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Hospital Leadership, Management and
Governance
Contents
Section 1 Introduction .................................................................................................................................. 2
Section 2 Operational Standards ................................................................................................................. 4
Section 3 Practices of Leadership, Management and Governance Practices............................................. 5
Section 4 Implementation Gguidance ........................................................................................................ 28
Section 4. Performance Indicators............................................................................................................. 41
Source Documents ..................................................................................................................................... 52
Section 1 Introduction
Effective hospital governance is imperative for ensuring the delivery of high-quality, efficient,
and impactful healthcare services that cater to the needs of the served population. The hospital
board, as the authorized body entrusted with providing strategic direction and overseeing the
hospital's overall operations, plays a crucial role. Concurrently, the management committee is
tasked with executing managerial functions within the hospital.

Hospital leaders must possess a comprehensive skill set to strategically guide and manage the
institution, facilitating collaboration with external stakeholders and the local community. They
are expected to offer clear vision and drive necessary changes to enhance service quality,
proactively addressing emerging challenges.

The Federal Government of Ethiopia, through its Health Care Financing Strategy, has established
a legislative framework aimed at empowering hospitals with enhanced autonomy and
decentralized authority. Consequently, hospitals have instituted governing bodies such as the
Hospital Board (HB), the hospital Management Committee (MC), and Chief Executive Officers
(CEOs)/Chief Executive Directors (CEDs) to provide strategic direction, oversee operational
coordination, and manage functions, respectively. In alignment with the national Health Sector
Investment and Development Plan, hospitals develop and implement their own strategic, long-
term, medium-term, and operational plans. They also engage in revenue generation and various
activities to enhance healthcare service quality.

However, several hospitals face challenges in effectively exercising their governance

responsibilities. Common obstacles include deficiencies in leadership and managerial skills,
unclear delineation of roles and responsibilities between the board and management committee,
lack of vision and focus, insufficient accountability and functionality, delays in decision-making,
inadequate resource mobilization and utilization, and suboptimal implementation.

To address these challenges and ensure the long-term vitality of hospitals in pursuing their
mission, the hospital board and management committee must strive to achieve strategic goals and
objectives effectively. This necessitates hospital leadership possessing the requisite skills to
navigate the dynamic and rapidly evolving healthcare landscape. Emphasizing good governance
in healthcare, all levels of leadership, including the governing board, management committee,
and operational leaders, must acquire comprehensive knowledge and proficiency in their
respective mandates, leadership practices, management principles, and governance protocols.
Specifically, the hospital governing board should adeptly engage in a mission-driven and people-
centered decision-making process that entails;
 Setting strategic directions and objectives for the hospital

 Making policies, rules, regulations, or decisions

 Mobilizing and deploying resources to accomplish the hospital’s mission, strategic goals,
and objectives;
  Overseeing the work of the hospital to achieve its mission

In parallel with the aforementioned challenges, the hospital governing board and management
committee are tasked with devising strategies to effectively achieve strategic goals and
objectives while enhancing the long-term sustainability of the hospital to fulfill its mission. Both
entities require a comprehensive skill set to effectively direct, manage, and lead the hospital
amidst the dynamic and evolving healthcare landscape. To promote good governance in
healthcare, it is imperative for hospital governing boards, senior management teams, and leaders
at all levels to enhance their knowledge and proficiency in leadership practices, management
principles, and governance protocols. By becoming more knowledgeable and skillful in these
areas, hospital leadership can better navigate the complexities of healthcare governance and
ensure the delivery of high-quality, efficient, and impactful healthcare services that benefit the
population served.

This chapter describes the operational standards, implementation modalities, and tools to help
achieve the above stated strategic goals and objectives.

Section 2 Operational Standards

1. The hospital has a functional Governing Board mandated to provide strategic leadership
2. The hospital has a functional management committee that runs the overall function of the
hospital
3. The hospital increases resource generation and improves efficiency
4. The hospital establishes accountability mechanisms
5. The hospital has mechanisms and practices to continuously improve the quality of healthcare
6. The hospital accords adequate attention for implementation of projects, Programs, reforms
and initiatives
7. The hospital has a regular capacity building program for governing board members and
senior managers in accordance with High Impact leadership Program for Health.
8. The hospital board provides guidance and promotes good ethical practice
9. The hospital has created a link between the hospital and its catchment health centers.
Section 3 Practices of Leadership, Management and Governance
Practices

Leadership, management, and governance are interdependent, reinforce each other, interact in a
balanced way and overlap among the roles to serve a purpose and to achieve a desired result.
Effective leadership is a prerequisite for effective management and governance. Leaders need to
know how to scan, focus, align/mobilize, and inspire workforces. Managers need to know how to
plan, organize, implement, and monitor and evaluate. People who govern must know how to
cultivate accountability, engage stakeholders, set shared direction, and steward resources.
Working together and supporting all aspects of a hospital, these practices lead to improved
hospital performance, which, in turn, leads to better health outcomes.
Leadership Practices
Effective leadership practices are essential for guiding staff towards achieving results that meet
the needs and preferences of clients while addressing the interests of key stakeholders. By
providing comprehensive support, frontline staff delivering healthcare services can identify
obstacles to service quality, initiate improvements, and effectively serve clients. To uphold a
high impact leadership and foster a culture of excellence, the following guiding principles and
practices must be considered:
a. Scanning: Continuously gather up-to-date knowledge about management practices to
understand how one's behavior and values impact others, as well as staying informed
about staff, hospital operations, and the external environment.
b. Focusing: Direct the efforts of staff towards achieving the organizational mission,
strategy, and priorities, ensuring alignment with overarching goals.
c. Aligning and Mobilizing: Coordinate and mobilize stakeholders' and staff's time,
energy, as well as material and financial resources to support organizational goals and
priorities effectively.
d. Inspiring: Encourage and inspire staff to remain committed and engage in continuous
learning to adapt and improve their practices continually.

Management Practices
Effective management practices are crucial for ensuring that operational plans and reporting
structures are clear and aligned with organizational priorities. Staff members benefit from
feedback on their work through appraisal, supportive supervision, and monitoring and evaluation
systems that provide timely and reliable information. To effectively manage a hospital, managers
must maintain continuous attention to ensuring that healthcare services consistently meet high-
quality standards to meet clients' needs.
To facilitate effective decision-making, optimize resource utilization, and drive continuous
improvement in hospital management processes, the following guiding principles and practices
should be considered:
a. Planning: Develop plans outlining how to achieve results by assigning resources,
accountabilities, and timelines. Hospitals are required to have both a strategic plan and an
annual plan approved by the governing board. In Ethiopia, the Civil Service Reform
Program mandates public bodies to utilize the Balanced Scorecard (BSC) approach for
planning, a strategic planning and management system aimed at aligning everyone in an
organization towards a shared vision and strategy.
b. Organizing: Establish structures, systems, and processes to effectively execute the plan.
c. Implementation: Execute activities efficiently, effectively, and responsively to achieve
defined results and objectives.
d. Monitoring: Monitor and evaluate achievements and results against plans, continuously
updating information and using feedback to adjust plans, structures, systems, and
processes for future results.

Governance Practices

a) Cultivate Accountability
Cultivating accountability within a hospital setting involves several key strategies:
a. Enhancing Personal Accountability: Governing body members must demonstrate personal
accountability by attending meetings and completing assigned tasks promptly and with high
quality, recognizing their responsibility in managing resources for the common good.
b. Enhancing Internal Corporate Accountability: Internal transparency fosters employee loyalty
and collaboration. The hospital board should facilitate:
 A free flow of information within the organization,
 Encourage calculated risk-taking by acknowledging effort and courage even when
desired outcomes are not met, and
 Provide clear guidance to staff on goals and tasks for which they will be held
accountable, while allowing autonomy in accomplishing them without
micromanagement.
 Monitor the consistent implementation of Managerial Accountability in the hospital.

c. Enhancing External Corporate Accountability: External accountability is strengthened by

internal transparency and accountability. To establish effective external accountability, the
governing board should:
 Establish mechanisms such as hospital-community forums to communicate expected
standards, goals, and targets to the public.
  Ensure Mechanisms in place to hold responsible parties (board members, management
committee, and staff) accountable for failing to meet expected standards or to reward
them for exceeding standards.
 Establish a process where governance leaders, management, and staff are required to
defend their actions, answer questions, and explain themselves to the public and
stakeholders. Periodic community and hospital partnership forums can also serve as
platforms for accountability and transparency.
b) Involvement- Engage with staff, Community and Stakeholders
Involvement in engaging with staff, the community, and stakeholders is pivotal for effective
hospital governance:
a. Engaging Community, Civil Society, and Stakeholders: Building coalitions and networks
across government levels, community, civil society, and various sectors is vital as actions beyond
the health sector influence health determinants. Hospital governing boards and management
committees should:
 Foster partnerships with relevant ministries and bureaus to improve public health, such as
health, women and social affairs, environment, education, agriculture, and trade.
 Establish alliances with other hospitals and networks to facilitate joint action.
 Create community-hospital forums with clear action plans and trackable reporting
mechanisms, ensuring inclusivity in decision-making processes.

b. Addressing the Health Needs of Socially Disadvantaged Communities: Governance bodies

should proactively involve socially disadvantaged groups in decision-making processes to
address their health needs. This entails:
 Collaborating closely with communities at district and Kebele levels, as well as their
associations/organizations, to understand and address their health needs.
 Ensuring that the needs of socially disadvantaged communities are regularly assessed and
integrated into hospital plans and strategies.

c. Engaging with Staff and Senior Clinicians: Staff engagement is enhanced when they have
involvement in decision-making processes, leading to a sense of value, respect, and support.
Similarly, involving senior clinicians is crucial for improving services. The board and
management committee can enhance engagement with clinicians by:
 Establishing platforms for senior clinicians to contribute to service improvement
(Implementation of Clinical Leadership Improvement Program (CLIP).
 Aligning common goals, such as enhancing outcomes and efficiency.
 Making clinicians partners in quality improvement initiatives.
 Involving them from the inception of projects.
 Recognizing and encouraging champions among them.
c) Setting a Shared Direction
Setting a shared direction involves reaching a consensus on the desired 'ideal state' everyone
aims to achieve. Without agreement on this endpoint, devising approaches to reach it becomes
challenging. Establishing a common direction facilitates garnering support for the planning
process, assessing readiness, and defining strategies to realize the vision. This shared vision
enables the creation of a comprehensive action plan with measurable goals and establishes
accountabilities to ensure its accomplishment.
d) Stewarding Resources
Stewarding resources entails raising, mobilizing, and allocating them ethically, fairly and
efficiently to deliver high-quality, affordable, and appropriate services that improve public
health. Good stewards ensure proper resource utilization, advocate for maximizing health
outcomes, and use evidence-based decision-making. Hospital board members are responsible for
1. Defining resource requirements,
2. Sourcing them from diverse channels, and
3. Overseeing their prudent utilization by managers, clinicians, and staff.

Continuous governance enhancement involves a dynamic commitment to improving governance

practices through strategies such as
 Governance orientation and training,
 Regular governance assessments, and the development and monitoring of improvement
plans

Systems and Processes for Effective Leadership, Management and Governance

A. Healthcare Kaizen
Kaizen can be defined as a set of principles and specific practices for continuous improvement.
At a high level, kaizen is a process that, ideally engage everybody in identifying problems or
opportunities for improvement and then involves them in identifying, testing and evaluating
improvements in a scientific and iterative way. Kaizen is rigorous without being bureaucratic.
Kaizen is built upon the improvement cycle of PDSA or Plan, Do, Study and Adjust (sometimes
called PDCA or Plan, Do, Check and Act). In Kaizen PDSA cycle, employees, co-workers and
managers:
 Plan: Identify a problem or opportunity, understand the current situation and cause of the
problem and brainstorm various actions that can be taken.
 Do: Perform a small test of change aimed at making a quantitative or qualitative
improvement in a system.
 Study: Honestly evaluate the effectiveness of the action and use if created any unanticipated
results or any side effects.
 Adjust: based on the evaluation, one can choose to adopt the change or adjust it in some way,
or the change might be abandoned altogether. With kaizen, participants can go back to the
plan stage, to try again, without shame.
The following are key principles of kaizen:
 Continually improve.
 No idea is too small.
 Identify report and solve individual problems.
 Focus change on common sense, low-cost and low-risk improvements, and not major
innovations.
 Collect, verify and analyze data to enact change.
 Problems in the process are a major source of quality defects.
 Decreasing variability in the process is vital to improving quality.
 Identify and decrease non-value-added steps.
 Every interaction is between a customer and a supplier
 Empower the worker to enact change
 All ideas are addressed and responded to in some way.
 Decrease waste.
 Address the workplace with good housekeeping discipline.
B. Scientific Method of Problem Solving
See the Ethiopian Hospitals Clinical Audit Guide and Tools and the High Impact Leadership
Training Participant Manual for Frontline and mid-level leaders for the Scientific Method of
Problem-Solving approach that integrates the strategic function of leadership, involving goal and
objective setting with the subsequent organizational action required to achieve the set objectives.
Governing Board
A well-functioning Governing Board, that includes representatives from the hospital’s
community, can have a significant impact on the quality and efficiency of the hospital service
and its daily performance.
The establishment of a Governing Board builds in two essential characteristics for good
hospitals:
 Autonomy to do what is necessary to provide good care and
 Accountability to those served for the results of that care.
Governing Boards must be committed to creating and maintaining a strong bond between the
hospital and the community it serves and maintaining a good working relationship with higher
government authorities.
Responsibilities of the Governing Board
The following sections set out the basic principles related to the establishment, responsibilities
and operating mechanisms of Governing Boards. More detailed information on the specific
powers and duties of Governing Boards within each region and Federal hospitals are described in
the Health Service Delivery and Administration Proclamations, Regulations and Directives of
each Region and Guidelines for Management of Federal hospitals.

The roles and responsibilities of the board include:

A) Determine the organization’s mission, vision and values

It is the Governing Board's responsibility to create and regularly review a statement of vision that
articulates the organization’s goals and values, but should be in line with the stated mission.
 Mission statement can be defined as ‘purpose, reason for being’ or simply ‘who we are
and what we do’.
 A Vision statement can be defined as ‘an image of the future we seek to create’.
B) Establish corporate policies
 The Governing Board should ensure that corporate policies (such as policies for staff
recruitment and retention, for income generation and expenditure, for quality assurance
etc.) are available to govern the operations of the facility.
C) Ensure effective organizational planning
 Governing Boards must actively participate in an overall organizational planning process
including examining and approving the strategic and annual plans of the hospital, and
ensuring that such plans are in accordance with the mission, vision and values of the
hospital and aligned with local, regional and national health sector priorities and targets.
D) Direct and supervise the overall activities of the hospital
 Governing Boards must monitor progress towards the goals and targets of the strategic
and annual plans.
E) Provide proper financial oversight
Providing proper financial oversight involves the following key responsibilities for the
Governing Board:
 Review and Approval of Annual Budget and proper financial controls to monitor its
utilization and ensure that the hospital operates within its budgetary constraints.
 Compliance with Financial Regulations: This entails ensuring compliance with Federal or
Regional financial rules and regulations regarding revenue retention and utilization.
 Oversight of Financial Audits: The Governing Board must oversee both internal and
external financial audits as required by legislation.
F) Ensure adequate resources
 The Governing Board must identify what constitutes adequate resources for the hospital
and ensure the effective means to access these resources.
 The Board and management committee must devise strategies and the means to improve
revenues and diversify the source.
o Such mechanisms could include fee revision, outsourcing of activities or the
establishment of private wings in accordance with the Regional financial rules
and regulations.
G) Oversee Implementation of Health Financing reforms
To effectively oversee the implementation of health financing reforms, the Governing Board and
Management Committee must ensure the proper execution of reforms aimed at enhancing the
sustained provision of quality health services, promoting equity in access, ensuring financial
protection, and establishing efficient and sustainable financing within the hospital/sector.
Key responsibilities include:
 Overseeing the proper implementation of health financing reforms, reimbursement of
expenses, resources management, maximizing retained revenue and allocation of
resources.
H) Oversee quality management activities
The Governing Board must ensure:
 Hospital services are provided to the highest possible standard.
 Systems are in place for monitoring and evaluating the quality and outcome of patient
care, customer services and use of resources.
 Appropriate mechanisms and activities to minimize risk, to identify and correct problems,
and to identify opportunities to improve patient care and services.
I) Oversee the implementation of national level hospital initiatives
 The Governing Board must closely monitor the implementation of national level hospital
initiatives.
 Incorporate these initiatives into the hospital’s annual plan, and monitor their
implementation through regular reports and observation visits.
J) Set strategies to balance the public private partnership
 It is the responsibility of the Governing Board to ensure that the public hospital should
leverage technical capabilities available only in the private hospitals, and that the private
hospitals should not engage themselves in practices that compromise the quality of
services in public hospitals.
 The Governing Board should oversee the outsourcing of clinical and non-clinical services
to the private vendors.
K) Select the Chief Executive Officer
 Governing Boards must ensure that the most qualified individual is appointed to the
position of Chief Executive Officer (CEO), following the processes set out in Federal or
Regional Directives.
L) Support, monitor, and assess the performance of the CEO
 The Governing Board should ensure that the performance of the CEO is assessed at least
biannually by the Board or appointing authority.
 Should the CEO fail to meet the expectations of the Governing Board, his/her
employment should be terminated, following the processes described by Federal or
Regional Directives.
M) Provide orientation for new Board members and ensure ongoing education for
existing members
 All Governing Boards should participate in ongoing education to assist members to carry
out their role in the hospital.
 For newly appointed board members, there should be a planned orientation program that
ensures members understand their responsibilities.
N) Review effectiveness of its own performance (Conduct Leadership audit)
The Governing Board should periodically and comprehensively evaluate its own performance,
taking into consideration areas such as:
 Regularity of and attendance at Board meetings
 Knowledge, skills and awareness of Board members on hospital operations, finance, on
key issues affecting the hospital and any national, regional and local health priorities
 Approval of the strategic and annual plans by set deadline
 The relationship between the Governing Board, CEO and hospital Senior Management
Team
 The relationship between the hospital and communities served by the hospital
 Engagement with the wider stakeholders such as woreda, zonal and regional health
departments and any local health partnerships
O) Ensure legal and ethical integrity and maintain accountability
 The Governing Board is responsible for ensuring adherence to legal standards and ethical
norms.
 It ensures that activities of the hospital are carried out with transparency and
accountability and that all required reports are submitted to higher authorities (e.g., RHB,
BOFED, FMOH, and MOFED) in accordance with government requirements.
P) Ensure community involvement in hospital service planning and delivery
 The Governing Board should ensure that mechanisms are established to enhance the
involvement of patients and the public in the planning, services delivery, and monitoring
phases.
o The governing board should establish hospital-community forums and conduct
them at least every quarter.
Q) Enhance the organization’s public standing
 The Governing Board should clearly advocate the hospital's mission, vision, values
accomplishments and goals to the public and garner support from the community.
Membership of Governing Board
A robust governing board engages in macro-level management rather than micromanagement,
and it consists of members who:
 Act on behalf of the community as a whole;
 Are interested and committed to serve as a board member;
  Have a variety of expertise as a collective whole, including finance, administration,
public health, government bureaucracy, legal and marketing;
 Maintain high ethical principles, integrity and competence;
 Deliver results while using resources wisely;
 Are hospital leaders;
 Commit the time required for meetings, dialogue, etc;
 Subscribe to the principles of accountability for themselves and others;
 Prioritize the benefits of the hospital rather than personal benefits;
 Are participatory in planning, decision-making, and activities; and
 Declare any conflicts of interest and excuse themselves from any decisions that have
immediate benefit for themselves, their families or their business interests.
A) Appointment of Board Members
The rights, roles and responsibilities, tenure of the board members, rules and procedures, for the
appointment of Governing Board members are described within Federal and Regional
Proclamations, Regulations and Directives. Usually, Boards are comprised of between 5 to 7
members, or as specified in Federal and Regional Directives. Governing Board members should
be residents of the area where the hospital is established. Additional factors to be taken into
consideration when appointing board members include:
 Due consideration to gender and professional mix,
 Community representation, and
 Professional efficiency, time and experience that will enable the Board member to
contribute to the improvement of the health sector.
B) Tenure of Board membership
The tenure of service of Board members should be between 3-5 years, and Board members may
serve a maximum of two terms, as determined by Federal and Regional Directives. The specifics
should be outlined in the TOR of specific Hospital’s governing board.
C) Revocation of Board membership
The membership of any Board member should be revoked when:
a) The Board member has no interest to continue membership. In such circumstances the Board
member should give one to two months advance notice (as determined by Federal and Regional
Directives) in writing to the Board Chairperson and RHB Head or Minister of Health;
b) The Board member changes residence address or leaves the office he/she represented;

c) In the case of people’s or employees’ representative if the Board member loses the faith of
his/her constituency and a request is made by the constituency to replace him/her; or

d) The Board member has failed to fulfill the duties of his/her membership. This includes
considerations such as:
i. Repeated absence from Board meetings without sufficient reason
ii. Proven corruption such as earning benefits in the health facility other than the legally
permitted benefits or other corrupt practice

iii. Repeated failure to follow up on actions agreed by the Board

iv. Breach of confidentiality

 In such cases, the Board should reach consensus that membership should be revoked and
should make this recommendation to the RHB Head or Minister for Health who will
reach a final decision on the matter.
 If a Board member leaves office during his/her period of tenure the remaining Board
members should select one or more possible replacements and nominate the candidate(s)
to the RHB or FMOH or the appointing authority to make the final appointment.
D) Duties and responsibilities of Board members
Board members have a duty to:
a) Attend ordinary and extraordinary meetings, respecting the time;

b) Accept and implement a decision passed by the majority;

c) Prepare for each meeting by reading agendas, minutes of the previous meeting and other
documents distributed for consideration;

d) Follow up on any actions agreed by the Board in a timely manner; and

e) Maintain confidentiality on all matters discussed by the Board.

E) Board accountability
 Board members have individual and joint responsibility for the decisions they pass and
are responsible individually and jointly for any damage caused to the hospital due to their
failure to accomplish the duty entrusted to them.
  In the event a Board member solely opposes a decision or an agenda for discussion,
he/she may explain the reason for his/her unique opposition and make it noted on the
minutes. He/she shall not be responsible for any damage occurred due to this decision or
agenda item.
 Governing Boards are accountable to their respective HB, ZHO/Sub-City HO, or WorHo.
or to the FMOH and should meet all expectations places on the Board.
F) Allowance for Board members
 Reimbursement of expenses for Board members and allowances for Board duties should
be provided as established by Federal and Regional Directives.
Officers of the Governing Board
The Governing Board should appoint three to five Officers, who form the Executive Committee
of the Board.
Officers of the Board include:
a) The Chairperson

b) The Vice-Chairperson
c) The Secretary
Roles of the Chairperson of a Governing Board
The Governing Board should be led by a chairperson, who is appointed by the RHB or FMOH or
appropriate appointing authority from among the Board members. The main responsibilities of
the Chairperson are to:
A) Preside over the Board
 The Chairperson should chair Board meetings and direct the overall functioning of the
Board.
 The Chairperson should take the lead in clarifying the goals of the Governing Board.
B) Convene and facilitate board meetings and set meeting agendas
 The Chairperson must:
 Ensure regular and extraordinary Board meetings take place in compliance with the
periods prescribed in Federal or Regional Directives.
 Ensure meetings are conducted in a professional manner and are constructive for both the
hospital and the individual Governing Board members.
  Oversee the development of a well thought out agenda and supporting materials in
collaboration with the CEO.
 Be expected to ensure that all members arrive fully prepared to participate in Governing
Board meetings.
 Possess the skills to clarify, summarize, and guide Governing Board members toward
decisions, while also allocating time at the end of the meeting for feedback on its
effectiveness.
C) Manage Governing Board structure
 The Chairperson should create, in collaboration with the CEO, a structure that supports
the mission and work of the Governing Board.
o Where appropriate he/she should establish standing committees to undertake
specific functions of the Board.
In addition to the above, an effective Chairperson will:
1. Understand the organization:
The Chairperson must have an expert understanding of the hospital’s history, mission, current
role, finances, program and services, and staff. He/she must also be knowledgeable of any
external forces that affect the hospital’s inner workings, making certain to execute any health
policies as required by the appropriate government body.
2. Know his/her own responsibilities and authority as Chairperson
By understanding his/her own responsibilities, the Chairperson serves as a model for other
Governing Board members to follow. The Chairperson’s real authority and influence rests in
how he/she develops and manages relationships with the rest of the Governing Board and staff.
3. Create a safe environment for decision making
The Chairperson should take the lead in establishing the tone for shared decision making by
inviting participation, encouraging varying points of view and promoting an open and honest
exchange of ideas about issues.

4. Build a working culture

The Chairperson should encourage a participatory working culture that focuses on collective
responsibility and accomplishment.
5. Cultivate future leadership and develop succession Plan
It is essential that the Chairperson is capable of cultivating and nurturing Governing Board
members who have expertise and personal qualities that the hospital needs. He/she must be able
to prepare Governing Board members and hospital senior management for future leadership,
which requires encouraging periodic self-assessment and preparing succession plan in order to
highlight Governing Board members’ strengths and leadership possibilities.
6. Communicate with the Governing Board through an effective information system
Providing information about hospital operations is an essential responsibility of the Governing
Board Chairperson and CEO. Materials for Governing Board and committee meetings should be
distributed in advance of the meeting to allow time for review by members. Establishing a
reliable system to distribute information at other times is also important, for regular, interim
updates and in the event of unexpected matters that demand Governing Board attention.

7. Maintain a productive relationship with the CEO and the appropriate government
body:
Maintaining productive relationships with both the CEO of the hospital, plus the appropriate
government body, are extremely important. It requires clarity of roles, trust, honesty and frequent
communication.
Roles of the Vice Chairperson of the Governing Board
 The Vice Chairperson is appointed from among Board members and acts on behalf of the
Chairperson in the Chairperson’s absence.
Roles of the Secretary of the Governing Board
The Secretary of the Governing Board is appointed from among Board members. This position
could be filled by the hospital CEO. The Secretary is responsible for taking minutes of Board
meetings. Minutes should be reviewed and approved by the Chairperson before distribution to
Board members.
Procedures of Board meetings
The main purpose of Board meetings is to ensure effective governance of the hospital. This
includes developing, deliberating and approving strategic and annual plans, monitoring
implementation, discussing and approving corporate policies and addressing any legal and
ethical issues that arise. Board meetings are also an opportunity to provide structured education
sessions for Board members on emerging issues concerning the hospital and/or the community it
serves.
(NB: General guidance/etiquette to ensure that any type of committee or meetings function
effectively are presented in Appendix D.)
A) Frequency of Board meetings
It is recommended that during the first year of establishment the Governing Board meets once
every month to become familiar with its own responsibilities, with the hospital and the health
sector in general. Thereafter the Board should develop a schedule whereby the Board meets no
less than the frequency set out in Federal or Regional Directives. Extra-ordinary meetings may
be convened should a matter of particular importance arise. Such meetings will be convened
upon the decision of the Chairperson, or if called for by a minimum of one-third of Board
members.
B) Agenda items
The agenda should be set jointly by the Board Chairperson and Hospital CEO. All Board
members should be invited to nominate agenda items for consideration by the Chairperson and
CEO. The agenda and any documents for discussion at the meeting should be distributed to
Board members at least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the Board:
a) Approval of previous meeting minutes;
b) Committee reports;
c) CEO’s report – providing an overview of hospital operations, discussion of pressing
issues and immediate concerns;
d) Old business – issues unresolved from last meeting;
e) New business – any issues Governing Board members want to raise; and
f) Next steps – plans for taking action on decisions reached by the Board, with the
assignment of follow up responsibilities to individuals as appropriate.

C) Decision making
Decisions by the Board should be made by majority vote. In the case of a tie the Chairperson has
the deciding vote. Voting may only take place when a full quorum of Board members is present.
A vote passed by less than a full quorum is invalid. The criteria for a full quorum vary from
Region to Region (from 50% + 1 of Board members to 2/3rd of Board members) and are
described in Federal and Regional Directives. The CEO is an ex officio Board member and
hence has no vote on the Governing Board.
Governing Board standing committees
The Governing Board should assign standing committees to carry out specific functions of the
Board and report on their activities to the full Board. As a minimum the following standing
committees should be established:
a) Executive committee
b) Finance committee
c) Audit committee

Other standing committees may be established on a temporary or permanent basis as the need
arises (for example a CEO selection committee, strategic planning committee, quality assurance
committee or a committee to address an emerging clinical matter).
When selecting members for each committee the following principles should be followed:
a) Committee members should be selected from the current Board members
b) Selection should be transparent and fair, without favoritism of any kind
c) The Governing Board Chairperson should be a member of all committees
d) Each committee should have its own chairperson who will preside over the actions of the
committee
e) Hospital staff, representatives of appropriate external bodies (e.g. MOF or Woreda Health
Office) or prominent members of the community with an active interest in the hospital
and appropriate professional expertise (e.g. an accountant for the Finance committee)
may be appointed as non-voting members to support the functions of the committee
A) Executive Committee
The Executive Committee should be chaired by the Governing Board Chairperson and should be
comprised of Officers of the Board and all key Governing Board committee chairpersons. The
Committee acts on behalf of the full Governing Board in their absence and is responsible for
reporting to the full Governing Board on such actions.
B) Finance Committee
The Finance Committee oversees the hospital’s financial planning and ongoing financial
operations to ensure the viability of the hospital. This includes monitoring that adequate funds
are available for the organization’s financial plan, safeguarding hospital assets, and ensuring that
the hospital has adequate fiscal policies. Moreover, the Finance Committee must anticipate
financial problems by reviewing hospital financial information provided at regular intervals. The
Finance Committee should be comprised of selected Governing Board members, the hospital
Finance Head and possibly representatives from the Regional or Woreda Bureaus of Finance and
Economic Development and business leaders from the local community. Other than those
individuals who are members of the hospital Governing Board, all finance committee members
have no voting rights.
C) Audit Committee
The Audit Committee should make sure that all required financial audits are conducted and that
reports are presented to appropriate bodies. The committee should be chaired by the Treasurer of
the Governing Board and comprised of selected Governing Board members, the hospital internal
auditor, the Finance Head and possibly representatives from the Regional or Woreda Bureaus of
Finance and Economic Development or a respected local accountant with knowledge of
bookkeeping and auditing. Other than those individuals who are members of the hospital
Governing Board, all audit committee members have no voting rights.
Chief Executive Officer
Selection and Appointment of the CEO
Each hospital should be managed by a CEO who is appointed by the Governing Board or
appointing authority following the processes set out in Federal or Regional Directives. A
qualified CEO should have a diverse set of leadership and management skills, as well as
considerable healthcare/hospital experience as either a clinician or management professional.
He/she must be capable of working with diverse groups, such as the Governing Board, various
community groups, government officials and hospital staff, patients and families. He/she should
be able to think strategically to provide vision and direction to the hospital with special attention
to professional development. An individual with an entrepreneurial spirit and who is fiscally
responsible will be valuable to the organization. He/she should be a results-oriented leader with
an eye for understanding how to improve the quality of patient care.
Roles and responsibilities of CEO
The CEO is the highest-ranking management officer in the hospital and as such, directs and
administers the activities of the Hospital in accordance with instructions and plans developed by
the Governing Board. The CEO must ensure that decisions of the Governing Board are
implemented effectively and efficiently throughout the hospital and must ensure the efficient
planning and utilization of all hospital resources in order to achieve the organization’s goals.
This entails the management of human resources, supplies, revenues, and physical and capital
assets based on detailed plans developed for all aspects of the hospital’s operations. CEO
responsibilities should be described in a job description developed by the board that clarifies the
expectations of performance and boundaries of his/her responsibilities. Areas of responsibility
include:
A) Governing Board development, communication and relationships
The CEO collaborates closely with the Governing Board and any Standing Committees, assisting
them by providing relevant information to enable effective and efficient performance of their
functions. Serving as the Governing Board's secretary, the CEO promptly communicates any
issues or risks impacting the hospital. Furthermore, the CEO works with the Board to organize or
facilitate trainings for Governing Board members to ensure they possess the necessary skills for
their roles.
B) Planning, monitoring and evaluation of hospital operations
The CEO is responsible for preparing hospital strategic and annual plans and presenting them to
the Board and relevant higher authorities for approval. It is the CEO's duty to effectively
implement these plans and achieve the outlined strategic goals, including all hospital
improvement initiatives. Additionally, the CEO must provide the Board with regular
performance and financial reports, indicating progress towards the objectives of the strategic and
annual plans, with specific emphasis on any areas of concern. Furthermore, the CEO ensures
timely submission of any required reports to higher authorities, such as Woreda, Zonal, or
Regional Health & Finance Departments.
C) Budgeting

The CEO should prepare and submit the budget of the hospital to the Board for approval. After
approval the CEO should maintain the hospital budget within the agreed upon parameters,
effecting payments in accordance with the approved budget and plans. In partnership with the
Governing Board, the CEO is also responsible for designing various mechanisms to increase
hospital revenue such as:
  Revenue collection and utilization procedures
 Outsourcing non clinical services to improve the overall quality of care,
 Establishing, organizing, and controlling private wing health services
 Community contributions, donations of any kind.

The CEO should ensure that financial audits are performed in accordance with government
requirements and submitted to the Board for approval, and subsequently to the appropriate higher
authority in a timely manner.
The CEO should ensure that any recommendations made by internal or external financial audits
are acted upon appropriately.
D) Development of hospital management committee and other structures
Each hospital must maintain an organization chart delineating hospital functions and personnel,
including reporting structures. Developed by the CEO and senior management, this chart
requires approval from the Governing Board. A proficient CEO identifies capable staff members
to share workload responsibilities and delegate specific powers and duties to hospital employees
as necessary. The CEO is accountable for establishing an effective Senior Management Team to
oversee daily hospital operations and may establish additional committees as needed. Ensuring
each committee has clearly defined membership and responsibilities, and ensuring their
functional efficacy, falls under the CEO's responsibility
E) Personnel management and development
The CEO should strive to empower and advance the professional capacity of hospital staff and
ensure:
 The recruitment and retention of a qualified workforce that enables the hospital to
discharge its activities.
 An Employee Manual and incentive schemes are developed and submitted to the Board,
and should implement these upon approval.

F) Quality of care
 The CEO should establish mechanisms to measure the quality of care and establish
programs to continuously strive for improved levels of quality.
 The CEO should ensure that patients’ rights are respected by all staff.
G) Regulations compliance
  The CEO should oversee compliance with all relevant regulations from government
bodies.
o Such regulations may include safety regulations, employment regulations, and
finance and audit regulations among others.
H) Management of hospital buildings, campuses and physical assets
 The CEO should establish and meet goals for the maintenance and improvement of
hospital buildings and campuses and all physical assets including medical equipment and
vehicles.
I) Public Relations: community, governmental and professional audiences
 The CEO is the chief spokesperson for the hospital’s various audiences and should
represent the hospital in its dealings with third parties.
 The CEO should strive to enhance the reputation of the hospital by strengthening
relationships with the community, government and professional audiences.
J) Professional development
 The CEO should keep current with emerging issues and technologies and ensure that staff
members are also kept current in these areas through training, access to resources, and
related opportunities.
K) Strengthen and improve good governance practice of the hospital
 The CEO should identify major public concerns and challenges of the staff and strive to
solve through developing a ‘quick wins’ plan.
L) Leadership
 The CEO is responsible for establishing and enhancing leadership presence throughout
the hospital and fostering leadership practices across all levels of management.
o This is achieved by properly planning and executing high impact leadership
program at the hospital level and inspiring the hospital's vision and serving as a
role model in all aspects of leadership.
Accountability and evaluation of the CEO
The CEO is accountable to the Hospital Governing Board, and is the only staff member under
the direct supervision of the Board. Evaluations of the CEOs performance should be conducted
at least every six month by the Board and/or appointing authority. Evaluation criteria should be
based on the job description of the CEO. Annual performance expectations should be spelled out
at the beginning of each year in discussion between the Governing Board Chairperson, or
appropriate member of the appointing authority, and the CEO.
If the Governing Board is concerned about the CEO’s performance at any time it should use the
evaluation criteria to address these concerns. The discussion can lead to goals for performance
improvement in the future. If these concerns have been addressed in the past and no
improvements have been made, the discussion may ultimately lead to the termination of
employment of the CEO following the process described by Federal or Regional Directives.
Relationship between CEO and Governing Board
The CEO and the Governing Board Chairperson must effectively manage their relationship to
ensure optimal hospital operations. While the CEO bears primary responsibility for maintaining
a professional, courteous, and informative relationship, defining the organization's leadership,
the Chairperson's role is temporary, given their defined terms of service as an appointed
volunteer. The CEO, as the hired professional, plays a crucial role in continuity during
Chairperson Successions, working alongside successive Chairs to uphold organizational stability.
With the Governing Board as the ultimate authority overseeing the hospital, the CEO serves at
their pleasure and that of the Chairperson. Attending to the Chairperson's needs and directives is
the CEO's duty, and fostering a constructive relationship relies on mutual understanding of each
other's strengths, weaknesses, management/governance styles, and respective responsibilities.
The CEO must garner support from the Chairperson on matters vital to the hospital and its
community, enabling collaborative design of strategies endorsed by the Governing Board for
implementation within the hospital.

Section 4 Implementation Guidance

4.1. The hospital has a functional governing board mandated to provide strategic leadership
The Hospital Board provides strategic direction for ensuring quality and equitable healthcare
within its jurisdiction, guided by the Health Service Delivery and Administration legal
frameworks established by the Ministry of Health (MOH), Ministry of Education (MOE), and
relevant regional or City Administrations. With oversight of the hospital's overall functioning,
the Hospital Board actively engages the local community to foster a sense of ownership among
community members and hospital staff. This engagement facilitates decentralized decision-
making, allowing public hospitals to address concerns promptly. Moreover, the establishment of
the Hospital Board prioritizes gender balance and professional diversity. At least half of the
Board members, or a minimum of two members, should be women, and members from various
sectors must be selected based on the hospital's specific needs and contextual factors.
Additionally, the Hospital Board should have by-laws detailing operational procedures and a
code of conduct for Board members. These guidelines ensure effective discharge of the Board's
powers and duties
4.2. The hospital has functional management committee that runs the overall activities of the
hospital
The Hospital Management Committee (HMC) is an integral part of hospital governance,
established to advise and support the hospital CEO/D in making decisions on pertinent hospital
issues. While the Hospital Governing Board provides strategic guidance, the HMC is responsible
for overseeing day-to-day activities.
The HMC formulates strategic and operational plans based on directives from the hospital board,
incorporating SWOT analysis to drive fundamental improvements in healthcare provision. It is
crucial for the HMC to coordinate and manage hospital operations efficiently to achieve
organizational objectives.
Additionally, the HMC conducts periodic assessments to explore innovative approaches for
enhancing health services and achieving hospital objectives. Regular monitoring of plan
implementations enables the HMC to identify successes and areas for improvement, facilitating
timely adjustments for enhanced plan implementation
The roles and responsibilities of the HMC include:

 Prepare strategic and annual plan including the budget approved by GB

 Advice and support the hospital CEO/CED
 Support lower structures of the hospital during planning
 Regular performance evaluation
 Regular management meeting

Department based Sub-Quality Improvement taskforce

Achieving the objective of providing quality health services requires collaborative efforts from
health facilities, particularly hospitals, and various departments within them. To ensure
adherence to national and global health service standards, the hospital board and management
committee must prioritize the establishment of modern data generation, management, and
utilization systems. Additionally, adequate attention should be given to continuous capacity
development of hospital staff to facilitate necessary quality improvements. This includes not
only formal trainings but also fostering skills and knowledge transfer among senior and junior
staff through in-house mentoring and coaching initiatives.
Role and responsibility of department-based Sub Quality Improvement taskforce
 Prepare service area based annual plan
 Conduct clinical audit
 Conduct Regular performance evaluation, identify gaps, prepare quality improvement
plan and actions

4.3. The hospital increases resource generation and utilization

The scarcity of resources poses a significant challenge to the provision of quality health services
in hospitals, leading to limitations in the supply of essential items such as drugs, medical
supplies, and equipment, primarily due to financial constraints. It is the responsibility of the
Hospital Board (HB) and Management Committee (MC) to provide effective leadership aimed at
continuously augmenting hospital resources to enhance healthcare quality.
One approach to address financial resource constraints is by increasing revenue retention and
utilization within hospitals. According to the Health Service Delivery and Administration
(HSDA) legal framework of the Ministry of Health (MOH), regional governments, and City
Administrations, Revenue Retention and Utilization (RRU) is designated as a budgetary addition
to the hospital's treasury allocation. It is crucial to ensure that RRU does not replace or reduce
the government-allocated treasury budget; rather, it should supplement it in accordance with
government financial regulations.
Therefore, it is imperative that the HB and MC prioritize the continuous augmentation and
efficient utilization of retained revenue. The focus should not only be on increasing the absolute
amount of retained revenue but also on allocating a higher proportion towards activities that
significantly enhance healthcare quality, such as improving the availability of drugs, medical
supplies, and equipment.
Furthermore, the HB and MC should engage partners and stakeholders, including the local
community, to increase hospital resources. To achieve this, they need to devise mechanisms,
develop plans, and implement strategies to generate additional financial and non-financial
resources from partners and the broader local community.
4.4. The hospital establishes accountability mechanisms
The Hospital Board and Management Committee bear responsibility for decision-making, crucial
for ensuring efficient resource allocation and overall hospital operations. To uphold
accountability, the hospital must establish an accountability mechanism, assessed through:
 Adherence to hospital rules and regulations.
  Allocation of adequate budget by the Governing Board (GB) and Management
Committee (MC) to enhance quality of care through resource-efficient utilization.
 Review and corrective action based on external audit findings by the GB and MC.
 Periodic self-evaluation by the GB and MC, followed by corrective actions as necessary

4.5. The hospital has mechanisms and practices to improve the quality of healthcare
Ensuring quality healthcare remains the primary objective of our health system. While
significant progress has been made in recent years, there remains a need to further enhance the
delivery of quality health services. Quality challenges are particularly prominent in hospitals,
with clinical quality governance identified as a key challenge during the Health Sector
Transformation Plan Implementation (HSTPI) and beyond. The Hospital Board (HB) and
Management Committee (MC) play vital roles in addressing this challenge by fostering
continuous improvement in healthcare quality. To achieve this, the HB and MC are expected to:
 Include quality issues as a standing agenda item and monitor progress against the
approved quality strategy/plan of the hospital using quality outcome measures.
 Regularly review major outcome measures:
o BOR/IPD Admission
o Referral Rate
o Satisfaction Rate
o Surgical Volume
o OPD Visits/OPD Per Capita and
o Mortality Rate.
 Consider additional quality outcome measures based on the hospital's specific
contexts and needs

4.6. The hospital accords adequate attention for implementation of projects and initiatives
Various reforms and initiatives have been implemented to enhance the accessibility, equity,
quality, and sustainability of the health system. These include the Health Insurance (HI)
Program, Health Care Financing reforms, and the Motivated, Competent, and Compassionate
(MCC) health workforce initiative. Additionally, hospitals independently undertake projects such
as new construction, expansion, renovations of existing infrastructure, and the adoption of new
technologies.
Health Care Financing
The Health Care Financing Reform, also known as the first-generation health care financing
reform, is a major initiative within the health sector aimed at achieving multiple objectives.
These include generating sustained additional resources for health, enhancing the utilization of
available resources, improving equity in healthcare provision, and fostering community
ownership of public health facilities through local community engagement in decision-making
processes. Implemented across all public health facilities over several years, this reform has
yielded significant improvements.
It remains a key strategic objective of the Health Sector Medium-Term Development and
Investment Plan (HSDIP), requiring continued attention from the Hospital Board (HB) and
Management Committee (MC). The HB and MC are tasked with providing clear directives and
making timely decisions related to generating additional resources, improving the utilization of
these resources for quality improvement activities, and enhancing other components of the
Health Care Financing reform.
Health Insurance
Health Insurance (HI) represents the second generation of health financing reform in Ethiopia,
aimed at improving access to health services and protecting households and individuals from
catastrophic health expenditure. Its main objectives include reducing or eliminating payment for
health services at the point of service, increasing health service utilization, and improving health
outcomes. Founded on the principle of solidarity, HI ensures that the healthy support the ill, and
the better-offs support the indigents. Effective implementation of HI enhances health service
utilization and safeguards households and individuals from financial hardship, ultimately
contributing to the country's vision of achieving Universal Health Coverage (UHC) by 2035.
The Hospital Board (HB) and Management Committee (MC) play crucial roles in providing
leadership and guidance for the successful implementation of HI, particularly by enhancing the
quality of health services. These reforms and programs necessitate specific attention from the HB
and MC to ensure their proper implementation. Without adequate attention, the quality of these
reforms may be compromised, resources could be misused, and desired objectives may not be
achieved. Therefore, the HB and MC should establish mechanisms to objectively review the
implementation status, identify gaps, and take timely corrective actions.
Furthermore, the HB and MC are expected to closely monitor recommendations and feedback
provided by regulatory bodies, and prepare work plans to improve implementation based on
these recommendations. This proactive approach will ensure the effective and efficient
implementation of HI and other related reforms and programs within the hospital setting
4.7. The hospital has a regular capacity building program for governing board members
and managers (Implemented through High Impact leadership program for Health)
Capacity building for board members, management, and health leaders at all levels is essential to
achieve hospital objectives effectively. Board members must understand health strategies,
reforms, and initiatives aimed at providing equitable, high-quality healthcare without financial
hardship. They should comprehend the hospital's mission, values, strengths, and limitations to
transform service delivery effectively.
Similarly, Management Committee (MC) members and leaders need a mutual understanding of
health policies, strategies, standards, laws, and initiatives to fulfill their roles. Formulating
evidence-based long-term and operational plans requires improved implementation capacity at
all levels.
The MC should assess training needs, allocate budget in consultation with the board, and conduct
capacity-building activities. These activities may include training in various centers, CPDs,
online courses, and collaboration with stakeholders like professional societies and the Ministry
of Health.
Furthermore, hospitals can enhance their implementation capacity through networking and
sharing experiences with best-performing hospitals via platforms such as the Ethiopian Hospitals
Alliance for Quality (EHAQ
4.8. The board and the management committee provide guidance and promote good ethical
practice
Measuring performance and appraisal system
Creating conducive working environment and implementing mechanisms to motivate the health
workforce are crucial for achieving hospital objectives. The Hospital Board (HB) and
Management Committee (MC) continuously strive to improve working conditions and safety,
objectively assess staff performance, and recognize top performers while providing support to
those who need improvement. To achieve this, the HB and MC must establish clear plans for
objectively assessing overall hospital performance, including individual staff performance.
Hospital leadership is responsible for setting transparent and objective criteria for recognizing
top performers and regularly evaluating service areas' overall performance. This includes
objectively assessing staff performance, recognizing top performers, and providing support for
staff who require improvement on an ongoing basis.
4.9. The hospital has created a link between the hospital and its catchment health centers.
Hospitals and health centers play vital roles in providing healthcare services to individuals and
communities. While hospitals offer specialized and advanced medical care, health centers
provide primary care services that are accessible and affordable for underserved communities.
Strengthening the link between hospitals and catchment health centers improves the quality of
health services by fostering synergy, enhancing resource utilization, and improving health
outcomes.

Collaboration between these facilities ensures patients receive comprehensive, coordinated care
addressing both immediate medical needs and long-term health goals. Moreover, this
collaboration improves community health outcomes by addressing social determinants of health,
promoting preventative care, and enhancing patient care coordination and management.
Source Documents

1. Addis Ababa City Administration Health Bureau. (2009, January). Directive No. 1/2001
issued to provide for the execution of Addis Ababa City Government Health Services
Provision and Health Institutions Administration and Management Regulation No. 26/2001.
Addis Ababa: Addis Ababa City Government.
2. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 117/ 2005.
3. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 39/ 2006.
4. Department of Health. (1999, March). Clinical Governance, Quality in the New NHS.
London: Department of Health.
5. Department of Health. (2009, January). The NHS Constitution for England. London:
Department of Health.
6. Federal Democratic Republic of Ethiopia Ministry of Health. (2007). The Health Sector
Development Program Harmonization Manual.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, July). Policy, Business
Process Reengineering: Policy, Planning and Monitoring & Evaluation Core Process.
8. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Strategic Plan for Ethiopian Health Sector.
9. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Indicator Definitions. HMIS/M&E Technical Standards Area 1.
10. Federal Democratic Republic of Ethiopia Ministry of Health. (2007, May). HMIS/M&E.
Disease Classification for National Reporting. Technical Standards Area 2.
11. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
HMIS Procedures Manual: Data Recording and Reporting Procedures. HMIS/M&E
Technical Standards Area 3.
12. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Information Use Guidelines and Display Tools. HMIS/M&E Technical Standards Area 4.
13. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
14. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, June). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
15. Federal Democratic Republic of Ethiopia Ministry of Health. Data Collection Guide for
Healthcare Quality Assessment.
16. NHS Quality Improvement Scotland. (2005, October). Clinical Governance and Risk
Management: Achieving safe, effective, patient-focused care and services.
17. Oromia Regional Government Administrative Council. (2005). Oromia Regional State
Health Service Delivery and Administration Regulation No. 56/ 2005
 Chapter 2

Liaison, Referral and Social

Services Management
 Table of Contents

Section 1 Introduction
Section 2 Operational standards
Section 3 Implementation Guidance
3.1 Reception Service
3.2 Liaison Service
3.2.1 Admission and Discharge Process
3.2.2 Hospital Bed Management
3.3 Referral Service
3.3.1 Receiving Inpatient Referrals
3.3.2 Coordinating referral out cases
3.3.3 A feedback loop to track referrals
3.4 Hospital Based Social Work Service
3.5 Ambulance Service Management
Source Documents
Annexes
Annex I, Combined Liaison Register of Referrals Out/In
Annex II, Liaison Combined Instructions
Annex III, Liaison and Referral Office Report
Annex IV, Ministry of Health National Referral Form
Annex V, Ministry of Health National Referral Feedback Form
Annex VI, Basic Ambulance Service Medical Equipment and Supplies List
Annex VII, Advanced Ambulance Service Emergency Equipment and Supplies List
Section 1: Introduction
Liaison, referral processes and hospital based social services pave a way to efficient flow of
patients with in services and between hospitals. Properly designed and implemented Liaison,
referral processes and hospital based social services will reduce patient waiting times, increase
provider efficiency, staff/ client satisfaction as well as improve overall quality of care. Providing
psychotherapy as part of the psychosocial service will further improve the satisfaction.

Incorporating technology shall also be part of the care continuum and the initiation of web based
referral system will improve lots of obstacles related to patient referral and overall health care
delivery system. All hospitals are expected to provide 24/7 a liaison, referral and social services
throughout the year. A well-organized liaison and referral office composed of adequate human
recourse, equipment and technology.

This chapter details with management structures, roles and responsibilities of reception, liaison,
referral and social services. It also includes the processes of admission and discharge, hospital
bed management and ambulance services.
Section.2. Operational Standards for Liaison, Referral and Social Work Services

1. The Hospital has established liaison, referral and social service management structures

2. The hospitals provide 24/7 a liaison, referral and social services throughout the year.

3. There is a known and adhered written protocol for admission and discharge of patients.

4. The hospital established efficient bed management System

5. The hospital implements Referral Service Directory.

6. Standard referral system is in place

7. The hospital provides holistic social services

8. The hospital established an efficient ambulance service management system

Section 3. Implementation Guidance
3.1. Reception Service
A patient’s experience at a hospital is often impacted by their first encounter. Therefore, it is
critical that a patient’s reception at the gate is a positive experience. Reception personnel should
be stationed close to the main gate and at main service entry sites (e.g. Card room, outpatient
department, IPD, EOPD, Lab, Imaging and Pharmacy etc) to direct patients or visitors to the
appropriate location in the facility by providing appropriate information and support.

The number of reception staff differs based on the complexity of the hospital but at least a
minimum of two receptionists should be available. Reception staff should be easily identifiable
(by uniform or identification badges). There should be a system (manual or electronic) to track
admitted patients whereabouts (Ward, Bed No etc.) and deliver information to visitors.

Reception staff‘s ability to communicate additional local language would be a plus so as to

deliver appropriate information or to direct a patients/visitors to the right track. The reception
staff should be knowledgeable of the services provided by the hospital, the staff that provides
services (case team leaders etc.), and the layout of the hospital. He/she is directly responsible
(accountable) to the Liaison office. Reception staff should ascertain the following from each
patient and direct the patient accordingly to where the services are available.
1. Is the patient an emergency?
2. Is the patient a labouring mother?
3. Is the patient having an appointment for a follow-up clinic?
4. Is the patient having an appointment for admission?
5. Is the patient a private wing service client?
6. Did the client come for non-medical reason
3.2 Liaison Service
Liaison service was introduced during the implementation of BPR in Ethiopian Hospitals. It is
vital for effective communication and sustainable smooth flow of patients that need to be
operated by liaison officers with special training for the position. Based on the capacity/patient
load of the hospital can set the number of liaison officers. At least two liaison officers (BSc or
MSc in nursing) and two runners per shift. The liaison office should be equipped with,
Computers, Office furniture (chair and table), Wheelchair, Stretcher, Telephone (direct line and
Mobile) and Shelve.

The hospital should provide liaison services 24 hours a day and 7 days a week throughout the
year. Each health facility should establish a liaison and referral and service that is responsible to:

 Coordinate the overall referral activities, ambulance services, bed management and a
regular patients’ appointments within the health facility
 Manage waiting lists and communicate patients when the service is available
 Records and reports the referral activities, bed census and ambulance services to facility
management
 Compiles, analyses and interprets referral data to improve the referral service
 Involvement in the quality assurance programs of the referral system by participating in
referral forum within and outside the health facility
 Update catchments, and service directory regularly
 Communicate referring and receiving facility
 Ensure proper utilization of ambulances
 Ensure patients that are transported with ambulance are escorted with health
professionals/paramedics
 Send and receive all referral in and out based on the service directory and availability of
patient bed
 Ensure feedback is sent to referring facility
 Receive feedback from receiving facility and take corrective action/ report to concerned
body
 Coordinate all admission and discharge processes.
3.2.1 Admission and Discharge Process
Effective and coherent admissions and discharge policy for emergency and elective patients are
very important for proper utilization of hospital beds. Based on admitting physician’s
recommendation liaison officer should coordinate beds for admission

Emergency Admission process

Ideally the emergency patient’s length of stay should not be greater than 24 hours. Emergency
patients should be admitted, discharged or referred after stabilization. If the patient is to be
admitted as an inpatient, a clinical member of emergency case team should contact the liaison
officers. Then transfer to ward has to be facilitated for proper inpatient admission.

