ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL

FMOH/CSD ETHIOPIA
Name of the Hospital ----------------------------------Region/City Administration ----------------------------------------- Zone/Sub-City ------------------

Hospital CED/CEO------------------------------------------------------ Cell Phone------------------------------------ Email address-------------------------------------------

Hospital CCD/MD------------------------------------------------------ Cell Phone------------------------------------- Email address-------------------------------------------

Name of Assessor----------------------------------------------------- Cell Phone------------------------------------- Email address-------------------------------------------

SBFR:1 Leadership and Coordination Verification criteria Met/

Unmet
Change Interventions Major Activities
Change Intervention 1: Each multi-disciplinary team at the point of patient care should be administratively accounted to a -Protocol (Department,
Enhanced team lead (Case team leader) and clinically accounted to the clinical leader (the one with the higher case team)
multidisciplinary team scope) -Interview Staffs (2) from
function and clinical randomly selected 3 case
leadership culture teams including seniors
All clinical case team leaders in a department should be administratively accounted to the -Protocol
department head -Interview
All clinical case team leaders in a department will be functionally coordinated by professional heads -Protocol/MOU
(Nursing director, heads of laboratory/pharmacy/imaging departments) -Interview
Professional heads (Nursing director, heads of laboratory/pharmacy/imaging departments) will -Protocol/MOU
coordinate the overall operation and quality of respective clinical functions (HR distribution and -Evidence for HR
reassignments, quality of nursing, diagnostic and pharmaceutical care) distribution/professional
quality assessment
-Interview
Institutionalizing clinical leadership functions -scope of practice
guidance
-Protocol for Clinical
leaders (system-oriented
responsibilities, MDT roles
and functions)
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FMOH/CSD ETHIOPIA

Change Intervention 2: Prepare and approve institution specific SBFR dashboard (adapt / adopt from national SBFR
SBFR dashboard based project document)
intensive SMT A). Adapt/adopt National KPI and HMIS indicators -Document Review
monitoring and -Observation
supervision (1) -Interview (Staff)
B). Develop Facility specific indicators -Document Review
-Observation
-Interview (Staff)
Daily CED/CCD SBFR task force forum
A). Should be held before departmental morning meeting - Document Review
/Minute
- Observation
-Interview (Staff)
B). Identified gaps will be communicated to department heads - Document Review/TOR
-Interview (Staff)
Weekly clinical forum led by CED and CCO
A). Should involve all department heads, clinical team leaders, administrative wing heads - Document Review
/Minute
-Interview (Staff)
B). Forum agenda: Weekly SBFR dashboard data summary - Document Review
/Minute
-Interview (Staff)
Change Intervention: Display major service areas performances weekly and make the data - Document Review
SBFR dashboard based accessible to team leaders, department heads, and CEO/CCO /Minute
intensive SMT -Interview (Staff)
monitoring and Intensive supportive supervision led by SMT
supervision (2)
A). sudden supervision during night time, weekends and holidays - Document
Review/supervision
finding and actions
-Supervision Schedule
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
FMOH/CSD ETHIOPIA
B). Each supervision should address SBFR focus areas and should be guided by a standard -Checklist
checklist -Result finding
communicated
Change Intervention 3: SBFR Task force established led by senior champions
SBFR taskforce and A). Multidisciplinary - Physicians, nurses, clinical pharmacists -TOR
quality team led -Interview
Intensive performance B). TOR prepared -Document Review
monitoring and linking C). Define roles and responsibilities of all actors in the system (clinical staffs, team leads, - Document Review
all identified gaps with department heads, professional heads,
reactive and proactive D). Team members will be assigned officially for full time job -Letter of assignment
repair mechanisms: (1) SBFR task force perform daily dashboard-based performance audit and feed in to database for
analysis
A). Service audit for start time, productivity etc. -Document review, TOR
B). Chart audit -Document review, TOR
C). Client interview (scope adherence, quality of care) -Document review, TOR
D). Observation -Document review, TOR
E). Corridor audit -Document review, TOR
Change Intervention 4: SBFR task force acts for SMT and manage incidents during duty hours, weekends and holidays
SBFR taskforce and A). Resource sharing b/n units and departments (including admission beds) -Protocol/TOR
quality team led B). Manage supporting function interruptions (water, electricity etc.) -Protocol/guide/TOR
Intensive performance C). Manage disagreement b/n staffs with in a team or b/n different teams -Protocol/guide/TOR
monitoring and linking SBFR task force analyze the data and identify operational or clinical care gaps
all identified gaps with A). Conduct root cause analysis for all identified gaps and present on daily CEO/CCO-SBFR forum -Document review, TOR,
reactive and proactive and weekly SBFR forum Minute
repair mechanisms: (2) B). Department level issues will be communicated to department head before morning forum -Document review, TOR
and feedback /or accountability will be ensured -Interview
C). Reactive/proactive measures are taken for all identified gaps -Document review, TOR
-Interview
D). Record and document minute -Document review, TOR
SBFR task force forum (For AA hospitals only)
A). Conduct SBFR task force focals forum every 2 weeks -Document review, TOR,
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FMOH/CSD ETHIOPIA
Minute, attendance…
Interview
B). Evaluate inter-facility referral and communication system -practice review,
interview
SBFR 2: Emergency and Critical Care

Change Intervention 1: The hospital should accept all emergency clients who already arrived to the facility (with or w/o
Implement scope referral paper, within or outside a hospital catchment)
based clinical care A). In case of lack of service/resource, referral to other institution should only be considered after -Protocol, chart audit
practice initial evaluation and stabilization of the patient from liaison, interview (Pt
and staff), observation
B). Inappropriate referrals and /or other gaps should only be investigated and addressed later -Protocol, chart audit
through the hospital management from liaison, interview (Pt
and staff), observation
Implement triaging and scope-based disposal system at all emergency units (Adult emergency,
pediatric emergency and obstetrics emergency)
A). Develop institution specific scope based clinical practice protocol which defines scope for - scope based clinical
initial evaluation of patients practice guide, chart
audit, interview(staff)
B). Define institution specific scope for all interdepartmental consultation -Protocol, chart audit,
interview(staff)
C). Ensure clients are disposed to the specific scope level -chart audit
D). Ensure clients are initially evaluated as per scope defined for the case -chart audit
E). Ensure an emergency evaluation corner / room for all scopes -Observation

