

Godfrey Kaggwa continuing professional development Senior Ophthalmic Clinical Officer and workshops which most eye care workers outgoing President of the National Association of Ophthalmic Clinical attend. OCOs are represented at the

Officers and Cataract Surgeons, Godfrey Kaggwa National Prevention of Blindness Kampala City, Uganda. Committee and its technical arm at the [email protected] Ministry of Health. Background NAOCOCS has identified the following priorities for action: The population of Uganda is estimated to be over 33 million, with a prevalence of • creation and establishment of posts for blindness of about 1%. senior and principal OCOs at district level The following eye team members • promotion or better remuneration for OCOs deliver eye care services at different An OCO refractionist (right) with a patient who have qualified as cataract surgeons, levels. refractionists or low vision therapists complicated refractions are referred to • a review of the OCO training curriculum • Tertiary level: ophthalmologists (there optometrists. They review patients after to ensure it meets international and are about 40 in the country) and ophthalmic operations, perform extra-ocular surgery, regional standards and is relevant to nurses (there are two), working at assist surgeons in theatre, and conduct each country’s current eye care needs national and regional referral hospitals. eye care outreach to schools, rural parts of • improving community involvement in • Secondary/district level: ophthalmic the community and remote health facilities. eye care services clinical officers (OCOs). There are over At district level, OCOs coordinate eye • improving eye care data collection, reporting, 200 in the country. care services (including planning and analysis and utilisation at all levels. • Primary level: nurses, midwives and other budgeting) and also train and supervise health workers who are trained in eye other eye care personnel. Reference care and who work at health centres; they 1 Palmer J, Chinanayi F, Gilbert A, et al. Mapping human resources for eye health in 21 countries of sub-Saharan are known as primary eye care workers. Challenges Africa: current progress towards VISION 2020. 2014, • Community level: community health An OCO can become a senior and then a Human Ressources for Health, In review. workers (trained volunteers) who work principal OCO. This is, however, only in village health teams to provide health available to OCOs working at regional services at household level. level. OCOs working at district level can be OCOs in Africa promoted within general medicine; There is an existing referral system, with a Ingrid Mason however, they can then be CBM Regional Director Central Africa good degree of teamwork, sent to any health facility across all the levels. ‘The majority of Ophthalmic clinical officers (OCOs) were (sometimes to lead such Clinical officers or introduced into East and Central African OCOs work in a facility), where they will Uganda Registered Nurses health worker government schemes in have very little time to (URN) can undergo a the mid-1980s. Given the desperate rural settings, practice ophthalmology. one-year diploma in shortage of ophthalmologists, their OCOs can specialise as ophthalmology (offered at where there is no main purpose was to identify and treat cataract surgeons, refrac- the Jinja School for OCOs patients with common eye conditions. tionists or low vision since 1989) in order to ophthalmologist’ A similar cadre, the Technologiste workers; however, these qualify as an OCO. The Superior d’Ophthalmologie (TSO) was skills are not formally recognised within qualified OCO practices with the super- later introduced in several Francophone the existing government public service vision of an ophthalmologist attached to countries in West Africa for much the structure. Specialist OCOs therefore miss the nearest regional referral hospital. same reason. out on promotion and any accompanying The majority of OCOs work in rural settings, OCOs and TSOs remain the backbone salary increments. where there is no ophthalmologist. of the eye health workforce in many Other challenges include: According to the VISION 2020 targets, countries in East, Central and West there should be ten OCOs or ophthalmic • lack of funding for outreach activities Africa. They are primarily deployed in nurses per million population. This is not and supervision (particularly for OCOs secondary health care units. They see patients referred from the community being achieved, however, as there are working in remote areas) and refer patients with complicated currently only 6.3 OCOs per million • ageing equipment problems to the tertiary setting. population.1 By 2020, Uganda will be • lack of funding and opportunities for In the district or secondary health even further away from meeting this continued professional development. care setting, OCOs and TSOs work target, as the population growth is alongside the other eye health workers exceeding the growth in the number of New developments such as ophthalmic nurses, optome- OCOs and mid-level personnel.1 OCOs in Uganda are organised in a regis- trists, refractionists and low vision tered association called the National Core activities of therapists as a comprehensive eye Association of Ophthalmic Clinical Officer health team. In many countries, the ophthalmic clinical officers and Cataract Surgeons (NAOCOCS). The OCO and TSO remains a valuable team In the rural areas, OCOs refer patients association addresses coordination, member who is able to independently with complicated clinical problems to governance and the social concerns of manage many eye conditions. ophthalmologists and those requiring OCOs. The association organises annual

