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Ruli hospital map 12.253 presentation v11 1
 

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    Ruli hospital map 12.253 presentation v11 1 Ruli hospital map 12.253 presentation v11 1 Presentation Transcript

    • Improving Data Collection and Usage at Ruli District HospitalDavid Bernardi, Gregory Fisher, John Ranz, Bryson Smith
    • AgendaBackground on Health Care in Rwanda Project Overview & Objectives Assessment of Current Situation RecommendationsNext Steps
    • BackgroundRuli District Hospital’s Role in Rwandan Health Care
    • Rwanda – Country Overview Population2010 10.62M Size – Land Mass 26.3 M KM2 10.15M Mi2 Gross National Income $5.54B (GNI) 2010 GNI Per Capita (PPP $1,110 International $) 2009 Health Care Spending Per $102 Capita2009 (PPP International $) Health Care spending as % 9% of GDP Life Expectancy(m/f) 57/60 Poverty Rate 56.9%Source: WHO (http://www.who.int/countries/rwa/en/index.html), World Bank Country Report(http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/RWANDAEXTN/0,,menuPK:368741~pagePK:141132~piPK:141109~theSitePK:368651,00.html) 3
    • Health care delivery in Rwanda utilizesprogressive specialization Community Health Health Centers Workers • Level of Care: Nurses • Level of Care: Volunteers • Area Served: Sector • Area Served: Village Referral Hospitals District Hospitals • Level of Care: Specialists • Level of Care: Doctors • Area Served: Nationwide • Area Served: District 4
    • Overview of Ruli District Hospital Health Centers 7 – In District Served 6 - 8 – Out of District Catchment Size 94,0931 Departments Outpatient Consultation Emergency Services In-patient hospitalization Maternity Ophthalmology Dentistry Mental Health Patients per year ~9,000 Outpatient ConsultationsSource: 1) Bossart,et al “Solving Ruli District Hospital’s Referral System Challenges” March 2011 5
    • Project Overview Project Goals, Objectives and MethodologyBackground Project Overview Assessment Recommendations Next Steps
    • Goal to increase efficiency at Hospitaland Health Center through data usage Hospital • Improve operational efficiency of administrative and support staff • Increase availability and use of patient referral and appointment data • Provide technology solutions for manual processes to ease impact of Ministry of Health and other reporting requirements • Reorganize administrative responsibilities to maintain consistency of patient interactions Health Centers • Eliminate duplicative and ineffective processes Patients • Improve quality of care • Reduce wait times 7Background Project Overview Assessment Recommendations Next Steps
    • Interviews, data analysis and processmapping were foundation of analysis Staff Interviews • Interviewed hospital and health center personnel to develop understanding of patient and information flows, as well as staff roles, responsibilities, and common challenges Data Analysis • Analyzed patient arrival and appointment data to determine how effective the existing system has been at predicting patient arrivals Process Mapping • Created diagrams to illustrate each stage of patient and information flows Observation • Observed Hospital registration desk to better understand underlying patient registration data and to audit appointment data Patient Interviews • Interviewed patients to validate information received from staff interviews 8Background Project Overview Assessment Recommendations Next Steps
    • Patients currently arrive at Hospital through one of three channelsPatient Flow Health Center Referral to Hospital WITH AppointmentHealth Center Health Center Health Center Patient visits Patient visits refers patient sets Hospital on Health Center Hospital to Hospital appointment scheduled date Hospital Follow-up Referral to Hospital WITHOUT Appointment Hospital Hospital treats Patient visits Patient visits patient and Hospital on Hospital gives referral for unknown date follow-up visit Hospital Follow-up Referral to Hospital WITH set date but WITHOUT Appointment Hospital Hospital treats Doctor sets date for Patient visits Hospital patient and gives follow-up visit but on scheduled Patient visits Hospital referral for follow-up doesn’t set formal date, date unknown visit appointment to Hospital 9 Background Project Overview Assessment Recommendations Next Steps
    • Assessment of Current Process Analysis of Appointment, Registration and Reporting ProcessesBackground Project Overview Assessment Recommendations Next Steps
    • Referral process has solid foundation,opportunities not fully exploitedS Strengths W Weaknesses • Increased communication • Slow data collection between health center and hospital • Some patient segments are not • Strong foundation for data captured exchange • Inter-departmental data sharing • Creates awareness with is low constituentsO Opportunities T Threats • More complete data capture can • Better implementation, and thus reduce arrival variability service, at other district hospitals • Faster analysis and reporting with  Reduced referrals and revenue electronic data management for Ruli • Increases to staff efficiency • Changes to MoH mandates through planned work limiting Ruli’s ability to comply 11Background Project Overview Assessment Recommendations Next Steps
