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Global HIV/AIDS Program, HIV/AIDS Bureau, HRSA

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Title: Global HIV/AIDS Program, HIV/AIDS Bureau, HRSA


1
CLINICAL ASSESSMENT FOR SYSTEMS STRENGTHENING
(CIASS) International Center for AIDS Care and
Treatment Programs (ICAP) Nursing Education
Partnership Initiative (NEPI), Lesotho USG
Debrief
  • Global HIV/AIDS Program, HIV/AIDS Bureau, HRSA

2
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

3
NEPI Lesotho ClASS Purpose and Goals
4
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

5
  • Cross-cutting ClASS Areas for Improvement
  • Administrative
  • Finance

6
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    inconsistent or outdated (All)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)

7
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)

8
Cross-cutting Finance Areas for Improvement
  • 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)

9
National Health Training College (NHTC)
10
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.

11
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
    administrations ability to fill positions in a
    timely manner and manage performance problems of
    day to day personnel issues.

12
NHTC Administrative Areas for Improvement (2)
  • 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
  • NHTCs does not have administrative policies and
    procedures
  • (Priority)

13
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.

14
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

15
NHTC Finance Areas for Improvement (2)
  • 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)

16
NHTC Program Strengths
  • 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

17
NHTC Program Areas for Improvement
  • There is no plan to fill vacancies after Global
    Funding support ends for tutors (n18)
  • 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 learners
    demonstration
  • Accommodation of students and staff could be
    strengthened
  • Clinical rotations pose many challenges

  • Adequate space/location
  • Appropriate transport
  • Increased classroom space needed

18
Paray Hospital and School of Nursing
19
Paray Administrative 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

20
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)

21
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

22
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

23
Paray Finance Areas 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.

24
Paray Finance Areas for Improvement (3)
  • 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

25
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

26
Paray SON Program Areas for Improvement
  • 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

27
Maluti Hospital and School of Nursing
28
Maluti Administrative 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

29
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

30
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

31
Maluti Finance Areas 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)

32
Maluti Finance Areas for Improvement
  • 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 MOUs (Priority)

33
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

34
Roma College of Nursing
35
Roma Administrative 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

36
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

37
Roma Administrative Areas for Improvement
  • 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)

38
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

39
Roma Finance Areas 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

40
Roma Program Strengths
  • 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)

41
Roma Program Areas for Improvement
  • 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

42
Scott Hospital and School of Nursing
43
Scott Administrative Strengths
  • 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

44
Scott Administrative Areas for Improvement
  • 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)

45
Scott Administrative Areas for Improvement (2)
  • 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

46
Scott Finance Strengths
  • Leadership of Hospital and Nursing School are
    committed to NEPI Program
  • Leadership stressed that ICAP has been responsive
    and helpful

47
Scott Financial Areas for Improvement
  • 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

48
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

49
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)

50
Scott Program Strengths
  • 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

51
Scott Program Areas for Improvement
  • 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

52
Department of Nursing National University of
Lesotho
53

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

54
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)

55
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

56
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)

57
NUL Finance Areas
for Improvement
  • 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)

58
Questions Clarification
59
  • Considerations for
  • ICAP
  • MOHSW
  • CHAL
  • USG

60
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

61
ICAP Administrative/Program Monitoring
Considerations
  • Assess CHALs capacity building needs and
    organizations 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

62
Administrative Planning Considerations for MOHSW
  • 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

63
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

64
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

65
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

66
Considerations for CHAL
  • Re-evaluate agreements with Nursing Schools to
    ensure coordination of donors requirements, a
    detailed scope of work, reporting requirements
    and the approved budget

67
Considerations for USG
  • Guidance requested on coordination role of NEPI
    in pre-service nursing activities.

68
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

69
Questions Clarification
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