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

    1. 1. Improving Ruli District Hospital’s Referral System<br />Kate Bossart, Chris Chojnacki, Kristin Girouard, Jessica Meyer, Katie O’Hare<br />4/12/2011<br />
    2. 2. Agenda<br />Background<br />Project Description & Overview<br />Recommendations<br />Next Steps<br />
    3. 3. District Hospital System Background<br />
    4. 4. Rwanda: Facts & Figures<br />Population: 11M<br />Land Mass Comparative: slightly smaller than Maryland<br />GDPPer Capita: $465 (216th Worldwide)<br />Population Below Poverty Line: 60%<br />Urbanization: 18% of total<br />90% of population engaged in mainly subsistence agriculture<br />Median Age: 18.5<br />Age Structure:<br />0-14 years: 42.7% <br />15-64 years: 54.8% <br />65 years and over: 2.5% <br />Life Expectancy at Birth: 57 years<br />Ruli<br />Source: CIA World Factbook, WHO Country Profile, IMF<br />
    5. 5. Healthcare in Rwanda<br />Healthcare in Rwanda is provided through a tiered system in which the level of care increases as needed to serve the population.<br />Level of Care<br />Geographic Market<br />Nation<br />Specialists<br />District<br />Doctors<br />Sector<br />Nurses<br />Village<br />Volunteers<br />
    6. 6. Ruli District Hospital<br />Ruli District Hospital is a full service facility that aspires to be a local Center of Excellence. <br />Provides:<br />Emergency, inpatient and outpatient care<br />General surgery<br />Dentistry<br />Physical therapy<br />Psychological care<br />Performs monthly:<br />60 surgeries <br />250 immunizations<br />300 pre-natal checkups<br />100 deliveries<br />Has 8 doctors and a full staff of nurses, technicians and administrators<br />Source: Greg Thorne internship “Hospital Operating Statistics”, 8/2010<br />
    7. 7. Ruli District Geography<br />The Ruli District Hospital System has 7 affiliated Health Centers, but also supports a number of neighboring, out of district Health Centers.<br />Gayanke<br />Rulindo<br />District Hospital<br />Muhanga<br />In District Health Center<br />Gasagara<br />Out of District Health Center<br />Gasabo<br />Kamonyi<br />
    8. 8. Ruli District Health Centers<br />The team visited 6 of the 7 district Health Centers. They vary widely in population served and number of patients referred. <br />Provides:<br />Outpatient consultation and basic inpatient care<br />Staffs ~9 generalist nurses<br />Other employees: data manager, accountant, lab technician, social worker, community workers and maintenance <br />Muhondo Health Center not interviewed<br />
    9. 9. In District & Out of District Referrals<br />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.<br />In District<br />Out of District<br />Maternity Referral<br />Hospitalization Referral<br />Consultation Referral<br />In District Referrals<br />Out of District Referrals<br />
    10. 10. Project Description & Overview<br />
    11. 11. Where We Fit<br />Our project focuses on the patient referral process from the Health Center to the next level of care at the District Hospital.<br />Level of Care<br />Geographic Market<br />Nation<br />Specialists<br />District<br />Doctors<br />Sector<br />Nurses<br />Village<br />Volunteers<br />
    12. 12. Process Flows<br />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. <br />Step 1: Patient visits Health Center<br />Step 2: Patient is referred to Hospital <br />Health Center<br />Hospital <br />Patients<br />Village<br />Patients<br />Information<br />Information<br />
    13. 13. Referral Process Flows<br />Patients may be referred to a District Hospital through one of three channels.<br />Outpatient Referral<br />Outpatient Referral Process shows greatest opportunity for improvement<br />Inpatient Referral<br />Emergency Referral<br />
    14. 14. Patient Flow<br />Patients and information flow between the village, Health Center and Hospital.<br />Patients travel from village to local Health Center for medical care<br />Based on illness, patients are treated or referred to District Hospital<br />When referred, patients travel to District Hospital for continued care<br />Patients are treated at Hospital <br />Village<br />Health Center<br />District Hospital <br />Patients<br />Patients<br />Information<br />Information<br />
    15. 15. Information Flow<br />Patients and information flow between the village, Health Center and Hospital.<br />Village<br />Health Center<br />District Hospital <br />Patients<br />Patients<br />Information<br />Information<br />Patients travel with symptoms and insurance information <br />Disease information is reported weekly and referrals are reported monthly<br />Hospital collects referral form and treats patient <br />Health Centers collect patient and disease information and provide referral forms<br />
