Ministry of Health-Ethiopia

System Bottlenecks Focused Reform (SBFR)

National Pilot Project Management and Implementation Guide

Draft Document

March-30/2022
Table of Contents
Chapter-One .................................................................................................................................... 3

Introduction ................................................................................................................................. 3

Background ............................................................................................................................. 3

Rationales ................................................................................................................................ 5

Chapter-Two ................................................................................................................................... 6

Scope ........................................................................................................................................... 6

Goal ............................................................................................................................................. 6

Objectives ................................................................................................................................... 6

Chapter Three.................................................................................................................................. 7

SBFR Improvement area 1: High impact leadership for better quality of care .......................... 7

Chapter Four ................................................................................................................................. 11

SBFR intervention area 2: Improve Emergency and Critical Care service access and quality 11

Chapter Five .................................................................................................................................. 14

SBFR intervention area: Improve inpatient care access and quality of care ............................ 14

Chapter Six.................................................................................................................................... 19

SBFR intervention area: Improve outpatient Service access and quality ................................. 19

Chapter Seven ............................................................................................................................... 23

SBFR intervention area: Surgical and Anesthesia Service quality and access ......................... 23

Chapter Eight ................................................................................................................................ 26

SBFR intervention area: Diagnostic Service access and quality .............................................. 26

Chapter Nine ................................................................................................................................. 27

SBFR intervention area: Pharmaceutical Service access and quality ....................................... 27

Chapter Ten ................................................................................................................................... 29

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 SBFR intervention area: Motivated, Competent, and Compassionate care interventions ........ 29

Chapter Eleven .............................................................................................................................. 31

SBFR intervention area: Data quality and its use for decision making .................................... 31

Chapter Twelve ............................................................................................................................. 32

SBFR Leadership and Implementation Arrangement ............................................................... 32

National level ........................................................................................................................ 32

Regional level ....................................................................................................................... 32

Hospital level ........................................................................................................................ 33

Chapter Thirteen ........................................................................................................................... 34

SBFR assessment tool ............................................................................................................... 34

ANNEX......................................................................................................................................... 35

SBFR-Project Implementation Sites (1st phase)....................................................................... 35

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 Chapter-One
Introduction
Background

Health systems play a critically important role in improving health. Well-functioning health
systems enable achievement of good health with efficient use of available resources.
Effective health systems also enable responsiveness to legitimate expectations of citizens
and fairness of financing. Strengthening of health systems requires ever evolving system
innovations which translate into improved delivery of health services with an effect on the
overall quality of care and health outcomes. Health system innovations involve designing/re-
designing health care processes which help to improve the quality of health care. This
amounts to a call for top management commitment to constant organizational self-
evaluation and innovation. Central to the approach are such techniques as setting standards,
monitoring performance against standards, determining the causes of inappropriate
variation (including “quality waste” and low productivity), eliminating that variation, and
starting over at a higher level of expectation.

Ministry of health-Ethiopia in collaboration with regional, city administration and other key
stakeholders has been putting various efforts to transform and improve hospital service
delivery system in which access for comprehensive and quality essential services are
guaranteed by communities across the country. Designing and implementing number of
strategies, initiatives and programs have been the central efforts of the ministry through
which hospitals have been supported while improving patient outcomes. The most notable
strategic measures taken by the ministry include implementation of Ethiopian Hospital
Services Transformation Guide (EHSTG), Health Care Financing Reform, National Hospitals
Health Services Performance Monitoring and Improvement framework (HPMI), National
Healthcare Quality Strategy (NHQS), National Surgical Care Improvement Program (SaLTs),
National Emergency and Critical Care Improvement Strategy and Ten years National
Specialty and Sub-specialty Service Road Map.

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Even though the implementation of these reforms and initiatives have been showing
positive results, the overall system establishment and improvement of care is not moving as
expected. Fragmentation and lack of alignment among the various national strategies,
initiatives and programs are the most challenging problems including inefficiencies and lack
of proper accountability mechanisms.

Hospitals are central to these reform efforts and a number of recent national initiatives have
specifically sought to improve hospital performance and quality of services. Some selected
national hospital key performance indicators (KPI) have shown the need for an urgent action
across the health service delivery system. The annual national emergency mortality and ICU
mortality rates found to be 0.45% and 25.5% respectively. Similarly, if not worst, provision of
basic and essential surgical, neonatal and chronic cares have been challenged by many
factors leading the country to have high rates of mortality due to poor quality of care, low
patient satisfaction and experience of care, high rates of senior professionals attritions,
resource wastages and organizational failures as indicated on different national strategies
evaluation reports such as HSTP-I, NQS-I, SaLTS, MNCH, and Mini-EDHS including ARM
reports published during the year between 2019-2020.

The multifaceted challenges of the current hospital care provision necessitate the ministry
to design, test and implement a new approach namely called System Bottlenecks Focused
Reform (SBFR).

System Bottleneck Focused Reforms (SBFR) may be applied to achieve the highest possible
quality at the lowest possible cost (high value care). SBFR will help institutions to begin
discussion, prepare for, and implement the change packages that may be needed to
improve system bottlenecks associated with poor quality of care.

SBFR mainly aims to bring visible improvements through addressing the major system
bottlenecks such as inefficiencies, system disintegrations, poor practices of evidence us for
decision making and lack of proper accountability mechanisms which resulted high rates of

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institutional morbidities and mortalities during provision of clinical, diagnostic and
pharmaceutical services.

Such a system requires that quality goals (both for a process's final outputs and sub-
processes with their intermediate outputs) be explicitly defined in a measurable form
(standards); then that all outputs (not just quality failures/bad health outcomes) be
evaluated against the standards.

