Global HIV/AIDS Program, HIV/AIDS Bureau, HRSAMarch 5-9, 2012

CLINICAL ASSESSMENT FOR CLINICAL ASSESSMENT FOR SYSTEMS STRENGTHENING SYSTEMS STRENGTHENING

(CIASS)(CIASS)

International Center for AIDS Care and International Center for AIDS Care and Treatment ProgramsTreatment Programs (ICAP)ICAP)

Nursing Education Partnership Initiative Nursing Education Partnership Initiative (NEPI), Lesotho(NEPI), Lesotho

USG DebriefUSG Debrief

Presentation Outline

NEPI Lesotho ClASS Purpose and Goals

Cross-cutting Issues

Institution and School of Nursing Strengths & Areas for Improvement

National Health Training College (NHTC)

Paray School of Nursing

Maluti Adventist Hospital and School of Nursing

Roma College of Nursing

Scott Hospital and School of Nursing

National University of Lesotho (NUL)

NEPI Lesotho Planning Considerations: ICAP, MOHSW, CHAL

Discussion & Next Steps

NEPI Lesotho ClASS Purpose and Goals

Purpose and Goals

Purpose: to better understand the financial and administrative systems of the NEPI schools of nursing in Lesotho, which will be used to inform the development of a comprehensive technical assistance plan Goal 1: Each school of nursing will have the

financial and administrative capacity to receive PEPFAR funds through a sub-contract agreement with the NEPI Coordinating Center

Goal 2: Information revealed during this ClASS assessment will assist USG offices in providing on-going guidance and support to the NEPI/Lesotho project

Cross-cutting ClASS Areas for Improvement Administrative Finance

Cross-cutting Administrative Areas for Improvement

Lack of adequate Human Resources functions and HR staffing (All)

Performance evaluations for staff Institutions have limited experience with grant writing

and funding identification (All) Institutions do not have general operating policies,

procedures or regulations or are inconsistent or outdated (All)

Lack of sufficient IT support, computer equipment, maintenance contracts and internet capacity (All)

Institutions and staff have limited experience with managing donor funded projects (5)

Long range strategic planning (3-5 years) does not exist (5)

Cross-cutting Finance Areas for Improvement

Lack of policies and procedures that address donor funding requirements (All)

No grants management experience or systems in place (All)

Lack of detailed procurement processes for purchasing goods and services (All)

No processes for documenting and tracking time and effort (All)

No SOPs for budget development and management process (5)

Minimal internal controls or internal review process to ensure compliance with donor requirements (5)

No risk management planning for general organization (4)

Additional training and support is required on the Pastel Accounting System (3)

Bank reconciliations are not conducted monthly due to staffing shortages (3)

Financial infrastructure is lacking that prevents segregation of duties (3)

Lack of a sustainability plan to address decreases in funding (3)

No documented process in place for resolving audit findings and improving systems (3)

Lack of a technology policy or plan for financial information systems (3)

Cross-cutting Finance Areas for Improvement

National Health Training College National Health Training College (NHTC)(NHTC)

NHTC Administrative Strengths

Staff are flexible in meeting challenges through identifying creative alternative measures.

Executive management team is aware of country policies impacting operations and are active in trying to remedy.

Organogram shows accurate lines of authority, existing and desired positions for when funding becomes available.

The minutes of the executive management team meeting were detailed.

Management team has the ability to modify and update job descriptions as needed.

NHTC Administrative Areas for Improvement

Lack of autonomy for NHTC from MOHSW creates administrative barriers which could be problematic if NHTC wants direct funding as a subcontractor from ICAP. (Priority)

NHTC does not have an internal IT staff person on site, making it difficult to maintain equipment and software necessary for administrative and programmatic functions. (Priority)

NHTC is dependent on the Ministry of Communications for their internet services; service interruptions significantly impact administrative and programmatic functions. (Priority)

Most HR functions (recruitment and hiring, etc.) reside at the MOHSW, which impacts administration’s ability to fill positions in a timely manner and manage performance problems of day to day personnel issues.

