Developed in partnership with the College of Pathologists of East, Central & Southern Africa and the British Division of the International Academy of Pathology, a 30-month pilot of the LabSkills Africa model has just been completed. Below we describe the differences that the initiative has made.
I am sitting in the busy office of Jonathan Whande, the Chief Medical Scientist at Parirenyatwa Group of Hospitals in Harare, Zimbabwe. ‘Pari’, as it is often called, started out as a small hospital in 1890. Additional small satellite health facilities were built within the complex and by 1963 this ‘group’ of hospitals included the Salisbury Central Hospital, Princess Margaret Hospital, Lady Chancellor Maternity Hospital, an orthopaedic centre and an outpatient clinic. By 1974, the Andrew Fleming Hospital was commissioned and when the complex was renamed ‘Parirenyatwa Group of Hospitals’ after Independence, the names of the health facilities were also changed in order to reflect the new political order. Today, Pari is the largest hospital complex in Zimbabwe, with a capacity of 1800 beds and a workforce in excess of 2000.
Whande describes one of the positive, unintended consequences of the LabSkills Africa initiative at Pari:
“LabSkills has brought several changes in the culture here in the laboratory. A good example is the working relationship between laboratory scientists, technologists and pathologists. Prior to LabSkills, we all had a very strained professional relationship; this project has forced us to work closely together, resulting in a considerable improvement in our working relationship.”
Implementing LabSkills Africa: what we did
LabSkills Africa was piloted in 20 laboratories in Kenya, Uganda, Tanzania, Zambia and Zimbabwe. In total, these laboratories serve a combined population of 110 million people and perform more than 1.7 million tests annually. Over a period of 30 months, we worked with country and regional partners to train and mentor 100 pathologists, biomedical scientists, laboratory technologists and technicians across the 20 laboratories, to improve their diagnostic testing and services. The pilot focused on improving the following key tests:
- rapid HIV
- rapid malaria
- peripheral blood film
- haemoglobin/haematocrit estimation
Each laboratory was assessed in order to:
(i) identify areas where improvement was needed
(ii) develop and implement an action plan
(iii) monitor laboratory progress
(iv) devise and deliver onsite training within the laboratory (where possible) or create additional workplace-based assignments in order to address the need
(v) evaluate the impact of the improvement action on
- the health worker trained
- the laboratory service
- the laboratory user (i.e. clinician, etc.)
- the patient.
We also recruited and deployed 30 volunteer pathologists, clinical scientists and biomedical scientists, who acted as mentors and trainers. During the pilot, we:
- facilitated the attendance of 150 delegates and mentors to training retreats in Kenya and Tanzania
- facilitated 33 mentor visits to participating laboratories
- developed two laboratory capacity-building courses covering leadership, quality management and bench competencies, in partnership with the University of Stellenbosch in South Africa and the Aga Khan University Hospital
in Nairobi, Kenya
- facilitated three external quality assurance (EQA) assessment exercises
- implemented five national laboratory improvement projects, which focused on:
– improving quality and accuracy of HB estimation results and reporting
– point-of-care testing (POCT) for HIV
– improving standards and practices for Malaria diagnosis
– strengthening the clinician/laboratory interface
– standardising methods and equipment validation for HIV, TB, peripheral blood film, HB, urinalysis and malaria
- established the LabSkills Africa Recognition Awards (LARA) scheme in order to acknowledge and showcase improved performance, as well as examples of best practice and innovation.
Kenya: Building capacity in the face of challenges at the Garissa Provincial General Hospital
Situated in the North Eastern region of Kenya, Garissa Provincial General Hospital is the largest in the province. The hospital faces a number of challenges including:
- its location in an area consistently in international news for an alarming amount of terrorist attacks
- lack of infrastructure
- low staff numbers
- high staff turnaround
- low medicine stock.
