Post on 16-Jul-2015
Improving Data Collection and Usage at Ruli District Hospital
David Bernardi, Gregory Fisher, John Ranz, Bryson Smith
Background on Health Care in Rwanda
Project Overview & Objectives
Assessment of Current Situation
Recommendations
Next Steps
Agenda
Background
Ruli District Hospital’s Role in Rwandan Health Care
Rwanda – Country Overview
Source: WHO (http://www.who.int/countries/rwa/en/index.html), World Bank Country Report (http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/AFRICAEXT/RWANDAEXTN/0,,menuPK:368741~pagePK:141132~piPK:141109~theSitePK:368651,00.html) 3
Population2010 10.62M
Size – Land Mass 26.3 M KM2
10.15M Mi2
Gross National Income (GNI) 2010
$5.54B
GNI Per Capita (PPPInternational $) 2009
$1,110
Health Care Spending Per Capita2009 (PPP International $)
$102
Health Care spending as % of GDP
9%
Life Expectancy(m/f) 57/60
Poverty Rate 56.9%
Health care delivery in Rwanda utilizes progressive specialization
Community Health Workers
• Level of Care: Volunteers
• Area Served: Village
Health Centers
• Level of Care: Nurses
• Area Served: Sector
District Hospitals
• Level of Care: Doctors
• Area Served: District
Referral Hospitals
• Level of Care: Specialists
• Area Served: Nationwide
4
Overview of Ruli District Hospital
Health Centers Served
7 – In District6 - 8 – Out of District
Catchment Size 94,0931
Departments Outpatient ConsultationEmergency ServicesIn-patient hospitalizationMaternityOphthalmologyDentistryMental Health
Patients per year ~9,000 Outpatient Consultations
Source: 1) Bossart,et al “Solving Ruli District Hospital’s Referral System Challenges” March 2011 5
Background Project Overview Assessment Recommendations Next Steps
Project Overview
Project Goals, Objectives and Methodology
Background Project Overview Assessment Recommendations Next Steps
Goal to increase efficiency at Hospital and Health Center through data usage
• Improve operational efficiency of administrative and support staff
• Increase availability and use of patient referral and appointment data
• Provide technology solutions for manual processes to ease impact of Ministry of Health and other reporting requirements
• Reorganize administrative responsibilities to maintain consistency of patient interactions
Hospital
• Eliminate duplicative and ineffective processes
Health Centers
• Improve quality of care
• Reduce wait times
Patients
7
Background Project Overview Assessment Recommendations Next Steps
Interviews, data analysis and process mapping were foundation of analysis
• Interviewed hospital and health center personnel to develop understanding of patient and information flows, as well as staff roles, responsibilities, and common challenges
Staff Interviews
• Analyzed patient arrival and appointment data to determine how effective the existing system has been at predicting patient arrivals
Data Analysis
• Created diagrams to illustrate each stage of patient and information flows
Process Mapping
• Observed Hospital registration desk to better understand underlying patient registration data and to audit appointment data
Observation
• Interviewed patients to validate information received from staff interviews
Patient Interviews
8
Background Project Overview Assessment Recommendations Next Steps
Patients currently arrive at Hospital through one of three channels
9
Health Center Referral to Hospital WITH Appointment
Patient visits Health Center
Health Center refers patient
to Hospital
Health Center sets
appointment
Patient visits Hospital on
scheduled date
Hospital Follow-up Referral to Hospital WITHOUT Appointment
Patient visits Hospital
Hospital treats patient and
gives referral for follow-up visit
Patient visits Hospital on
unknown date
Patient Flow
Health Center
Hospital
Hospital
Hospital Follow-up Referral to Hospital WITH set date but WITHOUT Appointment
Hospital
Patient visits Hospital
Hospital treats patient and gives
referral for follow-up visit
Doctor sets date for follow-up visit but doesn’t set formal
