SYSTEM BOTTLENECKS FOCUSED REFORM

(SBFR) IMPLEMENTATION
LEADERSHIP INTEGRATION AND

COORDINATION PROTOCOL

OROMIA HEALTH BUREAU

AUGUST 2022

TABLE OF CONTENTS

pg. 0
1. INTRODUCTION...................................................................................................................................2

2. RATIONALE...........................................................................................................................................3

3. SCOPE....................................................................................................................................................3

4. OBJECTIVES.........................................................................................................................................3

5. THE ROLES AND RESPONSIBILITIES OF SBFR IMPLEMENTATION ACTORS AND

THEIR INTEGRATION..............................................................................................................................3

5.1. THE ROLES AND RESPONSIBILITIES OF ACTORS AT REGIONAL LEVEL..................3

5.2. THE ROLES AND RESPONSIBILITIES OF ACTORS AT HOSPITALS LEVEL.................5

Checklists......................................................................................................................................................7

Chapter Seven.............................................................................................Error! Bookmark not defined.

SBFR intervention area: Surgical and Anesthesia Service quality and access.....Error! Bookmark not
defined.

Chapter Eleven............................................................................................Error! Bookmark not defined.

SBFR intervention area: Data quality and its use for decision making. .Error! Bookmark not defined.

Chapter Twelve...........................................................................................Error! Bookmark not defined.

SBFR Leadership and Implementation Arrangement.............................Error! Bookmark not defined.

National level......................................................................................Error! Bookmark not defined.

Regional level.....................................................................................Error! Bookmark not defined.

Hospital level......................................................................................Error! Bookmark not defined.

Chapter Thirteen.........................................................................................Error! Bookmark not defined.

SBFR assessment tool.............................................................................Error! Bookmark not defined.

ANNEX......................................................................................................................................................20

SBFR-Project Implementation Sites (1st phase)....................................................................................20

1|Page Oromia Health Bureau SBFR Project Document

1. INTRODUCTION

The health care delivery system is characterized by complexity and the involvement of multiple
players or actors, including Regional, Zonal, Town and Woredas, and other lower governmental
administrative structures, as well as the organization of leadership structures in health care
facilities, which influences the health care delivery system and patient care . Regional Health
Bureau in collaboration with Zonal, Town and Woreda health offices 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 region. Hospitals have been the major focuses of these efforts and a number of
recent initiatives have specifically sought to improve hospital performance and quality of
services.

Despite the fact that different transformation agendas, reforms, and initiatives have yielded
excellent outcomes, the overall system establishment and enhancement of care is not
progressing to achieve the desired outcomes. The most difficult problems are fragmentation
and lack of alignment among the various players in the health and non-health sectors, as well
as poor integration and coordination in the implementation of strategies, initiatives, and
programs, as well as inefficiencies and a lack of proper accountability mechanisms.

Integration improves clinical, economic, and also non-economic values and results in
healthcare delivery. Integration can be either horizontal or vertical. Horizontal integration is
defined as the coordination of activities across operating units that are at the same stage in
coordination programmes/ delivering services at various levels of the healthcare system.
Whereas vertical integration is defined as the coordination of programmes/ services among
operating units that are in different stages of coordinating programmes/ delivering patient
services at various levels of the healthcare system.

Horizontally and vertically integrated and coordinated healthcare delivery system and the
implementation of strategies, initiatives, and programs is instrumental to enhance efficiency
and effectiveness of the healthcare services provide in healthcare facilities.

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System Bottlenecks Focused Reform (SBFR) is a new approach designed to address the
multifaceted challenges of the current hospital care provision to bring visible improvements
through addressing the major system bottlenecks such as inefficiencies, system
disintegrations, poor practices of evidence use for decision making and lack of proper
accountability mechanisms which resulted high rates of institutional morbidities and mortalities
during provision of clinical, diagnostic and pharmaceutical services. This protocol is aimed to
enhance the horizontal and vertical integration and coordination among actors in the health
sector in the implementation of System Bottlenecks Focused Reform (SBFR) across the health
sector.

2. RATIONALE
A major shift is required in organizational governance and management integration and
coordination to avoid inefficient operations and duplication of efforts at all levels in the health
sector. A significant change in organizational values and cultures are also required towards
enhancing person centred care.

