The partnership focused on targeted, measurable improvements in the quality of care, clinical outcomes, functional status, and patient satisfaction in a variety of clinical areas, according to individual hospital needs. Concepts of continuous quality improvement, leadership development, infection control, nursing, pharmacy management, and critical care medicine were also introduced across all partner institutions. Specific objectives by area and partner institution are listed below.

Management, Leadership, and Continuous Quality Improvement (CQI)

• Develop capacity for long-term change in thinking about work in the following areas: clinical, operations, finance, management, teams, and planning.
• Plan and implement improvement cycles with specific results measured, in many cases, by statistical process control charts and survey instruments.

Infection Control

• Develop interdisciplinary, comprehensive infection control programs in each partner hospital, applying measures of quality outcome criteria.
• Develop country-wide standards for laboratory protocols.
• Design and implement a national infection control conference to disseminate learning, methodologies and tools gained through partnership.

Nursing

• Improve nursing management and leadership by increasing nurses' skills in these areas.
• Implement a human resource model for nursing practice at Srebrnjak Hospital as a pilot for dissemination to other hospitals.
• Disseminate partnership nursing lessons learned and activities to nurses throughout Croatia.
• Develop a Nursing Resource Center (NRC) in Zagreb, Croatia.

Pharmacy Management

• Improve pharmacy services at all three partner hospitals by developing specific improvement projects at each hospital. For example, establish unit-dose distribution system at Srebrnjak Hospital.

Critical Care Medicine

• Establish measures of quality outcome criteria for critical care medicine.
• Develop and establish a collaborative practice model for critical care practitioners.
• Develop methods for assessing and responding to issues of "burnout" in critical care providers.
• Develop a core faculty of critical care providers to act as resources and educators to continue improvement work in the area of critical care medicine.

Asthma and Tuberculosis (Srebrnjak Hospital)

• Implement a comprehensive asthma program (CAP) at Srebrnjak Hospital by assessing clinical capabilities, understanding US outpatient management of asthma, developing clinical skills, and developing patient/family education activities.
• Establish a TB referral center at Srebrnjak Hospital by assessing TB clinical capabilities, providing in-depth training in diagnostics and treatment of TB, and developing additional resources.
• Disseminate partnership work in asthma and TB to wider health care community in Croatia.

Hepatitis (University Hospital for Infectious Diseases)

• Develop a Hepatitis Reference Center and increase early identification and outpatient management for Hepatitis B and C.

Chronic Renal Disease (Sveti Duh Hospital)

• Develop an interdisciplinary team approach to management of dialysis patients with a goal to improve the functional status of the patients.

Women and Infants Health (Sveti Duh Hospital)

• Improve the clinical management of low birthweight babies in the neonatal intensive care unit.
• Improve methodology for in-vitro fertilization procedures.
• Improve the organization of delivery service for obstetrics.

• On September 7 a Memorandum of Understanding (MOU) was signed, marking the formal initiation of the partnership. Representatives from all three Croatian hospitals, Dartmouth-Hitchcock Medical Center, and AIHA signed the MOU.

• Two leadership development seminars for approximately 60 participants from the three partner hospitals were conducted in October 1995 and 1996. The two-week courses included sessions on teambuilding, communications, leadership and strategic planning.

• The OB/Ultrasound team from "Sveti Duh" shared innovative advances in ultrasound detection of breast and ovarian cancer with DHMC radiologists in March 1996.
• A national infection control conference was conducted in May 1996 and November 1997 for a total of 250 participants representing all regions of the country. During the conference, protocols for surveillance and control were adopted and antibiotic policies were examined. A resolution for a national strategy on infection control was developed and submitted to the Ministry of Health for adoption.

• A "Training of Trainers" course was held in June 1997 for about 20 of the original course participants to enable them to train their colleagues.
• Three surgeons from "Sveti Duh" trained to use laparascopic techniques for gall bladder and colon surgeries and appendectomies in April 1997 as part of an effort to decrease length of stay and the morbidity associated with the more invasive surgical techniques.
• Held a countrywide 2-day respiratory care conference: "Together Against Asthma and TB -- Partners in Diagnosis and Treatment" in October 1997, with 152 participants.
• Croatian and US partners presented partnership achievements and successes at the Second and Third Annual AIHA Partnership Conferences held in Zagreb, Croatia and Bucharest, Romania in May 1997 and 1998.
• A second infection control conference was held in November 1997 for a total of 200 participants from Croatia as well as other CEE partnerships, where new knowledge and skills gained through participation in the program was disseminated.

• A Critical Care Conference was held in March 1998 entitled "Teamwork and Success in the Intensive Care Unit."
• A National Nursing Conference was conducted in Zagreb in April 1998. During the conference partnership nurses shared with their colleagues from all regions of Croatia the research and lessons learned through participation in the partnership. Themes of the presentations included leadership, quality management, occupational health, family-centered care, teambuilding and collaborative practice.
• A Latvian physician spent three weeks training on ultrasound techniques at Sveti Duh Hospital with an eminent physician who has developed model women's reproductive health services.
• A Family Centered Care Conference was held June 1998, with over 100 participants and presenters from all of Croatia and neighboring Bosnia-Herzegovina.
• A National Pharmacy Conference was conducted in June 1998, with over 120 participants from hospitals all over Croatia.
• On Tuesday, 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.
• An opening ceremony for the Lebanon-Zagreb partnership's Nursing Resource Center held on October 20, 1998. The main Center is located at "Dr. Fran Mihaljevic" University Hospital of Infectious Diseases in Zagreb, with smaller resource rooms also set up in Sveti Duh General Hospital and Srebrnjak Children's Hospital for Respiratory Diseases.

