Information flow and_referral_system_project_-_wdi_internship_2012-1

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As a dual MD-MBA student at University of Michigan, Dan brought a unique perspective to our Sustainable Hospital work. His role was to understand the complex chain of information flowing between clinicians and administrators and between different levels of the Rwandan health care system.

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Information flow and_referral_system_project_-_wdi_internship_2012-1

  1. 1. William Davidson Institute Ruli Hospital Summer Internship 2012 Daniel BickleyTable of ContentsIntroduction......................................................................................................................................................3 Rwanda...............................................................................................................................................................3 1
  2. 2. The Rwandan Health Care System......................................................................................................................3Background.......................................................................................................................................................5 Summary of 2012 MAP Project...........................................................................................................................6 Expansion of MAP Project Scope........................................................................................................................7Information Flow Study....................................................................................................................................8 Description of Project.........................................................................................................................................8 Methods.............................................................................................................................................................8 Findings...............................................................................................................................................................8 Information Flow............................................................................................................................................9 Patient Flow..................................................................................................................................................31 Discussion.........................................................................................................................................................33 Recommendations for Improvements..............................................................................................................34Implementation 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...................................................................................................47Conclusion......................................................................................................................................................49 Summary of Information Flow Study................................................................................................................49 Summary of Implementation............................................................................................................................50 Summary of Recommendations and Next Steps...............................................................................................50I. Introduction 2
  3. 3. a. RwandaRwanda is a landlocked country in Central-East Africa with a population of roughly 11.7 million. Witha 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 populationdensity of any country on the continent. Interestingly, it is also predominantly a rural nation, with 90percent of the population carving out an existence as subsistence farmers. The nation features a smallnumber 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 teaproduction. The country has a tumultuous past, attaining independence only 50 years ago and sufferinga devastating genocide and period of lingering violence in 1994. Therefore, although there has beenrelative stability and increased development in the last decade or two, the poverty rate remains elevatedat around 45 percent. Despite this state of relative poverty, the Rwandan government commits sizeablefunding to health care, spending 9% of GDP on health-related expenditures annually1. b. The Rwandan Health Care SystemThe health care system in Rwanda operates on a tiered basis. There exist 4 separate levels of caredelivery: community health workers, health centers, district hospitals, and referral hospitals. Each tierdelivers care to patients with an appropriately complex disease state, and refers those patients whocannot 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 certain1 . "CIA World Factbook." . CIA, 11 Sep 2012. Web. 15 Aug 2012. https://www.cia.gov/library/publications/the-world-factbook/geos/rw.html 3
  4. 4. 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. 4
  5. 5. Gakenke District Health Centers and HospitalsII. BackgroundIt is within this system that The Ihangane Project has been working for the last decade. In addition tosponsoring work towards economic and infrastructure development in the wider community aroundRuli, Rwanda, The Ihangane Project has also made commitments to improving the efficiency of thehealth 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 andfaculty from the University of Michigan. Students have contributed to health care and public healthprojects through William Davidson Institute fellowships as well as through Multidisciplinary ActionProjects. Since 2010, the focus of many of these projects has been on learning about the flow ofpatients 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 withinthe hospital, specifically through evaluation of a new appointment system that had been implemented 5
  6. 6. within the last year. They conducted an analysis of the situation and made recommendations forimprovements to the hospital’s referral and registration processes. a. Summary of 2012 MAP ProjectThe spring 2012 MAP team conducted interviews with patients and staff, and observed and mapped outdifferent processes related to appointment-making and patient registration. They found that eventhough an appointment system had been mandated by the Ministry of Health, a majority of patientswere still arriving to the hospital without appointments. Furthermore, they identified duplicative orinefficient processes within the hospital registration system which prevent hospital administrators fromeffectively using the collected data. They made a number of short and long-term recommendations toimprove 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 6