3. SCOPE
The leadership integration and coordination protocol in the implementation of SBFR will be
applicable in hospitals candidate for implementation of BFR project, RHBs, ZHOs, THOs and
WHOs with its agencies during the implementation period.

4. OBJECTIVES

 To optimize coordination of activities across operating units that are at the same stage in
coordinating programmes/ delivering services at various levels of the healthcare system
 To enhance coordination of programmes/ services among operating units that are in
different stages of coordinating programmes/ delivering patient services at various levels
of the healthcare system.
 To improve institutional culture of leadership and accountability practices
 To improve institutional efficiency and effectiveness

5. THE ROLES AND RESPONSIBILITIES OF SBFR IMPLEMENTATION ACTORS AND

THEIR INTEGRATION

5.1. THE ROLES AND RESPONSIBILITIES OF ACTORS AT REGIONAL LEVEL

3|Page Oromia Health Bureau SBFR Project Document

 Regional health bureaus with their respective regional agencies will have the following major
responsibilities, but not necessarily limited to:

 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

Table 1. Oromia Regional Level Leadership Structures Integration and Key Tasks

[Link] Regional Level Integration Key Tasks

1 Bureau  Oversee the overall customization, planning,
Heads implementation and coordination of SBFR project at
Executive bureau, zonal and town level
Committee  Mobilize and provide necessary resources for better
implementation of SBFR priority areas
Oromia Jointly with MoH, establish hospital service continuity
Regional and inspection senior leadership covert team with clear
(ORHB) TOR and checklist
 Ensure the proper alignment and resource sharing
2 Senior actions for the effective and efficient implementation of
Management SBFR & major hospital flagship initiatives
Forum  Regularly discuss, advocate and support institutional
accountability and ownership mechanisms for the
effective and efficient implementation of SBFR & major
4|Page Oromia Health Bureau SBFR Project Document
 hospital flagship initiatives
 Oversee the overall customization, planning,
implementation and coordination of SBFR project at
bureau and hospital level
 Assign SBFR regional focal person with clear roles and
responsibilities
 Mobilize and provide necessary resources for better
implementation of SBFR priority areas
3 Project  Monthly review performance reports and take corrective
Coordinating actions on major challenges affecting the effective and
Core efficient implementation of SBFR & major hospital
Process flagship initiatives
Department  Align the SBFR priority areas with Joint Facility Support
and Performance management activities such as
supportive supervision, service assessment,
performance review meeting
 If needed, conduct sudden hospital visits four times per
month any-day anytime of the month including
o After midnight
o Weekends
o Holly days
 Flag critical findings and necessary actions immediately
to the concerned body

5.2. THE ROLES AND RESPONSIBILITIES OF ACTORS AT HOSPITALS LEVEL

The regional SBFR project implementation hospitals 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 officially agreed with
MoH as joint implementation and accountability framework for SBFR project

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  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

Table 2. Hospital Level Leadership Structures Integration and Key Tasks

S.N Hospital level Key Tasks

o leadership structures
 Ensure proper customization of the national SBFR
technical documents based on their institutional
1 CEO/ contexts
CED/  Ensure the establishment and functions of the
Provost different technical forums and focal of SBFR
Hospital  Ensure the establishment and utilization of dashboard
(SBFR by the technical forums
Implementing)  Oversee the overall customization, planning,
implementation and coordination of SBFR project at
2 Senior hospital level
Manageme  Oversee performance reports and take corrective
nt Forum actions every two weeks on major challenges
affecting the effective and efficient implementation of
SBFR & major hospital flagship initiatives
 Ensure proper implementation of institutional
accountability and ownership mechanisms based on
SBFR priority intervention
Clinical  Ensure proper alignment and integration of the SBFR
3 Governanc with major hospital flagship initiatives
e and  Regularly support and monitor the effective
Quality functionalities of the different SBFR forums and focal
Manageme in the hospital
nt Unit
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  Organize report based on template and submit to
concerned bodies

Checklists

Priority 1: Leadership and coordination Met Unmet

Change Intervention 1.1: Enhanced multidisciplinary team function and clinical leadership 1 0
culture
MA Institutional structure and reporting relationships should be designed to enhance
1.1.1 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

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 Clinical leadership functions need to be institutionalized

1.1.2
 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 Prepare and approve institution specific SBFR dashboard (adapt / adopt from national
1.2.1 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

