SBFR Project Document March
SBFR Project Document March
SBFR Project Document March
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
SBFR intervention area 2: Improve Emergency and Critical Care service access and quality 11
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
SBFR intervention area: Surgical and Anesthesia Service quality and access ......................... 23
SBFR intervention area: Data quality and its use for decision making .................................... 31
ANNEX......................................................................................................................................... 35
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.
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
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:
Chapter-Two
Scope
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
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
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.
MA 3.1.2 All MDT rounds are participatory , system oriented and addresses roles of all
team members
Nursing care
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
19 | P a g e National SBFR Project Document
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.
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.
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
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.
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.
Regional level
Regional health bureaus will have the following major responsibilities, but not necessarily
limited to:
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
Nationally 38 hospitals are selected for the first phase of SBFR-Project implementation
period. These are;