The structure and authority of the “Council”, the designated management oversight body, has not been legally authorized and therefore cannot provide adequate support to the Administration on policy issues (Priority)

A recently developed strategic plan, providing a vision and “way forward” for the institution, falls short on inclusiveness in its design and was not completed due to contract funding issues

NHTC’s does not have administrative policies and procedures

(Priority)

NHTC Administrative Areas for Improvement (2)

NHTC Finance Strengths

Finance team work efficiently to accomplish tasks

Oversight from the Ministries provides NHTC a degree of stability

MOHSW has a history of receiving funding from multiple donors.

NHTC has a strong desire for autonomy.

NHTC Finance Areas for Improvement

Absence of financial infrastructure (Priority) Lack of NHTC specific policies and procedures

that address government as well as donor funding requirements (Priority)

Lack of an accounting package with a chart of accounts to be used for processing of general ledger, accounts payable, payroll, and billing transactions (Priority)

Lack of financial capability to meet donor reporting requirement such as budget to actual variance reporting

Lack of a procurement process for purchasing goods and services (Priority)

Minimum comprehensive budget development process (Priority)

No grants management experience (Priority) No fixed asset management system (Priority) No internal review process to ensure compliance

with donor requirements NHTC does not have an established bank account

to receive funding Lack of time and effort documentation to meet

donor requirements (Priority)

NHTC Finance Areas for Improvement (2)

Good communication between NEPI focal person and the ICAP/INCI/NEPI/Lesotho staff

New skills laboratory is being built Curricula development is completed every 4-5

years by bringing in all SONs, and hiring an technical expert to facilitate

NHTC Program Strengths

There is no plan to fill vacancies after Global Funding support ends for tutors (n=18)

Salary does not reflect level of expertise (novice, medium, experienced)

Access to educational resources; Computer lab & library

HSS expert tutors need to tailor training to meet skill levels. Training needs to include learner’s demonstration

Accommodation of students and staff could be strengthened

Clinical rotations pose many challenges:

Adequate space/location

Appropriate transport Increased classroom space needed

NHTC Program Areas for Improvement

Paray Hospital and School of Paray Hospital and School of NursingNursing

ParayAdministrative Strengths

Principal Nurse Educator is a dedicated leader, demonstrates openness, connectedness to community and a desire to improve all operational systems

Documentation of administrative activities including meeting minutes, contracts, MOUs and policies and procedures, etc. were well organized and current

Personnel files were comprehensive and complete

Principal Nurse Educator is actively seeking funding

Paray Administrative Areas for Improvement

Lack of performance evaluations for staff for several years. A new template from the MOH is being reviewed for implementation

Human Resource policies and procedures and employee contracts have limited details and lack information on key areas

Institution and staff have limited experience with managing projects and funding outside of MOHSW nursing program activities (Priority)

Long range strategic planning (3-5 years) is missing and is confined to 12 month goal setting based on a strategic plan from 1996.

Senior management staff lacks experience with fundraising and grant writing (Priority)

Paray Finance Strengths

School of Nursing Current finance staff work efficiently to

accomplish tasks

Governance minutes document discussion and direction on resolving financial issues

SON stressed that ICAP has been responsive and helpful

Paray Finance Areas for Improvement

Absence of financial infrastructure at SON and Hospital prevent segregation of duties (Priority)

Lack of SON specific policies and procedures that address government as well as donor funding requirements (Priority)

Lack of time and effort tracking to meet donor requirements (Priority)

Staff do not have sufficient training and support on the Pastel Accounting System resulting in:

Under-utilization of Pastel Postings to general ledger are several months behind Routine backups do not occur and are not properly stored; anti-virus software is outdated

Paray FinanceAreas for Improvement (2)

Lack of Technology policy guidance and support Financial reports do not include budget to actual

variance justification for under and overspending No comprehensive budget development and

management process (Priority) Lack of a detailed procurement process for

purchasing goods and services (Priority) No grants management experience or system in

place (Priority) Training opportunities are not available for

finance staff.

