William Davidson Institute

Ruli Hospital Summer Internship 2012

Daniel Bickley

Table of ContentsIntroduction...................................................................................................................................................3

Rwanda...............................................................................................................................................................31

The Rwandan Health Care System......................................................................................................................3

Background....................................................................................................................................................5

Summary of 2012 MAP Project...........................................................................................................................6

Expansion of MAP Project Scope........................................................................................................................7

Information Flow Study..................................................................................................................................8

Description of Project.........................................................................................................................................8

Methods.............................................................................................................................................................8

Findings...............................................................................................................................................................8

Information Flow............................................................................................................................................9

Patient Flow..................................................................................................................................................31

Discussion.........................................................................................................................................................33

Recommendations for Improvements..............................................................................................................34

Implementation of Appointment System Improvements...............................................................................35

Background.......................................................................................................................................................35

MAP Team Recommendations.........................................................................................................................35

Additions to MAP Recommendations...............................................................................................................36

Implementation Report....................................................................................................................................40

Problems and Solutions................................................................................................................................42

Recommendations for Future Improvements...................................................................................................47

Conclusion....................................................................................................................................................49

Summary of Information Flow Study................................................................................................................49

Summary of Implementation............................................................................................................................50

Summary of Recommendations and Next Steps...............................................................................................50

I. Introduction

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a. Rwanda

Rwanda is a landlocked country in Central-East Africa with a population of roughly 11.7 million. With a land area of approximately 10,000 square miles, it is the 149th smallest country in the world, comparable in size to Maryland. However, despite its small size, it boasts the highest population density of any country on the continent. Interestingly, it is also predominantly a rural nation, with 90 percent of the population carving out an existence as subsistence farmers. The nation features a small number of urbanized areas, most notably the capital of Kigali, which serves as an economic, cultural, and political hub.

The primary drivers of the Rwandan economy include tourism, mineral extraction, and coffee and tea production. The country has a tumultuous past, attaining independence only 50 years ago and suffering a devastating genocide and period of lingering violence in 1994. Therefore, although there has been relative stability and increased development in the last decade or two, the poverty rate remains elevated at around 45 percent. Despite this state of relative poverty, the Rwandan government commits sizeable funding to health care, spending 9% of GDP on health-related expenditures annually1.

b. The Rwandan Health Care System

The health care system in Rwanda operates on a tiered basis. There exist 4 separate levels of care delivery: community health workers, health centers, district hospitals, and referral hospitals. Each tier delivers care to patients with an appropriately complex disease state, and refers those patients who cannot be treated effectively to the next level. A brief description of each level follows:

1) Community Health Workers: Broadly speaking, this tier of the health system is responsible for disseminating health maintenance and public health information at the village level. Each village elects four lay-people to function as community health workers. Of these four, two are designated as responsible for nutrition outreach efforts. This outreach includes regular monitoring of height and weight for each child living in the community, as well as counseling and education for mothers on adequate nutrition and demonstrations of proper cooking techniques and meal composition. Another community health worker is assigned to maternal/child health within the village, and helps to keep track of pregnant and peri-partum women in that community. This worker must report problems – or potential problems – to health centers. The last of the four volunteers is assigned to coordinate large meetings and events, and may assist the other community health workers in their roles if needed. Community health workers may refer patients to health centers when they find a condition requiring treatment, and patients may also self-refer whenever they have a complaint.

2) Health Centers: The health centers that exist in Rwanda function as primary care outpatient clinics. A single health center will serve several villages and outlying areas, and may see between 30 and 100 patients daily, depending on its location. The primary clinic of the health center is labeled “Consultation”, but there are other auxiliary services housed in the health center as well. These services include HIV/AIDS, Tuberculosis, Malnutrition, Vaccination, and Maternity, among others. Neither the primary clinic nor the ancillary services employ physicians at the health center level; all are staffed by nurses. A wide variety of common acute complaints are addressed satisfactorily on this tier of the health care system, as well certain

1 . "CIA World Factbook." . CIA, 11 Sep 2012. Web. 15 Aug 2012. https://www.cia.gov/library/publications/the-world-factbook/geos/rw.html

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chronic but uncomplicated conditions. Patients are referred to the next level, the district hospital, when the health center either lacks the laboratory or radiographical tools to make a firm diagnosis, finds a diagnosis which cannot be treated adequately at the Health Center, or when patients present emergently (at which time they can be transferred by an ambulance belonging to the health center or district hospital).

3) District Hospital: At this tier of the system, patients are referred from large areas of the district that the hospital is located in, as well as nearby areas of adjacent districts. Each hospital therefore receives patients from roughly six to ten health centers on a regular basis. District hospitals treat patients both on an outpatient and inpatient basis. As is the case at health centers, the primary outpatient clinic is “External Consultation”, which sees non-urgent cases referred from health centers. In addition, there are emergency services, including ambulances and an exam room dedicated to emergencies. Additional outpatient services include such ancillary specialties as dentistry and ophthalmology. On the inpatient side, district hospitals typically have general adult and pediatric wards, a maternity ward, some level of critical care, and the ability to perform some surgeries. All of these services, both inpatient and outpatient, are staffed by doctors who are aided by a complement of nurses. Doctors at the district hospital level are all generalists. District hospitals rarely have specialists on hand, and when they do, it is typically on a visiting basis. Patients are referred to the next level, referral hospitals, when they have a very rare or complicated condition that is not easily treated with the resources available at the district level. This is an uncommon step that is reserved for the sickest patients, or those who require diagnostic capabilities that are too complicated or expensive to distribute to district hospitals, such as CT and MRI scanners.

4) Referral Hospital: The highest level of the Rwandan health care system consists of hospitals located in Kigali which have access to advanced diagnostic and treatment modalities. Few patients are referred to this level, and only when other options are exhausted.

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Gakenke District Health Centers and Hospitals

II. Background

It is within this system that The Ihangane Project has been working for the last decade. In addition to sponsoring work towards economic and infrastructure development in the wider community around Ruli, Rwanda, The Ihangane Project has also made commitments to improving the efficiency of the health care system, specifically at Ruli Hospital and its affiliated health centers. In the last few years, this partnership between the community and The Ihangane Project has grown to include students and faculty from the University of Michigan. Students have contributed to health care and public health projects through William Davidson Institute fellowships as well as through Multidisciplinary Action Projects. Since 2010, the focus of many of these projects has been on learning about the flow of patients through the hospital system, and making recommendations to improve the existing system. The latest MAP team to spend time in Ruli focused on ways to improve the utilization of data within the hospital, specifically through evaluation of a new appointment system that had been implemented

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within the last year. They conducted an analysis of the situation and made recommendations for improvements to the hospital’s referral and registration processes.

a. Summary of 2012 MAP Project

The spring 2012 MAP team conducted interviews with patients and staff, and observed and mapped out different processes related to appointment-making and patient registration. They found that even though an appointment system had been mandated by the Ministry of Health, a majority of patients were still arriving to the hospital without appointments. Furthermore, they identified duplicative or inefficient processes within the hospital registration system which prevent hospital administrators from effectively using the collected data. They made a number of short and long-term recommendations to improve the functionality of the registration system. The short term recommendations are as follows:

1) Collect all data points via phone call: Health centers should give the hospital all the information needed to make an appointment during a phone call at the time of the patient’s visit to the health center. This recommendation would eliminate a duplicative task, wherein health centers would transmit information on referred patients via a phone call and a follow-up email. Moreover, as internet connectivity is slow and highly unreliable in most areas of Rwanda, transmission of all necessary information via phone eliminates the possibility of the required information arriving late or not at all.

2) Modify data points collected: The MAP team proposed collecting the following information for each appointment: Patient Name, Hospital ID Number, Illness, Health Center, Village, and Desired Appointment Date. Having the Hospital ID number would allow for pre-emptive searches for patient charts (see recommendation 4, below). Foreknowledge of illnesses would allow for allocation of staff (including, the MAP team suggested, specialist doctors, though they are not normally available at district hospitals). Finally, a record of the patients’ health center and village would allow for closer follow-up (see recommendation 7, below).

3) Shift appointment setting to registration: The benefit of this recommendation is twofold. Firstly, by relieving the hospital data manager, who currently receives appointment phone calls, that position is given greater latitude to cover other responsibilities including monthly Ministry of Health report generation. Furthermore, the data manager can assume a more supervisory role over the referral system (see recommendation 7, below). The second benefit is that the registration desk is naturally more central to the flow of patients and doctors in the hospital, and will be able to easily verify that patients have arrived – or not – at the point of entry into the consultation process.

4) Gather patient files ahead of time: The MAP team found that registration workers currently spend considerable lengths of time searching for patient files upon arrival at the registration office. With patients’ hospital ID numbers available in real time as the registration workers schedule appointments throughout the day (see recommendations 2 and 3, above), it will be possible to collect files for the next day’s patients during periods when the registration desk is less busy, typically towards the end of the day. This will reduce patient waiting time at the registration desk.

5) Add doctor-scheduled follow-ups to appointment log: Referrals from health centers are not the only source of patients at the hospital. Doctors can also request that patients return for a follow-up visit after an initial evaluation. If this follow-up visit occurs within 30 days of the initial referral, no second referral from the Health Center is required. However, doctors at Ruli Hospital have not scheduled these appointments through the normal channel via the data manager. Therefore, a second stream of patients has been avoiding the appointment log

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altogether, and limiting the ability of the system to truly forecast patient arrivals. This failure to schedule appointments undermines the effectiveness of the system, and therefore should be corrected. Adding doctor-scheduled follow-up appointments to the general appointment log will contribute to a well-functioning referral and registration process.

6) Shift to electronic log only: The registration desk currently uses paper logbooks to record data when patients arrive at the hospital. The MAP team suggested replacing these logs with electronic versions in order to derive the benefits of an electronic system. These benefits would include faster data entry, the ability to perform data analytics, ease of generating monthly Ministry of Health reports, and a decrease in the number of logs required to be maintained (three logs for different patient types are currently kept by registration employees to satisfy MOH reporting requirements). To this end, the MAP team created a Microsoft Excel spreadsheet that could function as a database and automatically generate monthly Ministry of Health reports. With this system in place, the hospital could discard the paper registration system.

7) Modify feedback loop with health centers: This recommendation is intended to combat the low proportion of patients (38% by the MAP team’s count) who currently arrive at the hospital with appointments. As the registration desk will be responsible for taking appointments (see recommendation 3, above) as well as verifying that patients have arrived for scheduled appointments, it will be an easy next step for registration workers to tabulate the number and names of patients who arrive without appointments. The data manager can then take this compiled list and contact the health centers which are sending patients without setting appointments, and troubleshoot the issues affecting low appointment rates. After some time, this step should increase adherence to appointments by health centers and patients alike, and will allow the appointment system to function as intended.

b. Expansion of MAP Project Scope

The MAP team spent 4 weeks on the ground in Ruli during March and April of 2012, and spent a good deal of time weighing options and considering recommendations during the next three weeks after their return to the United States. With the efforts of 4 talented students and guidance from their faculty advisors, it appeared likely that the recommendations that they settled on would be good ones.