34 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. aPort

CLINICAL SKILLS How to test for the red reﬂ ex in a child

Examination of pupil reflections, also most serious of which is retinoblastoma. the retina. It cannot be used, however, to known as the red reflex text, can reveal It is essential to test the red refl ex identify causes of poor vision related to problems in the cornea, lens and after birth, at the age of six weeks and retinal or optic nerve damage, such as sometimes the vitreous, and is particu- also during routine consultations or when retinal dystrophy or optic atrophy. For this, larly useful in young children. These parents are concerned about the child's appropriate referral is needed. photographs show what can occur in the vision or the appearance of her or his eyes. Note: A dim red refl ex may reveal an case of certain major eye conditions, the The test can alert us to large lesions in unequal or high refractive error.

Procedure • The red reflex is much easier to see in a darkened room, so

Heiko Philippin switch off the lights, draw the curtains or ask the parents and child to accompany you into a room which does not have a window. • Use a direct ophthalmoscope with the lens power set at '0'. Make sure the batteries are charged. • Sit about half a metre (50 cm) away. Hold the ophthalmoscope close to your eyes. • Encourage the child to look at the light source and direct the light at the child's eyes individually and together. You should see an equal and bright red reflex from each pupil. • Pay attention to the colour and brightness of the red reflex. It should be identical in both eyes (Figure 1). Any difference between the eyes, an absence of the red reflex or an abnormal colour (Figures 2–4) may indicate a serious illness. NOTE: The precise colour of the red reflex will depend on the degree of pigmentation in the eye. To determine whether the red The red reflex is easier to see in a darkened room reflex is normal, comparison with the red reflex of a parent of the child may be helpful. If you are not sure whether the reflex is normal, ✔ ✔ dilate the pupil for a complete examination. Heiko Philippin Figure 1. The normal red reﬂ ex

1 ✔ ✘ Figure 2. Right eye: the normal red reﬂ ex. Left eye: the absence of a red reﬂ ex is abnormal and could indicate a serious condition. Refer the child to a specialist

✔ ✘ Figure 3. The wrong colour in a red reﬂ ex is abnormal and could

Heiko Philippin indicate a serious condition

3a. The child in this image has a cataract in the left eye. Refer the child to a specialist 3a ✔ ✘ 3b. The child in this image may have retinoblastoma in the left eye. Refer the child to a specialist

Figure 4. The red reﬂ ex is less bright in the left eye and the corneal ✔ ✘ reﬂ ection is not centred. This is a squint, which may be the result of a serious underlying condition. Even if there is no underlying condition, squint may lead to amblyopia (loss of function in the visual cortex), which is irreversible if not treated urgently. Refer © Childhood Eye Cancer Trust 4 the child to a specialist

Adapted from the poster: ‘See RED’ produced by JR Ainsworth, UK National Retinoblastoma Service, Birmingham, UK and the Childhood Eye Cancer Trust. www.chect.org.uk First published in the Community Eye Health Journal French edition, Issue 8, 2011.

36 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. aPort

EQUIPMENT CARE AND MAINTENANCE Sponsored by the IAPB Standard List: a great platform to source and compare eye health products www.iapb.standardlist.org Understanding your operating microscope’s assistant scope and beamsplitter