    • Referral and registration assessmentuncovered systemic issues Areas Investigated Issues IdentifiedReferral Data Inconsistent Data CollectionCollection and • Referrals logged via phoneUsage and email Registration Inefficient Processes Process and Data • Maintenance of electronic Collection and paper records Registration Lack of Data Usage • Infrequent communication of Reporting Process appointments logged 12 Background Project Overview Assessment Recommendations Next Steps
    • Inconsistent data collection results inmany exceptions to standard processExisting Appointment Book Existing Registration Book• Appointment data is collected in • Registration data is captured in multiple formats multiple log books – Phone Calls – Uncertain benefit for separate first time maternity – Emails patients log • Data format varies by health center – Not all referring Health Centers set appointments • Registration is not provided with• Follow-up patient appointments are patient information prior to patient not currently tracked arriving at registration window 13 Background Project Overview Assessment Recommendations Next Steps
    • Reduced data usage due to hard copyrecords and inconsistent processes• Handwritten logs reduce opportunities for data analysis – Analysis requires manual review and is more prone to error• Inter-departmental data sharing is complicated by need to review and utilize log simultaneously – Paper logs limit total users to one• Patient files may become split if patient ID is unknown by returning patient – Older patient records may become orphaned utilizing limited storage space while not providing benefit 14 Background Project Overview Assessment Recommendations Next Steps
    • Process inefficiencies create potentialfor errors and reduce effectiveness• Referral data is currently tracked on a scratch pad, electronic log and handwritten log – No calendar is kept for number of total appointments• Instances of inaccurate numbering due to illegible handwriting impacting reporting – Multiple numbering errors were found during review of registration logs• Registration and consultation do not have access to accurate and timely patient projections, limiting work planning 15 Background Project Overview Assessment Recommendations Next Steps
    • Appointment system accounts for lowproportion of arriving patients12010080604020 0 8/2/2012 10/2/2012 14/2/2012 16/2/2012 20/2/2012 22/2/2012 24/2/2012 28/2/2012 3/1/2012 3/5/2012 3/7/2012 3/9/2012 15/3/2012 19/3/2012 21/3/2012 23/3/2012 27/3/2012 29/3/2012 Total Outpatient Arrivals 13/3/2012 Appointments 16 Background Project Overview Assessment Recommendations Next Steps
    • Appointment system has not reduced volatility in outpatient arrivals 45.0 50.0 40.0 45.0 40.0 35.0 35.0 30.0 30.0 25.0 25.0 20.0 20.0 15.0 15.0 10.0 10.0 5.0 5.0 - - Before Current Before Current Lower 25th Percentile of Arrivals Daily Average St. Dev. Upper 25th Percentile of ArrivalsBefore is the period from January 3rd, 2011 through the implementation of the referral system in February 2012. Current isFebruary 2012 through present. 17 Background Project Overview Assessment Recommendations Next Steps
    • On April 3rd, majority of referred patients arrived without appointments In/Out of Patient Type Number Percentage Health Center Patient Referrals District Appointments Coko In 2 1 Had referral only 39 78% Gasgara Out 4 0 Had referral and 10 20% appointment Gitega Out 2 0 Chronic or follow-up 1 2% Kabuga Out 1 0 Kayenzi Out 2 0 Total 50 100% Muhondo In 7 0 Nyabikenke Out 7 1 • In district Health Centers Nyange In 1 1 had appointments 36% of Ruli In 10 5 Rushashi In 2 2 the time (9 of 25) Rutonde Out 1 0 • Out of district Health Rwahi Out 1 0 Centers had appointments Rwankuba In 3 0 6% of the time (1 of 18) Unknown N/A 6 0 Total 49 10Patient arrival data gathered at registration on April 3rd, 2012. Six patients’ registrations were unobserved. 18 Background Project Overview Assessment Recommendations Next Steps
    • RecommendationsBackground Project Overview Assessment Recommendations Next Steps
    • Recommendations range from quickwins to long-term strategyShort-Term• Changes that can be enacted in the next six months• Form the basis for mid-range and long-term strategic vision for data usageMid-Range• Modifications in the one to three year time horizon• Build upon foundation of short-term recommendations• May require capital allocationsLong-Term• Guiding principles for data management at the Health Center and Hospital levels• May require support from, and modification of, MoH directives 20 Background Project Overview Assessment Recommendations Next Steps
    • Changes to the Health Center andHospital appointment processProposed Changes: Immediate Intended Impact Action Collect all data points during Information is available sooner phone call and actionable Elimination of unused data points Modify data points collected speeds data transfer More natural fit for work Shift appointment setting to task, easier inclusion of follow-up registration visits Add doctor scheduled follow-ups Provides more complete view of to appointment log total patient volume Eliminates duplicative Shift to electronic log only effort, increases analytical capability Modify feedback loop with Health Increased ability to communicate Center need to see physician 21Background Project Overview Assessment Recommendations Next Steps
