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

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Presentation by team of MBA students from Ross School of Business at University of Michigan. Describes recommendations for improving the referral process for rural health centers to the district …

Presentation by team of MBA students from Ross School of Business at University of Michigan. Describes recommendations for improving the referral process for rural health centers to the district hospital in rural Rwanda.

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  • Gray indicates what portion of referral process we are focusing on for this project.
  • Although referred by the Health Center, patients often do not show up at the hospital for various reasonsRecommend this be observed to understand exactly what the implications are


  • 1. Improving Ruli District Hospital’s Referral System
    Kate Bossart, Chris Chojnacki, Kristin Girouard, Jessica Meyer, Katie O’Hare
  • 2. Agenda
    Project Description & Overview
    Next Steps
  • 3. District Hospital System Background
  • 4. Rwanda: Facts & Figures
    Population: 11M
    Land Mass Comparative: slightly smaller than Maryland
    GDPPer Capita: $465 (216th Worldwide)
    Population Below Poverty Line: 60%
    Urbanization: 18% of total
    90% of population engaged in mainly subsistence agriculture
    Median Age: 18.5
    Age Structure:
    0-14 years: 42.7%
    15-64 years: 54.8%
    65 years and over: 2.5%
    Life Expectancy at Birth: 57 years
    Source: CIA World Factbook, WHO Country Profile, IMF
  • 5. Healthcare in Rwanda
    Healthcare in Rwanda is provided through a tiered system in which the level of care increases as needed to serve the population.
    Level of Care
    Geographic Market
  • 6. Ruli District Hospital
    Ruli District Hospital is a full service facility that aspires to be a local Center of Excellence.
    Emergency, inpatient and outpatient care
    General surgery
    Physical therapy
    Psychological care
    Performs monthly:
    60 surgeries
    250 immunizations
    300 pre-natal checkups
    100 deliveries
    Has 8 doctors and a full staff of nurses, technicians and administrators
    Source: Greg Thorne internship “Hospital Operating Statistics”, 8/2010
  • 7. Ruli District Geography
    The Ruli District Hospital System has 7 affiliated Health Centers, but also supports a number of neighboring, out of district Health Centers.
    District Hospital
    In District Health Center
    Out of District Health Center
  • 8. Ruli District Health Centers
    The team visited 6 of the 7 district Health Centers. They vary widely in population served and number of patients referred.
    Outpatient consultation and basic inpatient care
    Staffs ~9 generalist nurses
    Other employees: data manager, accountant, lab technician, social worker, community workers and maintenance
    Muhondo Health Center not interviewed
  • 9. In District & Out of District Referrals
    In 2010, most patients came from Health Centers within the Ruli District system; however, a significant number (~30%) came from out of district Health Centers.
    In District
    Out of District
    Maternity Referral
    Hospitalization Referral
    Consultation Referral
    In District Referrals
    Out of District Referrals
  • 10. Project Description & Overview
  • 11. Where We Fit
    Our project focuses on the patient referral process from the Health Center to the next level of care at the District Hospital.
    Level of Care
    Geographic Market
  • 12. Process Flows
    Patients must travel to the Health Center first and then may be referred to the Hospital to receive a higher level of care. At each step there is a transfer of patients and information.
    Step 1: Patient visits Health Center
    Step 2: Patient is referred to Hospital
    Health Center
  • 13. Referral Process Flows
    Patients may be referred to a District Hospital through one of three channels.
    Outpatient Referral
    Outpatient Referral Process shows greatest opportunity for improvement
    Inpatient Referral
    Emergency Referral
  • 14. Patient Flow
    Patients and information flow between the village, Health Center and Hospital.
    Patients travel from village to local Health Center for medical care
    Based on illness, patients are treated or referred to District Hospital
    When referred, patients travel to District Hospital for continued care
    Patients are treated at Hospital
    Health Center
    District Hospital
  • 15. Information Flow
    Patients and information flow between the village, Health Center and Hospital.