However, some concern remained that the scope of the project and analysis was too narrow to simply begin implementing the recommendations. While the Rwandan health care system is a complicated machine, composed of hundreds of interlocking pieces, the MAP team had focused specifically on only one process among them. Moreover, it was possible that the MAP project recommendations overlooked an important part of this specific process, as the referral system overlaps the jurisdiction of both the Health Centers and the District Hospital. The MAP team had spent most of their time at Ruli Hospital, seldom visiting the Health Centers. Therefore, The Ihangane Project leadership felt it prudent to investigate the process of patient referral and registration from the point of view of the Health Centers.

Rather than simply complete this task in isolation, it was thought that it would be of benefit to future projects of this nature to attempt to understand the total flow of information and patients between the community health worker level, health center level, and district hospital level. With this type of “big picture” approach, information could be discovered that could be used to inform future projects as well as critically analyze the referral system as a specific process within the larger whole. This project could therefore lead to potential modifications to the MAP team’s recommendations, ensuring that the

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changes to the appointment and registration processes would be beneficial for all stakeholders – patients, health centers, and Ruli Hospital.

III. Information Flow Study

a. Description of Project

The Information Flow Study consisted of investigations at the community health worker level, health center level, and district hospital level. The aim of the study was to characterize and map out the entire flow of information, as well as patients, through the bottom three levels of the Rwandan health care system. In the context of this analysis, the flow of information is inclusive not only of the transmission of clinical information and reports, but also the administrative information that is exchanged to keep the health care system running, and even the higher-level information exchange that helps employees to know how to do their jobs. Tracking the flow of patients includes defining their exact trajectory in an episode of care, and sometimes the time required to complete various stages in the process.

b. Methods

The primary method of gathering information in the Information Flow Study was through interviews with representative members of health center and district hospital staff. Interviews were attempted to be held with both clinicians and administrators in the main service lines of each facility. A standard line of questioning was developed and applied to each interview, attempting to detail the job functions and a portrait of a typical day for each employee, as well as the type and manner of information exchanged with patients and other health care employees.

Although the general line of questioning was held relatively constant for most interviews, the framework of questions was kept flexible to allow each conversation to unfold in a way that would reveal each employee’s unique insights. In addition to this interview process, direct observation of many processes was carried out. Specifically, these processes included hospital supervision of Health Centers, appointment setting and receiving, health center registration and cashier workflow, Ruli Hospital registration and cashier workflow, and Ruli Hospital patient reception. After data was gathered through interviews and direct observation, it was condensed and analyzed to produce a picture of the flow of information and patients through three levels of the health care system.

c. Findings

The investigation uncovered networks of communication relying primarily on four methods: phone calls, electronic communications including email, hard copies of written communications, and in-person meetings. There is also a trend towards more complicated networks of communication from the Community Health Worker level to the District Hospital employee level. The networks tend to grow in complexity both in types of communication utilized and number of other workers with whom information is exchanged. Below are descriptions of the networks of several employees at hospital, health center, and community levels, along with flowchart-style maps to illustrate many of them.

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1. Information Flow

Hospital Nutrition Service ChiefJob Description: The Chief of the hospital Nutrition Service has five basic activities which comprise his or her job. The first is to make reports about nutrition data analysis. The second is to follow up with nutrition services at all health centers which report to the district hospital, depending on the results of the data analysis report. The third is to make home visits to difficult cases as reported by Community Based Nutrition association. Fourth is to attend meetings of health center chiefs and the monthly Coordination Meeting with the community and social affairs workers of different sectors. The fifth and last major responsibility is to transmit counter-referral forms and quarterly supervision reports to the health centers and district hospital, respectively. These five responsibilities represent the main activities necessary to control the Nutrition Service at the district hospital level.

The counter-referrals that the Nutrition Chief is responsible for consist of 1 of 3 copies of the referral forms that patients bring to the district hospital from the health center. One of these forms is intended for hospital staff, another is for insurance records, and the third is meant to record the treating doctor’s remarks and be sent back to the health center.

The Nutrition Service at the district hospital level provides nutritional rehabilitation to inpatients. This can mean milk and other diet supplementation, as well as medication and education for patients and families. The Chief of the service administers this treatment at times, but it is primarily carried out by a number of other nurses. The Chief receives Ministry of Health training twice, and district-level training once per year, for a total of at least 3 weeks of instructional time. This training must then be passed on to the other hospital nurses who cover malnourished patients, as well as to nutrition workers at the health center level and community health workers.

The Chief of Hospital Nutrition is also tasked with supervision of nutrition workers at

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health centers, but at least in the case of the Ruli Hospital Nutrition Service Chief, this responsibility is too time-consuming. Instead, at Ruli, one of the employees who is dedicated to health center supervision carries out this supervision function. While the health centers send monthly nutrition reports to the Nutrition Service Chief who briefly looks them over, the reports are forwarded to one of the full-time supervisors for the actual task of supervision.

Once quarterly, the hospital Nutrition Service Chief attends the Coordination Meeting with hospital supervisors, health center representatives, social affairs workers (sector-level government representatives), the head of the district hospital, and others as necessary to explain the status of certain programs including nutrition.

Patient Flow: There are two types of patients who flow through the Nutrition Service: those who are treated at the health centers and those who are referred to the hospital. Patients who come to the hospital are referred in the same way as other patients and are received by a doctor in charge of malnourished patients with complications, typically a pediatrician.

They are admitted to a separate ward from other pediatric patients as a precaution due to the low-immunity state that accompanies severe malnutrition. By Ministry of Health protocol, there should be two rooms in this separate ward for the two stages of treatment: the first treating complications and the second treating malnutrition alone. However, due to space constraints at Ruli Hospital, these two rooms are combined.

The doctor on the malnutrition service evaluates the complications which brought the patient to the hospital, and then calls the Chief of Nutrition to make diet recommendations to treat the malnutrition component. Occasionally doctors will write a diet order without consulting the Nutrition Service, but most patients receive a consultation.

From there, the theoretical length of stay for these patients is between 21 and 30 days, though in practice it ranges from 2 to 6 weeks depending on the severity of malnutrition and complications. After discharge, patients follow up at their Health Center for a period of 1 to 3 months. If improvement is verified, then patients return to surveillance at the village level by community health workers.

It is rare for patients not to improve with sustained treatment, but if it happens, the Chief of Hospital Nutrition is informed and writes a letter to the village and sector-level governments asking for investigation into the family’s food security and ability to care for the patient in question. These patients who have not improved are then treated in the same pathway as before.

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Types of Communication:Electronic: Meeting minutes, new policies and supervisor findings from the hospital are sent to the Nutrition Service Chief via email, and the Chief may email the Nutrition Chiefs of other district hospitals. The nutrition workers at health centers also send monthly reports by email, and the Nutrition Service Chief emails the health center Titulaire after training events to disseminate updates.Phone: The Ministry of Health sometimes calls the Chief to verify receipt of emails, pass on information about new malnutrition treatment products, or to ask for short reports. The district may call for many of the same reasons. Within the district hospital, the Chief speaks on the phone with the Director of the hospital regarding messages and reports, and with doctors regarding diet choices and other clinical questions. At the health center level, the Chief has phone calls with the health center Nutrition Chief about home visits, treatment product stock levels, new policies, and email receipt verification. Also, when the health center calls the ambulance phone at the district hospital, the nurse answering that phone calls the Nutrition Chief afterwards when the patient is being received for malnutrition treatment. Very occasionally a community health worker will make or receive a call from the Chief, typically for messages that are normally supposed to be passed on through health centers.In-Person: At the hospital level, the Chief meets with the head of the hospital in person to talk about reports, MOH messages, and new policies. The Chief also meets with supervisors to share certain job tasks, administrators to get approval for expenses and site visits, and the hospital accountant/cashier to get money after being approved for travel or expenses. At health centers, the Chief speaks with the Titulaire and health center Nutrition Chief to review supervision results and recommendations. Finally, the Chief meets with community health workers to deliver hospital directives and follow up with home visits for patients who have been discharged from the hospital.Paper: Used to confirm electronic communication; in other words, an email may be sent first and then later a hard copy with signatures. Meeting minutes and summaries are sent

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via hard copy to meeting participants. Official letters and requests and new policy changes are also sent via hard copy, as are monthly reports from health centers.

Hospital Data ManagerJob Description: The district hospital Data Manager is responsible for the collection and quality assurance of demographic and epidemiological data at the district hospital and all of its referring health centers. He or she must travel to the health centers to do data quality auditing roughly 1 week total per month.

Another task that the hospital Data Manager must do is to set appointments for patients referred from health centers to the district hospital. This task falls to the Data Manager whether working at the hospital or on the road. To set an appointment, the Data Manager receives a phone call from the health center, typically from the health center Data Manager. During this phone call, the hospital Data Manager writes down on a paper pad the name, sex, and age of the patient, and the desired appointment date.

Later, an email is sent from the health center which has an excel spreadsheet attached which includes further information including: date of appointment phone call, name, sex, age, sector, cell, zone, referring health center, presumptive diagnosis, and appointment date. Information is sometimes not received in a timely manner due to the internet connection being down on either the hospital or health center end.

After receiving this information, the hospital Data Manager writes the number of appointments for each day on a piece of paper, along with the patients’ names. This paper is given to the hospital Registration Desk. Registration is supposed to keep records of which patients came to their appointments and which did not, but it disrupts their work and is inconsistently done.

The Ruli Hospital Data Manager also reports problems with patients coming from health centers outside the Ruli Hospital Zone, which send patients to the hospital but are not directly controllable.

Other parts of the hospital Data Manager’s job include data auditing within the hospital and at the health centers, and generation of a substantial number of reports. There are two weekly reports – neonatal and epidemiological – which are sent to the Ministry of Health, along with monthly reports of disease incidence stratified by age. The neonatal report necessitates phone calls to each health center once per week to retrieve the data. The epidemiological report is filled out electronically in a Ministry of Health program and sent automatically to report the prevailing diseases in the district.

The monthly report entails gathering data from health centers and hospital services, drafting the report in Microsoft Word, and entering the data in a Ministry of Health program to send electronically, as well as printing a hard copy for transfer at a later meeting or during MOH supervision of the district hospital. Each monthly report must also have a graphical analysis generated, which is also supervised by MOH to determine the most common pathologies seen in the hospital.

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There are also quarterly reports on maternal and child health in the catchment area. Furthermore, an annual hospital report must be made each year summarizing the monthly reports with some added data points and indicators. It is a high level report with few details, including human resources and training information to produce a total picture of the district hospital.

Data quality auditing is divided into quantitative and qualitative indicators determined by MOH. The hospital Data Manager at Ruli Hospital is in charge of overseeing qualitative indicators, while another supervisor is in charge of quantitative ones.

The hospital Data Manager must also attend the monthly Coordination Meetings which take place at the health centers and at the district hospital. At the health centers, this meeting includes the hospital and health center Data Managers, the Titulaire, and the Chief of Supervisors of the Hospital. At the hospital level, this meeting includes the Chiefs of all hospital services, the Data Manager, and the hospital supervisors. Each meeting is centered around analysis of the data collected during the preceding month.

