Oromia Health Bureau

Healthcare Quality Bulletin

Whole System Thinking for Improved Health Outcome

July 2024
Table of Contents
MESSAGE FROM OROMIA HEALTH BUREAU HEAD...........................................................III
FOREWORD .................................................................................................................... IV
ACKNOWLEDGMENT ....................................................................................................... V
OROMIA HEALTHCARE QUALITY BULLETIN CORE TEAM .................................................. VI
SECTION I – LESSON FROM QUALITY IMPROVEMENT PROJECTS ....................................... 1
IMPROVING PAIN-FREE MEDICAL CARE IMPLEMENTATION: THE CASE OF WALLAGA UNIVERSITY COMPREHENSIVE
SPECIALIZED HOSPITAL, JUNE 2023 ............................................................................................................. 2
IMPROVING WAITING TIME FOR CONSULTATION AT EMERGENCY DEPARTMENT, SEKA CHEKORSA HOSPITAL, OROMIA... 11
REDUCING ELECTIVE SURGERY CANCELATION RATE IN YABELLO GENERAL HOSPITAL, OROMIA ................................ 17
DECREASE EMPIRICAL TREATMENT OF MALARIA AT TULU BOLO GENERAL HOSPITAL IN OROMIA REGION, ETHIOPIA .... 24
REDUCE DATA DISCREPANCIES IN DOCUMENTATION AND REPORTING BETWEEN THE LIAISON AND INPATIENT UNIT AT
MATTU KARL SPECIALIZED HOSPITAL.......................................................................................................... 29
REDUCING NEONATAL MORTALITY IN MOJO HOSPITAL .................................................................................. 34
IMPROVING ADHERENCE TO PAPER-BASED PARTOGRAPH AT MODJO TOWN HEALTH CENTER ................................... 42
IMPROVING ADHERENCE TO APPROPRIATE NURSING CARE PLAN AT DEDER GENERAL HOSPITAL, OROMIA, ETHIOPIA... 46
IMPROVING ELECTIVE SURGERY PERFORMANCE IN METU KARL COMPREHENSIVE SPECIALIZED HOSPITAL, OROMIA ....... 52
IMPROVE THE PERCENTAGE OF CERVICAL CANCER SCREENING OF WOMEN LIVING WITH HIV, ADAMA HOSPITAL MEDICAL
COLLEGE .............................................................................................................................................. 60
IMPROVE UTILIZATION OF IMMEDIATE KANGAROO MOTHER CARE AT NEONATAL INTENSIVE CARE UNIT, TULU BOLLO
GENERAL HOSPITAL, OROMIA, ETHIOPIA .................................................................................................... 64
IMPROVING COMPLETENESS OF NURSING PROCESS AT NICU WARD, BISIDIMO GENERAL HOSPITAL, OROMIA ............. 69
IMPROVING MATERNAL AND NEWBORN PRE-REFERRAL COMMUNICATION AND MANAGEMENT ................................. 75
IMPROVE HEALTH LITERACY ADEQUACY IN NON-COMMUNICABLE DISEASE CLIENTS BAKO PRIMARY HOSPITAL .............. 80
REDUCING PERINATAL MORTALITY RATE IN ROBE DIDEA GENERAL HOSPITAL: A QUALITY IMPROVEMENT PROJECT ..... 87
SECTION II – LESSON FROM RESEARCH PROJECTS FINDINGS ........................................... 97
MATERNAL ANEMIA AND THE RISK OF LOW BIRTH WEIGHT IN ETHIOPIA; A SYSTEMATIC REVIEW AND META-ANALYSIS
.......................................................................................................................................................... 98
A COMPREHENSIVE APPROACH TO REDUCE THE BURDEN OF ESOPHAGEAL CANCER IN SOUTHEASTERN ETHIOPIA
THROUGH ADVOCACY FOR EQUITABLE AND ACCESSIBLE HEALTH SERVICES ........................................................ 104
MAGNITUDE OF HYPERTENSION AND ASSOCIATED FACTORS AMONG WEST WOLLEGA ZONAL SECTORS CIVIL SERVANTS,
WESTERN OROMIA, 2023..................................................................................................................... 110
MAGNITUDE OF CESAREAN DELIVERY AND ASSOCIATED FACTORS AMONG WOMEN WHO GAVE BIRTH AT GIMBI TOWN
HOSPITALS, WEST WOLLEGA, OROMIA, 2023........................................................................................... 116
PARTOGRAPH UTILIZATION AND ITS ASSOCIATED FACTORS AMONG OBSTETRIC CAREGIVERS IN QELLEM WOLLEGA ZONE
PUBLIC HEALTH INSTITUTIONS, WESTERN ETHIOPIA, 2023 ........................................................................... 122
SECTION III – LESSON FROM INNOVATION EXPERIENCES .............................................. 130
HEALTH FACILITIES NETWORK OF CARE: LEARNING FROM TULU BOLO GENERAL HOSPITAL AND BACHO WOREDA HEALTH
OFFICE ............................................................................................................................................... 131
HIV/AIDS PERFORMANCE MONITORING INFORMATION SYSTEM (HAPMIS)................................................... 138
HEALTH REGULATORY MANAGEMENT INFORMATION SYSTEM (HRMIS) .......................................................... 142

II
 Message from Oromia Health Bureau Head
Unlocking Healthcare Excellence: Oromia's Path to Quality and Equity
As we convene at the 3rd Annual Healthcare Quality Improvement
Summit, it's an opportune moment to reflect on Oromia's journey
towards unparalleled healthcare excellence, safety, and equity. Under
the leadership of the Oromia Health Bureau, our efforts have focused
on elevating health quality, ensuring patient safety, promoting equity,
fostering innovation, and cultivating impactful leadership programs.
One of our primary objectives has been the strategic expansion of healthcare
infrastructure to cater to the needs of diverse communities. Through meticulous
planning and resource allocation, we have facilitated the establishment of new health
facilities in underserved areas, ensuring that every individual, regardless of location, has
access to essential healthcare services. This expansion has been complemented by the
availability of state-of-the-art medical equipment, supplies, and medicines, as well as
the equipping of our facilities with the tools necessary to deliver high-quality care.
Human resource recruitment and retention of a skilled and diverse healthcare workforce
are central to our efforts. Our over 94,900 workforce is the backbone of our healthcare
system. Targeted capacity-building programs and continuous professional development
initiatives empower healthcare professionals to deliver comprehensive and
compassionate care to those in need.
Equity lies at the heart of our healthcare philosophy, helps to address disparities, and
promotes inclusivity at every level. Through targeted health insurance initiatives, we
seek to ensure that financial barriers do not hinder access to essential healthcare
services. Additionally, we actively address geographical and town-rural disparities
and gender-related challenges to ensure everyone has equitable access to quality care.
Innovation serves as a driving force in our quest for healthcare excellence, and we
are committed to harnessing the power of technology and innovation to improve service
delivery and patient outcomes. From the pioneering Health Extension Program to the
integration of digital health solutions, we are continually exploring new avenues to
enhance the efficiency, accessibility, and effectiveness of healthcare delivery in Oromia.
Accreditation and leadership development are integral to our strategy to foster a culture
of excellence and accountability within the healthcare sector. By creating centers of
excellence and investing in high-impact leadership programs, we are nurturing a new
generation of healthcare leaders equipped to drive meaningful change and innovation in
the field. At the Annual Healthcare Quality Improvement Summit, let us reflect on our
collective achievements and reaffirm our commitment to advancing healthcare
excellence, safety, and equity in Oromia and beyond. Together, we can continue to push
the boundaries of what is possible and create a future where everyone has access to the
quality healthcare they deserve.
Sincerely,

Mengistu Bekele (MD, MPhil-HE)

Head, Oromia Health Bureau

III
 Foreword

As the Vice Head of the Oromia Regional Health Bureau, I am

pleased to introduce this Regional Healthcare Quality Bulletin.
In our relentless pursuit of excellence in healthcare delivery,
this bulletin serves as a beacon of knowledge, innovation, and
collaboration. Within the pages of this bulletin, you will find a
rich tapestry of insights, initiatives, and projects aimed at
elevating the quality of healthcare services across our region.
From the meticulous efforts of our healthcare professionals to the strategic
partnerships forged with various stakeholders, each contribution underscores
our unwavering commitment to enhancing healthcare quality for all residents of
Oromia. I sincerely appreciate all individuals and organizations who have
contributed to the creation of this bulletin. Your dedication, expertise, and
collaborative spirit have brought valuable insights and best practices. I also
commend the authors of the quality improvement projects and studies featured
in this bulletin for their innovative approaches and dedication to advancing
healthcare quality. By sharing your experiences and lessons learned, you inspire
us to strive for continuous improvement and excellence in our respective fields.
I am particularly grateful to the Health Service Quality and Equity Unit experts
and the technical core group for their diligent efforts in compiling and reviewing
this bulletin's content. Your expertise and guidance have ensured the
information's quality and relevance.
Finally, I would like to thank the Different stakeholders, especially Fenot-
Harvard project, for their support in printing this publication. Together, we stand
at the forefront of healthcare quality improvement, united in our mission to
provide equitable, accessible, and high-quality healthcare services to the people
of Oromia. This bulletin will serve as a valuable resource for healthcare
professionals, policymakers, and stakeholders, inspiring collaboration,
innovation, and continuous improvement in healthcare quality throughout our
region.

Best regards,

Bokona Guta (MD)

Vice Head, Oromia Health Bureau

IV
 Acknowledgment
As we eagerly anticipate the release of the upcoming
Oromia Health Bureau Quality Summit Bulletin, I am
honored to extend my heartfelt appreciation to all who have
contributed to its creation and publication. Thank you to
the authors who have generously shared their expertise and
experiences.

Your dedication to advancing healthcare quality is greatly appreciated. Your

contributions have enriched the content of this bulletin, providing valuable
insights and inspiration for quality improvement initiatives across our region.

I sincerely thank our esteemed partners and stakeholders for their unwavering
support and collaboration. We have worked tirelessly to drive progress and
foster innovation in healthcare quality, equity, and patient safety. A special
acknowledgment goes to the organizing committee for the Oromia Health
Bureau Quality Summit. Your meticulous planning and execution of this event
have created a platform for meaningful dialogue, learning, and collaboration
among healthcare professionals and stakeholders. Furthermore, I express my
appreciation to the leadership of the Oromia Health Bureau for their vision
and guidance in prioritizing healthcare quality improvement. Your steadfast
commitment to excellence has been instrumental in shaping the direction of
our efforts and ensuring the success of initiatives such as this summit and the
accompanying bulletin.
Finally, I extend my gratitude to those who have provided technical and
financial support for preparing and publishing this bulletin. Your
contributions have been essential in bringing this valuable resource to fruition
and disseminating knowledge and best practices in healthcare quality
improvement across our region. In conclusion, the Oromia Health Bureau
Quality Summit Bulletin will catalyze continued progress and excellence in
healthcare quality, ultimately leading to better health outcomes for the people
of Oromia. Together, let us continue to strive towards our shared vision of a
healthier, more equitable future.
Warm regards,

Dereje Abdissa (MPH)

Head, Healthcare Quality, Equity, and Patient Safety Unit

V
 Oromia Healthcare Quality Bulletin Core Team
Name Organization Position
Dr Bokona Guta OHB Deputy Bureau Head
Medical Service and Higher Health
Daniel Tesfaye OHB
Facilities Directorate Director
Head, Healthcare Quality, Equity,
Dereje Abdissa OHB
and Patient Safety Unit
Healthcare quality officer, IA
Meaza Hailu OHB
Scientific Committee Coordinator
Fenot-Harvard
Dr. Tizta Tilahun Senior Scientific Advisor
Project
Teshome Oljira IHI Improvement Advisor
Nutrition
Wondwosen Retta Senior Program Officer-MNHN
International
Omer Hussen WHO WHO-RMNCAH Consultant
Tekalign Woldesemayat OHB/CDC HIV/AIDS Program QI officer
Gemechis Mesfin OHB Speciality and Rehabilitation Expert
Muzemil Kemal JSI/QHA Primary Healthcare Specialist
Senior Quality Improvement Advisor
Dr. Birhanu Tekele ICAP-Ethiopia
and IPC Lead
Dr. Kananisa Layo OHB Emergency and Critical Care Officer
Mestawot Getachew JSI/QHA Area Manager
Quality Assurance and Training
Mitiku Uma PSI/Ethiopia
Coordinator
Galmesa Bekana WHO Immunization TA
Birehanu Kenate OHB Health research team coordinator
Chala Bafikadu OHB Research officer
Cordaid, Clinical Quality
Tarekegn Jabara Cordaid
Improvement Specialist
Thomas Mohammed OHB Communication Designer
Adisu Tesfaye OHB System Administrator
Heyo Garedew OHB Healthcare Quality officer
Gemechu chala OHB Healthcare Quality officer
Tadele Debebe OHB Healthcare Quality officer
Mohammedamin Adem IHI Improvement Advisor

VI
Section I – Lesson from Quality Improvement
Projects

1
 Improving Pain-Free Medical Care Implementation: The
Case of Wallaga University Comprehensive Specialized
Hospital, June 2023
Authors: 1Gedefa Bayisa, 1Temesgen Tilahun, 1Amsalu Takele, 1Indalkachew Shifera,
1Kebena Limenu, 1Mohamademin Tafese, 1Mulugeta Ababa, 1Diriba Fayisa, 1Nemomsa

Dugasa, 1Bikila Regassa, 1Asefa Negari, 1Habtamu Deressa

Affiliation: 1Wallaga University Comprehensive Specialized Hospital

Abstract
Background: Pain is among the most common reasons patients visit
hospitals and other health facilities. However, because of different factors,
pain management practices are found to be poor and inconsistent,
particularly in resource-limited settings. This increases patient suffering,
decreases satisfaction, and results in a negative patient experience.
Objectives: This quality improvement project aims to increase pain-free
hospital implementation from 21% to 80% at Wallaga University
Comprehensive Specialized Hospital (WUCSH) from January 1 to June 30,
2023.
Methods: A hospital-based baseline survey was conducted at WUCSH. A
fishbone and driver diagrams were used to identify root causes and develop
changes. The Plan-Do-Study-Act (PDSA) cycle was used to test change ideas.
Major interventions included training health professionals, initiation of pain
as the fifth vital sign, policy and protocol development, and regular
supportive supervision.
Results: Pain as 5th vital sign implementation increased from 14.7% to
92.3%. Standardized treatment protocols for chronic and acute pain for
adults and pediatrics have been developed, and pain-free focal persons have
been established. Regular pain assessment and management audits have
improved from 28% to 82%. More than 80% of healthcare providers were
trained in appropriate pain assessment and management. Overall, pain-free
proper implementation was increased from baseline data of 21% to 88.7 %
after completion of this project.
Conclusion: Compliance with pain-free hospital implementations was
significantly improved in the study area. This was achieved by applying
multidimensional change ideas related to health professionals, standardized
guidelines and protocols, supplies, and leadership. Therefore, we recommend
providing regular technical updates and conducting a frequent clinical audit
on pain management.

Keywords: Pain-free hospital, Quality improvement project, PDSA cycle,

Ethiopia

2
Introduction
Pain is a distressing sensory and emotional sensation connected to, or like,
existing or potential tissue injury. It can be classified as acute or chronic based
on its time course. Acute pain has an abrupt onset and may last up to 6
months if poorly managed (1). All persons experience pain differently, and
biological, psychological, and social variables all have an impact. People come
to understand the concept of pain because of their experiences in life. It is
important to respect someone's right to describe something as painful (2).

The American Pain Society has designated pain as the fifth vital sign due to
its significant prevalence and suffering to enhance awareness of pain
management among medical professionals, improve patient care, and
increase the likelihood that patients will receive effective treatment. Most
patients report pain, which is one of the most prevalent symptoms. Assessing
the patients' pain before and after an intervention is one of the pain
management techniques. Different factors affect pain management. Any
healthcare system has three main obstacles: patients, facilities, and staff (3).

Developing countries tend to prioritize the eradication of poverty and hunger

and the reduction of maternal and child mortality and pay little attention to
pain management. However, the Ethiopian Federal Ministry of Health
(FMOH) launched the Pain-Free Hospital Initiative (PFHI) in 2014, where
pain management was integrated into other services. Still, pain management
needs attention in different health facilities (4). Hence, the Wallaga
University Comprehensive Specialized Hospital Quality Improvement Team
conducted a baseline survey on Pain-free hospital implementations and
identified low compliance.

Context
This project was conducted in Wallaga University Comprehensive Specialized
Hospital by a multidisciplinary team (MDT) from the quality improvement
unit, anesthesia, physicians, nurses, and pharmacists. The team consists of 2
senior physicians (1 anesthesiologist, 1 emergency critical care medicine
specialist), 7 different professionals from the quality improvement unit (1
general practitioner, 1 pharmacist, 1 laboratory technologist, 1 midwifery
professional, 4 nurse professionals), and 1 nurse (from Oncology Unit). It was
led by the clinical quality coordinator of the hospital.

3
Problem statement
The Pain-Free Hospital Implementation rate at Wallaga University
Comprehensive Specialized Hospital was 21%. Low compliance with pain
assessment and management leads to increased patient suffering, poor
quality of care, and negative patient experience.

Aim of Statement
Wallaga University Comprehensive Specialized Hospital Pain-Free
Implementation Quality Improvement Team aims to increase the pain-free
implementation rate from the baseline of 21% to 80% from 1 January to 30
June 2023.

Assessment of the problem and analysis of its causes

Five departments were selected based on high reports of moderate to severe
pain. Fifty (50) charts (10 from each department) were selected. Additionally,
25 patients (5 patients from each department) and 25 health professionals (5
from each department) were selected for interview. Physical observations like
pain as the 5th vital sign, protocol availability, meeting agenda, and letter of
pain-free focal person assignment were also assessed. The overall compliance
with Pain-Free Hospital Implementations was 21%, with specific compliance
rates of 14.7% for Pain as the 5th vital sign and 28% for regular patient
assessment and management audits. There were no trained health
professionals on pain assessment and management, no approved
standardized pain treatment protocol, and no assigned focal person for pain
assessment and management (Figure 1).

Pain free medical care, WUCSH

36.00%
22% 24% 21%
16%
7%

Emergency and Surgery Pediatrics Internal Oncology Total

critical care Medicine

Figure 1: Baseline data of pain-free medical care at Wallaga University

Comprehensive Specialized Hospital, 2022

4
Intervention
Using a fishbone diagram, the root causes of the problem were identified.

Figure 2: Fishbone diagram for identifying root causes of painful medical care
at Wallaga University Comprehensive Specialized Hospital, 2022

The identified causes were inadequate training for health care professionals,
a lack of written protocols and guidelines, no assigned hospital pain-free focal
person or team, no regular audit on pain assessment and management, not
recognizing pain as the 5th vital sign, weak regular monitoring and evaluation
from head nurses and department heads, and no health education on pain
and its management (Figure 2).

Change Ideas/Interventions prioritized

Depending on the root causes identified (Figure 2), 12 change ideas/
interventions were identified to achieve a pain-free hospital environment
(Figure 3). Seven of these change ideas were prioritized for testing.
1. Onsite refreshment training for all healthcare professionals on pain
assessment and its management to improve skill gaps and attitudes.
2. Preparing standardized treatment policies, guidelines, and protocols for
managing acute and chronic pain.
3. Implement pain as the fifth vital sign.
4. Patient education on how to report pain and utilize pain medication.
5. Assigning a focal person for pain management.

5
 6. Using medications for pain management.
7. Regular coaching, mentoring, and supervision on pain assessment and
management.

Driven Diagram
Outcome Primary Driver Secondary Driver Change Ideas

Provide Staff recognition and

Healthcare Attitude reward
provider

Skill gaps Provide on-job training on pain

assessment and management

Increasing rate Policy, protocol,

Develop written policy,
of Proper and guidelines
protocol & guidelines on pain
assessment and management
Implementatio
Supply Improve availability of pain
n of pain free Drugs drugs
hospital from
Develop vital sign sheet with
baseline of Formats pain
21% to 80%
Patient education on how to
from March - report pain and utilization of
Awareness pain medication
May 2023 G.C
Patient
Regular coaching, mentoring
Monitoring and supervision should be given

Provide training for provider as

Training needed

Assign pain focal person

Pain focal Person

Leadership Construct room for pain clinic

Establish pain Avail all necessary human

clinic resources and materials

Figure 3: Driver diagram for increasing Proper Implementation of pain-free

hospital rate at Wallaga University Comprehensive Specialized Hospital

Measurement
Different pain assessment and measurement tools were adopted from trusted
sources. These are the WHO analgesic ladder, the Wong-Baker Scale, the
Numerical pain Scale, the FLACC scale, the PAINAD scale, the NIPS scale

6
(neonatal infant pain scale), the CRIES scale, the Behavioral pain scale, and
the Critical care pain observation tool (5-9).

Outcome measurement
Proportion of Pain-Free Hospital Implementation at Wallaga University
Comprehensive Specialized Hospital

Process measures
– Proportion of proper implementation of Pain as the 5th Vital Sign
– Proportion of availed standardized treatment protocols for management of
acute and chronic pain
– Proportion of assigned Hospital Pain-Free focal person
– Proportion of regular audit of pain assessment and management practices
and outcomes
– Proportion of trained healthcare staff on knowledge and skills in pain
assessment and management

Balancing measures
– Percentage of unnecessary pain medication given to patients.
– Number of staff with work overload.
– Financial costs incurred for availing different formats, posters, protocols,
and management guidelines.

Results
Implementation of pain as the fifth vital sign during baseline assessment was
14.7% and showed improvement after project implementation (Figure 4).
Two standardized chronic and acute pain protocols for adults and pediatrics
were developed. Pain-free focal person assigned by CCD of the hospital.
Regular audit of pain assessment and management practices and outcomes
was 23% during baseline assessment, and this has also shown signs of
improvement during the project period (Figure 4).

7
 Implementation of Pain as Fith vital sign, WUCSH
100

50

0
Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Apr-23 May-23 Jun-23

Pain as fifth Vital Sign Baseline Median

Figure 4: Rate of implementation of pain as a fifth vital sign from 1st January
to 30th June 2023 at WUCSH

More than 80% (239) of health care providers are trained in pain assessment
and management from different departments.

Pain assessment and management audits were poor (27.3%) before project
implementation. Still, their trend improved during the project period, as
evidenced by the consecutive increase of pain assessment audits for 6 months
above the baseline median of 27.3% (Figure 5). An improved trend in pain
assessment and management audits has enhanced pain-free medical care
implementation in WUCSH, as shown in Figure 6.

% Audit of Pain Assessment and MAnagement Practices, WUCSH

100.0

50.0

0.0
Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Apr-23 May-23 Jun-23

Audit of Pain Assessment Baseline Median

Figure 5: Percent Audit of Pain Assessment and Management from 1st

January to 30th June 2023 at WUCSH

8
 Pain Free Medical Care Implementation
100
90 Assin pain
80
70 Staff
60
50
Regular
40 Baseline
Audit of
30 protocols
20
10
0
Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Apr-23 May-23 Jun-23

Pain free % Baseline Median

Figure 6: Run chart showing implementation of the pain-free rate at Wallaga

University Comprehensive Specialized Hospital from 1st January to 30th June
2023

Overall, pain-free hospital proper implementation results at Wallaga

University Comprehensive Specialized Hospital were consecutively above the
baseline median value for six months in the project implementation period,
indicating a signal of improvement. The median value of the pain-free
medical care implementation in the six months of the project period was
57.5%, nearly three-fold the baseline value (21%).

Lesson learned
– Use of standardized checklist in pain assessment and management.
– Regular refreshment training on essential topics is preferable to improve
the quality of care.
– Assigning a focal person to each service improves attention and the
owner of the services, which generally improves the quality of care.
– Policy, Procedures, and protocols available for all services, followed by
continuous supportive supervision, are important.
– Continuous communication with the drug supply unit made easy the
process of availing drugs and other materials.

9
Limitation
The project does not include Labor pain management due to limited
resources.

Conclusion
After the project was conducted, the proper implementation of a pain-free
hospital improved from its baseline. Establishing a Labor Pain management
system, staff training, Regular monitoring, and assigning a focal person were
some of the interventions tested for the positive outcome of implementing
pain-free medical care at WUCSH.

Recommendation
Regular monitoring and training for health care providers, establishing a
Labor Pain management system, integrating pain-free proper
implementation in evaluation mechanisms of staff and students, and
establishing MDT for pain assessment and management, if properly tested,
will result in improved pain-free medical care.

References
1. Alzghoul BI, Abdullah NAC. Pain Management Practices by Nurses: An
Application of the Knowledge, Attitude and Practices (KAP) Model. Glob J
Health Sci. 2015;8(6):154–60.
2. Pattison N, Brown MRD, Gubbay A, Peacock J, Ross JR, Chapman S, et al.
Towards a pain free hospital: An in-depth qualitative analysis of the pain
experiences of head and neck cancer patients undergoing radiotherapy. Br J
Pain. 2016;10(1):29–37.
3. Eshete MT, Baeumler PI, Siebeck M, Tesfaye M, Haileamlak A, Michael GG, et
al. Quality of postoperative pain management in Ethiopia: A prospective
longitudinal study. PLoS One. 2019;14(5):1–22.
4. Sugawara E, Nikaido H. Pain free hospital initiative Implementation Manuai. a
prgram Am Cancer Assoc with Collab Ethiop public Heal. 2014;58(12):7250–7.
5. Noah Brown MGH. Numeric pain assessment tool [Internet]. Available from:
https://medicalxpress.com/news/2022-07-emoji-shown-effective-numerical-
pain.html
6. Faces Pain Scale – Revised (FPS-R). 2001;7858.
7. Rose J. CRIES Pain Scale [Internet]. Available from:
https://basicsofpediatricanesthesia.com/section-v-pain/chapter-32-pediatric-
pain-assessment/

10
 Improving waiting time for consultation at Emergency
Department, Seka Chekorsa Hospital, Oromia
Authors: Lalisa Biftu, Amen Abdulkarim, Tolasa Abdeta, Ibrahim A/Temam, Dafis
Negash, Milkessa Ketema, Teshome Shitta, Mohammed Ibrahim, Merry Wondimagegn,
Abraham Tefera
Affiliation: Seka Chekorsa Primary Hospital

Abstract
Background: Timeliness of care is one of the six critical quality dimensions,
particularly in the ED, where urgent care is needed to save lives. Due to
numerous complicated factors, reducing wait times at the ED is challenging
and requires an evidence-based and system-wide approach.
Objectives: The project aims to determine if implementing a series of
interventions would decrease the Waiting Time for Consultation (WTC) for
patients at the ED within six months.
Method: A baseline assessment was done from May to June 2023 to
determine the patient experience and the average time patients see physicians
for consultation after being registered and triaged. A model for improvement
(MFI) framework was employed, and Rapid PDSA (Plan, Do, Study, Act)
cycles were used to implement a series of interventions. Changes in waiting
time were tracked with concurrent patient load, status of manpower, and
number of admissions from ED using structured checklists. Progress of re-
design activities, patient experience, staff satisfaction, and incidence of
violence were also monitored throughout the project period. Fourteen PDSA
cycle ramps were designed to test intervention ideas with the support of a
predictive tool (run chart rules) to reduce waiting times for consultation.
Results: The average consultation waiting times improved within six
months of initiating interventions. The improvements demonstrated
appeared consistent and sustained. The average WTC decreased by 100%,
from the baseline duration of 96 min to 32 min. The improvements occurred
despite a greater patient load of 1458 per month, compared with a baseline
monthly average of 512 patients. Patient experience and staff satisfaction
improved, while violence at the ED and staff burnout decreased significantly.
Conclusion: We demonstrated how implementing low-cost interventions,
leadership engagement, improved department relations, and optimizing ED
structure and layouts can help reduce patient waiting times. Quality
improvement efforts were sustained by a data-driven approach, support from
senior physicians, and constant feedback on outcomes.
Keywords: Waiting time, Consultation, Emergency, Seka Chekorsa
Hospital, Oromia

11
Introduction
Emergency departments (EDs) have long been described as complex,
overwhelming, and stressful environments characterized by high patient
volumes, rising service demands, overburdened staff, and an atmosphere of
continual exigency. While diverse structural and process elements constitute
this environment, the ED is typically designed to prioritize its main function:
to save lives and minimize morbidity. (Bailey et al., 2011; Aaronson et al.,
2018; Gordon et al., 2010; Sonis et al., 2019; Ulrich, 1991; Cypress, 2014;
Brysiewicz et al., 2020).

