ORGANIZE DELIVERY OF HEALTH SERVICES
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ORGANIZE DELIVERY OF
HEALTH SERVICES - extracted text
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Training for Health Committees and Health Staff at Health Unit Level
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ORGANIZE DELIVERY OF
HEALTH SERVICES
Monitoring and Service Delivery
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FACILITATOR GUIDE
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Training for Health Committees and Health Staff at Health Unit Level
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ORGANIZE DELIVERY OF
HEALTH SERVICES
Monitoring and Service Delivery
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FACILITATOR GUIDE
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Copyright © 1996
United Nations Children’s Fund
3 UN Plaza
New York, NY 10017
USA
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The purpose of this training course is to improve the management of resources at health unit level
and to build the capacity of health committee members and health staff to work with communities.
The training course was developed by Dr Kasa Pangu and Dr Helene Gaumerais of the Health
Systems Development Unit with the technical collaboration of the Center For Effective Performance
(Atlanta, Georgia) and with the inputs from all the Unit’s programme staff. The Health Systems
Development Unit wishes to express its gratitude to the colleagues from other sections who gave
comments on the draft.
The design and content of the training course benefited greatly from the work undertaken by
participants from panel review meetings held in New York, including E. Alihonou, M. Bah, G.
Bukenya, B. Criel, K. Drame, J. Eshuis, H. Gorgen, M. Kader Konde, H. M. Kahssay, R.
Knippenberg, B. McPake, L. Mpande, K. Mukelabai, M. Murro, V. Oketcho-Oketh, I. Rizzo and A.
B. Touray.
The designations employed in this publication do not imply on the part of UNICEF the expression
of any opinion whatsoever concerning the legal status of any country or territory. Furthermore, the
training modules are intended to be practical tools for adaptation to country local situation and as
such have not been edited to the official publication standards of UNICEF, nor do they necessarily
reflect the policies or views of UNICEF.
All correspondence should be addressed to :
Dr Kasa Pangu
Senior Advisor
Health Section, TA-24A
UNICEF
3 UN Plaza
New York, NY 10017, USA
Phone:
Facsimile:
Internet:
212-824-6339
212-824-6462
kpangu @ unicef.org
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Facilitaior Guide
Monitoring and Service Delivery: Organize Delivery of Services
MONITORING AND SERVICE DELIVERY:
ORGANIZE DELIVERY OF SERVICES
Facilitator introduction
Module Overview ..............................................................
Module Preparation ............................................................
Introduction to module..............................................
Activity 1 - Organize Delivery of Services ............
Activity 2 - Ensure Referral of Patients....................
How to Conduct Performance Checks and Practice Exercises
3
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4
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Module
Introduction ......................................
Overview of Learning Process
Package of Services..............
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Activity 1 - Organize Delivery of Health Services ........
Learning Objective..............................................
Overview of Learning Process ..........................
Introduction to Activity 1....................................
Establish Hours of Operation..............................
Offer Accessible and Convenient Health Services
Improve Patient Flow and Management ............
Ensure Proper Maintenance of Patient Records ..
Performance Check 1..........................................
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Activity 2 - Ensure Referral of Patients.........................................................
Learning Objective.............................................................................
Overview of Learning Process...........................................................
Introduction to Activity 2...................................................................
When and Why to Refer Patients.......................................................
How to Refer Patients .......................................................................
Step 1 - Register Patients At the Health Unit Before Referral
Step 2 - Determine Where to Refer Patients ........................
Step 3 - Complete Paperwork for Referral............................
Step 4 - Help Transport Referred Patients............................
Why and How to Keep Track of Referred Patients..........................
Performance Check 2.........................................................................
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
FACILITATOR INTRODUCTION
MODULE OVERVIEW
One objective of a health unit is to provide services that address the main health problems
and concerns of the community. To meet the objective, the health unit should organize and
deliver health services as effectively and efficiently as possible. This means that the health
unit should:
establish hours of operation that provide the community with access to health
services at all times
offer health services which are accessible, affordable, and convenient for most
patients
improve patient flow and management to reduce long lines and excessive waiting
periods for patients
ensure proper maintenance of patient records.
In this module, participants will learn how to organize the delivery of services to more
effectively and efficiently serve their customers.
Participants will also learn how to refer patients they cannot treat at the health unit.
Training Audience
Health committee
Health staff
Recommended Prerequisite Modules
Course Introduction
Community Participation: Conduct Community Diagnosis
Community Participation: Conduct Participatory Planning
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Monitoring and Service Delivery: Monitor and evaluate at the Health Unit Level
Monitoring and Service Delivery: Monitor and evaluate at the Community Level
Estimated Length of Module
Entire module
1 day
Introduction
1 hour
Activity 1
3 hours
Activity 2
2 hours
MODULE PREPARATION
Because organizing the delivery of health services and procedures for referring patients may vary
from one district to another, the content of this module is intended to serve as guidelines. It is
your responsibility as the facilitator to ensure that participants learn how to perform these tasks
according to the established procedures and policies in their area.
