Ministry of Health - SBFR ORHB Presentation

Ministry of Health-Ethiopia
System Bottlenecks Focused Reform-SBFR

A Path for Hospital Accreditation: Investing Less & Harvesting More!
Technical Orientation on SBFR Conceptual Framework and

Implementation Guidance for ORHB
August13,2023
Adama, Ethiopia
SBFR: Concept SBFR outputs / Outcomes
• High impact leadership

“Newly designed and unique national pilot project • Productivity
• Efficiency
... mainly focused and intervene on system level major • Data use culture (Improvement, PBP)
• Accountability
bottlenecks through introducing measurable high
impact positive system changes (concepts and
• Access
intervetnions) • Quality
... while creating clear strategic alignments and • Safety
• Client experience
Integrations among key stakeholders with defined • Equity
responsibilities and accountability mechanisms”
• Health outcomes
• Health care cost
• Client satisfaction
2
Why SBFR: Rational and Urging factors
Health system Innovation to bridge the quality

chasm
“Between the health care we have and the health care we
can have lies not only a gap but a chasm…”
PRIORITIZATION ACCOUNTABILITY RESOURCES INTEGRATION
• No habits for • No written roles & • No resource alignments • No shared responsibilities

evidence use responsibilities • Unrealistic expectations • No regular Joint site visits
• Micromanagement • Weak work ethics and support

• Enormous wastages
• Too many • No practical institutional • No strong co-investment
• Huge disparities: Plan
policy for actions on wrong approach
engagements Vs Commitments
doers • Weak stakeholder
• All in one service • MOFED budget
• Unhealthy race and management
provision approach allocation
professional egoism
P A R I
SBFR - Integrations & Innovations!!!!
Vertical
Integration
SBFR - Innovations!!!!
SBFR vs Existing National Initiatives
... It builds on the existing quality initiatives & tools…
ENQS
EBC/EHAQ
EHMI EHRIG EHAQ CLIP
speciality roadmap
2006 2007 2010 2011 2012 2014 2015 +
Blue
HPMI CASH
print
Federal Ministry of Health

Path for Accreditation
SBFR: Scope
 Pilot project on 36 + 2 hospitals
 Selection criteria - high volume, tertiary care service, academic and
research role, equity
 Clinical service and academic service quality with patient first priniciple
 1 year project (April 2014 to April 2015 E.C)
 Path to accreditation - Phase 1
 to be followed by Quality and COE phases

8
SBFR: Scope and Priority
1 2 3
16
SBFR: Change
Priorities
Leadership S B F R Project Management and Support
Access, Quality and Comprehensive Hospital

Clinical Care Care
Data Quality Strong M&E for evidence use
Feedbacks Strategic Joint visits and Support
Accountability Clear Manadates and integrations
Transparency Recognition and Humilation

SBFR: Strategic Goal and
Objectives
Goal Objectives
▪ Improve hospital’s clinical care  To improve institutional culture of leadership
and accountability practices
outcomes and client satisfaction
 To digitalize hospital’s clinical and non-clinical
through introducing significant care processes and improve data
quality and performance management
and measurable positive system
 To improve institutional efficiency gains and
changes on access and quality of system integration
clinical, diagnostic and
 To improve access and quality of
pharmaceutical care. clinical,
diagnostic and pharmaceutical services
13
SBFR Changes
Change interventions
Vs
Change bundle
S B F R C H A N G E B U N D L E - Organizational structure
• Point of care level

Organizational • Vertical Scope based Clinical leadership structure
structure • Vertical Unit based administrative leadership structure
and
accountability • Service level - Departmental
relationship • Vertical Service based administrative leadership structure
• Vertial Dual Governance administrative leadership structure
Health care system is

• Institution level
a complex system
• Vertical Profession based functional leadership structure
requiring hybrid  Overall coordination and quality assurance
model of leadership • Vertical Institutional goal oriented functional &/or administrative leadership
structure structure
LEADERSHIP & COORDINATION
Administrative leadership
Health care team
leadership
Clinical leadership
Service
Units, departments leadership
leadership
Professional Nursing, laboratory, pharmacy,

leadership anesthesia ...
Intensive M & E
Institutional taskforce, SMT, RHB, MOH
leadership Academic and Clinical service integration
Client centered and system oriented medical education
MOH/RHB/Univerisity
Dual Governance administrative
structure Governing Board
CED
Medical Vice Academic/Research Vice Administration/

Development Vice
Service department Heads
CASE TEAMS
Case team coordinator
Professional
leaders Staffs
(Specialists, GPs, nurses, lab/pharmacy, cleaners, runners, Guards etc )
SBFR CHANGE BUNDLES
System Bottlenecks
Focused Reform
SBFR
WHY, WHAT, HOW, Where and When…
9
Group Exercise: What should be
done..?
Country Hospital Individua

level level l level
11
SBFR:
Strategic Priority Areas and
Interventions
SBFR:1
Leadership and Coordination
SBFR: Leadership and Coordination
Change Intervention 1: Enhanced

multidisciplinary team function and clinical
leadership culture
 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
SBFR: Leadership and Coordination
Change Intervention 1: Enhanced multidisciplinary team
function and clinical leadership culture
 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)
SBFR: Leadership and Coordination…
Change Intervention 2: SBFR dashboard based intensive SMT monitoring and

supervision (1)
▸ Prepare and approve institution specific SBFR dashboard (adapt / adopt from national
SBFR
project document)

Adapt/adopt National KPI and HMIS indicators

Develop Facility specific indicators - new indicators require a user manual which clearly
define the indicator, determine the data source, data collection mechanism,
mathematical formula and unit of measurement
▸ Daily CED/CCD SBFR task force forum

Should be held before departmental morning meeting

Identified gaps will be communicated to department heads (as an agenda for morning
forum) and other concerns which require immediate attention will be communicated to
respective heads for an action
▸ Weekly clinical forum led by CED and CCO

Should involve all department heads, clinical team leaders, administrative wing heads