Ismael Cordero In the case of a 50:50 beam Figure 1 Assistant binoculars Clinical Engineer, Philadelphia, splitter, the amount of light is split USA. Main binoculars equally between the main binoculars [email protected] Eye pieces and the attachment(s), which is what In a previous issue (Community Eye is needed when an assistant scope Health Journal Vol 27 Issue 85) we is used. reviewed ophthalmic operating A 70:30 beam splitter is used for microscopes. We learnt that they Rotating photography and video. In this case, often include a second set of binoc- prism 70% of the light is directed to the ulars, part of what is commonly main binoculars while the other 30% called an assistant or teaching is directed to the attachment where Assistant/teaching scope scope, which allows another person the camera is connected. to view the operation at the same Binocular The assistant scope, camera and tube time as the surgeon in charge. other attachments connect to the beam This is made possible by the beam Beam splitter splitter by means of a coupler that is splitter, which connects the assistant made to fi t the port of a particular scope to the main visual path of the model of beam splitter (Figure 3). operating microscope. The optical components of the assistant scope Useful tips (Figure 1) are almost identical to the main • It is important to note that scope and consist of either fi xed or Figure 2a beam splitters, assistant scopes and inclinable binoculars. These have other attachments are made for specific adjustable eyepieces for users with models of operating microscopes. For refractive error and a stereo observation instance, if you have a Zeiss model tube that makes it possible to adjust the microscope you will need a compatible binoculars to a position comfortable for the Zeis model beam splitter and assistant assistant surgeon or trainee. scope. Many beam splitters and other In modern microscopes, the magnifi- attachments made by one manufacturer cation and focus of the assistant scope will not work on other brands of match those of the main scope and are microscopes. controlled by the surgeon in charge, using Figure 2b • You may need to adjust the balance and the foot pedal. tension settings of the microscope The assistant scope has a rotating prism suspension arm following the addition of that allows the observer to orient the fi eld of beam splitters, assistant scopes, view. For observation or teaching, the cameras and other accessories. Also, field of view of the assistant scope the surgeons may need to get used to coincides with that of the main scope, the weight and balance of the additional used by the surgeon. For example, if the equipment. There is a limited amount of surgeon says ‘See the spot at 3 o’clock’, weight a suspension arm can effectively the observer must also see it at 3 hold. This weight is normally o’clock. For an assistant surgeon, labeled on the suspension arm and, the field of view of the assistant Figure 3 if not, this information can be found scope must be oriented to match the Main binoculars in the microscope’s user manual. assistant's own position. The position • If you are considering obtaining an of 3 o’clock as seen by the main Camera mount operating microscope for surgeon would thus be at the Open port microsurgical training, it is an 6 o’clock or 12 o’clock position for the absolute necessity to have an assistant, depending on whether she/ Port dust cap assistant or teaching scope. he is located to the right or left of the Without it, microsurgical training main surgeon. cannot be effective. The beam splitter splits the light • You can find refurbished assistant path to allow a video camera, digital scopes and beam splitters that camera, or an assistant scope to be cost much less than new units. attached to the microscope. Beam • If you are not planning to use an splitters can have one port, or adapter assistant scope or camera, or to Beam splitter (Figure 2a), or two ports (Figure 2b). video record the operation, it is Each beam splitter has a specifi c Coupler always good to remove the beam split ratio such as 50:50 or 70:30. splitter and assistant microscope, The split ratio is marked on the body Camera mount camera or other attachment so of the beam splitter. that the image brightness is better.

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 2627 ISSUE 8486 | 20132014 37 article distributed under the Creative Commons Attribution Non-Commercial License. TRACHOMA UPDATE SERIES The Trachoma Update series is kindly sponsored by the International Trachoma Initiative, www.trachoma.org