    16. 16. Data Collection<br />Over one week, the team compiled a significant amount of information through interviews and data collection.<br />
    17. 17. Challenges in Process Flows<br />Opportunities exist to improve both the patient and information flows between the Health Centers and Hospitals, leading to more effective and efficient patient care.<br />Village<br />Health Center<br />Hospital <br />Patients<br />Patients<br />Information<br />Information<br />
    18. 18. Recommendations<br />
    19. 19. Strategies <br />We developed 4 recommendations to address 4 key challenges. <br />1<br />2<br />4<br />3<br />
    20. 20. 1: Revised Nurse Consultation Process<br />
    21. 21. 1: Revised Nurse Consultation Process<br />Why is this a challenge?<br />Patient Care: Patients delay travel to Hospital for variety of reasons:<br />Inability to pay for care<br />Transportation<br />Family issues<br />Social norms: often no urgency to visit Hospital<br />Other<br />Hospital Operations: Variability makes it difficult for Hospital to plan resources effectively <br />
    22. 22. 1: Revised Nurse Consultation Process<br />Increase predictability of referrals by collecting information as patients are referred<br />Health Center staff will have better understanding of when patients will go to Hospital<br />
    23. 23. 1: Revised Nurse Consultation Process<br />Revised Nurse Consultation Process<br />Process where nurses discuss timing of arrival at Ruli Hospital with patient at time of referral<br />
    24. 24. 1: Revised Nurse Consultation Process<br />Sample Referral Arrival Form<br />Discusses Urgency of Condition with Patient<br />Assesses Factors for Potential Delay<br />
    25. 25. 2: Daily Referral Text<br />
    26. 26. 2: Daily Referral Text<br /><ul><li>Why this is a challenge?
    27. 27. Operations: Hospital cannot allocate resources efficiently to handle patient load
    28. 28. Patient Care: On heavy days, patients have excessive wait times and may not even be seen that day</li></li></ul><li>2: Daily Referral Text<br />Increase referral awareness through daily communication with Health Center<br />How it addresses the problem<br />Hospital can better allocate resources on heavy referral days<br />Data collection enables long term trend analysis and planning<br />
    29. 29. 2: Daily Referral Text<br />Current Communication:<br />Referrals are only tallied for monthly reports<br />Daily communication is limited to emergencies<br />
    30. 30. 2: Daily Referral Text<br />Proposed Process<br /><ul><li>Data Manager:</li></ul>Collect Referral Arrival Forms (Recommendation #1) at EOD<br />Calculate referrals for next three days <br />Transmit data via SMS to Ruli Hospital by 4pm<br />Log referral data at Health Center <br /><ul><li>Assistant to Hospital Administrator:</li></ul>Receives SMS<br />Record referrals per Health Center<br />Calculate total arrivals by day for next three days<br />Record data in Hospital referral log<br />Complete Daily Referral Tally Form and provide to Chief of Staff by 5pm<br /><ul><li>Chief of Staff:</li></ul>Allocates staff to expected demand<br /><ul><li>Hospital Administrator:</li></ul>Oversees collection of long-term data for forecasting, budgeting, and staffing needs<br />
    31. 31. 2: Daily Referral Text<br />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.<br />CokoM.5.9.11<br />#10<br />T:7<br />W:2<br />Th:1<br />Location<br />Day and date<br />Total daily referrals<br />Arrival estimates for next three days<br />
    32. 32. 2: Daily Referral Text<br />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.<br />Plus the last three days of information<br />Today’s health center referral counts<br />Gives an accurate estimate for tomorrow<br />
    33. 33. 3: Close Feedback Loop<br />
    34. 34. 3: Close Feedback Loop<br />Why is this a challenge?<br />Patient Care: May lead to poor patient outcomes<br />Barriers to arrival, including lack of financial resources and burdensome travel, are hard to rectify <br />Health Center Redundancies: May see same patient for same illness that has worsened due to lack of referral follow-through<br />Community Health Worker Resource Strain: current system of follow-up is reactive and can be improved<br />
    35. 35. 3: Close Feedback Loop<br />Ensuring patient follow through by increasing responsibility of Health Center for patients may:<br />Allow for appropriation of resources, such as financial aid or transportation, to help patient arrive at Hospital<br />Lead to the ability to identify drivers of patients follow-through failure<br />
    36. 36. 3: Close Feedback Loop<br /><ul><li>Proposed solutions for closing the feedback loop:
    37. 37. Implement process where Hospital sends weekly report reconciling referrals to all Health Centers
    38. 38. Health Centers will </li></ul>know which patients<br />went to the Hospital <br />and which patients <br />did not go to the <br />Hospital<br />
    39. 39. 3: Close Feedback Loop<br />Create a referral database between Hospital and Health Centers automatically updating patient referral information and providing proactive feedback to Health<br />Centers<br />Establish communication procedures<br />down the ladder<br />Prioritize Community Health <br />Worker follow-up with patients<br />not presenting to the Hospital<br />either through phone call <br />or visit<br />Village<br />Formal Health System<br />
    40. 40. 4: Data Capture<br />
    41. 41. Why is this a challenge?<br />Hospital Budgeting and Operations: Long-term budgeting and resource planning decisions uninformed by hard data<br />Patient Care: Will improve as hospital refines care using data-backed quantitative analysis<br />4: Data Capture<br />
    42. 42. Categorize and plan<br />Identify goals<br />Select variables to collect<br />Collect data<br />Design collection process<br />Analyze periodically <br />Act upon findings<br />Identify trends<br />Create action based on insights<br />4: Data Capture<br />
    43. 43. Near term: Electronically store data from earlier recommendations<br />Record referral data on weekly basis<br />Use existing computers and software<br />Periodically analyze<br />Long term: Consider future University of Michigan project team<br />4: Data Capture<br />
    44. 44. Near Term Example: Referrals<br />4: Data Capture<br />Record paper based information in Excel<br />Periodically analyze<br />Create actionable insight<br />
    45. 45. Phased Implementation<br />Launch recommendations with in district, regional Health Centers first<br />Expand to include all Health Centers that refer to Ruli Hospital<br />Start with largest out of district referral centers<br />In District ReferralsOut of District Referrals<br />
    46. 46. Next Steps <br />
    47. 47. Next Steps<br />
    48. 48. Future Projects<br />
    49. 49. Transportation <br />
    50. 50. Transportation <br />
    51. 51. Town of Ruli<br />
    52. 52. Children<br />
    53. 53. Fishbowl <br />
    54. 54. GORILLAS!<br />
    55. 55. Disaster<br />
    56. 56. Murakoze!<br />
    57. 57. Appendix<br />
    58. 58. Key Stakeholders<br />We incorporated the interests of all of all key stakeholders into our analysis and recommendations <br />All Stakeholders operate in the Ministry of Health’s system, which benefits from improved communications between its components and therefore better care<br />
    59. 59. Additional Considerations<br />
    60. 60. Ruli Hospital Interview<br />The number of expected daily referrals would allow Ruli Hospital to better allocate resources and see patients faster.<br />Hospital Chief of Staff:<br />Referral information received by 5:00 PM the day prior would be actionable in 7:30 AM staff meeting<br />Advanced warning of ailment and additional health history would be even more helpful<br />6 doctors and 2 doctor interns on staff<br />3 working at any given time<br />
    61. 61. In District Health Center Interviews<br />Inconsistent Health Center Characteristics:<br />Consistent Health Center Characteristics:<br /><ul><li>Ruli Health Center refers the greatest number of patients due to its location next to the Hospital
    62. 62. Coko Health Center shares staff with Ruli
    63. 63. Data Manager role is inconsistent across centers
    64. 64. Hours ranging from .6 to 1.5 FTE
    65. 65. At some centers, the Data Manager is also a nurse
    66. 66. Centers further from Ruli have mixed influenceas some patients will go to other district hospitals</li></ul>Reporting requirements<br />weekly, monthly, quarterly<br />Regular and periodic Doctor/Supervisor visits<br />Data reconciliation<br />primarily paper with some weekly/monthly electronic filing<br />Hours of operation (9am-5pm)<br />Referred patients walk to Ruli Hospital<br />Patients have similar ailments <br />Health Centers have a similar busy season<br />Health Centers outside the catchment area may differ from those analyzed, especially in reporting, communication methods, and operations<br />
    67. 67. Health Center Consistency<br />Current Consultation Log:<br />Information tracking is inconsistent across Health Centers and between months/years leading to inability to analyze data/information<br />Current Log Book<br />Nyange (Recommended) Log Book<br />
    68. 68. Communication at Health Centers<br />
    69. 69. Regional Health Center Communication Options <br />