Forum agenda: Weekly SBFR dashboard data summary
Change Intervention: SBFR dashboard based intensive SMT

monitoring and supervision (2)
▸ Display major service areas performances weekly and make

the data
accessible to team leaders, department heads, and
CEO/CCO
▸ Intensive supportive supervision led by SMT


Supervision time should be guided by the existing institutional
periods where our systems are challenged including sudden
supervision during night time, weekends and holidays (times of
high patient load, challenging times where staffs fails to adhere to
agreed operational standards)

Each supervision should address SBFR focus areas and should be
Change Intervention 3: SBFR taskforce and quality team led Intensive

performance monitoring and linking all identified gaps with reactive and
proactive repair mechanisms: (1)
▸ SBFR Task force established led by senior champions

Multidisciplinary - Physicians, nurses, clinical pharmacists

TOR prepared

Define roles and responsibilities of all actors in the system (clinical staffs, team leads,
department heads, professional heads,

Team members will be assigned officially for full time job
▸ SBFR task force perform daily dashboard based performance audit and feed in to database
for analysis

Service audit for start time, productivity etc

Chart audit

Client interview (scope adherence, quality of care)

Observation

Corridor audit
Change Intervention 4: SBFR taskforce and quality team led Intensive

performance monitoring and linking all identified gaps with reactive
and proactive repair mechanisms: (2)
▸ SBFR task force acts for SMT and manage incidents during duty hours, weekends
and holidays

Resource sharing b/n units and departments (including admission beds)

Manage supporting function interruptions (water, electricity etc)

Manage disagreement b/n staffs with in a team or b/n different teams
▸ SBFR task force analyze the data and identify operational or clinical care gaps

Conduct root cause analysis for all identified gaps and present on
daily CEO/CCO-SBFR forum and weekly SBFR forum

Department level issues will be communicated to department head before
morning forum and feedback /or accountability will be ensured

Reactive/proactive measures are taken for all identified gaps

Record and document minute
▸ SBFR task force forum (For AA hospitals only)

 Conduct SBFR task force focals forum every 2 weeks
 Evaluate inter-facility referral and communication system
▸ National SBFR forum
 Weekly virtual National SBFR forum, led by ministers
 Participants: MOH directors, RHB heads and relevant directors,
CEDs, CCOs, hospital SBFR task force focals
 Weekly SBFR performance will be presented by MOH
 Independent supervision team will be established at MOH and
RHB level and expected to conduct facility supervision for
verifying major performances
 Quarterly review meeting
 Review quarterly performance
Expected Result:

High impact leadership

Well functioning team work at the point of
care level

Well institutionalized clinical leadership

System components of care (IPPS, Hotel
services, MCC… ) are well integrated with
clinical care
SBFR:2
Emergency and Critical Care
SBFR: Emergency and Critical Care
Change Intervention 1: Implement scope

based clinical care practice
 The hospital should accept all emergency clients who
already arrived to the facility (with or w/o referral
paper, with in or outside a hospital catchment)
 In case of lack of service/resource, referral to other
institution should only be considered after initial
evaluation and stabilization of the patient
 Inappropriate referrals and /or other gaps should only
be investigated and addressed later through the
hospital management
Change Intervention 1: Implement scope

based clinical care practice
 Implement triaging and scope based disposal system at
all emergency units (Adult emergency, pediatric
emergency and obstetrics emergency)
 Develop institution specific scope based clinical
practice protocol which defines scope for initial
evaluation of patients
 Define institution specific scope for all
interdepartmental consultation
 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
SBFR: Emergency and Critical Care…
Change Intervention 2: One-stop shop initial evaluation and

decision making practice for all emergency cases
 Emergency department patient evaluation rooms
and/or
corners are designed to avail all physicians of different
scope at a time (at least during 2/3rd of the day where case
flow is high) such as Interns, R1, R2, R3, R4, Consultants
 Clients will be evaluated by the appropriate scope (as per

the disposal from the triage), and when needed, all intra-
departmental consultations (assistance for diagnosis,
workup or management) has to be made immediately from
Change Intervention 3: Enhanced senior engagement for better quality

of care
 Leading and supervising one stop shop initial evaluation and decision making
practice
 Twice a day MDT round for all kept cases (Morning and Evening)
 Morning: starts at 9am and ends before 12pm; address all kept cases including at
corridors
 Evening: B/n 6pm to 7pm; address only critical and newly admitted patients and led
by duty emergency consultant
 Daily clinical audit for
 All newly kept cases of the day
 All adult emergency, pediatric, maternal and perinatal deaths, if any
 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
 Daily emergency corridor audit
 Consultant led QI project which addresses SBFR related gaps
Change Intervention 4: All inpatient nursing care standards including

nursing process is implemented for all kept cases
 All kept cases should have a nursing process outlined as per the
standard
 Regular nursing care audit linked with an improvement
and/or accountability mechanism (For details, see inpatient
chapter below)
 Nursing handover practice b/n all shifts with the different modalities (For
details, see inpatient chapter below)
 Implement effective health education system for all kept cases (For
details, see inpatient chapter below)
 Adequate pain control practice is implemented (For details, see inpatient
chapter below)
Change Intervention 5: Institutionalize clinical leadership culture

 Administrative and clinical leadership roles clearly
defined and implemented
 All MDT rounds are participatory and addresses roles of all team members
which includes
 Nursing care
 IPPS practice
 Hotel service including bed making, food quality
 MCC practice including information provision, client provider interactions
Change Intervention 6: Conduct emergency team forum

