Sawla General Hospital
System Bottlenecks
Focused Reform
(SBFR) Taskforce
Term of Reference
(TOR)
Contents
1. Background.........................................................................................3
2. SBFR Taskforce Objectives................................................................4
1. General Objective.............................................................................4
2. Specific Objectives...........................................................................4
3. Team Composition..............................................................................5
4. Organizational Structure.....................................................................6
5. Task Description.................................................................................7
6. Expected Daily Outputs......................................................................8
1. Background
System Bottlenecks Focused Reform (SBFR) is a Newly designed and
high impact national unique pilot project which will mainly focus and
intervene system (hospital service delivery) level major bottlenecks while
creating clear strategic alignments and Integrations among key
stakeholders with defined responsibilities and accountability
mechanisms”
SBFR is a new initiative launched by Ministry of Health (MOH) on
2022G.C. with the aim of improving Health care institutions performance
and outcome by focusing on main cross-cutting bottlenecks which are
mostly shared by different health institutions across Ethiopia.
2. SBFR Taskforce Objectives
A. General Objective
To Improve hospital’s clinical care outcomes and client satisfaction
through introducing significant and measurable positive system
changes on access and quality of clinical, diagnostic and
pharmaceutical care.
B. Specific Objectives
1. To improve institutional culture of leadership and accountability
practices
2. To digitalize hospital’s clinical and non-clinical care processes
and improve data quality and performance management
3. To improve institutional efficiency gains and system integration
4. To improve access and quality of clinical, diagnostic and
pharmaceutical services
C. Team Composition
The composition of the SBFR Taskforce is recommended to be
multidisciplinary which would include Nurses/Midwifes, General
Practitioners, Consultants, Medical Laboratory Professionals, Pharmacy
Professionals, Environmental Health Professionals, Health Informatics,
etc.
Based on Job Description, it is recommended to include those (but not
limited to) working in Quality Directorate, In-Patient, Out-Patient and
Emergency Directors, Matrons and so on.
D. Organizational Structure
CEO/Provost
SBFR Task
Force
Chart Audit
Sub-Team
Medical Admin
Vice CEO Sub-Team
Director
Admin Medical
Departments Departments
E. Task Description
1. SBFR Taskforce Leader
SBFR Taskforce Leader answers directly to the CEO/Provost.
It is recommended that
The taskforce leader will act as the team Leader. He/She will deligate a
Team Captain (the most senior) for each duty team that will carry the
taskforce leaders tasks during duty times.
He/She will distribute tasks to each team Member.
He/She will make sure each taskforce member performs their task
efficiently and timely.
2. SBFR Taskforce Members
Taskforce members will carry out the tasks given to them by the
taskforce leader/team captain
F.Expected Daily Outputs
1. Administrative Outputs
At the start of duty time, all taskforce members will meet at once and
tasks will be distributed by the team captain
Clinical round will be performed by respective professionals
Duty Consultants will do duty sensitization on their respective wards
General Practitioners will do rounds at Emergency and ICU
Any administrative issues will be managed by this team
Resource sharing between units and departments
Manage supporting function interruptions (water, electricity etc.)
Manage disagreement between staffs within a team or between different
teams
Corridor audit will be performed after 10:00 PM and any patients who
are waiting at any service delivery points (for example waiting for lab
results) will be interviewed and root cause analysis will be done if any
delay is identified.(Corridor audit checklist)
Surprise visits will be performed usually after 2:00AM at all service
delivery points to ensure 50% of the staff are available at their service
stations.
Conduct root cause analysis for all identified gaps and present on daily
CEO/CCO-SBFR forum and weekly SBFR forum
Every morning, the team will meet with the hospitals CED/CCD/Provost
and present a 24hr report about the hospitals incidents. The meeting
minute will be documented using the SBFR-CED/CCD/Provost forum
2. Chart Audit Outputs
Performing Daily Chart Audit
o Duty Consultants:
All new duty time admissions in their respective departments should be
audited using consultant clinical audit format(see Annex___)
Duty consultants will be members of the taskforce during duty time and
will support the taskforce when clinical decision is required.
Duty Sensitization will be performed (See Duty sensitization Protocol)
o General Practioners
Chart audit regarding
All Patients at Emergency who stayed > 24hrs
Emergency and ICU round ( pts >24hrs stay, patients who stay at ER
due to Lack of Decision, Consultation delays, check Emergency
Preparedness,
Ward Chart Audit ( old admissions, using sampling method, 15% of
admitted patients and if total bed < 10, take 3 samples using inpatient
chart audit tool)
OPD Chart Audit using outpatient chart audit tool
Incase absent physician is there, He/She will cover the place of the
absentee
Audit findings will be filled on the database
o Clinical Pharmacists
Chart Audit on selected wards where poly-pharmacy is common
(Internal Medicine, Pediatrics ward and ICU)
Audit findings will be filled on the database
o Clinical Nurses/Midwives
Chart Audit will be performed
Audit findings will be filled on the database
Pain and palliative care
o Environmental Health Professionals
Ward Audit will performed using IPC Audit tool
Based on the audit tool finding, they will improve
the gaps and give feedback during duty time
Audit findings will be filled on the database
o Client Education Professionals
Client education professionals are those who are
working in health literacy unit during the day time
Client education will be given for newly admitted patients using the
client education checklist
Client Interview will be performed using Client interview checklist
Based on the audit tool finding, they will improve the gaps and give
feedback during duty time
Client education and interview checklist findings will be filled on the
database
o Medical Laboratory Professionals
Duty Sensitization will be performed by them at laboratory team
During duty time, they make sure that all laboratiory machienes are
functional and weather essential laboratory tests are being provided.
Laboratory Audit will be performed using Laboratory Audit tool
Based on the audit tool finding, they will improve the gaps and give
feedback during duty time
Audit findings will be filled on the database
3. Report presentation
o Daily CCD/CED/Provost-SBFR task force forum
Should be conducted before 8:00 AM(preferably 7:30AM)
Department level issues will be communicated to department head
before morning forum and feedback /or accountability will be ensured
o Weekly SBFR Forum
Daily dashboard summary of the week will be presented
Quarterly SBFR forum
1. Document Approval
1. Mr.
Signature ________________ Date___________
2. Mr/dr
3. Mr.
Signature ________________ Date___________
4. Mr
5. Mr.
Signature ________________ Date___________
6. Mr
7. Mr.
Signature ________________ Date___________
8. Mr
9. Mr.
Signature ________________ Date___________
10.Mr.
Signature ________________ Date___________
11.Mr.
Signature ________________ Date___________
12.Mr.
Signature ________________ Date___________
13.Mr.
Signature ________________ Date___________
14.Mr.
Signature ________________ Date___________
15.Mr.
Signature ________________ Date___________
16.Mr.
Signature ________________ Date___________
17.Mr.
Signature ________________ Date___________
18.Mr.
Signature ________________ Date___________
19.Mr.
Signature ________________ Date___________