If the processes for organizing the delivery of health services and referring patients in an area
differs from what is presented in the module, modify the content of the module so that you
accurately teach how to perform the tasks in that area.
Preparation for Introduction to Module
Thoroughly read the introduction to the module to familiarize yourself with
the content.
Modify the material to accurately reflect the delivery of health services and
patient referral guidelines in the participants’ area.
Prepare the appropriate flipcharts that you will need for the module.
Prepare for a field visit to a health unit.
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Materials
These materials are needed for the entire module:
Pencils - one for each participant
Notebooks - one for each participant
Participant Guides - one for each participant
Two flipchart stands with pads and colored markers or one flipchart stand with
pad and colored markers and one blackboard with colored chalk
Preparation for Activity 1 - Organize Delivery of Health Services
Thoroughly read Activity 1 - Organize Delivery of Health Services to familiarize
yourself with the content.
Modify the material to accurately reflect existing guidelines and procedures for
organizing delivery of health services in the participants' area.
Prepare the appropriate flipcharts that you will need for the module.
Collect and bring the following tools to training:
□ patient register
□ referral forms or notes
□ maternal and child cards
□ family files
Encourage participants to bring sample tools from their health unit, if it does not
disrupt health unit operations.
Prepare and bring to training an example of how a health unit stores patient
information. For example, a health unit might store maternal cards in a wooden
box that is divided into 12 sections, one for each month of the year. Each card is
filed in the month that the patient is supposed to come in for his or her next
appointment.
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Facilitator Guide
Monitoring and Service Delivery : Organize Delivery of Services
Preparation for Activity 2 - Ensure Referral of Patients
Thoroughly read Activity 2 - Ensure Referral of Patients to familiarize yourself with
the content.
Modify the material to accurately reflect existing guidelines and procedures for
referring patients in the participants' area.
Prepare the appropriate flipcharts that you will need for the module.
Prepare the following Patient Register on a separate flipchart or blackboard.
6
PATIENT REGISTER
12-11- 96
Number of Reattendances = 0
Serial
No.
Patient Name
Village
Age
M/F
101
Mabalo Lokela
Kaloufla
8m
M
dysentery - no dehydration Cotrimoxazole Ped: Vi tab x 2 x 5 days (*)
Give fluids and continue feeding
2.00
102
Ekombe
Mongwa
Gohitre
24m
M
severe malnutrition,
clouding of cornea
Vit A 200.000 IU, 1 caps x 2
Refer urgently to hospital
0.10
103
Mbuzu Sophie
Zralou
15
F
malaria
Chloroquine 150 mg base: dayl (3+l)tab,
day2 Itab, day3 Itab
AAS 500 mg: lep x 3 x 3 days
0.40
104
Sebo Dombe
Pakouabo
18m
F
pneumonia - chest
indrawing, unconscious
Cloramphenicol inj 500 mg 1/2 vial IM
Refer urgently to hospital
0.10
105
Euza Ngongo
Tokamo
30m
F
measles - no complication
Paracetamol 100 mg Itab x 3 x 5 days
2.00
Diagnosis
13-11- 96
106
Myriam Ngwete Bawada
107
Gizi Dobola
108
Lizenge Embale Koulouro
109
Sukato
Manzomba
110
reatt.
Ill
Sabar
42
Drugs/Treatment
Price
(USD)
Referral
No.
26
27
Number of Reattendances - 1
F
4m
backache
AAS 500 mg 1 tab x 3 x 5 days
0.10
convulsions, severe malaria Diazepam inj 1/2 amp IR
Paracetamol Itab x 4
Quinine 150 mg/ml inj 1/2 amp IM
Refer urgently to hospital
3.00
20
F
anemia
Fer 60 mg 2tab x 3 x 60 days
Folic Acid 5 mg, 2tab x 1 x 30 days
0.20
Yatawa
12
M
scabies
Benzylbenzoate lotion 25%
0.50
Ngoi Lintak
Goujia
14m
M
persistent cough, difficulty
breathing
Amoxycillin 250 mg 1 tab x 3 x 5 days
Patrick Saboya
Nafouta
31
M
wound right hand
Chlorhexidine, bandage
TT vaccination
(*) Cotrimoxazole Ped = Sulfamethoxazole lOOmg + Trimethoprim 20 mg
1.50
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Facilitator Guide
Monitoring and Service Delivery : Organize Delivery of Services
HOW TO CONDUCT PERFORMANCE CHECKS AND
PRACTICE EXERCISES
Follow these guidelines when you conduct Performance Checks or Practice Exercises:
Before You Conduct a Performance Check/Practice Exercise
Thoroughly read the appropriate Module Preparation section and entire Performance
Check/Practice Exercise.
Modify the Performance Check/Practice Exercise to reflect local procedures and policies.
