improving ruli district hospital's patient referral system, final, 4.12.11
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Presentation by team of MBA students from Ross School of Business at University of Michigan. Describes recommendations for improving the referral process for rural health centers to the district hospital in rural Rwanda.TRANSCRIPT
Improving Ruli District Hospital’s Referral System
Kate Bossart, Chris Chojnacki, Kristin Girouard, Jessica Meyer, Katie O’Hare
4/12/2011
Agenda
• Background• Project Description & Overview• Recommendations• Next Steps
Background Overview Recommendations Next Steps
District Hospital System Background
Background Overview Recommendations Next Steps
Rwanda: Facts & Figures
• Population: 11M• Land Mass Comparative: slightly smaller
than Maryland• GDP Per Capita: $465 (216th Worldwide)• Population Below Poverty Line: 60%• Urbanization: 18% of total
– 90% of population engaged in mainly subsistence agriculture
• Median Age: 18.5• Age Structure:
– 0-14 years: 42.7% – 15-64 years: 54.8% – 65 years and over: 2.5%
• Life Expectancy at Birth: 57 yearsSource: CIA World Factbook, WHO Country Profile, IMF
Background Overview Recommendations Next Steps
Ruli
Healthcare in Rwanda
Referral
Hospitals
District Hospitals
Health Centers and Posts
Community Health Workers
Nation
District
Sector
Village
Specialists
Doctors
Nurses
Volunteers
Geographic Market Level of Care
Healthcare in Rwanda is provided through a tiered system in which the level of care increases as needed to serve the population.
Background Overview Recommendations Next Steps
Ruli District Hospital
• Provides:– Emergency, inpatient and outpatient care– General surgery– Dentistry– Physical therapy– Psychological care
• Performs monthly:– 60 surgeries – 250 immunizations– 300 pre-natal checkups– 100 deliveries
• Has 8 doctors and a full staff of nurses, technicians and administrators
Source: Greg Thorne internship “Hospital Operating Statistics”, 8/2010
Ruli District Hospital is a full service facility that aspires to be a local Center of Excellence.
Background Overview Recommendations Next Steps
Ruli District Geography
Gayanke Rulindo
Gasabo
Kamonyi
Muhanga
Gasagara
District Hospital
In District Health Center
Out of District Health Center
The Ruli District Hospital System has 7 affiliated Health Centers, but also supports a number of neighboring, out of district Health Centers.
Background Overview Recommendations Next Steps
Ruli District Health Centers
• Provides:– Outpatient consultation and basic
inpatient care• Staffs ~9 generalist nurses
– Other employees: data manager, accountant, lab technician, social worker, community workers and maintenance
Health Center Interviewed Ruli Nyange Rwankuba Rushashi Coko RukuraPopulation of community 18,740 9,757 17,429 19,000 16,625 12,542
Patients per day 118 50 60 50 48 25Average daily Hospital referrals 15 2 5 5 1 2
Staff 28 16 16 24 16 17Nurses 10 10 9 11 9 9
Muhondo Health Center not interviewed
The team visited 6 of the 7 district Health Centers. They vary widely in population served and number of patients referred.
Background Overview Recommendations Next Steps
In District & Out of District Referrals
Coko
Muhondo
Nyange
Rukura Ruli
Rushash
i
Rwanku
ba
Gasaga
ra
Kayen
zi
Nyabike
nke
RutondeRwah
iOther
0
500
1000
1500
2000
2500
Out of Zone In Zone0
1000
2000
3000
4000
5000
6000
7000
8000
9000
In 2010, most patients came from Health Centers within the Ruli District system; however, a significant number (~30%) came from out of district
Health Centers.
Maternity ReferralHospitalization Referral
Consultation Referral
In District ReferralsOut of District Referrals
Background Overview Recommendations Next Steps
In DistrictOut of District
Project Description & Overview
Background Overview Recommendations Next Steps
Where We Fit
ReferralHospitals
District Hospitals
Health Centers and Posts
Community Health Workers
Nation
District
Sector
Village
Specialists
Doctors
Nurses
Volunteers
Geographic Market Level of Care
Background Overview Recommendations Next Steps
Our project focuses on the patient referral process from the Health Center to the next level of care at the District Hospital.
Process Flows
Village
Patients
Information
Health Center Hospital
Patients
Information
Patients must travel to the Health Center first and then may be referred to the Hospital to receive a higher level of care. At each step there is a
transfer of patients and information.
