A Path to Solving Ruli Hospital’s Patient Tracking Challenges

Annie Snider, Kevin Wooster, Matthew Downer, Penelope Mallinckrodt, Yasuo Tsurumi

3/8/2013

Ruli Hospital and Health Centers provide an impressive array of health care services

Scale

Complexity

Pride

Impact

Further elevate center of excellence through improved patient tracking

Health Care Center

Home

Hospital

Summer 2012 Project

Spring 2013 Project

Spring 2012 Project

Status Update

Recommendation Successful?

Include patient phone numbers in appointment setting call

Use Microsoft Access for electronic registration and appointment logs

Sort new charts as created to reduce search time

Return charts to registration after doctor consults

Triage patients with appointments

Shift appointment making from data manager to cashier

Adopt electronic registration log

Centralize patient record keeping

Ru

liH

osp

ital

Hea

lth

Cen

ters

Four Areas of Focus

Patient Tracking Process Improvements

Behavioral Dynamics

Implementation

Future Opportunities

Behavioral Dynamics

Behavioral Dynamics Intro Slide

Area Need Recommendation

Capabilities Knowledge

Variability of Demand

Quick way to understand and display staff capabilities

Resources to meet demand at peak times

Cross-Team Collaboration

Skills Matrix

Create a skills matrix to better understand capabilities

Annie

Matt

Yasu

Kevin

Penelope

Registration FileSystem

ComputerSkills

FrenchLanguage

EnglishLanguage

InterpersonalRelations

Adapts to Change

Encourage cross-team collaboration to meet demand at peak times

8:00 14:00

Reception Reception

Consults Consults

Registration

Accounting

Registration

Accounting

Patient Tracking Process Improvements

Data collection and management systems are inhibiting accurate patient tracking

Data Collection

Area Need Recommendation

Standardize patient forms throughout system

Current tracking system duplicates work at every level

Data Management Use Mutuelles Data

Current resources do not easily allow for consistent and thorough data management

Standardizing records between health centers will make processes more efficient

Rukura Health Center

Ruli Hospital

Ruli & Nyange Health Center

Other Health Centers

Hospital Record

Patient Form

Patient Form

MutuelleDocument

Patient Form

MutuelleDocument

MutuelleCard

By visit date

No record stored

Record KeepingForms

MutuelleCard

Referral Form

Location

Appoint-mentCard

No record stored

MutuelleCard

Multiple forms with the same information lead to inaccurate data, duplicated work and bottlenecks

1. Reception

Make copy of patient insurance card

Orientation

2. Insurance and

accounting

Fill in the insurance file

Remit Payment

5.Accounting

Remit payment for diagnostics and treatment

3.Registratio

Submit referral form

Pick up blue record

4.Consultation

Examination, treatment, etc.

6. Pharmacy

Pick up medication

ID

Insurance

ReferralForm

Patient Card

ID

Insurance

ReferralForm

Patient Card

Patient Record

ID

Insurance

ReferralForm

Patient Card

Patient Record

ID

Insurance

ReferralForm

Patient Card

Nurse delivers to reception

Record may be filed and stored at hospital

Health Center Data Manager

Info maybe sent to CHW

Patient takes home

Invoice to mutuelle

ID

Insurance

ReferralForm

Patient Card

ID

Insurance

Patient Card

MutuelleDocument

Same Data

Result of complicated data collection

• Disorganized files• Duplicated records• Cluttered workspace• Long patient wait

times

Mutuelle Office

The Mutuelles are excellent source of existing patient data

Substantial

Accurate

Organized

Connected

High adoption rates mean that 80+% of population already have a health record

Mutuelles verify symptoms, diagnosis and treatment twice in the same month of health facility visit (this is done at the district level)

Both paper and electronic records are highly organized and accessible

• There is already a mutuelle office at every health center• Mutuelles already understand the health center patient file system• Mutuelles already partner with health centers for community

health education

Patient arrives with ID/Insurance card, one form circulates and information is utilized

MutuelleOffice/Reception

•Check in

•Pick up medical chart

Accounting

•Remint payment for consultation

Reception

•Enter system (wait area)