Leadership Development

• The use of quality outcome measures was introduced in all three partner institutions. Leadership training provided to the Croatian partners' reinforced their ability to use quality management principles in their daily work.
• Methods were introduced to improve collaborative practice and resolve communication and decision-making among team members. As a result, interpersonal relationships (physician to physician; physician to nurse; nurse to nurse), as well as intra- and inter-departmental collaboration have all improved. Change is observed particularly amongst younger nurses and physicians.
• Meetings are more efficient. Important meetings are held monthly and agendas are prepared one week in advance. Problems are discussed, and conclusions are identified and reviewed at follow-up meetings.
• The Leadership Development programs at Trakoscan and Stubicka Toplice were especially important in setting the stage for more collaborative interactions rather than "top-down" directives. Head nurses now hold regular meetings where subordinate nurses are asked their opinions, and problem-solving is more participatory and constructive.
• Projects implemented at "Sveti Duh" Hospital (involving cardiology, orthopedics hematology, trauma and nephrology departments) achieved measurable improvements in provider teamwork, patient satisfaction, effectiveness of care, and clinical outcomes.

Infection Control

• A national resource center for infection control microbiology was established at University Hospital for Infectious Diseases.
• As a result of the partnership, the Ministry of Health established a new Committee for Control and Surveillance of Infectious Diseases. The Committee meets monthly to discuss nosocomial infections and laboratory diagnostic procedures.
• The hospitals have begun to measure risk factors for nosocomial infections, representing a major impact of the conferences and partnership activity.
• "Srebrnjak" Children's Hospital changed visiting hours due to patient surveys, and began isolating tuberculosis patients to reduce hospital infection rates.
• Laboratory staff from three Croatian hospitals attended a one-week training in WHONET, a database system designed and introduced by the World Health Organization to monitor and analyze data related to anti-microbial resistance. WHONET software was introduced in the microbiology laboratories, and data was collected and sent to WHONET collaborating centers on a regular basis following the training workshop.

Nursing

• The partnership upgraded a wide variety of clinical skills and knowledge, and introduced management and leadership functions into the role of the nursing staff.
• Introduced human resource tools for nursing practice - e.g., job descriptions, staff orientation, performance evaluation.
• A formal link was established between the School of Nursing in Zagreb and the partnership for purposes of education, research and leadership training.

Pharmacy Management

• Opportunities were developed to improve pharmacy management, including drug selection/decision-making, ordering, processing and dispensing. The pharmacist's role in managing the medication process was strengthened, and quality improvement objectives in problem identification and process planning were introduced. Several pilot programs within the pharmacy initiative demonstrated excellent outcomes in cost reduction. Results included:
• A 35% reduction in hospital pharmacy costs in select wards at "Srebrnjak" Children's Hospital for Respiratory Diseases, due to the introduction of a unit dose dispensing pilot, and a program to control the use of high-cost antibiotics.
• A reduction of medication wastage by 16%. Prior to the partnership, surveillance of antibiotic infections did not exist and there was a monthly stockpile of medications. This resulted not only in wastage, but also led to the potential for patients to be overmedicated, or to receive more medication than necessary. Since the introduction of a unit dose system, a monthly process control flow chart of medication consumption shows steady reduction of medication wastage.
• An antibiotic monitoring system was developed and implemented at "Sveti Duh", which resulted in an estimated annual savings of DM 400,000 (approx. USD 260,000). Savings were primarily due to the more targeted use of effective antibiotics for particular organism strains.
• Training in database development resulted in programs to track the use of medications, leading to significant cost reductions. Programs were established to collect clinical information to monitor patients' diagnosis, treatment, and follow-up care.

Critical Care Medicine

• A comprehensive program for diagnosis and treatment of asthma and TB was introduced at "Srebrnjak" Children's Hospital for Respiratory Diseases.
• An asthma camp to teach patients and families about prevention and treatment was opened in rural Croatia. An integral component of the program was the development of patient education materials in a developmentally appropriate manner.
• Renovation of the physical space for treatment of patients with TB was completed during the partnership period.
• Disinfection and infection control procedures within the hospital were upgraded and improved.

Chronic Renal Disease

• Collaboration between the renal teams at "Sveti Duh" and DHMC tested an innovative method to evaluate the functional health status of patients on dialysis, looking at ways to improve the quality of care for chronic renal patients. The study represents a breakthrough approach, pioneered by the Croatian team, to enhance activities of daily living for patients with chronic illness.

Family Centered Care

• The family-oriented care initiative, implemented at "Srebrnjak" and "Dr. Fran Mihaljevic" hospitals, dramatically influenced new policies permitting increased family visitation on inpatient units.
• Improved parent/baby contact, increased nurse involvement in parent education, and improved care of babies 1000 to 2500 grams, was noted at "Sveti Duh" Hospital.

Information Technology

• The informatics component of the partnership enabled the Croatians to acquaint themselves with information technology and to widen use of the Internet throughout their institutions. Clinical and managerial decision-making became more scientifically based as a result and the Learning Resource and Nursing Resource Centers provided expanded access to a wide variety of providers within the partner institutions.