Step 1: Patient visits Health Center
Step 2: Patient is referred to Hospital
Background Overview Recommendations Next Steps
Referral Process Flows
Patient
Visits Health Cente
r
Health Center Unable
to Provide Needed Care
Average Wait of 1 or More Days
Patient Ambulatory:
Walk to Hospita
l
Patient Reports
to Outpati
ent Consult
ation
Patient Visits Health Center
Health Center Admit
s Inpatie
nt
Prognosis
Worsens
Ambulance
Requested to Transp
ort Patien
t
Admitted as
Hospital
Inpatient
Medical Emergency
Occurs
Health Center Requests
Ambulance to Transport
Patient
Admitted to Hospital
Emergency Room
Out
patie
nt
Refe
rral
Inpa
tient
Re
ferr
alEm
erge
ncy
Refe
rral
Outpatient Referral Process shows greatest opportunity for improvement
Background Overview Recommendations Next Steps
Patients may be referred to a District Hospital through one of three channels.
Patient Flow
Village Health Center District Hospital
Patients
Information
Patients
Information
Patients travel from village to
local Health Center for
medical care
Based on illness, patients are treated or referred to
District Hospital
When referred, patients travel
to District Hospital for
continued care
Patients are treated at Hospital
Patients and information flow between the village, Health Center and Hospital.
Background Overview Recommendations Next Steps
Information Flow
Village Health Center District Hospital
Patients
Information
Patients
Information
Patients and information flow between the village, Health Center and Hospital.
Patients travel with symptoms and insurance information
Health Centers collect patient and
disease information and provide referral
forms
Disease information is
reported weekly and referrals are
reported monthly
Hospital collects referral form
and treats patient
Background Overview Recommendations Next Steps
Data Collection
Hospital Interviews• Interviewed key staff from Ruli
Hospital
Health Center Interviews• Visited 6 of 7 in distict regional
Health Centers
Data Collection
• Analyzed data from log books and records
Background Overview Recommendations Next Steps
Over one week, the team compiled a significant amount of information through interviews and data collection.
Challenges in Process Flows
Village Health Center Hospital
Patients
Information
Patients
Information
Opportunities exist to improve both the patient and information flows between the Health Centers and Hospitals, leading to more effective and
efficient patient care.
Background Overview Recommendations Next Steps
Recommendations
Background Overview Recommendations Next Steps
Strategies
We developed 4 recommendations to address 4 key challenges.
Challenge
• Hospital does not now how many daily referrals they will receive
Strategy• Increase
referral awareness through daily communication with Health Centers
Challenge
• Variation in short-term patient arrivals
Strategy
• Increase predictability of referrals
Implementation
• Revised nurse consultation process
Background Overview Recommendations Next Steps
1 2
3Challenge
•Patients do not always go to the Hospital
Strategy
•Ensure patient follow through
Implementation
•Close Feedback loop from Hospital to Health Center
Challenge
• Lack of long-term information capture and analysis hampers operations
Strategy
•Categorize available data, determine a collection plan and act on new findings
Implementation
•Begin by electronically recording referral data
•Consider additional long term projects
4
1: Revised Nurse Consultation Process
Challenge
• Variation in short-term patient arrivals
Strategy
• Increase predictability of referrals through collecting information as patients are referred
Background Overview Recommendations Next Steps
Challenge Objective
1: Revised Nurse Consultation Process
• Why is this a challenge?– Patient Care: Patients delay travel to Hospital for variety of
reasons:• Inability to pay for care• Transportation• Family issues• Social norms: often no urgency to visit Hospital• Other
– Hospital Operations: Variability makes it difficult for Hospital to plan resources effectively
Challenge Strategy
Background Overview Recommendations Next Steps
1: Revised Nurse Consultation Process
• Increase predictability of referrals by collecting information as patients are referred
• Health Center staff will have better understanding of when patients will go to Hospital
