• Introduce a model home care service in Vac.
• Strengthen the family physician primary care system within the Vac region.
• Provide education about and promote the use of home care to physicians, nurses, and other health care professionals.

Management

• Use the concepts of Continuous Quality Improvement (CQI) to provide hospital and community health leaders with the management and team-building tools they need in order to manage change within Vac Municipal Hospital and its regional health system.
• Develop and improve management processes and enhance management skills of hospital leaders to operate the hospital more effectively and efficiently.
• Improve hospital management and administration, as well as increase efficiency in the clinical areas of diabetes, oncology, one-day surgery, emergency care and acute stroke/rehabilitation.

Clinical Areas

• Reduce length of stay of diabetes patients in Vac Municipal Hospital by improving the diagnosis, treatment and follow-up care of diabetic patients, developing an organizational structure for home care delivery, and developing a comprehensive and intensive diabetes patient education program.
• Reduce length of stay of colostomy patients by improving nurse education for home care of colostomy patients and improving patient education in colostomy management.
• Decrease length of stay of stroke victims in Vac Municipal Hospital through improved nurse and patient education.
• Provide training for clinical personnel in Vac Municipal Hospital and primary care physicians in the Vac region through educational outreach and exchange.

Community Health

• Develop a community health project in Vac to involve different sectors of the Vac community - public and private - in an inclusive process designed to educate the Vac citizenry, especially the community's youth, on methods to improve their well-being.
• Convene regularly a Healthy Community Task Force to develop and implement projects educating the Vac citizenry on pertinent health issues.
• Open a Healthy Community Center in Vac to serve as a venue for community education programs and meeting place for the Healthy Community Task Force.
• Garner the support of municipal government leaders, public health care officials, leading businessmen, and other stakeholders in the community health project.

1995

• The Winston-Salem and Vac partners celebrated the official launching of their partnership twice -- first on October 10 in Winston-Salem, and again in Hungary at a ceremony honoring Vac Municipal Hospital's 25th Anniversary. A Memorandum of Understanding was signed by the president of Carolina Medicorps, Inc. (now NovantHealth) and the medical director of Vac Municipal Hospital.
• The Winston-Salem partners conducted a five-day course in Continuous Quality Improvement (CQI) in November for management staff at Vac Municipal Hospital, to help improve the administrative and clinical operations at the hospital.

1996

• The US partners held two diabetes workshops. In March, they trained forty physicians and nurses from Vac Municipal Hospital and family practices in diabetes education and care. In June, twenty-three Vac nurses attended a two-day diabetes management course.
• The US partners conducted follow-up training in Continuous Improvement tools and methods for hospital leaders, including managers, nursing leaders, and financial staff. Topics covered in the April training included quality improvement and team building.
• Partners participated in the first annual AIHA Partnership Conference for Central and Eastern Europe (CEE) and the first annual CEE Nursing Task Force meeting, both held in Budapest in May. US Partners facilitated workshops on the continuum of care and CQI, and Vac Municipal Hospital hosted a site visit, including tours of the inpatient departments, diagnostic laboratories, outpatient clinic, and diabetes outpatient center.
• In August, Vac Municipal Hospital, with the support of the US partners, applied for and received a grant award from the Hungarian Ministry of Welfare to fund the development of home care as a demonstration project for other prospective sites in Hungary.
• The Vac Municipal Hospital Information Coordinator participated in AIHA's first workshop for CEE information coordinators, held in Tallinn, Estonia in September. AIHA staff presented a training curriculum that included instruction on the use of 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. During the workshop, information coordinators started creating Web pages for their own institutions. AIHA staff also introduced the Learning Resource Center Project workplan and led "training-of-trainers" group exercises to emphasize the need to make Internet access universally available at their institutions. The Vac Information Coordinator used knowledge gained at the workshop to educate the Hungarian partners on the use of Internet and e-mail. He also began developing Vac Municipal Hospital's web site.
• The CEE partners established a home care agency for the Vac region in November, utilizing nurses in conjunction with private practitioners and providing patient education.

