• Improve knowledge and skills related to the prevention and diagnosis of cardiovascular disease.

Nursing

• Introduce a theoretical framework for collaborative practice and improve the management skills of nurse leaders within the partnership institutions and other national-level nursing organizations in Croatia.

Oncology

• Improve knowledge and skills related to the prevention, screening and diagnosis of cancer.

Total quality management (TQM)

• Introduce tools and techniques of TQM and improve management knowledge, skills and practices.

Post Traumatic Stress Disorder (PTSD) in children

• Increase recognition of PTSD and improve related diagnosis and treatment modalities.

Fundraising and development

• Create a fundraising program within the partner institutions, and increase awareness of and community support for hospitals.

Orthopedics

• Increase the knowledge and skills of clinicians in the treatment of orthopedic conditions related to osteomyelitis and reconstructive surgery.

Gerontology

• Develop a theoretical framework and policy alternatives for the care of the elderly population in Croatia.

Infection control

• Introduce standard policies and procedures to reduce the rate of nosocomial infection in partner institutions.

1995

• A Memorandum of Understanding (MOU) was signed on November 6 among US and Croatian partners and AIHA to initiate the partnership program.

1996

• During the partnership's first gerontology exchange in May, partners from Ohio toured hospitals, retirement homes, and clinics in Zadar and Biograd. They met with county government officials and representatives of the United Nations, and participated in the First Croatian National Congress on Physical Medicine and Rehabilitation. As a result of this and subsequent trips, the Franciscan and Zadar partners developed a set of national and regional recommendations and long and short-term goals for partnership initiatives in geriatrics.
• Partners held the first in a series of training workshops in Leadership Development/Total Quality Management on September 1-13 for fifty-nine Zadar and Biograd leaders, including administrators, physicians and nurses.
• In October, a Train-the-Trainer program started with hospital-based oncologists meeting with family practice physicians to teach necessary skills for the early detection of cancer. An anatomical model was donated for urologists to teach family practice physicians to perform digital rectal exams.

1997

• Croatian surgeons and therapists were given "temporary student privileges" to gain hands-on training experience in both the operating room and the rehabilitation setting during their visit to Greenville, South Carolina in April.
• As part of the partnership's fundraising initiative, Croatian partners established a foundation called "The Croatia Children and Family Association." Lawyers, bankers, and representatives of the Ministries of Health and Finance have pledged support to this philanthropic initiative.
• From May 3-11 and October 11-18, US partners held additional training workshops in Leadership Development/Total Quality Management.
• Zadar and Biograd Hospital leaders presented the results of their quality improvement projects in Zagreb and Bucharest at the AIHA annual partnership conferences in 1997 and 1998.
• In support of the cardiology initiative, US partners secured a donation worth $45,000 of equipment for coronary angiograms.
• In August, an arthroscopic system was donated to the Croatian surgeons at Biograd Hospital valued at approximately $40,000.
• In November, the first arthroscopy procedure in the Southern half of Croatia was performed by Dr. Pace, the first hand therapy/splinting was also performed in Biograd, and the first blood autotransfusion technique was performed during a joint replacement operation in Zadar.
• In November, Zadar General Hospital and the Orthopedic Hospital of Biograd held a press conference to honor the partnership's first anniversary. Local television, radio, and print media covered the conference, during which the Croatians outlined their partnership highlights to date and future plans.

• Biograd Hospital received a national award for their service during the war and for their significant achievements in improving healthcare. The partnership was mentioned specifically in helping them achieve these improvements.
• A study tour by representatives from the Ministry of Labor and Social Welfare and the Ministry of Health on geriatric policy was conducted in Dayton, Ohio and Washington, DC in April.
• Partners sponsored the first Health Week in April, which consisted of five days of fundraising events including an art auction, soccer match, basketball game, and music and theatrical performances. Health Week culminated in a very successful community Health Fair sponsored jointly by the US and Croatian partners. Overall, the Health Week activities raised approximately $10,000 for Zadar General Hospital.
• In April, a cardiologist from the Franciscan Health System in Cincinnati, Ohio, was honored as the recipient of the 1998 Zadar Distinguished Service Award for his outstanding work and contributions to Zadar General Hospital and the City of Zadar.
• Partners conducted the first Croatian International Conference on Aging in May.
• Dr. Jim Karageannes, from Greenville, SC, performed the first ACL arthroscopy and also the first shoulder arthroscopy procedure in the southern half of Croatia in June.
• Also in June, a digital camera was donated to the project by Dr. Tom Pace, which is being utilized to send pictures of x-rays and patients via the Internet to Dr. Pace's office in Greenville, to discuss complications, procedures, progress, implants, etc.
• One hundred thirty health care professionals attended a national symposium on PTSD, which took place in Croatia on June 19 & 20.
• Twenty participants who completed the initial management course were selected to attend a Leadership Development/Total Quality Management Train-the-Trainer course from June 6-12.
• The Nursing Resource Center opened at Zadar General Hospital in September. The goals and objectives of the Center were identified by the US and Croatian nurses, and approximately $15,000 worth of educational materials and equipment was provided by USAID/AIHA. The US nurses also secured a donation totaling $1,000 from Sigma Theta Tau Nursing Society and the Franciscan Sisters of the Poor Foundation, both in Dayton, Ohio.
• On September 22, the closing ceremony for the Croatia Hospital Partnership Programs took place at the Old City Hall in the Upper Town of Zagreb. Over 100 representatives attended the event, which marked closure for the three year and four year partnership programs in Croatia. Partners from the five Croatian institutions, US partners, representatives of the Ministry of Health, Ministry of Labor and Social Welfare, city government officials, and representatives of agencies who have supported the exchanges over the years attended the ceremony. The Deputy Chief of Mission of the US Embassy presented on behalf of the US Ambassador to Croatia. The Director of the Office for Democracy and Governance in Washington, DC spoke on behalf of USAID and its role in supporting the partnership initiatives in Croatia. AIHA's Hospital Program Coordinator presented remarks on behalf of AIHA, followed by presentations by partner representatives from both the Croatian and US sides.

