FACTORS INFLUENCING SCALING UP QUALITY OF REFERRAL PROCESSES IN KENYA: A STUDY OF KENYATTA NATIONAL HOSPITAL. AGNES CHIKA MSc -HSM Fellowship in Quality Management in Health Care (Germany) THURSDAY 15 JUNE 2017
Background of the study The study investigated factors influencing scaling up quality of referral processes in Kenya. This study was conducted at Kenyatta National Hospital. Referral process is whereby an initiating facility refer patients to another facility that can better provide the level of care needed (Ramirez B, 2013). Quality health care falls under Service delivery, one of the six health system strengthening building blocks (WHO, 2007).
Background Cont’d.. Referral process can be streamlined through; Appropriate communication, Implementation of standardized guidelines and policies. (Barouch P.G, 2011; Zadry &Yusof, 2009). These interventions lead to effective referral systems, and; Ensures continuity and promptness of care hence reduces mortality rate (Bowling A. & Redfern J, 2006).
Objectives of the study To determine the factors influencing scaling-up of quality referral processes at KNH. Specifically, the study investigated: How the management of referrals can scale up the quality referral processes at KNH. How the pre-referral communication scale-up the quality referral processes at KNH. How referral staff can scale up quality referral process at KNH.
Methodology Study design: The study adopted a descriptive cross – sectional, retrospective study design. Sampling Technique: The desired sample size was determined using the Fisher et al . formulae and 384 number of patient health records were entered between June and August 2015. The 10% Gay principle was adopted for computation of the sample size of staffs and 100 staffs were sampled .
Methodology Cont’d.. Data collection procedures: Self-administered structured questionnaire and a checklist. . Data analysis was done using SPSS Version 21 Data presentation: Statistical tables, Bar graphs and Pie Charts
Ethical considerations Ethical Considerations Approval of the study was obtained from KeMU Ethical Research committee, KNH & UON Ethics and Research Committee. A study registration certificate from KNH research and programmes department.
Findings and Discussions Gender Of The Respondent Majority of the referrals were male 246(64.1%). Female referrals comprised 138(35.9%). Fig. 4.1. Disagrees with Ayeni B. et al , (2007) who found out that referral to tertiary hospitals was common amongst females because of the perception of quality maternal and newborn health services offered particularly during delivery.
Age Of Referred Patients Fig. 4.2 Agrees with Ayeni B. et al , (2007) who found out that referral to tertiary hospitals was common on patients above 50 years.
Health Care Providers Majority of the respondents 28(32.6%), were staff from A&E , Neurosurgeon 13(14%), physician 6(5.8%), ophthalmologist 3(3.5%), 1(1.2%) Anesthetist, 1(1.2%) ENT doctor, 1(1.2%) dentist, and 35(40.7%) indicating others. Fig. 4.3
Management of referrals; Staff's Knowledge On Existence Of Policy Objective 1 Tab.4.1 Referral policy Frequency(n) Percent(%) Yes 25 25 No 39 39 I don’t know 36 36 Total 100 100 Junghans C. et al, (2007); policy increases the effectiveness of changing referral timeline, continuity of care and pre-referral management.
Staff's Knowledge On Existence Of Guidelines Tab.4.2 Referral Frequency (n) Percent (%) guidelines Yes 28 28 No 43 43 Don’t know 29 29 Total 100 100 Junghans C. et al, (2007);referral guidelines can be effective in changing referral behaviors.
Staff's Knowledge On Existence Of Standard Operating Procedure Tab.4.3 The staff’s knowledge on Existent Frequenc Percent of Standard Operating y (n) (%) Procedure Yes 27 27 No 37 37 Don’t know 36 36 Total 100 100 The findings are in agreement with Franks. O.S.W, (2009); SOPs establish a systematic way of doing work and ensure that work is done consistently.
Referral Channels Of Communications Objective 2 FIG. 4.5 A study by Speed C.A. (2008) indicated that lack of clear communication channels among facilities in a referral network increases patients mortality.