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MA Daily CED/CCD SBFR task force forum
1.2.2
 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 action

MA Weekly clinical forum led by CED and CCO

1.2.3
 Should involve all department heads, clinical team leaders,
administrative wing heads
 Forum agenda: Weekly SBFR dashboard data summary

MA Display major service areas performances weekly and make the data accessible to
1.2.4 team leaders, department heads, and CEO/CCO

MA Intensive supportive supervision led by SMT

1.2.5
 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 SBFR Task force established led by senior champions

1.3.1
 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

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MA SBFR task force perform daily dashboard based performance audit and feed in to
1.3.2 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 SBFR task force acts for SMT and manage incidents during duty hours, weekends and
1.3.3 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 SBFR task force analyze the data and identify operational or clinical care gaps
1.3.4
 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

Priority 2: Emergency and critical service

Change Intervention 2.1: Implement scope based clinical care practice

MA  Implement triaging and scope based disposal system at all emergency units (Adult
2.1.1 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

pg. 0
MA Digitalize patient triage and disposal system
2.1.2
 Implement EMR triaging system
Change Intervention 2.2: Enhanced senior engagement for better quality of care

MA Twice a day MDT round for all kept cases (Morning and Evening)
2.2.1
 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 Daily clinical audit for

2.2.2
 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

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 Daily emergency corridor audit (client interview and chart audit)

2.2.3
MA Consultant led QI project which addresses SBFR related gaps requiring system change
2.2.4  Should at least graduate 1 QI project per quarter

Change Intervention 2.3: Institutionalize clinical leadership culture

MA Administrative and clinical leadership roles clearly defined and implemented

2.3.1

Oromia Health Bureau SBFR Project Document 1

MA All MDT rounds are participatory and addresses roles of all team members
2.3.2
 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 Weekly emergency unit/directorate/department forum led by the emergency

2.4.1 department head

MA Forum members include emergency unit/department nursing head, residents, interns,

2.4.2 lab head, pharmacy head, imaging head if it applies, porter head

MA Evaluates weekly performance based on the emergency service dashboard

2.4.3
MA All identified gaps will be linked with an improvement and / or administrative and
2.4.4 academic accountability mechanisms

Change Intervention 2.5: Standardize and implement intra/interdepartmental consultation,

patient transfer and patient transport protocols

MA Prepare intra/inter departmental consultation protocol which clearly defines

2.5.1
 patient flow process

 time b/n consultation request and arrival for evaluation in case of urgent and  

non-urgent consultations
 physician scope responsible for consultation

MA Prepare and implement patient transport protocol for all admitted and emergency kept
2.5.2 cases

 Protocol should specify type of patients to be accompanied by porter/runner

alone, porter and nurse, physician and anesthesia team

Priority 3: Inpatient service

Change Intervention 3.1: Institutionalize clinical leadership culture

Oromia Health Bureau SBFR Project Document 2

MA Administrative and clinical leadership roles clearly defined and implemented
3.1.1

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

 IPPS practice  

 Hotel service including bed making, food quality

 MCC practice including information provision, client
provider
interactions
MA Senior physicians should lead all respective weekly MDT forums
3.1.3
 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 Twice a day MDT round

3.2.1
 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 Daily clinical audit for all newly admitted cases of the day
3.2.2
(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 Consultant led QI project which addresses SBFR related gaps requiring system change
3.2.3
 1 QI project per quarter

Change Intervention 3.3: Improving nursing care quality through regular audit feedback
mechanisms

Oromia Health Bureau SBFR Project Document 3

MA Nursing director / Matron led daily nursing management rounds
3.3.1
 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

 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 Staff interview for

3.3.2
 Knowledge and skill (adopt/adapt core competencies from national competency
lists)
 Awareness of different reform standards

MA Nursing handover practice b/n all shifts

3.3.3
(Summary notes of all patients should be kept on nursing handover register)

MA All admitted patients in the ICU/HDU are followed closely with 4P’s (Pain,
3.3.4
Position, Potty, Possess)

Oromia Health Bureau SBFR Project Document 4

MA Establish full time nursing/midwifery clinical audit team
3.3.5
(Prepare institutional nursing protocols. Conducts regular nursing care audit and link
identified gaps with and improvement &/or accountability mechanism)

MA Protocol for common nursing procedures (at least 20)