Lack of sustainability plan to address decreases in funding

A fixed asset registry is not maintained (Priority) No internal controls or internal review process to

ensure compliance with donor requirements Most recent bank reconciliations are July and

August 2011 (Priority) Petty cash is not reviewed and reconciled in a timely

manner No process in place to resolve audit findings No risk management plan

Paray FinanceAreas for Improvement (3)

Paray SON Program Strengths

Resources are well utilized Committed staff coordinate with each other on a

regular basis Despite distance from Maseru, connected to

networks: CHAL, NEPI, and curricula reviews Good communication with NEPI Lesotho

There are not enough educators, especially in technical areas.

Insufficient educational tools including skills lab, internet access, laptops, LCD projector, etc.

There is a significant lack of dormitory space and lecture halls.

No policies and procedures related to new resources (eg. Skills lab needs to be maintained and secure)

Needed resources to support the nursing program are not available. e.g. internet access, LCD

Staff shortages prevent adequate supervise at all clinical practicum locations

Lack of funds to support transport and accommodations for students doing clinical practicums

Paray SON Program Areas for Improvement

Maluti Hospital and School of Nursing

MalutiAdministrative Strengths

Maluti has begun to develop a business operations model with the hiring of a CEO and Business Manager

Hospital management team works well together and maintains detailed documentation of meetings

Governance Board minutes show staff are keeping members well informed of critical issues

Human resources is well organized considering a single staff person for 250 employees

Hospital has a retention plan with a range of options for management to consider

Maluti Administrative Areas for Improvement

Minutes of the Board meetings do not provide sufficient detail

The draft hospital strategic plan (2011-2015) does not include an action plan (Priority)

Hospital operating policies and procedures were unavailable for review (Priority)

Performance reviews are not completed as required by the Personnel policies and procedures (Priority)

A single HR person is expected to support 250 employees

Managers and supervisors promoted from within the organization are not trained

Maluti Finance Strengths

SON is a stand alone financial entity within hospital; revenue and expenses or profits are not co-mingled with hospital funds

An annual audit is performed by the Seventh Day Adventist General Conference Audit Services in addition to the annual independent audit commission by the Board

There is a comprehensive budget process that starts with departmental requests

Maluti FinanceAreas for Improvement

Employee time and effort is not allocated by funding source (Priority)

Existing CHAL and Seventh Day Adventist policies and procedures do not address donor funding requirements (Priority)

Insufficient internal controls due to the understaffing of the accounting department

No procurement policies and procedures that standardize the procurement of services, equipment (Priority)

Lack of budget development and management process (Priority)

There is no process for responding to audit findings The accounting department does not have familiarity of

USG financial requirements (Priority) Additional training and support is required on the Pastel

Accounting System Minimal internal controls or internal review process to

ensure compliance with donor requirement No grants management experience or systems in place

(Priority) Lack of sustainability plan to address decreases in funding There is no policy or process to analyze and minimize risk.

No legal reviews of MOU’s (Priority)

Maluti FinanceAreas for Improvement

Maluti Program Areas for Improvement

There are not enough faculty to adequately train the current class size

The SON does not have operating policies and procedures such as meeting and reporting intervals etc.

There is no formal documentation of the appointment of the NEPI Nurse Focal person in the personnel file

Clinical Instructors positions do not exist There is no vehicle for use to conduct supportive

supervision visits for nursing students at very rural practicum locations

The School of Nursing library is not being used due to lack of current resources for students

Roma College of Nursing

RomaAdministrative Strengths

The HR department of the hospital is addressing retention issues by implementing a range of new and creative benefits for all staff

College of Nursing staff are actively involved in the hiring process for new employees including development of the job description, interviewing, selection and orientation

The hospital has a wide range of quality assurance related sub-committees in which the College leadership staff are actively involved and can forward their concerns and promote their interests

The College annual operation plan for the 2011 was ambitious, but was detailed and matched issues identified as current challenges

Roma Administrative Areas for Improvement

HR functions are managed by the hospital, but there was no evidence of any comprehensive, written policies and procedures outside of a few key issues covered in the employee contract (Priority)

No formal, written performance evaluation system is in place

Job descriptions were not dated, not all staff positions in the College have written job descriptions

There is an absence of long range (2-5 year) strategic planning within the College

Resource development skills are lacking with too much focus on existing government funding (Priority)

No internet connectivity impacts efficiency and quality of work (Priority)

