A management information system for nurse/midwives.

A management information system for nurse/midwives Ibukun Ogunbekun1 The experiences of nurse/midwives with a simple management information system in the private sector are reported from four facilities in Nigeria. When such a system is being introduced, special attention should be given to strengthening the ability of health workers to record and collate data satisfactorily. Voir page 188 le re´sume´ en franc¸ais. En la pa´gina 188 figura un resumen en espan˜ol. In developing countries there is often a paucity of reliable information on health care, and providers may find it difficult to deal with whatever data are available. The experiences of independent nurse/midwives ser- ving low-income urban populations in Nigeria’s Osun State illustrate what can be achieved with a management information system in which the analysis and inter- pretation of data are made as simple as possible. Determinants and characteristics Preliminary investigations in health care facilities A, B, C and D (see table) during August 1995 revealed that no proper health information system existed. There were major deficiencies in record-keeping, data collation and related matters. The staff of 45 health facilities managed by nurse/midwives agreed to collaborate in a project involving the introduction and use of a management information system, while administrative, accounting and financial control systems were also being brought into play. The aim was to improve operational efficiency so that the prices of services could be reduced, demand could be boosted, and, ultimately, revenues increased. The systems were installed in January 1996. The management information system was primarily designed to strengthen operational management, although it was also intended to provide reliable epidemiological information that would complement data obtained in the public sector. The design was influenced by: – the preventive and curative services provided in the facilities, including inpatient care; – the educational level of the personnel and their ability to perform numerical tasks; – the cost of installation and maintenance; – the need to integrate with the National Health Management Information System being developed by the Federal Ministry of Health and Social Services. The preferred formats for a simplified system shared many properties with those adopted in public sector primary care facilities. However, variations were required which favoured the use of data for purposes other than epidemiological surveillance and research. A manual rather than an electronic system was desired because of low computer literacy, an unreliable power supply, and the high cost of acquiring and maintaining computers. The system that emerged is described below. . Visits of clients to the facilities were recorded in attendance registers according to the type of service requested: general outpatient consulta- tions, inpatient care, maternity care, family plan- ning, and child welfare, including immunization. The information placed in the registers included patients’ personal details, working diagnoses, and outcomes of care. Case notes and folders on individuals and families were designed for ease of storage and retrieval of clinical information. . The information in attendance registers was collated on special forms at health facility level and copies were sent to the National Private Nurses and Midwives Association for further collation. Up-to- date statistics were thus provided on all the facilities attached to this nongovernmental organization. . Monthly average figures for patients’ visits were transferred to quarterly summary forms, together with revenue and expenditure data generated from the financial control system. In this way a simple tool was provided for monitoring performance. These forms helped to strengthen day-to-day management of facilities and provided a basis for strategic decision-making. Because they contained financial information they were intended only for internal use. Outputs Compliance with recommended procedures was assessed by conducting staff interviews in February 1997, and output data for 1996 were analysed. Utilization varied markedly between the four facilities even though they offered similar services, covered the same socioeconomic group, were equally acces- 1 Managing Director of Mediplan Limited (health consultants) in Lagos, Nigeria, at the time of writing this article. He is now in the Country Department West of the African Development Bank, 01 BP V316 Abidjan 01, Coˆte d’Ivoire; e-mail: I.Ogunbekun@Afdb.org). 