F). Implement EMR triaging system -Observation

Change Intervention 2: Emergency department patient evaluation rooms and/or corners are designed to avail all physicians -Observation
One-stop shop initial of different scope at a time such as Interns, R1, R2, R3, R4, Consultants -Interview(staff)
evaluation and Clients will be evaluated by the appropriate scope (as per the disposal from the triage), and when -chart audit
decision-making needed, all intra- departmental consultations (assistance for diagnosis, workup or management) -Observation
practice for all have to be made immediately from the assigned pool of physicians with different scope -Interview(staff)
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
FMOH/CSD ETHIOPIA
emergency cases
Change Intervention 3: Leading and supervising one stop shop initial evaluation and decision-making practice
Enhanced senior Twice a day MDT round for all kept cases (Morning and Evening)
engagement for better A). Morning: starts at 9am and ends before 12pm; address all kept cases including at -protocol, chart audit
quality of care corridors -Observation
-Interview(staff)
B). Evening: B/n 6pm to 7pm; address only critical and newly admitted patients and led -protocol, chart audit
by duty emergency consultant -Observation
-Interview(staff)
Daily clinical audit for
A). All newly kept cases of the day -Protocol, review clinical
audit and crosscheck by
taking sample charts
B). All adult emergency, pediatric, maternal and perinatal deaths, if any -Protocol, review clinical
audit and crosscheck by
taking sample charts
C). Green and Yellow for adults / priority and non-urgent cases for pediatrics / non admitted -Protocol, review clinical
obstetric and gynecologic emergency cases (sample cases) audit and crosscheck by
taking sample charts
D). Audit should address scope adherence, adequate documentation of history and P/E, -Protocol, review clinical
diagnostic workup justification, management justification and rational use of drugs audit and crosscheck by
taking sample charts
Daily emergency corridor audit -protocol, Document
review
Consultant led QI project which addresses SBFR related gaps quarterly(graduated) -Review QI project
document, Interview staff
Change Intervention 4: All kept cases should have a nursing process outlined as per the standard -protocol, Chart audit,
All inpatient nursing staff interview
care standards Regular nursing care audit linked with an improvement and/or accountability mechanism -protocol, review audit
including document
nursing process is Nursing handover practice b/n all shifts with the different modalities -Protocol, chart audit,
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
FMOH/CSD ETHIOPIA
implemented for all interview
kept cases Implement effective health education system for all kept cases -Protocol, chart audit,
client and staff interview,
Adequate pain control practice is implemented -Protocol, client and staff
interview
Change Intervention 5: Administrative and clinical leadership roles clearly defined and implemented
Institutionalize clinical All MDT rounds are participatory and addresses roles of all team members
leadership culture which includes
A). Nursing care Protocol, Chart audit, staff
interview
B). IPPS practice Protocol, Chart audit, staff
interview
C). Hotel service including bed making, food quality Protocol, Chart audit,
client interview
D). MCC practice including information provision, client provider interactions Protocol, Chart audit,
client interview
Change Intervention 6: Weekly emergency unit/directorate/department forum led by the emergency department head -protocol, Minute
Conduct emergency Forum members include emergency unit/department nursing head, residents, -protocol, Minute
team forum interns, lab head, pharmacy head, imaging head if it applies, porter head

Evaluates weekly performance based on the emergency service dashboard -protocol, Minute
All identified gaps will be linked with an improvement and / or administrative -document review/minute
and academic accountability mechanisms
Change Intervention 7: Prepare intra/inter departmental consultation protocol which clearly defines:
Standardize and A. patient flow process Protocol
implement
B. time b/n consultation request and arrival for evaluation in case of urgent and non-urgent Protocol, chart audit, staff
intra/interdepartment
consultations interview
al consultation,
C. physician scope responsible for consultation Protocol, chart audit, staff
patient transfer and
interview
patient transport
Prepare and implement patient transport protocol for all admitted and emergency kept cases:
protocols
A. Protocol should specify type of patients to be accompanied by porter/runner alone, porter -Protocol, chart audit,
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
FMOH/CSD ETHIOPIA
and nurse, physician and anesthesia team Interview (staff and
patient)
SBFR 3: Outpatient Services
Change Intervention 1: Scope based triage disposal system
Better triage, A). Define scope of practice for top 20 clinical conditions in each discipline (if a need arises, more Scope of practice guides
registration and clinical conditions can be included to the list) (for each discipline)
payment systems
B). Define scope for triage professionals to be assigned and it should be at least GP or R1 and Letter of assignment,
above interview

C). Referred clients should be disposed to at least 1 step higher scope than the referring health Protocol, chart audit
care provider
D). Triaging process should follow; R/O Emergency, Specialty/discipline and Scope in that order Protocol
of significance

Establish system of digital/short code / phone based initial application for registration, and this will Protocol, observation
be followed with telephone triaging and appointment system

Setup one stop shop triage, registration and payment system integrating all payment modalities in Observation
any payment corners/windows (credit/cash/social …)