    Health Center
    District Hospital
    Patients travel with symptoms and insurance information
    Disease information is reported weekly and referrals are reported monthly
    Hospital collects referral form and treats patient
    Health Centers collect patient and disease information and provide referral forms
  • 16. Data Collection
    Over one week, the team compiled a significant amount of information through interviews and data collection.
  • 17. Challenges in Process Flows
    Opportunities exist to improve both the patient and information flows between the Health Centers and Hospitals, leading to more effective and efficient patient care.
    Health Center
  • 18. Recommendations
  • 19. Strategies
    We developed 4 recommendations to address 4 key challenges.
  • 20. 1: Revised Nurse Consultation Process
  • 21. 1: Revised Nurse Consultation Process
    Why is this a challenge?
    Patient Care: Patients delay travel to Hospital for variety of reasons:
    Inability to pay for care
    Family issues
    Social norms: often no urgency to visit Hospital
    Hospital Operations: Variability makes it difficult for Hospital to plan resources effectively
  • 22. 1: Revised Nurse Consultation Process
    Increase predictability of referrals by collecting information as patients are referred
    Health Center staff will have better understanding of when patients will go to Hospital
  • 23. 1: Revised Nurse Consultation Process
    Revised Nurse Consultation Process
    Process where nurses discuss timing of arrival at Ruli Hospital with patient at time of referral
  • 24. 1: Revised Nurse Consultation Process
    Sample Referral Arrival Form
    Discusses Urgency of Condition with Patient
    Assesses Factors for Potential Delay
  • 25. 2: Daily Referral Text
  • 26. 2: Daily Referral Text
    • Why this is a challenge?
    • 27. Operations: Hospital cannot allocate resources efficiently to handle patient load
    • 28. Patient Care: On heavy days, patients have excessive wait times and may not even be seen that day
  • 2: Daily Referral Text
    Increase referral awareness through daily communication with Health Center
    How it addresses the problem
    Hospital can better allocate resources on heavy referral days
    Data collection enables long term trend analysis and planning
  • 29. 2: Daily Referral Text
    Current Communication:
    Referrals are only tallied for monthly reports
    Daily communication is limited to emergencies
  • 30. 2: Daily Referral Text
    Proposed Process
    • Data Manager:
    Collect Referral Arrival Forms (Recommendation #1) at EOD
    Calculate referrals for next three days
    Transmit data via SMS to Ruli Hospital by 4pm
    Log referral data at Health Center
    • Assistant to Hospital Administrator:
    Receives SMS
    Record referrals per Health Center
    Calculate total arrivals by day for next three days
    Record data in Hospital referral log
    Complete Daily Referral Tally Form and provide to Chief of Staff by 5pm
    • Chief of Staff:
    Allocates staff to expected demand
    • Hospital Administrator:
    Oversees collection of long-term data for forecasting, budgeting, and staffing needs
  • 31. 2: Daily Referral Text
    As an example, Coko made 10 referrals on Monday, September 5th 2011. 7 are expected to come to the hospital on Tuesday, 2 on Wednesday and 1 on Thursday.
    Day and date
    Total daily referrals
    Arrival estimates for next three days
  • 32. 2: Daily Referral Text
    By tracking the last three days of referrals and adding that number to the average same-day arrivals an accurate estimate can be made for Thursday’s patient load.
    Plus the last three days of information
    Today’s health center referral counts
    Gives an accurate estimate for tomorrow
  • 33. 3: Close Feedback Loop
  • 34. 3: Close Feedback Loop
    Why is this a challenge?
