Emergency Medicine

• Establish an Emergency and Disaster Medicine Center at Mustamae Hospital.
• Improve the existing system of emergency care through training of physicians, nurses, and paramedics.
• Provide management training for EMS system management, emphasizing training for multi-disciplinary groups of providers (i.e. physicians, nurses, and paramedics).

Management

• Expose a broad-based group of physicians, nurses, and administrators to modern principles of management and hospital administration.
• Develop a cadre of Estonian health management instructors.
• Establish a management resources library.
• Organize a clinical and management internship program.
• Decrease hospital average length of stay (ALOS).

Women's Health

• Enhance the cognitive skills of general internists, family practitioners, and gynecologists working within the hospital and in ambulatory care facilities on issues of women's health.
• Enhance the procedural skills of referral center gynecologic surgeons.
• Assist in the development of women's health patient education programs and Estonian-language patient education materials.

Nursing

• Develop a basic nursing curriculum.
• Strengthen the organizational structure of nursing within the partner hospitals.
• Assist in developing a documentation system for maintaining patient records.
• Develop a nursing in-service training and patient education capability within the Estonian partner hospitals.

Family Practice (added in 1995)

• Strengthen the education and residency system for family practitioners.
• Develop models for integration of family practice services into existing polyclinic and tertiary care systems.
• Develop clinical protocols and standards of care for family practice in Estonia.
• Research new models of reimbursement to support the emergence of family practice as a specialty, in conjunction with the Central Health Insurance Fund.

• Partnership representatives signed a Memorandum of Understanding in Tallinn on August 10. The ceremony, which was televised and included a press conference, formalized and publicly announced the newly-created partnership.
• Partners attended the AIHA Annual Conference in St. Petersburg, Russia. The September conference presented partnership representatives an opportunity to share experiences and reinforce the efforts of the respective programs.

• The US partners conducted the first "Management Academy" at George Washington University in May. Ten Estonians representing both partner hospitals, ambulatory care facilities, Tartu University, the Ministry of Health and the health insurance funds attended the training. The Management Academy included both didactic and practical instruction. Topics covered included: introduction to management theory; financial management; organizational behavior; and planning, marketing and development.
• Partners added the Family Practice initiative to the partnership objectives. With the introduction of this initiative in June, the Estonian partner hospitals were able to take advantage of a World Bank Project to develop family practice model services and educate practitioners.
• The Estonian partners participated in the first Polish-American EMS Congress in Warsaw, Poland, at the invitation of the Milwaukee International Health Training Center. Two doctors from Mustamae Hospital, involved in the partnership's emergency medicine initiative, participated in the June conference.
• Tallinn partners participated in AIHA's second EMS Train-the-Trainers workshop, conducted at the Medical College of Virginia in Richmond in July and August. The workshop allowed Estonian instructors from the newly established EMS Center in Tallinn to gain insights from the faculty of the established NIS programs on instructor skills and training management. The course provided continuing education to the directors and instructors on the following topics: 1) emergency medicine and first-responder protocols, 2) principles of adult learning, 3) case-based learning and utilization of videos in developing audio-visual aids, 4) disaster planning, and 5) training equipment maintenance and repair. In addition, the directors participated in sessions on administration and data management.
• The Estonian partners opened a new Emergency Medical Services (EMS) Training Center at Mustamae Hospital in Tallinn on September 23. The facility includes EMS, poison control, and disaster medicine components.
• The CEE partners attended the Congress of Clinical Toxicology in Rochester, New York in September and the Scientific Assembly in Environmental Disorders and Toxicology in Washington, DC in October.
• In October, the Washington partners conducted an Advanced Life Support Training course in Tallinn. Seven representatives of the Emergency Medicine Department at GWUMC served as faculty for the five-day course, which included didactic case presentations and skill stations. The goal of this training was support the development of Mustamae Hospital's Disaster Medicine Center, which includes a poison control center, a disaster/HAZMAT program, and an advanced life support course. GWUMC faculty delivered lectures and monitored lectures given by Estonian medical personnel.
• Partners attended the AIHA Third Annual Partnership Conference for NIS, entitled "Managing Quality for Healthy Outcomes," in St. Petersburg, Russia. The conference provided didactic overviews of continuous quality improvement (CQI) and small working groups that examined the application of CQI to partnership programs, including nursing, EMS, telemedicine, diabetes, infection control, maternal and child health, and hospital privatization. A nurse from GWUMC attended the conference, working with other CEE partnership representatives in planning the first AIHA Annual Conference for CEE.
• Tallinn partners participated in the AIHA/Association of University Programs in Health Administration (AUPHA) Introductory Management Skills Workshop held outside Tallinn. Faculty at the August workshop included AIHA Regional Staff, AUPHA personnel, and the partnership representative from the St. Louis-Riga partnership. Topics included communication skills, management, leadership, and financial management.
• The US partners conducted a second "Management Academy" in Tallinn, designed as a continuation of the process begun at the first Management Academy in Washington in May 1995. The November workshop had three components with differing target audiences. The first day covered broad management issues and over 100 physicians and nurses from health institutions throughout Estonia attended. Day two targeted chief physicians and their senior staff, focusing on human resources development and financial management. The second day attracted 60 participants from over 20 hospitals nation-wide. Lohusalu Retreat Center was the site for sessions on days three through five. Faculty tailored this part of the program as a follow-up for participants who attended the first Management Academy.
• Estonian partners opened the Emergency/Disaster Medicine Center at Mustamae Hospital in Tallinn in December. The Center assists victims of emergencies and disasters and assists in coordinating the response to Mass Casualty Incidents (MCI). There are five full-time staff members who provide training, assisted by a specialist for poison control, and two nurses.