  7. 7. 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 ScopeThe MAP team spent 4 weeks on the ground in Ruli during March and April of 2012, and spent a gooddeal of time weighing options and considering recommendations during the next three weeks after theirreturn to the United States. With the efforts of 4 talented students and guidance from their facultyadvisors, 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 simplybegin implementing the recommendations. While the Rwandan health care system is a complicatedmachine, composed of hundreds of interlocking pieces, the MAP team had focused specifically on onlyone process among them. Moreover, it was possible that the MAP project recommendationsoverlooked an important part of this specific process, as the referral system overlaps the jurisdiction ofboth the Health Centers and the District Hospital. The MAP team had spent most of their time at RuliHospital, seldom visiting the Health Centers. Therefore, The Ihangane Project leadership felt it prudentto investigate the process of patient referral and registration from the point of view of the HealthCenters.Rather than simply complete this task in isolation, it was thought that it would be of benefit to futureprojects of this nature to attempt to understand the total flow of information and patients between thecommunity health worker level, health center level, and district hospital level. With this type of “bigpicture” approach, information could be discovered that could be used to inform future projects as wellas critically analyze the referral system as a specific process within the larger whole. This projectcould therefore lead to potential modifications to the MAP team’s recommendations, ensuring that the 7
  8. 8. 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 ProjectThe Information Flow Study consisted of investigations at the community health worker level, healthcenter level, and district hospital level. The aim of the study was to characterize and map out the entireflow of information, as well as patients, through the bottom three levels of the Rwandan health caresystem. In the context of this analysis, the flow of information is inclusive not only of the transmissionof clinical information and reports, but also the administrative information that is exchanged to keepthe health care system running, and even the higher-level information exchange that helps employees toknow how to do their jobs. Tracking the flow of patients includes defining their exact trajectory in anepisode of care, and sometimes the time required to complete various stages in the process. b. MethodsThe primary method of gathering information in the Information Flow Study was through interviewswith representative members of health center and district hospital staff. Interviews were attempted tobe held with both clinicians and administrators in the main service lines of each facility. A standardline of questioning was developed and applied to each interview, attempting to detail the job functionsand a portrait of a typical day for each employee, as well as the type and manner of informationexchanged with patients and other health care employees.Although the general line of questioning was held relatively constant for most interviews, theframework of questions was kept flexible to allow each conversation to unfold in a way that wouldreveal each employee’s unique insights. In addition to this interview process, direct observation ofmany processes was carried out. Specifically, these processes included hospital supervision of HealthCenters, appointment setting and receiving, health center registration and cashier workflow, RuliHospital registration and cashier workflow, and Ruli Hospital patient reception. After data wasgathered through interviews and direct observation, it was condensed and analyzed to produce a pictureof the flow of information and patients through three levels of the health care system. c. FindingsThe investigation uncovered networks of communication relying primarily on four methods: phonecalls, 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 theCommunity Health Worker level to the District Hospital employee level. The networks tend to grow incomplexity both in types of communication utilized and number of other workers with whominformation 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. 8
  9. 9. 1. Information Flow Hospital Nutrition Service Chief Job 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 9
  10. 10. health centers, but at least in the case of the Ruli Hospital Nutrition Service Chief, thisresponsibility is too time-consuming. Instead, at Ruli, one of the employees who isdedicated to health center supervision carries out this supervision function. While thehealth centers send monthly nutrition reports to the Nutrition Service Chief who brieflylooks them over, the reports are forwarded to one of the full-time supervisors for theactual task of supervision.Once quarterly, the hospital Nutrition Service Chief attends the Coordination Meetingwith hospital supervisors, health center representatives, social affairs workers (sector-level government representatives), the head of the district hospital, and others asnecessary 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 arereceived by a doctor in charge of malnourished patients with complications, typically apediatrician.They are admitted to a separate ward from other pediatric patients as a precaution due tothe low-immunity state that accompanies severe malnutrition. By Ministry of Healthprotocol, 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, dueto space constraints at Ruli Hospital, these two rooms are combined.The doctor on the malnutrition service evaluates the complications which brought thepatient to the hospital, and then calls the Chief of Nutrition to make diet recommendationsto treat the malnutrition component. Occasionally doctors will write a diet order withoutconsulting 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 malnutritionand complications. After discharge, patients follow up at their Health Center for a periodof 1 to 3 months. If improvement is verified, then patients return to surveillance at thevillage level by community health workers.It is rare for patients not to improve with sustained treatment, but if it happens, the Chiefof Hospital Nutrition is informed and writes a letter to the village and sector-levelgovernments asking for investigation into the family’s food security and ability to care forthe patient in question. These patients who have not improved are then treated in thesame pathway as before. 10
  11. 11. Types of Communication:Electronic: Meeting minutes, new policies and supervisor findings from the hospital aresent to the Nutrition Service Chief via email, and the Chief may email the NutritionChiefs of other district hospitals. The nutrition workers at health centers also sendmonthly reports by email, and the Nutrition Service Chief emails the health centerTitulaire after training events to disseminate updates.Phone: The Ministry of Health sometimes calls the Chief to verify receipt of emails, passon 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 Chiefspeaks on the phone with the Director of the hospital regarding messages and reports, andwith doctors regarding diet choices and other clinical questions. At the health centerlevel, 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, whenthe health center calls the ambulance phone at the district hospital, the nurse answeringthat phone calls the Nutrition Chief afterwards when the patient is being received formalnutrition treatment. Very occasionally a community health worker will make orreceive a call from the Chief, typically for messages that are normally supposed to bepassed on through health centers.In-Person: At the hospital level, the Chief meets with the head of the hospital in person totalk about reports, MOH messages, and new policies. The Chief also meets withsupervisors to share certain job tasks, administrators to get approval for expenses and sitevisits, and the hospital accountant/cashier to get money after being approved for travel orexpenses. At health centers, the Chief speaks with the Titulaire and health centerNutrition Chief to review supervision results and recommendations. Finally, the Chiefmeets with community health workers to deliver hospital directives and follow up withhome visits for patients who have been discharged from the hospital.Paper: Used to confirm electronic communication; in other words, an email may be sentfirst and then later a hard copy with signatures. Meeting minutes and summaries are sent 11