Types of Communication:Electronic: The MOH emails the hospital Data Manager about meetings and changes in policy, and reports are sent to MOH and also to district governments electronically. The health centers send reports electronically as well, and send emails regarding appointments. The hospital Data Manager also uses email to inform health centers of MOH policy changes that have been handed down.Phone: The hospital Data Manager sets hospital appointments by phone calls with the health center Data Managers or other employees, calls the health center Data Managers for weekly reports and monthly reports if they are not done by the 5th of the month. Furthermore, the hospital Data Manager makes phone calls to the health centers to report feedback or mistakes on reports, as well as to inform of MOH visits or new policies. The MOH calls the hospital Data Manager from time to time to coordinate supervisor visits and communicate about data quality auditing.

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In-Person: The hospital Data Manager attends meetings and trainings at the district hospital and health centers, supervises services at the hospital and the Data Manager at the health center, and asks questions and exchanges information informally with employees of the district and MOH when delivering hard copies of reports by hand or reporting for MOH training exercises.Paper: The hospital Data Manager sends written copies of MOH policy changes and written requests to appear for training exercises to health centers and receives written monthly reports. All reports are transmitted to MOH, the district government, and district hospital administrators and service chiefs by hard copy.

Hospital Environmental OfficerJob Description: The Environmental Officer of the district hospital works with affiliated health centers and surrounding communities to supervise hygiene and nosocomial infections, as well as water quality and insect control. This employee is responsible for visiting commercial establishments within the hospital’s catchment area to evaluate hygiene, and subordinate employees at each health center do the same for households in the outlying villages. He or she also supervises construction at the district hospital to ensure that no harm comes to the surrounding environment. Environmental quality officers at the health center level and community health workers send monthly or quarterly reports to the district hospital Environmental Officer. From these, monthly hospital hygiene reports and quarterly summaries of health center hygiene reports are generated, both of which are sent to the hospital, and the latter of which is also sent to the Ministry of Health. This officer also functions as the secretary of the hospital’s hygiene committee.

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Types of Communication:Electronic: The Environmental Officer sends email to health centers with any relevant documents, and sends and receives emails for any of the reasons that a phone call might also be made (see above).Phone: The Environmental Officer calls the heads of health centers and chiefs of services to arrange meetings, verify email receipts, and ask questions regarding submitted reports. He or she calls the Ministry of Health or vice versa to exchange protocol information and instructions for work.In-Person: The Environmental Officer does in-person education to patients and families in the hospital about environmental hygiene, and performs supervisory functions in person at the hospital each morning. In addition, the Environmental Officer provides educational presentations to the doctors and nurses at the hospital, and interfaces directly with administrators whenever there is a request for materials or funds. The officer also travels to health centers for direct supervision of environmental quality officers and custodians, and goes to outlying communities for education sessions with the local population.Paper: All reports, both received and sent, are done in hard copies. Formal requests for materials and funding from the district hospital or MOH are also made on paper. Finally, the Environmental Officer prints out any invitations to meetings that are received through email to bring to the meeting.

Hospital Reception AreaJob Description: The hospital Receptionist is the first employee to receive patients when they arrive at the hospital. Typically, many patients are waiting at the beginning of the day and the Receptionist processes them in batches.

First, the patients’ insurance information is gathered and photocopied (note: this only applies to patients with MUSA insurance, though they make up the large majority of visits). Patients pay the receptionist a small fee at this time for the photocopies. The receptionist then collects each patient’s referral form and gives that form along with the photocopy of insurance paperwork to the outpatient cashiers.

The cashiers call 1 or 2 people at once, depending how many are working simultaneously, to pay for their appointment. They check the services which the patients have been referred for and calculate a charge according to each patient’s insurance plan. MUSA members pay 10% to the MUSA officer who is located nearby, while patients with other insurances pay 100% of the charge up front and seek their own reimbursement later. For insurance purposes, each patient receives a receipt and a form from the MUSA officer noting the services to be received, which is stapled to the insurance information photocopy. This process has been observed taking anywhere from 3 to 11 minutes per patient.

After paying and receiving all their paperwork, patients are oriented to the registration desk and shown where to wait for one of the doctors. Once a patient has been seen, the doctor marks the prescribed medication on the patient’s forms and the patient goes to the cashier again to pay for the prescription. The patient gives the cashier a form listing the services rendered by the doctor and hospital, takes a receipt, and picks up medications

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from the pharmacy.

Most patients arrive between 7:30am and 10:00am, and then the rate of arrival slows to only a few per hour. Registration workers cover the receptionist when he or she is gone, in addition to having to fulfill their usual responsibilities.

Hospital Registration DeskJob Description: The hospital Registration Desk functions to check patients in to see doctors in the consultation service. Patients arrive from the reception area and cashier and hand their documents to the registrars who enter demographic information in a registration log book. A valid receipt from the cashier must be presented to verify payment. For patients with chronic diseases who do not require health center referrals to be seen at the hospital, the registrars fill out an in-house referral form.

The registrars then hunt for the patient’s chart or make a new one if the patient has not been to the hospital before (if two registrars are working simultaneously, this can be done while the registration log book is being filled out). To make a new chart, three forms are completed and stapled together: a full-page blue cover sheet, a half-page white cardstock demographic form, and a small yellow rendez-vous card on which are written the dates of future appointments.

The patients are sent off to wait for a doctor, while the charts sit in a pile on the registrar’s desk until a circulating emergency room/consultation service nurse arrives to pick them up. The nurse then takes each patient’s vital signs and directs them to an available doctor, transferring the patient’s chart as well.

On the weekends, the registrars come to work to fill in the second half of the registration log. Aside from the previously entered demographic information, they must record each patient’s presenting complaints, diagnostic tests, eventual diagnosis, and treatment information, among other data points. As finished charts are not returned until the following morning, at which time there is a rush of new patients at the registration desk, this task typically is left until the weekend when the registrars have enough time to complete it.

Health Center Registration DeskJob Description: The registration desk at the health centers serves a similar function to that of the District Hospital, though it assumes some of the functions associated with the reception area at the hospital. Patients arrive at the health center and either go to the MUSA office or the registration desk first. If they arrive at registration prior to the MUSA office, they are redirected there to pick up insurance paperwork before they return to registration.

The patients bring from home a small half-sheet of blue paper which serves as a medical record. The registrar at the health center asks about the problem bringing the patient to the health center and then measures weight and temperature, recording all on the half-sheet. After recording this information, the patient waits until a consultation nurse is available. Unlike registration at the district hospital, the registration log book is not

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located at the registration desk at the health center. Instead, each consultation nurse fills out the necessary information in the log book during the visit with the patient.

After the visit, the registrar takes the MUSA form from each patient and uses it to calculate the amount to be reimbursed to the health center by MUSA. These forms are taken to the MUSA office to be added to the monthly reimbursement cycle for the health center. The blue half-sheet which comprises the health center’s medical record is kept by the patient and taken home. If patients require medication from the pharmacy, they pay at the cashier prior to going there. The cashier stamps their clinical forms to verify payment.

This flow of patients is not exactly the same at all health centers. At Ruli Health Center, for example, returning patients do not pass through the registration process, but are seen directly by consultation nurses instead after going to the MUSA office. Only new patients go through registration to receive their clinical forms. The registration worker may take temperatures among the waiting patients, but not weights, and will defer temperature and other vital signs to the consultation nurses if the clinic is busy.

There is not necessarily a dedicated employee at the registration desk. The health center cashier and several nurses were observed performing this task at the Nyange Health Center, in addition to their normally scheduled activities. However, at Ruli Health Center, there is a dedicated cashier who is assisted in the large volume of patients by a part-time assistant cashier and the health center accountant when she is not otherwise occupied.

The cashier has a number of other duties in addition to covering registration. He or she must receive and calculate revenues and expenses at the health center. Other responsibilities include issuing stipends to health center employees who are traveling for work, traveling to a bank (which may be several villages away) to withdraw and deposit money from the health center’s account, calculating and exacting payment from non-MUSA insurance holders, and collecting money for other patient expenses such as the paper forms used as medical records.

The cashier has no communication with the hospital. The cashier does have in-person communication with Community Health Workers when attempting to track down patients who have not paid their Health Center bills.

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Health Center OrganizationThe health center is partly governed at the village level, in the COSA (Community Health) committee where each health center holds one representative position. The health center is run internally by the COGE (Steering Committee), which is composed of representatives from health center clinical workers, service lines, and administrative staff. The president of the COGE is the Titulaire, or head, of the health center. Under the Titulaire is a vice-Titulaire who handles the operations of the health center in the Titulaire’s absence. Underneath the layer of top administrators, each service line has one person responsible for it, who reports to the Titulaire. In addition to the medical service lines and administrative functions of the health center, there are also a number of support staff such as security guards and building custodians.

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Health Center Data ManagerJob Description: The health center Data Manager is responsible for managing all patient data from all services at the Health Center. He or she verifies that the data is collected and enters it into computer systems (DHS and HMIS) which transfer it electronically to the relevant district hospital and the Ministry of Health. This patient data is used to help the MOH and hospitals to monitor trends and epidemiology for various diseases.

In addition to this primary responsibility of data collection and transmission, the health center Data Manager must also set appointments for patients who are referred to the district hospital. For patients with non-emergent conditions, the Data Manager first asks the patient which dates they would be available to travel to the hospital. Then, the health center Data Manager makes a phone call to the hospital Data Manager to inform them which day the patient will arrive. The hospital Data Manager typically accepts the appointment, and very rarely, if ever, responds negatively to a proposed appointment date.

In this phone call, the health center Data Manager tells the hospital only the patient’s name, age, and the date of the appointment. Later, the health center Data Manager sends an email containing an excel spreadsheet with further demographic and medical details about the referred patients. Although the health center Data Manager has all of this information prior to the phone call, it is not currently transmitted via phone.

For patients with emergent conditions, the transfer process omits the step of calling for an appointment. In these situations, the health Center Data Manager only calls the hospital if the health center ambulance is busy or malfunctioning, and the phone call is then a request for a district hospital ambulance rather than a request for an appointment.

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Types of Communication:Electronic: appointment-setting, communications to and from MOH (usually sent and received via District Hospital), to and from district hospital regarding data, meetings, changes in health policy and protocols, monthly reports, and official requests, to and from the District regarding development, meetings, and reports.Phone: appointment-setting, guidance and explanation for reporting, new MOH rules and regulationsIn-person: supervisor visits, meetings at the district hospital, training eventsPaper: filling out information in paper appointment log kept at health center (if not Data Manager, the Data Entry worker will do this task), summary and tally of number of patients with each designated tracked illness in each service line’s written registration logs, monthly reports, and letters for official requests

Email communications are the most important to the job of the health center Data Manager because they allow for larger and more detailed messages than phone calls, despite connectivity issues in rural areas. However, sending messages via email is also problematic because of issues in electrical infrastructure as well, which provide a second layer of communication insecurity. Although dissimilar to the rest of the job responsibilities, the task of appointment setting does not necessarily present itself as a problem to health center Data Managers, as vice-Data Managers or other employees can perform this task if the primary Data Manager is busy or otherwise unable.

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The health center Data Manager at Nyange currently has 3 desktop computers to work with – one for data entry, one for the Data Manager’s use, and one for the IT Manager of the Health Center. One laptop also exists as a portable workstation for the Data Manager. They will have to new system soon to transfer information directly from each service line’s registration log books to electronic files. This system will begin in the VCT/HIV service.

