The purpose of the partnership was to improve the quality and availability of care for the citizens of Tuzla Canton in the clinical areas of women's health, cardiology, surgery, and neonatal care/pediatrics. The partnership also addressed several cross-cutting areas such as nursing, management, and infection control.

Women's Health

• Introduce screening and enhance treatment of gynecological malignancies.
• Enhance primary care referral networks.
• Develop a Women's Wellness Center.
• Establish linkages with ambulatory care providers.

Cardiology

• Open a regional cardiovascular diagnostic center.
• Open a regional cardiovascular surgery center.
• Enhance regional referral networks.

Surgery

• Enhance skills for performing minimally invasive surgery.
• Enhance pediatric surgery skills.

Neonatology/Pediatrics

• Improve care of the neonatal patient.
• Improve care of the pediatric patient.
• Enhance pediatric critical care and step-down unit capabilities.
• Establish links to other pediatric programs.

Nursing

• Restructure in-service training programs for nurses.
• Improve effectiveness of organizational structure of nursing.
• Expand the role of the nurse through autonomous and collaborative practice.
• Establish a Nursing Resource Center.
• Strengthen nursing leadership throughout the country.

Management

• Develop a healthcare management team for the UCCT "Centers of Excellence" which possesses modern management skills and capabilities.
• Introduce the continuous quality management (CQI) approach.

Infection Control

• Improve infection control procedures in each department.
• Develop the role of the nurse with regard to infection control.

• The partnership Memorandum of Understanding (MOU) was signed on October 21 at a White House ceremony officiated by the First Lady of the United States, Hillary Rodham Clinton. The MOU was signed by representatives of Buffalo General Hospital, University Clinical Center Tuzla, Ministry of Health of the Federation of Bosnia and Herzegovina, AIHA, and the respective Mayors of Tuzla and Buffalo.
• Eli Lilly Company pledged to donate $250,000 worth of drugs to the University Clinical Center Tuzla. The Tuzla and Buffalo partners collaborated on defining a list of drugs that the Tuzla partners needed most, and submitted the request to Eli Lilly.

• Four partnership nurses attended AIHA's second annual CEE Nursing Task Force Meeting held in Zagreb, Croatia May 13-14. They joined about 35 other partnership nurses from other CEE countries to discuss partnership accomplishments in nursing, nursing management, and leadership development.
• Representatives from Buffalo General Hospital and University Clinical Center Tuzla joined almost 200 other US and CEE partnership colleagues May 15-17 in Zagreb, Croatia for AIHA's Second Annual CEE Partnership Conference.
• Part I of the Healthcare Management Development Program conducted in May with the Association of University Professionals in Health Administration (AUPHA) and Buffalo General Hospital faculty was held in Bizovac, Croatia. Over fifty clinical leaders from Tuzla, Mostar, Sarajevo, Zenica, Travnik, and Bihac attended. This was the first time that the clinical leadership from the various cities in Bosnia came together since the war. A team of administrative and clinical leadership from the Buffalo General Hospital and AUPHA jointly coordinated, and conducted the workshop. The topics at this week-long program included: Concepts on Management and Leadership, Leading Organizational Change, Quality Improvement Tools and Measurement, Motivation and Team-Building.
• AUPHA, with BGHS Administration, conducted Part II of the Healthcare Management Program for the same participants who attended the first session. Part I provided a foundation for the development of management and quality concepts, while Part II focused on approaches to implementing specific management tools in the participant's home setting. Topics of the second workshop included: Planning and Project Management, Decision-Making, Human Resource Management, Financial Management, and Free Market Economics.
• The first cardiac catheterization laboratory in Bosnia and Herzegovina was opened at the University Clinical Center Tuzla in July.
• The Tuzla information coordinator participated in the Second CEE Information Coordinator Workshop in Krk, Croatia from July 21-25. The workshop's focus was to provide skills in interactive learning, conferencing, and communications. The workshop emphasized the application of technology and information through sessions on advanced Internet applications and evidence-based medicine. After the conference, the information coordinators conducted a survey among hospital staff to determine barriers to information access and then developed a program to implement solutions.

