2016 Report


Trauma Project, Lam Dong province, Vietnam.

Executive summary
This is the third time the course was run – the first was in November 2014.
Local ownership has again moved forward. The course was again presented entirely by Vietnamese doctors in the Vietnamese language. Additionally, younger doctors were brought forward as presenters and facilitators of the practical sessions in accordance with our previous aims of promoting an instructors course.
As always, the active support of Dr Hy (the Director of Lam Dong General Hospital) has been integral to its success. Drs Nhuan and Sinh were the backbone of the course and brought in younger doctors from various disciplines to present topics with which they were familiar. La Cuong, Peter and John assisted as mentors with the practical sessions and left the daily conduct of the course to the local presenters.

The instructor’s course, which we imagined would be a separate entity, became part of an extended three-day doctors’ course with additions on the first morning and then groups preparing and presenting on the fourth and fifth days. The instructors course program (designed by Dr Nhuan) split the larger group of 20 into four groups with each collaborating in putting together their own version of a topic to be presented to the entire group. Nurses are in the frontline of trauma reception in Vietnam and they were especially keen participants in the two-day nurse’s course. Finally, two of the doctors from Duc Trong, a nearby regional hospital organised and presented their own two-day, combined doctors and nurses course.
Staff safety is an issue brought up previously by many Vietnamese doctors and nurses. Dr Hiep, the newly appointed director of Emergency is canvassing support to re-design the Emergency Department to improve patient flow and reduce access of the public to acute treatment areas. MESCH has advised him on this and we await the response of the executive of Lam Dong General Hospital.