As a minimum the following information has to be delivered:

 Patient name and medical record number

 Summary of the clinical history and reason for emergency admission

 Case team to which patient should be admitted like surgical case team, internal medicine
case team etc

 Expected date of discharge

When request for admission is made the liaison officer should follow the steps below:
 Is a bed immediately available in the relevant inpatient case team/ward? If yes – admit
patient. The liaison officer should inform the case team leader of the receiving ward that
the patient should be transferred to that ward and any necessary administrative tasks
carried out with the assistance of runner.
 Is there any patient in the relevant case team /ward due to be discharge that day?
If yes --- confirm that patient will be discharged. Identify and address any factors that are
delaying discharge, consider moving patient to transit lounge (if available) or another
waiting area. In this way the bed can be freed and the new patient can be admitted
  Is a bed available within another case team/ward? If yes --- discuss with director of
inpatient service and the responsible physician for the patient where the patient is located,
ensure the patient will be properly followed and managed by appropriate case team, and
ensure that the patient is transferred to correct case team bed/ward as soon as a bed is
available.
Elective Admission process

Liaison officer has to book elective admission. When a patient requires elective admission a
clinical member of the relevant case team should send at minimum the following information:
 Patient name, phone number and medical record umber
 Summary of the clinical history and reason for admission.
 Case team to which patient should be admitted like surgical case team, internal
medicine case team etc.
 Urgency of admission (set criteria related to: pathology of the disease, socio-
economic status of the patient, and distance of the patient’s residence).
 The liaison officer should book the admission date and give an appointment card to
the Patient and patient number, and take contact information of patient and/or care
giver. The liaison officer should also give his/her or office contact address to the
patient so that the patient can phone and get information about his/her admission
schedule.

On the day of admission, the patient should report to the liaison officer and from there he/she
will be assisted to make any necessary payment or registration and will be directed to the
relevant inpatient case team/ward.

 On a daily basis, the liaison officer should inform each inpatient case team of planned
admissions for the following day to ensure that the required service is available and
allow the case team to make all necessary preparation for the admission.
 In case admission schedule or treatment is changed the liaison officer should inform
the patient and family.
 The following key requirements have been identified to facilitate effective elective
admission practices:
 o All patients should have a treatment plan within 24 hours of admission.
o Centralized waiting list management.
o Agreement on the parameters for scheduling operation theatre lists with the
OR team.
 After patient admission proactive discharge planning and informing to patient /
family is important
 Effective management of the admission process requires knowledge of:
o The total number of beds

o The number of occupied beds at the evening census (bed occupancy)

o The number of beds that are to be evacuated that day

Number of beds with prolonged length of stay and its causes

The hospital should provide an admission and discharge service 24 hours a day, 7 days a week,
365 days a year, including holidays and weekends. Admissions and discharges should be
arranged and facilitated through the Liaison office. A written protocol for the admission of
patients should include: mechanism for arrangement of admission, and activities to be
undertaken at the arrival of the patient at the ward. Upon arrival on the ward, there should be a
quick assessment of the condition of the patient by the receiving nurse.
 Patients in critical condition or with emergency signs needing immediate attention,
should be received by a nurse who will evaluate the nature and severity of the illness and
inform the responsible physician in 15 minutes. If there are emergency clinical signs to
be addressed by physicians, the informed physician must come and see the patient
immediately.

 For patients in a stable condition, the nurse will initiate the ward admission process,
including orienting patients and families to the facilities such as toilets, showers,
introducing relevant staff, giving instructions for care-givers etc. The responsible duty
physician should then complete the evaluation of the patient in no less than 2 hours.
Being the most critical patients directed to the inpatient department, these patients should
have comprehensive evaluation, addressing all components of health and diagnosis
 should not rely on OPD evaluation notes as there may be a misdiagnosis or developments
in the condition of the patient.

 Nursing process need to be completed in no later than 8 hours (before the next shift) and
all efforts have to be made to make patient centered and improve the overall quality of
the care beyond documentation.

Discharge Process

The hospital should establish a written protocol for patient discharge. The hospital should also
design and own a discharge summary and mechanism of handling medical records afterwards.
Decision for discharge should be made by the treating physician, who should complete a
discharge summary. First copy of the discharge summary should be given to the patient, while
the second copy has to be documented in the Medical Record. If the patient was referred from
another facility, the discharging physician should also complete the feedback section of the
referral paper, and, that should, be given to the patient, to give to the referring health institution.
Patients ready for discharge should be counseled by the attending physician, nurse in charge and
clinical pharmacist before discharge.

Pre-discharge counseling encompasses the following:

 Share the discharge plan while patient is on the ward, before starting the process

 An explanation of the patient’s diagnosis, investigation results and treatments given

 An explanation of any medications that the patient should continue to take upon
discharge

 Arrangements for follow up, if any

 Inform any ‘caution or attention’ that the patient has to be aware of

The discharging nurse has to make sure all the necessary registers are filled and administrative
duties, including financial issues are settled before the patient is sent to the liaison office
The discharge process should be complete in no more than 2 hours (including administrative
issues). The patient with their medical record must to be sent to the liaison office, with the help
of a runner. The liaison officer has to check the completeness of all the necessary documents and
send the patient home after filling the necessary registers (With appointment card and
appointment register filled, if appointment was asked for on the discharge summary sheet.

Patient Death / Post Mortem Care

There shall be a policy or a protocol that states the procedure to be followed for dead body care,
including how the staff breaks or informs the families and also considers the cultural ceremony
to be followed. A death occurring in the hospital should be confirmed by at least an attending
physician or any independent practitioner and the nurse giving care. The Inpatient service should
have a separate room for ‘after death care’. A death summary should be completed and
documented in the patient’s medical record, to ensure accuracy and easy retrieval. Death
notification should be also completed.

In case of a need for pathologic examination and confirmation for cause of death, a post mortem
examination form should be completed and the body should be transferred to the pathology case
team or morgue. Following completion of necessary medical examinations, the body shall be
stored in the hospital’s morgue until it is collected by the patient’s relatives or other responsible
person. If the patient does not have a next of kin, the local authority is responsible for collecting
the body. Any unexpected deaths should be reported to and investigated by the hospital’s CGQI
unit.

3.2.2 Hospital Bed Management

The aim of bed management is to make maximum use of hospital beds, ensuring high bed
occupancy, high patient turnover and minimum waiting times for elective admission. The liaison
officer survey IPD beds at least three times per day and notify available beds manually or with
electronic notification mechanisms

Whenever the hospital is in acute shortage of beds for emergency admission, the hospital should
practice active interdepartmental bed adjustment and shift. Try to find beds in other wards by
communicating with ward clinicians. Look for likely discharges or cancel appointed elective
admission patient/s for that day. If all the above mentioned solutions are not applicable, refer to
the nearest health facility after the patient is made stable and bed/service is secured in the
accepting health facility.
Methods for ensuring appropriate utilization of bed

 Follow hospital Admit ion & Discharge protocol

 Develope and implement bed management protocol

 Reduce inappropriate length of stay

o Regular ward rounds

o Make maximum use of Administrative service

 Implement bed management information system

o Bed survey should be done at least 3x a day/3 times/24hrs/

At any time the liaison should and have the following information:
 Free beds in the health facility

 Number of bed that are due to be evacuated

 Likely discharges planned during admission

 Number of beds Occupied in the facility

 Number of patients transfer ins and outs

 Number of ‘reserved beds for elective admissions that day

3.3 Referral Service
A referral system is a system that consists of client, expertise and medical equipment transfer
between health facilities. It is a two way process which helps to ensure continuum of care to
patients in Ethiopian’s three tier health system, from PHCU to general and tertiary hospital.

The clients transfer of the referral system consist of receiving clients from the pre-facility
services which is called Pre-facility to facility referrals, and inter-facility referrals which consists
of referral of clients between health facilities.

Each hospital should establish a Referral Protocol that outlines the criteria for making a referral
to another facility and the process to be followed when making a referral, including use of the
Referral and Feedback Form and any necessary clinical documents that should accompany the
referred patient. The protocol should be known and adhered to by all relevant staff.

Each hospital should establish a referrals service directory that lists facilities to/from which
patients can be referred or received and the services available at each facility (the Referral
Network). The contact details of each facility in the Referral Network should be documented.
The criteria for receiving/referring patients to each facility should also be documented and
agreed between all facilities participating in the Network. Standardized Referral and Feedback
formats should be used by all facilities participating in the Network.

3.3.1 Receiving Inpatient Referrals

A hospital can be both a ‘Receiving Unit’ for patients referred from other facilities and a
‘Referring Unit’ to refer patients to another facility. Referrals can be made for both outpatient
services and for inpatient admissions.

Emergency referral in
 Each day, (every 8 hours) the liaison officer should asses the number of unoccupied beds,
number of patients in the emergency unit/department waiting to be transferred to
inpatient wards, and number of patients in the ICU to be transferred to the ward.
 If dispatch/command center is available, the liaison officer has to give report on vacant
beds three times a day to the center and update information of the particular day.
  If the service is not available direct communication will be made between health
institutions.
 Ensure the ambulance service is in place for 24 hour and is equipped with the necessary
medical supplies for critical emergency patients. When a facility calls to refer emergency
cases a liaison officer should check the following things before accepting the referral:
1. The availability of beds in the case team where the patient requires service
2. The availability of the service and professional (some service can be given by a
highly trained individual professional; in such case the liaison should check the
presence of the professional and the service).
3. Appropriateness of the referral, that is, the referral should be based on the
referral network and any referrals should not be out of the referral network
agreement, or the importance has to be justified with a discussion with the
accepting physician.
4. Information on the patient’s clinical condition, to insure safe transportation and
to consider patient is accompanied by a professional who has life-saving skills.
5. Inform the accepting unit about the incoming patient’s status, and the estimated
time of arrival to the unit so that the accepting unit will make the necessary
arrangements accordingly.

Non-Emergency Referral in
When a facility calls to refer a non-emergency case that needs admission, the liaison should
check the appropriateness of the referral (the same procedure listed above) and the nature of the
disease in case the waiting time is becoming prolonged. This information helps to identify the
disease progress such as if cancer is diagnosed at its early stage and prolonged appointment may
lead for worsening of the diseases, therefore this information will help to prioritize admissions.
There could be arrangement of elective admission date and inform the patient through the
referring liaison officer

3.3.2 Receiving Outpatient Referrals

When a facility calls to refer outpatient referrals a liaison should confirm the appropriateness of
the referral, nature of the illness and arranges appointment date and passes the information
through the referring liaison officer.
3.3.3 Coordinating Referral Out Cases

Emergency referral out

Once a client transfer is decided a patient should be immediately linked with liaison and
referral office. All clients should be told why, when and where to be transferred. All
emergency and critical patients should be stabilized and resuscitated with maximum capacity
of the hospital before transfer but it should not delay the referral

 All emergency patients should be transferred with equipped ambulance escorted with
health professionals/paramedics.
 A referral form should be filled and signed by referring health professionals with his/her
telephone number in legible writing and stamped
 Relevant laboratory and imaging result need to be attached to the referral format
 All referral should be communicated to receiving facilities through telephone or web
based referral providing detailed identification and situation of the patients to be sure that
bed and required care and services are available at receiving health facility
 In addition to this before referring a patient a liaison officer should check the following
things
o Register the patient on referral register (sample on annex )
o A receiving facility liaison officer should inform the emergency and inpatient
case teams to be ready for the management of the patient.
o Referring facility’s liaison and referral should follow the condition of patients on
the way by telephone
o Referring facility’s liaison and referral shall ensure the patient arrived at receiving
facility
 If the liaison can’t find the service to refer the patient, the patient should stay in the
facility with necessary care until the liaison gets the needed service
 The facility with the services are obliged to receive an emergency patient from the lower
level health facility (no administrative problem like unavailability of beds can be taken as
an excuse not receive an emergency patients)
 When there is a need to transfer a clients to a lower level health facility it depends on:
 o The condition of the patient
o The capacity of the lower level health facility

The patient should be transferred with the necessary documentation on:

How the management of the patient should be

The anticipated complications and how to manage them

When to refer them back

 Both the referring and receiving health institution liaison officers should make sure
critical patients are transported safely and accompanied by professionals who have
lifesaving skills.

Non-emergency Referral Out

After checking all necessary steps listed above and identifying appropriate facility the
liaison officer should communicate with receiving facility liaison officer to pass the
appointment information to the patient.

3.3.4 A feedback loop to track referrals

The hospital should collaborate with other facilities in the network and the Regional Health
Bureau to promote, monitor and evaluate the referral system. In particular, the hospital should
promote and publicize the referral system through the community in order to ensure that all
constituents are aware of the applicable service pathway.

 A system to track a referral from point of initiation to point of delivery and, as a feedback
loop, from point of service delivery back to point of initiation is needed to ensure that the
client is using the service(s) needed.
 It is clear that the capacity of the lower level health facilities has a great impact on overall
health delivery system of a country; in particular the referral linkages of the health delivery
system. Feedback and communication in the referral system is a critical step in addressing
capacity issues. In addition effective communication facilitates learning and, can inform
professionals about the outcomes of the patients that they refer.
 Written feedback provides evidence that the referral process was completed and the service
was delivered, and should indicate whether there were problems. Using the original referral
 request, documenting the status of service delivery and other pertinent information and
returning the form to the site of referral initiation is one method of feedback communication.
 The effectiveness of a referral system is determined by the individuals being referred, so it is
essential to find out if a client is satisfied with the service received and whether her or his
need was met. One method of getting this information is that the facility that made the
referral will contact the client directly for feedback, if the client agrees. Another way is to
carry out periodic surveys at different points (hospital, health center etc) in the system.
 3.4 Hospital Based Social Work Service
Provide non-medical support for the patient and family in the hospital. The main aim of hospital
based social service is to resolve and support issues affecting heath provision environment.
Depending on the need of the patient social workers may help with housing, food, transportation,
clothing’s and other social needs. These professionals require strong social skill like
communication and empathy.

Hospitals are expected to develop and implement of social service protocol. The minimum
human resource need is at least one social workers for Primary Hospital, two for General
Hospital and three for Comprehensive Specialized Hospitals. (BSc or MSC in Sociology/Social
work). The social worker can organize voluntary donors, partners, and staffs to support the social
service or else the hospitals should establish fund raising mechanism for social service. Regular
quarterly social service audit is expected to be conducted and based on the identified gaps
improvements actions should be made.

Social work is an academic and professional discipline that seeks to facilitate the welfare of communities,
individuals and societies. It may promote social change, development, cohesion, and empowerment.
Principles of social justice, human rights, collective responsibility, and respect for diversities are central
for social service. A social work service in a hospital is organized to help to meet basic and complex
needs of patients and their family during clinical case management. Hospital based Social Service has
the following four basic components

1) Counseling /Psychotherapy: assigned psychologist to facilitate psychosocial counseling

services. Psychotherapy enhances coping capacities related to feelings of loss, grief and
role changes. It also assesses and intervene mental health related concerns such as
anxiety, and anger management. The hospitals should develop and implement their own
psychosocial and spiritual service protocol. It is also advised to prepare praying area to
patient/ attendants according to their type religion.
2) Patient/Family Education: Educate patients and families to facilitate understanding of
hospital processes; increase understanding of illness/disability on relationships; and
facilitate life transitions when health conditions require a modified lifestyle.
3) Resource Counseling Locate and map available resources, identify options and
available supports; advocate for access to resources
4) Discharge Planning: identify and address barriers to discharge, coordinate referrals
and/or placement plans; facilitate referrals and applications to government/community
agencies; assist patient and family to emotionally prepare for transitions; prevent
readmission for non-medical reasons.
3.5 Ambulance Service Management
All ambulances should operate under the guidance and direction of the liaison unit. The
ambulance shall be labeled and have a siren. It should be parked within its base office
compound or the local health facility which have contractual agreement.

The liaison unit should prepare ambulance management protocol and all staffs should be
oriented. The liaison unit should ensure availability of minimum equipment and supplies for
basic and advanced life support (See annexes VI and VII). Ambulance drivers and assigned
professionals should be trained on basic life support.

The ambulance service shall provide the following services:

 Patient transportation service from health facility to other health facilities and
from home to the health facility.
 Clinical examinations including brief history, vital signs, very pertinent physical
examination and glucose test when needed
 Clinical lifesaving support that includes:

 ABC of life
 oxygen administration
 Splinting
 Delivery attending
 Immobilization
 Iv securing
 pain management
 Oxygen administration, monitoring of vital signs,
basic emergency medical care)
 Advanced airway management;
 ECG monitoring; and defibrillation,
 Ventilator management;
 Circulatory management and support
 Source Documents

1. Federal Ministry of Health, Clinical Service Directorate,2020, Hospital based Psycho-Social

service guideline

2. Federal Ministry of Health Medical services, Emergency and Critical Care Directorate(2020),
National Emergency Services Leveling Guideline

3. Federal Ministry of Health(2022), National Referral Guideline

4. Federal Ministry of Health ,ETHIOPIAN HOSPITAL SERVICES TRANSFORMATION

GUIDELINES, Volume 1, September 2016

5. National Minimum requirement for Ambulance Services, November 2016

6. Federal Ministry of Health. National Liaison and Referral Manual. Unpublished. Federal
Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business Process
Study Report. Addis Ababa, Ethiopia.
Annexes
Annex I, Combined Liaison Register of Referrals OUT / IN

Liaison Referral-in/out Register

Identification Referral service

Address Type of referral Name of Referral in or out
Department linked Emergency referral Feedback
Service Date Referring Facility Referral in or out Reason for with
S/N MRN Name of the patient Age Sex Type of Case** to or that referred- with Ambulance received or Remark
(DD/MM/YY) Subcity/ or facility to which Diagnosis Referral in or out* Communication
Region Woreda/Kebele Referral in (√) Referral out (√) out the patient (Y/N) Sent (Y/N)
Zone client referred to (Y/N)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20)

*Reasoin for referral (column 12) **Type of case (column 13) Count Count Count referrals
1 = Better diagnosis and care 1 = Emergency
2 = Lack of Bed 2 = Cold Total referral-in with
3 = Self referral Emergency referral-in
4 =Administrative reason Referrals with ambulance
5 = Expaert advice
6 = Others
Annex II, Liaison Combined Instructions

Instruction for Liaison Referral in/out register

This register is to be kept at the Liaison Office
Region Write region name where the facility is located
Zone/Sub city /Woreda Write Zone/Sub-City /Woreda name where the facility is located.
Facility Name Write the name of the health facility where the service was provided
Write the date of the first entry in the register, written as (EC) Day /
Register begin date
Month / Year (DD/MM/YY)
Write the date of the last entry in the register, written as (EC) Day /
Register end date
Month / Year(DD/MM/YY)
Description of the patients' information filled on main part of register
Column Number Datum Description
Enter sequentially starting from 1 until the budget year end and start
1 S/No again from 1 at the first day of new budget year
2 MRN Enter Medical Record Number from individual folder
3 Date Write the date the patient is referred in as DD/MM/YY
4 Name of the patient Write the name of the patient
Write age of patient (if it is under 1 month enter in days, if it is under 5
5 Age year, enter in month and enter in year if it is above 5 year old)
6 Sex write sex of patient as M for male and F for Female
7 Address: Region Write the current region of the patient
8 Address: Sub City/zone Write the current sub city/zone of the patient
9 Address: Woreda/kebele Write the current woreda of the patient
10 Tick if the case is referral in
11 Type of referral Tick if the case is referral out
Name of referring or Write the name of the health facility that referred the patient or the
12 receiving facility facility to which the patient is referred to from the referral paper
Type of case can be emergecy or cold. Write 1 if the case is
13 Type fo case emergecny and 2 if the case is cold in the column space.
Referral in or out Write the diagnosis of the patient (either referred in or out) that is
14 Diagnosis written on the referral paper
Department linked to or
that referred-out the Write the name of the department that either referred out or to which
15 patient the patient was linked
Choose the reason for referral in or out from the lists provided at the
bottom of the coumn and write the corresponding number. 1= Better
Diagnosis & Management, 2=Lack of Bed, 3=Self-referral (eg.
Reason for referral in or financial reasons,etc) 4=Administrative (eg. Power outage, equipment
16 out malfunction) 5= Others (eg. medico-legal)
If the patient was referred in with ambulance write "Y for Yes. If not,
17 Referral with ambulance write 'N" for No.
Referral in or out with If the patient was referred in with communication write "Y" for Yes. If the
18 Communication patient was referred without communication write 'N" for No.

Write "Y' for Yes if feedback was received from or sent to the facility
Feedback received or the patient was referred. Write "N" for No if feedback was not received
19 sent or sent to the facility at the end of the monthly reporting period.
20 Remark Write any thing regarding the patient in the remark section
 Annex III, Liaison and Referral Office Report

Quarter_______________________________From________________to__________________

Name of Health facility _________________________________________________________

S.N Nominators Number

1. Total number total attendant of the hospital (Emergency and cold)

2. Total number emergency visit

3. Total number referral in

4. Total number referral out

5. Total Number of Emergency referral in

6. Total number of Emergency referral out

7. Total number of Referral out with communication

8. Total number Referral in with communication

9. Total number of emergency referral in with ambulance

10. Total number of feedback sent

11. Total number of feedback received

12. Total number of referral in arrived dead

Name of the liaison office _________________________Sign _____Date__________

Annex IV, Ministry of Health National Referral Form

National Patients referral Format

Referring Health Facility

Name of facility ________________________________Liaison office telephone___________

Receiving Health Facility

Name of facility _______________________________Liaison office telephone__________

Patients Identification

Name_______________________________________ Age __________________Sex ________

Chief Complaints of the patient________________________________________________

Condition of the pities (circle one) Critical Emergency stable

History of present illness

______________________________________________________________________________

Finding BP __________PR _________RR _______Body T0_________O2saturation________

P/E

______________________________________________________________________________

Diagnosis
______________________________________________________________________________

Treatment given

______________________________________________________________________________

Reason For Referral

______________________________________________________________________________

Recommended Health Professions to escort the patients(state the profession not name)

_____________________________________________________________________________

Referring Health professional

Name____________________________ Cell phone __________________Sign_____________

Escorting Health professional

Name ____________________________Cell phone ___________________________________

Referring liaison officer _________________________Phone _______________Sign_________

Annex V, Ministry of Health National Referral Feedback Form

National Patients referral feedback Format

Referring Health Facility

Name of facility ________________________________Liaison office

telephone___________

Receiving Health Facility

Name of facility _______________________________Liaison office telephone__________

Patients Identification

Name_______________________________________ Age __________________Sex

Condition of patients on arrival(circle one)

Critical Emergency Stable Dead (No any sign of life)

Diagnosis ________________________________________________________

Circle one____ (the Same) or (Different) from the referring facility (check the referral
format)

Treatment

Comment of receiving health professional

Referring Health professional (Fill from referral format)

Name__________________________ Cell phone _________________Sign_____________

Receiving liaison officer ____________________Phone _______________Sign__________

Commenting Health professional

Name__________________________ Cell phone _________________Sign_____________

Annex VI, Basic Ambulance Service Medical Equipment and Supplies List
The BLS ambulance service shall include the following medical equipment and supplies:
a. Ventilation and Airway Equipment

 Oxygen cylinder(2)
 O2 Face Mask(Adult & Pedi)
 non- rebrether mask adult and pedi
 O2 Nasal Catheter adult and pedi
 Ambubag Adult and pedi
 Nasopharengial Air Way d/t size
 Oropharengial Air way(1-4)
 Suction Chateter adult and child
b. Immobilization Devices

 Cervical collars large medium and small

 Soft
 Hard
 Arm Splint Adult and pedi
 Leg splint Adult and pedi
c. Hemorrhage Control/Trauma kit
 Cotton Roll 100gm
 Elastic Bandege small,medium & large
 Roll Bandege(Guaze Bandege)18cm x 5cm
 Sterile Guaze 10 x 10
 Adhesive Plaster
 Triangulare Bandege
 Scisores
 Arterial Tourniquet

d. Obstetrical Kit

 Kit (separate sterile kit) sterile scissors

 Towels Larg
 sterile gloves
 sterile gauze pads
 clamps for cord
 bulb suction

 Container for carrying placenta

 blanket small And Large
 Oxitoxin/ergometrine

e. Diagnostic and Miscellaneous

 BP Apparatuse/Sphygmomanometer
  Stethescope
 Thermometer
 Pulsoximeter
 Functional flash light
 Linen
 Pillows
 Towels
 NGT
 Folly catheter
 Canulla of Diff.Size(16-24)
 Syringe with needel 5ml &10ml

f. Infection Control
 goggles
 face shield/Mask e.g., N95 or N100
 Gloves non sterile/disposable
 overalls or gowns
 Standard sharps containers
 disposable trash bags/Basket

g. Injury-prevention Equipment/PPE
 Restraint systems for all passengers and patients transported in
groundambulances.
 Shoes
 Reflective safety wear
h. Communication
 Phone
i. Emergency medicine and analgesics
 Adrenalin 1ml inj
 oral glucose
 Nitroglycerin sublingual tablet
 Asprine 300 mg tab
 Hydrochortison 100mg inj
 Tramadol 50mg inj
 Diclofinac 75 mg inj
 Diazepam 10mg in 2ml inj
 Panadol Po 1gm
 Diclofinac 50 mg po
j. IV Fluids
 R/L 1000ml
 N/S 1000ml
 D/W 1000ml
 40% Glucose
Annex VII, Advanced Ambulance Service Emergency Medicine List

The ALS ambulance service shall include the following medical equipment andsupplies:
a. Ventilation and Airway Equipment

 Oxygen cylinder(2)
 O2 Face Mask(Adult & Pedi)
 non- rebrether mask adult and pedi
 O2 Nasal Catheter adult and pedi
 Ambubag Adult and pedi
 Nasopharengial Air Way d/t size
 Oropharengial Air way(1-4)
 Suction Chateter adult and child
b. Immobilization Devices

a. Cervical collars large medium and small

b. Soft
c. Hard
d. Arm Splint Adult and pedi
e. Leg splint Adult and pedi
c. Hemorrhage Control/Trauma kit
a. Cotton Roll 100gm
b. Elastic Bandege small,medium & large
c. Roll Bandege(Guaze Bandege)18cm x 5cm
d. Sterile Guaze 10 x 10
e. Adhesive Plaster
f. Triangulare Bandege
g. Scisores
h. Arterial Tourniquet

d. Obstetrical Kit

a. Kit (separate sterile kit) sterile scissors

b. Towels Larg
c. sterile gloves
d. sterile gauze pads
e. clamps for cord
f. bulb suction
 g. Container for carrying placenta
h. blanket small And Large
i. Oxitoxin/ergometrine

e. Diagnostic and Miscellaneous

a. BP Apparatuse/Sphygmomanometer
b. Stethescope
c. Thermometer
d. Pulsoximeter
e. Functional flash light
f. Linen
g. Pillows
h. Towels
i. NGT
j. Folly catheter
k. Canulla of Diff.Size(16-24)
l. Syringe with needel 5ml &10ml

f. Infection Control
a. goggles
b. face shield/Mask e.g., N95 or N100
c. Gloves non sterile/disposable
d. overalls or gowns
e. Standard sharps containers
f. disposable trash bags/Basket

g. Injury-prevention Equipment/PPE
a. Restraint systems for all passengers and patients transported in
groundambulances.
b. Shoes
c. Reflective safety wear
h. Communication
a. Phone
i. Emergency medicine and analgesics
a. Adrenalin 1ml inj
b. oral glucose
c. Nitroglycerin sublingual tablet
d. Asprine 300 mg tab
e. Hydrochortison 100mg inj
f. Tramadol 50mg inj
g. Diclofinac 75 mg inj
h. Diazepam 10mg in 2ml inj
i. Panadol Po 1gm
 j. Diclofinac 50 mg po
j. IV Fluids
a. R/L 1000ml
b. N/S 1000ml
c. D/W 1000ml
d. 40% Glucose
k. Intubation kit
a. Respirator
b. Chest tube set
c. Cardiac monitor

Name of Medicine Dosage form and strength

Adenosine Injection: 3mg/ml in 2ml
Adrenaline Injection 0.1mg/ml, 1mg/ml
Adrenaline Injection: 0.1%, 1:1000 1mg/ml
(Epinephrine)
Amiodarone Injection: 50mg /ml
Acetylsalicylic acid Tablet: 300mg
Activated charcoal Powder: 15gm/120ml
Atropine Injection 1mg/ml
Dextrose in water Injection: 5% in 500mll, 1000ml: 40%
Dextrose in Sodium Injection: 5% in 500ml, 1000ml:
chloride
Diazepam Injection: 5mg/ml
Diclofenac Injection: 25mg/ml in 3ml,
Hydrocortisone Injection: 100mg,200mg
Ketamine Injection: 50mg/ml
Lactated Ringer’s Injectable Solution: K+4mEq + Na + 130mEq + Ca+, 3mEq +
Cl- 110mEq + Lactate 28mEq in 1000ml
Metoclopramide Injection: 10mg/ml, syrup: 10mg/ml
Nitroglycerine Tablet: Sublingual: 0.4 mg
Naloxone Injection: 0.4mg
hydrochloride
Nitrofurazone Ointment: 1% 30gm
Oxygen Pure oxygen
Ergotamine Injection: 0.2mg/ml, Tablet: 2mg
Salbutamol Oral Inhalation (aerosol): 0.1 mg/dose
Sodium chloride Injection: 0.9% 500ml,1000ml
Suxamethonium Injection 50mg/ml
chloride
Tramadol Injection: 50mg/ml
hydrochloride
Water for Injection Sterile water for Injection:5ml, 10ml
Chapter 3: Emergency and Injury Care Services Management
2

Section 1, Introduction .................................................................................................................................. 2

Section 2, Operational Standards .................................................................................................................. 4

Section 3, Implementation guidance ............................................................................................................ 5

3.1, Emergency Services Management and Organization .................................................................... 5

3.2, Emergency Services Layout........................................................................................................... 6

3.3, Emergency patient flow/pathway................................................................................................. 14

3.3.1, Emergency patient Triage ................................................................................................. 15

3.3.2, Emergency Patient Resuscitation ...................................................................................... 18

3.3.3, Emergency Case Management .......................................................................................... 18

3.4, Ambulance service ....................................................................................................................... 21

3.5, Hospital Emergency Preparedness and Responses ...................................................................... 21

Chapter Summary ....................................................................................................................................... 22

Source Documents ...................................................................................................................................... 23

Appendices.................................................................................................................................................. 24

Appendix 1, Emergency Triage Format .............................................................................................. 24

Appendix 2, Resuscitation minimum equipment’s and supplies list .................................................. 27

Appendix 3, General minimum Equipment and Supply Needs for Emergency unit/departments ...... 29
Section 1, Introduction

Hospital based emergency medical services are part of the patient flow in a hospital setting and
includes the processes and procedures needed to ensure the efficient flow of patients between
services. Patient flow requires various inputs including human resources, infrastructure,
equipment, protocols and pathways. Properly designed and implemented hospital based
emergency medical care services will reduce patient emergency triage and treatment times,
increase provider efficiency and staff and client satisfaction as well as improve overall quality of
care. Emergency Medical Services (EMS) are a network of services and resources coordinated
to provide aid and medical assistance from primary response to definitive care, involving trained
personnel and use of appropriate technologies in the rescue, stabilization, transportation, and
advanced treatment of traumatic, obstetric and medical emergencies. EMS can be given in a pre-
hospital or hospital setting. Pre-hospital refers to all environments outside an emergency
department resuscitation room or a place specifically designed for resuscitation and/or critical
care in a healthcare setting. It usually relates to an incident scene but includes the ambulance
environment or a remote medical facility. Emergency Medical Service processes described in the
chapter include EMS organization, triage and treatment and case management processes are also
outlined.

Injuries; as defined by the world health organization (WHO) are conditions most commonly
result from traffic collisions, drowning, poisoning, falls, burns and violence (assault, self-
inflicted violence or acts of war). Since injuries comprises majority of ER admission in our
country’s context, the emergency department shall give those services. Based on the level of the
services they provide, Emergency Services are categorized into four according to the 2020
Ethiopian Emergency service Leveling Guideline and each category have their own minimum
requirements.

 Basic level - Health center and Primary hospitals

 Intermediate level: General hospital

 Advanced level: Tertiary hospital

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  Center of Excellence

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Section 2, Operational Standards

1. The hospital shall have emergency medical service department led by an emergency and
critical care professional in accordance with the hospital tier level.

2. The emergency department shall be easily accessible, labeled and clearly visible upon
entry to the facility with an ambulance parking area and it is in close proximity to the ICU
and OR
3. The emergency unit has separate areas for triage, resuscitation, examination, procedure,
short stay beds, isolation room and decontamination area.
4. The hospital has an Emergency department/unit equipped with necessary equipment,
drugs and supplies needed to provide emergency medical services as per the hospital tier
level.
5. All emergency department clinical staff shall have emergency care training.
6. The emergency department shall use a triage system of screening and classifying patients
to determine their priority needs and to ration patient care efficiently.
7. The hospital provides emergency medical service 24 hours a day and 365 days a year
with a 24-hours’ access to diagnostic laboratory, radiology, pharmacy services, blood
products and oxygen with priority for emergency clients.
8. The hospital shall have an emergency management team with a documented emergency
preparedness and response plan.
9. Emergency department or Unit has policies, protocols and treatment guidelines for
running ED/EU.
10. The emergency unit shall have a staff facility room for rest and refreshment.
11. The hospital has guards, porters and cleaners dedicated for emergency unit.

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Section 3, Implementation guidance

3.1, Emergency Services Management and Organization

The emergency case team should be overseen by a director of emergency services. He/she is
responsible for all activities conducted in Emergency Services including:

 Patient triage,
 Case management, and
 Laboratory, pharmacy and diagnostic services of emergency unit.
The director of emergency services is responsible for managing all department staff and should
ensure that equipment and supplies are available for the patient load. The emergency department
or unit shall serve as the definitive specialized care area/facility, equipped and staffed to provide
rapid and varied emergency care to all people with life-threatening conditions. The emergency
department or unit shall provide initial appropriate care and arrange subsequent disposition as
per domain of care. (See figure1 below).

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Figure 1 Domains of Acute Care

3.2, Emergency Services Layout

The Emergency Services should be organized so that the Emergency Service’s entrance can be
easily accessed by ambulances and patients. This means that the emergency unit should be
located on the ground floor for ease of access and should be clearly labeled in a way that is
visible from the hospital’s gate. Its entrance signage should be clearly illuminated and has multi-
lingual labels, preferably red background with white color labels, that is visible from the street
(even at night) and addressing the cultural and linguistic diverse needs of its communities. There
should also be an area dedicated for patient drop-off and ambulance parking.

The hospitals should have adequately designated space for emergency unit and emergency
services should have the following facilities in required standards:

A) Ambulance parking space and entrance

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The ambulance parking space should be close to the emergency unit entrance, well-lit and
available exclusively for patients, their relatives and staff. Protected proximate parking areas
should be available for urgent staff on-call shifts. Hospitals’ ambulance entrance environments
provide important reception and treatment areas in the event of a disaster or
chemical/biological/radiation incidents. Direct access to an internal decontamination room
should be available. Appropriate physical barriers should protect “drop off” zones. All doors
through which patients may pass must be of sufficient size to accommodate a full hospital bed
with attached intravenous flasks and traction apparatus with ease. The floor covering of the
emergency unit should be a non-slippery surface, impermeable to water, easy to clean; acoustic
properties that reduce sound transmission and shock absorption to facilitate movement of beds.

B) Patient assistant area at Emergency gate

Patient assistant staff (receptionist) at the emergency gate receives; support and direct patients
arriving for emergency care and ensure proper handover of patients. They should be easily
identified with reflective jackets. All patient assistants should be trained in patient moving and
handling, basic life support, communication skill and infection prevention and control
procedures.

There should be communication and patient support devices in the patient assistant area of the
emergency reception area, including:

 Wheelchairs and stretchers

 Telephone or walky-talkies
 Tricycle ambulance(optional)

Patients arrive at emergency departments/units in different ways, including ambulance, public

transport or/and independently walking /supported by family and support should be provided as
per individual patient needs.

For example: for patients arriving to the ED/EU by public transport or walking, a receptionist at
the hospital gate should guide or give appropriate support to the patient either by providing a
wheelchair, stretcher or assist the family to reach to the triage area.
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For critically ill patient arriving by ambulance, the ambulance crew should notify the hospital
ED/EU about the nature of the patient's condition and receive instruction on en-route patient
management plan. This will enable the hospital ED/EU to prepare well ahead of the incoming
patient. The triage nurse and a porter and/ emergency physician should be on standby at the
ED/EU gate to receive the patient from the ambulance crew and commence appropriate
emergency care and treatment based on the patient’s condition. The ED/EU receiving team
should ensure they receive the patient care sheet from the pre-hospital ambulance care giver as
part of the patient handover.

C) Triage area

The triage area is the 1st contact point for patients with the ED/EU staff and should be situated at
the entrance of the ED/EU with easily recognizable signage for patients and the general public.
The triage area should be equipped with the required triage equipment and supplies (see annex),
and staffed by trained and experienced triage professionals, including patient assistants. Staff
assigned to the triage area of the ED/EU should be available onsite and ready at all time to
receive incoming patients. The patient assistant is responsible for patient support, safe moving
and handling, and, preparing wheelchairs and stretchers for use when they are needed. Patient
assistants, therefore, need to be trained on basic life support (BLS), infection prevention (IP), and
communication skills. Patients with life or limb-threatening conditions may bypass the triage
area to be managed in the resuscitation area. The triage documentation for patients requiring
resuscitation should be done retrospectively.

D) Resuscitation area

The resuscitation area is a key area of an emergency department. It usually contains several
individual resuscitation inlets, usually with a dedicated fully equipped resuscitation area adjacent
to triage area. Each bay is equipped with resuscitation equipment and supplies (see annex) with
systematic refill mechanism and displayed in one cart (crash cart)

E) Waiting area

The emergency-waiting area should be located near to the triage area with easy access and
suitable for observation and follow up of patients by the triage nurse. Patients with stable

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conditions should remain in the waiting area until the physician is ready to evaluate their
conditions. The triage nurse should continue to observe, communicate, reassurance and re-triage
waiting area patients, as per need, until they are transferred to another service within the hospital.
The waiting area should be kept clean, brightly lit and well ventilated.

F) Examination area

A separate examination room for each patient and physician is not mandatory at the ED/EU since
emergency patients’ physical examination can be done in the resuscitation room. However,
multi-purpose examination cubicles should be organized for less critical patients. ED/EU
physicians should use the multi-disciplinary station/counter in-between patient interventions for
writing. Implementing such an arrangement will ensure one cubicle can serve many physicians
and patients.

G) Procedure area

This is an area where clean and sterile procedure equipment are stored and non-critical
procedures like minor wound care and others are carried out. Procedures for critical patients
should be carried out in the resuscitation area with continued/ongoing resuscitation.

H) The observation and treatment area

This is an area for stabilization and observation of patients who still need to be confined to bed
or an area to keep patients for 24hrs or less until they are transferred to inpatient wards or other
health institutions. The observation area is a continuum of the resuscitation area, and patients in
this area require strict follow up and continuation of initiated treatment. Nurses need to monitor
patients’ vital signs regularly and most senior physicians’ need to conduct frequent medical
rounds (expected 2-3times/day), write up progress notes 2-3times/day according to patients’
conditions and as per national treatment guidelines.

I) Utility areas

Clean Utility

This should be of sufficient size for the storage of clean and sterile supplies with
adequate bench top area for the preparation of procedure trays and equipment.

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Dirty Utility/Disposal Room

Access should be available from all clinical areas. There should be sufficient space to house the
following:

 Stainless steel bench top with sink and drainer

 Pan and bottle rack
 Bowl and basin rack
 Utensil washer
 Pan/bowl washer sanitizer
 Flushing sink
 Storage space for testing equipment, eg. urinalysis
 An optional disposal room adjacent to the dirty utility should be considered.

J) Isolation room

Isolation rooms should be provided for the treatment of potentially infectious patients. They
should have a room with scrub up facilities, negative ventilation, and be self-contained linen-
suite facilities. The rooms should be fitted with acute treatment area facilities and located
adjacent to patients’ reception area, i.e. triage to allow for the immediate isolation of potentially
highly infectious based on the hospital’s standards.

Isolation rooms may also be used to treat patients with conditions which require separation from
other patients e.g. patients who require privacy for clinical conditions, or who are a source of
visual or auditory distress to others. Deceased patients may be placed for grieving relatives to
spend time with their deceased ones. These rooms must be enclosed completely from floor to
ceiling. IPC protocols should be implemented for potentially infectious conditions.

K) Decontamination Room

A decontamination room should be available for patients who are contaminated with toxic
substances. In addition to the requirements of an isolation room, this room must:

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Be directly accessible from the ambulance bay without entering any other part of the department.

Have a flexible water hose, floor drain and contaminated water disposal system.

Have storage space for personal protective equipment and decontamination equipment

L) Medical records/Cashier/Social worker

An operational relationship between medical records, cashier and social worker should exist to
ensure patient details are recorded, or a previous medical record is retrieved. The patient assistant
should assist patients or their relatives with registration payments to the cashier, the latter which
should be situated next to the medical record personnel. Patients without the ability to pay for
their treatment should be handled by the hospital social services without delay.

There must be a separate emergency medical record corner (under the main MR in the hospital).
Access is required to ensure patients’ previous medical histories are obtainable without delay. So
emergency patients must not have to line up to get registered. A system of mechanical or
electronic medical record transfer is desirable to minimize delays and labour costs. Access to
medical records must be available 24 hours/day and 365 days a year.

Regardless of the availability/non-availability of accompany family member of an emergency

patient, medical registration should be carried out with the help of or fully by the nurse
assistants/ Porters.

Serving patients in a single window (one stop shopping) is strongly recommended to ensure
cashiers are located next to the medical registration room.

M) Pharmacy

All medications and equipment for the resuscitation and management of emergency patients
should be readily available at each treatment and or procedure areas. Proximity is desirable to
enable prescriptions to be filled by patients with limited mobility. The aim of having readily
accessible pharmacy services is to ensure speedy refilling of fast moving essential emergency
drugs and supplies without delay and auditable drug and supply management. The

3-12
pharmacist/druggist should work closely with the nurse responsible for refilling and establish an
efficient refilling process.

N) Laboratory/ sample collection and testing facilities

Laboratory samples should be obtained within the emergency department and analyzed either
within the department or at the central laboratory, depending on the test requested.

More complex tests may be performed in the Central Laboratory. If the sample is to be tested in
the central laboratory then a porter should take the specimen to the laboratory and collect the
result.

O) Emergency OR and ICU

The operating room and ICU should be readily accessible to the Emergency Services Case
Team. If the workload is high, there should be a specific operating theatre for Emergency
Services only. However, the general operating theatre may be used if the workload is less, in
which case emergency cases should always be given priority over elective/cold surgical cases.

P) Portable imaging facilities and bay

This is used to house and charge mobile x-ray equipment which should readily be accessible to
the major treatment areas including the plaster room. Having the portable X-ray and ultrasound
minimizes delay of management of patients. And there should be a 24/7 radiology service with a
radiologist or a delegate available.

Q) Nurses and physicians station

This is an area where a counter table with multiple chairs and computer is placed. All
documentation tools and patient charts are kept electronically and manually here. Additionally,
the station should have an internet access and reading materials for easy reference.

R) Administration room

Offices provide space for the administrative, managerial safety and quality, teaching, and
research roles of the emergency department. Office spaces should be provided based on the role
delineation of the emergency department.

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 S) Staff room /Meeting room

This is an area where staff in the ED/EU will have refreshment during duty hours. Ideally
emergency staff should not go out for tea/ lunch/dinner, or to duty rooms for rest. Such rooms
should be equipped with comfortable chairs, equipment’s and supplies for refreshment.

Adjacent to or in the ED/EU, hospitals should also provide nurses and physician’s morning
meeting room according to discuss cases and resolve identified major problems through quality
improvement trainings and discussions within the ED/EU.

T) Supportive service (security, cleaning, porter)

ED/EU could be a unit where agitated patient or relative present. And also, it is also a place
where expensive equipment are placed at the bays. Considering this, there always have to be a
security personnel assigned to protect the safety and environment of the ED/EU.

To maintain cleanliness and orderliness in the emergency unit, it is essential to have a dedicated
cleaner available round the clock. This ensures prompt action in maintaining environmental
safety and hygiene.

In the emergency department, it is essential to maintain separate facilities for staff and patients,
as well as separate male and female restrooms and bathrooms. These areas should have
continuous water availability and proper lighting according to recommended standards.
Additionally, the rooms on the emergency floor must be equipped with an adequate ventilation
system.

The Emergency Unit heavily relies on porters to facilitate the movement of patients and
materials within and between all hospital buildings. These porters play a crucial role in ensuring
the smooth flow of operations. They receive specialized training in handling emergency patients.
Their primary focus is on transferring patients from the gate, ambulance, and between various
departments within the hospital. Additionally, they transport essential items such as blood
products, lab specimens, X-ray results, wheelchairs, stretchers, and medical charts as needed.

When dealing with the transportation of critical patients, other healthcare professionals,
including nurses and physicians, may be summoned to provide emergency care. This approach

3-14
ensures that urgent cases are not delayed and receive prompt attention. The porter service should
be available at all units 24 hours a day.

Communication system: ED/EU of hospitals needs to communicate with Dispatch center, pre-
hospital care providers, other health facilities, and community. For this purpose the ED/EU has
to be equipped with direct telephone, radio communication, walky-talky and Internet services.
For fast and efficient communication between the ED staff, all staffs in the ED/EU have to have
pager.

Equipment/store room: This is used for the storage of equipment (eg. IV poles) and disposable
medical supplies for the department. There should be sufficient space to store and charge battery
powered equipment, e.g. Infusion pumps. This does not include storage space within treatment
areas. As a general principle, emergency departments should have sufficient storage space to
carry 72 hrs of medical supplies. Local logistic issues and risk management considerations may
dictate larger storage capacity. This area should be accessed by the nursing and physician staff
available.

U) Emergency and mass causality equipment store

This should be located near the ambulance entrance and should be of a size consistent with the
role of the ED in a major incident or disaster. There needs to be hanging space for specialized
clothing/ protective suits, work benches for equipment checking and power outlets for battery
banks. There shall be a trained emergency medical team (EMT) in the hospital which will
respond during time of disaster and mass casualties.

V) Blood and blood products

There shall be 24 hours access to blood products. Considering the need for blood product
transfusion, the laboratory staffs should make sure blood products are available at any time.

3.3 Emergency patient flow/pathway

Patients entering the hospital through the separate emergency department entrance, via
ambulance, from the reception desk or those referred to the emergency department from central
triage should undergo emergency triage. If further investigations and/or treatments are required

3-15
following triage, these should be provided by the Emergency Case Team. Patients that are not
classified as emergency cases should be referred to Central Triage.

3.3.1, Emergency patient Triage

A) Emergency Triage Activity

Triage can be defined as the “sorting of patients into priority groups according to their need and
the resources available.” It is a method of ranking sick or injured people according to the severity
3-16
of their sickness or injury thus minimizing delay, saving lives, and making the most efficient use
of available resources. During emergency triage any problems identified with critical body
functions (airways, breathing or circulation) should be given due attention and resuscitated
immediately. Adult and pediatric Emergency triage areas and triage staff for emergency patients
should be separate. For ease of access and preparation of emergency staffs and facilities, triage
officers should be communicated before patient arrival via liaison service. Conditionally the
triage officer will notify the proper case management team for possible resuscitation or urgent
procedures.

The Emergency triage service should be provided 24 hrs. a day, 365 days a year. National Adult,
obstetric and Pediatric Triage Protocols should be developed and implemented. Protocols should
be posted on the walls of triage areas as an ‘aide memoire’ for triage staff.

Emergency Patients should access to the triage area without hindrance of their financial capacity
and/or security guard. Initially a patient arrived in emergency triage area should be assessed by a
nurse (typically the “triage” nurse), who makes an initial judgment of how rapidly emergency
care needs to be rendered. If a patient needs decontamination, he/she must be directed
immediately to decontamination area. The triage nurse(s) has to have training on triage and
emergency life saving techniques. The triage nurses have to be at the triage area all the time
24/7.

The main activities

 Initiate appropriate triage assessment

 Make a decision on the level of patient acuity (Red, Orange, Yellow, Green and
Black) using the standardized triage format and supportive guidelines.
 Dispose patients according their level of acuity to the resuscitation, examination
or waiting area.
 Initiate appropriate nursing interventions when necessary.
 Re-triage, reassure and make very important investigations for patients waiting in
the waiting area.
 Secure the safety of patients and staff of the department.
 Maintain patient privacy.
3-17
  Provide patient and public education where appropriate to facilitate.
 Act as liaison for members of the public and other health care Professionals.

All Adult patients need to be triaged by five level color coded emergency triage system as Red,
Orange, Yellow, Green, Black or Blue using emergency severity index level. Then the triage
officers should make sure that the patient can actually receive appropriate treatment for his/her
presentation or acuity level.

Whereas for pediatric patients the triage officers decides whether the patient will be seen
immediately and will receive life-saving treatment/Emergency/, or will be seen soon /priority/, or
can safely wait his/her turn to be examined /Queue (Non-Urgent)/ based on Emergency Triage
and Treatment/ETAT/ protocol.

Following the initial assessment and triage to stabilize vital functions, patients should be
assigned to the Case Management Team for further investigations, treatment and follow up. The
triage nurse should always make sure that the triage sheet is completed and attached to patient
triage.

During triage and case management of emergency cases, Porters should handle relevant
administrative processes (such as patient registration, retrieving the patient’s medical record,
making payments etc.). For further information on the process of registration (see Medical
Records Management Chapter.)

B) Emergency Triage Human Resource Requirements

The Emergency Triage Officer should be trained in Emergency Triage and Emergency Case
Management. He/she should be a nurse or physician but if this is not possible another skilled
health worker may take this role. He/she should be assisted by a Clinical Nurse and porter. If the

3-18
workload is high the hospital may appoint more than one Emergency Triage Officer, Nurse and
Porter.

C) Emergency Triage Equipment and Supply Requirements

The emergency triage should be equipped with items to deliver at least a minimum of basic
emergency care. Each hospital should conduct its own assessment to determine the quantity of
each item and any other necessary items in addition to the basics according to the tier level

D) Emergency staffs Training Requirements

All emergency clinical staff should be trained to conduct triage and emergency treatment,
following the established triage protocols and emergency medicine manual.

3.3.2, Emergency Patient Resuscitation

All patients with life threatening conditions and with CVS arrest should be admitted to this area
for resuscitation. In one ED/EU there must be 2-3 resuscitation couches for adult and same
number for children. The staff ratio has to be 1:1 (one nurse for one patient). At the beginning of
the resuscitation multiple specialty physicians and nurses might participate according the
patient’s condition. The nurse on charge for this coach is responsible for availing and
maintaining emergency supplies and drugs. After resuscitation the patient must be transferred to
the appropriate designated area (observation room, ward, OR, or can be referred to the
appropriate level of health facility for continuation of management)

3.3.3, Emergency Case Management

After triaging and resuscitation, patients who require temporary short-term observation and
management is admitted to this area. Appropriate care is then initiated by the emergency case
management team and based on the outcome the patient is admitted, discharged (with or without
a follow up appointment) or referred. The number of beds for observation varies from hospital
to hospital according to their load, but it is advisable to have 5-10 beds as a minimum. Patients
3-19
kept in this area need frequent evaluation by the ED/EU physicians, available senior physicians
and nurses. The nurse patient ratio is 1:3.

A) Emergency Case Management Activity

The emergency case management team should perform primary and secondary survey of the
patient and facilitate any diagnostic and/or therapeutic procedures as required. The physician on
duty should take a full history and examine the patient and arrange for any investigations
required. In addition, emergency nursing assessment should also be done for all patients stayed
in the ED/EU.

Every patient in ED/EU should be continuously being monitored and re-evaluated by nurses and
physicians. Depending on information obtained by this continuous monitoring, previously
chosen course of diagnostic testing or therapeutic intervention may need to be modified. If
patients with complicated social and psychological dimensions are encountered, all of their
problems must be sorted out in the ED by a social worker. Once the necessary evaluations made,
a decision is made as to whether the patient needs to be admitted to the hospital or can be safely
discharged home

If radiology tests are required these too should be conducted in the Emergency Department using
a portable X-Ray. If this is not possible, a Porter should transport the patient to the X-Ray
department where the test will be conducted. Results should be taken back to the Emergency
Department by a porter.

A cashier service should be available within the emergency department for the payment of all
emergency room treatments, investigations, drugs and consumables. Porters should assist the
patient and/or caregiver with making payment.

Patients who require close observation and needs emergency treatments (such as IV fluid
administration, a loading dose of IV antibiotics etc.) may be transferred to a bed in the
Emergency Services and kept for a maximum of 24 hours. Any patient who requires treatment
for a longer period of time should be admitted to an inpatient ward.

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Following assessment, investigation and treatment the patient may be discharged home, referred
for a follow-up appointment at the outpatient services admitted to an inpatient ward or referred to
another facility.

If an outpatient follow up appointment is necessary this should be arranged by the Liaison

Officer and an appointment card should be given to the patient before he/she leaves the
emergency department.

If the patient is to be admitted to the hospital the Liaison Officer will check the availability of a
bed and arrange for the patient to be transferred to the appropriate ward/ICU, escorted by a
porter or appropriate scope of professional with his/her medical record.

If a bed or the service required is not available at the hospital, the Liaison Officer will contact
other facilities or the Regional Emergency Command Centre (if available) to identify a hospital
with the capacity to provide care to the patient and will facilitate referral following agreed
protocols. If the service is not available in another facility the patient must be kept in the hospital
to receive treatment.

B) Emergency Case Management Human Resource Needs

A case team comprised of clinical and support staff will provide emergency services. Specialists
working in other departments/Case team, should be readily available to provide
support/consultation to the Emergency Case Team whenever required. The Emergency Case
Team should have ready access to the Liaison and Referrals Service.

C) Emergency Case Management Equipment and Drugs Needs

Each triage and treatment room should be equipped with equipment and Drugs needed to provide
at least basic emergency services. Each hospital should conduct its own assessment to determine
other items in addition to those needed for the basics according to the tier level.

Those hospitals with intermediate, advanced and center of excellence emergency department
services are supposed to have additional equipment and drugs which are clearly stated in the
national Emergency Services Leveling Guidelines. So General hospitals, Tertiary hospitals, and

3-21
Center of excellence in emergency care shall full fill their requirements in terms of leadership,
human recourse, equipment, drugs based on their level.

3.4 Ambulance service

Hospitals should have in house ambulance/Emergency patient care and transportation service/
for inter- hospital or inter facility transfer of patients and whenever there is need for advanced
life support to be deployed to assist the pre-hospital providers. The ambulance has to serve only
for emergency patient transport and management. All ambulances in hospital has to be equipped
with equipment and supplies to render minimum Basic Life Support/BLS/, Advance Life
Support/ALS/ and trained ambulance drivers. Hospitals’ caseloads and availability of ambulance
access areas should determine the appropriate number of ambulances in hospitals, including
those used for non-emergency patients. In Hospital ambulances should be managed by liaison
service.