  12. 12. via hard copy to meeting participants. Official letters and requests and new policychanges 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 andquality assurance of demographic and epidemiological data at the district hospital and allof its referring health centers. He or she must travel to the health centers to do dataquality auditing roughly 1 week total per month.Another task that the hospital Data Manager must do is to set appointments for patientsreferred from health centers to the district hospital. This task falls to the Data Managerwhether working at the hospital or on the road. To set an appointment, the Data Managerreceives a phone call from the health center, typically from the health center DataManager. During this phone call, the hospital Data Manager writes down on a paper padthe 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 attachedwhich includes further information including: date of appointment phone call, name, sex,age, sector, cell, zone, referring health center, presumptive diagnosis, and appointmentdate. Information is sometimes not received in a timely manner due to the internetconnection being down on either the hospital or health center end.After receiving this information, the hospital Data Manager writes the number ofappointments for each day on a piece of paper, along with the patients’ names. This paperis given to the hospital Registration Desk. Registration is supposed to keep records ofwhich patients came to their appointments and which did not, but it disrupts their workand is inconsistently done.The Ruli Hospital Data Manager also reports problems with patients coming from healthcenters outside the Ruli Hospital Zone, which send patients to the hospital but are notdirectly controllable.Other parts of the hospital Data Manager’s job include data auditing within the hospitaland at the health centers, and generation of a substantial number of reports. There are twoweekly reports – neonatal and epidemiological – which are sent to the Ministry of Health,along with monthly reports of disease incidence stratified by age. The neonatal reportnecessitates phone calls to each health center once per week to retrieve the data. Theepidemiological report is filled out electronically in a Ministry of Health program andsent 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 Healthprogram to send electronically, as well as printing a hard copy for transfer at a latermeeting or during MOH supervision of the district hospital. Each monthly report mustalso have a graphical analysis generated, which is also supervised by MOH to determinethe most common pathologies seen in the hospital. 12
  13. 13. 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 monthlyreports with some added data points and indicators. It is a high level report with fewdetails, including human resources and training information to produce a total picture ofthe district hospital.Data quality auditing is divided into quantitative and qualitative indicators determined byMOH. The hospital Data Manager at Ruli Hospital is in charge of overseeing qualitativeindicators, while another supervisor is in charge of quantitative ones.The hospital Data Manager must also attend the monthly Coordination Meetings whichtake place at the health centers and at the district hospital. At the health centers, thismeeting includes the hospital and health center Data Managers, the Titulaire, and theChief of Supervisors of the Hospital. At the hospital level, this meeting includes theChiefs of all hospital services, the Data Manager, and the hospital supervisors. Eachmeeting 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 inpolicy, and reports are sent to MOH and also to district governments electronically. Thehealth centers send reports electronically as well, and send emails regardingappointments. The hospital Data Manager also uses email to inform health centers ofMOH policy changes that have been handed down.Phone: The hospital Data Manager sets hospital appointments by phone calls with thehealth center Data Managers or other employees, calls the health center Data Managersfor 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 reportfeedback or mistakes on reports, as well as to inform of MOH visits or new policies. TheMOH calls the hospital Data Manager from time to time to coordinate supervisor visitsand communicate about data quality auditing. 13
  14. 14. In-Person: The hospital Data Manager attends meetings and trainings at the districthospital and health centers, supervises services at the hospital and the Data Manager atthe health center, and asks questions and exchanges information informally withemployees of the district and MOH when delivering hard copies of reports by hand orreporting for MOH training exercises.Paper: The hospital Data Manager sends written copies of MOH policy changes andwritten requests to appear for training exercises to health centers and receives writtenmonthly reports. All reports are transmitted to MOH, the district government, and districthospital administrators and service chiefs by hard copy.Hospital Environmental OfficerJob Description: The Environmental Officer of the district hospital works with affiliatedhealth centers and surrounding communities to supervise hygiene and nosocomialinfections, as well as water quality and insect control. This employee is responsible forvisiting commercial establishments within the hospital’s catchment area to evaluatehygiene, and subordinate employees at each health center do the same for households inthe outlying villages. He or she also supervises construction at the district hospital toensure that no harm comes to the surrounding environment. Environmental qualityofficers at the health center level and community health workers send monthly orquarterly reports to the district hospital Environmental Officer. From these, monthlyhospital hygiene reports and quarterly summaries of health center hygiene reports aregenerated, both of which are sent to the hospital, and the latter of which is also sent to theMinistry of Health. This officer also functions as the secretary of the hospital’s hygienecommittee. 14
