The Team

Future improvement advisors in Accra.

Day 4 of Improvement Advisor Training

Day 4 of training and my brain is buzzing... I'm loving all the training on statistical analysis (Shewhart charts, scatter plots and what-not), and applying this to our work and quality improvement projects.

The morning was spent reflecting on our "Strength Deployment Inventory" -- similar to Myers-Briggs indicator, but which I like better due to its focus on motivation -- instead of behaviors. Interestingly, it tests for your motivation when things are going well, and again when you're feeling stressed and in conflict with others.

It reminds me of work with Ralph in business school, specifically in the smaller individual study that I did after his capstone course on Top Management Processes. It really is amazing how differently leaders act in stress or when feeling under attack, and how contagious this is for others on the team.

In fact, much of our work this week reminded me of Ralph and business school -- specifically things like "ladders of influence" and "psychology of change". Other concepts I realized were really fancy words for things I've picked up along the way; for instance, "affinity charts" really just means grouping items together into "buckets" or categories.

Because of this, by far my favorite part of the past few days has been learning about other participants' improvement programs. For instance, a project in Ghana aims to reduce under-5 mortality by 70% by working with nine hospitals with the highest rate of mortality since October 2009. The project focuses on the top three causes of under-5 mortality: birth asphyxia, prematurity, and neonatal sepsis. The main drivers identified for the situation include delay in seeking care, delay in responding to care, and unreliable use of protocols.

Indeed, one of the biggest learnings is comparing and contrasting maternal health in all of the countries that are represented. For instance, one participant talks about the challenges working in Afghanistan, where the rate of institutional delivery is 19%. At the same time, he talks about the influx of women doctors into Afghanistan from Pakistan and neighboring countries since the US invasion -- including his wife. Another participant talks about working in Malawi, where gloves are rationed and doctors often use only one glove during surgery. Or Ghana, where antenatal care registration is a whopping 90%, but where quality and standardization of care highly varies.

This cross-pollination of ideas, challenges, and best practices is definitely one of the best parts of the workshop. Looking forward to going back to India and applying these lessons!

The Black Stars

Twenty minutes into the Ghana-Germany time and things are CRAZY. I struggle to think about a time where I've been in the midst of such a frenetic atmosphere of emotional highs and lows, and I come up with nothing.

There's a radio-sponsored party at the hotel bar, with the game projected outside, next to the bar itself. The viewers come prepared -- waving (or wearing) huge Ghana flags, sporting red-yellow-green afros, and blowing massively loud horns.

I've never experienced anything like it: every time Ghana drove towards Germany's goal, everyone was out of their seat, screaming, dancing -- even if the ball was nowhere near the goal. When the situation was reversed and Germany was in scoring position, everyone would again be out of their seats -- screaming, jumping, punching the air, punching walls, and wailing as though in literal physical pain. The fury was exponentially more frenetic and emotional than a Yankees-Sox game, and the noise louder than any concert I've been to. There was something so visceral and emotional about the entire experience that seemed to elevate the atmosphere so much more than a sporting match.

The emotional anger and fury came to a head at ninety minutes, when it was clear that even with extra minutes Ghana would not win. Screaming, punching, jumping.

...and then: dancing?! A live salsa band comes on (again sponsored by the radio station), and everyone just starts DANCING. It's incredible. After two years in India, I'm taken aback by all the flesh and sexy dance moves. My Indian colleague stands in awe. I ask her if she's ever seen salsa, and she answers: "once, on the television." It's a scene straight out of Dirty Dancing, where Baby finds the staff quarters where everyone shows off their moves, and Baby stands, jaw dropped.

I go to bed soon after, drifting off to the sounds of salsa outside.

Arriving early, dressed appropriately for the occasion.

Hotel bar... it seems quiet and subdued, but this doesn't last long.

On Cloud Nine

AMAZING!!!! My favorite were the signs that read "Yes We Can". Absolutely incredible.

So many matches, so little time...

Two hours 'til the US - Algeria game and finding it hard to concentrate. And if I'm excited for that, the Ghanians in the room are practically jumping out of their seats looking forward to the Ghana - Germany match tonight.

There's no lack of places to watch the game in Accra -- the hotel here is hosting a huge party for the game. Same with all the five stars. But given how on-fire the whole country is around the match, it's interesting to think about how or where much of the country will watch... especially those living in slums or rural areas outside the city. I think about my recent trip to Mathare, a large slum in Kenya. One of the residents proudly showed his business -- a television inside a fairly small shack, which he estimates could hold 250+ people to watch the World Cup.

In rural Ghana, many towns are off the grid and do not have access to power. I'm feeling less cynical about the hotel sign I saw earlier this week on watching World Cup on renewable energy. I read an article this morning about that same organization, World Future Council, partnering with a renewable energy company in Ghana, to bring the World Cup to remote villages in Ghana through solar energy. While displaying the game on solar energy at a hotel resort seems a bit silly, doing the same in a remote village seems extremely empowering. It's pretty interesting, really -- leveraging the emotional and national pride of World Cup to strengthen support for renewable energy.