You also may need to adapt the Performance Check/Practice Exercises to fit the
availability of local resources.
Make all necessary preparations (e.g., make copies of forms).
Work through the Performance Check/Practice Exercise to make sure you understand
how to conduct the activity.
Prepare answers to the Performance Check/Practice Exercise.
Review the Performance Check/Practice Exercise the day before you teach the module.
During the Performance Check/Practice Exercise
Read all instructions to participants. Answer any questions they may have about the
instructions.
Circulate among the participants while they are working to answer any questions. Be
attentive so that you can correct any errors or misunderstandings.
Take notes on the common difficulties participants may be experiencing.
If a participant or group does not successfully complete the Performance Check/Practice
Exercise, explain what is incorrect. Ask the participant(s) to redo the work. If needed,
refer the participant(s) to someone who has fulfilled the objective.
If a participant or group fulfilled the objective, give positive feedback.
Listen carefully during group presentations. If you see any errors, first ask other
participants to provide feedback to the presenters. If the error is not corrected by the
participants themselves, explain what participants are doing incorrectly. Work through
an example, if needed.
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
MONITORING AND SERVICE DELIVERY:
ORGANIZE DELIVERY OF SERVICES
This introduction gives participants an overview of how to
organize the delivery of health services and ensure referral of
patients.
Welcome Participants
Introduce yourself and welcome participants to the training.
Ask participants to introduce themselves if this is the first
time they are working together on a module.
Introduction
Organize afield visit to a health unit, if it is convenient and
feasible.
If the visit to the health unit is to be brief, visit the health
unit and then teach the module.
If the field visit can be arrangedfor a longer period of time,
teach the module at the health unit if it does not disrupt
health unit functions and if it is convenient given the
number ofparticipants.
During the field visit, observe and then discuss with health
workers the following:
hours of operation
when, how often, and where they offer health services
patient flow and management
(continued)
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
how the health unit stores and maintains patient
information
how patients are referred
how health workers keep track of referred patients
• The package of services your health unit offers should
address the main health problems and concerns of the
community.
• Use information obtained during community diagnosis,
participatory planning, and monitoring and evaluating
to organize the delivery of health services to address the
main health problems and concerns of the community.
• Organize the delivery of health services so that:
working hours are convenient for most community
members
patients can easily move through the health unit and
receive quality care, and
patient information is maintained and regularly updated.
• Because your health unit may not have the drugs,
equipment, or staff to treat every type of illness and disease,
it may have to send or refer patients to another health unit
or hospital to receive treatment.
• Your health unit should ensure that patients are referred and
be able to track referred patients.
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Monitoring and Service Delivery : Organize Delivery of Services
Facilitator Guide
Overview of Learning Process
• In the first activity, you will learn how to organize the
delivery of services to more effectively and efficiently
serve the community.
• In the second activity, you will learn how to ensure that
patients are referred and that they are properly tracked.
Package of Services
• When your health unit is first established, the District
Management Team (DMT) works with the health unit
staff to define the health services it will offer. This is
called the “package of services.”
• The package of services should be based on existing
national policy, cost of health programmes, and available
resources.
• When you define the package of services for your health
unit, consider the services provided by the district
hospital. The two packages should complement each
other.
• The package of services should address the main health
problems and concerns of the community.
• What is the package of services your health unit offers?
Solicit responses. Answers may include:
childhood immunizations
prenatal care
curative care based on the health needs of the
community
(continued)
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
deliveries
• Your health unit can use information obtained during
community diagnosis, participatory planning, and
monitoring and evaluating to add to its package of services.
• Examples of information that can be obtained:
the frequency and seriousness of diseases in the
community
the concem/demand of the community regarding some
health problems or health services (e.g., you may learn
that your community wants family planning services.)
the geographical accessibility to health services
(obtained from village mapping)
• When your health unit defines or expands its package of
services, it must decide what equipment and resources it
needs to offer the services.
• For example, what equipment and resources does your
health unit need to offer family planning services?
Solicit responses. Answers may include:
contraceptive products
staff trained on family planning methods
• Your health unit must inform the community about the
services it offers and which main diseases can be
prevented.
• What will happen if your health unit does not inform the
community about the services it offers?
(continued)
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
Solicit responses. Answers may include:
people may seek treatment elsewhere
people will not know to go to the health unit for the
particular service (e.g., family planning, immunizations,
deliveries)
if many people do not use the services, the health unit
may lose the money it invested to offer the services (e.g.,
buying equipment)
• How does your health unit let the community know which
services it offers?
Solicit responses. Answers may include:
informs community through community leaders and the
health committee during meetings, such as participatory
planning meetings
posters at health unit show services it offers
• After the package of services has been determined, the
health unit staff and health committee work with the DMT
to identify coverage and quality standards for the health
unit.
• You will use the coverage and quality standards during
monitoring and evaluating to monitor and improve health
unit performance.