appointment
Patient visits Hospital on scheduled
date, date unknown to Hospital
Background Project Overview Assessment Recommendations Next Steps
Assessment of Current Process
Analysis of Appointment, Registration and Reporting Processes
Background Project Overview Assessment Recommendations Next Steps
Referral process has solid foundation, opportunities not fully exploited
11
StrengthsS• Increased communication between health center and hospital• Strong foundation for data exchange• Creates awareness with constituents
WeaknessesW• Slow data collection• Some patient segments are not captured• Inter-departmental data sharing is low
OpportunitiesO• More complete data capture can reduce arrival variability• Faster analysis and reporting with electronic data management• Increases to staff efficiency through planned work
ThreatsT• Better implementation, and thus service, at other district hospitals Reduced referrals and revenue
for Ruli• Changes to MoH mandates limiting Ruli’s ability to comply
Background Project Overview Assessment Recommendations Next Steps
Referral and registration assessment uncovered systemic issues
Areas Investigated
Referral Data Collection and Usage
Registration Process and Data Collection
Registration Reporting Process
Issues Identified
Inconsistent Data Collection
• Referrals logged via phone and email
Inefficient Processes
• Maintenance of electronic and paper records
Lack of Data Usage
• Infrequent communication of appointments logged
12
Background Project Overview Assessment Recommendations Next Steps
Inconsistent data collection results in many exceptions to standard processExisting Appointment Book Existing Registration Book
13
• Registration data is captured in multiple log books– Uncertain benefit for separate first time maternity
patients log
• Registration is not provided with patient information prior to patient arriving at registration window
• Appointment data is collected in multiple formats– Phone Calls
– Emails
• Data format varies by health center
– Not all referring Health Centers set appointments
• Follow-up patient appointments are not currently tracked
Background Project Overview Assessment Recommendations Next Steps
Reduced data usage due to hard copy records and inconsistent processes• Handwritten logs reduce opportunities for data
analysis– Analysis requires manual review and is more prone to
error
• Inter-departmental data sharing is complicated by need to review and utilize log simultaneously– Paper logs limit total users to one
• Patient files may become split if patient ID is unknown by returning patient– Older patient records may become orphaned utilizing
limited storage space while not providing benefit
14
Background Project Overview Assessment Recommendations Next Steps
Process inefficiencies create potential for errors and reduce effectiveness• Referral data is currently tracked on a scratch
pad, electronic log and handwritten log– No calendar is kept for number of total appointments
• Instances of inaccurate numbering due to illegible handwriting impacting reporting– Multiple numbering errors were found during review
of registration logs
• Registration and consultation do not have access to accurate and timely patient projections, limiting work planning
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Background Project Overview Assessment Recommendations Next Steps
Appointment system accounts for low proportion of arriving patients
0
20
40
60
80
100
120
8/2
/20
12
10
/2/2
01
2
14
/2/2
01
2
16
/2/2
01
2
20
/2/2
01
2
22
/2/2
01
2
24
/2/2
01
2
28
/2/2
01
2
3/1
/20
12
3/5
/20
12
3/7
/20
12
3/9
/20
12
13
/3/2
01
2
15
/3/2
01
2
19
/3/2
01
2
21
/3/2
01
2
23
/3/2
01
2
27
/3/2
01
2
29
/3/2
01
2
Total Outpatient Arrivals Appointments
16
Background Project Overview Assessment Recommendations Next Steps
Appointment system has not reduced volatility in outpatient arrivals
-
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Before Current
Daily Average St. Dev.