There was a lot more "post course" activity this year than in previous years. This suggests that there is a strong interest in advancing trauma care - or perhaps just advancing hospital care in general.
This is a great initiative of Lam Dong Hospital with a very positive future.  We would like to continue to assist to make this a sustaibnable idea with good outcomes for the people. Our continued involvement would require some changes from this year. Specifically: all course content and presenters briefed; an agreed timetable; a designated person who knows the course intimately, can be there the whole time and with authority to sort things out.
What’s in a name?
The name of the course is still undecided but many of the Vietnamese participants call it PTC (Primary Trauma Care). Strictly, this is not the case. Many of the slides were based on PTC material generously supplied to us but subsequently extensively modified. We continue to seek clarification on this.
 What were the aims?
For the most part, these have not changed since 2015
1) Assess general progress of trauma courses begun in Lam Dong General Hospital (LDGH) in 2014.
2) Expand Vietnamese ownership of the courses – in particular, to identify and train new instructors.
3) Assist, in limited terms, with delivery of courses for doctors and nurses in LDGH and Duc Trong Hospital.
4) Determine participants’ perceptions of these courses and trauma care in general.
5) Assess how acute trauma care is delivered in LDGH and DucTrong emergency departments.
6) Continue conversations with local staff and medical directors about trauma in order to:
 understand the perceived need for these and similar courses
 discuss what resources (people, infrastructure and equipment) might be required for various hospitals and medical centres to improve trauma care
 understand what other impediments might need to be resolved in order to improve trauma care in Lam Dong Province
 progress our understanding of the structure and processes behind trauma care in Lam Dong province.
7) Continue collaborative qualitative research with LDGH
8) Understand more about logistics of preparation and presentation for these courses and assist both with ideas and practical solutions to how to improve them
Who was involved? 
Dr Nhuan (Director quality improvement LDGH, Course co-ordinator LDGH)
Dr Hy (Director hospital)
Võ Xuân Khang (Interpreter)
Trương Bảo Khuê (Interpreter)
Vy An (Interpreter)
Dr Sinh (Director anaesthetics LDGH, Principal lecturer & course director)
Dr Hiep Ngoc (Director of Emergency Department)
La Cuong Vu (Biomedical engineer, Negotiator, Australian co-ordinator & interpreter)
Drs Nguyen, Lu’ong, Tien, Khoi (Department of Surgery    
John Cassey (Paediatric surgeon, Australian co-ordinator, Facilitator)
Drs Hiep Bui and Tru’ong (Lecturers Duc Trong Hospital
Peter Armstrong  (Anaesthetist,  Facilitator _Australia)          
Dr Doan (Director Duc Trong Hospital) 
Lois Meyer Advisor (Australia)
What happened?
Unfortunately Dr Lois Meyer (UNSW) was not able to attend this year’s courses because of her academic commitments. She has continued to advise us on the practical and ethical requirements of collecting quantitative and qualitative data in an overseas setting.
The course material has evolved further in response to local requests and our perception of participants’ understanding of medical concepts. With the essential help of La Cuong and his family and friends a series of videos detailing responses to distressed relatives was filmed in Sydney. This was professionally shot and edited by Ahn Nguyen. The plan was to open with a three-day doctors course followed by a two day instructors course followed the next week by the nurses course and the Duc Trong combined course. The major addition this year was the instructor’s course.
The revised course material, with more emphasis on diagrams, drawings and video was discussed with Drs Nhuan and Sinh. With the exception of the videos, the other material was provided to them some months prior to the course. In accordance with our stated aim of local ownership of these courses, timetables, scenarios and evaluations were to be organised by Dr Nhuan’s office. The changes to multiple-choice questions (MCQs) were reviewed by both parties. Võ Xuân Khang provided prompt and accurate translation.
After arrival
John and La Cuong arrived one week prior to the courses starting. The arrival date had been set at least 6 weeks prior. La Cuong, Nhuan, Vy, Khue and John met for the first time on the Sunday afternoon along with an interested younger doctor (son of Dr Thuan – outgoing director of ICU). The course outline was dramatically different than what had been previously discussed and agreed to by email. After discussion, it was altered back. There were several meetings with Dr Nhuan and various members of teaching staff LDGH. These almost always included Dr Sinh, Hiep Ngoc and Nguyen. Drs Lu’ong and Tien less often; Dr Duong attended infrequently; Dr Khoi once. Much of the discussion concerned issues that should have been resolved internally before our arrival. This was extraordinarily inefficient and frustrating both for ourselves and other teaching staff. Avoidance of this must be a priority for future courses.
A meeting with Dr Nhuan on the day prior to the course provided the first definitive programme. This differed from our understanding of the course material by some margin. The first morning of the doctor’s course was to be devoted to a dissertation on educational principles and the statistics relating to trauma in Vietnam. Dr Nhuan’s idea of splitting into groups was initially brought up at this meeting. Each group was to prepare and present a part of the course and design a scenario they felt was typical of their situation. The nurse’s course was discussed on the Saturday before beginning on Monday, August 8. The Duc Trong course (August 11-12) was prepared by Drs Hiep and Tru’ong in the five days (including a weekend) after their attendance at the doctor’s course. We reviewed their material the day prior. As no course material had been provide to them, we provided this year’s nurses course material.
The courses themselves
All course content at LDGH was delivered by Drs Sinh, Nhuan, Hiep, Nguyen, Khoi, Lu’ong & Tien(????) . Dr Duong gave a late apology which resulted in some last minute scrambling to cover his topics. Peter and John assisted Sinh and Nguyen with the skills and scenarios sessions. We mentored Drs Nguyen and Lu’ong during the nurse’s course but tried to stay well in the background. The detailed VN program is in Appendix 1. All documents and presentations are available in digital format.
Participants - There were 20 doctors scheduled to attend but due to a variety of factors (including unavoidable work commitments) only 17 attended regularly. Twenty nurses attended the two days of their course. The attendees are listed in Appendix 2. Course content at Duc Truong was delivered by Drs Hiep Bui and Tru’ong.
Venues and equipment
The LDGH courses were held in the same large, well equipped location as last year. The insertion of intercostal drains continues to be a point of confusion which has been difficult to resolve. We had planned to leave out an animal model of this technique but we were not getting the message across so used a dog chest wall to create this scenario. The DucTrong course was again held in a lecture room remote from ED – also with good quality audio-visual equipment and seating. We dispensed with the dual projection of Vietnamese and English slides at both sites because we were able to follow the presentations on our laptops and our interpreters translated any discussion. Equipment utilised in the scenarios included the two Laerdal intubating mannequins (purchased by MESCH in 2014 and left at LDGH) and other equipment previously supplied and supplemented from Australia
Drs Sinh has given repeated formal and informal ultimatums about his “retirement” from the course if it continues to require the level of his current input. Course implementation takes up a great amount of time from the already busy schedule of many of the presenters and they need recognition of this. Scenario development and implementation is close to locally independent and skill stations are not far behind (completely so with Dr Sinh involved). Dr Hy and the hospital executive have continued their strong support. We met with Dr Thuan, the upcoming director and he seemed broadly supportive of MESCH and these courses.
WHO have set a target for reducing death and injury following trauma by 50% by 2020.  The course in LDGH is part of improving outcomes after trauma. The fact that WHO’s target and the post course interest have occurred together seems to make NOW an ideal opportunity to make a huge change in outcomes of trauma across the province. The funding for this can best be sought at national level - and WHO can assist.
Quite apart from improvements in outcomes for patients, this change has the potential to improve the reputation of LDGH, other hospitals and medical centres and Lam Dong province as a whole. This change will:
1) Make staff happier and prouder in their work. Staff with this attitude want to try harder because they can see value in their work. They will be more interested in what they can do to help. This is aligned with Dr Nhuan’s quality improvement research and initiatives
