Ethiopian Hospital Alliance for Quality

4th Cycle
Evidence Based Care (EBC)
Project Document and Change Package
Clinical Service Directorate
November 2021
 Background
1
Presentation
Outline 2
Rationale

Objectives
3

Key change concepts and Interventions

4
Project management
5
Monitoring and evaluation
6
 Background

• MoH is implementing various initiatives aiming to improve the quality of

health care services
• EHAQ: aims to promote collaborative learning between hospitals.
• EHAQ was first introduced in 2012 and this is the 4th cycle
• The pervious cycles were focused on improving client satisfaction, CASH &
MNCH services and the CATCH –IT respectively.
• The 4th cycle thematic area is Evidence Based Practice (EBC) with the aim
to improve evidence-based decision making practices in hospitals
• Mainly focuses on emergency, surgical, neonatal and chronic hospital
cares
03/12/2024
 Rationale for EBC
• The NHQS Strategy (2021-2025) specified weak
compliance of evidence- based practice as the major
weakness of the healthcare system.
• Evidence-based care (EBC), a fundamental element
and key indicator of high quality patient care
• Effective implementation of EBC improves the patient
EBC experience through providing quality care, enhances
patient outcomes, reduces costs, and empowers
clinicians, leading to higher job satisfaction.
• To provide service by clinicians with the right skills
and experience
• To strengthen the culture of conducting regular audit
 Rationale for EBC…
Rationale for EBC
• To ensure consistent utilization of evidence based
guidelines and clinical standards
• To strengthen the culture of continuous quality
improvement
• To improve overall health care efficiency, efficient
EBC use of health care resources.
• To ensure data is formatted and used consistently
throughout an organization for evidence based
decision making.
• To ensure implementation of patient focused care
(patient preference and values).
Evidence based care Conceptual framework

Context of Caring

Mechanism to avail high

quality evidences
Scope Based Practice
Protocol based Practice
Regular Clinical Audit

Quality Patient Outcomes in

Evidence- Emergency Care
Clinical Expertise based clinical Surgical care
CQI (Continuous Quality Decision Neonatal Care
Improvement) Making OPD Care (DM, HTN , CRD &Mental Health)
Clinicians’ Engagement
Efficiency gain
Data Quality
System Redesign

Patient Engagement
Client Education
Client Feedback
 Focus area of Evidence based care

Emergency
• The 4 cycle EHAQ with
th
services
theme of EBC has
selected core change
concepts with prioritized
key interventions.
Surgical
• These concepts are Outpatient EBC services
expected to be primarily service
implemented in the
national focus areas
namely
Neonatal intensive
care unit services
1 Emergency Injury and critical care(EICC)

• Lack of clarity of scopes and mandates,

• Lack of laws and regulations, limited career structures
and training for EICC professionals,
• Visible gap in data quality and comprehensiveness,
• Significant gap in proper use and maintenance of
equipment,
• Weak multi-sectoral, inter-sectoral and private sector
collaboration,
• Shortage of allocated funds,
• Limited awareness among the community in EICC
conditions, services and utilization of these services.
2 Surgical Care

• Large burden of surgical disorders

• Cost-effectiveness of essential surgery
• Ethiopia has the lowest measured surgical rate in the
world
• Strong public demand for surgical care
• The application of EBC components to improve
surgical care will be implemented in harmony with the
SaLT II initiative
3 Neonatal care

• The current under-five and neonatal mortality rates for

the country that stand at 59 and 33 per 1,000 live
births, respectively.

• The neonatal mortality reduction was not as

progressive as expected.
4 OPD Service for Selected NCD

• NCDIs have become a major public-health problem in

Ethiopia, resulting in 44% of total annual mortality.
• One of the most rapid shifts in NCD burden globally
with an estimated 65% of disability adjusted life years
(DALYs) attributable to NCDs by 2040.
• Chronic patient-centric care is not yet integrated
across different level of facilities or among providers.
 General Objective

• To improve and sustain the provision of evidence based clinical care

that results in improved quality of patient outcome in neonatal,
emergency, surgical and selected NCDs cares.
 Specific Objectives

To promote and support

the implementation of To Improve
scope-based practice in People-Centered
hospitals enrolled in Care
EHAQ platform.