  15. 15. Types of Communication:Electronic: The Environmental Officer sends email to health centers with any relevantdocuments, and sends and receives emails for any of the reasons that a phone call mightalso be made (see above).Phone: The Environmental Officer calls the heads of health centers and chiefs of servicesto 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 andinstructions for work.In-Person: The Environmental Officer does in-person education to patients and familiesin the hospital about environmental hygiene, and performs supervisory functions inperson at the hospital each morning. In addition, the Environmental Officer provideseducational presentations to the doctors and nurses at the hospital, and interfaces directlywith administrators whenever there is a request for materials or funds. The officer alsotravels to health centers for direct supervision of environmental quality officers andcustodians, and goes to outlying communities for education sessions with the localpopulation.Paper: All reports, both received and sent, are done in hard copies. Formal requests formaterials 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 throughemail to bring to the meeting.Hospital Reception AreaJob Description: The hospital Receptionist is the first employee to receive patients whenthey arrive at the hospital. Typically, many patients are waiting at the beginning of theday and the Receptionist processes them in batches.First, the patients’ insurance information is gathered and photocopied (note: this onlyapplies to patients with MUSA insurance, though they make up the large majority ofvisits). Patients pay the receptionist a small fee at this time for the photocopies. Thereceptionist then collects each patient’s referral form and gives that form along with thephotocopy 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 beenreferred for and calculate a charge according to each patient’s insurance plan. MUSAmembers pay 10% to the MUSA officer who is located nearby, while patients with otherinsurances pay 100% of the charge up front and seek their own reimbursement later. Forinsurance purposes, each patient receives a receipt and a form from the MUSA officernoting the services to be received, which is stapled to the insurance informationphotocopy. This process has been observed taking anywhere from 3 to 11 minutes perpatient.After paying and receiving all their paperwork, patients are oriented to the registrationdesk and shown where to wait for one of the doctors. Once a patient has been seen, thedoctor marks the prescribed medication on the patient’s forms and the patient goes to thecashier again to pay for the prescription. The patient gives the cashier a form listing theservices rendered by the doctor and hospital, takes a receipt, and picks up medications 15
  16. 16. from the pharmacy.Most patients arrive between 7:30am and 10:00am, and then the rate of arrival slows toonly 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 seedoctors in the consultation service. Patients arrive from the reception area and cashierand hand their documents to the registrars who enter demographic information in aregistration log book. A valid receipt from the cashier must be presented to verifypayment. For patients with chronic diseases who do not require health center referrals tobe 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 notbeen to the hospital before (if two registrars are working simultaneously, this can be donewhile the registration log book is being filled out). To make a new chart, three forms arecompleted and stapled together: a full-page blue cover sheet, a half-page white cardstockdemographic form, and a small yellow rendez-vous card on which are written the dates offuture appointments.The patients are sent off to wait for a doctor, while the charts sit in a pile on the registrar’sdesk until a circulating emergency room/consultation service nurse arrives to pick themup. 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 registrationlog. Aside from the previously entered demographic information, they must record eachpatient’s presenting complaints, diagnostic tests, eventual diagnosis, and treatmentinformation, among other data points. As finished charts are not returned until thefollowing 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 tocomplete it.Health Center Registration DeskJob Description: The registration desk at the health centers serves a similar function tothat of the District Hospital, though it assumes some of the functions associated with thereception area at the hospital. Patients arrive at the health center and either go to theMUSA office or the registration desk first. If they arrive at registration prior to theMUSA office, they are redirected there to pick up insurance paperwork before they returnto registration.The patients bring from home a small half-sheet of blue paper which serves as a medicalrecord. The registrar at the health center asks about the problem bringing the patient tothe 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 isavailable. Unlike registration at the district hospital, the registration log book is not 16
  17. 17. located at the registration desk at the health center. Instead, each consultation nurse fillsout 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 tocalculate the amount to be reimbursed to the health center by MUSA. These forms aretaken to the MUSA office to be added to the monthly reimbursement cycle for the healthcenter. The blue half-sheet which comprises the health center’s medical record is kept bythe patient and taken home. If patients require medication from the pharmacy, they pay atthe cashier prior to going there. The cashier stamps their clinical forms to verifypayment.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 seendirectly by consultation nurses instead after going to the MUSA office. Only new patientsgo through registration to receive their clinical forms. The registration worker may taketemperatures among the waiting patients, but not weights, and will defer temperature andother vital signs to the consultation nurses if the clinic is busy.There is not necessarily a dedicated employee at the registration desk. The health centercashier and several nurses were observed performing this task at the Nyange HealthCenter, 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-timeassistant 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 shemust receive and calculate revenues and expenses at the health center. Otherresponsibilities include issuing stipends to health center employees who are traveling forwork, traveling to a bank (which may be several villages away) to withdraw and depositmoney from the health center’s account, calculating and exacting payment from non-MUSA insurance holders, and collecting money for other patient expenses such as thepaper forms used as medical records.The cashier has no communication with the hospital. The cashier does have in-personcommunication with Community Health Workers when attempting to track down patientswho have not paid their Health Center bills. 17
  18. 18. Health Center OrganizationThe health center is partly governed at the village level, in the COSA (CommunityHealth) committee where each health center holds one representative position. The healthcenter is run internally by the COGE (Steering Committee), which is composed ofrepresentatives 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 theTitulaire is a vice-Titulaire who handles the operations of the health center in theTitulaire’s absence. Underneath the layer of top administrators, each service line has oneperson responsible for it, who reports to the Titulaire. In addition to the medical servicelines and administrative functions of the health center, there are also a number of supportstaff such as security guards and building custodians. 18