 Weekly emergency unit/directorate/department forum led by the emergency
department head
 Forum members include emergency unit/department nursing head, residents,

interns, lab head, pharmacy head, imaging head if it applies, porter head
 Evaluates weekly performance based on the emergency service dashboard
 All identified gaps will be linked with an improvement and / or administrative
and academic accountability mechanisms
Expected Results
o Improved quality of care leading to Improvement in emergency and critical care
morbidity and mortality indicators (HMIS, KPI, SBFR, Facility specific)
o Improvement in emergency and critical care client centeredness indicators (HMIS,
KPI, SBFR, Facility specific)
o Improvement in resource use efficiency including HR and major supplies
o Decreased waiting time to clinical consultation
o Decreased emergency care waiting time (arrival to service completion which
includes time for clinical evaluation, workup, consultations, medication etc)
o Decreased incidence of unnecessary laboratory and imaging requests and/or
repeats
o Increased patient experience and satisfaction
o Improved rational use of medications
o Better undergraduate and postgraduate medical education through
improved
SBFR: 3
Outpatient
Services
SBFR: Outpatient Services
Change Intervention 1: Better triage, registration and payment systems
 Scope based triage disposal system

 Define scope of practice for top 20 clinical conditions in each discipline (if a need
arises, more clinical conditions can be included to the list)
 Define scope for triage professionals to be assigned and it should be at least GP
or R1 and above
 Referred clients should be disposed to at least 1 step higher scope than the
referring health care provider
 Triaging process should follow ; R/O Emergency, Specialty/discipline and Scope in
that order of significance
 Establish system of digital/short code / phone based initial application for registration, and this
will be followed with telephone triaging and appointment system
 Setup one stop shop triage, registration and payment system integrating all payment modalities
in any payment corners/windows (credit/cash/social …)
SBFR: Outpatient Services…
Change Intervention 2: Early initiation of outpatient service and full

working hours service
 All OPDs should start at 8:00am (OPD assignment can be done in
rotation and
OPD assigned physicians can not join morning meeting)
 Shift based physicians assignment
 Shift 1: 8am to 1pm (including lunch time)
 Shift 2: 1pm to 5:30pm
 Time bound assignment: Assigned physician cannot leave even if he/she
completes available chart
Change Intervention 3: One-stop shop initial evaluation and

decision making practice for all new clients
▸ Outpatient department patient evaluation rooms are
designed to avail all physicians of different scope at
a time
▹ GP, R1, R2, R3, R4, Consultants
▹ Should be established for all
departments/disciplines
▹ Number of rooms per department/discipline should
be guided by the client load
▸ Clients will be evaluated by the appropriate scope (as per
the disposal from the triage), and when needed,
all intra- departmental consultations
(assistance for diagnosis, workup or management) has to
be made immediately from the assigned pool of
physicians with different scope
Change Intervention 4: Enhanced senior engagement for

facilitated and better quality of care
▸ All specialty/referral clinics should only be run by a
specialist or above
▸ Regular clinics should have a full time senior physician for
supervision and verbal consultation of junior staffs (One
stop shop consultation service) (At least 1 senior
physician per discipline)
▸ Unjustified specialty and sub specialty service
fragmentation
should be avoided
▹ Ensure all sub-specialists and above have a general
specialty and sub-specialty engagement with at
least
80% - 20% share
▹ Full time sub-specialty and above engagement can
Change Intervention 5: Better appointment system

 Appointment system should be in blocks of hours
 There should be a digital based appointment system for those who want
to schedule/reschedule appointment
 Define minimum interval required to be evaluated by a consultant for
common chronic clinical condition
 Refill mechanism should be in place
 Virtual clinic
Change Intervention 6: Clinical audit linked with an improvement

&/or accountability mechanism
 Conduct monthly 3R audit (Right physician or scope, Right time, Right way)
 Should be integrated with the existing academic
platform (if applicable), where monthly clinical audit will be done by
residents.
 Sampling procedure will be applied
 General and program based audits will be audited based on the respective
departments/disciplines
 Internal medicine - TB care, HIV/AIDS care, chronic illness care
 Ob/gy - FP, ANC, cancer screening programs, general and referral
clinic services
 Pediatrics: EPI, Well baby clinic, general and referral clinic services
 Other departments: General outpatient and referral clinic services
Change Intervention 7: Improvement of Chronic care follow up clinic

 Chronic clinic management protocol should be established based on hospital tier
level and communicated
 Clinic should be made functional in morning and afternoon with different
specialist allocation
 For controlled patients who meet the criteria appointment should be made at
least quarterly
 During the quarter wait period facility should arrange clinical pharmacy
visit with drug refill options, and mechanism to alarm client if monitoring
parameters out of range
 Facilities should establish a a telemedicine follow up system for selected chronic
diseases with drug refill system
 Facilities should establish a referral back system , for patients who fulfill certain
criteria’s
Change Intervention 8: Better client education and counseling

system for common chronic illnesses
▸ Facilities should establish a Health literacy Unit which links and
closely works with DIS
▸ Should be led by health literacy professional or at least GP
▸ Standardize selected chronic health education materials
▸ Establish a a phone line where by clients can get phone based
consultations when need be
▸ Link chronic follow up clinic follow up patients with the unit
▸ Establish a Focus group discussion for selected chronic follow
up patients
▸ Standardize and prepare short videos, brochures and leaflets
to enhance health education efforts (shall be given to clients
too)
SBFR: Outpatient Services
Expected Results

Decreased number of patients not seen the same day

Decreased registration to clinical consultation time

Decreased outpatient waiting time (arrival to outpatient service completion which
includes time for registration, clinical evaluation, workup, consultations, medication etc)

Decreased incidence of unnecessary laboratory and imaging requests and/or repeats

Increased patient experience and satisfaction

Improved quality of care

Improved morbidity and complication indicators

Improved rational use of medications

Improved supervision and mentoring practice for undergraduate and postgraduate
medical students
SBFR:4
Inpatient
Services
SBFR: Inpatient Services
Change Intervention 1: Institutionalize clinical leadership culture

 Administrative and clinical leadership roles clearly defined and implemented
 All MDT rounds are participatory , system oriented and addresses roles of all
team members
 Nursing care
 IPPS practice
 Hotel service including bed making, food quality
 MCC practice including information provision, client provider
interactions
 Senior physicians should lead all respective weekly MDT forums
 Co-led by the respective units/wards nursing heads