Change Intervention 2: All OPDs should start at 8:00am (OPD assignment can be done in rotation and Protocol, chart audit,
Early initiation of OPD assigned physicians can not join morning meeting) observation
outpatient service and Shift based physicians’ assignment Protocol
full A). Shift 1: 8am to 1pm (including lunch time) Schedule, observation
working hours service
B). Shift 2: 1pm to 5:30pm Schedule, observation
C). Time bound assignment: Assigned physician cannot leave even if he/she completes Protocol, observation
available chart
Change Intervention 3: Outpatient department patient evaluation rooms are designed to avail all physicians of different Protocol
One-stop shop initial scope at a time
evaluation and A). GP, R1, R2, R3, R4, Consultants observation
decision making B). Should be established for all departments/disciplines observation
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practice for all new C). Number of rooms per department/discipline should be guided by the client load observation
clients
Change Intervention 4: All specialty/referral clinics should only be run by a specialist or above Chart audit, observation
Enhanced senior Regular clinics should have a full-time senior physician for supervision and verbal consultation of Protocol, schedule,
engagement for junior staffs (One stop shop consultation service) (At least 1 senior physician per discipline) observation
facilitated and better Unjustified specialty and sub specialty service fragmentation should be avoided
quality of care
A). Ensure all sub-specialists and above have a general specialty and sub-specialty engagement
with at least 80% - 20% share

B). Full time sub-specialty and above engagement can happen only if a sub-specialty unit is
established and the work load requires full time engagement

Change Intervention 5: Appointment system should be in blocks of hours Protocol, review

Better appointment appointment register
system There should be a digital based appointment system for those who want Observe appointment
to schedule/reschedule appointment practice
Define minimum interval required to be evaluated by a consultant for common chronic clinical Protocol
condition
Refill mechanism should be in place Protocol, observe practice
Virtual clinic Observation
Change Intervention 6: Conduct monthly 3R audit (Right physician or scope, Right time, Right way) Protocol, guide
Clinical audit linked A). Should be integrated with the existing academic platform (if applicable), where monthly Review audit, interview
with an improvement clinical audit will be done by residents
&/or accountability
mechanism B). Sampling procedure will be applied protocol
C). General and program-based audits will be audited based on the respective Protocol/guide
departments/disciplines
a). Internal medicine - TB care, HIV/AIDS care, chronic illness care Audit review
b). Ob/Gyn - FP, ANC, cancer screening programs, general and referral clinic services Audit review
c). Pediatrics: EPI, Well baby clinic, general and referral clinic services Audit review
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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d). Other departments: General outpatient and referral clinic services Audit review
Change Intervention 7: Chronic clinic management protocol should be established based on hospital tier level and Protocol
Improvement of communicated
Chronic care follow up
Clinic should be made functional in morning and afternoon with different specialist allocation Protocol, observation,
clinic
schedule

For controlled patients who meet the criteria appointment should be made at least quarterly Protocol/guide, chart
audit

A). During the quarter wait period facility should arrange clinical pharmacy visit with drug refill Protocol, observe practice
options, and mechanism to alarm client if monitoring parameters out of range
Facilities should establish a telemedicine follow up system for selected chronic diseases with drug observe practice
refill system
Facilities should establish a referral back system, for patients who fulfill certain criteria’s observe practice
Change Intervention 8: Facilities should establish a Health literacy Unit which links and closely works with DIS Observation, practice
Better client education guide
and counseling Should be led by health literacy professional or at least GP Letter of assignment
system for common Standardize selected chronic health education materials Review standardized
chronic illnesses education materials
Establish a phone line where by clients can get phone-based consultations when need be Observe practice
Link chronic follow up clinic follow up patients with the unit Protocol, Observe practice
Establish a Focus group discussion for selected chronic follow up patients Protocol, Observe practice
Standardize and prepare short videos, brochures and leaflets to enhance health education efforts Review documents,
(shall be given to clients too) Observe practice
Change Intervention 9: Establish a scope of practice for chronic follow up clinics, specialty clinics and subspecialty clinics, Scope of practice guide
Establish scope based where subspecialists are engaged with specialty activity 90% of the time
OPD system and When available establish a cubicle form of management in chronic follow up where junior residents Observation
Clinical Audit with and senior residents provide service together
appraisal and Perform Regular clinical audit and link with appraisal and accountability Observe practice
accountability
SBFR:4 Inpatient Services
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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Change Intervention 1: Administrative and clinical leadership roles clearly defined and implemented -Protocol, Staff interview
Institutionalize clinical All MDT rounds are participatory, system oriented and addresses roles of all team members -Protocol, Staff interview,
leadership culture chart audit
A). Nursing care -Protocol, chart audit,
Staff interview
B). IPPS practice -Protocol, chart audit,
Staff interview
C). Hotel service including bed making, food quality -Protocol, client and staff
interview
D). MCC practice including information provision, client provider interactions -Protocol, client and staff
interview
Senior physicians should lead all respective weekly MDT forums
A). Co-led by the respective units/wards nursing heads Protocol, minute,
interview
B). Forums should evaluate performances Protocol, minute,
interview
Change Intervention 2: Twice a day MDT round
Enhanced senior A). Morning: starts at 9am and ends before 12pm; address all admitted patients Protocol, chart audit, staff
engagement for better interview
quality of care B). Evening: B/n 6pm to 7pm; address only critical and newly admitted patients and led by duty Protocol, chart audit, staff
emergency consultant interview
C). Daily clinical audit for all newly admitted cases of the day to reduce inappropriate variation in Protocol, Audit review
diagnosis and treatment (chart audit)

Unjustified specialty and sub specialty service fragmentation should be avoided

A). Ensure all sub-specialists and above have a general specialty and sub-specialty -protocol, interview,
engagement with at least 80% - 20% share observation

B). Full time sub-specialty and above engagement can happen only if a sub-specialty unit is protocol
established and the work load requires full time engagement

