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

1. Improving Ruli District Hospital’s Referral System Kate Bossart, Chris Chojnacki, Kristin Girouard, Jessica Meyer, Katie O’Hare 4/12/2011

2. Agenda Background Project Description & Overview Recommendations Next Steps

3. District Hospital System Background

4. Rwanda: Facts & Figures Population: 11M Land Mass Comparative: slightly smaller than Maryland GDPPer Capita: $465 (216th Worldwide) Population Below Poverty Line: 60% Urbanization: 18% of total 90% of population engaged in mainly subsistence agriculture Median Age: 18.5 Age Structure: 0-14 years: 42.7% 15-64 years: 54.8% 65 years and over: 2.5% Life Expectancy at Birth: 57 years Ruli Source: CIA World Factbook, WHO Country Profile, IMF

5. Healthcare in Rwanda Healthcare in Rwanda is provided through a tiered system in which the level of care increases as needed to serve the population. Level of Care Geographic Market Nation Specialists District Doctors Sector Nurses Village Volunteers

6. Ruli District Hospital Ruli District Hospital is a full service facility that aspires to be a local Center of Excellence. Provides: Emergency, inpatient and outpatient care General surgery Dentistry Physical therapy Psychological care Performs monthly: 60 surgeries 250 immunizations 300 pre-natal checkups 100 deliveries Has 8 doctors and a full staff of nurses, technicians and administrators Source: Greg Thorne internship “Hospital Operating Statistics”, 8/2010

7. Ruli District Geography The Ruli District Hospital System has 7 affiliated Health Centers, but also supports a number of neighboring, out of district Health Centers. Gayanke Rulindo District Hospital Muhanga In District Health Center Gasagara Out of District Health Center Gasabo Kamonyi

8. Ruli District Health Centers The team visited 6 of the 7 district Health Centers. They vary widely in population served and number of patients referred. Provides: Outpatient consultation and basic inpatient care Staffs ~9 generalist nurses Other employees: data manager, accountant, lab technician, social worker, community workers and maintenance Muhondo Health Center not interviewed

9. In District & Out of District Referrals In 2010, most patients came from Health Centers within the Ruli District system; however, a significant number (~30%) came from out of district Health Centers. In District Out of District Maternity Referral Hospitalization Referral Consultation Referral In District Referrals Out of District Referrals

10. Project Description & Overview

11. Where We Fit Our project focuses on the patient referral process from the Health Center to the next level of care at the District Hospital. Level of Care Geographic Market Nation Specialists District Doctors Sector Nurses Village Volunteers

12. Process Flows Patients must travel to the Health Center first and then may be referred to the Hospital to receive a higher level of care. At each step there is a transfer of patients and information. Step 1: Patient visits Health Center Step 2: Patient is referred to Hospital Health Center Hospital Patients Village Patients Information Information

13. Referral Process Flows Patients may be referred to a District Hospital through one of three channels. Outpatient Referral Outpatient Referral Process shows greatest opportunity for improvement Inpatient Referral Emergency Referral

14. Patient Flow Patients and information flow between the village, Health Center and Hospital. Patients travel from village to local Health Center for medical care Based on illness, patients are treated or referred to District Hospital When referred, patients travel to District Hospital for continued care Patients are treated at Hospital Village Health Center District Hospital Patients Patients Information Information

15. Information Flow Patients and information flow between the village, Health Center and Hospital. Village Health Center District Hospital Patients Patients Information Information Patients travel with symptoms and insurance information Disease information is reported weekly and referrals are reported monthly Hospital collects referral form and treats patient Health Centers collect patient and disease information and provide referral forms

16. Data Collection Over one week, the team compiled a significant amount of information through interviews and data collection.

17. Challenges in Process Flows Opportunities exist to improve both the patient and information flows between the Health Centers and Hospitals, leading to more effective and efficient patient care. Village Health Center Hospital Patients Patients Information Information

18. Recommendations

19. Strategies We developed 4 recommendations to address 4 key challenges. 1 2 4 3

20. 1: Revised Nurse Consultation Process

21. 1: Revised Nurse Consultation Process Why is this a challenge? Patient Care: Patients delay travel to Hospital for variety of reasons: Inability to pay for care Transportation Family issues Social norms: often no urgency to visit Hospital Other Hospital Operations: Variability makes it difficult for Hospital to plan resources effectively

22. 1: Revised Nurse Consultation Process Increase predictability of referrals by collecting information as patients are referred Health Center staff will have better understanding of when patients will go to Hospital

23. 1: Revised Nurse Consultation Process Revised Nurse Consultation Process Process where nurses discuss timing of arrival at Ruli Hospital with patient at time of referral