Rationales

Improving both the access and quality of basic medical services in the country’s public
hospitals has become top priority and ultimate goal of the ministry, by systematically,
effectively and efficiently tackle these major challenges leading the development of SBFR.
From the pushing factors:

 Absence of clear accountability and enforcement framework on the overall

hospital care delivery system
 Ineffective and poor hospital performance management and data quality tracking
mechanisms
 Absence of standard scope based clinical practices during service provision by the
different health professionals working in the hospital including students (interns,
residents and other clinical students)
 Inaccessibility of basic and essential hospitals’ services such as but not necessarily
limited to laboratory, pharmaceutical, imaging and specialty services. For
example, SARA 2018 has indicated that access for critical care service/ICU service
is 36%. Long waiting time to get services is also a big challenge, for example an
individual should wait in average more than 35 days to get basic surgical care.
 Presence of inefficient hospital working system for example the average hospital
bed occupancy rate less than 60% with all data quality issues. It is also known that
there are no clear or enforced accountability mechanisms for key stakeholders’

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 engagement and their expected contributions in the overall process of care
delivery.

Chapter-Two
Scope

This national SBFR project is newly designed to be tested in selected 38 hospitals

across the country. This project mainly focusses to effectively identify and address
system related major bottlenecks while bringing significant improvements on both
accessibility and quality of clinical, diagnostic and pharmaceutical services through
implementing high impact interventions from March-18/2022 to February-30/2023.

Goal

The goal of SBFR is to improve hospital’s clinical care outcomes and client satisfaction
through introducing significant and measurable positive system changes which helps
to improve the access and quality of clinical, diagnostic and pharmaceutical care.

Objectives

 To improve institutional culture of leadership and accountability practices

 To digitalize hospital’s clinical and non-clinical care processes and improve data
quality and performance management
 To improve institutional efficiency gains and system integration
 To improve access and quality of clinical, diagnostic and pharmaceutical services
o To improve access and quality of emergency, injury and critical care services
o To improve access and quality of outpatient and inpatient services
o To improve access and quality of surgical and anesthesia services
o To improve access and quality of imaging and laboratory services
o To improve access and quality of pharmaceutical services

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 Chapter Three
SBFR Improvement area 1: High impact leadership for better quality of care

Leadership is a process whereby an individual influence a group of individuals to achieve a

common goal. Hospital leadership requires unique set of skills and system thinking to ensure
the provision of effective, efficient, safe and client centered services. Even though a lot has
been done to improve the capacity and structure of hospital leadership still major bottleneck
such us leadership gaps and poor data use for decision making remains unsolved. Similarly,
different platforms established under healthcare service provision system have missed their
objectives due to different reasons. Their input for system improvement, knowledge
transfer/learning, client centeredness and provision of information for decision making had
left behind; which were the rationale of establishing the platforms.

Therefore, establishing Multidisciplinary Taskforce that supports the leadership to take

actions on major identified gaps of day to day service provision process will help the
CEO/CCO to address the above mentioned bottlenecks. This taskforce will be mandated for
daily 24 hours service delivery audit, analyze the data (including root cause analysis for
identified gaps) and report to CEO on daily bases which helps the CEO to share with
department heads, act up on identified gaps and strengthen informed decision making
process to improve service quality that ultimately impact the outcome of care. Furthermore,
institutionalizing data use for decision making will result in creating accountability and
transparency within the hospital setting.

Priority 1: Leadership and coordination

Change Intervention 1.1: Enhanced multidisciplinary team function and clinical leadership
culture
MA 1.1.1 Institutional structure and reporting relationships should be designed to
enhance team function at patient care level
 Each multi-disciplinary team at the point of patient care should be
administratively accounted to a team lead (Case team leader) and

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 clinically accounted to the clinical leader (the one with the higher
scope)
 All clinical case team leaders in a department should be
administratively accounted to the department head
 All clinical case team leaders in a department will be functionally
coordinated by professional heads (Nursing director, heads of
laboratory/pharmacy/imaging departments)
 Professional heads (Nursing director, heads of
laboratory/pharmacy/imaging departments) will coordinate the overall
operation and quality of respective clinical functions (HR distribution
and reassignments, quality of nursing, diagnostic and pharmaceutical
care)
MA 1.1.2 Clinical leadership functions need to be institutionalized
 Led by scope of practice guidance
 Clinical leader should execute system oriented responsibilities and all
mediation's should address multi-disciplinary team roles and functions
Change Intervention 1.2: SBFR dashboard based intensive SMT monitoring and supervision
MA 1.2.1 Prepare and approve institution specific SBFR dashboard (adapt / adopt from
national SBFR project document)
 Adapt/adopt National KPI and HMIS indicators
 Develop Facility specific indicators - new indicators require a user
manual which clearly define the indicator, determine the data source,
data collection mechanism, mathematical formula and unit of
measurement
MA 1.2.2 Daily CED/CCD SBFR task force forum
 Should be held before departmental morning meeting
 Identified gaps will be communicated to department heads (as an
agenda for morning forum) and other concerns which require
immediate attention will be communicated to respective heads for an

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 action
MA 1.2.3 Weekly clinical forum led by CED and CCO
 Should involve all department heads, clinical team leaders,
administrative wing heads
 Forum agenda: Weekly SBFR dashboard data summary
MA 1.2.4 Display major service areas performances weekly and make the data
accessible to team leaders, department heads, and CEO/CCO
MA 1.2.5 Intensive supportive supervision led by SMT
 Supervision time should be guided by the existing institutional periods
where our systems are challenged including sudden supervision during
night time, weekends and holidays (times of high patient load,
challenging times where staffs fails to adhere to agreed operational
standards)
 Each supervision should address SBFR focus areas and should be
guided by a standard checklist
 Prepare supervision schedule
 Major supervision findings and actions taken should be shared to all
staffs (on a common platform like telegram) and to respective
department heads for follow up
Change Intervention 1.3: SBFR taskforce and quality team led Intensive performance
monitoring and linking all identified gaps with reactive and proactive repair mechanisms
MA 1.3.1 SBFR Task force established led by senior champions
 Multidisciplinary - Physicians, nurses, clinical pharmacists
 TOR prepared
 Define roles and responsibilities of all actors in the system (clinical
staffs, team leads, department heads, professional heads,
 Team members will be assigned officially for full time job
MA 1.3.2 SBFR task force perform daily dashboard based performance audit and feed
in to database for analysis