  19. 19. Health Center Data ManagerJob Description: The health center Data Manager is responsible for managing all patientdata from all services at the Health Center. He or she verifies that the data is collectedand enters it into computer systems (DHS and HMIS) which transfer it electronically tothe relevant district hospital and the Ministry of Health. This patient data is used to helpthe MOH and hospitals to monitor trends and epidemiology for various diseases.In addition to this primary responsibility of data collection and transmission, the healthcenter Data Manager must also set appointments for patients who are referred to thedistrict hospital. For patients with non-emergent conditions, the Data Manager first asksthe patient which dates they would be available to travel to the hospital. Then, the healthcenter Data Manager makes a phone call to the hospital Data Manager to inform themwhich day the patient will arrive. The hospital Data Manager typically accepts theappointment, 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’sname, age, and the date of the appointment. Later, the health center Data Manager sendsan email containing an excel spreadsheet with further demographic and medical detailsabout the referred patients. Although the health center Data Manager has all of thisinformation 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 anappointment. In these situations, the health Center Data Manager only calls the hospital ifthe health center ambulance is busy or malfunctioning, and the phone call is then arequest for a district hospital ambulance rather than a request for an appointment. 19
  20. 20. Types of Communication:Electronic: appointment-setting, communications to and from MOH (usually sent andreceived via District Hospital), to and from district hospital regarding data, meetings,changes in health policy and protocols, monthly reports, and official requests, to and fromthe District regarding development, meetings, and reports.Phone: appointment-setting, guidance and explanation for reporting, new MOH rules andregulationsIn-person: supervisor visits, meetings at the district hospital, training eventsPaper: filling out information in paper appointment log kept at health center (if not DataManager, the Data Entry worker will do this task), summary and tally of number ofpatients with each designated tracked illness in each service line’s written registrationlogs, monthly reports, and letters for official requestsEmail communications are the most important to the job of the health center DataManager because they allow for larger and more detailed messages than phone calls,despite connectivity issues in rural areas. However, sending messages via email is alsoproblematic because of issues in electrical infrastructure as well, which provide a secondlayer of communication insecurity. Although dissimilar to the rest of the jobresponsibilities, the task of appointment setting does not necessarily present itself as aproblem to health center Data Managers, as vice-Data Managers or other employees canperform this task if the primary Data Manager is busy or otherwise unable. 20
  21. 21. The health center Data Manager at Nyange currently has 3 desktop computers to workwith – one for data entry, one for the Data Manager’s use, and one for the IT Manager ofthe 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 serviceline’s registration log books to electronic files. This system will begin in the VCT/HIVservice.Health Center Reception Desk EmployeeJob Description: The health center Receptionists typically start work around 7am, havea break in the middle of the day for lunch, and wrap up operations around 5pm. They arethe first point of contact for patients within the health center and receive patients atreception, making some attempt to triage patients who are already waiting according toseverity of illness. Reception sends patients to the health center Nurses, who thenevaluate and treat them, deciding whether treatment at the health center is appropriate orhospital 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 sicktypically walk to the hospital.Some patients are sick enough to be treated as inpatients, but not sick enough to requiretransfer to the district hospital. These patients can take advantage of a limited number ofbeds 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), therebydetermining which of two consultation rooms they will go to. In principle, Receptionistsshould also separate patients according to whether or not they present with a cough, inorder to reduce transmission of respiratory illnesses. In practice, this is not done (at leastat Nyange) because of limited space; there are simply not enough consultation rooms forcoughing patients to occupy one of their own.When patients arrive, the Receptionist fills out a sheet with their demographic andinsurance information. Then vital signs are taken (except in emergencies) and patients aresent to see nurses based on the above criteria.In addition to responsibilities with patients, the Receptionist may orient new health centerworkers to the layout and operations of the facility. The Receptionist’s responsibilities arecovered by the cashier or a nurse while at lunch or after 5pm. Likewise, the Receptionistcovers the cashier’s job during breaks in the day.Types of communication: The only communication the Receptionist has with the districthospital is through the health center Nurses and Data Manager. Every nurse can call thehospital when necessary for patient care, and the Titulaire of the health centercommunicates changes to policy from higher up in the hierarchy directly to theReceptionist. 21
  22. 22. Health Center Head of Community Health WorkersJob Description: The Head of the community health workers at the health center isresponsible for overseeing the work of those volunteers in all the villages within thehealth center’s catchment area. At the beginning of each month, the Head of CHWsmakes a quarterly plan and a monthly calendar, submits them to the health center andSector for approval, and then makes a summary of operations and collected information atthe end of each quarter. The Head visits villages, makes monthly reports, and performstraining of CHWs. He or she is also in charge of environmental hygiene for thecatchment area. This duty entails visiting commercial centers and households to evaluatehygienic 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 isdifficult to fit in with the somewhat unpredictable course of other work, the Head ofCHWs there spends only 1 day per month on environmental hygiene. Findings arereported to the sector government and to the Chief of Environmental Hygiene at thedistrict hospital.Types of Communication:Electronic: No email is sent or received at the village level. However, electronic versionsof forms are sent from the Ministry of Health via the district hospital to the health centerfor delivery to the Head of CHWs. In addition, monthly hospital meeting reminders andminutes may be delivered via email. Finally, the Head of CHWs sends electronic copiesof monthly and quarterly reports to the district hospital by email in addition to hardcopies.Phone: Community health workers all have telephones and call the Head of CHWs tonotify of events happening at the village level such as complicated patients or pregnantwomen about to give birth. The community health worker can also call an ambulancefrom the health center or district hospital. This kind of communication helps emergentpatients bypass the health center and proceed directly to the district hospital. At thehospital level, the Head of CHWs receives phone calls communicating about monthlymeetings, 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 overan 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 22
