Health referral systems form a major component of the healthcare structure globally. Referral has been defined as a process in which the treating physician at a lower level of the health service, who has inadequate skills by virtue of his qualification and/or fewer facilities to manage a clinical condition, seeks the assistance of a better equipped and/or specially trained person, with better resources at a higher level, to guide him in managing or to take over the management of a particular episode of a clinical condition in a beneficiary (Al Mazrou et al, 1990).
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The healthcare structure in Kenya employs a referral system where patients are transferred from lower level facilities to higher level centres depending on their need for specialized care. The public national referral hospitals namely; Kenyatta National Teaching and Referral Hospital (KNH) in Nairobi city and Moi Teaching and Referral Hospital (MTRH) in Eldoret town are at the apex of the healthcare system providing sophisticated diagnostic, therapeutic and rehabilitative services. These two facilities serve a complex network of over 4700 health facilities countrywide categorized into various levels depending on the degree of speciality of services they provide. The private sector contributes about 49% of these facilities with several privately owned hospitals complementing the national referral hospitals by providing highly specialized services.
The Ministry of Medical Services has committed itself to “re-invigorate” the hospital referral system with an aim of achieving capacity to offer quality cost efficient referral services by revising the current referral procedures, upgrading basic skills of service providers and enhancing communication and transport facilities. (Ministry of Medical Services Strategic Plan 2008-2012). This will be in keeping in line with Kenya Vision 2030, Kenya’s development blueprint covering the period 2008 to 2030 which aims at providing an efficient and high quality health care system with the best standards. Having this commitment in mind, it is necessary to examine the effects of the current referrals on health service provision to bring out the positives and limitations of the referral system. This will culminate into focused interventions to make the system more efficient.
Just as any system comprises of a set of interacting or interdependent components forming an integrated whole (Buckland 2000), the referral system is made up of several interrelated processes geared towards improving the health of the patient. One of the key components of the referral process is communication. Effectiveness of a hospital referral system depends largely on the ability to make the transfer of patient medical information from one healthcare worker to another in a timely and comprehensive manner. Poorly handled paperwork, incomplete notes and inadequate pre-referral investigations can result in missed and delayed diagnosis eventually increasing the burden of morbidity and mortality.
This study will examine the mode of communication of laboratory investigations carried out by the primary clinician to the referral facility. It aims to highlight any effects of this referral system on the quality of information transferred and the resultant impact on the process of investigation. It is hoped that any gaps identified will form a useful beginning point towards making investigations of referred patients more timely, cost-efficient and appropriate.
The study will be carried out in Kenyatta National Teaching and Referral Hospital (KNH). Being the largest and busiest national referral centre in Kenya it is hoped that the information gathered will not only be used to enhance the referral process to KNH but will used to improve the referral system countrywide.
1.2 Problem Statement:
The process of referral largely involves the transfer of patient information from one clinician to another. This information is expected to contain the general clinical history of the patient, the type and findings of pre-referral investigations and the reasons for referral. With the initial baseline investigations having been done, the receiving clinician will focus on specialist investigations and management of the patient.
The process of communicating pre-referral investigations is prone to mishandled or lost paperwork. The information is also likely to be inadequate due to time pressure required to write complete notes. In such cases the receiving clinician will be forced to repeat these investigations increasing the cost burden to the hospital and the patient. This may also lead to increased waiting times and delayed diagnosis resulting in disease complications and increased morbidity and mortality.
1.3 Justification:
The results of this study can be used to generate secondary data as to the magnitude, scope and socio-demographic characteristics of patients referred to KNH which can be used as baseline data for strategic planning, putting up of other referral facilities and targeting of specific disease zones.
The results of this study can give clinicians and hospital administrators in KNH an insight into the current referral process and its effects on investigating patients with an aim of addressing gaps identified.
This study will also provide the policy makers at the Ministry of Health with information on the referral constraints faced by other peripheral health facilities which refer patients to KNH with an aim of addressing them.
1.4 Research Questions:
The need to improve the current referral process means understanding its effects on delivery of healthcare.
This research aims to bring this understanding by answering the following questions;
What are the socio-demographic characteristics of patients referred to KNH?