2) Make "users" (ie the community) trust the hospitals more. People with this mentality are more likely to use their local hospitals than go to eg HCMC; they are less likely to sue doctors and nurses for bad outcomes because they believe the staff were trying their best; they are less likely to abuse and threaten staff. This is aligned with new funding arrangements due to commence late 2107. Even simple things like the production of good quality trauma videos posted on You-tube will draw attention from other medical centres in Vietnam.
1) Assess general progress of trauma courses begun in LDGH in 2014 
Participants come from a range of “hospital” types (regional, remote, medical centres) and many different locations. The course is well known, at least at LDGH, and resources continue to be given by LDGH CEO. How much negotiation about funding, presenters or content happens between each year is unclear. We suspect not a lot of issues are resolved.   
2) Expand Vietnamese ownership of the courses – in particular, to identify and train new instructors.
There is no longer a perception that western doctors are needed to give credibility to the course.
The courses have been adapted by the local doctors and some new scenarios created by them
Suggestions for course improvement were again made from LDGH (Nhuan and Sinh) and Duc Truong (Hiep Bui). These included adoption of suggestions about video production – both for scenarios and relationships. We suspect others were/ will be made during and after the course.
A major aim of this year’s courses was to emerge with an expanded set of instructors. This has been achieved. They will need mentoring in order to realistically reduce the teaching load upon Drs Sinh and Nhuan.
3) Assist, in limited terms, with delivery of courses for doctors and nurses in LDGH and Duc Trong Hospital.
4) Determine participants’ perceptions of these courses and trauma care in general.
Informal feedback positive. Formal written feedback given during and at end of courses has been translated into English and awaits analysis by either LDGH or Lois and John. Letter of permission to collect data requested of Dr Hy. Not yet provided
5) Assess how acute trauma care is delivered in LDGH and DucTrong emergency departments.
We were keen to follow through the dialogue begun last year with Dr Hiep Ngoc (Director of Emergency Department LDGH) and his staff about changes to the ED for the reception and treatment of very ill patients. Several hours were spent over 2 days (one evening) running through his and our proposed changes. These are directed towards improving  patient flow and limiting access of non-patients to the acute treatment area. They will involve minor structural changes (including a heavy door on entry to ED and positioning of reception staff outside ED protected by security glass. He took some preliminary drawings to the hospital executive for approval and seems very motivated to achieve these.  Approval by the hospital executive and availability of funding remain hurdles. MESCH will NOT provide finances for the changes. It does not have that capacity. It WILL seek sponsors on behalf of LDGH. This may involve expertise and/or money. A submission by LDGH would need to be received by MESCH before we acted on anything. Dr Hiep Ngoc is a significant local champion for improvement of trauma care.
Duc Trong hospital is adjacent to Da Lat airport and on a main highway. There is a well-perceived realisation that this ED will be the major receiving station for casualties (including mass disasters) from either area. A preliminary inspection of their ED prior to and during the trauma course there revealed a reasonable amount of space but significant deficiencies in the layout and infrastructure (such as piped oxygen or suction).
Information about this is till only available to us from informal conversations and the response to evaluation forms. There is a consistent comment, backed up by participant’s behaviour, that no systems are used and that participant’s are desirous of change   
6) Continue conversations with local staff and medical directors about trauma in order to:
 understand the perceived need for these and similar courses - Seen as desirable & actively supported by Dr Hy, Thuan, Dr Doan (Director Duc Trong Hospital) & director of health LD province. They remain tacitly supported by regional hospital directors with the exception of Bao Loc. All participants see the relevance of the course in solving their common trauma dilemmas; want the course to thrive and continue to ask for more courses in more diverse geographical locations.
 discuss what resources (people, infrastructure and equipment) might be required for various hospitals and  medical centres to improve trauma care -Since inception, and for all courses, participants are asked to write down what additional resources they felt were needed to improve trauma care in their individual hospitals. More time was spent on it in 2016. -The answers given by the nurses have not been analysed to date. In summary, the 3 major areas for the doctors were: improvements in both the knowledge and skills of staff, together with increased clarity in roles and communication (teamwork); a safer working environment and increased awareness in the community of early trauma care. Only 25% wanted more equipment (including a better supply of blood).
The following suggestions were made to address these:
 Human resources
It is our current view that staff numbers are sufficient. We suggest:
 rotation of doctors within the health area so that they get experience with both large and small units; a better    understanding of their personal limitations; keeping an appropriate level of skill in rural areas and sharing   long working hours – remote solo doctors remain limited in what they can offer both in terms of treatment   and transfer. 
 formalised training within each hospital so that doctors educate others within their own hospitals. Although    previously rejected, this year there seems to be acknowledgement that there is scope to do this.
 increased numbers of courses, with an emphasis on practice rather than theory.
 increased practice in teamwork and role setting. It is impossible to manage a mass disaster without a system to   manage a single person. This will require long term attitudinal changes including setting and accepting   team roles (including a designated leader who directs people what to do)
 establishing formalised, simple & clear processes for common conditions (eg management of lower limb    fracture, wound management - we have provided VN versions of these- no formal feedback)
 looking at using the available equipment more effectively. That is one of the things the course emphasisies.
 consider a mobile trauma group (“paramedics”) with equipment
 developing a culture of support for each other eg non punitive system for analysis of critical incidents; online   anonymous forum with moderators, sharing information,  questions/suggestions.  These could form the   basis of a knowledge bank, giving solutions (“how I got around this problem, providing resources (eg a   new You tube video), making suggestions for workable policies.
 Community education
The potential benefits are improvement in patient status on arrival in ED and protection of medical staff from concerned family and friends.
The previous proposals to the MaiLinh taxi group have not been fruitful. There is ongoing discussion about delivering “first aid” courses to community groups. This has been particularly championed by Dr Hiep Bui (Duc Truong) – perhaps because of his job as an educator in public health with DOH. 
 Safety and security
On occasion, staff can be threatened by concerned family and friends wishing to push priority care for their relatives. Dr Hy and MOH have stressed the need for staff to improve their interpersonal skills, acknowledge concerns and calm family and friends down. As a response to that, all the courses this year featured the series of videos filmed and edited by Ahn Nguyen in Sydney. These videos featured Australians of Vietnamese heritage acting out scenarios of concerned and angry relatives and friends dealing with a doctor trying to care for a severely injured person. The emphasis was on using interpersonal skills to defuse a potential confrontation. They were not as well received as we had hoped  eg participants were distracted by the fact that the “doctor” did not wear a white coat; that the relatives did not behave aggressively enough (we found that a little surprising given what we had witnessed in LDGH ED). Unfortunately, there were sufficient distractors that the message was lost for many participants. There was a strong suggestion that LDGH would make its’ own video. How this will happen is unclear though Vy An, Dr Nhuan and Hiep Bui are keen and have some skills to bring to this. Video production and expansion of courses requires some capital outlay. Karen Lanyon (Australian consul general, HCMC, Vietnam) has recently responded positively to enquiry about suitability of PTC to funding under the direct aid program http://hcmc.vietnam.embassy.gov.au/hchi/media.html
Individual hospital arrangements with local police and in-hospital security staff need to be reviewed. It was acknowledged that relationships and money were impediments to change
 understand what impediments might need to be resolved in order to improve trauma care in LD Province
Much of the above and the section below on research has addressed this point. In addition, Sinh has offered to teach skills in airway management (including intubation) & IV cannulation.
  progress our understanding of the structure and processes behind trauma care in Lam Dong province
Processes need to be formalised, simple & clear. Nhuan emphasised quality control, patient safety and analysis of critical incidents. See research (below)   .