Health Center Reception Desk EmployeeJob Description: The health center Receptionists typically start work around 7am, have a break in the middle of the day for lunch, and wrap up operations around 5pm. They are the first point of contact for patients within the health center and receive patients at reception, making some attempt to triage patients who are already waiting according to severity of illness. Reception sends patients to the health center Nurses, who then evaluate and treat them, deciding whether treatment at the health center is appropriate or hospital transfer is needed.

Patients requiring hospital transfer fall into two categories: emergent and non-emergent. Patients who are very ill require ambulance transfer, while those who are not so sick typically walk to the hospital.

Some patients are sick enough to be treated as inpatients, but not sick enough to require transfer to the district hospital. These patients can take advantage of a limited number of beds at the health center (~25 at Nyange, for example, including maternity beds).

The Receptionist separates patients by age (greater or less than 5 years old), thereby determining which of two consultation rooms they will go to. In principle, Receptionists should also separate patients according to whether or not they present with a cough, in order to reduce transmission of respiratory illnesses. In practice, this is not done (at least at Nyange) because of limited space; there are simply not enough consultation rooms for coughing patients to occupy one of their own.

When patients arrive, the Receptionist fills out a sheet with their demographic and insurance information. Then vital signs are taken (except in emergencies) and patients are sent to see nurses based on the above criteria.

In addition to responsibilities with patients, the Receptionist may orient new health center workers to the layout and operations of the facility. The Receptionist’s responsibilities are covered by the cashier or a nurse while at lunch or after 5pm. Likewise, the Receptionist covers the cashier’s job during breaks in the day.

Types of communication: The only communication the Receptionist has with the district hospital is through the health center Nurses and Data Manager. Every nurse can call the hospital when necessary for patient care, and the Titulaire of the health center communicates changes to policy from higher up in the hierarchy directly to the Receptionist.

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Health Center Head of Community Health WorkersJob Description: The Head of the community health workers at the health center is responsible for overseeing the work of those volunteers in all the villages within the health center’s catchment area. At the beginning of each month, the Head of CHWs makes a quarterly plan and a monthly calendar, submits them to the health center and Sector for approval, and then makes a summary of operations and collected information at the end of each quarter. The Head visits villages, makes monthly reports, and performs training of CHWs. He or she is also in charge of environmental hygiene for the catchment area. This duty entails visiting commercial centers and households to evaluate hygienic status. It is a relatively minor duty, accounting for 2 days per month of work. However, at least at Ruli Health Center, it is not always a duty that is fulfilled; as it is difficult to fit in with the somewhat unpredictable course of other work, the Head of CHWs there spends only 1 day per month on environmental hygiene. Findings are reported to the sector government and to the Chief of Environmental Hygiene at the district hospital.

Types of Communication:Electronic: No email is sent or received at the village level. However, electronic versions of forms are sent from the Ministry of Health via the district hospital to the health center for delivery to the Head of CHWs. In addition, monthly hospital meeting reminders and minutes may be delivered via email. Finally, the Head of CHWs sends electronic copies of monthly and quarterly reports to the district hospital by email in addition to hard copies.Phone: Community health workers all have telephones and call the Head of CHWs to notify of events happening at the village level such as complicated patients or pregnant women about to give birth. The community health worker can also call an ambulance from the health center or district hospital. This kind of communication helps emergent patients bypass the health center and proceed directly to the district hospital. At the hospital level, the Head of CHWs receives phone calls communicating about monthly meetings, and may also make direct phone calls for a hospital ambulance in emergencies.In-Person: The Head of CHWs travels to villages at least twice per week, averaged over an entire month, to meet with CHWs and villagers and exchange information and reports, as well as speak about preventive health issues. There is also a monthly meeting at the

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health center which CHWs all attend to meet with the Head and analyze the monthly reports to find gaps in data, errors, and determine prevailing illnesses and trends. It is also possible for the Head of CHWs to meet CHWs in person if they escort patients to the health center. There is another monthly meeting which takes place at the district hospital and is attended by Heads of CHWs from many health centers, wherein similar report analysis is done. Occasional other meetings at the hospital level may require the Head of CHWs to attend, typically regarding reports, new Ministry of Health programs, or training. In addition, at Ruli Health Center at least, there are informal conversations which transmit information regarding epidemiology in the villages, reasons for levels of referrals to the hospital, and so forth. While health centers in close physical proximity to their district hospitals may have these types of communications between employees, they appear to be uncommon in more remote health centers.Paper: The Head of CHWs receives 5 hard copy reports from each village each month, and an additional 2 reports from each village on a quarterly basis. The information in these reports covers childhood illnesses, family planning, maternal health, deaths, and nutritional status reports. The Head of CHWs then summarizes these reports and submits a hard copy to the district hospital. In addition, Ministry of Health letters are sometimes sent to the district hospital which forwards them to the health center for delivery to the Head of CHWs.

Health Center Hospitalization Service ChiefJob Description: This employee is responsible for the limited number of beds that health centers offer for moderately-ill patients and expectant mothers. Patients are hospitalized at health centers for lengths of 1-2 days, for illnesses such as uncomplicated pneumonias, diarrhea, or simple traumas, which are not quite severe enough to be referred to the district hospital, yet require some form of extended observed treatment. The process is as follows:

1. The chief verifies that the patient has a hospitalization form from the consultation service

2. The chief checks to see if the patient is registered in the hospitalization registration log book. If the patient has not been registered, the chief enters the patient’s name, the date, the illness, length of stay, time of first dose of medication, and the time of the second dose

3. The chief verifies that the patient has taken all necessary medication4. Patients are followed to document progress. If they do not demonstrate improvement,

they will be sent to the hospital. Patients not responding to the first dose of medication are given a different medication for their second dose. If improvement cannot be seen after two doses, or if the patient’s condition worsens after a single dose, the patient is referred to the district hospital.

5. An official transfer form is filled out including name, date, illness, age, sex, insurance information, and treatment already rendered. A health center representative, typically a nurse, travels with the patient by ambulance to the district hospital and signs a form, along with the head of the health center and a hospital representative, to verify the transfer. The hospital representative is a nurse, unless the patient is arriving for a cesarean section, in which case a doctor receives the patient at the hospital directly.

6. The same information contained on the transfer form is copied to an ambulance transfer log book.

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The decision to hospitalize a patient is made by the nurse who evaluates them in consultation. Once a patient is hospitalized at the health center, the decision to transfer to the hospital is made during the daily staff meeting after the patient has spent one night at the health center but shown no improvement. The staff exchange ideas for alternative treatments, then may consider a transfer if appropriate. Although the normal process is collective, on weekends a single individual may make the decision to transfer.

The Nyange health center has 25 beds – 6 for me, 6 for women, 6 for children, and 7 for maternity patients. Roughly 12 patients are admitted there each month for illnesses, though this figure jumps to 20-25 per month when maternity admissions are included. Women delivering children stay for 3 days unless complications occur, in which event they are transferred to the hospital.

The chief of the hospitalization service may also have another job function. At Nyange, this employee is also the vice chief of hygiene for the health center, working closely with the district hospital Environmental Officer to control hygiene in all health center areas and ensure adequate performance by custodians.

This service chief must generate a monthly hospitalization report for the health center Data Manager and health center chief (Titulaire). Once this report is signed and verified, it is delivered to the district hospital Data Manager. There is no specific monthly report that must be given to the district hospital Environmental Officer, but the Education Communication Information that is given to patients is kept track of, and simple reports are transmitted regarding the cleaning supplies needed for the health center. Periodically, this health center Environmental Officer must make reports to the sector government about the state of the health center grounds and gardens.

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Types of Communication:Electronic: The Hospitalization Chief receives emails through the health center Chief regarding changes in policy, medication utilization, meeting requests, and other general information. This information is then transferred in person during meetings or via hard-copy printouts of the emails. The monthly report is sent electronically as well, via the HMIS system.Phone: District hospital nurses sometimes call for more information on referred patients; these calls typically go to the health center Chief or to the Data Manager, but the Hospitalization Chief will receive them after normal clinic hours. The Hospitalization Chief calls ahead to the hospital for maternity patients after normal clinic hours, typically speaking with a nurse.In-Person: The Hospitalization chief has face-to-face interactions with supervisors regarding reports sent to the district hospital and recommendations for improvements. Occasionally the chief will also travel with transferred patients and interact with the receiving nurse at the hospital.Paper: The monthly report to the hospital is sent via hard copy, and referrals for children under 5 years old to the health center, as well as feedback to community health workers, are all done on paper.

Health Center Consultation Service NursesJob Description: The consultation service at the health centers is the general outpatient clinic. It is staffed entirely by nurses and has responsibility for seeing all new and returning patients. When patients arrive at the clinic, they are registered in the consultation log book by a consultation nurse after verification that the patient came from

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the reception area with properly collected basic information and vital signs. The nurses interview and examine each patient, including measuring blood pressure, respiratory rate, and pulse (the vital signs taken by the reception desk include weight and temperature).

The patient’s history and an assessment of the illness is written on the proper forms and labs and studies are ordered if necessary. The required studies are written on a piece of paper that the patient takes to the health center laboratory. Within 10-20 minutes, the patient receives the results and returns them to the nurse in consultation, informing the diagnosis. With a diagnosis in mind, the nurse writes a prescription (if necessary) which the patient picks up at the health center pharmacy after paying the cashier. The pharmacist (also often a nurse) explains how to take the medication and the patient takes the first dose while at the pharmacy to verify tolerance before going home.

It is also possible for the consultation nurse to decide to hospitalize a patient at the health center or refer to the district hospital. This decision to refer to the district hospital hinges on the type or severity of the disease, whether the patient has had multiple health center visits without improvement, or if a diagnosis can only be made with the resources of the hospital. Hospitalization within the health center is done when the nurse is sure of the diagnosis and the patient cannot go home safely (i.e. the patient requires intravenous treatment). When the decision is made to hospitalize a patient, the nurse must fill out a hospitalization form, enter the patient in the hospitalization registration log book, escort the patient to the designated bed, and deliver treatment and follow up at specified intervals.

One nurse from the health center is supposed to be assigned to hospitalized patients during the day, but this nurse is usually assigned to other services and there is no consistent staffing. Consultation nurses end up checking on hospitalized patients in between their other, normally scheduled duties. 2 consultation nurses work per day and at Nyange, each sees about 20 patients daily. At busier health centers, both figures are increased. Though the consultation nurses try, it is difficult for them to make time to see hospitalized patients in addition to outpatients.

When hospitalized patients are discharged, the date is noted in the hospitalization register log book. The patient then takes a form with information about their hospitalization to the cashier to pay, then heads to the pharmacy to pick up outpatient medication, and leaves for home.

When patients are referred to the hospital, the consultation nurse must fill out a referral form with the patient’s name, vital signs, and the reason for referral. Then, the process is somewhat different for urgent and non-urgent referrals.

For non-urgent referrals, the patient is sent to the health center Data Manager who calls the district hospital Data Manager to make an appointment. The patient is given three copies of the referral form filled out by the consultation nurse. The patient is logged in the health center’s transferred patient registration log and the Data Manager’s appointment date log. Then the patient arranges for travel to the district hospital by themselves, often walking. At the hospital, one copy of the referral form is given to the patient’s health insurance provider, one copy is kept by the hospital, and the last copy is

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used by the doctors and sent back to the health center later for performance-based financing requirements. The patient keeps the original form filled out by the consultation nurse.