What are the effects of the referral process on investigating patients referred to KNH?
1.5 Objectives of the study:
To determine the socio-demographic characteristics of patients referred to KNH in the year 2013.
To determine the number of repeated investigations attributed to improper or mishandled documentation of pre-referral investigations among patients referred to KNH in the year 2013.
To establish the extra cost attributable to repeated investigations due to improper or mishandled documentation of pre-referral investigations among patients referred to KNH in the year 2013.
CHAPTER TWO:
LITERATURE REVIEW:
2.1 Introduction
The whole process of generating a clinical referral for a patient and the resulting transfer from the primary physician to the specialist and back again, are key components in the struggle to deliver less costly and more effective clinical care. As larger and more complex integrated healthcare delivery networks continue to emerge, the problems of finding an appropriate specialist and communicating patient information from one provider to another has become increasingly important (Clancy et al, 1996). The competition between healthcare delivery systems keeps increasing resulting in the need to provide customer service in terms of prompt, polite and informative communication to referring physicians (Montalto, 1998).
2.2 Socio-demographic Factors
Socio-demographic characteristics have been found to influence the process and extent of referral of patients from primary care to specialized care (McBride et al, 2010). While carrying out research in variation in referral in the United Kingdom, McBride et al (2010), were able to establish the following; that the likelihood of referral to secondary care was associated with patient’s age, sex and social deprivation; older patients were less likely to be referred for all symptoms and that socioeconomic inequalities in referral were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions.
While carrying out a customer satisfaction survey at the Accident and Emergency Department of Kenyatta National Hospital where referred patients are first received, Chika et al (2010), found out that there was almost the same number of females as there was of males visiting the Accident and Emergency Department. 28.7% of the patients had their highest level of education as Primary School while 39.9% had their highest level of education as Secondary School. 7.9% had no formal education while 3.2% had their highest level of education as University. The study also revealed that 70.6% of the patients received at this department had an average monthly income of less than KShs 10,000.
2.3 Referral process
Kenya’s healthcare system is structured in a stepwise manner so that complicated cases are referred to a higher level. The diagram below illustrates this:
6
Tertiary hospitals
5
Secondary/Provincial hospitals
4
Primary/District Hospitals)
3
Health centers, maternities, nursing homes
2
Dispensaries/clinics
INTERFACE
1
Community: Villages/Households/Families/Individuals
Figure 2.1 Levels of health care delivery in the Kenya (Source: Muga et al, 2005)
Kenya’s National Health Sector Strategic Plan II proposes the rationalization of service delivery from level 1 where community based services are to be provided to level 6 which provides services at the national level. National Referral Hospitals are at the apex of the healthcare system, providing Tertiary care with sophisticated, diagnostic, therapeutic and rehabilitative services. Patients who need these speciality services are sent to the national referral hospital upon recommendation from the primary clinician from a lower level facility.
The Norms and Standards for Health Service Delivery from the Ministry of Health define the expected service standards for different activities to be delivered at different levels of the health system to ensure comprehensive health service delivery.
Level 1 is the community level which is the foundation of service delivery. Activities here emphasize on promoting appropriate healthy behaviours and recognition of signs and symptoms of conditions that need to be managed at other levels of the system. Level 2 is the interface between the community and the physical health system. It ensures provision of curative services like case management of suspected malaria cases, acute respiratory tract infections, fevers, diarrhoea, simple skin conditions, other simple common illnesses and chronic illnesses like tuberculosis and HIV AIDS.
Level 3 provides the following additional support services for level 2 facilities: limited emergency inpatient services (emergency inpatient, awaiting referral and 12 hour observation), limited oral services, maternity for normal deliveries, specific laboratory tests (routine tests like Full Haemogram; Malaria; Smear test for TB; HIV Testing).
Level 4 facilities focus on appropriate curative care and constitute the principal referral level for all Kenya Essential Package of Health (KEPH) interventions. In addition to level 2 and 3 services they provide the following: referral level outpatient care, inpatient services, emergency obstetric care, oral health services, surgery on inpatient basis, more specialized laboratory tests and radiological services.
Level 5 introduces a broader range of specialized referral curative services. They also include training facilities for cadres of health workers who function at primary care level (nurses and clinical officers). They also serve as internship centres for all staff up to the Medical Officers.