Refer participants to the module Monitoring and Service
Delivery: Monitor and evaluate at the health unit level.
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Monitoring and Service Delivery : Organize Delivery of Services
Facilitator Guide
ACTIVITY 1 - ORGANIZE DELIVERY
OF HEALTH SERVICES
This activity teaches participants how to more effectively and
efficiently organize the delivery of services. Modify the activity
to reflect procedures in the participants’ area.
Flipchart
Learning Objective
• The objective for this activity is:
Activity 1 - Organize Delivery of Health Services
Learning Objective
At the end of the session, participants will be able to describe
how to more effectively and efficiently organize the delivery of
health services.
Overview of Learning Process
• During this activity, you will learn how to organize the
delivery of health services to meet the community’s needs.
• At the end of the activity, you will work in small groups to
complete the Performance Check.
Introduction to Activity 1
• Why is it important to organize the delivery of services so
that it addresses the main health problems and concerns of
the community?
Solicit responses. Record accurate answers on the
flipchart or board.
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Answers may include:
Organize Delivery of Health Services
so the community will use the health services
the community may be more willing to pay for services if the
health unit is meeting their needs
to give the community ownership of the health unit
so the health status of community members can be improved
• The patient is your customer.
• Meeting customers’ needs and making sure that they are
satisfied with health services is important to your health
unit’s success.
• Your health unit will go out of business if patients stop
using its services.
• You should continuously get feedback from the
community about how the health unit is meeting or not
meeting their needs.
• Is your health unit meeting the community’s needs? Are
most of the patients satisfied with health services?
Solicit responses.
To further the discussion, ask
participants the following questions:
Is your health unit open when it is most convenient for
patients?
How does your health unit provide access to those
patients who cannot visit the facility during regular
hours of operation?
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
What procedures are in place to make sure that patients
do not have to wait in long lines for long periods of
time?
How are patients managed at your health unit?
How does your health unit store and maintain patient
information ?
• During this activity, we will discuss how you can
effectively and efficiently organize the delivery of health
services. You will learn how to:
Flipchart
2
How to Organize the Delivery of Health Services
Establish hours of operation that provide the community with
access to health services at all times.
Offer health services that are accessible and convenient for
most patients.
Improve patient flow and management to reduce long lines
and excessive waiting periods for patients.
Ensure proper maintenance of patient records.
Establish Hours of Operation
• Patients are customers.
• They must have access to health services at all times.
• Sometimes, patients cannot visit the health unit during
regular hours of operation because of other commitments or
responsibilities.
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
• For example, if many women are only able to visit the
health unit in the early afternoon after they complete their
morning household chores, the health unit should be open
during that time.
• Use information obtained during community diagnosis,
participatory planning, and monitoring and evaluating to
learn if your health unit’s hours of operation are convenient
for patients.
Lead a discussion about the obstacles of maintaining
convenient hours of operation and how participants can
overcome them.
• Why is it important that patients always have access to
health services?
Solicit responses. Answers may include:
Ifpatients are very ill, they need treatment.
Because the community helps support the health unit, it
should have access to health services.
• What are some ways you can make your health unit
accessible beyond its regular hours of operation?
Solicit responses. Possible answer:
have a rotating schedule where one health worker is "on
call" at all times for emergencies
Offer Accessible and Convenient Health
Services
• Determine if your health unit is meeting the community’s
needs about when, how often, and where it provides health
services.
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Review the information in the following flipchart:
When, How Often, and Where to
Deliver Health Services
When
Are health services convenient for most patients?
How often
Are health services offered frequently enough to meet patient
demands?
Flipchart
Where
Is the location accessible and convenient for most patients for
preventive services?
When
• Determine whether your health unit delivers health services
on the day of the week and the time of day that is
convenient for most patients.
• For example, if market day is Wednesday, you may want to
offer prenatal care or family planning services on that day.
• During certain seasons (e.g., harvest time when people are
busy with field work), health unit staff may consider
keeping the health unit open during the evening hours.
How Often
• Determine if your health unit is offering health services
frequently enough to meet patient demands.
(continued)
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• If a health service is not offered frequently enough, consider
offering the service on additional days.
• For example, if your health unit offers family planning
services only once a week and the lines are always long,
consider offering the service on additional days.
• To reduce the amount of time patients wait in line, you can
also offer services for specific areas or villages on
designated days, so that people from only one area attend
the health unit on a given day.
Where
• For preventive services, determine whether the location is
accessible and convenient for most patients.
• For example, if the attendance of children is very low on the
days your health unit offers immunizations, consider setting
up outreach.
• For curative services, if the location of the health unit is not
convenient and accessible for most members of the
community, health staff and health committee members
should discuss the problem with the DMO.
Refer to Flipchart 3.
Flipchart
• Because patients are your customers, you should ask these
questions periodically to ensure that you are providing
services that are accessible and convenient for most
members of the community.