In the ED, patient perceptions of service value are tied to the time it takes to
receive care. Overcrowding and wait times are major factors influencing
patient experience, which happens when existing designs do not adequately
meet the needs and demands of the dynamic ED environment. Patient
experience positively correlates with improved health outcomes and care
quality, higher staff satisfaction, and reduced medicolegal risk. Patient
experience is “the sum of all interactions, shaped by an organization’s culture
that influences patient perceptions, across the continuum of care, thus
indicating a corresponding need for patient-centered health settings and
services. (The Beryl Institute, 2016, Mazzocato et al., 2012, Sonis et al., 2019)

A combination of process flow mapping, value-stream mapping, and root

cause analysis to determine that ED flow is affected by limited bed capacity,
unavailability of necessary staff, ED layout, and lack of understanding among
patients about the nature of emergency services could help to streamline ED
activities, minimize wait times and substantial cost savings for the hospital.
(Alowad et al. 2020)

According to an assessment done by observing the time it took for yellow and
green patients to see providers after registration and triaged from May to
June 2023, average wait times at the emergency department were found to be
96 minutes, which was longer than average waiting times recorded by existing
study 25 minutes (Timeliness of emergency services, Dr. Lia T 2017). The
prolonged waiting times, in turn, lead to ED overcrowding, an increased
number of patients leaving without treatment, reduced patient satisfaction,
and compromised service quality in general. Therefore, Seka Chekorsa's
primary hospital emergency department team linked the gap to the QI unit
and developed an improvement project to improve wait time (to decrease wait
time by 65%) within six months, from July 2023 to January 2024.

12
Seka Chekorsa Hospital is in Seka town, Seka Chekorsa district of Jimma
zone, Oromia regional state, southwestern Ethiopia, 20 km from Jimma town
and 370 km from the capital, Addis Ababa. The hospital started service in
2007 E.C as a primary hospital providing health services for about half a
million people (495,010) residing in Seka Chekorsa and Shabe Sombo
districts of Jimma zone, including neighboring villages of Mana, Dedo, and
Gera districts.

Our hospital delivers integrated health services, which include Emergency

and critical care, Adult and pediatric outpatient services, integrated maternal
and child healthcare, Inpatient and social services, liaison and referral
services, minor and major surgical services, neonatal intensive care, mental
health services, ophthalmic care, laboratory and imaging services, TB,
HIV/AIDS, and NCDs screening and follow-up care.

Additionally, we provide mentorship and coaching services for 15 health

facilities in catchment areas and serve as training Centres for different
university and college students. Currently, the hospital strives to ensure
healthcare quality by successfully implementing different change packages
(hospital reforms and initiatives), including ideas for continuous quality
improvement.

Problem Justification
Waiting at the ED, if prolonged, would compromise the quality of care and
patient safety by increasing morbidity and mortality. It increases the number
of patients who leave without being seen by physicians and readmission rates,
leading to economic loss for both clients and hospitals. Timeliness of care,
one of the seven quality dimensions, is critically important, particularly in
ED, where urgent care is needed to save lives. Overcrowding and waiting
times are major factors influencing patient experience, which happens when
existing designs do not adequately meet the needs and demands of the
dynamic ED environment. Increasing attendance to the ED and greater
disease complexity, coupled with manpower and physical infrastructural
limitations, have made reducing waiting times at the ED more difficult. The
average waiting time for consultation at our hospital emergency department
was 96 minutes, which is longer than the average waiting time recorded by
the existing study, 25 minutes (Timeliness of emergency services, Dr. Lia T
2017), which needs to be improved.

13
Aim statement
We, Seka Chekorsa Hospital's quality improvement team, aim to reduce
waiting time for consultation at the Emergency Department from an average
of 96 minutes to 28 minutes by the end of January 2024.

Assessment of the problem and analysis of its causes

ED waiting time was checked during baseline assessment for patients waiting
to be seen by Emergency care providers using a structured checklist. In
collaboration with hospital administration and the ED sub-quality team, the
quality unit held a deep discussion and conducted process mapping of
emergency services. It underwent root cause analysis to identify the possible
causes further.
Interventions
Prioritized interventions include re-designing the ED structure, rearranging
workflow, matching manpower to patient flow, and strengthening
interdepartmental relations and leadership engagement by involving the
emergency department sub-quality team. Senior physicians participated
throughout the project period.
Measurement of improvement
A model for improvement (MFI) framework was employed, and Rapid PDSA
(Plan, Do, Study, Act) cycles were used to implement a series of interventions.
Changes in waiting time were tracked, including concurrent patient load,
status of manpower, and number of admissions from ED, using structured
checklists. Progress of re-design activities, patient experience, staff
satisfaction, and incidence of violence were also monitored throughout the
project period. Twelve PDSA cycle ramps were designed to test intervention
ideas with a predictive tool (run chart rules) to reduce waiting time for
consultation.
Outcome measure
Average waiting time to consultation at ED after being triaged.

Process measure
– Number of staff received on-the-job training/orientation.
– Number of care providers added to match with patient flow.
– Percentage of ED expansion progress
– Number of discussions held with other words.

14
Balancing measure
– Number of patients admitted to Inpatient.
– Percentage of decreased staff from other departments
– Percentage of hospital revenue increased.
– Patents and staff satisfaction rate

Results
There was an improvement in average waiting time for consultations within
6 months of initiating interventions. The improvements demonstrated
appeared consistent and sustained. The average WTC decreased by 100%,
from the baseline duration of 96 min to 32 min. The improvements occurred
despite a greater patient load of 1458 per month, compared with a baseline
monthly average of 512 patients. Patient experience and staff satisfaction
improved, while violence at the ED and staff burnout decreased significantly.
After five consecutive PDSA cycles and when the ED expansion and redesign
were completed, the average wait time started to drop to a near target and
continued to be sustained. The emergency department’s floor layout was
changed so that each service room is proximal to each and easily accessible
and observable to care providers so that they can freely move and respond to
the urgent needs of emergent patients.

Average waiting time to consultation at Emergency

department, Seka Chekorsa Primary hospital, Oromia

100 96
Work flow
80
rearrangement
60 ED lay out redesign
Baseline
40
30.5
20
On-job training Discussion with other department
0
WK2
Wk1

Wk3
Wk4
Wk5
Wk6

Wk7
Wk8
Wk9
Wk10
Wk11
Wk12
Wk13
Wk14
Wk15
Wk16
Wk17
Wk18
Wk19
Wk20
Wk21
Wk22
Wk23
Wk24
Wk25
Wk26
Wk27
Wk28

Waiting time to consultation Median

Figure 1: Average waiting time to consultation (WTC) at the emergency

department from July 2023 to January 2024

15
Lessons learned
We demonstrated how low-cost interventions, leadership engagement,
improved departmental relationships, and optimization of ED structures and
layouts can help reduce patient waiting times. Quality improvement efforts
were sustained by a data-driven approach, support from senior physicians,
and constant feedback on outcomes.

Messages for others

We recommend that other health facilities implement such best practices, as
they are cost-effective interventions that significantly improve service quality
and patient experience.

16
 Reducing Elective Surgery Cancelation Rate in Yabello
General Hospital, Oromia
Authors: Abdi Kedir1, Getu Gudisa1, Arero Bikicha1, Ibsa Ilmi1, Dereje Giduma¹, Galgalo
Doyo¹
Affiliation:1Yabello General Hospital, Yabello, Oromia

Abstract
Background: Elective surgical case cancellation refers to a scheduled
surgical procedure not performed on a given day at a scheduled time for
different reasons. It has been a long-standing problem for healthcare
organizations across the world. The proportion of elective surgical case
cancellations ranged from 8.9% to 33.9% in the Ethiopian setting. Based on
available data, the elective surgical case cancelation rate accounted for 38%
at Yabello General Hospital, which is leading to psychological effects
including disappointment, frustration, and dissatisfaction. Hence, the
Yabello General Hospital Operation Room (OR) QI team aimed to reduce the
elective surgical case cancelation rate from 38 % to less than 5 % in Yabello
General Hospital, OR, by the end of Nov 2023.

Interventions: The MDT preadmission evaluation clinic has separate beds

for elective cases, adequate supply, improved documentation of vital events,
and accountability established with regular audits.

Results: The percentage of elective surgical case cancelation rate has

significantly reduced from 38% to less than 5% using before and after
intervention as a reference. Following the baseline assessment during the
intervention period i.e., there were only eight cancelations in six months out
of 318 elective surgical procedures planned for surgery.

Lesson learned: Leadership and monitoring were instrumental in building

problem-solving and clinical skills among the surgical team. Surgical leaders
played a catalytic role in strengthening surgical systems and processes,
contributing to reduced elective surgical case cancellation. The leadership
intervention and communication could be scaled up locally and globally.

Keywords: Elective Surgery, Cancelation Rate, Yabello General Hospital,

Oromia

17
Introduction
An elective surgical case cancellation occurs when an operation is planned but
not scheduled (1). Previous research showed that the prevalence of surgery
cancellations ranged from 1.9 to 49% (2, 3). The cancellation rate surpasses
20% in wealthy nations (4). However, among less-developed nations, the
percentage is 48.5%, with Ethiopia at 33.9% (3, 5). The cancelation of elective
surgery is a problem with the health care system’s quality that impacts
individuals and wastes resources. Particularly, it depresses the spirits of
workers, patients, and family members, which may result in lower efficiency
at work.

There are many reasons for canceling elective surgical cases, but they might
differ from hospital to hospital. Unexpected cancellations of planned surgery
are divided into avoidable and unavoidable cancellations. According to
studies, just 20% of cancellations were inevitable, while more than 80% might
have been avoided. Most cancellations occur because of administrative or
structural processes that are potentially preventable. Scheduling errors,
equipment shortages, and inadequate preoperative evaluation are avoidable
cancellations. Targeting these processes may reduce cancellations for elective
surgeries and improve economic efficiency and patient outcomes.
Unexpected, unavoidable cancellations are emergency encounters and
changes in patients' medical status. The pooled result of root causes for
cancellation of elective surgery from three studies (6, 7, 8) showed that
administration-related reasons (34.5%) were most prevalent, followed by
surgeon-related reasons (25.3%), medical-related reasons (13.9%), and
patient-related reasons (13.3%).

The body of evidence shows that the cancelation of elective surgery had
significant psychosocial and economic impacts on patients and their families.
Besides, it affects healthcare delivery and hospital revenue, which entails
mitigating strategies to prevent avoidable surgical cancelations. Identifying
reasons for elective surgical case cancelation can help the management body
develop appropriate strategies and better use its operating theatre facility.

Context
Yabello General Hospital serves a catchment population of 1,273,701 million
people in the southern part of Oromia. It was established in Nehase10, 2002
E.C. It provides services for around 6000 inpatients and 82,000 outpatient

18
attendees per year with around 144 functional inpatient beds. The hospital
offers a comprehensive emergency and elective surgical procedure facilitated
by one major and two minor operating rooms. Surgical services include
emergency and elective, major, and minor procedures. On average, over 335
major surgeries are performed monthly on both an emergency and elective
basis. In 2015, the E.C. annual report indicated that Yabelo General Hospital
conducted approximately 1550 major surgeries yearly.

We conducted an operation room registration and cancelation logbook audit

to measure the cancellation rate over six months. The average cancellation
rate for the past six months was 38 % of scheduled elective cases, affecting
the quality of care and patient satisfaction, leading to decreased surgical
volume indicators and disappointment in our clients. Conducting this QI
project may increase the awareness of the sensitivity of the problem to health
professionals and hospital management for better management of the
problem at any level.

Problem description
In Yabello General Hospital, the High Elective Surgical Case Cancellation rate
in the operation room (OR) due to the lack of preadmission MDT clinic with
no blood and no monitoring mechanism for essential supplies, along with the
fluctuation of light, was leading to wastage of resources. From December
2022 to May 2023 G.C, we conducted operation room registration and
cancelation logbook audit to measure the cancellation rate over six months.
The average cancellation rate for the past six months was 38 % of scheduled
elective cases, which affects the quality of care and patient satisfaction.

Aim statement
Reduce elective surgery case cancelation rate in Yabalo General Hospital from
38 % to less than 5 % at the end of November 2023.

Assessment of the problem and analysis of its causes

To assist healthcare providers in avoiding surgical cancelation, a quality
improvement project was designed to standardize the care provided to
surgical patients using the model for improvement. To identify the
performance gap and determine the reason for an increased number of
elective surgical case cancelations, a root causes analysis was conducted using
a bone diagram. (Figure 1)

19
Figure 1: Fishbone analysis for elective surgery cancelation

Interventions
Based on the quality gaps identified, change ideas for intervention were
preadmission MDT evaluation to identify those who are fit for surgery by
having a multidisciplinary assessment involving the surgeon and anesthetist
having preadmission format used appropriately for patients before
admission, regularly monitoring the availability of supplies using different
formats to avoid unintended cancelation on the day of surgery, For big
surgical operations like Thyroid operations, BPH & the likes, blood
availability should be checked before admission is made, Fluctuations of light
along with non-cooperation of electricity employee were also a major
contributor for cancellations. They solved this after discussions with
stakeholders and conducting regular awareness and knowledge audits of
clients on their clinical condition. Their involvement in decision-making was
a crucial intervention for the success of the QI project.

20
Study of the interventions
Repeated PDSA cycles were used to test the change ideas individually. Each
process was documented using a data collection tool for a routine QI team
meeting, and improvement actions were taken. The project's progress was
monitored every two weeks, and a run chart was used to analyze the data
collected over time with annotation of the interventions.

Measurements
Outcome measure: Elective surgery cancellation rate
Once the patient is scheduled for Elective surgery by the clinician and posted
on the dashboard, unable to operate is considered an elective surgery
cancellation by the Hospital and calculated as elective surgery Cancellation
Rate = Total number of elective surgeries performed divided by the total
number of elective surgeries scheduled times by one hundred.

Process measures:
- Percent of availed blood for elective surgeries
- Percent of surgical cases for whom preadmission MDT evaluation was
conducted
- Percent of Elective Surgery Cancelled due to lack of supplies

Analysis
After enough performance data points were achieved, a run chart was used to
see the impacts of interventions. Two medians, one before and the other after,
were developed to compare the impacts and draw inferences from the data.
The MDT team's regular preadmission evaluation and availing of the
necessary supplies led to the success of the QI project.

Results
The percentage of elective `surgery cancelation rate has significantly reduced
from 38 % to less than 5% using before and after intervention as reference.
Following the baseline assessment during the intervention period i.e., there
were only eight cancelations in six months out of 318 elective surgical
procedures planned for surgery. Reasons for cancellation of elective surgeries
were lack of supplies, shortage of blood, and operation room. The run chart
of elective surgery cancellations revealed a shift on the run chart, which
indicated improvement due to interventions undertaken. The median elective

21
surgery cancellation before intervention decreased from 40% to 10% after the
successful QI implementation in Yabalo General Hospital.
Measure
Run Chart : % of elective surgery cancelation Median
90.00%
80.00%
70.00%
60.00%
50.00%
40.00% LS #
30.00%
20.00% pre-admission MDT Regular
10.00%
0.00%
Regular monitoring for

Oct 1st 2wks

Jan 2nd 2wks
Feb 1st 2wks
Feb 2nd 2wks
March 1st 2wks
Dec 2nd 2 wks
Jan, 2023 1st 2wks

March 2nd 2wks

April 1st 2wks
April 2nd 2wks
May 1st 2wks
May 2nd 2wks

June 2nd 2wks

July 1st 2wks

Aug 1st 2wks

Aug 2nd 2wks

sept 2nd 2wks

Nov 1st 2wks

Nov 2nd 2wks
Dec,2022 1st 2wks

Oct 2nd 2wks

June 1st 2wks

Sept 1st 2wks

July 2nd 2wks

Figure 2. Percentage of elective surgery cancelation at Yabello General

Hospital, June 2023 – November 2023
Lesson Learned and Limitations
Lesson Learned
We have understood that the project significantly changed some staff's
knowledge, skills, and attitudes regarding readiness and communication. To
improve the quality of care we provide, we must conduct a preadmission MDT
evaluation by assessing blood and supply availability and developing an
implementation action plan.

Limitations
Lack of adequate Operation room, data quality problems, and blood
unavailability.

Conclusions: The elective surgery cancelation rate was significantly

reduced in Yabello General Hospital below the intended target due to the
above-mentioned interventions, conducted according to the preplanned

22
schedule and close follow-up from the QI team. To maintain the progress, the
continuum of the QI interventions is recommended.

References
1. Solak A, Pandza H, Beciragic E, Husic A, Tursunovic I, Djozic H. Elective case
cancellation on the day of surgery at a general hospital in sarajevo: causes and
possible solutions. Mater Soc Med. (2019) 31:49. 10.5455/msm.2019.31.49-52
2. Trentman T, Mueller S, Dormer CL, Weinmeister KP. Day of surgery
cancellations in a tertiary care hospital. J Anesth Clin Res. (2010) 1:2.
10.4172/2155-6148.1000109
3. Gajida A, Takai I, Nuhu Y. Cancellations of elective surgical procedures
performed at teaching hospital in northwest Nigeria. J Med
Trop. (2016) 18:108–12. 10.4103/2276-7096.192244
4. González-Arévalo A, Gómez-Arnau J, delaCruz F, Marzal J, Ramírez S, Corral E,
et al. Causes for cancellation of elective surgical procedures in a Spanish general
hospital. Anesthesia. (2009) 64:487–93. 10.1111/j.1365-2044.2008.05852.x
5. Ayele A, Weldeyohannes M, Tekalegn Y. Magnitude and reasons of surgical case
cancellation at a specialized hospital in Ethiopia. J Anesth Clin Res. (2019) 10:2
6. Bekele M, Gebru S, Mesai D. A cross-sectional study investigating the rate and
determinants of elective case cancellations at St. Paul’s Hospital Millennium
Medical College, Addis Ababa, Ethiopia. ECAJS. 2020;25(2).
7. Ayele A, Weldeyohannes M, Tekalegn Y. Magnitude and reasons of surgical case
cancellation at a specialized Hospital in Ethiopia. J Anesth Clin
Res. 2019;10(927):2.
8. Desta M, Manaye A, Tefera A, Worku A, Wale A, Mebrat A, et al. Incidence and
causes of cancellations of elective operation on the intended day of surgery at a
tertiary referral academic medical center in Ethiopia. Patient Saf
Surg. 2018;12(1):1–6. doi: 10.1186/s13037-018-0171-3.

23
 Decrease Empirical Treatment of Malaria at Tulu Bolo
General Hospital in Oromia Region, Ethiopia
Authors: Engida Kabeta1, Dereje Moti1, Tensay Bekele1, Workinesh Ajema1, Nigatu Hirko1,
Bogale Merga1, Ahmed Muhammed2, Dr Meron Teshome2
Affiliation: 1Tulu Bollo General Hospital, 2ICAP

Abstract
Background: In Ethiopia, about 75% of the total area of the country is
considered malaria, and about 52% of the population living in these areas is
at risk of malaria. According to the annual performance report of the FMOH,
2013 (2020/21), there were 1,220,027 cases, of which 1,135,338 (93.1%) were
laboratory-confirmed. 80.1% were due to plasmodium falciparum. There
were 132 deaths due to malaria. Ethiopia is currently working concertedly
towards malaria elimination by 2030.

Method: A model for improvement is used to design and implement the QI

project. Fishbone and driver diagrams were employed to identify the root
causes of the problem and generate change ideas. PDSA cycle and run chart
were used to test selected interventions and measure the results.

Interventions: Following the root cause analysis, selected interventions,

including training health care providers on malaria case management,
availing adequate equipment at the laboratory unit, availing relevant
guidelines for malaria case management, and conducting client chart and
prescription audit

Result: Quality of care improved by reducing empirical treatment of malaria

from 54% to 5%. The reduction of empirical treatment will decrease the
wastage of antimalarial drugs and prevent clients from unnecessary drug side
effects.

Conclusion: This QI project showed that implementing tested and effective

change ideas can significantly improve the quality of care.

Keywords: Treatment, Malaria, Tulu Bolo General Hospital, Oromia

Region

24
 Introduction
Globally, in 2021, there were an estimated 247 million malaria cases in 84
malaria-endemic countries, an increase of 2 million cases compared with
2020. In 2020, the mortality rate increased to 60.4 per 100,000 population
before decreasing in 2021 to 58.2. In 2020, a total of 241 million malaria cases
and 627,000 malaria deaths were reported globally; 96% of deaths occurred
in Sub-Saharan Africa, and 77% of deaths were children under five (WHO
2021). The malaria incidence rate is estimated to have decreased by 37%
globally between 2000 and 2015. Malaria death rates have decreased by 60%
over the same period (WHO, 2015). The trends of malaria have shown a
consistent decline in Ethiopia. It has successfully achieved the Millennium
Development Goals. According to the FMOH (2015) Health Management
Information System (HMIS) report, confirmed malaria cases declined from
1.7 million in 2016 to 0.9 million in 2019, respectively.

Generally, the FMOH developed four national malaria guidelines in 2002,

2007, 2012, and 2022. The main recommendation consists of adding radical
cure with primaquine for mixed malaria infections at the health post level; AL
is indicated for pregnant women in the first trimester; weekly chloroquine
prophylaxis for pregnant women with plasmodium vivax malaria; second-line
drug; management of severe malaria; and approaches to management of
possible treatment failures at each health care setting. Hospitals in Ethiopia
should use updated and standardized malaria guidelines and training
materials. To this end, the Federal Ministry of Health has developed updated
training material for proper malaria case management in the country. Tulu
Bolo General Hospital has been provided standard guidelines and training for
health care providers in collaboration with Oromia Health Bureau and ICAP
for malaria case management.

Problem
Based on the clinical audit conducted on client charts, prescriptions, and
laboratory results, 53.5% of malaria cases were treated empirically from
February 2022 to September 2022 at Tulu Bolo General Hospital. High
empirical treatment of malaria shows poor adherence to standard treatment
guidelines, which results in morbidity and mortality, including non-rational
use of antimalarial drugs.

25
Aim Statement
This study aimed to decrease the empirical treatment of malaria from 53.5%
to 5% from October 2022 to March 2023.
Assessment of the problem and analysis of its causes
A clinical audit was conducted on charts of selected 172 clients treated for
malaria in Tulu Bolo Hospital from Feb 2022 to Aug 2022 to assess the quality
of care and identify gaps related to malaria treatment. The assessment report
indicates that the empirical treatment of malaria in Tulu Bolo Hospital was
54%. In addition, the assessment was conducted on the knowledge, attitude,
and practice of healthcare providers regarding malaria treatment, and the
team also assessed the availability or applicability of standard lab procedures,
health management information systems, essential equipment and drugs,
standard treatment guidelines, and protocol by using a standardized
checklist. A problem prioritization matrix was used to prioritize the problems,
and a fishbone diagram was utilized to analyze the root causes of the
problems. Furthermore, the team used a driver diagram to identify ideas for
change for the specific problems identified.

Patient Provider

Awareness on Adherence on
importance of test standard Rx guideline

Dispensing
e Hi
system tre mp gh
at iric
m men al
a t
Shortage of (5 laria of
Strengthening 4%
Guideline and job monitoring )
aid

Lack of Lab reagent Poor Supportive

and slide Supervision

Resource Leadership

Figure 1: Fishbone Diagram

26
Interventions
We trained healthcare providers on malaria case management guidelines and
provided adequate diagnostic equipment at the laboratory unit. We printed
and provided relevant guidelines for malaria case management for easy
access and reference. We conducted biweekly audits of client charts,
prescriptions, and lab results and provided post-training supportive
supervision.

Measurement of improvement
The QI team used two levels of measurement (process and outcome
measures) to assess the effectiveness of the change ideas. The
multidisciplinary team meets monthly to monitor the intervention's progress
using PDSA.

Process measures
– Proportion of health care providers provided orientation training.
– Proportion of internal supportive supervisions conducted.
– Proportion of clinical audit conducted.

Outcome measures
- Percentage of empirically treated malaria cases

Results
Significant progress has been made in strengthening malaria treatment
practices. Staff orientation training has increased from 0% to an average of
50%. Clinical audits of malaria cases and internal supervisory support have
also jumped from 0% to 100% and 75%, respectively. Furthermore,
multidisciplinary team meetings are now held consistently, with an average
attendance rate of 100%.

The combined interventions effectively reduced unnecessary malaria

treatment. Empirical treatment rates dropped from a baseline of 54% to an
average below 5% (Figure 2).

27
 70 QI Project Orientation
started training provided
60

50

40
Supportive
30 supervision
and feedback
20
Clinical audit
10 and feedback

0
week2
week4
week6
week8
week10
week12
week14
week16
week18
week20
week22
week24
week26
week28
week30
week32
week34
week36
week38
week40
week42
week44
week46
week48
week50
percentage of empirical malaria treatment Base line median

Figure 2: Empirical treatment rates Malaria at Tulu Bolo General Hospital in

Oromia Region, Ethiopia

The reduction in empirical treatment will save antimalarial drugs for patients
who truly need them and prevent patients from experiencing side effects from
unnecessary medication.

Lessons learned
Improving malaria case management requires multiple approaches, which
include equipping staff with up-to-date guidelines, training sessions, and
regular clinical audits to empower them to deliver high-quality care.
Furthermore, the active involvement of senior clinicians and internists is
crucial for the project's success. Their expertise provides valuable guidance
and ensures the program's sustainability.

Messages for others

Regular on-site capacity building/orientation of health care providers on
standard malaria case management and promoting adherence to standard
treatment guidelines are central to sustainably reducing empirical malaria
treatment.

28
 Reduce data discrepancies in documentation and reporting
between the liaison and inpatient unit at Mattu Karl
Specialized Hospital
Authors: Almaz Asefa, Solan Bekele, Girma B, Regassa, Taka K, Solomon German,
Mintewab T, Firehiwot T.
Affiliation: Mattu Karl Specialized Hospital

Abstract
Introduction: Establishing a robust routine health information system is
paramount for the success of the healthcare information infrastructure and
the broader healthcare system. The MKCSH liaison quality team aims to
reduce the data discrepancy in documentation and reporting between liaison
and inpatient unit admission and discharge of patients from 10% to 0% from
January 15, 2015, to the end of June 2015 EC.
Methods: Baseline assessment data was collected from the IPD registration
and liaison registration book and analyzed using an Excel sheet. In addition,
the hospital's multidisciplinary team conducted an assessment using the
Avedis Donabedian framework, which encompasses structure, process, and
outcome. The QI team used the Fishbone diagram with the five why principle
to identify the root cause and the driver diagram to identify change ideas.

Intervention: key interventions identified to address the root cause of the

problem include orientation of staff on protocol and SOP of admission and
discharge, data triangulation b/n unit before report submission to DHIS2
weekly, assigning one staff every week to track/check patients admitted
without the approval of the liaison officer and take corrective action and
monitor daily admission and discharge by using dashboard to identify data
discrepancy and take corrective action.

Result: The data inconsistency between admission and discharge in the

Inpatient Department (IPD) has significantly decreased from 15% in
November 2022 to just 1% in June 2023. This improvement in data reliability
has enabled the hospital to accurately forecast the necessary medical supplies
based on caseloads and allocate manpower to units more proportionally.

Conclusion: Decreasing discrepancies between documentation/recording

and reporting will enhance data quality, foster informed decision-making,
and increase internal revenue.

Keywords: Data, discrepancy, documentation, Reporting, Inpatient unit

29
Introduction
A poor-quality data ecosystem leads to poor decision-making and inefficient
resource allocation. It also undermines confidence in the healthcare system
and threatens the validity of impact evaluations. This issue is particularly
prevalent in many developing countries, where routine health information
systems often need to be more effective.

A well-functioning routine health information system is the cornerstone of a

successful health information system—and, by extension, the entire health
system. Quality data is imperative for ensuring the safety and reliability of
healthcare delivery, with data from health facilities playing a pivotal role in
monitoring performance. However, existing studies predominantly focus on
identifying determinants of data utilization across various locations,
neglecting comprehensive data quality assessments. Hospital admission and
discharge processes are inpatient services' initial and concluding stages.
When these processes are affected by poor data quality, it directly translates
to compromised quality of care. Additionally, it adversely impacts hospital
revenue collection and bed management, highlighting the critical importance
of addressing data quality issues at these junctures.