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  Service audit for start time, productivity etc
 Chart audit
 Client interview (scope adherence, quality of care)
 Observation
 Corridor audit
MA 1.3.3 SBFR task force acts for SMT and manage incidents during duty hours,
weekends and holidays
 Resource sharing b/n units and departments (including admission
beds)
 Manage supporting function interruptions (water, electricity etc)
 Manage disagreement b/n staffs with in a team or b/n different
teams
MA 1.3.4 SBFR task force analyze the data and identify operational or clinical care gaps
 Conduct root cause analysis for all identified gaps and present on daily
CEO/CCO-SBFR forum and weekly SBFR forum
 Department level issues will be communicated to department head
before morning forum and feedback /or accountability will be ensured
 Reactive/proactive measures are taken for all identified gaps
 Record and document minute
Change Intervention 1.4: SBFR task force forum (For AA hospitals only)
MA 1.4.1 Conduct SBFR task force focals forum every 2 weeks
MA 1.4.2 Evaluate inter-facility referral and communication system
Change Intervention 1.5: National SBFR forum
MA 1.5.1 Weekly virtual National SBFR forum, led by ministers
 Participants: MOH directors, RHB heads and relevant directors, CEDs,
CCOs, hospital SBFR task force focals
 Weekly SBFR performance will be presented by MOH
 Independent supervision team will be established at MOH and RHB
level and expected to conduct facility supervision for verifying major

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 performances
MA 1.5.2 Quarterly review meeting
 Review quarterly performance
Expected Result:

Chapter Four
SBFR intervention area 2: Improve Emergency and Critical Care service access and
quality

Emergency and critical care service is part of the hospital care service where emergency care
and critical care is provided across the age groups and sect of services in coordination with
diagnostic and pharmacy service. Considered to be resource intensive both in human and
capital resources and is an area of multi-disciplinary team involvement and integration is
needed. The MOH has designed national health system policies, strategies, programs,
guidelines and protocols and tries to address an issue of efficient and quality emergency and
critical care services and with all the effort to address the challenges in the area there has
been some positive changes. But data shows that the efforts have been short in achieving
the target goals and more to the expectation of the clients. For example, emergency stay
greater than > 24 hours being high, emergency and critical care mortality is still high, timely
emergency care triage and treatment has been reported to be longer and neonatal mortality
is high. These problems with poor data quality management, lack of integration and
inadequate leadership engagement has led to low patient satisfaction and source of
grievance.

This will require a clear strategy within which the principles of quality improvement are
embedded, with a commitment to continuous improvement, integration of all efforts,
improved data management and client centered approach. this chapter tries to address the
most relevant gaps and challenges those facilities are facing in emergency and critical care

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service with the following intervention in a targeted and fast mechanism by reinforcing it
with close M&E and accountability.

Priority 2: Emergency and critical service

Change Intervention 2.1: Implement scope based clinical care practice
MA 2.1.1  Implement triaging and scope based disposal system at all emergency
units (Adult emergency, pediatric emergency and obstetrics emergency)
 Develop institution specific scope based clinical practice protocol
which defines scope for initial evaluation of patients
 Define institution specific scope for all interdepartmental
consultations
 Ensure clients are disposed to the specific scope level
 Ensure clients are initially evaluated as per scope defined for the case
 Ensure an emergency evaluation corner / room for all scopes
MA 2.1.2 Digitalize patient triage and disposal system
 Implement EMR triaging system
Change Intervention 2.2: Enhanced senior engagement for better quality of care
MA 2.2.1 Twice a day MDT round for all kept cases (Morning and Evening)
 Morning: starts at 9am and ends before 12pm; address all kept cases
including at corridors
 Evening: B/n 6pm to 7pm; address only critical and newly admitted
patients and led by duty emergency consultant
MA 2.2.2 Daily clinical audit for
 All newly kept cases of the day
 Green and Yellow for adults / priority and non-urgent cases for
pediatrics / non admitted obstetric and gynecologic emergency cases
(sample cases)
 Audit should address scope adherence, adequate documentation of
history and P/E, diagnostic workup justification, management

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 justification and rational use of drugs
(All audit findings should be linked with improvement and/or administrative
and academic accountability (mechanisms using different platforms including
morning and round sessions. All audit summary reports should be submitted
to quality unit/directorate on daily basis)
MA 2.2.3 Daily emergency corridor audit (client interview and chart audit)
MA 2.2.4 Consultant led QI project which addresses SBFR related gaps requiring
system change
 Should at least graduate 1 QI project per quarter
Change Intervention 2.3: Institutionalize clinical leadership culture
MA 2.3.1 Administrative and clinical leadership roles clearly defined and implemented
MA 2.3.2 All MDT rounds are participatory and addresses roles of all team members
 Nursing care
 IPPS practice
 Hotel service including bed making, food quality
 MCC practice including information provision, client provider
interactions
Change Intervention 2.4: Conduct emergency team forum
MA 2.4.1 Weekly emergency unit/directorate/department forum led by the emergency
department head
MA 2.4.2 Forum members include emergency unit/department nursing head, residents,
interns, lab head, pharmacy head, imaging head if it applies, porter head
MA 2.4.3 Evaluates weekly performance based on the emergency service dashboard
MA 2.4.4 All identified gaps will be linked with an improvement and / or administrative
and academic accountability mechanisms
Change Intervention 2.5: Standardize and implement intra/interdepartmental consultation,
patient transfer and patient transport protocols
MA 2.5.1 Prepare intra/inter departmental consultation protocol which clearly defines
 patient flow process