186 # World Health Organization 1999 Bulletin of the World Health Organization, 1999, 77 (2) Policy and Practice sible and charged similar fees (see table). All the facilities experienced a steady decline in patient throughput, perhaps reflecting a decline in household incomes. Approximately a quarter of outpatients and inpatients were aged up to 4 years, and about 60% were in the age range of 15–59 years. Factors such as perceived technical competence, the availability of credit and the physical state of the facilities were probably more influential than gender in determining patients’ choice of providers: there was no evidence, for example, of female patients demanding to be seen by female providers. The conditions most commonly associated with admission were malaria and gastrointestinal, respiratory, obstetric and gynaecological disorders, accounting for 83% of persons admitted and 66% of bed-days. Of the persons admitted for reasons unrelated to maternity, 63% were females. The highest bed occupancy rate was only 33% (see table). Maternity care visits amounted to 35% of total throughput, most of them being follow-up visits to antenatal clinics. Only one of the facilities employed a full-time registered midwife, reflecting the general shortage of trained maternity personnel. In Nigeria, deliveries are mostly handled by community health extension workers, whose technical skills are seldom updated. Attendance at postnatal clinics was gen- erally very poor, possibly because the importance of postnatal check-ups was not made clear to women attending antenatal clinics or at delivery. However, some postnatal check-ups were not recorded as such because they coincided with the administration of diphtheria/pertussis/tetanus vaccine and were noted as child welfare clinic visits. Obstacles The adoption of a systematic approach to informa- tion storage, retrieval and analysis added a new dimension to the work of the nurse/midwives, who tended to regard such an innovation as unnecessary and, indeed, to resist it. This proved to be the greatest difficulty encountered. It transpired that the period of three months allowed for installing the system and familiarizing users with it was not long enough. The simultaneous setting up of accounting and financial control systems created considerable confusion. Falling throughput of patients appeared to dampen enthu- siasm for management reforms. On the whole, the data generated did not seem to have a significant influence on decision-making in the facilities. Some aspects of the management information system contained errors of design which became apparent as implementation progressed. For in- stance, the child welfare clinic register made provi- sion for records of height, which was rarely measured in clinics and hospitals because height-for-age and height-for-weight charts were generally unavailable. This register had to be amended to suit local conditions and operational needs. Benefits The following benefits were derived from the management information system. . Reliable information became available on the pattern of demand for services, as deduced from changes in throughput. The data allowed future revenues to be estimated with increased reliability and enabled facility heads to make adjustments for periodic fluctuations in demand. . The ability to plan expenditure was improved. . Excessive investment was avoided in technologies and services for which potential demand was low. . Data were used to refute allegations of malpractice and high mortality in one of the facilities. Major gains were made in the generation of information relevant to clinic management, and insights were provided into the pattern of demand for private health care. The ultimate yield will depend on the use to which the information is put. Along with reliable financial statistics, utiliza- tion data offer a potent instrument for planning low- cost community health insurance schemes. In the present instance, unfortunately, the simultaneous installation of a range of systems overloaded the technical and administrative capacities of the facil- ities, whose heads encountered difficulty in calculat- ing and interpreting the bed occupancy rate and other indicators. Particularly in developing countries, management information systems for private provi- ders of basic health services should be as simple as possible in order to facilitate the realization of such non-clinical tasks. It is also desirable that they should require minimal additional cash outlays in view of the limited financial resources of the providers. Selected indicators of utilization in four health facilities, Osun State, Nigeria, 1996 Health facility A B C D General outpatient consultations Mean monthly visits 65 84 27 101 As % of total clinic visitsa 70 26 70 49 Admissions Monthly means 2 9 2 12 As % of outpatient visits 3 10 8 12 Mean length of stay (days) 3 7 11 4 Bed occupancy rate (%) 3 33 14 21 Maternal and child health Mean monthly visits to antenatal clinic 11 137 10 59 Maternity care visits as % of total clinic visits 15 50 30 34 Postnatal clinic visits as % of total births 3 0 30 33 Mean monthly child welfare clinic visitsb 8 71 0 8 a Total visits = outpatient + antenatal + postnatal + child welfare visits + deliveries. b Mainly for immunization. 187Bulletin of the World Health Organization, 1999, 77 (2) A management information system for nurse/midwives When a management information system is being introduced, special attention should be given to strengthening the ability of health workers to document information accurately and to collate it in simple formats. A prolonged effort may be needed before it becomes possible to achieve advanced data analysis and its application to decision-making. n Acknowledgements The project described above was sponsored by John Snow Inc., Arlington, Virginia, USA, under a cooperative agreement with the United States Agency for International Development. The author wishes to acknowledge the support of the staff of Mediplan Ltd, the Initiatives Project, the National Private Nurses and Midwives Association of Nigeria, and Gusle Associates Ltd. Re´sume´ Syste`me d’information gestionnaire