The discrepancy between admission and discharge reports and IPD reports
signifies a potential breakdown in the hospital's operational processes.
Inadequate documentation or reporting procedures may contribute to this
consistency, resulting in accurate patient admissions and discharge records.
Consequently, the hospital may be experiencing challenges in effectively
managing bed availability and patient flow, leading to inefficiencies in
resource allocation and service delivery.

Moreover, the compromised data quality stemming from these discrepancies

not only hampers the hospital's ability to assess its performance accurately
but also undermines the credibility of its internal reporting systems. This lack
of data reliability can erode trust among stakeholders, including patients,
staff, and external partners, further exacerbating the hospital's operational
challenges.

Problem
Mattu Karl Specialized Hospital has observed a concerning trend during the
past two months, specifically from November 2015 to December 2015EFY.

30
The review of admission and discharge reports reveals a consistent shortfall
compared to the inpatient department (IPD) reports, with a median
difference of 15%. This disparity has led to several adverse outcomes,
including inappropriate admissions and discharges, suboptimal utilization of
beds, compromised data quality, and a consequential negative impact on the
hospital's internal revenue.

Aim Statement
The MKCSH liaison quality team aims to reduce the data discrepancy in
documentation and reporting between liaison and inpatient unit admission
and discharge of patients from 10% to 0% from January 15, 2015, to the end
of June 2015 EC.

Assessment of the problem and its causes

The Hospital quality improvement team conducted a baseline assessment by
collecting data from the IPD registration and liaison registration book and
analyzing it using an Excel sheet. In addition, the multidisciplinary team of
the Hospital has also conducted an assessment using the Avedis Donabedian
framework, which encompasses structure, process, and outcome. The QI
team used the Fishbone diagram with the 5 why principle to identify the root
cause and the driver diagram to identify change ideas. The brainstorming
session was conducted with a multidisciplinary team (liaison staff runners,
IPD department heads, and another supportive team) to analyze the root
causes of the problem further.

Interventions
– Prepare data triangulation protocol and SOP and orient staff on adherence
to protocols and SOP of admission and discharge.
– Conduct data triangulation b/n unit before report submission to DHIS2
weekly. All IPD and liaisons do data triangulation to identify gaps and make
weekly action plans for improvement.
– Assigned one staff weekly: The assigned liaison staff will track/check if
patients are admitted without the approval of the liaison officer and take
corrective action.
– Daily monitoring: Monitoring daily admission and discharge using the
dashboard to identify data discrepancies and take corrective action.

31
Measurement of improvement
Daily data collection was performed from both liaison and IPD registrations.
This data was then entered into an Excel spreadsheet for analysis. A run chart
was generated weekly to track improvement in outcomes. Weekly meetings
and discussions were convened among the team members to review and
interpret the data findings.

Results/Effects of Changes
The data inconsistency between admission and discharge in the Inpatient
Department (IPD) has significantly decreased from 15% in November 2016 to
just 0% in June 2016. This improvement in data reliability has enabled the
hospital to accurately forecast the necessary medical supplies based on
caseloads and allocate manpower to units more proportionally.

Measure prepare data

triangulation protocol Run Chart Median
25

​ start data tracking

20 /triangulation

15
​ data monitoring daily
​
​
​
10 ​ ​
​
5
​ ​
​ ​ ​ ​ ​ ​
baseline ​ ​ ​ ​ ​ ​ ​ ​ ​ ​
0
Novem…

Decem…

May…
January…

March2…

June…
Februar…
w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4
July w1
w2
w3
w4

Figure 1: Run chart shows the reduction in inpatient admission data

discrepancy

32
Measure
Run Chart Median
25

20

15
Baseline data
10

0
Nove…

Dece…

Janu…

Marc…
Febr…

May…

June…
w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4

w2
w3
w4
Figure 2. Run chart shows the reduction in data discrepancy of patients
discharged from inpatient

Lessons learned
It's essential to capture performance data daily with the guidance of
dashboards and conduct daily root cause analyses to address any identified
gaps swiftly. Utilizing QI data monitoring tools for continuous data
monitoring, alongside system redesign based on findings, is crucial for
improvement efforts.

33
 Reducing Neonatal Mortality in Mojo Hospital
Authors: Rabira Edesa, Alemayehu Sertse, Beyene Deraro, Dereje Beyene, Asaminew
Birhanu, Selamawit T/Birha, Birke Desmise, Abaynesh Irkihun, Samrawit Ayalew, Tegene
Ayano
Affiliation: Modjo Hospital

Abstract
Background: The first month of life is a critical period for child survival,
with vulnerability at its peak. Globally, 2.4 million newborns lost their lives
in 2020 during this vulnerable window. Sub-Saharan Africa faces an alarming
neonatal mortality rate (NMR) of 29 deaths per 1000 live births. In Ethiopia,
the NMR is 20.7 per 1000 live births (EDHS 2016 data).

Local context: Mojo Hospital experienced a neonatal mortality rate of 18

per 1000 live births. Retrospective death summary audits revealed that
neonatal sepsis (60%), asphyxia (22%), and premature birth (18%) were
major causes of neonatal deaths.

Methods: We utilized the Model for Improvement framework and Plan-Do-

Study-Act (PDSA) cycles. In addition, qualitative and quantitative data
analysis methods were employed to identify the root cause of problems
further and propose ideas for change.

Interventions: Interventions include standardization of the referral system

through the NOC initiative, renovation of the NICU to disaggregate neonatal
admission based on clinical and improvement infection prevention practices
by availing handwashing stations in NICU, and availing gowns for mothers.
Strengthening referral communication with the catchment facilities through
the Networks of Care (NOC) communication WhatsApp platform, use of
clinical bundle approach, periodic joint clinical and quality improvement
mentorship visits, and application of 5S Kaizen principles.

Results: The interventions have gradually reduced neonatal deaths in Modjo

Hospital, as evidenced by a shift in our run chart.

Conclusion: Addressing neonatal mortality requires concerted efforts

(adherence to IPP, measuring care content using the clinical bundle
approach), improving infrastructure, and a commitment to providing quality
care during the critical early days of life.

Keywords: Neonatal Mortality, Improvement, Networks of Care, Mojo

Hospital

34
Introduction
The first month of life is the most vulnerable period for child survival, with
2.4 million newborns dying in 2020. Globally, 2.4 million children died in the
first month of life in 2020. There are approximately 6700 newborn deaths
every day, amounting to 47% of all child deaths under the age of 5 years, up
from 40% in 1990 (1). The world has made substantial progress in child
survival since 1990 (2). The number of neonatal deaths declined from 5
million in 1990 to 2.4 million in 2020. However, the decline in neonatal
mortality from 1990 to 2020 has been slower than that of post-neonatal
under-5 mortality(2). The chance of survival from birth varies widely
depending on where a child is born. Sub-Saharan Africa had the highest
neonatal mortality rate in 2020 at 27 deaths per 1000 live births, followed by
central and southern Asia with 23 deaths per 1000 live births(3). A child born
in sub-Saharan Africa is ten times more likely to die in the first month than a
child born in a high-income country(4). Country-level neonatal mortality
rates in 2020 ranged from 1 death per 1000 live births to 44, and the risk of
dying before the 28th day of life for a child born in the highest-mortality
country was approximately 56 times higher than the lowest-mortality
country.

Most neonatal deaths (75%) occur during the first week of life, and in 2019,
about 1 million newborns died within the first 24 hours. Preterm birth,
childbirth-related complications (birth asphyxia or lack of breathing at birth),
infections, and birth defects caused most neonatal deaths in 2019. From the
end of the neonatal period and through the first five years of life, the main
causes of death are pneumonia, diarrhea, birth defects, and malaria.
Malnutrition is the underlying contributing factor, making children even
more vulnerable to severe diseases(3). Ethiopia has attained prominent
attainments in improving the health status of children in the last two decades.
Between 1990 and 2015, child deaths have diminished by two-thirds. The
under-5 mortality rate decreased from 123 per 1,000 LBs in 2005 to 59 in
2019 (5,6). Similarly, the infant mortality rate decreased from 77 per 1,000
LBs to 47 in 2019. However, neonatal mortality remains high with a modest
decline—from 39 deaths per 1,000 LBs in 2000 to 33 in 2019 (7). Startlingly,
according to EDHS reports, there is an increment in neonatal mortality from
29 deaths per 1,000 LBs in 2016 to 33 in 2019. Ethiopia has planned to
diminish neonatal mortality from 33 per 1,000 LBs to 21 per 1,000 LBs by

35
2024/25(7). The leading causes of neonatal deaths in Ethiopia are
Prematurity, asphyxia, and neonatal sepsis. In Mojo Hospital, the major
causes of neonatal deaths were Infection (Neonatal sepsis) 60%, asphyxia
22%, and premature birth 18%, respectively.

Context
Mojo Hospital’s neonatal ICU Service began in April 2012 and admitted 250
newborns till June 2015 from all referring facilities from the catchment health
centers. As per the retrospective death audit we’ve made, the major causes of
neonatal deaths were Infection (Neonatal sepsis) 60%, asphyxia 22%, and
premature birth 18%, respectively. Accordingly, we designed a quality
improvement project to Reduce the neonatal death rate with quality
improvement members. All teams were involved until the project's success,
and their contribution was vital for reducing the death rate, including the
change generation of change ideas. The model for improvement was a
framework used to explain the problem, set an aim, and develop an
intervention.

Problem statement
A retrospective audit of death reveals that the percentage of neonatal deaths
was found to be 17.5% for the past 6 Months in Mojo Hospital Newborn
Intensive care unit, which decreases staff and patient satisfaction.

Aim statement
The project aim is to decrease the neonatal mortality rate from 17.5% to 2%
from March 26/2015, by the end of June 30, 2015, in Mojo Hospital Neonatal
Intensive Care Unit (NICU).

Methods
After basic quality improvement training, a baseline assessment was
conducted by the Quality improvement team. Following baseline assessment,
performance gaps were identified in the NICU, ranging from inputs and
process of care to technical competence. The facility team utilized the Model
for improvement: the three questions and Plan-Do-Study-Act cycle approach
(PDSA) to guide the improvement work. Problems were identified,
prioritized, and rooted because the analysis used the fishbone method. The
teams will develop problem statements, set aims, generate change ideas, and

36
set indicators to monitor the changes. Using the PDSA cycle, generated
change ideas were tested. Interventions were tested during the action period
using a testing framework PDSA.

Assessment of the problem and analysis of its cause

We planned to assess the cause and extent of the problem through Fishbone
diagram analysis for route cause of the problem and driver diagram for
possible solution and extent of the problem. All relevant staff from the
Neonatal intensive care unit (NICU), SMT, and quality improvement teams
were involved in problem identification and generating change ideas. After
the project starts, quality improvement teams will follow the progress of the
change Ideas using (PDSA) cycle. At the end of the project's findings, if any
problems occurred, opportunities were disseminated to all other staff through
morning session meetings, SMT meetings, and other inter-departmental
interactions.

Data related Finance/ supply Leader ship

-Lack of regular - Stock out of -poor follow-up of
chart review essential drugs and content during PMT
-Lack Clinical audit lab reagents meeting
- Inadequate number -Poor Internal
- Lack of follow up Supportive supervision
for protocol of essential life
- No data analysis for
adherence saving equipment's decision

Neonatal
Death
- Poor pre-referral and
- Poor Infection referral management in HC
- Number of visitors prevention practice
not restricted/absence •Non-functionality of
- Absence of hand life saving equipment's
of traffic flow
management in NICU washing service •Poor Design of NICU
- Frequent stock out of - Poor Nursing Care •Inadequate NICU
IPPS Supplies -Poor adherence to Nurses
-Poor hand washing guidelines •Lack of waiting area
practice of staffs/ -Lack assigned for attendants
Mothers during Breast physician in NICU •Poor communication
feeding with MCH staffs
IPPS Related Staff related Facility

Figure 1: Root cause analysis for reduction of neonatal death rate in Mojo
Hospital NICU

37
Interventions
The Quality Improvement (QI) team proposed the following interventions
after thoroughly assessing the prevailing gaps using quality improvement
tools (Fishbone with the five why techniques and driver diagram).
– Redesign/ Renovation NICU
– Redesigning referral slips for the NOC facilities
– Conducting clinical mentorship to NOC facilities on improving pre-
referral communication and management
– Installation and Maintenance of machines used for Neonatal Care
– Give on-the-job refreshment training
– Conduct regular internal supportive supervision
– Discussion with MCH Staff (Midwives, IESO, Gynecologists)
– Controlling Traffic flow in the NICU
– Data-driven discussion with Senior clinicians and the management
team
– Developing improvement projects targeted towards the main cause of
neonatal mortality.
– Use of clinical bundle approach to assess adherence to standard clinical
protocols.
– Periodic joint clinical and quality improvement mentorship visits
– Application of 5 S Kaizen principles

Study of Intervention
The quality improvement team used the following monitoring techniques to
assess the effect of the proposed intervention:
– Run chart (data plotted over time with median line)
– Periodic spot-checking to assess real-time adherence to infection
prevention practice both by NICU staff and client family(mothers)
– A monthly clinical audit was performed to assess if the changes positively
impacted adherence to the bundle elements.

38
Measurement plan
Table 1: Outcome Measures
Aim Statement Outcome Measures
Indicator Proportion of neonatal
The project aim is to decrease death reduced
neonatal mortality rate from 17.5% Numerator Number of neonatal
to 4% from March 26/2022 to by deaths
the end of December 2023, in Mojo Denominator Total number of
Hospital Neonatal Intensive Care Neonates discharged
Unit (NICU). with recovery
Data Source Monthly Report data,
Register

Table 2: Process Measures and Balancing Measures

Process Measure Balancing

Change measure
Ideas Indicator Numerator Denominator Data source

Redesign/ Proportion # of rooms Total # of Observation

Renovate of rooms availed in rooms to be
NICU availed NICU per availed for
room for standard NICU per
NICU per standard
standard # Proportion
Installation Percentage # of Total # of of neonates
and of Equipment’ equipment’s Observation managed as
Maintenanc Equipment’s s installed needed for protocol
e of availed in and availed NICU
machines NICU
Facilitate % of trained # of trained Total # of Minute
on job NICU staffs HW staffs planned book and
refreshmen for training attendances # Quality of
t Training care given to
Percentage neonates
# of staff’s
of
who Total # of
To give nursing care
give nurses
Nursing given
nursing to be Checklist
care per to all
care participated
standard neonates
per on care # Increase
per
standard Data Quality
standard
Regular % of # of Total # of Checklist for
Follow-up neonates protocols protocols and protocol
for managed availed in guidelines to adherence
guidelines per protocol NICU be availed in and
and and NICU Performanc
Protocols guideline e
adherence monitoring

39
Results
Outcome Measures
Measure Proportion of Neonatal Mortality in Modjo Hospital
Networks of
100% Care(NOC)
implementation
started
Preventive
Blended QI and NOC
80% maintance- NICU NICU training given by
equipment's renovation/redesig Institute for
Onsite clinical n Healthcare
trainings and Improvement
60% Physician in charge
QI support given by
of NICU assigned
Institute for
Baseline Healthcare
40% Improvement

​
​ ​ ​ ​
20% ​ ​ ​ ​
​
​ ​
​ ​

0%
Apr-22

Oct-22

Oct-23
Nov-22

Jan-23

Apr-23

Nov-23
Jun-22

Jun-23

Sep-23
May-22

Jul-22
Aug-22
Sep-22

Dec-22

Feb-23
Mar-23

May-23

Jul-23
Aug-23

Dec-23
Figure 2: Percentage of Neonatal Death in Modjo Hospital
Process Measures
Measure
% adherence to Preterm Newborn care
100% Median
90%
management protocol Linear…

80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr-22

Jul-22

Sep-22
Oct-22
Nov-22

Feb-23
May-22
Jun-22

Dec-22
Jan-23

Mar-23
Apr-23

Sep-23
Oct-23
Nov-23
May-23
Jun-23
Jul-23

Dec-23
Aug-22

Aug-23

Figure 3: Percent of adherence to preterm Newborn care management

protocol in Modjo Hospital

40
 Measure
100%
% adherence to Neonatal sepsis
80%
Management Protocol
60%

40%

20%

0%
Apr-22

Jul-22

Nov-22
May-22
Jun-22

Aug-22
Sep-22
Oct-22

Dec-22
Jan-23
Feb-23

Jul-23
Mar-23
Apr-23
May-23
Jun-23

Aug-23
Sep-23
Oct-23
Nov-23
Dec-23
Figure 4: Percent of adherence to Neonatal sepsis Management Protocol in
Modjo Hospital

Lessons learned
A multifaceted approach notably improving pre-referral communication,
management, and virtual consultation with senior clinicians using the
Networks of Care model, process of care improvements, enhancement of
infrastructure, improved infection prevention practices, measurement of
adherence to clinical bundle elements, and application of the Model for
Improvement has led to an unprecedented level of better neonatal outcomes.

Messages for others

- Adapting the Networks of Care model to the local context will
enhance virtual consultations, pre-referral communications, and
management.
- Invest in NICU redesign and periodic preventive maintenance
sessions.
- Prioritizing infection control measures.
- Ensuring consistent adherence to evidence-based clinical
protocols.
- Applying continuous quality improvement principles.
- Collaboration with the Governing board (Mayor of the town) for
resource mobilization

41
 Improving adherence to paper-based partograph at Modjo
Town Health Center
Authors: Besu Kufa, Hailu Asefa, Tulu Bedada, Gosa Megersa, Meseret Tesfaye,
Lalise Teso, Adane Tafese, Adam Kuri, Hafiza Hussein, Shemisiya Edeo,
Tigist Gebre
Affiliation: Modjo Town Health Center

Abstract:
Background: The paper-based partograph is critical for monitoring
labor progress and detecting deviations. However, adherence to proper
partograph use has been suboptimal, leading to potential risks for
mothers and newborns.
Local context: Modjo Health Center serves many maternal, newborn,
and child health (MNCH) clients from Modjo Town and Lume Woreda
populations. The health center operates a functional operating room
(OR) block, where more than 700 cesarean sections have been
performed over the past three years.
Methods: We utilized the Model for Improvement framework and
Plan-Do-Study-Act (PDSA) cycles. In addition, qualitative and
quantitative data analysis methods were employed to identify the root
cause of problems further and propose ideas for change.
Interventions: Tested change ideas include the provision of refresher
training by veteran IESO, handover of the progress of labor using a
partograph sheet during each shift, a setting buffer stock of necessary
supplies and equipment needed to attend labor and delivery, peer-to-
peer mentoring by matching experienced mentors with a relatively less
skilled mentee, educating term pregnant mothers on ted interventions
that collectively contribute to safer deliveries, better outcomes, and
improved quality of care for both mothers and the newborn sign of
labor, weekly reviewing and analyzing labor and delivery records
completed by skilled birth attendants and provision of timely feedback.
Results: The interventions have steadily adhered to the standard
protocol (the run chart qualifies as a rule of shift).
Conclusion: Optimizing intrapartum care requires concerted and
multifaceted interventions that collectively contribute to safer
deliveries, better outcomes, and improved quality of care for both
mothers and newborns.

Keywords: Adherence, paper-based, partograph, Modjo Town,

Health Center

42
Background
Partograph is a graphical tool used during labor to monitor the
progress of cervical dilation, fetal descent, and maternal vital signs. It
helps identify deviations from normal labor patterns and prompts
timely interventions. Globally, maternal mortality remains a significant
concern. Obstructed and prolonged labor contributes to a substantial
percentage of maternal deaths. The partograph is a cost-effective and
essential intervention to prevent adverse outcomes during childbirth
(1). However, adherence to partograph use varies worldwide. In some
resource-limited countries, health workers need help to utilize the
partograph consistently. Factors influencing global utilization include
training, knowledge, attitude, and supervision (2). In Ethiopia,
partographs are only sometimes used during labor. Studies from
various regions report varying levels of utilization: Asella Referral and
Teaching Hospital: 26%, Sidama Zone: 50.7%, Bale Zone: 70.2%, Addis
Ababa City Administration: 53.85% and East Gojjam Zone: 69% (2).

A systematic review and meta-analysis involving 19 studies found that

Ethiopia's overall pooled prevalence of partograph utilization among
obstetric care providers was 59.95% (1). Determinant factors for
partograph use in Ethiopia include being in the midwifery profession,
presence of supervision, Basic Emergency Obstetric and Newborn Care
(BEmONC) training, knowledge of the partograph, on-the-job
refresher training, favorable attitude, and working at health centers (1).

Context
Modjo Health Center serves many maternal, newborn, and child health
(MNCH) clients from Modjo Town and Lume Woreda populations. The
health center operates a functional operating room (OR) block, where
more than 400 cesarean sections have been performed over the past
three years. Additionally, the health center handles an average of 80
normal deliveries per month. Despite having experienced clinical staff
attending labor and delivery, the quality of intrapartum care could be
better, with only 50% meeting the desired standards.

43
Problem statement
In the past year (from April 2022 to March 2023), a retrospective
review of Modjo Town Health Center client records indicated that the
partograph utilization was only 50%. Unfortunately, this suboptimal
utilization led to inadequate management of labor and delivery,
resulting in delayed detection of complications, including stillbirths.

Aim statement
This study aimed to improve the percentage of partograph utilization
from the baseline of 50% to 90% from July 2023 to June 2024.

Methods
We utilized the Model for Improvement framework and Plan-Do-
Study-Act (PDSA) cycles. In addition, qualitative and quantitative data
analysis methods were employed to further identify the root cause of
problems and propose ideas for change.

Root causes
The following problems were identified as hindrances to proper
partograph utilization at the health center using fishbone analysis.
- Late identification of labor
- Poor counseling
- Lack of feedback
- No regular supervision
- Poor adherence to implementation
- Skill gap

Interventions
The team tested and adapted the change ideas targeted to improve the
real-time utilization of the partograph for clinical decision-making.
These include the provision of refresher training by veteran IESO,
handover of the progress of labor using a partograph sheet during each
shift, setting buffer stock of necessary supplies and equipment needed
to attend labor and delivery, peer-to-peer mentoring by matching
experienced mentors with relatively less skilled mentee, educating
term pregnant mothers on early sign of labor, weekly reviewing and
analyzing labor and delivery records completed by skilled birth
attendants and provision of timely feedback.

44
Result and effect of changes

% Adherence to Labor & Delivery QoC at Modjo

100% Town Hc
QI
90% traini…
80%
70%
60%
50% Weekly
40% clinical
audit &…
30% Orientatio
20% Basline nn to MNH
staff Peer to
10% Assessment peer…
0%
Jul-22

Jul-23
Agust-23
Apr-22
May-22
Jun-22

Aug-22
Sep-22
Oct-22
Nov-22

May-23
Jun-23

setp-23
Dec-22
Jan-23

Mar-23
Feb-23

Apr-23

Oct-23
Nov-23
Dec-23
Figure 1: Adherence to Labor and Delivery QoC at Modjo Town Health
Center
The run chart graph depicted that partograph completion increased to
96% within ten months. Cases of obstructed and prolonged labor were
reduced (from 6.2% to 2.4%). Neonatal referrals due to birth asphyxia
were decreased (from 8% to 3.4%). Maternal and neonatal outcomes
were improved.
Conclusion
Optimizing intrapartum care requires concerted and multifaced
interventions that collectively contribute to safer deliveries, better
outcomes, and improved quality of care for both mothers and
newborns. Furthermore, staff and community satisfaction increased.

Lessons Learned
Throughout the process, we learned the importance of staff
engagement and clear communication from the project's inception and
throughout the project's implementation cycles is paramount.
Furthermore, flexibility in adapting interventions based on feedback
(test cycles) is the cornerstone of our success. In addition, proactively
addressing workload concerns is crucial for the project's success.

45
 Improving Adherence to Appropriate Nursing Care Plan at
Deder General Hospital, Oromia, Ethiopia
Authors: Abdi Tofik, Nuredin Yigezu, Derese Gosa, Redwan Sharfuddin, Hamza
Jemal, Ibrahim Tahir, Mohamed Abdi, Abdella Aliyi, Jafer Dine
Affiliation: Deder General Hospital, Oromia

Abstract
Introduction: A nursing care plan is a systematic process
documented for better patient health recovery. Adherence to an
appropriate nursing care plan is vital for delivering comprehensive and
consistent patient care. However, the current level of adherence needs
to be revised, leading to variations in care delivery, compromised
patient safety, and potentially negative patient outcomes.
Objective: This QI project aimed to improve adherence to appropriate
nursing care plans at Deder General Hospital from 47% to 90% from
September 02, 2016, E.C. to February 30, 2016, E.C.
Methods: To improve adherence to the appropriate nursing care plan,
the QI team used the model for improvement model (MFI). The PDSA
(Plan-Do-Study-Act) cycle was used to test the change ideas. We used
Fishbone and Driver diagram techniques to identify and address the
root causes. The key change ideas implemented consisted of on-the-job
training, availing lists of nursing diagnoses and care plans, and
intensive night rounds with immediate corrective action by the QI
team.
Result: Upon completion of the QI project, the overall adherence to
the appropriate nursing care plan was improved from 47% to 89%.
Thus, it improved each component of the nursing care plan from 53%
to 945, 58% to 89.5%, 47% to 95%, 37% to 96%, and 42% to 95% in
Assessment, Nursing diagnosis, plan of care, intervention, and
evaluation, respectively. The implementation of the project brought
positive consequences in improving the average length of stay and
patient satisfaction as balancing measures. It decreased the patient’s
hospital average length of stay (ALOS) from 7.3 days to 4.2 days and
increased patient satisfaction from 53% to 84%.
Conclusion: Adherence to the appropriate nursing plan has improved
since the start of the QI project. Implementing “provide on-the-job
training, availing lists of nursing diagnoses and their care plans, and
conducting intensive night rounds with immediate corrective actions”
were key improvement ideas implemented to improve adherence to the
appropriate nursing care plan.
Keywords: Adherence, Nursing Care Plan, Deder General Hospital,
Oromia, Ethiopia

46
Introduction
The nursing care plan is a continuous process that is documented
systematically to ensure the patient's better health recovery. If
medications heal the patient’s illness, the nursing care improves
comfort and helps them recover through gentle touch and care.
Adherence to nursing care plans is vital for delivering comprehensive
and consistent patient care. However, the current level of adherence is
suboptimal, leading to variations in care delivery, compromised patient
safety, and potentially negative patient outcomes. Low adherence may
include inadequate understanding of care plans, lack of standardized
documentation practices, insufficient communication among
healthcare team members, and limited accountability (1,2).

Context
Deder General Hospital is one of the oldest and earliest hospitals in
Oromia. It was established in 1957 GC in East Hararghe Zone, Deder
town, by Mennonite missions. The hospital's mission is to reduce
morbidity, mortality, and disability. This improves the health status of
people in the catchment areas by providing comprehensive
rehabilitative, promotive, and curative health services to all
stakeholders. It has a well-organized, multi-disciplinary QI team
comprising physicians, nurses, pharmacists, laboratory technologists,
anesthetists, and midwifery professionals.

Statement of Problem
The nursing care plan adherence audit conducted from August 01-30,
2016, E.C., shows that the nursing care plan adherence at Deder
General Hospital was suboptimal (47%). This resulted in medication
errors, missed interventions, delayed treatment, and decreased patient
satisfaction.

Aim Statement
Deder General Hospital QIT aims to improve adherence to nursing care
plan from 47% to 90% from September 02, 2016, E.C to February 30,
2016, E.C.

Assessment of problem and analysis of its causes

47
The QI project team assessed baseline data for improving adherence to
appropriate nursing care plans in five hospital wards (Medical,
Pediatrics, Surgery, OBGYN, ICU) over one month (Aug 1-30, 2016EC).
We reviewed 38 randomly chosen patient records in 2 rounds for five
specific criteria (assessment, Nursing Diagnosis, Nursing care plan,
Intervention, and Evaluation). A standardized national nursing care
audit tool is used to gather data. Accordingly, the baseline data results
against the nursing process elements were assessment (53%), nursing
diagnosis (58%), plan of care (47%), intervention (37%), and evaluation
(42%). The overall rate of appropriate nursing care plans was 47%.
(Figure 1)
Baseline data of improving adherence of appropriate filling
of nursing care plan
70
58
60 53
47 47
50
42
Percentage(%)

40
37
30 %

20

10

0
Assess ment Nurs ing Plan of care Intervention Evaluation Overall NCP
Diagnos is

Figure 1: Baseline data showed the rate of appropriate nursing care

plan at Deder General Hospital, from August 01-30, 2016, E.C

Intervention
The QI team analyzed the root causes using a fishbone diagram, plotted
possible intervention packages using a driver diagram, and designed an
implementation plan. A series of PDSA cycles were conducted.
Intervention data were collected and analyzed every two weeks. The
target unit heads and care providers implemented changes and
received feedback after thoroughly interpreting the results.

