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Ruli Hospital Improves Patient Tracking with Standardized Forms and Mutuelle Partnership
1. A Path to Solving Ruli Hospital’s
Patient Tracking Challenges
Annie Snider, Kevin Wooster, Matthew Downer, Penelope Mallinckrodt, Yasuo Tsurumi
3/8/2013
2. Ruli Hospital and Health Centers provide an
impressive array of health care services
Scale
Complexity
Pride
Impact
3. Further elevate center of excellence
through improved patient tracking
Home Spring 2013 Project
Health Care
Center
Spring 2012 Project Hospital
Summer 2012 Project
4. Status Update
Recommendation Successful?
Include patient phone numbers in appointment setting call
Use Microsoft Access for electronic registration and
Ruli Hospital
appointment logs
Sort new charts as created to reduce search time
Return charts to registration after doctor consults
Triage patients with appointments
Health Centers
Shift appointment making from data manager to cashier
Adopt electronic registration log
Centralize patient record keeping
5. Four Areas of Focus
Behavioral Dynamics
Patient Tracking Process Improvements
Implementation
Future Opportunities
7. Behavioral Dynamics Intro Slide
Area Need Recommendation
Capabilities Quick way to understand
Skills Matrix
Knowledge and display staff capabilities
Variability of Resources to meet demand Cross-Team
Demand at peak times Collaboration
8. Create a skills matrix to better understand
capabilities
Registration File Computer French English Interpersonal Adapts to
System Skills Language Language Relations Change
Annie
Matt
Yasu
Kevin
Penelope
9. Encourage cross-team collaboration to
meet demand at peak times
8:00 14:00
Consults Consults
Registration Registration
Accounting Accounting
Reception Reception
11. Data collection and management systems
are inhibiting accurate patient tracking
Area Need Recommendation
Current tracking system
duplicates work at every Standardize patient
Data Collection
level forms throughout system
Current resources do not
easily allow for consistent
Data Management Use Mutuelles Data
and thorough data
management
12. Standardizing records between health
centers will make processes more efficient
Location Forms Record Keeping
Patient Hospital
Form Record
Ruli
Appoint- By visit date
Hospital Referral Mutuelle
ment
Form Card
Card
Ruli &
Nyange Patient Mutuelle Mutuelle No record
Health Form Card Document stored
Center
Other Patient Mutuelle Mutuelle No record
Health Form Card Document stored
Centers
Rukura Health Center
13. Multiple forms with the same information lead to
inaccurate data, duplicated work and bottlenecks
1. Reception 2. Insurance 3.Registratio 4.Consultation 5.Accounting 6. Pharmacy
Make copy of and Submit Examination, Remit Pick up
patient accounting referral form treatment, etc. payment for medication
insurance Fill in the diagnostics
card insurance file and
Pick up blue treatment
Remit record
Orientation Payment
Same Data
ID ID ID ID ID ID
Invoice to Mutuelle
Insuranc Insuranc Insuranc Insuranc Insuranc Insuranc
mutuelle Document
e e e e e e
Patient Card Patient Card Patient Card Patient Card Patient Card Patient Card
Patient
takes
home
Health Info may
Referral Referral Referral Referral Referral be sent to
Form Form Form Form Form
Center Data
Manager CHW
Nurse Record
Patient Patient
delivers to may be
Record Record
reception filed and
stored at
hospital
14. Result of complicated data collection
• Disorganized files
• Duplicated records
• Cluttered workspace
• Long patient wait
times
16. The Mutuelles are excellent source of
existing patient data
High adoption rates mean that 80+% of population already have a
Substantial health record
Mutuelles verify symptoms, diagnosis and treatment twice in the
Accurate same month of health facility visit (this is done at the district level)
Both paper and electronic records are highly organized and accessible
Organized
• There is already a mutuelle office at every health center
• Mutuelles already understand the health center patient file system
Connected • Mutuelles already partner with health centers for community
health education
17. Patient arrives with ID/Insurance card, one
form circulates and information is utilized
Mutuelle
ID/Insura Document
nce
Mutuelle
Office/Reception
•Check in
•Pick up medical chart
Pharmacy Accounting
Mutuelle Mutuelle
Document •Pick up medication •Remint payment for Document
consultation
Data Mutuelle Community
Manager Worker Health
Worker
Accounting Reception
Mutuelle •Pay for tests and treatement •Enter system (wait area) Mutuelle
Document Document
Consultation
Mutuelle
Document
18. Benefits to both patient care facilities and
mutuelles outweigh challenges
Challenges Solutions
Perceived conflict of interest Governance system proposed
by the senate in March will
strengthen checks and balances
and improve the Mutuelles’
ability to maintain quality data
Mutuelles currently do not track Maintaining hospital and health
non-members or lapsed center records enables local
members Mutuelles to implement
targeted marketing to increase
adoption
Some mutuelles only keep Central government oversight
electronic records of costs, not will enable efficient training and
diagnoses resource allocation
19. Integrated Mutuelle Governance
Central Government
MoH Mutuelle Fund
Administrators
Hospital/Health Center
Mutuelle District
(Audits and Overviews)
Clinicians Finance/Accounting
Mutuelle Sector
Administrative Staff HR (Day-to-day Management)
Operations Data Manager
Mutuelle Data
(Local Mutuelle office)
Reception/Registration
20. Mutual gains create impact on overall
health of the community
Action Benefit to Mutuelle Cost Impact
Collect and Consumer data allowing Minimal There is a positive correlation
maintain records targeted marketing between mutuelle membership and
for non-members which increases the quality of health. A mutuelle
adoption rate member is 51% more likely to visit a
health center than a non-member1
Store patient data Data representing entire None Better community education lowers
at the community population enables spread of disease and poor health
health center mutuelle to act faster practices
with education
Lowers costs
Serve as hub for Clear understanding of Minimal Consistent reporting of health status
dissemination of health status allows for to all stakeholders; better informs
data efficient actuarial community health workers which
processes. In addition, improves follow-up care
better follow-up care
lowers mutuelle costs.