Consultant led QI project which addresses SBFR related gaps requiring system change
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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A). QI project per quarter QI document review
Change Intervention 3: Nursing director / Matron led daily nursing management rounds
Improving nursing care A). Daily nursing round schedule Schedule
quality through regular
B). Nursing care units including OR will be grouped in to five nursing round zones and one zone Protocol/guide, staff
audit feedback
will be supervised per day interview, supervision
mechanisms
document review
C). Team members are nursing director/matron and nursing heads of different units/wards Protocol, interview
D). Nursing management round should at least address:
a). Emergency preparedness of each unit/ward (List of emergency drugs and supplies with Protocol, Document
their minimum quantity to be availed should be standardized, there should be a review, observation, staff
mechanism to refill and handover in each shift) interview

b). All patient medications should be kept separately in a Room/central cabinet and Observation, interview
secured safe
c). Dressing code adherence for all health work force (Nurses/midwives, physicians, Protocol, observation,
cleaners, runners, lab/pharmacy/imaging staffs) interview

d). Attendance of all responsible staffs (Nurses/midwives, physicians, etc. - as above) Protocol, review
supervision document
e). IPPS practice - cleanliness of wards, adherence to waste segregation and instrument Protocol, review
processing standards (cleaning to storage) supervision document,
observation
E). Weekly summary reports should be submitted to quality unit/directorate Protocol, submitted
document review,
interview
F). All audit findings should be linked with improvement and/or administrative accountability document review,
mechanisms interview
Nursing management should conduct regular nurse’s competency assessment
A). Prepare competency assessment protocol describing the schedule, assessment procedures, protocol
roles and responsibilities etc.

B). Staff interview and/or observation for

ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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a). Knowledge and skill (adopt/adapt core competencies from -guide for core
national competency lists) competencies, Staff
interview based on the
competency guide
b). Awareness of different reform standards Staff interview
Nursing handover practice b/n all shifts with the different modalities
A). Cardex for medications the client is taking Protocol, cardex review
B). handover register (Summary notes of all patients should be kept) Register review
C). clinical forms in the client chart (v/s sheet, input and output monitoring form, nursing care Chart audit, staff
plan and progress notes, medication administration form etc.) interview

All admitted patients in the ICU/HDU are followed closely with 4P’s (Pain, Position, Protocol, chart audit, staff
Potty, Possess) interview

Establish full time nursing/midwifery clinical audit team Observation, interview

Protocol for common nursing procedures (at least 20) protocol

Protocol for common nursing problems and their management (at least 20) protocol
Standardized ICU nursing care protocol which addresses all the follow up and care packages protocol
Nursing stations Observation
Culture of daily nursing care audit, with all identified gaps linked with an improvement and/or
accountability mechanisms
a). Chart audit for nursing process cycle implementation, V/S follow up as per patient met
condition, twice daily progress note, medication administration (at least 3 charts/ward)
b). Client interview for client satisfaction in relation to hotel service (food quality, linen and met
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 protocol
carepractice.
Chart audit will be based on sampling procedure (At least 3 charts should be audited from each Protocol, audit review
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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unit/ward.
Client interview for hotel services, adherence to MCC principles and quality of client education Protocol, audit review
(At least 1 per 10 clients from each unit/ward should be interviewed)
Weekly summary reports should be submitted to quality unit/directorate) Protocol, summary report
review
Implement effective client education system:
A). Standardize health education package and materials (at least, the package should include the Protocol
following health information
a). Type of clinical condition they have Client and staff interview
b). Treatment provided and the expected outcome Client and staff interview
c). awareness on discharge planning Client and staff interview
d). Client’s rights and responsibilities Client and staff interview
e). Client’s IPPS practice expectation particularly waste segregation Client and staff interview
f). Other information’s which the institution assumes important Client and staff interview
B). Quality of health education should be regularly assessed with client interview and identified Client and staff interview
gaps should be linked with an improvement and/or accountability mechanism (during client
interview, patients should clearly understand and state the health information listed above)

Establish a skill lab Observation

A). standardized package available Protocol/ guide
B). SOP for common nursing procedures present (at least 20) SOP review
C). Use the skill lab for need based capacity building activities, based on gaps identified from Review activities done
clinical audits and staff interview
Change Intervention 4: Pain management protocol is adopted/adapted and clearly states rational use of pain medications Protocol/guide
Adequate pain control based on the pain score level
practice Regular pain scoring and control practice is done for all admitted patients (as per institution Chart audit
protocol)
Pain control practice is regularly audited;
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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A). Chart audit for regular pain scoring practice and appropriate Audit review, chart audit
management as per the score.
B). Client interview for adequacy of pain control (At least 1 per 10 clients from each unit/ward Audit review, client
should be interviewed) interview
C). All audit findings should be linked with improvement and/or accountability mechanisms. Review linked
improvement gaps
Weekly summary reports should be submitted to quality unit/directorate) Review summary audit
Rational use of narcotic drugs and narcotic prescription is regularly audited; Review audit
A). Signs of pethidine and/or its prescription abuse should be linked with accountability Review practice
Improved pressure ulcer tracking and surveillance
A). Ensuring all discharged patients have screened for pressure ulcer based on an Checklist, chart audit
adopted/adapted checklist
B). Availing pressure ulcer register Register
C). Use of surveillance data for improvement purpose Review practice
Change Intervention 5: Weekly Inpatient unit/ ward forum led by the assigned senior Protocol, Minute,
Inpatient team forum interview
Forum members include the specific unit/ward nursing head, residents, interns, porterhead Protocol, minute

