Implementing a Family Medicine Residency Program in a

Implementing a Family Medicine Residency Program in a Low-resource Country through Collaborative Work Kerling Israel, MD, MPH Rodney Destine, MD Emmanuel Fabrice Julceus, MD 10/6/2017

Disclaimer • There is no financial interest to disclose 2

It's important to have a sound idea, but the really important thing is the implementation. Wilbur Ross 3

Objectives of the session • Outline key steps in the process of designing and implementing an FMR program in a low-resource setting • Describe the characteristics of a successful and sustainable program • Explain the need for strong public, private, and academic partnership 4

Haiti and its health system • • • Caribbean low income country with 10. 7 million population Life expectancy: 62 and 66 years Maternal mortality: 359/100, 000 live births Total expenditure on health per Capita in 2013: USD 64** Generalist physicians: 50%* West Department: 35% population, 85% specialist physicians* http: //www. who. int/countries/hti/en/ retrieved 02/01/2017 *Dubois CA, Brunelle. F & Rousseau C. 2007. Analyses et Projection: Recensement des Ressources Humaines en Sante en Haiti Projet. 2007 Projet PARC. Universite de Montreal **Rapports de Comptes Nationaux de Sante 2013 -2014 http: //mspp. gouv. ht/site/downloads/Rapport%20 des%20 CNS%202012 -2013%20 compressed. pdf retrieved 02/10/17 5

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Graduate medical education in Haiti • Teaching hospitals: 6 • Residency programs: 29 • Faculty and educational resources in teaching hospitals - Part-time teaching faculty: 82. 5% - Internet access: 45% - medical library: 50% • Outdated legislation on graduate medical education Morse, M. , Franciska , L. , & Pierre, P. (2012). Graduate Medical Education Needs Assessment in Haiti: Opportunities for Strengthening Health Workforce Development and Retention Through Academic Partnerships. Unpublished work 7

Hospital Saint Nicolas of Saint Marc • • Public referral community hospital Support from Zanmi Lasante/Partners in Health since 2006 Capacity: 170 beds Services: OBGYN, Pediatrics, Internal Medicine, Surgery/Orthopedics, Emergency care, Dental care, Ophthalmology, Outpatient clinic • Catchment area of 443, 007 population (IHSI census 2015) • High bed occupancy • High volume patients in clinics 8

Key partners involved in the residency project • Ministry of Health (MOH) • Zanmi Lasante (ZL) / Partners in Health (PIH) - Over 30 years in supporting health system in Haiti - Preferential option for the poor • Faculty of Medicine and Pharmacy (FMP) - Collaboration with ZL on other education projects - Managing all public residency programs with MOH 9

1. What could be the steps in designing the program?

What we did • • • Seized the momentum Conducted a needs assessment Identified the leaders for the project Refined goals and objectives Developed strategies with stakeholders - Learning and working environment and support - Policies and curriculum development - Academic partnership management 11

Goal and objectives of the project Goal: • Contribute to the improvement of the health system through stronger graduate medical education Objectives: • Improve quality of care at the hospital • Pilot a new system of residency program in a remote area • Graduate qualified family doctors who are agents of change from a sound medical education system 12

Development of strategies • What are the international standards? • What are the national standards? • What international approach should be integrated? How? and why? • What could be anticipated as unintended consequences? 13

2. What would you suggest to implement the program?

Implementation process • Evaluate all resources (available, potential) • Use your professional network to seek for help • Set priorities and identify core activities to ensure quality of the system being built • Develop plan B for essential parts of curriculum that have inadequate resources (creativity) • Be at the workplace • Reassess regularly and adjust accordingly 15

Implementation • Transform the facility into a teaching hospital (4’S) - Space - Staff - Stuff - Equipment and materials (clinical and educational) - Systems • Create a learning environment • Establish strong communication system with all stakeholders • Monitor regularly and adjust as needed then evaluate 16

Policies and structure • Staffing • Structure of the residency program and residents’ support • Policies regarding the education system (admission, graduation, etc. ) 17

Curriculum • • • Clinical rotations Didactic activities /seminars Community activities Quality improvement and research projects Supervision Evaluation system – ACGME-I competencies – Requirements for promotion – Remediation 18

Support to residents • • • 19 Housing Food Transportation Stipends Psychologic support when necessary

Our faculty members • • • 20 Full-time Clinical expertise Interest in medical education CME and professional development Support (Housing) Visiting faculty program (local, international)

Academic partnership management • • Seeking resources Addressing requests Creating synergy Filling gaps / support for curriculum implementation - Ultrasound training - Faculty development program - Research training 21

Communication system Program director met: • • • Weekly with the director of the hospital (MOH) Monthly with residents Monthly with faculty Regularly with the leadership of ZL and Medical Education Department Quarterly with the national medical school Program director implemented changes based on feedback, observations and data analysis 22

FMR program at Hospital Saint Nicolas in Saint Marc, Haiti • • Start 2012 - Implemented by Zanmi Lasante/PIH Aligned with Ministry of Health’s priorities Three-year program with 6 residents per class Innovations - ACGME-I standards - Social and community medicine, research and quality improvement - Evaluation system 23

3. How would you measure success? 4. How would you address the sustainability issue?

FMR program in Saint Marc is successful • Strong education system • Graduates’ satisfaction • Graduates’ current work (clinical and systems change) • # of graduates: 16 • Lifelong learner attitude of the graduates • Informal national recognition as the best residency program in the country • Comfortable to be cared for by our former residents 25

Addressing sustainability • • Program is part of the public system Commitment of stakeholders Accreditation from ACGME-I Design and implementation of a business plan - Seek for more financial support from MOH - Engage private foundations / health insurance companies - Develop robust partnership with international institution 26

5. Why is strong public /private and academic partnership needed ?

Strong partnership • In limited resource-settings, we tend to lower standards and don’t strive for quality. • Strong partnerships with private/public and academic sectors create a situation where quality promotion is an answer to scarcity. 28

Strong partnership • Trust • Shared vision and goals • Common understanding of each partner’s: - Interests - Concerns - Level of engagement - Accountability • Expertise and resources 29

Take away points • • 30 Find a local champion (trustful, competent, passionate) Define specific goals and objectives Evaluate all resources and determine feasibility of activities Set priorities and non-negotiables to maintain quality Engage stakeholders Monitor, seek feedback and adjust accordingly Regularly assess partner’s engagement and share information

Take away points • • 31 Bring innovations to improve the system Determine qualitative indicators to measure success Deal with uncertainty while keeping commitment Build trustful long-term relationships - Remember expertise in the culture and local environment matters - Be creative, respectful, humble - Display a sense of solidarity and equity

Thank You !!!