48
Root causes
The identified major causes were skill gaps, the absence of lists of
nursing diagnoses at service areas, and the lack of intensive night
rounds with immediate corrective action.

Interventions and Change Ideas

The following change ideas are targeted to improve adherence to the
Nursing Care plan from 47% to 90%. Using a prioritization matrix, we
focused on four specific change ideas from a pool of 8 possible Change
ideas. These proposed interventions and change ideas were:
– Provide on-the-job training for nursing staff.
– Provide the lists of nursing diagnoses and their care plans.
– Provide feedback.
– Conduct intensive rounds at night with immediate corrective
actions.
Table 1: Measurement
Change ideas Process measures
care plan from 47% to 95% from statement

Outcome
Measure

Indicator Numerat Denominator Data source

or
To improve adherence to nursing Aim

September 02, 2016, E.C to

Proportion of Provide on job Proportion of Number of Total Planned Minute

adherence to training training training training
appropriate NCP session session session
provided provided
February 30, 2016 E.C.

Numerator Number Provide lists of Proportion of Number of Number of Minute

charts with Nursing service areas service service areas
appropriate diagnosis and received lists of areas planned
ly filled its care plan nursing received
NCP diagnosis lists of
nursing
diagnosis

Results
Finally, after completing the project, adherence to the appropriate
nursing care plan in the inpatient wards at Deder General Hospital
improved from 47% to 95% (Figure 2). There was an improvement in
all components of nursing care plans, such as assessment (98%),
nursing diagnosis (89.5%), care plan (95%), intervention (96%), and
assessment (95%).

49
 Rate of appropriate Nursing care Plan, Dedere
general hospital
100
90
80
70 Regular
Night
60
50
40
30
20 Nsg dx
On job
10
training
0
e

10

12

14

16

18

20

22

24
lin

k
ee

ee

ee

ee

k
se

ee

ee

ee

ee

ee

ee

ee

ee
w

w
Ba

w
% Baseline Median

Figure 2: Rate of appropriate Nursing care Plan, Dedere General

Hospital at Deder General Hospital, from August 01-30, 2016, E.C.

Balancing Measure Outcomes

Implementing the quality improvement project had positive
consequences, including a reduction in patient average length of stay
(ALOS) from 7.3 days to 4.2 days (Figure 6) and improved patient
satisfaction from 53% to 84% (Figure 7).
AVERAG E LENGTH OF STAY (ALOS)
8
7.3
7
6
PERCENT(%)

5 4.2
4
3
2
1
0

B e f o re A f t e r I n t e r ve n t i o n

Figure 3: Adherence to appropriate nursing care plan Decreased the

average length of stay (ALOS) in inpatient wards of Deder General
Hospital, 2016, E.C

50
Lesson learnt
Leadership's involvement in using a task force for intensive night rounds
with immediate corrective actions and conducting frequent and regular
nursing care audits with feedback is important in improving adherence to
appropriate nursing care plans.

Conclusion
Adherence to the appropriate nursing plan has improved since the start of
the project period. Implementation of “provide on-the-job training, avail
lists of nursing diagnoses and their care plans, and conduct intensive night
rounds by QI team with immediate corrective actions” were key
improvement ideas implemented to improve adherence to the appropriate
nursing care plan.

References
1. The Nurse's Guide to Writing a Care Plan | USAHS
https://www.southalabama.edu/departments/academicadvising/advisinggui
des/nursing/nursing.html
2. Nursing Care Plan (NCP): Ultimate Guide & List [2024 Update] - Nurseslabs
https://nurseslabs.com/nursing-care-plans/98

51
 Improving elective surgery performance in Metu Karl
Comprehensive Specialized Hospital, Oromia
Authors: Almaz Asefa1, Abduselam Jemal1, Solan Bekele1, Edosa Habtamu1, Eyasu
Regassa1, Rediet W/silase1, Teka Koina1, Sabila, Solomon German1
Affiliation: 1 Mattu Karl Specialized Hospital, 2 Oromia Health Bureau

Abstract
Background: Elective surgery cancellation refers to canceling planned
surgical procedures initially scheduled but not on the intended day. The
prevalence of elective surgical case cancellation in Ethiopia varies between
8.9% to 33.9%. In our hospital, elective surgery cancellations are critical due
to a substantial waiting list of 201 elective surgery cases when we identified
our gaps.

Objective: This project aimed to improve elective surgery performance

from the baseline of 45% (Median %) to 95% from February 2022 to
December 2022 E.C.

Methods: Our hospital’s improvement team analyzed data from DHIS-2

and the surgical cancellation logbook over the past six months. Using
Statistical Process Control (SPC), we examined trends in cancellations for
elective surgery/efficiency of elective surgery. The median cancellation rate
was 55%, causing emotional distress for patients, families, communities, and
staff.

Results/Effects of changes: The percentage median of elective surgery

performance has significantly improved to 90%, compared to the baseline
median of 55%. The run chart qualified the rule of shift, indicating
improvement. Furthermore, the result was sustained.

Conclusion: The marked improvement in elective surgery performance

demonstrates the power of a holistic approach that involves improving
inputs, designing efficient clinical care processes, ensuring the availability of
supplies and medications, and engaging leadership, clinical teams,
paramedics, and the community. The hospital’s commitment to system
redesign has been instrumental in this achievement.

Keywords: Elective surgery, Performance, Metu Karl, Comprehensive

Specialized Hospital

52
Introduction
Operating rooms (ORs) are among the most important areas of the hospital,
contributing to both the workload and internal revenue—the efficient
workflow of the Operating. Theater is central to patient satisfaction due to
timely intervention. The efficient use of OR time depends on the scheduling
of cases, allocation of staff and equipment, the time required for preparation
and induction of anesthesia, the performance of surgery, recovery from
anesthesia, preparation of the OR for the next patient, and other resources.
Inefficient OR management can result in case cancellations and long patient
waiting lists. A well-managed OR results in a high surgical turnover, reduced
postoperative complications, improved patient-centered outcomes, and
greater patient satisfaction.

In MKCSH, Concern about the long waiting times for elective surgery is not a
recent phenomenon that is due to only having one surgeon; due to inflation of
market scarcity of resources, drugs, and supply leads to a heightened list
/backlog, which means (201 patients/90 days waiting to get the service. This
might reduce client satisfaction, advance the disease condition, and impact
the hospital’s internal revenue. One way to alleviate the problem might be to
prioritize the case according to the severity and geography of patients and
increase efficiency/capacity to manage those cases.

These include 1) prepare own elective surgery protocol 2) accurate case-

duration estimate: Measures the percentage of cases where patient-in-room
duration is within 15 minutes of the estimated in-room duration. This is a
performance parameter for the scheduling of cases. 2) Percentage of on-time
first case starts: In a good OR, there should be no reason for the patient to be
wheeled in late. Delayed starts may reflect inefficiencies in the hospital
systems from the wards to receiving the patient in the OR. 3) Pre-anesthesia
evaluation measures the percentage of cases with pre-anesthetic checkups
before surgery. Inadequate prescreening may be responsible for a proportion
of cancellations or delayed starts. 4) Patient-in-to-incision time: Measures the
average time between the patient entering the operating room and the first
incision. This includes the time for induction of anesthesia, positioning, and
surgical preparation. This is variable depending on the nature of the
anesthetic and the surgery. 5) Average turnover time measures the time
elapsed between the prior patient exiting the room and the next patient

53
entering the OR. Many factors drive turnover. There is a high need for
unmated surgery in developing countries due to the underutilization of the
existing operation theater according to protocols.

Context
Mattu Karl Comprehensive Specialized Hospital (MKCSH), Established in
1952 EC, serves a catchment area of approximately 3.6 million people,
including neighboring regions such as Gambella and Southern Ethiopia. Our
hospital provides outpatient and inpatient emergency services, with 214
functional beds. Among these, 65 beds are dedicated to the surgical ward. We
operate three fully equipped operating theaters: two for elective procedures,
one for emergencies, and a minor operating room.
Our comprehensive surgical services cover a range of specialties, including
general surgery, orthopedic surgery, obstetrics, and gynecological surgery.
Our hospital handles a substantial number of surgeries throughout the year.
The collaborative team involved in this quality improvement project includes
operation theater staff, the surgical ward, liaisons, and senior surgeons. We
strive to enhance OR efficiency, reduce waiting times, and improve patient
outcomes.

Problem statement
In Mattu Karl Comprehensive Specialized Hospital, inefficient utilization of
the operating theater has resulted in a significant burden of surgical waiting
backlog and frequent cancellations. Over the past three months (from
November to January 20/2015), our liaison backlog and operation theater
logbook reveal that only a median of 48% of elective surgeries were performed
compared to the number of patients on the waiting list. This situation has
decreased client satisfaction due to prolonged service waiting and secondary
complications from disease progression.

Aim statement
The Metu Karl Comprehensive Specialized Hospital improvement team aimed
to improve elective surgery performance from the baseline of 45% (Median %)
to 95% from February 2022 to December 2022 E.C.

Assessment of problem and analysis of its causes

The quality improvement team of the Hospital conducted baseline assessment
data collection from DHIS2, OR registration, and liaison. Backlog registration

54
book data was analyzed using an Excel run chart constructed; then, the
median shows the performance of elective surgery VS backlog. The team used
the Avedis Donabedian framework, which encompasses the structure,
process, and outcome of assessment carried out by a multidisciplinary team
of the Hospital. The finding was displayed for higher leadership of the
Hospital, OR team, and general surgeon, consequently creating a burning
platform for the leadership and senior surgeons who acted on most to improve
OR efficiency and delivery of high-quality surgery.

The brainstorming session was conducted with a multidisciplinary team: the

general surgeon, anesthetist, scrub nurse, surgical ward staff, and another
supportive team. The QI team used a QI tool like a Fishbone diagram with the
5why principle to identify the root cause. Then, proposed change ideas were
set for the root cause, tested step by step, and scaled up.

Summary of root cause analysis

Root cause Proposed solution
1 Delay first incision time/start, between Daily Monitoring by using dashboard
cases, availability of drapes, not
monitored daily.
2 Preadmission and pre-anesthesia Arrange Preadmission and Pre
evaluation not done prior to admission anesthesia evaluation Clinic integrated
& surgery day with surgical referral clinic & Pre
anesthesia evaluation Daily Monitoring
by using SBFR dashboard
3 Elective surgery (surgery side) was not Add additional day by shifting OR
done in all working day only 2days/week cleaning day to Saturday /3 days per
week for surgery side.
4 Shortage of supply and anaesthesia Assigning responsible person Setting
drugs minimum and maximum amount on
stock and request RRF 25%remaining
on stock
5 Surgeon and table productivity not Prepare monitoring format and enter
monitored the data daily
6 Unavailability of surgical protocols By engaging seniors prepare surgical
service protocol giving orientation
7 Ineffective PMT meeting/at OR by Weekly QI meeting conducted.
guided data plotted over time
8 Poor M&E performance of next day Daily Monitoring by using dashboard
schedule SBFR task force
9 Turnaround time between cases not Daily monitoring & assigning stand by
monitored additional cleaners
10 Inadequate table per standard From existed 3table, 2 of them
dedicated for elective surgery and 1
open for emergency cases

55
Major Interventions
After conducting a root cause analysis using the 5 Why approach, the QI
team selected major interventions. The outcome of the fishbone analysis and
brainstorming was to test a change idea step by step. The major change ideas
tested and scaled up to the sustainability and success of the project are
depicted below.

Change idea 1: Prepare own Elective Surgery Protocol

The surgical ward staff and the operation theater team developed a new
surgical service protocol. The protocol was holistic and included topics such
as elective surgery admission, pre-operative workup, preadmission, and
anesthesia evaluation before surgery. It also included an early first-case
incision time before 8:00 AM, a turnaround time between each case of 15 to
20 minutes, and Scheduled communication before 3:00 PM.

Change idea 2: Monitor On-Time First Case Starts

Prepare a daily dashboard for monitoring early incision time and turnaround
time between cases conducted. In an efficient OR, patients should experience
timely entry. Late starts may indicate system inefficiencies, from ward
processes to patient reception in the OR.

Change idea 3: Conduct regular data-driven QI team meetings.

By guided data plotted over time, QI meetings are conducted weekly based
on the presence of stakeholders.

Change idea 4: Pre-Anesthesia Evaluation and establish preadmission

evaluation.
Evaluating the percentage of cases that underwent pre-anesthetic checkups
before surgery. Inadequate prescreening can contribute to cancellations or
delayed starts.

Change idea 5: Monitor table productivity at least 3/table /surgeon &

surgeon productivity.
A standardized dashboard for daily monitoring of table productivity &
surgeon productivity was prepared.

Change idea 6: Facilitating campaign for consecutive 7 days

Higher leadership was communicated to mobilize resources and manpower
during the campaign session.

56
Change idea 7: Daily monitoring of the schedule
The SBFR task force prepared a dashboard for daily monitoring. It increased
the elective surgery schedule by 50% from the previous schedule. The
scheduled communication format was sent to the operating room before
3:00 PM, which helps check operation theater readiness, such as equipment,
supplies, and anesthesia medications. Biomedical workers also performed
preventive and curative maintenance daily. The availability of drapes was
monitored.

Measurements for improvement

Measures chosen to assess the effect of the changes implemented included
outcome measures, process measures, and balancing measures.

Outcome measures: % of elective surgery performed /week

Process measurement
– The number of days the first incision time before 8:00 AM started
– # Of days all essential supplies and drugs are available in the OR,
including drape/day/guided by equipment checklist filled before
surgery day in the OR, and the availability of drapes is monitored
daily by the SBFR task force
– Mean duration of time turnaround time between cases
– Average Pre-anesthesia evaluation for scheduled cases done/day
– # Nursing Pre-elective evaluation done prior a day before surgery
guided by a checklist
– # Days schedule communication format to inform OR timely before
3:00 PM
– The number of days of elective surgery scheduled increased from the
previous one by 50%
– Monitor the Number of table productivity/ and major surgeries per
surgeon/day
– Number of days with adequate availability of drapes per schedule
monitored daily

Method of data collections

The project's success can be attributed to continuous assessment and
monitoring through Quality improvement team meetings, leadership follow-
up, regular data collection, and quality checks, which the SBFR task force
team ensured.

57
Method of data analysis
Microsoft Excel was used for data analysis. A run chart was used to assess
the process and outcome improvement from the baseline median to show
above the median and study the impact of changes. The SBFR team
monitored daily data collection and quality checks for system stability.

Results

Figure 1: Major Elective performance in Metu Karl Comprehensive

Specialized

Benefit of the project on the health system

The impact of the change in our intervention increased our elective surgery
productivity. It dramatically reduced the surgical backlog list from 201 to
20 patients, which resulted in increased service taker satisfaction with the
service and increased healthcare provider satisfaction due to
clients/patients being prevented from further complications due to the
advancement of the disease. The health organization also benefited
/increased internal revenue collection from surgery procedures done fee.

Challenges
Acknowledging our challenges, notably supply chain disruptions and staff
turnovers is important. Managing ambitious community expectations can
be a delicate process. Furthermore, collecting, analyzing, and interpreting
data for decision-making can be an overwhelming task, especially with the
introduction of new data-capturing tools and dashboards.

58
Lesson for the others
The following lessons will guide other hospitals toward improving elective
surgery performance and overall healthcare delivery.

Holistic Approach: Improving surgical performance is not just about

clinical care but also involves efficient processes, supplies, medications,
leadership, and overall system redesign.

Data-Driven Decision-Making: Using a data capturing and analysis

dashboard to track performance metrics highlights the value of data-driven
decision-making. It allows for real-time tracking and management, leading
to more informed and effective decisions.

Continuous Improvement: Seeking guidance from improvement

science guru’s is a cornerstone in guiding the team along the right pathway
to the final destiny and beyond. Regular monitoring, feedback, and
adjustments are necessary for continuous improvement and sustainability.

Staff Engagement: Everyone plays a crucial role in successfully

implementing changes.

Community Involvement: Engaging the community is equally

important. Their understanding and support can significantly contribute
to the success of the interventions.

59
 Improve the percentage of cervical cancer screening of women
living with HIV, Adama Hospital Medical College
Authors: Bekana Lemessa1, Beshir Abdella1, Asiya jilan1, Tsegaye Beyene1,Wassei Gebi1,
Mubarek Hamdi1, Seyifedin Kesim1 ,Fikadu1, Hilina 2, Debela3
Affiliation:1Adama Hospital Medical College, 2 Oromia Health Bureau, 3ICAP

Background
Globally, cervical cancer is the fourth most common cancer in women, with
around 660,000 new cases in 2022GC. In the same year, about 94% of the
350,000 deaths caused by cervical cancer occurred in low- and middle-
income countries. The study shows that the prevalence of Precancerous
Cervical Lesions among HIV-infected women in Africa ranges between 4.4
and 42.4%. In Ethiopia, the various prevalences of Precancerous Cervical
Lesions among HIV-infected women were reported at 22.1% in southern
Ethiopia, 20.2% in the Northwest, and 9.9% in Amhara Regional State. Lack
of timely identification and treatment of pre-cervical cancer lesions leads to
high maternal morbidity and mortality due to invasive cervical cancer.
Baseline data collection was conducted using the digital system and
registration logbook. After implementing selected interventions based on the
matrix, cervical cancer screening orientation, strength offering and health
education, system monitoring and feedback, and line list from the database,
using phone calls, cervical screening for WLWHIV increased to 76%.

The obstetrics and gynecology department, ART units, and quality

department participated in the project. Participants were women living with
HIV and eligible for cervical screening aged 15-49 and sexually active were
included on this project. Cervical screening among these people is affected
due to poor screening offering systems, lack of awareness, lack of privacy,
and staff commitment.

Aim
The study aimed to increase the percentage of cervical cancer screening of
WLWHIV from 19% to 90% from Megabit 21, 2014 to Meskerem 20, 2015
EC.

Root Cause Analysis

Fish-bone analysis and brainstorming: Midwifery, ART providers, case
managers, mother supporter groups, and FGD clients were used to identify

60
the cause. The result was disseminated to the department and presented to
service providers and clients.

Figure 1: Root cause analysis to increase percentage cervical cancer

screening among WLWHIV at AHMC

Change Ideas prioritized for test

From the suggested multiple intervention-prioritizing matrices, the
following have been used: baseline assessment was conducted and presented
its findings to staff to show the gap, supervision at ART provider service units
to strengthen screening offerings through cervical cancer screening,
counseling, and documentation to identify eligible women. Offering registers
in service provision areas for proper documentation is required. Providing
orientation to staff on cervical cancer screening, creating and displaying
daily and weekly performance on telegram page, and giving feedback and
motivation for best performer staff. Strengthen health education to increase
client awareness and clarify rumors about screening procedures. Providing
training for additional staff on screening and assigning at screening OPD.
Finally, line listing was conducted from a database, and phone calls were
made to eligible women.

61
Figure 2: Show driven diagram to increase the percentage of cervical
cancer screening among WLWHIV at AHMC
Measurement
The data clerk and the quality officer collected and analyzed data weekly.
Table 1: Measurement to increase the percentage of cervical cancer screening,
AHMC, 2015E.C
Measurement Indicators Numerator Denominator Source
Outcome %WLWHIV #WLWHIV of # client eligible Registration
measure cervical screening client screened /visit
% Staff oriented # staff oriented Expected staff to Attendance
be oriented
Process % Heath # of ART visit HE # ART visit Participant
measure education given /week list
provided
% Screening # client get # ART visit Registration
offering screening offering /week

The HTS Coordinator continuously followed up on screening offerings and

documentation with the service providers. A QI meeting was held to evaluate
the PDSA cycle change and discuss staff performance, which was displayed
on the telegram page. Finally, we displayed the trend of our outcome and
process indicators on the run chart.

62
Results
Based on our project, the percentage of cervical screening was increased
from 19% to 76% by implementing selected change interventions. Providers
were motivated and compassionate to offer and give screenings. Clients’
interest in screening was changed, and there was no fear of the procedure.

Figure 3: Run chart to increase the percentage of cervical cancer among

WLWHIV at AHMC

Lesson Learnt
Fears of screening procedures due to a lack of awareness and rumors in the
community make counseling difficult, and they refuse the screening link
when offered to them. They also need privacy, confidentiality, and nearby
services. This type of test also increased the participants' interest and
comfort during the screening procedure. This is true for self-administered
tests like HPV DedNA tests.

Conclusion
Mortality and morbidity of cervical cancer on WLWHIV were decreased
by access to effective screening services that facilitate early detection and
treatment of cervical cancer lesions. Healthcare providers should offer
cervical screening and increase clients' awareness through continuous
health education and counseling.

63
 Improve Utilization of Immediate Kangaroo Mother Care at
Neonatal Intensive Care Unit, Tulu Bollo General Hospital,
Oromia, Ethiopia
Authors: Teka Degefa1, Dereje Moti1, Tujo Dechasa1, Engida Kabeta1, Tadela Efa1,
Chaltu Meskelu1 ,Alemtsehay Debela1, Olana Jeldu1, Teshome Oljira2
Authors affiliation: 1Tulu Bolo General Hospital, 2IHI

Abstract
Background: The Ministry of Health of Ethiopia has included KMC as
one of the neonatal survival interventions in its successive child survival
strategies. The Health Sector Transformation Plan II (HSP-II) aims to
increase KMC utilization to at least 70% of eligible newborns by 2025.
Despite the intervention's inclusion in the national strategies since 2005,
the progress made in implementing the interventions and increasing the
utilization of quality KMC could have been more impressive. KMC
implementation was mainly limited to referral hospitals.

Method: A clinical audit was done to identify gaps in implementing

immediate kangaroo mother care. A quality improvement project was
developed using a model-for-improvement framework to identify root
causes, generate change ideas, test interventions, and study the results.

Interventions: Different interventions were made based on the

identified gaps in the quality project on implementing immediate kangaroo
mother care.

Result: Implementation of immediate kangaroo mother care improved

from the baseline median. QI team meetings were performed bi-weekly
from a baseline median of 52% to 75%. The percentage of clinical audits
improved from 60% to 100%. The percentage of routine KMC counseling
has increased from 0 to 50%. Overall, the implementation of immediate
KMC improved from a baseline medium of 22.5% to 85%.

Conclusion: Using the science of quality improvement, the utilization of

immediate KMC can be increased.

Keywords: Kangaroo Mother Care, Utilization, Neonatal Intensive Care

Unit, Tulu Bollo General Hospital

64
Introduction
Newborn mortality continues to be the leading cause of under-5 deaths
globally and accounted for 47% of all these deaths in 2021. Of these deaths,
preterm-related complications accounted for 34% of under-5 deaths.
Preterm and low birth weight (LBW) infants have a 15 times higher risk of
death than those born term and appropriate for gestational age. In
Ethiopia, neonatal mortality is unacceptably high, with 33 deaths per 1,000
live births. Based on the 2019 Ethiopia Mini-Demographic and Health
Survey, preterm-related complications are among the leading causes of
mortality. Several evidence-based interventions are known to improve
survival among preterm or LBW infants. Kangaroo mother care (KMC) is
one of the effective interventions that play a significant role in reducing
mortality and morbidity, thus improving the survival of preterm and LBW
infants. Based on the new evidence, it is estimated that about 150,000
neonatal lives could be saved every year globally. For Ethiopia, this
translates to saving 20,000 neonatal lives each year. Furthermore, a
community-initiated KMC in low-birth-weight infants (2,000-2,500g)
reduced mortality by 30% at the 28th and 180th days of life.

There needs to be more technical and implementation guidance for

providers and program managers to establish KMC as a safe and effective
method for LBW babies at all levels of care, including the community level.
Studies on KMC practice and actual visits to KMC sites at different levels
of the healthcare system in Ethiopia found low levels of appropriate KMC
initiation, inadequate infrastructure and staffing, poor record keeping,
poor data quality, and poor survival among LBW babies. KMC is
recommended for routine care of all preterm and/or LBW newborns. KMC
can be initiated in facilities or at home and should be given 8-24 hours daily
(as many hours as possible). KMC should be initiated as soon as possible
after birth for both stable and unstable preterm and or LBW neonates. At
facilities, immediate KMC should be initiated before the baby is clinically
stable unless the baby is unable to breathe spontaneously after
resuscitation, is in shock, or requires mechanical ventilation. Immediately,
KMC can be provided at home for babies with no danger signs. Mothers
should provide skin-to-skin care (SSC); if the mother is unavailable, fathers
and other family members can also provide skin-to-skin care. Tulu Bolo

65
General Hospital provided new WHO KMC guidelines and training for the
staff to implement immediate Kangaroo Mother Care.

Methods
The quality improvement team used a model for improvement to increase
the utilization of immediate KMC following the steps mentioned below. A
clinical audit was done to assess the implementation of immediate KMC
and identify gaps. The utilization of Immediate Kangaroo Mother Care
percentage median was 22.5% from April 1, 2015, to June 30, 2015. A
standardized tool assesses staff’s knowledge, attitude, practice, essential
medical equipment, gowns and shoes, television, drugs, standard
treatment guidelines, and protocol.

Prioritization of the identified quality of care gaps was done.

Major problems identified and prioritized. Low utilization of immediate
KMC is the leading priority.
– Baseline data was collected for the prioritized problems
– Baseline data collection tool developed to assess the utilization of
immediate Kangaroo Mother Care
– Detail problem analysis done
– Model for improvement used to improve utilization of immediate
Kangaroo Mother Care
– Detail problem analysis was done for the identified problems
– Change ideas were generated, and interventions tested
– The outcome measure is monitored over time using a run chart

Problem statement
The result of the clinical audit conducted from April 1, 2015, to June 30,
2015, reveals that successful Immediate Kangaroo Mother Care is 22.5%
for eligible neonates, which contributes to early neonatal death in our
hospital.

Aim statement
We, the Tulu Bollo General Hospital QU team, aim to improve the success
rate of immediate KMC for eligible neonates from a baseline of 22.5% to
80% from July 1, 2015, to September 30, 2016.

66
Root causes analysis
The major causes identified for poor KMC application and adherence at
Tulu Bolo General Hospital were:
- Lack of routine KMC counseling
- No on-job training for staff
- Poor application of recommended guidelines
- Lack of involvement of senior physicians in improvement process
- Poor clinical audit
- Absence of some IPC materials like gowns for mothers and
television for video-assisted health education

Table 1: Outcome and process measures

67
Result

Figure 1: Showing improvement in KMC utilization, Tulu Bolo GH

Implementation of immediate kangaroo mother care improved from the
baseline median. QI team meetings were performed bi-weekly from a
baseline median of 52% to 75%. The percentage of clinical audits improved
from 60% to 100%. The percentage of routine KMC counseling has increased
from 0 to 50%. Overall, the implementation of immediate KMC improved
from a baseline medium of 22.5% to 85%.
Lesson learnt
By providing gowns and relevant material for the mother and regular
counseling through video assistance, successful KMC utilization can be
increased. On the other hand, the involvement of senior
clinicians/pediatricians in the quality improvement work is crucial for the
project's success story.