Kenyatta National Hospital falls into Level 6 category. It is expected to handle all the remaining specialized services that are most efficiently provided at National level. It also provides training facilities for cadres of specialized health workers that function at the Secondary and Tertiary care up to degree and postgraduate level.
According to the Standard Operating Procedures (SOPs) of KNH Emergency Department, referred patients are required to bring with them a document with a comprehensive summary of the nature of their illness, pre-referral investigations, treatment provided and the reason for referral usually written by the referring clinician. The doctor then uses the information to make a decision on the next phase of management required for each of the referred patients.
In a study on communication between primary care physicians and subspecialty consultants by Mcphee et al (1984), referrals were found to suffer from vague consult questions that make it difficult to identify the exact reason for referral. Rosemann (2006) noted that many referrals are never completed or lead to unintended events because of the time pressure required to write complete notes. Poor communication between referring clinicians and specialists may lead to inefficient use of specialist services (Kim Hwang et al, 2010). Paper based referral processes have been found to be “notoriously slow and inefficient” resulting in providers frequently resorting to end runs to obtain services for their patients, such as calling personal contacts, sending patients to the emergency room, or having them show up at speciality clinics as walk ins even for minor medical problems (Fischer et al (2010).
Kim Hwang et al (2010) were able to demonstrate how some referrals are inappropriate due to inadequate pre-referral investigation, incomplete, mishandled or lost paperwork. This led to delayed communication and duplication of procedures resulting in increased patient waiting times, ambiguous expectations, delayed diagnosis and fragmented care with a high possibility of disease complications.
Improving a referral system has been shown to result in physician satisfaction and improved quality of health care (Gandhi et al, 2000). In their evaluation of Kenya’s healthcare organization, Muga et al (2004), note that patients may only have access to tertiary care through a well developed referral system. Kenya’s National Health Sector Strategic Plan II advocates for improved efficiency and effectiveness of service delivery through improved infrastructure, equipment and ICT investment.
2.5 Conceptual Framework:
This study will be guided by the conceptual framework presented in the figure below;
Independent variables Intervening variables Dependent variables
Government(Ministry of Health) Regulations and Support
Hospital Policy
Efficient healthcare delivery:
Low cost of Investigations
Decreased Patient waiting times
Timely diagnosis
Socio-demographic factors:
Age, Sex, Marital status
Education, Occupation
Income
Referral process:
Communication of pre-referral investigations
Tools and Equipment
Referral tools and Equipment
Processing of referred patients
Figure 2.2 (Source: Author)
CHAPTER THREE:
METHODOLOGY:
Study Area:
This study will be conducted in Kenyatta National Hospital (KNH) which is located in the Upper Hill Area of Nairobi City, Kenya. Kenyatta National Hospital was selected because it is the oldest and largest hospital in Kenya. It is also the main national referral, teaching and research hospital in Kenya.
The hospital has a total bed capacity of 1800 with average bed occupancy rate going up to 300% at times. It has 50 wards, 22 Out-patient Clinics, 24 Theatres (16 Specialized) and an Accident and Emergency Department. On average the hospital caters for over 80,000 in-patients and over 500,000 out-patients annually translating to over 1000 patients daily.
This hospital attends to both emergency and non-emergency referral cases from the whole country, with cases coming from as far as the East and Central African regions for specialized care.
Study population:
The population of interest in this study will comprise of all referred patients presenting at the Accident and Emergency Department of Kenyatta National Hospital.
Study Design:
This study will employ a Cross Sectional Study Design. The case will describe and analyse variables relating to the referral system in KNH as they exist in the year 2013.
