improving ruli district hospital's patient referral system, final, 4.12.11

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


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


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.


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.


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.


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.


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


In DistrictOut of District

Project Description & Overview


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


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


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


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.


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


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


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.


Recommendations


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


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


Challenge Objective


• 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



• 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



• 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



• 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


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



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



• 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


Current Communication:• Referrals are only

tallied for monthly reports

• Daily communication is limited to emergencies

Challenge Strategy




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




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


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


• 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




• 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



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



• 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


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


• 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


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


• 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


Near Term Example: Referrals

4: Data Capture

Challenge Strategy


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


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


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


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


• No formal relationship with Ruli Hospital

• More proximate option for their patients

Ruli District Hospital


• Uncertain patient flows• Doctors not allocated

efficiently or profitably

• Better utilization of doctors• Greater income now and

in future

In Network Health Centers


• 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





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





# 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

improving ruli district hospital's patient referral system, final, 4.12.11

Health & Medicine

paper logscomputer

close feedback

daily referral

receive phone

district health

district health

ruli district

health center