7) Continue to push for collaborative qualitative research with LDGH
Collaboration with UNSW will NOT be sufficient to cover the amount of work involved in this research. Hence, re-establishment of contact with Dr Nguyen Minh Tam, MD, PhD of the University of Hue about the possibility of assessing the effectiveness of the trauma course in reducing death and disability was important. This would be a long-term project requiring a largely DaLat based PhD researcher or as separate masters projects. The project would require a large amount of work setting up methodology to accurately record outcomes - eg an assistant to record both in hospital and post discharge data; define meaningful QALYs and DALYs; and qualitative measurements and tools;... For the PhD, it is possible that they will NOT see any trauma outcome changes over the three years. However, we should be able to demonstrate changes (or not) in eg the culture of care; greater use (or not) of existing resources; establishment of networking (online forums etc); best practice of learning for doctors and nurses; etc.
With established methodology, a further or current candidate will be in a position to produce the first publications in the English literature demonstrating the outcomes of a trauma course - something not yet achieved for ANY trauma course! In a country with high levels of trauma and poor outcomes from it, this is, of course, especially important.
The advantage of a VN candidate is, the more readily available access to people and data.
Funding and supervision for this research will not come from MESCH. We can, of course, be an applicant for Australian based grants. Involvement of UNSW will be determined by BOTH local VN and UNSW capacity and timeframes.
A simple trauma registry would be a good start in collecting data (ideally software based -? Excel).
Lois Meyer pointed out that the lack of a functioning ethics committee is a problem for Australian Universities as far as data collection from Vietnam was concerned. At a minimum, we need a letter of approval from the Director of LDGH (Dr Hy till January 2017) to collect data. The following was agreed to by Dr Hy:
1) The collection of evaluation data from the PTC training courses
2) Collection of other trauma data collected by LDGH. 
3) Publication of any of this data subject to approval of the final publication(s) from LDGH
See appendix 5 for EOI to DR Thuan
8) Understand more about logistics of preparation and presentation for these courses and assist both with ideas and practical solutions on how to improve them
The slide set has been progressively modified from the original one based on the official Primary Trauma Care slide set. It is now significantly different with various parts simplified or expanded; many diagrams, videos and explanatory cartoons added. These changes were based on feedback and assessment of results of MCQ’s. We are not yet sure if they have been beneficial. The local presenters need to add or subtract material. The time involved in this is substantial and we are happy to advise or facilitate.
Scenarios can be significantly improved both in construction and delivery.  To be more effective (“real”), requires more effort in preparation (both “make-up” and explanation for the actor AND planning for its’ conduct by the presenter). Perhaps a preliminary video would assist. Scenario teaching style remains different but immediate feedback by the facilitators to the local presenters was of use to them and resulted in more standardisation. Consider feedback to whole group after each scenario.
Teaching materials are reasonable and can be supplemented by LDGH and, perhaps, Duc Truong. They need to be catalogued, better organised and some need repair. Spinal boards and more realistic equipment including O2 and suction could be added. The dog chest is an acceptable model for intercostal catheter insertion and issue of supply needs to be addressed. A short video on emergency drainage of a pneumothorax was filmed by John, La and Peter. This and some additional resources (iamges, sounds and video) have been sent to Dr Nhuan for further editing and VN narration overlay
Duration of  the first doctors course ran to 5 days. This included too much theory on the first day but ended with the very successful group presentations of familiar course material spiced up with their own scenarios. The teams presenting developed teamwork and achieved good results. Having an experienced mentor will be important if this style is to continue
Lecturers were better at keeping to time and staying on the topic. Forethought on the part of some presenters is lacking
Issues of financial support for individuals and instructors will be less relevant when courses are delivered closer to individual hospitals and by local instructors. Ongoing financial support within Lam Dong /Vietnam will still need to be addressed.
Other issues that arose during the course:
1) Transfer:
Transfer of injured and sick people from outlying hospitals continues to be a problem. There is seldom a doctor available to travel several hours to a major centre. There is a perceived arrogance and a sometimes unhelpful response on behalf of accepting hospitals. A culture of blame for poor outcomes is common. Communication within and between hospitals; and to-from ambulances is almost totally by mobile phone. An extensive address book is essential! Effective communications between LDGH and participants’ hospitals/medical centres for courses
2) Equipment:
Whilst equipment is always mentioned as a deficiency, it is our view that it is generally sufficient.
We wonder if there is still money from Japanese donations which could be spent on equipment like mannequins (~4,000 USD for 2), resuscitation kits or spinal boards.
The culture of equipment maintenance needs to be improved.
3) Communication:
Language was only an issue in scenarios. All interpreters did very well and, towards the end of the courses were able to do many of the explanations themselves. Acquisition of medical terminology is definitely improving.
4) Dr Hy will retire end of 2016.
Summary of suggestions and future plans for 2017
1) Name the course. It needs a name so it can be referred to or supported
2) Create a “participant map” so that numbers and roles of attendees within the province are known and inequities addressed 
3) Continue to develop the slide set and videos. Our ongoing suggestions include:-
 Remove: secondary survey except as a concept – mainly achieved
 add:  analgesia, disaster management and snake bite – analgesia addressed this year.
  team roles and communication between team members (including a designated leader) ?video
 expand: safety and security- perhaps using the video supplied as a starting point
 produce: videos both for scenarios and relationships
 Scenarios: modify / vary depending on the needs of individual hospitals; improve scenarios both in construction  and delivery  - preparation (both for the actor AND the presenter). Standardise scenario teaching style; feedback  to whole group after each scenario – at least to facilitator ; staff choose the equipment they need for a scenario  beforehand from what equipment they have in ED
 lecturers need to keep to times, address the slide set and not add extra material ad lib
4) Share thoughts on expansion – the course is now established for doctors and nurses. Do we try to expand to neighbouring provinces or consolidate in Lam Dong province
5) The Instructors course needs work. The success of Dr Nhuan’s ‘team’ approach in 2016 was encouraging. However, a smaller group of identified talented teachers might be a better use of time and resources. They will need mentoring in order to be best utilised. What would the local reaction be to nurse instructors?
 6)  Infrastructure – LDGH ED approval awaited. Visit other hospitals or medical centres within Lam Dong province to assess their ability to deal with serious trauma. Take advice from DOH as to the order in which hospitals should be visited. Perform a needs analysis on each particular hospital
 7) Consider mentoring as a separate meeting at another time of the year
8) Continue to advocate for suggestions in “human resources”, “community education” and “safety and security” above including with DOH and People’s committee . ?possible resourcing of this through people’s committee and DOH
9) Issues of financial support (including secretarial support) for individuals and instructors within Lam Dong /Vietnam still need to be addressed. Particularly opportune givenWHO decade on road safety and new funding arrangements due to commence late 2107.
10) Continue to push for collaborative qualitative research with LDGH. Letter of permission to collect data requested of Dr Hy. Not yet provided
11) Teaching materials need to be catalogued, better organised and some need repair. More mannequins, resuscitation kits, spinal boards and more realistic equipment including O2 and suction could be added (?money from Japanese donations). Use of the dog chest needs to be addressed. A short video on emergency drainage of a pneumothorax.
The culture of equipment maintenance needs to be improved
12) Duration of the first doctors needs to be addressed
13) Our continued involvement would require: all course content and presenters briefed; an agreed timetable; a designated person who knows the course intimately, can be there the whole time and with authority to sort things out.
Hopefully local management changes do not impede progression next year.
Next course planned for 2017.