1997

• The Winston-Salem partners conducted Health Management and Leadership Courses in Eger, Hungary for about 65 members of Vac Municipal Hospital's upper management, physicians, and head nurses. The goal of the two courses, held in March and October, was to improve and develop management processes and enhance management skills of hospital leaders, enabling them to operate the hospital more effectively and efficiently. The course brought together people from different hospital departments, provided physicians and nurses the forum for breaking down barriers between them, and taught more open communication skills. Topics covered included: management and leadership, quality and information management, human resources management, teambuilding and communications, and financial management.
• Partners participated AIHA's Second Partnership Conference for CEE and the CEE Nursing Task Force meeting in Zagreb, Croatia in May. US and Hungarian partners facilitated or served as panelists for sessions on "Nursing Task Force," "Responding to a Changing Health Care Environment," "Improving Health Care Outcome through Patient/Family Education Initiatives," "Options for Health Care: Home Care and Hospice," and "Leadership Development."
• The Information Coordinator from Vac Municipal Hospital attended the week-long Second CEE Information Coordinator Workshop in Krk, Croatia in July. The workshop aimed to transform the Learning Resource Centers into centers for interactive learning, conferencing, and communication. To encourage the continuation of this transformation, the workshop emphasized the application of technology and information through sessions on advanced Internet applications and evidence-based medicine. After the conference, the Vac Information Coordinator conducted a survey among hospital staff to determine barriers to information access and then implemented a program to implement approaches for overcoming them.
• The Vac partners attended the First World Conference of Hungarian Nurses and Care-givers in Budapest in October. Nurses from Vac Municipal Hospital presented a paper on case management in home care, which focused directly on the partnership program.
• The partners participated in the First World Congress on Home Care in Boston in October, sponsored by the National Association for Home Care (NAHC). The Vac Home Care Director made a presentation on the partnership home care initiative and participated in a roundtable discussion of home care in Central and Eastern Europe. The NAHC published the article "US-Hungarian partnership: Strengthening Home Care's Stand" in its October 1997 international issue of CARING.
• In November, the Vac partners established a model diabetes program including patient education, data collection and evaluation, and a patient support group. To mark the World Day of Diabetes, Vac Municipal Hospital organized a public session for diabetes patients and members of the community Diabetes Club. The event, attended by 77 participants, featured lectures by physicians and nurses, diabetic refreshments, and presentations of diabetes products by two companies. A local Vac newspaper and radio station reported on the event.
• The Winston-Salem partners taught a home care education seminar focused on agency management operations and clinical issues. The US faculty conducted the seminar in December for 28 participants, including nurses, physicians, social workers, and physical therapists representing four area home care agencies. Topics covered included a study of US home care, staffing and practice issues, clinical pathways, documentation, standards and accreditation, and public relations.