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  time b/n consultation request and arrival for evaluation in case of
urgent and non-urgent consultations
 physician scope responsible for consultation
MA 2.5.2 Prepare and implement patient transport protocol for all admitted and
emergency kept cases
 Protocol should specify type of patients to be accompanied by
porter/runner alone, porter and nurse, physician and anesthesia team
Expected Result:
o

Chapter Five
SBFR intervention area: Improve inpatient care access and quality of care
Inpatient care is the most important service that defines a hospital. Despite the significant
improvement in expanding beds and increasing the health workforce number and mix, there is
substantial room for improvement. According to the routine data and published research, the care
processes are not the best quality. Medication safety issues, pressure ulcers, and surgical site
infections are common in inpatient setups. Therefore, this shows that infection prevention and
control, rational medication use, and evidence-based nursing care are not up to the best practice.
Besides the essential clinical processes like daily multidisciplinary rounds, proper nursing
assessment and care planning, and following the relevant guidelines and scope-based clinical
practice are areas that need adequate attention.

Priority 3: Inpatient service

Change Intervention 3.1: Institutionalize clinical leadership culture
MA 3.1.1 Administrative and clinical leadership roles clearly defined and implemented

MA 3.1.2 All MDT rounds are participatory , system oriented and addresses roles of all
team members
 Nursing care

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  IPPS practice
 Hotel service including bed making, food quality
 MCC practice including information provision, client provider
interactions
MA 3.1.3 Senior physicians should lead all respective weekly MDT forums
 Co-led by the respective units/wards nursing heads
 Forums should evaluate performances
Change Intervention 3.2: Enhanced senior engagement for better quality of care
MA 3.2.1 Twice a day MDT round
 Morning: starts at 9am and ends before 12pm; address all admitted
patients
 Evening: B/n 6pm to 7pm; address only critical and newly admitted
patients and led by duty emergency consultant
MA 3.2.2 Daily clinical audit for all newly admitted cases of the day
(All audit findings should be linked with improvement and/or administrative and
academic accountability mechanisms (using different platforms including
morning and round sessions. All audit summary reports should be submitted to
quality unit/directorate on daily basis)
MA 3.2.3 Consultant led QI project which addresses SBFR related gaps requiring system
change
 1 QI project per quarter
Change Intervention 3.3: Improving nursing care quality through regular audit feedback
mechanisms
MA 3.3.1 Nursing director / Matron led daily nursing management rounds
 Daily nursing round schedule
 Nursing care units including OR will be grouped in to five nursing
round zones and one zone will be supervised per day
 Team members are nursing director/matron and nursing heads of
different units/wards

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  Nursing management round should at least address
o Emergency preparedness of each unit/ward (List of emergency
drugs and supplies with their minimum quantity to be availed
should be standardized, there should be a mechanism to refill and
handover in each shift)
o Dressing code adherence for all health work force
(Nurses/midwives, physicians, cleaners, runners,
lab/pharmacy/imaging staffs)
o Attendance of all responsible staffs (Nurses/midwives, physicians,
etc - as above)
o IPPS practice - cleanliness of wards, adherence to waste
segregation and instrument processing standards (cleaning to
storage)
(Weekly summary reports should be submitted to quality unit/directorate. All
audit findings should be linked with improvement and/or administrative
accountability mechanisms)
MA 3.3.2 Staff interview for
 Knowledge and skill (adopt/adapt core competencies from national
competency lists)
 Awareness of different reform standards
MA 3.3.3 Nursing handover practice b/n all shifts
(Summary notes of all patients should be kept on nursing handover register)
MA 3.3.4 All admitted patients in the ICU/HDU are followed closely with 4P’s (Pain,
Position, Potty, Possess)
MA 3.3.5 Establish full time nursing/midwifery clinical audit team
(Prepare institutional nursing protocols. Conducts regular nursing care audit and
link identified gaps with and improvement &/or accountability mechanism)
MA 3.3.6 Protocol for common nursing procedures (at least 20)
MA 3.3.7 Protocol for common nursing problems and their management (at least 20)

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  Nursing problem => Subjective and objective evidences => Nursing care
management => Nursing follow up parameters and evidences for
improvement
MA 3.3.8 Standardized ICU nursing care protocol which addresses all the follow up and
care packages
MA 3.3.9 Nursing stations
MA 3.3.10 Culture of daily nursing care audit linked with an improvement and/or
accountability mechanisms
 Perform daily nursing care quality audit for
o Chart audit for nursing process cycle implementation, V/S follow
up as per patient condition, twice daily progress note, medication
administration
o Client interview for client satisfaction in relation to hotel service
(food quality, linen and pyjama change etc), adherence to MCC
principles, quality of client education
(Audit team selection should be based on their competence and role modeling in
nursing care practice. Chart audit will be based on sampling procedure. At least 3
charts should be audited from each unit/ward. Client interview for hotel services,
adherence to MCC principles and quality of client education. At least 1 per 10
clients from each unit/ward should be interviewed. All audit findings should be
linked with improvement and/or administrative accountability mechanisms
Weekly summary reports should be submitted to quality unit/directorate)
MA 3.3.11 Client education: during client interview, patients should clearly understand
and state
 Type of clinical condition they have
 Treatment provided and the expected outcome
 Awareness on discharge planning
 Client’s rights and responsibilities
 Client’s IPPS practice expectation particularly waste segregation