Raga Sewing Project, Pentecost Vanuatu

August 2016 Narelle Cassey, John Cassey

The business is currently looking for a new manager but the ladies are currently finishing the orders until a new manager is appointed. All the dresses are being sold successfully at various markets.
Hollingsworth enquiring whether training course could be run on his island. Trish is in contact with a few sewers who might be interest in volunteering their skills eg. Thorpe and Co team.

Objectives and Outcomes:
1) Assess progress of manager

Gerole's abilities as a manager are far less than previously thought. He clearly has reasonable logistical skills (he organised the luggage transfer) though tunes out when it comes to many office tasks. He lacks self-confidence, readily slips into a passive role and has difficulty giving direction. The origins of these are multifactorial and include his age, family position, social status, pre-existing social relationships and lack of knowledge. He uses tabac (mild local euphoric - smoked) and did so during a working day. Nevertheless, he seems honest, genuinely wants to learn and, supportively mentored, shows promise.   
Current solutions:
Both he and we need to work on ways in which he can do his "office tasks" outside an "office" environment.
Clear and precise directions for task accomplishment were begun and will continue
Clear negative consequences (up to and including dismissal) written down, discussed and agreed to  - including failure to complete specified communication tasks on time
Ongoing acquisition of interpersonal skills to deal with difficult situations
All of above to be incorporated into a policy and procedures manual 
Regular (weekly) emails and data calls between Gerole and Narelle and/or John scheduled
Sales strategy needs to be developed as a priority (current assets in completed but unsold or assigned stock ~500K Vt.)