• You can learn which services are not accessible and
convenient for most members of the community during
community diagnosis, participatory planning, and
monitoring and evaluating.
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Lead a discussion on some obstacles of providing health
services that are accessible and convenient for patients.
Ask participants to identify ways to overcome these
obstacles.
Improve Patient Flow and Management
• What is “patient flow?” What is “patient management?”
Solicit responses. Answers may include:
-
Patientflow: how patients move through the health unit
from registration until they leave the health unit.
Patient management: how patients are cared for by the
health unit staff from registration until they leave the
health unit.
• Why is it important to establish good patient flow and
management procedures?
Solicit responses. Possible answers:
Because the patient is the customer, the health unit
should treat him or her with care and respect.
Ifpatients have to wait in long lines for long periods of
time, they might stop coming to the health unit.
• What is desirable patient flow?
Solicit responses. Answers should include:
Patients should move easily from one work station to
another (e.g., registration and weighing, consultations,
delivery of drugs and payment).
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Health workers should inform patients where to go and
why they are going to a particular work station.
Draw a picture of how patients should move from one work
station to another in a health unit.
• Identify bottlenecks in patient flow and reasons for the
bottlenecks, such as:
lack of personnel
inadequate allocation of tasks among staff
inadequate resources for properly managing patients,
e.g., no scales, no patient register
• Patient flow is linked to the tasks of health unit staff.
• To make sure that patients move through the health unit
quickly and efficiently, assign specific tasks for the health
staff.
• By assigning specific tasks, you can also avoid duplication
of work and improve the quality of health care.
• In some health units, it may be necessary to assign health
staff to each work station (e.g., registration, consultations).
• In other health units, it may not be necessary or feasible to
assign health staff to each work station.
• There should be at least one health worker responsible for
the patient flow and global management of the patient. This
person should check the waiting area periodically to see
whether patients should be seen in an emergency.
• Health workers should manage patients with care and
respect.
(continued)
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Monitoring and Service Delivery : Organize Delivery of Services
Facilitator Guide
• How else should health workers manage patients from
registration to payment of services/drugs?
Solicit responses. Record accurate answers on the flipchart
or board. Answers should include:
How Patients Should be Managed
Health workers should see patients in private areas.
Health workers should listen attentively to patients and allow
them to speak and finish what they are saying.
Health workers should identify patients’ problems as quickly
as possible.
Health workers should explain the treatment carefully using
local language and simple words. They should check for
patients’ understanding.
Health workers should answer patients’ questions or they
should refer patients to someone who can answer them.
• It is important that health staff and patients know each
other so that the health unit can deliver quality health care.
• While patients are waiting for services, health workers can
learn about the patient’s family, environment, and health
problems.
• Encourage patients to provide feedback to health workers
on how they feel they are being managed at the health unit.
• You can also gather valuable information during
community diagnosis and monitoring and evaluating
about how patients think they are being managed at the
health unit.
(continued)
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Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• During participatory planning, you can work with the
community and health staff to identify ways to improve
how patients are being managed.
Lead a group discussion on how to overcome problems
identified in the management ofpatients such as:
The health unit staff does not see patients in private
areas.
The waiting time is too long.
The waiting area has no roof and when it rains, patients
do not know where to go.
After treatment, patients do not know what to do when
they go back home.
Ensure Proper Maintenance of Patient
Records
• What records and forms at your health unit contain patient
information?
Solicit responses. Possible answers:
patient register
under five cards
maternal cards
health booklets
familyfiles (records containing information concerning
members of the family)
(continued)
23
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
patient summary sheet
The patient summary sheet serves 2 purposes:
• It provides the summary ofpersonal history form;
• It is a reference document for epidemiological
surveys.
If you and/or participants have brought any records to
training, briefly display and discuss them.
• Why do you keep this patient information at your health
unit?
Solicit responses. Possible answers:
to determine the quality of health services that is
provided in terms of:
— accessibility to health care
— utilization of health care
coverage of target groups
— continuity of health care
Explain the above definitions as follows, if needed.
• Accessibility is the percentage of people in a defined area
living less than 5 kilometers from the health unit.
• Utilization is the number of attendances per population in
a defined area per period.
• Coverage is the number of people from the target group
receiving a service per period divided by the population of
the target group.
(continued)
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Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
• Continuity of health care is the percentage of consultants
(per period) completing the full treatment based on
diagnosis and treatment guidelines.
• What may happen if your health unit does not maintain or
regularly update patient information?
Solicit responses. Answers may include:
You cannot use records to monitor, evaluate and
improve the quality of health care (access, coverage
and continuity).
Supervisors cannot use records to monitor, evaluate
and improve health workers’ performance. For
example, they cannot look at the appropriate use of
drugs in the patient register.
You cannot use records to track patients who do not
complete treatment.
• How does your health unit store and file patient records
and forms?
Solicit responses.
Show participants the example you brought to class about
how a health unit can store and file patient records.