The SAFE strategy for trachoma control: poised for rapid scale-up

Paul Emerson resourced – to implement the SAFE Nigeria, Malawi, Mozambique, Solomon Director: International Trachoma strategy in 541 districts, a 55% increase Islands, Guinea, Yemen, and Zambia. Initiative, Decatur, USA. [email protected] since 2010. Several other countries, such as Nepal, In 2012 the International Coalition for Sudan, Burkina Faso, Mali, Niger, In 1998, all member states of the United Trachoma Control (ICTC) produced a Cameroon and Guinea-Bissau, are Nations signed up for the Global Alliance strategic plan that laid out actions to already implementing at or near national for the Elimination of Blinding Trachoma take, and milestones to meet, in order to scale (where internal security allows it). by 2020 (GET 2020) through World achieve global elimination of blinding With the confl uence of data, fi nancial Health Assembly resolution 51.1. This trachoma by 2020.2 This included a list of resources, donated drugs, and – most called on member states to complete the confi rmed trachoma endemic countries, importantly – political will to get the job mapping of blinding trachoma in the and another 1,293 districts suspected to done by the endemic countries, the GET remaining endemic areas and implement be trachoma endemic, which needed to 2020 Alliance is poised for the required the SAFE strategy for trachoma control. be mapped. scale-up, making the prospects for Compiled data held by the International Sightsavers, in collaboration with ICTC achieving the target of freeing the world of Trachoma Initiative (ITI) and the World partners, secured funding from the British blinding trachoma that much more real. Health Organization (WHO) indicated that, government for the Global Trachoma by 2010, as many as 1,090 districts in Mapping Project (GTMP).3 Since the start References 1 Available at: www.cartercenter.org/resources/pdfs/ 36 of the estimated 57 trachoma of this project, 1,061 districts repre- news/health_publications/itfde/ITDFE- endemic countries had been mapped. senting a population of 124 million summary-101210.pdf 2 Available at: www.trachomacoalition.org/node/713 Moreover, the full SAFE strategy, including people in 20 countries have been 3 Solomon A, Kurylo E. The Global Trachoma Mapping mass drug administration with oral mapped4 and the GTMP has plans to Project. Community Eye Health Journal. 2014;27(85): 18. azithromycin (Zithromax®) donated by survey an additional 862 districts (including 4 Read more at: www.trachomaatlas.org Pfizer, was underway in 347 districts. districts in 11 additional countries). Global progress in trachoma mapping The purpose of the GTMP is to provide The SAFE strategy for and implementation of the integrated the data required to chart the progress of trachoma control SAFE strategy (see panel) was reviewed the WHO-led GET 2020 Alliance, and to by the International Task Force for indicate which countries and districts Surgery: For patients with severe Disease Eradication (ITFDE) in 2010.1 require the greatest investment. Impact blinding trachoma, eyelid surgery is The ITFDE concluded that the elimination assessment data reported to ITI by the needed to reposition turned-in of blinding trachoma was achievable and national programmes demonstrate that eyelashes (trichiasis) so they do not that signifi cant progress had been made. where trachoma is entrenched (baseline scrape against the cornea. However, it also noted that the pace and prevalence of TF in children aged 1–9 Antibiotics: an annual dose of oral scale of interventions needed to be accel- years is 30% and above), even 5 years of azithromycin or topical tetracycline is erated in order to reach these goals. intervention with SAFE is insuffi cient to used to treat infection and decrease Progress in the scale of implementation achieve the elimination goals of reducing transmission in endemic districts. of the ‘A’ component of the SAFE strategy TF to less than 5%, and of reducing the Facial cleanliness: face washing from 2010 to 2014 is shown in Figure 1. prevalence of TT in the whole population helps to reduce transmission of In 2014, 25 trachoma endemic countries to less than 0.1%. These districts need to trachoma by discouraging have planned – and are adequately be immediately prioritised for urgent eye-seeking flies and washing away action and intensive intervention as we the bacteria they leave behind. Figure 1. Expansion in countries and are working against the clock to reach Environmental improvements, such districts receiving Zithromax® for elimination of blinding trachoma by 2020. as access to water and basic sanitation, trachoma elimination 2010–2014 The ICTC membership have worked tirelessly with funding organisations, and, reduce exposure and infection. Districts Countries with generous support from the Queen 600 25 Elizabeth Diamond Jubilee Trust, USAID,

approval What is ‘scale-up’? ® DFID, Lions Clubs International 500 Foundation, the Conrad N Hilton ‘Scale-up’ means making a special 20 Foundation and others, anticipate being effort to do something in a bigger way able to bring in US $180 million in new 400 in order to improve some aspect of a funding for trachoma implementation 15 population’s health. Approaches to over the next 5 years. Pfi zer, which scaling up the SAFE strategy include 300 donates the antibiotic used in mass drug improving the infrastructure for distri- 10 administration, is also preparing to bution of azithromycin, increasing the 200 donate over 100 million doses a year number of qualified surgeons who can Recipient countries starting in 2015. provide trichiasis surgery, and enhancing 5 100 Rapid scale-up for maximum impact is the promotion of facial cleanliness, ongoing, or planned, in Ethiopia, Kenya, hygiene and environmental change in Uganda, Senegal, Tanzania, Chad, 0 0 order to interrupt transmission.