• In January, the Director of Tallinn Central Hospital, was named Chancellor of the Ministry of Social Affairs of Estonia, the second highest position in the Ministry.
• Twenty-five Estonian and Latvian nurses participated in a Baltic Nursing Workshop in Pirita, Estonia. The February workshop brought together 25 nurses from partner hospitals in Tallinn and Riga, Latvia. The workshop enabled partners to learn from each other about the status of nursing in the two countries and the role of the partnerships in effecting change in the profession. Participants identified joint nursing activities in the Baltics, exchanged nursing resources, and planned for a follow-up conference in Riga.
• US partners helped conduct an AUPHA/AIHA Advanced Training-of-Trainers workshop in Tallinn. Twenty-eight health management educators, hospital directors, chief physicians, and chiefs of medical departments from the Estonian partnership hospitals and the Ministry of Health participated in the March workshop. The workshop covered principles of didactic and adult education, adult learning techniques, materials development, teamwork, communication and presentation skills, development of curricula, and evaluation. The workshop was the first academic program of the new Health and Management Training Center of the MOH.
• In April, US partners presented an Advanced Women's Life Support workshop in Tallinn. Eighty Estonian nurses, midwives, and physicians attended the workshop facilitated by a six-member delegation from GWUMC. Topics covered included breast and cervical cancer screening, family planning and contraception, counseling, health promotion, and treatment of depressive disorders in women.
• Three partnership nurses participated in the first meeting of the Central and Eastern Europe (CEE) Nursing Task Force in Budapest, Hungary. The April meeting successfully created new bonds among the nurses who share many common challenges, most notably in the areas of nursing education, in-hospital nursing practice, and economics and resources.
• Partners attended AIHA's First Partnership Conference for Central and Eastern Europe, May 1-3 in Budapest, Hungary. The conference gave AIHA's CEE partnerships, health ministry officials, and other senior health care professionals an opportunity to explore the progress and challenges of health care and health reform in the region.
• The Estonian partners hosted a five-day hazardous materials (HAZMAT) course in Tallinn in May. In addition to participants from several Estonian hospitals and agencies, a number of participants from AIHA partnerships in countries of the New Independent States (NIS), including Armenia, Georgia, Moldova, Ukraine, and Russia attended the course. Over 30 individuals attended the course from the partner hospitals, as well as the Estonian Department of Defense, the Estonia Border Guard, the Municipal Department of Defense, the Fire and Rescue Board, and the Estonian Police Department. The training introduced new concepts for the control and treatment of incidents related to hazardous materials and situations with mass casualties. The National Border Guard hired a professional translator to translate the course materials into Estonian.
• The Tallinn partners participated in a Family Practice Residency Program Directors Workshop in Kansas City, Missouri. The June workshop focused on medical education, including residencies and postgraduate education for family practitioners. The Estonian partners returned with the goal of developing a new residency program for family medicine and undertaking research in family practice.
• American and Estonian partners welcomed First Ladies Hillary Rodham Clinton of the United States and Helle Meri of Estonia to Tallinn Central Hospital in July. During the visit, AIHA donated laparoscopy equipment to Tallinn Central Hospital for the women's health initiative, and the First Ladies observed a prenatal visit, a childbirth education class, and an in-service training program for nurses.
• The Estonian partners conducted a three-day management training program in Tallinn. Two faculty from GWUMC assisted the Estonian faculty in the design, delivery, and execution of the August workshop. Over 25 participants from a variety of hospitals and health institutions attended the training, which covered topics such as strategic planning, financial management, team-building, and quality management. Faculty came from partner hospitals, the Health Sickness Funds, the Ministry of Health, and the Center for Public Health Training. Instructors incorporated the use of a variety of training methodologies covered in the Training-of-Trainers workshop held in March 1996 in Tallinn. The successful delivery of this workshop demonstrated the emergence of a qualified team of health management trainers in Estonia.
• The EMS Training Center at Mustamae Hospital conducted a mock train-accident disaster drill outside of Tallinn in September. The center simulated a real emergency with 60 "injured" and 26 "dead." EMS personnel from the EMS/Disaster Medicine Center transported the victims by ambulance and helicopter. The incident received widespread media coverage.
• An AUPHA/AIHA Financial Management workshop was held in Tallinn in September. Thirty representatives from the two Estonian partner hospitals, Ministry of Social Affairs, Department of Defense, Estonian Border Patrol, Health Labor Union, and Latvian partner hospitals participated in the workshop. Topics included financial systems models, cost accounting, cost-finding, payment system incentives, budgeting, and cost/benefit analysis.
• The US partners conducted a five-day Family Medicine Workshop in Tallinn in September. The workshop identified steps required to integrate family practice services into existing polyclinic and acute care services.
• The EMS Center director from Tallinn participated in a joint NIS-CEE conference on Emergency Medical Services (EMS) in Vladivostok, Russia. EMS Center directors and instructors from eight AIHA EMS Training Centers in the NIS and CEE participated in the October conference, which focused on disaster medicine and emphasized the importance of planning, training and communications in disaster management.
• Estonian partners hosted AIHA's First Information Coordinators Workshop in Tallinn. AIHA staff presented a training curriculum that included instruction on Internet applications such as Netscape and Eudora, copies of which were distributed during the workshop. The curriculum also covered Web searching and Web page design.
• In September, the Tallinn partners participated in the Second Cardiovascular Seminar in Budapest, Hungary. Two Estonian family practitioners took part in the international seminar, sponsored by St. Frances Hospital in Budapest.
• USAID's assistance program to Estonia officially closed on September 30, 1996. Estonian President Lennert Meri, US Ambassador to Estonia Lawrence Taylor, and Tom Dine of USAID/Washington officiated at a ceremony marking the end of the program. On October 20, the hospital partnership between GWUMC and the two Tallinn hospitals officially closed. AIHA partners held a ceremony at the Tallinn City Hall, which was attended by 75 guests, including Ambassador Taylor, the Chancellor of the Ministry of Social Affairs, and key partnership representatives from Washington and Tallinn. Partners used the days following the ceremony to evaluate the program, the results of which were published in a scientific journal.