3.5 Hospital Emergency Preparedness and Responses

Disaster is a serious disruption of a household, community, ecosystem or society that results in

human, material, economic or environmental losses which exceeds the ability of those affected to
manage, using their own resources.

A disaster response is treating any acute event, natural or man-made, in which patients, acutely
or chronically ill or injured have medical needs, which exceed available resources, resulting in
patients receiving inadequate or even no care. NEEDS > RESOURCES. Health facilities have to
prepare to disaster when it occurs in the hospital, in their own jurisdiction and for assistance of
neighboring regions and/or for national response.

Hazard is potentially damaging physical event or action that may harm people, their economic
assets, infrastructure and environment. Hospitals must plan for both internal and external
disasters. Effective planning is essential for an optimal preparedness and response to disasters by
hospitals based on the identified Hazard vulnerability analysis.

A National or regional incident command system will integrate activities and resources to guide
healthcare facilities’ response to disasters. All hospitals should have an emergency/disaster

3-22
response coordinator to oversee hospital disaster preparedness and response, training and
implementation.

When there is a significant health impact from a disaster, hospitals may face demands that place
enormous strains on their capacity. It is therefore essential that all hospitals have plans in
advance in place to cope with an unexpected influx of patients.

There shall be a trained emergency medical team (EMT) in the hospital which will respond
during time of disaster and mass casualties.

Disaster preparedness and response plan uses all hazards, all agencies, and comprehensive
approaches and focuses the importance of careful planning. For detail information, please see
the National Disaster Health Preparedness and Response Guideline.

Chapter Summary

Emergency and injury care service is mainly about hospital based emergency medical services
from the patient’s arrival at the entrance of the hospital until the patient is either admitted as
inpatient/transferred to outpatient services, referred to other health facilities, discharged home
and exits the hospital. This chapter also emphasizes on injury and mass causality management
and its implementation mechanism. It also elaborates the expected levels of emergency service
from hospitals according to their hospital tier and the service can be leveled as Basic level
(Primary hospitals), intermediate level (General hospital), advanced level (tertiary hospital) and
center of excellence and their service should be assessed with their respective level.

3-23
24

Source Documents

1. Federal Ministry of Health Medical services, Emergency and Critical Care

Directorate(2020), National Emergency Services Leveling Guideline

2. Federal Ministry of Health(2022), National Referral Guideline

3. Federal Ministry of Health ,ETHIOPIAN HOSPITAL SERVICES

TRANSFORMATION GUIDELINES, Volume 1, September 2016

4. Federal Ministry of Health. National Liaison and Referral Manual. Unpublished. Federal
Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business
Process Study Report. Addis Ababa, Ethiopia.

5. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, November).

Guideline for Implementation of a Patient Referral System in Ethiopia. Addis Ababa.

6. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Patient

Flow: A Manual Prepared for Heads of Hospitals and Service Providers. Addis Ababa,
Ethiopia

7. WHO. (2016). Pocket Book of Hospital Care for Children. Guidelines for the
Management of Common Illnesses with Limited Resources. Geneva: World Health
Organization.

8. World Health Organization. 2016. Updated guideline: pediatrics emergency triage,

assessment and treatment.Geneva: World Health Organization.

9. Federal Ministry of Health. Ethiopian Hospital Reform Implementation Guidelines

(EHRIG). May 2010. Addis Ababa, Ethiopia.

10. Federal Ministry of Health. The National Admission and Discharge Protocols for
Ethiopian Hospitals. July 2012. Addis Ababa, Ethiopia.
25

Appendices

Appendix 1, Emergency Triage Format

Arrival Date
_______________

1. Patient Name ____________________Card No.__________ Age ___Sex ___Address

_____________

2. Time of Illness/accident _____________ Time at arrival to ED ___________ Triage time

___ ______

3. A. Mode of arrival to the Hospital/ED - Ambulance  Private car Walking Carried 

Taxi

B. Origin of Referral – Government Hosp  Private Hosp  Health cent  Police 

Self 

4. Pre- Hospital care/First aid given Yes  NO 

5.Chief Complaint
____________________________________________________________________

A. Non trauma - Chest pain Fever Diarrhea/Vomiting  Headache Sudden

collapse poisoning Convulsion Respiratory problem. Abdominal pain 
others___________

B. Trauma - RTI  Fall accident  Suicide  Gunshot  Stab  Burn 

Foreign body swallow  other specify _________

C. Ob/Gyn - Vaginal bleeding  Labor pain  Lower abdominal pain  seizure  other
specify ____________
6. Past Medical illness
__________________________________________________________________

7. History of allergy No  Yes  (specify)

___________________________________________

8. Vital sign recording BP____________ RR ___________ HR ___________ T

_________ SpO2_________ RBS_________

9. Condition on arrival Modified Early Warning Score (MEWS)

Score 3 2 1 0 1 2 3
Mobility Walking With help Stretcher/imm Total
HR ≤ 40 41-50 51-100 101-110 111-129 >129
RR ≤8 9-14 15-20 21-29 >29 MEWS
Spo2 ≥94% 90-94% ≤90%--- (not for CO score
Temp ≤35.0 35.1- 37.3-37.9 ≥38.5
CNS/AV Confuse Alert Respond to Respond to Unresponsiv
SBP ≤7 71-80 81- 101-199 ≥200
Trauma NO YES
Pain No pain 1—3/10 4—7/10 ≥ 7/10

Determine Triage Color

Triage >7 5-6 3-4 0-2

Score

Presentatio * Seizure * Reduced consciousness * Burn (other)

n (current)
* Seizure (post-ictal) * Hemorrhage
* Burn (controlled) Dead on
* Acute focal neurology
(face/inhalat arrival
symptoms * Closed fracture
ion) All
* Psychosis/aggression * Minor dislocation (BLAC
other
* K)
Hypoglyce * Burn (>20%, electric, chemical, * Pregnancy + patients

mia (Glu<3) circumferential) vaginal bleeding

* Hemorrhage (uncontrolled) * Pregnancy + non-

abdominal trauma
* Pregnant + abdominal trauma /
* DM (Glucose>17
 pain no ketonuria)

* Threatened limb OR * Abdominal pain

(acute)
* Compound fracture.
* Vomiting (ongoing,
* Major dislocation (not
no blood)
finger/toes)

* Diabetic &Glucose > 11 with

ketonuria

* SOB or Chest pain (acute)

* Coughing blood OR Vomiting

blood

* Poisoning / Overdose

Pain -- Severe Moderate Mild

10. Assessment- Red  Orange  Yellow  Green  Blue/Black 

11. Transfer to- Resuscitation room  procedure room Waiting room  Regular OPD 
Home 

12. Treatment and investigation on triage

__________________________________________________

13. Triage Officer Name

______________________________________________Sign_______________
28

Appendix 2, Resuscitation minimum equipment’s and supplies list

Basic

 Airway equipment,

 Oxygen system-cylinder, concentrator, face mask, nasal prong, flow meter

 Suction machines

 Intravenous set/cannula and fluids,

 Emergency and analgesia drugs

 ECG machines,

 Non-invasive ventilation (NIV)

 Foley catheters

 Chest drain sets

 Tracheotomy sets

 Tubes; NG, Rectal,

 Wide bore needle/cricothyrotomy / optional for primary hospital/

 Defibrillator,

 Monitors

 Ventilator –optional for primary hospital

 Intubation sets

 Anesthesia drugs

 Portable X-ray facilities

 Portable ultrasound devices

 Intraosseous needles and drill

 Central lines
Appendix 3, General minimum Equipment and Supply Needs for Emergency
unit/departments

Equipment and Supplies

 The basic equipment and supplies needed for effective running of the Emergency
Department or Unit are listed below:

 Airways/Breathing

 Bag valve mask:

 Chest tube / underwater seal drainage

 Combitube

 Elastic gum bougies

 Endotracheal tube TT

 Laryngeal Mask Airway

 Laryngoscope, various size s of blades

 McGill forceps

 Nasal prongs

 Nasopharyngeal airways

 Nebulizers

 Oropharyngeal airways

 Oxygen cylinder with a flow meter

 Suction machines and tubes

 Thoracotomy set

 Tongue depressor

 Tracheostomy set
 Transport Ventilators

 Ventilator (ICU)- optional for primary hospital

 Ventury airway mask/ poly mask

 Yankeur suction

 Circulation/Haemodynamics

 12 lead ECG machine

 Blood and fluid warmer

 Central venous catheters

 Cut-down set 1 (phased out)*

 Defibrillator/ Automated External Defibrillator (AED)

 Foleys catheter

 High capacity catheters

 Infusion pumps

 Intraosseous Needles

 IV cannulae 14, 16 18 20 and 22

 Syringe pumps

 Splints

 Bandages

 cervical collar –soft/hard collar

 POP

 Spine board

 Splints (specify the types needed)

 Trac 3 traction kit* (trade name)

 Monitoring Devices

 Pulse oximeter

 Patient Monitors (invasive and non invasive)

 Glucometer

 Spirometer/ peak flow meter

 Thermometer

 Diagnosis set

 Stethoscope

 Sphygmomanometer (Digital & Aneroid)

 Other Emergency Equipment

 Bradlow tape measure (for children)

 Weighing scale

 Telephone and directory

 Pedal operated color-coded waste bins

 Safety box for sharps

 Blood fridge

 Cabinets

 Computer and accessories and appropriate software

 Consumable cabinet

 Drug cabinet

 Examination couch

 Examination lamps

 Hoist
 Instrument trays

 Office furniture

 Refrigerator

 Resuscitation trolley/tray

 Rollers

 Stretchers

 Suction machine

 Telephones

 Trolleys

 Wheel chairs

 Diagnostic

 Blood gas/electrolyte analyzer

 Mobile X-ray machine

 Diagnostic set

 Diagnostic Peritoneal Lavage set

 Glucometer

 Laboratory sample set

 Lumber puncture set

 Minor surgical set

 Fetal heart monitor

 Hand held Doppler machine

 Suprapubic catheter sets

 Ultrasound machine
Medicines

 Essential medicines needed for effective running of Emergency are listed below:

 50% Dextrose

 Adrenaline

 Nor-adrenaline

 Anti-snake venom serum

 Aspirin

 Atropine

 Anti-Tetanus Serum

 Dextran/Voluven

 Diazepam

 Dobutamine

 Etomidate

 Fresh Frozen Plasma

 Gelofusin

 Group O Negative whole blood

 Heparin

 Hydralazine

 Hydrocortisone

 Glucagon (IM)
 Insulin

 IV calcium Gluconate

 IV Dopamine

 IV Fluid - all type

 IV Frusemide

 IV KCl

 IV Vitamin K

 Labetalol

 Lignocaine

 10% xylocaine spray

 Magnesium Sulphate

 Mannitol

 Midazolam

 Morphine

 Naloxone

 Nitroglycerine

 Oral Rehydration Salt (ORS)

 Oxygen supply

 Pethidine

 Phenylephrine

 Propofol

 Salbutamol

 Sodium bicarbonate
 Suxamethonium

 Blood and blood products

6 Medical Records Management
Table of Contents Pages

Section 1 Introduction
Section 2 Operational Standards for Medical Record Management
Section 3 Implementation Guidance
3.1 Organization of Medical Record Management Unit
3.2 Retrieval of Existing MRN or Generation of New MRN
3.2.1 Master Patient Index
3.2.2 Patient registration
3.2.3 Starting a Medical Record for a new patient
3.2.4 Service Card
3.2.5 Storage of Medical Records
3.2.6 Retrieving existing Medical Record for a returning patient
3.2.7 Appointment Card

3.3 Documenting Patient Information

3.3.1 Purpose of clinical documentation
3.3.2 How and when to document
3.3.3 General rules in clinical documentation
3.3.4 Standardized documentation and forms
3.3.5 Key components of clinical documentation and Medical Record forms
3.3.6 Correcting medical record data

3.4 Handling of Medical Records

3.4.1 Tracking the location of Medical Records
3.4.2 Who should handle Medical Records?
3.4.3 Archiving Medical Records
3.4.4 Medical Records at discharge
3.4.5 Destruction of inactive Medical Records
3.4.6 Removal of Medical Records from hospital
3.4.7 Confidentiality

3.5 Electronic Medical Records

Section 4 Implementation Checklist and Indicators
4.1 Assessment tool for Operational Standards
4.2 Implementation Checklist
4.3 Indicators
Source Documents
Appendices
Appendix A Inpatient Medication Profile Form
Appendix B Pharmaceutical Care Progress Note Recording Sheet
Appendix C Drugs & Medical Supplies Credit Sales/Consumption Registration Book
Appendix D Inpatient Medicines Consumption Summary Sheet
Section 1 Introduction

Medical records are documents that explain all details about the patient’s history, clinical findings,
diagnostic test results, pre and post-operative care, patient’s progress and medications. (NLM, 2011)
Medical records management (MRs) is one of the components of health information system that
documents information related to a patient generated during patient-to-health care provider encounters at
a health care facility.

The goals of recording information in medical records are to support the delivery of good care, clinical
decision-making, communication between healthcare workers, continuity of care, scientific research,
quality assurance and transparency of the delivered care. It is also important for measuring and improving
the quality and coverage of health services and policy directions and promote equity, to detect and control
emerging and endemic health problems and for empowering individuals and communities with timely and
understandable information.

A well-managed medical records system is critical to improve the provision of quality health care services
to ensure safe medical practice, efficient and effective services and improve the patient’s experience and
satisfaction with their medical encounter. A strong medical records system is also equally important to
make clinical and public health evidence based practices as well as making informed decisions. In
addition, medical records may serve as a reliable source of information for medico-legal issues and
medical/ public health researchers.

A well-organized medical recording system ensures the availability of reliable healthcare data in the
health system; in which it can serve as an input for the implementation of national health sector
transformation strategic plan (HSTP II) in particular to the information revolution agenda. Poor data
quality management system including incomplete medical recording and reporting practices, lack of
information technology and its use, shortage of human resource and professional mix, failure to audit
medical records and failure to adhere with existing guidelines and SOPs are the major observed
challenges in hospital’s medical record management system.

1
Section 2 Operational Standards for Medical Records Management

1. The hospital has functional medical record management unit.

2. The hospital has standard MR room.
3. The hospital has created a system to register and retrieve medical records.
4. The hospital avails and utilizes a standard set of formats for medical record registration.
5. The hospital complies with national guidelines to manage access to patients’ medical records.
6. The hospital has a system for proper handling and confidentiality of medico legal patients’
medical records.
7. The hospital performs medical record auditing and takes corrective actions on a regular basis.
8. The Hospital ensures patients’ medical record tracing system.
9. The hospital implements fully automated medical recording system.

2
Section 3 Implementation Guidance
3.1 Organizational Structure of Medical Record Management Unit
The hospital need to establish a functional medical record management unit. The unit should develop
annual, quarterly and monthly plan clearly aligned with the hospital’s strategic plan. The Medical record
management unit incorporates professional mix of IT professionals, HIT workers, registration officers,
runners and cashiers. The unit is led by MR unit coordinator, preferably HIT professional.

The unit should regularly meet on a weekly basis among the case team members and discussion agendas
should be clearly documented. The Medical Management Record unit should create smooth
communication platform with other interrelated case teams/departments.

All personnel that work in the Medical Records Department should be qualified to conduct their jobs,
which require reading, keyboarding, and organizational skills. Depending on the size of the facility and
volume of patients, the number of personnel working in the Medical Records Department will vary and
hospitals should hire according to updated regulatory standard as per respective health tire level.
However, there should be enough staff to cover the following duties, particularly during the prime hours:
 Patient registration
 Authorization of free and credit services
 Development and maintenance of the MPI
 Retrieving and filing MRs
 Delivering files to various locations of the hospital
 Recording chart location
 Collection of MRs from individual service units
 Checking and ensuring completion of MRs after discharge or death
 Filing reports generated by the Medical Records Department
 Handling of medico-legal issues relating to releasing patient information and other legal issues.

All MR personnel should undergo MR orientation and subsequent annual training on all departmental
policies. Professional mix of the staffs of medical record unit should incorporate MRU head, Information
Technology professional, Health Information Technology (HIT) workers, runners and cashiers.

The Hospital should have single and unified medical record room with adequate service delivery
windows. There should also have enough amounts of labeled shelves, office furniture, MPI box, computers,
UPS, etc.

3
3.2 Medical Record Generation and Retrieval

When a patient arrives at a hospital, the hospital’s primary role is to identify the patient’s status as an
emergency or non-emergent case and to identify, if the patient is a new patient (i.e., has never been given
a medical record number (MRN) before at the facility) or a returning patient (i.e. has an MRN at the
facility from a previous visit).

Each patient should have one MRN for all visits to the health facility i.e. the MRN generated during the
registration process at the patient’s first visit to the health facility. Subsequently, the same MRN should
be used for all other visits, including outpatient, inpatient and emergency visits.

3.2.1 Master Patient Index

The Master Patient Index (MPI) is a database of patients’ name, sex, contact information, registration
dates, phone number and the MRN for each patient ever treated at the health facility. The MPI is an
essential element of existing, retrieving and generating new MRNs. MPI contains no medical data.

Each health care facility should have an MPI. The MPI is recommended to be computer-based with paper
based back up.

The index cards should be filled alphabetically by first name. When the hospital learns that, a patient has
changed his/her name legally, a cross-index file should be made to identify the initial record with the
previous name. The MRN of the original registration should be recorded on the cross-index card.

If a patient changes any other contact details (such as address or telephone number) a new MPI card shall
be prepared to replace the original. The patient’s name, MRN, date of registration and any other
unchanged information should be transcribed exactly as written on the original onto the new card. The old
card should be scored through with the signature of the individual preparing the new card. The new card
should be stapled to the top of the old card and both should be filed together so that, the updated
information is readily available without losing any prior information. In a computer based MPI, the
contact details can be amended directly in the appropriate computer fields.

If duplication of MRN is identified the number in the MPI should not be canceled rather cross-referring
should be made linking the duplicated number.

Since digitization is one of the health sector’s plan agenda, hospitals are expected to provide paper-free
medical recording system. So, manual MPI is not encouraged.

4
The use of a computerized MPI permits faster retrieval of patients’ MRN. Electronic Health Management
Information System (E-HMIS) is being rolled out across Ethiopian hospitals that include a computerized
MPI component. However, a paper-based card file should also be maintained in case of computer
technical failure/downtime. Interruptions in the system can be caused by a variety of factors, including
electrical outages or hardware/software problems. Therefore, hospitals should maintain a back-up, paper-
based system in order to ensure no interruption in MRN retrieval.

If a computer based system is used in addition to a manual system, similar procedures should be followed
for both MR management systems to ensure optimal patient care. Both systems are effective when
implemented and used correctly.

3.2.2 Patient Registration

Patient registration is the process of documenting the patient’s visit to the facility and assigning an MRN.
When the patient arrives at registration, the clerk should ask the patient’s name (first, father’s first name
and grandfather’s name) and then look for an existing MRN in the computerized MPI or paper-based
backup print. This should be done whether the patient reports that he/she has been to the hospital before
or not.

If there is an existing MRN for that patient, the registration clerk should facilitate the retrieval of the
existing MR stored in the record room. The MRU worker should retrieve the patient’s MR and then, a
runner will take the MR to the area where the patient is to be treated as per the request of health care
provider.

If no previous MPI card or MRN can be found, the registration clerk should generate a new MRN. New
MRNs should be issued in straight numeric sequence, without skipping any numbers. Each MRN should
be assigned to one and only one patient. Reissuing an MRN to another patient should never occur.
Registration staffs should both create a service card and an MPI card for a specific attending client and
then finally will give to the client and placed in the MPI box respectively. All patients regardless of which
service they will access should be registered at one central registration site.

5
Figure 1 Patient registration process and patient card path in a hospital

Centeral
Triage

Emergency
Is Emergency? Yes
Service Unit
No

*R Runner/Patient-Attendant

Avail Medical Record

Return Medical Record

New/Repeat

New Repeat

New Retrieve Patient

Registeration Record

Avail Patient
Record to
Service Units

Return Medical Record Return Patient Record

to Centeral Medical
Recording Room

i.e.* - Registration
All patients/clients regardless of which service they will access should be registered at one central
registration site (i.e., the MR Unit).

6
3.2.3 Starting a Medical Record for a new patient
After the MRN is generated (i.e., the next number in the sequence is assigned to the selected patient), an
individual hospital-approved folder should be assigned to the patient. Any patient information generated
by hospital staff during the period of care should be kept in this folder. A paper fastener or metallic
fastening tool should be used to keep all per-approved clinical documents/forms in the folder. The MRN
should be clearly displayed on the folder as a form of identification.

3.2.4 Service Card

Each new patient registered for outpatient or inpatient services should be issued a service card. This card
is a small pocket-sized card used as an identification card for each patient, which should be shown to the
MR staff whenever the patient attends the hospital. All the necessary registration information should be
recorded on the card. Contents of the patient service card include: Name of the Facility, Date of
Registration, Medical Record Number, Name of client, DOB.
or age at registration, Sex, Client’s address, Phone number and free service stamp space.

Figure 1 A Service Card Template for use in Ethiopian health facilities

የአገልግሎት መ
ታወቂያ ካርድ
Service Identification Card
የግል ድርጅት የማ
ህበረሰብ አቀፍ የህብረተሰብ አቀፍ የነጻ /የዱቤ አገልግሎት

ታካሚ ኢንሹራንስ ታካሚ ኢንሹራንስ ታካሚ ማህተም

CBHI SHI Free/Credit

Private Service stamp

7
3.2.5 Storage of Medical Records
Hospitals are expected to implement EMR and store all medical records in server with backup

data. All active MRs should be filed in a single, centralized file room, i.e., the Medical Records
Department or Card Room. MRs should be filed numerically according to MRN. If more than one room
is needed for file storage, files should be stored numerically (i.e. MRN 1,000-5,000 in one room 1; MRN
5,001 – 10,000 in room 2). Hospitals should audit the files periodically (quarterly or as per hospital
policy) to ensure correct filing. All patient files should be stored together, using one MPI, including those
from specialized clinics (Eg. ART, EPI etc). If separate record numbers and/or filing systems exist the
hospital should integrate these within a single system.

3.2.6 Retrieving existing Medical Record

1. Use the MRN to find the MR.

If the patient knows his/her MR number or brings his Service Card then the MR number can be used to
find the patient’s MR. The MR is filed numerically in the MR room and hence can be easily retrieved
from the shelf.

2. Retrieving a MR by phone number

Searching patients MR by mobile number is an easy way of retrieving. It can be used for all patients
whose contact number is registered.

3. Retrieving a MR by name

If the patient does not remember their MRN or does not have their service card or phone number can not
be accessed then electronic MPI can be used to search for the patient information.

3.1.7 Appointment Card

An appointment card should be given to the patient stating the date and time of planned outpatient visits
or admission.

8
Figure 2. Patient Appointment Card

የቀጠሮ መ
ስጫካርድ

Appointment Card

የቀጠሮ ቀጠሮ የሰጠዉባለሙ

ያ ቀጠሮ የሰጠውአገልግሎት

Appointing ክፍል

ቀን ሰዓት Professional Appointment

Date time with service

9
 Figure 4. How information being created in patient’s chart during service delivery

MRU
Client Seekig Healthcare
MR Opened

M PI
Indexed

M R li sted & dis patched

Personal & Inpateint Service

Register Demographic Data Unit Register
Ward Data

Procedure,

Searched by MPI
Outpateint Prescription &
Register Seervice Units Concent Data Register
Outpatient Data

Referral, Financial
Register Investegation Register
Data

Service

M RU
M R As semb led & Compl eted

MR Filed
_________

Primary source: HMIS Medical Records Training Manual, June 2008

10
3.3 Documenting Patient Information
3.3.1 Purpose of clinical documentation and what should be documented
MR documentation is essential to ensure quality of care for every patient. All information
regarding the patient and his/her course of care at the hospital should be recorded in the MR.
This includes his/her presenting symptoms and medical history, any diagnostic test orders and
results, all documentation from care providers and consultants, interventions, diagnostics,
medications, therapy, and information and instructions at discharge. Any subsequent return visits
to the hospital should be recorded in the same MR.

The MR provides each clinician responsible for patient care with access to a record of the
patient’s health status, medical history, investigation procedures (lab tests, etc.), treatments and
outcomes.

3.3.2 How and when to document

The health care professional responsible for administering each clinical event, intervention,
instruction or observation, as soon as possible after the occurrence, should document each
clinical event, intervention, instruction or observation. MRs of discharged patients should have
all documentation completed by the discharging physician before the patient is discharged from
the hospital and the record should then be returned to the card room.

All entries should be dated and authenticated with full signatures. Professional designation (i.e.
MD, RN, etc.) should also be included.

This information is to be filed in one folder divided in separate sections for each visit/admission
in chronological order.

If the patient has a chronic disease and regularly attends a Specialized Clinic (e.g. HIV, TB etc)
then a separate section may be created in the MR folder to record all visits to the Specialized
Clinic.

11
 3.3.3 General rules in clinical documentation

 The patient's name and MRN should appear on each page.

 All handwriting should be in permanent ink that is legible when photocopied. Pencil
entry in any part of the record is not permitted.
 All entries should be dated and authenticated, including signature and title of the author.
 Each clinician should sign those portions of the MR containing documentation of care for
which he/she is responsible.
 Transcription of verbal orders or other information should be accurate and complete. It
should be signed by the person who transcribed the verbal order or other information and
co-signed by the person giving the verbal order within one working day of the verbal
order.

3.3.4 Standardized documentation and forms

Only approved and standard clinical forms (approved by government agencies or hospital
management) should be used in the MR. A standardized format should be used throughout the
hospital’s forms to facilitate the entry, review, and retrieval of information.

The following criteria can be applied to ensure standardization.

 All forms should be of the same size, usually maximum of A4.

 Key identifiers such as the name of the form, patient’s name and medical record number
should be located in the same place on all medical record and clinical documentation
forms.

3.3.5 Key components of clinical documentation and Medical Record forms

The MR should contain the following components, filed in the following order:

 Demographic sheet
 Summary sheet of all visit dates (including inpatient, outpatient, and emergency care)
For each inpatient admission, the following forms can be used depending upon the need for a
specific client:
 Admission Card

12
  History and Physical Examination Assessment
 Progress notes
 Consultation request form (if relevant)
 Consent form (if relevant)
 Physician order sheet
 Laboratory order and report form(s)
 Radiology order and report form(s)
 Pathology order and report form(s)
 Pharmaceutical care plan (if relevant)
 Nursing Process Forms
a) Nursing admission assessment form
b) Nursing problem statement list
c) Nursing care plan
d) Nursing patient progress report
 Routine observation chart
 Medication administration record
 IV fluid and additive administration record
 Fluid balance chart
 Discharge summary
 Post mortem request and report (if relevant)
 Death summary (if relevant)
 Referral form(s)
NB: While the patient is in hospital some of the above forms (e.g. Nursing Care Plan, Routine
Observation Chart, Medication Administration Record, IV fluid and Additive Administration
Record); may be kept in a clip folder by the patient’s bedside or at the nurses’ station for ease of
reference. When the patient is discharged these forms should all be entered into the MR before
the MR is returned to the Medical Record Room.
For each outpatient attendance additionally needed:

13
  History and physical examination assessment
 Consultation request form (if relevant)
 Consent form (if relevant)
 Progress notes
 Laboratory order and report form(s)
 Radiology order and report form(s)
 Pathology order and report form(s)
 Triage form
 Referral form(s)
 Trauma flow sheet
 Critical Care flow sheet
 Emergency Nursing care sheet
 Wound assessment format
 Pain assessment format
 Inpatient 24 hour flow sheet (Emergency)
 Nurse to nurse shift report
 Burn Unit National Data Registry format
Samples of the Nursing Process Forms are presented in Chapter 7 Nursing and Midwifery Care
Standards and the pharmaceutical care plan is described in Chapter 10 Pharmacy Services.
Templates of all other forms listed above are presented in Appendix B.

Other forms that could be included in the MR if relevant include, but are not limited to:

 Immunization and growth monitoring records, for paediatrics

 Obstetrical care forms (Mothers prenatal, intra-natal and postnatal follow up form, safe
child birth checklist, per-anesthesia evaluation form, emergency obstetric triage form,
etc.)
 Service record form
 Pte-anesthetic and post-anesthesia follow up form, critical care follow up form, blood
request and transfusion report forms.

14
3.3.5.1 Forms included in a Medical Record include

1. Demographic sheet

Function: A page recording all patient demographic and contact information for all clinicians to
reference (patient name, date of registration, date of birth/age, sex, address, emergency contact
information).

Location: Front of MR.

Work process: When the patient is first registered, a demographic sheet will be put in the
patient’s MR.

2. Summary sheet of all visit dates

Function: To capture patient visits to the facility.

Location: Inner side of the front page of medical folder

Work process: All visit dates, for both inpatient and outpatients, will be recorded on the
summary sheet.

3. History and physical examination assessment

Function: To record patient history and physical examination assessment findings.

Location: MR

Work process: When a patient is admitted as an in-patient a full history and physical examination
should be conducted by the attending physician.

4. Progress notes

Function: To record clinical findings and progress.

Location: MR

Work process: When the patient is seen by a clinician, the information obtained will be recorded
with date, clinical details, and signature of the attending clinician.

5. Consultation request sheet

15
Function: When a different specialty opinion is sought, the form serves as a communication tool
for the different consulting parties.

Location: MR as a permanent record.

Work process: When any consultation is needed, the form is filled in two copies; one to be sent
to the consulted physician and the other attached in the MR. i.e. The original one will be placed
the request in the physician’s order sheet and sign a consultation request. Nurses or appropriate
case team member will contact the consulting specialist to see the patient. The consulting
specialist should record the result/opinion on the consultation request.

6. Consent forms

Function: The consent form outlines the risks associated with a particular procedure. A signed
consent form indicates that the patient (or designated proxy) has been informed of the risks and
has authorized the procedure.

Location: MR

Work process: Before any procedure that has associated risks, the patient should be counseled
regarding all risks and alternative options for treatment and asked to sign a consent form to
indicate his/her agreement to the procedure. Consent should be obtained by the person who will
perform the procedure.

7. Physician order sheet

Function: All physicians will write orders on this form, including diet, nursing care, medication,
and investigation procedures (lab, imaging, consultation, etc.).

Location: MR.

Work process: When patient is admitted to a ward, a physician order form will be put in the MR.
A physician will write his/her orders on this form and other individual request forms (i.e.,
medication prescription, lab order form, consultation request form, etc.).

8. Laboratory order and report result forms

Function: Informs laboratory of any individual patient’s lab investigation order and allows lab
result to be recorded on these forms.

16
Location: MR.

Work process:

Inpatient: When any lab test is ordered, the ordering physician will sign a lab order and report
form. The lab order will be sent to lab. Lab will collect the sample and conduct corresponding
test(s) upon receiving the order. The test results will be recorded on the lab order form as well as
in the log book in the laboratory department. The completed lab order will then be sent back to
the ward and kept in the MR.

Outpatient: When any lab test is ordered, the ordering physician will sign a lab order. The lab
order will be given to the patient. Sample will be collected either in the outpatient department if
phlebotomists or other appropriate personnel is assigned or will be collected by the laboratory
department. For other tests the patient takes the lab order to the laboratory for the corresponding
test(s). The test results will be recorded on the order form as well as in the log book in the
laboratory department. The completed lab order will then be sent back to the ordering
clinic/physician and kept in the MR. If the patient goes to an external lab for test; the completed
lab order will be brought to the physician by the patient upon next follow up visit, to be filed in
the MR.

9. Radiology order and report form

Function: Informs diagnostic imaging department of any individual patient’s imaging

investigation order and allows result to be recorded on this form.

Location: MR as a permanent record.

Work process:

In-patient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be sent to diagnostic imaging department. The radiology
technician will schedule a test appointment upon receiving the order form. The test results will
be recorded on the order form by the radiologist, as well as in the log book in the diagnostic
imaging department. The completed radiology request and film will then be sent back to the
ward and kept in the MR.

17
Outpatient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be given to the patient. The patient takes the radiology
request to a diagnostic imaging department for the corresponding test(s). The test results will be
recorded on the order form, as well as in the log book in the diagnostic imaging department. The
completed radiology request will then be sent back to the ordering clinic/physician and kept in
the MR. If the patient goes to an external imaging clinic for test, the completed radiology request
and film will be brought back to the physician by the patient upon next follow up visit, to be filed
in the MR.

Emergency: When any imaging test is ordered, the ordering physician will sign a radiology
request. If a mobile diagnostic imaging machine is available, the test will be done in the
emergency room. The test results will be recorded on the order form. If mobile unit is not
available, steps outlined for outpatients above should be followed.

10. Pathology order and report form

Function: Official record for the pathology request/results

Location: MR

Work process: When a pathology sample is collected (e.g. fluid aspirate, tissue biopsy) the
ordering physician will complete a Pathology Request Form. The sample and form will be taken
to the pathology department for analysis. If the required service is not available in the hospital
the sample and request form should be taken to the central laboratory where they will be stored
and then transferred to the appropriate facility, in accordance with hospital policy for sample
referral.

11. Nursing Process Forms

a) Nursing admission assessment form

b) Nursing problem statement list

c) Nursing care plan

d) Nursing patient progress report

Function: To describe the nursing assessment, care plan and outcome of nursing care of an
admitted inpatient.

18
Location: Every MRs made during the patient’s stay must ultimately be included in the patient’s
MR as a permanent record.

Work process: When a patient is admitted, a nurse completes a nursing assessment and care plan
within 8 hours. The outcomes of nursing care are documented on the problem list, care plan and
progress report during the course of the patient’s admission.

Further discussion on the Nursing Process is presented in Chapter 7 Nursing and Midwifery Care
Standards.

12. Routine Observation Chart

Function: To record the vital signs of each specific patient during the hospital stay.

Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as a permanent record at patient discharge

Work process: When vital sign measurements are needed, the observation sheet will be put in
the bed-side clip board. The nurse will record all vital sign measurements on this form. When
one sheet is finished, a new blank sheet will be put on top of the finished sheet. When the patient
is discharged, all the forms will be put in the MR.

13. Medication Administration Record

Function: To record all medications ordered and administered to a patient.

Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.

Work process: When medication is ordered for an in-patient the name of the medication, route
of administration, dosage, time and frequency of administration should be documented on the
medication administration record and signed by the transcriber. When the medication is
administered, the nurse should sign the appropriate box on the form.

14. IV Fluid and Additive Administration Record

Function: The record should detail all specific infusions, including rate of drops and duration of
infusions while the patient is confined.

19
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.

Work process: When medication or IV fluid is ordered for an in-patient the name of the IV fluid
and rate of infusion should be documented on the IV fluid administration record. The name and
dosage of any additives should also be documented. When the IV infusion is given, the start time
and end time of the each bag of fluid should be documented and signed by the responsible nurse.

15. Fluid Balance Chart

Function: To record all fluid inputs and outputs for patients at risk of fluid overload or
dehydration.

Location: Bed-side clip board during the patient’s stayed, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.

Work process: All fluid inputs both oral and intravenous and all outputs including urine and
other outputs such as blood loss should be documented on the chart by the nurse. At the end of
every 24 hours the balance is calculated as ‘total input’ minus ‘total output’.

16. Discharge Planning sheets

Function: To provide full information for patients on their disease condition, total expected
hospital stay and presumptive date of discharge, so that patients get psychological and economic
preparedness.

Location: Every MRs made during the patient’s stay must ultimately be included in the patient’s
MR as a permanent record.

Work process: The hospital should establish a protocol for discharge planning. Standardized
discharge plan format should be filled by the treating clinician. Beside filling the format the
patients should be provided all the necessary information about their disease condition, the total
expected days of stay and the clinicians treatment plan.

17. Discharge summary Sheets

Function: An instruction sheet to summarize all needed information for the patient upon
discharge.

Location: One copy in the MR and one copy to patient.

20
Work process: Discharging physician will fill out the discharge summary that includes a
summary of the patient’s diagnosis, treatment and investigations and any instructions following
discharge (for example medications, wound care, diet, activity and follow-up appointments). The
form will be kept in the MR for hospital record and a copy will be given to the patient to bring it
during the day of appointment.

18. Death summary sheet (if relevant)

Function: In the event that a patient dies, to document patient’s health records, care received
and cause of death.

Location: MR

Work process: After death the attending physician should complete a death summary. If a post
mortem examination is required, the death summary should be completed AFTER the results of
the post-mortem examination are known.

19. Referral and Feedback Form (if relevant)

Function: To document patient history at the hospital and to provide reason for referral

Location: One copy in the MR and one copy to patient.

Work process: If it is necessary to refer a patient to another facility the attending clinician should
complete a referral request, indicating the reason for referral, summary of the patient history and
examination and the results of any investigations conducted.

3.3.6 Correcting Medical Record Data

If any data contained within a MR require correction, the following rules should apply:

 No erasure or other obliteration should be made.

 Incorrect data should be lined out with a single line.
 The date of correction, full name, signature and profession of the person making the
correction, the correct information, and the reason for the correction should be added.

21
3.4 Handling of Medical Records
All hospitals with functional EMR should organize Data Management system with full time
assigned IT offices. A comprehensive MR management system encompasses the handling the
MR from time of patient registration, during active care delivery, through patient discharge, and
ongoing filing/storage of the MR, until removal/destruction of old MRs from storage. The flow
of MRs/charts is important to ensure a balance between availability of clinical information and
patient confidentiality. A well-designed system minimizes the loss of MRs.

The hospital should avail national guidelines and develop institutional SOPs to manage access
and keep the confidentiality of patients’ medical records. All MR unit staffs, all clinical
professionals and admin staffs should receive training on EMR, medical record handling.

Only authorized personnel should have access to MRs, and only on a “need to know basis.”
Selected employees who have been designed by hospital management to handle MRs and who
have received MR training should only access the Medical Records Unit (MRU). When other
hospital employees need access to MRs, a request should be made to the MR staff. Patients
should never handle MRs without staff assistance.

Hospitals should develop strict procedures based on these principles and ensure that all staff
members are properly informed and trained for proper implementation practice

3.4.1 Tracking the location of Medical Records

A MR location tracking system should be established in order to find MRs. The system varies
depending on whether or not a paper-based or computerized patient registration system is used.
Manual Paper-Based System: A check in/out log book should be used by Medical Record Room
staff. Entries on the log should include the following information:

22
Fig 4. Tracer Card

MRN Date dispatched Name & signature of Location MR Date returned to

from MRU person dispatched taken to & Name MRU
of care provider

On a daily basis, assigned MR staff should refer to the logbook and ensure that all MRs are
returned to the card room. The only exception is for admitted inpatients whose treatment is
ongoing. This step is important, as it prevents loss and misuse of MRs. In addition, when a MR is
removed, one can put in its place a tracer card, which is a card the size of the MR, on which is
written the patient name, the MRN, where the MR is going, and the date it was removed from the
file. This can help track where records are outside the Medical Records Room. When not in use
the tracer card should be stored in the back of the MR. A sample tracer card is included in
Appendix A.

Computer-Based System: In a computerized patient registration system, a MR tracking feature

should allow an easy and effective method to locate MRs.

3.4.3 Medical Records at Discharge

The MR of discharged or deceased patients should be returned to the Medical Record Case Team
within 24 hours of discharge. The Medical Record Case Team should review the MR to see if all
forms have been properly signed, particularly the discharge summary. If they are not signed, the
MR Department should alert the physician on record or case team leader to complete and sign
the discharge summary.

3.4.4 Archiving Medical Records

Inactive files (i.e., MRs with no clinical activities for a per-defined period of time (i.e. 2 years)
may be archived by MR staff in order to regain shelving space. Individual hospitals should
establish an archiving policy.

23
When archiving, these files should be numerically stored in a separate area, according to their
MRNs. The corresponding MPI index card of the patient should be labeled “archived”. NEVER
create another file numbering system for archived files. If archived files needed to be retrieved,
the same MR retrieving mechanism should be used.

3.4.5 Destruction of Inactive Medical Records

The FMOH “Hospitals Patients/Clients/Records Retention Schedule” guideline details the length
of time a MR is retained in inactive status. In general, a facility is required to retain a MR for up
to 7 years after the patient’s last episode of care at that facility. In the first 2 years of registration
it will be retained to be active, then after 2 years till 7 years of patient registration made; the
patient medical chart will regain other shelving time as in active archival. After the pre-defined
retention period, the MR should be destroyed by burning, shredding or another method that is
certain to maintain the patient’s confidentiality.

A note should be included with the retained documents stating that the records have been
destroyed according to the retention policy. The MR Department should establish a folder to
collate the information above for all MRs that are destroyed.

Destruction of the medical record should also be supervised by the head of the MR department.
If medical records are destroyed, the following key information should be maintained
permanently:
 Medical record name
 Full name, Sex and Date of birth;
 Last visit/Admission/Discharge date
 Patient first date of visit
 Diagnosis/Patient status;
 Name of the attending doctor(s);
 Investigations and operations/Procedures performed; and
 Discharge summary for each admission if more than one

24
Fig 6 - Registration logbook for retaining vital patient information while destroying
Medical Full name Sex/Date of Last Patient first Diagnosis/Patient Name of the Investigations and Discharge
record birth visit/Admission/Discharge date of visit status attending operations/Procedures summary
number date doctor(s) performed
(MRN

25
3.4.6 Access to Medical Records from the Hospital
MRs should be accessed from the facility only upon an order from the appropriate jurisdiction
bodies. The hospital should establish its own policy regarding MR removal from the premises,
and this policy should comply with federal and regional health policies.

Hospitals implementing EMR should restrict access of MR for specific service delivery points.
For example, laboratory department should have a privilege of only accessing laboratory
requests and reports. Other service areas are also permitted to access medical information
according to service relevance and practice.

If a patient seeks health care from another hospital and has consented to the release of his/her
clinical information to the new hospital, only a photocopy should be given to the requesting
hospital. The original MR should never be transferred out of the hospital.

3.4.7 Confidentiality
MRs should be maintained in the strictest confidence, as they contain personal and private
information about patients, including their health status, personal, family and contact
information. MRs should be stored in a secure area, and there should be clear policies regarding
confidentiality and the release of patient information. Particularly for the medico legal cases, a
separate locked MR store should be available on place. Focal person who handles medico-legal
patient medical records should be assigned with official letter. Medico legal card registration,
submission and return check-up system is in place.

Access to the content of MRs should be granted only to personnel who are undertaking the above
activities. Other supporting staffs who are granted access to MRs but are not involved in
delivering patient care (e.g., porters, runners) should not read and/or disclose the content of the
records. All employees should sign a ‘Code of Conduct’ that includes a statement regarding the
confidentiality of patient information

26
3.5 Electronic Medical Records
3.5.1 What is an electronic medical record system?
Electronic Medical Record (EMR) is a digital collection of medical information about a patient
that is stored on a health network and a medical record is a multifunctional document that is used
to communicate and document information about patients’ medical care among healthcare
professionals.

EMR is an important tool that enables healthcare facilities to optimize healthcare quality, safety,
accessibility, equity, and efficiency. It is believed that EMR has the potential to provide clinical
decision-makers with complete and accessible information for every patient at the point of care.
The following are major components of an EMR system:- Patient data storage and retrieval;
Clinical tests and results management; Order entry and management; Decision support
management; Electronic communication and connectivity; Patient support ; Administrative
processes support and Reporting.

Computer literacy was found to be a factor that affects EMR use and user satisfaction. Hence,
EMR implementer and managers must emphasize improving the quality of services in health
facilities like technical support; providing continuous basic computer training to health
professionals. Implementer should accept that stakeholder coordination is crucial for successful
implementation and use of an EMR, and often involves a large and diverse group of people and
organizations because the health sectors in low and middle-income countries often have many
actors i.e. national ministries of health, education, and technology; health facility staff and
managers; donors and nongovernmental organizations; telecommunications providers, and
clients.

The data, which is collected using the electronic medical record system, will be reflected as well
as primary input for HMIS. Maintaining the implementation and ensuring the sustainability of
the implementation will be the responsibility of the facility; however, hospitals can request
technical support from the MOH, RHB and other stakeholders when necessary.

27
3.5.2 Resources Needed to Implement an Electronic Medical Record

The organization readiness will be conducted on the health facilities’ organizational alignment,
management commitment, technical capacity, and operational capacity. Data will be collected
using observation, survey, and interview methods. The Health Facility higher officials including
each department head will be interviewed and a questionnaire will be distributed to them. The IT
infrastructure status will also be observed and inspected using EMR readiness assessment tool.

Hospital will need to deploy ICT infrastructure to support integrated e-health applications and
also study their ICT infrastructure needs. Need with the appropriate and qualified IT
professional. Required ICT infrastructure in the hospital includes cabled/wireless local area
network, computer with better performance capacity and server computers but not limited to this.
Specification for the items needed should be defined ensuring that all equipment meets
international standards and budget set for the procurement and installation of the needed items.

In addition, hospitals will need to determine their need for appropriate and qualified IT/ HIT
professionals and employ IT/ HIT professionals required to fit their ICT infrastructure need and
the specifications of the system deployed in the hospital. The hospital should assign EMR focal,
preferably trained physician.

The hospitals should also consider expansion and upgrading the system through time when there
is service relocation or new construction in their premises. After the completion of EMR IT
structure and hiring IT and HIT professionals appropriate EMR software should be installed.
Additionally system integration is expected from different service delivery area softwares like
laboratory, digital X-ray, APTS, DAGU, HRIS, finance, etc. All health professionals and
administration staffs should obtain training on regular basis depending on the need assessment.
Adequate electronic data collection tools and reporting formats should be installed and harmonized with
EMR software.

28
Assessment tool for Operational Standards

S/N Operational Standards Yes No

1. The hospital has functional medical record management unit.
2. The hospital has standard MR room.
3. The hospital has created a system to register and retrieve medical records.
4. The hospital avails and utilizes a standard set of formats for medical record
registration.
5. The hospital complies with national guidelines to manage access to
patients’ medical records.
6. The hospital has a system for proper handling and confidentiality of
medico legal patients’ medical records.
7. The hospital performs medical record auditing and takes corrective actions
on a regular basis.
8. The Hospital ensures patients’ medical record tracing system.
9. The hospital implements fully automated medical recording system.

29
Source Documents

1. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, June). Health

Management Information System (HMIS). Medical Records Training Manual.
2. Federal Democratic Republic of Ethiopia. (2007). Hospitals Patients /Clients Records
Retention Schedule.
3. World Health Organization (WHO), “Ethiopian Health Sector Transformation Plan-
II.2020/21 - 2014/25,” FMOH, May, 2021.
4. Federal Ministry of Health (FMOH)- ''Electronic Medical Record Manual " July 2021.
5. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, June). Health
Management Information System (HMIS). Medical Records Training Manual.
6. Federal Democratic Republic of Ethiopia. (2007). Hospitals Patients /Clients Records
Retention Schedule.
7. National Information Revolution Roadmap. (2021-2025)

30
Appendices
Appendix A Template of Medical Records Department Forms

Item 1: Master Patient Index Card

"[Name of Facility]"
Master Patient Index Card

¾I¡U“ "`É lØ` ¾}S²Ñu<uƒ k”

Medical Record Number: Date Of Registration(DD/MM/YY)

eU ¾›vƒ eU

Patient’s Name: Father’s Name:

¾›Áƒ eU ï•

Grand Father’s Name: Sex: F M

¾MŃ: k” ¨` ¯ /U °ÉT@

Date Of Birth Day Month Year Age:

›É^h ¡MM ¨[Ç kuK?

Address: Region Woreda Kebele

ÔØ ¾u?ƒ lØ`

Gott: House Number:

Item
2: Service card (Front & Back) – next page
 የ አ ገ ልግሎት መታወቂያ ካር ድ
Service Identification Card

የ ማህ በ ረ ሰ ብ የ ህ ብረ ተሰ ብ የ ነ ጻ /የ ዱቤ
አ ቀፍ አ ቀፍ አ ገ ል ግሎት ማህ ተም
የአገልግሎት መ
ታወቂያ ካርድ
ኢን ሹራን ስ ኢን ሹራን ስ
Free/Credit Service
Service Identification Card ታካ ሚ ታካ ሚ
stamp
የተÌ ሙስም CBHI SHI
__________________
Name of facility
በጤ
ና ድርጅቱ የተመ
ዘገበበትቀን
Date of Registration__________________

ስም
Name__________________________ Age___ Sex____

የህክምና ካርድቁጥር
Medical Record Number ______________

/ዞን
ክፍለ ከተማ ወረዳ
Subcity/Zone ____________ Woreda __________

Item 3:ር__________________________
የቤትቁጥ Appointment card (Front & Back)
House No

ስልክ ቁጥር__________________________________ የ ቀጠሮ የ ቀጠሮ መስጫካር ድ

Appointment Card
ቀን ሰ ዓት ቀጠሮ የ ሰ ጠዉ ቀጠሮ የ ሰ ጠው
ባ ለ ሙያ አ ገ ል ግሎት ክ ፍል
DATE TIME
Appointing Appointment with
Professional service
የ ቀጠሮ መስጫካር ድ
APPOINTMENT CARD

¾Ö?“ É`Ï~ eU ____________________________

Facility Name

eU ________________________________________

Name

¾I¡U“ "`É lØ` __________________________

Medical Record Number

Item 4: Tracer Card

Tracer card
Facility Name: ________________________________________________
MRN #: ________________________________________________
Patient’s Name: ________________________________________________
# Department/Person MR is sent to Receiver’s Signature Date
Appendix B Template of forms is included in a Medical Record

Item 1: Patient Information Demographic Sheet

PATIENT INFORMATION
MRN: Patient’s name: Sex: Registration date:

F M / /

Phone no.:

( )

City/Town: Woreda: Kebele: House no:

Emergency contact information:

Contact’s Name:_______________________________

Telephone Number:____________________________
Item 2: Summary Sheet of all Visit Dates

INTEGRATED FOLDER SUMMARY SHEET

(One line per visit – not for clinical notes)
MRN #: ________________________________________________

Patient’s Name: ________________________________________________

Date Diagnosis / Complication

(DD/MM/YY) Service* or Service Detail ** Serial number in service registration book Cost

* Write the department providing service: IPD, OPD, ANC, FP, EPI, etc
** OPD / IPD Service – write diagnosis
FP, ANC, PNC – write complication, if any
EPI – write antigen given
Item 3: Admission and Discharge Card (Front)
¾Ö?ና ጣቢያ ¾N=dw Te}¨mÁ lØ`

_________________________Health Center CASH SHEET NO __________________

¾QSU}™‹ SkuÁ "`É

ADMISSION CARD

¾I¡U“ "`É lØ`

Medical Record Number (MRN) __________________

eU ¾›vƒ eU

Name _________________________________ Father’s Name _______________________

¾›Áƒ eU ï•

Grand Father’s Name _____________________ Sex ___________________

›É^h ¡MM ¨[Ç/¡õK-Ÿ}T

Address: Region _________________ Woreda/Subcity _______________

ÔØ kuK?

Gott ___________________ Kebele_______________________

¾u?ƒ lØ`

House Number___________

¾¡õK< lØ` ¾›MÒ lØ`

Ward No. _______________________________________ Bed No. ____________

c=Ñv ¾QSS< G<’@•

Admission Diagnosis __________________________________________________________

¾}[ÒÑÖ¨< QSS<

Discharge Diagnosis ___________________________________________________________

ŸJeú}M c=¨× ¾’u[¨< G<’@}

Condition on discharge

ŸISS< É•/}iKAƒ V„ ¨Å K?L Ö?“ É`σ }M¢

ŸNŸ=U ðnÉ ¨<ß uѳ ðnÆ H@Ê Öõ„

ጠና ጣቢያ ¾Ñvuƒ k” ¾}kuK¨< NŸ=U ò`T

 Date of admission _________________ Signature of Admitting Dr. _________________________

¾¨×uƒ k” Ác“u}¨< NŸ=U

Date of Discharge _________________ Discharged by ___________________________________

¾S˜• ¡õM • Lòª ’`e ò`T KSÓv~ ¾S˜• ¡õM • Lòª ’`e ò`T KS¨<×~

Sign. Of Ward Nurse for Admission ____________ Sign. Of Ward Nurse for Discharge _________

¾Ç_¡}\ ò`T KSÓv~ (›eðLÑ> ŸJ’) KS¨<×~ (›eðLÑ> ŸJ’)

Director’s Sign. For Admission (if required) _____________For Discharge (if required) ___________

¾›=ƒ/w` X

Birr Cts.

¾}—uƒ k” w³ƒ ¾›”É k” ¡õÁ w`

Number of days admitted __________________ Amount per day in birr

________________

¾›?¡e_Ã U`S^ N=dw

For X-Ray Examination _______________________________________________________

¾SÉH’>ƒ N=dw

For Medicine ______________________________________________________________

¾*ý^c=Ä” N=dw

For Operation _____________________________________________________________

¾Lx^„` N=dw

For Laboratory ____________________________________________________________

M¿ M¿ ›ÑMÓKAƒ N=dw

For Various Services ________________________________________________________

}ŸóÃ

Total Payment

uSÁ¹ ›ekÉV ¾}ŸðK

Deposited

¾_Ïeƒ^\ ò`T

Signature of Registrar

}SLi

_____________________ Amount to be Reimbursed

 }ÚT] ¡õÁ

Amount to be paid

¾N=Xw g<U ò`T

Signed by The Chief Accountant ____________________________

Item 3: Admission and Discharge Card (Back side)

KQ¡U“¨< H>Xw }ÖÁm

FINANCIAL RESPONSIBILITY

¾Ñ”²w Ÿóà eU

Name of Individual Responsible for Bill ____________________________________________________

¾Y^ x} ¾eM¡ lØ`

Occupation _____________________________________ Tel. ________________________

kuK? ¨[Ç/¡õK-Ÿ}T ¾u?ƒ lØ` ¾eM¡ lØ`

Kebele ____________ Woreda/Subcity ____________ House No. _________ Tel. __________

¾´UÉ“¨< ¯Ã’ƒ ¨Å ጠና ጣቢያ ÁSר<

Relationship _______________________ Brought to Health Center by __________________________

eT@ ŸLà ¾}ÑKì¨< ŸLà ¾}Ö¾k¨<” Ñ”²w uS<K< ¾S¡ðM • Lò’ƒ • ”ÇKw˜ uò`T ›[ÒÓ×KG<::

I, the above named person, accept full responsibility for payment of the charges incurred during this
period of Hospitalization.