 Forums should evaluate performances
SBFR: Inpatient Services…
Change Intervention 2: Enhanced senior engagement for better quality of care

 Twice a day MDT round
 Morning: starts at 9am and ends before 12pm; address all admitted patients
 Evening: B/n 6pm to 7pm; address only critical and newly admitted patients and led
by duty emergency consultant
 Daily clinical audit for all newly admitted cases of the day to reduce inappropriate
variation in diagnosis and treatment
 Unjustified specialty and sub specialty service fragmentation should be avoided

 Ensure all sub-specialists and above have a general specialty and sub-specialty
engagement with at least 80% - 20% share
 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
 Consultant led QI project which addresses SBFR related gaps requiring system change
 QI project per quarter
Change Intervention 3: Improving nursing care quality through regular

audit feedback mechanisms
 Nursing director / Matron led daily nursing management rounds
 Daily nursing round schedule
 Nursing care units including OR will be grouped in to five nursing round zones and one zone
will be supervised per day
 Team members are nursing director/matron and nursing heads of different units/wards
 Nursing management round should at least address
 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)
 All patient medications should be kept separately in a Room/central cabinet and secured
safe
 Dressing code adherence for all health work force (Nurses/midwives, physicians,
cleaners, runners, lab/pharmacy/imaging staffs)
 Attendance of all responsible staffs (Nurses/midwives, physicians, etc - as above)
 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
Change Intervention 3: Improving nursing care quality through

regular audit feedback mechanisms
 Nursing management should conduct regular nurses competency
assessment
 Prepare competency assessment protocol describing the
schedule, assessment procedures, roles and responsibilities etc
 Staff interview and/or observation for
 Knowledge and skill (adopt/adapt core competencies
from
national competency lists)
 Awareness of different reform standards
 Nursing handover practice b/n all shifts with the different modalities
 Cardex for medications the client is taking
 handover register (Summary notes of all patients should be
kept )
 clinical forms in the client chart (v/s sheet, input and output
Change Intervention 3: Improving nursing care quality through regular audit

feedback mechanisms
 All admitted patients in the ICU/HDU are followed closely with 4P’s (Pain, Position,
Potty, Possess)
 Establish full time nursing/midwifery clinical audit team (Prepare institutional nursing
protocols. Conducts regular nursing care audit and link identified gaps with and
improvement &/or accountability mechanism)
 Protocol for common nursing procedures (at least 20)
 Protocol for common nursing problems and their management (at least 20)
 Nursing problem => Subjective and objective evidences => Nursing care
management => Nursing follow up parameters and evidences for
improvement
 Standardized ICU nursing care protocol which addresses all the follow up and care
packages

feedback mechanisms
 Culture of daily nursing care audit, with all identified gaps linked with an improvement
and/or
accountability mechanisms
 Chart audit for nursing process cycle implementation, V/S follow up as per patient
condition, twice daily progress note, medication administration
 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)
 Weekly summary reports should be submitted to quality unit/directorate)

feedback mechanisms
 Implement effective client education system:
 Standardize health education package and materials (at least, the package should include the
following health information
 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
 Adequate and clear health information should be delivered to all clients
 Quality of health education should be regularly assessed with client interview and identified 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
 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 4: Adequate pain control practice

 Pain management protocol is adopted/adapted and clearly states
rational use
 Regular pain scoring and control practice is done for all admitted
patients (as per institution protocol)
 Pain control practice is regularly audited
 Chart audit for regular pain scoring practice and appropriate
management as per the score.
 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)
Change Intervention 4: Adequate pain control practice

 Rational use of narcotic drugs and narcotic prescription is regularly
audited
 Signs of pethidine and/or its prescription abuse should be linked
with accountability
 Improved pressure ulcer tracking and surveillance
 Ensuring all discharged patients have screened for pressure
ulcer based on an adopted/adapted checklist
 Availing pressure ulcer register
 Use of surveillance data for improvement purpose
Change Intervention 5: Inpatient team forum

 Weekly Inpatient unit/ ward forum led by the assigned senior
 Forum members include the specific unit/ward nursing head, residents, interns, porter
head
 Evaluates weekly performance based on the inpatient service dashboard
 All identified gaps will be linked with an improvement
Change Intervention 6: Improved clinical pharmacy service and rational use of
drugs
 Clinical pharmacy service is availed for all admitted patients
 Clinical pharmacist is member of MDT and their impact on the clinical decision making
process should be well recognized by other clinical care team members like physicians
and nurses
 Clinical pharmacy service audit well addresses
 Rational use of drugs (2nd and 3rd line antibiotics, polypharmacy …)
 Abuse for most expensive or narcotic medications (top 20 drugs prioritized by
the specific institution)
 All audit findings should be linked with improvement and/or
administrative accountability mechanisms.
 Weekly summary reports should be submitted to quality unit/directorate
Change Intervention 7: Establish good patient care practice culture

during night time duty hours
 5pm to 12am (midnight) and 6pm to 8am (morning): All staffs
on duty
should be available in working stations and wards
 12am to 6pm: Only if conditions allows, 50% staff from a team will rest and
50% should stay at working stations and wards irrespective of the
availability of work (100% of the staff may work the whole night if a need
arises)
 All corridor lights should be switched on
 Internally, sudden supervision shall be done by the SBFR task force,
quality team, SMT, regional and federal officials
 Non compliance with the protocols should be linked with an
improvement and/or accountability 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: Inpatient Services
Expected Results
 Improved quality of care leading to improvement in inpatient
care morbidity and mortality indicators (HMIS, KPI, SBFR,
Facility specific)
 Improvement in nursing care quality index
 Improvement in pharmaceutical care quality index
 Improved discharge planning
 Less ALOS
 Decreased incidence of unnecessary laboratory and imaging
requests and/or repeats
 Improved rational use of medications
SBFR: 5
Surgical and Anesthesia Care
SBFR: Surgical and Anesthesia Care
Change Intervention 1: Improve Operating theater Leadership
 Organogram revision and installing a temporary

