Partnership between a health municipality in Kosova, in the former Republic of Yugoslavia and Dartmouth Medical School, New Hampshire, to rebuild the primary care system after the war. The project, which included nurses from both countries, is described, focusing on the changing roles of nurses

Hammond, Cristina

Harding, A. Laurie

Pond, Fred C.

Taylor, Mary

Thompson, Ellen

English

ScholarWorks @ UVM

University of Vermont ScholarWorks @ UVM University Libraries Faculty and Staff Publications University Libraries 11-2016 A Partnership to Improve Health Care in Kosovo: Dartmouth Medical School and Kosovar nurses worked together on a two-year project to rebuild primary health care in the postconflict city of Gjilan Fred C. Pond Dartmouth College, pondfc@yahoo.com Ellen Thompson A. Laurie Harding Mary Taylor Cristina Hammond Follow this and additional works at: https://scholarworks.uvm.edu/libfacpub  Part of the Nursing Commons, Primary Care Commons, and the Quality Improvement Commons Recommended Citation Thompson, Ellen Laurie, A. Harding, Fred Pond, Cristina Hammond, and Mary Taylor. "A Partnership to Improve Health Care in Kosovo: Dartmouth Medical School and Kosovar Nurses Worked Together on a Two-year Project to Rebuild Primary Health Care in the Postconflict City of Gjilan." AJN, American Journal of Nursing 106.11 (2006): 72CC-2DD. Web. This Article is brought to you for free and open access by the University Libraries at ScholarWorks @ UVM. It has been accepted for inclusion in University Libraries Faculty and Staff Publications by an authorized administrator of ScholarWorks @ UVM. For more information, please contact donna.omalley@uvm.edu. ajn@wolterskluwer.com AJN t November 2006 t Vol. 106, No. 11 72CCIn 2001 the Gjilan HealthMunicipality in Kosovopartnered with the Dart-mouth Medical School toimprove primary healthcare in Gjilan, Kosovo. Located in Eastern Europe in the former Republic ofYugoslavia, Gjilan faces thechallenges of postconflict recon-struction in an emerging democ-racy.1 The U.S. Agency forInternational Development(USAID) has funded numerousprojects, including this healthimprovement project in Gjilan.The American InternationalHealth Alliance (AIHA) admin-istered it as a bilateral profes-sional exchange to promote andsustain better health care. NEW PRACTICE MODELAs a cornerstone of buildingKosovo’s health services, theWorld Health Organization rec-ommended a “family medicine”approach to primary care, focus-ing on prevention, managementof chronic diseases, and continu-ity of care. Family medicine wasa new concept for this region.Most patients received their careEllen Thompson is the nursing andmicrosystems consultant on the USAID-funded project pairing DartmouthMedical School and Kosovo’s Ministryof Health, the Alliance for HealthyNewborns. She is a senior care managerat Dartmouth–Hitchcock MedicalCenter in Lebanon, NH. A. LaurieHarding is a New Hampshire state legis-lator and consultant for the VisitingNurse Association and Hospice ofVermont and New Hampshire in WestLebanon, VT. Fred Pond is the interna-tional biomedical librarian at DartmouthMedical School in Hanover, NH. CristinaHammond manages health improvementprojects at Dartmouth Medical School,including the Alliance for HealthyNewborns. Mary Taylor is a microsys-tems specialist for international healthsystems and management in Norwich,VT. Contact author: Ellen Thompson,ellen.thompson@hitchcock.org.By Ellen Thompson, MS, RN, A. Laurie Harding, RN, Fred Pond, MLS,Cristina Hammond, MPH, and Mary Taylor, PhDExtraCRITICAL CAREA Partnership to Improve HealthCare in Kosovo Dartmouth Medical School and Kosovar nurses worked together on a two-year project to rebuild primary health care in the postconflict city of Gjilan.Kosovar nurses Lirije Isufi (left) and Syzana Rexhepi practicing their skills on coauthor CristinaHammond at the Gjilan Main Family Medical Center, Gjilan, Kosovo, in March of 2003.Courtesy of A. Laurie HardingThere were no appointments, no medical records, no systematic patient flow.72DD AJN t November 2006 t Vol. 106, No. 11 http://www.nursingcenter.comExtraCRITICAL CAREseen next and sometimes evenrushing through the door, inter-rupting the patient before them.Nurses did not assess or preparepatients before the physicians’examinations. Little teachingoccurred, and there were nopatient education materials. Thiswas the starting point for theproject. PROJECT OVERVIEWThe main goal of the project,established by our Gjilan part-ners, was to improve the qualityof family medicine practice in theGjilan Health Municipality. Ourfirst steps included an assessmentof the family medicine center,using patient demographics andstaff satisfaction data. Using a“clinical microsystems” approach,teams were developed to plan,implement, and evaluate changesthat would eventually improvethe clinic’s work processes andthe satisfaction of those givingand receiving care. (A clinicalmicrosystem is a small group ofclinicians, administrators, infor-mation technologists, andpatients working together for acommon purpose or aim.3 Formore information, see