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  Other information’s which the institution assumes important
MA 3.3.12 Establish a skill lab
 standardized package available
 SOP for common nursing procedures present (at least 20)
(Use the skill lab for need based capacity building activities (based on gaps
identified from clinical audits and staff interview))
Change Intervention 3.4: Adequate pain control practice
MA 3.4.1 Pain management protocol is adopted/adapted and clearly states rational use
of pain medications based on the pain score level
MA 3.4.2 Regular pain scoring and control practice is done for all admitted patients (as
per institution protocol)
MA 3.4.3 Pain control practice is regularly audited (chart audit and client interview) and
gaps are linked with an improvement mechanism
(Chart audit for regular pain scoring practice and appropriate management.
Client interview for adequacy of pain control. At least 1 per 10 clients from each
unit/ward should be interviewed. All audit findings should be linked with
improvement and/or accountability mechanisms. Weekly summary reports
should be submitted to quality unit/directorate)
MA 3.4.4 Rational use of narcotic drugs and prescriptions is regularly audited
(Signs of pethidine and/or its prescription abuse should be linked with
accountability)
Change Intervention 3.5: Inpatient team forum
MA 3.5.1 Weekly Inpatient unit/ ward forum led by the assigned senior
MA 3.5.2 Forum members include the specific unit/ward nursing head, residents,
interns, porter head
MA 3.5.3 Evaluates weekly performance based on the inpatient service dashboard
MA 3.5.4 All identified gaps will be linked with an improvement and / or administrative
and academic accountability mechanisms
Change Intervention 3.6: Improved clinical pharmacy service and rational use of drugs

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MA 3.6.1 Clinical pharmacy service is availed for all admitted patients
MA 3.6.2 Clinical pharmacist is member of MDT
MA 3.6.3 Clinical pharmacy service audit well addresses
 Rational use of drugs (2nd and 3rd line antibiotics, polypharmacy …)
 Abuse for most expensive or narcotic medications (top 20 drugs
prioritized by the specific institution)
(All audit findings should be linked with improvement and/or administrative
accountability mechanisms. Weekly summary reports should be submitted to
quality unit/directorate)
Change Intervention 3.7: Duty time human resource availability and function
MA 3.7.1 5pm to 12am (midnight) and 6pm to 8am (morning): All staffs on duty should
be available in working stations and wards
MA 3.7.2 12am to 6pm: Only if conditions allows, 50% staff from a team will rest and 50%
should stay at working stations and wards irrespective of the availability of
work (100% of the staff may work the whole night if a need arises)
MA 3.7.3 All corridor lights should be switched on
(All these duty time procedures also apply to other units and departments
including emergency, laboratory, pharmacy etc)
Expected Result:

Chapter Six
SBFR intervention area: Improve outpatient Service access and quality

An outpatient department or outpatient clinic is the part of a hospital designed for the treatment
of outpatients, people with health problems who visit the hospital for diagnosis or treatment, but
do not at this time require a bed or to be admitted for overnight care. Modern outpatient
departments offer a wide range of treatment services, diagnostic tests and minor surgical
procedures. The MOH over the past three decades has strived to increase the number, quality and
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modality of Outpatient clinics; which can be seen by increase in the number of clients being
served, increase in number of specialty and subspecialty clinics, relative increase in satisfaction.
However, despite the strive to increase the number and quality of Outpatient clinics, MOH has
come short of achieving most relevant quality indicators such Waiting time to treatment which
has been increasing exponentially, weak archiving system which contributes of poor data quality,
increased stay at facility and decreased satisfaction, weak appointment system and disarrayed
care being provided at chronic and specialty and subspecialty clinics. This document tries to
address the most relevant gaps and challenges those facilities are facing with the following
intervention in a targeted and fast mechanism by reinforcing it with close M&E and
accountability.

Priority 4: Outpatient service

Change Intervention 4.1: Better triage, registration and payment systems
MA 4.1.1 Scope based triage disposal system
 Define scope of practice for top 20 clinical conditions in each discipline
(if a need arises, more clinical conditions can be included to the list)
 Define scope for triage professionals to be assigned and it should be at
least GP or R1 and above
 Referred clients should be disposed to at least 1 step higher scope
than the referring health care provider
(Triage objectives in order of significance: R/O Emergency, Specialty, Scope)
MA 4.1.2 Establish system of digital/short code / phone based initial application for
registration, and this will be followed with telephone triaging and appointment
system
MA 4.1.3 Setup one stop shop triage, registration and payment system integrating all
payment modalities in any payment corners/windows (credit/cash/social …)
(Payment system should integrate all payment modalities in one payment
corners/windows (credit/cash/social …))
Change Intervention 4.2: Early initiation of outpatient service and full working hours
service

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MA 4.2.1 All OPDs should start at 8:00am (OPD assignment can be done in rotation and
OPD assigned physicians can not join morning meeting)
MA 4.2.2 Shift based physicians assignment
 Shift 1: 8am to 1pm (including lunch time)
 Shift 2: 1pm to 5:30pm
(Time bound assignment. Assigned physician cannot leave even if he/she
completes available chart)
Change Intervention 4.3: Better appointment system
MA 4.3.1 Appointment system should be in blocks of hours
MA 4.3.2 There should be a digital based appointment system for those who want to
schedule/reschedule appointment
MA 4.3.3 Define minimum interval required to be evaluated by a consultant for common
chronic clinical condition
MA 4.3.4 Refill mechanism should be
MA 4.3.5 Virtual clinic
Change Intervention 4.4: Enhanced senior engagement for facilitated and better quality of
care
MA 4.4.1 All specialty/referral clinics should only be run by a specialist or above
MA 4.4.2 Regular clinics should have a full time senior physician for supervision and
verbal consultation of junior staffs (One stop shop consultation service)
(At least 1 senior physician per discipline)
Change Intervention 4.5: Better client education and counseling system for common
chronic illnesses
MA 4.5.1 Establish health literacy unit for clients with chronic care follow up
(Should be integrated with reappointment registration system)
MA 4.5.2 Standardize and approve health education materials for selected chronic
illnesses
 All health education providers should use
(Shall include leaflets and brochures in local language and to be given for clients)

