Global HIV/AIDS Program, HIV/AIDS Bureau, HRSA

1. March 5-9, 2012 CLINICAL ASSESSMENT FOR SYSTEMS STRENGTHENING (CIASS) International Center for AIDS Care and Treatment Programs (ICAP) Nursing Education Partnership Initiative (NEPI), Lesotho USG Debrief Global HIV/AIDS Program, HIV/AIDS Bureau, HRSA

2. Presentation Outline • NEPI Lesotho ClASS Purpose and Goals • Cross-cutting Issues • Institution and School of Nursing Strengths & Areas for Improvement • National Health Training College (NHTC) • Paray School of Nursing • Maluti Adventist Hospital and School of Nursing • Roma College of Nursing • Scott Hospital and School of Nursing • National University of Lesotho (NUL) • NEPI Lesotho Planning Considerations: ICAP, MOHSW, CHAL • Discussion & Next Steps

3. NEPI Lesotho ClASS Purpose and Goals

4. Purpose and Goals • Purpose: to better understand the financial and administrative systems of the NEPI schools of nursing in Lesotho, which will be used to inform the development of a comprehensive technical assistance plan • Goal 1: Each school of nursing will have the financial and administrative capacity to receive PEPFAR funds through a sub-contract agreement with the NEPI Coordinating Center • Goal 2: Information revealed during this ClASS assessment will assist USG offices in providing on-going guidance and support to the NEPI/Lesotho project

5. Cross-cutting ClASS Areas for Improvement • Administrative • Finance

6. Cross-cutting Administrative Areas for Improvement • Lack of adequate Human Resources functions and HR staffing (All) • Performance evaluations for staff • Institutions have limited experience with grant writing and funding identification (All) • Institutions do not have general operating policies, procedures or regulations or are inconsistent or outdated (All) • Lack of sufficient IT support, computer equipment, maintenance contracts and internet capacity (All) • Institutions and staff have limited experience with managing donor funded projects (5) • Long range strategic planning (3-5 years) does not exist (5)

7. Cross-cutting Finance Areas for Improvement • Lack of policies and procedures that address donor funding requirements (All) • No grants management experience or systems in place (All) • Lack of detailed procurement processes for purchasing goods and services (All) • No processes for documenting and tracking time and effort (All) • No SOPs for budget development and management process (5) • Minimal internal controls or internal review process to ensure compliance with donor requirements (5)

8. Cross-cutting Finance Areas for Improvement • No risk management planning for general organization (4) • Additional training and support is required on the Pastel Accounting System (3) • Bank reconciliations are not conducted monthly due to staffing shortages (3) • Financial infrastructure is lacking that prevents segregation of duties (3) • Lack of a sustainability plan to address decreases in funding (3) • No documented process in place for resolving audit findings and improving systems (3) • Lack of a technology policy or plan for financial information systems (3)

9. National Health Training College (NHTC)

10. NHTC Administrative Strengths • Staff are flexible in meeting challenges through identifying creative alternative measures. • Executive management team is aware of country policies impacting operations and are active in trying to remedy. • Organogram shows accurate lines of authority, existing and desired positions for when funding becomes available. • The minutes of the executive management team meeting were detailed. • Management team has the ability to modify and update job descriptions as needed.

11. NHTC Administrative Areas for Improvement • Lack of autonomy for NHTC from MOHSW creates administrative barriers which could be problematic if NHTC wants direct funding as a subcontractor from ICAP. (Priority) • NHTC does not have an internal IT staff person on site, making it difficult to maintain equipment and software necessary for administrative and programmatic functions. (Priority) • NHTC is dependent on the Ministry of Communications for their internet services; service interruptions significantly impact administrative and programmatic functions. (Priority) • Most HR functions (recruitment and hiring, etc.) reside at the MOHSW, which impacts administration’s ability to fill positions in a timely manner and manage performance problems of day to day personnel issues.