2) Assess adoption of processes

Invoicing and receipting not being followed
No maintenance, cleaning
Gerole has made his own spreadsheet for staff production - not very easy to understand. Previous ones supplied by us (and apparently well received by Gerole) not being used. Reasons not explored through lack of time
Both Gerole and sewing staff are being paid for production. This is different to previous agreement where manager was paid for sales and sewing staff for production.
Production seems to be “feeling” based as opposed to order based
Attitude to work seems to be partly based on the concept that this is Aid money – not their own work.
Current solutions:
Paper based invoicing and receipting procedure (at 2 sites- Angoro and Debra's school) written down and practised with Gerole (though not yet with Debra). This involves original invoice to be either attached to
 lay-by items (which are put in plastic bag behind manager's desk)
 clip behind manager's desk for jobs in progress
Maintenance and cleaning tasks to be identified and responsibilities given.
 Generator was serviced by VAS (fortuitous alignment of dates after months of negotiation!!!) - many issues  arising because of poor design of shed and no adoption of maintenance  schedule. Design solutions in  progress. Generator operating hours clock (designed, built and donated by Steve Threlfo) installed.
Pay structure changes to begin immediately
Production timelines need to be made, published for all staff to see and adhered to
Attitudinal change
 Meeting with all staff showing them balance sheets and discussion of how individual roles work to make the  whole business work - to begin change in attitude from "aid money" to THEIR responsibility and needing to  work together.
 Behaviours which will result in suspension include: charging of non-customers phones; giving out the hot- spot password; giving fuel to friends
 Staff (and Ephraim and Deborah) to provide an answer to "who owns this business?" within next 2 weeks.  Raga Sewing Project Facebook page was launched….this was enthusiastically received.

3) Identify current issues

Ephraim has reluctantly accepted a payment of *** Vt/hr
Printer not being maintained - cleaned on this trip with cover to be made by staff and used when printer not in use
Space within sewing room is not well utilised. The area needs to be cleaned up and a better organisation solution arrived at by staff. May involve minor shelving etc changes
Separation of production and display areas again raised and the benefits of a more accessible display area are obvious. The possibility of people buying off photos and samples was raised - this is not currently seen as viable for individual items
At least 1 and preferably 2 new staff need to be recruited and trained to accommodate staff leave and changes in production quotas. This is a priority for Gerole and board
 Maintenance and replacement budget does not exist - 3k Vt/mth assigned to cover sewing machines and laptop. Nothing yet for generator
The adoption of responsibility of the school management (with the exception of payment of teachers’ wages) by the Anglican church seems to be going smoothly with Clemson reporting good communication with them. An older brother of Gerole is manager for the Anglican administration responsible for the school. He has not been made aware of any upcoming issues 

4) Remediate communication issues

 A signal booster was installed and is working well. Some minor changes needed to make power supply more robust in long term. Currently in negotiation.
  Mobile phone for manager (LG) with data credit shipped to Gerole by Air Vanuatu (courtesy Tusty) on 14th. Gerole knows how to setup hotspot. Clearly stated notice that damage to the phone from accident must be paid for by the manager
  Some clothing was made by Raga staff using material supplied by a retailer and then sold by that person at Sara airport. This or similar processes are NOT to happen. Raga is a retailer which designs, manufactures and distributes its' own range of quality and innovative products. If it sells to another retailer, that retailer must agree that the final customer price can be no greater than 10% of the Raga advertised price.
  Regular communication with Narelle (and/or John) scheduled
Task list made. Not prioritised at time of departure. This will be done by Gerole in consultation with Narelle (and/or John). Consequences of not supplying activity statements and income/expenditure statements documented and explained. This include warnings, temporary suspensions and dismissal
  A meetings document made and translated to Bislama by Deborah – approved by Ephraim, Deborah and Gerole.  It will need to be explained by Gerole to staff. It includes:
 Monthly meetings between Gerole and sewing staff to go over processes and any issues
 Individual annual staff reviews by Board members
 Warnings, temporary suspensions and dismissal meetings and processes
  Leave must be arranged and approved through Gerole

Travel and accommodation
"Hibiscus" (Santo) remains excellent and Marie (Co-owner) a great source of advice and information. Baggage removed from Luganville-Sara flight by Air Vanuatu without notification (plane too heavy). Put on flight to Ambae (invaluable contact "Tusty" - international chief baggage handler Luganville), boat to Laone (Nth Pentecost) and truck to Angoro (Raga project site) - organised by Gerole and Ephraim. NOTE: Must be watchful of luggage loading (AND UNLOADING at domestic airports) and speak with staff if any concerns. Air Vanuatu likely to load most of your luggage and are liable for 7K Vt if you have minimal clothes for 4 days should they fail to transport your luggage.
Accommodation Angoro and Abwatuntora both good
Trip from Abwatuntora to Lonorore was by truck - boat seems less stressful and similar duration. However, circumstances may dictate final choice.