To strengthen
continuous
To improve
quality
patient outcome
improvement and
of priority health
culture of
conditions
learning.
identified for this
cycle.
Change concepts and Key interventions

01 02 03

Standard Person
Scope based
based clinical centered care
practice
services
 04 05 06 07

Quality Evidence Surgical System

nursing care generation service redesign and
and efficiency EHSTG
utilization and safety Boosters
 08 09 10
EBC
Efficient use Improve Improve
of healthcare neonatal Emergency,
resources intensive trauma and
care critical care
 Change Concept 1:Scope Based Practice

• Allows healthcare services provided by a healthcare practitioner to

be performed based on the level they are authorized to practice.
• Defined based on level of education, training, experience, and
demonstrated clinical competencies.
• To ensure that HCW is practicing safely, effectively and legally.
• Every institution is expected to outline its services and establish a
scope of practice manual at least on the national focus areas.
• The scope of practice manual should be established after
assessment of facilities’ available human resource and services and
should address level of knowledge and experience of clinical
professionals.
 Key Interventions:

1. Define scope: based on levels of care for the selected priority

health conditions.
2. Dispose patients to the appropriate scope level by arranging an
emergency and non-emergency triage system based on the
EHSTG Standards.
3. Client evaluation at the initial point of contact should be by
physicians with the appropriate level of scope
4. All consultations are carried out by senior residents and above
Change Concept 2:Standard Based Clinical Service

• A protocol states the course of action to be adopted by people

working within a particular organization, profession or service.
• Clinical protocols are basically rules of how to proceed in certain
situations.
• They provide health practitioners with parameters in which to
operate.
• Supports the implementation through evidence-based clinical practice
guidelines and protocols.
• The health facility is expected to avail clinical protocols and
adopt/adapt treatment guidelines of at least priority health conditions.
 Key Interventions:

1. Prepare adapt or adopt guideline or protocol based on hospital

morbidity and mortality burden of priority focus area.

2. Avail the established Protocol / STG to Clinical Staff.

3. Monitor the consistent utilization of the clinical protocols.

 Change Concept 3:Person Centered care

• An approach that assures the privacy of individuals’ health and life goals in
their care planning and in their actual care.

• One of the six pillars of quality health care and described it as “providing
care that is respectful and responsive to individual patient preferences,
needs, and values and ensuring that patient values guide all clinical
decisions.”

• The institution is expected to develop a client/person centered care protocol

by assessing the needs of the clients and the demand of the facility.
 Key Interventions:

1. Establish health literacy unit/desk with full time working health care
provider/s.
2. Clinical information standardization - prepare education materials.
3. Comprehensive Information provision is delivered entirely and consistently.
4. Practice patient discharge planning.
5. Regular Client awareness and knowledge audit and identified gaps linked
with QI projects.
6. Control pain for all emergency, outpatient and admitted patients
7. Regular audit for adequacy of pain control and identified gaps linked with
QI projects.
8. The hospital has established hospital based social service which
addresses the psycho-social care needs of clients.
 Change Concept 4:Quality Nursing Care

• It is an integration of research evidence, clinical expertise, and a

patient’s preference.
• It primarily focus on:
– establishing and conducting regular nursing clinical audit,
– establish a protocol for most common nursing procedures and
provide orientation,
– conduct regular nursing round and shift handover, implement
package/bundle of ICU care (enteral nutrition, gastric ulcer
prophylaxis),
– regular assessment of selected nursing procedure knowledge,
attitude and practice with link to quality improvement project.
 Key Interventions:

1. Nursing care protocol and procedure prepared for prioritized

health conditions
2. Regular nursing care audit and identified gaps linked with QI
project
3. Conduct daily nursing round
4. Implement ICU nursing care packages as per the standard
5. Established a skill Lab and regular need based capacity building
for nursing staff
6. Standardizing nursing stations
7. Patient preference included in decision making
 Change Concept 5: Evidence generation and
utilization

• Importance of high-quality data for decision makers in health care.