-
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Before Current
Lower 25th Percentile of Arrivals
Upper 25th Percentile of Arrivals
Before is the period from January 3rd, 2011 through the implementation of the referral system in February 2012. Current is February 2012 through present. 17
Background Project Overview Assessment Recommendations Next Steps
On April 3rd, majority of referred patients arrived without appointments
Type Number Percentage
Had referral only 39 78%
Had referral and appointment
10 20%
Chronic or follow-up 1 2%
Total 50 100%
Health CenterIn/Out of District
Patient ReferralsPatient
Appointments
Coko In 2 1
Gasgara Out 4 0
Gitega Out 2 0
Kabuga Out 1 0
Kayenzi Out 2 0
Muhondo In 7 0
Nyabikenke Out 7 1
Nyange In 1 1
Ruli In 10 5
Rushashi In 2 2
Rutonde Out 1 0
Rwahi Out 1 0
Rwankuba In 3 0
Unknown N/A 6 0
Total 49 10
Patient arrival data gathered at registration on April 3rd, 2012. Six patients’ registrations were unobserved. 18
• In district Health Centers had appointments 36% of the time (9 of 25)
• Out of district Health Centers had appointments 6% of the time (1 of 18)
Background Project Overview Assessment Recommendations Next Steps
Recommendations
Background Project Overview Assessment Recommendations Next Steps
Recommendations range from quick wins to long-term strategyShort-Term• Changes that can be enacted in the next six months• Form the basis for mid-range and long-term strategic vision for data
usage
Mid-Range• Modifications in the one to three year time horizon• Build upon foundation of short-term recommendations• May require capital allocations
Long-Term• Guiding principles for data management at the Health Center and
Hospital levels• May require support from, and modification of, MoH directives
20
Background Project Overview Assessment Recommendations Next Steps
Changes to the Health Center and Hospital appointment process
Proposed Changes: Immediate Action
Intended Impact
21
Collect all data points during phone call
Modify data points collected
Shift appointment setting to registration
Add doctor scheduled follow-ups to appointment log
Shift to electronic log only
Modify feedback loop with Health Center
Information is available sooner and actionable
Elimination of unused data points speeds data transfer
More natural fit for work task, easier inclusion of follow-up visits
Provides more complete view of total patient volume
Eliminates duplicative effort, increases analytical capability
Increased ability to communicate need to see physician
Background Project Overview Assessment Recommendations Next Steps
Electronic logs improves efficiency and analytical capabilities
Electronic Registration Log
• Benefits include:– Reduction in errors caused by illegible entries
– Ability to recover lost patient IDs
– Stored information can be used to perform analysis of patient trends
– Increased speed in data entry and month end reporting
– Hospital can track which Health Centers refer patients without scheduling appointments
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Electronic Appointment Log
• Benefits include:– Returning patients’ files can be pulled day prior to
their appointment to reduce registration time
– Reduction in variability as appointment log will account for greater percentage of appointments, allowing for improved scheduling
– Improved system for tracking which referred patients arrived at Hospital
Background Project Overview Assessment Recommendations Next Steps
23
Changes to data storage and usage
Proposed Changes: Mid/Long-Term Action
Intended Impact
23
Centralize patient paper records
Develop central hospital information network
More complete patient records, easier retrieval of entire patient history
Increased inter-departmental information sharing and reporting
Move to electronic patient records
Easier retrieval of patient history, increased analytics, eases reporting process
Background Project Overview Assessment Recommendations Next Steps
Key Takeaways
Move appointment
setting to registration
desk
Utilize digital logs for
registration and
appointments
Have registration
desk pull next-day
appointment files
Record doctor scheduled follow-up
referrals in appointment
log
24
Background Project Overview Assessment Recommendations Next Steps
Next Steps
