Managing risk in South Africa

For Improving Global Health (IGH) through Leadership Development programme, managing risks is more than just completing a register; the partnership has developed

formal processes for close management of NHS volunteers so that their placements can be as benefical as possible for them and their host institution.

The Improving Global Health (IGH) through Leadership Development programme recruits volunteers from the NHS in the UK who each complete a six-month placement as a ‘Fellow’ with, currently, one of five overseas partnerships. The programme has three key aims: supporting sustainable improvement in healthcare; providing an unparalleled personal and leadership development experience;

and creating a cadre of skilled leaders with quality improvement skills who are able to use these skills on their return to the UK.

Dr Fleur Kitsell is the Programme Lead in the UK. Michael Vonk is the Chief Executive Officer of George Hospital in the Western Cape, South Africa, one of the partner organisations which host Fellows.

Managing risk is about much more than assessment and registers.

I think if you are aware that something can be improved, you should take care of it and improve it, as soon as possible, and not just log it and wait for a formal meeting in the way that many risk registers work

says Fleur.

Formal processes and structures remain vital, of course, particularly in relation to more palpable risks such as safety of Fellows.

Fleur continues: “We don’t always use the word ‘risk’, but a lot of our conversations and processes are about eliminating it.”

The programme follows advice from the Foreign and Commonwealth Office, conducts safety assessments prior to selecting partner organisations, issues all Fellows with a handbook which includes guidance on steps to reduce risk, and mandates that a security briefing is given to Fellows on arrival at their placement.

As well as being dealt with as they arise, any concerns are reported to the operational management group in the UK which meets every couple of months, and where appropriate are escalated to the biannual meeting of the overarching steering group.

The health of Fellows is, obviously, a prime concern. All Fellows are required to see an occupational health advisor prior to going overseas on placement and take account of any advice given. There is a higher risk of TB in George Hospital than in the community as a large proportion of patients arrive undiagnosed. Fellows generally haven’t had immunisation at birth or any exposure throughout life. Accordingly, the risk of contracting TB and the importance of correct wearing of masks is actively discussed with all of the Fellows as part of their induction.

Michael recalls discussions with one Fellow who, as a result of their own particular medical condition, was at a higher than usual risk of infection, and for whom the potential impact would be more serious.

Following discussions, the Fellow started the project as planned, but it was agreed to change both how and where they worked. The hospital’s clinicians were able to advise the Fellow on the management of their condition and associated risks of TB during the lifetime of the project.

The team in the UK assesses suitability of Fellows to the local conditions when initially considering whether an individual will fit in with the operating environment. Not being able to drive (and lack of public transport) may be a more significant risk to a successful project than concerns about health or safety.

The support offered to Fellows, both structured and informal, provides an appropriate duty of care and also ensures an ongoing assessment of risk.

In the host country, each project that the Fellow is leading on must have an overseer as well as a local supervisor. Michael takes on the role of overseer in George, and also runs orientation and induction with Fellows to help them get up to speed quickly, and so that they have a clear link with senior support. “One of the greatest risks is a Fellow having an unsuccessful Fellowship. The consequence for the Fellow is not achieving their desired learning outcomes. The risk for the hospital and the IGH programme is the potential reputational damage and the missed opportunity if the partnership was not sustained.

We have a duty of care to a range of audiences, and it is also our responsibility to make sure the work is reasonable and achievable.”

As the programme has developed, Michael now spends more time considering the appropriate match between Fellows and supervisors. Based on his knowledge he in particular considers whether the supervisor in George has the appropriate skills, supervision and leadership to take on this role, as well as looking at their interest of the subject matter of the project, and what both parties may get from working together. If the supervision is right and the project is carefully selected, the risk of an unsuccessful Fellowship experience reduces significantly.

From the UK side, each Fellow is assigned a trained mentor, has access to Fleur and to an informal network of previous Fellows, and will also receive a routine visit from the dedicated partnership link person.

The requirement for a routine visit every 6 months by the partnership link person was debated in both the UK and in South Africa. Michael recounts how he considered initially if it could be justified from a financial perspective, but recognises how face-to-face links have been very positive, and would be even more relevant if at any point things weren’t going well.

Fleur concurs:

“The feedback from all our partners is that it really is important to them for us to continue with those visits. In terms of relationship-building, and mutual understanding – however you work out the cost benefit analysis – it’s worth it”.

The partnership link person is required to write a formal report for the operational group on their return, again ensuring that both formal and informal monitoring of risk is ongoing.

Each UK mentor meets with their Fellow in the UK before they travel overseas for the placement, and supports them throughout the programme with fortnightly contact as a minimum. They also meet again on the Fellow’s return. The programme started by using a group of senior ‘wise heads’ as mentors, and as the programme has expanded and developed many returned Fellows have taken up this role. Mentors attend an initial 2-day training programme and attend a CPD event every 2 years.

They play the part of a safety net, often picking up issues early, before they become problematic.

Fleur doesn’t apologise that the programme overall is tightly managed. “I’m really clear when we recruit Fellows to this programme that if you want to disappear for six months this isn’t the programme for you.” It is through this close management that risks of failure and of harm to anyone are reduced.