and
permanent leadership structure at major OR
 As part of the permanent leadership, an OR director assigned to
the major OR and clear reporting relationships and roles and
responsibilities were defined for all staffs working in the major OR
 Clinical leadership role of an operating surgeon once any surgery
is initiated
 Weekly regular forum involving all OR clinical staffs, supporting
staffs and staffs from CSR and head of medical equipment
department
 Undertake performance audit and other relevant issues; And, all
gaps identified are linked with a reactive and/or proactive repair
mechanisms (There should be evidence of improvement based
on a displayed data on a run / control chart)
SBFR: Surgical and Anesthesia Care…
Change Intervention 1: Improve Operating

theater Leadership
 Strong planning and monitoring system
 OR should have an annual plan which includes
targets for surgical KPI reviewed and corrective
action taken based on identified gaps
 Establishing OT Dashboard
 Identify key OR performance indicators that address
at least efficiency, safety, and access (eg. TAT,
cancellation rate, incision time, SSC adherence, Table
output)
 Mechanism should be established to track the
indicators (Daily and weekly analysis of performance
and action taken)
Change Intervention 2: Improve operation room performance

 Standardized surgical workflow system
 A digital backlog management system
 Elective surgery appointment system should only be based on case
category pool
 Clearly defined prioritization criteria and monthly audit
 System of prioritizing cancer cases and
other conditions demanding urgent intervention
 System of prioritizing based on geography and other social
issues
 Regular backlog data analysis and linking all gaps with a
repair mechanism
 System of assigning additional tables
temporarily for
departments/units with high backlog

 Unjustified specialty and sub specialty service fragmentation should
be avoided
 Procedures requiring a sub specialty intervention should be
clearly defined (sub specialty scope) and a sub-specialist and
above should have a general specialty and sub-specialty
engagement with at least 80% - 20% share
 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

 Avail a pre-admission surgical and anesthetic evaluation
clinic and establish system of
 Ensuring all clients called from the waiting list are
evaluated and the indication for the surgical intervention
is still there ;
 Ensuring all the minimum preparations are made –
Investigations, blood etc;
 Conducting a pre-anesthetic evaluation and decide on
their fitness
 clients who are not done with the preparations and/or are
unfit for anesthesia and/or surgery should not be admitted

 Standardized scheduling system and pre-operative admission stay
 Pre-operative hospital stay for all elective
surgical admissions
should not be more than 2 days (audit every month)
 All schedules should be posted 1 day ahead and not later than 3 pm
 The nursing team should ensure all required instruments, drapes

and other needed materials are ready
 The anesthesia team ensures all the preparations are made
 Standardize table productivity per day and ensure minimum number of
cases are scheduled and operated on each working day
 A minimum of 3 surgeries/table/day is expected unless there is a
clear justification due to the nature of a specific procedure and/or
unexpected peri-operative incidents

 Preventive and curative maintenance check for all major OR medical
equipment to ensure safety and avoid unnecessary cancellations
 To be done and be documented by duty medical equipment
team, every morning before 6:30am
 Should at least address OR tables, anesthesia machines, cautery
machines, suction machines, and others which are deemed
necessary
 Establish system of early initiation of surgery with and incision time at or
before 8 am (anesthesia induction time should be b/n 7:30-8:00am)
 Establishing follow-up and feedback and/or accountability
mechanism to ensure adherence

 Establish a system which helps to reduce time b/n procedures
 Time b/n procedures should not take more than 15 minutes
 Use of patient preparation room for parallel anesthetic
evaluation and preparation
 Standby cleaners when skin closure start
 Avoid unjustified cancellation for a scheduled patient (on the day of surgery, on
table)
 System of approving such cancellations only by an anesthesiologist or most
senior anesthesia staff
 Mechanism to verify all cancellation daily and system of ensuring an
accountability

 Decreasing OR downtime and days
 Introducing a concept of shift based schedule (morning, afternoon) to
improve OR end time
 Arrange OR disinfection days for weekends
 Weekend and holidays elective surgery practice if elective surgical cases
with higher backlog
 A surgical team other than the regular duty team can be established
(1 surgeon, 1 assistant, 2 anesthetists, 2 scrub nurses, 1 cleaner, 1
porter)
 Issue duty payment if 2 major cases are operated by the team
 The other part of the care shall be executed by other regular team
members (Eg. Inpatient care, lab service, pharmacy service etc)
Change Intervention 3: Reduce the surgical site infection and other safety
related problems
 Consistent and correct use of safe surgery checklist
 OR zoning based on the national IPPS guideline (Restricted, Semi-
restricted, Transitional and Unrestricted) and adherence to the
recommendations
 Standardize and Protocolize OR operational management and
monitoring its adherence
 Work flow and standards (incision time, time b/n procedures,
roles and responsibilities of different team members etc)
 Cleaning procedures and schedules
 Instrument processing, packaging and storing procedures
 Patient preparation procedures
 Dressing protocols including jewelery, personal watch, nail
and hair management
 Antibiotic prophylaxis (indications, choice of antibiotics, timing)
Change Intervention 3: Reduce the surgical site infection and other

safety related problems
 Improving surgical site infection tracking and surveillance
 Ensuring all surgical patients have screened for SSI based on WHO SSI
surveillance checklist at the time of discharge
 Availing SSI register
 Use of SSI surveillance data for improvement
Change Intervention 4: Efficiency gain in supply utilization

