Bringing management strategies to Ethiopia’s hospital system

In December 1995, Elizabeth H. Bradley, M.B.A., Ph.D. ’96, professor of public health, received a call from the William J. Clinton Foundation about a project in Ethiopia. Because she had never been to Africa and wasn’t an expert on global health issues, her first thought was, “Who can I triage this call to?”

But two weeks later, when foundation representatives visited Yale and discussed the Ethiopian Hospital Management Initiative, Bradley concluded, “I guess I have something to offer.” The project involved improving hospital management systems—an area in which Bradley is an expert.

The foundation chose Ethiopia because the need there is great and government officials wanted to focus on improving health. The reputation of Yale’s hospital administration and health management programs made the university a logical choice for partnering with the foundation.

Bradley, who is director of Yale’s Health Management Program in the Division of Health Policy and Administration, was formerly an administrator at Massachusetts General Hospital. When she came to Yale, she and Harlan Krumholz, M.D., M.Sc., the Harold H. Hines Jr. Professor of Medicine and professor of epidemiology and public health, demonstrated how hospitals could shorten “door-to-balloon” time—the crucial period between a heart attack patient’s arrival at the hospital and the restoration of blood flow through angioplasty.

The goal of Bradley’s Ethiopian project is similar: to improve the quality of health care through better management practices. During two visits to the country, she found that the hospitals lacked a set of reliable systems. “The hospitals have limited patient registration systems, incomplete medical records and inadequate inventory controls,” she said.

Whereas Ethiopia’s population is about one-quarter the size of that of the United States, it has only 2 percent the number of hospitals. The World Health Organization standard is to have one health worker for every 10,000 people, but in parts of Ethiopia the ratio is one to 50,000. A scarcity of supplies, low salaries and patients who can rarely pay for their care add to the challenge.

Bradley hopes to institute the “fundamental elements” of good hospital management, including triage systems, inventory management and improved infection prevention practices.

To implement these measures, she assembled a team of 23 Yale-Clinton Foundation fellows in international health care management, who have been working side by side with Ethiopian hospital medical directors and managers for 10 months. She received more than 150 applications worldwide for the 23 slots. The successful applicants had hospital administration and public health experience, with master’s degrees in public health, health administration or business. After an orientation at Yale, the team left for Ethiopia in July 2006. A subset of the fellows will continue for a second year.

Bradley’s team administered a baseline assessment of 100 management indicators to Ethiopian hospitals before the program began. These included the percentage of staff with job descriptions and performance evaluations, whether nurses were trained in standard practices, and the percentage of medical records that could be retrieved on readmission. The average score was 60 percent.

When the project ends, another assessment will determine whether the management methods were implemented and, if so, what impact they had.

But Bradley already sees evidence that the program is working. “Now, when you walk down the hall of one of the hospitals, it’s not unusual to hear the medical director and nurses using terms like ‘fishbone diagrams,’ ‘flow charting’ and ‘quality improvement.’ ”