• The Minister of Education and the President of Tuzla University approved the formation of a University-level nursing program.
• An AIHA-sponsored Nursing Resource Center opened on March 6 at the University Clinical Center. The Center will be open to nurses from all of Tuzla canton, and will provide a meeting space as well as a training site for educational sessions. AIHA provided over $15,000 worth of training manikins, books, charts, and office equipment to facilitate the work of the Center's staff in planning educational programs for nurses. Prior to the opening ceremony, partnership nurses gave lectures on a range of nursing topics to other nurses from districts throughout Bosnia and Herzegovina.
• Part III of the Healthcare Management Program was conducted by the Buffalo partners and AUPHA in March 1998. The third part in this series of workshops reinforced previous topics covered, and continued to build upon the creation of a cadre of health management trainers from the University Clinical Center Tuzla.
• Four partnership nurses attended AIHA's third annual CEE Nursing Task Force Meeting held in Bucharest, Romania May 4-5. They joined 40 other partnership nurses from CEE countries to discuss partnership accomplishments in nursing leadership development, and the building of nursing associations.
• Representatives from Buffalo General Hospital and the University Clinical Center Tuzla joined almost 200 other US and CEE partnership colleagues May 6-8 in Bucharest, Romania for AIHA's Third Annual CEE Partnership Conference.
• Two 10-day courses in Health Management were offered for members of the Bosnian Ministry of Health. The courses were held in Sarajevo in March and in Livno in June. Over 60 participants attended these workshops that covered areas such as basic management theory, financial management principles, teambuilding and communications, leadership, and quality management. Participants were from 8 different regions throughout the country and the capital of Sarajevo.
• The Tuzla-Buffalo partners held a regional Pediatric Surgery Conference in Mostar in June with more than 45 attendees including surgeons from the Bosnian and Herzegovina, Republika Serpska, Croatia, USA, and France. This conference was the first held in Bosnia where all ethnic groups were represented. It included major discussions on development of referral networks, building infrastructure and educational venues for pediatric surgeons. Surgeons presented forty papers on a variety of topics including esophageal reconstruction, anorectal anomalies, genito-urinary reconstruction, parasitic diseases, and neonatal surgery. The conference included video presentations of surgical procedures.
• Five nursing leaders from Bosnia and Herzegovina attended a conference in Riga, Latvia entitled "Nursing Associations: Leadership and Organization for the 21st Century." Nurses from throughout the CEE and NIS regions attended this conference in June. Participation in this conference formed the basis for a Bosnia and Herzegovina-wide nursing association workshop, which took place later in the year.
• The Tuzla information coordinator attended AIHA's third annual training workshop for Information Coordinators from the 36 Learning Resource Centers (LRCs) in CEE. The workshop was held in Kosice, Slovakia in July. The main themes of this workshop 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.
• Tuzla surgeons presented four major papers based on work done with their US partners at the second Croatian Pediatric Surgery Congress held in Zagreb, Croatia in September.
• The Cardiac Surgery Center opened at UCCT in September. Seven cases were performed by US and Bosnian partners to inaugurate the Center. The President of Bosnia and Herzegovina, Alija Izetbegovic, was the guest of honor at the opening ceremony, which was attended by over 250 guests.
• In conjunction with the opening of the Cardiac Surgery Center, US and Tuzla cardiologists provided a cardiology symposium for over 200 physicians, nurses and medical technicians. The lectures covered topics on the most up-to-date cardiac surgery procedures.
• Over 200 people attended a ceremony held on September 30 to mark the formal graduation of the AIHA hospital partnership program between Buffalo and Tuzla. The ceremony featured an address by US Ambassador to Bosnia and Herzegovina, Richard Kauzlarich; the Governor, Mayor and Minister of Health of Tuzla Canton; and USAID, AIHA and partner representatives.
• Fifteen nurses representing the three nursing associations in Bosnia and Herzegovina participated in a meeting held in Sarajevo in October which was facilitated by the Executive Director of the US-based Association of Nurse Executives (AONE), and AIHA staff. The meeting offered the first opportunity for nursing leaders from all three of the primary ethnic groups in the region to come together since the beginning of hostilities in Bosnia and Herzegovina. The formation of a unified Nursing Association for Bosnia and Herzegovina was established as a common goal.