 For every client, establish a registered and prescription based system of
requesting and dispensing OR supplies
 OR coordinators should only have an emergency stock of supplies which
should only be utilized based on paid replacement from OR pharmacy
 Establish OR pharmacy and all required supplies for all surgeries should
be supplied from it (prescription based request for each client and to be
paid during discharge)
 Cost per a patient can be estimated and payment issued for items to be
shared for more than 1 client (eg. Anesthesia drugs, iodine, plaster etc)
Expected Results
o Improve quality of care evidenced by surgical outcome
measures
o Increase OR productivity (at least 3
major
procedures/table/day)
o Increase staff efficiency
o Decrease in elective surgical waiting list and waiting
time
o Low pre-operative hospital stay
o Decrease in SSI and other safety
related incidents
o Very low/no incident of major OR
medical equipment
failure during the date of/at the time
of surgery
SBFR:6
Diagnostic Care
SBFR: Diagnostic Care
Change Intervention 1: Improve access to quality diagnostic

services
 Ensure availability of all test menu based on expected standard (self
sufficient
/ partially or fully outsourcing major machines, including CT and MRI)
 Standardize productivity for imaging services - US scanning, reading CT/MRI if

there is a significant backlog
 Productivity will be set based on the bottleneck identified
 Productivity per machine per day if the limiting factor
is number of machines
 Productivity per health care provider per hour if the limiting
factor is number of professionals
 Monitor the performance (against the expectation) and link identified

gaps with an improvement and/or accountability mechanism
SBFR: Diagnostic Care…
Change Intervention 2: Establish client centered system sample collection

and result delivery

Assigning phlebotomist and decentralizing sample collection sites
to clinical service areas (Service will approach to sites where clients
are)

Emergency sample collection and result delivery service

OPD sample collection and result delivery service

Inpatient sample collection and result delivery service

Microscopic examination and other tests requiring simple machines should
be done at major clinical service areas

For tests requiring big machines, samples will be collected from the
clinical service areas and the test will be done at the central laboratory
( Result should only be delivered by a runner)
Change Intervention 2: Establish client centered system sample collection and result delivery

Sample clotting / hemolysis incidents should be minimized to reduce/avoid unnecessary and repeated sample
requests

Result should be delivered based on the agreed TAT

Undertake specific tests based methods of TAT monitoring for compliance to the TAT and link identified
gaps with an improvement and/or accountability mechanisms

client interview, patient walk, laboratory register data review etc

Result should be delivered electronically or by a runner

Monitor for unnecessary lab repeats and establish system of repairing the causes (system of notification, capacity
building etc)
Change Intervention 2: Establish client centered system sample collection and result delivery
 Establish system of auditing justifications of major laboratory/imaging requests and link identified gaps with
an improvement and/or accountability mechanism
 Scope might be defined for some diagnostic workups like US, CT, MRI
 Use of audit-feedback cycle to improve the identified gaps
 Establish system of auditing laboratory and imaging requests which are sent outside the institution for
unacceptable reason and linking all identified gaps with an accountability mechanism
Change Intervention 3: Improve diagnostic service equipment and supply

management system
 System of preventive and curative maintenance system
for
laboratory and imaging medical equipment
 Establish agreement for equipment maintenance
through
outsourcing (Public and private)
 Partially Outsource the management of
selected diagnostic service(MRI, CT Scan)
Change Intervention 4: Laboratory has implemented quality

management system, incident handling and reporting system,
LMIS
 Implement a process control system that monitors the processes
from pre analytical to post analytical phases of testing, including
an established internal quality control (IQC) and participates in
external quality assurance (EQA).
 established incident handling and reporting system which
includes errors or near errors ( near misses).
 The hospital has established laboratory management
information system.
 The hospital laboratory should be designed and organized at least
for bio safety level 2 or above and work environment is clean and
well maintained at all times.
Change Intervention 5: Hospital implemented appropriate and safe

blood transfusion service
 Appropriate storage and stock management system for blood
and blood products
 Blood mobilization strategy in collaboration with nearby blood
bank (at least proportional to the amount they require)
 Appropriate cold chain system for blood and blood products
 Actively functioning HTC and regularly audits
practice of
appropriate and safe use of blood, reports safety related incidents to
all stakes
SBFR: Diagnostic Care
Expected Results

Improve ED/OPD/IPD lab turn-around-times

Decrease incidence of hemolyzed/Clotted specimens

Decrease incidence of unnecessary lab repeats

Decrease in backlog for imaging services and acceptable performance level for the available resource (HR,
diagnostic machines)

Improved diagnostic service quality index
SBFR: 7
Pharmaceuticals and Medical
Devices
SBFR: Pharmaceutical and Medical devices
Change Intervention 1: Establish system of control over top 20 prioritized drugs
 Decide on list of 20 prioritized drugs
 Prioritization should be based on cost, addiction risk and risk for drug resistance; And,
shall include 2nd and 3rd line antibiotics, pethidine, anti-coagulants, PTU, anti-D etc
 Define scope for prescribing selected items

 Daily stock status report for the prioritized drugs with an emphasis on near stock out items
 Daily prescription audit (who prescribed, how much, rational use)
 Audit for possible evidences of abuse or irrational use
 Link all identified gaps with an improvement and/or accountability mechanism
SBFR: Pharmaceutical and Medical devices…
Change Intervention 2: Establish system of control over prioritized 5 supply items
 Decide on list of 5 prioritized supply items

 Prioritization should be based on cost and availability on market
 Define scope for prescribing selected items
 Daily stock status report for the prioritized supplies with an emphasis on near stock out items
 Daily prescription audit (who prescribed, how much, rational use)
 Audit for possible evidences of abuse or irrational use

SBFR: Pharmaceutical and Medical devices…
Change Intervention 3: Regular audit on appropriate use of drugs and supplies for an exempted, CBHI and other
credit services
 Staff clinic establishment
 Weekly audit on dispensed drugs and supplies for an exempted, CBHI and other credit services
 Compare register vs prescription agreement with a focus on prioritized drugs and supplies listed out
above
 Use a sampling procedure
Change Intervention 4: The hospital implements auditable, transparent and accountable pharmaceutical
transactions and services (APTS).
 Presence of properly recorded and filed prescriptions, sales tickets and registers at dispensaries
 Implementation of coding to uniquely identify medicines (service areas, stores)
 Bin ownership and updating is implemented
 Presence of regular monthly reports for products, finance and services which is evaluated by DTC and SMT with
corrective actions
 Annual ABC and VEN analyses report
SBFR: Pharmaceutical and Medical devices
Expected Results
o Improved drug availability
o Decreased drug abuse
o Improved rational use of drugs leading to less AMR risk