Evaluates weekly performance based on the inpatient service dashboard Document review based
on dashboard
All identified gaps will be linked with an improvement Review practice
Change Intervention 6: Clinical pharmacy service is availed for all admitted patients Chart audit
Improved clinical Clinical pharmacist is member of MDT and their impact on the clinical decision making Chart audit, staff
pharmacy service and process should be well recognized by other clinical care team members like physicians interview
rational use of and nurses
drugs Clinical pharmacy service audit well addresses
A). Rational use of drugs (2nd and 3rd line antibiotics, polypharmacy …) Chart audit (audit
checklist)
B). Abuse for most expensive or narcotic medications (top 20 drugs prioritized by Chart audit (audit
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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the specific institution) checklist)
All audit findings should be linked with improvement and/or administrative Review practice
accountability mechanisms.
Weekly summary reports should be submitted to quality unit/directorate Review summary report
Change Intervention 7: 5pm to 12am (midnight) and 6pm to 8am (morning): All staffs on duty Protocol, interview,
Establish good patient should be available in working stations and wards observation (50% duty
care practice culture bed availability)
during night time duty 12am to 6pm: Only if conditions allow, 50% staff from a team will rest and Protocol, interview,
hours 50% should stay at working stations and wards irrespective of the observation (50% duty
availability of work (100% of the staff may work the whole night if a need bed availability)
arises)
All corridor lights should be switched on Observation
Internally, sudden supervision shall be done by the SBFR task force, Review practice
quality team, SMT, regional and federal officials
Noncompliance with the protocols should be linked with an improvement and/or accountability Review practice
mechanism which includes omitting from duty assignment
All these duty time procedures also apply to other units and departments including emergency, laboratory, pharmacy etc.
SBFR: 5 Surgical and Anesthesia Care
Change Intervention 1: Organogram revision and installing a temporary and permanent leadership structure at major OR Organogram approved by
Improve Operating SMT
theater Leadership A). As part of the permanent leadership, an OR director assigned to the major OR and clear -letter of assignment
reporting relationships and roles and responsibilities were defined for all staffs working in the -job description
major OR
B). Clinical leadership role of an operating surgeon once any surgery is initiated -protocol, job description
C). Weekly regular forum involving all OR clinical staffs, supporting staffs and staffs from CSR and -protocol, Minute review
head of medical equipment department
D). Undertake performance audit and other relevant issues; And, all gaps identified are linked -review performance
with a reactive and/or proactive repair mechanisms (There should be evidence of audit
improvement based on a displayed data on a run / control chart)
Strong planning and monitoring system
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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A). OR should have an annual plan which includes targets for surgical KPI reviewed and corrective -review plan
action taken based on identified gaps
Establishing OT Dashboard
A). Identify key OR performance indicators that address at least efficiency, safety, and access -Review dashboard
(e.g., TAT, cancellation rate, incision time, SSC adherence, Table output)
B). Mechanism should be established to track the indicators (Daily and weekly analysis of -Review analysis report
performance and action taken)
Change Intervention 2: Standardized surgical workflow system OR guide
Improve operation A). A digital backlog management system Observation
room performance
B). Elective surgery appointment system should only be based on case category pool Protocol, Review practice
C). Clearly defined prioritization criteria and monthly audit Protocol/ guide, Review
audit report and practice
a). System of prioritizing cancer cases and other conditions demanding urgent intervention Protocol/guide, Review
practice
b). System of prioritizing based on geography and other social issues Protocol/guide, Review
practice
D). Regular backlog data analysis and linking all gaps with a repair mechanism Protocol/guide, Review
practice
E). System of assigning additional tables temporarily for departments/units with high backlog Protocol/guide, Review
practice
F). Unjustified specialty and sub specialty service fragmentation should be avoided
a). Procedures requiring a sub specialty intervention should be clearly defined (sub Protocol/guide, Review
specialty scope) and a sub-specialist and above should have a general specialty and sub- practice
specialty engagement with at least 80% - 20% share
b). Full time sub-specialty and above engagement can happen only if a sub-specialty unit is Protocol/guide, Review
established and the work load requires full time engagement practice

G). Avail a pre-admission surgical and anesthetic evaluation clinic and establish system of; Observation
a). Ensuring all clients called from the waiting list are evaluated and the indication for the Protocol, Review practice
surgical intervention is still there;
b). Ensuring all the minimum preparations are made – Investigations, blood etc.; Protocol, Review practice
ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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c). Conducting a pre-anesthetic evaluation and decide on their fitness Protocol, Review practice
H). clients who are not done with the preparations and/or are unfit for anesthesia and/or surgery Protocol, Review practice
should not be admitted
I). Standardized scheduling system and pre-operative admission stay
a). Pre-operative hospital stays for all elective surgical admissions should not be more than Protocol, chart audit,
2 days (audit every month) Review audit report
b). All schedules should be posted 1 day ahead and not later than 3 pm Protocol, schedule
c). The nursing team should ensure all required instruments, drapes and other needed Protocol, interview
materials are ready
d). The anesthesia team ensures all the preparations are made Protocol, interview
e). Conducting per-operative conference (Multidisciplinary) before patient scheduling (to Protocol, schedule,
finalize patient preparation plan) interview
J). Standardize table productivity per day and ensure minimum number of cases are scheduled
and operated on each working day
a). A minimum of 3 surgeries/table/day is expected unless there is a clear justification due Protocol, Document
to the nature of a specific procedure and/or unexpected peri-operative incidents review OR register review
-Triangulate the table
output with hospital
backlog
K). Preventive and curative maintenance check for all major OR medical equipment to ensure
safety and avoid unnecessary cancellations
a). To be done and be documented by duty medical equipment team, every morning Protocol, Review practice
before 6:30am
b). Should at least address OR tables, anesthesia machines, cautery machines, suction Protocol, Review practice
machines, and others which are deemed necessary
L). Establish system of early initiation of surgery with and incision time at or before 8 am Protocol, Review practice
(anesthesia induction time should be b/n 7:30-8:00am)
a). Introducing team briefing and debriefing to improve communication Protocol, review practice
b). Establishing follow-up and feedback and/or accountability Protocol, Review practice
mechanism to ensure adherence
M). Establish a system which helps to reduce time b/n procedures
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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a). Time b/n procedures should not take more than 15 minutes Protocol, chart audit
b). Use of patient preparation room for parallel anesthetic evaluation and preparation Observation
c). Standby cleaners when skin closure start Observation
N). Avoid unjustified cancellation for a scheduled patient (on the day of surgery, on table)
a). Standardization of peri-operative patient evaluation Protocol/guide, chart
audit
b). Using pre-operative checklist for patient preparation a day before surgery Checklist, cross check
patient chart
c). Communication platform and regular inspection of Laundry and CSR Protocol/guide, review
practice
d). System of approving such cancellations only by an anesthesiologist or most senior Protocol, interview
anesthesia staff
e). Mechanism to verify all cancellation daily and system of ensuring an accountability Protocol, review practice
Decreasing OR downtime and days
A). Introducing a concept of shift-based schedule (morning, afternoon) to improve OR end time Protocol, schedule
B). Arrange OR disinfection days for weekends Protocol, interview,
review last date for OR
cleaning
C). Weekend and holidays elective surgery practice if elective surgical cases with higher backlog
a). A surgical team other than the regular duty team can be established (1 surgeon, 1 Review practice
assistant, 2 anesthetists, 2 scrub nurses, 1 cleaner, 1 porter)
b). Issue duty payment if 2 major cases are operated by the team Review practice
c). The other part of the care shall be executed by other regular team members (E.g., Review practice
Inpatient care, lab service, pharmacy service etc.)
Change Intervention 3: Consistent and correct use of safe surgery checklist Chart audit
Reduce the surgical OR zoning based on the national IPPS guideline (Restricted, semi restricted, Transitional and Observation
site infection and other Unrestricted) and adherence to the recommendations
safety related Standardize and Protocolize OR operational management and monitoring its adherence Protocol
problems
A). Work flow and standards (incision time, time b/n procedures, roles and responsibilities of Protocol, review practice
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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different team members etc.)
B). Cleaning procedures and schedules Protocol, review practice
C). Instrument processing, packaging and storing procedures Protocol, review practice
D). Patient preparation procedures Protocol, review practice
E). Dressing protocols including jewelry, personal watch, nail and hair management Protocol, review practice
F). Antibiotic prophylaxis (indications, choice of antibiotics, timing) Protocol, review practice
Improving surgical site infection tracking and surveillance
A). Ensuring all surgical patients have screened for SSI based on WHO SSI surveillance checklist at Chart audit, interview
the time of discharge
B). Availing SSI register Register
C). Decrease SSI (mapping the IPPS practice, capacity building on IPPS, establishing checkpoints Review practice
for safety)
D). Use of SSI surveillance data for improvement Review practice