Challenge Strategy
Background Overview Recommendations Next Steps
1: Revised Nurse Consultation Process
• Revised Nurse Consultation Process• Process where nurses discuss timing of arrival at Ruli
Hospital with patient at time of referral
Challenge Strategy
Nurse discusses likely timing of arrival at Ruli Hospital with
patient
Nurse completes Referral Arrival
Form
Data Manager collects forms at
EOD
Information related to Hospital
and Community Health Workers
for follow up
Background Overview Recommendations Next Steps
1: Revised Nurse Consultation Process
• Sample Referral Arrival Form
Challenge Strategy
Referral Arrival Form
Date:_____________________ Referring Nurse: _______________ Referring Health Center: _______________________________ Patient Name:________________________ Patient Age: _______________________________ Reason for Referral: __________________________________________________________________ When does the patient expect to travel to District Hospital? □ Today
□ Tomorrow □ 2 Days
□ 3 Days □ Other _____________ □ Never
If the patient is waiting to travel 2+ days, what is their reasoning: ______________________________ __________________________________________________________________________________
__________________________________________________________________________________ For Data Manager Use: □ Information provided to Hospital □ Information provided to CHW
Background Overview Recommendations Next Steps
Discusses Urgency of Condition with
Patient
Assesses Factors for Potential Delay
2: Daily Referral Text
Challenge
• Hospital does not know how many referrals they will receive on a daily basis
Strategy
• Increase referral awareness through daily communication with Health Centers
Background Overview Recommendations Next Steps
2: Daily Referral Text
Challenge Strategy
• Why this is a challenge?– Operations: Hospital
cannot allocate resources efficiently to handle patient load
– Patient Care: On heavy days, patients have excessive wait times and may not even be seen that day
Background Overview Recommendations Next Steps
2: Daily Referral Text
• Increase referral awareness through daily communication with Health Center
• How it addresses the problem– Hospital can better allocate resources on heavy
referral days– Data collection enables long term trend analysis
and planning
Challenge Strategy
Background Overview Recommendations Next Steps
Current Communication:• Referrals are only
tallied for monthly reports
• Daily communication is limited to emergencies
Challenge Strategy
Background Overview Recommendations Next Steps
2: Daily Referral Text
2: Daily Referral Text
Proposed ProcessCollect data at Health Center Transmit data to Ruli Hospital Allocate Ruli Hospital Resources
• Data Manager:1. Collect Referral
Arrival Forms (Recommendation #1) at EOD
2. Calculate referrals for next three days
3. Transmit data via SMS to Ruli Hospital by 4pm
4. Log referral data at Health Center
• Assistant to Hospital Administrator:
1. Receives SMS2. Record referrals per
Health Center3. Calculate total arrivals
by day for next three days
4. Record data in Hospital referral log
5. Complete Daily Referral Tally Form and provide to Chief of Staff by 5pm
• Chief of Staff:1. Allocates staff to
expected demand
• Hospital Administrator:1. Oversees collection of
long-term data for forecasting, budgeting, and staffing needs
Challenge Strategy
Background Overview Recommendations Next Steps
2: Daily Referral Text
Background Overview Recommendations Next Steps
CokoM.5.9.11#10T:7W:2Th:1
As an example, Coko made 10 referrals on Monday, September 5th 2011. 7 are expected to come to the hospital on Tuesday, 2 on
Wednesday and 1 on Thursday.
Location
Day and date
Total daily referrals
Arrival estimates for next three days
2: Daily Referral Text
Date: Wednesday, September 7th 2011 Referrals Today Thursday Friday MondayCoko 1 0 1 0 0Muhondo 3 0 0 1 2Nyange 2 0 1 1 0Rukura 2 0 2 0 0Ruli 15 12 3 0 0Rushashi 5 0 3 1 1Rwankuba 5 0 4 1 0Total 33 12 14 4 3
Forecast Date Monday Tuesday Wednesday Thursday Friday
Repor
t Dat
e
Monday 7 2 1 Tuesday 10 3 2Wednesday 3 14 4Thursday Friday Forecasted 3 18 6Average 17 13 12 14 15Total 32
By tracking the last three days of referrals and adding that number to the average same-day arrivals an accurate estimate can be made for Thursday’s
patient load.