For urgent referrals, the patient is given the same three copies of the referral form, but this time an ambulance is called. The patient pays an ambulance fee and receives a receipt. Then, the patient is logged in an ambulance registration log book, and a nurse accompanies the patient on the ambulance ride to the hospital. At the district hospital, the receiving nurse signs the ambulance registration log book to verify the patient’s arrival. The nurse returns to the health center with the ambulance.

Types of Communication:Electronic: Electronic communications are done at the health center level, and not sent to nurses directly. The chief of the health center relays any relevant messages, and reports that nurses make to the health center Data Manager are sent to the district hospital electronically.Phone: Nurses call community health workers when patients fail to arrive at the health center for follow-up appointments, attempting to discover the reason for the absence and to direct the patient to the health center. Nurses also receive calls from the district hospital when the referral forms were not completed with enough detail and further information is needed about referred patients. Consultation nurses may also call the

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hospital when pregnant women are being transported there emergently in order to prepare the doctors and time their arrival correctly.In-Person: Nurses have direct contact with community health workers when maternity patients arrive at the health center to give birth. Community health workers accompany all delivering patients and give the nurse information regarding the woman’s clinical course. Hospital supervisors also see the nurses in person to collect information on clinical operations and give guidance. Furthermore, nurses often attend training events at the district hospital or even in other districts where they interact with hospital supervisors and representatives from the Ministry of Health for educational sessions.Paper: Consultation nurses receive paper notes about patients from community health workers when they refer patients to the health center. Nurses write their findings on those paper notes along with their recommendations and patients return them to the community health workers. Nurses also fill out referral forms for patients who they send to the district hospital, receiving the copy with doctor’s comments as a “counter-referral” later.

Health Center Nutrition ServiceJob Description: The employees of the health center Nutrition Service work primarily out of their health center, but also have many activities they are responsible for in the field. They primarily serve women and their children to evaluate nutritional status, provide education regarding proper nutrition, teach practice cooking classes and sample food from the community to ensure nutritional appropriateness, and give nutrition counseling to pregnant and postpartum women for 6 months after birth, as well as to women with HIV.

After evaluation, patients are treated according to their nutritional status, being divided into green, yellow, and red zones. Patients in the green zone are normal and continue to be monitored at the village level but not seen at Health Centers. Those in the yellow zone are moderately malnourished, while those in the red zone exhibit severe malnutrition. Patients in these latter two zones are referred to the health center Nutrition Service by community health workers. Community health workers assist in all villages to follow children, especially newborns, to determine nutritional status. These community health workers are elected by Community Based Nutrition Programs in each village to perform these tasks. The employees of the health center Nutrition Service are responsible for educating the 4 lay people elected as community health workers.

For children under 6 months old who are found to have malnutrition, the mothers are sent to the local health center for education. Children and women in the red zone are given Ready to Use Therapeutic Food (RUTF) which is distributed to health centers centrally by the Ministry of Health. Patients in the yellow zone are treated with SoSoMa supplementation in their diet.

At the time of treatment, women and children are sent to the health center from their villages. Women are only treated if the child is less than 6 months of age, as Ministry of Health policy states that infants that young should be fed exclusively with breast milk unless requiring oral medication or their mothers are unable to breastfeed. Mothers of these children receive RUTF and nutritional counseling.

For children over 6 months old who are found to be malnourished, the World Health

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Organization recommendations are followed. These include beginning treatment with SoSoMa as a supplement to breastfeeding if the child is in the yellow zone, or with RUTF if the child is in the red zone. In addition to supplementation, the health center Nutrition Service provides weekly education sessions for the mothers, as well as practice in cooking, hygiene, family planning, and other useful skills. Typically in this case, the child is the only one who is treated. If the mother is found to be malnourished as well, then the case is typically referred to the hospital for a more comprehensive medical workup. This type of case is quite rare.

Community health workers, who work very closely with the health center Nutrition Service, receive training at the health center, district hospital, and Ministry of Health levels. The health center Nutrition Service workers and the health center Chief of Community Service are responsible for part of this training, and must also observe community health workers to ensure that their work is being done correctly. They also collect reports from all the villages in the health center’s catchment area for forwarding to the district hospital Nutrition Service Chief. These reports detail the number and location of children in the yellow and red zones of malnutrition so they can be followed up. The community health workers and health center Nutrition Service make the diagnosis of malnutrition by evaluating weight, height, weight gain over time, and upper arm circumference.

From the health center level, patients with malnutrition are referred to the district hospital if they are discovered to have malnutrition with complications which cannot be treated at the health center. Diarrhea and pneumonia, for instance, can be treated locally, while more serious complications such as cognitive deficits must be referred to the hospital. Once at the hospital, the malnutrition is treated in a similar fashion as at the health center, in accordance with Ministry of Health policies. At the same time, the complications are addressed by whatever medical means necessary. The district hospital Nutrition Service makes recommendations for much of the malnutrition treatment while the inpatient medical service determines the correct course for the complications to be treated. Upon discharge, the patients return to their communities and continue to be followed by community health workers there.

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Types of communication: Electronic: Monthly reports are sent by email and contain a summary of malnutrition cases from all villages in the health center catchment areaPhone: Call to chief of hospital Nutrition Service to apprise of patients being transferred to hospital – this call contains no other information aside from arrival notification, unless the patient is not one who has been logged in prior monthly reports. Phone calls are also made to and from the hospital Nutrition Service to relay information about new MOH policies.In-person: Giving training to CHWs, receiving training at hospital/district/MOH level at district hospital or other location from hospital Nutrition Service representative, district hospital doctor, or another outside expert.Paper: Paper forms are filled out with a nurse’s assessment, malnutrition status, and measurements whenever a patient is referred to the hospital in order to help the Chief of the hospital Nutrition Service. A paper copy of the aforementioned monthly report is also filed with the Chief.

Community Health WorkersJob Description: Community health workers form the base of the health care system in Rwanda, operating at the village level to provide preventive care, public health education, and appropriate referral to the next level of care. There are four community health workers in each village, typically lay-people who are elected to the position. Two of the four focus on nutrition in the community, primarily in children and pregnant women. One is tasked with maternal/infant health monitoring. The last functions as a coordinator for events involving community health workers and representatives from health centers.

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The community health workers who monitor the nutritional status of children in the village give each mother a card to record her children’s health status. It includes a height-for-weight chart to track malnutrition, a table to mark vaccination status, and areas to note doses of vitamin A and albendazole/mebendazole treatment. The community health workers organize periodic (typically monthly) meetings for all the mothers in the village with young children. These meetings include weighing of children, educations sessions taught by community health workers and visiting employees from the local health center, and a didactic session focused on proper cooking techniques and healthy meal composition.

Types of Communication:Electronic: CHWs do not use email or other electronic communications.Phone: CHWs can call the head of the health center or the head of CHWs for ambulances when they are responding to medical emergencies in their village. Furthermore, health center nurses who live in the vicinity may be called by CHWs for clinical guidance in emergencies or ambiguous situations. Nurses call CHWs to arrange appointments for field work in the villages, and the head of CHWs at the health center calls them to relay information about patients in their care or to discuss problems with their monthly reports. In-Person: There is a monthly meeting at the health center that all CHWs attend, where they submit the hard copies of their reports and discuss community health issues with the head of CHWs. They also receive several days of medical and public health training in person at the health center when they are elected as CHWs. The head of CHWs also comes to supervise them in person, usually once per month at the malnutrition screening meeting.Paper: The CHWs deliver paper copies of monthly reports to the head of CHWs at their local health center. They receive blank copies of these reports from the head of CHWs at the time that they turn in the completed reports.

2. Patient Flow

The Information Flow Analysis also focused on the way that patients physically move through the health care system. From the data gathered, these charts were generated to show the path that patients take from the Community Health Worker level through the District Hospital.

The first diagram shows the pathway which patients follow to be seen at health centers, and then referred onwards to the district hospital if needed.

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The second diagram below shows an example of the flow of patients for a specific illness. The treatment of malnutrition was selected as a specific example to highlight the way that a particular disease state is handled within the general framework in first diagram above.

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e. Discussion

Through this extensive investigation, a number of interesting points and overarching patterns emerged. Although the study did not include all employees at the health center or hospital levels, it provides what appears to be a largely representative sample of the type of communication used by health care workers in the course of their jobs. Therefore, the information gathered here can be used to draw a number of conclusions and make some recommendations for future improvements in communication.

One of the first clear trends that is present in the data is the increasing complexity of information flow networks at the higher levels of the health care system. Health center workers communicate with more people than community health workers, and they use more types of communication. The same is true at the district hospital level compared to the health centers.

Another pattern that can be seen in the flow diagrams above is that a surprising amount of the information being exchanged is internal to the health care system and non-clinical in nature. This includes training, supervision, and transmission of reports. These broad categories encompass a wide variety of activities and account for a significant portion of many employees’ time and effort. Comparatively little effort is spent communicating clinical information needed to care for patients.

In the same vein, many of the employees who were interviewed had chiefly administrative lines of communication, while a few performed primarily clinical duties. Another subset, including the nutrition service employees, for example, treat and educate patients and therefore may exchange some clinical information, but have many other duties to attend to as well.

It is possible that this apparent preponderance of non-clinical communication is due to a selection bias in the interview process. Many of the people who were interviewed were the chiefs of their particular service, and not ordinary workers within that service. Therefore, it is possible that the focus of these employees is tilted more heavily to administrative communication than the full-time clinicians. In addition, it is also conceivable that some of the portrait being painted here is the ideal flow of information as the system is currently designed, rather than the day-to-day actuality of communication.

A third theme that appears is the consistent reduplication of communication efforts. Often, the same information or message is sent twice, in two different formats. Although in many cases this may cause only a small inconvenience or extra burden on employees’ time for each instance, it may add up to a significant extra effort in the long run. However, it is thought to be necessary to repeat communications because of the significant insecurity in electricity and internet access that exists in large portions of the country. If a better way can be found to deal with this insecurity, this duplication may represent an opportunity for consolidation and information flow improvement.

It is also notable that some responsibilities have been shifted, or MOH directives ignored. Sometimes this is due to overwork, as in the case of the district hospital Nutrition Service Chief outsourcing supervision duties to one of the other supervision employees. Other times it is due to physical resource restriction, as in the case of Nyange Health Center not being able to segregate patients by the presence of a cough on presentation, due to a lack of consultation

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exam rooms. Breakdowns in the prescribed methods of communication might indicate potential areas of improvement for the future.

One fine point relating to the recommendations of the 2012 MAP team (see section IV(b) below) is that the health center Data Manager has several tasks, but the only one involving patients is the setting of appointments. The other duties involve collection and validation of aggregated clinical data points and the generation of reports, but no patient contact. Therefore, the job of setting appointments is incongruous with the rest of the Data Manager’s responsibilities.

Finally, it should be noted that this study of information flow comes with a few limitations. It is somewhat incomplete for two reasons. It proved difficult to find time to meet all the employees who could have been included. Due to job responsibilities and vacations, many people spent significant time away from work over the course of the summer. It was also inherently difficult to schedule appointments and make firms plans to travel at particular times, and some employees were missed. Furthermore, some employees, particularly clinicians at the hospital level, were present at work daily but simply could not make time to explore their communication networks. For these two reasons, this study can best be thought of as a detailed approximation that may have gaps in important areas. Nevertheless, it can be used to make certain recommendations, as seen below.

f. Recommendations for Improvements

Based on the information flow study, a number of broad recommendations can be made for future Ihangane Project workers to pursue.