Change Intervention 4: For every client, establish a registered and prescription-based system of requesting and dispensing
Efficiency gain in OR supplies
supply utilization A). OR coordinators should only have an emergency stock of supplies which should only be Protocol, review practice
utilized based on paid replacement from OR pharmacy
B). Establish OR pharmacy and all required supplies for all surgeries should be supplied from it Protocol, observation,
(prescription-based request for each client and to be paid during discharge) review practice,
interview(client)
C). Cost per a patient can be estimated and payment issued for items to be shared for more than Protocol, review practice
1 client (e.g., Anesthesia drugs, iodine, plaster etc.)
Change Intervention 5: Conducting a facility-based surgical backlog analysis by type of surgery Review backlog analysis
Decrease the backlog document
intervening in major bottlenecks for backlog for specialty surgical procedures (ENT, Plastic, Review interventions
Ophthalmology and neurosurgery done
Procurement of supplies for backlog clearance Review practice
Using weekend and holydays for elective surgery Review practice
SBFR:6 Diagnostic Care
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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Change Intervention 1: Ensure availability of all test menu based on expected standard (self sufficient/ partially or fully -review lab diagnostic
Improve access to outsourcing major machines, including CT and MRI) menu and outsource
quality diagnostic document, observe
services practice, interview
Standardize productivity for imaging services - US scanning, reading CT/MRI if there is a significant
backlog
A). Productivity will be set based on the bottleneck identified
a). Productivity per machine per day if the limiting factor is number of machines Protocol/guide, review
practice
b). Productivity per health care provider per hour if the limiting factor is number of Protocol/guide, review
professionals practice
B). Monitor the performance (against the expectation) and link identified gaps with an Review practice
improvement and/or accountability mechanism (Asses adherence for selected
lab/imaging/pathology requests on daily bases)
C). Conduct diagnostic service provision audit using standardized accreditation tools on monthly Review audit result
bases
D). Establish backup system for diagnostic service Review the practice
E). Develop and implement policy and procedures for the resolution of complaints or feedback Protocol, review practice
received from clinicians, patients or other parties. (internal/external)
Change Intervention 2: Assigning phlebotomist and decentralizing sample collection sites to
Establish client clinical service areas (Service will approach to sites where clients are)
centered system A). Emergency sample collection and result delivery service Review practice
sample collection B). OPD sample collection and result delivery service Review practice
and result delivery
C). Inpatient sample collection and result delivery service Review practice
Microscopic examination and other tests requiring simple machines should be done at major clinical
service areas
A). For tests requiring big machines, samples will be collected from the clinical service areas and Review practice
the test will be done at the central laboratory (Result should only be delivered by a runner)
Sample clotting / hemolysis incidents should be minimized to reduce/avoid unnecessary and Review tracking and audit
repeated sample requests mechanisms by lab,
interview staff
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Result should be delivered based on the agreed TAT
A). Undertake specific tests-based methods of TAT monitoring for compliance to the TAT and link Review assessment result
identified gaps with an improvement and/or accountability mechanisms (Assess TAT on and practice
weekly bases)
a). client interview, patient walk, laboratory register data review etc. Review practice
B). Result should be delivered electronically or by a runner (Implement electronic diagnostic Review practice, interview
services request) patient and staff
Monitor for unnecessary lab repeats and establish system of repairing the causes (system of Review notification
notification, capacity building etc.) system, staff interview
Establish system of auditing justifications of major laboratory/imaging requests and link identified Protocol, Review audit
gaps with an improvement and/or accountability mechanism results and practice
A). Scope might be defined for some diagnostic workups like US, CT, MRI Scope guide/ protocol
B). Use of audit-feedback cycle to improve the identified gaps Review audit finding
Establish system of auditing laboratory and imaging requests which are sent outside the institution Review auditing system
for unacceptable reason and linking all identified gaps with an accountability mechanism and improvement
activities, staff interview
Change Intervention 3: System of preventive and curative maintenance system for laboratory and imaging medical Protocol, review practice
Improve diagnostic equipment (Develop protocol and implement equipment conditions periodic assessment
service equipment and and Preventive maintenance)
supply management Establish equipment downtime electronic notification system Review practice
system Establish agreement for equipment maintenance through outsourcing (Public and private) Review agreement
document and practice
Partially Outsource the management of selected diagnostic service (MRI, CT scan) Review outsources
document and practice
Change Intervention 4: Implement a process control system that monitors the processes from pre analytical to post Review practice
Laboratory has analytical phases of testing, including an established internal quality control (IQC) and participates in
implemented quality external quality assurance (EQA)
management system, established incident handling and reporting system which includes errors or near errors (near Review practice
incident handling and misses).
reporting system, The hospital has established laboratory management information system. Review practice
LMIS The hospital laboratory should be designed and organized at least for bio safety level 2 or above and Observation, interview
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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work environment is clean and well maintained at all times.
Change Intervention 5: Appropriate storage and stock management system for blood and blood products Observation, interview
Hospital implemented Blood mobilization strategy in collaboration with nearby blood bank (at least proportional to the Review practice, interview
appropriate and amount they require)
safeblood transfusion Appropriate cold chain system for blood and blood products Observation, interview