3.3.6
MA Protocol for common nursing problems and their management (at least 20)
3.3.7

 Nursing problem => Subjective and objective evidences => Nursing care
management => Nursing follow up parameters and evidences for improvement
MA Standardized ICU nursing care protocol which addresses all the follow up and care
3.3.8 packages

MA Nursing stations
3.3.9
MA Culture of daily nursing care audit linked with an improvement and/or accountability
3.3.10 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)

Oromia Health Bureau SBFR Project Document 5

MA Client education: during client interview, patients should clearly understand and state
3.3.11
 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

 Other information’s which the institution assumes important

MA Establish a skill lab

3.3.12
 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 Pain management protocol is adopted/adapted and clearly states rational use of pain
3.4.1 medications based on the pain score level

MA Regular pain scoring and control practice is done for all admitted patients (as per
3.4.2 institution protocol)

MA Pain control practice is regularly audited (chart audit and client interview) and gaps are
3.4.3 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 Rational use of narcotic drugs and prescriptions is regularly audited (Signs of

3.4.4 pethidine and/or its prescription abuse should be linked with accountability)

Change Intervention 3.5: Inpatient team forum

MA Weekly Inpatient unit/ ward forum led by the assigned senior

3.5.1

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MA Forum members include the specific unit/ward nursing head, residents, interns, porter
3.5.2 head

MA Evaluates weekly performance based on the inpatient service dashboard

3.5.3
MA All identified gaps will be linked with an improvement and / or administrative and
3.5.4 academic accountability mechanisms

Change Intervention 3.6: Improved clinical pharmacy service and rational use of drugs

MA Clinical pharmacy service is availed for all admitted patients

3.6.1
MA Clinical pharmacist is member of MDT
3.6.2
MA Clinical pharmacy service audit well addresses
3.6.3
 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 5pm to 12am (midnight) and 6pm to 8am (morning): All staffs on duty should be
3.7.1 available in working stations and wards

MA 12am to 6pm: Only if conditions allows, 50% staff from a team will rest and 50% should
3.7.2 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 All corridor lights should be switched on

3.7.3
(All these duty time procedures also apply to other units and departments including
emergency, laboratory, pharmacy etc)

Priority 4: Outpatient service

Change Intervention 4.1: Better triage, registration and payment systems

Oromia Health Bureau SBFR Project Document 7

MA Scope based triage disposal system
4.1.1
 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 Establish system of digital/short code / phone based initial application for registration,
4.1.2 and this will be followed with telephone triaging and appointment system
MA Setup one stop shop triage, registration and payment system integrating all payment
4.1.3 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

MA All OPDs should start at 8:00am (OPD assignment can be done in rotation and
4.2.1
OPD assigned physicians can not join morning meeting)

MA Shift based physicians assignment

4.2.2
 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 Appointment system should be in blocks of hours

4.3.1
MA There should be a digital based appointment system for those who want to
4.3.2 schedule/reschedule appointment

Oromia Health Bureau SBFR Project Document 8

MA Define minimum interval required to be evaluated by a consultant for common chronic
4.3.3 clinical condition

MA Refill mechanism should be

4.3.4
MA Virtual clinic
4.3.5
Change Intervention 4.4: Enhanced senior engagement for facilitated and better quality of care

MA All specialty/referral clinics should only be run by a specialist or above

4.4.1
MA Regular clinics should have a full time senior physician for supervision and verbal
4.4.2 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 Establish health literacy unit for clients with chronic care follow up
4.5.1
(Should be integrated with reappointment registration system)

MA Standardize and approve health education materials for selected chronic illnesses
4.5.2  All health education providers should use
(Shall include leaflets and brochures in local language and to be given for clients)

Change Intervention 4.6: Clinical audit linked with an improvement &/or accountability
mechanism

MA Conduct monthly 3R audit (Right physician or scope, Right time, Right way)
4.6.1
 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 Chronic clinic management protocol should be established based on hospital tier level and
4.7.1 communicated

Oromia Health Bureau SBFR Project Document 9

MA Clinic should be made functional in morning and afternoon with different specialist
4.7.2 allocation

MA For controlled patients who meet the criteria appointment should be made at least
4.7.3 quarterly

MA During the quarter wait period facility should arrange clinical pharmacy visit with drug refill
4.7.4 options, and mechanism to alarm client if vital out of range