SBFR: 8
Motivated, Competent, and Compassionate care
SBFR: Motivated, Competent and Compassionate Care
Change Intervention 1: Conducive working environment for general duty staffs

without compromising timely access for patient care
 Gender based (not scope or profession based) duty room arrangement with
bathroom and hand washing
facility
 Number of beds: 50% of duty staff number
 Equipped with furniture, computer
 Cup board for all staffs to secure all their personal belongings, gowns and
uniforms
 24 hrs access to water (portable purifier)
 Central coffee and tea service
 Duty room regular housekeeping service with daily cleaning and linen change
Change Intervention 2: Conducive working environment for consultant physicians
without compromising timely access for patient care
▸ Should have bathroom and hand washing facility
▸ Equipped with furniture, computer, internet, tv
▸ Cup board for all staffs to secure all their personal belongings, gowns and uniforms
▸ 24 hrs access to water (portable purifier)
▸ Central coffee and tea service
▸ Duty room regular housekeeping service with daily cleaning and linen change service
▸ Zonal duty room service focal assigned and manage the above requirements (shared
with general duty
management)
SBFR: Motivated, Competent and Compassionate Care …
Change Intervention 3: Incentives and work load based payments management

 All duty payments should be played only if the responsive individual executed
all activities and submitted all expected
reports including audit activities
 Department head may omit someone from a duty schedule if the
responsible person including consultants fails to adhere to the minimum
expectations as stated above
 Teaching overload payments should only be paid if the responsible individual has actively engaged
in the following activities
 Morning meetings
 Referral clinics
 MDT rounds
Expected Results
o Motivated workforce
o Improved productivity of health care workers
o Improved access and safety of care

SBFR: 9
Data Quality and Evidence Use
SBFR: Data Quality and Evidence Use
Change Intervention 1: Full automation of electronic medical record system for

quality data and its use for decision making
 Invest on full digitization of the clinical care process
 Use of daily, weekly, monthly, quarterly, biannually etc EMR dashboard
encompassing facility specific, regional and national HMIS and KPI
indicators
 Monitor overall productivity, clinical and non clinical functions of the
hospital using facility specific, regional and national HMIS and KPI
indicators (as per the timeline set for an individual indicator)
Change Intervention 2: IT structure to support digital health activities
 Established IT structure and has adequate staffs to support EMR system
 24 hrs IT personnel is assigned (Working and duty hours including
weekends and holidays
SBFR: Data Quality and Evidence Use …
Change Intervention 3: Data quality audit for completeness,

correctness and timeliness
 There is ≥85% consistency between data reported on HMIS
forms and
data recorded in registers and patient / client records
 HIT department in collaboration with quality team and SBFR task
force conducts sampling based daily data audit for completeness
and correctness (Every service unit should at least be audited once a
week)
 Data audit gaps are analyzed and linked with a repair
and /or accountability mechanism
Change Intervention 4: DHIS2 implementation
 Hospital submits reports timely
 Hospital keeps hard copy of all reported data and it is consistent with
DHIS2 data
SBFR: Data Quality ad Evidence Use …
Change Intervention 5: Use of data for decision making

 HR productivity related data and its use for motivation and/or
ensuring accountability (Linking with available payment
mechanisms (duty payment, teaching overload))
 Quality of care gaps are linked with a reactive and/or
proactive improvement programs
 Diagnostic and drug/supply access gaps are linked with an
improvement and/or accountability mechanisms
SBFR: Data Quality and Evidence Use
Expected Results
o HR productivity (dis-aggregated by
type of
profession) variation is less than 15%
o Morbidity and Mortality indicators are with in an
acceptable range (Ensure all HMIS, KPI, SBFR
and
facility specific indicators are addressed)
o Process indicators for SBFR and
other facility specific measurements are with in
an acceptable
range
SBFR: 10
Academic and Clinical Services Integration and high quality
culture for institutional transformation
SBFR: Academic and Clinical Services Integration
Change Intervention 1: Client centered and system

oriented medical education
 Department heads are responsible to manage both service
and academic activities and are accounted
to both academic and clinical
 service
Systemwings
thinking is integrated with the
undergraduate and postgraduate existing
training and evaluation) curricula (for
Change Intervention 2: Certified by ESA both

health facilities regulatory standards
 Certified as per health facility regulatory standards
 An action plan is developed for all identified gaps /
feedback provided
 Evidence of implementation for the action plan developed
SBFR: High quality culture for institutional transformation
Change Intervention 3: effective and efficient EHSTG

implementation
 Well established workshop and system for facility
maintenance
(water, electric, buildings, sewerage lines)
 Maintenance tools
 Adequate staff and spare parts
 Regular and programmed
preventiveand curative
maintenance system for major facility
functions
 Well established medical equipment maintenance
workshop
 Maintenance tools
 Adequate staff and spare parts
Change Intervention 4: CASH
▸ Hospital compound and surrounding (with in 3 meters of

hospital fences) are clean and green
▸ All sockets are fixed, electric lines are safely

secured/covered and sewerage lines are tightly closed
Change Intervention 5: Quality culture

▸ Strong quality structure is established
▸ Multidisciplinary team which includes physicians, nurses, laboratory
and pharmacy professionals, other experts such as health
information etc
▸ Quality unit coordinates all hospital reform activities, SBFR
implementation and other quality related agendas
▸ HR productivity related data and its use for motivation and/or
ensuring accountability (Linking with available payment mechanisms
(duty payment, teaching overload))
▸ Quality unit in collaboration with other units/departments graduate
at least 2 QI projects per quarter
▸ Strong institutional learning culture with bench marking activities
with in or b/n health facilities
Change intervention 6: Health care financing