• When organizing patient records, consider:
that health workers should update patient records
at every patient visit (for a new episode of illness)
the length of time to keep patient records, (to be
discussed with the DMO.)
(continued)
25
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• You can also use health unit records to track patients
who do not complete treatment or who do not return for
subsequent visits.
• For example, if your health unit files patient cards by the
month of the next appointment, health workers can easily
keep track of patients who miss their appointments.
26
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
ACTIVITY 1 - ORGANIZE DELIVERY OF SERVICES
PERFORMANCE CHECK 1
Facilitator Instructions
Read the following instructions to participants. Write or
draw any instructions on the flipchart or board, as needed.
• For the Performance Check, you will work in small groups
to describe how to effectively and efficiently organize and
deliver health services at your health unit.
• If you have any questions while you are completing the
Performance Check, let a facilitator know.
• When you have completed the Performance Check, let a
facilitator know.
• When everyone has completed the exercise, we will discuss
the Performance Check.
Divide the participants into groups of four to five.
Participants in each group should be from the same health
unit. Assign each group to their own work area.
After all participants have completed the Performance
Check, reconvene them for the plenary discussion.
Refer to the following pages which show the Performance
Check exercise in the Participant Guide.
27
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
ACTIVITY 1 - ORGANIZE DELIVERY OF SERVICES
PERFORMANCE CHECK 1
STOP
Do not begin the Performance Check until the facilitator has given you the instructions!
For this Performance Check, you will work in small groups.
Your task is to examine how service delivery is currently organized at your health unit and to
describe whether it could be improved to meet the needs of the community.
1. What are your health unit’s hours of operation? Should you change your hours of operation so
that hours be convenient for most patients?
2. What can your health unit do to make services available to patients who are unable to go to your
health unit during regular hours of operation?
(continued)
28
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
3. In the table below, describe when, how often, and where your health unit offers its five main
health services. Also describe how to improve when, how often, and where the health unit offers
its health services to better meet the needs of the community.
Type of Health
Services
When
How
Often
Where
How to Improve
1.
2.
3.
4.
5.
(continued)
29
Facilitator Guide
Monitoring and Service Delivery; Organize Delivery of Services
4. In the table below, describe problems or obstacles with patient flow and management at your
health unit. Also describe how your health unit can overcome these problems or obstacles.
How to Overcome Problems/Obstacles
Problems or Obstacles with Patient
Flow and Management
30
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
5. In the table below, describe any problems or obstacles your health unit has in storing and
maintaining patient information and how to overcome these problems or obstacles.
How to Overcome Problems/Obstacles
Problems or Obstacles with Storing
and Maintaining Patient Information
6. Let a facilitator know when you have completed the Performance Check.
TM-UO
O
31
W
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Plenary Discussion
When participants reconvene, ask each group to present
their answers to the Performance Check questions.
Encourage participants to share any observations,
problems, or concerns they experienced in completing the
Performance Check.
Discuss the difficulties that you noted participants
experienced during the Performance Check.
Ask participants the following questions:
• How often should you examine how your health unit
delivers health services?
• How do you think your health staff would respond to the
reorganizing of the services?
• How do you think the community would react to the
reorganizing of the services?
Conclude the activity with positive comments about how the
participants performed the activity. Provide a summary of
the major points of the activity:
• Use information obtained during community diagnosis,
participatory planning, and monitoring and evaluating to
organize the delivery of services to address the main health
problems and concerns of the community.
• Patients are customers.
• Meeting customers’ needs and making sure that they are
satisfied with health services is important to your health
unit’s success.
32
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
Briefly review how to organize the delivery of health services:
!
Flipchart
2
How to Organize the Delivery of Health Services
Establish hours of operation that provide the community with
access to health services at all times.
Offer health services that are accessible and convenient for
most patients.
Improve patient flow and management to reduce long lines
and excessive waiting periods for patients.
Ensure proper maintenance of patient records.
33
Monitoring and Service Delivery': Organize Delivery of Services
Facilitator Guide
ACTIVITY 2 - ENSURE REFERRAL OF PATIENTS
In this activity, participants learn how to ensure referral of
patients. They learn how to refer patients and how to keep track
of referred patients. Modify the activity to reflect procedures in
the participants ’ area.
Learning Objective
• The learning objective for this activity is:
I
Flipchart
4
I
Activity 2 - Ensure Referral of Patients
Learning Objective
At the end of the session, participants will be able to identify:
how health workers should refer patients
how to keep track of referred patients
Overview of Learning Process
• During this activity, you will learn how to ensure referral of
patients.
• At the end of the activity, you will work in small groups to
complete the Performance Check.
Introduction to Activity 2
• Patients usually seek treatment from the health unit closest
to them.
(continued)
34
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• If a patient has an illness that your health unit cannot treat,
health workers may refer the patient to another health unit
or hospital that has the staff, drugs, and equipment to help
him or her.
• How does your health unit refer a patient?