Number of districts in all countries with Zithromax 2010 2011 2012 2013 2014 Central African Republic, South Sudan,

38 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 © The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License. CONTINUING PROFESSIONAL DEVELOPMENT (CPD) Test your knowledge and understanding

This page is designed to help you test your own understanding of the concepts covered in this issue and reflect on what you have learnt. We hope that you will also discuss these questions with your colleagues and other members of the eye care team, perhaps in a journal club. To complete the activities online – and get instant feedback – please visit www.cehjournal.org

1. Good team work in eye care requires: True False Picture quiz Communication pathways, both among personnel and between the a. different levels of service

b. A clearly defi ned hierarchy

c. Protocols to support the team, e.g. referral protocols

d. An incentives and promotions structure

2. Leadership of the eye team means: True False Setting a direction and vision for the team, and fostering the right a culture and values A 3 year-old child in Africa presented with b Problem solving using existing systems and procedures a history of sore eyes following an illness with fever. There was no history of injury. c The same as management of an eye team Both eyes had similar findings. Motivating people by identifying opportunities for them to learn and 1. What is the diagnosis? (Select one.) d practise new skills a. Ophthalmia neonatorum b. Fungal keratitis

ANSWERS

functioning. It requires innovative approaches and motivation to do the right things. things. right the do to motivation and approaches innovative requires It functioning. c. Episcleritis

A leader focuses on the people in the team and how they should/could be developed to enhance its its enhance to developed be should/could they how and team the in people the on focuses leader A

d. True. True. d. d. Herpes simplex ulcer

ensuring that teams have the practical support they need, but are supported by managers in order to achieve this. this. achieve to order in managers by supported are but need, they support practical the have teams that ensuring

are focused on ensuring that each day functions well; i.e. managers maintain a team. Leaders have a role in in role a have Leaders team. a maintain managers i.e. well; functions day each that ensuring on focused are e. Use of traditional eye medicines

their eye on the vision and direction of the team; i.e., leaders are responsible for developing the team. Managers Managers team. the developing for responsible are leaders i.e., team; the of direction and vision the on eye their

Leaders have have Leaders False. c. protocols, whereas a leader with be focused on the outcome and impact of service delivery. delivery. service of impact and outcome the on focused be with leader a whereas protocols, 2. Which of the following are known risk

A manager is focused on procedure-driven activities, e.g. accounts or or accounts e.g. activities, procedure-driven on focused is manager A False. b. mission for a programme. programme. a for mission factors for the answer to question 1?

will focus on planning, budgeting and setting up management systems. Good leaders foster clear values and set a a set and values clear foster leaders Good systems. management up setting and budgeting planning, on focus will (Select all that apply.) the focus is on inspiring people and ensuring that the attention is on the bigger picture, whereas managing a team team a managing whereas picture, bigger the on is attention the that ensuring and people inspiring on is focus the

In leading a team, team, a leading In True. 2.a.

team whereas a training workshop for a surgeon may only support her or his career. his or her support only may surgeon a for workshop training a whereas team a. Measles

motivating team work. For example, feedback on cataract outcome monitoring will motivate and encourage the the encourage and motivate will monitoring outcome cataract on feedback example, For work. team motivating

Incentives and promotions provide individuals with a career pathway, but cannot be regarded as central to to central as regarded be cannot but pathway, career a with individuals provide promotions and Incentives d. False. False. d. b. HIV infection

A protocol is a standardised guide that will ensure that quality of services is reproducible. reproducible. is services of quality that ensure will that guide standardised a is protocol A True. c.

teamwork diffi cult. diffi teamwork c. Malaria

imbalances. People who feel that they have less power may be unwilling or unable to communicate, which makes makes which communicate, to unable or unwilling be may power less have they that feel who People imbalances.

A hierarchy can have inherent power power inherent have can hierarchy A False. b.

is essential to keep the information fl owing between team members. members. team between owing fl information the keep to essential is d. Iritis

of useful contacts and having SMS update systems between the different levels of service delivery. Communication Communication delivery. service of levels different the between systems update SMS having and contacts useful of e. Malnutrition

This can be done through regular direct communication (including meetings) with the team, compiling lists lists compiling team, the with meetings) (including communication direct regular through done be can This True. 1.a. 3. Which of the following is the first line recommended treatment for the answer Time to reﬂ ect to question 1? (Select one.) a. Prednisolone drops 1 How relevant to your 3 As a result of reading this issue, will day-to-day work was the material you be changing your practice/teaching/ b. Chloramphenicol ointment covered in this issue of the leadership/policies/management? c. Acyclovir ointment Community Eye Health Journal? Yes / No (circle as appropriate). d. Natamycin ointment Please select one: 4 If ‘Yes’, give examples of planned e. Atropine drops Extremely relevant changes in the box below, in your own