    Patient Care: May lead to poor patient outcomes
    Barriers to arrival, including lack of financial resources and burdensome travel, are hard to rectify
    Health Center Redundancies: May see same patient for same illness that has worsened due to lack of referral follow-through
    Community Health Worker Resource Strain: current system of follow-up is reactive and can be improved
  • 35. 3: Close Feedback Loop
    Ensuring patient follow through by increasing responsibility of Health Center for patients may:
    Allow for appropriation of resources, such as financial aid or transportation, to help patient arrive at Hospital
    Lead to the ability to identify drivers of patients follow-through failure
  • 36. 3: Close Feedback Loop
    • Proposed solutions for closing the feedback loop:
    • 37. Implement process where Hospital sends weekly report reconciling referrals to all Health Centers
    • 38. Health Centers will
    know which patients
    went to the Hospital
    and which patients
    did not go to the
  • 39. 3: Close Feedback Loop
    Create a referral database between Hospital and Health Centers automatically updating patient referral information and providing proactive feedback to Health
    Establish communication procedures
    down the ladder
    Prioritize Community Health
    Worker follow-up with patients
    not presenting to the Hospital
    either through phone call
    or visit
    Formal Health System
  • 40. 4: Data Capture
  • 41. Why is this a challenge?
    Hospital Budgeting and Operations: Long-term budgeting and resource planning decisions uninformed by hard data
    Patient Care: Will improve as hospital refines care using data-backed quantitative analysis
    4: Data Capture
  • 42. Categorize and plan
    Identify goals
    Select variables to collect
    Collect data
    Design collection process
    Analyze periodically
    Act upon findings
    Identify trends
    Create action based on insights
    4: Data Capture
  • 43. Near term: Electronically store data from earlier recommendations
    Record referral data on weekly basis
    Use existing computers and software
    Periodically analyze
    Long term: Consider future University of Michigan project team
    4: Data Capture
  • 44. Near Term Example: Referrals
    4: Data Capture
    Record paper based information in Excel
    Periodically analyze
    Create actionable insight
  • 45. Phased Implementation
    Launch recommendations with in district, regional Health Centers first
    Expand to include all Health Centers that refer to Ruli Hospital
    Start with largest out of district referral centers
    In District ReferralsOut of District Referrals
  • 46. Next Steps
  • 47. Next Steps
  • 48. Future Projects
  • 49. Transportation
  • 50. Transportation
  • 51. Town of Ruli
  • 52. Children
  • 53. Fishbowl
  • 54. GORILLAS!
  • 55. Disaster
  • 56. Murakoze!
  • 57. Appendix
  • 58. Key Stakeholders
    We incorporated the interests of all of all key stakeholders into our analysis and recommendations
    All Stakeholders operate in the Ministry of Health’s system, which benefits from improved communications between its components and therefore better care
  • 59. Additional Considerations
  • 60. Ruli Hospital Interview
    The number of expected daily referrals would allow Ruli Hospital to better allocate resources and see patients faster.
    Hospital Chief of Staff:
    Referral information received by 5:00 PM the day prior would be actionable in 7:30 AM staff meeting
    Advanced warning of ailment and additional health history would be even more helpful
    6 doctors and 2 doctor interns on staff
    3 working at any given time
  • 61. In District Health Center Interviews
    Inconsistent Health Center Characteristics:
    Consistent Health Center Characteristics:
    • Ruli Health Center refers the greatest number of patients due to its location next to the Hospital
    • 62. Coko Health Center shares staff with Ruli
    • 63. Data Manager role is inconsistent across centers
    • 64. Hours ranging from .6 to 1.5 FTE
    • 65. At some centers, the Data Manager is also a nurse
    • 66. Centers further from Ruli have mixed influenceas some patients will go to other district hospitals
    Reporting requirements
    weekly, monthly, quarterly
    Regular and periodic Doctor/Supervisor visits
    Data reconciliation
    primarily paper with some weekly/monthly electronic filing
    Hours of operation (9am-5pm)
    Referred patients walk to Ruli Hospital
    Patients have similar ailments
    Health Centers have a similar busy season
    Health Centers outside the catchment area may differ from those analyzed, especially in reporting, communication methods, and operations
  • 67. Health Center Consistency
    Current Consultation Log:
    Information tracking is inconsistent across Health Centers and between months/years leading to inability to analyze data/information
    Current Log Book
    Nyange (Recommended) Log Book
  • 68. Communication at Health Centers
  • 69. Regional Health Center Communication Options