ò`T

Signature

__________________________
Item 4: History and Physical Examination Assessment

History and Physical Examination Assessment

Name: Ward:

MRN: Bed Number:

Date of Admission:

Presenting Complaint:

History of Presenting Complaint:

Past Medical History:

Drug History:

Family History:

Personal/Social History:

PHYSICAL EXAMINATION

General Appearance:

Vital Signs: Temp: BP: Pulse: Resp:

HEENT:

Glands:

Chest:

CVS:

Abdomen:
Genito-Urinary:

Musculo-Skeletal:

Skin:

Central Nervous System:

Motor:

Sensory:

IMPRESSION:

DIFFERENTIAL DIAGNOSIS:

PLAN OF ACTION (investigations, treatments and medication ordered):

Name of physician: Signature:

Date of assessment: Time of assessment:

/ /
Item 5: Progress Note

PROGRESS NOTE

Name: OPD

MRN: IPD Ward: Bed Number:

Date &
Progress Note
Time
Item 6: Consultation Request Form

CONSULTATION REQUEST FORM

Patient Name: ___________________________ OPD

MRN: ___________________________ IPD Ward: _______ Bed No: ___
Consultation requested by: ______________ Position/Designation: ________________
Signature: ___________________________ Date of request: ________________

Type of consultation needed:

Reason for consultation:

Consultation report:

Consulting Physician\Health Officer\Nurse Name: Signature:

Specialty: Date:

/ /
Item 7: Consent Form

CONSENT FORM

MRN #: ________________________________________________

Patient’s Name: ________________________________________________

1. Name of proposed procedure or course of treatment (include brief explanation of medical terms are not clear):
__________________________________________________________________________________________________
____________________________________________________________________________

2. Statement of health professional (to be completed by health professional with appropriate knowledge of proposed procedure):

I have explained the procedure to the patient. In particular I have explained:

The intended benefits:

____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________

Serious or frequently occurring risks:

____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________

Any extra procedures which may become necessary during the procedure:

Blood transfusion

Other procedure (please specify) ________________________________________________

I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no
treatment) and any particular concerns of this patient.

This procedure will involve:

General and/or regional anaesthesia Local anaesthesia Sedation

3. For females of reproductive age (if relevant):

During the operation it may be necessary to take an X-ray to assist the surgeon with the procedure. It is important that X-Rays should be
avoided if there is a possibility of pregnancy.

Date of Last Menstrual Period: ____________________________

Is there a possibility of the patient being pregnant? Yes No

If yes, can this procedure be deferred or does the clinical urgency override the risk to the pregnancy?

Yes, the procedure should be deferred No, the procedure must be performed

Signed:_______________________________ Date: ____________________________

Name: _______________________________ Job title: _________________________

Do ask if you have further concerns. We are here to help you. You have the right to change your mind at any time, including after
you sign this form. You may ask for a relative or a friend or a nurse to be present whilst the procedure is being explained and
consent obtained.

Please tick boxes to indicate that you have understood and agreed to the statements below:

I agree to the procedure or course of treatment described on this form.

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will however
have appropriate experience.

I agree that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to
prevent serious harm to my health.

I have been told about additional procedures that may become necessary during my treatment. I have listed below any procedures
which I do not wish to be carried out without further discussion.

I acknowledge that the nature and purpose of the foregoing procedures and the risks associated with the procedure have been
explained to me and I have been given the opportunity to ask questions.
Patient’s signature: ____________________________ Date: ________________________
Name (print): _________________________________

If the patient is unable to sign, but has indicated his or her consent, a witness should sign below:
Signature: ___________________________________ Date: ________________________

Name (print): ________________________________

Item 8: Physician\Health Officer\Nurse Order Sheet

HEALTH PROFESSIONAL ORDER SHEET

Name: Ward:

MRN: Bed Number:

Transcriber’ Date and

s signature Time
Date Time Order Signature Signature
order
(if relevant) completed
Item 9: Haematology Order and Report Form
HAEMATOLOGY ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Test ordered Result Reference

Total CBC ________ cells/mm3 ________ cells/mm3

Differential

Neutrophil ________ % ________ %

Lymphocyte ________ % ________ %

Eosinophil ________ % ________ %

Basophil ________ % ________ %

Monophil ________ % ________ %

Haemoglobin ________ G/dL ________ G/dL

Haematocrit ________ % ________ %

MCV ________ Fl ________ Fl

MCH ________ Pg ________ Pg

MCHC ________ Pg ________ Pg

RBC ________ cells/mm3 ________

Platelet Count ________ x 103 ________ x 103

ESR ________ mm/hr ________ mm/hr

Bleeding time ________ ________

Clot retraction ________ ________

Coagulation time ________ ________

Prothrombin time ________ ________

P.T.T. ________ ________

Fibrinogen ________ ________

Coomb’s test ________ ________

CD4 (absolute) ________ Cell/ul ________ Cell/ul

Other (describe):

______________________
Ordered by: __________________ Sample collected by: __________
Date of order: __________________ Date of collection: ____________
Time of order __________________ Time of collection: ____________
Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________
Result checked/approved by: _______________________________________________________
Item 10: Clinical Chemistry Order and Report Form
CLINICAL CHEMISTRY ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Test ordered Result Reference

SGOT ________ IU/L ________ IU/L

SGPT ________ IU/L ________ IU/L

ALP ________ IU/L ________ IU/L

AST ________ IU/L ________ IU/L

Sodium ________ MEQ/dL ________ MEQ/dL

Potassium ________ MEQ/dL ________ MEQ/dL

Calcium ________ mg/dl ________ mg/dl

Creatinine ________ mg/dl ________ mg/dl

Bilirubin direct ________ mg/dl ________ mg/dl

Bilirubin total ________ mg/dl ________ mg/dl

Blood urea nitrogen ________ mg/dl ________ mg/dl

Total Protein ________ G/dL ________ G/dL

Albumin ________ G/dL ________ G/dL

Uric Acid ________ ________

Fasting Blood Glucose ________ mg/dL ________ mg/dL

Random Blood Glucose ________ mg/dL ________ mg/dL

Amylase ________ U/L ________ U/L

Triglycerides ________ mg/dL ________ mg/dL

Cholesterol ________ mg/dL ________ mg/dL

Other (describe):

_________________________

Ordered by: __________________ Sample collected by: ___________

Date of order: __________________ Date of collection: ____________

Time of order __________________ Time of collection: ____________

Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________

Result checked/approved by: _______________________________________________________
Item 11: Serology Order and Report Form
SEROLOGY ORDER AND REPORT

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Test ordered Result

HIV serology rapid test _________________

HIV serology by EIA _________________

Cryptococcal Ag _________________

Hepatitis B _________________

Hepatitis C _________________

TPPA/TPHA/RPR _________________

Syphilis _________________

Pregnancy test (HCG)

Other (describe): _________________

______________________ _________________

Ordered by: __________________ Sample collected by: ___________

Date of order: __________________ Date of collection: ____________

Time of order __________________ Time of collection: ____________

Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________

Result checked/approved by: _______________________________________________________

 MICROBIOLOGY ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Item 12: Microbiology Order and Report Form

Sample type/site:

Test ordered Result

AFB smear _________________

India Ink Stain _________________

Gram Stain _________________

Microbiology smear _________________

C+S _________________

Wet mount - direct microscopy _________________

Other (describe): _________________

VDRL _________________

Skin scraping _________________

Skin snip _________________

Other (describe below):

_________________ _________________

Ordered by: __________________ Sample collected by: ___________

Date of order: __________________ Date of collection: ____________

Time of order __________________ Time of collection: ____________

Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________

Result checked/approved by: _______________________________________________________

Item 13: Stool Analysis Order and Report Form
STOOL ANALYSIS ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Result

Consistency _________________

Occult blood _________________

Cells _________________

Ova or parasite _________________

Other _________________

Ordered by: __________________ Sample collected by: ___________

Date of order: __________________ Date of collection: ____________

Time of order __________________ Time of collection: ____________

Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________

Result checked/approved by: _______________________________________________________

Item 14: Urine Test Order and Report Form
URINE TEST ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Clinical history:

Result

Colour _________________

Appearance _________________

Protein _________________

Glucose _________________

pH _________________

Blood _________________

Ketones _________________

Bilirubin _________________

Pregnancy test (HCG) _________________

Other(describe below):

_________________ _________________
Ordered by: __________________ Sample collected by: ___________

Date of order: __________________ Date of collection: ____________

Time of order __________________ Time of collection: ____________

Lab tech comments:

Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________

Result checked/approved by: _______________________________________________________

Item 15: Radiology/Ultrasound Order and Report Form

RADIOLOGY/ULTRASOUND ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex:

Investigation (s) requested:

Summary of clinical history,relevant clinical findings and investigation results:

Requesting physician: Signature:

Date of request: Time of request:

Report: To be completed by trained radiologist/ultrasonographer if available.

Name of reporter: ___________________________ Signature__________________________________

Designation/Position: ________________________ Date of report: ______________________________

NB: The X ray film or Ultrasound pictures should also be sent to the requesting physician for review and
interpretation if no radiologist/ultrasonographer is available.
Item 16: Pathology Order and Report Form
PATHOLOGY ORDER AND REPORT FORM

Name: OPD

MRN: IPD Ward: Bed Number:

Age: Sex: Date specimen collected:

Specimen type and site:

Time specimen collected:

Investigation (s) requested:

Summary of clinical history,relevant clinical findings and investigation results:

Requesting physician: Signature:

Date of request: Time of request:

Report:

Name of reporter: ___________________________ Signature__________________________________

Designation/Position: ________________________ Date of report: _________________________

 Item 17: Routine Observation Sheet
Name:____________________

MRN: ____________________

DATE
Time
TEMPERAT

>41
URE

41

40
X

Ward: _________Bed: ______

 39

38

37

36

35

<35
C

>200

Pulse 200

190

180

170

160

Systolic BP 150

140
PULSE and BP

130

120

110

100

Diastolic BP 90

80

70

60

50

40

<40

Respiration / min

O2 Saturation %

Foetal Heart Rate

Blood Sugar

Dip- Protein
stick
Urine Blood

Sugar

Ketones
_ Circum. Of head
(cm)

_ Circum. Of arm
(cm)

Bowel

Weight (kg)

Remarks:

Staff Initial:
Item 18: Medication Administration Record

Name:____________________
MRN:
____________________
Ward: _________Bed: ______

Diagnosis: Allergy:
Medications
Time to give Signature Date Date Date Date Date Date Date Date
# Date (Name, dose, of
one time each line Given by Given by Given by Given by Given by Given by Given by Given by
route, freq) Transcriber
Item 19: IV fluid and Additive Administration Record

Name:____________________
MRN:
____________________
Ward: _________Bed: ______

Diagnosis: Allergy:

Mixed,
Discontinue Date of Time of checked, Time
# Date IV Fluid (Name, Volume, Rate) Additives date start start given by completed Completed by
Item 20: Sample Referral and Feedback Form
Section 1: Patient Details (to be completed by Referral Unit)

Name:

MRN:

Date of birth/Age: Next of kin name:

Address: Next of kin address:

Telephone number: Next of kin telephone number:

Section 2: Administrative Details (to be completed by Referral Unit)

Name of Referring Unit: Name of Receiving Unit:

Name of Liaison Officer: Name of Liaison Officer:

Contact Telephone Number: Contact Telephone Number:

Date referral made: Date referral received (to be completed by Receiving Unit):

Section 3:Referring Clinician Information (to be completed by Referral Unit)

Name of Referring Clinician: Name of Consultant (if relevant):

Profession/Qualifications: Address:

Registration number: Telephone number:

Address:

Telephone number:

Signature:

Section 4: Clinical Information (to be completed by Referral Unit)

Reason for referral:

Basic history and statement of the problem:

 Physical examination findings:

Results of investigations performed:

Treatments given:

Current medication:

Social/psychological factors:

Known allergies:

Any other relevant information:

Section 5: Feedback information (to be completed by Receiving Unit)

Summary of history:

Physical examination:

Investigation results:

Diagnosis:

Treatment given:

Management plan/advise:

Follow up appointment date (if given):

Any other relevant information:

Section 6: Receiving Clinician Information (to be completed by Receiving Unit)

Name of Receiving Clinician: Name of Consultant (if relevant)

Profession/Qualifications: Address:

Registration number: Telephone number:

Address:

Telephone number:

Signature:
 Item 21: In-patient Medication Profile Form
(Follow the instructions when completing this form)

Name of Hospital: ____________________________________ Region: _______________

Patient Information Past Medical and Medication History

Name___________________________ Medical history:
Card #: __________ Sex: _______ Age: Medication history and adherence:
_______ Wt.: ______ Height: ______ BSA: ADRs and/or Allergies:
__________ Immunization Status:
Pregnancy status: _____________ Diagnosis:
Date of admission: ________________
Ward: _________ Bed No: __________

Current Medications
Indication Drug & Dosage Regimen Start Date Stop Date
(Name, Dosage Form, Dose, Frequency)
Pharmacist’s Assessment and Care Plan:

Recommendations/Interventions:

Discharge Medication and Counseling

Item 22: Pharmaceutical Care Progress Note Recording Form

Form 2: Pharmaceutical Care Progress Note Recording Sheet

(Follow the instructions when completing this form)
Patient Name: ______________________ Card No. ___________________
Annex 17: Medication Reconciliation Form
(Follow the instructions when completing this form)

Hospital __________________________Region________________
Patient name: ____________________________ Age ______ Sex _______Weight _____
Source(s) of medication list ________________________________________________________
Allergic: _______________________________________________________________________
Reconciliation
Plan
Plan On
on Disc
Plan on transfe harg Adjustments/
Medication Regimen (Drug name, admission r e Changes made
information Dose, Frequency, D D
source Duration) C DC C C C C
Pre-admission
Medication
Current Medication
C – Continue, DC - Discontinue

Recorded by: Name _____________________________ Signature ____________ Date ______________

Item 23: Fluid Balance Chart

FLUID BALANCE CHART

Please Complete or Affix Label

MRN: Ward:
Name Bed No.:

Date:

Previous days balance (+ or -)

INTAKE OUTPUT
Total Fluid
Intra- Intra- Total Others Total Balance
Time Oral Urine (ml/24hr)
Venous Venous Intake Output

01.00

02.00

03.00

04.00

05.00

06.00

07.00

08.00

09.00

10.00

11.00

12.00

13.00

14.00

15.00

16.00

17.00
18.00

19.00

20.00

21.00

22.00

23.00

24.00

Sub
Total

TOTAL + OR - TOTAL
Item 21: Discharge Summary Sheet

Print Name:
Signature:
Date and time completion:
DISCHARGE SUMMARY SHEET

Name: MRN:

Ward: Date of admission:

Bed number: Date of discharge:

Hospital Course:

Diagnosis/Diagnoses:

Diagnostic procedures and laboratory findings:

Condition on discharge:

Cured Improved No change Worse Left against medical ad vice

Instructions for home:

Diet:

Activity:

Specific care needs:

Sick leave recommended (if relevant):

Medications:

Drug: Dosage: Frequency:

1.
2.
3.
4.
Follow up care:

Appointment date: Place: To be s een by:

1.
2.
Form completed by:

Designation/Position: Patient/Care giver name:

Signature: Signature:

Date: Date:

One copy of form should be given to the patient or caregiver and a second copy should be filed in the patient’s Medical Record.
 Item 24: Death Report

DEATH REPORT

Health Facility: Region: City:

Deceased Name: Age (Year): Sex:

F M

Date of admission: Date / Month / Year Time Hrs : Min

Date of death : Date / Month / Year Time Hrs : Min

Cause Of Death Approximate Interval Between Onset And Death

I. Disease or condition leading to death*: -

Due to (as consequence or )

a)
b)
Antecedent cause: Morbid conditions, if any, giving rise to the above cause,
stating: - Due to ( as a consequence or)

c)
d)
* This does not mean the mode of dying, e.g. heart failure, respiratory failure. it means the disease, injury or complication that caused
death.
II. Other significant conditions contributing to the death, but not related to the disease or condition causing it

Management/Treatment given :

Consider Collecting the following Information

III. If the deceased is a female, was she:

Not pregnant
Pregnant at the time of death (Approximate gestation age ______ (WKS))
During labour ( stage of labour ______________)
Unknown pregnancy status

IV. If the deceased is a newborn:

 Still birth  Death after birth Weight: . . . . . . . . . g  Not Known

Reported by (Dr./ Mr/Ms): Profession :

Signature: Date : / /
Approved by: Medical Director:
Item 25: Post Mortem Request Form

POST MORTEM REQUEST FORM

Section A: Identification
MRN: Name of deceased:
Age: Date of Death: / /
Sex:
Occupation:
Address:-
Region: Zone: Woreda/Sub-city: Kebele: House No.: Tel:

Brief history of the deceased:

Physical examination findings:

Possible cause(s) of death:

Reason for Referral:

Referring Institution:
Requesting Physician:
Name: Signature: Date: / /

*Responsible professional must fill and send the following note to requesting institution

……………………………………………………………………
………
Index No.____________________
To (Requesting Institution):
Dead body received by:
Name: Position: Signature: Date: / / Time:

1
Chapter 5: Outpatient Services Management
Table of Content
Section 1: Introduction .................................................................................................................................. 2

Section 2: Operational Standards for Outpatient Services Management ...................................................... 3

Section 3: Implementation Guidance ............................................................................................................ 4

3.1. Outpatient Organizational Structure ............................................................................................... 4

3.2. Outpatient Service Layout .............................................................................................................. 4

3.3. Central Triage................................................................................................................................. 5

3.4 Outpatient Service Activity ........................................................................................................... 8

Section 4: Summary ................................................................................................................................... 13

Section 5: Source Documents ..................................................................................................................... 14

Section 1: Introduction
Hospital outpatient services management refers to the processes and procedures needed to ensure
the efficient flow of patients between outpatient services and providing quality health care to
clients. The outpatient service mainly includes Triage, Regular OPD, Speciality and sub
speciality referral clinics, Patient appointment system, Pharmacy, Imaging and Laboratory.
Efficient flow of patients requires various inputs including human resources, infrastructure,
equipment, protocols and pathways. Properly designed and implemented patient flow will reduce
patient waiting times, increase provider efficiency and staff/client satisfaction, proper resource
utilization as well as improve overall quality of care. This chapter details the inputs and process
required to ensure well-organized patient flow at the outpatient department and describes the
flow of services from the patient's first encounter with the reception service at the entrance of the
hospital until the patient exits the outpatient department.

Section 2: Operational Standards for Outpatient Services Management

1. The Hospital has established management structures and job descriptions that detail the roles
and responsibilities of each discipline within services/departments/units and case team, including
reporting relationships.

2. The hospital has well-equipped service specific OPD rooms with necessary equipment and
supplies as per hospital tier level.

3. The Outpatient department has established functional relationship with outpatient specific
laboratory, radiology, and pharmacy service units.

4. The hospital has an outpatient department waiting area with adequate lightening, ventilation
and multimedia facilities.

5. The hospital has an OPD staffed with adequate and appropriately trained personnel and OPD
service rooms are managed by GP or above and specialty clinics by a service specific specialist/
sub- specialty clinic by sub specialist as per hospital tier level of care.
6. Outpatient department (OPD) specific central triage procedure is established to ensure
efficient patient flow and seek to reduce patient crowding.

7. The hospital has established OPD patient appointment system.

8. The hospital has health literacy unit to provide health education to patients and clients.

9. The hospital has established OPD procedure room.

10. The hospital has ensured and maintained timely OPD service initiation and make sure that
every staff provided the service throughout working hours.

11. The hospital has conducted regular OPD service audit and develop QI project

Section 3: Implementation Guidance

3.1. Outpatient Organizational Structure

The hospital's outpatient services should be organized in clinical teams according to the clinical
services provided by the hospital. The outpatient department will be led by full time Outpatient
Director/Outpatient case team manager with nurse coordinator and will be accountable to the
hospital's CCO/MD. Clinical and support staff should be organized into Case Teams by type of
Specialty (e.g., Surgery, Internal Medicine, pediatrics, Gynecology, etc.). The outpatient
directorate/case team manager will have an office with office furniture, secretary, plan, report
and evaluation system.

3.2. Outpatient Service Layout

Outpatient Services should be organized in a manner that reduces the length of time that might
take a patient to travel from one service area to another. Although each facility has a different
layout and plan, clinical services should be organized as close to one another as possible.

Outpatient services consist of

a) Central triage and patient waiting area

b) Medical Record Room

c) Examination (clinical assessment) room, sample collection and treatment rooms

d) Pharmacy dispensing unit and cashier

e) Laboratory team, with cashier

f) Imaging diagnostic team, with cashier

3.3. Central Triage

A. Central Triage Pathway

The central triage is the first point of patient contact in outpatient services. The central triage
infrastructure should include a waiting area with adequate seats, registration and clinical
assessment areas.

Patients will be directed to Central Triage from the reception service or Emergency Department.
Within Central Triage the patient will undergo a triage assessment and all relevant administrative
processes (registration, medical record retrieval, payment etc) will be conducted. The triage
assessment will assign each patient to appropriate case team (emergency, ROPD, specialty and
sub- specialty clinic or back referral with appropriate counseling.) The patient will then be
directed to the relevant case team and his/her medical record will be delivered to the case team
by a runner. (Electronic medical recodring are preferred)

B: Central Triage Activity

The central triage should be open at least an hour before and during regular working hours. All
patients should undergo Central Triage using guideline EXCEPT:

 Emergency cases (should immediately attend emergency department),

 Laboring mothers (should immediately attend delivery unit),
 Those with an appointment (should immediately go to relevant case team), and
  Private wing patients

The first step in Central Triage activity is aiming in identifying and treating emergency signs.
The Triage Officer should identify patients who would be more appropriately treated by the
emergency case team and after resuscitation, should transfer these patients to the emergency case
team. If a patient does not have an emergency condition, the Triage Officer should then
determine the nature and urgency of the client's medical problem and determine the appropriate
service/case team required by the patient. If the service is available the patient should be
transferred to the appropriate case team or given an appointment for the next available date while
a referral should be arranged to another facility for services not available in the hospital. When
scheduling appointments for the same, or a future date, staff should take all relevant patient
information into account, including:

 The severity of the condition

 Geographic/Distance travelled by patient/
 Financial status of patient (for example financial difficulties that could prevent the patient
returning to the hospital at a future date taking into consideration transport and/or hotel
costs
 Social circumstances of patient (for example loss of income due to absence from work,
childcare needs of dependent children and etc).

The criteria by which a patient is given priority for treatment should be written and visible to
patients and staff to ensure transparency in the process.

 If the patient can receive services on the same day he/she will complete all necessary
registration and payment requirements in medical record management unit and then be
directed to the relevant outpatient case team.
 If the appointment is scheduled for a future date, the patient will complete all necessary
registration and payment requirements in medical record management unit, given an
appointment card and advised to report to the appropriate case team on the date of their
appointment, without undergoing Central Triage again.
  Triage team will register patients not seen on the same day and report to the outpatient
department leader for future improvement purposes.
 The hospital should have a clear management system for isolating patients with
communicable diseases like patients having chronic cough and suspected of TB. The
hospital should also have a separate waiting area for children and adults.
 The hospital central triage service should be started an hour before the regular OPD
working hours to ensure efficient and smooth flow of patients

C) Central Triage Human Resource Requirements

The Central Triage Case Team consists of both clinical and non-clinical staff. Ideally, triage
should be carried out by a General Practitioner. However, depending on the availability of human
resources, it can be conducted by a Health Officer or BSc Nurse. Non-clinical members of the
Central Triage case team include runners, cashiers, registrars/ clerks and cleaners. The runners
are responsible to facilitate the registration of patients and to transport patients as needed. The
Central Triage Case Team should have ready access to the Liaison and Referrals Service.

D) Central Triage Equipment and Supply Requirements

The central triage should have sufficient equipment and supplies considering patient workload.

The following is a list of the minimum items that should be available at central triage:

 Triage room with office furniture

 Examination bed
 Thermometer
 Glucometer
 Adult stethoscope
 Adult sphygmomanometer (automatic or manual)
 Adult weight and height scale
 Resuscitation tools
 Patient monitor with ECG monitoring (for general and tertiary hospitals)
  Pulse oximetry
 Wheelchair
 Stretcher
 Screens, partitions or separate rooms
 Gloves, face masks and other personal protective equipment
 Wall clock
 Microphone/Public address system

3.4 Outpatient Service Activity

 The outpatient case team will take a history, examine the patient and record the findings.
If diagnostic laboratory or imaging tests are needed, a request filled with all the necessary
information (as per the laboratory and imaging standard) and the patient has to be sent to
the respective departments guided by a runner. A note entered to the patient card should
include at least pertinent history, physical examination and laboratory/imaging findings
pointing to the patient diagnosis. If diagnostic or therapeutic procedures as lumbar
puncture, abscess drainage etc is required, it has to be performed at the outpatient
department. The results of any investigations and treatment options should be explained
and discussed with the patient.
 If the patient needs consultation with Specialist (intra or interdepartmental) this should, as
far as possible, take place on the same day. Consultation can take place face-to-face, with
phone consultation or direct linkage to the consulted department with reason for
consultation documented in the patient record.
 The hospital should have a well defined scope based practice protocol.
 Any minor procedures that are required (such as dressings change or injections) should be
carried out in the outpatient department.
 If the patient needs to be admitted to hospital or be referred to other hospital, he/she will
be guided to the Liaison office with the help of runner for admission or referral
arrangement.
 Sample collection, procedure and payment area at the OPD should be easily accessible to
all OPD patients and should have sufficient staff to prevent delay.
  Runners are responsible to facilitate patient registration, transport patients (if needed),
transport samples from the collection area to the laboratory unit and back results to the
clinical case team (if needed).
 The Diagnostic Imaging department should be located in close proximity to OPD and
every patient who requires imaging services should be directed there with the assistance
of a runner, if necessary.
 The hospital should ensure documentation of all HMIS diagnosis in to the HMIS register
daily and complete, correct and timely reports have to be compiled and sent to the plan
and monitoring or other units.
 If medication is required the patient should be directed to the OPD pharmacy dispensing
unit from where he/she will make payment (if necessary) and obtain the necessary drugs
and appropriate counselling.
 If appointment is required for future date, the treating professional will determine the
appropriate time frame for appointment and send the patient to liaison office. The patient
will be told the exact date and time of appointment at the liaison office and will be given
appointment card. On the appointment date, the patient will proceed directly to the
service unit without waiting at the central triage.
 Appointment should follow block based appointment system to avoid crowding and long
patient waiting time
 Outpatient service coordinators will regularly monitor timely service delivery in
accordance with local government working hours and take corrective actions on gaps
identified.

A. Outpatient Human resource needs and their roles

Outpatient Director / outpatient case team manager

 Organize and lead the outpatient service as per the national standards and treatment
guidelines
 Ensure the availability of adequate human power and equipment's for outpatient services.
 Plan, budget and report the outpatient activities
Nurse coordinator
 Coordinate the outpatient nursing service
 Plan the necessary supplies, drugs and equipment's for patient care
 Coordinate and Monitor daily recording of all patient diagnosis in to the HMIS register
 Monitor and evaluate the implementation of outpatient specific nursing standards

General medical practitioner per discipline (Internal medicine, pediatrics, surgery, gynecology
and obstetrics) to run the regular outpatient service for eight hour in each working hour
 Examine, treat and counsel a patient
 Perform minor procedures (foreign body removal, abscess drainage etc) at OPD level
 Plan, document and report daily activities

Specialists or sub specialist per discipline (specialty) to run the respective specialty and sub
specialty clinic services assigned
 Examine, treat and counsel a patient at a specialty follow up clinic
 Plan, document and report daily activities

Nurse should be assigned at outpatient unit as per patient load

 Complete and implement nursing care including minor procedures (wound care,
emergency resuscitation)
 Record all patient diagnosis in to HMIS register
 provide health education and counseling service

Adequate number of laboratory, pharmacy and imaging workers based on the tier level of the
hospital. Implement all standards listed under laboratory, pharmacy and speciality and sub-
speciality chapters.

Runners
 Assist patients whenever necessary
 Collect lab and imaging results from the respective unites and attach with patient’s
medical record.

Cashier
 Collect daily cash from outpatient service users
  Number of cashiers and windows should depend on the case load

Cleaner
 Clean and protect the outpatient facilities as per standards

Phlebotomist
 Take and collect samples from patients and deliver to lab units

Security guards will be assigned based on the hospital context.

 Will safe guard the patients and staff and visitors

B. Outpatient case team equipment and supply needs

Each case team room should be equipped with equipment and supplies needed to provide patient
care. The following (Table: 1) is a list of suggested items that should be found in the case team
room. It is not an exhaustive list of all possible equipment and supplies, but should be used by
each facility as a guide when determining equipment needs.

Table 1: Minimum Equipment and Supply Needed for Outpatient Services

Equipment and Furniture Supplies

Examination bed, Chairs and tables , Patient forms:

Stretcher, Wheel chair, Stethoscope,  History and examination sheets
Sphygmomanometer (automated or  Consultation request form
manual), Otoscope, Tongue depressor,  Referral form
Ophthalmoscope, Thermometer, Weight  Laboratory, X ray request form
and height scale, Measuring tape, Prescription pads
Screen for patient, Minor procedure
Sample collection supplies
kits, Computer and
Dressing supplies
Communication materials (TV....)
Personal protective equipment
Other materials as per hospital tier level.
C. Health literacy unit

Health literacy Unit should be established and work closely works with DIS. The unit should be
led by health literacy professional or at least GP. The team will work in close proximity with
departments and service delivery units to develop and deliver health education materials. Health
education materials should be developed for selected prioritized topics. There should be a regular
health education session on face to face basis at waiting areas and wards. Focused group
discussions should alos be established on selected chronic diseases with health education
component.

Standardized health education materials should be availed to patients in the form of brochures,
leaflets, posters, billboards, audiovisual materials displayed at waiting areas. Clients should get
access to a phone line whenever they need consulation to health professionals.

D. Procedure room at outpatient clinic

The outpatient clinic should encompass a procedure room where diagnostic and therapeutic
minor procedures and tests can be performed and where simple bedside tests can be carried out.
The procedure room should be staffed and equipped with: nurse, cleaner, dressing set, minor OR
set, hand washing facilities, coach, IV stand, IPPS materials. The infrastructure at the outpatient
clinic should facilitate easy access way to treatment services for differently abled people and
other people in need of special help.

E. Waiting Area at outpatient clinic

Waiting area of the hospitals should be located closest to the reception and should incorporate
the followings:

 Designated, spacious with washable sits and floor

 Natural or mechanical ventillaton
 Natural or artificial light sources
 Usher/guide
 Audiovisual corner with TV for educating patients and their families.
Staff assigned at waiting area of the outpatient clinic should be trained on special need training in
order to ease their communication between people with special needs, thereby give necessary
information (guide) for differently abled people. Supporting devices such as wheelchair, stretcher
should also be accessible at waiting area.

The hospital should have a clear management system to for isolating patients with communicable
diseases like patients having chronic cough and suspected of TB. The hospital should also have a
separate waiting area for children and adults.

F. Clinical Audit and Quality Improvement Project

The outpatient department should conduct regular OPD clinical audit and develop QI project.
The quality improvement projects are expected to graduate with the timeline set during the
project. Each outpatient service area conducting QI projects should monitor the progress of
implementation of QI the projects.

Section 4: Summary

Outpatient chapter were designed to increase efficiency and quality of patient service provide
at a hospital level. The outpatient chapter has 11 operational standards with verification
criteria to assess performance against the standard and develop quality improvement plan.
Section 5: Source Documents

1. Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative

and Treatment Sub-Business Process. The New General and Specialized Hospital Business
Process Study Report.

2. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Patient Flow: A
Manual Prepared for Heads of Hospitals and Service Providers. Addis Ababa, Ethiopia

3. WHO. (2005). Pocket Book of Hospital Care for Children. Guidelines for the Management of
Common Illnesses with Limited Resources. Geneva: World Health Organization.

4. Federal Ministry of Health. Ethiopian Hospital Reform Implementation Guidelines (EHRIG).

May 2010. Addis Ababa, Ethiopia.

5. Federal Ministry of Health. The National Admission and Discharge Protocols for Ethiopian
Hospitals. July 2012. Addis Ababa, Ethiopia.

6. Federal Ministry of Health. National Liaison and Referral Manual. Unpublished.

Chapter XX:
Inpatient Service Management
Chapter Outline

1. Introduction
2. Operational Standards for Inpatient Services
3. Implementation Guidance for Inpatient Services
3.1. Inpatient Services Management and Organization
3.2. Inpatient Services Layout
3.3. Inpatient Case Management
3.4. Inpatient Service Human Resource Requirements
3.5. Inpatient Service Equipment and Supply Requirements
3.6. Inpatient Care Communication
3.6.1. Handover of Clinical Care
3.6.2. Multidisciplinary Ward Rounds
3.7. Documentation and Record-Keeping
3.8. Patient Attendants or Visitors Management
4. Implementation
4.1. Implementation Strategy
4.2. Implementation Checklist
4.3. Inpatient Service Management Indicators
References
Abbreviations
- CLD - Chronic Liver Disease
- COT - Central Operation Theatre
- DM - Diabetes Mellitus
- HCW - Healthcare Worker
- HMIS - Health Management Information System
- HTN - Hypertension
- ICU - Intensive Care Unit
- IPC - Infection Prevention and Control
- IPD - Inpatient Department
- MDT - Multidisciplinary Team
- OPD - Outpatient Department
- PSA - Pressure Swing Adsorption
- QI - Quality Improvement
- SOP - Standard Operating Procedure
- SPO2 - Oxygen Saturation
- TAT - Turnaround Time
Section 1: Introduction

Inpatient Hospital Services are medical care and treatment of inpatients provided under the
direction of a physician in an organized, furnished and licensed hospital, established and
maintained primarily for the care and treatment of patients with various health conditions,
including mental health problems.

Inpatient hospital services vary across hospitals depending on the tier level and may include units
like Pediatrics, Internal Medicine, Surgery, Obstetrics-Gynecology, Orthopedics, Oncology,
Rehabilitation, Critical Care, Adult and Neonatal Intensive Care, Labor and Delivery, Operating
Rooms, and Post Anesthesia Care. Academic or specialized hospitals may offer additional sub-
specialty units.

Inpatient services encompass use of facilities, diagnostic and therapeutic services, medications,
supplies, room and board, nursing care, and all necessary provisions for adequate patient care.
The inpatient department is a major area for provision of hospital services. Patients referred from
other departments, clinics or healthcare facilities are admitted based on the hospital's admission
criteria to receive comprehensive inpatient care services. Duration of hospital stay depends on
the patient's condition and available resources. Care provided ranges from routine admission to
advanced treatments depending on the patient's problems and hospital tier level.

The inpatient department is staffed by multi disciplinary team including physicians, nurses,
dietician, clinical pharmacists, laboratory professionals, and other cadres.

This chapter aims to provide guidance on establishing effective, efficient and integrated inpatient
care services from admission through discharge.
 Section 2: Operational Standards for Inpatient services

 The inpatient department has a management structure, annual and monthly services plan,
with departments/units/case teams

 The Hospital provides standard inpatient services meeting relevant regulatory standards

 Inpatient staff regularly follow and implement the hospital's admission and discharge
protocols

 All inpatient records contain completed medical record formats

 The Hospital conducts multidisciplinary team rounds twice per day and conduct chart
audit by senior for newly admitted patient

 The inpatient department is staffed with adequate personnel appropriately trained and
equipped for inpatient care per regulatory standards

 The department has guidelines for verbal and written communication on patient care
including handovers within and between disciplines

 Established procedures exist for inter-professional and inter-departmental consultations

and patient transfers to ensure continuity of care

 A policy requires accompanying all patients by appropriately trained staff during

diagnostic services outside the department and for inter-ward/department transfers

 Nutrition guidelines and services are in place for inpatients

 Informed consent is provided to all patients admitted

 Continuous oxygen supply and appropriate utilization are ensured and monitored

 Regular clinical audits are conducted and quality improvement projects implemented
Section 3: Implementation guidance for Inpatient services

3.1. Inpatient Services Management and Organization

The Inpatient Services Director should oversee all inpatient activities. Clinical and support staff
should be organized into specialty-based Case Teams (e.g. Internal Medicine, Surgery,
Pediatrics, Gynecology). Case Teams should comprise specialists, general practitioners, clinical
pharmacists, phlebotomists, health officers, nurses, midwives, runners, cleaners, etc. An assigned
Case Team Leader reports to the Inpatient Director. Pharmacy, Radiology and Laboratory should
also form part of inpatient services and provide support and advice on individual patient care as
needed.

Efficient inpatient services require coordination with Nursing, Clinical Support Services
(Physiotherapy, Radiology, Social Work), Ancillary Services (Laboratory, Transport, Food
Services), Health Information Services (Admissions, Medical Records, IT) and Facility
Management (Housekeeping, Maintenance, Security). The Inpatient Director coordinates these
services for seamless integrated care.

The Nursing Director led nursing services and reports to the Medical Director/Chief Clinical
Officer. Responsibilities include preparing annual plans, managing and staffing nursing units,
conducting quality improvement initiatives, among others.

3.2. Inpatient Services Layout

Safe, comfortable inpatient rooms facilitate healing. Room sizes should meet minimum standards
per the hospital's tier level.

Patient wards should be near the Emergency Department, Outpatient Department, and easily
accessible from elevators, ramps or stairs. Wards should be in quiet locations based on site
analysis, safe and comfortable yet accessible. Each ward should have at least 1 nurse station for
every 35 beds located close to patient rooms.
Psychiatric facilities should enhance patient dignity, comfort, self-esteem and autonomy while
ensuring safety. Wards should have adequate well-ventilated rooms with functional toilet, sink
and shower facilities. Separate rooms for males and females are required in mixed-sex wards.
Similarly, adult and pediatric wards require separate rooms. Products and layout should meet
minimum inpatient unit requirements. Screens/curtains allow privacy during procedures. A
separate procedure room in each ward enables bedside tests and minor diagnostic/therapeutic
procedures.

The hospital inpatient unit should estimate the oxygen requirements for each ward to determine
the total supplemental oxygen needs. The findings can help identify the most suitable oxygen
source, whether an on-site PSA plant, cylinders, or Concentrators. The hospital should install a
piped oxygen system with digital oxygen concentration monitors, flow rate drop alarms, and
manifold connectors throughout the inpatient wards. If feasible, medical gases including oxygen,
suction, and medical air should be available at every bedside. In that case, cylinders should be
avoided in patient areas due to safety risks. The UNICEF oxygen planning tool can assist in
quantifying oxygen demand.

The inpatient unit can allocate 15% of total beds for private services operating 24 hours a day,
365 days a year. However, meeting the needs of routine inpatient services should take priority
regarding human resources, supplies, and other hospital support services. Laboratory and
pharmacy services should also be readily accessible for inpatients. Mobile diagnostic services
like ultrasound, mobile x-ray, and ECG should be available in the wards.

3.3. Inpatient Case Management

Inpatient admission allows direct observation, monitoring and therapeutic support in a secure
environment for patients meeting admission criteria. Established processes guide initial and
periodic reassessments. Patients may be admitted from Emergency, Operating Rooms,
Outpatient and Intensive Care. At admission, ambulatory patients are guided through registration
while non-ambulatory patients are transported to wards with medical records for seamless care.
Below are key activities:
- Efficient bed management to avoid inappropriate hospitalization and improve bed access
- Patient-centered services
- Patient involvement in decision-making
- Available beds for elective admissions to reduce waiting times

3.3.1. Admission process

The Hospital provides 24/7 year-round admission/discharge services including holidays. The
Liaison Service coordinates admissions/discharges per the process in the Liaison, Referral and
Social Services chapter.

A written admission protocol outlines steps for arranging admission and ward activities. Staff
should be aware of and adhere to this protocol.

On arrival, a nurse receives and orients the patient and care givers. Receiving nurses should
assess all patients/clients' conditions on arrival in the ward and make the patient feel welcome,
comfortable and at ease. For critically ill patients, the nurse informs the physician for immediate
assessment. All patients should be assessed by a doctor within 2 hours of arrival and a history
and physical examination completed. This assessment guides immediate management. The
nursing process needs to be completed within 8 hours (before the next shift). Delayed
nursing/medical care risks compromising safety. A sample History and Physical Examination
Assessment Form is presented in Chapter Medical Records Management.

3.3.2. Clinical care Service Activity (Nutrition)

After initial assessment, the Care Team reviews patients regularly (stable patients - physicians
daily, nurses 4 hourly; critically ill - physicians twice daily or more, nurses more frequently).
Contacts are documented using physician progress notes and nursing/midwifery progress sheets.
Further guidance on inpatient nursing care provision is presented in Nursing and maternal,
neonatal, RH and midwifery service Chapters and the Ethiopian Hospital Alliance for Quality
Change Packages consecutive guidelines. The latter contains guidance on nurse rounding, central
medicines storage, and administration of medicines.
Medications are administered and documented per standardized formats. Like other essential
medications, supplemental oxygen is fully prescribed, delivered and adherence monitored by
clinical pharmacists. Complete oxygen orders specify:

1. Flow rate

2. Delivery system/mode

3. Monitoring frequency

4. When to report

5. When to change delivery device

6. When and how to stop administration

Ordered investigations use relevant request forms. Phlebotomists/lab team/nurses collect

specimens in wards. For x-ray/ultrasound, the physician contacts the department to schedule the
patient, who is transported by a runner or clinical staff. If mobile x-ray/ultrasound are available,
the physician provides the service where patient dignity is respected. Findings are documented
and explained to the patient.

The Hospital has an important role in preventing and treating illnesses. Nutrition has an
important role in the health outcomes of the patients. Studies show that when health facilities
provide nutritionally sound meals, it can result in faster recovery, shorter Hospital stays, and
ultimately reduced costs.
Figure 1:. Typical Pathway for Inpatient Admission.
3.3.2.1. Food/Nutrition service

Menu planning is the cornerstone of food services. Menus should meet needs of patient groups
like children, elderly, ethnic minorities with adequate choices. Meal timing should align with
customary patterns.

Hospital food service aims to provide safe, adequate and appropriate meals. All hospitals should
develop meal planning through a multidisciplinary committee with representatives from:

1. Administration

2. Procurement Unit

3. Ward in-charges/Nursing head (Matron)

4. Food Services / Dietitians (where available)

5. Store in charge

6. Cooks

7. IPC Focal

8. Other relevant officials

Roles and responsibilities

I. The kitchen /Store in charge

  Menu planning for inpatients

 Planning food item purchases

 Directing, supervising and monitoring meal preparation and service

 Managing inventory, consumption and cost records

II. Cooks

 Receiving ward food requests

 Planning, cooking, transporting and serving inpatient meals

 Ensuring food areas including storage are clean, pest-free and have minimum
contamination risk

 Receiving and communicating patient feedback to the kitchen in-charge

 Prescribing therapeutic diets and modifications based on disease status

 Planning and periodically monitoring food services for best practices

III. Dieticians/Nutritionists (where available)

IV. Physician

 Prescribing therapeutic diets based on patient diseases

V. Nurse in charge

 Completing and submitting diet request forms to cooks

VI. Management

 Planning and periodically monitoring food services for best practices

3.3.3. Isolation rooms

Isolation of a patient is essentially an escalation of the core healthcare process. As our

understanding of the transmission of infection has improved, isolation practices have developed
and moved away from early empirical approaches to become more evidence-based and targeted.
Best practice demands that isolation rooms be provided where optimal care for the underlying
medical condition.

Infection control is emerging as the biggest challenge to health services worldwide. All hospitals
knowingly or unknowingly admit patients with communicable diseases. In recent years,
emerging infectious diseases represent an ongoing threat to the health and livelihoods of people
everywhere. Over the last few decades, several emerging infectious diseases (EIDs) have taken
the global community by surprise and drawn new attention to EIDs, including HIV, SARS,
H1N1, and Ebola.

FUNCTIONS
Isolation rooms are for potentially infectious patients like drug-resistant TB. Rooms should have
negative pressure ventilation, scrub facilities, and private bathroom. Separate isolation rooms
should be available for patients requiring separation to avoid sources of visual or auditory
distress, like tetanus cases. Well-designed isolation rooms are very essential:

 To separate patients who are likely to be infectious to other persons

  To provide an environment that allows reduction of the concentration of
airborne Particles through various engineering methods

 To prevent the escape of airborne particles from such rooms into the corridor
and other areas of the facility using directional airflow

 To protect patients who are immune-compromised from potentially harmful

pathogens.

3.3.4. Specific Inpatient facilities and services

 Patient gowns, linen, mattresses - The Hospital ensures adequate supply of clean
blankets, sheets, and gowns. Mattresses should be plastic-covered without holes. Beds
should be changed at least every 48 hours and more frequently as needed. All patients
should wear gowns with their clothes stored separately to prevent cross-infection.

 Operating theatre – As part of inpatient services, particular attention should be given to

the organization of operating theatre activities. Surgical and Anesthesia Services
management chapter has recommendations on operating theatre management and layout.

 Intensive care units should also receive attention. ICU management recommendations
are in Speciality and Sub-Speciality services management chapter.

 - Mental Health Services – The Hospital should implement written protocols for inpatient
psychiatric care including admission, consultation, transfer, discharge and follow-up.
(Please refer to minimum requirements as per the hospital tier level.).
3.3.5. Discharge process
The Hospital should have a written discharge protocol defining all steps including summary
preparation and medical record handling post-discharge. When discharge is planned, the Care
Team counsels the patient. The treating physician decides discharge and completes a summary -
first copy given to the patient and second copy retained in the record. For referred patients, the
discharging physician also completes the feedback section of the referral form given to the
patient to return to the referring facility.

Pre-discharge counseling by the physician, nurse and pharmacist should cover:

- Diagnosis, investigations and treatments

- Medications to continue

- Follow up arrangements

- Warning signs to watch out for

Before sending the patient to the Liaison Office, the discharging nurse ensures all registers are
completed and administrative issues including finances settled.

The discharge process takes a maximum of 2 hours. The patient is sent to the Liaison Office with
medical records. The Liaison Officer checks document completeness, registers the discharge and
sends the patient home with an appointment card if follow-up was requested.

If the outcome is death, a protocol defines deceased care procedures including informing next of
kin considering cultural/religious factors. Death is confirmed by the attending physician or any
independent practitioner and nurse. A death summary and notification are completed and
documented to ensure accurate retrievable records. The Inpatient service should have a separate
room for 'after death care'. If post-mortem examination is needed to confirm cause of death,
relevant forms are completed and the body transferred to pathology or the morgue. After
examination, the body is kept in the morgue until collected by relatives or responsible persons.
Unclaimed bodies become the responsibility of local authorities. Unexpected deaths are reported
to and investigated by the Hospital's quality improvement unit.

3.3.6 Patient Death

There shale be a protocol that states the procedure to be followed for dead body care, including
how the staff informs the next of kin/family members of the deceased taking all religious and
cultural consideration in to account. A death occurring in the hospital should be confirmed by at
least an attending physician or any independent practitioner. Post mortem care should be
provided by the attending nurse based on their culture.
The inpatient service should have a separate room for after death care. A death summary should
be completed and documented in the patient medical record to ensure accuracy and easy
retrieval. In case of a need for pathological examination and confirmation for cause of death post
mortem examination form should be completed and the body should be transferred to the
pathology case team or Morgue until it’s collected by family or other responsible person. If the
deceased dose not have any next of kin the local authority is responsible for collecting the body.

3.4. Inpatient Service Human Resource Requirements

The actual number of personnel shall be determined by workload analysis using recognizable

methods; however, inpatient services should be provided by Case Teams comprised of:

• Specialist (s)

• General practitioner(s)

• Nurses, Psychiatrist, psychologists, radiology (x-Ray technician)

• Pharmacy technicians and clinical pharmacists

• Laboratory technologists, phlebotomists

• Anesthetist

• Dietitian
 • Porters/runners

• Cleaners

• Cashiers

• Security guards

3.5. Inpatient Service Equipment and Supply Requirements

The minimum equipment and supplies for patient wards include:

• Beds, mattresses, pillows, linens, and blankets

• Chairs, tables, and bedside tables

• Emergency trolley with resuscitation equipment and emergency drugs

• Oxygen, pulse oximeter

• Suction machine

• Vital sign and diagnostic Set; sphygmomanometer(s), stethoscope(s), thermometer(s),

Fundoscopies, Otoscope

• Reflex hammer

• Weight scale and measuring tape

• IV stands, bed screens

• Trolleys, wheelchairs and stretchers

• Personal protective equipment

• Minor Set procedure sets according to the type of ward/case team, dressing sets
• Enema Set, LP set, Catheterization set

• Refrigerators

• Autoclave (at least one, not in central sterilization unit)

• Shelves

3.6. Inpatient Care Communication

The Hospital should implement communication guidelines detailing interactions between same
and different disciplines/services on inpatient care to ensure timely appropriate care. Contacts
like referrals, task allocation/prioritization should be clearly documented. Structured
written/electronic forms should record communications with patients/caregivers per national
guidance. Clear communication ensures care continuity, avoids duplication and is essential
legally. Guidelines should cover handovers, multidisciplinary rounds and communication with
patients/relatives.

3.6.1 Handover of Clinical Care

Handover involves transferring professional responsibility/accountability for some or all aspects
of patient care. Effective handovers are vital for care continuity and should align with
documentation like referrals, transfers and discharge summaries. Handover needs systemic and
individual attention, education, facilitation and sustained effort to maintain importance amidst
busy schedules. Standard handover processes improve safety by ensuring critical information
transfer and action. Relevant, accurate and timely information should be communicated
unambiguously using standardized electronic or structured written forms. Handover aims to
efficiently convey quality clinical information to support safe care.

Handovers occur daily in all hospital settings during shift changes, transfers within/between
facilities, admission/referral/discharge. Methods include face-to-face, telephone, electronic tools.
Locations include bedside, staff areas, reception desks.
Consequences of poor handover include:

 Unnecessary delays in diagnosis, treatment, and care;

 Repeated tests, missed or delayed communication of test results; and

 Incorrect treatment or medication errors

The use of a standard process for clinical handover has been shown to improve the safety of
patient care because critical information is more likely to be transferred and acted upon. The
information that is transferred between healthcare providers should include all relevant data, be
accurate, unambiguous, and occur in a timely manner. Clinical handover aims to efficiently
communicate high-quality clinical information and ensure timely, relevant, and structured
clinical handover that supports safe patient care.

Benefits include:

Patients

 Improved safety - lapses can lead to mistakes

 Care continuity

 Less repetition - multiple histories are vexing

 Better satisfaction - team knowledge continuity is accepted

 Increased efficiency - timely diagnosis/management

Healthcare providers
  Professional protection - clear documentation prevents wrongful responsibility

 Reduced stress - information enables confident care

 Educational - communication skill development in open environments

 Job satisfaction - quality care provision is rewarding

In summary:

 The Hospital implements effective clinical handover systems with documented structured
processes.

 Handover mechanisms include patients and caregivers.

3.6.2 Multidisciplinary ward rounds and chart audit for newly admitted patient
Multidisciplinary ward rounds allow joint patient assessments and care planning. Effective
coordination of assessments plans and communication is vital for efficient quality care.

Round composition varies across specialties depending on service organization. It includes

doctors of different specialties, nurses, clinical pharmacists, dieticians, psychiatrists, and
caregivers, etc. Opportunities exist for condition review, care planning, communication, team
building and shared learning. However, competing priorities often constrain execution.
Contributing factors include workforce gaps, inadequate planning, practice variations and limited
training in complex team skills. This frustrates staff and patients, increases errors, prolongs
hospitalizations and readmission.

To improve quality of inpatient care and reduce average length of stay hospital should implement
multidisciplinary team round twice per day (morning and afternoon) and conduct chart audit by
senior physician for newly admitted patient. The MDT round decisions should be documented
using the format and attached in the patient’s medical record.
 3.6.2.1 Communicating with patients

Communicating information in an easily comprehensible manner supports shared care

management with the patient and promotes future patient self-care management at the point of
discharge. Healthcare providers should inform the patient/s and their careers/relatives about
pending ward rounds and prepare forward rounds with relevant information on diagnostic tests
and clinical findings and with whom they can raise questions after the ward rounds. Providing
clear explanations about symptoms and disease severity and answering even the simplest of
questions can remove patients' fear and anxiety and aid recovery. However, patient
confidentiality should be maintained during discussions.

3.7. Documentation and Record-Keeping

Comprehensive clinical documentation is integral to quality care and relies on accessible records
(electronic/paper). Effective record-keeping enables care continuity and communication between
providers. Thus records should be updated by all involved multidisciplinary staff - physicians,
nurses, pharmacists, physiotherapists, psychologists etc. Patients should access records to
understand care provisions. Clinical records enable care audits and investigations of incidents,
complaints and claims.

Benefits of keeping good records versus disadvantages of poor records

Good clinical records Poor clinical records

Share relevant information Misinformation risks

Coordinate care Care fragmentation

Enable continuity Test/investigation repetition

Good clinical records Poor clinical records

Inform decisions Incorrect treatment/medication errors

Assess risks Jeopardies patient care

Investigate incidents Lead to serious incidents

Prolonged admissions- Audit capabilities -

Improve audit capabilities
Compromised care

Legal evidence Litigation risks

Targeted diagnostics/treatment

Time management
3.8. Patient attendants or Visitors management

Hospitals have hundreds of daily visitors, patients and staff. Uncontrolled visitor influx creates
tensions and disrupts services. Effective visitor management is imperative for smooth
functioning.

3.8.1. Reception Management System for Hospital

Hospitals have complex security and operational needs. Digital systems enable efficient, secure
and contactless visitor check-in, replacing manual paper logbooks. The system facilitates visitor
management, enhancing reception operations.
References

1. Hospital inpatient services [Internet]. [cited 2022 May 4]. Available from:
https://publichealth.gwu.edu/departments/healthpolicy/CHPR/nnhs4/GSA/Subheads/gsa56
.html

2. Types of Inpatient Facilities | HSM111 [Internet]. [cited 2022 May 4]. Available from:
https://courses.lumenlearning.com/atd-clinton-hsm111/chapter/types-of-inpatient-
facilities/

3. Issn PE, Hartuti S, Mustika W. Available online through

http://ejournal.undip.ac.id/index.php/modul ( Case Study : Bhakti Asih Hospital , Brebes
Central Java ). 2020;2877:1–9.

4. Oxygen System Planning Tool | UNICEF Office of Innovation [Internet]. [cited 2022
May 5]. Available from: https://www.unicef.org/innovation/oxygen-system-planning-tool

5. National Accreditation Board for Hospitals and Healthcare Providers (NABH) Standards.
Accreditation standards for hospitals. Nabh. 2020.

6. The Health Boards Executive. Admissions and discharge guidelines: health strategy
implementation project. 2003; Available from: http://lenus.ie/hse/handle/10147/43554

7. "Reception Management," 4 May 2022.