12. NHTC Administrative Areas for Improvement (2) • The structure and authority of the “Council”, the designated management oversight body, has not been legally authorized and therefore cannot provide adequate support to the Administration on policy issues (Priority) • A recently developed strategic plan, providing a vision and “way forward” for the institution, falls short on inclusiveness in its design and was not completed due to contract funding issues • NHTC’s does not have administrative policies and procedures (Priority)

13. NHTC Finance Strengths • Finance team work efficiently to accomplish tasks • Oversight from the Ministries provides NHTC a degree of stability • MOHSW has a history of receiving funding from multiple donors. • NHTC has a strong desire for autonomy.

14. NHTC Finance Areas for Improvement • Absence of financial infrastructure (Priority) • Lack of NHTC specific policies and procedures that address government as well as donor funding requirements (Priority) • Lack of an accounting package with a chart of accounts to be used for processing of general ledger, accounts payable, payroll, and billing transactions (Priority) • Lack of financial capability to meet donor reporting requirement such as budget to actual variance reporting

15. Lack of a procurement process for purchasing goods and services (Priority) Minimum comprehensive budget development process (Priority) No grants management experience (Priority) No fixed asset management system (Priority) No internal review process to ensure compliance with donor requirements NHTC does not have an established bank account to receive funding Lack of time and effort documentation to meet donor requirements (Priority) NHTC Finance Areas for Improvement (2)

16. NHTC Program Strengths • Good communication between NEPI focal person and the ICAP/INCI/NEPI/Lesotho staff • New skills laboratory is being built • Curricula development is completed every 4-5 years by bringing in all SONs, and hiring an technical expert to facilitate

17. NHTC Program Areas for Improvement • There is no plan to fill vacancies after Global Funding support ends for tutors (n=18) • Salary does not reflect level of expertise (novice, medium, experienced) • Access to educational resources; Computer lab & library • HSS expert tutors need to tailor training to meet skill levels. Training needs to include learner’s demonstration • Accommodation of students and staff could be strengthened • Clinical rotations pose many challenges: • Adequate space/location • Appropriate transport • Increased classroom space needed

18. Paray Hospital and School of Nursing

19. Paray Administrative Strengths • Principal Nurse Educator is a dedicated leader, demonstrates openness, connectedness to community and a desire to improve all operational systems • Documentation of administrative activities including meeting minutes, contracts, MOUs and policies and procedures, etc. were well organized and current • Personnel files were comprehensive and complete • Principal Nurse Educator is actively seeking funding

20. Paray Administrative Areas for Improvement • Lack of performance evaluations for staff for several years. A new template from the MOH is being reviewed for implementation • Human Resource policies and procedures and employee contracts have limited details and lack information on key areas • Institution and staff have limited experience with managing projects and funding outside of MOHSW nursing program activities (Priority) • Long range strategic planning (3-5 years) is missing and is confined to 12 month goal setting based on a strategic plan from 1996. • Senior management staff lacks experience with fundraising and grant writing (Priority)

21. Paray Finance Strengths School of Nursing • Current finance staff work efficiently to accomplish tasks • Governance minutes document discussion and direction on resolving financial issues • SON stressed that ICAP has been responsive and helpful

22. Paray Finance Areas for Improvement • Absence of financial infrastructure at SON and Hospital prevent segregation of duties (Priority) • Lack of SON specific policies and procedures that address government as well as donor funding requirements (Priority) • Lack of time and effort tracking to meet donor requirements (Priority) • Staff do not have sufficient training and support on the Pastel Accounting System resulting in: • Under-utilization of Pastel • Postings to general ledger are several months behind • Routine backups do not occur and are not properly stored; anti-virus software is outdated

23. Paray Finance Areas for Improvement (2) • Lack of Technology policy guidance and support • Financial reports do not include budget to actual variance justification for under and overspending • No comprehensive budget development and management process (Priority) • Lack of a detailed procurement process for purchasing goods and services (Priority) • No grants management experience or system in place (Priority) • Training opportunities are not available for finance staff.