Conclusion
– Implementing prolonged KMC remains a challenge
– Education, counseling, and video demonstration improved the
utilization of successful KMC
– The QI initiative needs to be sustained and further strengthened to
improve the utilization of successful KMC

68
 Improving completeness of nursing process at NICU ward,
Bisidimo General Hospital, Oromia
Authors: Ahmedzekuwan Adem1, Adisu Tilahun1, Obse Asfaw1, Ayman Musa1, Tesfaye
Chimdesa1, Usmael Hassen1, Asnake Belete1
Authors Affiliation: Bisidimo General Hospital, Oromia
Abstract
Introduction: The nursing process leads to improved quality of care and
stimulates the construction of theoretical and scientific knowledge based on
the best clinical practice.
Objective: This QI project aimed to improve the completeness of the
nursing process at the NICU ward of Bisidimo General Hospital from 17.9%
to 60% from June 2015 to December 2016 E.C.
Methods: To improve the completeness of the nursing process at the NICU
ward, the Bisidimo Hospital NICU department sub-team used the model for
improvement model (MFI). The PDSA (Plan-Do-Study-Act) cycle was used
to test the change ideas. We used Fishbone and Driver diagram techniques
to identify and address the root causes. The key change ideas implemented
consisted of onsite training for all NICU Nurses, conducting internal
supportive supervision, and Avail nursing process format.
Result: At the end of the six-month intervention period, with the stepwise
introduction of change ideas, the completeness of the nursing process in
Bisidimo General Hospital's NICU ward increased by 48.4% from the
baseline of 17.9% to 66.3%, which is greater than our stated aim.
Conclusion: Completeness of the nursing process is about more than just
the quality of the nursing care plan. It is about saving lives by improving the
overall quality of care. This project benefited the patient by reducing
neonatal mortality and the risk of nosocomial infection by reducing the
length of stay. As the patient’s length of stay was reduced by our project, the
efficiency of the hospital & hospital service was improved. Thus, good
documentation of nursing care plans can save the lives of many patients &
improve our efficiency.

Keywords: Nursing, NICU ward, Bisidimo General Hospital, Oromia

69
Introduction
The nursing process is widely accepted and has been suggested as a scientific
method to guide procedures and qualify nursing care. More recently, the
process has been defined as a systematic and dynamic way to deliver nursing
care, operating through five interrelated steps: assessment, diagnosis,
planning, implementation, and evaluation [1]. According to current
American and Canadian practice standards, nursing practice demands the
efficient use of the nursing process and professional participation in
activities that contribute to the permanent development of knowledge about
this methodology [2].
The nursing process should be established in care practice at all healthcare
institutions, hospitals, and the community [3, 4]. Despite their knowledge of
the nursing care process, certain factors limited the ability of nurses to
implement it in their daily practice, including lack of time, high patient
volume, and high patient turnover [5]. Despite these difficulties, the daily
application of the nursing care process is characterized by the scientific
background of the professionals involved since it requires knowledge and
provides individualized human assistance [6, 7]. However, failures were
shown among the nursing diagnoses in the patient's history and the
implementation of nursing prescriptions without recording the evaluation of
the expected results [8].
Effective nursing process implementation leads to improved quality of care
and stimulates the construction of theoretical and scientific knowledge based
on the best clinical practice. Aiming to collect information to improve the
nursing care currently provided, a quality improvement project on the
nursing process at Bisidimo General Hospital was performed to enhance the
progress of nursing process completeness in the NICU ward of Bisidimo
General Hospital.
Context
Bisidimo General Hospital was established in 1958 by the German Leprosy
&TB Relief Association (GLRA) and the Ministry of Health and Catholic
Mission. It is found in Oromia Region, East Haraghe Zone, Babile Woreda.
It is 23 Km from Harar town & 549 Km from the capital city of Ethiopia,
Addis Ababa. It is a General Hospital with more than 120 beds & it provides
services for more than 1,496,345 populations from more than eight districts
in the area. To reduce morbidity, mortality & disability and improve the

70
health status of the people in the catchment area by providing quality
preventive, curative, and rehabilitative health services.
Statement of Problem
The 2015EFY 4th quarter audit report of Bisidimo General Hospital shows
that the nursing process completeness at the NICU ward was only 17.9%.
This resulted in poor quality of nursing care, missed interventions, delayed
treatment, and affected patient outcomes.
Aim Statement
Bisidimo General Hospital NICU Department QIT aims to improve the
completeness of the nursing process from 17.9% to 60% from June 2015 to
December 2016 E.C.
Assessment of the Problem and Analysis of Its Causes
The clinical audit identified and assessed the problem. After the problem was
identified and its magnitude measured, staff identified the cause through
FGD, and a Fishbone diagram was used to identify the main cause and basic
cause. The run chart was used to analyze data collected over time. Plan-Do-
Study-Act (PDSA) cycles were used to test the change ideas.
Each process was documented on the data collection tool for routine QI team
meetings conducted every month and presented to all staff participating in
the project and the corrective actions taken. The progress was monitored
using data collection and plotted against run charts over time.

Figure 1. Fishbone Diagram on root cause for nursing process completeness

at NICU ward at Bisidimo General Hospital

71
Intervention
After prioritizing all the alternative interventions, we selected the following
interventions. These interventions include the following:
– Senior nurses qualified in the nursing care plan, and the quality unit
head provided onsite training for all NICU nurses.
– Regular supportive supervision was conducted bi-weekly by senior
nurses qualified for the nursing care plan.
– Avail the nursing process format by adding 5% from the previous
six-month admission rate.
– A regular performance report review was conducted on the nursing
process's completeness.

Measure For Improvement

Outcome measure:
Percentage of completeness of nursing process.
Process measures:
– % of trained NICU ward nurses on nursing care plans
– % of nursing care plan format availed
– % of supportive supervision conducted
– % performance report review on nursing process conducted
The run chart was used to analyze data collected over time. Plan-Do-Study-
Act (PDSA) cycles were used to test the change ideas. Each process was
documented using the data collection tool for routine QI team meetings and
the corrective actions taken. Progress was monitored over time using data
collection and plotting. To assess the overall completeness of the nursing
care process, the proportion of patient cards with complete documentation
of the nursing care process forms was calculated for both baseline
assessment and post-intervention periods. To assess the completeness and
accuracy of the data, the supervisor checked the collected data by data
collectors at the end of each data collection day.
Results
At the end of the six-month intervention period, with the stepwise
introduction of change ideas, the completeness of the nursing process in
Bisidimo General Hospital's NICU ward increased by 48.4% from the
baseline of 17.9% to 66.3%, which is greater than our stated aim.

72
 – All the nurses assigned to the NICU ward were trained on the
nursing care plan (100%).
– 100% of the nursing care plan format was bought as requested.
– Supportive supervision was conducted every two weeks for 24
consecutive weeks (100%).
– A performance report review of the nursing process was conducted
for 5 months (100%).
– Completeness of inpatient medical records was increased to 74%

Figure 2. The run chart on improvement in the completeness of the nursing

process at the NICU ward of Bisidimo General Hospital

Lesson learnt
Based on the interventions you described, here are the key lessons learned:
– Regularly reviewing health workers’ performance was effective. It
allowed for timely feedback and adjustments.
– Having senior nurses qualified in NCP conduct regular supportive
supervision helped maintain quality standards.
– Hospital leaders providing the necessary formats and resources
facilitated the implementation process.
– Regular capacity building for staff contributed to successful
intervention implementation.
– Iterative Testing: Using PDSA cycles for iterative testing allowed for
efficient adjustments and improvements.
– Introducing organized changes can significantly enhance the quality
of nursing processes.

73
Message for Others
The completeness of the nursing process is not only about the quality of the
nursing care plan. It is about saving lives by improving the overall quality of
care. This project benefited the patient by reducing neonatal mortality and
the risk of nosocomial infection by reducing the length of stay. As the length
of stay for patients was reduced by our project, the efficiency of the hospital
and hospital service improved. Thus, good documentation of nursing care
plans can save the lives of many patients and improve our efficiency.

References
1. Doenges, ME., Moor house, MF, Murr, AC., 2008 Nurses pocket
guide diagnosis, prioritized interventions, and rationales. F. A. Davis
Company.
2. Zewdu S. Determinants towards Implementation of Nursing Process.
American Journal of Nursing Science. April 14, 2015; 4(3):45-49.
3. Hale CA, Thomas LH, Bond S, Todd C. The nursing record as a
research tool to identify nursing interventions. 1997. J Clin Nurs
1997; 6:207-14.
4. FMOH. Nursing care practice standards, version 2. Addis Ababa,
Ethiopia Dec, 2011.
5. Fadia A, Abdelkader W. Factors Affecting Implementation of
Nursing Process: Nurses' Perspective. IOSR Journal of Nursing and
Health Science. 2017; 6(3):82.
6. Zeray B, Kalayou K, Hadgu G, Dejen G and Hafte Teklay. A cross-
sectional study on nursing process implementation and associated
factors among nurses working in selected hospitals of Central and
Northwest zones, Tigray Region, Ethiopia. Open Access. 2017:1-9.
7. FMOH. Ethiopian Hospital Service Transformation Guidelines.
Volume1. Chapter7. Nursing/Midwifery Care Standards. September
2016.
8. Shewangizaw Z, Mersha A. Determinants towards Implementation of
Nursing Process. American Journal of Nursing Science. 2015;
4(3):45–49.
9. Sabona EA. The perception of, and use of, the nursing process in four
African Countries. Afr J Nurs Midwifery. 2005; 6(1):67–77.

74
 Improving maternal and newborn pre-referral
communication and management
Authors: Belachew Niguse1, Mekdes Desalegn1, Olyad Bilbila2, Gemechu Tafese2,
Tezeru Adeba2, Dereje Asefa2, Tikesa Legese1
Affiliation: 1Biyo Health center, 2Lume Woreda Health Office

Abstract
Background: Effective pre-referral communication is essential for a
functional referral system. It ensures seamless coordination between
different levels of care and timely and smooth transition of
patients/clients. At the same time, proper management per standard
protocol before referral can significantly impact outcomes.
Local context: A robust referral system ensures timely and effective
management of maternal and newborn health (MNH) cases. The
absence of a network-of-care approach across multiple interconnected
levels of care hinders optimal care for critical patients, emphasizing the
urgent need for improved referral processes and seamless
communication among healthcare providers.
Methods: We utilized the Model for Improvement framework and
Plan-Do-Study-Act (PDSA) cycles. In addition, qualitative and
quantitative data analysis methods were employed to further identify
the root cause of problems and propose change ideas.
Interventions: The team tested and adapted the change ideas
targeted to improve pre-referral communication and management.
These include real-time virtual consultation with senior clinicians at
the Hospital, conducting biweekly emergency drill exercises, an
adaptation of referral forms, monthly clinical audit of referral cases
against the standard protocols, community sensitization on the
conspicuous signs of MNH complications, setting the sufficient stock
level of emergency drugs/supplies/equipment.
Results: The interventions have steadily adhered to the standard
protocol (the run chart qualifies as a rule of shift).
Conclusion: Effective communication and timely pre-referral
management are vital in ensuring safe maternal and newborn care.
Adapting the Networks of care model testing process obtained
promising results.
Keywords: Maternal, Newborn, Communication, Management

75
Introduction
Every year, approximately 303,000 mothers and 2.7 million newborn
infants die around the time of childbirth, and many more suffer from
preventable illnesses. The World Health Organization (WHO)
recognizes the importance of quality care for women and children in
addressing preventable maternal and child mortality. The referral
system plays a crucial role in ensuring that patients receive timely and
appropriate care by connecting different levels of healthcare facilities.
Sub-Saharan Africa's Primary healthcare systems have grown
substantially to expand access to appropriate facilities through a well-
functioning referral system. The referral system is critical in ensuring
efficient and effective patient management within care networks, such
as those in healthcare systems. The referral system involves the
interrelationships and coordination of patient care services from one
health facility to another. It aims to facilitate the seamless transfer of
patients based on their needs and the available resources at different
levels of care.
A study conducted in Ethiopia found that only 10% of all patients
interviewed had been formally referred to their current place of care.
Among those in the hospital population, 14% had been referred, while
among those in health centers, only 6% had been referred. This calls for
an improved referral system across facilities. Accordingly, WHO MNH
Networks of Care (NOCs) are recommended to improve the quality of
care, continuity of care, and maternal and newborn outcomes.

A network of care for maternal and newborn health is a collection of

public and/or private health facilities and health workers deliberately
interconnected to promote multidisciplinary teamwork and
collaborative learning to provide comprehensive, equitable, respectful,
person-centered care from home/community to primary through to
tertiary levels. They focus on relational elements that are key to health
system functioning and are context specific. NOCs focus on creating
intentional connections between people and services and
strengthening the functional aspects of health systems while
incorporating and emphasizing core relational aspects. They can also
strengthen referral systems, thus promoting continuity of care.

76
Context
Biyo Health Center is in the Southeast Shewa Zone, Lume Woreda. The
health center currently serves many maternal, newborn, and child
health (MNCH) clients to Lume Woreda populations and populations
from adjacent Woreda. Biyo Health Center is one of Lume-Modjo's
network of care facilities to improve pre-referral communication,
virtual consultations, and pre-referral management of maternal and
newborn referral cases.

Problem statement
The baseline assessment made from April 2022 to May 2023 through a
clinical audit of referral papers and charts reveals a gap in the pre-
referral management of obstetric and newborn cases, including poor
pre-referral communication with the receiving facilities and senior
clinicians. This leads to delayed case management and poor outcomes
(stillbirth, neonatal death, and maternal complications). This issue will
also affect our trust in the Hospital staff.

Aim statement
This study aimed to improve pre-referral communication and
management of maternal and newborn cases from the current baseline
of 0% to 95% from July 2023 to June 2024.

Methods
The project utilized the Model for Improvement framework and Plan-
Do-Study-Act (PDSA) cycles. In addition, qualitative and quantitative
data analysis methods were employed to identify the root cause of
problems further and propose ideas for change.

77
Figure 1: Cause-Effect Diagram

Interventions
The team tested and adapted the change ideas to improve pre-referral
communication, virtual consultations, and pre-referral management.
These include real-time virtual consultation with senior clinicians at
the Hospital, conducting biweekly emergency drill exercises, adapting
referral forms, conducting a monthly clinical audit of referral cases
against the standard protocols, sensitizing the community to the
conspicuous signs of MNH complications, and setting a sufficient stock
level of emergency drugs/supplies/equipment.

78
Result and effect of changes

% Adherence to pre-referral communication, virtual

consultation and management of maternal & newborn
referral cases at Biyo Health center
100% Emergen
90% cy drill
80%
70%
60%
50% Baseline data Assigned
40% focal
30% person to
20% Adaptation truck…
10% of NOC…
0%
23
3
23

24
3

23
3
23

23
3

23
23

24
r-2

-2

l-2

t-2
-2

n-

p-
b-

b-
v-
n-

n-
g-

c-
ay
ar

Ju
Ap

Oc

No
Au
Ju

De
Fe

Fe
Ja

Ja
Se
M

% Median

Figure 2: % of pre-referral communication, virtual consultation, and

management of maternal & newborn referral cases at Biyo Health Center

Conclusion
The network of care model is a promising optimization mechanism for the
existing referral system that can facilitate continuity of care throughout
pregnancy, childbirth, and the postpartum period and from the community
to tertiary levels. While envisioning the strengthening of the primary health
care unit, the NOC model will be instrumental in facilitating a smooth
transition of care and strengthening public-private partnerships.

Lessons Learned
From our implementation, we learned that virtual consultation among
Networks of care facilities and pre-referral management salvaged the lives of
maternal and neonatal patients. Furthermore, getting buy-in among
networked facilities and collaboration is key to success.

79
 Improve health literacy adequacy in non-communicable
disease clients Bako Primary Hospital
Authors: Yomiyyu Boressa, Zelalem Temesgen, Roba Dechasa, Tsehay Bekele, Teshale
Goshu, Temesgen Debissa, Bahilu Ababe, Rabira Nega
Affiliations: Bako Primary Hospital
Abstract
Background: Health literacy is the most crucial time for a client’s survival
in chronic disease. It is well established that high-quality medical care than
prescribing medication.
Aim: We, Bako Primary Hospital, aim to improve health literacy on non-
communicable diseases (DM, Hypertension, and cardiac disease) from 18%
to 60% from Sene 30/2015 to Tir 30/2016 EFY.
Methods: The quality improvement team has conducted a clinical audit on
health literacy using a standard checklist. The Model for Improvement was
applied for data collection table development, and PDSA cycles were used to
test the change ideas of the driven diagram and were monitored monthly.
The contribution of change ideas to the aim set was monitored using data
collection and plotted monthly. Tools used were a prioritization matrix,
Driver diagram, Fishbone diagram, assessment tools, PDSA, and Run chart,
which was used to draw inferences.
Interventions: Depending on gaps, the quality improvement team
prepared a checklist, orientation was given to staff, and a proposal was
prepared. Health workers provide health education twice a week. Ensuring
the availability of leaflets, posters, and mini media through daily audits,
monthly clinical audits conducted, and health workers’ performance
recognition was given.
Result: In the intervention conducted over the last seven months, health
literacy on non-communicable diseases has significantly improved from 18%
to 64%. Staff were orientated and trained for the focal person. Leaflets were
also distributed, and health education was given twice weekly by assigned
health workers.
Conclusion: Finally, after Eight months of intervention, we have seen an
improvement in health literacy on non-communicable diseases, and clients
improved information on their disease to management effectiveness from
18% to 64%
Keywords: Health Literacy, DM, Hypertension, Cardiac Disease, NCD

80
Introduction
Health literacy plays a pivotal role in healthcare utilization and health-
related lifestyle choices. This makes health literacy a pressing concern,
particularly in low-income countries like Ethiopia, which have intricate
health challenges. Prioritizing health literacy as a key research and
intervention area is essential for improving the health of individuals and
populations and achieving health-related Sustainable Development Goals in
Ethiopia (1).

Diabetes mellitus (DM) is an important public health problem causing

premature disability and death. These are mainly due to a wide spectrum of
complications, of which cardiovascular disease (CVD) and kidney disease
stand out as the leading causes of death in diabetic people worldwide.
Literacy, “people’s ability to make informed daily decisions at home, in the
community and the workplace in the use of health services," is an
enablement strategy to increase people’s control over their health, to seek
information and to assume responsibilities” (2). In this study, we aimed to
determine the association between health literacy and the development of
cardiovascular diseases (CVDs) among an older population. A significant
association between health literacy and the prevalence of CVDs and their risk
factors has been reported in other populations, including the general
population (3). Only 55% of patients with hypertension with the lowest
reading level knew that a blood pressure reading of 160/100 mmHg was
high, whereas 92% of patients with adequate health literacy skills knew this
level was above normal (4).

Ethiopia is currently suffering in terms of providing educational facilities to

its population. Most people still need access to education due to the need for
more institutions in their regions, especially in rural areas. Moreover,
despite many regions having a high enrollment rate in primary education
courses, the drop rate also tends to be significant. The reasons for this
include the uncertain security situation, such as the conflict in Tigray
(Northern Ethiopia (5).

Context
Bako Hospital is a primary Hospital that supervises five health Centers. The
management and the QI team were very interested in implementing this QI

81
 project. Moreover, the project used a local resource allocated through the
hospital management. The project was conducted by the quality team after
being linked from the Non-Communicable Disease OPD to the literacy unit,
which involved 385 clients.
Problem
Bako Primary Hospital reports for the 3rd and 4th quarters of 2015 show
poor health literacy regarding non-communicable diseases (DM,
Hypertension, and cardiac disease), only 18% among clients who had follow-
up at chronic OPD.
Aim Statement
Bako Hospital's quality improvement team aims to increase health literacy
on non-communicable diseases (DM, Hypertension, and cardiac disease)
from 18% to 60% by Sene 30/2015 to Tir 30, 2016 E.C.
Assessment of problem and analysis of its causes
The first client awareness and knowledge audit checklist were prepared
depending on last year's data reported, and patient awareness was assessed;
accordingly, an action plan was developed. Then, a quality team composed
of quality officers, medical directors, CEOs, matron OPD directors, focal
persons, and department heads was given orientation on quality
improvement projects by quality officers. The quality team analyzed the
problem and prioritized the problem using a matrix scale. Lastly, an
improvement plan for a quality improvement project was devised.

Table 1: Problem identification and prioritization Matrix (score 1-10)

Lists of problems Prioritization criteria Rank
identified
Magnitude Feasibility Importance Total
Difficulty to get patient card 5 4 4 13 3rd
Poor pain assessment and 4 4 4 12 4th
treatment
Weak health education 6 4 5 15 2nd
program and activities
Low health literacy coverage 5 6 5 16 1st
NCD clients

82
Figure 1: Fish Bone Diagram

Interventions
Over one day, the project core team and all staff received training on the
general quality of health literacy. A quality team in the department identified
gaps and prioritized them using a prioritization matrix. An aim statement
was developed, and change ideas were generated for each identified problem.
Change ideas were tested, and lessons learned were documented.

The following change ideas were generated and tested using the root cause
analysis and a driver diagram.
– Ensuring the availability of leaflets, posters, and mini media through
daily audit
– Orienting all medical doctors, nurses, and environmental health on
health literacy adequacy
– Twice per Week, health education by campaign and mini media
given
– A monthly clinical audit conducted
– Health worker’s performance recognition was given
Measurement of improvement
The quality team monitored the implementation of change ideas to improve
health literacy adequacy. After staff orientation, a schedule of health

83
 education was programmed, a Leaflet and posters were distributed, and
video health education was given on mini media (the hospital’s TV). We, the
quality unit team, then assessed their awareness and knowledge using a
checklist.

Table 2: awareness and knowledge using a checklist

Indicator Numerator Denominator
Give training % of training No of health Total health Focal Increase
on literacy given worker training worker planned person patient
given for training letter efficiency(+ve)
Budget
expense(-ve)
Give feedback Percentage of No of No of feedback Once Having many
and feedback and feedback and and recognition skilled
recognition recognition recognition planned manpower
given (+ve) and Time
wastage (-ve)
Start client Percentage of No of client number of client Register Increase client
linkage to client linked links to literacy planned for knowledge (+)
literacy clinic linkage and Time
wastage (-ve)
Give health Percentage of No of clients No of clients Register Client
education by clients get gets health planned for knowledge
campaign and health education health education increase (+ve)
TV education and
Time wastage(-
ve)
Avail the % of poster and No of poster No of posters Storeroo Improvement
poster and leaflet avails and leaflet and leaflets m quality (+)
leaflet avails planned avails Budget
expense(-ve)
Proper % of health Number of Number of Register
recording literacy health literacy health literacy
document coverage coverage coverage planned

Measurement
The team used process and outcome measurements to measure the
improvement of health literacy adequacy.
Outcome measure
- percentage of clients get health literacy received Process
measure
– Percentage of clients get health education by campaign and
mini media
– Proportion of regular monitoring done

84
 – Percentage of staff got orientation and onsite training on
improving health literacy
– Percentage of feedback and follow-up given
– Balancing measure: percentage of clients got health literacy
and clients linked to NCD OPD
Results
An audit was conducted on health literacy for half of 2015 EFY, and literacy
coverage on non-communicable diseases was only 18%. The hospital's
health literacy adequacy of seven months increased from 18% to 64 % (see
fig). The monitoring run chart showed significant improvement, which is
in line with the run chart rule 1(Shift) and rule 2(trend), which vividly
indicated that the change observed was due to introduced change ideas by
the project. These change ideas include orientation for staff, assigning all
staff for health education by schedule, distributing lessons prepared by
local language on NCD, regular follow-up, and giving feedback and
recognition for staff performance. QI team aimed to improve health
literacy adequacy by 18% to 60% within seven months. After intervention
using the PDSA cycle, health literacy was improved from 18% to 64% from
Sene to Tir /30/2016 EFY.

70

60
Post Intervention Assessment

ic
50
Baseline Intervention L Clin by ia
n H n d
40 ib utio age to atio i me
r c
dis
t link u
ed & m
in
aflet lient h
30 Le C al t le
He hedu Averag
20 ive
n sc
n g e
io
tat
10 rien aff median
O st
for
0
ab 15
15

M ase 5
5

km 16

16
Hi 016

16
6
aiz 15

nb 15

Se 015
Ha 201

01
ke 201
Ye r 20

Na 20

20
20

20

Ta r 20
M t2

s2
a2

t2
le

tir
ot

ne
it
Ti

da

sa
ti

re
ka

ha
h
eg

Ti
Gi

es

Figure 2: Run chart on health literacy from Sene 30, 2015, to Tir 30,
2016

85
Conclusion
The interventions significantly improved the health literacy of NCDs in
this catchment area. Onsite training and orientation for staff and monthly
feedback on the health workers' performance improved health literacy.
Increased client awareness, decreased disease complications, and reduced
the burden on the hospital. Regular clinical audits and health education
through mini media and campaigns continue as scheduled.

Lessons learned
In implementing the project, the team of hospitals developed an
improvement plan. Regular monitoring was developed with scheduled
time after orientation given for all health providers to understand what
needed to be done, especially on regular health education and leaflet
distribution. Written feedback was often given depending on workers'
performance. Conversely, the project impacted the clients with a
significant change in literacy. From this, we learned that the sustainability
of change using an improvement plan and regular monitoring greatly
affects patients' health literacy adequacy.

Messages for others

During the seven months of the quality improvement project, we
quality teams gained experience by having common goals and
proposing change ideas for identified gaps. Finally, we significantly
improved the clients’ health literacy adequacy. Therefore, regular
monitoring, client linkage to the literacy unit, and a structured health
education program greatly improved literacy.
Reference
1. Adamu Amanu A, Ameyu Godesso (2023), Health Literacy In Ethiopia:
Evidence Synthesis And Implications
2. Maria Vieira (2021) - Family Medicine & Primary Care. Health Literacy
And Cardiovascular Complications In People With Type 2 Diabetes.
3. Nobutaka Hirooka (2023), Association of Health Literacy With The
Prevalence Of Cardiovascular Diseases And Their Risk Factors Among
Older Japanese Health Management Specialists
4. Richard Safeer (2006), The Impact of Health Literacy On
Cardiovascular Disease
5. MOE (2023), Education Statistics for Ethiopia [100% Updated]

86
 Reducing Perinatal Mortality Rate in Robe Didea General
Hospital: A Quality Improvement Project
Authors: Endale Gebre, Sharew Teshome, Bottu Adamu, Fikadu Girma, Tamene
Mersha, Belay Tadesse
Affiliation: Robe Didea General Hospital

Abstract
Background: Perinatal mortality rate is a crucial indicator of
obstetric care, representing the sum of institutional early neonatal
death rate and stillbirth rate in the hospital. In Ethiopia, 33 per 1000
deliveries perinatal mortality was recorded in 2016(EDHS 2016) and
30 per 1,000 live births in 2019 (EDHS 2019), while the perinatal
mortality rate of Robe Didea General Hospital is still higher than that
of the national prevalence figuring 74.5 per 1000 live births as of
DHIS2 report of 2013 EFY. (DHIS report available at https://Dhis2.moh.gov.et)

Problem Statement: The perinatal mortality rate of Robe Didea

General Hospital was found to be 74.5 per 1000 in 2013 EFY (July 2012
to June 2013 EFY) as of the DHIS2 report, which was higher than the
national burden of 30 per 1,000 live births. This could result in low
patient flow for delivery services and psychosocial problems for the
families.

Methods: We have used a Model for improvement to propose

interventions and a Run chart to indicate results.

Interventions: Outreach obstetric ultrasound Service, Peer-to-Peer

Mentorship at Nearby Health centers, strengthening Early Partograph
utilization, Infection prevention practices, and Health education were
major interventions undertaken in this project.

Results: The results of interventions were measured /indicated by a

Run chart based on the rules of the run chart (Shift), which revealed
that this project had improved the outcome of perinatal service. The
Perinatal Mortality rate has been reduced from 74.5 to 41/1000 median
line.

Keywords: Perinatal, Mortality, Rate, Robe Didea, Quality,

Improvement

87
Introduction
The perinatal mortality rate is a crucial indicator of obstetric care. It
represents the sum of the institutional early neonatal death rate and
stillbirth rate in the hospital. The institutional early neonatal death rate
mainly defines the quality of obstetric care in the facility in the
Ethiopian context (HMIS indicator reference 2021).

Though causes of neonatal mortality are not well documented in

Ethiopia, reports from studies identified sepsis, asphyxia, birth injury,
tetanus, preterm birth, congenital malformations, and “unknown
causes” as reasons for neonatal mortality (Orsido et al., 2019) and the
National HMIS inpatient morbidity and mortality report identifies the
three main causes as prematurity, birth asphyxia, and neonatal sepsis.

Stillbirth is the birth of a baby with no signs of life at or after 28 weeks

of gestation. Stillbirth includes Intrauterine Fetal Death (IUFD) (HMIS
indicator reference 2021). Though the stillbirth rate in the country has
declined over the past ten years (Tesema et al. 2020), Ethiopia ranked
7th among the top 10 countries with a high stillbirth rate, contributing
to 65% of the global stillbirth rate (National QI Bulletin 2021).