    • Electronic logs improves efficiency andanalytical capabilitiesElectronic Appointment Log Electronic Registration Log• Benefits include: • Benefits include: – Returning patients’ files can be pulled day prior to – Reduction in errors caused by illegible entries their appointment to reduce registration time – Ability to recover lost patient IDs – Reduction in variability as appointment log will – Stored information can be used to perform account for greater percentage of analysis of patient trends appointments, allowing for improved scheduling – Increased speed in data entry and month end reporting – Improved system for tracking which referred patients arrived at Hospital – Hospital can track which Health Centers refer patients without scheduling appointments 22 Background Project Overview Assessment Recommendations Next Steps
    • Changes to data storage and usage Proposed Changes: Intended Impact Mid/Long-Term Action More complete patient records,Centralize patient paper records easier retrieval of entire patient history Easier retrieval of patientMove to electronic patient history, increased analytics, easesrecords reporting process Increased inter-departmentalDevelop central hospital information sharing andinformation network reporting 23Background Project Overview Assessment Recommendations Next Steps
    • Key Takeaways Have Record doctor Move Utilize digital registration scheduledappointment logs for desk pull next- follow-up setting to registration day referrals in registration and appointment appointment desk appointments files log 24Background Project Overview Assessment Recommendations Next Steps
    • Next Steps Implementation steps for immediate recommendationsBackground Project Overview Assessment Recommendations Next Steps
    • Modifications to appointment settingprocess• Modify data collection to mirror excel template (provided)• Switch appointment recording to registration• Include doctor scheduled follow-ups in appointment log – Doctors to stack patient files in separate piles to indicate which require follow-up appointments • Registration enters relevant data onto appointment log from patient files, prior to refiling• Health Center appointments – Phone call • Exchange all data points via standardized phone call – Email • Discard email from Health Center to Hospital 26 Background Project Overview Assessment Recommendations Next Steps
    • Modifications to appointment settingprocess (cont.)• Utilize new appointment schedule to reduce variation in patient arrivals – Reduce appointment cap on dates known to have high volume of chronic patients (i.e. last Thursday of each month) – Use historical data to predict trends in patient arrivals 27 Background Project Overview Assessment Recommendations Next Steps
    • Modifications to appointmentfeedback loop• Shift appointment attendance check to registration – Aligns with shift of appointment setting – Natural fit due to dependency on registration logs• Change from negative check (i.e. marked if missed) to positive verification (i.e. marked when registered)• Email appointment log to all Health Centers on Friday of each week – Alerts Health Centers to missed appointments• Investigate reasons for non-conforming Health Centers and reiterate the importance of their cooperation 28 Background Project Overview Assessment Recommendations Next Steps
    • Modifications to registration and filingprocess• Capture all pertinent patient information in electronic registration log (excel templates provided) – Electronic data in same format as paper logs, with the addition of maternity flag, Health Center and appointment verification• Retrieve patient files for next day appointments at end of each day• Communicate following day’s appointment schedule (volume and illnesses) to Head Nurse for use in staffing 29 Background Project Overview Assessment Recommendations Next Steps
    • AppendixBackground Project Overview Assessment Recommendations Next Steps
    • Outpatients registered per day 90 80 70 60 50 40 30 20 10 0 3/7/2011 3/1/2012 3/1/2011 3/2/2011 3/3/2011 3/4/2011 3/5/2011 3/6/2011 3/8/2011 3/9/2011 3/10/2011 3/11/2011 3/12/2011 3/2/2012 3/3/2012 3/4/2012Above data excludes the last Thursday of every month. 31 Background Project Overview Assessment Recommendations Next Steps
    • Outpatient arrivals Daily averages for outpatient Monthly averages for outpatient arrivals arrivals 45 50 40 45 35 40 35 30 30 25 25 20 20 15 15 10 10 5 5 0 -Above data from January 3rd, 2011 through present, excluding last Thursday of every month and holidays. 32 Background Project Overview Assessment Recommendations Next Steps
    • Outpatient arrivals on last Thursday ofeach month12010080604020 0 33 Background Project Overview Assessment Recommendations Next Steps
    • Current appointment data from HealthCentersAppointments by Health Center Days after referral call that appointment is set In/Out ofHealth Center Appointments Percentage Days Appointments Percentage District Coko In 92 16% 0 23 4% Gasagara Out 44 7% 1 486 82% Muhondo In 51 9% 2 56 9% Nyabikenke Out 98 17% 3 15 3% Nyange In 47 8% 4 6 1% Rukura In 16 3% 5 0 0% Ruli In 125 21% 6 1 0% Rushashi In 51 9% Rwankuba In 66 11% N/A 3 1% Total 590 100% Total 590 100% 34 Background Project Overview Assessment Recommendations Next Steps
    • Per week appointments made by Health Centers Health In/Out of 30/1/2012 6/2/2012 13/2/2012 20/2/2012 27/2/2012 5/3/2012 12/3/2012 19/3/2012 26/3/2012 Total Center District Coko In 0 5 10 9 14 19 13 10 12 79 Gasagara Out 0 5 2 14 8 2 9 4 0 43Muhondo In 0 5 6 13 7 1 5 7 7 39Nyabikenke Out 0 13 13 23 3 10 4 16 16 78 Nyange In 0 12 9 5 0 8 4 3 6 41 Rukura In 1 2 2 5 3 0 0 3 0 13 Ruli In 1 19 26 29 19 14 10 3 4 121 Rushashi In 2 4 11 5 7 8 9 1 4 46Rwankuba In 8 18 6 6 8 7 7 6 0 60 Total 12 83 85 109 69 69 61 53 49 590 35 Background Project Overview Assessment Recommendations Next Steps