Today’s health center referral counts
Plus the last three days of information
Gives an accurate estimate for tomorrow
3: Close Feedback Loop
Challenge
• Patients do not always go to the Hospital after a referral is made
Strategy
• Ensure patient follow through by increasing Health Center responsibility for patients
Background Overview Recommendations Next Steps
• Why is this a challenge?– Patient Care: May lead to poor patient outcomes
• Barriers to arrival, including lack of financial resources and burdensome travel, are hard to rectify
– Health Center Redundancies: May see same patient for same illness that has worsened due to lack of referral follow-through
– Community Health Worker Resource Strain: current system of follow-up is reactive and can be improved
Challenge Strategy
Background Overview Recommendations Next Steps
3: Close Feedback Loop
3: Close Feedback Loop
• Ensuring patient follow through by increasing responsibility of Health Center for patients may:– Allow for appropriation of resources, such as financial aid
or transportation, to help patient arrive at Hospital– Lead to the ability to identify drivers of patients follow-
through failure
Challenge Strategy
Background Overview Recommendations Next Steps
3: Close Feedback Loop
Challenge Strategy
• Proposed solutions for closing the feedback loop:– Implement process where Hospital sends weekly report reconciling
referrals to all Health Centers– Health Centers will
know which patientswent to the Hospital and which patients did not go to the Hospital
Background Overview Recommendations Next Steps
3: Close Feedback Loop
• Create a referral database between Hospital and Health Centers automatically updating patient referral information and providing proactive feedback to HealthCenters
• Establish communication proceduresdown the ladder
• Prioritize Community Health Worker follow-up with patientsnot presenting to the Hospitaleither through phone call or visit
Patient
Health Center
Ruli Hospital
Health Center
Community
Health Worker
Challenge Strategy
Background Overview Recommendations Next Steps
Village
Formal H
ealth Syste
m
4: Data Capture
Challenge
• Lack of long-term information capture and analysis hampers operations
Strategy
• Categorize available data, determine a collection plan and act on new findings
Background Overview Recommendations Next Steps
• Why is this a challenge?– Hospital Budgeting and Operations: Long-term
budgeting and resource planning decisions uninformed by hard data
– Patient Care: Will improve as hospital refines care using data-backed quantitative analysis
4: Data Capture
Challenge Strategy
Background Overview Recommendations Next Steps
1. Categorize and plan– Identify goals– Select variables to collect
2. Collect data– Design collection process– Analyze periodically
3. Act upon findings– Identify trends– Create action based on insights
4: Data Capture
Challenge Strategy
Background Overview Recommendations Next Steps
• Near term: Electronically store data from earlier recommendations1. Record referral data on weekly basis2. Use existing computers and software3. Periodically analyze
• Long term: Consider future University of Michigan project team
4: Data Capture
Challenge Strategy
Background Overview Recommendations Next Steps
Near Term Example: Referrals
4: Data Capture
Challenge Strategy
Background Overview Recommendations Next Steps
Record paper based information in Excel Periodically analyze Create actionable
insight
Phased Implementation
– Launch recommendations with in district, regional Health Centers first– Expand to include all Health Centers that refer to Ruli Hospital
• Start with largest out of district referral centers
Coko
Muhondo
Nyange
Rukura Ruli
Rushash
i
Rwanku
ba
Gasaga
ra
Kayen
zi
Nyabike
nke
RutondeRwah
iOther
0
500
1000
1500
2000
2500
In District Referrals Out of District Referrals
Background Overview Recommendations Next Steps
Next Steps
Background Overview Recommendations Next Steps
Next Steps
Pilot• Pilot at in district Health Centers• Refine and roll out to top three out of district
Health Centers• Refine again and roll out to remaining out of
district Health Centers
Train• Health Center Nurses and Data Managers• Hospital staff (Data Manager, Head Nurse, Chief
of Staff, etc)• Community Health Workers
Capture• Utilize existing computers and software (Excel)
to collect data on expected versus actual number of referrals electronically at Hospital
Background Overview Recommendations Next Steps
Future Projects
Patient Flow
Improve patient education on importance of seeking medical care
Include follow-up importance rankings in
referral forms and patient conversations
Information Flow
Increase frequency of physicians visits to Health
Centers:1. Develop appointment
system2. Install treatment
equipment in Health Centers
Improve disease/ailment information handoff
between Health Centers and District Hospital
Miscellaneous
Develop process to integrate the Community Health Worker network
Transfer protocols up to Ministry of Health to be implemented in other
districts
Optimize use of Hospital vehicles and ambulances
Background Overview Recommendations Next Steps
Transportation
Transportation
Town of Ruli
Children
Fishbowl
GORILLAS!
Disaster
Murakoze!
Appendix
Key Stakeholders
We incorporated the interests of all of all key stakeholders into our analysis and recommendations
Patients
Challenge Potential Benefit
• Lack of funding and medical knowledge• Travel barriers
• Improved care• Shorter wait for care
Out of Network Health Centers
Challenge Potential Benefit
• No formal relationship with Ruli Hospital
• More proximate option for their patients
Ruli District Hospital
Challenge Potential Benefit
• Uncertain patient flows• Doctors not allocated
efficiently or profitably
• Better utilization of doctors• Greater income now and
in future
In Network Health Centers
Challenge Potential Benefit
• Uncertainty regarding community care after patient leaves Health Center
• Improved care for community• Better relationship with
superiors in Ruli
All Stakeholders operate in the Ministry of Health’s system, which benefits from improved communications between its components and therefore better care
Additional Considerations
Health Center staff are already at or past capacity.