1) Eliminate duplicative processes: Communications which are repeated in different ways may represent a substantial usage of time and resources which could be redirected. Future studies could spend time analyzing whether these should continue or if they could be simplified.

2) Minimize modes of communication: When considering future changes to these communication networks, it may be beneficial to avoid assigning new communications that employees aren’t used to. For instance, since most health center workers do not directly utilize electronic communications, adding these to their repertoire of tasks should be carefully considered, as it will add to training costs. Unless the benefit is truly worth the up-front investment, such changes should be avoided.

3) Consider existing responsibilities: Examples can be seen of employees being overburdened with responsibilities by top-down directives and failing to fulfill those requirements. When thinking about which communication an employee should be responsible for, future Ihangane Project workers should take into account whether recommendations are realistic given the existing demands placed upon the health care workers.

4) Utilize existing channels: Certain employees already have close relationships with other employees. For instance, the supervisors at the hospital level are very familiar with the service chiefs at the health centers. If one employee is already in close contact with another, particularly if those employees connect two different levels of the health care system, then it could be advantageous to align multiple communications through those employees to make

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use of the existing relationship.

5) Eliminate extra steps: In the charts describing the flow of patients through health centers and hospitals, there are extra steps that could possibly be eliminated or consolidated (see Appointment System recommendations, section IV(c) for one example). Consolidation of these steps in the process has the potential to improve the patient experience.

6) Approximate sequential steps: Steps in patient flow which occur sequentially should be placed in close proximity to whatever extent possible. This has the potential to speed patient flow and improve the patient experience.

7) Assign communications according to skill: Certain types of communication require a skilled worker to transfer specialized information, while other types of communication can be carried out by any employee. Where possible, non-specialized communications should be carried out by the lowest-skilled employee, especially if it will even out the relative share of responsibilities.

8) Break bottlenecks: Future Ihangane Project workers could spend time measuring the time spent on each step of patient flow to identify bottlenecks. The communication burden of the employees at those bottlenecks could be shifted to increase total throughput of patients.

IV. Implementation of Appointment System Improvements

a. Background

The system for referrals and appointment-setting between the health centers and the district hospital is a small piece of the larger picture of information flow within the health care system. Within this process lies an opportunity to improve not only the way that district hospitals collect data, but also the ability to utilize that information to plan for the future and allocate resources more effectively. Changes to the way that this system functions have the potential to be very high-yield in their positive impact to the patient experience and to the work flow of the hospital employees. Once the place of the referral system among the other vital processes of the health system was understood, the MAP team’s recommendations could be fine-tuned and implemented.

b. MAP Team Recommendations

As detailed in section II(a) above, the MAP team came up with a series of 7 recommendations to enhance the referral and appointment systems. These recommendations were:

1) Collect all information needed to make appointments during a single phone call2) Modify the information collected for appointments to include name, ID number, illness,

health center, village, and appointment date3) Shift appointment-setting responsibility at the hospital to the registration desk4) Gather patient files ahead of time

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5) Add doctor-scheduled follow-ups to the appointment log6) Shift to electronic copies of the appointment and registration logs7) Modify the feedback loop with Health Centers to encourage them to make appointments

and follow up on patients who do not appear for scheduled appointments

c. Additions to MAP Recommendations

During the Information Flow Study, the recommendations made by the MAP team were critically evaluated in the context of the larger information flow between health centers and district hospitals. Special attention was given to whether the proposed changes would have an adverse impact on health centers or on other intra-hospital processes. Furthermore, opportunities were sought to make parallel recommendations for health centers, as the MAP team’s thoughts were centered mainly on alterations to be made within the district hospital. After thorough exploration, it was determined that the MAP recommendations were sound even when considering the larger context. A few slight alterations were thought to be beneficial:

1) Include patient phone numbers in appointment-setting phone calls: Doctors at Ruli Hospital made the suggestion that patient phone numbers should be collected in order to facilitate communication between clinicians and their patients. Doctors’ phone numbers are already publicly available to patients, and collecting a list of patient phone numbers will enhance the two-way flow of information even more. This is especially important in an environment like the Rwandan health care system, where it is not easy for all patients to physically travel to the district hospital each time a doctor needs to communicate medical results or advice, or even just wants to check in.

2) Use a Microsoft Access database as the format for the electronic registration and appointment logs: Microsoft Access is superior to Excel in a number of technical aspects relevant to the redesigned appointment and registration systems. Access allows multiple users, can store data securely on an on-site server, and is a powerful tool for querying databases to generate automated reports. The drawbacks of using an Access database include a need for more advanced information technology management systems and personnel. However, per conversations with the Ruli Hospital IT manager, all hospitals in the Rwandan system have IT managers and the computing resources necessary to host a secure database on an internal server. Therefore, the benefits appear to outweigh the drawbacks, and an Access database should replace the Excel database template generated by the 2012 MAP team.

In addition to these small changes, it was thought that the MAP recommendations could be augmented by a few more modifications to the system. Those new recommendations include the following changes at both the district hospital and the health center levels:

District Hospital Level

1) Sort new charts as they are created to reduce search time:  Currently, the charts of new patients are put in a large pile until the end of the month, at which time they are sorted.  However, new patients are more likely than other patients to have a follow-up

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appointment within a month of their first visit.  This leads to a significant delay in finding the charts for these patients, as the registrars must sift through several large piles of charts that have no organization.  There is no barrier to sorting these charts on a rolling basis, rather than at the end of the month, and it will save hours in search time.

2)  Return charts to registration as doctors finish with them:  Currently, a nurse periodically picks up charts from registration, takes patient vital signs, and delivers the chart and patient to a doctor.  Doctors keep charts in their consultation room after they are finished until they are collected by registration workers the next morning.  If doctors traded any finished charts for new ones when interacting with the nurse, the nurse could bring those finished charts back to registration during her next trip for new charts.  This would allow a near real-time return of finished charts with no extra trips and minimal extra effort.  

With finished charts in hand, the registrars can quickly add doctor-scheduled follow-up visits to the appointment log, and if time permits, they can begin entering the second half of the information in the registration log (diagnosis, treatment, etc.) during the day.  Right now, the two employees in registration are working long hours on the weekends to catch up with this half of the data entry.  If they have any time freed up by the electronic system, it can be used to do this during the week, hopefully saving them time on the weekend.  If they cannot find time to enter this data during the week, they can still make doctor-scheduled follow-up appointments in a timely manner.

3) Triage patients with appointments: With foreknowledge of patient’s presenting symptoms/presumptive diagnoses, the clinicians can attempt to see the sickest patients first.  Furthermore, if there are patients with conditions thought to be complicated but non-urgent, clinicians can see those patients at the end of the day.  Deferring complexity in this way will result in smoother flow for patients earlier in the day.  This may not always work, as patients are not all waiting in the early morning (although a large percentage of them are), but it should be relatively easy to quickly scan the day’s appointments for these types of patients and make the attempt.

Health Center Level

At the health center level, the referral system is less complex.  Health centers generally refer less than 10 patients daily, and in some cases much less.  There appear to be fewer changes necessary at this level for a well-functioning referral system. One short-term opportunity for change was found which would make a smoother process for patients who are referred to the district hospital. Potential longer-term changes in the way that health centers do their work were also identified.

1) Shift appointment-setting responsibility from the data manager to the cashier:  As seen in the following diagrams depicting proposed changes, shifting this responsibility eliminates an extra step for patients.  The cashier’s job also aligns more with this type of task, as the data manager otherwise has no patient contact.  We have observed the cashier’s work flow in a low-volume (Nyange) and

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high-volume (Ruli) health center to evaluate the potential impact of this change.  Although there are differences in the activity level of each health center, the cashiers appear to have enough capacity to make several appointments per day without becoming a bottleneck in the overall process (though the wait of a few patients behind the patient receiving a referral may be lengthened by a few minutes).

           The short-term recommendations above are represented in the diagrams below. The first diagram shows the referral system as it existed prior to any intervention. The second diagram shows the impact of the original MAP project proposals. Finally, the third diagram depicts the flow of patients through the referral system with the current recommendations, including the ideas from the MAP project and those generated above.

The Existing Referral System

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Referral System with MAP Recommendations

Referral System with Current Recommendations

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In addition, there are some longer-term recommendations that could be useful at the health center level, though these could be accomplished in the time allotted for this project:

2) Switch to an electronic registration log:  This is a step that will significantly ease monthly reporting and allow greater analysis of data, but will require a change in workflow (right now, nurses fill out the registration logs in the consultation room) and significant investments in computer/electricity infrastructure, as well as extensive computer training.  It would be fairly simple to adapt the existing hospital registration spreadsheet to the needs of the health center, but might run into similar concerns about Ministry of Health approval.  Coupled with the extensive time needed for computer training, this undertaking would require another significant investment of time from an Ihangane Project worker, and would benefit from being its own project in the future.

3) Centralize patient record-keeping:  Patients currently are responsible for their own records.  They bring them to and from the health center when needed, and appear to be very responsible about it. However, the potential for loss or damage is there, and indeed many of the health center cards we’ve seen are in tatters.  There’s not much information kept on them, just very basic diagnoses and treatments, but if the health centers kept them in a safe area on the premises, they could keep them safe, make them larger (i.e. expand the data collected), and make changes (like including hospital ID numbers, for instance) retroactively.  It’s a medium-to-long term change for sure, and needs a more detailed look, but might be beneficial in the future.

d. Implementation Report

The implementation of the changes to the referral and appointment system was challenging and encountered a number of problems that jeopardized the success of the project. Moreover, because roughly half of the time of the internship was allocated to the Information Flow Study, time became a critical factor in the last month of the project while trying to speed up the rate of implementation. Despite some periods of adversity, the system was installed reasonably well by the end of August 2012. However, while many of the barriers to implementation were overcome, some still remained at the end of the internship. These barriers which still exist could pose a threat to the continuation of the system.

The implementation process was begun with a series of interviews, surveys, and conversations regarding the nature of the existing registration process. It was important to understand how each participant in the potential changes understood how the work was currently done, and how they each viewed the potential changes. A formal presentation was also made to the general hospital staff at one of their daily morning meetings in order to explain the recommendations that the MAP team had generated and the process by which implementation would occur. Once the final recommendations for both health centers and Ruli Hospital were determined, meetings were held with hospital administrators, the Chief of Nyange Health Center and its Data Manager, and the reception and registration workers at the hospital to explain the rationale and intended effect of each change.

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The final recommendations were altered during these discussions. Due to Ministry of Health regulations, it was deemed necessary to use an electronic system and a paper system for registration simultaneously, rather than switching solely to an electronic one. Furthermore, the idea to switch appointment-setting responsibility at the health centers from the Data Manager to the cashier was abandoned (see details below). Once the remaining recommendations were agreed upon, the head of Ruli Hospital asked to wait to begin implementation until he had had a chance to speak with the chiefs of the Health Centers. These meetings never took place, but incurred a waiting period of about 1.5 weeks. While this time was well-used in further developing the information collected during the previous 6 weeks, the delay period also could have been used to begin instituting changes.