• In March, the US partners conducted two week-long advanced Senior Health Management and Leadership Level II Courses in Sopron, Hungary for fifty-one Vac hospital leaders, including doctors and nurses. The team of US faculty taught modules on Managing Change and Transition, Methods for Organizational Improvement, Communication Skills, and Planning Tools. The courses helped hospital leaders to improve and develop management processes and enhance management skills, building upon the lessons learned at the Level I courses taught in Eger the previous year.
• Vac partners participated in and provided local support for AIHA's regional Health Care Workforce Conference in Budapest in March. Two Hungarian partners, along with relevant ministry officials, health care educators and other practitioners from Hungary attended the conference. Vac Municipal Hospital hosted a pre-conference orientation and hospital tour.
• In April the Hungarian partners established the Association for the Health of the Citizens of Vac, a task force consisting of local government officials, educators, public health officials, and leading businessmen. The Association was created in order to develop and implement a community health program in Vac municipality.
• Vac Municipal Hospital developed and implemented the new Emergency Department treatment area. On April 24 a ceremonial opening of the newly renovated Emergency Department of Vac Municipal Hospital took place in the presence of the Chairman of the Hungarian Parliament, hospital CEOs and other guests. The design and re-organization of the department was based on observations and training received at NovantHealth. Advances incorporated into the new area include triage criteria development and implementation of the triage system, a method of providing information to the family and patients regarding their tests and treatment, and a centralized transportation system to transport patients more efficiently. Other innovations include the joining of trauma and internal medicine emergency departments, a shock-prevention/life-saving unit at the ambulance entrance, the immediate separation of infectious patients, a new operating theater with air conditioning, and overall better facilities for the doctors and nurses.
• US and Hungarian partner nurses participated in the third annual CEE Nursing Task Force meeting in Bucharest, Romania in May. This meeting brought together over 45 nurses from all partnerships in the region to share accomplishments and discuss Nursing Resource Centers, nursing association building, and plans for future collaboration.
• In May, the partners participated in AIHA's Third Annual Partnership Conference for Central and Eastern Europe in Bucharest, Romania. This year's conference highlighted the partnership experience and issues of partnership sustainability. Three Hungarian and three US partners participated and presented in sessions on "Building Relationships with National and Local Governments" and "Uses of Video-Conferencing."
• Members of the Vac Healthy Community Task Force participated in a WHO/AIHA Community Health Conference in Latvia in May, which featured a successful community health project supported by the Riga/St. Louis partnership. Following the conference, the five community health leaders from Vac spent a day with the Latvian partners to learn more about the AIHA-funded community health project in the towns of Tukums and Engure. The Vac partners met with Tukums municipal leaders, student leaders, school directors and program coordinators to discuss community health issues such as sexual responsibility, healthy lifestyles, mental health, and first aid. The Hungarians left Latvia with many new ideas about community health, along with copies of English-language materials used to implement the project in Tukums.
• The Vac partners participated in a three-day June conference organized by AIHA in Riga, Latvia, entitled "Nursing Associations: Leadership and Organization for the 21st Century." The conference gathered together key nursing leaders from 16 countries in CEE and the NIS and from the US to discuss the role of nursing associations, organizational leadership, professional development of nurses, nursing power and influence, policy development and uses of technology. The four Hungarian nurses developed a country action plan for implementation upon return to their home country.
• Members of the Vac Healthy Community Task Force participated in the WHO-sponsored International Healthy Cities Conference in Athens, Greece in June. The team of Hungarians was comprised of a teacher, police captain, and a physician (the Vac healthy community project coordinator). They joined conference participants from project cities in the WHO Healthy Cities project; government representatives in the areas of health, environment, social welfare and urban development; public health, health promotion and environmental professionals; and academics and researchers. The team engaged in discussions and networked with professionals involved in the Healthy Cities movement, with a view to learning lessons for application in Vac. Workshop topics included health promoting settings (including schools), engaging the business sector, strategies for high visibility and working with the media, and community participation.
• In July, the Vac Municipal Hospital Information Coordinator participated in AIHA's third annual training workshop for Information Coordinators from the 36 Learning Resource Centers (LRCs) in CEE. The main themes of this workshop, held in Kosice, Slovakia, were information management and sustainability of the LRCs. Participants, including Vac Municipal Hospital's Information Coordinator, learned about database design, improving time management, developing annual budgets, and generating internal and external sources of funding. The training in database design was important to the development of Vac Municipal Hospital's cancer database, created to monitor treatment outcomes.
• The Winston-Salem partners conducted community health training in July for Vac teachers and students in two workshops held in Eger, Hungary. An important component of the healthy communities initiative in Vac was to mobilize the public schools to get involved. To help accomplish this, a team of community health experts representing NovantHealth taught back-to-back courses, first for teachers and then for students. The first course taught 25 teachers how to lead health promotion efforts in their schools, to train other teachers, and to become involved in the overall healthy lifestyle effort in Hungary. The second course trained a group of 24 students from Vac to be peer counselors, trainers, and role models for other high school students in Hungary. In both courses, topics covered included responsible sexual behavior, addictive behavior, and nutrition.
• In August, Vac Municipal Hospital, with the support of the US partners, applied for and received a grant award from the Hungarian Ministry of Welfare to further develop home care as a demonstration project for other prospective sites in Hungary. This grant for equipment, education of Vac home care staff, and development of hospice services demonstrated the Ministry of Welfare's continued support for the partnership's home care initiative.
• In September, the partners presented a national dissemination conference of partnership successes to approximately 200 health care professionals from throughout Hungary. Topics included nursing, management and leadership development, emergency medicine, quality improvement and assurance, one-day surgery, the continuum of care and home care, stroke rehabilitation, diabetes, and healthy communities. Participants included hospital head doctors and nurses, family doctors, district nurses, home care nurses, public health officers, and representatives of the national and local governments and professional health associations.
• On December 15, the partners celebrated the opening of the Healthy Community Center in Vac. The opening ceremony, held at the Vac Town Hall, was attended by numerous community members along with several important guests, including the deputy to the USAID Regional Director for Hungary, the USAID/Hungary Project Manager, and the Deputy State Secretary of the Ministry of Health. Local dignitaries included the mayor of Vac, police chief, bishop of Vac, and representatives of local businesses, schools, and health care organizations. After opening speeches by the mayor, the USAID Deputy Regional Director, the Vac Public Health Officer, and AIHA, the Vac Healthy Community coordinators described the development and future plans of the project. Partners signed a Memorandum of Understanding (MOU) and certificates of appreciation were given to the Vac Healthy Community Task Force. After the ceremony, participants visited the Healthy Community Center for a ribbon cutting ceremony and tour. The Center will serve as a venue for community education programs and as a resource center and meeting place for the Task Force.
• On December 16, the partners celebrated the opening of a Nursing Resource Center (NRC) with an MOU signing ceremony at Vac Municipal Hospital. Hospital management, head doctors and head nurses of the hospital, nurses from the community, the US partnership coordinator, and AIHA staff attended the event, which was covered by the local press. The hospital has extensive regular training programs for nurses, which will take place in the new NRC. The NRC will be used also by the local nursing high school, whose students practice at the hospital, for training of the home care nurses and in some cases also for nurses of the Vac district. The center will provide an educational and training site for nurses from the Vac region and will assist Vac Municipal Hospital in four areas: graduate nursing education, support of a credit-based system of nursing professional education currently being introduced in Hungary, continuous improvement, and patient education.