Generating operational efficiencies through the better utilization of current resources is key to
solving short-term capacity constraints.
Health Centers have a variety of record-keeping practices and Data Manager staffing models.
Consistency across all Health Centers regarding record-keeping and transmission of patient
referral information would streamline adoption of a new system.
Out of district Health Centers make a significant number of referrals (~30%).
Ruli Hospital Interview
• Hospital Chief of Staff:– Referral information received by 5:00 PM the day prior would be
actionable in 7:30 AM staff meeting– Advanced warning of ailment and additional health history
would be even more helpful– 6 doctors and 2 doctor interns on staff
• 3 working at any given time
The number of expected daily referrals would allow Ruli Hospital to better allocate resources and see patients faster.
In District Health Center Interviews
– Reporting requirements• weekly, monthly, quarterly
– Regular and periodic Doctor/Supervisor visits
– Data reconciliation• primarily paper with some
weekly/monthly electronic filing
– Hours of operation (9am-5pm)– Referred patients walk to Ruli
Hospital– Patients have similar ailments – Health Centers have a similar
busy season
– Ruli Health Center refers the greatest number of patients due to its location next to the Hospital
– Coko Health Center shares staff with Ruli
– Data Manager role is inconsistent across centers• Hours ranging from .6 to 1.5 FTE• At some centers, the Data Manager is also a
nurse
– Centers further from Ruli have mixed influence as some patients will go to other district hospitals
Health Centers outside the catchment area may differ from those analyzed, especially in reporting, communication methods, and operations
Consistent Health Center Characteristics: Inconsistent Health Center Characteristics:
Health Center Consistency
Current Consultation Log:• Information tracking is inconsistent across Health Centers and between
months/years leading to inability to analyze data/information
Current Log Book Nyange (Recommended) Log Book
Communication at Health Centers
Communication Issues Ruli Nyange Rwankuba Coko Rukura RushashiHow do they communicate with the Hospital
In personPersonal phones
Radio phone, personal phones
Radio phone, personal phones
Radio phone, personal phones
Radio phone, personal phones
Radio phone, personal phones
How often do they visit Ruli/Ruli visit Health Center Daily
Every Monday, for Emergencies
2 people visit Ruli per week and twice per week someone from Ruli visits them
Paper or computer recordsPaper logsComputer reports
Paper logsComputer reports
Paper logsComputer reports
Paper logsComputer reports
Paper logsComputer reports
Paper logsComputer reports
# of computers3- (one does not work) 3 6 2 3 4
Primary user of computers Data ManagerData Manager (uses 1) Data Manager ? ?
Data Manager, Accounting, Mutuelle
Internet use Daily Daily Daily Weeklyonce per two days ?
Mobile phone usage (airtime provided) airtime provided 15,000 RF
96,000F for the Health Center for the month
5,000 RF per month for 12 people
100,000 RF for 3 months for 9 people to share
30,000 RF per month, ~5,000 per data manager
Who provides the air time Global Fund Health Center
Regional Health Center Communication Options
Personal Cell Phone with Airtime Radio Phone Phone Text Email In Person
Hardware
Radio PhoneLines between Health Centers and Hospital
Personal cell phoneProvided airtime
Personal cell phoneProvided airtime
ComputerInternet accessNecessary software
Negligible
Financial Resources
None (unless needed to create more lines)
$0.10 - $4.00 per month (assuming approx 22 calls per month, 3-100F per text)
Negligible Negligible
Health Center Staff
Time to count # of referralsTime to radio phoneApprox 15 minutes
Time to count # of referralsTime to call phoneApprox 15 minutes
Time to count # of referralsTime to textApprox 15 minutes
Time to count # of referralsTime to emailApprox 15 minutes
Time to count # of referralsTime to visitApprox 15 minutes
Hospital Staff
Person to receive phone call, record information, for up to 13 Health Centers = approx 30-60 minutes
Person to receive phone call, record information, for up to 13 Health Centers = approx 30-60 minutes
Person to receive text, record information, for up to 13 Health Centers = approx 15 minutes
Variable, depending on their pre-existing relationship with each Health Center and its staff
Reliability High High High Low Medium
Amount of Information High Low High High High
Scalability Medium Medium-High Medium Medium Low-Medium