My Last Weeks in Kenya

Andrea Arathoon – University of Michigan School of Public Health

Twelve weeks went by faster than I anticipated. August 3^rd was my last day at Jacaranda Maternity, and after traveling for a couple of weeks, I’m now back in Ann Arbor.

In my last post I described how we would be testing an outpatient checklist for prenatal visits for two weeks, in the hopes of making any changes after the testing period and then implementing it.  After the two weeks ended, I had a feedback meeting with the nurses to understand how the implementation was going. During this meeting, the nurses explained that the checklist was repetitive and redundant, and added more work to every patient visit. After talking to the senior management team, the decision was made to go back to the previous patient file and use the checklist template for when the clinical part of the EMR is implemented in the future.

However, the patient reminders are still being utilized at every prenatal care visit and have simplified the check-in process for patients in the clinic, reminding receptionists of the tests that patients need to be completed before their appointment with the nurse or the physician. Staff is pleased with this implementation and report that it’s making their lives easier by reminding them of what needs to be done.

Reflecting on my time in Nairobi, I believe I learned much more than I had previously anticipated. I was fortunate to work with a team of passionate, highly motivated nurses, as well as an empathetic and dedicated group of leaders. I was given the freedom to test and implement new ways of doing things, and although not everything turned out as I expected, it was a great learning experience overall. I brushed up on my clinical skills by observing clinicians at the hospital, learned about healthcare policy in Kenya, and developed a relationship with the organization that I hope will last for years to come. I also picked up a few words in Swahili, with the help of the staff members at Jacaranda Maternity.

Although I’m back in the US, I am still working on a marketing project with Jacaranda Maternity. This consists of rebranding the hospital, reviewing the mission, vision and values of the organization, and making sure that communications within the organization and with patients are consistent and well percieved.

My time in Kenya also allowed me to make new friends. I was lucky to have three other interns from different schools working in Jacaranda’s sister organization (JHSL), and we had the chance to travel to different parts of the country during the weekends. We took a trip to Lake Naivasha, where we visited Hell’s Gate National Park and Crescent Island. We also took a day trip to Lake Nakuru and went to Lamu for a weekend. During a holiday, I visited Ol Pejeta Conservancy, where I had the opportunity to interact with the last two Northern White Rhinos in the world. After my internship, I also traveled to Amboseli National Park, The Maasai Mara National Reserve and Naboisho Conservancy, where I had the chance to meet people from the Maasai tribe, arguably the most famous tribe in Kenya.

Overall, I am very happy with my summer in Kenya at Jacaranda Maternity, and am grateful for the opportunities I was given to challenge myself, expand my skills, and have new experiences.

 Admiring one of the last Norther White Rhinos in Ol Pejeta Conservancy

Baby giraffe at Crescent Island, Naivasha

Our vehicle for the weekend in Lamu, a dhow

Having fun with our guides during my trip to Naboisho

The gorge at Hell's Gate National Park

Lake Nakuru

Naboisho Conservancy

Amboseli National Park, with Mount Kilimanjaro in the back

Project Update - Jacaranda Maternity

Andrea Arathoon – University of Michigan School of Public Health

Tuesday was a very exciting day because I reached a milestone in my summer project! After 8 weeks of work, we started testing the new outpatient care checklists for prenatal visits.

During the past few weeks we’ve been working on developing this checklist to improve patient flow within the outpatient clinic. Currently, waiting times can be longer than expected due to certain inefficiencies in patient flow,  and we anticipate that the new care checklists will address these issues. We are also making sure that Jacaranda Maternity follows WHO and Kenyan Ministry of Health guidelines on prenatal care. After designing the new outpatient checklist, we consulted with physicians, nurses, patient care assistants and the administrative staff to ensure that the document was complete and easy to understand, and that it served its purpose of being a decision-support tool for clinicians during the prenatal visits.

Two weeks ago, we made the last changes to our prototype checklist and trained nurses, patient care assistants, and receptionists on this new tool. What I hadn’t considered was the fact that printing of the checklist would take time, because the process is a bit slower than I expected. This delayed the project by over a week. We finally received the printed files on Monday afternoon, and we started the testing period Tuesday morning.

At the same time that we rolled out this prototype checklist, we also implemented a new document called “Patient Reminders”. This idea came up after my week of observing the outpatient flow. When patients come for their prenatal visits, they bring a “Maternity Card” which is a booklet that contains all the relevant information about the patient’s pregnancy in case she needs to visit another health facility during pregnancy or for delivery. Patients understand the importance of this Card, and make sure to always have it with them when they seek care.