service Actively functioning HTC and regularly audits practice of appropriate and safe use of blood, reports Review practice
safety related incidents to all stakes
SBFR: 7 Pharmaceuticals and Medical Devices
Change Intervention 1: Decide on list of 20 prioritized drugs
Establish system of A). Prioritization should be based on cost, addiction risk and risk for drug resistance; And, Review document,
control over top 20 shall include 2nd and 3rd line antibiotics, pethidine, anti-coagulants, PTU, anti-D etc. interview
prioritized drugs
B). Define scope for prescribing selected items Protocol, interview, chart
audit
Daily stock status report for the prioritized drugs with an emphasis on near stock out items
a). Audit for possible evidences of abuse or irrational use Review audit and practice
b). Link all identified gaps with an improvement and/or accountability mechanism Review practice
Change Intervention 2: Decide on list of 5 prioritized supply items
Establish system of A). Prioritization should be based on cost and availability on market Review document
control over prioritized
B). Define scope for prescribing selected items Protocol, interview, chart
5 supply items
audit
Daily stock status report for the prioritized supplies with an emphasis on near stock out items Review report and
interview
Daily prescription audit (who prescribed, how much, rational use)
A). Audit for possible evidences of abuse or irrational use Review audit result,
interview
B). Link all identified gaps with an improvement and/or accountability mechanism Review practice
Change Intervention 3: Staff clinic establishment observation
Regular audit on Weekly audit on dispensed drugs and supplies for an exempted, CBHI and other credit services Audit review, interview
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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appropriate use of A). Compare register vs prescription agreement with a focus on prioritized drugs and supplies Review practice
drugs and supplies for listed out above
an exempted, CBHI B). Use a sampling procedure Protocol, interview
and other C). Link all identified gaps with an improvement and/or accountability mechanism Review practice
credit services
Change Intervention 4: Presence of properly recorded and filed prescriptions, sales tickets and registers at dispensaries Review practice,
The hospital observation
implements auditable, Implementation of coding to uniquely identify medicines (service areas, stores) Review practice,
transparent and observation
accountable A). Bin ownership and updating is implemented Review practice,
pharmaceutical observation
transactions and B). Presence of regular monthly reports for products, finance and services which is evaluated by Review Report, interview
services (APTS) DTC and SMT with corrective actions (monthly clinical audit on selected drugs and supplies
and financial audit)
C). Annual ABC and VEN analyses report Report review
Change Intervention 5: Improve ware house management forecasting and supply of medicine using digitalization such us Review practice
Develop and LMSM
implement good Establish agreement to ensure uninterrupted supply of medicine and supplies with private vendors. Review agreement
warehouse practice, document, interview
demand-based Design and implement pharmaceutical disposal plan including out sourcing the service Review plan, interview
forecasting and supply
planning at the health
facilities
Change Intervention 6: Implement medical device inventory system and applying MEMS every 3month Observation, review
Improve Medical practice
device management Outsource Medical Device maintenance Review practice, interview
system
Change Intervention 7: Improve DIS by integrated the system to all clinical areas and dispensing unit Review practice
Improve appropriate Conduct drug formulary management meeting by a multidisciplinary committee to update hospital Review minute and
medicine use formulary and conduct ongoing drug use review every month practice, interview
Improve Medication treatment record practice by implementing innovative methods such as e- Review practice, interview
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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prescription
Individual medication order system and automated medication dispensing Review practice, interview
Strengthen clinical pharmacy in all clinical areas including daily round and consultations of clinical Protocol, interview, chart
pharmacy audit
Implement antimicrobial resistance stewardship Review practice, interview
SBFR: 8 Motivated, Competent, and Compassionate care
Change Intervention 1: Gender based (not scope or profession based) duty room arrangement with bathroom and hand Observation, interview
Conducive working washing facility
environment for Number of beds: 50% of duty staff number observation
general duty staffs Equipped with furniture, computer observation
without compromising
Cupboard for all staffs to secure all their personal belongings, gowns and uniforms observation
timely
access for patient care 24 hrs. access to water (portable purifier) observation
Central coffee and tea service observation
Duty room regular housekeeping service with daily cleaning and linen change service observation
Zonal duty room service focal assigned and manage the above requirements Review practice, letter of
assignment, interview
Change Intervention 2: Should have bathroom and hand washing facility observation
Conducive working Equipped with furniture, computer, internet, tv observation
environment for
Cupboard for all staffs to secure all their personal belongings, gowns and uniforms observation
consultant physicians
24 hrs. access to water (portable purifier) observation
without compromising
timely Central coffee and tea service observation
access for patient care Duty room regular housekeeping service with daily cleaning and linen change service observation
Zonal duty room service focal assigned and manage the above requirements (shared with general Review practice, letter of
duty management) assignment, interview
Change Intervention 3: All duty payments should be played only if the responsive individual executed all activities and Review practice, interview
Incentives and work submitted all expected reports including audit activities
load-based payments A). Department head may omit someone from a duty schedule if the responsible person including Review practice, interview
management consultants fails to adhere to the minimum expectations as stated above
Teaching overload payments should only be paid if the responsible individual has actively engaged in Review practice, interview
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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the following activities
A). Morning meetings Review practice, interview
B). Referral clinics Review practice, interview