Consultation

Accounting

•Pay for tests and treatement

Pharmacy

•Pick up medication

ID/Insurance

MutuelleDocument

MutuelleDocument

MutuelleDocument

MutuelleDocument

MutuelleDocument

MutuelleDocument

Data Manager

MutuelleWorker

Community Health Worker

Benefits to both patient care facilities and mutuelles outweigh challenges

SolutionsChallenges

Governance system proposed by the senate in March will strengthen checks and balances and improve the Mutuelles’ ability to maintain quality data

Maintaining hospital and health center records enables local Mutuelles to implement targeted marketing to increase adoption

Central government oversight will enable efficient training and resource allocation

Perceived conflict of interest

Mutuelles currently do not track non-members or lapsed members

Some mutuelles only keep electronic records of costs, not diagnoses

Integrated Mutuelle GovernanceH

osp

ital

/Hea

lth

Cen

ter

Clinicians

Administrative Staff

Administrators

Finance/Accounting

HR

Data ManagerMutuelle Data

(Local Mutuelle office)

Reception/Registration

Operations

Mutuelle Sector

(Day-to-day Management)

Mutuelle District

(Audits and Overviews)

MoH Mutuelle Fund

Central Government

Mutual gains create impact on overall health of the community

Action Benefit to Mutuelle Cost Impact

Collect and maintain records for non-members

Consumer data allowingtargeted marketing which increases the adoption rate

Minimal There is a positive correlation between mutuelle membership and quality of health. A mutuellemember is 51% more likely to visit a health center than a non-member1

Store patient data at the communityhealth center

Data representing entire population enables mutuelle to act faster with education Lowers costs

None Better community education lowers spread of disease and poor health practices

Serve as hub for dissemination of data

Clear understanding of health status allows forefficient actuarial processes. In addition, better follow-up care lowers mutuelle costs.

Minimal Consistent reporting of health status to all stakeholders; better informs community health workers which improves follow-up care

1. Bayege, Innocent. Contribution des mutuelles de sante à l'accessibilite de la population aux services de sante. Université Nationale Rwanda. [Online]. 2005

Implementation

Identify obstacles and solutions for implementation

Prior RecommendationsProcess Change

Resource Addition

Successful

Include patient phone numbers in appointment setting call

Use Microsoft Access for electronic registration and appointment logs

Sort new charts as created to reduce search time

Return charts to registration after doctor consults

Triage patients with appointments

Shift appointment making from data manager to cashier

Adopt electronic registration log

Centralize patient record keeping

Ru

liH

osp

ital

Hea

lth

Cen

ters

Manage change carefully to ensure long term success

Align key stakeholders

Motivate and Communicate

Consolidate

Align Key Stakeholders

• Define stakeholders more broadly• Include the three sisters

• Enlist a core change team• Ensure suitable personal attributes

• Endow with positional power & credibility

• Map stakeholder resistance and support• Focus on neutral and positive to generate critical mass

Motivate and Communicate

• Create a sense of urgency• Securing verbal buy-in is not enough

• Connect changes to a deeper purpose• Link to impact on patient

• Implement visual management tools (Whiteboards)

• Information becomes more widely accessible

• Celebrate successes

• Enhance cross-team collaboration

Sample Whiteboard

Record Keeping

IssuesKey Personnel

Friday, March 8th, 2013

Outstanding Records

27Mon Tues Wed Thurs

Patients Treated / Electronic Records Entered

Ministry of Health supervisor visits Friday

X-Ray machine is not working

Drug X stock is low

Only one doctor next Thursday

Dr. Avite

Sister Carmen

MOH Admin

Dept. Chiefs

Doctor #1

Doctor #2

In Office

In Office

In Office

In Office

In Office

Out of OfficeIn Kigali until Thurs.