Home Care

• Hungary's Ministry of Welfare awarded a 1.8 million forint grant (approximately $127,000 USD) to Vac Municipal Hospital to fund the development of a home care health model. The award is evidence of the Ministry's respect for the partnership institution and the work that the partners have achieved in home health. The Director of Vac Home Care received another grant of 700,000 forints (approximately $50,000 USD) from the Ministry of Welfare to purchase rehabilitation equipment and mobile phones for patients. Vac Home Care also received an award to fund the addition of hospice services.
• The partners established an independent home care agency that works closely with Vac Municipal Hospital. The hospital changed its operation guidelines, incorporated home care into its continuum of care, set criteria for home care treatment, and created the new position of Home Care Coordinator, who cooperates with the home care agency. The number of procedures the home care service is able to perform has increased because of the enhanced training for staff members.
• The Vac partners developed a financing mechanism for community home care, serving as a model to be replicated in other Hungarian communities via the National Health Insurance Fund. The partners developed clinical guidelines, instituted a system for nursing documentation, created a leaflet on patient rights, developed accreditation requirements, and created and utilized promotional materials for public relations.
• Making home care a focus area for 1998, the Public Health Officer of the City of Vac established a new position of Head Nurse to supervise Vac home care, to serve as a coordinator between home care and district nurses. Hospital physicians, primary care physicians, patients and families are informed about the opportunities of home care services. Home care now offers physical therapy and electrotherapy.
• Home Care service has been expanded to include most areas of Vac, as well as some neighboring villages, and Nograd and Nagymaros counties.
• With the introduction of home care services in Vac, some patients are not even admitted to the hospital or spend less time there. For example, fewer hospital admissions into the Emergency Department are made possible because of the new alternative of referring the patient to home care.