The progress of Ethiopia in preventing childhood deaths has been less

successful in the prevention of neonatal mortality. In addition,
equivalent numbers of stillbirths occur, representing a “silent
epidemic.” Close to half of the stillbirths occur during the process of
labor and delivery. More than 80% of all newborn deaths are caused by
preventable and treatable conditions, while Congenital anomalies are
also becoming notable contributors to neonatal mortality, morbidity,
and disability. Generally, half of neonatal deaths occur on the first day
of life, and three-quarters of all neonatal deaths occur within the first
week of life. Despite increasing accessibility of services, sub-optimal
quality of care, low child health care seeking behavior of communities,
low coverage of Kangaroo mother care (KMC) services, and shortage of
essential health commodities and equipment at service delivery points
remain key challenges contributing to high rates of neonatal mortality
(HSTP II). In Ethiopia, 33 per 1000 deliveries perinatal mortality was
recorded in 2016(EDHS 2016) and 30 per 1,000 live births in 2019
(EDHS 2019), while the perinatal mortality rate of Robe Didea General

88
Hospital is still higher than that of the national prevalence figuring 74.5
per 1000 live births as of DHIS2 report of 2013 EFY (DHIS report
available at https://Dhis2.moh.gov.et). The MNCH QI team of the
hospital has developed this project to reduce this alarming figure by
involving all stakeholders and implementing change concepts and
ideas.

Context of the Project

This project was undertaken in Robe Didea General Hospital and nine
(9) health centers found in Robe Woreda and neighboring woredas
(Sude and Ticho Woreda) by health professionals from the hospital and
respective health centers. Robe Didea General Hospital was established
at 225 KM SE of Addis and 98 KM E of Zonal Center Asella in Robe
Woreda in 2002 E.C with primary level. It was the only hospital serving
about a million populations from Seven (7) woreda. Currently, it has
the level of a general hospital and serves about 606,086 populations
from three woredas.
The hospital has 1 Gyn/obs specialist, 1 Integrated emergency surgery
officer (IESO), 14 Midwives, 4 Neonatal nurses, 2 medical Radiation
technologists, and about six cleaners serving Delivery, the Obstetric
ward, and the NICU. The hospital provides broad services, including
about 2000 attended deliveries annually.
Problem Statement
As of the DHIS 2 report, Robe Didea General Hospital's perinatal
mortality rate was 74.5 per 1,000 in 2013 EFY (July 2012 to June 2013),
which was higher than the national rate of 30 per 1,000 live births; this
could result in low patient flow for delivery services and a series of
psychosocial problems for the family.
Aim Statement
The Robe Didea General Hospital MNCH QI team aims to reduce
perinatal mortality from 74.5 in July 2013 to 30 Per 1000 By the End
of June 2015 E.C.
The following are root causes of the problem
- Low data utilization
- Poor IPPS practice

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 - Shortage of trained clinical staff
- Absence of death audit
- Incomplete referral form
- Inappropriate internal referral system
- Shortage of rooms for KMC
- Lack of CPAP, heater, radiant warmers, and incubator
Assessment of Problem and Analysis of Causes
The problem (high perinatal mortality rate) was identified by retrospective
analysis of the routine HMIS report of 2013 E.C., and stakeholders used a
Fishbone diagram to identify the root causes of this problem.
Interventions
Outreach obstetric ultrasound Service
The QI team communicated with the Gyn/OBS team to conduct outreach
obstetric ultrasound at nearby health centers. The gynecologist agreed after
discussing the issue with the QI team. Then, the midwife communicated
with the health center's PHCU director and MCH focal to appoint pregnant
mothers to health centers for ANC and other services, saying they would be
seen by a specialist from the hospital that day. The Gynecologists, Midwives,
and drivers moved from the hospital to the health center with a portable
ultrasound machine and served more than 50 pregnant mothers on the first
day. Then, this activity was expanded to eight other health centers with
slight team modification (Gynecologist replaced by Medical Radiology
Technologist) to not compromise other hospital services.
Peer to Peer Mentorship at Nearby Health centers
Senior midwives of the hospital discussed the issue of stillbirth happening
to pregnant mothers coming by referral from six health centers. They
divided these health centers to support comprehensive clinical midwifery
mentorship. Then, each midwife from the hospital moved to their respective
health center and stayed there for five days at the health center every month,
and finally, they graduated at least one midwife from each health center.
Early Partograph Utilization Strengthening
A quick review of proper partograph utilization at the hospital was
conducted by chart review using the partograph utilization bundle. It was
on the spot by the improvement advisor of IHI during coaching. The gap in
partograph utilization was discussed with the hospital delivery head and

90
 other midwives available. A consensus was reached to utilize it properly,
and the available midwives took responsibility for sensitizing their
colleagues, which they did within a week. Finally, all Midwives started using
partographs appropriately for every labor.
Infection prevention practices
As sepsis was one cause of Neonatal mortality in our hospital, the team
agreed on the importance of infection prevention activities such as weekly
fumigation of the labor ward, Establishment of a hand hygiene facility at the
NICU, Restriction of NICU access, and utilization of mothers' gowns.
Health education about harmful traditional practice
Uvulectomy was also another cause of infection for a considerable number
of neonates admitted to NICU, and health education was started for
mothers at ANC, PNC, and NICU.
Table 1: Measurements for Perinatal Mortality Rate Reduction
Family of Indicator Name Numerator Denominator
measure
Outcome Perinatal mortality rate Institutional early neonatal Total Live birth
measure death
Still birth (IUFD >28 weeks Skilled Birth attended
GA) in the hospital
Process Proportion of days water Number of days water and 7
Measure and soap available at soap available
NICU gate
Availability of restriction N/A N/A
signals at NIU entry
Proportion of mothers Number of mothers Total number of
wearing gown in NICU attending neonate who are mothers attending
using mothers’ gown Neonate
Proportion of Catchment Number of Catchment 9
Health centers received Health centers received
Outreach ultrasound service Outreach ultrasound service
Proportion of High-risk Number of High-risk Total number of
mothers identified by mothers identified by pregnant mothers
outreach ultrasound outreach ultrasound service Received outreach
service in Catchment in Catchment health centers ultrasound service
health centers
Percentage of laboring Number of laboring Total Sampled
mothers appropriately mothers appropriately mothers’ chart
followed by Partograph followed by Partograph
Proportion of births Number of births followed Total Sampled
followed by safe birth by safe birth checklist mothers’ chart
checklist
Proportion of peer-to-peer Number of peer-to-peer Total number of
mentorship session mentorship session Planned peers to peer
conducted conducted mentorship
Proportion of mentees Number of mentees scored Total mentee
scored pass mark pass mark

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Data collection
Data collection tools include observation checklists, clinical audits,
bundle adherence, and personnel assessment checklists. And chart
review tools have been utilized.
Result
Perinatal Mortality rate
The result of interventions was measured /indicated by a run chart
based on the run chart (Sift) rules, which revealed that this project had
improved the outcome of the hospital's perinatal service. Twenty -
sessions of Outreach ultrasound service provided for 1207 pregnant
mothers in nine health centers have identified a total of 180 high-risk
mothers and linked them to hospitals for further follow-up, of which
4.4% were with anencephaly and have been terminated. Generally, the
perinatal mortality rate has been reduced from a baseline of 74.5 to 41
per 1000 live births.

Figure 1: Run chart of perinatal mortality (baseline and intervention

period data) in Robe Didea General Hospital

Stillbirth has improved the main outcome indicator (Perinatal

Mortality Rate), as the following run chart indicates.

1
Figure 2: Run chart of stillbirth rate at Robe Didea General Hospital
for baseline and intervention period data, June 2023

Early Neonatal Mortality Rate

Even though many change ideas have been implemented, Early
Neonatal Mortality did not show the expected improvement.

Figure 3: Run chart of Early Neonatal mortality rate in Robe Didea

General Hospital for Baseline and intervention period data
Process indicators
Outreach Obstetric Ultrasound
– All Nine health centers have been reached by the service at
least once quarterly
– Proportion of high-risk mothers identified 180/1207*100=150
per 1000

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 – Proportion of potential stillbirth reduced by early
identification (Congenital anomaly) =8/1207 *1000=7 per
1000 attended delivery
– Peer-to-peer mentorship has been conducted in 6 health
centers, and all are graduated by the Hospital’s senior
Midwives

Partograph Utilization

Figure 4: Partograph bundle adherence run chart of Robe Didea

General Hospital

Problems encountered during the process of change

– Shortage of logistics such as fuel for outreach ultrasound activity
– Shortage of transportation during health center mentorship
– Work overload at the hospital for midwives and Radiology
departments
– Politicizing of the activities from some individuals

Lessons Learned
From this project, the team learned that interventions such as Outreach
obstetric ultrasound Scanning, Proper Partograph Utilization, Adherence
to the ANC clinical bundle, and Clinical mentorship for midwives at
health centers can reduce the Perinatal Mortality rate. Moreover, we
learned that only the Outreach Obstetric Ultrasound Service can help
reduce the Perinatal mortality rate by 7 per 1000.
Additionally, we learned that community-level interventions such as
outreach ultrasound services can improve the health-seeking behavior of
the community, develop trust between hospitals and health centers, and
identify problems early.

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We also learned that interventions such as hand washing, wearing
mothers’ gowns, health education, and fumigation of rooms alone
could not reduce Neonatal mortality in our hospital and that we must
seek other interventions to reduce it.

Messages for Others

It is better if hospitals, especially those in rural areas, conduct
Outreach obstetric ultrasound Services. By early detecting congenital
anomalies, hospitals can help reduce the Perinatal mortality rate and
further medical, Physical, and psychosocial problems that a family can
face.

References
1. Federal ministry of health Ethiopia, Health Sector Transformation
Plan II
2. Tesema et al, Trends of infant mortality and its determinants in
Ethiopia: (https://doi.org/10.1186/s12884-021-03835-0)
3. Federal ministry of health Ethiopia,7th National health care quality
and safety bulletin
4. Federal Ministry of Health Ethiopia, HMIS indicator definition 2017

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Section II – Lesson from Research Projects Findings

97
 Maternal Anemia and The Risk of Low Birth Weight in
Ethiopia; A Systematic Review and Meta-Analysis
Authors: Gemechu Gelan Bekele1, Galana Takele2, Berhanu Ejara2, Dajane Negesse2,
Ephrem Yohannes2 and Daniel Belema2
Affiliations: 1Department of Midwifery, College of Health Science, Madda Walabu
University, Shashemene, Ethiopia;2Department of Midwifery, College of
Medicine and Health Science, Ambo University, Ambo, Ethiopia

Abstract
Background: Maternal anemia and low birth weight are significant
public health issues that require investigation. However, developing
countries like Ethiopia need more systematic reviews and meta-
analyses. As a result, the objective of this review was to evaluate the
total pooled effect of maternal anemia on low birth weight in Ethiopia.
Methods: PubMed, Web of Science, EMBASE, CINHAL, Google
Scholar, AJOL, and the Ethiopian University Repositories were all
searched. Data were extracted using Microsoft Excel (v. 14) and
analyzed using STATA version 17 software. Publication bias was
investigated using a forest plot and Egger's regression test. To explore
heterogeneity, I2 was calculated, and an overall estimated analysis was
performed.
Results: A total of 31 articles, including a total of 29,012 study
participants, were involved in this analysis. The overall pooled
estimate indicates that women with anemia during pregnancy had a
2.84 times higher risk of low birth weight (OR=2.84, 95% CI: 2.23-
3.44). The subgroup analysis also revealed differences in the effect size
as the geographical region differed. The result showed that the odds of
perinatal mortality were highest in the Amhara region (OR=3.84, 95%
CI: 2.71-4.97, I2=0.0 and p-value=0.977) and lowest among the studies
conducted at the national level (OR=1.26, 95% CI: 1.11-1.42).
Conclusion and recommendation: The overall pooled estimate in
this analysis reveals that women with anemia during pregnancy had a
2.84 greater risk of low birth weight. As a result, healthcare
practitioners and other stakeholders must improve targeted measures,
such as access to affordable iron supplements, prenatal care, and
nutritional support programs, to reduce the prevalence of low birth
weight.
Keywords: Anemia, Low birth weight, Ethiopia

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Introduction
Low birth weight (LBW), defined by the World Health Organization
(WHO) as a birth weight below 2500gm, remains a major public health
issue worldwide with various short—and long-term consequences.
Over 20 million births per year are LBW. The majority of LBW births
occur in developing countries, with the highest rates in South Asia
(28%), followed by Sub-Saharan Africa (13%) (2, 3) (1). However, the
true prevalence may be underestimated due to underreporting of
births in homes in developing countries (4).
Several maternal factors, including anemia and underweight before
and during pregnancy, as well as maternal hypertension, diabetes, and
infection, may influence birth weight (5). WHO defines anemia as
hemoglobin below 110 g/L in pregnancy (6, 7). Diminished
hemoglobin levels negatively impact placental angiogenesis, limiting
the fetus's access to oxygen and potentially restricting intrauterine
growth, resulting in LBW (8). Anemic women are more likely to deliver
LBW babies compared to non-anemic women (9). Globally, 36.5% of
pregnant women were anemic, while the prevalence in Ethiopia was
29% in 2019 (10). Babies born with LBW have vast complications,
including stunting, lower IQ, heart disease, diabetes, and death (5).
Despite maternal anemia and low birth weight being significant public
health issues, developing countries like Ethiopia lack systematic
reviews and meta-analyses on the subject. Considering the scarcity of
such studies from various regions of Ethiopia, this review aims to
systematically assess the relationship between maternal anemia and
LBW. This information can guide policymakers and healthcare
providers in implementing interventions to reduce the risk of LBW
and improve maternal and child health.
Methods
Search strategy
The systematic review and meta-analysis used published studies from
June 5 to 15, 2023, searching Medline/PubMed, Web of Science,
EMBASE, CINHAL, Google Scholar, and Ethiopian University online
research repository. The following MeSH terms were used to search
studies: birth weight, low birth weight, underweight, macrosomia, big

99
baby weight, small baby, below normal birth weight, anemia, low
hemoglobin, iron deficiency anemia, low hematocrit, AND Ethiopia.
Study design: included only observational studies
Population: Women of reproductive age
Exposure: Women diagnosed with anemia during pregnancy
Control: Women without anemia during pregnancy
Outcome: LBW

Data extraction and quality assessment

Two authors independently extracted all the crucial information using
a standardized JBI data extraction format, with any disputes settled
through discussions with two additional reviewers (11). The extracted
data included the study's first author, area, publication year, measure
of association, sample size, and confidence interval for the target
group.
Data processing analysis
Egger's test and funnel plot assessed publication bias within and
between studies. Heterogeneity was evaluated with the Cochrane Q-
test and I2 statistic (12). Pooled analysis was conducted using a
random-effects model (13). A subgroup analysis was performed based
on the study setting. Data analysis was done using STATA version 17,
with results presented using a forest plot. The relationship between
maternal anemia and LBW was indicated using a log OR, and the
pooled effect size was reported with 95% CI.

Results
Identification and documentation of studies
Of 1,082 studies identified, 187 duplicates were removed, and 805
were excluded after title and abstract screening. Subsequently, full
texts of 90 studies were evaluated for eligibility, with 31 studies
deemed suitable for inclusion in quantitative meta-analysis (Figure ).

100
Figure 1: PRISMA flow diagram
Characteristics of included studies
This analysis included 31 studies with 29,012 participants. Most were
cross-sectional studies conducted between 2016 and 2023, with
sample sizes ranging from 211 to 11,872. Most studies were from the
Amhara regional state.
The impacts of maternal anemia on LBW in Ethiopia
The pooled association between maternal anemia and LBW in the
random-effects model was statistically significant. The overall pooled
estimate indicates that women with a history of anemia had a 2.84
times higher risk of LBW (OR=2.84, 95% CI: 2.23-3.44). The
heterogeneity test for this study was I2 =86.2, and the p-value was
0.001, showing the presence of substantial heterogeneity among
studies.
Subgroup analysis
Subgroup analysis by region showed that the pooled odds ratio
remained statistically significant across most regions, though the
effect size varied. The odds of low birth weight were highest in the
Amhara region (OR=3.84, 95% CI: 2.71-4.97) and lowest in studies
conducted at the national level (OR=1.26, 95% CI: 1.11-1.42).

101
Risk of publication bias
The results of this systematic meta-analysis were heterogeneous.
Visual analysis of the funnel plot and Egger's test (p=0.495) revealed
no evidence of publication bias (p =0.495).
Discussion
The overall pooled estimate indicates that women with a history of
anemia had a 2.84 times higher risk of LBW. This may be because
Anemia can restrict oxygen delivery to developing fetus through the
placenta, potentially leading to LBW by impacting fetal growth and
development (8, 9, 14, 15). Furthermore, anemia can hinder the
absorption and utilization of vital nutrients like iron, folate, and
vitamin B12 necessary for fetal growth, potentially causing LBW by
impeding proper development (16-19). Maternal anemia is often
associated with complications such as premature birth, preeclampsia,
and IUGR, which can further contribute to LBW (20-24). This finding
is congruent with previous studies (14, 20).
The effect sizes in the subgroup analysis varied by geographical region,
but pooled effect size remained statistically significant across all
regions. The odds of low birth weight were highest in the Amhara
region and lowest in studies conducted at the national level. This
variation could be attributed to socio-demographics, study settings,
and regional cultural differences. As the included studies covered
larger areas of the country, this review provides comprehensive,
evidence-based data to support interventions like iron
supplementation and dietary adjustments among pregnant women to
prevent maternal anemia and LBW.
Conclusion
The effect of maternal anemia on LBW in Ethiopia has been assessed
in this meta-analysis. According to the findings, pregnant mothers
who had anemia were 2.84 times more likely to have LBW. To reduce
the occurrence of LBW, healthcare professionals, and other
stakeholders must enhance targeted initiatives, such as access to
affordable iron supplements and prenatal.

102
References
1. Organization WH. Global nutrition targets 2025: low birth weight policy
brief. World Health Organization; 2014.
2. Kim D, Saada A. The social determinants of infant mortality and birth
outcomes in Western developed nations: a cross-country systematic
review. International journal of environmental research and public
health. 2013;10(6):2296-335.
3. Muglia LJ, Katz M. The enigma of spontaneous preterm birth. New
England Journal of Medicine. 2010;362(6):529-35.
4. Organization WH. Global Nutrition Monitoring Framework: operational
guidance for tracking progress in meeting targets for 2025. 2017.
5. Organization WH. UNICEF-WHO low birthweight estimates: levels and
trends 2000-2015. World Health Organization; 2019.
6. Control CfD. CDC criteria for anemia in children and childbearing-aged
women. MMWR Morbidity and mortality weekly report.
1989;38(22):400-4.
7. Organization WH. The global prevalence of anaemia in 2011. Geneva:
World Health Organization; 2015. 2017.
8. Stangret A, Wnuk A, Szewczyk G, Pyzlak M, Szukiewicz D. Maternal
hemoglobin concentration and hematocrit values may affect fetus
development by influencing placental angiogenesis. The Journal of
Maternal-Fetal & Neonatal Medicine. 2017;30(2):199-204.
9. Rahman MM, Abe SK, Rahman MS, Kanda M, Narita S, Bilano V, et al.
Maternal anemia and risk of adverse birth and health outcomes in low-
and middle-income countries: systematic review and meta-analysis, 2.
The American journal of clinical nutrition. 2016;103(2):495-504.
10. Organization WH. WHO global anaemia estimates, 2021 edition. World
Health Organization. 2021.
11. Munn Z, Tufanaru C, Aromataris E. JBI's systematic reviews: data
extraction and synthesis. AJN The American Journal of Nursing.
2014;114(7):49-54.
12. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-
analysis. Statistics in medicine. 2002;21(11):1539-58.
13. Viechtbauer W. Conducting meta-analyses in R with the metafor
package. Journal of statistical software. 2010;36:1-48.
14. Figueiredo A, Gomes-Filho IS, Silva RB, Pereira PPS, Mata F, Lyrio AO,
et al. Maternal Anemia and Low Birth Weight: A Systematic Review and
Meta-Analysis. Nutrients. 2018;10(5).
15. Rahmati S, Delpishe A, Azami M, Hafezi Ahmadi MR, Sayehmiri K.
Maternal Anemia during pregnancy and infant low birth weight: A
systematic review and Meta-analysis. Int J Reprod Biomed.
2017;15(3):125-34.
16. Abu-Ouf NM, Jan MM. The impact of maternal iron deficiency and iron
deficiency anemia on child's health. Saudi Med J. 2015;36(2):146-9.

103
 A Comprehensive Approach to Reduce the Burden of
Esophageal Cancer in Southeastern Ethiopia Through
Advocacy for Equitable and Accessible Health Services
Author: Abebe Megerso1, Haji Aman Deybasso1, Biniyam Tefera Deressa1, Jibril Bashir
Adem2, Dagim Tekeba3,Mohammedaman Mama3, Didha Batu2, Bonso Bude2, Gebi
Agero2, Gudeta Hinika4, Ismael Tura5, Mohammed Kabeto6, Abdella Amano Abdo7,
Desalegn Fikadu1, Abashamo Lencho8, Melik Tiba9
Affiliation: 1Adama Hospital Medical College, Adama, Ethiopia; 2Arsi University, Asella,
Ethiopia; 3Madda Walabu University, Goba, Ethiopia; 4California Hospital Medica
Center, USA; 5Sinai Hospital in Maryland, USA; 6University of Michigan,
Michigan, USA; 7Negele Arsi General Hospital and Medical College, Negele Arsi,
Ethiopia; 8Ohio State University, Columbus, USA; 9Mid-Atlantic Kaiser
Permanente, USA

Abstract
Background: Esophageal cancer ranks as the second most common
cancer after breast cancer in the Arsi, Bale, and adjacent areas where
health facilities are inaccessible and unaffordable to most patients.
This document illustrates esophageal cancer's collaborative task force
formation process as a serious public health problem.
Methods: Extensive formal and informal discussions were conducted
over two years. After several meetings, a collaborative multi-sectoral
and multidisciplinary task force was established. The task force
identified the magnitude of the problem and the gaps in healthcare
provisions and policy.
Results: Ethiopia's first guidelines for treating esophageal cancer
developed. Additionally, an endoscopy curriculum was designed to
train surgeons and internists for Asella and Goba teaching and referral
Hospitals. The trained physicians began endoscopy services that
fundamentally improved access to diagnostic services and better
detected and treated cases in the area. A memorandum of
understanding was signed between stakeholders to work on capacity
building, system strengthening, research, and nationally channeled
esophageal cancer actions.
Lesson Learned: Esophageal cancer is currently considered a
serious public health problem in Ethiopia. Collaborative efforts were
fundamental tools for identifying policy gaps, advocating public health
concerns, and garnering national attention and action from
policymakers.
Keywords: Esophageal, Cancer, Advocacy, Southeastern, Ethiopia

104
Introduction
Esophageal cancer (EC) is a formidable malignancy arising from
alterations in the esophageal epithelial lining. It ranks as the seventh
most common cancer by incidence and the sixth leading cause of
cancer-related deaths globally (1). It is challenging to know the exact
burden of EC in Ethiopia. Low awareness about symptoms of EC, poor
health-seeking behavior, absence of a cancer registry system, reporting
EC under all Gastrointestinal (GI) cancers without assigning disease
classification codes, and inaccessible and unaffordable healthcare
services all contribute to the challenges.

Over the years, Arsi and Bale Zones have been identified as endemic
areas for esophageal cancer within the African Esophageal Cancer belt,
where more than 50% of cases originate (2,3). According to the data
obtained from the oncology units of Adama, Asella, and Goba
Hospitals, EC ranks as the second most common cancer after breast
cancer in these areas (unpublished data).

Recent studies, however, revealed a significant increase in EC

incidence across various parts of Ethiopia. Research conducted in ten
rural hospitals found EC to be the third most prevalent cancer overall,
the second most common cancer among males after prostate cancer,
and the third most common among females, following breast cancer
and cervical cancer. Aira Hospital in Western Oromia accounted for
64.2% of EC cases, an unusually high number of reports (4). In another
study, Addis Ababa and the Southern nation and nationality regions
each accounted for a 15% prevalence of esophageal cancer patients.
The prevalence of EC stood at 7.4% and 4.9% in Amhara and other
regional states, respectively (5). Furthermore, a recent study in
Amhara regional state revealed that EC was the tenth most prevalent
cancer, with a prevalence of 2.7% in Felege Hiwot Hospital in Bahirdar
Town (6).

The gender and age distributions in EC endemic areas in Ethiopia

showed that 51.8% of EC patients were females; 7.1% were ≤ 39 years
of age; the youngest male and female patients were 19 & 25 years old,
respectively(7). Occupationally, 92.3% were farmers from rural areas,
and 9.6% reported a family history of cancer(3). The median survival

105
time after diagnosis is 6 months. The majority (about 80%) of EC
patients presented at advanced stages (stages III and IV). As a result,
most patients have poor treatment outcomes and survival (8). Patients
diagnosed with EC exhibit a lack of knowledge of the early symptoms
associated with the disease. The majority of cancer patients preferred
to go home due to a large waiting list and a chronic scarcity of cancer
medications due to supply and demand imbalances (9). Such a
disproportionate burden of the disease and persistent challenges
highlight the need for policy attention to design interventions for
prevention, early diagnosis, and treatment and collaborative research
between different stakeholders. However, EC was never on the agenda
in Ethiopia until the Southeastern Upper GI Collaborative Task Force
(SE_UGI task force) implemented advocacy efforts for policymakers,
health professionals, and researchers in Ethiopia and abroad.

Context
The primary focus areas for the collaborative work were the Arsi and
Bale Zones in the Southeastern part of the Oromia Regional state in
Ethiopia. Arsi and Bale Zones are EC endemic areas that account for
more than 60% of EC cases in Ethiopia. Then, a multi-sectoral and
multidisciplinary team was established from Arsi University, Adama
Hospital Medical College, Madda Walabu University, Negelle Arsi
General Hospital and Medical College, IOHPA, Arsi University and the
Ministry of Health. The team comprises health professionals born in
the Arsi and Bale, individuals who lost their families, close relatives,
and friends, and experts who witnessed the severity of the problem
during professional activities.
Problem
Even though the disease's exact burden is unknown, studies show that
EC is alarmingly increasing in Ethiopia, with a clustering of cases in
hot spot areas. However, the risk factors for clustering EC cases were
not well investigated. Esophageal cancer patients are diagnosed at an
advanced stage of the disease due to poor knowledge of the early
symptoms associated with the disease. In addition, healthcare services
are inaccessible and unaffordable.
Therefore, most EC patients face a large waiting list and a chronic
scarcity of cancer medications due to supply and demand imbalances.