Relevant notes or in your own continuing ANSWERS

professional development portfolio. ulcer. geographic

Steroids are contraindicated in dendritic/ in contraindicated are Steroids

Neither relevant nor irrelevant Note:

Irrelevant HSV. by caused epithelium the of ulceration corneal

Extremely irrelevant for treatment suitable a is days 10 for day per times

Recommended treatment: c. Acyclovir ointment fi ve ve fi ointment Acyclovir c. treatment: Recommended 3. 2 How much of what you read in infection. HSV for factors risk also are these of

this issue was new to you? both so immunity, suppress can malnutrition and infection immunity, so both are risk factors for HSV infection. HIV HIV infection. HSV for factors risk are both so immunity,

Please give a percentage: suppress and fever cause can malaria and Measles

. Risk factors: a, b, c, and e are possible. possible. are e and c, b, a, factors: Risk . 2 (HSV). virus

dendritic/geographic ulcer caused by herpes simplex simplex herpes by caused ulcer dendritic/geographic

Diagnosis: d. Herpes simplex ulcer. This is a large large a is This ulcer. simplex Herpes d. Diagnosis: 1.

Visit www.cehjournal.org to complete the questions on this page online.

© The author/s and Community Eye Health Journal 2014. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 39 article distributed under the Creative Commons Attribution Non-Commercial License. NEWS AND NOTICES

Useful resources: Community Eye Health Institute, Visit our updated website teamwork for eye care University of Cape Town, South Africa. Now available for Training Short courses and MSc. Contact Zanele mobile and tablet too! A World Health Organization (WHO) Magwa, Community Eye Health Institute, www.cehjournal.org module on supportive supervision is University of Cape Town, Private Bag 3, Subscribe to available for free download from: Rondebosch 7700, South Africa. our mailing list: www.who.int/immunization/ Tel: +27 21 404 7735. Email: www.cehjournal.org/subscribe documents/MLM_module4.pdf [email protected] Lions Medical Training Centre, CEHJ online article MSc and short courses in human This issue contains one article which is resources for health are available at Nairobi, Kenya Small Incision Cataract Surgery (SICS). available online only: 'Near visual acuity in Queen Margaret University, Edinburgh, an inner city Hispanic community: under- Scotland, UK. Visit www.qmu.ac.uk Write to: The Training Coordinator, Lions Medical Training Centre, Lions SightFirst standing the barriers and benefits of Courses in management are available at Eye Hospital, PO Box 66576-00800, correction'. Visit www.cehjournal.org to Aravind Eye Care System in India. Visit Nairobi, Kenya. Tel: +254 20 418 32 39 read it or download the PDF. Available on www.aravind.org/aurovikas/ the next Community Eye Health Update CD. Kilimanjaro Centre for Community WebTrainingCalendar.aspx Ophthalmology International Write to us Visit www.kcco.net or contact Genes Further reading Share your questions and experi- Mng’anga at [email protected] and/or ences with us at exchange@ Garg P, Reddy S, Nelluri C. training [email protected] the eye care team: principles and cehjournal.org. Find out more at practice. Middle East African Journal of Paediatric cataract DVD www.cehjournal.org/author-guidelines/ Ophthalmology, 2014; 21(2). This paediatric cataract surgery DVD, by BCPB grants Araujo E, Maeda A. 2013. How to Albrecht Hennig, is for ophthalmologists recruit and retain health workers in undertaking cataract surgery on children The British Council for rural and remote areas in developing on a regular basis. To receive a free copy, the Prevention of countries. Available from: http:// send your address details and a brief Blindness Research documents.worldbank.org/curated/ description of the service you provide to: Grants Programme en/2013/06/17872903/recruit-retain- Anita Shah, International Centre for Eye has the following health-workers-rural-remote-areas- Health, London School of Hygiene and grants available: developing-countries Tropical Medicine, London WC1E 7HT, • Fellowships leading to the award UK. [email protected] of PhD or MD: up to £63,333 per Courses year over 2 or 3 years. ICO fellowships • Research grants – up to £60,000. London School of Hygiene and • Research mentorship awards – up Tropical Medicine, London, UK One-year and 3-month fellowships are to £15,000. MSc Public Health for Eye Care, starting available to ophthalmologists working in September 2014. To apply, visit low- and middle-income countries. Visit Closing date: 10 October 2014. www.lshtm.ac.uk/study/ masters/ www.icoph.org/refocusing_education/ Please visit www.bcpb.org mscphec.html fellowships.html or contact Diana Bramson, Administrator, BCPB, 4 Bloomsbury German Jordanian University, Subscriptions Square, London WC1A 2RP. Amman, Jordan Send your name, occupation, Tel: 44 (0) 20 7404 7114 Professional diploma and MSc in Vision email and home address to: Anita or email: [email protected] Rehabilitation. For more information, Shah, ICEH, London School of BCPB is a registered charity – visit http://tinyurl.com/rehabcourse. Hygiene and Tropical Medicine, London number 270941. Email: [email protected] WC1E 7HT, UK. [email protected] C ommunity Eye Health Next issue