MA Facilities should establish a a telemedicine follow up system for selected chronic diseases
4.7.5 with drug refill system

MA Facilities should establish a referral back system , for patients who fulfill certain criteria’s
4.7.6

Change Intervention 4.8: Establish a Health Literacy Unit

MA Facilities should establish a Health literacy Unit which links and closely works with DIS
4.8.1

MA Should be led by health literacy professional or at least GP

4.8.2
MA Standardize selected chronic health education materials
4.8.3
MA Establish a a phone line where by clients can get phone based consultations when need be
4.8.4

MA Link chronic follow up clinic follow up patients with the unit

4.8.5
MA Establish a Focus group discussion for selected chronic follow up patients
4.8.6
MA Standardize and provide short videos for health education , brochures and
4.8.7
leaflets

Change Intervention 4.9: Establish scope based OPD system and Clinical Audit with appraisal and
accountability

MA Establish a scope of practice for chronic follow up clinics, specialty clinics and subspecialty
4.9.1 clinics, where subspecialists are engaged with specialty activity 90% of the time.

Oromia Health Bureau SBFR Project Document 10

MA When available establish a cubicle form of management in chronic follow up where junior
4.9.2 residents and senior residents provide service together.

MA Perform Regular clinical audit and link with appraisal and accountability
4.9.3

Priority 5: Surgical and Anesthesia Service

Change Intervention 5.1: Improve Operating theater Leadership

MA 5.1.1 Organizational structure

 Assigned OR director/manager

• 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 Planning and monitoring

5.1.2
• OR should have an annual plan which includes targets for surgical KPI

• Annual plan regular reviewed and corrective action taken

MA Establishing OT Dashboard
5.1.3
• 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

Oromia Health Bureau SBFR Project Document 11

MA Standardize scheduling system
5.2.1
• Introduce a digital backlog management system

• Standardization of surgical workflow

• Conducting per-operative conference before patient scheduling

MA Improve incision time/induction time
5.2.2
• Introducing team briefing and debriefing to improve communication

• Have agreed institutional incision time

• Establishing follow-up scheme for adherence

MA Shorten Transition time(TAT)
5.2.3
• Establishing patient preparation room

• Establish a protocol

• Data analysis and feedback

MA Reduce cancelation rate
5.2.4
 Identifying top causes of reason for cancelation and design
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 Decreasing OR downtime
5.2.5
• 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 Improving surgical site infection tracking and surveillance

5.3.1
• Improving documentation of surgical wound condition using WHO SSI surveillance
checklist for every surgical patient

• Availing SSI register

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MA Decrease surgical site infection
5.3.2
• Mapping the IPPS practice

• Capacity building on IPPS

• Establishing checkpoints for safety

Change Intervention 5.4: Decrease the backlog

MA Conducting a facility-based surgical backlog analysis by type of surgery

5.4.1
MA intervening in major bottlenecks for backlog for specialty surgical procedures(
5.4.2
ENT, Plastic, Ophthalmology and neurosurgery

MA Procurement of supplies for backlog clearance

5.4.3
MA Using weekend and holydays for elective surgery
5.4.4

Priority 6: Diagnostic service

Change Intervention 6.1: Improve access to quality diagnostic services

MA Conduct analysis on lab test availability, volume, for potential service sourcing
6.1.1
MA Develop lab diagnostic menu
6.1.2
MA Establish backup system for diagnostic service
6.1.3
MA Determine hospital-based turnaround time (TAT) for each diagnostic service
6.1.4
MA Conduct diagnostic service provision audit using standardized accreditation tools on
6.1.5 monthly bases

MA Assess TAT on weekly bases

6.1.6
MA Asses adherence for selected lab/imaging/pathology requests on daily bases
6.1.7
MA Implement electronic diagnostic services request
6.1.8

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MA Develop and implement policy and procedures for the resolution of complaints or
6.1.9 feedback received from clinicians, patients or other parties.
(internal/external)

Change Intervention 6.2: Improve diagnostic service equipment and supply management system

MA Establish equipment downtime electronic notification system

6.2.1
MA Establish agreement for equipment maintenance through outsourcing (Public and private)
6.2.2
MA Partially Outsource the management of selected diagnostic service(MRI, CT
6.2.3
Scan)
MA Develop protocol and implement equipment conditions periodic assessment and
6.2.4 Preventive maintenance

Priority 7: Pharmaceutical Service

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

forecasting and supply planning at the health facilities

MA Improve ware house management forecasting and supply of medicine using digitalization
7.1.1 such us LMSM

MA Establish agreement to ensure uninterrupted supply of medicine and supplies with private
7.1.2 vendors.