Implementation steps for immediate recommendations
Background Project Overview Assessment Recommendations Next Steps
Modifications to appointment setting process• Modify data collection to mirror excel template (provided)• Switch appointment recording to registration• Include doctor scheduled follow-ups in appointment log
– Doctors to stack patient files in separate piles to indicate which require follow-up appointments• Registration enters relevant data onto appointment log from patient
files, prior to refiling
• Health Center appointments– Phone call
• Exchange all data points via standardized phone call
– Email• Discard email from Health Center to Hospital
26
Background Project Overview Assessment Recommendations Next Steps
Modifications to appointment setting process (cont.)• Utilize new appointment schedule to reduce variation in
patient arrivals– Reduce appointment cap on dates known to have high volume
of chronic patients (i.e. last Thursday of each month)– Use historical data to predict trends in patient arrivals
27
Background Project Overview Assessment Recommendations Next Steps
Modifications to appointment feedback loop• Shift appointment attendance check to registration
– Aligns with shift of appointment setting
– Natural fit due to dependency on registration logs
• Change from negative check (i.e. marked if missed) to positive verification (i.e. marked when registered)
• Email appointment log to all Health Centers on Friday of each week– Alerts Health Centers to missed appointments
• Investigate reasons for non-conforming Health Centers and reiterate the importance of their cooperation
28
Background Project Overview Assessment Recommendations Next Steps
Modifications to registration and filing process• Capture all pertinent patient information in
electronic registration log (excel templates provided)– Electronic data in same format as paper logs, with the
addition of maternity flag, Health Center and appointment verification
• Retrieve patient files for next day appointments at end of each day
• Communicate following day’s appointment schedule (volume and illnesses) to Head Nurse for use in staffing
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Background Project Overview Assessment Recommendations Next Steps
Appendix
Background Project Overview Assessment Recommendations Next Steps
Outpatients registered per day
0
10
20
30
40
50
60
70
80
90
3/1
/20
11
3/2
/20
11
3/3
/20
11
3/4
/20
11
3/5
/20
11
3/6
/20
11
3/7
/20
11
3/8
/20
11
3/9
/20
11
3/1
0/2
01
1
3/1
1/2
01
1
3/1
2/2
01
1
3/1
/20
12
3/2
/20
12
3/3
/20
12
3/4
/20
12
Above data excludes the last Thursday of every month. 31
Background Project Overview Assessment Recommendations Next Steps
Outpatient arrivals
Daily averages for outpatient arrivals
-5
10 15 20 25 30 35 40 45
Monthly averages for outpatient arrivals
05
101520253035404550
Above data from January 3rd, 2011 through present, excluding last Thursday of every month and holidays. 32
Background Project Overview Assessment Recommendations Next Steps
Outpatient arrivals on last Thursday of each month
0
20
40
60
80
100
120
33
Background Project Overview Assessment Recommendations Next Steps
Current appointment data from Health CentersAppointments by Health Center
Health CenterIn/Out of District
Appointments Percentage
Coko In 92 16%
Gasagara Out 44 7%
Muhondo In 51 9%
Nyabikenke Out 98 17%
Nyange In 47 8%
Rukura In 16 3%
Ruli In 125 21%
Rushashi In 51 9%
Rwankuba In 66 11%
Total 590 100%
Days after referral call that appointment is set
Days Appointments Percentage
0 23 4%
1 486 82%
2 56 9%
3 15 3%
4 6 1%
5 0 0%
6 1 0%
N/A 3 1%
Total 590 100%
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Background Project Overview Assessment Recommendations Next Steps
Per week appointments made by Health CentersHealth Center
In/Out of District
30/1/2012 6/2/2012 13/2/2012 20/2/2012 27/2/2012 5/3/2012 12/3/2012 19/3/2012 26/3/2012 Total
Coko In 0 5 10 9 14 19 13 10 12 79
Gasagara Out 0 5 2 14 8 2 9 4 0 43
Muhondo In 0 5 6 13 7 1 5 7 7 39
Nyabikenke Out 0 13 13 23 3 10 4 16 16 78
Nyange In 0 12 9 5 0 8 4 3 6 41
Rukura In 1 2 2 5 3 0 0 3 0 13
Ruli In 1 19 26 29 19 14 10 3 4 121
Rushashi In 2 4 11 5 7 8 9 1 4 46
Rwankuba In 8 18 6 6 8 7 7 6 0 60
Total 12 83 85 109 69 69 61 53 49 590
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