Roma Administrative Areas for Improvement

Roma Finance Strengths

Screening committees are used to prioritize purchases and payments

Accounting staff is knowledgeable of operations and proficient in Pastel

Financial investments have created reserves

Roma FinanceAreas for Improvement

Financial policies and procedures (2009) do not adequately address key areas to support donor requirements (Priority)

No process for tracking time and effort (Priority)

No policies and procedures that standardize the procurement of services, equipment, and supplies

No internal review process

Staff are unaware of USG financial requirements (Priority)

There is no Information Technology plan

No risk management plan

Existing resources are well utilized A significant number of faculty are in the

process of, or have completed “above and beyond” continuing education requirements

Students are well cared for i.e. free housing and health care provided at hospital

SON is linked to other capacity building resources (HSS expert tutors)

Roma Program Strengths

Lack of resources for: accommodation, office, internet access, etc.

College does not have enough space for classes and other student activities

Clinical challenges: space, transport and staffing needs

Roma Program Areas for Improvement

Scott Hospital and School of Nursing

Hospital: Management team meets consistently and

maintains detailed minutes An accreditation committee meets to

anticipate upcoming requirements Personnel files are well organized and contain

current job descriptions Hospital provides excellent oversight to their 5

health centers

Scott Administrative Strengths

It is unclear if there is full board membership (12) since it appears that staff are being included in the number required

Board minutes do not provide sufficient detail (Priority)

There is no process to train new or to update existing Board members on governance requirements

No conflict of interest or confidentiality documents for Board members to sign

There is no strategic planning process (Priority) The organization does not use legal representation

to review existing contracts and other risk areas (Priority)

Scott Administrative Areas for Improvement

There are no hospital operating policies and procedures to ensure standardization of processes, i.e. general operations, safety, facility maintenance, and information technology (Priority)

Staff lack grant writing and funding identification experience (Priority)

Performance reviews are not being completed annually as per the HR policies Employee contracts are being renewed and promotions given without performance reviews (Priority)

Employee contracts are open-ended with no official end date

Scott Administrative Areas for Improvement (2)

Scott Finance Strengths

Leadership of Hospital and Nursing School are committed to NEPI Program

Leadership stressed that ICAP has been responsive and helpful

Financial infrastructure is lacking at the SON which prevents segregation of duties (Priority)

Training opportunities are not available for finance staff at Hospital or School

Lack of policies and procedures that address donor funding requirements (Priority)

Lack of a sustainability plan to address decreases in funding

No documented process in place for resolving audit findings and improving systems

Board minutes do not reflect detailed review of financial statements

Scott Financial Areas for Improvement

Additional training and support is required on the Pastel Accounting System Under-utilization of system Postings to general ledger are several months

behind Technology policy guidance and support is lacking

No SOPs for budget development and management process (Priority) No exemption from VAT taxes An assessment of operational costs has not been

done (Priority) Unclear of basis for allocation of resources between

Hospital and School (Priority) Financial reports do not include budget to actual

variance justification for under and overspending

Scott Financial Areas for

Improvement

Lack of detailed procurement process for purchasing goods and services (Priority)

No grants management experience or systems in place (Priority)

There is no evidence of updates for the fixed asset registry (Priority)

Minimal internal controls or internal review process to ensure compliance with donor requirements

Most recent bank reconciliations are July 2011 for Hospital and April 2011 for SON (Priority)

Lack of time and effort tracking for donor compliance (Priority) No risk management plan Lack of insurance coverage (Priority)

Scott Financial Areas for

Improvement

School of Nursing: The management team has had stable

membership, meet weekly and keep detailed minutes

Management receives significant administrative support from the hospital

Quality assurance processes are being implemented

Scott Program Strengths

There is no strategic plan specific to improving operational needs of the school and educational needs of the faculty and students

There is a need to provide continuing education opportunities for faculty. Determine if specialty nurses would benefit the hospital

There is no clear process about how current clinical faculty could move into the clinical instructor role when available

Scott Program Areas for Improvement

Department of Nursing: National University of Lesotho

NUL Administrative Strengths

Despite going through a significant reorganization, the administration was able to identify its own areas of weaknesses and is aggressively addressing them