• In May, partners attended the annual Nursing Task Force meeting and AIHA Second Partnership Conference for CEE in Zagreb, Croatia. The nurses shared reports of their partnership activities and participated in lectures on nursing education, management, and home care/hospice. The partnership conference provided an opportunity for partners to share experiences and successes through plenary sessions, partnership displays, concurrent workshops and seminars, and site visits to the Zagreb partner hospitals. The Director of Tallinn Eye Clinic highlighted the successes of the graduated Washington-Tallinn partnership in a plenary session.
• The Estonian information coordinators participated in the Second CEE Information Coordinator Workshop in Krk, Croatia from July 21-25. The workshop sought opportunities for interactive learning, conferencing, and communications. The workshop emphasized the use of technology and information through sessions on advanced Internet applications and evidence-based medicine. Upon return to their home countries, the information coordinators conducted surveys amongst hospital staff on barriers and solutions to providing information access.
• Four Estonian partners participated in a special, two-week train-the-trainers course in September, entitled "Medical Education and Inter-regional Harmonization Program for Nuclear Accident Preparedness." Developed by the Boston University School of Medicine, and funded jointly by AIHA and the International Atomic Energy Agency (IAEA), the workshop focused on the management of patients and disaster situations following radiation exposure. The course was hosted by the Radiation Emergency Assistance Center/ Training Site (REAC/TS) in Oak Ridge, Tennessee.