And in the meantime... Go Black Stars!! Go USA!!

A night out

After three days of being holed up in the conference center, I finally explore a bit of Accra.

9:30pm and I take a taxi downtown. Soon enough I begin to feel like I've made a mistake, when the cab drops me off at a dark parking lot, saying it can't go further because it's a private club.

Guards are everywhere, while there are practically no cars on the street or people walking. It feels the complete opposite of India (especially since my taxi -- despite being the ONLY one on the road -- screeched to a stop when the traffic light turned red... something you'd never see in Hyderabad).

I step through the gate and feel like I've been transported to another land. Lush green grass surrounding me. I'm at "Cavaliere Pazza" -- Accra's Polo Club, although I'm told they've removed all the horses after illness spread across the group. I sit and wait at the bar -- I'm meeting a friend of a friend from business school for drinks. Looking around, it strikes me that I can be pretty much anywhere in the world (well, maybe not NYC because of all the lush grass, but easily somewhere in LA). Hip hop blaring, World Cup playing, and beautiful people all around.

The friend of the friend arrives -- an Italian from Milan who's been here three months working with an oil company, and who graduated a year before me at Columbia. I learn more about the oil industry in Africa than I thought I'd know. It's always interesting to me what types of expats end up living in a particular city. In Hyderabad, it's highly stratified, with one group of expats working in social enterprise, another group working in IT, and not much of anything else. Here in Ghana, I'm told it's all expats working in oil, non-profits, or telecom. He talks about how much safer Accra is than other African capitals -- although he still has a car and driver who doubles as his bodyguard.

It's a fun night out, which leaves me wanting to explore the city even more.

Some nuggets of wisdom

Three of my favorite quotes from Day 2 of IHI's Improvement Advisor training:

(1) "If you don't know what to do, start."

(2) "Every system is perfectly designed to achieve exactly the results it gets"

(3) "Fail often to succeed sooner"

Feel good footy

I see a sign on my way to breakfast:

"Do your part: Watch World Cup powered by Renewable Energy."

Love it. There's a conference on renewable energy at our same hotel, and seems like a key part of the workshop is getting out and watching the World Cup on televisions powered by renewable energy. Feel good footy!

On the subject of watching World Cup... just before I left for Ghana, got a surprise in the Hyderabad Times. Apparently our goal of getting Kunal in the society pages before he left Hyderabad paid off (see below)... but the unintended consequence of that was getting a new pseudonym, "Candy". Oh geez. Ah, Hyderabad. Where the 7 million+ city is so small that watching the World Cup at the one sports bar chain is enough to get you on page 3. Will miss this some day!

An unlikely education

It's amazing what you take for granted, even when living in a developing country and traveling to another.

Like money. Or rather, access to it.

I arrive in Ghana, having barely thought of the local money situation. After all, I have my ATM card, credit cards, and even some US dollars to be safe. Having spent the last of my dollars on a local sim card, phone minutes, and a Coldstone ice cream in Dubai, I try to withdraw money from the airport ATM. Denied. Hmm, that's weird. I try again at the hotel. Denied. Down the street. Denied. You get the point... It's only later when I start asking around that I realize that every Ghana bank and nearly every international bank only takes Visa ATM cards.

Lovely. I have a Visa credit card (which no one seems to take -- credit cards are still barely used in Ghana), but my ATM card is a Mastercard. I talk to the hotel staff, but they're hardly accommodating -- suggesting that a taxi can take me around to find an ATM (mind you, this is around 8pm, which does NOT seem like the smartest thing...) I think back to my first trip to Africa in 2005... where Rwanda still had yet to open its first ATM machine (they were planning on opening their first the next year), and where I completely ran out of cash in Ethiopia... not only were the ATMs not working, but their phone lines were "different" and completely incompatible with the international numbers provided by credit card companies!

The only saving grace was my hotel manager -- straight out of the scene from Pretty Woman where Julia Roberts shows him all her credit cards and cries that no one will take her money.

This time my saving grace was in an unlikely source: Nana, who I met today at the IHI workshop. Appalled that the hotel told me to take a taxi to run around from bank to bank at night, she offered to take me around herself. We stopped at three more ATMs before I was nearly ready to give up. We decided to try one more -- Stanbec -- a bank from South Africa. Hallejulah! -- success!

Little did I know, however, that our ride was just getting started. In an effort to avoid u-turns to get back to my hotel, we end up getting exceedingly lost.

But it was an incredible ride -- I ended up seeing much of Accra (albeit unintentionally!), and learning a great deal about the country itself. One of the areas we find ourselves in is the Fort -- right by the coast. I ask what the Fort was used for and am stunned by the answer due to the sheer size of the enormous structure: the Fort was used to hold slaves before they were taken to the New World. Many of the nearby houses are still the original structures from hundreds of years ago; it's now the slum area of Accra, and Nana talks about the trans-generational effects of poverty.