  23. 23. health center which CHWs all attend to meet with the Head and analyze the monthlyreports to find gaps in data, errors, and determine prevailing illnesses and trends. It isalso possible for the Head of CHWs to meet CHWs in person if they escort patients to thehealth center. There is another monthly meeting which takes place at the district hospitaland is attended by Heads of CHWs from many health centers, wherein similar reportanalysis is done. Occasional other meetings at the hospital level may require the Head ofCHWs to attend, typically regarding reports, new Ministry of Health programs, ortraining. In addition, at Ruli Health Center at least, there are informal conversationswhich transmit information regarding epidemiology in the villages, reasons for levels ofreferrals to the hospital, and so forth. While health centers in close physical proximity totheir district hospitals may have these types of communications between employees, theyappear 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 inthese reports covers childhood illnesses, family planning, maternal health, deaths, andnutritional status reports. The Head of CHWs then summarizes these reports and submitsa hard copy to the district hospital. In addition, Ministry of Health letters are sometimessent to the district hospital which forwards them to the health center for delivery to theHead of CHWs.Health Center Hospitalization Service ChiefJob Description: This employee is responsible for the limited number of beds that healthcenters offer for moderately-ill patients and expectant mothers. Patients are hospitalizedat 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 thedistrict hospital, yet require some form of extended observed treatment. The process is asfollows:1. The chief verifies that the patient has a hospitalization form from the consultation service2. 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 dose3. 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. 23
  24. 24. The decision to hospitalize a patient is made by the nurse who evaluates them inconsultation. Once a patient is hospitalized at the health center, the decision to transfer tothe hospital is made during the daily staff meeting after the patient has spent one night atthe health center but shown no improvement. The staff exchange ideas for alternativetreatments, then may consider a transfer if appropriate. Although the normal process iscollective, 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 formaternity 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 eventthey 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 withthe district hospital Environmental Officer to control hygiene in all health center areasand ensure adequate performance by custodians.This service chief must generate a monthly hospitalization report for the health centerData 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 reportthat must be given to the district hospital Environmental Officer, but the EducationCommunication Information that is given to patients is kept track of, and simple reportsare transmitted regarding the cleaning supplies needed for the health center. Periodically,this health center Environmental Officer must make reports to the sector governmentabout the state of the health center grounds and gardens. 24
  25. 25. Types of Communication:Electronic: The Hospitalization Chief receives emails through the health center Chiefregarding changes in policy, medication utilization, meeting requests, and other generalinformation. 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 theHMIS 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 theHospitalization Chief will receive them after normal clinic hours. The HospitalizationChief calls ahead to the hospital for maternity patients after normal clinic hours, typicallyspeaking with a nurse.In-Person: The Hospitalization chief has face-to-face interactions with supervisorsregarding reports sent to the district hospital and recommendations for improvements.Occasionally the chief will also travel with transferred patients and interact with thereceiving nurse at the hospital.Paper: The monthly report to the hospital is sent via hard copy, and referrals for childrenunder 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 outpatientclinic. It is staffed entirely by nurses and has responsibility for seeing all new andreturning patients. When patients arrive at the clinic, they are registered in theconsultation log book by a consultation nurse after verification that the patient came from 25
  26. 26. the reception area with properly collected basic information and vital signs. The nursesinterview 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 andlabs and studies are ordered if necessary. The required studies are written on a piece ofpaper that the patient takes to the health center laboratory. Within 10-20 minutes, thepatient receives the results and returns them to the nurse in consultation, informing thediagnosis. With a diagnosis in mind, the nurse writes a prescription (if necessary) whichthe patient picks up at the health center pharmacy after paying the cashier. Thepharmacist (also often a nurse) explains how to take the medication and the patient takesthe 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 healthcenter or refer to the district hospital. This decision to refer to the district hospital hingeson the type or severity of the disease, whether the patient has had multiple health centervisits without improvement, or if a diagnosis can only be made with the resources of thehospital. Hospitalization within the health center is done when the nurse is sure of thediagnosis and the patient cannot go home safely (i.e. the patient requires intravenoustreatment). When the decision is made to hospitalize a patient, the nurse must fill out ahospitalization form, enter the patient in the hospitalization registration log book, escortthe patient to the designated bed, and deliver treatment and follow up at specifiedintervals.One nurse from the health center is supposed to be assigned to hospitalized patientsduring the day, but this nurse is usually assigned to other services and there is noconsistent staffing. Consultation nurses end up checking on hospitalized patients inbetween their other, normally scheduled duties. 2 consultation nurses work per day and atNyange, each sees about 20 patients daily. At busier health centers, both figures areincreased. Though the consultation nurses try, it is difficult for them to make time to seehospitalized patients in addition to outpatients.When hospitalized patients are discharged, the date is noted in the hospitalization registerlog book. The patient then takes a form with information about their hospitalization to thecashier to pay, then heads to the pharmacy to pick up outpatient medication, and leavesfor home.When patients are referred to the hospital, the consultation nurse must fill out a referralform with the patient’s name, vital signs, and the reason for referral. Then, the process issomewhat different for urgent and non-urgent referrals.For non-urgent referrals, the patient is sent to the health center Data Manager who callsthe district hospital Data Manager to make an appointment. The patient is given threecopies of the referral form filled out by the consultation nurse. The patient is logged inthe health center’s transferred patient registration log and the Data Manager’sappointment date log. Then the patient arranges for travel to the district hospital bythemselves, often walking. At the hospital, one copy of the referral form is given to thepatient’s health insurance provider, one copy is kept by the hospital, and the last copy is 26