www.clinicalmicrosystem.org.) Ourpartners in Kosovo chose a com-mon condition, hypertension, asa benchmark to evaluate ourobjectives, which included thefollowing:  • improving interdisciplinarycollaboration and teamwork• enhancing clinical knowledge • developing and implementingpractice guidelines • promoting positive patientinteractions • providing patient education • promoting continuity of care  • establishing a system to assessand improve the quality of care During the course of the proj-ect, both nurses and physicianswere required to deal with docu-mentation. Fundamental ques-tions arose, such as how andwhere medical records would bestored, how they could be madeavailable to providers, and howpaperwork would move throughthe family medicine center intandem with the patient. THE UNITED STATES AND KOSOVO:ROLES AND CULTURESU.S. nurses in Gjilan led groupsto design and implementchanges. Kosovar nurses strug-gled in a culture in which nursesdeferred to physicians. Withcoaching from their U.S. coun-terparts, the Kosovar nurseslearned to assert themselvesaround physicians. RamizeIbrahimi, a nurse in the Gjilanfamily medicine center, becamethe head nurse for patient educa-tion during the project. “By thetime the partnership entered itssecond year,” she said, “I hadthe self-confidence, courage, andpower to feel free to express myopinions and share my ideasduring training courses andother meetings. I am no longerscared to raise my voice.” U.S. nurses encouraged andcommended the work ofIbrahimi and all the nursesfrom specialists, consistent withthe Soviet model of care deliveryprior to 2000. Kosovo’s Depart-ment of Health and SocialWelfare wrote, “The referral system does not work. Manypatients refer themselves directlyto specialist care at health housesor hospitals. The result is an inef-ficient use of resources at all lev-els and crowding in hospitals.”2STATE OF NURSING PRACTICE When this project began in2001, medical secondary schoolsin Kosovo provided minimalclinical experience to nurses. Inclinics the nursing role consistedof giving injections, carrying outbasic registration procedures,and general office administra-tion. Nurses, frustrated withtheir limited role, expressed astrong desire to learn new skillsand interact more with patients.They were especially eager tostart teaching patients aboutlifestyle changes associated withcontrolling hypertension. USAID and the AIHA, inrecognition of the strong leader-ship at Gjilan’s newly namedMain Family Medicine Center,selected its 62 physicians and152 nurses serving 23,079patients to participate in thepartnership. The Dartmouthteam’s primary investigator, aphysician, and two lead nurses,considered themselves to bementors and coaches of theirKosovar counterparts.The center was highly disor-ganized; there were no appoint-ments, no medical records, nosystematic patient flow. Patientsarrived at the clinic, were regis-tered in a logbook, and made anominal copayment. Theycrowded around examinationroom doors (there were no wait-ing room chairs), jostling to beKosovar nursesstruggled in a culture in which nurses deferred to physicians.72FF AJN t November 2006 t Vol. 106, No. 11 http://www.nursingcenter.comExtraCRITICAL CAREfamily medicine practice. Theyobserved patient education andstaff interactions in the commu-nity. These visits inspired themto make changes at home suchas establishing medical records,infection control, continuingeducation, and evaluating patientsatisfaction.SURPRISESOver the project’s two-yearperiod, the Kosovar nursesimpressed our team with theirprofessionalism and commitment.Although skeptical initially, theyresponded with enthusiasm andwillingness to make changes nec-essary for better health care.Together, the nursing partnerscreated a vision for the future.During one of the U.S. visits, atrip to Colby–Sawyer College inNew London, New Hampshire,introduced our colleagues to thenotion of a college education fornurses in Kosovo.  Some unanticipated outcomesof this project delighted us.Nurses established an ongoingnursing education series whichwas previously unheard of inprimary care in Kosovo. Kosovarphysicians started attendingsome of the sessions and offeredpositive feedback regarding program content. The familymedical center became smoke-free, in part because of nurses.Educational posters and soap forhandwashing appeared in bath-rooms. Finally, we celebrated thefirst class of university nursingstudents in Kosovo; there wereeight. LESSONS LEARNEDOne of the major challenges forthe partnership was long-termsustainability of the changes thathad been implemented. Toachieve continuity, it was neces-sary to focus on three levels ofintervention: the individual, themicrosystem, and the “macrosys-tem.” We focused on fosteringwithin each individual nurse avision of her work in family prac-tice. We shared nursing andpatient education materials andencouraged ideas and participa-tion. Most important, werespected what each personbrought to the work. Professional development fornurses was nonexistent when westarted the project in 2002. Butto verify the sustainability of theproject, an