Ten minutes later and we're passing the University of Ghana, the country's most prestigious university. I ask what the most popular major is; business, economics, and engineering is the answer -- everyone who wants to be rich goes into banking, IT, or telecom. Straight from undergraduate, the top grads in these fields can make 1000-2000 cedi per month ($700 - $1400/month); those with Masters in these fields can make 2000-3000 per month.

I ask Nana about herself and her family. She's a doctor, having come from a family of physicians. Given Ghana's huge healthcare needs, I'm shocked to hear that the universities only have spots for 150-200 medical school seats per year. She instead chose to study in the US, in Boston... I should have asked earlier, since "Boston" always seems to be code for Harvard, and indeed it turns out that she did both her undergraduate and medical school studies at Harvard. I ask how she came to apply there. She laughs and says it was purely by chance. When I press more, she said that a friend of the family saw potential in her and her sister, and urged them to apply to Harvard. She had nothing to lose, so she did -- always intending to return to Ghana and focus on public health to improve the healthcare systems of the country. Indeed, she's now working on an IHI project to improve the quality of maternal health across the country.

Pretty inspiring. We soon find our way back to the hotel, and I return to my room a bit richer than before -- both literally and figuratively :)

Day 1 at IHI's Improvement Advisor Course

I'm a student again and loving it. I'm joined by 26 other students from around the world, representing 10+ countries. In my table of six, fellow students are coming from Afghanistan, Russia, India, and the US. We're all here to learn the same thing: how to improve quality in low-resource settings, in a way that's sustainable and scaleable. Many represent hospitals or lead projects to decrease maternal mortality or ensure their institutions are more patient-centric. Quite a few come from URC, an organization that works with USAID to improve healthcare quality abroad. While most are clinicians, others are country heads of their organization and quite a few of us have business backgrounds... which is helpful, since "What's the business case for quality improvement?" is an important question that often gets ignored in conversations such as this.

It's still morning of Day 1, but already learning a ton. The first morning is around the "Model for Improvement", which encompasses three questions for every quality improvement project:

1) What are we trying to accomplish?

2) How will we know that a change is an improvement?

3) What changes can we make that will result in improvement?

Concurrent with that is Deming's PDSA cycle:

Plan - Do - Study - Act, which can be considered the "scientific method" for improvement. I really liked the quote: "Failing often to succeed sooner" -- which seems much easier to say than to implement.

To reinforce this, we played a game around predicting the number of the next card. Some reflections from this:

- Keep the theory simple and use evidence to refine theory

- Recognize that everyone will be at varying degrees of belief that the change will result in improvement -- can't force someone to jump to implementation

And just like school, we have 150+ pages of reading for tonight. That part perhaps is not as fun (especially when the World Cup is on!), but I wouldn't want to be anywhere else.

Welcome to Ghana!

First sign I see, stepping off the plane in Accra:

Unbelievably excited to be here for the Institute of Healthcare Improvement's "Improvement Advisor" course, which starts first thing tomorrow morning. As an added bonus, am here during World Cup -- and Ghana plays on Wednesday (right after the big US-Algeria and UK-Slovenia games)!!

The build-up was well underway when I was in Kenya a month ago (despite the fact they don't even have a team!), but the World Cup energy here is completely contagious. The cynical can cough it up to good advertising (I've had Coke's "Wavin' Flag" song in my head all day), but there's something about the World Cup that feels so uniting. Signs all around Accra read: "Let's go Africa! Let's go 2010!" and "Africa United!"

The poolside hotel bar is packed tonight with people watching Brazil play Cote d'Ivoire -- with everyone cheering for the Ivory Coast. My favorite commercial is one that shows players from all the African teams, all going to South Africa together. The energy is optimistic and happy. The Shakira song, "This time for Africa," comes on, taken from an old African lullaby. Some in the bar sing along. I'm grateful to be here, and can only imagine what it must be like in South Africa.

The "Other" New Recruits

With LS's new summer interns, who are joining us from graduate school programs in medicine, law, business, public health and engineering from the US and Europe.

Hallelujah, the rains have started!!!

Just like clockwork. 1st June, and the rains have started here in Hyderabad. When I first arrived, I always found it funny that everyone said "monsoons start on 1st June" -- as though it's something that can be predicted with such precision... except that it can. Everything here revolves around the rains starting, including the first day of classes for school children.

The smell of the first rain is almost indescribable... strong earthy, musky scents... I started to get my first whiff today during a meeting with my CEO. I had a huge urge to jump up and open the windows, a welcome respite from the 110+ degree weather... but he beat me to it! He opened the window shades and threw the windows open, remarking: "This is what India waits for."

I felt a bit like a dog, with my head sticking out the window taking in the cool air... but looking around, tons of people were doing the same thing. Children had run to the rooftops of their building, dancing in the rain; while older Indians looked out their windows, huge smiles on their faces.

I know at some point soon, I'll likely complain about the rains as much as I complained about the heat. But for now, I'm loving it.