Documents Submitted Tab.4.4 Documents Frequency Percent (%) submitted (n) Referral letter 65 65 Lab results 23 23 X-ray results 12 12 Total 100 100 Agrees with Bodek S. et al , (2006); absence of key information can prevent reliable decisions with regard to triage.
Previous Treatment / Investigations Before Referral Fig. 4.6 Findings agree with Williams PT, (2009); information gaps including; poor explanation of why the patient is being referred and missing clinical information, provisional diagnosis affects the management of referral patients. .
Knowledge Of Health Care Provider On Referral Procedures Objective 3 Tab.4.5 Knowledge of Health care Frequency Percent (%) providers on referral procedures (n) Yes 13 13 No 80 80 Don’t know 7 7 Total 100 100 Sibbald B, et al , (2007); inappropriate referrals usually result from lack of knowledge, skills, insufficient tools and supplies required to treat.
Availability Of Staffs: Person Escorting Patient FIG. 4.7 The referral guidelines MOH (2014); all emergency referrals shall be accompanied by a trained staff and also the referred clients to receive priority attention at the receiving health facility.
Quality Of Delivery Pre Referral Communication Referring health worker should communicate directly to the receiving health worker to ensure advance notice of the impending referral to allow adequate preparation and continuity of care for quality of patient care (MOH,2014); Fig. 4.8 .
Timeliness Of Care Time Taken Before Seeing A Doctor Fig 4.9 Findings disagrees with Levine D. I. (2010); organizational outcomes like promptness of treatment translates into reduced mortality and increase customer satisfaction.
Referring Institutions Hospitals near KNH prefer to refer their patients there probably as a result of the affordability, accessibility and quality of services. Tab.4.6 Name of referring Frequency (n) Percent (%) Institution Machakos 51 18.0 Kiambu 36 12.7 Mama Lucy 26 9.2 Muranga D H 22 7.7 Mbagathi 21 7.4 Kikuyu PCEA 14 4.9 Garissa 11 3.9 Embu County 10 3.5 Maragua 9 3.2
Conclusion There is inadequate knowledgeable by the staff on the existence of referral policy and guidelines. Referring institution to call before transferring a patient; avoid investigations duplications, reducing delays, cost to patients and reducing mortality rate. Timeliness to see a doctor can be reduced with previous communication and availing the complete referral documents
Recommendations KNH management to disseminate and do awareness of the referral policy, guidelines and SOPs for the staffs. MOH management should ensure Referral tools and forms are distributed at all levels of the health system. The staff allocated at the referral office to ensure prioritization and prompt treatment of the referred patients.
Recommendations For Further Research Future studies is required to examine whether scaling up referral processes can improve customer satisfaction.
Acknowledgement Supervisors: Musa Olouch and Susan Njuguna. Mr. Douglass Owino QA Manager and Dr. Mark Mudenyo, Assistant Director Health information for their guidance and support during the study. Research Assistance; Mr. Ali Wagara, Ms Rael Maina and Mr. Vincent Chagara. Kenyatta National Hospital Staff. 25
Key References • Ayeni B, Rushton G. McNulty LM. (2007). improving the geographical accessibility of health care rural areas: a Nigerian case study. Social Science and Medicine , 25 (10), 1083 – 94. in • Bowling A. Redfern J. (2006.). The process of outpatient referral and care: the experiences and views of patients, their general practitioners, and specialists. British Journal of General Practice , 50 (451), 116 – 20. • Franks. O.S.W. (2009). A Theoretical Model for Implementing Quality Management in an Automated Environment. International Journal of Control and Automation , 2 (2). • Junghans C, Feder G, Timmis AD, Eldridge S, Sekhri N, Black N, & Shekelle P, Hemingway H. (2007). Effect of patient-specific ratings vs conventional guidelines on investigation decisions in angina: Appropriateness of Referral and Investigation in Angina (ARIA) Trial. Archives of Internal Medicine , 167 (2), 195 – 202. • Ministry of Health. (2014). Kenya Health Sector Referral Implementation Guidelines. • WHO . (2007). everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action, Geneva .
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