C). MDT rounds Review practice, interview
D). OR service including adherence to the operation theatre operational and quality standards Review practice, interview
E). Bedside Review practice, interview
F). Duty rounds Review practice, interview
G). Daily clinical audit Review practice, interview
H). Quality improvement activities Review practice, interview
I). Other academic or service-related activities which are clearly stated by the institution Review practice, interview
SBFR: 9 Data Quality and Evidence Use
Change Intervention 1: Invest on full digitization of the clinical care process Observation, interview
Full automation of Use of daily, weekly, monthly, quarterly, biannually etc. EMR dashboard encompassing facility Review practice, interview
electronic medical specific, regional and national HMIS and KPI indicators
record system for Monitor overall productivity, clinical and non-clinical functions of the hospital using facility specific, Review practice, interview
quality data and its use regional and national HMIS and KPI indicators (as per the timeline set for an individual indicator)
for decision making
Change Intervention 2: Established IT structure and has adequate staffs to support EMR system Observation, interview
IT structure to support 24 hrs. IT personnel is assigned (Working and duty hours including weekends and holidays Review practice, schedule,
digital health activities interview
Change Intervention 3: There is ≥85% consistency between data reported on HMIS forms and data recorded in registers and Review practice, interview
Data quality audit for patient / client records
completeness, HIT department in collaboration with quality team and SBFR task force conducts sampling based Review practice, interview
correctness and daily data audit for completeness and correctness (Every service unit should at least be audited once
timeliness a week)
Data audit gaps are analyzed and linked with a repair and /or accountability mechanism Review practice, interview
Change Intervention 4: Hospital submits reports timely Review practice, interview
DHIS2 implementation Hospital keeps hard copy of all reported data and it is consistent with DHIS2 data Review practice by cross-
checking, interview
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Change Intervention 5: HR productivity related data and its use for motivation and/or ensuring accountability (Linking with Review practice, interview
Use of data for available payment mechanisms (duty payment, teaching overload)
decision making Quality of care gaps are linked with a reactive and/or proactive improvement programs Review practice, interview
Diagnostic and drug/supply access gaps are linked with an improvement and/or accountability Review practice, interview
mechanisms
SBFR: 10 Academic and Clinical Services Integration and high-quality culture for institutional transformation
Change Intervention 1: Department heads are responsible to manage both service and academic activities and are Organogram, legislation,
Client centered and accounted to both academic and clinical service wings interview
system oriented System thinking is integrated with the existing undergraduate and postgraduate curricula (for both Curriculum, review
medical education training and evaluation) practice, interview
Change Intervention 2: Certified as per health facility regulatory standards Certificate, interview
Certified by ESA health An action plan is developed for all identified gaps /feedback provided Action plan review,
facilities regulatory interview
standards Evidence of implementation for the action plan developed Review implementation
practice
Change Intervention 3: Well established workshop and system for facility maintenance (water, electric, buildings, sewerage
effective and efficient lines)
EHSTG A). Maintenance tools Observation, practice
implementation review, interview
B). Adequate staff and spare parts Observation,
C). Regular and programmed preventive and curative maintenance system for major facility Program, practice review,
functions interview
Well established medical equipment maintenance workshop
A). Maintenance tools Observation, practice
review, interview
B). Adequate staff and spare parts Observation, practice
review, interview
C). Regular and programmed preventive and curative maintenance system for major medical Program, practice review,
equipment interview
Change Intervention 4: Hospital compound and surrounding (within 3 meters of hospital fences) are clean and green Observation
 ETHIOPIAN NATIONAL SYSTEM BOTTLENECKS FOCUSED REFORM (SBFR)IMPLEMENTATION ASSESSMENT TOOL
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CASH All sockets are fixed, electric lines are safely secured/covered and sewerage lines are tightly closed Observation
Change Intervention 5: Strong quality structure is established
Quality culture Multidisciplinary team which includes physicians, nurses, laboratory and pharmacy professionals, Observation, interview
other experts such as health information etc.
Quality unit coordinates all hospital reform activities, SBFR implementation and other quality related practice review, interview
agendas
HR productivity related data and its use for motivation and/or ensuring accountability (Linking with practice review, interview unmet
available payment mechanisms (duty payment, teaching overload))
Quality unit in collaboration with other units/departments graduate at least 2 QI projects per practice review, interview
quarter
Strong institutional learning culture with bench marking activities within or b/n health facilities practice review, interview
6Change intervention Regular audit for exempted service and identified gaps are linked with feedback and /or Review audit, interview
6: Health care accountability mechanisms
financing Social service is provided Observation, interview
A). Staff clinic is established and is led by a protocol Protocol, observation
B). Social service is provided based on an established protocol Protocol, observation
C). Regular audit for social service provided and identified gaps are linked with feedback and/or Protocol, Audit review,
an accountability mechanism interview
Change intervention 7: MOU signed b/n both parties MOU
Provide CBHI based Timely request claim and payment collection Review document
and other credit
Audit finding from CBHI and other customers comply with more than 90% of the Review audit, interview
services
expectations(documentation, service availability, clinical audit and other defined requirements)
Provide stamped stock out prescriptions for unavailable medications Protocol, review practice
(sample prescription),
interview
Provide stamped stock out laboratory and or imaging requests for unavailable diagnostic tests Protocol, review practice
(sample prescription),
interview
Total score %
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