Friday, January 27, 2012

Thanjavur Report – PINCC Consults to a sister organization for Quality Improvement

Dr. Aarti and Dr. Rhoda reviewing the ICTPH Screening Program

On Monday, January 16, 2012 we were driven after breakfast from READ, in Andimadam, down to Thanjavur for our consulting visit to the IKP Centre for Technologies in Public Health (ICTPH). The drive was a pleasant roll through countryside and small villages – to the extent that any drive can be pleasant in India! After two hours we arrived at our hotel in Thanjavur, and had the rest of the day for site seeing.


When we got settled into our rooms, we went for lunch and then some of our team got massages at the hotel spa. (In spite of having a spa, this hotel is NOT a nice place to stay, and the next morning we moved across the street to a slightly less not nice place to stay.)


After the spa visit we all five piled into an auto-rickshaw and went to the Chola Palace (built about 1200 CE) to see ancient bronze statues of deities and to climb up the eight level breeze tower to look out over the city. The Palace itself is a bit the worse for wear, but is still owned and operated by descendants of the original ruling family. The various museum rooms contained incredible old statues, jewelry, artifacts and artwork.


From the Palace, we hired another "auto" to take us to the "Big Temple" – also a 1200 CE period Chola dynasty Hindu temple. The Temple is in excellent condition and is protected as a world heritage site. January 16 was at the end of Pongal, so there was much celebrating and exchanging of best wishes with strangers! After dark, we sat on the ground and watched a recital of young girls playing traditional Indian stringed instruments and troupes of young girls doing traditional Indian Nataraj dances.


After breakfast on Tuesday morning, we hauled our gear across the road to the PL.A Residency Hotel – a small cut above the one we left, but right on the RR tracks and next to the station, so very little real advantage – we traded darkness and dinginess for immense noise pollution. At least there was hot water!


At 11:00, a driver from ICTPH picked us up and we spent a few hours with Dr. Aarti Sahasranaman, VP for Interventions (which means health programs like vision, dentistry, cardiovascular and women's health), and the ICTPH Research Analyst Ms. Vani Priya. We learned about the history of ICTPH (4 years) and the women's health program, where their screening work is located (about 3 months). VIA and VILI screenings are presently carried out opportunistically at two of their first four Regional Micro Health Centres.


After a nice lunch at a really good hotel restaurant nearby, we went out to visit one of the RMHCs, about an hour's ride out of town, where VIA and VILI are being carried out whenever women who come in for other reasons agree to be screened. We were all exceptionally impressed with the quality of the physical space and also the supplies and equipment – for all their programs, including VIA and VILI. For example, the have locally designed and built gyne tables with built-in lighting and foot rests that are very innovative. When we got back to the hotel, all were pretty tired, so Joy, Liz and Janis went to eat snacks in their rooms while Rhoda and John went to the hotel restaurant for soup and "Chicken 65" – a new to us menu item that presents chunks of deep fried boneless chicken marinated in a similar manner to Chicken Tikka – garnished with red onion rings and cut limes.


Wednesday morning, we got picked up at 9:30 and spent the whole day at ICTPH. Joy and John interviewed Vani, Dr. Aarti, Kartik (AVP for Finance and newly appointed ICTPH COO), and Zeena Johar, President of ICTPH. The focus of these explorations was on the organization and administration. All of these folks are young and full of energy and passion for their project – which is to ultimately build a Kaiser Permanente-like prepaid health network of 10 RMHCs that each offer comprehensive care. Most impressive!


Rhoda, Janis and Liz went to the second clinic that is currently offering screening and met with the people trained to carry out the screening at that clinic. In the afternoon, they returned to town along with some of the clinic staff and met further in the ICTPH conference room.


Wednesday evening was Joy's last night with the team, so we went back to the nice hotel dining room for an exquisite celebration dinner. As we were tucking in to appetizers, Zeena, Kartik and a few other ICTPH senior staff came in for their own dinner party. Not really a surprise, according to Kartik, since there are so few acceptable restaurants in Thanjavur!


Thursday morning we saw Joy off to Chennai and Delhi for her holiday tour, and then went to ICTPH at about 11:00 for a feedback session to the entire ICTPH staff about what we had learned from our meetings and interviews. They were most eager to learn, since most are new to ICTPH, and especially since the VIA & VILI screening program, the focus of our visit, is just getting off the ground.


Both the organizational and the clinical interviews and observations converged on the same four areas for improvement recommendations:

1.     Community engagement and public education

2.     Training and continuous learning of screeners

3.     Documentation

4.     Referral system


We felt that little cervical cancer reduction can take place in the region under the current model, which again is just getting started. Relatively few orientation sessions have been held with community women's self help groups. These sessions to date stay away from mentioning cancer, so there is little compelling reason for an asymptomatic woman to choose to come to the clinic for such an invasive procedure for no reason that she understands as urgent. Also, the screenings do not account for inadequate screenings and when they see lesions, the do not do Paps or biopsies, but refer the women to the city cancer hospital for having these procedures done – another invasive process for reasons still not clearly understood by the women.


Not surprisingly only a couple of women have actually gone for Paps and biopsies. So we made several recommendations about how they could engage the community more realistically, how they need to move towards doing their own Paps and biopsies (and ultimately to single visit see and treat).


We also recommended creating a system for proctoring and supporting the continuous learning of the existing screeners and, as they scale up to 10 RMHCs, new screeners. Certain shortcomings were pointed out in their documentation system, which is an in-house created software program that is over-all very impressive! We also recommended that when the bugs are worked out, their record keeping system would be a commercial success that could generate more income for the ICTPH.


Finally we attempted to show how their present referral system would not ever be viable and that with the implementation of the above recommendations (plus a few more referral-specific ones) their overall operation could be built into a successful and important contribution to local women's well-being.


Our team went out to a final night dinner at another of the "acceptable" restaurants in Thanjavur for a veritable vegetarian south Indian feast – one of the best meals of the entire trip! On Friday morning, we went to the train station to go to Chennai, on our way home!!!

After a lovely evening in Chennai, we took off on time and landed at SFO a few minutes early.

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