a` l’intention des infirmie`res/sages-femmes Dans les communaute´s urbaines a` faible revenu de l’Etat d’Osun, au Nige´ria, les dispensateurs de services de sante´ de base ont constate´ une nette diminution du nombre de patients ces dernie`res anne´es. Quatre e´tablissements de sante´ ont e´te´ retenus pour mettre en oeuvre la phase pilote d’un projet d’aide a` la gestion a` long terme reposant sur l’installation de syste`mes d’information gestionnaire et de controˆle financier. Les syste`mes ont pour but d’accroıˆtre l’efficacite´, ce qui, en abaissant les frais de fonctionnement, devrait permettre d’augmenter le taux d’utilisation et les recettes. Les re´formes de la gestion clinique ont conside´- rablement ame´liore´ la qualite´ des informations sur l’utilisation des services et celle des informations financie`res dont disposaient les dispensateurs et donc, dans une certaine mesure, les de´cisions en matie`re d’affectation des ressources. On a ainsi pu obtenir des donne´es fiables sur les couˆts qui ont pu eˆtre utilise´es comme point de de´part pour e´tablir les prix des services. Toutefois, l’adoption d’une me´thode syste´matique de stockage, de recherche et d’analyse de l’information a ajoute´ une nouvelle dimension aux taˆches que le personnel des e´tablissements de sante´ (et leurs proprie´taires) avait pourtant l’impression d’exe´cuter de fac¸on satisfaisante. Il semble par ailleurs que la baisse du nombre de patients ait freine´ l’enthousiasme suscite´ par ces re´formes, car aucune ame´lioration appre´ciable des recettes n’est apparue au cours de l’anne´e, et cela en raison principalement de l’aggravation de la crise e´conomique dans le pays. Les syste`mes d’information gestionnaire destine´s aux dispensateurs de services de sante´ de base dans les pays en de´veloppement doivent eˆtre aussi simples que possible et doivent tenir compte du fait que les agents de sante´ travaillant a` ce niveau n’aiment pas beaucoup les chiffres et ne sont gue`re enthousiasme´s par les taˆches non cliniques. Les syste`mes impliquant un minimum de sorties d’argent supple´mentaires ont davantage de chances d’eˆtre adopte´s durablement, compte tenu des faibles marges de be´ne´fices de beaucoup de prestataires. Les syste`mes recommande´s devraient eˆtre mis en place progressivement en privile´giant dans un premier temps le renforcement de l’aptitude des agents de sante´ a` re´unir les informations avec pre´cision et a` les assembler sous une forme simple. L’analyse plus perfectionne´e des donne´es et son application a` la prise de de´cision exigeront sans doute beaucoup de temps et d’efforts. Resumen Un sistema de informacio´n para la gestio´n destinado a enfermeras/parteras En los u´ltimos an˜os se ha observado una marcada disminucio´n del nu´mero de pacientes atendidos por los dispensadores de servicios de salud ba´sicos de las comunidades urbanas de bajos ingresos del Estado de Osun, en Nigeria. Se seleccionaron cuatro estableci- mientos de salud para la fase piloto de un proyecto de ayuda a la sostenibilidad centrado en la implantacio´n de sistemas de informacio´n para la gestio´n y de control financiero. Los sistemas se disen˜aron al objeto de mejorar la eficiencia, para que la consiguiente disminucio´n de los gastos de funcionamiento y de los precios diese lugar a un aumento de la utilizacio´n de los servicios y de los ingresos. Las reformas introducidas en la gestio´n clı´nica mejoraron considerablemente la calidad de la utilizacio´n y la informacio´n financiera a disposicio´n de los dispensadores de asistencia, y en cierta medida mejoraron tambie´n las decisiones de asignacio´n de recursos. Adema´s proporcionaron datos fiables sobre los costos, que pudieron emplearse para fijar el precio de los servicios. Sin embargo, la aplicacio´n de un enfoque sistema´tico al almacenamiento, recuperacio´n y ana´lisis de la informacio´n an˜adio´ una nueva dimensio´n a tareas que a juicio del personal sanitario (y de los propietarios) se desempen˜aban ya bastante bien. Parado´jicamente, la disminucio´n del nu´mero de pacientes parecı´a atenuar el intere´s por este tipo de reformas, pues no se aprecio´ una mejora sensible de los ingresos a lo largo del an˜o, a causa sobre todo del agravamiento de la crisis econo´mica sufrida por el paı´s. Los sistemas de informacio´n para la gestio´n destinados a dispensadores de atencio´n sanitaria ba´sica de los paı´ses en desarrollo deberı´an ser lo ma´s simples posible, teniendo en cuenta que con frecuencia los agentes de salud que trabajan a ese nivel tienen escasa habilidad para los ca´lculos nume´ricos y poco intere´s por las tareas no estrictamente clı´nicas. Los sistemas que requieren poco desembolso adicional 188 Bulletin of the World Health Organization, 1999, 77 (2) Policy and Practice tienen ma´s probabilidades de ser adoptados y mantenidos, habida cuenta del escaso margen de beneficio con que trabajan muchos de esos dispensa- dores. Los sistemas prescritos deberı´an escalonarse, insistiendo inicialmente en fortalecer la capacidad de los agentes de salud para documentar la informacio´n con precisio´n y cotejarla empleando formatos simples. La implantacio´n de sistemas avanzados de ana´lisis de datos y su aplicacio´n a la adopcio´n de decisiones puede requerir bastante tiempo y ayuda. 189Bulletin of the World Health Organization, 1999, 77 (2) A management information system for nurse/midwives