  27. 27. used by the doctors and sent back to the health center later for performance-basedfinancing requirements. The patient keeps the original form filled out by the consultationnurse.For urgent referrals, the patient is given the same three copies of the referral form, but thistime 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 nurseaccompanies the patient on the ambulance ride to the hospital. At the district hospital, thereceiving 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 tonurses directly. The chief of the health center relays any relevant messages, and reportsthat nurses make to the health center Data Manager are sent to the district hospitalelectronically.Phone: Nurses call community health workers when patients fail to arrive at the healthcenter for follow-up appointments, attempting to discover the reason for the absence andto direct the patient to the health center. Nurses also receive calls from the districthospital when the referral forms were not completed with enough detail and furtherinformation is needed about referred patients. Consultation nurses may also call the 27
  28. 28. hospital when pregnant women are being transported there emergently in order to preparethe doctors and time their arrival correctly.In-Person: Nurses have direct contact with community health workers when maternitypatients arrive at the health center to give birth. Community health workers accompanyall delivering patients and give the nurse information regarding the woman’s clinicalcourse. Hospital supervisors also see the nurses in person to collect information onclinical operations and give guidance. Furthermore, nurses often attend training events atthe district hospital or even in other districts where they interact with hospital supervisorsand representatives from the Ministry of Health for educational sessions.Paper: Consultation nurses receive paper notes about patients from community healthworkers when they refer patients to the health center. Nurses write their findings on thosepaper notes along with their recommendations and patients return them to the communityhealth workers. Nurses also fill out referral forms for patients who they send to thedistrict 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 primarilyout of their health center, but also have many activities they are responsible for in thefield. They primarily serve women and their children to evaluate nutritional status,provide education regarding proper nutrition, teach practice cooking classes and samplefood from the community to ensure nutritional appropriateness, and give nutritioncounseling to pregnant and postpartum women for 6 months after birth, as well as towomen with HIV.After evaluation, patients are treated according to their nutritional status, being dividedinto green, yellow, and red zones. Patients in the green zone are normal and continue tobe monitored at the village level but not seen at Health Centers. Those in the yellow zoneare 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 bycommunity health workers. Community health workers assist in all villages to followchildren, especially newborns, to determine nutritional status. These community healthworkers are elected by Community Based Nutrition Programs in each village to performthese tasks. The employees of the health center Nutrition Service are responsible foreducating the 4 lay people elected as community health workers.For children under 6 months old who are found to have malnutrition, the mothers are sentto the local health center for education. Children and women in the red zone are givenReady to Use Therapeutic Food (RUTF) which is distributed to health centers centrally bythe Ministry of Health. Patients in the yellow zone are treated with SoSoMasupplementation in their diet.At the time of treatment, women and children are sent to the health center from theirvillages. Women are only treated if the child is less than 6 months of age, as Ministry ofHealth policy states that infants that young should be fed exclusively with breast milkunless requiring oral medication or their mothers are unable to breastfeed. Mothers ofthese children receive RUTF and nutritional counseling.For children over 6 months old who are found to be malnourished, the World Health 28
  29. 29. Organization recommendations are followed. These include beginning treatment withSoSoMa as a supplement to breastfeeding if the child is in the yellow zone, or with RUTFif the child is in the red zone. In addition to supplementation, the health center NutritionService provides weekly education sessions for the mothers, as well as practice incooking, hygiene, family planning, and other useful skills. Typically in this case, thechild 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 medicalworkup. This type of case is quite rare.Community health workers, who work very closely with the health center NutritionService, receive training at the health center, district hospital, and Ministry of Healthlevels. The health center Nutrition Service workers and the health center Chief ofCommunity Service are responsible for part of this training, and must also observecommunity health workers to ensure that their work is being done correctly. They alsocollect reports from all the villages in the health center’s catchment area for forwarding tothe district hospital Nutrition Service Chief. These reports detail the number and locationof children in the yellow and red zones of malnutrition so they can be followed up. Thecommunity health workers and health center Nutrition Service make the diagnosis ofmalnutrition by evaluating weight, height, weight gain over time, and upper armcircumference.From the health center level, patients with malnutrition are referred to the district hospitalif they are discovered to have malnutrition with complications which cannot be treated atthe health center. Diarrhea and pneumonia, for instance, can be treated locally, whilemore 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 areaddressed by whatever medical means necessary. The district hospital Nutrition Servicemakes recommendations for much of the malnutrition treatment while the inpatientmedical service determines the correct course for the complications to be treated. Upondischarge, the patients return to their communities and continue to be followed bycommunity health workers there. 29