1. Bayege, Innocent. Contribution des mutuelles de sante à l'accessibilite de la population aux services de sante. Université Nationale Rwanda. [Online]. 2005
22. Identify obstacles and solutions for
implementation
Process Resource
Prior Recommendations Successful
Change Addition
Include patient phone numbers in appointment setting call
Use Microsoft Access for electronic registration and
Ruli Hospital
appointment logs
Sort new charts as created to reduce search time
Return charts to registration after doctor consults
Triage patients with appointments
Health Centers
Shift appointment making from data manager to cashier
Adopt electronic registration log
Centralize patient record keeping
23. Manage change carefully to ensure long
term success
Align key Motivate and
Consolidate
stakeholders Communicate
24. Align Key Stakeholders
• Define stakeholders more broadly
• Include the three sisters
• Enlist a core change team
• Ensure suitable personal attributes
• Endow with positional power & credibility
• Map stakeholder resistance and support
• Focus on neutral and positive to generate critical mass
25. Motivate and Communicate
• Create a sense of urgency
• Securing verbal buy-in is not enough
• Connect changes to a deeper purpose
• Link to impact on patient
• Implement visual management tools (Whiteboards)
• Information becomes more widely accessible
• Celebrate successes
• Enhance cross-team collaboration
26. Sample Whiteboard
Friday, March 8th, 2013
Record Keeping
Outstanding Records
Mon Tues Wed Thurs Fri
27
Patients Treated / Electronic Records Entered
Key Personnel Issues
Dr. Avite In Office
Ministry of Health supervisor visits Friday
Sister Carmen In Office
In Kigali X-Ray machine is not working
MOH Admin Out of Office
until Thurs.
Doctor #1 In Office Drug X stock is low
Doctor #2 In Office Only one doctor next Thursday
Dept. Chiefs In Office
27. Consolidate gains
• Align systems with the changes
• Recruitment & training
• Performance appraisal and rewards
• Align structures with the changes
• Fill key positions with right people
• Plan for quick wins
• Start small
• Maintain momentum
29. Rotational programs expand training and
help make Ruli a center of excellence
Hospital
Registration Ruli
Rukura
Data
Reception
Manager Already has clinical
rotational program
Nyange
Surgical
Rushashi
Consults Maternity Muhondo
30. The Community Health Worker program can
be expanded to improve Patient tracking
Potential Opportunities Impacts
Patient Interaction - Improved quality of care
- Serve more Rwandans - May identify unknown contributors
- Can get holistic view of Patients to patients’ maladies
- Can have more time with patient
Observation + Monitoring - Improved patient outcomes
- Chronic conditions - Earlier interventions
- Signs of infection - Fewer secondary visits to HC s or Hospital
- Side effects of medication
- Lower recurrence rate
Follow through of treatments
- Less need for 2nd visit to HC or Hospitals
- Less development of drug resistant
strains (e.g., tuberculosis)
32. Key Takeaways
• Skills Matrix
Behavioral Dynamics
• Cross-Team Collaboration
Patient Tracking • Record Standardization
Process Improvements • Mutuelles Data
• Align stakeholders
Implementation • Communicate and motivate
• Act and consolidate
• Rotational Program
Future Opportunities
• Expand Community Health Worker Role
36. Patient flow: Ruli Hospital
2. Insurance
1. Reception and 3.Registration 4.Consult- 5.Accounting 6. Pharmacy
accounting
-Make copy of - Fill in/submit ation - Make - Medicine to
patient - Fill in the documents payment for be pick up
insurance file - Necessary medicine and
insurance -pick up treatment,
card - Make examination
personal blue examination,
- Orientation payment for record etc. given
consultation
• Blue • Blue Patient
Patient record is carried
record back to registration
Patients bring in by nurse Patients bring back
• White • White • Yellow • Yellow • White
• Yellow • Yellow
appoint Insurance Patient
Appoint Insurance Referral Patient
Form Card ment Card Card
ment Card Card
card
- General Info (name, address, etc.)