• Regular audit for exempted service and identified gaps are linked with feedback and /or accountability
mechanisms
• Social service is provided
• Staff clinic is established and is led by a protocol
• Social service is provided based on an established protocol
• Regular audit for social service provided and identified gaps are linked with feedback and/or an
accountability mechanism
Change intervention 7: Provide CBHI based and other credit services
• MOU signed b/n both parties
• Timely request claim and payment collection
• Audit finding from CBHI and other customers comply with more than 90% of the expectations
(documentation, service availability, clinical audit and other defined requirements)
• Provide stamped stock out prescriptions for unavailable medications

• Provide stamped stock out laboratory and or imaging requests for unavailable diagnostic tests
SBFR: Academic and Clinical Services Integration &
High quality culture for institutional transformation
Expected Results
o Client centered and system oriented medical
education
o Increased revenue collection and efficient use
of scarce resource
o Improved safety
o Institutionalized quality culture
Upcoming
tools ...
▸ Dashboard ▸ SBFR assessment

▸ Nursing care quality tool
index
▸ Pharmaceutical service
quality index
▸ chart audit tool
▸ client interveiw
checklist
103
Group Exercise
TBD by the
team
SBFR: Project Coordination and Implementation
Arrangement
National Level (MoH)

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

 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
Arrangement…
Facility Level (SBFR-Hospital)

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

ultimate aim to effectively and efficiently realize the goal and core
objectives of the project
•▸ The application of processes,
the methods, knowledge,
skills and experience to achieveproject
objectives
▸ Has clear concepts and practical steps:

■ Performed by people
■ Constrained by limited
resources
including time
■ Planned, executed and controlled
SBFR: Institutional Project Management & Coordination…
▸ The success of Institutional efforts to effectively and efficiently

meet all the ultimate expectations of the project will always
depend on three planning factors; Scope, Time and Cost:
▸ Time – deadline, milestones, allocation of work between team
members and business as usual.
▸ Cost – the project budget, additional/unexpected costs, staff

time, comparable value.
▸ Scope – directly effected by time and cost, and vice versa.

SBFR: Institutional Project Management & Coordination…
Effective and efficient project implementation

requires:
▹ Working team
■ Responsible experts and units
▹ Strategy
■ Clearly known plan
▹ Milestones
■ Clearly Defined deliverables
▹ Resource allocation
■ Time, budget..
▹ Adjustments
■ CQI, feedback cycle
▹ Documentation
■ Proper data capturing, Reporting
▹ Communication
■ Dashboard, review meeting,
recognition
Group
TBD by the
team
Exercise
SBFR: Project Adoption and Cascading
Understanding Contextualize Implement
 Taking and  Cascade the technical and Approve hospital’s SBFR

technical concept  plan and with
clarity training concept clarity training deliverables required
 Be clear on national, resources
regional and
 Establish SBFR team with clear units,
expectations institutional roles and responsibilities  departments
Ensure and team are
all
 Conduct assessment and define well
service informed
 Collect all the necessary gaps based on SBFR priorities on expectations
technical documents such and interventions
as project doc, templates,  Officially launch the starting
presentations  Develop implementation plan of Hospital SBFR project
with defined time, responsibility implementation
 Provide your contacts and and deliverables
 Design integrate

get registered on common Regularly monitor
and performance monitoring,
platforms performances,
feedback and
feedback support
cycle platforms learning
and cycles
113

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Ministry of Health-Ethiopia

System Bottlenecks Focused Reform-SBFR

Technical Orientation on SBFR Conceptual Framework and

• High impact leadership

Health system Innovation to bridge the quality

• No habits for • No written roles & • No resource alignments • No shared responsibilities

• Micromanagement • Weak work ethics and support

2006 2007 2010 2011 2012 2014 2015 +

Federal Ministry of Health

 Selection criteria - high volume, tertiary care service, academic and

research role, equity

 1 year project (April 2014 to April 2015 E.C)

 Path to accreditation - Phase 1

 to be followed by Quality and COE phases

Leadership S B F R Project Management and Support

Access, Quality and Comprehensive Hospital

Data Quality Strong M&E for evidence use

Feedbacks Strategic Joint visits and Support

Accountability Clear Manadates and integrations

Transparency Recognition and Humilation

• Point of care level

Health care system is

Professional Nursing, laboratory, pharmacy,

Medical Vice Academic/Research Vice Administration/

Service department Heads

Country Hospital Individua

Change Intervention 1: Enhanced

Change Intervention 2: SBFR dashboard based intensive SMT monitoring and

Change Intervention: SBFR dashboard based intensive SMT

▸ Display major service areas performances weekly and make

▸ Intensive supportive supervision led by SMT

Change Intervention 3: SBFR taskforce and quality team led Intensive

Change Intervention 4: SBFR taskforce and quality team led Intensive

▸ SBFR task force forum (For AA hospitals only)

Change Intervention 1: Implement scope

Change Intervention 1: Implement scope

Change Intervention 2: One-stop shop initial evaluation and

 Clients will be evaluated by the appropriate scope (as per

Change Intervention 3: Enhanced senior engagement for better quality

Change Intervention 4: All inpatient nursing care standards including

Change Intervention 5: Institutionalize clinical leadership culture

Change Intervention 6: Conduct emergency team forum

 Forum members include emergency unit/department nursing head, residents,

Change Intervention 1: Better triage, registration and payment systems

 Scope based triage disposal system

Change Intervention 2: Early initiation of outpatient service and full

Change Intervention 3: One-stop shop initial evaluation and

Change Intervention 4: Enhanced senior engagement for

Change Intervention 5: Better appointment system

Change Intervention 6: Clinical audit linked with an improvement

Change Intervention 7: Improvement of Chronic care follow up clinic

Change Intervention 8: Better client education and counseling

Change Intervention 1: Institutionalize clinical leadership culture

 Senior physicians should lead all respective weekly MDT forums

 Co-led by the respective units/wards nursing heads

Change Intervention 2: Enhanced senior engagement for better quality of care

 Unjustified specialty and sub specialty service fragmentation should be avoided

Change Intervention 3: Improving nursing care quality through regular

Change Intervention 3: Improving nursing care quality through