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Change Intervention 4.6: Clinical audit linked with an improvement &/or accountability
mechanism
MA 4.6.1 Conduct monthly 3R audit (Right physician or scope, Right time, Right way)
 Should be integrated with the existing academic platform (if applicable)
(Monthly clinical audit will be done by residents. Sampling procedure will be
applied)
Change Intervention 4.7: Improvement of Chronic care follow up clinic
MA 4.7.1 Chronic clinic management protocol should be established based on hospital
tier level and communicated
MA 4.7.2 Clinic should be made functional in morning and afternoon with different
specialist allocation
MA 4.7.3 For controlled patients who meet the criteria appointment should be made at
least quarterly
MA 4.7.4 During the quarter wait period facility should arrange clinical pharmacy visit
with drug refill options, and mechanism to alarm client if vital out of range
MA 4.7.5 Facilities should establish a a telemedicine follow up system for selected
chronic diseases with drug refill system
MA 4.7.6 Facilities should establish a referral back system , for patients who fulfill certain
criteria’s
Change Intervention 4.8: Establish a Health Literacy Unit
MA 4.8.1 Facilities should establish a Health literacy Unit which links and closely works
with DIS
MA 4.8.2 Should be led by health literacy professional or at least GP
MA 4.8.3 Standardize selected chronic health education materials
MA 4.8.4 Establish a a phone line where by clients can get phone based consultations
when need be
MA 4.8.5 Link chronic follow up clinic follow up patients with the unit
MA 4.8.6 Establish a Focus group discussion for selected chronic follow up patients
MA 4.8.7 Standardize and provide short videos for health education , brochures and

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 leaflets
Change Intervention 4.9: Establish scope based OPD system and Clinical Audit with
appraisal and accountability
MA 4.9.1 Establish a scope of practice for chronic follow up clinics, specialty clinics and
subspecialty clinics, where subspecialists are engaged with specialty activity
90% of the time.
MA 4.9.2 When available establish a cubicle form of management in chronic follow up
where junior residents and senior residents provide service together.
MA 4.9.3 Perform Regular clinical audit and link with appraisal and accountability
Expected Result:

Chapter Seven
SBFR intervention area: Surgical and Anesthesia Service quality and access

Ethiopia launched its’ first safe surgery strategic plan (Saving Lives through safe surgery) in
2016; to improve access to essential and Emergency surgical care as part of achieving
universal health coverage. After the implementation of this strategic plan; significant
improvement was observed based on the findings of the strategic plan evaluation report.
This evaluation also identified a major gap that needs to be addressed regarding access,
efficiency, and safety of surgical services. Based on the finding s the MoH has approved the
second strategy (SaLTS II) which gives emphasis to surgical efficiency, surgical safety and
access to surgical care.

Priority 5: Surgical and Anesthesia Service

Change Intervention 5.1: Improve Operating theater Leadership
MA 5.1.1 Organizational structure
 Assigned OR director/manager

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Briefing basically means giving information; its synonyms include orientation, meeting, and rundown. In comparison, debriefing is popularly defined as
questioning someone; its synonyms include examine, interrogate, and cross-examine.

Sequence
Briefing is generally done in the beginning while debriefing is conducted at the end. For instance, during the briefing phase in conducting research, a
prospective participant will be informed of the aim of the study, duration of the process, confidentiality, and related details during the briefing phase. The
prospective participant will then either agree or refuse to take part. On the contrary, during the debriefing phase, the researchers express their gratitude and
explain that the information gathered from the participant will remain confidential.
 Clear organogram approved by the SMT
 clearly outlined Role and responsibilities of staff
 Regular forum established which includes departments, supporting
structures (CSR, ME, CSR, porters)
MA 5.1.2 Planning and monitoring
 OR should have an annual plan which includes targets for surgical KPI
 Annual plan regular reviewed and corrective action taken
MA 5.1.3 Establishing OT Dashboard
 Identify key OR performance indicators that address at least efficiency,
safety, and access (eg. TAT, cancelation rate, incision time, SSC
adherence, Table output)
 Mechanism should be established to track the indicators. Daily, weekly
analysis of performance and action taken
Change Intervention 5.2: Improve operation room performance
MA 5.2.1 Standardize scheduling system
 Introduce a digital backlog management system
 Standardization of surgical workflow
 Conducting per-operative conference before patient scheduling
MA 5.2.2 Improve incision time/induction time
 Introducing team briefing and debriefing to improve communication
 Have agreed institutional incision time
 Establishing follow-up scheme for adherence
MA 5.2.3 Shorten Transition time(TAT)
 Establishing patient preparation room
 Establish a protocol
 Data analysis and feedback
MA 5.2.4 Reduce cancelation rate
 Identifying top causes of reason for cancelation and design

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 improvement plan
 Establishing Pre-admission Anesthesia clinic (all elective patients need
anesthesia evaluation before admission)
 Standardization of peri-operative patient evaluation
 Using pre-operative checklist for patient preparation a day before
surgery
 Communication platform and regular inspection of Laundry and CSR
MA 5.2.5 Decreasing OR downtime
 Improve incision time (interventions mentioned above)
 Introducing a concept of half-schedule to improve OR end time
Change Intervention 5.3: Reduce the surgical site infection
MA 5.3.1 Improving surgical site infection tracking and surveillance
 Improving documentation of surgical wound condition using WHO SSI
surveillance checklist for every surgical patient
 Availing SSI register
MA 5.3.2 Decrease surgical site infection
 Mapping the IPPS practice
 Capacity building on IPPS
 Establishing checkpoints for safety
Change Intervention 5.4: Decrease the backlog
MA 5.4.1 Conducting a facility-based surgical backlog analysis by type of surgery
MA 5.4.2 intervening in major bottlenecks for backlog for specialty surgical procedures(
ENT, Plastic, Ophthalmology and neurosurgery
MA 5.4.3 Procurement of supplies for backlog clearance
MA 5.4.4 Using weekend and holydays for elective surgery
Expected Result:
o

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 Chapter Eight
SBFR intervention area: Diagnostic Service access and quality

Diagnostic Service means services that are provided to clients who have been assessed as
having special needs and that will assist in their recovery which are directed toward
evaluation or progress of a condition, disease or injury. Such tests include, but are not
limited imaging, pathology services, and clinical laboratory tests. Despite all effort made in
the past decades to improve access and quality of diagnostic services there is still a lot
remains in service comprehensiveness, service interruption, sustainable consumable and
reagent supply, timely equipment maintenance, and service quality.