[Online].Available:https://www.vizitorapp.com/medical-receptionist-software.
Chapter 7:
Nursing Care Service Management
Contents
Section 1: Introduction ...............................................................................................................................2
Section 2: Operational Standards for Nursing Services Management ......................................................3
Section 3: Implementation Guidelines .......................................................................................................2
3.1. Organizational structure of the Nursing Care Service .................................................................2
3.2. Nursing Workforce Plan ..............................................................................................................3
3.3. Team Work ..................................................................................................................................5
3.4. Nursing Process and it’s components ..................................................................................................5
3.5. Nursing Assessment ....................................................................................................................6
3.6. Nursing Diagnosis/ Problem Identification .................................................................................6
3.7. Purposes of Nursing Diagnosis ...................................................................................................7
3.8. Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems ...............7
3.9. Nursing Care Plan .....................................................................................................................11
3.10. Implementation of the Plan .....................................................................................................12
3.11. Nursing Evaluation of the plan ................................................................................................13
3.12. Accountability and Responsibility ..........................................................................................14
3.13. Nursing Ethics .........................................................................................................................15
3.14. Communication and Documentation .......................................................................................16
3.15. Patient Education.....................................................................................................................16
3.16. Medication Management .........................................................................................................17
3.17. Nursing care practice audit ......................................................................................................21
3.18. Purposes of Nursing Audit ......................................................................................................21
3.19. Shift Nursing Services handover and round ...........................................................................23
3. 20. Nursing Station .......................................................................................................................23
3.21. Skill lab ...................................................................................................................................23
4. Chapter Summary .................................................................................................................................24
5. Annexes ................................................................................................................................................25
5.1. Monitoring & Evaluation Tools ....................................................................................................25
5.2. Nursing Assessment Format ..........................................................................................................27
6. Source Documents..................................................................................................................................5
Section 1: Introduction
Nursing care service is an essential part of the hospital system in improving the health
outcomes of individuals, families and communities. Nursing is a profession that ensures the
successful implementation of interventions that welcome and nurture life, promotes or restores
health, enables the means to improve the quality of life, dignified and peace full death. Nursing
encompasses autonomous and collaborative care of individuals of all age, families, groups and
communities, sick or well and in all settings.

Nurses are expected to provide quality nursing care for the public with safe and ethical manner.
They are fully accountable and responsible for their entire practice. To ensure quality nursing
services in any health facility, nursing workforce is expected to be motivated, competent and
compassionate. Nursing staff work closely with their own team and with other health
professionals, making sure patients’ care and treatment is coordinated.

As individuals, members and coordinators of inter-professional teams; nurses bring client–

centered care close to the communities where they are needed most. Thereby contributing
greatly in improving the health outcomes of those under their care as well as improving the
overall cost effectiveness of health care system. Understanding the individual’s needs, giving
care with dignity and humanity, showing compassion and sensitivity, and provide care in a way
that respects all people equally is expected.
Section 2: Operational Standards for Nursing Services Management
1. The hospital has established nursing care service management structure and job description
including reporting relationships.
2. The hospital has a nursing workforce plan and sets standardized nurse to patient ratio in
each service area.
3. The hospital has written Protocol describing the responsibilities of nurses for implementing
nursing process.
4. All admitted and emergency patients/clients have a nursing process that describes holistic
nursing interventions.
5. All hospital nurses comply with the professional code of conduct and ethics which governs
their professional practice.
6. The hospital has established guidelines for verbal and written communication about
patient/client care to work as independent, inter dependent and collaborative team work.
7. The hospital has standardized procedures and practice for the safe and proper
administration of medications by nurses or designated clinical staff.
8. The hospital has conducted regular nursing care practice audit and the findings are linked
with QI projects.
9. The hospital has implemented nursing shift regular handover and rounds.
10. The hospital has a centralized nursing station set-up in each ward with adequate space,
equipment and consumables.
11. The hospital established skill lab and regular need based capacity building program for
nursing staffs.
Section 3: Implementation Guidelines
Implementation is the steps which involve action or doing and the actual caring out of in each
specific standards, protocols and guidelines. The implementation Guide design to explain how
to intervene each standards, additional tools and documents and capacitate professional
knowledge and skill to perform a specific intervention and to achieve the agreed standards.

3.1. Organizational structure of the Nursing Care Service

The hospital has established nursing care service management structure and job description
including reporting relationships.

Nurses play a pivotal role in any health facility. Encompassing the largest workforce in
hospitals, nurses act as direct caregivers who serve a hospital twenty-four hours a day, seven
days a week. This gives a unique perspective on hospital operations. Nurses should be allowed
to assume managerial roles that will enable them to make decisions affecting patient/client care
at the case team, unit and department levels

Given the complexities of hospital management and the direct relationship between hospital
operations and patient care, nursing responsibilities have expanded to include a greater
managerial role. This includes assuming an increased role in hospital leadership and
contributing to effective decision-making within the overall hospital structure, as well as within
case teams, wards/units or departments.

Nursing Director (matron) is a member of the senior management team (SMT) and responsible
for the overall function of nursing activities in the hospital.

Nursing Director is responsible for the overall function of nursing activities in the Hospital and
accountable to the Medical Director.
 The ward head nurses are responsible for the administrative and nursing functions in the
specific Ward/Unit. It is essential that within a case team, ward/unit there exists a clear
management structure that delineates the ultimate roles and responsibilities within the given
team and clinical setting, determining who has clear authority over certain decision-making
processes.

Each nurse in the hospital has written job description singed and attached in his/her file. Copy
of the job description should be given to each nurse.

The hospital should implement supervision and delegation mechanism.

Clinical supervision is “a formal process of professional support and learning which enables
individual practitioners to develop knowledge and competence, assume responsibility for their
own practice and enhance client/patient protection and safety of care”.

Student nurses should practice under the supervision of preceptors or word nurses

Nurses may delegate tasks and responsibilities to junior nurses, student nurses or parallel
position nurses. Before delegating, he/she must ensure that anyone they delegate to, is able to
carry out the responsibility of what she/he delegates, and must provide adequate supervision to
ensure that the outcome of any delegated task meets required standards.

Senior Nurses should have responsible for junior nurses on professional practical knowledge
and skill development all the time.

3.2. Nursing Workforce Plan

Shortages of appropriate nursing staff or inappropriate distribution of available staff adversely

affects the quality of patient care. The effect of inappropriate nursing workforce planning will
lead to staff dissatisfaction, burnout and nurse turnover which in turn contributes to poor
quality of nursing care. As the result, health care associated infection and mortality will
increase.

The hospital should establish a nursing workforce plan that:

 establishes minimum nurse to patient ratios for each inpatient ward/service, taking the skill
mix of staff into consideration,
 identifies priority areas where the nurse count must at all times meet the minimum ratio
requirements (for example intensive care/high dependency units, post-operative recovery,
emergency department, etc.)
 Establishes a procedure for transferring nurses across clinical settings, or calling in extra
nurses from home in order to maintain minimum nurse to patient ratios, especially in the
priority areas.
 To determine the minimum nurse to patient ratio the following factors to be considered
include:

 The severity of the clinical condition of patients,

 The intensity of nursing care needed, for example the frequency of nursing interventions
such as observations, medication administration, wound care, stoma care, bathing etc.,
 The number of admissions and discharges,
 The availability of technology (patient monitors, beepers etc.),
 The skill mix of staff, availability and responsibilities of caregivers.

There should be a minimum of a registered professional head nurses in-charge of each

ward/unit that has relevant knowledge, skills and experience with compassion and respect to
manage a ward/unit and the nursing staff therein. The nurse management team, together with
hospital management should determine the minimum nurse to patient ratio for the unit. The
ratio should be kept under review and amended as necessary.
 The hospital nursing workforce plan should address the mechanism to answer/cover when
there is vacant nursing schedule as the result of sick leave, maternity leave, annual leave and
other problems.

The nursing workforce plan should also consider the role of nurses in outpatient, inpatient and
specialty clinics and the nursing contribution to hospital management and governance
structures (such as quality committees, infection prevention committees etc.).

3.3. Team Work

Nursing practice must have teamwork, an on-going interaction between members of the
multidisciplinary team, the patients, patients’ relatives and hospital managers. In working with
colleagues and hospital management, the nurses must be:

 Work with collaborate the patients and their caregivers, plans and decisions related to patients,
colleagues in the formulation of overall goals.
 Work with other members of the multidisciplinary team in caring for patients.
 Consult with other health care providers on patient care, as appropriate,
 Make referrals, including provisions for continuity of care, as appropriate,
 Collaborate with other disciplines in teaching, consultation, management, and research
activities as opportunities arise
 Participate in an organized sub quality Improvement team, and Nurses should assume
responsibility for monitoring, evaluating and reporting of their activities within the sub quality
Improvement and nursing Audit team.

3.4. Nursing Process and it’s components

The nursing care process is an organized, systematic and holistic approach through which
nursing care provision is organized to achieve patient/client centered care. The nursing
process involves Nursing Assessment, Nursing Diagnosis, Nursing Planning, Nursing
Implementation and Nursing Evaluation of care (ADPIE). This should be done in collaboration
 with the patient/client, family and community. Assessment: the nurse collects comprehensive
data pertinent to the patients’/client’s health or situation.

3.5. Nursing Assessment

Nursing Assessment is the gathering of information about patients physiological,

Psychological, Sociological and spiritual status by a licensed registered Nurse. A nurse collects
and documents critical data regarding patient/client health status. This assessment remains
accessible to the entire health care team during the course of the client/patient stay and beyond,
in order to assist the team in determining proper client care and treatment. In the nursing
assessment, the nurse gathers and examines both Subjective and Objective data.
 Subjective data are what the patient/client actually states (e.g. "I'm tired"). These are
his/her feelings and perceptions.
 Objective data are concrete, observable information and investigation.

Sample Examples:

Subjective data ObObjective data:

 "I feel sick.”  Blood pressure of 110/70 mm Hg.

 "I have a stabbing pain in my side."  Rash on right arm
 "I wish I were home."  Walks with a limp
 "I feel like nobody likes me."  Ate all of his breakfast
 Urinated 150 ml clear urine
3.6. Nursing Diagnosis/ Problem Identification

What is a Nursing Diagnosis?

A nursing diagnosis is a clinical judgment concerning human response to health
conditions/life processes, or vulnerability for that response, by an individual, family, group, or
community. A nursing diagnosis provides the basis for the selection of nursing interventions to
achieve outcomes for which the nurse has accountability. Nursing diagnoses are developed
based on data obtained during the nursing assessment and enable the nurse to develop the care
plan.

3.7. Purposes of Nursing Diagnosis

The purpose of the nursing diagnosis is as follows:

 Helps identify nursing priorities and help direct nursing interventions based on
identified priorities.
 Helps the formulation of expected outcomes for quality assurance requirements of
third-party payers.
 Nursing diagnoses help identify how a client or group responds to actual or potential
health and life processes and knowing their available resources of strengths that can be
drawn upon to prevent or resolve problems.
 Provides a common language and forms a basis for communication and understanding
between nursing professionals and the healthcare team.
 Provides a basis of evaluation to determine if nursing care was beneficial to the client
and cost-effective.
 For nursing students, nursing diagnoses are an effective teaching tool to help sharpen
their problem-solving and critical thinking skills.
3.8. Differentiating Nursing Diagnoses, Medical Diagnoses, and Collaborative Problems

The term nursing diagnosis is associated with three different concepts. It may refer to the
distinct second step in the nursing process, diagnosis. Also, nursing diagnosis applies to the
label when nurses assign meaning to collected data appropriately labeled with NANDA-I-
approved nursing diagnosis. For example, during the assessment, the nurse may recognize that
the client is feeling anxious, fearful, and finds it difficult to sleep. It is those problems that are
labeled with nursing diagnoses: respectively, Anxiety, Fear, and Disturbed Sleep Pattern.
Lastly, a nursing diagnosis refers to one of many diagnoses in the classification system
established and approved by NANDA. In this context, a nursing diagnosis is based upon the
response of the patient to the medical condition. It is called a ‘nursing diagnosis’ because these
are matters that hold a distinct and precise action that is associated with what nurses have the
autonomy to take action about with a specific disease or condition. This includes anything that
is a physical, mental, and spiritual type of response. Hence, a nursing diagnosis is focused on
care.
COMPARED: Nursing diagnoses vs medical diagnoses vs collaborative problems:
A medical diagnosis, on the other hand, is made by the physician or advanced health care
practitioner that deals more with the disease, medical condition, or pathological state only a
practitioner can treat. Moreover, through experience and know-how, the specific and precise
clinical entity that might be the possible cause of the illness will then be undertaken by the
doctor, therefore, providing the proper medication that would cure the illness. Examples of
medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic
Kidney Disease. The medical diagnosis normally does not change. Nurses are required to
follow the physician’s orders and carry out prescribed treatments and therapies.

Collaborative problems are potential problems that nurses manage using both independent
and physician-prescribed interventions. These are problems or conditions that require both
medical and nursing interventions with the nursing aspect focused on monitoring the client’s
condition and preventing the development of the potential complication.

Actual nursing diagnoses should be written as a three-part statement(s) which includes:

1. The problem (P)

2. Its cause or etiology (E)

3. Signs and symptoms (S)

The PES format describes the problem and its etiology, together with data (signs and
symptoms) that validate the chosen diagnosis. To write a diagnostic statement for an actual
nursing diagnosis, link the problem and its cause by using “related to” then add “as manifested
by” or “as evidenced by” and state the major signs and symptoms that validate the diagnosis.

Example:

Problem Etiology (cause) Symptom/Sign

“Ineffective airway clearance related to incisional pain as manifested by poor cough effort’

Potential Diagnosis should be written as a two part statements which include: problem and
etiology.

Nurses may also note that a patient/client has certain risk factors that put him/her at risk of a
particular nursing diagnosis. These risk factors and the related ‘potential diagnosis’ should be
documented so that the nursing care plan can include actions to prevent the problem. For
example: ‘at risk of impaired skin integrity due to patients’ age, weight, immobility and
confinement to bed’. The care plan would then include action to prevent irritated or broken
skin such as regular turning, massage etc.).
 3.9. Nursing Care Plan

After the nursing diagnoses and collaborative problems have been identified, they are recorded
on the plan of nursing care.

The care plan is a record of interventions that will address the identified problems. It should be
based on the problem identification and the diagnoses, and should be individualized or tailored
to the patient’s/community’s health problems. The care plan guides each nurse to intervene in a
manner congruent with individual or community needs and goals and provides outcome criteria
for measurement of progress.

This phase entails the following:

1. Assigning priorities to the nursing diagnoses and collaborative problems.
2. Specifying expected outcomes.
3. Specifying the immediate, intermediate, and long-term goals of nursing action.
4. Identifying specific nursing interventions appropriate for attaining the outcomes.
5. Identifying interdependent interventions.
6. Documenting the nursing diagnoses, collaborative problems, expected outcomes, nursing
goals, and nursing interventions on the plan of nursing care.
7. Communicating to appropriate personnel any assessment data that point to health needs that
can best be met by other members of the health care team.
The plan of nursing care serves as the basis for implementation:
The immediate, intermediate, and long-term goals are used, and, are the focus for the
implementation of the designated nursing interventions. The following aspects of nursing care
should be considered when developing and implementing a nursing care plan:

Four key steps to care planning:

 Patient assessment. Patient identified goals

 Planning with the patient. How can the patient achieve their goals?
 Implement. ...
 Monitor and review.

3.10. Implementation of the Plan

Nursing interventions are actions a nurse takes to implement their patient care plan,
including any treatments, procedures, or teaching moments intended to improve the
patient's comfort and health.

Examples of nursing interventions include discharge planning and education, the provision of
emotional support, self-hygiene and oral care, monitoring fluid intake and output, ambulation,
the provision of meals, and surveillance of a patient's general condition

There are three types of nursing interventions:

 independent,
 dependent, and
 collaborative.

The care plan should be implemented by all nurses who care for patients/clients. Hence, all
staff should be familiar with the care plan and should ensure that the activities described in the
care plan are carried out during each shift.

In implementing the care plans, nurses should use a wide range of interventions designed to
promote, maintain, and restore mental and physical health.

All nursing interventions are patient-focused and outcome-directed and implemented with
compassion, confidence and a willingness to accept and understand the patient’s responses.
Although many nursing actions are independent, others are interdependent, such as carrying
out prescribed treatments, administering medications and therapies, and collaborating with
other health care team members to accomplish specific expected outcomes and to monitor and
manage potential complications. Such interdependent functioning is just that—interdependent.
Requests or orders from other health care team members should not be followed blindly but
should be assessed critically and questioned when necessary.

The Nursing interventions/implementation should be:

 For each admitted patient, the nursing process form should be attached and the assessment
should be completed immediately after admission.
 Based on current knowledge and principles of relevant preventive and therapeutic
modalities.
 Selected based on the needs and /or desires of the individual or community.
 Selected according to the nurse’s level of practice, education and certification.
 Implemented within the established plan of care.
 Performed in a safe, ethical and appropriate manner.
 Adapted to changing patient needs and situations.
 Reviewed in order to recognize the progress or lack of progress and, reassignment of
priorities is required towards identified goals.
 Nurses should document progress reports at the end of each shift which should consist of
nursing interventions, patient/client responses, patients/clients emotional adjustment and
rendered patient/client education.

3.11. Nursing Evaluation of the plan

Evaluation is the process of determining the extent to which the set goals have been achieved.
The nurse must evaluate the results to determine whether the interventions were effective or
not. Nursing care evaluation is a dynamic process involving change in the patients/clients
health status over time, giving rise to the need for new data, different diagnoses, and
modifications in the plan of care.

As new problems arise they should be entered on the Problem Index List and related goals and
activities should be established to address the problem. Similarly, if a problem is resolved, this
should be recorded on the Problem Index List to indicate that goals and activities related to that
particular problem are no longer necessary.

Nursing Evaluation involves the following activities:

1. Have the goals of the care plan been achieved?

2. If not, why not? Were the goals realistic?
3. Was the client/patient committed to the goals?
4. Was there enough time to achieve the goals?
5. Did other problems arise that impeded progress?
6. Which interventions were consistently performed as prescribed?
7. Have any new problems developed that have not addressed?
8. Could more have been achieved than originally hoped?
9. Should new goals be set?
10. The action plan should be checked at intervals, randomly by the nurse supervisors/head
nurses and should be documented.

3.12. Accountability and Responsibility

1. The nurse remains accountable for his/her own practice as well as for the delivery of the
care plan and for ensuring that the overall objectives are met.
2. Reassessing the condition of the person in their care at appropriate intervals and
determining that it remains stable and predictable;
3. Observing the competence of the caregiver(s) and determining that they remain competent
to perform the delegated task of care, safely and effectively.
4. Hospitals should ensure that nurses have access to and are trained on how to use resources
(including equipment and consumables) correctly and cost-effectively. Nurses are
responsible for forecasting stock-outs of nursing formats and other consumables on the
ward, and should inform the appropriate party of the need for additional resources to
prevent stock out.

3.13. Nursing Ethics

Ethics and code of conduct Provides:-for the professional standards for nursing activities,
Concerned with fundamental principles of right and wrong, what people ought to do and
inform our judgments and values and help individuals decide on how to act. Ethics determines
the characteristics of a profession and is also called as a “code of conduct” which protects the
nurses and the patients from legal and ethical issues. The International council of nurse’s code
of ethics is grouped into four distinct areas.

o Promote health,
o Prevent illness,
o Restore health, and
o Alleviate suffering.

Principle of Nursing Ethics

 Respect the Autonomy: - individuals have a right to self-determination, which is to make
decisions about their lives without interference from others and respecting a client’s rights,
values and choices is synonymous to respecting a person’s autonomy. Informed consent is a
method that promotes and respects a person’s autonomy.
 Beneficence and none maleficence: - Doing good by providing health benefits to the
patients and don’t harm or hurt your clients.
 Justice:-Equal and fair distribution of resources, based on analysis of benefits and burdens
of decision. Justice implies that all citizens have an equal right to the goods distributed,
 regardless of what they have contributed or who they are. Promote justices ensuring fair
allocation of resources. Example: appropriate staffing or mix of staff to all clients and
priority treatments for the clients in pain)
 Privacy and Confidentiality:-Privacy belongs to each person and, as such, it cannot be
taken away from that person unless he/she wishes to share it. Confidentiality, on the other
hand, means that the information shared with other persons will not be spread abroad and
will be used only for the purposes intended.

3.14. Communication and Documentation

The hospital should establish clear guidelines for both verbal and written forms of
communication for in-patient, Emergency; Outpatient and Delivery Case Teams.
a) Written communication: This includes the written documentation of all findings, progress,
care and treatment provided to the client by the multidisciplinary team. A written record
permits immediate access to all information related to the patient’s care and facilitates the
exchange of information between all members of the case team.
b) Verbal communication: this entails the act of reporting and conversing with other
members of the health care team regarding the client’s progress and status.
Verbal orders will only accepted in emergency situation. The nurse will only accept verbal
orders in an emergency situation in the presence of two nurses. However the verbal order
should be translated to written document by the responsible HCWs within 24 hours.

3.15. Patient Education

Nurses should give health education for all patients, also incorporate family members and other
caregivers who often play a strong role in facilitating patient care in coordination with the
medical staff. One suggestion to improve the family and staff relationship is with the use of a
Patient Caregiver Contract, whereby the relationship is formalized between families/caregivers
and medical staff.
3.16. Medication Management

It is the nurse’s responsibility to safely administer the medications to a patient as ordered by

the physician. Nurses should be aware of the desired outcome, dosage, preparation and side
effects of each prescribed medication.

Procedure
1) Physician Order: A physician’s order is required for the administration of all
medications. There are several types of orders:
 Standing order: To be carried out as specified until it is canceled by another
order (including PRN orders).

 Single order: To be carried out only once, as directed.

 Stat order: To be carried out immediately.

 Verbal order: An order that has been communicated through the phone or
verbally. These orders are reserved for times when the physician is unable
to reach the patient’s medical record. Verbal orders can only be taken by a
nurse, who must immediately transcribe the verbal order into the Physician
Order Sheet. Verbal orders from a physician to a nurse must be told to 2
nurses simultaneously in order to ensure that instructions are clearly
understood and verifiable. All verbal orders must be co-signed by the
physician within 24 hours.
Physician orders need to include the following information when they are transcribed into
the Physician Order Sheet in order to be considered complete. Orders are not to be carried
out unless all of these elements are present including OXYGEN order and administration.
If an element is missing, the physician who issued the order should be called to complete
the order.
 Date and time: When the order was written.
 Full name of the medication: Either the chemical or generic name can be
used without abbreviations.
 Dosage: Specify the amount of medicine to be given. Abbreviations are
discouraged.
 Concentration: If the medication is to be diluted in IV fluid, the amount and
type of diluent/s ordered.
 Duration: If the medication is to be given over a period of time, such as IV
administrations, the duration of the infusion ordered should be recorded by
the physician. Nurses should then translate and document the duration of
infusion into number of (micro) drops per minute.
 Time and frequency: The time of day and how often a medication is to be
given, as ordered by the physician. The nurse who transcribes the order will
identify the specific time that the medication is to be given by following a
standardized schedule.
 Route: For medications that can be given in several ways, the route of
administration needs to be clearly written.
 Physician Signature: Is to be clearly written immediately following the
order.
 OXYGEN : Flow rate (liter/min), mode of delivery, Target Saturation,
frequency of monitoring,
 2) Transcribing the Order: Medication orders are transcribed by the nurse from the
physician order sheet to the Medication Administration Record. The nurse will
document that the order has been transcribed by putting a signature next to the
order.

The nurse is responsible for questioning the physician regarding any medication order or
element of an order that is in his/her judgment an error. The perceived error may be in the
drug ordered, dosage, route, time and/or frequency to be given.

3) Administration of Medications: The following steps should be followed by the

nurse when administering medications. Two processes are outlined which differ
based on whether the medication is stored at the patient’s bedside or in a central
cabinet. There are three distinct steps to administering medications: preparation,
administration and documentation. Each step requires safety checks to ensure that
the right drug is given to the right patient.
4) The Right Rule of Medication Administration
- The Right Patient
- The right Medication
- The right Rout
-The right Dose
-The Right Time
- The Right Reason
- The Right Documentation
- The Right Response
Medications in a Cabinet

All prescribed patient medication should be stored in a place where protected from affecting its
potency and only managed by the authorized nurse/HCWs. Central medication storage is the
recommended medication management.
When the nurse deliver the medication to the patient always follow bill of drugs (the right
patient , the dose, the right rout, the right time and right medication)

4) Administration:
 The nurse who prepares the medication should always be the nurse who
administers the medication.
 During administration, medications should never be out of the sight of the
administering nurse.
 The nurses shall facilitate for OXYGEN availability, stock out and confirm
fully prescribed as other medication in specific ward/Unit.
 It is the nurse’s responsibility to confirm that they are giving the correct
drug to the correct patient. When the nurse arrives at the patient’s bedside,
the nurse must confirm using two methods that the patient is properly
identified.
 Check the name on the Medication Administration Record with the
patient’s posted name.
 Ask the patient to repeat their name.
 Once the correct patient is verified, administer the medication. If it is an
oral medication do not leave it for the patient to take later. The nurse needs
to observe all medications being taken to assure that the medication has
been adequately administered.
  If a patient refuses a medication, the physician should be notified and it
should be clearly documented in the medical record.

5) Documentation: Immediately following the administration of a patient’s

medication, the nurse who administered the medication must document on the
Medication Administration Record that the medication has been given. The nurse
must document the time that each drug was given and then sign and initial the
record including OXYGEN.

3.17. Nursing care practice audit

The nursing care practice audit should be part of the overall hospital quality improvement
project.

Nursing practice audit is one of the tools to ensure the clinical effectiveness of nursing care
patients/clients receive. Refer to Clinical Governance chapter for more information on clinical
audit process.

3.18. Purposes of Nursing Audit

 Evaluates nursing care patients/clients receive.

 Promotes quality improvement of nursing care.
 Improves quality of record keeping.
 Focuses on care provided and not on care provider.
 Contributes to research.

There are two methods of nursing audit

1. Retrospective Review - this refers to an in-depth assessment of the quality of care after the
patient has been discharged. The patient’s chart is the source of data.
Retrospective audit is a method for evaluating the quality of nursing care by examining the
nursing care, as it is reflected in the patient care records for discharged patients. In this type of
audit, specific behaviors are described then they are converted into questions and the examiner
looks for answers in the record. For example, the examiner looks through the patient's records
and asks:

 Was the problem solving process used in planning nursing care?

 Was patient data collected in a systematic manner?
 Was a description of patient's pre-hospital routines included?
 Were laboratory test results used in planning care?
 Did the nurse perform a physical assessment? How was the information used?
 Did the nurse write nursing orders? And so on.

2. Concurrent Review - this refers to the evaluations conducted on behalf of patients who are
still undergoing care. It includes assessing the patient at the bedside in relation to a per-
determined criterion; interviewing the staff responsible for this care and reviewing the patient’s
record and care plan.

Criteria to conduct nursing audit

 Define patient population
 Identify a time framework for measuring outcomes of care
 Identify commonly recurring nursing problems presented by the defined patient population
 State patient outcome criteria
 State acceptable degree of goal achievement
 Specify the source of information
 Determine the design and type of data collection tool
 3.19. Shift Nursing Services handover and round
 hospital implements shift based nursing services (the hospital should
implement based on the area setup ,staff conveniences and available
resources they can arrange the 3 shift hrs)
 Nursing staffs conduct and participate in all types of patient rounds:
Grand Round, Nursing Round and hand over shift round based on
developed round protocol, hourly round for critical patients and
document the process.

3. 20. Nursing Station

 The Hospital should have Nursing Station with the presence of necessary
equipment and supplies to accomplish nursing care practice in each unit and
the unit has equipped for specific minor procedures.
 The Nursing station equipped with necessary relevant and updated
guidelines, policy, protocols, magazine, books, studies, computer with
internet access.

3.21. Skill lab

Skill Lab refers to specifically equipped Practice Rooms functioning us training facilities offering
skill/based training for the practice of clinical skills prior to their real life application.
The following groups will be benefited from Skill Lab:

 New graduated nurses

 Student nurses
 Assigned but found incompetent during Nursing Audit ( Sample of skill Lab Equipment’s and
supplies are annexed)
4. Chapter Summary
A nurse is a caregiver for patients and helps to manage physical needs, prevent illness, restore health and
alleviate suffering. To do this, they need to observe and monitor the patient, recording any relevant
information to aid in treatment decision-making.

Nurses help people and their families cope with illness, deal with it, and if necessary live with it, so that
other parts of their lives can continue. Nurses do more than care for individuals. They have always have been
at the forefront of change in health care and public health.

In addition, a nurse employs an appropriate strategy to establish a good rapport with a patient and is able to
understand a patient’s condition in such a way that they can motivate him or her to actively participate in
every nursing activity. Each nursing activity should consider patient safety. Nurses are responsible for
preventing patients from falling and from developing pressure ulcers, urinary tract infections, and
nosocomial infections. They provide education and information regarding the procedures involved in nursing
interventions beforehand and involve patients for their own safety; effective communication is the key to
patient safety.

In conclusion, strengthening nursing care will greatly contribute the highest health outcome and efficiency in
the health care system of a country.
5. Annexes

5.1. Monitoring & Evaluation Tools

Hypoxic Patient Registry

Region ____________________Zone
__________________Woreda_______________Name of Health Facility
________________

Name of Ward/ Department/Un_________________________________ Month and

year ______________ sure
Registration Patient Name Kebele/ Sex Age Wt Date of Patient SpO2 Patient Treatment SpO2 at Date of
number Village admissi diagnosed at received outcome discharge discharge
on to have admiss oxygen
(1. Cured 2.
hypoxia ion therapy:
Improved/o
by:
n follow up
 5.2. Nursing Assessment Format

Patients’ Nursing Process Documentation

Name: Father Name: HOSPITAL

Address:- City: Sub city:
Kebele: House no.
Ward:
_____________________________________
MRN: Age:
Bed No.:
Tel. No.:
___________________________________

Personal Details

 Male  Female Nationality: Ethnic group:

Language:

Marital Status: Religion:

Occupation (previous and current):

Patient’s support

1. Name: 2. Name:

Relationship: Relationship:

Address: Tel No.: Address: Tel No.:

 City: Sub city: City: Sub city:
Kebele: House no. Kebele: House no.

Health Perception/Management

Patient’s understanding of reason of admission:

Significant Others’ understanding reason for admission:

Understanding of Medication (what, how and why) Patient is taking before admission (incl. “over the
counter” and known allergies)

Drug name Dose Freq. Drug name Dose Freq.

 Role and Relationships

_______________________________________________________________

Discharge Arrangements and Other Social Details

Lives alone?  Yes  No Comments:

__________________________________________

 Yes  No Comments:
Employee?
__________________________________________

 Yes  No Comments:
Self-employed? __________________________________________

 Yes  No Comments:
________________________________________
Dependents?

 Yes  No If no, please state who helps with & how many
Is patient independent?
times per week:
 Cooking: __________ Washing / Dressing: __________

Shopping: _________ Cleaning:

____________________

Other: ____________ Other: _____________________

Ability to Pay for treatment: __________

Vital sign

Vital Sign Additional For Pediatrics

Respiratory Rate MUAC(Med-Upper-Arm-Circumference)

Blood Pressure Head Circumference

Pulse Rate Immunization Status

Temperature Growth Monitoring

Pain score

Weight

Height

Patient Assessment for Activity of Living

1. Cognitive and Perceptual

 Level of consciousness
 Reflexes (Eye , hand grasp and movement of extremities)
 Sensorial (eye, ear, nose, tongue and skin)
 Pain
 Cognition (primary language, speech deficit and any LD)

2. Activity and Exercise

 Breathing – respiratory
patterns, lung sounds,
cough, oxygen supplement,
any respiratory tubes
 Circulation: Peripheral
pulse, cardio vascular
check, chest pain, jugular
ventilation, history of
murmur, pacemaker
 3. Nutrition and Metabolism

 5.Special diet
Psychological Care
 Pattern
Coping withof daily food
stress
 Fluids intake
 Response to stress
 Appetite
 Relaxation methods
 Weight
 Support groups/ counselling resources
 Nausea and vomiting
 GI Pain
 Condition of mucous membrane
 4.
Dental condition
Elimination-Urine and faeces Assessment results
Skin (warm, dry, cold, moist, thurgor)
 Usual time of bowel movement
 Mobility
 Any recent changes in elimination
 Colour (pink, pale, dark, jaundice,
 Any excess perspiration
cyanosed,)
 Bowel sounds
 Odema
 Abdominal tenderness
 Wound/drainage/dressings
 Stoma (type)
IV Line
 Any brut
 Use of anything to manage bowels
(laxatives, enema, suppositories, home
remedies, etc.)
 Urinary pattern (frequency, character,
amount, incontinence, retention, nocturia,
etc.)

6. Spiritual/Dying
Value and belief:

 Cultural practice (yes or no)

 Religious practice(yes or no)
  Familial traditions (yes or no)
 Would you like your religious leader to be contacted?
(yes or no)

7. Sleeping
Sleep/rest pattern:

 Adequacy of sleep(yes or no)

 Difficulty of sleep(yes or no)
 Factors affecting
sleep/rest…….
Methods to promote
sleep………

8. Sexuality and Reproductive

Female : menopausal ( yes or no),
Menstrual pattern:,
Date of LMP:,
Use of contraceptive(type)
Monthly self-breast examination
Vaginal discharge/bleeding, lesion

Male
Monthly testicular examination
 Prostate problems
Penile discharge

Summary subjective data Summary objective data

NAME OF ACCEPTING/RECEIVING NURSE: _________________ DATE: ___________

TIME: ___________

SIGNATURE AND DESIGNATION OF ADMITTING NURSE:


 Nursing Diagnosis or Problem Index List
Full name___________________________________ Age __Sex____ MRN: Tel. No.: Ward: Bed No.:

Problem no Diagnoses/ problems Date identified Signature and Date Signature

designation resolved and
designation
 Nursing Care Plan

Full name___________________________________ Age __Sex____ MRN:

Tel. No.: ________________________________Ward:___________________ Bed No.:_______

Date and Proble Goals Expected outcomes Interventions Signature

Time m No and
designation
Implementations

Full name___________________________________ Age __Sex____ MRN:

Tel. No.: ________________________________Ward:___________________ Bed No.:______

Date Problem No Implementations Interventions Signature

Identified and
and Time designation
Progress note
Progress report no. ____ Shift: Morning  Afternoon Night Date___________ Time___
Signature_____________ Subjective:
____________________________________________________________________________
___________________________________________________________________________________
___Objective:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_______________________________________
Analysis/ Assessment: Plan:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________
Progress report No. ____: Shift: Morning  Afternoon Night Date___________ Time____
Signiture______
Subjective:__________________________________________________________________________
__________________________
_______________________________________________________________________________
Objective:
___________________________________________________________________________________
___________________________________________________________________________________
______________________________________
_____________________________________________________________________________
Analysis/ Assessment:
_____________________________________________________________________________ Plan:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
________________________ Progress report No. ____:Shift: Morning  Afternoon Night
Date___________ Time___ Signature______
Subjective:__________________________________________________________________________
__________________________
_______________________________________________________________________________
Objective:
___________________________________________________________________________________
_________
___________________________________________________________________________________
______________ Analysis/ Assessment:
_____________________________________________________________________________ Plan:
___________________________________________________________________________________
______________
___________________________________________________________________________________
______
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33. Healthy Ageing Strategy: The Health Sector Response 2020 – 2025 (MOH,Sep.2020)
Chapter 8
Pediatric and Child Health Services
 Table Content
Section I: Introduction ..............................................................................................................5
Section II: Operational Standards for paediatric and child health Services .............................6
Section III: Implementation guideline ......................................................................................7
3.1. Paediatric and child health services management and organizational structure ................7
3.2 Paediatric and child health services layout .........................................................................7
3.3 Paediatric and child health outpatient services ...................................................................8
3.4. Pediatric and Child Health inpatient Services .................................................................10
3.5. Pediatric and Child Health Service Human Resource Requirements ..............................14
3.6. Pediatric and Child Health Service Equipment and Supply Requirements .....................14
3.7. Clinical Audit and Continuous QI project .......................................................................14
References ..............................................................................................................................17
Abbreviations

- CCO - Chief Clinical Officer

- ED - Executive Director

- EPI - Expanded Program on Immunization

- ETAT - Emergency Triage Assessment and Treatment

- FMOH - Federal Ministry of Health

- HR - Human Resources

- ICU - Intensive Care Unit

- IPD - Inpatient Department

- KMC - Kangaroo Mother Care

- LBW - Low Birth Weight

- NICU - Neonatal Intensive Care Unit

- OPD - Outpatient Department

- QI - Quality Improvement

- RHB - Regional Health Bureau

- SAM - Severe Acute Malnutrition

Section I: Introduction

Pediatric and child health care encompasses the physical, psychosocial, developmental, and
mental health care of children. The pediatrics component focuses on the curative aspect while
child health includes preventative components where care is provided from birth to young
adulthood as per the American Academy of Pediatrics. Most literature categorizes patients under
15 years as pediatric, however if weight exceeds 36kg they may still be considered pediatric
given their chronological age, and adult dosages should then be used.

Ideally pediatric services begin periconceptionally and continue through gestation, infancy,
childhood, adolescence and young adulthood. Though adolescence and young adulthood are
distinct phases, an upper age limit for pediatric services is not easily defined. The decision to
continue care with a pediatric provider should involve the patient, family and physician, taking
into account developmental needs and care capabilities. (Hackell, 2017), (Hackell, 2018).

The World Health Organization defines child health as "a state of physical, mental, intellectual,
social and emotional well-being and not merely the absence of disease or infirmity”. Healthy
children live in environments that provide opportunity to reach their fullest potential. Child
health services, provided by healthcare workers, enhance holistic growth and development to
attain optimal child health outcomes. A key goal is reducing preventable morbidity and mortality
across neonatal, infant, toddler, preschool, school age and adolescent groups.
Section II: Operational Standards for paediatric and child health Services

1. The Hospital has established management structure and developed job descriptions
detailing roles and responsibilities for all pediatric and child health services staff.

2. The hospital pediatric and child health services have adequate space, as per national
standards for its tier level.

3. The hospital has separate pediatric and child health inpatient and outpatient services.
4. The hospital pediatric and child health services are equipped with necessary equipment,
essential drugs and supplies as per its tier level.

5. The hospital has implement child friendly health services at pediatric and child health
services points/areas

6. The hospital regularly conducts clinical audit at pediatric and child health services and
links findings to QI projects.

7. The hospital has established separate pediatric emergency, triage, assessment and treatment
(ETAT) services.

8. The hospital has separate pediatric intensive care services with written protocols and
procedures as per the tier level.

9. The hospital provides immunization, growth monitoring, developmental assessment and

promotion services.

10. The hospital has established Neonatal Care services with trained staff.

11. The hospital has provided nutritional screening, assessment & treatment services.

12. The hospital has provided outreach pediatric and child health services.
Section III: Implementation guideline

3.1. Paediatric and child health services management and organizational

structure

Efficient patient flow requires appropriate inputs including human resources, infrastructure,
equipment, protocols and pathways. Proper design and implementation of patient flow minimizes
wait times, increases provider efficiency and satisfaction, optimizes resource utilization, and
improves quality of care. This section details inputs and processes required to ensure organized
client flow at pediatric and child health services, from first encounter at hospital reception
through to service exit.

 Pediatric and child health services should be led by a pediatrician or general practitioner
with minimum 2 years’ experience, accountable to the hospital Chief Clinical
Officer/Chief Executive Director per national standards and hospital tier level.
 The head leads and coordinates outpatient and inpatient services as detailed in this guide.

 All pediatric and child health service units have monthly, quarterly and annual plans with
adequate budget allocation.

3.2 Paediatric and child health services layout

Proper service area alignment facilitates simplified, comprehensive care delivery. Pediatric and
child health services should have good structural or functional proximity to minimize care delays
and enhance continuity. Thus, a seamless system is created where test results and supplies are
moved quickly to where needed.

Layout recommendations:

 Pediatric outpatient services should be separate from adult and include emergency
triage/treatment (ETAT) nearby.
  The service areas should be well ventilated and illuminated with adequate supplies,
guidelines/job aids, drugs and equipment per tier level.

 Spacious waiting area with seats/benches for patients/parents or caregivers.

 Play area for visiting children at waiting area and child friendly settings at all service
points.

 Pediatric & child health services clearly labelled for easily identification.

 Pediatric and child health services structurally close or functionally aligned to minimize
delays and enhance continuity..

 For safety, pediatric and child health services preferably on ground floor if building is
multi-storey.

 Room space and alignment meets national standards for service type.

3.3 Paediatric and child health outpatient services

Pediatric outpatient services are a key component, organized with emergency services included.
Hospitals should have separate pediatric and child health areas. Care starts with emergency
triage, actively categorizing patients to outpatient or emergency services. Outpatient services
primarily manage clinically stable patients not needing urgent intervention, including healthy
children visiting for immunizations, growth monitoring and promotion. Outreach identifies and
addresses common childhood illnesses through community-based prevention programs.

Outpatient care goals are providing safe, effective, comprehensive care to minimize
complications, restore health for routine activities, and prevent common childhood illnesses. Key
activities include: nutritional screening, assessment and treatment; growth monitoring, promotion
and developmental assessment; immunization services; and pediatric/child health outreach.

Nutritional screening, assessment and treatment

Early childhood is crucial for rapid brain development and establishing cognitive, language,
social and emotional growth. Ages 0-3 are most critical with 80% of brain growth by age 3.

Integrated age-appropriate developmental assessment and counseling should be provided at

outpatient visits for both sick and well child care. Facilities should have play areas to stimulate
early childhood development and strong referral linkages across health facilities and sectors

Immunization service

Immunization boosts immunity and reduces vaccine-preventable diseases across the lifespan. In
Ethiopia, the Expanded Program on Immunization (EPI) launched in 1980 with six antigens,
expanding over the years to currently provide 12 antigens routinely. EPI significantly contributes
to preventing child mortality and disability. Introduction of new vaccines such as Hep-B and Hib
(as Pentavalent vaccine) in 2007, PCV in 2011, Rotavirus Vaccine in 2013, Inactivated Polio
Vaccine (IPV) in 2015, HPV in 2018 and Measles second dose (MCV2) in 2019 were among the
greatest achievements of the program. Hospitals should have functional EPI services providing
all primary vaccines to eligible children and neonates on all working days.

Pediatric and child health outreach services

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality, preventable and
treatable with simple, low-cost interventions. Outreach care delivery through community health
workers, in collaboration with hospitals, can substantially increase coverage and reduce child
mortality. Hospitals should establish outreach services through community health workers
(CHWs) to conduct community-level childhood illness prevention and treatment.

The outreach service is a key part of the outpatient services where there is a dedicated personnel
to lead it. The outreach service starts by doing structured assessment at the community level and
additionally reviewing the data from the pediatric and child health hospital services. Activities
are planned based on identified problems and epidemiology, implemented regularly, and
reviewed quarterly against plans. Outreach service shall include assessment of nutritional status,
EPI status, developmental milestones and congenital anomalies including spinal bifida,
hydrocephalus, clubfoot, cleft lip & palate.

Pediatric Emergency care services

Hospitals should establish pediatric Emergency Triage and Treatment (ETAT) services within
pediatric outpatient areas. Rapid triage of all children categorizes cases as emergency, priority or
non-urgent for appropriate care. Children with emergency signs receive immediate stabilization
treatment in the adjacent emergency room. ETAT services should be staffed by trained
professionals using pediatric emergency protocols.

Emergency treatment room with necessary equipment and emergency drugs should be prepared
adjacent to the triage area where children with emergency signs are given emergency treatment
such as oxygen administration for children with severe respiratory distress, anticonvulsant
treatment for those children who are convulsing etc. Professionals with training in ETAT should
be assigned in the emergency and triage point of care.

A critical emergency service is Oral Rehydration Therapy (ORT). The ORT corner provides
treatment and prevents dehydration complications. The corner should be a separate area in
emergency services with supplies to manage pediatric diarrhea and dehydration, and clear patient
flow patterns for immediate care and transfer to inpatient services as needed.

3.4. Pediatric and Child Health inpatient Services

Inpatient care involves regular ward or specialty services like neonatal, pediatric ICU, and severe
acute malnutrition (SAM) care. Patients are admitted from outpatient or emergency services.
Some come via referral and enter through either pathway. Inpatient care by an interdisciplinary
team provides comprehensive assessment, stabilization and standardized treatment so patients
can return home and resume growth and development. Standardized evidence-based care
shortens stays and minimizes complications. Establishing good team dynamics and culture using
science and quality improvement is crucial.

SAM care service

A key inpatient service is caring for patients with severe acute malnutrition (SAM) following
national guidelines. Although malnutrition prevalence has declined in Ethiopia, SAM
management remains important. Children with SAM are vulnerable to infections and metabolic
issues, so the standard of care environment must address these risks. ( refer to: Government of
Ethiopia, Federal Ministry of Health. 2019. National Guideline for the Management of Acute
Malnutrition. Addis Ababa: FMOH.)

Pediatric ICU

The pediatric intensive care unit (ICU) provides continuous monitoring and care for critically ill
children. Specialized equipment and trained staff are essential to functionality. Respiratory
support capabilities must exist. Patients may be admitted directly from pediatric emergency or
transferred from inpatient services.

Regularly updating staff, supplies and equipment ensures sustainable, quality care. Following
quality improvement plans and responding to assessments is advised. (Refer: the national
guideline for general and specialized hospitals. The Minimum Standards for Specialized
Hospitals 2011)

Neonatal care services: NICU and KMC

Globally 4 million neonates die in the first 4 weeks of life annually and a similar number are
stillborn, mostly in low and middle-income countries with about half of deaths at home. Most
neonatal deaths could be prevented with simple, low-cost tools like antibiotics, sterile blades,
warmers and kangaroo care.

In Ethiopia, about 81,000 babies die every year in the first four weeks of life, about three-
quarters within the first week. This accounts for 42% of all deaths in children younger than five
years of age.

Neonatal care is critical where preterm birth and neonatal infection are high. Strategies include
leveling neonatal care based on degree of care capabilities. Major components are establishing
NICU care and Kangaroo Mother Care (KMC) services. NICU capabilities depend on the
healthcare tier level and follow standards to care for sick and critical newborns accordingly.

NICU care service

Neonatal intensive care units (NICUs) provide advanced technology and specialized care for
critically ill or preterm newborns. Facilities without NICU capabilities must transfer babies
needing intensive care. Outcomes improve if high-risk babies are born at hospitals with NICUs
instead of being moved after birth. .

The neonatal intensive care unit (NICU) is established with the standards set by the national
guideline as the tier level of the hospitals. Each hospital is supposed to give the neonatal care
service as a spectrum of care and cascade the transfer of neonates to advanced settings when
needed. The NICU is preferred to be organized with a close proximity to the delivery room or
have a functional proximity to transfer the neonates in a thermo neutral environment.

The functional capabilities of facilities that provide inpatient care for newborn infants are
classified uniformly, as follows:

Level I (basic): Staff and equipment for neonatal resuscitation, care of healthy newborns, and
stabilizing pre-35 week or ill infants until transfer. All hospitals should have this capability.
Level II (specialty): Care for >32 week gestation and >1500g infants with issues like apnea,
temperature/feeding instability, or short-term moderate illness not requiring subspecialists.

Level III (subspecialty): Continuous life support and care for extremely preterm and critically
ill infants, plus advanced medical and surgical care options. Specialized hospitals should have
this level of care.

District hospitals in Ethiopia are expected to have at least Level I, regional hospitals Level II,
and specialized teaching hospitals Level III NICU capabilities.

Kangaroo Mother Care

Kangaroo Mother Care (KMC) is an integral part of the neonatal care services which is
structured to provide care for low birth weight babies .This includes early, prolonged and
continuous skin-to-skin contact with the mother (or any caregiver) and exclusive and frequent
breastfeeding (optimal feeding). This natural form of humane care stabilizes body temperature,
promotes breastfeeding and prevents infection. KMC is initiated in the hospital and continued at
home as long as the baby needs it. KMC must not be confused with routine early skin-to-skin
care at birth. The World Health Organization (WHO) recommends skin-to-skin care immediately
after birth for every newborn to ensure that all babies stay warm in the first hours of life helps in
early initiation of breastfeeding. This intervention for all newborns, irrespective of weight,
promotes newborn transition and promotes exclusive breastfeeding.

For stable babies, KMC is nearly equivalent to incubator care in terms of safety and thermal
protection. Studies have shown that KMC cared LBW infants could be discharged from the
hospital earlier than the conventionally managed babies. The babies gain more weight on KMC
than on conventional care. Babies receiving KMC have more regular breathing and fewer
predispositions to apnea. KMC protects against nosocomial infections. Even after discharge from
the hospital, the morbidity amongst babies managed by KMC is less. KMC is associated with
reduced incidence of severe illness including pneumonia during infancy. Studies have shown that
KMC leads to a significant reduction of neonatal mortality when compared to conventionally
cared babies.
Health benefit of KMC to babies and emotional satisfaction to mothers helps in its scaling up in
health facilities. KMC does not require extra staff or expensive articles. It can be provided by
anyone (who is motivated), anywhere and anytime. Researches show effective thermal control,
increased breastfeeding rates, early discharge, decreased neonatal mortality, less morbidity such
as apnea and infection, less stress, and better infant bonding. KMC satisfies all five senses of the
baby; feels mother's warmth through skin-to-skin contact (touch), listens to mother's voice and
heartbeat (hearing), sucks breast milk (taste), has eye contact with mother (vision) and smells.
Hospitals should therefore have KMC service area in close proximity to the NICU which is
accompanied by a separate area for mothers’ to rest and breast feed.

3.5. Pediatric and Child Health Service Human Resource Requirements

Hospital pediatric and child health services should be staffed with pediatricians, general
practitioners, trained nurses, health officers and paramedical staff as required. Details depend on
the hospital tier level aligned with Ethiopian standards agency 2012 hospital level standards.

3.6. Pediatric and Child Health Service Equipment and Supply Requirements
Pediatric and child health services provide comprehensive care for children from birth through
age 14 years (per national standard). Medical equipment and supplies are essential for quality
care and depend on hospital tier level.

3.7. Clinical Audit and Continuous QI project

Clinical audit is a quality improvement process reviewing care against explicit criteria to identify
areas for improvement and confirm progress through change implementation and monitoring.

 The hospital shall conduct regular/quarterly clinical audit, analyze the finding and
develop QI project for the pediatric and child health services.

 The quality unit of the hospital monitors the graduation of QI projects according to its
schedule.
 All the clinical audit findings shall be communicated to the concerned decision makers
and providers.
.

References

Addisse, M. (2003) ‘Maternal and Child Health Care’, (January).

Hackell, J. M. (2017) ‘Age Limit of Pediatrics (American Academy of Pediatrics)’, 140(3), pp.
3–5.
Hackell, J. M. (2018) ‘Age Limit of Pediatrics’, (August 2017). doi: 10.1542/peds.2017-2151.
Health, Y. R. (2004) Adolescent and Youth Reproductive Health.
WHO (2002) ‘Adolescent friendly Health Services’.
WHO (2007) ‘Child Health - Definition Health workgroup, First things first’, pp. 1–2.
WHO (2013) ‘Guidelines For The Management Of Common Childhood Illnesses’.
Chapter -9
Maternal,
Newborn, RH
and Midwifery
Services
Management

0
 Table of Content
Abbreviations ................................................................................................................................................ 2
Section 1: Introduction .................................................................................................................................. 3
Section 2 Operational Standards for Maternal Newborn Reproductive health & midwifery services
Management ............................................................................................................................................ 5
Section 3. Implementation Guidance ............................................................................................................ 6
3.1. Maternal, newborn, RH and midwifery services Implementation guideline ..................................... 6
3.1.1. Guiding Principles .............................................................................................................................. 6
3.1.2. Preconception Care: ............................................................................................................................ 6
3.1.3. ANC .................................................................................................................................................... 7
3.1.4. Labor and delivery .............................................................................................................................. 8
3.1.5. Postnatal Care ................................................................................................................................... 13
3.1.6. Cesarean section............................................................................................................................ 13
3.1.7. Maternity waiting homes .................................................................................................................. 14
3.1.8. Abortion care (CAC) service ............................................................................................................ 15
3.1.9. Essential neonatal care ...................................................................................................................... 17
3.2. Maternal and Perinatal Death Audit and Response.............................................................................. 18
3.3. Adolescent and youth-friendly health service ...................................................................................... 19
3.4. Roles and Responsibilities ................................................................................................................... 20

1
Abbreviations
MMR -Maternal Mortality Ratio
HSTP - Health Sector Transformation Plan
ANC - Antenatal Care
CQI - Continuous Quality Improvement
CCO - Chief Clinical Officer
FMOH - Federal Ministry of Health
UVP (POP) - Utero-vaginal Prolapse (Pelvic Organ Prolapse)
ToR -(Term Of Reference)
KMC - Kangaroo Mother care
WHO - World Health Organization
FANC - focused antenatal care
ICU - Intensive Care Unit
HDU - High Dependency Unit
HGB - Hemoglobin
RH - Rhesus
VDRL - Venereal Disease Research Laboratory
HBsAg - Hepatitis B Surface Antigen
HIV- Human Immunodeficiency Virus
NICU - Neonatal Intensive Care Unit
C/S - Ceasaran Section
IESO - Integrated Emergency Surgery Officer
ENC -Essential newborn care
MPDSR - Maternal and perinatal death surveillance and response
SMT - Senior Management team

2
Section 1: Introduction
The Ethiopian population estimated more than 121 million in 2024, and the country is
characterized by rapid population growth (2.6%). The country also has a high fertility rate of 4.6
births per woman (2.3 in urban and 5.2 in rural areas) and a crude birth rate of 32 per 1000 in
2016. Around 23% of the population is women in the reproductive age group.
During the implementation period of the first phase of HSTP I, it was marked by improvements
in life expectancy after birth. This included notable reductions in maternal mortality (decreased
from 676 deaths per 100,000 live births in 2011 to 401 in 2017). And it is planned to reduce the
MMR to 279 per 100,000 live births in the HSTP II implementation period. To realize such an
ambitious plan requires efforts to reduce the likelihood that a woman will have a high-risk
pregnancy, reduce the likelihood that a pregnant woman will experience a serious complication
of pregnancy, or improve the outcomes for women with complications by starting early
preconception care and enrolling to ANC and follow up to pregnant mothers, quality intrapartum
and postpartum care and counseling service to women in the reproductive age group.
Most of the causes of maternal and neonatal deaths in Ethiopia can be averted by providing
quality service at health setups, and most can be prevented by putting measures, systems, and
maternal and neonatal death audits in place and by designing CQI projects at the hospital level.
To provide such service, the hospital shall have an obstetric and gynecologic department led by a
physician, preferably by an OB-GYN specialist or higher, and provide service to both obstetric
and gynecologic pathologies. The department will be under the hospital's CCO or medical
director and must collaborate with other departments as a continuum of service and good patient
outcomes. The units under this department shall fulfill the minimum standard requirements (4
P's) according to the tier level of the hospital. Additionally, all hospitals shall work towards
reducing maternal mortality and morbidity and newborn deaths by treating a mother according to
the Obstetrics management protocol on Selected Obstetrics Topics (FMOH)
Furthermore, this guide also comprises comprehensive neonatal care, a service provided from the
preconception to the postnatal period, including early childhood development service in the
hospital. The units under this department shall have a newborn corner and mother's waiting
room, and the units must fulfill the minimum standard requirements (4 P's) according to the tier

3
level of the hospital.
Furthermore, the care for gynecologic problems like Fistula, UVP (POP), cervical cancer
screening and management, breast cancer screening, and other management shall not be
neglected and be institutionalized according to the tier level.
This chapter put the provision of maternal and newborn care as a continuum service at its highest
quality on condition that the OB-GYN and pediatric departments work in an integrated manner
to improve maternal and neonatal outcomes. Even though the hospital practices those activities
by default, a great deal of emphasis is still needed, and the departments will have a ToR that
entails roles and responsibilities, modes of communication, and others for smooth
communication and creating accountability in work.
Hospitals need to implement the operational standards contained in this chapter, use the revised
standard management protocols, and meet the minimum standards of the hospital. Hospitals
shall also establish a neonatal triage setting for neonates, institute preconception service, provide
early childhood development service, prepare maternal waiting rooms, establish a well-equipped
neonatal unit, and assign an adequate number of qualified health workers in all neonatal and
obstetric units with training on revised national guidelines to address the challenges of high
perinatal and maternal mortality rates.
The purpose of the Standards for Maternity and Newborn Care RH and midwifery service is to
assist program managers and healthcare providers of a hospital to:
 Introduce standards-setting and a quality improvement process at the facility level as a
means to improve access and quality of maternal and neonatal health services;
 To institute new services and further strengthen the changes registered by the previous
version of ESHTG.
 Provide effective maternal and neonatal health services;
 Use existing resources to achieve optimal healthcare outcomes; and improve individuals,
families, and community's satisfaction and utilization of maternal and neonatal health
services.

