SUCCESS STORY: TRANSITION

In good hands: Sustainable systems at Adams Clinic

With a bulging diary balanced on her lap, and a shadow of concern across her face, the Nursing Services Manager at Adams Clinic leaned forward in her chair.

"We have so much to do, and too few people to do it," she told the group of Clinic staff and Zoë-Life Transition Team members gathered in the small room one afternoon in July 2010.

As Sister-in-Charge, she was voicing the collective unease of her colleagues at the prospect of Zoë-Life's transition out of the primary healthcare clinic over the ensuing three months.

For many years, Zoë-Life's primary partner - McCord Hospital - had been running clinic services in Adams Mission, south of Durban in KwaZulu-Natal. When the eThekwini Municipal Health authority opened the Adams Clinic in February 2009, Zoë-Life was engaged as part of this association to provide capacity-building to the Clinic staff in HIV and TB service management.

This service had fallen within the first phase of our strategic project to conduct skills development and systems strengthening at several municipal clinics situated in various regions of the province. By June 2010, however, we had resolved to adopt an epidemiologically formulated approach for our second strategic phase, by focusing on community-centred strengthening of HIV prevention and treatment access.

Zoë-Life had informed all clinic partners of our intention to extend our operations within these locales, through deeper engagement with community structures, so helping to decongest over-burdened health care facilities by lowering the demand for services at clinic level. Although our collaboration with clinic personnel would continue in the form of roving technical support, the time had come to phase out our full-time presence at the clinics, and to ensure that the systems we had helped to establish there would be sustainable once the Transition was complete.

As the meeting proceeded, the Clinic sisters shared their own anxieties about the transition. The Professional Nurse assigned by Zoë-Life to Adams Clinic had been co-ordinating mentorship in HIV-related down-referral systems, and so excellent was her service in this role that the Clinic sisters were reluctant to lose her. Zoe-Life's Transition Team intervened at this point to allay these fears.

Zoë-Life had developed a Project Board - a simple but powerful planning management tool designed to conduct the effective hand-over of a range of project systems towards full ownership of the processes by the Clinic staff. The multi-disciplinary Transition Team -representing Zoe-Life's clinical, psychosocial, and monitoring and evaluation expertise - had surveyed every case management task undertaken at the Clinic, in line with the flow-path of the KwaZulu-Natal Department of Health's Operational Plan.

They had analysed the volumes, time, human capacity and other resources required to fulfill these functions, and formed the completed Project Board grid by defining each task and system within a weekly time-frame, covering the three-month Transition period. The finished portrait revealed various work-flow implications and gaps, and even solutions to bottle-necks.

In presenting the Project Board to the Adams Clinic staff that afternoon, the Transition Team members adopted a participatory approach towards resolving the challenges it illustrated. This was important in order to ensure that the Sisters would finalise their own Transition Plan, in contexts familiar to and influenced by them. The Team's role was solely to facilitate the journey to these solutions, by posing open questions, fostering full involvement and synthesising input.

By the end of the meeting, all the tension in the room had lifted. The Clinic Sisters saw that taking full responsibility for the systems they had been trained to apply was entirely feasible. Zoë-Life's Professional Nurse would spend the next three months mentoring them intensively, so that at the end of September 2010, they would be confident and equipped to manage the processes independently. Now they could envisage the PN's departure from her full-time role at the Clinic not as a stressful event, but as one that would herald their status as empowered healthcare service providers.

"The results speak for themselves," says Zoë-Life's Transition Project Leader. 'The Sisters are now handling the down-referrals seamlessly."

Another challenge had been the need to place a counsellor at Adams Clinic for HIV testing, and the group realised that a volunteer would be needed. Thirty community health workers came forward in response to a call disseminated via the Clinic, and two of our most experienced counsellors took the candidates through our HIV and TB skills programme. Two of the best trainees were subsequently appointed to the Clinic on a probationary basis, and the remaining numbers of the trained intake are conducting HCT outreach services.

"This is another example of the commendable sense of initiative that has emerged from the partnership between Adams Clinic and Zoë-Life - and indeed, from the Transition process itself," our Project Leader observes. "Human resources existing within the community were drawn into the Adams Clinic structure, and more skilled counsellors are now available to the wider Adams Mission community."

Zoë-Life has adapted the Project Board tool for further application in our new work-plan. The grid components emblazon the wall-panels in the Project Leader's office, providing a ready reference for management of ongoing mentoring and monitoring services to Zoë-Life's five partner clinics. It will enable efficient implementation and reporting of the Transition Project, and as a template, it can be modified for use in any number of our training and skills development projects.

Reflecting on the partnership between Adams Clinic and Zoë-Life, our Transition Project Leader concludes:
"When we first engaged with the Sisters in capacity-building, it was as though we'd given them something new to drink; they tried it, found it so refreshing that they finished it all, and then were distressed to think that there'd be no more. But what we gave them was the recipe, and delivering the Project Board as part of the Transition process confirmed this for all of us. As partners, we created valuable and enduring bonds, and look forward to sharing a new dimension of the relationship in the coming years."