Supported by: JOURNAL Clare Gilbert

The next issue of the Community Eye Health Journal is called Diseases at the back of the eye

40 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 EXCHANGE Near visual acuity in an inner city Hispanic community: understanding the barriers and benefits of correction

Thomas Wubben MSc/PhD student, College of Medicine, University of Illinois at Chicago, Chicago, USA. [email protected]

Gregory Wolfe Optometrist: Southern Arizona VA Health Care System, Southern California College of Optometry, Fullerton, USA.

Christopher Guerrero Physician: Department of Family Medicine, University of Illinois at Chicago, Chicago, USA.

Wanda Jettka Korcz Clinical instructor: College of Nursing, University of Illinois at Chicago, Chicago, USA.

David J Ramsey Vitreoretinal fellow: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, USA.

Presbyopia is age-related loss of accom- modation that gradually impairs near vision. Few studies have examined the burden of presbyopia in the United States of America (USA)1,2 and none have examined it in economically disadvan- taged or minority populations, in which there are increased rates of visual impairment and decreased use of eye Pilsen neighborhood, Chicago, IL care services.3,4 In our study, individuals ≥35 years of what they considered to be the barriers to or not at all were younger (50±6 years age who attended an employment fair having their near vision corrected. All 133 versus 56±9 years: p<0.01) and had sponsored by the Illinois Department of completed the questionnaires. better uncorrected near visual acuity Employment Services (IDES) in the Pilsen The 133 respondents ranged in age (>6/12 versus <6/15: p<0.05). Similar neighborhood of Chicago were invited to from 36–85 years old. Their average age associations were observed between undergo testing of their near vision and to was 55 years and 57% were female (74 uncorrected near vision and the perceived be fitted with reading spectacles, if out of 133). Over 70% (n=96, 50 male impact of reading spectacles on other needed. Individuals with bilateral visual participants and 46 female participants) tasks such as preparing meals, using impairment or blindness, as determined were unemployed. The average uncor- hand tools or sewing, as well as grooming, by both a history and a rected near acuity was shaving, or applying makeup. Neither screening examination ‘Employment status 20/50 (6/15). After employment status nor gender had a with a penlight (to receiving reading statistically significant impact on the exclude gross abnor- correlated with the spectacles, 80% perceived benefits of reading spectacles. malities) were given achieved a near acuity of With regards to barriers to obtaining information and frequency with ≥20/25 (6/7.5). near vision correction, 49 per cent instructed to seek an which patients Uncorrected near acuity (n=64) of the respondents said that the eye examination. In the <20/50 (6/15) was cost of spectacles was a disincentive and remaining individuals, accessed an eye associated with greater 48 per cent (n=63) said that the lack of near acuity was difficulty reading print availability of an eye care professional measured at 40 cm, care professional’ (p<0.02) and perceived greatly impeded them from obtaining and 133 people were worse eyesight spectacles (Table 1). Considering that a identified as having functional presbyopia (p<0.0001) compared to those with store selling reading spectacles for US $1 (i.e., near acuity could be improved by at uncorrected near visual acuity of ≥20/50. was located next to the IDES office, this least one line by placing a plus lens in More than 98 per cent of respondents distribution of responses most likely front of either eye).5 After this inter- stated they could read. An improved reflects a lack of knowledge about the vention, the 133 individuals with ability to read was cited as the most condition and its readily accessible presbyopia were invited to complete a important benefit of reading spectacles, treatment. Many people who require near questionnaire based on the National Eye with minimal impact perceived on other vision correction can benefit from ready- Institute’s Visual Function Questionnaire. daily tasks (Table 1). Those who stated made or 'over-the-counter' reading They were asked about the benefits to that reading spectacles would impact the spectacles. These individuals should, them of correcting near vision and about task of reading print only to some degree however, undergo a full eye examination