Due to increasing concerns about the security situation in Garissa, no international volunteers could be deployed there. This obstacle was overcome by recruiting Kenyan volunteers who were able to visit the area safely and provide hands-on bench training to the Garissa team, while international volunteers provided support using online tools.
As a result, LabSkills Africa successfully trained and mentored laboratory professionals at Garissa PGH, building their capacity in a number of areas including writing and updating important laboratory documents, e.g. standard operating procedures (SOPs). At the beginning of the project, the laboratory did not have any SOPS. Now the Garissa team has written and implemented 30 new SOPs.
Hussein Aden, Laboratory Manager, at Garissa Provincial General Hospital said:
“Our participation in the LabSkills technical skills course was a revelation. It was like a sharp finger of lightening in the forest. We had read SOPs before, but did not understand how to use them. During the course, mentors explained that SOPs are a valuable store of technical knowledge, which should be used to teach staff how to run tests properly and which can be modified to include new procedures when we find better ways of doing things. Now we have good SOPs that we use every day in our normal analytical work. Our test results have improved, we use fewer reagents and have reduced our waste. As our analytical results have improved, the confidence of doctors in our work has also increased. It has been a wonderful experience.”
Tanzania: Sowing seeds for inter-country/inter-region networking
LabSkills training retreats brought together health professionals from across East, Central and Southern Africa, setting the stage for the development of inter-country and inter-regional networks.
When Mayala Lushina, the Quality Officer at Muhimbili National Hospital, Tanzania, could not find a supplier for a particular reagent, he utilised his list of LabSkills Africa contacts. First he contacted laboratory staff at the Aga Khan University Hospital in Nairobi, Kenya, and when they explained that they were also having difficulties locating a supplier, he sent a message to the laboratory manager at Kilimanjaro Christian Medical Centre, Tanzania, who gave him the name a of supplier which he shared with the staff at the Aga Khan University Hospital.
On another occasion, Mayala wanted advice on the protocol for measuring sample turnaround times, so he consulted another LabSkills Africa participant, Donhadzo Ndoro, at Chinhoyi Provincial Hospital in Zimbabwe.
“I am very excited about being able to use the LabSkills network. If you hide yourself when you are having problems, you will not solve your problems, but when you have good neighbours they will help you. It is wonderful to have these new friends.”
Uganda: Supporting national health strategy plans
Due to the high prevalence of fevers in Uganda in the early 1990s, a pre-2008 Ministry of Health (MoH) directive encouraged doctors to treat all patients presenting with fever for malaria. As a result, doctors moved away from the practice of relying on laboratory tests to make a diagnosis for malaria to relying on a clinical diagnosis. In 2011, the MoH changed its malaria case management guidelines and recommended that doctors test all fevers before treatment.
In Mubende Regional Referral Hospital, clinicians used to prescribing anti-malarial drugs at first diagnosis were reluctant to wait for tests to confirm their diagnosis. They complained about the length of time it took for laboratory staff to run tests and deliver results. In an effort to respond to these concerns, the lab embarked on a programme of improving their proficiency in malaria testing and updating their quality management systems. Laboratory staff attended LabSkills Africa training retreats and were assigned course mentors who provided support in implementing these initiatives.
Juliet Nayiga, a laboratory technologist at Mubende, was appreciative of the training on peripheral blood smears, which she received as part of the project.
“Not only could I count the parasites in a patient’s blood, I was suddenly transformed into a new world, one were I could see the parasites so clearly I could distinguish the four types”.
A 2015 Mubende hospital report indicates that 93.5% of all patients now presenting with suspected malaria are tested before a course of treatment is prescribed.
Zambia: Changing culture and practice in Kafue District Hosptial
Kafue District Hospital is located in Lusaka province in Zambia and serves an estimated district population of 150,217 people.
Dr Mercy Imakando, the Hospital Chief, said:
“Before the laboratory staff went for their LabSkills training, there was strife in the hospital. Patients waited a long time for results, mothers were reluctant to attend antenatal clinics and samples occasionally just went missing”.