Fri

Consolidate gains

• Align systems with the changes• Recruitment & training

• Performance appraisal and rewards

• Align structures with the changes• Fill key positions with right people

• Plan for quick wins• Start small

• Maintain momentum

Future OpportunitiesRotational Program

Expand the Community Health Worker Role

Rotational programs expand training and help make Ruli a center of excellence

Registration

ReceptionData

Manager

Surgical

MaternityConsults

Nyange

Rukura

Ruli

Rushashi

Muhondo

Hospital

Already has clinical rotational program

The Community Health Worker program can be expanded to improve Patient tracking

Potential Opportunities Impacts

Observation + Monitoring

- Chronic conditions

- Signs of infection

- Side effects of medication

Patient Interaction

- Serve more Rwandans

- Can get holistic view of Patients

- Can have more time with patient

Follow through of treatments

- Improved patient outcomes

- Earlier interventions

- Fewer secondary visits to HC s or Hospital

- Improved quality of care

- May identify unknown contributors

to patients’ maladies

- Lower recurrence rate

- Less need for 2nd visit to HC or Hospitals

- Less development of drug resistant strains (e.g., tuberculosis)

Conclusion

Key Takeaways

Patient TrackingProcess Improvements

Behavioral Dynamics

Implementation

Future Opportunities

• Record Standardization• Mutuelles Data

• Skills Matrix• Cross-Team Collaboration

• Rotational Program• Expand Community Health Worker Role

• Align stakeholders• Communicate and motivate• Act and consolidate

Questions

Contact Info

Matt DownerAnnie Snider

Yasuo TsurumiKevin Wooster

Team Members Email Address

RwandaTeam2013@umich.edu

Penelope Mallinckrodt

Appendix

Patient flow: Ruli Hospital

1. Reception

-Make copy of patient

insurance card

- Orientation

2. Insurance and

accounting

- Fill in the insurance file

- Make payment for consultation

5.Accounting

- Make payment for

medicine and examination

3.Registration

- Fill in/submit documents

-pick up personal blue

record

4.Consult-

ation

- Necessary treatment,

examination, etc. given

6. Pharmacy

- Medicine to be pick up

Patients bring in

• YellowInsuranceCard

• White PatientCard

- General Info (name, address, etc.)- Information about vital, diagnosis, medicine

ID number

• White ReferralForm

• BluePatient record

• Blue Patient record is carried

back to registration by nurse Patients bring back

• YellowInsuranceCard

• White PatientCard

• Yellowappointmentcard

• YellowAppointment Card

1. Insurance Office

-Pick up personal sheet (Blue)

2. Reception

- Check symptom and sort out

- Check vital signs

4.Accountings-

- Make payment

3.Consult-

ation

- Necessary treatment,

examination, etc. given

5. Pharmacy

- Medicine to be pick up

6. Insurance Office

-Bring back personal

sheet (Blue)

Patient flow: Ruli & Nyange Health Centers

Patients bring in

• YellowInsuranceCard

• White PatientCard

Patients bring back

• YellowInsuranceCard

• White PatientCard

- General Info (name, address, etc.)- Information about vital, diagnosis, medicine

ID number

Data Manager

set appointment if patient needs to

be referred.• White ReferralForm (if referredto hospital)

1. Reception

- Check symptom and

sort out

- Check vital signs

2. Insurance Office

-Pick up personal

sheet (Blue)

4.Accountinga

- Make payment

3.Consult-

ation

- Necessary treatment,

examination, etc. given

5. Pharmacy

- Medicine to be pick up

6. Insurance Office

-Bring back personal

sheet (Blue)

Patient flow: Other Healthcare Centers

Patients bring in

• YellowInsuranceCard

• Pink SimpleNotebook

Patients bring back

• YellowInsuranceCard

• Pink SimpleNotebook

ID number

Data Manager

set appointment if patient needs to

be referred.

- Information about vital, diagnosis, medicine

• White ReferralForm (if referredto hospital)

• For more efficiency and future needs

Detach from daily operation

Reception

Registration

AccountingConsultation

Pharmacy

Assign inputting electronic data to others with computer skills

A new way of electronic recording in the hospital

• Hire temporary (young) staff havingcomputer skills for a day per weekonly for data input

or

• Assign existing staff (in both hospitaland healthcare centers) having computer skills and quite low-utilization time in a week to data input for a certain hours per week

Basic patient info(ID, address, etc)

-Top side

-reverse side

Year &date

Diagnosisinformation

Diagnosisinformation

0000 1000

1001 2000

2001 3000

3001 4000

Standardization among hospital and healthcare centers

Long term proposal

Image (example)

• Start keeping records also at healthcare centers

• Manage with the same format among the hospital and healthcare centers

• Track and Keep patient information based on ID number unified among the hospital and healthcare centers

Image (example)

-Shelf for patient record-Patient card

ID number: XXXX