Improving access to quality diagnostic services in the hospital through redesigning the
diagnostic service provision system, implementing quality management & assurance
programs, and digitalizing the service is expected to solve the challenge that hospitals
currently face.

Priority 6: Diagnostic service

Change Intervention 6.1: Improve access to quality diagnostic services
MA 6.1.1 Conduct analysis on lab test availability, volume, for potential service sourcing
MA 6.1.2 Develop lab diagnostic menu
MA 6.1.3 Establish backup system for diagnostic service
MA 6.1.4 Determine hospital-based turnaround time (TAT) for each diagnostic service
MA 6.1.5 Conduct diagnostic service provision audit using standardized accreditation
tools on monthly bases
MA 6.1.6 Assess TAT on weekly bases
MA 6.1.7 Asses adherence for selected lab/imaging/pathology requests on daily bases
MA 6.1.8 Implement electronic diagnostic services request
MA 6.1.9 Develop and implement policy and procedures for the resolution of complaints
or feedback received from clinicians, patients or other parties.
(internal/external)

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Change Intervention 6.2: Improve diagnostic service equipment and supply management
system
MA 6.2.1 Establish equipment downtime electronic notification system
MA 6.2.2 Establish agreement for equipment maintenance through outsourcing (Public
and private)
MA 6.2.3 Partially Outsource the management of selected diagnostic service(MRI, CT
Scan)
MA 6.2.4 Develop protocol and implement equipment conditions periodic assessment
and Preventive maintenance
Expected Result:
o

Chapter Nine
SBFR intervention area: Pharmaceutical Service access and quality

Pharmaceutical supply chain, pharmacy services, and medical device management systems
and ensuring uninterrupted availability and accessibility of safe, effective, and affordable
medicines and medical devices has paramount impact in addressing the health problems of
the community.

This Pharmaceutical service remains one of the major bottlenecks the provisions of care at
all levels of the care. prioritize areas for improvement in hospital setting includes is ware
house management, proper planning including standardization of procedures for
procurement and management of medicine and medical supplies and devices, rational use
of medicine including good prescription and dispensing practice and pharmaceutical
wastage and disposal management including for medical devices.

Priority 7: Pharmaceutical Service

Change Intervention 7.1: Develop and implement Good warehouse practice, demand-based

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forecasting and supply planning at the health facilities
MA 7.1.1 Improve ware house management forecasting and supply of medicine using
digitalization such us LMSM
MA 7.1.2 Establish agreement to ensure uninterrupted supply of medicine and supplies
with private vendors.
MA 7.1.3 Design and implement Pharmaceutical disposal plan including out sourcing the
service
Change Intervention 7.2: Improve Medical device management system
MA 7.2.1 Implement medical device inventory system and applying MEMS every 3month
MA 7.2.2 Outsource Medical Device maintenance
Change Intervention 7.3: Improve appropriate medicine use
MA 7.3.1 Improve DIS by integrated the system to all clinical areas and dispensing unit.
MA 7.3.2 Conduct drug formulary management meeting by a multidisciplinary
committee to update hospital formulary and conduct ongoing drug use
review every month
MA 7.3.3 Improve Medication treatment record practice by implementing innovative
methods such as e-prescription
MA 7.3.4 Individual medication order system and automated medication dispensing
MA 7.3.5 Strengthen clinical pharmacy in all clinical areas including daily round and
consultations of clinical pharmacy.
MA 7.3.6 Implement antimicrobial resistance stewardship
Change Intervention 7.4: Strengthen implementation of auditable pharmaceutical
transactions and services
MA 7.4.1 Conduct regular clinical audit on selected drugs and supplies every month
MA 7.4.2 Initiate and conduct regular financial audit every month
MA 7.4.3 Design and implement quality improvement of the pharmaceutical service
Expected Result:
o

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 Chapter Ten
SBFR intervention area: Motivated, Competent, and Compassionate care
interventions

Priority 8: Motivated, Competent, and Compassionate care

Change Intervention 8.1: General duty room management
MA 8.1.1 Gender based (not scope based) duty room arrangement with bathroom and
hand washing facility
MA 8.1.2 Number of beds: 50% of duty staff number
MA 8.1.3 Equipped with furniture, computer, internet, tv
MA 8.1.4 Cup board for all staffs to secure all their personal belongings, gowns and
uniforms
MA 8.1.5 24 hrs access to water (portable purifier)
MA 8.1.6 Central coffee and tea service
MA 8.1.7 Duty room regular housekeeping service with daily cleaning and linen change
service
MA 8.1.8 Zonal duty room service focal assigned and manage the above requirements
Change Intervention 8.2: Consultant duty room management
MA 8.2.1 Should have bathroom and hand washing facility
MA 8.2.2 Equipped with furniture, computer, internet, tv
MA 8.2.3 Cup board for all staffs to secure all their personal belongings, gowns and
uniforms
MA 8.2.4 24 hrs access to water (portable purifier)
MA 8.2.5 Central coffee and tea service
MA 8.2.6 Duty room regular housekeeping service with daily cleaning and linen change
service

