This document summarizes a quality improvement initiative implemented in Ethiopia to strengthen referrals and integration between community and health facility services. The Strengthening Ethiopian Urban Health Program piloted the initiative in one health center, establishing a quality improvement team of health center staff and community health workers. Their goal was to increase referral feedback from 43% to 90%. Through interventions like orientation, file folders for referrals, and supportive supervision, they achieved their goal and saw a large increase in total referrals and feedback over time. The initiative demonstrated the benefits of integrated teamwork and quality improvement approaches. Next steps include expanding and institutionalizing the approach.

1. Strengthening ReferralsandIntegration ofCommunity
andFacilityHealthServices through Quality
Improvement
​Yonas Yilma
​Durban, South Africa
​February 20, 2018

2. BACKGROUND  Strengthening Ethiopian Urban Health Program
(SEUHP) is funded by USAID and
implemented by John Snow, Inc.(JSI)
 Support the Ethiopian Health extension
program in 49 major towns
 In August 2015 , SEUHP in collaboration with
the local health office piloted QII in Jinela HC
in Harar town.
 QI initiative intend to improve referral
feedback and linkages between facility-based
primary health services(HC) and community-
based health extension program (UHEP)
 Implement model for improvement using a
PDAS approach through establishing QI team
(QIT)

3. 1. Discuss with the stakeholders: Includes the
regional health bureau, city/town health office, and
health center management
2. Form QI team: Consist of HC staff, urban
health extension professionals (UHE-ps), and UHE-
ps supervisors and led by HC head.
3. Capacity building: Provide training on basics of
QI
4. Implement: QIT Identify and prioritize
improvement objectives, identify and analyze root
causes the problem, plan and execute
interventions
5. On-the-job support and follow up: Support
the QI team as they implement QI plan
6. Monitor implementation: Hold review
meetings to assess the progress, and what’s
working well; re-plan and set improvement
objectives as needed
IMPLEMENTATION
STEPS

4. QIT support
and follow up
Fish bone analysis for
prepared by QI team
for the identified
problem.
QI Monitoring
Visit by SEUHP
staff

5. INTERVENTION
 Piloted in Jinela HC in August 2015
 Improvement objective: To increase referral feedback from 43% to
90% over seven months.
 Major interventions include:
 Conducted baseline assessment and developed action plan
 Provided orientation for HC staff on QII
 Avail file folder at each department for filing of referral and
feedback slips
 Referral feedback's collected weekly
 QIT meet monthly and review the progress
 HC staff provided supportive supervision and coaching for UHE-
ps
 Facilitated experience-sharing visit
 Organized team building events and provided certificates of
recognition

6. IMPROVEMENTS
OBSERVED
 The mean average of referral cases
increased from 7 to 32.9, an increase
from the baseline of more than four folds
 As of April 2016, four HCs in Harar are
implementing QI interventions and
promoting collaborative learning
 The quarterly average of referred cases
and feedback increased by 4.1 (104 to
428) and 2.5 (99 to 227) times from the
baseline, respectively
 QII motivates clients to take referral slips
and value their importance, believe the
HC become more welcoming, and
encourages acceptance of UHE-ps
services by community the and HC staffs.

7. 7
20
27
39 40
33
28
43
3
13
25
38 38
31
27
41
0
10
20
30
40
50
Aug'15 Sept'15 Oct'15 Nov'15 Dec'15 Jan'16 Feb'16 Mar'16
The trend in the number of referral and
feedback in Jinela Health Center, QII pilot,
HararTown
Total ≠ of referal Total ≠ feedback
43%
65%
93%
97% 95% 94% 96% 95%
90%
Aug'15Sept'15 Oct'15 Nov'15 Dec'15 Jan'16 Feb'16 Mar'16
Percent of referral feedback
% of referral with feedback Goal Line (90%)

8. 104
321
283
607
500
99
268
173
294
274
0
100
200
300
400
500
600
700
Jan-Ma'16 Apr-Jun'16 Jul-Sep'16 Oct-Dec'16 Jan-Ma'17
The trend in the number of referral and feedback of 4
HCs since QII scale up in Harar town
Referral Referral Feedback
3 HC
Added

9. LESSONS
LEARNED
 The QIT creates an opportunity
for UHE-ps integrate and work as
a team with HC staff
 Commitment, team spirit, and
ownership of the QIT are vital for
success
 Clients are more motivated to
take referral slips and started
valuing the referral
 Functional QIT motivated UHE-ps
to do more

10. NEXT STEPS  Work with the FMOH to prepare
community-based quality
improvement implementation guide
 Arrange advocacy meeting at all
levels to align the QI initiatives with
the government’s priorities
 Engage the quality improvement
process owner/team already
established at the regional level
 Strengthen review meetings,
experience sharing, and recognition
of the best performing QIT

11. THANKYOU
YonasYilma
yonas_yilma@et.jsi.com
This project is made possible by the support of the American People through the United
States Agency for International Development (USAID).The contents of this presentation
are the responsibility of John Snow Inc. (JSI) and do not necessarily reflect the views of
USAID or the United States Government.