• Thirty Estonian and seventy Latvian nurses attended a Baltic Nursing Workshop in Riga in February. This meeting built upon previous Baltic nursing activities, and was particularly significant because it was planned and executed entirely by the CEE partner nurses. Topics included the role of the nurse and the midwife in pre- and post-natal care, preparation of mothers and families for childbirth, and non-traditional methods of childbirth.
• The partners participated in AIHA's Health Care Workforce Conference in Budapest in March. Relevant ministry officials, health care educators and practitioners from Estonia also participated in the conference, called Shaping the Infrastructure of Health Professions.
• The Tallinn partners hosted a three-day conference organized by AIHA, from June 14-17. Entitled "Nursing Associations: Leadership and Organization for the 21st Century," the conference gathered nursing leaders from 16 countries in CEE and NIS, and from the US to discuss the role of nursing associations, organizational leadership, professional nursing development, nursing power and influence, policy development, and uses of technology.
• Partnership nurses attended the third annual CEE Nursing Task Force meeting in May in Bucharest, Romania. Forty-five nurses from all partnerships in the region came together to share accomplishments and discuss Nursing Resource Centers, nursing-association building, and plans for future collaboration. Following the nursing meeting, partners attended AIHA's Third Annual Partnership Conference for Central and Eastern Europe in Bucharest, Romania in May, which highlighted the partnership experience and issues of sustainability.
• In July, the Estonian information coordinators attended AIHA's third annual training workshop for Information Coordinators from the 36 AIHA-sponsored Learning Resource Centers (LRCs) in CEE. Main workshop themes were information management and sustainability of the LRCs. Participants learned about database design, improving time management, developing annual budgets, and generating internal and external sources of funding.

Emergency Medicine

• The EMS Training Center at Tallinn's Mustamae Hospital continues to provide instruction to paramedics, nurses, and other allied health personnel in disaster management, emergency medical services, and CPR. By September 1999, the center had provided 101,720 person hours of training to over 2,050 individuals. In addition, it is the only center in the country that provides training in the management of mass casualty incidents and nuclear preparedness. Four major disaster drills were conducted in 1998 involving a passenger and cargo train collision, a tanker and passenger ferry collision, a fire on a passenger ferry, and a rescue drill at Tallinn Airport. Estonian rescue agencies as well as international participants took part in the exercises.
• The Estonian government funds the EMS/Disaster Training Center through the Mustamae Hospital budget. Apart from this funding, the Center raises money through charging fees for training provided to rescue personnel of other government agencies and to the private sector.
• Among the new structural changes attributable to the partnership activity is the establishment in Mustamae Hospital of a separate, state-of-the-art 12-bed Coronary Care Unit (CCU). Nurse/patient ratios have improved with a total of nine nurses assigned to the CCU.
• As a result of the emergency health initiative, staff at the Emergency/Disaster Center report that many significant changes have taken place in patient arrival procedures. More emergency patients are arriving for care intubated and with IV lines already inserted. The stability of arriving patients and their outcomes have generally increased.

Management

• Decreasing the average length of stay (ALOS)-a major objective of the partnership-was achieved in both hospitals. In Mustamae, ALOS fell from 11.5 days in 1994 to 7.5 days in the first half of 1999, and from 8.1 to 5.22 days during the same period at Tallinn Central Hospital.
• Concomitant with the decrease in length of stay has been the steady growth of ambulatory care as a major service delivery option. In Tallinn Central, outpatient visits more than doubled between 1994 and 1998. (113,698 visits in 1998, as compared with 53,675 in 1994) While increasing outpatient visits and same-day surgery, the hospital managed to decrease its staff by 7.4% and maintain the same quality of care. Tallinn Central Hospital also increased the number of laparoscopic procedures performed. Prior to the initiation of the partnership, Tallinn Central performed only ten laparoscopies. Over the first 18 months of the partnership, the hospital had completed fifty procedures.
• Through the various management training workshops, the partnership contributed to an institutional capability for management training at both partner hospitals, as well as at the national level of the health care system.
• Through the efforts of the partnership management initiative, the partner hospitals have improved the level of customer service to patients and their families. Patient satisfaction surveys conducted on a regular basis report improvements in access to information about hospital services, patient status, and medical procedures.
• The hospital introduced new guest services, including a flower shop, a concierge/information booth, a small grocery shop, an interpreter agency, and a money exchange bank, to better serve its patients and to provide revenue to the hospital.
• Administrators at Tallinn Central Hospital have concentrated on finance issues. A cost accounting system of finance was introduced and budget development and monitoring responsibilities were shifted to the department level.

Women's Health

• Since the partnership's inception in 1994 through July 1996, the Women's Clinic decreased the average length of stay for obstetrics patients by 43%, for gynecology patients by 22% and for antenatal patients by 28%. During this time period, the Women's Clinic increased outpatient visits by 40% and increased outpatient same-day surgeries by 30%.
• One of the most dramatic outcomes reported by the partners has been the introduction of Western marketing techniques to promote women's services and to maintain an edge in the increasingly competitive Estonian health-care market. In 1998, Tallinn Central Hospital delivered 21 percent of all babies throughout Estonia, and nearly 70 percent of babies born in Tallinn. The next largest competitor handles only 14 percent of deliveries nationwide. Tallinn Central attributes much of its success to the partnership, including a focus on quality of care, state-of-the-art technology (laparoscopy equipment donated through the partnership as well a newly acquired ultrasound machine) and the increasingly popular family-centered delivery approach, first observed at GWUMC. According to Central Hospital staff, the more patient-centered approach adopted after spending time in Washington "builds trust, increases patient satisfaction, and keeps patients coming back".

