ruli hospital map 12.253 presentation v11 1

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%

http://www.who.int/countries/rwa/en/index.html

http://www.who.int/countries/rwa/en/index.html

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


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


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


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


Assessment of Current Process

Analysis of Appointment, Registration and Reporting Processes


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


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


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


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


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

15


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


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


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)


Recommendations


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


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


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

22

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


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


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


Next Steps

Implementation steps for immediate recommendations


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


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


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


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

29


Appendix


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


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


Outpatient arrivals on last Thursday of each month

0

20

40

60

80

100

120

33


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%

34


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

35

ruli hospital map 12.253 presentation v11 1

Health & Medicine

registration data

data analysis

data usage7interviews

reduced data usage

data exchangecreates

health centernot

health care spending

health care delivery