Solicit responses. Ask participants how they decide:
which health unit or hospital has the staff, drugs and
equipment to help the patient
how to keep track of the referred patient
When and Why to Refer Patients
• Some patients can only be diagnosed and treated at the
hospital or another health unit, where more equipment,
drugs and specialized staff are available.
• Health unit staff should use standard diagnosis and
treatment guidelines to determine when to refer patients.
How to Refer Patients
• How does your health unit refer patients?
Solicit responses. Record accurate answers on the flipchart
or board. Answers should include:
(continued)
35
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
How to Refer Patients
1. Register a patient at the health unit before referring him or
her.
2. Decide the correct health unit to which to refer the patient
(adequate equipment and skilled personnel).
3. Identify the paperwork to complete (e.g., a referral
form/note). Record the referral number from the referral
form in the patient register.
4. Help transport the patients to the health unit to which they are
referred.
Step 1 - Register Patients At the Health Unit Before
Referral
• What are the advantages of registering a patient at your
health unit before health workers refer him or her?
Solicit responses. Possible answers:
It helps to ensure the follow-up of patients when they
return to the health unit.
It is one way of keeping track of the referred patient.
Step 2 - Determine Where to Refer Patients
• Health workers should refer patients to health units or
hospitals that have the equipment, drugs, and
specialized staff to treat the patient.
(continued)
36
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• It is very important that health workers do not send the
patient to a health unit or hospital that cannot treat his
or her illness or disease.
• Encourage health workers from district health units and the
hospital to meet regularly. During these meetings, health
workers can learn more about the equipment, drugs and
staff available at the health units and the hospital.
• The DMT can give you information about different health
services at neighboring health units and the hospital.
Step 3 - Complete Paperwork for Referral
• When a health worker refers a patient, he or she should
complete a referral form or note.
• If your health unit uses a referral form, it should be
divided into two sections:
1) to be completed by the referring unit
2) to be completed by the health unit where the patient
has been referred.
• The health unit where the patient has been referred should
send the form back to the referring unit when the patient
has reported and been registered.
• What information should the referring unit complete on
the form?
Solicit responses. Possible answers:
patient’s name, address, sex, and age
district name or number
(continued)
37
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
patient’s symptoms and diagnosis
type of treatment given
drugs patient is receiving
reason for referral
name of the referral health unit
name of health unit to which patient is referred
date patient is referred
a referral number
• The health worker should record the referral number from
the referral form in the patient register.
Patient
Register
Show participants the sample patient register on the
following page. Point out the Referral No. column.
• What information should the health unit where the patient
has been referred complete?
Solicit responses. Possible answers:
patient’s name, age, and sex
date patient reported to health unit
treatment provided
follow-up actions (e.g., how to monitor and evaluate
health conditions of the patient, further
appointments to make at the referral unit/hospital,
what advice and drugs to give to the patient)
38
PATIENT REGISTER
12-11- 96
Number of Reattendances = 0
Serial
No.
Patient Name
Village
Age
M/F
Diagnosis
Drugs/Treatment
Price
(USD)
101
Mabalo Lokela
Kaloufla
8m
M
dysentery - no dehydration
Cotrimoxazole Ped: ‘A tab x 2 x 5 days (*)
Give fluids and continue feeding
2.00
102
Ekombe
Mongwa
Gohitre
24m
M
severe malnutrition,
clouding of cornea
Vit A 200.000 IU, 1 caps x 2
Refer urgently to hospital
0.10
103
Mbuzu Sophie
Zralou
15
F
malaria
Chloroquine 150 mg base: dayl (3+l)tab,
day2 Itab, day3 Itab
AAS 500 mg: lep x 3 x 3 days
0.40
104
Sebo Dombe
Pakouabo
18m
F
pneumonia - chest
indrawing, unconscious
Cloramphenicol inj 500 mg 1/2 vial IM
Refer urgently to hospital
0.10
105
Euza Ngongo
Tokamo
30m
F
measles - no complication
Paracetamol 100 mg Itab x 3 x 5 days
2.00
Myriam Ngwete Bawada
Sabar
107
Gizi Dobola
108
Lizenge Embale Koulouro
109
Sukato
Manzomba
110
reatt.
Ill
42
26
27
Number of Reattendances = 1
13-11- 96
106
Referral
No.
F
4m
backache
AAS 500 mg 1 tab x 3 x 5 days
0.10
convulsions, severe malaria Diazepam inj 1/2 amp IR
Paracetamol 1 tab x 4
Quinine 150 mg/ml inj 1/2 amp IM
Refer urgently to hospital
3.00
20
F
anemia
Fer 60 mg 2tab x 3 x 60 days
Folic Acid 5 mg, 2tab x 1 x 30 days
0.20
Yatawa
12
M
scabies
Benzylbenzoate lotion 25%
0.50
Ngoi Lintak
Goujia
14m
M
persistent cough, difficulty
breathing
Amoxycillin 250 mg 1 tab x3 x 5 days
Patrick Saboya
Nafouta
31
M
wound right hand
Chlorhexidine, bandage
TT vaccination
(*) Cotrimoxazole Ped = Sulfamethoxazole lOOmg + Trimethoprim 20 mg
1.50
28
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Step 4 - Help Transport Referred Patients
• If the health unit is responsible for transporting patients,
then it should have transportation available and a logbook
on transport.