  30. 30. Types of communication:Electronic: Monthly reports are sent by email and contain a summary of malnutritioncases from all villages in the health center catchment areaPhone: Call to chief of hospital Nutrition Service to apprise of patients being transferredto hospital – this call contains no other information aside from arrival notification, unlessthe patient is not one who has been logged in prior monthly reports. Phone calls are alsomade to and from the hospital Nutrition Service to relay information about new MOHpolicies.In-person: Giving training to CHWs, receiving training at hospital/district/MOH level atdistrict hospital or other location from hospital Nutrition Service representative, districthospital doctor, or another outside expert.Paper: Paper forms are filled out with a nurse’s assessment, malnutrition status, andmeasurements whenever a patient is referred to the hospital in order to help the Chief ofthe hospital Nutrition Service. A paper copy of the aforementioned monthly report is alsofiled with the Chief.Community Health WorkersJob Description: Community health workers form the base of the health care system inRwanda, 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 healthworkers in each village, typically lay-people who are elected to the position. Two of thefour focus on nutrition in the community, primarily in children and pregnant women. Oneis tasked with maternal/infant health monitoring. The last functions as a coordinator forevents involving community health workers and representatives from health centers. 30
  31. 31. 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. 31
  32. 32. The second diagram below shows an example of the flow of patients for a specificillness. The treatment of malnutrition was selected as a specific example to highlight theway that a particular disease state is handled within the general framework in firstdiagram above. 32
  33. 33. e. DiscussionThrough this extensive investigation, a number of interesting points and overarching patternsemerged. Although the study did not include all employees at the health center or hospitallevels, it provides what appears to be a largely representative sample of the type ofcommunication used by health care workers in the course of their jobs. Therefore, theinformation gathered here can be used to draw a number of conclusions and make somerecommendations for future improvements in communication.One of the first clear trends that is present in the data is the increasing complexity ofinformation flow networks at the higher levels of the health care system. Health center workerscommunicate with more people than community health workers, and they use more types ofcommunication. 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 theinformation being exchanged is internal to the health care system and non-clinical in nature.This includes training, supervision, and transmission of reports. These broad categoriesencompass 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 neededto care for patients.In the same vein, many of the employees who were interviewed had chiefly administrative linesof communication, while a few performed primarily clinical duties. Another subset, includingthe nutrition service employees, for example, treat and educate patients and therefore mayexchange 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 aselection bias in the interview process. Many of the people who were interviewed were thechiefs of their particular service, and not ordinary workers within that service. Therefore, it ispossible that the focus of these employees is tilted more heavily to administrativecommunication than the full-time clinicians. In addition, it is also conceivable that some of theportrait 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, thesame information or message is sent twice, in two different formats. Although in many casesthis may cause only a small inconvenience or extra burden on employees’ time for eachinstance, it may add up to a significant extra effort in the long run. However, it is thought to benecessary to repeat communications because of the significant insecurity in electricity andinternet access that exists in large portions of the country. If a better way can be found to dealwith this insecurity, this duplication may represent an opportunity for consolidation andinformation 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 Chiefoutsourcing supervision duties to one of the other supervision employees. Other times it is dueto physical resource restriction, as in the case of Nyange Health Center not being able tosegregate patients by the presence of a cough on presentation, due to a lack of consultation 33
  34. 34. exam rooms. Breakdowns in the prescribed methods of communication might indicate potentialareas 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 involvingpatients is the setting of appointments. The other duties involve collection and validation ofaggregated 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’sresponsibilities.Finally, it should be noted that this study of information flow comes with a few limitations. It issomewhat incomplete for two reasons. It proved difficult to find time to meet all the employeeswho could have been included. Due to job responsibilities and vacations, many people spentsignificant time away from work over the course of the summer. It was also inherently difficultto schedule appointments and make firms plans to travel at particular times, and someemployees were missed. Furthermore, some employees, particularly clinicians at the hospitallevel, were present at work daily but simply could not make time to explore theircommunication networks. For these two reasons, this study can best be thought of as a detailedapproximation that may have gaps in important areas. Nevertheless, it can be used to makecertain 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 34
  35. 35. 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 call 2) Modify the information collected for appointments to include name, ID number, illness, health center, village, and appointment date 3) Shift appointment-setting responsibility at the hospital to the registration desk 4) Gather patient files ahead of time 35
  36. 36. 5) Add doctor-scheduled follow-ups to the appointment log 6) Shift to electronic copies of the appointment and registration logs 7) Modify the feedback loop with Health Centers to encourage them to make appointments and follow up on patients who do not appear for scheduled appointmentsc. 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 36
  37. 37. 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 LevelAt the health center level, the referral system is less complex. Health centers generally referless than 10 patients daily, and in some cases much less. There appear to be fewer changesnecessary at this level for a well-functioning referral system. One short-term opportunity forchange was found which would make a smoother process for patients who are referred to thedistrict hospital. Potential longer-term changes in the way that health centers do their workwere 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 37

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