NUL-at-large and the Department of Nursing have significant experience with program management with multiple international donors

There is a high level of confidence in the ability of the Dean of the Health Sciences and Head of the Nursing Department to accept and manage NEPI funding

The faculty is eager to expand their knowledge and activities around research

NUL Administrative Areas for Improvement

There are no job descriptions, staff orientation process or performance appraisals (Priority)

No documented HR policies and procedures other than employment contract language (Priority)

Institutional operating policies and regulations have not been consolidated and are inconsistent (Priority)

Lack of computer equipment and internet capacity (including bandwidth) and inconsistent internet access limits management and teaching (Priority)

Dept. of Nursing and NUL-at-large lack capacity to respond to major grant, funding and research opportunities (Priority)

NUL Finance Strengths

NUL is restructuring to improve programs as well as their financial position

There is a corrective action plan for the findings of the past three years

Donor funding is considered restricted in the financial statements

Organizational structure includes a Project section where the accountants open a separate general ledger account for each project Expenses are approved and reports meet donor requirements

Finance committee receives financial, trend and performance reports

NUL Finance Areas for Improvement

Lack of an all-inclusive donor specific policies and procedures (Priority)

No time and effort tracking (Priority) No policies and procedures that standardize

the procurement of services, equipment, and supplies (Priority)

Bank reconciliation not completed on a timely basis (Priority)

No awareness of USG financial requirements (Priority)

There is no separation of cost units for cost tracking

Absence of a comprehensive budget process which includes appropriate budgetary controls (Priority)

NUL Finance Areas for Improvement

Questions & Clarification

Considerations for: ICAP MOHSW CHAL USG

ICAP Administrative/Program Monitoring Considerations

Job description duties for the NEPI Nurse Focal Person should come from ICAP to ensure consistency across institutions.

Expand the policies on monitoring site visits to include all processes from time frames for notice of a visit to action planning on areas for improvement.

Enhance safety policy with options for staff to check in with the office when traveling long distances or multiple days.

Consider using contents from the Sub-recipient management chapter to create a guide for grantees, if not in place.

Develop draft IT policies to share with SONs for modification

Assess CHAL’s capacity building needs and organization’s ability to provide support to Nursing Schools.

Consider creating a quality assurance process to evaluate the impact and knowledge base created by the capacity building activities provided to the six schools of nursing.

Identify a person to be responsible for assessing and tracking similar activities to avoid duplication

Interventions should be specific to each schools needs.

Role and need for the Regional Nurse Advisor unclear

ICAP Administrative/Program Monitoring Considerations

Authorize NHTC with flexibility to hire staff to adequately implement NEPI program

Allow NHTC the flexibility to modify job descriptions

Allow NHTC to develop IT capacity without dependency on the Ministry of Communication

Administrative Planning Considerations for MOHSW

Financial Planning Considerations for MOHSW

Assess the current financial processes with the goal of creating a more beneficial financial management system to properly utilize existing resources

Establish proper procedures for tracking employee time and effort allocated to different funding sources

Enhance existing financial system to accommodate NEPI funding

Financial Capacity Building Considerations for ICAP

Build financial management capacity at SONs Consider not contracting with NHTC and

maintaining the control of the funding until capacity can be built

Administrative Capacity Building Considerations for

ICAP

Consider conducting an assessment of CHAL program monitoring capabilities to assume oversight for the 4 nursing schools

Consider conducting technical assistance across all institutions on cross-cutting topics for consistency of skill building

Determine if hiring short-term contractual staff to be seconded to some of the institutions is a viable TA option

Considerations for CHAL

Re-evaluate agreements with Nursing Schools to ensure coordination of donor’s requirements, a detailed scope of work, reporting requirements and the approved budget

Considerations for USG

Guidance requested on coordination role of NEPI in pre-service nursing activities.

Next Steps

Debrief presentation provided to stakeholders for priority planning and implementation

Capacity building planning session to be held with nursing school support organizations

Draft report shared with USG, ICAP and local partners for comments

Final report and workplan to be used as a working tool to guide institutional capacity development

Questions & Clarification