• If the health unit is not responsible for transporting patients,
then the health unit may help transport the patients by:
finding a means of transportation
accompanying the patient to the referral unit
paying a partial amount of the transport cost. (The
health committee should decide whether to pay for
transport.)
Why and How to Keep Track of Referred
Patients
• Why is it important to keep track of referred patients?
Solicit responses. Possible answers:
to ensure that the patient went to the correct health
unit and was treated
to ensure the follow-up of the patient, when he/she is
back at the health unit
• The health unit staff, patients, community, and district
should work together to keep track of referred patients.
(continued)
40
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
• One way of making sure the referred patient obtained
treatment is to have the health unit/hospital return the
completed section of the referral note/form to the referring
health unit.
• The patient can return the completed referral note/form, or
it can be sent by mail. In places where transportation has
radio equipment, the radio can be used.
41
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
ACTIVITY 2 - ENSURE REFERRAL OF PATIENTS
PERFORMANCE CHECK 2
Facilitator Instructions
Read the following instructions to participants. Write or
draw any instructions on the flipchart or board, as needed.
• For the Performance Check, you will work in small groups
to discuss factors to consider when referring patients.
• If you have any questions while you are completing the
Performance Check, let a facilitator know.
• When you have completed the Performance Check, let a
facilitator know.
• When everyone has completed the exercise, we will discuss
the Performance Check.
Divide the participants into groups offour to five. Assign
each group to their own work area. Participants should be
from the same health unit.
After all participants have completed the Performance
Check, reconvene them for the plenary discussion.
Refer to the following pages which show the Performance
Check exercise in the Participant Guide.
42
»
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
ACTIVITY 2 - ENSURE REFERRAL OF PATIENTS
PERFORMANCE CHECK 2
STOP
Do not begin the Performance Check until the facilitator has given you the instructions!
Work in your small groups to complete the following:
1. Why is it necessary to register a patient at the health unit before referring him or her?
2. Complete the following table about how to refer a patient:
How to decide where
to refer the patient
What paperwork to
complete, and by
whom
How to help transport
referred patients
How to keep track of
referred patients
3. Let a facilitator know when you have completed the Performance Check.
43
Monitoring and Service Delivery: Organize Delivery of Services
Facilitator Guide
Plenary Discussion
When participants reconvene, review participants’ answers
to the Performance Check.
Encourage participants to share any observations,
problems, or concern they experienced in completing the
Performance Check.
Discuss the difficulties that you noted participants
experienced during the Performance Check.
Ask participants the following questions:
• What obstacles may you have in referring patients to
neighboring health units or hospitals?
• How can you overcome these obstacles?
• What obstacles may you have in trying to keep track of
referred patients?
• How can you overcome these obstacles?
Conclude the activity with positive comments about how
participants performed. Summarize the main points of the
activity.
Review the following flipchart about how to refer patients.
(continued)
4
44
Facilitator Guide
Monitoring and Service Delivery: Organize Delivery of Services
How to Refer Patients
1. Register a patient at the health unit before referring him or
her.
2. Decide the correct health unit to which to refer the patient
(adequate equipment and skilled personnel).
3. Identify the paperwork to complete (e.g., a referral
form/note). Record the referral number from the referral
form in the patient register.
4. Help transport the patients to the health unit to which they
are referred.
• Keep track of referred patients to ensure the follow-up of
the patient, when he/she is back at the health unit
Conclude the module with a summary of what participants
learned.
Discuss any plans you have for following up with
participants after training.
*
45
1
Health Systems Development Unit
UNICEF House
3 United Nations Plaza
New York, NY 10017 - USA
Fax: 212-824-6462
Community
participation
Monitoring and
service delivery
Management of staff
and equipment
Drug/supply
management
Financial management
1. Apply basic communication
skills
2. Conduct community
1. Monitor and evaluate at the
health unit level
2. Monitor and evaluate at the
community level
3. Organize delivery of
services
1. Hire and manage support
staff
2. Ensure training of health
unit personnel
3. Maintain equipment and
health unit facility
1. Store supply and establish
inventory procedures
2. Order and procure
3. Receive and inspect
4. Monitor and evaluate daily and
monthly inventory
1. Establish prices and exemptions
systems
2. Manage revenue and
expenditures
3. Establish a budget
4. Audit health unit financial
records
diagnosis
3. Organize and support health
committee
4. Establish relationships with
community leaders, local
organizations, and authonties
5. Conduct paracipatory
planning
J
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