For 4 weeks prior to beginning institution of changes, the employees at the registration desk underwent 2 hours of computer training each day in order to acclimatize them to working in electronic systems. These sessions covered basic computer skills, such as turning the machines on and off, moving the mouse, typing, and opening files. In addition, extensive exposure to the Excel spreadsheets that the employees would be using allowed the trainees to become comfortable with the specific application they would soon be using daily. Most of the employees had never used a computer before, and so the extended length of training was very beneficial (see details below). In fact, it would have been quite impossible to institute an electronic registration system without this type of instruction.

After the hospital administration found two laptops to use and cleared the project to begin, we were able to start implementation of the recommendations on 8/2/2012. At the last minute, we were informed that the staffing of the system would not be at the levels that had been requested. During the meetings with hospital administrators to discuss the recommendations, it was made very clear that the system as designed would require 3 full-time employees. However, it was revealed the day before the new changes went live that only two full-time employees would be allocated, and that the appointment-setting responsibility would not lie with the registration desk (see details below).

Despite this setback, a work-around was created whereby the reception desk would transfer a list of appointments to the registration desk each day via a USB drive. During the first few weeks of systemic changes, this responsibility did not appear to be an unreasonable burden on the receptionist. But during this time, there were generally fewer than 15-20 appointment phone calls daily. As the volume of calls increases in the future with higher health center compliance, this may represent a problem for the receptionist.

The registration desk assumed the responsibility of entering data in both electronic and paper registration logs, as well as finding patient charts. The workers quickly adapted to the new system within several working days, and although they could not register patients as quickly as with the paper system alone, they did not become a new bottleneck in the consultation process. At the end of the project period, the registration workers were comfortable with entering data electronically and improving the speed at which they could do so.

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However, despite this excellent progress, the implementation is at a crucial juncture. The old work habits of some employees still persist. Not all patients are arriving to the hospital with appointments made by phone, and the phone calls that are made do not usually communicate all necessary information (patient ID number, phone number, etc.). Also, some parts of the system remain untested. For example, since the implementation period did not exceed one month, there was no opportunity during the internship to assist and observe a monthly report being generated automatically. Although the workers were educated about how to perform this function, it is unclear if they will be able to do it in practice.

Furthermore, although the workers were becoming more independent, they still required prompting and detailed guidance to complete many simple tasks such as copying the appointment list or searching for patient files preemptively. Another issue overshadowing all others is the staffing insecurity detailed below – when employees are not available, it is difficult to complete all the work. In combination, these issues give rise to a distinct possibility that without direct support from an Ihangane Project worker, the hospital will revert to the old system.

1. Problems and Solutions

1) Ministry of Health Requirements: The first roadblock that was discovered in the project was that the MAP team’s recommendation to simply replace the paper registration system with an electronic one would not be feasible. That team had failed to anticipate regulatory hurdles to such a wholesale replacement. Through meetings with Ruli Hospital administration, it became clear that the Ministry of Health actually mandates the use of the specific paper log books that are used in hospital and health center registration systems. The books are tied to performance-based financing for each clinical unit, and so cannot be simply replaced without a loss of revenue.

A compromise was reached wherein Ruli Hospital would institute parallel paper and electronic registration systems simultaneously. This way, comparative data can be gathered to support the effectiveness and enhanced efficiency of electronic records both in terms of data entry and capability for data analysis. Once enough data has been gathered to show the superiority, or at least equality, of electronic record keeping, the hospital will be able to prepare a report for Ministry of Health officials and petition for acceptance of electronic registration logs for performance-based financing reviews.

In the same meetings with hospital administrators, it was found that the appointment system is under no such regulatory pressure. Therefore, Ruli Hospital has the ability to modify the way that it sets appointments from its affiliated health centers at will. The switch from a paper copy of the appointment list to an electronic copy did not face any barriers from the Ministry of Health, and could be enacted as recommended by the MAP team.

2) Physical Infrastructure: An unexpected challenge came from the electrical infrastructure of the room in which the registration workers are housed. There is a single electrical outlet there which at the beginning of the project was split three ways. The single outlet powered a scanner/printer, and typically the cell phones of two of the six employees in the room. It

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proved more difficult than anticipated to procure a power strip in order to serve more than three devices. Although not outside of the hospital’s financial means, it took roughly 3 weeks and multiple reminders to administrators, the data manager, and IT manager before a power strip was permanently allocated to that room.

Another small infrastructure challenge was the space in the room where registration is located. Registration shares the room with the outpatient and inpatient service cashiers, for a total of six employees in the same space. Three large shelves of medical records and other papers, as well as the scanner/printer table take up a fair amount of the square footage. It was necessary to find a larger desk for the registration workers in order to accommodate a computer in addition to the paper records, and it was unclear at first if it would fit in the room. This turned out to be a very minor inconvenience, but it was a potential issue that had not been considered before.

3) Difficulty of Computer Training: One of the more frustrating problems encountered with the implementation of the electronic records was that of training the employees to use computers. It was understood from the beginning of the project that a certain amount of training would be necessary to put the new systems in place, and the plan allowed for several weeks of instruction. However, what was not foreseen was the very basic level at which the training would need to begin.

The registration workers had essentially never used a computer before, and even with two hours each day of dedicated training time, they could not reliably perform simple manipulations of the mouse and keyboard after a week of study. Typing accuracy and speed took much longer to develop than anticipated, and even at the end of the project left much to be desired. In total, four weeks were spent on training prior to the electronic system going live.

With two hours of training each day, a total of 40 hours of computer experience were just barely sufficient to allow the employees to function upon the introduction of the new system. Functions such as copying and pasting, saving routinely, and navigating spreadsheet files remain quite difficult for them, even after the training period and 3 weeks of full-time work.

Future projects involving the introduction of computer systems should take this lack of experience into account. It would be wise to assume that no employees (except those in roles which already use computers in a significant way) will have had computer experience unless demonstrated otherwise. The time it takes to train will likely be greater than initial estimates because of this factor.

4) IT Resource Limitations: The MAP recommendations implicitly assumed that the hospital would have extra computer resources at hand. This assumption proved to be false; the hospital had to order two new laptops and allocated two older laptops to the tasks of appointment setting and registration entry. However, this process took roughly 7 weeks. The hospital administrators were notified of the need for two computers during the first week on the ground in Ruli, but the required computers did not materialize until mid-July. As it was also observed to take several weeks to receive a power supply for the registration room, it stands to reason that it will take several weeks to months for any future hardware requests, and that this lag time should be factored into planning.

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Moreover, although the hospital did procure the needed computers in this case, it was not without budgetary concerns. It is conceivable that other district hospitals, and especially health centers, would have difficulty coming up with funding for such infrastructure investments. In the longer-term outlook, hospitals can probably afford to make this type of purchase relatively easily, but may not be able to do it in the time frame of a given project. When making recommendations about computerization in the future, every effort should be made to balance computing requirements with strain on hospital or health center budgets, and to keep in mind possible delays in procurement when planning implementation.

5) Disagreement over Cashier’s Role: Upon hearing the recommendation to have health center cashiers make appointment phone calls with the hospital, the Ruli Hospital administration was skeptical about the idea. The administration’s concern was that the cashiers would be too busy to make phone calls and that the potential for mistakes with counting money was too high with the introduction of a new, distracting task.

After a lengthy meeting, the administrators understood the basic problem: sending patients to the data manager for appointment setting represents an extra step in patient flow, one which is not always physically close to the consultation area. Furthermore, they understood that in many cases, nurses are being asked to make appointments when data managers are not present, which is a misallocation of the time of workers with specialized knowledge.

Therefore, a compromise was reached wherein the hospital administration would not authorize cashiers to make appointments, but would instruct health centers to relocate data managers nearby the consultation rooms, and to develop a chain of employees (excluding clinicians) who would set appointments in the data manager’s absence.

6) Health Center Appointment-Setting: Although altering the daily activities of the registration workers and receptionist to include the recommendations above has been fairly successful, it has been difficult to get health centers to consistently make appointment phone calls. Every day, the receptionist (or registration worker, if covering the position) takes approximately 15 to 20 phone calls. However, somewhere between 35 and 55 patients generally arrive each day.

Many of the unannounced visits come from health centers outside Ruli Hospital’s district (Kayenzi, Nyabikenke, etc.), for which the hospital has no direct means of control. But many of the in-district health centers also make appointments inconsistently. The head of Ruli Hospital and its Data Manager have made announcements to the health centers via email that the new system is required, but with modest results.

Aside from further communications informing the health centers of their compliance, it is unclear what next steps to take to resolve this issue. It may be that it only takes time for health centers to become used to making appointment phone calls, but it is a critical problem to solve, as the appointment system will not reach full effectiveness until most patients arrive with appointments.

7) Physician Participation: In addition to outlying health centers failing to completely fulfill their responsibilities in the new system, doctors at Ruli Hospital have been somewhat

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inconsistent about making follow-up appointments with the registration desk and sending finished charts back to registration on a rolling basis. While these issues were improved by reminding the doctors in person several times, there is a concern that lapses in these responsibilities will crop up and not be dealt with later on.

The nurses who interact with the doctors do not feel confident in asking them to change the way that they work. If the nurses or other employees notice errors or omissions on the part of the doctors but do not feel comfortable correcting them, then it is possible that the doctors will go on with their business as usual, without contributing to improvements in the system. Therefore, if problems are noted with doctors completing their responsibilities under the new recommendations, it may need to be dealt with at a hospital administration level in order to effect real behavioral change.

8) Human Resource Limitations: The level of human resources allocated to the registration and appointment system has proven to be a serious problem. During the initial discussion of recommendations with hospital administrators, it was determined that both electronic and paper registration systems would need to be run side-by-side. Combined with the added responsibility of taking appointments, this setup ideally requires three full-time employees to run smoothly and efficiently.

It was communicated to the administrators that three full-time employees would be needed, and the administrators in turn gave the impression that three staff members would be allocated to the project. However, the day before beginning implementations, it was discovered that only two staff members would be assigned full-time to registration, and that the hospital receptionist would need to take appointment phone calls in addition to her normal responsibilities.

Furthermore, one of the registration workers that had undergone training during the previous month took a month-long vacation beginning the day of implementation, without any warning from her or the administration. Another nurse was pulled from the consultation staff to work with the system, but she had no computer training and no experience with registration in general.

The limitation of human resources led to problems maintaining adequate staffing levels at busy times. Registration of patients begins at 8 AM, but the replacement registration worker does not arrive at the hospital each day until roughly 9AM, leaving one of the busiest hours of registration staffed by one employee. Any time one employee is left alone in registration, it becomes impossible for them to enter data into both the paper and electronic logs. This becomes less of an issue after the initial rush of patients has been processed, and patients arrive at a rate of 2-3 per hour. But at times of peak flow, the system is fragile and cannot stand an employee missing.

This fragility is particularly problematic when employees have days off. For instance, at Ruli Hospital, the receptionist takes every Friday off to attend school. On one occasion, one of the registration workers was given the same day off, leaving only myself and my translator to cover registration while the other registration employee covered the reception desk. This type of human resource limitation is unsustainable and will result in significant problems in maintaining the recommendations as implemented so far. To attempt to solve this problem,

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two meetings with the head of the hospital were held, one of which was also attended by Dr. Jean de Dieu. The meeting concluded with a mutual understanding of the problem and a pledge to find a staffing solution with other hospital administrators. However, at the end of the project period, exactly what that solution would be remained unclear.