24. 1: Revised Nurse Consultation Process Sample Referral Arrival Form Discusses Urgency of Condition with Patient Assesses Factors for Potential Delay

25. 2: Daily Referral Text

27. Operations: Hospital cannot allocate resources efficiently to handle patient load

29. 2: Daily Referral Text Current Communication: Referrals are only tallied for monthly reports Daily communication is limited to emergencies

31. 2: Daily Referral Text As an example, Coko made 10 referrals on Monday, September 5th 2011. 7 are expected to come to the hospital on Tuesday, 2 on Wednesday and 1 on Thursday. CokoM.5.9.11 #10 T:7 W:2 Th:1 Location Day and date Total daily referrals Arrival estimates for next three days

32. 2: Daily Referral Text By tracking the last three days of referrals and adding that number to the average same-day arrivals an accurate estimate can be made for Thursday’s patient load. Plus the last three days of information Today’s health center referral counts Gives an accurate estimate for tomorrow

33. 3: Close Feedback Loop

34. 3: Close Feedback Loop Why is this a challenge? Patient Care: May lead to poor patient outcomes Barriers to arrival, including lack of financial resources and burdensome travel, are hard to rectify Health Center Redundancies: May see same patient for same illness that has worsened due to lack of referral follow-through Community Health Worker Resource Strain: current system of follow-up is reactive and can be improved

35. 3: Close Feedback Loop Ensuring patient follow through by increasing responsibility of Health Center for patients may: Allow for appropriation of resources, such as financial aid or transportation, to help patient arrive at Hospital Lead to the ability to identify drivers of patients follow-through failure

37. Implement process where Hospital sends weekly report reconciling referrals to all Health Centers

38. Health Centers will know which patients went to the Hospital and which patients did not go to the Hospital

39. 3: Close Feedback Loop Create a referral database between Hospital and Health Centers automatically updating patient referral information and providing proactive feedback to Health Centers Establish communication procedures down the ladder Prioritize Community Health Worker follow-up with patients not presenting to the Hospital either through phone call or visit Village Formal Health System

40. 4: Data Capture

41. Why is this a challenge? Hospital Budgeting and Operations: Long-term budgeting and resource planning decisions uninformed by hard data Patient Care: Will improve as hospital refines care using data-backed quantitative analysis 4: Data Capture

42. Categorize and plan Identify goals Select variables to collect Collect data Design collection process Analyze periodically Act upon findings Identify trends Create action based on insights 4: Data Capture

43. Near term: Electronically store data from earlier recommendations Record referral data on weekly basis Use existing computers and software Periodically analyze Long term: Consider future University of Michigan project team 4: Data Capture

44. Near Term Example: Referrals 4: Data Capture Record paper based information in Excel Periodically analyze Create actionable insight

45. Phased Implementation Launch recommendations with in district, regional Health Centers first Expand to include all Health Centers that refer to Ruli Hospital Start with largest out of district referral centers In District ReferralsOut of District Referrals

46. Next Steps

47. Next Steps

48. Future Projects

49. Transportation

50. Transportation

51. Town of Ruli

52. Children

53. Fishbowl

54. GORILLAS!

55. Disaster

56. Murakoze!

57. Appendix

58. Key Stakeholders We incorporated the interests of all of all key stakeholders into our analysis and recommendations All Stakeholders operate in the Ministry of Health’s system, which benefits from improved communications between its components and therefore better care

59. Additional Considerations

60. Ruli Hospital Interview The number of expected daily referrals would allow Ruli Hospital to better allocate resources and see patients faster. Hospital Chief of Staff: Referral information received by 5:00 PM the day prior would be actionable in 7:30 AM staff meeting Advanced warning of ailment and additional health history would be even more helpful 6 doctors and 2 doctor interns on staff 3 working at any given time

62. Coko Health Center shares staff with Ruli

63. Data Manager role is inconsistent across centers

64. Hours ranging from .6 to 1.5 FTE

65. At some centers, the Data Manager is also a nurse

66. Centers further from Ruli have mixed influenceas some patients will go to other district hospitalsReporting requirements weekly, monthly, quarterly Regular and periodic Doctor/Supervisor visits Data reconciliation primarily paper with some weekly/monthly electronic filing Hours of operation (9am-5pm) Referred patients walk to Ruli Hospital Patients have similar ailments Health Centers have a similar busy season Health Centers outside the catchment area may differ from those analyzed, especially in reporting, communication methods, and operations

67. Health Center Consistency Current Consultation Log: Information tracking is inconsistent across Health Centers and between months/years leading to inability to analyze data/information Current Log Book Nyange (Recommended) Log Book

68. Communication at Health Centers

69. Regional Health Center Communication Options