The steps to meet our objectives are:
- Needs assessment approved by Ministry of Health / development of business plan.
- Utilization of needs assessment for procurement of equipment, funding, and human resources.
- Build infrastructure / environmental functionality.
- Recruit and deploy surgical teams for clinical and educational support.
- Exit strategy with sustainability model for empowerment (education) and logistical/physical support (human resources /vendors).
- Permanent affiliate – medical school / preferably with school for global / public health, to provide clinical and curricular support.
Let’s first look at Needs Assessment. We need to know where we are to know where we are going. From a few weeks after the earthquake until approximately one and a half years out, a needs assessment had been written. This report cited aspects of clinical, educational, and infrastructural deficits at HUEH and was subsequently submitted to the Ministry of Health for review, editing and, ultimately, approval. The creation of this document, supported by the Haitian government increases ORSI’s credibility and potential to obtain funding, procure equipment and instrumentation, and send surgical and educational teams to support HUEH clinical services in the orthopaedic surgical residency. During the period of time where the needs assessment document was created, a sense of trust and partnerships with both the Haitian government and residency program was established. This sense of trust, camaraderie, and collaboration, we believe, is integral to future success and has been the model of the world’s most successful NGOs, i.e., Partners in Health. Going forward, the needs assessment will need to be updated based on changes in the status of Haiti’s public health system and the physical and human resources structure at HUEH.
2-Procurement of Equipment, funding and human resources and 3-Building infrastructure and environment of functionality
Following the creation of the needs document, the second stage of procurement, involving funding, equipment, and human resources has been ongoing. As mentioned, we have used the needs assessment as our case for support to get equipment donated from hospitals, vendors, and manufacturers. When we speak of building infrastructure, we not only are focused on the physical infrastructure, but also helping to support the educational infrastructure of HUEH’s residency programs. ORSI has been successful in providing educational support in the form of hundreds of textbooks, internet, and computer-based software. Improving educational infrastructure also includes a desire on the part of the residents and program directors to become a site for regional conferences in the Caribbean, i.e., clubfoot, trauma, etc. Building physical infrastructure and constructing an environment of functionality for orthopaedic surgical services is ongoing and has been supported by the delivery of many x-ray machines, ultrasound machines, orthopaedic equipment and many shipments of hard and soft goods. At the time of this document, a shipment with approximately 17 orthopaedic and medical suites is in Haiti and bound for HUEH, where we believe this will be a “game changer” for the hospital and will foster great progress and potentiate clinical services in the near future.
4-Recruitment and deployment of surgical teams for clinical and educational support
Once the needs document, procurement of instrumentation and educational needs, and infrastructure is provided, only then can we successfully deploy surgical teams from the US medical schools. In the past, we have sent surgical teams to outside centers such as St. Nicholas in St. Marcs. ORSI has teamed with Partners in Health in contributing teams to support the orthopaedic resident training at centers outside of Port-au-Prince while reconstruction of HUEH takes place. We have many United States medical schools and regional medical centers interested in sending teams in the future and ORSI has been developing a grid sheet for teams to travel over the next one and a half to two years. We are hoping to send eight teams per year, and these teams will represent a multitude of subspecialties. It should be noted that while many teams have come, representing reconstructive and trauma surgery, the orthopaedic surgical residents at HUEH, the attendings, and the entire public health system does recognize that other subspecialty clinical and educational teams are necessary so that a well- rounded group of orthopaedic surgeons trained in multiple orthopaedic subspecialties will be available in the future and serve Haiti. The surgical teams that are deployed will provide clinical services and clinical education by day, and this will be by way of surgeries and attending clinics. Late afternoons, into the evenings, PowerPoint lectures in multiple subspecialties will be given, and these didactic lectures will be given in the field of the subspecialty team providing services during any given period of time. By specialty core curriculum being supported by the respective teams over a period of two to three years, we believe that the orthopaedic surgical residents will receive a well-rounded, balanced education in all fields of orthopaedic surgery. Each team will range from four to seven members and include surgeons, nurses, OR techs, and possibly other subspecialists, such as plastic surgeons and emergency room physicians. Our teams will also utilize the concept of pre-deployment case review, such that complex cases that are not acute can be held for traveling teams. If these particular complex teams require careful preoperative planning and/or instrumentation, by teams knowing of these cases before their arrival, provisions for bringing equipment and proper planning can be accomplished so that outcomes can be the best possible. Utilization of communication via internet will expedite knowledge of those cases to upcoming traveling teams. We have developed detailed volunteer guides with information on travel, security, room and board, immunization, and inherent risks with disclaimer documents to be provided to all travelers under ORSI. We also will provide for pre-trip telephone conferences with team members to discuss all aspects of the experience for the traveling teams.
5-Exit strategy with clinical and educational sustainability models
Ultimately, after creating an environment of functionality with deployment of clinical and educational teams, we must look toward an exit strategy and a sustenance model. This would be part of the long-term goals at ORSI at HUEH and would require a number of steps, including economic support for human resources. This would include supporting the orthopaedic attendings and residents, possibly by virtue of a fee for service model. There is little financial incentive for Attending surgeons to work at the State hospital and for that reason as many as 80 percent of orthopedists leave Haiti within 5 years of training. There are under 50 Orthopaedic Surgeons in a country of 10 million. Prior to any exit strategy, sustenance model and functionality of operating room central supply, sterilization services, and biomedical services need to be insured. Additionally, part of any exit strategy or sustenance model would require vendors to replenish and maintain equipment, and this may require moneys. The fulfillment of core educational measures and benchmarks for residents in the program to meet are extremely important in assuring that HUEH’s orthopaedic residency turns out well trained surgeons to serve the country. ORSI, therefore, has the goal in time to raise funds for economic support for human resources, for orthopaedic attendings and residents, OR, central supply, sterilization, and biomed workers, as well as vendors to replenish and maintain equipment.
6-Development of permanant affiliate to provide permanant clinical and educational support for HUEH and it’s orthopaedic residency program
Finally, it is important that after an exit strategy with development of sustenance models, sustainability models, that a permanent affiliate is considered for HUEH well into the future. I strongly believe that some medical school or large entity needs to act as a permanent mentor for HUEH. Preferably, this would be a medical school with a school for public and/or global health. At this point in time, after the regular teams have exited, we still feel it would be important to have quarterly visits and conferences with a mentoring institution that should be considered a formal mentoring affiliate. In addition to the above, this permanent affiliate can help with teleconferencing of lectures, grand rounds, and perhaps even live surgeries. Tele-consulting via PACS systems should be considered long term so that we can view radiologic studies, comment and consult on them from the US. Any permanent affiliate should also assist with US grant applications in giving long-term sustained support. Other novel concepts for a permanent affiliate to consider would be the potential for Haitian residents to come up to the United States and to shadow clinicians at major medical centers. While it is understood that no direct patient contact could occur in this scenario, perhaps by being present, being involved in didactics, lectures, and conferences, as well as the potential to participate in practice cadaver dissections would allow for a very beneficial experience for the Haitian residents for HUEH. Other novel concepts involving permanent affiliates could be to expedite the rare, but necessary, transfer of gravely ill patients from Haiti to the mentoring institution for definitive surgery. In addition to providing invaluable service for the rare patient that is brought to the US, the mentoring institution would certainly benefit from reputation by participating in such activities.