Sample Size Determination:
The following formulae will be used to get the sample required; (Cochrane formulae, 1970)
Z2 pq
n = —————
L2
Where:
n = The desired sample
Z = The degree of confidence usually chosen at 95%.
p = The proportion in the target population estimated to have characteristics being
measured. 50% is chosen as recommended by Krejcie et al (1970).
q = The proportion in the target population estimated having no characteristics
being measured is 0.5 (q=1-p)
L = Accuracy level
Note; The target population with certain characteristics is .50, the z statistics is 1.96. and the accuracy level desired is at .05 level, then the sample size will be;
(1.96)2 (.50)(.50)
n = ________________ = 384
(.05)2
Data collection tools and Sampling Technique:
Interviewer guided questionnaires will be used. The questionnaires will be filled with the Medical Doctors at the Accident and Emergency Unit where referred patients first report. Systematic Random Sampling will be used to select the referred patients whose pre-referral investigations will be analysed. This will follow the order of every 5th consecutive new patient starting from a randomly selected patient.
Data Analysis:
The statistical methods to be used in this study will be descriptive and inferential statistics. The main type of descriptive analysis includes; measure of central tendency, measure of variability, frequency distribution and percentages. Computer software, Statistical Package for Social Science (SPSS) will be used for these statistical analyses.
Delimitations of the Study:
The study limits itself to examining the communication of pre-referral investigations leaving out pre-referral clinical notes and diagnosis.
Ethical Considerations:
Informed consent will be obtained from the participants in the study. They will be assured of confidentiality and will be free to decline participation. In addition they will be offered the opportunity to receive a report about the results and conclusions of the study.
There will be separate consent forms for adults, children and other vulnerable groups like the physically or mentally challenged patients.
BUDGET:
PROPOSED BUDGET:
SALARIES
RATE
DAYS/HOURS
CHARGE(KShs.)
1)Research Director (Geoffrey Marika)
400/hr
240hrs
96,000
2)Research Assistants (2)
200/hr
60hrs
24,000
3)Secretariat
150/hr
30hrs
4500
OTHER COSTS
4)Transport
10,000
5)Stationery
10,000
6)Telephone
2000
7)Equipment (laptop, printer, ink)
60,000
8)Data Analysis/Data Entry
30,000
9)Publication and other related costs
15,000
TOTAL DIRECT COSTS
251,500
Duration of Study:
The study is expected to last approximately 5 months: with 1 month allocated for data collection, 2 months for analysis and 2 months for publication and other related matters.
CONSENT FORM
Title: Effects of the hospital referral system on investigating patients at KNH.
Investigator:
Geoffrey Marika
Moi University, School of Public Health
P.O. Box 4606
Nairobi.
Tel: 0720757291
Purpose and Background
The purpose of this study is to examine whether the current hospital referral system has an impact on investigating patients referred to Kenyatta National Hospital. It is hoped that the findings will be useful as a baseline to improve the referral system and enhance service delivery.
Procedure
Patients referred to Kenyatta National Hospital shall be interviewed at their initial point of contact with the doctor through an interview guided questionnaire.
Benefits and Risks
There will be no direct benefits for those participating in the study; neither will there be any risks.
Confidentiality
All information given in the study will be kept confidential and will be used only for the purpose of the study
Voluntary Participation
The participation in the study is voluntary and participants are free to accept or not accept to take part in the study and to withdraw at any time.
Consent
I agree to participate in the study. I have a copy of this form, which I have read and everything clearly explained to me.
Signature: ______________________________________
Date: _________________________________________
Signature of investigator: ______________________Date: _______________________
CONSENT FORM FOR CHILDREN (for the parent)
Title: Effects of the hospital referral system on investigating patients at KNH.
Investigator:
Geoffrey Marika
Moi University, School of Public Health
P.O. Box 4606
Nairobi.
Tel: 0720757291
Purpose and Background
The purpose of this study is to examine whether the current hospital referral system has an impact on investigating patients referred to Kenyatta National Hospital. It is hoped that the findings will be useful as a baseline to improve the referral system and enhance service delivery.
Procedure
Patients referred to Kenyatta National Hospital shall be interviewed at their initial point of contact with the doctor through an interview guided questionnaire.
Benefits and Risks
There will be no direct benefits for those participating in the study; neither will there be any risks.
Confidentiality
All information given in the study will be kept confidential and will be used only for the purpose of the study. No names will be mentioned.
Voluntary Participation
The participation in the study is voluntary and participants are free to accept or not accept to take part in the study and to withdraw at any time.
Consent
I would really appreciate your help with this study if you allow me to use medical information relating to the referral of your son/daughter.