• Establishing standard protocols for documentation of data comes
prior to measuring.
• Establishing a system that ensure conformance with the standard is
the main task that needs every stakeholders’ engagement.
• In the EHAQ 4th cycle proposed change packages are
– implementation of partial or fully automated electronic medical record system,
– chart audits for completeness and quality,
– use of locally generated data for improvement of clinical care in emergency, neonatal,
surgical and outpatient care.
• The facility is expected to have a reliable data for decision making in
the clinical process and intervention prioritization.
 Key Interventions:

1. Implement electronic medical record system – fully automated

2. Chart audit system for completeness
3. DHIS2 implementation completeness and timeliness
4. There is a regular mechanism to ensure quality of data
5. Regular data driven decision making is practiced
Change Concept 6:Surgical service efficiency and
safety
• Access to Emergency and essential surgical care (EESC) is one of the
prioritized global initiatives with the aim of improving access to safe,
affordable and timely care for the population.
• Following this global initiative Ethiopia launched the first surgical care strategy
(SaLTs) in 2016.
• The new surgical care strategic plan (SaLTs II) identified Access, efficiency
and safety as the key focus areas.
• EHAQ 4th cycle focuses on change packages addresses:
– optimizing operating table utilization (table productivity),
– OR patient preparation rooms,
– reducing cancelations,
– building team functions,
– regular performance audits and improvement plans,
– establishing a day care surgery.
 Key Interventions:
1. Standardize OR efficiency and the minimum productivity per table
2. Establish OR patient preparation unit
3. Implement measures to reduce cancellation
4. Standardize and monitor pre-elective and postoperative hospital stay
5. Establish surgical governance and management structure that ensures
team functions
6. Establish Day care surgery unit and ensure its active functioning
7. Regular performance audit and identified gaps linked with QI and/or
accountability mechanisms
8. Established system of monitoring the adherence and completeness of
Surgical Safety Checklist (SSC) in the operating theater
9. Established system of SSI tracking and intervention to reduce SSI
Change Concept 7:System redesign and EHSTG Boosters

• System redesign in a hospital setting involves making systematic

changes to all segments of hospital service provision process in order to
improve the quality, efficiency, and effectiveness of patient care.
• It requires thinking through from the patient perspective, identifying
where delays, unnecessary steps or potential for error are built into the
process, and then redesigning the process to remove them and
dramatically improve the quality of care.
• It gives due attention to continuous quality improvement, clinical audit
and senior physician engagement.
• For successful hospital system redesign, top hospital management,
clinical leader and front-line staffs must be engaged.
 Key Interventions:

1. Establish a triage system which is well equipped and facilitate one stop
triage, registration and cashier service and accommodate for the needs of
highly infectious cases.
2. OPD clinics meets all the minimum standards required for an examination
room.
3. Early Initiation of Outpatient Clinics and block-based Appointment System.
4. Hospitals have separate Pediatric Wards composed of separate critical,
general, SAM, isolation and procedure rooms.
5. The hospital should have a rehabilitation and palliative care service with
necessary equipment.
6. The hospital has a general and Biomedical equipment maintenance center
with adequate resources.
 Key Interventions:
7. The hospital establishes and institutionalizes Human Resources Information
Management Systems (HRIS) that enhance the HR management functions.
8. The hospital has a human resource development plan that addresses staff
numbers, skill mix and staff training and development.
9. Standardize food and beverage service
10. Standardize duty room service provision
11. Improve functionality of medical equipment by establishing Medical Equipment
Management information system.
12. Develop a mechanism/system which encourages the rational use of medications
and stipulates mitigation strategy for irrational use of medications.
13. The hospital Conducts regular clinical audits and links improvement opportunities to
CQI.
14. Senior physicians are consistently engaged in all clinical care activities and
decisions which necessitate their involvement.
03/12/2024
Change concept 8: Efficient use of healthcare resources