24. Lack of sustainability plan to address decreases in funding A fixed asset registry is not maintained (Priority) No internal controls or internal review process to ensure compliance with donor requirements Most recent bank reconciliations are July and August 2011 (Priority) Petty cash is not reviewed and reconciled in a timely manner No process in place to resolve audit findings No risk management plan Paray Finance Areas for Improvement (3)

25. Paray SON Program Strengths • Resources are well utilized • Committed staff coordinate with each other on a regular basis • Despite distance from Maseru, connected to networks: CHAL, NEPI, and curricula reviews • Good communication with NEPI Lesotho

26. Paray SON Program Areas for Improvement • There are not enough educators, especially in technical areas. • Insufficient educational tools including skills lab, internet access, laptops, LCD projector, etc. • There is a significant lack of dormitory space and lecture halls. • No policies and procedures related to new resources (eg. Skills lab needs to be maintained and secure) • Needed resources to support the nursing program are not available. e.g. internet access, LCD • Staff shortages prevent adequate supervise at all clinical practicum locations • Lack of funds to support transport and accommodations for students doing clinical practicums

27. Maluti Hospital and School of Nursing

28. Maluti Administrative Strengths • Maluti has begun to develop a business operations model with the hiringof a CEO and Business Manager • Hospital management team works well together and maintains detailed documentation of meetings • Governance Board minutes show staff are keeping members well informed of critical issues • Human resources is well organized considering a single staff person for 250 employees • Hospital has a retention plan with a range of options for management to consider

29. Maluti Administrative Areas for Improvement • Minutes of the Board meetings do not provide sufficient detail • The draft hospital strategic plan (2011-2015) does not include an action plan (Priority) • Hospital operating policies and procedures were unavailable for review (Priority) • Performance reviews are not completed as required by the Personnel policies and procedures (Priority) • A single HR person is expected to support 250 employees • Managers and supervisors promoted from within the organization are not trained

30. Maluti Finance Strengths • SON is a stand alone financial entity within hospital; revenue and expenses or profits are not co-mingled with hospital funds • An annual audit is performed by the Seventh Day Adventist General Conference Audit Services in addition to the annual independent audit commission by the Board • There is a comprehensive budget process that starts with departmental requests

31. Maluti Finance Areas for Improvement • Employee time and effort is not allocated by funding source (Priority) • Existing CHAL and Seventh Day Adventist policies and procedures do not address donor funding requirements (Priority) • Insufficient internal controls due to the understaffing of the accounting department • No procurement policies and procedures that standardize the procurement of services, equipment (Priority) • Lack of budget development and management process (Priority)

32. There is no process for responding to audit findings The accounting department does not have familiarity of USG financial requirements (Priority) Additional training and support is required on the Pastel Accounting System Minimal internal controls or internal review process to ensure compliance with donor requirement No grants management experience or systems in place (Priority) Lack of sustainability plan to address decreases in funding There is no policy or process to analyze and minimize risk. No legal reviews of MOU’s (Priority) Maluti Finance Areas for Improvement

33. Maluti Program Areas for Improvement • There are not enough faculty to adequately train the current class size • The SON does not have operating policies and procedures such as meeting and reporting intervals etc. • There is no formal documentation of the appointment of the NEPI Nurse Focal person in the personnel file • Clinical Instructors positions do not exist • There is no vehicle for use to conduct supportive supervision visits for nursing students at very rural practicum locations • The School of Nursing library is not being used due to lack of current resources for students

34. Roma College of Nursing

35. Roma Administrative Strengths • The HR department of the hospital is addressing retention issues by implementing a range of new and creative benefits for all staff • College of Nursing staff are actively involved in the hiring process for new employees including development of the job description, interviewing, selection and orientation • The hospital has a wide range of quality assurance related sub-committees in which the College leadership staff are actively involved and can forward their concerns and promote their interests • The College annual operation plan for the 2011 was ambitious, but was detailed and matched issues identified as current challenges

36. Roma Administrative Areas for Improvement • HR functions are managed by the hospital, but there was no evidence of any comprehensive, written policies and procedures outside of a few key issues covered in the employee contract (Priority) • No formal, written performance evaluation system is in place • Job descriptions were not dated, not all staff positions in the College have written job descriptions