If you are happy for your son/daughter to take part, kindly go through the paragraph below and sign on the space provided.
I agree for my son/daughter to participate in the study. I have a copy of this form, which I have read and everything has been clearly explained to me.
Signature: ______________________________________
Date: _________________________________________
Signature of investigator: ______________________Date: _______________________
CONSENT FORM FOR MENTALLY DISABLED (for the kin)
Title: Effects of the hospital referral system on investigating patients at KNH.
Investigator:
Geoffrey Marika
Moi University, School of Public Health
P.O. Box 4606
Nairobi.
Tel: 0720757291
Purpose and Background
The purpose of this study is to examine whether the current hospital referral system has an impact on investigating patients referred to Kenyatta National Hospital. It is hoped that the findings will be useful as a baseline to improve the referral system and enhance service delivery.
Procedure
Patients referred to Kenyatta National Hospital shall be interviewed at their initial point of contact with the doctor through an interview guided questionnaire.
Benefits and Risks
There will be no direct benefits for those participating in the study; neither will there be any risks.
Confidentiality
All information given in the study will be kept confidential and will be used only for the purpose of the study. No names will be mentioned.
Voluntary Participation
The participation in the study is voluntary and participants are free to accept or not accept to take part in the study and to withdraw at any time.
Consent
How are you related to the patient? ………………………………………………………………………………..
Due to the nature of the condition of your patient, I would really appreciate your help with this study if you allow me to use medical information relating to his/her referral.
If you are happy for your patient to take part, kindly go through the paragraph below and sign on the space provided.
I agree for my patient to participate in the study. I have a copy of this form, which I have read and everything has been clearly explained to me.
Signature: ______________________________________
Date: _________________________________________
Signature of investigator: ______________________Date: _______________________
DRAFT QUESTIONNAIRE:
Socio-Demographic Factors
Date _________________________________________________________
Name of Interviewer (Doctor) _____________________________________
Name and level of Referring Institution ___________________ /__________________
Name of Patient (Optional) _______________________________________
Gender of Patient (M) (F)
Age of Patient (Years) ____________________________________________
Residential District _______________________________________________
Marital Status: (Married) (Widowed) (Divorced) (Single)
Occupation _____________________________________________________
Employment: (Formal Employed) (Formal Self-employed) (Informal employed) (Informal Self-employed) (None)
Income level (monthly): ___________________________________________
Level of Education: (Underage) (Primary) (Secondary) (College) (University)
(Informal) (None)
Referral Process
Do you have any referral documentation from the facility where you were referred from?
(Yes) (No) If Yes proceed to 2 below: If No proceed to 8 below:
Are pre-referral investigation findings included in the referral documents?
(Yes) (No) If Yes proceed to 3 below: If No proceed to 8 below:
How are the investigation findings presented?
(Documented in the referral letter)
(Separate documentation from the referral letter)
Can these findings be clearly interpreted?
(Yes) (No) If Yes, thank the patient and end the interview.
If No proceed to 5 below:
5) Why are the findings not clear?
(Incomplete) (Illegible) (Mishandled documents)
Which investigations will be repeated due to incomplete documentation, illegibility or mishandled documentation?
INVESTIGATION
COST AT KNH (KShs.)
i)
FULL HAEMOGRAM
ii)
MALARIA BLOOD SLIDE
iii)
RANDOM BLOOD SUGAR
iv)
UREA, ELECTROLYTES AND CREATININE
v)
LIVER FUNCTION TESTS
vi)
RADIOGRAPHS
vii)
OTHERS (Specify)
(Information to be obtained from KNH Laboratory SOPs)
What is the standard time set out to carry out the above investigation(s) in 6 above under optimum conditions?
INVESTIGATION
COST AT KNH (KShs.)
i)
FULL HAEMOGRAM
ii)
MALARIA BLOOD SLIDE
iii)
RANDOM BLOOD SUGAR
iv)
UREA, ELECTROLYTES AND CREATININE
v)
LIVER FUNCTION TESTS
vi)
RADIOGRAPHS
vii)
OTHERS (Specify)
Did you have any investigation(s) carried out to you in the facility that referred you to KNH?
(Yes) (No)
Proceed to thank the patient and end the interview after 8 above.
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