Nursing

• Nurses who participated in training exchanges have implemented a number of changes in Tallinn Central and Mustamae Hospital. In particular, at Tallinn Central Hospital's Women's Health Department, hospital administrators eliminated 24-hour nursing shifts - nurses now work 10-14 hour shifts. Midwives now admit and assess the patients and follow them through delivery.
• Mustamae Hospital's anesthesia nurses established a multi-disciplinary committee, including doctor and nurse department heads. The purpose of the committee is to strategize on ways to change department practices, approve developed patient teaching materials, and create a manual of best practices for Recovery Room nurses. The nurses at Mustamae were active in establishing a Society of Anesthesia Nurses in Estonia.
• At Mustamae Hospital, the very specialized nursing positions, such as dressing change nurse, were replaced with modified primary nurse positions. At Tallinn Central Hospital, nurses now complete the initial patient assessments, which include collecting information on allergy history, social and living conditions, and initial vital signs.
• The Estonian Nursing Association began publishing the journal Estonian Nurse, the first of its kind in the region. The Estonian partners distributed the journal at the AIHA Nursing Task Force meeting in Budapest, Hungary. The journal's second issue featured AIHA's nursing activities in Estonia.
• Through the nursing initiative, partners have made innovations in nursing education and patient education. Both Tallinn Central and Mustamae Hospitals have implemented new practices of in-service education. Tartu University revised its nursing curriculum, and nurses now participate in a new part-time study program. From September 1995 through graduation, 827 nurses took part in educational courses at the partner hospitals. Mustamae has two centralized education coordinators. A classroom has been prepared for the hundreds of nurses who will attend education classes such as CPR training, nurse assistant training, and anesthesia nurse training. Nursing units at Tallinn Central Hospital now schedule regular monthly in-service training sessions that last one to two hours.
• Patient education materials were developed in Estonian by partner nurses as part of their individual projects in areas ranging from eye care to women's health. The Head Nurse of the Urology Department at Tallinn Central Hospital trained at GWUMC in September 1995. Upon her return to Tallinn, she worked to develop patient education materials in prostate surgery, cystoscopy, diagnostic x-ray examination, bladder carcinoma, renal carcinoma, and techniques for obtaining a clean-catch urine specimen.
• The Tallinn Central Hospital Nursing Department has received several requests from regional hospitals to provide training to their nursing departments. This training focuses on the areas of quality management and nursing leadership development.
• Nursing departments at both Tallinn partner hospitals continue to make strides in improving the quality of nursing care in their institutions. One example of this is the development of a new patient records system implemented at Mustamae Hospital. Based on ideas gathered during her partnership nursing internship, Mustamae's Assistant Director for Nursing Education developed and piloted a patient record that allows for continuous monitoring of the patient's condition and allows for nurses' notes and observations. Prior to this, only physicians charted patients.

Family Practice

• The partnership developed a family practice residency training program. The University of Tartu now grants a certificate in family medicine.
• The Estonian partners instituted a licensing exam in family practice. Physicians are required to pass the exam every five years to continue to practice family medicine.
• The partners established a one-week continuous medical education course for family practitioners already working in the field. The topics covered in the course include curative, preventive, and palliative care, and management issues such as and team coordination and information systems.
• Tartu University developed a nursing specialization in family medicine. This training and education stresses teamwork and coordination among team members with clearly defined areas of responsibility.
• The Tallinn partners helped establish the Association of Estonian Family Doctors, which works closely with the academic health center to improve training. The main objectives of the association are to improve training, develop and promulgate standards, and lobby on behalf of family doctors.
• Over the past two years, Estonian family doctors have completed surveys to assess their needs and concerns. Based on these survey results, the Estonian partners established model independent private family medicine centers throughout the country. The centers are funded through direct contracts with the Estonian Sickness Funds. The goals of these centers are: focus on prevention and health promotion; use a standard set of equipment for the provision of basic services; establish a pleasant environment and accessible location for providing services; collect useful computerized management information; develop enhanced medical records systems; Promote home visits in order to reduce hospitalizations; use family doctors to fulfill the gate-keeping function and ensure continuity of care; and focus on improved quality of care.