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MA 8.2.7 Zonal duty room service focal assigned and manage the above requirements
(can be shared with general duty room)
Change Intervention 8.3: Incentives and work load based payments management
MA 8.3.1 All duty payments should be payed only if the responsive individual executed
all activities and submitted all expected reports including audit activities
MA 8.3.2 Department head may omit someone from a duty schedule if the responsible
person including consultants fails to adhere to the minimum expectations as
stated above
MA 8.3.3  Teaching overload payments should only be paid if the responsible
individual has actively engaged in the following activities
 Morning meetings
 Referral clinics
 MDT rounds
 OR service including adherence to the operation theatre operational
and quality standards
 Bedside
 Duty rounds
 Daily clinical audit
 Quality improvement activities
 Other academic or service related activities which are clearly stated by
the institution
(Ensure all these activities are well aligned with the academic activities)
Expected Result:
o

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 Chapter Eleven
SBFR intervention area: Data quality and its use for decision making

Priority 9: Data quality and use

Change Intervention 9.1: Full automation of electronic medical record system
MA 9.1.1
MA 9.1.2
Change Intervention 9.2: IT structure to support digital health activities
MA 9.2.1
MA 9.2.2
Change Intervention 9.3: Data quality audit for completeness, correctness and timeliness
MA 9.3.1
MA 9.3.2
Change Intervention 9.4: DHIS2 implementation
MA 9.4.1 Completeness and timeliness
MA 9.4.2
Change Intervention 9.5: Use of data for decision making
MA 9.5.1 HR productivity related data and its use for motivation and/or ensuring
accountability
(Linking with available payment mechanisms (duty payment, teaching overload))
MA 9.5.2 Quality of care gaps
Expected Result:
o

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 Chapter Twelve
SBFR Leadership and Implementation Arrangement
National level

Ministry of health will have the following responsibilities:

 Developing and sharing necessary generic technical documents related to the

national SBFR project
 Align and integrate the national SBFR project with other key national projects,
program and initiatives
 Coordinating and monitoring the overall implementation and performance
management of the national SBFR project
 Develop, Sign and enforce MOU with implementing hospitals as joint implementation
and accountability framework for SBFR project
 Providing technical, financial and material supports to implementing hospitals
through applying merit-based approaches
 Conduct surprising and planned visits both at night and day time in randomly
selected facilities from implementing sites
 Conduct monthly performance review and feedback virtual session with all heads of
implementing sites
 Develop and implement national SBFR performance monitoring and reporting
framework
 Create and implement recognition with financial award package for best performing
and innovative hospitals

Regional level

Regional health bureaus will have the following major responsibilities, but not necessarily
limited to:

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  Adopt and support implementation of various technical documents related to the
national SBFR projects
 Assign proper regional SBFR coordinating focal person and unit who will be
responsible for the overall communication and performance management of SBFR
implementation at regional level
 Provide the necessary technical, financial and material supports to SBFR
implementing hospitals in the region
 Support and closely monitor implementation of the signed MOU including the SBFR
performance monitoring and reporting framework
 Conduct surprising and planned visits both at night and day time in randomly
selected SBFR implementing facilities in the region
 Conduct monthly regular review and feedback provision forum with implementing
facilities on the specific and general performances of regional SBFR project
implementation

Hospital level

The national SBFR project implementation facilities will have the following core
responsibilities, but not necessarily limited to:

 Customize and implement all the technical, administrative and any other supportive
documents prepared by ministry of health for the national SBFR project
 Sign and effectively implement the MOU which the hospital has official agreed with
MoH as joint implementation and accountability framework for SBFR project
 Regularly evaluate and take timely actions at hospital’s SMT meetings on the proper
implementation of SBFR project
 Submit complete and timely SBFR performance report to RHB and MoH using the
right reporting tool
 Attend the monthly performance review and feedback provision virtual session to be
coordinated and chaired by ministry of health in coordination with RHBs

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 Chapter Thirteen
SBFR assessment tool
To be developed….

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ANNEX
SBFR-Project Implementation Sites (1st phase)

Nationally 38 hospitals are selected for the first phase of SBFR-Project implementation
period. These are;

S.No Name of Hospitals Type/Level

1 Gonder University H. University Hospital
2 Felegehiwot General Hospital
3 Dessie CSH General Hospital
4 Debrebirhan CSH General Hospital
5 Dilcho general H General Hospital
6 Haromaya Univ. Hiwotfana CSH University Hospital
7 Jigjiga Uni. Shek Hassen Yibre MH University Hospital
8 Degehabur GH General Hospital
9 Dupti GH General Hospital
10 Jimma Uni.H. University Hospital
11 Shashemene GH General Hospital
12 Bishoftu GH General Hospital
13 Bisdimo GH General Hospital
14 Nedjo GH General Hospital
15 Arbaminch GH General Hospital
16 Werabe CSH General Hospital
17 Asosa GH General Hospital
18 Mizan Tepi Unv.H University Hospital
19 Hawassa Unv.H University Hospital
20 Gambela GH General Hospital
21 St Peter SH Federal Hospital
22 Yekatit 12 HMC Teaching Regional Hospital
23 Adama HMC Teaching Regional Hospital
24 Bahirdar Univ. Tibebe Giyon University Hospital
25 Wachemo Univ. Nigist Eleni MMH University Hospital
26 Nakemet Univ. H. University Hospital
27 Ambo Univ. H. University Hospital
28 Welayita Sodo Univ. H University Hospital
29 Yirgalem GH General Hospital

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 30 St Paul HMMC Federal Teaching Hospital
31 Alert H. Federal Hospital
32 Tikur-Anbesa Hospital University Hospital
33 Minillik-II Teaching Regional Hospital
34 Eka Kotebe Federal Hospital
35 Tirunesh Beijing General Hospital
36 St Amanuel Federal Hospital
37 Zewditu General Hospital
38 Gandhi General Hospital
39 Ras Desta General Hospital

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