Prior to the intervention LabSkills Africa, the laboratory had never conducted a clinician satisfaction survey. As one of their designated LabSkills Africa assignments, the laboratory conducted a user satisfaction survey aimed at the clinicians and nurses. Judy Mwanza, laboratory technologist and LabSkills course participant, was in for an unpleasant surprise.
“I was quite shocked by their replies. I thought we were doing well, but the doctors weren’t happy”.
She rallied the lab staff and they worked hard to improve things. A key innovation was the establishment of a sample receipt register for nurses to sign samples in when they were dropped off at the lab. LabSkills supported this initiative by supplying the laboratory with an electric timestamp, so that sample request forms could have the time received stamped on them. After the samples were analysed the form was stamped with the time completed, then nurses collecting results signed the register.
“It was fantastic. Now we could see how long we took to deliver results. Previously a sample could take one or two days to turnover, now we could focus on bringing the time down to minutes”.
Judy and her colleagues then focussed on point-of-care sample analysis in the antenatal clinic.
“Pregnant women avoided the clinic because they had to hang around for four hours for their results, so we got direct reading instruments to measure haemoglobin. Now they are in and out in minutes.”
Dr Mercy Imakando said:
“The laboratory is now the heart of the hospital. We used to have patients admitted for two or three days, awaiting results. Now we can diagnose their ailment, treat them and discharge or refer them quickly. This has really saved the health service a great deal of money and transformed the service we give to the community”.
Judy described how the LabSkills management course had changed her outlook:
“The LabSkills training opened my eyes and changed the way I looked at things. I realised, maybe for the first time, that I had a responsibility for myself and the lab. It wasn’t good enough to wait for the government to do things. I should do something myself and I could improve the situation.”
“I had never flown before... When the LabSkills ticket [to attend the training retreat] arrived, I slept with it under my pillow to keep it safe. LabSkills has changed my outlook in so many ways”.
Dr Dorothy Marumahoko, Kafue District Medical Officer:
“Lab Skills learning has swept over the district like refreshing rain… We now encourage staff from other district hospitals and clinics to visit Kafue and see just what is possible. LabSkills has certainly made a difference here.”
Zimbabwe: Enhancing professional relationships between laboratory health workers and clinicians
Unlike several of the laboratories participating in LabSkills Africa, the laboratory at Parirenyatwa Referral Hospital utilises quite an advanced computer-based laboratory information management system. This system allows users to see when samples are registered, when they are being tested, the results of the tests and the time the results are ready. The automated analysers download results directly into the system. These results can be read on terminals in the wards and outpatient departments. The outputs of this web-based system can be read remotely on computers and smart phones anywhere in the world. The laboratory system is also interfaced with the hospital patient management system to correlate lab results with patients’ clinical notes.
Despite the use of this effective and efficient system, doctors complained that sample test turnaround times were too long.
Johnathan Whande, the Chief Medical Laboratory Scientist, said:
“Clinicians claimed that samples were left waiting in the reception area. We in the laboratory, however, suspected that the doctors were bringing samples late. So we asked LabSkills for an electric timestamp. Doctors were then asked to timestamp the sample test request form when they arrived at the lab reception and timestamp when they picked up the result report.”
This simple administrative procedure resolved this dispute and complaints about laboratory turnaround times reduced.
Dr Tinashe Gede, Head of the Department of Medicine, was supportive of the timestamp initiative. He used the evidence to instruct the junior doctors on time management as part of their clinical training.
“In a few cases, doctors with late results blamed the lab. However, I was able to use the timed sample test request forms to demonstrate that samples I asked to be taken at 9 am were not presented to the lab until 3 or 4 pm. At this time, the lab is transitioning from a busy day shift to a relatively less well-staffed night shift. So not only was the sample already 6 hours late, it would take longer to process.”