37. Roma Administrative Areas for Improvement • There is an absence of long range (2-5 year) strategic planning within the College • Resource development skills are lacking with too much focus on existing government funding (Priority) • No internet connectivity impacts efficiency and quality of work (Priority)

38. Roma Finance Strengths • Screening committees are used to prioritize purchases and payments • Accounting staff is knowledgeable of operations and proficient in Pastel • Financial investments havecreated reserves

39. Roma Finance Areas for Improvement • Financial policies and procedures (2009) do not adequately address key areas to support donor requirements (Priority) • No process for tracking time and effort (Priority) • No policies and procedures that standardize the procurement of services, equipment, and supplies • No internal review process • Staff are unaware of USG financial requirements (Priority) • There is no Information Technology plan • No risk management plan

40. Roma Program Strengths • Existing resources are well utilized • A significant number of faculty are in the process of, or have completed “above and beyond” continuing education requirements • Students are well cared for i.e. free housing and health care provided at hospital • SON is linked to other capacity building resources (HSS expert tutors)

41. Roma Program Areas for Improvement • Lack of resources for: accommodation, office, internet access, etc. • College does not have enough space for classes and other student activities • Clinical challenges: space, transport and staffing needs

42. Scott Hospital and School of Nursing

43. Scott Administrative Strengths Hospital: • Management team meets consistently and maintains detailed minutes • An accreditation committee meets to anticipate upcoming requirements • Personnel files are well organized and contain current job descriptions • Hospital provides excellent oversight to their 5 health centers

44. Scott Administrative Areas for Improvement • It is unclear if there is full board membership (12) since it appears that staff are being included in the number required • Board minutes do not provide sufficient detail (Priority) • There is no process to train new or to update existing Board members on governance requirements • No conflict of interest or confidentiality documents for Board members to sign • There is no strategic planning process (Priority) • The organization does not use legal representation to review existing contracts and other risk areas (Priority)

45. Scott Administrative Areas for Improvement (2) • There are no hospital operating policies and procedures to ensure standardization of processes, i.e. general operations, safety, facility maintenance, and information technology (Priority) • Staff lack grant writing and funding identification experience (Priority) • Performance reviews are not being completed annually as per the HR policies Employee contracts are being renewed and promotions given without performance reviews (Priority) • Employee contracts are open-ended with no official end date

46. Scott Finance Strengths • Leadership of Hospital and Nursing School are committed to NEPI Program • Leadership stressed that ICAP has been responsive and helpful

47. Financial infrastructure is lacking at the SON which prevents segregation of duties (Priority) Training opportunities are not available for finance staff at Hospital or School Lack of policies and procedures that address donor funding requirements (Priority) Lack of a sustainability plan to address decreases in funding No documented process in place for resolving audit findings and improving systems Board minutes do not reflect detailed review of financial statements Scott Financial Areas for Improvement

48. Additional training and support is required on the Pastel Accounting System Under-utilization of system Postings to general ledger are several months behind Technology policy guidance and support is lacking No SOPs for budget development and management process (Priority) No exemption from VAT taxes An assessment of operational costs has not been done (Priority) Unclear of basis for allocation of resources between Hospital and School (Priority) Financial reports do not include budget to actual variance justification for under and overspending Scott Financial Areas for Improvement

49. Lack of detailed procurement process for purchasing goods and services (Priority) No grants management experience or systems in place (Priority) There is no evidence of updates for the fixed asset registry (Priority) Minimal internal controls or internal review process to ensure compliance with donor requirements Most recent bank reconciliations are July 2011 for Hospital and April 2011 for SON (Priority) Lack of time and effort tracking for donor compliance (Priority) No risk management plan Lack of insurance coverage (Priority) Scott Financial Areas for Improvement

50. Scott Program Strengths School of Nursing: • The management team has had stable membership, meet weekly and keep detailed minutes • Management receives significant administrative support from the hospital • Quality assurance processes are being implemented