EMERGENCY AND CRITICAL CARE DIRECTORATE
REFERRAL SYSTEM SELF ASSESSMENT CHECK LIST
1. Name of Region _______oromia___________
2. Name of facility________cinaaksa____________
3. Date of assessment______25/1/2017__________
Instruction: Interview facility Director /person in charge or anyone who can provide information
about facility. REFERRAL SYSTEM Perform interview and Observation
I HEALTH FACILITY PROFILE Yes No Remark
Number of staff working in Liaison, social serves and Referral
team?
1 Total =------------6--------
Health professionals =-------------5------
Social services =-----0-----
Other Supportive =----1--
2 From how many health institutions You receive Referrals?
A. Health post______15____
B. Health Centers______2__
C. District Hospitals____0___
D. General Hospitals___1____
E. Tertiary Hospitals____0____
3 For how many health institution You referred a patients to:
A. Health post__________
B. Health Centers__________
C. District Hospitals________
D. General Hospital________
E. Tertiary Hospital_________
4 What is the nearest health facility you refer to
______130_____(KM)
5 What the furthest health facility you refer to
________________bisidimo 130________(km)
II ROLE AND RESPONSIBILITIES Yes No
A Regional health bureau Yes
6 Ensures emergency medical services are given without any Yes
restriction. (e.g. Emergency is open 24/7 days. receive any
emergency patient )
7 Design mechanisms for coordination of referral activities within Yes
the region and feedback system
8 Receive, compile, and analyze data and gives feedback to facilities No
to improve the referral system
9 Hold regular meetings in the region to analyze reports ,receive No
referral complaints, distributes guidelines, and increases public
awareness
B Health facility
10 Ensures liaison and referral office is staffed, equipped and Yes
providing service 24hours/7 days
11 Assigns referral coordinator with clear roles and responsibilities Yes
12 Has the facility provided training on referral system and guide line No
for the last one year?
13 Does the facility ensure the facility’s ambulance is equipped, and No
functioning according to the standard
14 Is there a mechanism/system to ensure patients are referred by No
appropriate most senior health professionals in the facility?
( observe )
15 How many QI projects were devised on referral service for the last
one year?
16 Does the facility collect data and send referral report to concerned
body?
17 Was a referral appropriate with respect to services directory of Yes
their receiving facility
C Liaisons and referral office Yes
18 Coordinates the overall referral activities, ambulance services, bed Yes
management and a regular patients appointments within the
health facility
19 Does liaison and referral record and report the referral activities, Yes
bed senses, and ambulance services to facility management
regularly?
20 Compiles, analyzes, and interprets referral data to improve the Yes
referral service
21 Involvement in the quality assurance programs of the referral Yes
system
22 Ensure feedback is sent to referring facility Yes
23 Ensure emergency patients are escorted with health professionals Yes
24 There is established real time digitalized centralized bed No
management system.
D Health professional
25 Do emergency health professionals resuscitate and stabilize any Yes
patients before referral process?
26 Does the health professional checks and sign a referral format Yes
which is Properly Filled in legible writing?
27 Ensure a transferred patient has arrived to receiving facilities with Yes
liaison office.
28 Responds promptly to consultation requests Yes
III MONITORING AND EVALUATION
29 Quarterly referral audit is performed Yes
30 Dose the facility Report Quarterly referral using referral reporting Yes
format?
31 Does the facility perform Bi-annual catchment meeting between No
health facilities within the same catchment
32 Write the last quarters Yes
Referral in rate (RIR)
Referral out rate (ROR) Yes
Emergency referral in rate (ERI) Yes
Emergency referral out rate (ERO) Yes
Rate of emergency referral in with ambulance (RIAM) Yes
Rate of self-referral Yes
Rate of referral out with communication (RIC) Yes
Rate of referral in with communication(ROC) Yes
Percentage of feedback sent (PFS) Yes
Percentage of feedback received (PFR) Yes
B Facility to Facility Clients transfer Yes
33 Did you inform all clients why, when and where to be Yes
transferred…………………………………
…………………………………………………………………….
34 Were referral cases communicated to receiving facilities though Yes
1,telephone,
2 web based referral system
35 Yes
If you are not using a web base referral system, what are the
reasons? ............................................................................................
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36 .How do you transfer critical patients? (multiple answers)
Transferred with equipped ambulance escorted with health
professionals. ………………………………
A referral form is filled and signed by referring health
professionals with his/her telephone number in legible writing
and stamped ………………..
Relevant laboratory and imaging results are attached to the
referral format ……………….. …………………………
37
Did the liaison officer check the following things before referring a
patient?
Register the patient on referral register………..
A receiving facility liaison officer should inform the emergency
and inpatient case teams to be ready for the management of the
patient………
Referring facility’s liaison and referral should follow the condition of
patients on the way by telephone………………………………………………………..
RESPONDENT RECOMMENDATIONS
1. Where does your health facility mostly refer patients
to? ............................................................................................................................................................
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2. What are the top 5 reasons for referral?
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3. What are the top 5 health facilities you receive referred patient from and their reasons?
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4. Do you have any recommendations on how the referral system could be improved?
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