No natural disasters          
"Hotel New Look" next to Santo Hardware best place to exchange AUD (NOTE: Will not exchange other currency)
Manager phone bought from "LCM" store Luganville - considerable trouble in accessing digital network (2 trips and > 4 hrs)
Informal meetings with: Pauline, Harriett and Cindy (Raga sewing staff). Gerole (manager), Ephraim and Deborah
Incidental meetings with Clemson (High school principal0, Gordon (primary school principal), Anthony (School handyman) - all positive with no issues identified
Formal meeting with Pauline, Harriett, Gerole, Ephraim, Deborah, Narelle and John
Like all other infant businesses, Raga has many issues to deal with.
The current manager needs a lot of mentoring and the outcomes of this will determine the eventual success or failure of the project. 
The repeated visits by Narelle (and an inconsistent variety of other people, MESCH and non-MESCH) have been critical to the current success of this project. She will not be visiting with the same frequency

Lam Dong Blind Association (LDBA) Massage Business, Vietnam

Need to step away from the business side of the organisation due to Mr Truong’s assistant being significantly involved with the Communist party and the likely misappropriation of building funds.
Jason (physiotherapist) will continue to be involved with the alternative and Western techniques of massage - perhaps with Khiem (private blind masseur business). 
Plan for another trip in April/May 2017 with Jason.
Marie to be sent some information about outstanding jobs for this project eg. marketing, ideas for fit-out. 

Vn Harvest, Ho Chi Min City, Vietnam

Kevin discussed meeting with Sven, a person who could be a potential contact locally to establish the model. Sven has a lot of commitments. However his wife, Jaqueline, could potentially do development work. This would require approximately $500/mth for 3 months to determine viability.
Various ideas floated including discussing with OzHarvest in Australia, and liaising with local organisations.
Ongoing: Still at feasibility stage of process. $500mth for 2-3 months as part of feasibility study.


Discusssion of core values and “what’s in it for me?”. How this is similar but different for all of us - a sense of being part of something bigger than ourselves and being proud of what we do together. Each of our projects has a focus on community development. This has been reflected in removal of the words “medical, educational, sustainable, community help” from our logo and replacement of the tag “..an Australian initiative” with “building communities through sustainable aid”.  This focus, our consistent adherence to “meshing” with our overseas partners and our commitment to the long term, define us as relatively unique in the enormous field of overseas aid organisations. It is precisely because we do things so differently, that we have so many supporters who not only want to assist with current projects but also expand this to a larger scale.
The strength of our organisation lies in combining this vision with the abilities and commitment of individuals and the collective will to carry projects. Together, these make for efficiency and sustainability. Compared to other voluntary organisations, this load sharing hopefully makes for a greater sense of ownership.
For some sponsors, the answers to “value” relate to external recognition of themselves and financial gain. As our projects have become more complex and diverse, we need to increase MESCH’s community recognition in order to access greater direct and in-kind support. To do that requires us to find a way of making them aware of the special nature of our “non-specialness. What sets MESCH apart from other aid agencies you know? Can you help with this discussion?  
 Name  Site  Duration  Status MESCH category  Co-ordinator
 Raga  Pentecost, Vanuatu     2013- current  Ongoing  Development Narelle Cassey
 Trauma care  DaLat, Vietnam  2014- current    Ongoing   Development  Peter Armstrong & John Cassey
 VN Harvest   DaLat, Vietnam  2012- Current  On hold  Development   Kevin Fell & John Cassey
 Massage business LDBA  DaLat, Vietnam  2015- Current  Ongoing  Development   Narelle & John Cassey