audit was conductedin 2005. It demonstrated thatnurses at the municipal levelwere still attending continuingeducation classes. They contin-ued educating patients in thescreening room and were nowteaching patient care for dia-betes. A new registry of patientswith diabetes had been added,and documentation of patientswith hypertension continued.When a leadership change forcedthe temporary closing of thescreening room, physicians andnurses insisted it reopen sopatient care could resume; theyrealized the team approach wasan efficient way to organize careand that the assessment databeing collected were valuable.On the microsystem level, wefocused on work processeswithin the family medicine cen-ter. Data collected before andafter interventions helped tomeasure improvements. It wasespecially important that nursingroles and responsibilities beexamined, revised, and formal-ized with expectations of dailyresponsibilities. For example,clinical practice guidelines onhypertension outlined evaluationand treatment responsibilities forphysicians and nurses. involved in the project. Thisaffirmation changed the rolesand responsibilities of the nurs-ing staff, encouraging them topursue new opportunities toimprove patient care. Nursestook on the dissemination of patient education and triageguidelines for patients withhypertension. Blood pressurecompetency testing was estab-lished to assure physicians thatnurses were capable of takingblood pressure accurately. U.S.nurses introduced the concept ofcommunity blood pressurescreening, which was promotedby community leaders, onposters, and through word ofmouth. Community members andpatients started to complimentthe staff on their care. Six visitsto the United States exposed theKosovar nurses to a more evolvedHere’s How You Can Get InvolvedDoctors Without Borders www.doctorswithoutborders.orgInternational Medical Corps www.imcworldwide.orgInternational Medical Volunteers Association www.imva.orgAmerican International Health Alliance www.aiha.comGlobal Health Council www.globalhealth.orgInternational Council of Nurses www.icn.chThe U.S. Agency for InternationalDevelopment www.usaid.gov/our_work/global_healthWorld Health Organization www.who.int/enPDF doc.qxd  10/10/06  3:41 PM  Page 1Nursing leaders emerged. The concept of supervisionwas discussed and incorporated into job descriptions inan effort to increase professional accountability, espe-cially on the second shift. In December 2003, a conference was held in the capi-tal, Pristina, where the work in Gjilan was discussedwith all the health care municipalities of the region.Presentations discussed the changing role of nurses, clini-cal practice guidelines on hypertension for physiciansand nurses, competency and training guidelines, anddocumentation forms. Sphygmomanometers, stetho-scopes, and training stethoscopes were distributed toencourage routine blood pressure measurement in fam-ily medicine centers. On the macrosystemlevel, the KosovarMinistry of Health’s sub-sequent support enabledthe growth of nursingroles throughout the 31health municipalities ofKosovo. Treatmentguidelines on hyperten-sion, explicitly includingnurses as part of a teamworking with physiciansand patients, were distributed to family medicine cen-ters in the municipalities. The audit process revealedsustained expansion and understanding of the nurse’srole. For the first time in Kosovo’s history, nurses wouldearn master’s degrees (in spring 2006).The use of the clinical microsystem approachworked well in this international collaborative project.It provided the framework necessary for us to focus onour mutual goal of improving the health of the peopleof Gjilan. System changes were far-reaching, andinvolved new concepts, such as the development of thenurse–physician team approach to patient care, theaddition of waiting rooms with educational materialsfor patients, and the enhanced role of the nurse aspatient educator. The nurses at the Gjilan Main Family MedicineCenter have continued to champion the changes initi-ated during this project. Safete, one of our nursing col-leagues in Gjilan, said, “We will never go back.” tREFERENCES1.Archer SE. Kosovo: present and future. Mil Rev 2003;83(6):31-40.  2. Joint Interim Administrative Structure. Health policy for Kosovo.Pristina, Kosovo: Department of Health and Social Welfare; 2001Feb. 3.Nelson EC, et al. Microsystems in health care: Part 1. Learningfrom high-performing front-line clinical units. Jt Comm J QualImprov 2002;28(9):472-93. http://www.nursingcenter.comExtraCRITICAL CAREOne nurse said, ‘I am no longer scared to raise my voice.’

A Partnership to Improve Health Care in Kosovo: Dartmouth Medical School and Kosovar nurses worked together on a two-year project to rebuild primary health care in the postconflict city of Gjilan

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A Partnership to Improve Health Care in Kosovo: Dartmouth Medical School and Kosovar nurses worked together on a two-year project to rebuild primary health care in the postconflict city of Gjilan

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