- Information about vital, diagnosis, medicine
ID number
37. Patient flow: Ruli & Nyange Health Centers
1. Insurance 2. Reception 3.Consult- 4.Accountings 5. Pharmacy 6. Insurance
Office - Office
- Check ation - Medicine to
symptom and - Make be pick up -Bring back
-Pick up - Necessary
sort out payment personal
personal treatment,
- Check vital examination, sheet (Blue)
sheet (Blue)
signs etc. given
Data Manager
Patients bring in set appointment
Patients bring back
if patient needs to • White • Yellow • White
be referred.
• Yellow • White Referral Insurance Patient
Insurance Patient Form Card Card
Card Card (if referred
to hospital)
- General Info (name, address, etc.)
- Information about vital, diagnosis, medicine
ID number
38. Patient flow: Other Healthcare Centers
1. Reception 2. Insurance 3.Consult- 4.Accountinga 5. Pharmacy 6. Insurance
- Check Office Office
ation - Make - Medicine to
symptom and payment be pick up -Bring back
sort out - Necessary
-Pick up treatment, personal
- Check vital personal examination, sheet (Blue)
signs sheet (Blue) etc. given
Data Manager
Patients bring in set appointment
Patients bring back
if patient needs to • White
• Yellow • Pink be referred.
• Yellow • Pink
Insurance Simple Referral Insurance Simple
Card Notebook Form Card Notebook
(if referred
- Information about vital, diagnosis, medicine to hospital)
ID number
39. A new way of electronic recording in
the hospital
• For more efficiency and future needs
Detach from daily operation Assign inputting electronic data to
others with computer skills
• Hire temporary (young) staff having
Reception
computer skills for a day per week
only for data input
Pharmacy Registration or
• Assign existing staff (in both hospital
and healthcare centers) having
computer skills and quite low-
Consultation Accounting
utilization time in a week to data
input for a certain hours per week
40. Standardization among hospital and
healthcare centers
Long term proposal
• Start keeping records also at
• Track and Keep patient
healthcare centers
information based on ID number
• Manage with the same format
unified among the hospital and
among the hospital and
healthcare centers
healthcare centers
Image (example) Image (example)
-Top side Basic patient info -Patient card -Shelf for patient record
(ID, address, etc)
0000
ID number:
Diagnosis 1000
XXXX
information -reverse side 1001
2000
2001
3000
Diagnosis
information
3001
Year &date 4000
Notas del editor
Scale, impact, complexity
Home to health care to hospital is going well! (dan’s and MAP team’s projects)Our project will focus on patient tracking to address follow up care and resource planning
Matt is the most skilled, Annie is the least skilled
<Point>Managed differently- Documentation: different among institutions- ID number: currently only for hospital- Record filing: currently only at hospital
Patient don’t have to carry the file for insuranceRegistrationFirst visit: Fill yellow appointment card, blue record, white patient card, submit 3 referral papersSecond visit and after: Submit yellow appointment card, white patient cardYellow card: Appointment card After consultation, date of the follow up visit written in the yellow card is different from yellow insurance cardAlmost everyone-Insurance 10% (hospital)-Insurance: over 200RFc covered (patient fee is maximum 200Rfc)ID number is not written in white patient card.ID number is only written in yellow appointment card(patient keeps) and blue record (hospital keeps)Even though the treatment finished once, patient have to keep that because it is the only wayTo know their each ID.
Create a vision for changeHelp staff connect with the vision of change. Help them understand their own roleE.g. survey. Not enough to obtain verbal approval. They understand the need for change, but not strong enough
Short term programs help address geographical constraints
Patient don’t have to carry the file for insuranceRegistrationFirst visit: Fill yellow appointment card, blue record, white patient card, submit 3 referral papersSecond visit and after: Submit yellow appointment card, white patient cardYellow card: Appointment card After consultation, date of the follow up visit written in the yellow card is different from yellow insurance cardAlmost everyone-Insurance 10% (hospital)-Insurance: over 200RFc covered (patient fee is maximum 200Rfc)ID number is not written in white patient card.ID number is only written in yellow appointment card(patient keeps) and blue record (hospital keeps)Even though the treatment finished once, patient have to keep that because it is the only wayTo know their each ID.
<Point>Based on the 3 background reasons, realistically, it is difficult to change current employee’s mind to do additional and unfamiliar work.However, electric data improves process efficiency, for example data to submit to MOH can be created at onceIn addition, it is evident that the day comes, when it should manage data electrically. (Maybe must convert paper data into electric data)There should be young, not so expensive worker with computer skills in younger generation. Hire those staff temporarily should be the best option. He might not need to come to Ruli. If it is not possible, assign staff with computer skills might be an option. For example, in Rukura healthcare center, there is less patient, less busy and several employee with computer skills. Not only assigning staff internal hospital, seeking also from heathcare center can be an option.
<Point>For mid-long term, the day will come, the day from when Health Center should manage patient record by its own decision or regulation of MOHCost efficient (same printing, purchase at once scale merit)Easy to manageBetter for information sharingStandardization makes employee transfer easier- Managing by ID number and consistent filing system helps patient tracking much- In additon, Fax transmission will help those patient information sharing