Nursing

• Through participation in AIHA's program, Bosnian nurses developed collaborative relationships with their Croatian counterparts, especially at the Croatian National Nursing Conference held in Zagreb in April 1998 and at the three AIHA CEE Nursing Task Force meetings. As a result, joint regional activities and further collaboration is anticipated.
• Nurses in Tuzla are actively performing patient assessments. Stethoscopes provided to the nurses by Buffalo partners have enabled them to monitor vital signs and conduct neuro/breath sounds.
• Increased hand washing has been noted in the area of infection control amongst nurses.
• University Clinical Center nurses developed competencies in a range of clinical areas including: use, care and maintenance of new vital signs monitors and IV infusion pumps; conducting exams and monitoring differences in pediatric patients; care of patients in shock; and thermo-regulation in infants and young children. Furthermore, nursing practice expanded to include cardiac and respiratory assessment. This was accomplished through changes in secondary medical school education, supported and approved by the Ministry of Education and UCCT leadership.
• Nursing committees, which are charged with developing policies, procedures and standards of care, have been established at UCCT. The committee system was first used to develop an IV therapy policy for pediatrics.
• Training and in-service programs for nurses have been established as part of the Nursing Resource Center. Nursing education is incorporated into weekly rounds and programs that are supported by the Center. An overwhelming number of nurses have responded and attended ongoing educational sessions held on the second Saturday of each month at the Nursing Resource Center. Furthermore, train-the-trainer programs for care of the surgical patient, critical care patient management and care of the cardiac patient have been held.
• Nurses are able to care for pre-cardiac procedure and surgery patients. They demonstrated their knowledge during the opening of the new Cardiac Surgical Center.
• The leadership of the nursing structure is stronger and has demonstrated the capability to use empowerment, adult education and team building techniques, as well as new clinical skills. They have integrated principles of continuous quality improvement into their work. Additionally, nurses now join physicians on rounds, educational meetings and evaluations.
• Performance expectations/competencies for the nurse educator role have been established. Eight staff nurses from across the Clinical Center's departments have assumed this role.
• The Minister of Education for Tuzla Canton and the President of the University of Tuzla approved the formation of a University-level nursing program. A curriculum was drafted and a task force convened to begin development of such a program. Partnership nurses on both the Buffalo and Tuzla sides were instrumental in lobbying for such a program.

Women's Health

• The University Clinical Center physicians and nurses gained clinical skills in areas related to obstetrics and gynecology including: patient management in Labor & Delivery; post-partum and prenatal care; pap smears and biopsies, GYN surgery (oncology, cesarean section); sterilization procedure for laparascopy and colposcopy; and post-partum circumcision of the newborn.
• The University Clinical Center collaborated with the Tuzla business community to establish a health outreach program which provides ambulatory screening services to employees. The program, paid for by employers, includes breast examination, colposcopy, pap smears and ovarian cancer screening through ultrasonography.

Cardiology

• A regional cardiology referral system was established through the assistance of the US partners. Mostar, Sarajevo and Tuzla were identified as the system's main cities, with Tuzla as the only site with open-heart surgery capabilities in Bosnia and Herzegovina. Through this new system, cooperation between the three cities was enhanced.
• A full cardiac surgical team was trained in Buffalo. The team includes four surgeons, five nurses, three anesthesiologists/perfusionists.
• Pediatric cardiology skills were enhanced in the treatment of congenital heart disease and the specific approach to cyanotic heart disease, cardiomyopathies and pulmonary hypertension.
• Over 300 angiograms were performed at UCCT in the first year of the cardiac catheterization laboratory's operation. Additionally, three stents were placed and angioplastic procedures were begun for the first time in Tuzla.