106
In general, the disease was not considered a public health priority due
to the absence of organized efforts to present empirical evidence for
policy decisions.
Aim Statement
This document aims to illustrate the collaborative task force formation
process and the advocacy work that led policymakers and stakeholders
in Ethiopia in 2024 to recognize esophageal cancer as a serious public
health problem.
Assessment of the problem and analysis of its causes
Extensive formal and informal discussions with health professionals
born in the affected areas, individuals who lost their families, close
relatives, and friends, and experts who witnessed the severity of the
problem during professional activities and a review of the relevant
literature were employed to identify the extent of the problem. The
major activities encompassed collaborative discussions, detailed
dialogues, and iterative reviews to capture the institutional priority
areas and policy gaps. Experts from clinical and public health fields,
actively involved throughout the program's lifecycle, contributed
insights from its inception to its current state.
Interventions
The advocacy works have been underway for over two years (since
2022) by talking to the mainstream and social media, community
mobilizations, communicating with international organizations, and
organizing regional and national conferences. In those notable
conferences, the task force efficiently communicated the empirical
evidence to key policymakers in the country's health system, people’s
representatives, clinical practitioners, researchers, and community
leaders. Subsequent activities were accomplished to illustrate the
burden of the disease, key clinical features, and the need for the
intervention.
Measurement of improvement
The effects of changes can be measured using multiple indicators. The
consideration of EC in national cancer prevention and management
strategies and guidelines is the principal indicator for checking the
effectiveness of collaborative advocacy efforts. The number of health

107
professionals trained in the prevention, early diagnosis, and treatment
of EC, physicians trained in endoscopy, number of patients diagnosed
and referred without delay, utilization of the standard guidelines,
research conducted using a standard tool, educational materials
produced, distributed and utilized, availability of accessible and
affordable health care services will be additional indicators for
assessing the effects of change. The consortium will coordinate,
facilitate, and monitor clinical services. It also guides health,
continued medical education, and research activities. The activities
will be reported through regular communication channels and
presented during regular meetings. The impacts of the intervention
will be evaluated by a reduced number of patients with an advanced
stage of the disease, improved survival, and reduced incidences of the
disease,

Results
Collaborative work led to the first conference at Arsi University in
2022, involving clinicians, researchers, public figures, and community
leaders, along with four educational institutions, namely Arsi
University, Madda Wallabu University, Adama Hospital Medical
College, and Arsi Negelle General Hospital and Medical College, and
International Oromo Health Professional Association (IOHPA). We
established the Southeast Esophageal Cancer Task Force (SEECTF) at
that conference. The task force developed the first endoscopy
curriculum in Ethiopia, trained physicians, and initiated endoscopy
diagnosis in two previously unequipped hospitals. Moreover, the task
force developed the country's first esophageal cancer treatment
guidelines and training manuals. In addition, the team conducted
community education in local languages by distributing pamphlets
and mass Media.
The advocacy work finally gained attention from policymakers, and
esophageal cancer is currently considered one of the serious public
health problems in Ethiopia. As a result, the federal Ministry of Health
organized a national conference in 2023, which led to the signature of
a memorandum of understanding (MOU) between different
stakeholders, including academic, research, and health institutions.
Finally, a centralized consortium was established in all four academic

108
institutions to work on advanced research, advocacy, and capacity
building, channeling esophageal cancer actions nationally.
Lessons learned
Esophageal cancer is currently considered a serious public health
problem in Ethiopia. Collaborative efforts were fundamental tools to
identify policy gaps, advocate public health concerns, and garner
national attention and action from policymakers.
Messages for others
Collaborative multi-sectoral and multidisciplinary teamwork is a
practical and effective tool for identifying community problems and
policy gaps and communicating empirical evidence to inform
policymakers' decisions.
References
1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer
statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for
36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018
Nov;68(6):394–424.
2. Deybasso HA, Roba KT, Nega B, Belachew T.2021. Clinico-Pathological Findings
and Spatial Distributions of Esophageal Cancer in Arsi Zone, Oromia, Central
Ethiopia. Cancer Manag Res.13:2755-2762
https://doi.org/10.2147/CMAR.S301978.
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al. Estimates of Cancer Incidence in Ethiopia in 2015 Using Population-Based
Registry Data. JGO. 2018 Dec;(4):1–11.
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and its Determinants in Ethiopia: A Facility Based Retrospective Cohort Study.
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2019 Mar 30;24(1):33–42.

109
Magnitude of Hypertension and Associated Factors among
West Wollega Zonal Sectors Civil Servants, Western
Oromia, 2023
Authors: Keneni Ephrem Dibisa1, Abiyot Lemma1 Mengistu Tamiru Dinka1, Lalisa
Mekonen Moti2, 1Mesfin Tasew1, Solomon Chala3Gemechis Mengesha 1, Getahun
Fetensa3, Gemechis Mesfin Bedane 1,4, Chala Befikadu4, Berhanu Kenea4
Affiliations:1West Wollega Zonal Health office, Oromia Health Bureau, Gimbi, Ethiopia,
2Gimbi, General Hospital, Oromia Health Bureau, Gimbi, Ethiopia, 3Jimma

University, Department of Health Behaviour and Society, Faculty of Public

Health, Jimma University, Jimma, Ethiopia, 4 Oromia Health Bureau, Finfinnee,
Ethiopia

Abstract
Background: Hypertension, a serious worldwide health concern,
affects 1.13 billion people and requires immediate attention due to its
considerable impact on global morbidity and mortality.
Objective: To assess the magnitude of hypertension and associated
factors among West Wollega Zonal sector civil servants, western
Oromia, 2023
Method: Cross-sectional research of 376 West Wollega Zonal civil
servants utilized a structured questionnaire and face-to-face
interviews, with p-values <0.25 and ≤0.05, suggesting statistical
significance.
Results: 376 study participants were interviewed during the study
period, with a response rate of 100%. The mean (+SD) age of the
respondents was 40.12+ 9.12. The magnitude of hypertension among
the study participants was 32.4%, 95% CI (27.9%–37.3%), the
magnitude of newly diagnosed hypertension was 14.9%, 95% CI (11.7–
18.8), and the magnitude of known hypertension was 17.6%, 95% CI
(14–21.7). In multivariable analysis, age, being male, body mass index,
self-report of high salt consumption, and family history of
hypertension were statistically significant for being diagnosed with
hypertension.
Conclusion: The study finds that participants have considerable
hypertension, with characteristics such as age, gender, obesity, high
salt consumption, and family history being strongly associated. It
advocates community-based screening, triage screening, and health
education about modifiable risk factors.

Keywords: Hypertension, Magnitude, NCD, Civil servant

110
Introduction
Hypertension is defined by high arterial blood pressure, which can
lead to issues in the heart, brain, and kidneys. It affects 1.13 billion
people globally and is the leading cause of illness and mortality.
Globalization, poor eating habits, urbanization, tobacco use, obesity,
strokes, diabetes, heart failure, income, alcohol consumption,
education, and family history are all risk factors for hypertension. The
Sustainable Development Goal is to reduce the severity of high blood
pressure by 25% by 2030. However, 76.6% of the population does not
measure their blood pressure, underscoring the critical need for
hypertension therapy (1, 2, 3). This study examined hypertension
prevalence and risk factors among Ethiopia's zonal government
employees.
Method and Materials
A study in the West Wollega government sector, involving 376
personnel from 32 sectors, investigated hypertension prevalence
among civil servants and independent variables such as age, gender,
education, religion, marital status, income, family size, BMI, diabetes,
salty diet, smoking, alcohol, and feeding habits.
Operational definition
Hypertension is diagnosed when systolic and/or diastolic blood
pressures are ≥140 mmHg or ≥90 mmHg over two days. It is
characterized as normal, high normal, grade 1, grade 2, grade 3, or
isolated systolic hypertension. BMI and RBS classifications are also
utilized. Blood pressure determines whether someone is diabetic.
Data collection tool, procedures, and analysis
A questionnaire and interviews were used to collect data on socio-
demographics, behavior, dietary habits, blood pressure, glucose
levels, and hypertension. The data were analyzed using SPSS software
to evaluate frequency distribution and hypertension risk variables.
Results
The survey interviewed 376 people, with a 100% response rate. The
average age was 40.12 + 9.12, with a median of 39. Most were married,
educated, and held protestant religious beliefs, with 63% being men.
Civil servants spend 91% of their time at work, with only 10.9%

111
exercising and 77.7% walking. 63% have high blood pressure, 44%
have high blood pressure, and 63.6% are on hypertension medication.
(Table 1)
Table 1: Anthropometric values, biochemical tests, status of
hypertension, and behavioral characteristics of study subjects among
West Wollega Zonal Sectors, Gimbi, Oromia, 2023
Variables Response Frequency (%)
Random blood sugar <140mg/dl 338(89.9)
140-199mg/dl 25(6.6)
>200mg/dl 13(3.5)
Duration of stay in office in hours 1-4 34(9)
5-8 342(91)
Did you drink alcohol within the No 302(80.3)
past 12 months? Yes 74(19.7)
Do you practice regular exercise? No 335(89.1)
Yes 41(10.9)
Have you ever measured your blood No 139(37)
pressure? Yes 237(63)
Does the client have hypertension? No 254(67.6)
Yes 122(32.4)
Status of Hypertension No hypertension (normal) 254(67.6)
Newly diagnosed 56(14.9)
Known 66(17.5)
Presence of stress? No 305(81.1)
Yes 71(18.9)
Yes 12(80)
Family history of DM? No 337(89.6)
Yes 39(10.4)
Perceived history of obesity No 315(83.8)
Yes 61(16.2)
Self-reported high salt No 303(80.6)
consumption? Yes 73(19.4)

Hypertension is associated with age, men's BMI, blood pressure

measurement, perceived obesity, high salt consumption, stress, family
history, and a family member's father's hypertension history, with
those who measure blood pressure having a 3.6-fold higher risk.

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 Table 2: Multivariate analysis among study participants, West
Wollega, Gimbi, Oromia, 2023

Variables Classification Does the client have OR (95% CI)

(n=376) hypertension?
Yes No AOR
Sex Male 90(38%) 147(62%) 2.33(95% CI;1.22-4.45)
Female 32(23%) 107(77%)
Age 20-29 5(12.5%) 35(87.55)
30-39 33(21%) 124(79%) 0.96(95% CI;0.32-2.94)
40-49 37(36.3%) 65(63.7%) 1,25(95% CI;0.39-4.03)
50-59 47(62.7%) 28(37.3%) 4.32(95% CI;1.31-14.28)
Body mass index <18.49 5(10.6%) 42(89.4%)
18.5-24.9 67(30.2%) 155(69.8%) 2.78(95% CI;0.50-15.32)
25-29.9 43(46.7%) 49(53.3%) 6.61(95% CI;2.04-21.43
30-34.9 5(38.5%) 8(61.5%) 0.41(95% CI;0.07-2.28)
Have you ever Yes 102(43%) 135(57%) 3.66(95% CI;1.96-6.82)
measured your BP? No 20(14.4%) 119(85.6%)
History of diabetic Yes 11(73.35) 4(26.7%) 3.26(95% CI;0.62-17.24)
mellitus No 111(30.7% 250(69.3%)
Perceived history of Yes 28(5.9%) 33(54.1%) 2.24 (95% CI: 1.22-4.81)
obesity No 94(29.8%) 221(70.2%)
Presence of stress Yes 32(43.7%) 40(56.3) 1.81(95% CI;0.94-3.50)
No 91(29.8%) 214(70.2%
Self-report of high Yes 9(31%) 28(38.4%) 2.19 (95% CI: 1.09–.39)
salt consumption No 45(61.8%) 209(69%)
Hx of hypertension: Yes 31(43.7%) 40(56.3%) 2.55(95% CI;1.29-5.04)
father? No 91(29.8%) 214(70.2%

Discussion
The study revealed that 32.4% of participants have hypertension, a
serious public health problem associated with advanced age, obesity, salt
consumption, and family history. With higher rates among newly
diagnosed and pre-existing cases compared to the Addis Ababa Federal
Ministry of Civil Service (27.3%) (8,9). The cultural food "qocqocaa,"
which is strong in salt and spices, may contribute to the study area's high
hypertension prevalence; however, it is lower than the 33.5% prevalence
among Gimbi people. (4). The study indicated that older age greatly
increased the likelihood of being diagnosed with hypertension, like a
study conducted in southern Ethiopia. (10-13) Men had higher odds of
developing hypertension compared to women; this finding is comparable
with research done in Sidama and different parts of Ethiopia (5). In most

113
cases, males are more likely than females to be exposed to hypertension-
related behavioral risks.

According to research in the Gurage Zone and nationally representative

surveys, there is a significant link between hypertension and a body mass
index of more than 25 kg/m2. (14, 15). Obesity causes hypertension
through a variety of processes, including increased sympathetic nervous
system activity and renal failure. (6). Self-report of high salt consumption
had a higher odd of developing hypertension, comparable to research
done in Northwest Ethiopia. High salt disrupts the natural sodium
balance in the body. This causes fluid retention, which increases the
pressure exerted by the blood against the blood vessel walls (7).

Conclusion
The study revealed a high prevalence of hypertension among
participants, with age, gender, obesity, excessive salt consumption, and
family history all strongly associated with the illness. It promotes
community-based screening programs and health information.

Reference
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Management Protocol, 2021 (November).
2. Hunter PG, Chapman FA, and Dhaun N. Hypertension: Current trends
and future perspectives. Vol. 87, British Journal of Clinical
Pharmacology, 2021, p. 3721–36.
3. Benken, ST. Hypertensive Emergencies Benken, S. T., and Cardiology,
B.-A. (n.d.). Hypertensive Emergencies. 2018;(7):7–30. Available from:
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4. Yadecha B, Bobo FT, Fetensa G, and Woyessa AH. Prevalence of
Hypertension and Its Associated Factors Among Gimbi Town Residents,
Ethiopia: A Community-Based Cross-Sectional Study.
2020;(November).
5. Id BB, Yoseph A, and Id AA. Prevalence and risk factors of hypertension
among civil servants in Sidama Zone, south. 2020;1–17.
6. Shariq OA, Mckenzie TJ. Obesity-related hypertension: A review of
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7. Sutradhar P., Mondal RN. Prevalence and Risk Factors of Hypertension
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8. Abebaw S, Id T, Bukayaw YA, Yigizaw T, and Angaw DA. Prevalence of
hypertension and its determinants in Ethiopia: A systematic review and
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9. Angaw K., Dadi AF, and Alene KA. Prevalence of hypertension among
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Ethiopia. Int J Chronic Dis. 2020;1–7.
11. Wolle SZ. To determine the prevalence of hypertension and its lifestyle
risk factors in the Amhara Region of Debre Birehan Town among Zonal
Civil Servants, Ethiopia. 2020;0–22.
12. Chuka A, Gutema BT, Ayele G, Megersa ND, Melketsedik ZA, and Zewdie
TH. Prevalence of hypertension and associated factors among adult
residents in Arba Minch Health and Demographic Surveillance Site,
Southern Ethiopia. PLoS One. 2020;15(8 August):1–13.
13. Laurent S., Boutouyrie P. Arterial Stiffness and Hypertension in the
Elderly. Front Cardiovasc Med. 2020;7(October):1–13.
14.Hossain FB, Shawon SR, Adhikary G, and Chowdhury A. Association
between body mass index (BMI) and hypertension in the South Asian
population: Evidence from the Demographic and Health Survey.
bioRxiv. 2019;605469.
15. Haligamo D, Ayalew A, Genemo H, and Yiriga N. Hypertension and
Management Undiagnosed Hypertension and Its Associated Factors
among Adult People Living in Southern Ethiopia: Evidence from
Gunchire Woreda of Gurage Zone. 2021;7(1):1–8.
16.Teshome DF, Balcha SA, Ayele TA, Atnafu A, Sisay M, Asfaw MG, et al.
High burden of hypertension amongst the adult population in rural
districts of Northwest Ethiopia: A call for community-based
intervention. PLoS One. 2022;17(10 October):55–64.

115
 Magnitude of cesarean delivery and associated factors
among women who gave birth at Gimbi town Hospitals,
West Wollega, Oromia, 2023
Authors:Keneni Ephrem1, Mengistu Tamiru1, Lalisa Mekonen, 2, Zemanu Shasho2,
Getahun Fetensa3*, Gemechis Mengesha 1, Kenanisa Leyo4, Gemechis Mesfin4,
Galmessa5, Muzemir5
Affiliations: 1West Wollega Zonal Health office, quality unit; 2Gimbi General Hospital;
3Departments of Nursing, Institute of Health Science, Wollega University; 4

Oromia Health Bureau, Finfinnee, Ethiopia, 5Partners (WHO and QHA)

Abstract
Background: A cesarean section is performed when safe vaginal
delivery is either not feasible (absolute) or would impose undue risks
to the mother or fetus (relative), and the most significant lifesaving
procedures play a key role in declining maternal and perinatal
morbidity and mortality rates. Therefore, this study is intended to
determine the magnitude of cesarean sections, associated factors, and
gaps at Gimbi town hospitals in West Wollega, Western Ethiopia, in
2023.
Method: A retrospective cross-sectional study of 420 women who
gave birth the previous year was undertaken at Gimbi town hospitals
from September 21 to October 1, 2023. Data was collected using
extraction sheets, entered Epidata, and then exported to SPSS. Results
with p-values <0.05 were considered significant.
Results and discussion: Charts were reviewed during the study
period. The mean (+SD) age of the respondents was 25+4.4. The
overall prevalence of cesarean sections was 33.3% (95% CI: 28.8–
37.8). Moreover, antenatal visits, the presence of risk factors, bad
obstetrics history, and partograph utilization are associated with
cesarean delivery: [AOR = 7.70 (95% CI: 1.79–33.17), [AOR = 3.39
(95% CI: 1.45-7.94), [AOR = 6.72 (95% CI: 2.81–16.1)], and [AOR =
3.74 (95% CI: 1.03–13.61].
Conclusion: High cesarean delivery rates in Gimbi town hospitals
are linked to antenatal care visits, risk factors, poor obstetrics, and
partograph use. Cesarean sections, photography during labor, and the
provision of informed antenatal care should all be governed by
national standards.
Keywords: Cesarean delivery, Magnitude, and Vaginal delivery

116
Introduction
A cesarean section is a life-saving technique used in comprehensive
emergency obstetric and newborn care to reduce morbidity and
maternal death when safe vaginal delivery is not possible or poses
unacceptable risks (1). A cesarean section is an optional treatment with
known hazards to the woman and fetus during childbirth. Still, it must
be performed immediately in situations of emergency that pose health
problems (2). The treatment was initially intended to save the
expecting mother's life, but it has evolved to include delivery due to
hidden risks and should be undertaken based on evidence (3).

Cesarean section has both immediate and long-term consequences,

including internal organ trauma, anesthetic concerns, maternal death,
and transient tachypnea, as well as long-term hazards such as uterine
rupture, infertility, and placental accretion (4). The World Health
Organization predicts that 5–15% of pregnancies may result in major
health problems; however, cesarean section births can reduce
maternal mortality, and success is dependent on adequate prenatal
care (5). The magnitude and what factors are predisposing mothers to
cesarean sections in Gimbi town, Western Oromia, have not been
investigated yet. Therefore, this study is intended to determine the
magnitude of cesarean sections and associated factors in the study
area.
Method and Materials
The study was conducted in two hospitals in Gimbi town from
September 21 to October 1, 2023.
Study Design: The study utilized an institution-based retrospective
cross-sectional design, focusing on charts of mothers who gave birth
the previous year at Gimbi General and Gimbi Adventist Hospitals
while excluding cesarean sections for extra-uterine pregnancy and
incomplete charts. The study employed a population of 422,
accounting for 10% of the missing data, and included individuals from
both hospitals in Gimbi town. It focuses on cesarean delivery and
independent variables such as sociodemographic, obstetrics, maternal
and fetal characteristics, medical problems, and health facility-related
factors. SPSS 25 was used for data analysis.

117
 Results
420 medical charts were reviewed during the study period, with a
response rate of 99.5%. The mean (+SD) age of the respondents was
25+4.4. Most participants were married, 406 (96.7%), and about 159
(37.3%) were Protestants.
Table 1: Socio-demographic characteristics of women who have given
birth at Gimbi town health facilities, West Wollega, Ethiopia,
2023
Variable(n=420) Variable categories Frequency Percent
Age of respondents 17-19yrs 36 8.6
20-34yrs 367 87.4
35-49yrs 17 4
Marital status Single 3 0.7
Married 406 96.7
Divorced 7 1.7
Widowed 4 1
Others 9 2.1
Others 8 1.9
Family size <4 84 20
>=4 336 80
Residence Urban 177 42.1
Rural 243 57.9

According to the study, 52.4% of mothers are multigravida, 50.5% are

multipara, and 49.5% give
birth after two years, with 85% having never had a cesarean birth.
Table 2: Obstetrics and medical illness-related factors of women who
have given birth at Gimbi town health facilities, West Wollega,
Oromia, Ethiopia, 2023
Variable Variable categories Frequency Percent
Gravidity Prim-Gravida 187 44.5
Multi-Gravida 220 52.4
Grand-multi-Gravida 13 3.1
Inter-pregnancy interval <=2yrs 17 4
(n = 225) >2yrs 208 49.5
Previous Hx of C-Section Yes 60 14.3
No 360 85.7
Fetus presentation Normal 369 87.9
Abnormal 51 12.1
ANC follow Yes 301 71.7
No 119 28.3
Number of ANCs (n = 301) <4 visit 66 21.9
>=4 visit 235 78.1

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The study showed a 33.3% prevalence of cesarean sections, with 79%
of deliveries owing to emergencies and 67% spontaneous vaginal
deliveries.

Table 3: Prevalence of CS among pregnant women who gave birth at

Gimbi Town Hospitals, 2023
Variables (n=420) CS performed
Yes (#/%) No (#/%)
Overall prevalence of cesarean delivery at both 140 (33.3%) 280(66.7%)
hospitals
Instrumentation applied (n = 280) 44(15.7%) 226(84.3%)
Types of Cesarean Delivery (n = Emergency 111(79.3%) 0
140) Elective 29(20.7%) 0

The study showed that women with fewer ANC visits, risk factors, poor
maternal history, and partograph use were more likely to have a
cesarean birth, with risk factors three times more likely and a bad birth
history four times more likely.

Table 4: Crude and adjusted odds ratios of factors associated with

cesarean delivery both at hospitals in Gimbi town, West
Wollega, Ethiopia, 2023
Variables Categories Cesarean Delivery
(n=420) Yes No Adjusted OR P-value
Number of ANC >= 4 visits 94(40%) 141(60%) 7.70(1.79-33.17) 0.006*
Visits < 4 Visits 9(12.9%) 61(87.1%)
Normal 109(29.5% 260(70.5%
Previous History Yes 48(80%) 12(20%) 0.35(0.1-1.2) 0.96
of CS No 92(25.6%) 268(74.4%)
Presence of risk Yes 118(54.1%) 100(45.9%) 3.39(1.45-7.94) 0.005*
factors No 22(10.9%) 180(89.1%)
Bad Obstetric Yes 25(46.3%) 29(53.7%) 3.74(1.03-13.61) 0.04*
History No 115(31.4% 251(68.6%
Partograph No 115(60.5%) 75(39.5%) 6.72(2.81-16.1) <0.001*
utilization Yes 25(10.9%) 205(89.1%

Discussion
According to the study, the study area had a 33.3% cesarean delivery
prevalence, which is lower than other countries but comparable to
other regions. The research site, population, socioeconomic status,
healthcare access, policies, technology monitoring, malpractice
concerns, and older motherhood are some factors influencing this
discrepancy (9,18,19). On the other hand, the findings of this study

119
were higher than the studies conducted in Bangladesh 23.94% (15),
Felegehiwot referral hospital 25.4% (17), Butajira general hospital 21%
(20), Suhul General Hospital of Tigray Region 20.2% (2), and Ado-
Ekiti (Nigeria) which was 19.9% (16). The study found a disparity in
cesarean deliveries, presumably due to improved access and hospital
referrals for obstetric patients, with 79.3% being emergency-related.
According to the study, mothers who have fewer than four antenatal
visits have a higher risk of cesarean birth, whereas women with risk
factors had a threefold increased risk. The study's results are
supported by the survey conducted at Felegehiwot Referral Hospital,
Northwest Ethiopia (17), and Addis Ababa hospitals (5)(22).
According to studies conducted in Dessie town hospitals, Northeast E
thiopia, and Hawwasa Hospital, moms who do not undergo partogra
ph monitoring are more likely to have a cesarean delivery (5).

Research conducted in multiple Ethiopian hospitals shows that

women with a poor obstetric history are more likely to have a cesarean
delivery. This suggests a substantial relationship between these factors
(5)(17)(18)(19)(2). However, after controlling confounding, previous
cesarean delivery, fetal presentation, antepartum hemorrhage, and
instrumental delivery did not correlate with the outcome variable.
Conclusions and Recommendations
The study discovered a high rate of cesarean sections in the area, with
55% of mothers utilizing a partograph during labor. Emergency
obstetric births were widespread, with increasing failure and unstable
fetal states being the primary indications. The study advocates
adhering to national guidelines, performing pathology, and providing
information about operation risks and benefits.

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 Partograph Utilization and Its Associated Factors Among
Obstetric Caregivers in Qellem Wollega Zone Public Health
Institutions, Western Ethiopia, 2023
Author: Kemal Hirko
Affiliation: Dambi Dollo University

Abstract
Background: A partograph is a graphic representation of labor used
by health professionals to monitor labor progress and fetal and
maternal well-being. However, its utilization and associated factors
have yet to be studied in Qellem Wollega Zone public health facilities
in Western Ethiopia. Hence, this study aimed to assess the magnitude
of partograph utilization and its associated factors among obstetric
care providers at public health facilities in Qellem Wollega Zone,
Western Ethiopia, in 2023.
Objective: To Assess the level of partograph utilization and its
associated factors among obstetric care providers in public health
facilities in the Qellem Wollega zone, western Ethiopia, in 2023.
Methods: A facility-based cross-sectional study design was
conducted from November 1–December 20, 2023. A single population
proportion formula was used to estimate the sample size, which was
289. A simple random sampling method was carried out on 20 health
facilities. A structured and pretested questionnaire was administered
to collect data. The collected data was cleaned and entered into the
Epi-Data version 4.6 statistical package, then exported to SPSS version
23.0 for analysis. Binary logistic regression analysis was used to detect
the association between variables.
Results: The overall magnitude of partograph utilization was 159
(55.0%) with a 95% CI of (20.0, 40.3). Good knowledge (AOR [95%
CI] =2.796 [1.019-7.673]) and a positive attitude toward partograph
use (AOR [95% CI] = 1.657 [1.637-4.310]) were significantly associated
with partograph use.
Conclusion: Overall, partograph utilization was low in this study.
Receiving on-the-job training for OCPs, having good knowledge, and
having a positive attitude toward partograph use were factors
associated with partograph use.
Keyword: Partograph, Obstetric, Qellem Wollega

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Background
Partograph is a graphic illustration of labor used by health
professionals in obstetric care to monitor the progress of labor and
fetal and maternal well-being (1). It consists of three components:
maternal, fetal, and labor progress. (2). In 1954, Friedman introduced
the concept of partograph by graphically plotting cervical dilatation
against time. Labor progress is assessed through cervical dilatation
and descent of head and uterine contractions. On the other hand, the
fetal condition is monitored by fetal heart rate, the color of the liquor,
and the molding of the fetal skull. Furthermore, the maternal
condition is also assessed by monitoring maternal pulse rate, blood
pressure, temperature, and urine for volume, protein, and ketone
bodies (3).
To reduce maternal and neonatal morbidity and mortality due to
obstructed and prolonged labor, especially in developing countries, the
World Health Organization (WHO) recommends universal and
routine partograph utilization. Obstructed labor is one of the common,
easily preventable causes of maternal and prenatal morbidity and
mortality in developing countries, including Ethiopia (3). It was first
used in 1950 and became an international standard method in 1987 in
Nairobi, Kenya. In 1994, the World Health Organization declared its
essential use in all settings for enhancing labor management and
lowering maternal and fetal mortality (4).
The utilization of the partograph allows early recognition of obstructed
labor and reduces the chances of prolonged labor and unnecessary
cesarean section (5). A cross-sectional study done in Southwest
Ethiopia in 2018 revealed that, in labor monitored by partograph,
prolonged labor was reduced from 6.4 to 3.4 %, augmentation was
reduced from 20.7 to 9.1 %, emergency cesarean section was reduced
from 9.9 to 8.3 %, and stillbirths were reduced from 0.5 to 0.3 % (6).
The cross-sectional study conducted in the Hadiya zone revealed that
the associated factors related to the utilization of partographs in many
health facilities are the type of health facility they are working in, the
job training on partographs, knowledge about the partographs, and
attitude toward partographs utilization (7). It has been indicated that

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utilization of the partograph was significantly associated with
improved maternal and neonatal labor outcomes (8).
Objective
To assess the magnitude of partograph utilization and its associated
factors among obstetric care providers at public health facilities in
Qellem Wollega Zone, Western Ethiopia, in 2023.
Methodology
Study Area and Period
Qellem Wollega Zone, Western Ethiopia, from November 1, 2023, to
December 20, 2023.
Study Design
A facility-based cross-sectional study design was implemented.
Source Population
Healthcare workers working in all public health facilities in Qellem
Wollega Zone during the study period in 2023.
Sampling Unit
Selected obstetric care providers working in selected Qellem Wollega
Zone 2023 public health facilities.
Sample Size Determination
The sample size was determined by using a single population
proportion formula by using Epi- info version 7.2.2.2.6, taking the
expected frequency or prevalence of partograph utilization as 64.4% of
the study conducted in Buno Bedele zone (9), LOC 95%, design effect
1 and source population was 639. The calculated sample size was 263
plus 10% non-response rate. Since the source population was less than
10,000, a correction formula was used to estimate the final sample.
Sampling Technique and Procedures
The study participants were selected using simple random sampling
(lottery method) after the sample size was proportionally allocated to
each selected health facility.
Data Collection Tool and Procedure
A structured questionnaire was adapted from previous relevant
literature related to the problem under study to include all the possible
variables that address the study's objectives. The study participants

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were instructed on how to fill out the questionnaire. Six trained data
collectors collected data from all selected obstetric care providers; they
were trained for one day. Two trained BSc midwives were also assigned
to supervise and review a recently used partograph to check its
completeness.
Data Quality Control and Management
The questionnaire was structured. The investigators supervised close
daily; all incomplete data were identified, and corrections were made
immediately. Every piece of data was cleaned and coded before
entering the Epi Data version 4.6. Questionnaires were reviewed and
checked for completeness and clarity, and the necessary feedback was
given to the data collectors.
Data Analysis
The questionnaire was checked for completeness, coded, and entered
Epi Data version 4.6 and then exported to SPSS version 23.0 for
analysis. Binary logistic regression assessed any association between
the dependent and independent variables. Hosmer-Lemeshow was
performed to test the goodness of fit result (p >0.3).
Ethical Consideration
The Research and Ethical Review Committee of Dambi Dollo
University granted permission to conduct the study.
Results
Socio-Demographic Characteristics of Study Participants
The questionnaire received a response rate of 100%. The mean and
standard deviation of the respondents’ ages were 35.5 and ±7.841
years, respectively. Female participants account for more than half
(149, 51.6%). Most participants' educational status (51.9%) was at
degree level. Most respondents (65.1%) were from hospitals, and 108
(34.9%) were from health centers. Most worked ≥ 6 years 168 (58.1%),
followed by a range of 3-5 years (109, 37.7%).
Knowledge of Partograph of Obstetric Care Providers
The knowledge status of respondents on partograph utilization was
assessed using criteria such as those who responded 50% and above
on knowledge-related questions classified as having good knowledge.
In this study, 106(36.7%) participants knew about the definition of a

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partograph, 170(55.7%), components of a partograph, 158(54.7%),
when to plot on the partograph, how often it is used once active phase
of labor started 141(48.8%), cervical dilation followed 238(82.4%), the
importance of partograph 203(70.2%).
Attitude of Obstetric Care Providers toward Partograph
Utilization
Participants agreed on the beneficial effects of the partograph on
laboring women at 184 (63.75%); it alerts skilled birth attendants of
any deviation from normal strongly agreeing at 197 (68.2%); by using
a partograph, healthcare providers can identify problems, recognize
complications early, strongly agreeing at 221 (76.5%), and using a
partograph enables health care providers to perform essential basic
interventions strongly agree at 168 (58.1%), that using the partograph
misleads management as the progress of labor and the partograph
alert line are not aligned in most pregnant women strongly agree 178
(61.6%).
The attitude of obstetric care providers toward partograph utilization
was assessed using Likert scale questions and classified as positive and
negative after calculating the mean score. The mean score calculated
was 1.38, and those who scored 1.38 and more were classified as having
a positive attitude. More than half, 178(61.6%) participants, scored
1.38 and above and were considered positive toward partograph
utilization.
Partograph Utilization
The magnitude of partograph utilization among participants to
monitor labor for all laboring mothers was 159(55.0%) with 95% CI.
Respondents who were not using partograph routinely endorsed their
reason as absence of job training (30.4%), lack of supervision (29.0%),
shortage of staff (15.9%), and non-availability of partograph (10.4%)
in the labor ward.