9) Access Database Development: One recommendation that sprung from conversations with Ruli Hospital administration and the IT manager was to switch from using an Excel spreadsheet to an Access database for the new electronic systems. Such a switch would have brought enhanced data security, a smoother user interface, and a powerful set of tools to generate database queries.

However, because of limited technical knowledge on the side of The Ihangane Project and the general hospital staff, the only person who could reliably construct such a database was the hospital IT manager. Unfortunately, the IT manager is a part-time student and is in Kigali roughly 1/3 to 1/2 of the time. When he is in Ruli, his services are very much in demand, and he does not have much time to devote to this type of project. After three weeks of putting the Access database development on hold, he was sent an email asking him to assist with the work in order to be able to train the registration workers on the new system before the end of the project period. After this prodding, he did find a few hours to work on the project, but left an unfinished product that is not usable in its current state.

Therefore, due to time limitations, the Access database was abandoned for the time being. If the IT manager or another person with sufficient technical knowledge finds time to work on it in the future, it would still be a worthwhile addition. However, it will require some retraining of the registration employees, which will likely take 1-2 weeks.

10) Hospital ID Numbers: A crucial piece of the puzzle for the original MAP recommendations was that registration employees could reduce patient waiting time and improve the patient experience (in addition to saving themselves time during the day) by hunting for patient charts the night before their arrival. This task requires foreknowledge of the patients’ hospital ID numbers, which requires the health centers to have that information available during the appointment-setting phone call.

When surveying the system used at the health centers, it was discovered that there is no medical record kept at the health center itself, and therefore no record of the patients’ hospital ID numbers. Instead, patients keep their records with them at home, and bring them to the health center each time. It was unclear though, if patients would bring the hospital forms which included their ID number with them to the health center. Several health center employees gave conflicting information on this point, leading to some concern that a linchpin of the MAP recommendations would give way. However, after direct observation of a busy health center (Ruli), all patients who were seen to have referrals did indeed bring their hospital documentation with them to the health center, allowing the data manager access to the hospital ID number when placing the appointment phone call.

A review of the real-world data will be needed after several weeks, to see if returning patients really do have their ID numbers reported when making appointments. If it turns out that patients are not bringing this information to the health center consistently, then it will necessitate some kind of mass cataloguing of patient ID numbers and transmission of that list

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to the health centers.

11) Future Supervision: Passing on the responsibility of rolling out recommendations, maintaining and improving the system at Ruli Hospital, and expanding the changes to other hospitals and centers has been a concern. A suitable person for this job was sought after for several weeks, but in the end it appears that these responsibilities will be shared after the end of this project.

The head of the hospital, of course, will be in charge of making sure that the system is implemented and functioning correctly. But for day-to-day matters, the hospital Data Manager has been assigned as the supervisor for this system. She will have to take the responsibility for a well-functioning registration office and put pressure on hospital and health center employees to abide by the recommendations.

Some of the more technical aspects of the work may be delegated to the IT manager. For instance, he may need to make alterations to the Excel spreadsheet or assist in generating automated monthly reports if such a task proves too confusing for the registration employees. The responsibility for system supervision was handed down officially from the head of the health center, so it is likely that the new system will have continued direction and guidance.

e. Recommendations for Future Improvements

The appointment and registration system is at a transitional stage which will require close monitoring and potential alterations as time goes on. A number of next steps exist for potential Ihangane Project interns or teams of students to work on to integrate the systemic improvements more fully into Ruli Hospital’s operations, ensure cooperation by health centers, or expand the system to the larger Rwandan health care system.

1) Ensure Hospital Employee Participation: At the end of the project period, most hospital workers who are involved in the appointment or registration systems were following through with any new responsibilities given to them. However, in many cases it was only with significant prompting. While it may be the case that mere repetition will be enough to ingrain new habits into the daily routine, it is also possible that without continued reinforcement by an Ihangane Project worker, old habits will die hard and the newly redesigned system will suffer as a result. It would be a great benefit for someone to check in on the system in several weeks or a few months and make sure it is functioning as intended. If workers are not performing tasks as planned, then perhaps fine-tuning will need to be done in order to make the recommendations easy to follow for the hospital employees.

2) Access Database Creation: One unfortunate casualty of time limitations during this project period was the inability to complete a satisfactorily functional Access database to replace the Excel spreadsheet in the appointment and registration processes. The benefits to this replacement are clear, and all interested parties have agreed that they outweigh the costs to the hospital. It would be a significant contribution, though not an extraordinary effort for someone with the right domain knowledge. Further down the line, once a preliminary version of the database is up and running, perhaps it could be standardized by working with the Ministry of Health and used in the expansion of the electronic appointment and registration systems to the entire country.

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One piece of this Access database transition that could take a large chunk of time is training the hospital employees to use it. At Ruli Hospital, the registration workers now have experience using computers on a daily basis, specifically with Excel spreadsheets. Much of their knowledge would be transferable to another Microsoft Office program, so training may take only a week or two. But with a fresh introduction to a new hospital environment, the training period could take many more weeks. It may also be beneficial to attempt to develop a standardized training program that can be administered by workers within the Rwandan health care system when expanding to a new hospital.

3) Continue Interviews with Clinicians: A limitation to the Information Flow Study was that it did not include as many clinicians as possible. Specifically, at the hospital level, it proved nearly impossible to meet with the busy doctors and nurses in a forum amenable to learning about their information flow. As these employees are central to patient flow and experience, it is vital to understand how they function in the framework of the larger system. Lamentably, this was not possible during this project period, but it should be attempted if a future team can spare a few hours to conduct interviews and construct diagrams. This all hinges on the clinicians being available for interviews of course, which may not be the case. But if it is possible to secure a few meetings with doctors and nurses, it may reveal low-hanging fruit to help improve the flow of clinical information between health centers and hospitals.

4) Ensure Health Center Participation: Just as workers within the hospital still required some prompting to perform new responsibilities at the end of the project period, so the in-district health centers were not consistently making appointments to send patients to Ruli Hospital. While there is an internal mechanism to deal with this problem (routine feedback from the hospital data manager to each health center about compliance with appointment-setting), it may prove to be ineffectual for some reason.

The Information Flow Study during this project period did not uncover an obvious reason that it should be difficult for health centers to set appointments consistently, so if this pattern of behavior is found to continue after the next several weeks, the source should be sought and remedied. It is important for the success of an appointment system that all, or nearly all, patients arrive at the hospital with appointments. This is especially true of a hospital like Ruli Hospital, which has little or no spare capacity in the form of emergency services. To reap the benefits of the appointment system, this should be a priority project if compliance with the system does not develop within a short time.

5) Influence Distant Health Centers: In the same vein as the project above, out-of-district health centers also send a significant number of patients to Ruli Hospital without appointments. They pose a tougher challenge though, as they are not under the direct regulation of the hospital itself, but answer administratively to other hospitals. If they continue to send large volumes of patients to Ruli Hospital unannounced, then the appointment system will lose effectiveness. Some way must be found to convince these health centers to adhere to appointment-setting phone calls.

6) Develop Triage and Staffing Systems: Once the system has been verified to be functioning well and doesn’t need gentle guidance or intervention to keep employees and

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health centers from lapsing into work patterns that defeat the purpose of the recommendations, then the next step will be to develop the ways that the new system can work for the hospital. This work should include models to predict patient arrivals, methods to determine necessary physician and nurse staffing, and ways to triage patients at external consultation. These are potential benefits of the system that so far have not had formal explorations. It would be time well-spent to come up with actual protocols for these uses of data, once the system’s stability is demonstrated.

7) Analyze Laboratory and Radiography Waiting Times: One aspect of patient flow that was not well-characterized during this project was the step of getting laboratory or radiographical studies done after seeing a doctor. From informal observations, it appears that patients may wait up to a few hours for these results to reach doctors. This delay negatively impacts patient waiting times and decreases the flow of completed charts back to the registration desk for data entry. It would be reasonable to look further into this area and see if there are any ways to improve the speed of test results or other interventions that prevent patients from finishing their visits.

8) Pursue Ministry of Health Approval: Depending on the timing of the next Ihangane Project worker or student team’s arrival, it might be an appropriate next step to help Ruli Hospital analyze the efficacy of electronic registration and appointment systems, and to help develop an application or presentations to the Ministry of Health. The end goal of the parallel electronic and paper record keeping systems in the current set-up at Ruli Hospital is to petition the Ministry for acceptance of electronic systems in determining performance-based financing. Getting MOH approval is the next step towards acceptance of this system and expansion to other hospitals in Rwanda. If no major problems arise in the system and need to be dealt with, and an intern or team of students can be sent to Ruli after a few months of data has been gathered with the electronic system, then this would be a good potential project.

V. Conclusion

a. Summary of Information Flow Study

The Information Flow Study utilized interviews with representative members of the health care system at the levels of the community, the health center, and the district hospital to construct an overarching understanding of how communication takes place throughout the medical system. The study uncovered a network of increasing complexity towards the top of the medical hierarchy, and led to greater knowledge about how patients move through the system.

Some apparent inefficiencies were discovered, including duplicative methods of communication and a few seemingly extraneous steps in patient care. These areas of inefficiency may be opportunities for future projects to make improvements to the system. In addition, the study will help such future projects to take into consideration the existing responsibilities and lines of communication for health system employees, thereby allowing for solutions which integrate well into the system which exists.

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In the short term, the Information Flow Study verified that the recommendations made by the 2012 MAP team regarding the health center to hospital appointment system would work well for all employees involved. The study also found that the recommendations could be improved by changing which employees would be responsible for scheduling appointments and in the longer term, by extending similar computerized record-keeping systems to health centers.

b. Summary of Implementation

The implementation of appointment system changes was a challenging step, but showed promising initial results. The hospital administration and the employees involved in the changes were all enthusiastic and eager to make improvements. However, despite hard work and helpful attitudes, it still proved difficult to implement a computerized registration and appointment system where computer literacy was close to nonexistent beforehand. Furthermore, although support was strong among local staff, it was found that Ministry of Health mandates required the continued use of a paper registration system, effectively doubling the workload of the registration employees during this implementation phase.

Despite these challenges and others, consistent effort paid off and led to a system utilizing electronic and paper registration systems in parallel. The registration employees were successfully trained to use the computerized system and were improving in their ability to move patients through the registration process in a timely manner. However, the situation was somewhat tenuous at the end of the project period. The employees still required significant prompting for some tasks, and health centers were not consistently setting appointments for referred patients. The new system as implemented is likely to require some follow up and support from an Ihangane Project worker in the future in order to make sure that the progress made so far is not lost.

c. Summary of Recommendations and Next Steps

The most important next steps for future Ihangane Project workers will be to maintain the progress attained so far. This will include initiatives ranging from simply following up to verify that the electronic registration system is seeing continued utilization to finding ways to encourage workers at the hospital and the health centers to use the new system more consistently. Later steps should include implementing a Microsoft Access database rather than the Excel files currently being used.

It will also be important to make sure that the hospital and health centers are realizing the touted benefits of the system, including a greater ability to control patient volume, the ability to triage patients, and time savings for registration workers. Once the system appears to be working as intended, or perhaps concurrently with these other initiatives, attention should be given to getting MOH approval to use the electronic system alone.

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