• Efficiency is one of the healthcare quality dimensions, related to avoiding waste—

including waste of equipment, supplies, ideas, and energy.
• The HSTP has prioritized three main causes of inefficiencies: procurement; supply
chain management; and, health human resource.
• Improving the transparency and accountability of the health procurement system,
including
– evidence- based specification setting,
– better forecasting of needs, reduction of procurement time, and
– encouraging generic and bulk purchasing, will enhance its efficiency.
• Further, improving storage and distribution of medical commodities, efficient
installation of medical equipment and reduction of wastage.
• Additionally, improving procedures pertaining to recruitment, deployment, training,
motivation, and retention of health professionals.
 Key Interventions:

1. Explore options to strengthen and outsource clinical and non-

clinical services (including the supply chain management).
2. Implement different staff incentive and recognition mechanism for
enhancing efficiency and effectiveness.
3. Assess sources of inefficiency in procurement, human resource for
health and supply chain.
4. Enhance transparent, accountable and sound resource utilization
and financial tracking management system.
 Change concept 9: Improve neonatal intensive care

• Improving the Neonatal ICU service is one of the critical areas that will
reduce morbidity and mortality of neonates in a hospital setting and
beyond.
• Additionally, NICU care for a hospital setting shows the quality of care
and it is by far the known litmus of better organizational function.
• The objective of having NICU is to develop the structures for good care,
and to ensure the processes are reliable.
• If it is implemented based on the Science of Improvement the outcome
for neonates will continually improve.
• This will require a clear strategy within which the principles of quality
improvement are embedded, with a commitment to continual
improvement and change.
 Key Interventions:

1. Provide a standard NICU service based on the level of the hospital

2. Avail all needed protocols and guidelines for Evidence based
neonatal care and adhere to protocols of services
3. Perform continuous clinical audits for NICU care services and link
with QI for the findings
4. Implement Neonate and Family centered care
 Change concept 10:
Improve Emergency, trauma and critical care

• Emergency, injury and critical care includes:

– pre-hospital care and transportation; initial evaluation, diagnosis
and resuscitation.
– in hospital care (emergency units and Intensive care units (ICU))
as well as referral system.
• Remarkable effort to improve emergency, injury and critical care ,
but a long way to go.
• Requires a clear strategy of quality and commitment to continual
improvement and change.

03/12/2024
 Key Interventions:

1. Provide a standard emergency service based on the national

leveling document.
2. Provide a standard critical care service based on the national
leveling document.
3. Avail protocols and guidelines for Evidence based emergency,
injury and critical care and adhere to protocols of services.
4. Use of standardized registries to capture a reliable data for
evidence-based decisions.
5. Perform clinical audit for selected conditions, used to inform QI
projects.
 Project Implementation Strategies

At National and Regional Level

• Nationally the project will be coordinated by MoH/CSD
– Nationally EHAQ steering committee
– EHAQ project team
– Audit team
• RHB are responsible for managing the project in their respective
regions
 Project Implementation Strategies

At hospital level
• Main implementer of the project
– Advocacy and communication
• create awareness and sense of ownership at all level
• Orientation for Management and staff
– Coordination and plan development
• Customize the project document in the context of their setup
• Assign focal person from hospital QU as the day to day
implementation
• Conduct overall baseline assessment
• Prepare hospital and service unit level implementation plan
• Establish Hospital level performance management mechanisms
 Scope of the Project