Factors Associated with Partograph Utilization by Obstetric

Care Providers
Attitude towards partograph use (COR =1.657), knowledge of
partograph use (COR=2.796), and Sex (COR =3.02) were candidate
variables for the multivariate binary logistic regression model. Three

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variables were significantly associated with the multivariable analysis:
good knowledge, positive attitude towards partograph, and job
training for partograph. In this study, respondents with a positive
attitude towards partographs are 1.6 times more likely to utilize
partographs (AOR =1.657), and those with good knowledge are 2.7
times more likely to use partographs (AOR =2.796).
Discussion
According to this study, the overall utilization level of partographs was
159 (55.0%) 95% CI of (20.0, 40.3). This finding is higher as compared
with studies conducted in the North Shoa zone, Central Ethiopia
(40.2%), Gojjam (53.85%), West Shoa Zone (41.22%), and Amhara
(31%; BAR & 3(5):291). The reason might be that the Federal Ministry
of Health has set targets and is working for institutional skilled
delivery coverage at 90%, enabling all health facilities to use
partograph and provide all BEmONC functions (10). The findings of
this study were lower than studies conducted in Addis Ababa (57.3%),
Bale Zone (73%), Gambia (78%), South Africa (64%), and Ghana
(87%). The differences between these findings might be due to
differences in the level of knowledge of obstetric care providers (11).
This study also revealed that a lack of on-the-job training was one
factor in using a partograph. As stated in this study, participants who
received on-the-job training (221, or 76.4%) utilized a partograph. In
contrast, obstetric health care providers who didn’t receive on-the-job
training (49, or 16.9%) did not use a partograph routinely.

The main reason might be that obstetric care providers who received
on-the-job training on partographs had better information, skills, and
confidence about using them, improving their use. The current study
participant’s attitude towards partograph use was shown as follows:
169 obstetric care providers had a positive attitude towards partograph
use (61.8%). When we compare the study conducted in West Shoa
Zone, obstetric care providers’ positive attitude towards partograph
use was 68(21.25) (10). The overall knowledge of obstetric care
providers in this study showed that participants with good knowledge
of partograph-related questions were 158 (54.6%). This study was low
compared to the study conducted in Addis Ababa 511 (86%), (4). The
possible reason might be the knowledge that qualifies them to

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understand what critical labor progress will occur and decide on
another option, such as referral and caesarian section, which
encourage obstetric care providers to use partograph as a decision-
making tool (6).

In this study, participants' reasons for not using the partograph were
as follows: lack of training 88 (30.4%), lack of supervision 86 (29.8%),
staff shortage 46 (15.95), and unavailability of partograph 30 (10.4%).
When we compare the above reasons with the study conducted in
Addis Ababa, it is not similar except for the lack of training (99, 16.7%)
and the lack of supervision (20.4%). This indicates that obstetric care
providers may have a skill gap and need more supervision in the
recording of partograph charts by the concerned body.
Conclusion
This study found that partograph utilization was low, and incomplete
recording of required parameters was observed. Partograph utilization
was significantly associated with on-the-job training, knowledge, and
obstetric care providers’ attitudes toward partographs. Lack of
supervision, unavailability of partographs, and shortage of obstetric
care providers were reasons for low partograph utilization.
Recommendation
Qellem Wollega Zone Health Department
- It is better if obstetric care providers receive on-the-job training
on how to use the partograph.
Woreda Health Offices and Health Facilities
- Employing more midwives in the labor and delivery ward at all
health facilities.
- Always have preprinted partograph charts available in labor
and delivery rooms.
- Conducting close supervision and following up with senior
obstetric care providers is better.
Obstetric Care Providers
- Using partographs as a vital tool for diagnosing abnormalities
like prolonged and obstructed labor during the progress of
labor and as a decision-making tool to reduce maternal and
neonatal mortality and provide quality health care.

128
References
1. Haile. (2020). Partograph utilization as a decision-making tool and
associated factors among obstetric care providers in Ethiopia: a
systematic review and meta-analysis. 1–11.
2. Hailu, T., Nigus, K., Gidey, G., Hailu, B., & Moges, Y. (2018). Assessment
of partograph utilization and associated factors among obstetric care
givers at public health institutions in central zone, Tigray, Ethiopia. BMC
Research Notes, 11(1), 1–6.
3. Markos D, Bogale D. Knowledge and utilization of partograph among
health care professionals in public health institutions of Bale zone,
Southeast Ethiopia. Public Health. 2016 Aug;137:162-8..
4. Gebreslassie, G. W., Weldegeorges, D. A., Assefa, N. E., Gebrehiwot, B.
G., Gebremeskel, S. G., Tafere, B. B., Gebreheat, G., Gebru, T. T., Kiros,
D., Tekola, K. B., & Welesamuel, T. G (2019). Utilization of the
partograph and its associated factors among obstetric care providers in
the eastern zone of tigray, northern ethiopia, 2017: A cross-sectional
study.
5. Lavender T, Hart A, Smyth RM. Effect of partogram use on outcomes for
women in spontaneous labour at term. Cochrane Database Syst Rev. 2013
Jul 10
6. Desta, M., Mekonen, Z., Alemu, A. A., Demelash, M., Getaneh, T.,
Bazezew, Y., Kassa, G. M., & Wakgari, N. (2022). Determinants of
obstructed labour and its adverse outcomes among women who gave
birth in Hawassa University Referral Hospital: A case-control study.
PLoS ONE, 17(6 June), 1–14.
7. Tegegne, B. S. (2020). Utilization of Partograph and its associated factors
among midwives working in public health institutions, Addis Ababa City.
BMC Pregnancy and Childbirth, 20(49), 1–9.
8. Zelellw, D. A., & Tegegne, T. K. (2018). Level of partograph utilization
and its associated factors among obstetric caregivers at public health
facilities in East Gojam Zone, Northwest Ethiopia.
9. Wakgari, N. (2022). Factors Associated with Partographs Utilization in
Jimma and Bedele Zones, Oromia Regional State, Ethiopia. Texila
International Journal of Public Health, 153–165.
10. Tilahun, A. G., Gebeyehu, D. G., Adinew, Y. Y., & Mengstu, F. W. (2021).
Utilization of partograph and its associated factors among obstetric
caregivers in public health institutions of Southwest Ethiopia. BMC
Pregnancy and Childbirth, 21(1), 1–8.
11. Tesfaye, N., Tariku, R., Zenebe, A., & Woldeyohannes, F. (2022). Critical
factors associated with postpartum maternal death in Ethiopia. PLoS
ONE, 17(6 June), 1–23.

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Section III – Lesson from Innovation Experiences

130
Health Facilities Network of Care: Learning from Tulu Bolo
General Hospital and Bacho Woreda Health office
Authors: Engida Kabeta1, Dereje Moti1, Teka Degefa1, Tujo Dechasa1, Olana Jeldu1, Tadela
Efa1, Dereje Mosisa2, Milkesa Girma2, Erena Negesa2, Talga Kapitano2, Kenenisa
Gelena2, Tolosa Jaleta2, Gudeta Teresa2, Jote Ararsa3, Guteta Degefa3, Teshome
Olijira4
Affiliation: 1Tulu Bolo General Hospital, 2Bacho Worede Health Office, 3Southwest Shoa
Health Department, 4IHI

Abstract
Background: The NOC Innovation project designated Becho Woreda
as one of the care network sites. The members of this network at Becho
Woreda comprised the Becho Woreda health office, four health
centers, and Tulu Bolo General Hospital. We wanted to examine the
feasibility and effectiveness of NOC implementation strategies in our
context.
Methods: The NOC project was introduced in Woreda-based
networking, where health facilities providing maternal and newborn
health services were deliberately interconnected to function as one
unit providing client-centered care. Clinical bundle indicators were
measured using all or no adherence every month. A time-series
analysis using an annotated run chart was employed to assess the
effect of system-level interventions.
Interventions: Networked facilities signed MOU. The interventions
outlined in the MOU include hospitals providing clinical support
through mentorship visits, conducting outreach sonography
screenings, offering virtual consultations by senior clinicians,
equipping ambulances with emergency supplies, and implementing
refined protocols: clinical management, communication, transport,
and referral systems.
Results: Implementing the district health facilities’ care innovation
network has fostered collaboration among health facilities and
healthcare workers, enhancing health service delivery. Pre-referral
communication improved significantly from a baseline of 53% to an
average of 87%. Additionally, health center staff engaged in virtual
clinical consultations with senior physicians, increasing from 0% to an
average of 70%. These improvements have enhanced pre-referral
clinical management, reducing unnecessary referrals. At the Becho
district NOC site, the innovation reduced early neonatal deaths (from
18/1000 live births to 10/1000 live births).
Conclusion: Though further testing is ongoing, the network of care
model is a promising approach to considering health system
improvement and clinical outcomes at the primary healthcare level.
Keywords: Network of Care, District health facilities, Innovation

131
Introduction
Network of Care (NOC) is a group of public and private health service
delivery sites deliberately interconnected through an administrative
and clinical management model that promotes a structure and culture
that prioritizes client-centered, effective, efficient operation and
collaborative learning, enabling providers across all levels of care, not
excluding the community, to work in teams and share responsibility
for health outcome. Public facilities within the Woreda health office
will play a major role in cascading the Maternal and Newborn Health
(MNH) care delivery as a group to improve maternal and newborn
health outcomes by strengthening the functionality of the Networks of
care. The MNH NOC promotes a structure and culture prioritizing
client-centered, effective, and efficient care. MNH NOC aims to reduce
neonatal mortality and stillbirth rate by focusing on standardizing
basic care for ANC, delivery, and birth, as well as improving the
management of preterm labor, low birth weight, premature newborns,
newborn infection, birth asphyxia, and severe
preeclampsia/eclampsia.
Bacho District Network of Care is an excellent innovation for the
national health service because of the following points:
– Collaborate with health facilities in the district as one family
member to deliver quality healthcare service for the
community.
– Active senior physicians' involvement in the district Network
of Care
– Active Woreda and zonal political leaders' participation in the
district Network of Care
– Active community representative involvement in the district
Network of Care
Criteria
Becho Health Facilities Network of Care is a new idea developed and
implemented involving clinical leadership from Woreda and hospital,
administrative leadership from Zone and Woreda administration,
senior physicians, community representatives, and NGOs to deliver
standard quality health service at all facility levels with shared
responsibilities. /Innovation defined by Van de Ven (19860) /. In the

132
Network of Care, the facilities collaborate with startups and adopt new
approaches to stay competitive. These innovative work activities
started with capacitating staff at all levels with knowledge, attitude,
and practice, equipping ambulances with essential drugs and
equipment, conducting mobile obstetric U/S at health centers by
obstetricians, pre-referral management at health centers by virtual
consultation, training health center staff to do obstetric U/S by
obstetrician, mentoring and coaching and sharing resources.
This activity, in turn, solves problems related to drugs, referrals, and
relations between health centers and hospitals. This results in the
decrement of patient morbidity and mortality. /Innovation defined by
Covin and Slevin (1991), Knox (2002), Lumpkin, and Dess (1996) /. To
sustain the improvement and implement the action plan for the gaps
in the NoC activities, an executive committee conducts regular
meetings, onsite and offsite training is given to capacitate the health
professionals, and regular clinical audits and coaching are conducted
on quality healthcare service delivery. Innovation is defined by Brunet
(2015).
Objectives
– To work towards creating a shared purpose.
– To establish operational norms using standards and protocols:
clinical protocols, referral communication protocols,
transportation protocols, translating the standards to the
standard of care (answer who, when, how, and why);
– To engage and communicate with NOC communities
(members, partners, communities, clients, and their families),
including creating communication platforms (face-to-face and
virtual) and huddles.
– For capacity-building mentorship, coaching, training, and
workshops.
– For resource mobilization and sharing.
– For learning monitoring and knowledge management:
establish/strengthen structures for learning, monitoring, and
knowledge management; generate and share data; establish
visual boards; create platforms for learning and sharing

133
 (learning session, review meetings, supportive supervision);
problem-solving methods; and
– Strengthening the quality structures at each facility.
Methodology
NOC implementation followed the six steps.
Assessment: Continuous measurement of various aspects of
functional NOC will be initiated through a baseline assessment
process. Such assessments will be done to capture relevant data within
facilities and across facilities.
Co-design: NOC member sites will co-design on joint interventions
and create an agreement to work as a network with clear protocols and
SOPs to be followed.
Collaboration: With a signed MOU and based on findings from the
continuous assessment process, the NOC members will collaborate to
address the readiness of facilities for MNH service provision. Such
collaborations include resource mobilization, capacity building,
mentorship, and coaching.

Integration: NOC members will, as shown in the Figure: NOC

implementation cycle, provide care as one team for maximum
integration and coordination of service provision across the
continuum.

CQI: Continuous quality improvement will be applied within and

across facilities to improve evidence-based and patient-centeredness
of care provision. Processes and outcomes of care will be targeted for
improvement.

Learning and adaptation: Learning and adaptation for the NOC

will be facilitated through learning sessions, data sharing, and review
meetings led by senior physicians. These will help improve care
provision and outcomes across the NOC.

Results
Overall, the establishment of Becho district NOC collaborates with all
health facilities in Woreda to execute standard health service delivery

134
as one family. This resulted in an increment of pre-referral
communication from a line of 53% to an average of 87% (Figure 1) and
an increase in health center staff to senior physicians' virtual
consultation from 0% baseline to an average of 70% (Figure 2), which
improve pre-referral management and avoid unnecessary referrals.
Early neonatal death decreased from the baseline of 17/1000 live
births to 7/1000 live births by the end of September 2016 E.C (Figure
3). Stillbirth decreased from a baseline of 30/1000 total births to
16/1000 total births at the NOC site. There were no maternal deaths
or complications at the site during the implementation of the project.

120 Air time Landline

charging… telephone…
100

80

60

40

20 NOC…
0
23
23

3
23
23

3
2

22

22

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Proportion pre-referral communication Baseline Average

Figure 1: Proportion of pre-referral communication at Becho District

Network of Care

135
 Proportion of pre-referral management at health
centers by virtual consultation
100
Communication
90
channels created:
80 WhatApp group,
Regular review
70 avialing telephone for
meeting
60 consultations
50
40 NOC stablished
30 Siniar Clinians
20 engagement
10 MOU
0 signed

23
23

3
2

22

22

3
3

23
23

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Figure 2: Proportion of pre-referral management at HCs by virtual

consultation, Becho District NOC

Measure
Early Neonatal Death rate, Tulu Bollo General Hospital Median
35
Blende
30 d QI
Virtual and QI
consultation with training Staff… weekly ICU-
25 NOC facilities Maternity…

use of
20 plastic
wrapping
18.0
with…
15

10 Baseline 10.0
Data

5 MOU signed with NOC WHO

Standeri
zed IPC
facilities IKMC…
practice
0
Apr-22

Oct-22
Nov-22

Apr-23

Oct-23
Nov-23
Jun-22
May-22

Jul-22
Aug-22
Sep-22

Dec-22
Jan-23
Feb-23
Mar-23

Jun-23
May-23

Jul-23
Aug-23
Sep-23

Dec-23
Jan-24
Feb-24
Mar-24

Figure 3: Early Neonatal death rate at Becho District NOC

136
Conclusion
Though further testing is ongoing, the network of care model is a promising
approach to considering health system improvement and clinical outcomes
at the primary healthcare level.

Scale Up
As the testing process is still ongoing with promising results, documenting
what was learned during the implementation of the NOC model is the
cornerstone for future successful scale tests and full scale up.

137
 HIV/AIDS Performance Monitoring Information System
(HAPMIS)
Author: Getachew Chala Dab
Affiliation: Oromia Health Bureau

Introduction
HAPMIS is a web-based application designed, developed, and deployed to
capture, process, and store HIV/AIDS Clinical data/information, generate
reports, and manage dashboards online. It is an independent platform. It
is one of OHB's strategies in the information revolution endeavor, one of
the HST transformation agendas.

HAPMIS contains different subsystems like Service Delivery (SDP),

Appointment Spacing Model, Clinical System Mentorship (GSM), Cervical
Cancer Screening and Treatment, Gender-Based Violence (GBV), HIV Self-
Testing, Key Population (KP) (both FCS and PREV), License Renewal, Lost
To Follow-up (LTFU), Linkage Audit Summary, Mental Health Integration
(MHI), PFB ICT, Partner Notification Services, Positive Tracking, Pre-
exposure Prophylaxis, Social Networking Services (SNS), ART Initiation
Status, and others.

Problems Solved
By implementing this innovation, HIV/AIDS clinical data are collected,
organized, summarized, and reported promptly for decision-making at all
levels. In addition, it served as a data source for DHIS2/ DATIM and a
central HIV/AIDS clinical data management.

Criteria
Among the criteria for selecting this were relative Advantages, the alliance
of multiple functions into one system, better service, better quality,
decreased need for equipment and supplies, improved interface, increased
customizability, longevity, empowerment of users, improved customer
satisfaction, reduced users’ effort and environmental impact, increased
productivity, and saving of time, money, space, and storage.

138
Compatibility
Designed, developed, deployed, and used with all stakeholders’
existing lifestyle, knowledge, skill, attitude, and technology (hardware,
software, and connectivity).

Simplicity
Because HAPMIS is a web-based system like Google, Telegram,
Facebook, and so on, it is intuitive and simple for users to adapt.

Trialability
The trialability period of HAPMIS was too short. With 5-day training
for experts at OHB, Zone/Cities/Towns, and ART Sites, there was no
trial period.
Observability
– Side-by-side comparison – manual vs digital
– Before and after – before HAPMIS and after HAPMIS
implementation
– Testimonials – feedback from stakeholders with gratitude

Newness
Oromia is the only region using online HIV/AIDS clinical data
gathering, storing, analyzing, and providing for decisions from all ART
Sites.

Objectives
This innovation aims to facilitate online decision-making, improve
healthcare quality, enhance healthcare digitization service, and
increase productivity.

Methodology
Different techniques were used as methods in this innovation. These
are:
- Requirement identification and analysis were done.
- System designing (back-end, front-end, and middleware) were
employed.
- System development happened,

139
 - system testing and rectification was done, system installation,
configuration, securing, and deployment
– Document preparation (end-user manual, technical manual,
and SOP) has done
– Training (for HIV/AIDS Directorate Experts at OHB,
Zones/Cities/Towns, and data clerks and providers at ART
Sites) was provided
– The system was launched by OHB Management.

Results
450 ART Sites are using the system for HIV/AIDS clinical data
gathering, storing, analyzing, and reporting. All ART Sites use
HAPMIS as a data source for DHIS2 and DATIM.
– The fund is raised by CDC for OHB to support HAPMIS.
– Report developed (Ontime and updated reports, which include
detail reports, exception reports and summary reports, tabular
and visualized reports, and interactive dashboard)

Figure 1: Percentages of CXCA – screen and treatment

140
Figure 2: Percentages of TX-New Summary by sex and Coarse age
Conclusion
The Main Point of the Innovation Work (HAPMIS)is online data capture,
storage, analysis, and reporting for decision-making.
Potential Impacts will be
- Practicing information revolution
- Increased loyalty, access to service
- Enhanced reputation since (Monitoring and Evaluation Officers
(simple data analysis and presentation mechanisms)
- Data Clerks and Providers (Improved data quality since HAPMIS
can serve as the data source for both DHIS2 and DATIM)
- Improved service, productivity, customer satisfaction, and
community service quality and time.
Scale-up
HAPMIS is already accessible across the border both locally (within
the region) and nationally (across the nation) as well as globally to
those who have authentication and authorization (including CDC)
because it is web-based (online accessible system) as far as there is an
internet connection. However, for the system to be used as a national
health system, we are cordially working with the Federal Ministry of
Health and other regions. We are also working to assure and legalize
the patent and copyright of HAPMIS.

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 Health Regulatory Management Information System
(HRMIS)
Author: Getachew Chala Dabi
Affiliation: Oromia Health Bureau

Introduction
HRMIS is a web-based application designed, developed, and deployed
to capture, process, and store professional licensing (from application
to license generating), manage license status, generate reports, and
manage dashboards online. It also manages professional license
history (hardcopy) archival, converting it to softcopy. It is platform-
independent. It is one of OHB's strategies in the information
revolution endeavor, one of the HST transformation agendas.
HRMIS contains subsystems such as professional licensing archival
management, competency licensing archival management, new
license management, license renewal management, license upgrading
management, license replacement (in case of lost/damaged)
management, and others. HRMIS is accessed online by OHB
regulatory experts, zone/City/town regulatory experts, and applicants
(health professionals) as per their respective authentication and
authorization.
Problems Solved
- Hardcopy professional license and competency license
converted to softcopy
- Archival tracing is also automated
- Professional Licensing service quality is improved (24 hours to
get a license without moving from their home or workplace
and without incurring any cost)
- Health professional challenges to get professional licensing is
eradicated
- OHB regulatory image is changed
- Printing and stationary cost for Professional Licensing is
eradicated
- Bureaucracy and corruption are minimized
- Los/damage of professional and competency licensing
documents is eradicated
- Health professionals’ cost is eradicated

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 - Community healthcare service quality is improved.
- Unnecessary queue for Professional Licensing at OHB is
eradicated.
- Zero-cost revenue is generated
- Responsibility and accountability are improved
- Complicated customer and service routes (workflow)
minimized
- Central data management
Criteria
Relative Advantages
- Alliance of multiple functions into one system
- Better service
- Better quality
- Decreased need for equipment and supplies
- Improved interface
- Increased customizability, longevity
- Empowerment of users
- Improved customer satisfaction
- Reduces users’ effort and environmental impact
- Increased productivity
- Saving time, money, space and storage
- Less bureaucracy and corruption
Compatibility
- Designed, developed, deployed, and used with all stakeholders’
lifestyles, knowledge, skills, attitudes, and technology
(hardware, software, and connectivity). The bureau incurred
zero cost to design, develop, deploy, and use the system.
Simplicity
- Because HRMIS is a web-based system like Google, Telegram,
Facebook, and so on, it is intuitive and simple for users to
adapt.
- Trialability—The HRMIS trialability period needed to be
longer. After five days of training for experts at OHB and
Zone/Cities/Towns, the trial period ended, and the system
started full service within one month.

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Observability
- Side-by-side comparison – manual vs digital
- Before and after – before HRMIS and after HRMIS
implementation
- Testimonials – feedback from stakeholders with gratitude
Newness
- HRMIS is a new online professional licensing system (without
customer physical contact) as a nation in the health system.
- Oromia is the only region using online professional licensing
without health professionals’ physical availability.

Objectives
The objectives of this innovation were to:
- Digitize existing hardcopy professional and competency
licenses
- Minimize service and customer routes to get a professional
license
- Eradicate health professionals’ challenges to get their
professional licensing
- Improve regulatory service quality
- Minimize bureaucracy and corruption
- Save customers time, and money
- Improve healthcare quality service since health professionals
never move from their routine duty to get a professional
license
- Enhance healthcare digitization service
- Increase regulatory experts’ productivity and
- Save space and storage for all stakeholders.

Methodology
- Requirement identification and analysis
- System designing (back-end, font-end and middleware)
- System development
- System testing and rectification
- System installation, configuration, securing, and deployment
- Document preparation (end-user manual, technical manual
and SOP)

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 - Training (for regulatory experts at OHB and
Zones/Cities/Towns)
- Launching the system by OHB Management

Results
The 73,889 professional licenses of health professionals and 6,107
competency licenses of facilities’ records of health professionals are
digitized and indexed. From nine thousand twenty-one licensed
applications, 5,667 new, 1,815 renewal, 1,247 upgrades, 286
designations and replacements. From 9311,391 Licenses with CPD, of
which were renewed.
Different reports were produced, such as
- Ontime and updated reports (detail reports, exception reports,
and summary reports)
- Tabular and visualized reports
- Interactive dashboard

Figure 1: Percentages of licensed professional license report by

application category

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Figure 2: Percentages of licensed professional license report by
application category and CPD

Figure 3: Percentages of income from professional licensing service

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Figure 4: Percentages of CXCA – screen and treatment

Conclusion
Main Points of the Innovation work (HRMIS) were:
o Professional and competency license archival digitization
and indexing
o Online application for professional licensing (New, Upgrade,
Renewal, Replacement, Designation and Letter of Good
Standing)
o Online approval of professional licensing (New, Upgrade,
Renewal, Replacement, Designation, and Letter of Good
Standing)
o Online Professional Licensing Service Payment and Approval
The potential Impacts sought for OHB were:
o Exercising the information revolution practically
o Increased loyalty, access to service
o Enhanced regulatory services and reputation
o Minimized bureaucracy and corruption
o Saved hardcopy storage staff, including shelves and rooms
o Saved stationary and other related costs

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 o Health Professionals (saved time and money, eradicated
challenges of bureaucracy and corruption, avoided
unnecessary moves from their chores and services for the
community, saved from theft and robbery on journey, and
on-spot service from OHB)
o Improved service quality, productivity, customer
satisfaction, community service quality, and time
Scale-up
HRMIS is already accessible across the border both locally (within the
region) and nationally (across the nation) as well as globally to those
who have authentication and authorization because it is web-based (an
online accessible system) as far as there is an internet connection.
However, for the system to be used as a nation's health system, we are
cordially working with the Federal Ministry of Health and other
regions. We are also working to assure and legalize the patent and
copyright of HRMIS.

148