MA Design and implement Pharmaceutical disposal plan including out sourcing the service
7.1.3

Change Intervention 7.2: Improve Medical device management system

MA Implement medical device inventory system and applying MEMS every 3month
7.2.1
MA Outsource Medical Device maintenance
7.2.2
Change Intervention 7.3: Improve appropriate medicine use

MA Improve DIS by integrated the system to all clinical areas and dispensing unit.
7.3.1

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MA Conduct drug formulary management meeting by a multidisciplinary committee to
7.3.2 update hospital formulary and conduct ongoing drug use review every month

MA Improve Medication treatment record practice by implementing innovative methods such

7.3.3 as e-prescription

MA Individual medication order system and automated medication dispensing

7.3.4
MA Strengthen clinical pharmacy in all clinical areas including daily round and consultations of
7.3.5 clinical pharmacy.

MA Implement antimicrobial resistance stewardship

7.3.6
Change Intervention 7.4: Strengthen implementation of auditable pharmaceutical transactions
and services

MA Conduct regular clinical audit on selected drugs and supplies every month
7.4.1
MA Initiate and conduct regular financial audit every month
7.4.2
MA Design and implement quality improvement of the pharmaceutical service
7.4.3

Priority 8: Motivated, Competent, and Compassionate care

Change Intervention 8.1: General duty room management

MA Gender based (not scope based) duty room arrangement with bathroom and hand washing
8.1.1 facility

MA Number of beds: 50% of duty staff number

8.1.2
MA Equipped with furniture, computer, internet, tv
8.1.3
MA Cup board for all staffs to secure all their personal belongings, gowns and uniforms
8.1.4

MA 24 hrs access to water (portable purifier)

8.1.5
MA Central coffee and tea service
8.1.6

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MA Duty room regular housekeeping service with daily cleaning and linen change service
8.1.7

MA Zonal duty room service focal assigned and manage the above requirements
8.1.8
Change Intervention 8.2: Consultant duty room management

MA Should have bathroom and hand washing facility

8.2.1
MA Equipped with furniture, computer, internet, tv
8.2.2
MA Cup board for all staffs to secure all their personal belongings, gowns and uniforms
8.2.3

MA 24 hrs access to water (portable purifier)

8.2.4
MA Central coffee and tea service
8.2.5
MA Duty room regular housekeeping service with daily cleaning and linen change service
8.2.6

MA Zonal duty room service focal assigned and manage the above requirements
8.2.7
(can be shared with general duty room)

Change Intervention 8.3: Incentives and work load based payments management

MA All duty payments should be payed only if the responsive individual executed all activities
8.3.1 and submitted all expected reports including audit activities

MA Department head may omit someone from a duty schedule if the responsible person
8.3.2 including consultants fails to adhere to the minimum expectations as stated above

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MA  Teaching overload payments should only be paid if the responsible
8.3.3
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)

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

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MA Completeness and timeliness
9.4.1
MA
9.4.2
Change Intervention 9.5: Use of data for decision making

MA HR productivity related data and its use for motivation and/or ensuring accountability
9.5.1 (Linking with available payment mechanisms (duty payment, teaching overload))

MA Quality of care gaps

9.5.2

Monitoring Strategy
 Day time in randomly selected facilities from implementing sites
 Conduct monthly performance review and feedback virtual session with all heads of
implementing sites

Oromia Health Bureau SBFR Project Document 18

ANNEX

SBFR-Project Implementation Sites (1st phase)

Regionally 8 hospitals are selected for the first phase of SBFR-Project implementation period.
These are;
[Link] Name of Hospitals Type/Level
1. Jimma Uni.H. University Hospital

2. Shashemene SCH Comp. Specialized Hospital

3. Bishoftu GH General Hospital

4. Bisdimo GH General Hospital

5. Nedjo GH General Hospital

6. Adama SCTH Comp. Spec. Teaching Hospital

7. Nakemet Univ. H. University Hospital

8. Ambo Univ. H. University Hospital

Oromia Health Bureau SBFR Project Document 19