• To promote an Evidence Based Care that and to achieve health

service standards and desired health outcomes across all hospitals
enrolled to the EHAQ platform.
• From October, 2021 – June, 2023
 In Scope
• Advocating EBC Project among stakeholders to gain a common understanding
• Introducing hospitals key interventions and change package
• Conducting baseline assessment at facility level
• Conducting supportive supervision
• Conducting onsite Mentorship
• Regional performance review meeting in all regions
• Cluster level review meeting and onsite visits
• Benchmarking of best practices
• Conducting preliminary regional assessment
• Conducting national validation and Recognition
• Use of ICT innovations that facilitate planning, implementation and monitoring
of the project
 Deliverables

• Project documents (Project document, EHAQ implementation

guideline, change package, monitoring and evaluation, audit tools)
• Baseline assessment repots of selected interventions
• Supportive supervision and mentorship reports
• Preliminary assessment report
• Final validation/evaluation reports of 4th cycle EHAQ
 Assumptions
• EHAQ platform will remain priority area of MOH top leadership.
• High level commitment across all level in implementing the project.
• All necessary sensitization and advocacy will ne done
• All necessary resources required will be dedicated by MoH/ RHBs
and Partners.
• Relevant partners remains in support of the project.
• Hospitals’ leadership and staff will sustain their commitment and
motivation for implementation of recommended interventions.
• People that are involved at the beginning of the project will remain
and stay in the project until the project is completed.
 Project Milestones

• Project documents approved by October 31/2021

• Launching (kick off) of the project by November 12/2021
• Baseline assessment conducted and report submitted from all
hospitals by Feb. 2022
• Preliminary assessment conducted by regions, hospitals for national
validation identified date February, 2023.
• National validation will be finalized by April, 2023
• National recognition of best performing hospitals by June,2023
 Monitoring and evaluation

• A list of key indicators that will be used to track project

implementation.
• Will be aligned with the existing platforms of the hospital
performance and improvement manual and DHIS2 tool.
• Additionally, structured approaches will be designed to regularly
follow progress of the project implementation.
• Methods and tools for review meetings, supportive supervisions and
mentorship will be defined in the audit tool.
 List of Key Indicators
List of Key Indicators
Neonatal Care:
• Institutional Neonatal Death Rate
• Proportion of Sick Young infant treated for Newborn infection
• Proportion of low birth weight or premature newborns for whom
Kangaroo Mother Care (KMC) was initiated after delivery
• Proportion of asphyxiated neonates who were resuscitated (with
bag & mask)
• Treatment outcome of neonates admitted to NICU
 List List
of ofKey Indicators
Key Indicators

Outpatient service / NCD:

• Six-monthly control of diabetes among individuals treated for diabetes.
• Proportion of individuals treated for priority mental health disorders.
• Six-monthly control of blood pressure among people treated for
hypertension.
IPD:
• Average Length of Stay (in days)
• Completeness of inpatient medical records
Emergency and Critical Care:
• Emergency room patients triaged within 5 minutes of arrival
• Facility emergency department mortality rate
• Emergency room attendances with length of stay > 24 hours
 List ofListKey Indicators
of Key Indicators

Surgical Care:
• Surgical site infection rate
• Rate of safe surgery checklist utilization
• Perioperative mortality rate
• Mean duration of in-hospital pre-elective operative stay
• Delay for elective surgical admission
• Major surgeries per surgeon

Cross-Cutting Indicators:
• Essential Drugs Availability
• Essential laboratory test availability
• Functionality of medical equipment
• Proportion of health Facility staffed as per the standard
• Percentage of health professionals with an active professional license
• Percentage of health professionals with defined scope of practice
 List List
of ofKey Indicators
Key Indicators

Data Quality:
• Reporting Completeness
• Reporting Timeliness
• Proportion of reporting consistency check conducted using LQAS
• Information use score
Patient Preferences and Value:
Patient satisfaction
Thank you !!