Picture of the outpatient checklist and my
mid-morning snack - coffee and Kenyan chapati

This Card is also important because nurses write the tests that are needed to be done before the patient’s next visit. There is just one problem with this care model: no one is held accountable for ensuring that the patient gets the tests she needs before she sees the nurse. And if she doesn’t get a test done before seeing the clinician, she might have to wait much longer because she needs to go back to the laboratory or ultrasound, wait for results and then return to her outpatient consultation. Receptionists are supposed to check the Card when the patient checks-in, but for many different reasons this is not always done.

The “Patient Reminders” document is meant to solve that problem. The document is small (about ¼ of a letter-sized paper) and is designed as a checklist. Now, when nurses see a patient, they only have to check the boxes for the tests that are needed before the next visit, and when the patient checks-in next time, receptionists have a much easier way of identifying the tests that were prescribed on the previous visit.

The new outpatient checklist tool for prenatal visits and the patient reminders document will be tested for the next two weeks, and we will make any adjustments needed after this trial period so that we can implement the final outpatient checklist and reminders document in the coming weeks. This outpatient checklist is the first step in moving the patient’s file to the EMR that was implemented approximately one month ago. The idea is to utilize this paper checklist while the hospital begins the process of redesigning the clinical portion of the EMR. Once the checklist has been incorporated into the EMR, clinicians will be able to take full advantage of the benefits of utilizing the system as a decision-support tool that aids them in their decision-making process.

Improving maternal health in Kenya - Jacaranda Maternity

Andrea Arathoon – University of Michigan School of Public Health

Jacaranda Health is an organization that “aims to make pregnancy and childbirth safer for women and newborns by transforming maternity care in East Africa”¹. They started operations in 2011 with a mobile clinic that provided prenatal care to women in Kenya. It has now grown into two distinct arms that still work towards the same goal but cover two different aspects of maternal health.  Jacaranda Health’s NGO arm focuses on research and healthcare innovations. In 2017 they worked with 15 public/mission hospitals in two counties and this year they are expanding to three counties and more facilities. Jacaranda’s other arm, Jacaranda Maternity, is an 18-bed private hospital located in the outskirts of Nairobi. The hospital conducts over 25,000 outpatient visits per year and delivers an average of 115 babies every month. I have the privilege of working as a summer intern with Jacaranda Maternity.  

Jacaranda Maternity, located in Kahawa West

Jacaranda Maternity focuses on delivering high-quality, affordable healthcare to women and children. Quality care is based on three pillars: accessibility, excellent outcomes and continuous improvement. Jacaranda provides outpatient services every day of the week and is open for deliveries and emergencies 24 hours a day. In terms of outcomes, the hospital has not had a maternal death in over 4,000 deliveries, which is a testament to the highly qualified staff in the institution. Continuous improvement is also an essential part of the care provided. The staff has daily huddles, during which the previous day’s activities are discussed, and where opportunities for learning constantly arise. They also attend weekly educational workshops that allow them to be up-to-date on a variety of topics related to patient care.

Jacaranda Maternity’s target population is primarily low-income women and children around Kahawa West, a peri-urban area located north-east of Nairobi. Most of the hospital’s patients are women receiving pre and post-natal care in the facilities. These women also deliver their babies in the hospital and return for their child’s immunizations and wellness checks. The hospital also offers general medical outpatient consultations for adults and children, and includes a pharmacy and laboratory where patients can purchase their medications and receive a wide variety of tests, respectively.

The biggest challenge for an organization like Jacaranda Maternity that provides high-quality care while serving mostly low-income populations is financial sustainability. Over the past few months, there have been many efforts by Jacaranda Maternity to reduce costs and to increase patient volumes, while at the same time maintaining the high quality of care that Jacaranda is known for. One potential intervention that can have a positive impact on profitability is the improvement of patient flow in the facility. If patient flow is streamlined, waiting times can be reduced and consultations can be more efficient, which in turn, increases patient volumes and reduces costs. As part of my summer internship project, I have been tasked with mapping and optimizing the processes for outpatient visits and inpatient stays.  These improvements in patient flow include the rollout of an outpatient care checklist, which will simplify the current medical record and will ensure that the organization complies with World Health Organization and Kenyan Ministry of Health guidelines for patient care. This checklist will also serve as a decision-support tool that can aid providers in their clinical decision-making process, promoting high quality care.

I am very excited about my summer project and the impact that it can have in improving maternity care for women and children in the country.  

References

1.     Jacaranda Health. (n.d.). Retrieved June 12, 2018, from http://jacarandahealth.org/