New Nurse, New Codes
As I’m writing this Chris is searching around our flat for a frog. More accurately, a half-frog, half-tadpole. While we were out at church and then the gym this morning one of her five remaining tadpoles all of whom were on the way to full “frog-dom” must have crawled out of the plastic tub they have been swimming around in all weekend and made a bid for freedom. He’s nowhere to be seen – I don’t fancy his chances.
First thing I shall do at the clinic tomorrow morning when I arrive there at 8am is spend some time chatting to the staff about something from the Bible and then we will pray together. This is a regular event on Mondays and Thursdays. The staff now includes Sister (all nurses here are called “sister”) Elsabet – third from the left. We appointed Sr Elsabet to replace Sr Aster who had gone to live in the USA with her family. Poor Sr Elsabet had a baptism of fire when she joined. On her second day in the job she was summoned to the local health office to be given a new code list; on her third day the inspectors turned up.
But first, a word about her appointment. We advertised for a Senior Nurse in a number of places, mostly Christian colleges and facilities, and had applications from 12 people – 11 women and one man. The applications and interviews were very different from what would happen in the UK. Firstly, every CV was accompanied by a small photograph of the applicant. The guy looked pretty grumpy, but all the women’s photos were of them fully made-up and “Photoshopped” to their most attractive state. Secondly, in a country where sex and gender are both binary and still the same thing, this was clearly stated (having been asked for) on the application form. Thirdly, their marital status and number of children were both proudly declared. Now, back to Sr Elsabet’s first few days.
Day 2: 1,849 new codes
Months ago Sr Aster had been summoned by the local health authority to attend “training” on a new method of data collection for all clinics and hospitals. The training took place all day in a run-down building on a derelict site with no running water, no toilets (sorry, “rest rooms”), no lunch, and only a small bottle of water each. She came back hungry, slightly dry and rather cross, with a sheaf of A4 reporting forms mostly irrelevant to us, but the one that we needed had been shrunk from A3 and required completing with almost microscopic hand-writing. We were being asked to record a monthly count split by sex and six age-groups of every diagnosis made, and a reason for every death (also split by sex and six age-groups). Given that no-one has died in our clinic for as long as anyone can remember half of the form will remain blank. (Long may it be thus.) How we were to record the diagnoses would be revealed at a later date. That date turned out to be Sr Elsabet’s second day.
She disappeared off in Haile’s taxi to a government office and came back with the same shrunk form, and an A4 document of some 20 pages listing 1,849 codes – a numerical code associated with a medical diagnosis. She asked if I could be sent it electronically. I received it the next day along with a PowerPoint “training” presentation consisting of 320 slides of pretty much pure text – no doubt what poor Sr Aster had endured (maybe that’s why she upped and went to the USA?) So, we have to put on the form not only the number of the code but also write out the associated text (completely defeating the object of “coding”), then give a total for the month (by age and sex). For examples of how surreal this gets, see below 1
How do you find the code you need in a 20-page list that starts with 1 and ends at 1849? Previously we were using a list of 116 codes, many of which I had memorised. They were numbered differently, so the old code number 799 that stood for “Other eye problem” (which I would use for anyone needing glasses) now in the new list stands for “Alcoholic fatty liver”. I have of course created a computer database to help my staff with code-hunting, but as the coding system changed mid-month we accidentally filed the April report in which everyone needing glasses was listed as having an alcoholic fatty liver. Oops. I wonder if they’ll notice all those alcoholic Christians?
Day 3: Inspected again
The next day, while Sr Elsabet was trying to re-code everything from January to March (yes, they want the new codes to be used from January despite having given them us in April) and while I was with Sr Tigist doing my Wednesday morning clinic at Bingham Academy, the inspectors turned up. Having inspected us seven months previously, scored us at 94% and having given me a “green” licence, they are back to make sure we are still behaving ourselves. A new list of demands was developed, and shortly after we had a clinic meeting to discuss how to proceed and to apportion the work between the five of us. Here are my notes of the meeting (with comments in italics):
1. An “Infection Prevention Nurse” must be appointed. A formal letter must be given to Sr Tigist for this. (We only have two nurses).
2. A Year Plan is needed, listing staff meetings, educational meetings, when ‘flu vaccinations are to be done etc. A record of all meetings must be kept in a file for the inspectors to see.
3. Our waste bins are unacceptable and the wrong colour. We need red (labelled “Infectious”), yellow (labelled “less infectious”), black and white bins - in the treatment room and also in the laboratory.
4. The yellow “sharps” containers are plastic – they should be cardboard, so they incinerate more easily. (On a previous inspection they told us cardboard “sharps” boxes were unacceptable and needed to be plastic…)
5. The large grey rubbish bin for transporting stuff to the incinerator is too small. We must get a bigger one.
6. A separate wheel-barrow clearly labelled “for clinic use only” is needed to transport the (currently too small) grey bin to the incinerator.
7. The ash from the incinerator needs to be put in an “ash pit” for clinic ash only, in case there are sharp things not burnt enough. It has to have a fence, a warning notice and a lid.
8. Personnel files for each member of staff (currently filed on the floor above the clinic in the HR department) must all be copied and put in a file in the clinic reception. They mustn’t just be upstairs.
9. Atsede (our cleaner) is badly equipped. She has to have “dirty shoes” (large plastic boots), plastic face goggles (to fit over her glasses), a plastic apron, heavy duty gloves, and a floor cleaning device that both sweeps and cleans at once.
10. The Lab Technician needs deodorant. (Yes, really…)
11. The ring binder of clinical protocols (which was acceptable 7 months ago) is inadequate. They have to contain a description of the disease, symptoms and signs, and details of management (that is of course a textbook).
Needless to say, we’re working on it. Chris subsequently suggested it was in the providence of God that they came while I was at Bingham. Because I might not have been able to control myself. Good point Chris.
For example, code “473” stands for “Migraine”. However, that’s only for clinics like mine. The code for “Migraine” in the code list for hospitals (which is 2055 codes long) is “505”, and in the “mini” code list for nurse clinics (they only have 617 codes, lucky them) it’s code “172”. As we simply have to submit a manual paper report each month of our codes, I have no idea how they will ever know how many people across all clinics and hospitals have migraine.