4
5
Section 2 Operational Standards for Maternal Newborn Reproductive
health & midwifery services Management

1. The hospital has established a preconception service per the national protocol for
improving obstetric outcomes.
2. The hospital ANC unit provides individualized, client-centered, and evidence-based care
to clients on all working days, and high-risk mothers should be seen in the referral clinic.
3. The hospital shall establish a separate obstetric triage unit and provide care services per
obstetric management protocols.
4. The hospital should ensure intra-parental care per national obstetric management
protocols.
5. The hospital should ensure the provision of Comprehensive Emergency Maternal and
Newborn Care (CEmONC) services.
6. The hospital has established a postnatal care unit and provides comprehensive postnatal
care for improving obstetric outcomes per national obstetric management protocol.
7. The hospital should ensure women-friendly services at all Maternal and neonatal units;
including pain management materials are available in maternity and neonatal units
according to the tier level.
8. Hospitals have comprehensive Neonatal Care service that includes KMC, mothers'
waiting room, and isolation rooms.
9. The hospital should ensure the provision of family planning (with a focus on long-term
methods) and comprehensive abortion care services following the national guideline and
policies.
10. The hospital maternity and neonatal unit undertakes CQI activities by conducting audit
programs and regularly implementing maternal and perinatal death surveillance and
response activities.
11. Midwives should implement the midwifery process for all admitted patients at all
hospitals.
12. The hospital has established a system for providing maternal and newborn-related
services, cooperation, and support packages with catchment facilities
13. The hospital shall provide adolescent and youth-friendly services.

6
Section 3. Implementation Guidance
3.1. Maternal, newborn, RH and midwifery services Implementation guideline

3.1.1. Guiding Principles

The maternity unit includes the ANC unit, labor and delivery ward, and postnatal ward. The unit
should be placed in an easily accessible location, and mothers should be treated with respect and
dignity. Respectful maternity and newborn care norms should be applied to all clients, and pain
should be managed appropriately.

The maternity unit should do audits regularly. Maternity unit audits should be performed every
month, and a client/mom's satisfaction survey should be performed every 3 months. Data should
be displayed on white board at ANC, labor and delivery, and postnatal ward and updated.
Regular review meetings should be held at least every week to discuss audit findings, ongoing
challenges, weekly ward activity, and other findings. Community involvement in the form of a
pregnant forum or community forum should be held at least every 3 months.

Midwives should implement the midwifery process at all hospitals for all admitted patients. All
midwives should assess, diagnose, plan, implement & evaluate their admitted patients according
to midwifery care practice. (Refer to a book, Standard of Midwifery Care Practice in Ethiopia)

3.1.2. Preconception Care:

Preconception care provides biomedical, behavioral, and social health interventions to women
and couples before conception to increase the chance of having a good obstetric outcome.
Preconception care aims to evaluate clinically, provide basic laboratory and imaging
investigations, treat/correct identified disorders for women (preferably in a couple) planning
pregnancy, and avoid fetotoxic exposures.

The wide range of services rendered related to preconception care in hospitals includes
assessments such as basic laboratory and imaging investigations and different categories of

7
intervention, such as treatment/correcting identified disorders for women (preferably in a couple)
who are planning pregnancy and avoid fetotoxic exposures, supplementation, and immunization.

The hospital should train and make aware healthcare providers of the standard healthcare
provisions during the preconception period as well as the integration of preconception services in
all MCH service outlets such as Family planning, Adolescent youth services, including other
units such as OPD, and all chronic care clinics

3.1.3. ANC
Antenatal care (ANC) is a health service provided to pregnant women in the continuum of
maternity care. The WHO defines ANC as the care skilled healthcare professionals provide to
pregnant women and adolescent girls to ensure the best health conditions for both mother and
baby during pregnancy.

This new national ANC guideline document is aligned with the 2016 World Health
Organization (WHO) released comprehensive recommendations on ANC for a positive
pregnancy experience, replacing focused antenatal care (FANC), which has been used for over a
decade. Recent evidence noted that the FANC model was associated with more adverse events
and significantly increased perinatal mortality compared to the previous model.

Therefore, Ethiopia is replacing the previous four-visit FANC model with the new ANC eight-
contact model. Accordingly, the first contact is recommended to be a single contact in the first
trimester (up to 12 weeks), two contacts in the second trimester (at 20 and 26 weeks of
gestation), and five contacts in the third trimester (at 30, 34, 36, 38, and 40 weeks). In addition,
in the current model, the word “visit” is replaced with “contact” as the connotation of the latter
indicates an active connection between a pregnant woman and a health care provider.

In addition to routinely done tests and procedures for all pregnant women, updates are included
in this guideline. Some of these are one ultrasound scan before 24 weeks of gestation (early
ultrasound) for all pregnant women to estimate gestational age, and selective or case-specific
screening is recommended for gestational diabetes mellitus, Tb, and group B streptococcus
(GBS). In addition, it introduces woman-held case notes, creating a woman-friendly
environment, pregnancy support during public health emergencies, caring for women with

8
special needs, and supporting pregnant women during humanitarian crises.

The section on health promotion, disease prevention, and treatment during pregnancy:
counseling on lifestyle modification, dangerous symptoms and signs, counseling on birth
preparedness, and complication readiness are discussed in detail. Besides, counseling on family
planning, infant and young children nutrition, stimulation for early childhood development, and
child immunization is briefly addressed.

Maintaining good nutrition and a healthy diet during pregnancy is critical for the health of the
mother and fetus. Maternal under nutrition is highly prevalent and is recognized as a critical
determinant of poor perinatal outcomes. In Ethiopia, the dietary intake of vegetables, meat, dairy
products, and fruit is often insufficient for many pregnant women. Therefore, nutritional
counseling primarily focuses on promoting adequate weight gain during pregnancy, Promoting
food and micronutrient supplements during pregnancy, assessing for adherence to iron, folic
acid, and calcium supplementation during each contact, and counseling on food safety and
quality is essential during pregnancy.

Hospitals should provide ANC service open throughout working days by trained professionals.
A midwife will be the head of the ANC unit, and all the service providers should be trained on
new national ANC guidelines (ensuring positive pregnancy); the ANC room should keep privacy
by using curtains/screens, and all ANC services will be free. The referral clinic should be open
throughout working days, with investigation results ready on the same day.

3.1.4. Labor and delivery

Laboring mothers are not supposed to visit the central triage but instead go directly to obstetrics
triage units and should be admitted to the labor-delivery ward without any administrative
procedures after rapid assessment and prioritization in the obstetrics triage unit. There should be
an obstetrics triage unit /reception functional 24/7, adjacent to the labor-delivery ward with
assigned competent health care providers, necessary equipment and supplies, triage assessment
tool/sheet with acuity scale, and clear admission criteria. There should be a log book at the
triaging site or reception for laboring mothers in the false or latent phase of labor. Rapid
assessment tool and client flow in labor and delivery posted at reception and obstetrics triage.

9
Figure 1: Rapid assessment of laboring mothers to advance care

Figure 2: Flow chart for triage and registration of laboring mothers

10
The labor ward rooms are clean, well-ventilated, and suitable temperature (neither hot nor cold).
The labor ward needs to have an emergency drug cabinet that has labeled essential drugs. The
labor-delivery ward should have a functional refrigerator with a temperature monitoring chart. It
should have all essential functional medical equipment. The delivery ward room should have a
functional clock, weighing scale, headlamp, and tape meter.

Privacy must be maintained for the first and second stages of labor by screens or curtains, and
sufficient space should be available for laboring mothers and one companion. Mothers are
allowed oral fluids and light food during labor. A family member/Companion/support person
should be allowed to remain with the woman constantly during labor and delivery. There should
be functional bathrooms and toilets with hand-washing basins and soap accessible to laboring
mothers. The labor ward has running water and soap for hand washing for the staff.

The labor and delivery ward should have at least four beds for the first stage of labor and two
delivery coaches for the second stage of labor. The maternity unit must have an ICU or HDU

11
near the nursing station for seriously ill patients.

Partograph should be consistently used, and the third stage should be managed actively. Date
and time of admission, identification and previous obstetric history, admission findings of BP,
PR, Temperature, lie and presentation, FHB, uterine contraction, cervical status (dilatation and
effacement), membrane status (intact or ruptured), molding and station should be documented.
The Partograph has to be used correctly and consistently. If an intervention has to be made, it
should be from the Partograph findings, and the action must be appropriate and timely when
applicable. All interventions, including instrumental delivery and C/S, should be based on
justified indications and performed timely. Pertinent findings and decision notes should be
entered into the medication record.

HGB, blood GP, RH, VDRL for syphilis, HBsAg, and HIV testing should be done for all, and
FHB and uterine contraction should be monitored every 30 minutes; cervical dilatation should be
assessed every four hours. And/or on indications (non-reassuring FHB, signs of 2nd stage, or
membrane ruptured). Maternal BP was measured every four hours for mothers with no pre-
eclampsia or eclampsia, and pulse rate every half an hour.

A safe childbirth checklist should be used for all laboring mothers. The delivery coach is
comfortable with all accessories, and mothers can deliver in their preferred position. The third
stage should be managed actively. Well-equipped newborn corner for routine essential newborn
care and neonatal resuscitation should be available in the labor ward; Clamp the cord after 1-3
minutes (unless the neonate is asphyxiated and needs to be moved immediately for resuscitation),
cut the cord with a sterile instrument, put sterile tie, and put identity label on the baby( the
identity label should contain mother's name, card number, gender of the baby and time of
delivery). The newborn corner facility should include a radiant warmer, a newborn-sized Ambu
bag of sizes 0 and 1, and a suction bulb and/or suction machine. All midwives should be trained
in Helping Babies Breath, and NICU should be available for advanced care. Ideally, NICU
should be adjacent to the labor ward. The delivery summary should be filled on the form at the
back of the Partograph and on a separate sheet when necessary.

12
The quality of care the mother and newborn receive in the first 24 hours after delivery is crucial
in ensuring both mother and neonate stay healthy beyond the immediate postnatal period. The
care that is provided should focus on prevention, early detection as well as treatment of any
birth-related complications while putting into consideration the physiological as well as
psychological changes that are common during childbirth.

All postpartum women should have regular assessments (immediately at birth, at one hour after
birth, and every four hours): Vaginal bleeding, uterine contraction, fundal height, temperature
and heart rate (pulse), blood pressure, urine void, breastfeeding status, pain, emotional wellbeing
and bonding with the newborn. In addition, to minimize the major risk of Complications during
the Postpartum Period, such as bleeding, hypertensive disorders of pregnancy, and infection,
healthcare providers should keep these in mind during care provision and patient teaching and
counseling. In addition,

Women who experience perinatal loss have an increased risk of postpartum blues and
depression. Therefore, it is crucial that women receive appropriate care and bereavement
counseling in the immediate postnatal period and beyond. In addition, every effort should also
be made to keep the woman in a non-­‐maternity ward to minimize the woman's distress from
being with mothers and newborns in the maternity ward.

The baby should be assessed immediately at birth, at one hour after birth, and every four hours
after that, as well as at discharge for danger signs of Stopped feeding well, History of
convulsions, fast breathing (breathing rate ≥60 per minute), severe chest in-­‐drawing, movement
only when stimulated or no movement even when stimulated, fever (temperature ≥37.5 °C), low
body temperature (temperature <35.5 °C), any jaundice in first 24 hours of life, or yellow palms
and soles at any age. The newborn should promptly refer to NICU for further evaluation if any
danger signs are present. After an uncomplicated vaginal birth at a health facility, healthy
mothers and newborns should receive care for at least 24 hours after birth. Discharge only if the
mother's bleeding is expected, the mother's and baby's vital signs are stable without any sign of
infection or other diseases, and the baby is breast-­‐feeding well.

The hospital should assign a responsible focal person, preferably a Senior Midwife, to coordinate
the implementation of 24-hour PNC, Equip and arrange postnatal rooms to sufficiently

13
accommodate delivered mothers and their neonates for at least 24 hours post-­‐delivery, ensure
availability of adequate supplies and materials required to implement the 24-hour PNC, ensure
the 24-hour PNC service is recorded and reported as per the HMIS, etc. The postnatal ward
should be clean, ventilated, appropriately illuminated, have a suitable temperature, be well
equipped, and be adjacent to the labor ward. The postnatal beds should be clean and comfortable
with accessories and bed sheets.

3.1.5. Postnatal Care

The postnatal ward should be clean, ventilated, appropriately illuminated, have a suitable
temperature, be well equipped, and be adjacent to the labor ward. The postnatal beds should be
clean and comfortable with accessories and bed sheets. The hospital should give comprehensive
postnatal care for at least 24 hours, and maternal BP, PR, temperature, uterine tone (contraction),
and vaginal bleeding should be checked every 15 minutes for the first 2 hours. Neonates are
checked for breathing problems, color, pulse rate, breastfeeding, and cord tie security. Mother
should be counseled for danger signs for both mothers (vaginal bleeding, fever, foul smelling
vaginal discharge, severe abdominal pain, safe sex, abnormal body movement) and neonate
(failure to suck, jaundice, cyanosis, fever, abnormal body movement, difficulty of breathing).

3.1.6. Cesarean section

The hospital needs to have a fully functional operating theatre (one table dedicated to cesarean
section) and be adjacent to the labor and delivery ward. Appropriate and adequate cesarean
section team members should be available 24/7 (OBY/GYN, OBGYN residents or IESO,
anesthetist, scrub nurses) with all essential drugs for cesarean section and functional essential
equipment. Patient consent sheet, safe surgery checklist should be used for all surgeries, and
documentation should be complete for all cesarean sections. An audit to assess the completeness
of documentation (Indication and evidence for C-section, time of decision and incision, operation
note with the outcome and name with the signature of the Surgeon, condition of the mother and
the baby, etc., with legible handwriting) should be done every three month and rate and
indications for C/S should be displayed in whiteboard every month. Spinal anesthesia is used in
the absence of contraindication

14
3.1.7. Maternity waiting homes
According to WHO, Maternity waiting homes are recommended to be established close to a
health facility, where essential childbirth care and/or care for obstetric and newborn
complications is provided to increase skilled care for populations living in remote areas or with
limited access to services. Especially for rural communities where the difficulty of topography,
distance, and unavailability of all-weather roads and transportation, the maternity waiting
significantly increases accessibility and addresses equity compared to home delivery.

Some of the admission criteria to maternity waiting homes are: Inaccessible for ambulance
transportation, residing long distance away from health facilities (hospital and health centers),
greater than 38 weeks of gestation (it is not advisable to stay more than a month), pregnant
women encountered with problems during the previous pregnancy such as premature labor,
cervical tear, stillbirth, etc.

The medical services provided in maternity homes include ANC follow-up, appropriate
treatment for sick mothers, health education about ANC, skilled birth attendance, postnatal, F/P,
danger signs, etc. The room is built from locally available materials and might depend on the
local community's culture. The room should be illuminated, ventilated, and clean and should
accommodate at least six mothers in one room. In addition, it should have a cooking area
(kitchen) with complete equipment. Furthermore, the room should have a bathroom, toilet, and
sink for hand washing.

Some of the implementation strategies that the hospital considers are Community mobilization to
contribute both in kind and financially, early imitation of ANC (12 weeks of gestation), strong
leadership (to collaborate with woreda and Kebele administrators), and ensuring the functionality
of obstetric referral network, etc.

15
3.1.8. Abortion care (CAC) service
Abortion services can be categorized as pre-abortion, abortion, and post-abortion services. Pre-
abortion services span from identification of cases, providing laboratory screening, antibiotic
prophylaxis, planning of management, and pain management to preparing the mother for the
procedure; abortion is the actual process of termination of pregnancy using either medical or
surgical methods, while post-abortion care incorporates follow-up of mother’s after receiving the
service, management of life-threatening and non-threatening complication and post abortion
contraception counseling service (including linkage to other needed services in the community or
beyond) that every hospital is expected to provide.

Abortion service shall be provided by the principles of respectful care in a manner that assures
women's right to have autonomy in decision-making, services expected to the tier level of the
hospital, free of abortion stigma, woman-centered, free of charge, available, accessible of high-
quality care in hospitals and early and clear mechanism referral to a higher facility and linkage.

This service unit will be part of or under the obstetric and gynecologic department. It is led by a
senior midwife/ GP or an OB-GYN specialist/higher, whichever is available. The unit must
collaborate with other departments as a continuum of service and good patient outcomes. The
unit shall also provide, as a minimum, the service according to the tier level put on technical and
procedural guidelines of abortion at the hospital. Additionally, all hospitals shall work towards
reducing maternal mortality and morbidity by treating a mother according to the Obstetrics
management protocol on Selected Obstetrics Topics (FMOH).

The hospital shall ensure that the abortion care services provided to women, as permitted by law,
are safe, affordable, and accessible to
֎ Granting all individuals of accessing relevant, accurate, and evidence-based health information
and counseling if and when desired;
֎ Providing comprehensive abortion care services that support women in exercising their sexual
and reproductive rights;
֎ Reduce morbidity and mortality due to unsafe abortion;
֎ Reduce deaths and disability from abortion complications through effective management and
stabilization, and referral;
֎ Improve women’s broader reproductive health by integrating abortion care services into other
sexual and reproductive health services;
֎ Organizing emergency abortion services to provide lifesaving procedures on a 24-hour basis;

16
֎ Help women make free and informed decisions regarding their pregnancy, be more informed
about health services and follow-up care needed;
֎ Prevent unwanted pregnancies through contraceptive services, including counseling and method
provision;
֎ All working staff shall have received appropriate training and demonstrate competent skills, and
the services shall be evidence-based, including the use of national guidelines and policies;
֎ The hospital shall also ensure the availability of safe abortion services, including medical and
surgical options, as permitted by the law.

17
3.1.9. Essential neonatal care
Essential newborn care (ENC) is care given to all newborn infants at birth to optimize their
chances of survival and well-being. ENC starts before birth (teaching parents about the unborn
child during ANC) and extends to the postnatal period. And this stage is characterized by 10
(ten) standardized procedures, from drying and stimulating the neonate to documenting all the
procedures applied to the neonate.
This service unit will be part of or under the obstetric and gynecologic department. It is led by a
senior midwife/ GP or an OB-GYN specialist/higher, whichever is available.
Neonatal resuscitation means to revive or restore life to a baby. It is a lifesaving intervention for
newborns who fail to initiate and maintain spontaneous and adequate breathing at birth. The
obstetrics unit must collaborate with other departments as a continuum of service and good
patient outcomes. The pediatrics department plays a crucial role, especially in early
identification, initiating communication, preparing, and providing care for high-risk pregnancies
that necessitate neonatal resuscitation and/or admission to the Neonatal Intensive Care Unit
(NICU). Hence, for high-risk pregnancies, the neonates shall be seen preferably by a
neonatologist, pediatrician, NICU care-trained general practitioner, and midwife available at the
facility. The early transfer should be instituted if the neonate indicates NICU admission. All
hospitals shall work towards reducing neonatal mortality and morbidity by treating a newborn
according to the Obstetrics management protocol on Selected Obstetrics Topics (FMOH).
Additionally, the unit must fulfill the minimum standard requirements (4 P’s) according to the
tier level of the hospital.
Furthermore, ECD is a process of continuous maturation in terms of cognitive, linguistic, and
executive functions and mental, emotional, and behavioral development in early childhood.
Early childhood represents the period from conception to six years of age. The early years are
critical because this is the period in life when the brain develops rapidly and has a high capacity
for change; the foundation is laid for health and wellbeing throughout life, which is expected to
be delivered in all hospitals.
Hospitals shall implement nurturing care and practice early detection and management of
developmental disorders. They also shall institute play and stimulation facilities for young
children and establish strong referral linkages within health facilities. This service will be led by

18
a physician, preferably a pediatrician/ higher or neonatal nurse. The unit will be under the NICU
of the hospital. The hospital shall ensure that the ENC services provided to neonates are safe,
affordable, and accessible to

Every delivery should be attended with the anticipation of the need for newborn
resuscitation.
The delivery room is clean & warm and has a newborn corner/ resuscitation area.
The unit meets the minimum requirement standards according to the tier level.
Early initiation (within one hour of delivery) of exclusive breastfeeding
The unit must provide all critical postpartum maternal and newborn health care
interventions according to the revised obstetric management protocol;
ENC standards steps are followed and adhered to by all professionals; and
All working staff shall have received appropriate training and demonstrate
competent skills, and the services shall be evidence-based, including national
guidelines and policies.

3.2. Maternal and Perinatal Death Audit and Response

Ethiopia has a high burden of maternal, perinatal, and neonatal death. A well-defined and
enforced MPDSR system stresses that maternal and perinatal deaths should be incorporated into
the existing fortifiable health events reporting system to ensure timely notification. The hospital
should have an MPDSR Committee led by the clinical director/CCD and consists of the main
stakeholders with transparent written TOR, roles, and responsibilities. The MPDSR Committee
should conduct timely maternal and perinatal death audits, identify gaps, prepare action plans, or
do CQI.

19
 3.3. Adolescent and youth-friendly health service
Adolescent and youth Friendly health services are an evidence-based approach to reducing
barriers to Sexual and Reproductive Health service uptake. Friendly health services are
accessible to and acceptable to adolescents and youth people. It laid the foundation for the
health system to meet the SRH needs and rights of the largely under-served adolescent
population (WHO, 2012). Adolescent and youth-friendly health services should have distinctive
features and, therefore, could attract and meet teenagers' needs and retain adolescents and youth
for sustainable utilization (Health, 2004). Adolescent and Youth Friendly Health Services
provides a safe environment at an accessible location, convenient hours, offers privacy, avoids
stigma, and provides information and education material. Adolescent and youth-friendly health
services have provided technically competent, high interpersonal and communication skills and
non-judgmental & considerate care providers who treat all young people equally, with respect
and support. Adolescent and youth-friendly health services could have a strategy and expected
service quality, Fulfill National/WHO standards and characteristics, and be comfortable to
customers and provided within appropriate settings. Adolescent and youth-friendly health
services could meet the SRH needs of Adolescents & retain them for follow-up and repeat visits.

Adolescent and youth-friendly health service organizational structure

 Adolescent and youth-friendly health services have unique nature. It has its separate unit
and should be led by a master of public health in reproductive health, alternatively by a
psychologist and accountable for the hospital's pediatric and adolescent and youth-
friendly health services director.
 The head of adolescent and youth-friendly health services is responsible for leading and
coordinating friendly health services and confidentiality clinics.
 Adolescent and youth-friendly Health service has developed a strategic and annual plan
with adequate budget allocation for planned activities.

20
 3.4. Roles and Responsibilities
I. The maternity unit will be led by an obstetrician and gynecologist or IESO, and they will have the
following responsibilities:

 The maternity head monitors all the activities of the maternity unit
 They should make sure that all services are provided to all women according to
respectful maternity care (please refer to the revised obstetric management protocol)
 The maternity QI subcommittee will conduct regular audit meetings and draw action
plans depending on the finding.
 They communicate with the hospital SMT, arrange training for all staff, and ensure
proper handover mechanisms and follow-up of day-to-day clinical activity.
 They should ensure that at least 5% of vaginal deliveries should be attended to by an
obstetrician or IESO.
 They should ensure that high-risk pregnancies are attended by the most senior health
care professional (OBGYN specialist) and that early communication has been initiated
with the pediatrics department.
The heads of the maternity units (ANC, delivery ward, and postnatal ward) will have roles and
responsibilities in each respective unit. They prepare and compile monthly, quarterly, and yearly
reports and action plans. They should be members of the maternal death audit committee/QI
committee, prepare schedules for the unit, and ensure that all the necessary materials and
supplies are always available. They communicate with the obstetrician/IESO whenever they
have any challenges in their respective units.

II. Mothers'/caregivers' rights and responsibilities

 Mothers and caregivers of newborns and children admitted to hospitals have the right to
know about the health status of their children, and should be regularly communicated.
 Informative, systematic, and regular communication is essential to engage families in the
care of their children. Mothers and caregivers should be encouraged to be involved in the
care of their children, and health education in the future care of their children should be
given.

21
SUMMARY
Most of the causes of maternal and neonatal deaths in Ethiopia can be averted by providing
quality service at health setups, and most can be prevented by putting measures, systems, and
maternal and neonatal death audits in place and by designing CQI projects at the hospital level.
To provide such service, the hospital shall have an obstetric and gynecologic department that is
led by a physician, preferably by an OB-GYN specialist or IESO, and provide service to both
obstetric and gynecologic pathologies. Reproductive, Maternal, Newborn and Child Health
(RMNCH) covers the health concerns and interventions across the life course involving women
before and during pregnancy; newborns, the first 28 days of life; and children to their fifth
birthday. This chapter contains thirteen Operational Standards and Thirteen indicators.

22
Reference

1. MOH, National Reproductive health strategy (2016-2020)

2. MOH, EHSTG (2016-2022) Vol.1, Chapter 8
3. REPRODUCTIVE AND CHILD HEALTH DEPARTMENT (republic of Uganda,2022)
4. . Federal Democratic Republic of Ethiopia: Ministry of Health, HSDP IV. Addis Ababa,
Ethiopia: Annual Performance Report EFY 2004 (2011/2012); 2013. 2.
5. Federal Ministry of Health, Health Sector Development Program IV 2010/11-2014/15.
Addis Ababa: Federal Ministry of Health; 2011.
6. Federal Ministry of Health of Ethiopia, Health Sector Transformation Plan (HSTP)
2014/15- 2019/20, Addis Ababa, 2015.
7. Windau-Melmer, Tamara. 2013. A Guide for Advocating for Respectful Maternity Care.
Washington, DC: Futures Group, Health Policy Project.
8. Federal Democratic Republic of Ethiopia: Ministry of Health, Standard of Midwifery
Care Practice in Ethiopia, August 2013.
9. Federal Democratic Republic of Ethiopia: Ministry of Health, Management Protocol on
Selected Obstetrics Topics, January 2010
10. Technical and Procedural Guidelines for Safe Abortion Services in Ethiopia, Second
edition, June 2014 8. Federal Democratic Republic of Ethiopia: Ministry of Health,
National Guideline for Family Planning Services in Ethiopia, February – 2011
11. WHO recommendations on postnatal care of the mother and newborn. Geneva
(Switzerland): World Health Organization (WHO); 2013 Oct. 62 (p. 120)
12. Federal Ministry of Health, National Mother and Baby Friendly Service Guideline, 2016
11. Integrated Management of Pregnancy and Childbirth, Standards for Maternal and
Neonatal Care, WHO, 2007.
13. Pocket book of hospital care for children, second edition: WHO, 2013
14. Global Initiatives for Improving Hospital Care for Children: State of the Art and Future
Prospects PEDIATRICS Volume 121, Number 4, April 2008
15. Assessment Tool for Hospital Care for Children, Second Edition: WHO 2015

0
ANNEX

Appendix 1: List of Emergency Drugs and Equipment for Child Health

No Equipment Yes No

1 Nebulizer

2 Spacer

3 Oropharyngeal (Guedel) Airways: at least 3 different sizes

4 Self-inflating bags: adult and children

5 Masks: 3 sizes for children

6 Electric (or foot) suction pump and suction catheters: size 15 FG.

7 Oxygen concentrator or oxygen cylinder with the regulator, pressure

gauge, and flow mete

8 Oxygen tubing, nasal prongs, or catheters

9 High-pressure oxygen source with oxygen adopter and oxygen bag

10 Sandbags

11 Blankets

12 Scissors

13 Iris forceps without teeth

14 Consumables

15 Adhesive tape, at least 2 different sizes

16 Cotton wool

17 Cardboard to make splints

18 IV Infusion sets

19 Scalp vein needles (size 21 or 23 G)

20 IV Cannula (size 22 or 24 G)

1
21 Needles for intraosseous insertion (size 21G)

22 Fluids and drugs

23 Ringer’s lactate or normal saline

24 Normal saline with 5% glucose solution or half-strength Darrow’s with

5% glucose

25 Solution

26 Glucose 10% or 50% glucose

27 ORS

28 ReSoMal (commercially bought or prepared)

29 Diazepam IV or Lorazepam

30 Adrenaline

31 Salbutamol puff

32 Corticosteroids:

- Hydrocortisone IV

- Dexamethasone IV

- Prednisolone PO

2
 Appendix 2: List of NICU equipment and essential drugs for child health

No Equipment’s Yes No

Incubators

Radiant warmers

Phototherapy machines

Cardiac monitors

CPAPs

Pulse oximeter

Perfumer

Oxygen concentrators

Oxygen cylinders with gauge

Nasal prongs

Room heaters

Suction machines

Ambu bags and different sizes of face masks

Neonatal cribs

Neonatal BP apparatus

Bulb syringes

Resuscitation table

Refrigerator

Endotracheal tubes

Oropharyngeal airways

Oropharyngeal airways

Infant weight scales

Umbilical catheterization set

Exchange transfusion set

0
IV stands

Thermometers

Supplies

Sterile and clean gloves

Syringes and needles

IV sets and blood transfusion sets

IV cannulas and butterfly needles

Soap and antiseptic solutions

NG tubes

Drugs

Antibiotics:  Ampicillin injection (250mg, 500mg, 1g)

 Cefotaxime sod (500mg, 1g vials)

 Ceftazidime (500mg, 1g, 2g vials)

 Ceftriaxone (250mg, 500mg, 1g vials)

 Clindamycin (150mg/ml)

 Gentamicin (10mg/ml, 40mg/ml)

 Nafcillin (1g, 2g vials)  Penicillin G (crystalline, 5MIU…)

 Vancomycin (500mg, 1g, 5g vials)

Ringer’s lactate or normal saline

Normal saline with 5% glucose solution

Glucose 10%, 40%, or 50% solution

Anticonvulsants
ampule

1
 Appendix3: List of guidelines and job aids for child health

Unit Unit (department) List of GL and job aids Yes No Yes No

Emergency Unit ETAT guidelines (manuals)

Pocketbook on hospital care for children (National)

ETAT flow sheets (for triage, airway, and breathing,

circulation, convulsion, etc)

Pediatrics OPD Hospital care for children (National)

ART guideline

TB guideline

Nutrition guideline

Neonatal unit Hospital care for children (National)

NICU guideline

Neonatal Resuscitation flow sheet

Standard pediatric textbooks

EPI clinic EPI guideline

Pediatric ART Consolidated HIV care/ART GL (national)

clinic
National TB guideline

National nutrition guideline

National PMTCT guideline

Pediatric wards Pocket Book on Hospital care for children (National)

Consolidated HIV care/ART guideline (national)

National TB guideline

National nutrition guidelines

Standard pediatric textbooks

2
 Appendix 4: List of pediatric ARVs and OI drugs

No ARV Drugs Yes No

1 ARV Drugs Yes No

8 ABC/3TC/LPV/r

10 OI drugs

11 -trimoxazole suspension (240mg/5ml)

12 -trimoxazole tablet (480mg)

13

14 Nystatin suspension (100,000 U/ml)

15

16 Miconazole tab (250mg), oral gel 25mg/ml

17

18

19

3
 Appendix 5: Facility, Supplies, and Equipment for Pediatric OPD and ART Clinic

No Equipment’s Yes No

1 Functional hand washing basins Yes No

2 Examination beds with clean sheets

3 Table and chair for the physician (clinician)

4 Weight and height measuring scales for infants and children.

5 MUAC tapes

6 Thermometers

7 Otoscopes and torches

8 Pediatric BP apparatus (different sizes)

9 Disposable and sterile gloves and alcohol swabs

10 Syringes and needles as required

11 Printed papers such as admission cards, prescription papers, lab request

forms, X. ray

12 and U/S request forms, referral papers

13 HMIS/IMNCI registers

4
Appendix 6 Essential drugs that must be available in the emergency drug cabinet of the L&
D ward

In the emergency drug cabinet on the L&D ward or Yes No

Refrigerator

1 Uterotonic medication (Oxytocin,

2 Misoprostol, Misoprostol Po, and/ or

3 Ergometrine)

4 . Magnesium sulfate

5 Diazepam

6 Antihypertensive medication (Nifedipine and

7 Hydralazine)

8 40% glucose

9 IV Cannula

10 Lidocaine

11 Syringe & needle

12 IV fluids (crystalloids)

13 Tetracycline eye ointment

14 Sterile gloves

15 Atropine

16 Vitamin K

17 Adrenaline

18 Ampicillin IV

19 Ca gluconate

5
Appendix 7 Medical equipment in labor and delivery ward and operation theatre
(equipment must be functional at the time of assessment)

No Item Yes No

1 Functional Sphygmomanometer (BP apparatus)

2 Stethoscope

3 Suction machine portable

4 Pinnardstethetescope(Fetoscope)/Doppler

5 Ultra Sound

6 Thermometer

7 Filled oxygen tank with flow meter

8 Nasal prongs for oxygen administration

9 Catheter for oxygen administration

10 Filled oxygen tank with flow meter

11 Nasal prongs for oxygen administration

12 Catheter for oxygen administration

13 delivery sets, at least two sterile

14 Sterile suture kit

15 Forceps

16 Vacuum extractor

17 Urinary Catheter

18 HIV test kits (KHB, Stat pack)

19 Stand lamp

20 Speculum for vaginal examination

21 Craniotomy set

6
22 Sterilizer (Steam or dry)

23 Ambu bag with sterile mask

24 Bed with accessories

25 IV stand

26 Mask for oxygen administration

27 Cord cutting/clumping set

28 Radiant Warmer

29 Towels for drying and wrapping newborn babies

30 weighing scale for baby

31 Tape to measure the baby's length and head circumference

32 Functioning clock

33 Two Episiotomy set

34 Suction bulb for NB resuscitation

35 Long sleeve glove for removal of retained placenta

36 NASG

37 MVA set (at least two)

38 E & C set (at least two)

7
 Chapter 10
Surgical and Anesthesia
Service Management
Out Line Pages

Section 1 Introduction

Section 2 Operational Standards for Surgical and Anesthesia Service Management

Section 3 Implementation Guidance

3.1 Surgical and Anesthesia Service Management Structure

3.1.1 Surgical and Anesthesia Service Organogram

3.1.2 OR Organization

3.1.3 SaLTS Team

3.2 Surgical Service Efficiency

3.2.1. Operation Theatre Dashboard:

3.2.2. Surgical Backlog Management System

3.2.3. Monitoring Surgeon Productivity:

3.2.4. Clinical Audits for Cancellation and Delays:

3.2.5.: Day Care Surgery

3.2.6. Daily Preventive Maintenance for OR Equipment:

3.3 Peri-Operative Hospital Care

3.3.1 Preoperative Preparations

3.3.2 Intraoperative care
3.3.2 Post-operative hospital stay
3.4 Anesthesia Service Management
4. Annex
5. References
Section 1: Introduction

Surgical and anesthesia services are fundamental pillars of comprehensive healthcare, providing
critical operative and perioperative care. However, approximately 5 billion people worldwide
lack access to safe, timely, and affordable emergency and essential surgical care. This gap
contributes to preventable morbidity, mortality, disability, and deformity.

Surgery is a medical specialty that uses operative manual and instrumental techniques on a
patient to investigate or treat injuries, diseases, or deformities. Anesthesiology is the medical
specialty concerned with the total perioperative care of patients before, during and after surgery.
It is provided to numb sensation, render unconsciousness, and monitor vital signs throughout
surgical, obstetric, or diagnostic procedures during preoperative, intraoperative, and
postoperative periods.

Surgical and anesthesia care requires coordinated inputs including human resources,
infrastructure, equipment, protocols, and follow-up. Universal access to these services would
prevent disability and save lives by improving the quality of care.

Ethiopia's Saving Lives through Safe Surgery (SaLTS) strategic plan aims to address the
substantial unmet need for basic surgical care. The proposed strategies align with major
international and national policies. The plan has been instrumental in defining and standardizing
minimum care packages to expand emergency, essential, and surgical anesthesia services.
Referencing and understanding the interventions in the strategic plan will facilitate successful
program implementation.

This chapter details the inputs required to ensure well-organized, hospital-based surgical and
anesthesiology services encompassing preoperative to postoperative care. It describes relevant
management structures, protocols, unit organization, and human resources.
Section 2: Operational Standards for Surgical and Anesthesia Service
Management
1. The hospital has established functional Surgical and Anesthesia Service management
Structure
2. The hospital has established standard surgical service working environment.
3. The hospital OR service is safe and patient-friendly
4. The hospital has established pre-operative patient preparation system
5. The hospital implements strategies to enhance efficiency and productivity of surgical
team
6. The hospital has established a system to track and reduce surgical site infections.
7. The hospital provides standard Anesthesia Service
8. The hospital has a mechanism to ensure availability and rational use of medical oxygen in
the OR.
9. The hospital regularly conducts surgical service performance audits and takes appropriate
actions on identified gaps
 Section 3: Implementation Guidance

3.1 Surgical and Anesthesia Service Management Structure

3.1.1 Surgical and Anesthesia Service Organogram

Hospitals can organize their surgical and anesthesia service organograms based on their health
system tier level. Surgical and anesthesia service is led by a surgeon, gynecologist, or
anesthesiologist. In primary hospitals (Figure 1), the OR director may coordinate both surgical
and anesthesia activities. Figure 2 shown below represents the structure for general and
comprehensive specialized hospitals.

Medical
Director Medical
Director/CCD

OR Head/ Surgical and

Anesthesia
Director Service
Coordinator/Head

Anesthesia
Anesthesia Service Team
SaLTS Team SaLT Team OR Director
Service Team Head

Figure 2: suggested general and comprehensive

Figure 1: suggested primary hospitals’ surgical and
specialized hospitals’ surgical and anesthesia
anesthesia services organogram
services organogram
 3.1.2 OR Organization

Hospitals operation rooms’ organization and arrangement depends on minimum hospitals

regulatory lists’ of respective tire level.

Operating Theatre

The Operating Theatre should have basic services of water, light and medical gasses and an adequate
place to store instruments. The number of OR tables depends on the number of beds in the Hospital.
There should be one OR table for every 25 surgical beds. Ideally, the Operating Theatre should be
located on the surgical ward floor and connected to the ward by the simplest possible route.
The Operating Theatre shall have a piped medical gas system or medical oxygen with digital
concentration and flow rate drop alarm system connected with a manifold system.
The following service areas are needed in an operating theatre suite:
1. Reception and office area,
2. Transfer area: large enough to transfer a patient from bed to trolley,
3. Holding bay: to allow supervision of patients waiting for the OR,
4. Staff changing room,
5. Operating theatre
6. Scrub room
7. Trolley parking
8. Recovery room
9. Specialists
10. Anesthetists
11. Scrub up
12. Circulate nurse etc… as per minimum regulatory standard of each tire level
12. Cleaners and
13. Porters.
3.1.3. SaLTS Team

The facility Surgical and anesthesia service office will be established and organized by the
hospitals’ management. It will be led by either a surgeon or gynecologist or anesthesiologist
or OR director of the hospital. This office will in turn establish and lead the SaLTS
Multidisciplinary team. SaLTS Multidisciplinary team is composed of Surgical staff,
OB/GYN staff, OR manager, Anesthesia staff, Scrub nurse head, PACU, Midwife, Surgical
ward nurse, Pharmacy, Quality and data management, Laboratory service, IPC, Biomedical
staff etc…

Role and responsibility of the SaLTS team

• Support the implementation of the facility SaLTS plan

• Conduct ongoing assessment to advise SMT and provide feedback to service units

• Provide training to clinical and non-clinical surgical staff

• Plan and supervise the activity of respective unit

• Discuss with team to improve the quality of surgical activities

• Organize hospital wide advocacy and communications

• Involve in all surgical team meetings

• Document all activities related to surgical activities and submit the report
3.2. Surgical Service Efficiency
Efficiency and productivity are crucial for surgical team success. By implementing various
strategies and utilizing modern technologies, healthcare facilities can improve surgical service,
patient outcomes and satisfaction.

By implementing change concepts such as the presence of an OR dashboard, computerized

surgical backlog management systems, monitoring surgeon and table productivity, conducting
audits for cancellations and delays, implementing day care surgery, and performing daily
preventive maintenance for OR equipment, healthcare facilities can optimize their surgical care
plans and provide high-quality care to patients. These measures not only improve efficiency but
also contribute to better patient outcomes and overall satisfaction.

3.2.1. Operation Theatre Dashboard

The Operating Theatre dashboard can significantly improve communication and coordination
within the surgical team. It provides real-time information on patient status, surgical schedules,
and resource allocation. It allows team members to monitor the progress of surgeries, identify
bottlenecks, and make informed decisions promptly.

The centralized data visualization streamlines workflow, reduces errors, and improves overall
efficiency. The OR dashboard should address efficiency and safety issues including: surgical
volume, waiting lists, admission delays, preoperative stay, checklist use, cancellations, average
incision/induction times, turnover time, adverse events, etc.
3.2.2. Surgical Backlog Management System

A computerized surgical backlog management system is an invaluable tool for optimizing

surgical schedules and reducing wait times. This system helps prioritize surgeries based on
urgency, available resources, and patient needs. By automating the scheduling process, surgical
teams can minimize delays, improve resource allocation, and ensure that patients receive timely
care. Additionally, the system can generate reports and analytics to identify areas for
improvement and enhance long-term planning.

Health facilities are to ensure patients are managed and treated within the assigned clinical
urgency category timeframe:

Category 1 – procedures that are clinically indicated within 30 days.

Category 2 – procedures that are clinically indicated within 90 days.

Category 3 – procedures that are clinically indicated within 365 days.

3.2.3. Monitoring Surgeon Productivity

Efficient utilization of surgical resources is essential for maximizing productivity. The hospital
should conduct a minimum of 3 cases per table per day and incision start time is expected to be
8:00 am for elective surgeries. Patient preparation and induction should start earlier as possible.

By tracking key performance indicators such as time, turnover, and case volume, teams can
optimize resource allocation and identify improvement opportunities. The standard turnover time
between cases should be < 20 minutes. Implementing 2-3 shifts (morning, afternoon, private
wing) can also increase efficiency.

3.2.4. Clinical Audits for Cancellation and Delays

Regular audits of cancellations and delays can identify underlying causes to implement
preventive measures. Analyzing the reasons enables teams to address issues like inadequate
preparation, equipment availability, or communication breakdowns. These audits enable the team
to develop strategies to minimize cancellations and delays. Developing follow up action plan and
linking prioritized gaps to QI projects can improve efficiency and patient satisfaction.
3.2.5. Day Care Surgery

Day care surgery involves procedures allowing discharge within 24 hours of admission. Planning
day care surgery from the outset optimizes resources, minimizes hospitalization, and improves
satisfaction. However, appropriate patient selection, preoperative assessment, and postoperative
care are crucial for safety.

Disadvantages mentioned regarding day Care surgery include the need for a responsible person
at home for day or two, the possibility of complications arising at home leading to increased
litigation, the high initial cost of setting up the unit, increased complications from anesthesia and
surgery and increased demand on ambulance services. However, compared to day care surgery,
inpatient surgery is associated with increased complications and readmission.

The day Care surgery case team is composed of:

 Team manager- consultant physician
 Coordinator- experienced nurse
 Ward nurse and PACU nurse
 Or team (optional)
 On call center
 Clerking staff-experienced data clerk
 Secretary
 Runner
 Cleaner

3.2.6. Daily Preventive Maintenance for OR Equipment

Regular preventive maintenance of OR equipment is essential to avoid unexpected breakdowns

and ensure smooth surgical operations. By conducting daily maintenance routines early in the
morning, surgical teams can identify and address any equipment issues promptly. This proactive
approach minimizes the risk of equipment failure during surgeries, reduces downtime, and
enhances overall efficiency.
3.3 Perioperative Hospital Care

3.3.1 Preoperative Preparations

The preoperative preparation has the following components;

 Educate patient and care giver about the day surgery pathway
 Ensure the patient is fully informed by providing verbal and written information
regarding the planned procedure
 Identify and optimize medical conditions before surgery.
The preoperative assessment should be done as early as possible after the decision to operate in
order to get adequate time to optimize any chronic medical condition. It is recommended that
the surgeon and anesthetist/ anesthesiologist should do the preoperative assessment.

The pre-schedule screening is to be completed by the surgical team, anesthesia team and nursing
team respectively, to assure patient, facility and staff readiness for surgery. The ward nurse shall
notify the operating surgeon and/or the assigned resident to evaluate the patient and perform the
pre-schedule screening. The surgeon, after evaluating the patient, shall notify the anesthesia team
for the pre-schedule anesthesia screening. Once the surgical team (surgeon, ward nurse, OR
nurse and anesthesia member) confirms that all necessary preparation is completed during the
preoperative conference, the patient can be scheduled for surgery.

Preoperative Supplies and Equipment Preparation

Pharmacy
The OR pharmacy shall notify the OR team on the available surgical and anesthesia supplies
weekly. Preferably the hospital should establish separate OR pharmacy.
Blood Bank
The blood bank shall notify availability of blood products to the OR nurse before the patient is
scheduled. This shall be in a written form as a response to blood product and cross match
requests from the ward. This information shall be made available on time. Availability of cross-
matched blood products will be confirmed by a signature and stamp of the blood bank head or
delegate on a written document, which shall be attached in the patient’s chart.
Biomedical Unit
The biomedical unit shall be responsible to check the functionality of OR equipment daily and
report weekly to the OR coordinator. Any equipment malfunction shall be corrected as it occurs
or an alternative solution should be sought out on the spot.

Informed Consent
Informed consent is a document a patient signs to verify that he/she has engaged in a discussion
with a health care practitioner about a proposed medical treatment. Obtaining informed consent
is an opportunity to guide a patient to the right decision for themselves, and dispel any unrealistic
expectations regarding the procedure.
The patient informed consent form should include the following:
▪ Type of the surgery/anesthesia
▪ Site of operation/anesthesia including laterality or level
▪ The expected benefits
▪ Risks and adverse effects
▪ Alternate treatments available
▪ The consequences of not having the surgery
A template of an ideal consent form in the local language of Amharic can be found below:

Pre-operative Conference
The pre-operative conference is an important surgical team forum for pre-operative discussion
and communication of surgical patients. It improves efficiency of the surgical team and
optimizes patient safety. Studies show if done right, it does not take time and causes no delays in
the operation. The World Health Organization (WHO) and other institutions have developed
guidelines for pre-operative briefings. However, it can be fully or partly adopted based on the
local need.
The following are short-thumb rules for conducting a pre-operative conference:
1. The pre-operative conference should bring the following team members together: The
surgeon, the anesthetist/anesthesiologist, the OR nurse, the ward nurse and others as necessary
2. The surgeon should be the leader of the pre-operative conference
3. The pre-operative conference time should be a day before the operation
4. The outcome of the pre-operative conference should be communicated based on the available
means to all stakeholders and most importantly to the patient
5. Operation list scheduling should take into account the inputs and outcomes of the preoperative
conference
6. The pre-operative conference checklist is used to ensure that all team members possess
accurate and explicit information regarding the patient and the procedural plans

Psychological Preparation of the Patient

Good communication and creation of rapport is key to prevent anxiety of patients scheduled for
surgery. The cause of anxiety includes, but is not limited to, fear of death, pain, and disability
and awaking in the middle of surgery. All health providers shall provide clear information to
patients during the preoperative visit to ease patients’ anxiety:
• Surgeons should inform the patients in detail about the procedure, the surgical complications
and ease any anxiety regarding the surgical procedure.
• The anesthesia team should inform the patients about the anesthetic medication type, route of
delivery, possible anesthesia related complications and address all anxiety regarding anesthesia
administration.
• The nursing team should inform the patients regarding general knowledge of surgery,
addressing the social aspects of the perioperative period.
In case of pediatric patients, family members must be around at all times to ease the patient’s
anxiety. Use of toys and games help alleviate fear.
Operating Theatre Scheduling
once the preschedule screening and preoperative conference is conducted and the readiness
checklist is complete, the surgical team shall schedule the patient. The schedule shall be
disseminated to the OR, respective patient ward and blood bank before the institution’s agreed
upon deadline for OR schedule submission. OT scheduling involves an arrangement of several
operating rooms to the available surgeons in a specified period. There are multiple variables that
go into consideration, including surgeon’s availability, the patient’s condition, and availability of
the operating room and the presence of the right medical devices / surgical instruments. If done
right, it contributes to improving the operational efficiency of the hospital and ensures timely
care to patients with minimal waiting time.
Preoperative Nursing Care
Once the patient has been scheduled for surgery, the ward nurse shall identify the patient and
procedure, confirm if procedure site is marked (if applicable), attach ID band on the patient,
review patient chart, confirm if surgical and anesthesia evaluation is done and assure informed
consent is taken.
The ward nurse shall ascertain all the necessary laboratory investigations and imaging are ready
and sent to the OR with the patient on the day of surgery. The ward nurse shall educate the
patient on pre-operative preparations including personal hygiene: preoperative showering and
removal of hair at surgical site. The ward nurse shall use the following checklist when preparing
a patient for OR.

Patient Transfer and Handover

On the morning of surgery, a ward nurse and porter shall bring the first surgical patient on the
schedule to the OR waiting area/gate at the facilities agreed upon time, after ensuring the patient
has completed all preoperative requirements. The ward nurse shall handover the patient to the
operating room team using the preoperative handover checklist provided below. Consecutive
patients on the schedule shall be accompanied by the ward nurse and porter to the OR gate once
notified by the OR team (surgical team). At the OR gate the anesthesia and OR nursing team
shall:
▪ Accept the patient and confirm the patient’s identity
▪ Confirm the patient’s NPO status
▪ Check if all pre-operative orders are executed accordingly, including the administration of
medications
▪ Check if new clinical events have developed since the last evaluation

The patient shall be made to change cloth in the way that keeps the patient’s dignity at the
designated area at the OR gate. The patient shall be transferred to the operating room table by the
runner nurse once the anesthesia and OR nursing team members confirm readiness.

Operating Room Readiness Checklist

The runner OR nurse must use the following checklist before bringing the patient to the
operating room and before preparing the specific case equipment cart.
3.3.2. Intraoperative Care
Intraoperative care begins when the patient is transferred and handed over to the operating room
team according to the facility’s operating theatre protocol and ends when the patient is handed
over to the anesthesia care unit or transferred to the ICU.

Intraoperative Patient Reception and Briefing

Handover
Formal standardized hand over/hand off protocols, and clear verbal and written communication
should be used during the transfer of a patient from one health professional/team to another to
ensure continuity of care. Once the patient has been handed over at the OR gate to the OR team,
the runner nurse should transfer the patient to the OR table, accompanied by the anesthesia team.
Transferring patient to OR table
Patients shall be wheeled in or transferred using a stretcher (or wheelchair when indicated),
accompanied by OR nursing and anesthesia team at all times. Be sure to take note of patient’s
drainage tubes and lines upon transfer. The patients’ body should be well covered and their
dignity is maintained at all times. For pediatric patients, the minor should be accompanied by the
family member/care giver to the OR table to reduce anxiety. The family member/care giver shall
leave the OR room once the patient is sedated.

The OR table legs are locked before attempting to transfer patients to avoid falls. Ensure the
table is fully covered with a plastic sheet to avoid skin burn. Lowering the table to the height of
the stretcher and transfer the patient on to the OR table (provide a foot stool if transferred via
wheelchair) is crucial. Using an adequate number of team members upon transferring the patient
to the OR table will avoid injury to the patients. It is not uncommon to see head trauma from
hanging OR light; push them away from the table up until the patient is transferred and laying
comfortably on the table.

Briefings
a surgeon-led preoperative briefing or "huddle" is a 1-5 minute session conducted on the day of
surgery in the OT, before the patient enters the OT. All members of the surgical team must be
present. As a team, the schedule of the day for a specific table is discussed in depth, allowing
timely communication of any new developments and/or schedule rearrangements to be made.

WHO Safe Surgery Checklist

The World Health Organization (WHO) Surgical Safety Checklist is a valuable tool designed to
enhance patient safety and reduce surgical complications (See Annex 1). Implementing this
checklist in healthcare settings can significantly improve surgical outcomes. To ensure safe
surgical care and patient safety, all hospitals should implement the Surgical Safety Checklist
(SSC). The surgical team should make an effort to reduce avoidable adverse events due to poor
communication, poor team work and organizational culture by using the SSC checklist
recommended by the WHO, and work toward improving safety. The WHO SSC is a standard
version that serves as a template. Modification of the original SSC is possible by adding
components that are pertinent to the facility, without removing the essential 19 items. Upon the
reports assessments of completeness and adherence of SSC should be indicated.

WHO’s Surgical Safety Checklist Structure

WHO Surgical Safety Checklist consists of three main sections: "Sign In" (before induction of
anesthesia), "Time Out" (before incision), and "Sign Out" (before the patient leaves the operating
room). Each section includes specific items to be checked, such as patient identification, surgical
site marking, and anesthesia safety.

