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“Recursos, siempre recursos…”

pcDR14.09 – “Recursos, siempre recursos…” – Day 6by: Minesh Shah, internal medicine physician

September 12, 2014

Today we met again with Dr. Estevez, the Medical Director of Guaymate hospital, to follow-up about how the COPE (quality improvement) process was going.  It’s best to recap at this point the history of our partnership for context:

PeaceCare was first contacted by PeaceCorps-DR to consider a partnership about 2 years ago.  The community of Guaymate was identified as an area that had high need and also an active Peace Corps Volunteer, Rosa Lopez.  The first site visit was in early 2013, and the possibility of a partnership was enthusiastically accepted by all involved.  Community assessment, in the form of focus groups, key informant interviews, and literature review continued for the rest of this year.  It was through this process that improving quality at the local municipal hospital was identified as a priority.

Our team reviewed the literature on programs for quality improvement in low-resource settings, and decided to use Engender Health’s COPE model, which was originally introduced in West Africa in the 1980s.

We spent months trying to understand the model, and adapting its tools to Spanish and the local context.  We had the great fortune of a nearby institution using COPE for several years – Clinica de Famillia la Romana – and they graciously offered the assistance of their facilitator, an inspiring woman named Johanna Lendor.

In March we introduced COPE to Guaymate hospital.  Participation was high, but certainly there was some trepidation about the additional roles & responsibilities that COPE asks of participants.  The Action Plan meeting in March identified several action items, and there has been notable progress in some of those areas.  It would be a stretch to say that COPE has been fully embraced by the staff, however.  A planned 3 month follow-up session was postponed, and the COPE committee has been unable to meet as a group.

It is with this background that we were meeting with Dr. Estevez again.  Johanna advised us on how to make COPE successful – it was comforting to know that there had been several start/stops at CFLR as well before it really took hold.

Dr. Estevez candidly told us that while he embraced the model and spirit of COPE, and recognized the importance of quality improvement, he felt the hospital staff was over-taxed and unable to follow-up to keep the process going.  He went through his monthly budget and constraints (the hospital seems underfunded, even by local standards), the number of staff positions currently unfilled, and the ongoing problems that have required his greatest attention (namely the generator/electricity problem).

As he discussed the circumstances of the hospital, I felt immense respect for how open and honest a leader he must be.  Our team comes in points in time, with great energy and enthusiasm, with no shortage of ideas, and frankly – with the understanding that we’ll be going back home in 2 weeks.  Dr. Estevez – and the rest of the staff at Guaymate hospital – fight battles every day, and there is no endpoint at which they can go home.  They are chronically under-funded and under-staffed.  They have support from the community but that support cannot fix basic problems like functioning electricity and working anesthesia equipment.  The staff that is most capable of taking on a project like COPE is also the most over-worked with other important priorities.

At one point in our discussion, I thought Dr. Estevez was going to ask us to put COPE on the back-burner, which it would be hard to disagree with.  Instead, he surprised us – he said that thinking about COPE had re-invigorated him, and that he wanted to make this a priority.  And he thought creatively – tapping into the energy and availability of retired physicians and other staff in the community – those who are invested in the health of the community but also able to put some time in.  There was enthusiasm in his voice and hope in his eyes.

Signs of hope – a new high school in Guaymate

We now have a plan to re-introduce COPE on surer footing, in the next month.  Johanna has graciously offered to continue her support and facilitation.  Dr. Estevez has asked me to call him once/week to follow-up.  For a man who carries 3 cell phones that seem to always be ringing, I’m humbled that he’s made our work a priority.

Starts and stops in this type of work are to be expected – if it were easy, it would have already been done.  I look forward to continuing to offer what we can to the Guaymate community and hospital, accompanying the many heroes on their daily struggles, and thinking about what lessons we have learned that we can apply back home as well.



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