41 COMMUNITY EYE HEALTH JOURNAL | VOLUME 27 ISSUE 86 | 2014 Table 1. Pereceived barriers and benefits to correcting near vsion

Percentage reporting perceived degree of impact (%)

Greatly Moderately Some Not at all

Barriera

Cost of reading spectacles (n=130*) 49.0 8.0 11.5 31.5

Employed (n=37) 46.0 2.7 18.9 32.4

Unemployed (n=93) 50.5 9.7 8.6 31.2

Availability of an eye doctor (n=131*) 48.0 6.0 9.0 37.0

Employed (n=37) 37.8 10.8 16.2 35.1

Unemployed (n=94) 52.1 4.3 6.4 37.2

Benefitb

Reading print (n=133) 82.7 10.5 5.3 1.5

Employed (n=37) 86.5 5.4 5.4 2.7

Unemployed (n=96) 81.3 12.5 5.2 1.0

Preparing meals, using hand tools, or sewing 47.4 15.0 12.0 25.6

Employed (n=37) 64.9 13.5 5.4 16.2

Unemployed (n=96) 40.6 15.6 14.6 29.2

Grooming, shaving or applying makeup (n=133) 30.8 10.5 10.6 48.1

Employed (n=37) 45.9 10.8 5.4 37.8

Unemployed (n=96) 25.0 10.4 12.5 52.1 a Degree to which each barrier was perceived to prevent correction of near vision. b Degree of impact of reading spectacles on selected tasks. * Three individuals from the overall study population did not provide answers to the cost barrier question and two individuals did not provide an answer to the question of availability of an eye doctor as a barrier Note: due to rounding, some rows may not add up to 100%. to check for other pathology or the effects than 64 per cent of respondents who spectacles. Health care providers should of systemic conditions such as diabetes were unemployed had similarly accessed also be educated about the increased or high blood pressure. care (p<0.05). rates of blindness and visual impairment Over two-thirds of the respondents In a country where services are in the African American and Hispanic (68 per cent) had been examined by an readily available and spectacles are populations so that they can encourage eye care professional at some point in affordable, nearly half of the participants and refer individuals in these population their lives, but only 30 per cent (n=40) were not aware that this was case. All of groups for regularly scheduled eye had been examined in the previous year. the participants would have benefited examinations. Our population was predominantly from a pair of reading spectacles. References Hispanic and African American. Our study is the first to examine how 1 McDonnell PJ, Lee P, Spritzer K, Lindblad AS, Hays RD. Considering that the rates of blindness presbyopia affects a resource-poor Associations of presbyopia with vision-targeted health- related quality of life. Arch Ophthalmol and visual impairment in these groups is population in the USA. The survey 2003;121:1577–81. significantly greater than that of highlights the need for continued efforts 2 Luo BP, Brown GC, Luo SC, Brown MM. The quality of non-Hispanic whites,3 this amounts to to ensure that economically disadvan- life associated with presbyopia. Am J Ophthalmol 2008; 145(4):618–22. suboptimal use of eye care services taged and minority populations gain 3 Munoz B, West SK, Rodriguez J, Sanchez R, Broman relative to the recommended guidelines access to eye care services and utilise AT, Snyder R, Klein R. Blindness, visual impairment and the problem of uncorrected refractive error in a for high-risk groups from the American them. Practical solutions include Mexican-American population: Proyecto VER. Invest Academy of Ophthalmology. outreach activities and education of Ophthalmol Vis Sci 2002; 43(3):608–14. Employment status correlated with the health care providers in low-resource 4 Baker RS, Bazargan M, Shahrzad BH, Calderon JL. Access to vision care in an urban low-income frequency with which patients accessed communities about the ease with which population multiethnic population. Ophthalmic an eye care professional. Whereas almost their patients may remedy their Epidemiol 2005;12:1–12. 5 Ramke J, du Toit R, Palagyi A, Brian G, Naduvilath T. 80 per cent of respondents who were prebyopic needs with inexpensive, over- Correction of refractive error and presbyopia in Timor- employed had seen an eye doctor, less the-counter, ready-made reading Leste. Br J Ophthalmol 2007;91:86–66.

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