Clinical Areas

• The project at Vac Municipal Hospital was intended as a complex model project of improving management, treatment and prevention, focused on elevating patient care to a qualitatively new level. The project fulfilled these expectations, and Vac Municipal Hospital started to serve as a model for other hospitals in Hungary. The Hungarian Ministry of Health continues to draw upon the successes of the Vac partners in developing national health care reform.
• The Winston-Salem/Vac partners have developed a set of "clinical paths" which detail exact responsibilities for hospital staff and a plan for testing and treating patients with specific pathologies during hospital stays. The clinical paths have allowed Vac Municipal Hospital to better anticipate costs associated with each patient. The hospital has increased staff efficiency by allowing hospital staff, particularly nurses, more independence to perform tests and therapy, using the clinical paths as a guide, without directly consulting with physicians.
• Hungarian physicians and nurses entered into an agreement with the national Health Insurance Fund, in which the Fund provides funding for Vac Municipal Hospital's efforts to introduce one-day surgery. New anesthesia "blocking" techniques have been used instead of general anesthesia for surgeries, allowing patients to return home the day of surgery.
• The Hungarian Ministry of Welfare incorporated Vac Municipal Hospital's diabetes patient education materials and procedures as official teaching instruments and will use them as educational tools in other hospitals throughout Hungary. The Ministry included the patient education materials prepared in Vac in a national program for primary care physicians on diabetes care follow-up. The Ministry has asked physicians and nurses from Vac to assist with training in hospitals around the country and with the dissemination of the materials.
• Vac Municipal Hospital improved its outpatient home care and rehabilitation of patients with the creation and development of an active Diabetes Club, Ostomy Club, and Oncology Outpatient Clinic. These activities, involving dozens of patients and many doctors and nurses, are direct outcomes of the partnership.
• A Vac family physician and his staff implemented a diabetes patient education program, with classes conducted every two months. Their office is equipped with a computer system that provides a connection with the hospital laboratory. In addition, the educators conduct classes with district nurses. Patients are very receptive to the classes and are learning to take responsibility for their own health. As a result, the office has had only two hospital admissions in the year following the implementation of the education program. Thirty-three nurses, twelve diabetes team members, three physicians, and one manager have been involved in the development of the program.
• The Vac partners created and adopted into regular use a series of diabetes patient education sheets to estimate the knowledge of the patient at the onset of the education and training. The hospital developed and utilized an educational sheet on the symptoms of hypoglycemia and hyperglycemia in the education of 1350 patients to date. Another instructional sheet, developed by the diabetes team members in collaboration with 85 members of the patient diabetes club, teaches patients how to tailor their diet. A follow-up sheet allows educators and patients to track their progress in the program. Partners utilized the hospital newsletter and local media to inform patients about the availability of diabetes patient education.
• Diabetic patients in Vac are now assigned to only one outpatient clinic and one hospital department, where previously they were treated in multiple departments in a less organized manner. The team developed a patient survey, to track customer satisfaction and ensure quality of care. After the diabetes team members received specialist training, they shared this training with some nurses representing all hospital departments. The hospital created the positions of diabetes nurse in the outpatient clinic and diabetes patient educator. Family physicians now keep better patient records.
• Quantitative results of the partnership diabetes initiative:
  

  Vac Municipal Hospital	1995	1996	1997
  Average Length-of-Stay (LOS) for Diabetes Patients (days)	11.65	10.98	6.52
  Average LOS for Patients with Diabetes as a Concomitant Disease (days)	15.54	11.22	10.61
  Hospitalizations because of Recurring Diabetic Episodes	7	5	2

• The knowledge level of diabetic patients and their participation in group activities has increased substantially. The percentage of diabetes patients in Vac who self-manage their condition has increased from 40% before the partnership initiative to 80% now.
• The Vac partners developed an internal cancer database to monitor treatment outcomes. The establishment of a cancer database was not anticipated at the beginning of the partnership. The need for such a database was not determined until the partners began to assess how information was currently being monitored. Without the information provided by the database, it would be difficult to know the impact of changes in the treatment of the cancer patient.