Cardiology

• Cardiac catheterizations performed in Zadar have increased from 5 cases per year to 2-3 per week. The hospital is also scheduling cases from outlying areas and other cities such as Split, the second largest city in Croatia.
• Zadar General Hospital's Cardiac Catheterization Laboratory was technologically to improve the quality of diagnostic cardiac care and has moved Zadar General Hospital to second behind Zagreb as a major cardiac center in Croatia.

Nursing

• As a result of the partnership, the status of nurses in the two Croatian partner hospitals is beginning to change. Nurses are beginning to be seen as a vital part of the medical team. Two hospital departments have added the position of nursing assistant, and the nursing school in Zadar has begun to examine and upgrade the nursing curriculum and standards.
• Croatian nurses expressed a better understanding of the importance of infection control in the hospital environment. An infection control nurse was appointed in Zadar General Hospital.
• An intensive decubitus ulcer skin care research project was implemented in both partner institutions over a seven-day visit of US partners to Croatia. The study demonstrated significant improvement in patient status as a result of improved nursing care. Nurses also demonstrated an improved understanding of skin care and the use of skin care products as well as overlay mattresses. Additionally, a train-the-trainers program was introduced to educate other nurses on assessment skills for specific patient populations with high risk for decubitus ulcers.
• The use of a dressing cart in the neurological unit was initiated. Use of the dressing cart saved time previously used to gather equipment for dressing changes. In addition, the use of the cart supported the introduction of new treatment plans and protocols that were established.

Oncology

• Zadar General Hospital started a public education campaign for the early detection of colon and breast cancer, which has proven very effective in increasing the public's knowledge and awareness of the disease.

Management

• Initiated and successfully completed two formal Quality Improvement Team Projects by each hospital utilizing multi-disciplinary teams. The first of these was implemented in Zadar and was aimed at increasing communication between departments and decreasing the burden of non-nursing tasks assigned to nurses. In Biograd, nosocomial infection rates fell substantially as a result of the partnership's focus on quality.
• Zadar General Hospital published two articles entitled the "Use of Patient Surveys" and "Communication Between Departments: A Quality Improvement Project" in a Croatian management journal.

Post-Traumatic Stress Disorder (PTSD)

• There were six study exchanges during the course of the PTSD project involving seventeen participants.
• Twelve different workshops and seminars were held over the course of the partnership focusing on group therapy for children. These varied in size from seventy-five to six participants and took place both in the US and Croatia. While in the US, the Croatian team observed and participated in many actual group therapy sessions for children suffering from PTSD.
• Mental health providers in Zadar report closer collaboration with other providers and improved resource sharing as a result of partnership efforts.

Fundraising

• As a result of partnership efforts in the area of fundraising, Croatian partners established the Croatia Children and Family Association, a foundation that seeks to raise funds to support activities of the partner hospitals in Zadar and Biograd. Since the first meeting of the foundation's Board in May 1997, the foundation has solicited and received numerous contributions, including seven initial gifts totaling approximately $30,000. Meanwhile, the Franciscan partners established the Croatian Childrens' Fund in New York City to raise money for the Croatian foundation.

Orthopedics

• The length of stay for new patients undergoing arthroscopy fell from 30 days to 3 days and then decreased again to same day of surgery at Biograd Hospital.

Gerontology

• A sub-acute geriatric unit in Biograd Orthopedic Hospital and an adult day care center in Sibenik were established as a result of partner efforts.
• Croatian and American partners jointly published an article in the Croatian Medical Journal entitled, "The Challenge of Elder Health Care in a Changing Croatia."
• Due to the active involvement of the Ministry of Labor and Social Welfare, partners initiated an exchange of nursing home and retirement home staff.

Infection Control

• Training was provided by US partners in a number of areas related to infection control including: surveillance techniques for the identification of nosocomial transmission including data collection, analysis and reporting; precautions for prevention of blood-borne pathogen transmission, disinfection and sterilization techniques, especially for reusable devices; and infectious waste disposal. Infection control policies and protocols were established for the institution and disinfection criteria were established. Infection Control personnel instituted a hospital-wide education program which covered basic infection control techniques for all employees.

Partnership Dissemination

• Partners presented their experiences and outcomes at various conferences. Croatian and American orthopedic teams addressed an international conference sponsored by The Mine Victims Fund in Washington, D.C., and the Annual Med Chi Society meeting in Baltimore, MD. Furthermore, Dr. Josip Labar, Director of the Orthopedic Hospital of Biograd, was the keynote speaker at the Third Annual Carolina Orthopaedic Research Foundation meeting.
• Communication and referral linkages between Zadar Hospital and local physicians have improved as a result of collaborative efforts for the health fair, physician lectures, and other partnership activities.