Intraoperative Safety
To ensure safety of the OR environment, every operating room must have proper lighting, good
ventilation, proper equipment for procedures, equipment to monitor patients as needed for the
procedure and drugs as well as other consumables required for routine and emergency use. The
staff, novice and old, must follow the national safety guide and hazardous waste management
policy. Various important components of the protocols include, but are not limited to, the
following:
▪ Applying the concept of aseptic technique (for example, respect the OR’s defined
restricted area)
▪ Demonstrating the national infection prevention and control (IPC) bundle protocol (for
example, appropriate surgical attire)
▪ Preventing and responding to various hazards in the surgical setting, as well as
identifying the role of each operating room member when facing safety threats
. Hazards such as electric burns, fire, blood splashes and falls.
▪ Customizing hazardous waste management policies
▪ Minimizing action-based, decision-based, technical and communication-based human
errors to increase patient safety

Intraoperative Documentation and Reporting

Operating room records that should be attached to the patient chart include complete: operation
note, order sheet, anesthesia record sheet, WHO surgical safety checklist, decision note and intra
operative nursing checklist. All procedures performed must be documented in the surgeon OR
book registry, anesthesia OR book registry and nursing registry.
✓ Operation Note- After each procedure, the surgeon/assistant must complete the operation
note for the patient and should include: patient identity (name, age, sex, card number), time,
indication, procedure type, surgeon name, assistant name, scrub nurse name, runner name,
anesthetist/ anesthesiologist name, type of anesthesia provided, intra operative finding, intra
operative complications and post-operative diagnosis.
✓ Order Sheet- After each procedure, the surgeon should record the finding-based order sheet,
which includes: patient name, age, sex, date and time, diagnosis, NPO time, postoperative
antibiotics, postoperative analgesics, wound care, patient positioning, tube management and
physician signature.
✓ OR Registry Book- All surgical procedures, upon completion, must be recorded on the
provided OR registry book- in paper form or digitally. The OR registry book should include:
name, age and sex of the patient, type of procedure/ surgery, indication, name of surgeon/
assistant surgeon/scrubs/runner, name of anesthetists/anesthesiologists, type of anesthesia,
outcomes and remarks.
3.3.3 Postoperative Surgical Care
the physicians should clearly prescribe and document different immediate, early and late
postoperative follow-up related care. This includes orders related to NPO time,
ambulation, venous-thromboembolism prevention strategies, pain management
modalities, antibiotic administration, postoperative care of tubes and catheters, fluid
management, frequency of follow-up, continuation of care, discharge plan and any other
concern specific to the patient’s condition.
Postoperative Transport and Transfer to PACU/ICU
Postoperative transport and transfer of patients requires involvement of all surgical team
members in-line with the national surgical safety guideline. The patient is moved
carefully off the operation table using a roller plate. A minimum of four persons are
required to safely transfer the patient on to the shifting trolley or the recovery bed. The
wheels of the trolley or recovery bed should be locked while moving the patient. The
team should give careful attention to the patient’s indwelling catheters, tubes and lines.
All team members will then wheel out the patient from the theater to the recovery room
for close observation. The patient should remain in the PACU/ICU for immediate
postoperative care until the discharge criteria, according to the institutions protocol, is
fulfilled. Once the patient is stabilized, the patient’s relatives should be informed
regarding the status of the patient by the operating team.

Handover for Postoperative Care

Effective handover plays a key role in ensuring the continuity, quality and safety of
patient care. Hence, standardization of the handover process can improve patient care and
the staff should comply with the local standardized processes for patient handover.
Handovers should be in both verbal and written form.
Handover Procedure:
a. Hand over from OR to PACU/ICU
A dedicated nurse should be present in the PACU/ICU to receive the patient. Upon
arrival to the PACU, monitoring of patient’s vital signs, level of consciousness and
airway patency should be initiated. Patient handover from runner nurse to the PACU/ICU
practitioner should include patient’s name, allergy status, details of operation performed,
details of any items left in situ (for example packs, drains, catheter), skin closure
technique, type of dressing used, any local anesthetic given during or after the operation,
and any specimen taken during the procedure.

The anesthetist provider should inform the PACU/ICU practitioner about the type of
anesthesia administered, specific intraoperative anesthesia events and/or complications,
as well as details of the parenteral drugs infused. The surgeon/assistant should inform the
PACU/ICU practitioner regarding the nature of the surgery performed, postoperative
orders and surgical complications to watch for.
b. Handover from PACU/ICU to Ward
The PACU team handovers the patient to the ward team based on the postoperative
handover checklist. Based on the institution’s set criteria, the patient’s readiness for
discharge must be met before discharge. The parameters used for discharging a patient
from the PACU/ICU are the following:
1. Uncompromised cardiopulmonary status
2. Stable vital signs
3. Pulse oximetry readings of adequate oxygen saturation
4. Adequate urine output – at least 30 ml/ hour
5. No signs of fluid volume imbalance
6. Orientation to time, person and place
7. Tolerable or minimized pain
8. Absence or controlled nausea and vomiting
c. Handover from OR/PACU to ICU/HDU (High Dependency Unit)
The PACU nurse following the same hand over protocol can transfer patients not on any
ventilator support to ICU/HDU. Patients on ventilator support should be escorted to the
ICU/HDU directly by the operating team, bypassing the PACU.
Surgical Site Infection (SSI)
Surgical site infection is defined as an infection that occurs in site of surgical wound after
48 hours of admission ,within 30 days after the operation or within 1 year if inplant left
during operation. It involves the skin and subcutaneous tissue (superficial), and/or fascia/
muscle (deep), and/or organs or spaces other than the incision that was opened.
Use WHO surgical site infection surveillance postoperative data collection form to
classify, diagnose and report surgical site infections. The form should be attached to each
major surgery operated patient’s chart.

The development of postoperative infections following microorganism contamination depends

on the following factors:
• Number of microorganisms entering the wound
• Type and virulence (i.e. ability to cause disease) of the bacteria
• Strength of the patient’s defense mechanisms (e.g status of the immune system)
• External factors, such as the patient’s preoperative length of stay at the health care
facility or the duration of the surgery (more than 4 hours)
Sources of bacterial contamination include:- the hands of the surgical HCWs, contaminated
instruments, drapes, surgical gloves, or other equipment used in the surgery and contaminated
surfaces and/or air in the OT
The Risk factors can be: Patient Related or Procedure/practice related
Patient related include:
 Age (e.g. elderly or < 5 years)
 Poor nutritional status
 Uncontrolled diabetes, Smoking, Obesity ,Altered immune response,
 Length of preoperative stay
Procedure (Preoperative/ post-operative) related include:
 Lack of preoperative bathing
 Inappropriate preoperative patient hair removal
 Inappropriate preoperative patient skin preparation
 Inadequate preoperative HCW hand and forearm antiseptic surgical scrub
 Lack of normal glucose levels
  Poor wound care practices
Surgical site Infection Prevention and Control Practice Bundle
 Patient preoperative bathing with plain or antiseptic soap
 Avoid hair removal or use clippers
 Optimize patient skin preparation with alcohol-based and chlorhexidine-based skin
disinfection products
 Optimize surgical hand preparation.
 Appropriate antibiotic prophylaxis.
 Improved OT discipline
Surgical site infections are a major cause of HAIs. Basic, lifesaving operations (e.g.
appendectomies and C-sections) are associated with high infection and mortality rates in limited-
resource settings. Relatively simple and inexpensive steps can be taken to reduce the risk;
however, success requires commitment at all levels of the health care system. Availability of OR
friendly sinks, easily accessible doors, hands washing tabs – elbows /pedal , disinfectants, soup,
anti-septic solutions, waste bins and other IPC equipment’s and supplies is crucial.
Discharge
The practice of discharging surgical patients from the hospital is dependent on many
factors such as the hospital norms, type and duration of surgery, coexisting medical
illness and need of postoperative care. The patient and family should be included as full
partners in the discharge planning process. Identify which family or friends will provide
care at home and include them in the conversation:
o Describe what life at home will be like
o Review medication administration
o Highlight warning signs and problems
o Explain test results
o Make follow-up appointments
• At the time of the discharge, provide patients with the brief summary of the procedure
• Advise the patient to avoid strenuous physical activities such as exercise and lifting of
heavy weights, for minimum period of 4–6 weeks following surgery
• Appoint the patient for a follow-up checkup within a week
• Upon discharge, the patient should be advised on warning signs and problems
Prior to discharging patients from hospital, a discharge summary should be completed.
Ideally, one copy is kept in the patient’s files and another copy is given to the patien

Thumb rules for discharge summary

1. Provide patient name, chart number, date of admission and admitting diagnosis. Avoid
lengthy descriptions.
2. Write the summary of patient’s initial presentation.
3. List test results and findings, state surgical procedures performed, including dates and
findings.
4. Write a brief summary of the hospital care. Include treatments pertinent to the
diagnosis, along with information regarding any complications.
5. Describe the condition of the patient at the time of discharge.
6. State the disposition. The disposition refers to where the patient is going upon
discharge.
7. State recommendations for the patient’s continued care. Include detailed instructions
regarding diet, wound care when applicable, symptoms requiring medical attention, and
outpatient appointments.
8. List discharge medications. Include dosage and instructions regarding frequency and
time of day the medication should be taken.
9. Write the date of the discharge and provide the name of the person who prepared the
report.
Follow up Care
After discharge, patients should be appointed to the outpatient department. During their
visit, the care provider should:
• Ask the condition of the patient and check for presence of complications
• Examine the patient: document findings regarding the surgical site
• Assess the adherence of the patient to the given medications
• Update investigations, if indicated
• Give follow up appointment, as needed
• Address the concern of the patient and the family
• Advice on warning signs and complications
3.4. Anesthesia service Management
Anesthesia service management refers to the comprehensive oversight and coordination of
anesthesia services within a healthcare facility or organization. It involves the efficient and
effective management of anesthesia providers, equipment, supplies, scheduling, billing, quality
assurance, and regulatory compliance. The goal of anesthesia service management is to ensure
the safe and optimal delivery of anesthesia care to patients while maximizing operational
efficiency and patient satisfaction.

The anesthesia service shall be directed by licensed anesthesiologist or BSC in anesthesiology/

anesthetist. The hospital shall ensure proper representation of anesthesia workforce at all levels of
SaLTS structure (executive, project, technical, facility, and OR teams). Policies, guidelines, standards,

protocols, and checklists should be utilized by hospital includes:

 written policy about administration of regional and general anesthesia

 Preoperative anesthesia assessment note
 Anesthesia Plan
 Informed consent form for Anesthesia
 Intraoperative Anesthesia Care preparation checklist
 Anesthesia Machine Test checklist
 Anesthesia recording template
 Anesthesia Log Book/Registration Book
 Anesthesia Adverse Event Tracking and Reporting template
 The preoperative anesthetic assessment is the evaluation of the patients’ medical,
physical and mental status before taking the patient to the operation theater. Anesthetic
drugs and techniques have profound effects on human physiology. Hence, a focused
review of all major organ systems should be completed prior to surgery. Inadequate pre-
operative planning and errors in patient preparation are the most common causes of
anesthetic complications.
 Initial assessment should occur in a pre-anesthesia clinic before admission, with a second
assessment the day before surgery. The anesthesiologist/anesthetist should conduct
evaluations.
 Preparing the anesthesia station
the anesthesia provider shall make sure of the availability and functionality of equipment,
supplies and medications before bringing the patient to the OR. The WFSA-WHO
minimum anesthesia standard guideline for LMIC shall be followed.
The provision of safe anesthesia depends on careful preparation, which includes:
1. Any machine or apparatus that supplies gases, vapors, local anesthesia or intravenous
anesthetic agents to induce or maintain anesthesia
2. Any equipment necessary for securing the airway
3. Any monitoring devices necessary for maintaining continuous evaluation of the patient
4. Medications
5. The patient himself or herself correctly identified, consensual and evaluated
preoperatively
 Documentation and Recording of Intraoperative Anesthesia Management
the primary purpose of anesthesia documentation is to capture accurate and
comprehensive information to communicate a patient’s anesthetic experience. The
following intraoperative anesthesia related activities should be documented on a
preformed anesthesia recording sheet
 The hospital shall have a post-anaesthesia care unit (PACU) or recovery room which is
close to operation theater
 The staffs working in PACU should be trained for their role, Eg. Basic and
Advanced Life Support and PACU care
 There should be communication between anesthetists, PACU and Surgical ward
nurse prior to handover.
 Written discharge criteria during patient transfer or discharge should be utilized
 There should be an effective emergency call system for immediate assistance
 The patient shall be monitored during the post-anaesthesia/surgery recovery
period & shall be documented.
 There should be anesthesia adverse outcome audit system is in place
4. Annex
Annex 1: World Health Organization's Surgical Safety Checklist
 Annex 2: Surgical preoperative checklist for adult patients
Patient Name: _________ MRN: _______Age: _____Gender: ____Ward and Bed number: ______
Present Absent Not Applicable
HISTORY
1. History of respiratory tract infections in the last
two weeks (runny nose, cough, fever)
2. History of fluid loss in the last 24 hours

(vomiting, diarrhea, bleeding)

3. History of COVID-19 vaccination
4. History of recent skin rashes
5. History of any current medication (antibiotics,
anticoagulants)
6. History of any chronic medical illness (diabetes,
hypertension, thyroid disorders, bleeding
disorders, liver disease, cardiac disease,
COPD, renal disease)
7. History of previous surgery
8. History of known allergies
9. History of substance abuse
10. Last menstrual period

PHYSICAL EXAMINATION Present Absent Not Applicable

1. General appearance:
Signs of respiratory distress:
If present, specify:
Signs of cardiovascular failure:
If present, specify:
2. Vital signs:
Blood pressure 22
 PR

(Regular/Irregular)

Respiratory rate

Temperature

3. BMI

4. Signs of anemia (assess conjunctiva, palm of hand)

5. Abnormality in respiratory system

If present, specify abnormality:

6. Abnormality in cardiovascular system

If present, specify abnormality:

7. Colostomy washout adequate (determined by nature

of colostomy output)- for patients on bowel
preparation

8. Presence of new skin lesions/rashes

INVESTIGATIONS Done Not Done Not Applicable

1. CBC within normal range and updated within the last

week

2. Blood group and Rh factor

3. Fasting blood sugar

4. Pregnancy test
 If done, specify result:

5. Serum electrolyte within normal range and updated in

the last one week

6. RFT within normal range and updated in the last two

weeks

7. LFT within normal range and updated in the last two

weeks

8. Echocardiography done

9. Chest X-ray done

TREATMENT Done Not Done Not Applicable

1. Patient/attendant counseled about the proposed

procedure and has given written consent

2. Patient/attendant counseled about keeping the patient

NPO for at least six hours before surgery

3. Required amount of cross matched whole blood

prepared

4. For Patients on bowel preparation:

- Clear fluid diets started 24 hours before day of

surgery
- Cleansing enema BID started 48 hours before day of
surgery
- Antibiotic bowel preparation initiated

5. Vitamin K administration (only for patients with

jaundice)
 6. Anesthesiologists/senior anesthetist notified about
subcritical/critical patients 24 hours prior to the day
of surgery

7. ICU bed reserved for patients requiring postoperative

ICU care

Diagnosis:_____________________________________________________________________

Is the patient fit for surgery? 1. Yes 2. No

If no, specify the reason: _______________________________________________

Physician’s Name: __________________________Signature: ____________

Date (DD/MM/YY): _________________

Once the surgical checklist is completed and the patient is deemed fit for surgery, the patient is
sent to the anesthesia clinic for a preoperative anesthesia assessment.

The preoperative surgical checklist for pediatric patients is annexed

 Preoperative anesthesia checklist

Name of patient : Date:

Age(Years) : Sex : Weight (Kg): Height (Meters):

BMI:

Card number: Ward: Surgical Diagnosis:

Planned Procedure: Presentation:

Past surgical Yes No If yes, document illness:

illness

Past medical Yes No If yes, document illness:

illness

Current medical Yes No If yes, document illness:

illness

Current Yes No If yes, document medications:

medications

Known Yes No If yes, document allergy:

allergy

Smoking Yes No If yes, document number of pack year

Alcohol Yes No If yes, specify how much Other substance

Previous History of air Ye No If yes document details: Functio

way/ anesthesia s nal
complications
status
(MET)

Vital signs: BP(Sys/Dia)= PR= RR= SPO2=

o
T= Pain score=
Air way MG= TMD= Mouth opening=
assessment Neck mobility= Dentations=

HE Conjunctiv a: Dehydratio Ye No For pediatric age group: <2 sec >2

EN Pink n s capillary refill sec
T Pale

Cardio vascular Abnormal heart sounds Yes No If yes write :

system heard

Arrhythmias Yes No If yes write:

Cardiac devices Yes No If yes write:

Respiratory Abnormal/decreased/ Yes No If yes what/where?

system absent breath sounds

Abdomen Hepatomegaly/ascite s Yes No If yes what/where?

/tenderness

Genito- urinary Catheterized Yes No If yes UOP= C YES NO

system V
A
T
:

Hematuria Yes No UT Yes No For females LNMP=

I

Musculoskel DVT Ye No If yes write medication:

etal system s

Edema Yes No If yes grade and cause:

Central nervous GCS= Pupillary response= Power: RU= RL=

LU= LL=

system

Electr Na+= K+= Ca+2= C Mg+2=

olytes L
=
 CBC BG&RH= HGB= HCT= PLT= WBC= Neutrophil
%=
OFT Cr= BUN= ALT= AST= Bilirubin = Albumin=

Endo RBS= HbA1C= TSH= T3= T4= Others=

crine
Coag INR= PT= PTT= Others=
ulatio
n
ECG if any

Echocardiography
If any
CXR if any

CT Scan report if any

Mode of anesthesia GA GA with GA with IV sedation

SpiL/A with LMA sedation with nal
ETT mask /Epi

dur
al
Medications to be Yes No If yes document details:
hold

Medications to be Yes No If yes document details:

continued

Premedication Yes No If yes document details:

needed
 Blood & blood Yes No If yes document details:
products needed
NPO
Time
Post-operative Analgesia plan
disposition
Anesthesia evaluator Signature
Name=
Preoperative conference checklist
Patient Full Name: Implant (s) Remark
N/A Yes

If yes, Specifics
Patient MRN Pertinent Lab Results

Names & Roles of Team Members Risk of >500 ml Blood Loss

1. No
Yes, and adequate IV access
2.
and fluids planned, and blood
3.
availability confirmed
4. If Yes, Screen Type &
Cross match

Procedure or surgical site marked or Need for prophylactic

on wristband antibiotics
Yes
N/A

Laterality/Side: DVT Prophylaxis:

Left/ Right Yes

N/A

Known Allergy Anticipated Critical Events:

Yes Surgeon___________________

No Anesthesia_________________
Nursing____________________
N/A
Anesthesia type Post-operative disposition & bed availability

Difficult Airway

Yes
No

Aspiration
Risk?

Yes No

If yes, equipment & assistance available_______

Safety check completed pulse oximetry_______
Instruments and special equipment Other
N/A
Yes, if yes specify

Recommended pre-operative screening test

Test Procedure Disease of Condition

ECG CVS CVS disease, Hypertension, Diabetes

Respiratory disease, CVS disease

Chest radiograph Thoracic
Heavy smoker (relative)

CVS disease, Renal disease ,Malignancy

Hemoglobin >500ml blood loss Diabetes ,Aspirin use ,NSAID use,
Full dose anticoagulation

Use of drugs with renal excretion, Renal

Possible perioperative
Creatinine disease, CVS disease, Hypertension,
renal failure
Diabetes, NSAID use
Glucose Diabetes, Steroid use

Genitourinary Use of drugs with renal excretion, Renal

Urinalysis Orthopedic implant disease (relative), CVS disease (relative) ,
Valve replacement Hypertension(relative), Diabetes

Pregnancy …. Female in reproductive age

Coagulation Bleeding risk by history, Plan full dose,

….
studies Anticoagulation

Operating schedule template

5. Source Documents

1) National Surgical Care Strategic Plan: Saving Lives Through Safe Surgery II (SaLTS II).
2021-2025.
2) Ethiopian Hospital Alliance for Quality 4TH Cycle, Evidence based care (EBC), Project
Document and Change Package. 2021.
3) Ethiopian day car surgery manual, volume 1. 2020.
4) National perioperative guideline. march, 2022.
5) Elective surgical waiting list management guideline. Jan, 2023.
6) Road map for anesthesia care in Ethiopia. 2016/7-2020/1.
7) System bottle neck focused reform (SBFR) document, mar, 2022.
8) Food, Medicines and Healthcare Administration and Control Authority standards for each
tier levels,2011
9) National Specialty and Sub-Specialty Service Road Map (2020-2029)
10) HMIS indicators reference guide,2022
11) Hospital Performance Monitoring and Improvement Manual, Third Edition. Feb, 2022
 Chapter 11
Specialty and Sub Specialty
Service Management
Section 1 Introduction

Section 2 Operational Standards

Section 3 Implementation Guidance

3.1 Specialty and subspecialty service Director
3.2 Specialty and subspecialty service MDT Committee
3.3 Specialty and subspecialty service plan
3.4 Scope of Practice for specialty and sub specialty service
3.5 Organization of Specialty and sub specialty service Services
3.6 Partnership and collaboration
3.7 Tele-health Platform
3.8 Diagnostic and investigation modalities
3.9 Research and innovation specialty and subspecialty service
3.10 Specialty and sub specialty service work load analysis.
3.11 Clinical audit and QI Projects on specialty and sub specialty service.
3.12 Radiology Service
3.13 Pathology service
3.14 ICU Service
3.15 Mental health service

References
Section 1 Introduction

This new chapter on Specialty and Subspecialty Services Management has been added to the
Ethiopian Hospital Service Improvement Guideline (EHSIG) in recognition of the growing
importance of strengthening and expanding specialty/subspecialty services across all tiers of the
healthcare system.

Mortality and morbidity from conditions requiring specialty care have been increasing in
Ethiopia, as the burden of non-communicable diseases such as cancer, cardiovascular diseases,
diabetes, and injuries continues to rise substantially. While primary care and communicable
diseases remain crucial priorities, it is now imperative to also invest in building capacity for
specialty and subspecialty care services
There are concerns about inadequate access to quality specialty/subspecialty services, shortage of
qualified healthcare professionals, weak hospital management systems resulting in inefficient use
of scarce resources, and limited financial investment to ensure optimal service coverage.

The main objectives of this chapter are to provide operational standards and implementation
guidance to help hospitals strengthen and thoughtfully expand specialty/subspecialty services,
aligned with Ethiopia's health sector goals and realities. The standards aim to accelerate
improvements in access to and quality of appropriate specialty care across all tiers of the health
system.

Successful implementation of this specialty and subspecialty service chapter needs not only
integration within different department but also demands integration across different systems in
the facility. It was prepared considering the economic, social, and epidemiological realities
which face Ethiopia today and, in the next 10 years.
Section 2 Operational Standards
1) The hospital has functional specialty and sub-specialty service program led by hospital
medical director or vice medical director.
2) The hospital has established protocols, guidelines, scope of practice for different specialty
and sub specialty services.
3) The hospital provides outpatient (OPD), inpatient (IPD) and emergency department (ED)
specialty and sub- specialty services in accordance with the hospital’s tier level of care.
4) The hospital has established inter-facility partnerships and collaboration platforms for
specialty and sub-specialty services.
5) The hospital ensures the suitability of its specialty and sub-specialty services.
6) The hospital applies technological innovations, research, and other systems to improve
the activities of its specialty and sub-specialty services.
7) The hospital has a system to monitor the workload and productivity levels of its specialty
and sub-specialty services.
8) The hospital provides radiology services.
9) The hospital provides Pathology services.
10) The hospital provides ICU service.
11) The hospital offers essential mental health services in line with the specified tier level.
Section 3 Implementation Guidance

3.1 Specialty and subspecialty service program lead

Effective management of specialty and subspecialty services requires an authorized senior

leader. The assigned lead, ideally the Hospital Medical Director or Deputy Medical Director,
provides strategic oversight and coordination of all specialty and subspecialty services.

3.2 Specialty and Sub-specialty Multi-disciplinary Committee.

This expert committee comprises specialists and subspecialists from each relevant department.
The committee's role is to provide technical leadership, coordinate planning and implementation
activities, set service standards, optimize resource use, monitor quality, and promote sharing of
best practices - to continually improve specialty and subspecialty services.

The committee should have clear Terms of Reference defining members' responsibilities. It
serves as the main collaborative body to advise and support the Specialty and Subspecialty
Services senior leader in strategic oversight of these services. The committee should participate
in planning (short-term, annual, strategic) plans, implementing, monitoring and evaluating
specialty and subspecialty services. The committee has a Chairperson, Deputy Chair, Secretary
and members, with defined roles.

3.3 Specialty and Sub-specialty Service Plan

Aligned with the national specialty/subspecialty roadmap, hospitals should develop short and
long-term strategic plans for these services - encompassing workforce development,
infrastructure upgrades, equipment, technologies, and financing needs. A robust monitoring and
evaluation framework is vital. Each department should have an annual plan aligned with the
overall hospital specialty/subspecialty services plan.

There should be a workforce development plan reflecting national priorities and service
expansion goals. Renovation and facility expansion plans should align with
specialty/subspecialty roadmap timelines. The hospital should regularly assess progress on
strengthening specialty services.
3.4 Scope of Practice for Specialty and Subspecialty Service

The hospital should adopt national or standardized protocols and guidelines for each
specialty/subspecialty service at emergency, outpatient, and inpatient departments. Clear scopes
of practice should be defined for all levels of health professionals. Specialty referrals should be
seen by at least one level higher qualified provider than the referring clinician.

Specialists/subspecialists should be physically present during working hours in their respective

units. At least one specialist or subspecialist per major discipline should be available 24/7 for
emergency consultations/interventions.

3.5 Organization of specialty and sub specialty Services

Outpatient, inpatient, and emergency specialty/subspecialty services should meet national

standards for the hospital's designated tier level. All outpatient, inpatient, and emergency
specialty/subspecialty departments should have clear policies and procedures for access, service
availability, and referrals. Outpatient specialty/subspecialty clinics should be open at least 8
hours daily on weekdays, with follow-up clinics at least weekly per discipline. Inpatient and
emergency specialty/subspecialty services should be available 24/7. Hospitals may provide after-
hours follow-up services based on tier level.

The medical assessment at these departments shall at least includes comprehensive medical
and social history, physical examination, diagnostics impression as well as laboratory and other
medical workups (x-ray, EEG, EMG, bronchoscope, panoramic x ray, echocardiogram
,ultrasound, CT scan etc) when indicated.

All outpatient, inpatient and emergency specialty and sub specialty departments shall have
clinical protocols for management of every disease entities and including locally significant
diseases in line with the national and international guidelines. The range of relevant treatment
options and the clinical impression shall be fully described to client and/or their families and
documented accordingly.

The outpatient clinic shall be well marked and easily accessible for disabled clients, elderly
patients, under five children and pregnant mother and where in coming client would not have to
pass through other care service outlets ( in- patient , laboratory etc ). At minimum, one specialist
(internal medicine, surgery, obstetrics/gynecology, pediatrics) should lead outpatient services
daily in tertiary hospitals, and a GP in general hospitals. The number of personnel should align
with workload. Specialized physicians, nurses, paramedics and support staff should be deployed
to each service area. All clinical areas should be equipped with appropriate technologies and
have trained biomedical engineers for maintenance.
3.6 Specialty and sub specialty service partnerships and collaboration.

To maximize quality and efficient use of scarce resources, hospitals should develop and
implement intra- and inter-facility partnerships and collaborations for specialty and subspecialty
services. After engaging stakeholders, priority areas for coordination should be identified and
captured in a dynamic partnership plan.

Formal partnership agreements, clear communication protocols, and patient transfer/referral

protocols should be established between collaborating facilities. The Ethiopian Hospital Alliance
for Quality platform should be leveraged to share best practices and accelerate quality
improvement. Specialty and subspecialty services should be integrated into hospital EHAQ
activities, with adequate resources and oversight. Public private partnership (PPP) is also highly
encouraged.

3.7 Specialty, sub- specialty tele-health platform

All hospital are expected to provide or receive tele-health services. Telehealth is the use of
digital technologies to deliver medical care, health education, and public health services by
connecting multiple users in separate locations. General Benefits of Telehealth :

 Reduces movement of patient travel burden;

 Provides access to a wider range of specialist advice and services;
 Enhance access and time management
 Enhance general health promotion including continuing professional education
 Improve and provide access to quality of healthcare
 Covers preventative, curative and rehabilitative aspects of health;
 Engages and links all types of users (from highly trained clinicians to minimally trained
community health care workers (CHWs), to patients, to the general population); and
 Can be used as an alternate or complementary approach for almost any health issue
imaginable.
Prerequisite for Telehealth Service

 Have an understanding of the scope of service being provided via Telehealth;

 Engage all stakeholders (health and IT professionals) for smooth running of the system
 Understand the limitation of technology and communicating under a variety of conditions
 Train and educate how to use the telehealth system
 Prepare operational protocols and procedures should prepare prior to the provision of any
telehealth services such as appointment date, start & end time, open source, technology,
device to use Establish a physician champion to be resource for all your telehealth service
users
The delivery of telehealth services must follow evidence-based practice guidelines to the degree
they are available, to ensure patient safety, quality of care and positive health outcomes.
Facilities that deliver telehealth services must establish protocols for referrals for emergency

Mid-level health practitioner at primary hospitals and general can initiate and coordinate the
Tele-health consultation for the patient with a licensed medical practitioner at a tertiary hospital.
The treating Licensed Medical Practitioner and shall be responsible for treatment and other
recommendations given to the patient.

Telehealth poses unique challenges in ensuring patient-safety and privacy of health information.
Therefore, Tele-health policies and procedures should address the following elements to
safeguard the integrity of care. Health facilities should analyze the status of existing regulations
for any intended healthcare service; based on the general guideline develop standard operating
procedure (SOP) for the provision of telehealth services.

A health facility intending to establish telehealth services should identify or prioritize healthcare
services which can be provided through telehealth system given its capacity and resources. There
are different modes of communication: Video, Audio, still-Image or Text (chat, messaging, email
etc.) .Therefore the technology to be chosen and apply has to be considered existing
infrastructure, and client’s circumstance.

The hospital should have the necessary guidelines, SOPs and protocols for the use of tele-
medicine in the hospitals. These guidelines should be updated annually and all healthcare
professionals working on telemedicine should receive training on these guidelines.

The following critical issues should be addressed in the SOP:

 Management system and organizational structure for the Telehealth services
 The type of Telehealth services provided by the health facility
 The modes of communication and technologies which are used for the Telehealth
service provision
 The process of Telehealth service provision
 Payment schemes
 Type of drugs eligible for e-prescription
The Hospitals should ensure that healthcare professionals have access to and are trained on how
to use telemedicine equipment and resources correctly and efficiently. Standard equipment for
telemedicine includes computers, cameras, teleconferencing equipment and etc…. (Annex List
of telemedicine equipment)

Health facilities should implement all relevant monitoring mechanisms for continuous quality
improvement of the telehealth services. There should be adequate emphasis for the proper
documentation of records and reports and also facilities should actively engage in the evaluation
process that should engage relevant actors. For more information refer the national telehealth
guideline.

3.8 Integration of specialty and sub specialty in to the facilities existing structure

To ensure optimal productivity and continuity of care, specialty and subspecialty services
expansion should be thoughtfully integrated into existing hospital systems and processes. This
includes synchronized planning for service upgrades, workforce development, infrastructure
renovations, equipment procurement, essential lab tests, drugs, and operating budgets. Specialty
and subspecialty services should also be incorporated into clinical audits and quality
improvement programs.

3.9 Research and innovation for specialty and subspecialty service

Hospitals should enable locally-relevant research and innovation to continually advance specialty
and subspecialty services. This may include implementing evidence-based new
technologies/procedures, enabling research on priority areas like NCDs, and promoting local
production of essential medical consumables.

3.10 Specialty and sub specialty service work load analysis

There should be a monitoring and evaluation framework assessing the productivity and workload
distribution of specialists and subspecialists across clinical, teaching, research, and community
roles. Workload for each specialty/subspecialty service should be regularly analyzed and
productivity benchmarks established.

3.11 Clinical audit and QI Projects on specialty and sub specialty service.

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit standards/ criteria and the implementation of
change. Clinical audit has been practiced across the globe to ensure the safe and effective
delivery of healthcare.

 The hospital clinical audit plan should include specialty and sub specialty services or else
separate specialty and sub specialty clinical audit plan has to be prepared. All specialty
and sub specialty units/departments are expected to conduct regular clinical audit. The
findings of clinical audit should be discussed in morning section seminars, grand rounds
and other communication platforms. Finally action plan and/or QI projects should be
developed and implemented.
3.12 Radiology service
The Radiology unit must be organized based on the national standards set by the Ethiopian
Radiation Protection Authority and the Ethiopian Standard Agency and should be periodically
evaluated to avoid any possible safety issues. The unit should ensure that all personnel in the unit
are oriented on and familiar with all available policies, protocols, guidelines and procedures. The
unit is expected to support and advise all clinical departments and other clinicians on all
radiological services being delivered by the unit. The unit must avail the following major
preconditions: 24 hour water and electricity supplies, toilets for males and females with hand
washing facilities, adequate service rooms, line telephone, waiting areas with all safety measures.
For radiologic service quality improvement activities, improved patient satisfaction and service
expansion, the radiology unit may establish a separate advisory committee comprising of
representatives from clinicians, administration and finance chaired and being accountable for
hospital senior management.

Personnel
The radiology unit maintains current job descriptions for all positions, which define the
responsibilities and authorities of personnel according to their qualifications. All radiology unit
personnel should be oriented on and aware of the radiology unit’s policies and procedures in
relation to the confidentiality and security of patient personal information. The radiology unit has
a radiologist, radiology technologist/radiographer and nurse, (radiographer technicians, as per
ESA and / or ERPA standards. The unit should also have administrative personnel with training
appropriate to the size and scope of the service.

Equipment
The hospital insures that appropriate and functioning diagnostic equipment is available as per
the standard. (see the national minimum requirement for hospitals for more details)

Maintenance, Calibration and Quality Control

One of the many challenges the radiology units hospitals have been facing are inappropriate and
non-functional equipment, absence of regular calibration and quality control testing for all
medical equipment procured by or donated to the hospital.

For any radiological medical equipment safety, maintenance, calibrations, quality control test,
commissioning, decommissioning and other related issues, the hospital management and mainly
the radiology unit are responsible and expected to abide with and implement all directives,
protocols, guidelines and standards set by the Ethiopian Radiation Protection Authority (ERPA),
Ethiopian Standard Agency (ESA) Please refer to Medical Equipment chapter for more
information. It is recommended that one of the radiology unit clinical staff shall be a member of
the hospital medical equipment management committee.

Radiology Unit Rooms and Layout

Based on the scope of the hospital and maintaining the efficiency and equitability of the service
provision, all radiological services should be availed and provided by the radiology unit of the
hospital in in an area that is accessible and convenient for both the patients and other clinical
departments of the hospital. Based on the Ethiopian Radiation Protection Authority (ERPA) and
Ethiopian Standard Agency (ESA) directives and standards, all radiology units’ design must be
organized for the hospital to deliver patientcentered, efficient and equitable diagnostic and/or
interventional radiology services. (see the national minimum requirement for hospitals for more
details)

Safety
When equipment is found to be defective it is taken out of service and clearly labeled as being
non-functional. It should not be returned to service until it has been repaired and shown by
calibration and/or checks to meet relevant acceptance criteria. The radiology unit documents &
implements all policies and procedures for all infection control issues, including sterilization/
disinfection and hand hygiene. Please refer to the Infection Prevention and Patient Safety chapter
for more guidance.
ALARA Principle - The radiology unit prepares radiation safety policies, procedures, and
radiology protocols that apply the ALARA (‘as low as reasonably achievable’) principle to each
radiological procedure that is performed.

Policies, protocols and guidelines

The radiology unit develops & implements patient management policies and procedures which
address: - patient transportation, - reception, - patient comfort, - patient preparation, - falls
prevention, - privacy, - clinical handover and - post-procedure observation and discharge; and -
Importantly the early identification and management of patients at increased risk of, or who are
critically ill.

3.13 Pathology service

Hospital setting pathology service organization

Hospital managers shall establish a pathology service according to the national facility standards
based on the levels of the hospital. The standards for a pathology services encompasses the major
areas of Practice, Professional, Products and Premises needed which are the minimum
requirements for a General and Comprehensive specialized Hospitals respectively.(see the
national minimum requirement for hospitals)

Human resources

Health workforce is the most valuable resource in setting up of pathology laboratory system.
Depending on national context, different occupations could fulfill each role. Adequate number
and mix of professionals such as cyto-screeners, Histotechnicians, Cyto technician, GPs,
Pathologists, Lab technicians etc are maintained as per ESA standards.

Supplies and reagents

The operation of a pathology laboratory depends on the availability of supplies and reagents to
meet the testing needs. Inventory management is a key component of a laboratory service, as
laboratory efficiency and productivity are compromised when supplies and reagents run out or
expire. It is critical to ensure that appropriate quantities of supplies and reagents are always
available, and wastage is prevented.
The system could be set up by taking the following steps:

 Assign responsible personnel

 Analyses the needs of the laboratory
 Establish the minimum stock needed for an appropriate time period
 Develop forms and logs
 Establish a system for receiving, inspecting and storing supplies
 Maintain an inventory system in all storage areas, and for all supplies and reagents
For Priority supplies and reagents for histopathology and cytopathology refer to the national
pathology laboratory service guideline.

Equipment

A pathology laboratory requires appropriate and functioning equipment to conduct quality

testing. Selecting the most appropriate equipment for the laboratory is important. Some criteria
to consider when selecting laboratory equipment include:
֎ Compliance with infrastructure requirements (e.g. uninterrupted power supply, constant
voltage, level of humidity, constant room temperature)
֎ Type of procedures and estimated workload
֎ Ability to ensure maintenance in accordance with manufacturers’ recommendations and
timely service
֎ Availability and competency of human resources
֎ Alignment with the availability and complexity of diagnostic and treatment procedures
֎ Ability to ensure adequate quality assurance and safety.
For more details refer the national pathology laboratory service management.

Physical infrastructure and safety

For safe and efficient operation, a pathology laboratory requires

 Appropriate ventilation with adequate humidity and temperature conditions,

  Specific ventilation installed in areas where biohazardous materials (e.g. formalin)
 Continuous and uninterrupted electrical supply of appropriate electrical voltage,
 Adequate lighting with maximum use of natural light Deionized or filtered water
 Walls and ceilings and floors made of a material suitable for regular cleaning and
resistant to a potential biohazardous material spill sanitation
 Storage for supplies and reagents, residual tissues from specimens, tissue blocks and
glass slides
 Security and communication tools Such as Telephones, computers and access to
electronic networks
 Safety considerations for biohazardous materials, flammable materials, toxic materials
and waste
 Access to the laboratory restricted to authorized staff only

Space layout

Space layout should be organized and arranged based on the workflow of the laboratory so that
there is maximum efficiency and minimum crossing of paths at different points in the handling
process.
Pathology services consist of pre-analytical, analytical and post-analytical phases, each of which
consists of multiple components according to the specimen management workflow Although the
components in the pre-analytical phase are the function of a clinical service, the pathology
laboratory makes decisions about their standard measures as they affect the overall quality of
pathology results.

Safety concerns
Laboratory service must be free from recognized biological, chemical and physical hazards that
may cause serious harm to the staff, public or environment. The greatest risk to the public and
environment is associated with wastes from pathology processes. Receipt and handling of fresh
specimens carry the highest risk for staff. Universal precautions and personal protective
equipment (PPE) must be required for handling potentially infectious specimens, needles and
sharps, and chemicals. Laboratory personnel must be trained and aware of potential hazards and
safe handling of such materials.
Quality Management Team

A pathology laboratory should have a designated quality manager, having staff with proper
training on all aspects of the quality system and standards who works with the hospital quality
management team. Responsibilities of the quality manager would include:

• Monitoring all aspects of the quality system;

• Developing and updating SOPs;
• Ensuring staff to follow quality policies and procedures;
• Regularly reviewing all records;
• Organizing internal audits and coordinating external audits; and
• Informing management on all aspects of the quality system monitoring

Occurrence management
Occurrence management is a process by which errors or near errors are identified and handled
and is an integral part of laboratory quality management. The goal is to document, correct the
identified errors and to change processes to prevent the error from recurring.

Standard operating procedure (SOP)

An SOP is a document with written step-by-step instructions of a procedure conducted in the

pathology laboratory. The laboratory would have many SOPs, one for each procedure. The SOP
should include the following information and updated as needed:
Title – name of the test;
Purpose – include information about the test
Instructions – detailed information for the entire testing process;
Name of the person preparing the SOP; and
Signatures of approving officials and dates of approval.

Documents and records

Record is basically laboratory information such as specimen logbook, registers, laboratory
workbooks, equipment maintenance records, quality control data, patient test reports, and results
of internal and external audits. It needs to be institutionalized in the laboratory system and used
for tracking, monitoring, evaluating, and managing pathology services.
Reviewing and Reporting Slides: The importance of providing comprehensive pathology
reports cannot be overemphasized, because their accuracy is fundamental to treatment decisions
and good outcomes. Reports should follow established guidelines and include diagnostic,
prognostic and predictive information based on the submitted specimen type.
Information management

The pathology information management system needs to be incorporated with the hospital
information management system.
Archiving of Patient Data and Report: Patient data and reports should be retained
permanently. Older data may be electronically archived or records may be stored offsite as long
as retrieval does not hinder patient care.

Every institute shall develop written policy and guidelines with respect to archiving and
accessing patient data, including hard copies, electronic data, and archived tissue samples e.g.,
FFPE, glass slides, etc.

Retention and Disposal of Tissue Blocks and Glass Slides: Pathology departments have a vast
number of paraffin blocks, slides and remnant tissue that remain after the completion of
pathology reports. Retention may be needed for future testing, second opinions or medico legal
purposes, and should be carried out in compliance with national regulations. In most cases, tissue
blocks and slides must be maintained for a minimum of 10 years. Remnant tissue can be
discarded 14 days to 30 days after the case is signed out officially by the pathologist. Every
institution shall have written policies and guidelines that include the following information:

• Retention time
• Location
• A system for storage organization (e.g., by day of receipt, by accession number)
• Disposal procedures.

3.14 ICU Services

Hospitals should have an ICU Head overseeing all ICUs, with designated focal persons for adult,
pediatric and neonatal units. A specialist in critical care is ideal for the lead ICU role. .

Scope of the Service

 The ICU rooms that accommodate 5-10% of total beds of a hospital. There should be
multiple isolation rooms to be utilized for patients with confirmed/suspected cases of
diseases that require airborne isolation such as tuberculosis.
 This service is also responsive to inpatient consultation requests from other clinical teams
to facilitate appropriate specialist management in the care of critical conditions to ensure
appropriate and realistic outcomes for the patient.
 All care provided is in accordance with current best practice and data relating to
performance is submitted for external audit by Federal and/or Regional Health Bearue
allowing comparison of our performance against national figures
Staffing Profile
The service is delivered by a team comprising of Intensive Care Consultants (intensivist,
anesthesiologist, and critical care specialist, pulmonary and critical care specialist, emergency
and critical care specialist, pediatric emergency and critical care specialist) , ICU trained
Physician, nurse and Health Officer , Emergency and critical care nurses ,Emergency and critical
care nurse practitioners , ICU trained pharmacists/clinical pharmacists,, Respiratory therapist ,
Physiotherapist ,Biomedical technicians , Data clerk, Nutritionist(dieticians) , House keeper ,
Security guards, ICU Secretary , Social workers and Patient assistants.
The nurse: patient ratio varies depending on the level of the patient. One to one nursing is
required in Level 3 patients. And, for level 2 patients a ratio of 1:2 is also acceptable. The
hospital should implement a minimum of 2 times per day multidisciplinary team patient round.

ICU Equipment
The Hospital should have ICU unit equipped with all necessary equipment as per National
Intensive care unit implementation guideline. All ICU equipment users should be appropriately
trained on the operation and preventive maintenance of such equipment (Refer to the national
guidelines)

Structure of an ICU can be divided in to four major parts.

1. Patient care area: patient rooms 2. Clinical support zone: pharmacy, lab, store room,
procedure area, radiology lobby 3. Unit support zone: nursing office, medical office, utility,
lockers etc 4. Family support zones: relative areas, family lounge, counseling room.

Layout
A high standard of intensive care medicine is influenced by good design and adequate space.
Whenever renovations or new structures are being planned there are certain features which must
be considered.
There should be multiple Isolation rooms to be utilized for patients with confirmed/suspected
cases of diseases that require airborne isolation such as tuberculosis.

Laboratory should have blood gas machine that allows stat measurement of blood gases, simple
electrolytes, hemoglobin and facility to measure blood glucose in the level II & III ICU levels.
The area should be functional 24/7.

For detail information refer to the national guidelines

Policy and guidelines
The hospital will develop and implement Admission, round, consultation, inter department
communication, discharge, nursing discharge process, counseling, end of life care, consent, dress
code and weekly meeting policy and guidelines. The service will be delivered in accordance with
and compliance to the national and regional standards and guideline and each hospital should
develop its own SOP according to hospital capacity. This is covered by the in house mandatory
training

Infection Prevention

 The service will be delivered in accordance with and compliance to the Infection
Prevention Policies.
 The unit has regular updates from the Microbiology consultant and infection control team
regarding any positive microbiology results and changes in therapy required as a result.
The unit has a minimum of one side room should a patient require barrier nursing
measures.
 Monthly infection control and environmental audits are carried out to comply with Trust
policy.

3.15 Mental Health Service

Mental health is an integral component of overall health and well-being. Ensuring access to
quality mental healthcare through specialized services and programs must be a priority for
hospitals and healthcare systems. A comprehensive mental health program should incorporate
evidence-based standards, appropriate staffing levels, continuity of care, and community support.

In Ethiopia, the burden of mental illness is significant, with common mental disorders being
highly prevalent. However, mental health services remain underdeveloped.

According to the National Specialty and Sub-Specialty Service Roadmap, hospitals at all three
tier levels should provide services for common mental health problems. They should have a
dedicated mental health unit or department staffed by full-time mental health professionals,
including psychiatrists, psychologists, and social workers, in line with their tier level.

Hospitals should establish and adhere to written policies, protocols, and guidelines for the
provision of all psychiatry services. It is mandatory for general and comprehensive specialized
hospitals to incorporate inpatient psychiatry services, while all hospitals are expected to provide
outpatient and mental rehabilitation services.

Essential psychotropic drugs should be included in the vital medication list of hospitals and
readily available in hospital pharmacies. This is critical as individuals with mental illness often
face economic hardship, stigma, and other barriers to accessing care.

Additionally, efforts should be made to raise awareness about mental health, reduce stigma, and
promote mental well-being within communities. Collaboration between hospitals, community-
based organizations, and other stakeholders is crucial in addressing the burden of mental illness
and improving access to quality mental healthcare in Ethiopia.
Source Documents

EHSTG Volume 1 and 2,MoH

National specialty and sub specialty service roadmap, MoH
National Minimum Standard for Primary Hospitals, ESA
National Minimum Standard for general Hospitals, ESA
National Minimum Standard for Specialty comprehensive Hospitals, ESA
National Intensive Care Unit Implementation Guideline, MoH
National radiology Service Management Guideline, MoH
National pathology laboratory Service Management Guideline, MoH
 Chapter 12
Rehabilitation Service
Outline Page
Chapter 12 ....................................................................................................................................................... 1
Rehabilitation Service ..................................................................................................................................... 1
Section 1 Introduction .................................................................................................................................... 3
Section 2 Operational Standards ................................................................................................................... 5
Section 3 Implementation Guidance.............................................................................................................. 6
3.1 Rehabilitation services Unit/department structure ............................................................................ 6
3.2 Work Force ............................................................................................................................................ 6
3.2.1 Capacity Building: ......................................................................................................................... 6
3.3.1 Rehabilitation Service Process ...................................................................................................... 8
3.4 Infrastructure ...................................................................................................................................... 12
3.4.1 Separate room for different purposes: ....................................................................................... 12
3.4.2 Accessibility for persons with disabilities................................................................................... 12
3.5 Device management for rehabilitation service ................................................................................. 13
3.6 Collaborations with public-private .................................................................................................... 13
3.7 The hospital rehabilitation unit/department clinical audit ............................................................. 13
Clinical Audit Cycle.................................................................................................................................... 14
3.7. Client education material and outcome measures. ......................................................................... 14
3.6.1 Education Materials ..................................................................................................................... 14
3.6.2 Outcome measures ....................................................................................................................... 15
3.8. Medical Record Management System .............................................................................................. 16
Annexes 1. Minimum equipment required: 19
Annex 2: National priority assistive products list .................................................................................. 19
Source Documents ......................................................................................................................................... 23

2
 Section 1 Introduction

Rehabilitation is "a set of interventions designed to optimize functioning and reduce disability in
individuals with health conditions in interaction with their environment” (WHO, 2022).
Rehabilitation’ refers to the participation and collaboration of professionals with clients, which
takes place within a hospital/medical environment to address physical, sensory, cognitive, and
mental impairments to facilitate improved functional outcomes for an individual. A process
aimed at enabling persons with disability to reach and maintain their optimal physical, sensory,
intellectual, psychological, and social functional levels.

Rehabilitation can include a wide range of interventions, as needed, including prevention of

disability through timely interference, counseling compensation, and supply of various
appliances. Rehabilitation professionals provide several services, including physical therapy/
physiotherapy, occupational therapy, orthotics and prosthetics, rehabilitation nursing, physical
medicine and rehabilitation, psychology, speech and language therapy, nutrition, and social work.
Ideally, These professionals work collaboratively in a multidisciplinary team, each contributing
their specialty to achieve comprehensive, high-quality care.

Rehabilitation professionals understand that rehabilitating individuals with disabilities of all ages
and providing basic counseling for mothers of children with disabilities requires a unique
combination of passion, commitment, and expertise. They know this work is challenging and
deeply rewarding as they help their clients achieve their maximum potential and improve their
quality of life. These professionals have acquired knowledge, skills, and experience in their
discipline, and they apply these tools with care, empathy, and kindness to provide top-quality
care to those they serve.

Currently, the need for rehabilitation is largely unmet. In some low- and middle-income
countries, more than 50% of people do not receive the required rehabilitation services (WHO,
2022). The WHO Rehabilitation Needs Estimator shows that in 2019, approximately 1 in 5
Ethiopians (21 million people) had health conditions that could benefit from rehabilitation,
conditions such as musculoskeletal disorders and injuries (approximately 57%) and sensory
impairments including vision and hearing loss (approximately 30%).

3
Even though the Rehabilitation service in Ethiopia started fifty years ago with an independent
non-profit organization, it doesn’t show remarkable improvement as expected relative to its era.
Few hospitals /rehabilitation centers are nationally engaged in providing rehabilitation services,
and the only service provided in most hospitals is physiotherapy with limited equipment,
inadequate rooms, training gaps, weak reporting systems, and interdepartmental communication.
Thus, the main objective of this chapter is to provide a set of operational standards that ensures
comprehensive rehabilitation care to fill the above-identified gaps and improve the Accessibility
and quality of rehabilitation services in hospitals.

4
Section 2 Operational standards

1. The hospital shall have a rehabilitation unit/department led by a physiotherapist or

equivalent rehabilitation professional who is a member of the senior management team
and accountable to the medical director.

2. The hospital's rehabilitation unit/department shall have a multidisciplinary team with

established job descriptions.

3. The hospital's rehabilitation unit/department shall provide physical therapy/physiotherapy,

psychosocial and mental rehabilitation, and occupational therapy and facilitate
community-based rehabilitation.

4. The rehabilitation unit/department premises shall be accessible for persons with

disabilities.

5. The rehabilitation unit/department shall have appropriate equipment and supplies per
regulatory standards.

6. The head of the rehabilitation unit/department shall be a member of the hospital's medical
equipment management committee and has to contribute to the inventory management
system.

7. The rehabilitation unit/department shall provide and facilitate rehabilitation services in

collaboration with public-private partnerships per the memorandum of understanding. The
unit displays the list of available services at appropriate locations.

8. The rehabilitation unit/department shall have a quality assurance system and conduct
regular clinical audits linked with quality improvement activities.

9. The rehabilitation unit/department shall have a plan for continued professional

development and performance appraisal and evaluation procedures.

10. The hospital's rehabilitation unit/department shall develop and implement client education
materials and outcome measures.

5
 Section 3 Implementation guidance
3.1 Rehabilitation services Unit/department structure
It is recommended that a rehabilitation team leader be assigned by senior management with a
formal letter and work in parallel with other team leaders, such as the emergency team, inpatient
and outpatient, to deliver an overall clinical service. The team leader should be a physiotherapist
or other equivalent rehabilitation professional.
The rehabilitation service head should be accountable to the hospital medical director and be a
member of the senior management team (SMT). The rehabilitation service should also be visible
as part of the hospital organogram and be incorporated into the hospital's strategic and annual
plans, including the budget
3.2 Work Force
A multidisciplinary rehabilitation team should include physiotherapists, psychosocial
professionals, occupational therapists, orthopedic appliances, medical social workers, health
education practitioners, speech therapists, ophthalmic nurses, and audiologists/Trained.
The unit/department should provide established job descriptions for the rehabilitation workforce
with detailed roles and responsibilities of each rehabilitation professional.
The hospital should establish a rehabilitation workforce that:
 Identifies priority areas of patient/client needs and establishes procedures for collaboration
with other rehabilitation healthcare professionals and cross-referrals within the unit.
 Takes into consideration the skill mix of professionals.
 Establishes procedures for referring patients/clients to specialized services.
Capacity Building:
 There should be an assessment of the training needs of rehabilitation professionals.
 A capacity-building plan should be developed based on the findings.
 Rehabilitation professionals should be capacitated as per the plan.

6
 3.3 Rehabilitation service
The rehabilitation service needs a multidisciplinary team approach, essential for successfully
implementing rehabilitation services. It allows for collaborative support from various experts,
improves service coordination, and enables comprehensive and continuous care.

The team collaborates to develop a treatment plan that addresses the client's specific goals and
needs. They may assess the client's physical, cognitive, and emotional functioning—the
developed interventions aimed at improving their quality of life and functional independence.

There are several types of rehabilitation services that healthcare professionals may provide
depending on the needs of the client. These include:

Physical therapy: Physical therapy involves exercise, manual therapy, and other techniques to
improve mobility, strength, and function. It may treat various conditions, including
musculoskeletal injuries, neurological disorders, and chronic pain.

Occupational therapy: Occupational therapy focuses on helping clients develop the skills
needed to perform activities of daily living, such as dressing, grooming, and cooking. It may be
used to treat conditions such as stroke, traumatic brain injury, and developmental disabilities.

Speech therapy: Speech therapy involves assessing and treating communication and swallowing
disorders. It may be used to treat speech disorders following conditions such as stroke, brain
injury, and developmental delays.

Cognitive rehabilitation: Cognitive rehabilitation involves using specific techniques and

exercises to improve cognitive function, such as memory, attention, and problem-solving.