Surgery

• Over the course of the partnership, an assessment of laparoscopic surgery was completed, equipment was obtained and laparoscopic procedures were started. Since its initiation, more than 130 cholecystectomies have been performed. Outcomes of these procedures have been excellent with minimal complications. Since the establishment of the partnership, over 300 laparascopic surgeries have been performed in Tuzla after 5 Bosnian surgeons were trained in Buffalo.
• The chief of surgery from Children's Hospital of Buffalo led six US teams to Tuzla over the course of the partnership to train Bosnian pediatric surgeons and nurses on specific surgical procedures such as neonatal surgery and anorectal malformations. The US surgeon performed over 120 operations over the course of his visits.
• Three pediatric surgeons from Buffalo gave over 35 hours of training on a wide variety of pediatric surgical topics while in Tuzla. General surgeons, pediatricians, pediatric surgeons, nurses and gynecologists were among the attendees.
• Two definitive referral patterns for pediatric surgery cases were established by the partners. The two major referral centers of Tuzla and Sarajevo were identified and agreed to by all pediatric surgeons in Bihac, Tuzla and Sarajevo. These sites will accept referrals of major neonatal and complex pediatric surgery patients.
• Tuzla doctors presented 4 major papers based on work done with Dr. Richard Azizkhan from Children's Hospital of Buffalo at the 2nd Croatian Pediatric Surgery Congress. Their work was published in a regional peer review journal.
• Dr. Richard Azizkhan was asked to co-chair the regional pediatric surgery conference in Sarajevo in March 1999. This will be the first Bosnian International Congress. Additionally, Dr. Azizkhan was elected Honorary President of the Association of Bosnian Pediatric Surgeons of Bosnia and Herzegovina. He will be responsible for giving Board certification for newly-named pediatric surgeons in Bosnia.
• The partnership secured Soros funding for Tuzla doctors to travel to Hungary to attend a European Surgery Congress.
• The Buffalo pediatric surgery team provided 250 hours of bedside and intra-operative training to nurses and physicians in pediatric surgery.
• Bosnian pediatric surgeons were exposed to over 600 major surgical procedures during their training in Buffalo in all areas of pediatric surgery. They participated in operations, clinical care, and all educational activities of the Department of Pediatric Surgery.

Management

• Forty staff of UCCT and ten clinical leaders from hospitals in five other cities received training in health care management skills. In addition, the partnership developed a cadre of health management trainers at UCCT who can now train their colleagues.
• Improvements in the managerial effectiveness of the Clinical Center Leadership team was implemented by the Center's Director. An atmosphere which promotes improvement and change has begun to develop.
• All Tuzla trainees in Buffalo underwent training in change management to help them maximize their learning process while in Buffalo, and the application of changes upon their return to Tuzla. The Bosnians completed action plans for improvement projects that could realistically be implemented upon their return to Tuzla.
• As a result of the two 10-day courses in Health Management that were offered for members of the Bosnian Ministry of Health in Sarajevo and Livno in 1998, plans are underway to create an association of health management executives that will continue the work begun by the partnership in establishing and training a cadre of health management leaders throughout Bosnia and Herzegovina. Dr. Bakir Nakas from the Ministry of Health is leading the development of such a group.

Infection Control

• An impact assessment visit in June-July 1998 confirmed a significant improvement in infection control at UCCT both in the in-patient and out-patient departments. Examples of improved infection control procedures include: glove use and hand washing; improved wound care and dressing disposal; improved isolation techniques; syringes and needle disposal in appropriate containers; improvement in separation, preparation and purchasing of reusable surgical instruments; and greater use of disposable surgical items.

Neonatology/Pediatrics

• Marked improvement was noted in newborn assessment skills by physicians and nurses.
• Other significant achievements include a reorganization of the nursery, the use of ventilators, improvements in the management of jaundiced patients and those with significant hyperbilirubinemia, improved treatment of critically ill newborns, intubation skills of physicians, extensive CPR training, and improved management of hypo/hyperglycemia.
• Pediatric rehabilitation and respiratory therapy were assessed and recommendations for improvement were provided to the Clinical Center staff.
• The mortality rate for pediatric patients with anorectal malformations and diaphragmatic hernias decreased from 70% to 20%.

Other

• Buffalo General Hospital physicians and staff donated hundreds of books, videos and journals for the Tuzla partners through a project called "Books for Bosnia" that addressed the Clinical Center's need for up-to-date medical literature. This project generated numerous current and/or new books, videos and journals. Other donations of medical supplies and equipment delivered to Tuzla throughout the partnership totaled approximately $160,000.
• A Wellness Center was opened in December 1998 at Tuzla University, which serves to educate both health professionals and the community in the fundamentals of health promotion and prevention behaviors. AIHA's primary role in the development of the Center was to establish a desktop publishing capability to develop health education materials and to provide technical assistance in the management of the Center.
• The University Clinical Center established an on-going relationship with the local USAID office, which donated $1.2 million to renovate a large wing of the hospital for twelve ICU beds. Buffalo General Hospital partners provided training for staff in new technology supplied to the hospital through the USAID grant.
• An important achievement of this partnership is that the relationship between the Buffalo and Tuzla partners is continuing despite the lack of funding from USAID. Select partners will be traveling to Tuzla in 1999 to continue the work begun during the partnership, which will help to ensure the sustainability of the program.