Management

• As a result of numerous improvements implemented through the partnership, the Vac Municipal Hospital reported a decrease in average length of stay in the hospital from 12.2 days in 1995 to 7.8 days in 1998. In the meantime, the number of outpatient visits increased from approximately 783,000 in 1995 to over 1.5 million in 1998.
• Vac Municipal Hospital introduced a system of supervising nurses. The role of the nursing supervisor (a separate position) is to help direct the professional activities of all nurses, help them resolve any human resource and professional issues, and manage the training of new staff members, as well as conduct continuous training of nurses. In addition, documentation by nurses has improved, and nursing techniques have become more consistent with the introduction of clinical guidelines. The supervising nurse plays a leading role in the development and elaboration of these guidelines.
• Vac Municipal Hospital instituted a patient discharge planning system. With this system, the hospital can make informed decisions on patient release, allowing patients to leave the hospital earlier than before, decreasing average patient length of stay in the hospital.
• The Vac partners have taken steps to improve the hospital's customer service level to patients. Through training and reinforcement of the idea that patient care is a service, the staff takes personal responsibility in caring for the patient. Patient satisfaction surveys track patient and family opinions of the services they receive, highlighting customer service opportunities.
• The partners were able to gain the support of individuals and organizations outside the partnership, notably the Ministry of Welfare/Health and the Hungarian Nursing Association. Successes in Vac have been hailed as a model for the rest of Hungary, with specific programs and protocols replicated throughout the country, with the support of and at the request of the Ministry. The Healthy Community Task Force has support and involvement from the Vac Municipality and the mayor, the Vac Public Health Service, schools, and local businesses.

Community Health

• The Hungarian partners established the Association for the Health of the Citizens of Vac, a task force consisting of local government officials, educators, public health officials, and leading businessmen. The Association was created in order to develop and implement a community health program in Vac municipality. Programs implemented to date include the "Healthy Corner" program, where participating local grocery stores set up a special section featuring healthy foods.
• Regular meetings of the Vac Healthy Community Task Force helped to bring together the community and the municipal policymakers and stakeholders, and convinced them that they were doing significant work for the benefit of the community. These meetings demonstrated to the mayor and local policymakers that everyone must share the responsibility for the community's health and well-being.
• The partners opened a Healthy Community Center in Vac. The Center serves as a venue for community education programs and as a resource center and meeting place for the Task Force.
• The Association for the Health of the Citizens of continues to remain active after the end of USAID/AIHA funding, and in February 1999, they conducted a two-day course in the city's schools on health education and nutrition. Thirty-one teachers and health services personnel from the local schools participated in the courses, where they shared ideas on improving health awareness in the schools and in the community. Participants decided to implement a program for improving school cafeterias by installing a new model school kitchen, where healthy food choice and preparation are practiced. Training programs will be developed for the staffs of the existing school cafeterias.

Additional Developments Since Partnership Graduation

• Partners utilized video-conferencing technology to maintain their partner relationship. Over the course of three, two-day videoconferences in 1999, they discussed the following: developing a process for grant writing; the status of wellness programs begun under the partnership; team meeting for the partners' diabetes team; a presentation on the train-the trainer model; and a team meeting of the various clinical teams, to discuss the status and future of partnership-related activities.
• After the 1999 AIHA Annual Partnership Conference, the Hungarian partners visited Winston-Salem for follow-up discussions related to activities initiated under the partnership. The Vac partners observed health information classes and activities, met with Winston-Salem community leaders, learned how to involve health professionals in their program, and met with a school nurse to learn about her role in the health of the students. They met with educators in NovantHealth's Corporate Education Department to learn about courses that have been developed for managers and staff, as part of their Continuous Improvement program. They learned about and observed a drug trial for acute health in the hospital's Emergency Department. Finally, the Vac partners met with leaders of the Medical Center to discuss current issues needing consultation at Vac Municipal Hospital.
• The Hungarian partners continued to actively implement the Healthy Community Project in Vac. In February 1999, the Association for the Health of the Citizens of Vac (the task force created by the partnership) conducted a two-day course on health education and better nutrition in schools. The "Healthy Corner" program, initiated in December 1999 in local Vac supermarkets, continues to be successful. Under the direction of the Association, participating local grocery stores set up a special section featuring healthy foods. The Vac partners utilize the new Healthy Communities Center, established with AIHA support, to hold weekly meetings with teachers and students. A student, in cooperation with the task force, is creating a web site to facilitate the analysis of questionnaires about local health education. The Hungarian partners have also secured funding for the production of educational materials.