New members: Penny Wayne and Kevin Fell warmly welcomed in 2016.
Support documents: Amended or added - project checklist for volunteers and co-ordinators; media documents
New Media: new MESCH organisational video in hands of Garth Russell; You tube videos – Raga update (English. Narelle); Massage LDBA (English. Narelle); managing difficult family/friends in emergency departments (Vietnamese. Anh Nguyen)
VN versions of website tags and reports complete – facility to upload now available.
Current organisational memberships: Statutory (ACNC, Dept Liquor, Gaming and Racing); Google not for profits
Current organisational associations/contacts: MedEarth (medical supplies); Newcastle Global Health; WHO road trauma; AVI; ABV
Other activities by MESCH members
Overseas volunteers - Raga (Narelle Cassey, Penny Wayne, John Cassey)
   -Trauma course (Peter Armstrong, John Cassey)
Steve Threlfo produced a schematic for a distress button system for LDBA and built a timer for the generator at Raga
Kevin Fell further developed the Vn Harvest project through a series of meetings in HCMC and met with the Australian consul to promote MESCH
John Cassey, Narelle Cassey and Peter Armstrong met with Leigh Bryant and other supporters 4 times 
Support by non-MESCH contacts (alphabetical)
ABC radio did an interview with Narelle pre Greek night
Anh Nguyen (Australian national of Vietnamese heritage living in Sydney) directed and produced a Vietnamese language video on how to handle difficult relationships in emergency departments with input from James Doan, Au Vu, Duong (Dee) Nguyen, Jasmine Vu, Michael Duy Nguyen, Alice Nguyen and La Vu (pro bono)
Anne Duggan (director clinical governance HNEAHS) proved documents relating to governance to Dr Le Thanh Nhuan at his request
Anthony McGavin (owner “The heights” café) donated prizes for the Greek night 2016
Ben Hofman (manager Cold rock franchises, Newcastle) donated prizes for the Greek night 2016
Dan Cox (ABC) did an interview for John pre Greek night
David Watson (long term supporter of MESCH living in Vietnam) assisted Kevin Fell with meetings in SGN (Vn harvest project) and shared with us some business contacts
Ferdinand Lehnard (director WOLFE, Australia) offered to include travel and accommodation for MESCH members doing education as part of  equipment installs
Garth Russell (independent producer) offered to renew the current MESCH organisational video (pro bono)
Giao Chi Nguyen (friend and interpreter living in Vietnam) translated portion of the trauma course report (pro bono)
Jamil Khan (University of Newcastle) assisted with clarification of options for communications at Raga
Jason Bradley (BodyWorx Physiotherapy) accompanied Narelle to teach massage in LDBA
Jesse Jesus (independent video producer, Newcastle) offered to assist with video recordings and awaits our reply
Khang Võ (friend and interpreter living in Vietnam) translated documents and PowerPoints for the trauma course and negotiated and costed the massage  project.  She also assisted with the VN versions of the videos for the trauma course (pro bono) 
Kim Colyvas (statistician University of Newcastle) offered to assist with statistical analysis of data from trauma course (pro bono) 
La Vu Cuong (Biomedical technician St George Hospital, Sydney) has continued to liaise with LDGH regarding plans for trauma course (pro bono) 
Leigh Bryant (Scorpion international) has continued to assist with networking for sponsorship
Lois Meyer (lecturer University of NSW) has continued to engage in conversations on research and invited a new colleague to assist with funding for the trauma course
Marie Martinelli (previous owner Darrell Lea, Kotara) organised the Greek night 2016 
Mark Widdhup (owner, Cooks Hill Gallery) attended supporters meeting organised by Leigh Bryant and confirms his support
Michael O’Brien (co-manager Nova discount liquor, Newcastle) donated prizes for the Greek night 2016
Mike Chapman (retired Newcastle businessman) attended supporters meeting organised by Leigh Bryant and confirms his support
Pat Armstrong (son of Peter Armstrong) assisted with further development of the MESCH website (pro bono)
Phil Cox (retired CEO Hunter TAFE) arranged a dinner meeting with a group of Newcastle businessmen for MESCH to present at and continues his support
Robyn Healey (lecturer Hunter TAFE) helped update and link our organisational spreadsheets (pro bono)
Simon Glover (manager, the Mecure Newcastle airport) donated prizes for the Greek night 2016
Steve Battaglia (Chandelier printing) for donating printing the program and sponsor cards for Greek night
Steven Mitchel (Hunter TAFE), through Andrew Young, assisted with TAFE/ MESCH partnership and donated 4 laptops
Susie Russell (Newcastle businesswoman) attended supporters meeting organised by Leigh Bryant and confirms her support
Sven Cahill (director Compassion Vietnam, living in Vietnam) assisted Kevin Fell with further development of the Vn Harvest project
‘telligence (website design and hosting) provided some assistance with website and are willing to give “how to” sessions in early December (pro bono)
Victoria Lehnard (daughter of Ferdinand, as above designed the new country graphic for the MESCH website (pro bono)
Vy An (friend and interpreter living in Vietnam) translated documents and PowerPoints for the trauma course and assisted with the VN versions of the  videos for the trauma course (pro bono) 
Will Creedon (Newcastle businessman), through Tim Jackson, manager offered a 5% donation for rooms booked through a Mesch “voucher “for 2016 at Newcastle Beach Hotel.
Website & Facebook changes nearing completion
In order to continue to deliver meaningful project support and evaluation we need financial backing, input from individuals with specialist skills and support for both the project co-ordinators and executive. Although we have made some in-roads with presentations and contacts, this has been frustratingly slow.
Proposed for 2017:
1) Advertise for and appoint a secretary if needed to supplement or replace a voluntary one appointed recently
2) Foster support for project co-ordinators.
3) Build community recognition of MESCH
4) Pursue meetings with individuals we have identified as potential sponsors – individuals, corporate, government and philanthropic organisations. We seek both financial aid and donations in kind. 
Fundraising and Sponsorship
Grants: Kevin discussed DFAT preferred provider application.  It requires that we raise has a $25000 annually- The government may then match dollar for dollar. Window for applications is 1st September to 1st December.
Ongoing involvement: Kevin, Penny, Amma, John B
Local Business Leaders “Newcastle Group” – John provided information to the relevant parties at the Newcastle Club. The possibility of financial or in-kind donations was floated. Kevin F took John C’s draft document, discussed it with Phil Cox (our contact with above group) and will further refine it before presenting it to Phil’s group for consideration.
Ongoing involvement: Kevin F, Amanda T and John C
Greek Night – Marie updated team: AV issues and duration of presentations were mentioned otherwise highly successful night. Compared to Trivia Night, tickets are slightly less profitable ($65 tickets=$40 to Greek Club + costs of bands).
Options presented include going back to Trivia night as profit ranged from $5000-12000 from Trivia Night vs $3000 from Greek Nights. Belford have offered their venue for free and Fordtronics have offered their services. Only catering needs to be arranged and thus may be cheaper in terms of overheads.
Media Contacts: Newcastle Herald, NBN have been predominately focused on news. ABC Radio is an avenue that has been accessed.
Media Training Day: Contacts Dianne Swain (a final year graduate in media design) has offered to have a training day with MESCH in early December on how we can become more media savvy. Concept of rebranding floated again.