Mental rehabilitation: Involves rehabilitation to individuals with depression, anxiety disorders,

post-traumatic stress disorder (PTSD), schizophrenia, substance use disorders via Psychotherapy,
diversion therapy, provision of medications, Group therapy, skills training, recreation therapy,
family therapy and so on

7
Cardiac rehabilitation: Cardiac rehabilitation involves the use of exercise, education, and
counseling to improve the health and function of clients with heart disease or who have
undergone cardiac procedures.

Pulmonary rehabilitation: Pulmonary rehabilitation involves using exercise, education, and

breathing techniques to improve the lung function and quality of life of clients with chronic
respiratory conditions, such as COPD and asthma.

These services aim to restore or support function and address safety, comfort, and quality of life
in clients.

3.3.1 Rehabilitation service process

The rehabilitation service involves assessment, treatment plan development,

progress monitoring, discharge, and referral to pertinent healthcare professionals
and facilities or rehabilitation units/departments.

Rehabilitation Process

Point of referral Rehabilitation Rehabilitation Referral or

Unit
Service Discharge

After the client has been referred to the rehabilitation service via central triage or inpatient or
outpatient services, the client arrives at the rehabilitation unit, where the client's relevant
information will be recorded to ensure that they are referred to the appropriate rehabilitation
personnel.
Once the appropriate rehabilitation personnel (s) have been identified, the rehabilitation staff
must make a complete and detailed assessment and identify the client's specific problem list.

8
The following factors should be considered when making a diagnosis:
When diagnosing clients with rehabilitation needs, there are several factors that rehabilitation
professionals should consider. These include:

Medical history: A thorough understanding of the client's medical history, including any
previous illnesses, injuries, or surgeries, can help inform the rehabilitation plan.

Functional limitations: Assessing the client's functional limitations, such as mobility, strength,
and balance, can help determine the appropriate rehabilitation interventions.

Psychosocial factors: The client's psychosocial factors, such as their living situation, social
support, and mental health status, can impact their ability to participate in and benefit from
rehabilitation.

Goals: Understanding the client's goals for rehabilitation, such as returning to work, improving
their quality of life, or increasing their independence, can help guide the rehabilitation plan.

All care and treatment of clients must be documented in the rehabilitation plan. This care plan
should be specific to the client's problems or needs. Factors to be considered when implementing
care include:
When implementing rehabilitation care, there are several factors that healthcare professionals
should consider. These include:

Assessment and evaluation: A comprehensive assessment and evaluation of the client's needs
and goals should be conducted to develop an individualized rehabilitation plan.

9
Goal setting: The client's goals for rehabilitation should be identified and incorporated into the
rehabilitation plan to ensure that it is client-centered and focused on achieving the desired
outcomes.
Evidence-based practice: Rehabilitation care should be based on the best available evidence,
and healthcare professionals should stay up-to-date with the latest research and guidelines.
Client education: Clients should be educated about their conditions, treatment options, and
rehabilitation goals and should be encouraged to participate actively in their rehabilitation.

Cultural competence: Healthcare professionals should be aware of and respectful of the client's
cultural background and beliefs and should adapt their rehabilitation care accordingly.

Continuity of care: Rehabilitation care should be coordinated and seamless, with clear
communication and handoffs between healthcare professionals to ensure that the client receives
consistent and effective care.
Use of technology: Technology, such as telerehabilitation or assistive devices, can enhance the
delivery of rehabilitation care and improve outcomes for clients.
Family and caregiver involvement: Family members and caregivers should be involved in the
rehabilitation care plan, as they can provide valuable support and assistance to the client. By
considering these factors when implementing rehabilitation care, healthcare professionals can
ensure that their practice is client-centered, evidence-based, and tailored to each client's needs.
This can lead to better outcomes and an improved overall experience for the client.
The particular rehabilitation healthcare professional involved in the client's care should
implement the rehabilitation care plan. Implementation of the care plan should be documented
on the follow-up sheet and/or the client's chart.
As rehabilitation is a dynamic process that involves changes in clients' health status over time,
the plan of care needs to be continuously evaluated. As problems are resolved, new goals and
activities related to the client's condition should be reassessed.

If the client gains lost functions, he/she will be discharged. The client is referred to the
appropriate service if further specialist treatment is required. The rehabilitation professional in
charge of the client's care is responsible for written and verbal communication with other

10
healthcare professionals and services; all communication should be documented in the
rehabilitation care plan

11
3.4 Infrastructure
3.4.1 Separate room for different purposes:
 Reception, recording & Waiting area, if possible 20 sq. m
 Consultation/ examination room, if possible 12sq. m
 Exercise room, if possible 20sq. m
 Treatment room, if possible 12sq. m
 Toilet room (male & female)
 The mental health rehabilitation room is separate from other discipline
 Reception, recording & Waiting area, if possible 20 sq. m
 Consultation/ examination room, if possible 12sq. m
 Exercise room, if possible 20sq. m
 Treatment room, if possible 12sq. m
 Toilet room (male & female)
 The mental health rehabilitation room is separate from other discipline
3.4.2 Accessibility for persons with disabilities
 For persons with physical impairment, the door's width must be 90 cm, and the door
handle should not have to be above 90 cm tall.
 Doors must be easy to open, and they should be long and easy to hold for the
opening, which should be accessible to wheelchair users.
 If the door is made of glass, a partial glass should be painted to prevent damage to the
person with low vision.
 Windows should be well-lit. This is ideal for treating clients with limited vision and
interpreting sign language or lip reading.
 Pathways must have a free space, allowing the wheelchair to rotate freely. The free
space size should be 1.50 cm in diameter
 The floor of the stairs should not be sleeper; it must be built with rough
substances/materials
 If there are various steps/stairs on the way to service delivery rooms and if there is no
elevator/lift, the ramp is required to be in place for wheelchair users
 The bathroom should be inaccessible location and suitable for persons with
disabilities

12
3.5 Device management for rehabilitation service
The rehabilitation unit/department head should be a member of the hospital device management
committee having TOR. Standard equipment and consumables shall be available for all
rehabilitation services. Equipment shall be clean and functional and stored in a safe and
accessible place. Hospitals should ensure that all rehabilitation healthcare professionals have
access to and are trained to use equipment and resources correctly and efficiently. Rehabilitation
healthcare professionals are responsible for keeping up to date about current equipment and
resources available for hospital use. Standard equipment and consumables that should be
available for rehabilitation services include (See Annex 1)
3.6 Collaborations with public-private
As per the agreement or memorandum of understanding, the rehabilitation unit/department has
to work with the public and private sectors to address the continuum of care for clients with a
wide range of rehabilitation demands.
3.7 The hospital rehabilitation unit/department clinical audit

Rehabilitation care providers and clients know where their service is doing well and where there
could be improvements. Quality improvement (Q.I.) for rehabilitation services aims to improve
client satisfaction and provide direction for rehabilitation professionals on their focus while
performing routine tasks.

Rehabilitation care providers and clients know where their service is doing well and where there
could be improvements. Quality improvement (Q.I.) for rehabilitation services aims to improve
client satisfaction and give direction to rehabilitation professionals on their focus while doing
routine tasks. Clients

Clinical Audit Cycle

Identifying a
problem

13
 Re-Audit Defining
Standards/Criteria
CLINICAL
AUDIT CYCLE

Implementing Collect Data

Changes

Analysis

3.8. Client education material and outcome measures.

3.8.1 Education materials
The client's education material will provide direction on self-help rehabilitation and prevention
of further complications that may arise secondary to existing impairments or disabilities. The
material should include pictorial messages and steps for rehabilitation, as well as precautions on
how to use assistive devices. (See annex 2)

Audiovisual materials may also be included to help beneficiaries and their families clearly
understand the procedures for the rehabilitation of identified conditions. The client's education
material will provide direction on self-help rehabilitation and prevention of further complications
that may arise secondary to existing impairments or disabilities. The material should include
pictorial messages and steps for rehabilitation, as well as precautions on how to use assistive
devices.

3.8.2 Outcome measures

Outcome measures are necessary in rehabilitation setups for several reasons:

14
Evaluation of Progress: Outcome measures help to evaluate the progress of clients undergoing
rehabilitation. By using standardized measures, healthcare providers can track changes in the
client's condition over time and adjust the treatment plan if necessary.

Goal Setting: Outcome measures can help clients and healthcare providers set realistic goals for
rehabilitation. By using objective measures, healthcare providers can determine what goals are
achievable and appropriate for the client's condition.

Quality Improvement: Outcome measures can be used to evaluate the quality of rehabilitation
services being provided. By tracking the outcomes of rehabilitation programs, healthcare
providers can identify areas for improvement and make changes to improve the quality of care.

Evidence-based practice: Outcome measures are an essential component of evidence-based

practice. By using standardized measures, healthcare providers can evaluate the effectiveness of
different treatment approaches and make evidence-based decisions about the care provided to
clients.

Accountability: Outcome measures can be used to demonstrate accountability to clients, payers,

and regulatory bodies. By tracking outcomes, healthcare providers can demonstrate the
effectiveness of their services and provide evidence of the value of rehabilitation services.

In summary, outcome measures are an essential tool for evaluating the effectiveness of
rehabilitation programs, setting goals, and improving the quality of care. By using standardized
measures, healthcare providers can make evidence-based decisions, demonstrate accountability,
and ultimately improve the outcomes for clients undergoing rehabilitation.

Things to be considered while using outcome measures

When using rehabilitation outcome measures, there are several things that should be considered
to ensure accurate and meaningful results. Some important considerations include:

Selecting the Appropriate Measure: It is essential to select an outcome measure that is

appropriate for the client's condition and the goals of the rehabilitation program. Choosing an
inappropriate measure can result in inaccurate or irrelevant results.

15
Validity and Reliability: The selected outcome measure should be valid and reliable, meaning
that it measures what it is intended to measure and produces consistent results.

Baseline Measurements: A baseline measurement should be taken before starting the

rehabilitation program so that progress can be tracked over time.

Standardized Administration: Outcome measures should be administered in a standardized

manner to ensure consistent results. This includes following the instructions for administering
the measure and using the same equipment and procedures for each assessment.

Interpretation of Results: Results should be interpreted in the context of the client's condition
and the goals of the rehabilitation program. It is essential to consider factors that may influence
the results, such as pain or fatigue, and to adjust the treatment plan accordingly.

Communication with the Client: Clients should be informed about the purpose of the outcome
measures and how the results will be used to guide their rehabilitation program. It is essential to
communicate the results in a clear and understandable manner and to involve the client in setting
goals and making decisions about their care.

The outcome measures should be attached to clients' individual folders, and it can help as a
reference for quality assurance.

3.9. Medical record management system

A medical record is a comprehensive document that contains all vital information related to a
client’s health and medical history, as well as details of their interactions with healthcare
professionals. A complete medical record should include the following:

Client Information: This includes the client's name, date of birth, address, contact information,
and other biographical details.

Medical History: This includes a record of the client’s past illnesses, surgeries, and medical
conditions. It should also include details of any medications the client is taking, including dosage
and frequency.

Physical Examination: This includes the results of physical examinations, including vital signs
such as blood pressure, heart rate, and temperature.

16
Diagnostic Tests: This includes the results of any laboratory tests, imaging studies, or other
diagnostic tests that have been performed on the clients.

Functional tests: used to evaluate a person's ability to perform activities of daily living (ADLs)
and instrumental activities of daily living (IADLs). ADLs include basic self-care tasks such as
bathing, dressing, grooming, and toileting, while IADLs include more complex tasks such as
cooking, shopping, and managing finances. These tests use appropriate tools to assess a person's
physical, cognitive, and psychosocial function and are an essential part of rehabilitation and
geriatric care.

Special tests: Special tests are diagnostic tools used in rehabilitation services to evaluate
specific impairments or dysfunctions that are not easily observed during a physical examination.
These tests are essential because they help healthcare providers identify the underlying causes of
a person's impairment or dysfunction and develop appropriate treatment plans.

Treatment Plan: This includes details of the treatments the clients have received, including
medications, surgeries, and other interventions.

Progress Notes: This includes notes from healthcare professionals documenting the clients’
progress, any changes to the treatment plan, and any other relevant information.

Consultation Notes: This includes notes from specialists or other healthcare professionals who
have been consulted regarding the clients’ care.

Informed Consent: This includes documentation of any informed consent obtained from the
clients or their representative for treatments, procedures, or other interventions.

Discharge Summary: This includes a summary of the client's care, including any follow-up
appointments or recommendations for ongoing care.

Legal Documents: This includes any legal documents related to the client’s care, such as
advance directives or power of attorney documents.

17
Annex 1. Minimum equipment required
• Physiotherapy mats
• Manipulation couch
• Splinting materials
• Playing cards
• Books
• Mirror
• Walking trail/ parallel bars
• Crutches
• Walking aids/ walking frames (adjustable)
• Pulley
• Electrical modalities
• Chair and table
• Physiotherapy ball (general and tertiary)
• Gonio meter
• Tape measure
• Stair ca
Annex 2: National priority assistive products list
Area/Type & Mobility

• Clubfoot braces
• Foot Orthoses (F.O.)
• Ankle Foot Orthoses (AFO)
• Knee Ankle Foot Orthoses (KAFO)
• Hip Knee Ankle Foot Orthosis (HKAFO)
• Spinal Orthoses (SO)
• Shoulder Elbow Wrist Hand Orthoses (SEWHO)
• Trans_ Tibial (Below Knee(BK))
• Above Knee (A.K.)
• Trans Femoral

18
• Trans-Radial (below elbow)
• Trans-Humeral (above elbow)
• Crutches
• Walking Canes/sticks
• Walker & Frames
• Manual wheelchairs
• Tricycle

19
Cognitive
• Fall detectors
• Apps That Help People with Speech and Communication
• Multiplication machine

Vision
• Spectacles
• Filters
• Audio Players with DAISY Capability
• Braille displays (note-takers)
• Manual Braille writing equipment
• White canes
• Talking/touching watch
• Global Positioning System (GPS)
• Balls with Bell sound
• Screen readers
• Keyboard and mouse emulation software
• Balls with Bell sound
• Braille embossers
• Magnifying Devices
• Audio players with DAISY

20
Hearing & communication
• Hearing aids
• Hearing loops /F.M. system/ personal wireless remote
• Microphone system
• Alarm signals with light /sound/ vibration
• Closed capturing displays
• Deafblind communicator
• Capability
• Step-by-step communicator
• Sets of picture exchange communication system
• Communication boards /books/ cards
• Talk pad

21
Source Documents

1. FDRE Ministry of Health (2020) National Rehabilitation and Assistive Technology

Services guideline

2. FDRE Ministry of Health (2018) Physical Rehabilitation Service guideline

3. FDRE Ministry of Health national specialty and sub-specialty service road map (2020 –
2029 G.C.)

4. EFMHACA standards for Primary, General, and referral hospitals

5. Previous version of EHSTG Volume II

6. Health Sector Disability Mainstreaming Manual Federal Democratic Republic of

Ethiopia Ministry of Health January 2017

7. Federal ministry of health National Rehabilitation and Assistive Technology Services

Management Guideline (December 2020)

22
Chapter 13
Pain and Palliative Service
Outline
Abbreviation ........................................................................................................................................................................... 3
Section 1 Introduction ............................................................................................................................................................ 4
Section 2 Operational standards ......................................................................................................................................... 5
Section 3. Implementation Guidance .................................................................................................................................... 6
3.1 Department of Pain and Palliative Care Services ....................................................................................................... 6
3.2 Pain and Palliative care multidisciplinary team ........................................................................................................ 6
Palliative care multi- disciplinary team members are....................................................................................................... 7
Very useful, but Optional, are........................................................................................................................................... 7
3.3 Standard documents and tools for pain and Palliative care ....................................................................................... 8
3.4 Medication, equipment and supplies .............................................................................................................................. 8
3.5.1 WHO Analgesic Ladder Step 1 – Non-opioids ..................................................................................................... 10
3.5.2 WHO Analgesic Ladder Step 2 – Weak Opioids .................................................................................................. 10
3.5.3 WHO Analgesic Ladder Step 3—Strong Opioids ................................................................................................. 10
3.6 Important consideration in pain assessment ................................................................................................................ 11
3.7 The Principles for Pain management ........................................................................................................................ 12
3.9 Pain and palliative care health education....................................................................................................................... 1
3.9.1 One to one education: .............................................................................................................................................. 1
3.9.2 Patient mass education: ........................................................................................................................................... 1
Types of home care .............................................................................................................................................................. 4
Personal Care and Companionship ....................................................................................................................................... 4
Essential Palliative Care Medicines List............................................................................................................................. 20
1. Numeric Pain Rating Scale ......................................................................................................................................... 27
Procedures ...................................................................................................................................................................... 27
Figure 6: Numeric Pain Rating Scale ............................................................................................................................. 27
Faces scale ...................................................................................................................................................................... 29
Annex 9 .................................................................................................................................................................................. 34
Job Description of Pain and Palliative Care Work Force ................................................................................................. 34
Job Description of palliative care Unit/ Department Head............................................................................................... 34
Abbreviation

WHO - World Health Organization

QI - Quality Improvement

MCH - Maternal and Child Health

SMT - Senior Management Team

NGO - Non Governmental Organizations

TOR - Term of Reference

GFR - estimated Glomerular Filtration Rate

NSAID - Non Steroidal antiinflamatory Drugs

Section 1 Introduction

The latest definition of palliative care as used by the World Health Organization is: ‘an approach that improves
the quality of life of patients and their families facing the problem associated with life-threatening illness,
through the prevention and relief of suffering by means of early identification and impeccable assessment and
treatment of pain and other problems, physical, psychosocial and spiritual WHO (2002). Palliative care for
children as defined by the World Health Organization is:‘ The active total care of the child's body, mind and
spirit, and also involves giving support to the family. It begins when illness is diagnosed and continues regardless
of whether or not a child receives treatment directed at the disease’. WHO (1998).

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is
a subjective experience. The experience varies from person to person and from time to time. Pain is whatever the
experiencing person says it. Palliative care is all about looking after people with illnesses that cannot be cured,
relieving their suffering and supporting them through difficult times. WHO (2004)

Pain and palliative care extends beyond just pain and symptom control, also addressing the psychosocial and
emotional suffering of patients and their families. Pain is now established as the 5th vital sign and the need for
palliative care in Ethiopia is rapidly increasing. Healthcare workers often underestimate the impact of poorly
managed pain in their work. Unmanaged pain affects individuals' daily functioning, emotional wellbeing, and
sometimes their families too. It can lead to reduced mobility and strength; compromise the immune system; and
interfere with eating, concentration, sleep, or social interaction.

Pain touches not only individuals; it affects any individual's ability to work and consequently impacts on both
their community and society. So the implementation guideline touches expected leadership engagement,
multidisciplinary team participation, trained human resource, budget, medications, equipment, supplies and
monitoring and evaluation system for the quality and sustainability of the service.

Recent relevant studies show that, with the rapidly growing population, pain and palliative care services must
expand accordingly to meet increasing demands. Therefore, the main objective of this chapter is to provide
operational standards that ensure comprehensive pain and palliative care provision in Ethiopian hospitals.
Section 2 Operational standards
1) The hospital has functional pain and palliative care service organization.
2) The hospital has multidisciplinary team for pain and palliative care service
3) The hospital has written standard Documents/tools for pain and palliative care services.
4) The hospital has all the necessary medications, equipment and supplies for pain and palliative care.
5) The hospital has implemented pain as a 5th vital sign
6) Pain is managed according to WHO analgesic ladder
7) The hospital has regular health education program on pain and palliative care
8) The hospital has regular pain assessment and management audit system
9) The hospital should provide pain management service at outpatient, inpatient, emergency, MCH, and
other needy area.
10) Pain and Palliative care unit/ department facilitates the delivery of home based care palliative care
Section 3. Implementation Guidance
3.1 Department of Pain and Palliative Care Services

All hospitals should have a department and assign a full time pain and palliative care service
director/coordinator. A pain and palliative care director should be a senior physician, general practitioner or
trained health officer. The director should have enough knowledge about the service, in addition to that take
basic pain free hospital initiative and palliative care training.

The pain and palliative care director shall report to the hospital's medical director and be a member of the SMT.
Pain and palliative care services shall also be incorporated into the hospital's organizational chart under the
medical director. The service shall have a detailed strategic and annual action plan with budgeting. The pain and
palliative care team leader shall work alongside other leaders to ensure integrated clinical services.

3.2 Pain and Palliative care multidisciplinary team

Pain assessment and management is cross-sectional issue. All service delivery points must incorporate patient
pain management into daily clinical activities. Most palliative care patients have comorbidities tied to multiple
hospital departments. Establishing a multidisciplinary committee/team is vital for quality pain and palliative care
services. The team members work exclusively within the department. The ideal and useful composition and
responsibilities are indicated below. Each member shall also understand and perform according to specific job
descriptions (See Annex 9).

The established team shall develop terms of reference (TOR) outlining members' roles and responsibilities and
an operational plan. All members must undergo training/orientation in pain and palliative care. Regular monthly
meetings and action plans shall address discussion topics. The team shall submit pain and palliative care agendas
to the SMT for decisions and follow-up schedules.

Team members may organize and manage community-based care. The member overseeing the patient's care is
responsible for written and verbal communication with other professionals and services, documenting all
communications in the palliative care plan.
Palliative care supports patients until end-of-life and continues family bereavement support. If struggling
physically, psychologically, or spiritually after a loved one's death, the team can assess and support the family at
the palliative care outpatient clinic.

Palliative care multi- disciplinary team members are

1. Focal person Department head
2. physician
3. Nurses
4. Social workers
5. Clinical Psychologist/General Psychologist/Counselor
6. Clinical Pharmacies
7. Spiritual leaders
8. Secretary

Very useful, but Optional, are

 Dietician

 Occupational therapist

 Music and art therapists ,volunteers

 Other personnel, as required

*Volunteers play an important role in many palliative care services
3.3 Standard documents and tools for pain and Palliative care
The hospital should avail pediatric and adult pain and palliative care protocols approved by the hospital
management. All the hospital wards and clinical areas should receive a soft and hard copy of the protocols. The
standard pain and palliative care guidelines should be available, understood and adhered to by all clinical staff in
all service delivery points. The service should be audited regularly by reviewing patient medical records and QI
activities should be done whenever gaps are identified.

All clinical staffs of the hospital should be trained on pediatric and adult pain management protocols. Pain and
Palliative care team members are also expected to be trained on palliative care service and appropriate use of
pain and palliative patient reporting formats.

3.4 Medication, equipment and supplies

Availability of medical equipment’s, Supplies and consumables are essential for the provision of pain and
palliative care. Hospitals shall identify and avail the national package of essential medications, standard
equipment, and minimum supplies (see Annex 4). An inventory checklist shall be prepared with capacity
assessment and gap identification in medications, supplies, and equipment.

Evidence-based quantification of medications, supplies, and equipment shall inform procurement of these
essential items. A robust follow-up system shall be established for procurement and distribution. Hospitals must
ensure pain and palliative care professionals are trained on proper and efficient use of equipment and resources.
Professionals are responsible for keeping current on available hospital equipment and resources.
3.5 WHO Analgesic Ladder
The WHO analgesic ladder provides a general guide for pain management based on severity. However, it does
not replace individualized management based on careful patient assessment.

Table-1 the WHO three-step analgesic ladder for Adult

SN - Step 1 - Step 2 - Step 3

NON-OPIOID WEAK OPIOID STRONG OPIOID

± adjuvants ± non-opioid
± non-opioid ±
± adjuvants adjuvants

1 Paracetamol 500mg 2 If pain is persistent or Persistent or worsening pain

tabs q/6 hrs. worsening: Commence strong opioid
Start codeine 30-60mg four e.g. oral morphine
times a day regularly Oral solution 10mg/5mL
2 NSAID e.g. ibuprofen, or Tramadol 50 mg twice a day

3 Naproxen250-500mg ± non-opioid ±non-opioid ±

twice daily adjuvants
± adjuvants
4 celecoxib100mg twice
daily, increased if
necessary to 200mg
twice daily
± adjuvants
Persistence and Worsening pain
N.B Consider Prophylactic Laxative to avoid Constipation for Morphine
 3.5.1 WHO Analgesic Ladder Step 1 – Non-opioids
- For patients without risk factors for Paracetamol hepatotoxicity, the standard regimen is 1g four times a
day.
- For patients with more than one hepatic risk factor (old age, weight less than 50kg, poor nutritional status,
fasting/ anorexia, chronic alcohol use) – reduced dose of 500mg four times a day, increased if necessary to a
maximum of 3g per day in divided doses, is advisable.
- For patients with severe renal impairment (eGFR<10ml/min) reduce dose (maximum 3g/24hrs)

3.5.2 WHO Analgesic Ladder Step 2 – Weak Opioids

- Low Dose Morphine generally provides quicker and better relief from cancer pain than weak opioids.
- If considering prescribing a weak opioid be aware that: Codeine has to be converted to morphine in the
body to achieve an analgesic effect. Poor metabolizers of codeine may not experience analgesia.
- Ultra-rapid metabolizers may experience toxicity.
- Tramadol 50 mg twice a day

3.5.3 WHO Analgesic Ladder Step 3—Strong Opioids

- Strong Opioids Morphine is the strong opioid of choice for management of moderate to severe pain in
palliative care patients, based on familiarity, availability and cost.
- The oral route is preferred as long as the patient has no problems with swallowing or absorption. Other
strong opioids are used mostly when morphine is not readily available.
- There are generally no absolute contraindications to the use of strong opioids in palliative care patients with
advanced progressive disease, provided the dose is titrated carefully against the patient’s pain.

Non-opioids ibuprofen or other NSAID, paracetamol (acetaminophen), or aspirin

Weak opioids codeine, tramadol, or low-dose morphine
Strong opioids morphine, fentanyl, oxycodone, hydromorphone, buprenorphine
Adjuvants antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate,
or corticosteroid
Combining an opioid and non opioid is effective, but do not combine drugs of the
same class.
Time doses based on drug half life (“dose by the clock”); do not wait for pain to recur
Table-2 - WHO Analgesic Pediatrics ladder

Step-1 Mild Pain Step-2 Moderate/Sever pain

Non-Opioid Strong Opioid
Morphine
± adjuvants ± non-opioid

± adjuvants

N.B Consider Prophylactic Laxative to avoid Constipation for Morphine

 .Step-1 For Mild Pain Age>3 months Ibiprufin, Paracetamol, Age <3 months Paracetamol based on
KG formula
 Step-2 Strong Opioid :Morphine is medicine of choice/may available or Phentaline, Oxicodine,
Hydromorphine,
 Adjuvants: Antidepresants, Anticonvelsant, Antispasmodics, Muscle relaxants, bisphosphonate or
Corticosteroid
- Combine an opoid and non-opoid is effective but, do not combine the same class
- Time doses based on drug half-life (dose by the clock) do not wait pain to recur
3.5 Pain as a 5th vital sign

Pain should refer to as the “fifth vital sign,” (along with temperature, pulse rate, blood pressure and
respiratory rate) and should be assessed regularly and frequently. Pain is individualized and
subjective; therefore, the patient’s self- report of pain is the most reliable gauge of the experience. All
hospitals should have proper assessment of pain and this is essential for successful management.
“Pain is a more terrible lord of mankind than even death itself”

Albert Schweitzer

3.6 Important consideration in pain assessment

◾ Pain is subjective and two patients may report severity differently from each other
◾ Despite the fact that pain is specific to each person, patients can usually accurately and
reproducibly indicate the severity of their symptom by using a scale
◾ Scales enhance the ability of patients to communicate the severity of their pain to health
 care professionals and the ability of clinicians to communicate among themselves
◾ Scales also allow the clinician to assess the effect of medications
◾ Pain is always subjective. Therefore, the patient’s self-report of pain is the single most
reliable indicator of pain. A clinician needs to accept and respect this self-report, absent
clear reasons for doubt.
◾ Assessment approaches, including tools, must be appropriate for the patient population.
Special considerations are needed for patients with difficulty
◾ Pain can exist even when no physical cause can be found. Thus, pain without an
identifiable cause should not be routinely attributed to psychological causes.
◾ Different patients experience different levels of pain in response to comparable stimuli.
That is, a uniform pain threshold does not exist.
◾ Pain tolerance varies among and within individuals depending on factors including
heredity, energy level, coping skills, and prior experiences with pain.

3.7 The Principles for Pain management

◾ By the Mouth: Giving analgesics by mouth are the simplest and most reliable method for
most patients. If the patient cannot take tablets by mouth, then the subcutaneous, rectal,
and ducal routes are alternatives.
◾ By the clock: Administer analgesics according to regular schedule based on duration of
effectiveness rather than “as needed”, except when titrating dose. Constant pain needs
regular analgesics to keep it away. Pain that is allowed to build up is more difficult to
Control. Do not wait for the pain to return but give analgesics at regular intervals according to
their duration of action, eg morphine 5mg every 4hourly.
◾ By the ladder: Use the WHO analgesic ladder. If after giving the optimum dose an analgesic
does not control pain, move up the ladder; do not move sideways in the same level (combination
to achieve maximal effects through analgesic synergy and to counter side effects of large doses
we can use multiple analgesia with different mechanism of Action.
By the patient: The right dose is the one that relieves pain
3.8 Common Pain Scales

There is a variety of pain scales used for pain assessment, for patients from neonates through
advanced ages. The three most common scales recommended for use with pain assessment are: all
scales are annexed on Annex 7
1. The Numeric Pain Rating Scale

2. The Hand scale

3. The Wong-Baker scale (also known as the FACES scale)

4. The FLACC scale

5. PAINAD

NB: Professionals should consider to assess the pain onset, Provoking factors, Radiation, Severity, timing
and impacts of the pain

Pain is influenced by many different factors and therefore total pain encompasses

14
 The following factors need to be considered when making a full assessment. Firstly, the
different components of ‘Total Pain’ should be assessed. Pain is not only a physical
alignment but has psychological, spiritual and social components (see diagram). A
baseline pain assessment score should be obtained during the initial assessment (pain is
the 5th vital sign) and should be reassessed regularly by the palliative care team.

3.9 Pain and palliative care health education

Hospital staff should give health education for all patients about reporting pain levels and seeking
health workers support whenever they feel pain, also to incorporate family members and other
caregivers, who often play a strong role in facilitating patient care. Patient education may be mass
education or one to one- educations.

3.9.1 One to one education:

Providers should explain pain assessment purpose and benefits (e.g. “this helps us determine the
right medication and dose”). For communicating adults, explain the scale (0 = no pain, 10 = worst
possible pain) and ask them to score their pain. Educate on safe handling and proper medication use,
stressing dangers of sharing without prescription. Support shall accommodate all patients (educated,
uneducated, disabled, etc.).

3.9.2 Patient mass education:

Hospitals can efficiently educate patients/caregivers through
 Post information about how to report pain in a visible area
 If the hospital has a video facility, a short video can teach patients and caregivers in the
patient waiting area.
 Lectures in patient waiting area; give education on how to report pain and proper utilization
of pain medication.
 Information pamphlets, brochures and other cost-effective education material can be used for
patients and care givers who can read and understand.
3.10 Regular pain and Palliative care clinical audit

12-1
 Clinical audits are quality improvement processes that review care against explicit criteria and implement
changes as needed to improve services (NICE, 2002). Regular audits are critical for good pain
management and palliative care practices. Comparing practice to standards identifies areas for
improvement.
3.10.1 Pain and Palliative Care Clinical Audit Process
 The hospital should ensure that clinical audit for pain and Palliative care. The audit should be
incorporated in the regular hospital wide clinical audit process and program.
 The hospital should conduct a monthly Pain and Palliative care clinical audit. Simultaneously quarterly
and monthly pain and palliative care service indicators listed below are also expected to be done. The
objective of the clinical audit is to review the practice of the patient’s pain management and palliative
care in the hospital, both inpatient and outpatient against the standard protocols and guidelines. The pain
and palliative care Service Director of the hospital shall be responsible to coordinate pain and palliative
care clinical audit aligned with clinical audit team of the hospital.
 The clinical audit result should be summarized to see if there is a discrepancy of pain management or
palliative care practice with the standard. Following the clinical audit findings, an action plan or quality
improvement project should be prepared with the appropriate timeline and with the responsible persons.
 Follow up actions should be recorded for the implementation of the action plan and QI project.
It is recommended to repeat the above process for 12 consecutive months. When pain management and
palliative care practice is well integrated to the routine health service delivery according to the protocol, the
frequency of clinical audit can be scheduled accordingly.
3.11 Palliative care service provision
A model of care is an overarching service design for delivering a particular type of healthcare. For palliative
care, services must address patient and family needs coping with life-threatening illness. Main models are
hospital and community-based, each with strengths and weaknesses. Hospital-based models alone cannot fully
address dying patients’ and families’ needs without home-based services. Community-based models often start
with home care before requiring inpatient hospice facilities.

In 2015, the Ministry of Health performed a palliative care service needs assessment, considering various
models. For Ethiopia's large, mostly rural population, a community-based model is most suitable (WHO 2009).
However, this requires a hospital "hub" supporting morphine access and specialized services and training. Since
morphine is currently hospital-level only, a hospital hub and spoke model was deemed most appropriate. The
hospital has a multidisciplinary palliative care team that supports other departments with inpatient and outpatient
care and assigns nurses for home-based care in the catchment area, linking to health centers and NGOs providing
home services. The backbone of services will be trained nurses and physicians supporting clinical delivery.
Nursing’s holistic focus on psychological, social, spiritual, and physical wellbeing positions nurses to deliver
palliative care. Hospital hub nurses and doctors will support community nurses, who will work with and mentor
health extension workers and family health teams. Health extension workers will provide basic care and refer
patients to health centers. All clinical services will be overseen by the palliative care working group/core team.
Capacity will also expand through developing a volunteer network and communication strategies between
providers and clinical pathways. Services shall be incorporated into existing healthcare systems like hospitals.
They will be established in tertiary, regional hospitals, and health centers with the following competencies:

3.11.1 Hospital Based pain/ Palliative Care

Hospitals will have inpatient units, outpatient clinics, and home-based care teams. The leadership will establish a
multidisciplinary team that provides consultations for admitted patients. Strong referral systems must exist
between hospitals, health centers, and home-based providers to ensure continuous care and support at home.

3. 11.2 Home Based Care and Regular Supervision Service

Home care includes any professional support services that allow a person to live safely in their home. In-home
care services can help someone who is aging and needs assistance to live independently; is managing chronic
health issues; is recovering from a medical setback; or has special needs or a disability. Professional
caregivers such as nurses, aides, and therapists provide short-term or long-term care in the home, depending
on a person's needs.

Home care can be the key to achieving the highest quality of life possible. It can enable safety, security, and
increased independence; it can ease management of an ongoing medical condition; it can help avoid
unnecessary hospitalization; it can aid with recovery after an illness, injury, or hospital stay—all through care
given in the comfort and familiarity of home. Home care can include:

 Help with daily activities such as dressing and bathing

 Assistance with safely managing tasks around the house
 Companionship
 Therapy and rehabilitative services
 Short- or long-term nursing care for an illness, disease, or disability—including tracheostomy and
ventilator care
Types of home care

Not all home care providers offer all the different types of home care services. This short guide will provide an
overview of the different types of home care. Care is customized to your individual needs and may include
services from one or more of the types described. While the multiple types of home care may serve different
needs, they share a common goal: to enable happier, more independent living for the people receiving care, and
to provide support and peace of mind for their families.

Personal Care and Companionship

Help with everyday activities like bathing and dressing, meal preparation, and household tasks to enable
independence and safety listed below:

- Assistance with self-care, such as grooming, bathing, dressing, and using the toilet
- Enabling safety at home by assisting with ambulation, transfer (eg, from bed to wheelchair,
wheelchair to toilet), and fall prevention
- Assistance with meal planning and preparation, light housekeeping, laundry, errands,
medication reminders, and escorting to appointments
- Companionship and engaging in hobbies and activities
- Supervision for someone with dementia or Alzheimer's disease

Private duty and Nursing Care

 Long-term, hourly nursing care at home for adults with a chronic illness, injury, or disability listed
below:
- Tracheostomy care
- Monitoring vital signs
- Administering medications
- Ostomy/gastrostomy care
- Feeding tube care
- Catheter care
- End stage chronic illness
Home health Care

 Short-term, physician-directed care designed to help a patient prevent or recover from an illness, injury,
or hospital stay listed below:(Bayada.com/home health care,2022)

- Short-term nursing services

- Physical therapy
- Occupational therapy
- Speech language pathology
- Medical social work
- Home health aide services
4. Annexes
Annex 1: Reporting Format
A. Registration format for palliative care service (Inpatient, Outpatient and HBC
Name of Hospital----------------------------------------

S.N. Name of patient Age Sex Religion Case/Dx management Outcome Progress
Annex 2. Palliative Care Assessment Form

Name: ____________________________________________ PC No._____________________

Age Date

Sex Religion

Nationality Tribe

Place of assessment Sub-city & Wereda

Seen By House No

Contact telephone (for Pt.)

Address:

Care giver name /relationship

Referred by: CVWs_________________ Nurse ______________ Self _______________

other________

Give name: ___________________________

Address _______________________

Contact tel No __________________

History from patient ___________ Career _____________ Volunteers ___________ other ___________

Reason for referral: Pain and Symptom control _______________ other __________________________

Diagnosis (Include details of metastasis)

Histology _________________________

HIV status Non-reactive  Reactive Unknown

Information on RVI status is obtained from Patient/Family/Referral paper. NB: If the result is Reactive, please
pass to PLWHA chart

History of Present Illness (HPI)

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Past Medical /Surgical History (list below with dates of onset e.g. diabetes, hypertension, TB, previous
unrelated hospital admission, other relevant information) list Medication given

__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________

Present Medication: all medication including ARVS, prophylaxis, anti-pain

Current medications Dose , frequency and Route Start date

Is the patient receiving herbal medicine? _______________ If yes, how long? ____________________

Is the patient receiving Opioids previously or now e.g. Morphine? ____________ Dosage__________

Is the patient on steroids? ______________________

If the patient stop the above medication/s, why? _______________________________

Give the details information if the patient has allergic history?

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________

Spiritual Assessment

Are you at peace with God? _____________________________________________________________

Has your illness in any way affected your relationship with god? What way, if yes?
____________________________________________________________________________________

Do you pray with other? If not, why? _____________________________________________________

Do you feel your illness is a punishment from God? __________________________________________

Do you need support from spiritual fathers? If yes, what type of help?
____________________________________________________________________________________
Social History

Family tree (Include age of children):

Male  Female ⃝

Male Female
(died)
(died)  

patient X

Marital status
________________________________________________________________________

Main physical
career___________________________________________________________________

Dependents including children and /or siblings

______________________________________________

No of children in school
_________________________________________________________________

Other household members

______________________________________________________________

Occupational history /source of income ___________________________________________

Employment status :- Employed __________ unemployed _______ retired _______house wife

_______

Present employment status = unemployed due to illness

_______________________________________

Main source of income & main economic career relationships to

patient__________________________

Physical Examination

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Functional assessment (FA)

Keys: - 1 fully independent

Function Score
2-independent with aid
Walking
3-needs assistance of one person \
Dressing
4- Assistance of two persons
Toileting 5- Completely dependent
Self-care NB- average FA scored ≤ 2 does not need CVW
Total > 3 needs assistance of care giver

Average score of FA

Pain Chart to be filled at First Visit

Describe the type of pain experienced using this table and give a possible cause of each pain

Mark site of pain and assign number Body chart

 Pain 1 Pain 2 Pain 3 Pain 4

Duration of pain

Character description of pain

Numerical scale 0-5

Periodicity (constant /intermittent/

Precipitating factors

Relieving factors

Does pain affect sleep? Y/N

Does pain affect mobility ?Y/N

Effect of current medication –none

, partial, complete controlled

Did you sleep last night

Possible causes of each pain?

Initial problem list

No Initial problem list

Problem Possible cause Management plan

Prescription &supplied

Understanding of illness and consequences

What do you understand by your illness? Diagnose and

prognosis

What does your family understand? ask the family too

What is your main distress? ask the family too

What is your expectation from the treatment?

Has your illness affected your relationship with

friends/families?

What do expect from Hospice Ethiopia? explain about HE

Case summary (Includes brief summary of present illness, and plan of care that include physical, psychological,
social and spiritual)

----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
-------

Conclusion: Physical __________ Psychological ___________ Social __________Spiritual __________

Seen by: ______________________________Signature: _________________ next visit _____________

Breaking Bad News delivery (to be done on 2nd or 3rd visit and please briefly write what is done)

----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------
---

Meaningful communication sheet

Date Note
Problem List

No Problems Active date Inactive date

Continuation Sheet

Date Site of Prob. Note on problem and plan of management

visit No
Medication Sheet

S. Date Medications Dose, Frequency and Prescribed Remark

N. Route by

4
Annex 3:

Palliative Care at outpatient department Patient satisfaction survey

Exit interview questionnaire

Date of survey………………………………

Facility Name………………………….. Survey code ...........Department name………………

Age…………………… Gender……………….. Level of educations…………………………

Instruction: Please circle or write in relevant boxes

Diagnosis Cancer HIV NCDs Others ……………………..

type…………………

Strongl Disagree Agree Strongly agree

y
2 3 4
disagree

1- During this visit, the health care worker 1 2 3 4

treated me with courtesy and respect
2- During this visit, the health care worker 1 2 3 4
listened carefully to me
3- During this visit, the health care worker 1 2 3 4
explained things in a way I understand
4- I had enough time to discuss my problems Yes No
with the health care worker
5- Were you given health information and Yes no
education on the disease you are told to
have?
6- How do you rate this health facility? 0 1 2 3 4 5 6 7 8 9 10
- On scale of 1 to 10 (0 being the worst
Worst ………….to………………………..best
and 10 being the the best facility)
7- Would you recommend this outpatient 1 2 3 4
department /clinic to your family and friends
no not sure yes Yes Very
,never ,probably sure
Annex 4:

Essential Palliative Care Medicines List

Drug Name Properties Clinical Uses Alternative Drugs

Paracetamol Non opioid Fever
Analgesic Pain

Aspirin Antipyretic
Non opioid Pain
Analgesic Antipyretic Fever

Ibuprofen Anti-
NSAID inflammatory Sore mouthbone
Pain (esp. Diclofenac
pain) Fever Indomethacin
Tramadol Weak opioid Pain
Anti-inflammatory Low dose
Codeine Analgesic morphine

Morphine liquid Strong opioid Pain Morphine slow

Analgesic Introduction release tablets
Breakthrough pain
Difficulty swallowing
children
Morphine (slow Strong opioid Pain Morphine
release tablets) Severe diarrhea Liquid
Dexamethasone Corticosteroid Painful swelling and Prednisolone
Anti- inflammatory inflammation

Amitriptyline Tricyclic Poor appetitepain

Neuropathic Carbamazepine
Antidepressant (nerve pain) Phenytoin
Amitriptyline Tricyclic Depression Imipramine
Antidepressant
Hyoscine Butyl Antimuscarinic Abdominal pain Propantheline
bromide Antispasmodic (Colic)
(Buscopan)
Diazepam Benzodiazepine Muscle spasm Lorazepam
Anticonvulsant Seizure
Anxiety, sedation
Phenobarbitone Anticonvulsant Seizure Diazepam
Metoclopramide Antiemetic Vomiting Haloperidol
Domperidone

Metoclopramide Pro-kinetic Abdominal Fullness Promethazine

Chlorpromazine Antipsychotic Hiccups Metoclopromide
Nifedipine
Magnesium Trislicate Antacid Indigestion
Gastro-esophageal

Loperamide Antidiarrheal reflux

Chronic diarrhea
Bisacodyl Stimulant Constipation
laxative
ORS Rehydration Diarrhea
Salt Rehydration

Chlorpheniramine Antihistamine Drug reactions

Flucloxacillin Antibiotic Chest infection

Skin infection

Cotrimoxazole Broad PCP treatment &

Spectrum prophylaxis
Antibiotic Infective diarrhea in
HIV/AIDS
Metronidazole Antibacterial Foul smelling
for anaerobic infections wounds
gingivitis dysentery
Lumefantrine Anti- malarial Malarial treatment
artemether (LA)
Acyclovir Antiviral Herpes zoster
Chloramphenicol eye Antibacterial Eye infections
ointment/drops
Fluconazole Antifungal Oral & esophageal
candidiasis

Clotrimazole 1% Cream Topical Cryptococcal

Fungal Skin
antifungal Infection
Nystatin Antifungal Oral & vaginal
Suspension and pessaries candidiasis Prophylaxis
for patients on steroids
Annex 5:

Pain medication drug availability reporting format

Record of Pain management drug

Name of reporting pharmacy…………………………………………………Address……………………………

Region……………………………….zone………………………woreda……………………………………….ke
bele………………………..tel………………..

Reporting month………………………………to……………………..of the

year………………………………….

Ser.No Type of pain Patient Drug prescribed Prescriber’s Date of

management prescription
Address
Drug

Name Card no. description quantity

 Pain Assessment and management Format

S.No Name of patients B.No Pressure Temperature pulse O2 Score 0-10

Saturation Mild Mode Severe
rate
0 to4 5 to7 7 to 10
Annex 6:

Palliative care Equipment and supplies list

 Examination room
 Patient Couch
 Pillows
 Sheets
 Blankets
 Slippers
 Desk for Health Care Professional
 Chairs for HCPs, patient and family members
 Filing Cabinet
 Nursing/Dressing Trolley
 Material for Dressings- Gauze, cotton wool, bandages.
 Stitch material
 Surgical blades
 Normal Saline for cleaning wounds
 Chlorhexidine
 Hydrogen Peroxide
 Antiseptic Cream
 Sphygmomanometer
 Stethoscopes
 Thermometers
 Lock box for medicines
 Syringes and Needles
 Pain Measurement Scales
 Coffee table and comfortable chairs for counselling and breaking bad news
 Oxygen, tubing and mask.
 Wheelchair
 Commode and bed pan
 Sanitary towels and pads for incontinence
 Incontinence Pants
 Mackintosh sheeting –plastic-for incontinent patients
 Gloves- surgical and clean-all-sizes
 Kidney dishes
 Vomit bowls
 Dressing sets
 Aprons
 Face Masks
 Hand Sanitiser-soap
 Cleaning Materials
 Air Fresheners
 Charcoal Dressings
 Jugs for vaginal douches
 Toilet Paper
 Paper Towels and Material towels
 Uretheral Catheters and catheter bags
 IV catheters
 IV fluids
 Blood Transfusion sets
 Bandages for IVS
 Adhesive Tape
 Small Gauze
 Rubbish bin
 Bin to dispose of dressings and soiled matter
 Patient gowns
 Stationary including paper, pens, markers, envelopes, stapler, tape.
 Log book for patients
 Suction Catheter
 Bedside commodes.
 Geriatric recliners (geri chairs)
 Nebulizers.
 Overbed tables.
 Shower chairs.
 Wheelchairs
 Pain assessment tools
Annex 7:

Common Pain Scales

There are a variety of pain scales used for pain assessment, for patients from neonates through
advanced ages. The three most common scales recommended for use with pain assessment are:
1. The Numeric Pain Rating Scale

2. The Hand scale

3. The Wong-Baker scale (also known as the FACES scale)

4. The FLACC scale

5. PAINAD

1. Numeric Pain Rating Scale

The health worker asks the patient to rate their pain intensity on a numerical scale that ranges
from (indicating ‘no pain’) to 10 (indicating the ‘worst possible pain’).

Procedures

a) Explain to the patient about what you are going to do (eg. ‘I want to assess your pain level
to help us properly manage the pain’
b) Ask the patient ‘please rate your pain in a scale from zero to 10 (0 = no pain and 10 =
worst Possible pain). You can use a scale like below
c) Numeric Pain Rating Scale Record the patient scored pain level on the necessary form to
make treatment decisions, follow-up, and compare between examinations

No pain Mild pain Moderate pain Severe pain Very severe pain Worst possible pain

0 1 2 3 4 5 6 7 8 9 10

Figure 6: Numeric Pain Rating Scale

 2. The Hand Scale

The hand scale ranges from a clenched hand (which represents ‘no hurt’) to five extended digits
(which represents ‘hurts worst’), with each extended digit indicating increasing levels of pain.

Note: It is important to explain this to the patient as a closed fist could be interpreted as worst
possible pain in some cultures
a) Explain to the patient about what you are going to do (eg.‘I want to assess your pain level
that will help us properly manage your pain’

Show your hands to the patient and ask ‘please rate your pain level. You should show your hands
like below or use the drawing use a scale

b) Multiply the result by two to score the pain to 0 to 10 and record on the necessary forms
( if the patient reports hurts whole lot mean four figures the result will be recorded as 4*2=
8 on the routine observation form).
Suggested tools for Pain Measurement in children

3. Faces Scale

*Use in children who can talk (usually 3 years and older)

Show the Child the Following picture and explain to the child that each face is for a person who feels
happy because he has no pain, or a little sad because he has a little pain, or very sad because he has a
lot of pain

Faces scale

a. Ask the child to pick one face that best describes his or her current pain intensity.
b. Multiply number of the pain level that the child reports by two and record on the necessary form
to make treatment decisions, follow-up, and compare between examinations.
c. Record the summation of observation on the necessary form to make treatment decisions,
follow-up, and compare between examinations

4) FLACC Scale

FLACC is the acronym for Face, Legs, Activity, Cry, and Consolability. This scale is based on
observed behaviors, and is most commonly used with paediatric patients less than three years of
age. The behaviors that are described are associated with a number; each component is totaled
for a number ranging from 0 to 10. This scale is also appropriate with patients who have
developmental delays or are non-verbal.
Use it like an APGAR (Appearance, Pulse, Grimace, Activity, Respiration) score, arriving at a
score out of 10.
5) Pain assessment in advanced dementia (PAINAD)

Items 0 1 2 Score

Breathing Normal Occasional labored Noisy labored

independent of breathing. Short breathing. Long periods
vocalization period of of hyperventilation.
hyperventilation Cheyne-Stokes
respiration

Negative None Occasional moan or Repeated troubled

vocalization groan. Low level calling out. Loud
speech with a moaning or groaning.
negative or Crying
disapproving quality

Facial expression Smiling or Sad. Frightened. Facial grimacing (an

inexpressive Frown ugly or disapproving
facial expression)

Body language Relaxed Tense. Distressed Rigid. Fists clenched.

pacing. Fidgeting Knees pulled up.
Pulling or pushing
away. Striking out

CONSOL ability No need to Distracted or Unable to console,

console reassured by voice or distract, or reassure
touch
Annex 8:

Palliative Care Audit Tool

1 Does the hospital clinic have a functioning palliative Yes NO Remark

care team?

2 Do they have the minimum number of palliative care

staff in the team? (according to WHO guidelines)

3 Have the palliative care team attended a one-week

training course?

4 Do they have a room or office to meet and see patients?

5 Do they have a hospital palliative care policy with

referral criteria?

6 Do they have palliative care notes which are stored

appropriately for their patients? Check 6 Patient
Records)

7 Do they have access to palliative care medicines

including morphine -including liquid form?

8 Is there evidence of a palliative assessment including

pain as the 5th vital sign Check 6 Patient Records)

9 Is there evidence of pain and symptom control

assessment and appropriate treatment (Check 6 Patient
Records)

10 Do they have palliative care equipment (according to

list)

11 Do they have a linked home-care service?

12 Do they offer a bereavement service?

13 Have any of the team any post-graduate education in

palliative care?

14 Does the palliative care hub have volunteers to support

patients and family?

15 Does the hub have a clear referral pathway for patients

from all appropriate departments?

16 Do the palliative care hub team provide basic

updates/experience sharing with other health care
professionals in the hospital

17 Do Pain and palliative care team have schedule for HBC

and working based on standard
Annex 9
Job Description of Pain and Palliative Care Work Force

Job Description of palliative care Unit/ Department Head

1. Lead the team
2. Timely report palliative care activity ,opoid consumption report monthly to the
stakeholders (IPD,MD,RHB,MOH)
3. Facilitate the working environment
4. Perform monthly meeting with the hospital management about palliative care
5. To procast training need and propose training for the team members
6. To procast opoid medication timely
7. Ensure medicine and other necessary medical supplies are purchased and available in
the hospital
8. To prepare documentation in collaboration with other stake holders ( protocols
,TOR,SOP,patient history form and others )
9. To prepare annual plan of the unity which is in favor of fulfilling national strategy
plan
10. To organize and deliver appropriate training for the team time

Job description of palliative care physician

1. Assess patient’s need for total pain and symptom control and offer quality care and support
based on the palliative care national guideline.
2. Take history, physical examination and necessary investigation to reach on diagnosis.
3. Treat the patient by using holistic approach and treat pain using standard WHO pain ladder
approach
4. To have regular schedule for the patient OPD and inpatient visit
5. Refer patient with the proper form to different discipline if needed.

Job description of palliative care nurse

1. Care out physician order and also assess patient’s need for total pain and symptom control
and offer quality care and support based on the palliative care national guideline.
2. Perform standard nursing care for kept palliative care patient
3. Keeping the patient information and records well
 4. Recording and controlling medicines useful for palliative care
5. Make sure bereavement support is provided for patient family as necessary
6. Ensure medicine and other necessary medical supplies are available in the unit
7. Ensure there is good patient referral system and linkage with necessary stakeholders
8. Facilitate and participate during case discussion among the clinical staff
9. Supervise and lead the work of care givers who are directly involved in patient care
10. Help students who may be assigned at hospital from medical school in PC attachment
11. Ensure psychosocial and spiritual supports are provided by experts when needed
12. Provide holistic Home care service as per the schedule in addition to the outpatient and
inpatient care
13. Develop work plan every month or quarter and communicate with palliative focal person
14. Have a great team approach
15. Perform any other duty assigned by immediate supervisory
16. Accept tasks assigned by the palliative care team leaders which is related to palliative care
service

Job description of palliative care Social workers

1. assess patient’s need for social pain and its management

2. asses patients family need for social pain and its management
3. to have regular visit with the team to palliative care patient
4. Have regular meeting with palliative care team and handling social problem happen in
the team ( involving in care for care giver service)
5. To prepare gate together ceremony for the team and if it can with other stakeholders
and patients
6. Accept tasks assigned by the palliative care team leaders which is related to palliative
care service

Job description of Psychologist

1. Asses the patient psychological problems of the patient and families

2. Document the patient psychological problems clearly
3. Manage the psychological problems of the patient and families
 4. Have regular meeting with palliative care team and handling psychological
problem happen in the team ( involving in care for care giver service)
5. To give onsite training on psychological problem identification and managing for
the team
6. Refer the patient if needed
7. Accept tasks assigned by the palliative care team leaders which is related to
palliative care service

Job description of Clinical Pharmacist

1. To assess the standard who pain management implemented to the palliative care
patient
2. To report opoiod consumption report to the focal person timely
3. To involve in DTC meeting regularly
4. To give health education on opoid medication use and there side effect
5. To promote appropriate use of opoid
6. To prepare and distribute leaflet about pain medication and how to use
7. Record and manage side-effect and negative outcome regarding to pain
medication
8. Update pain medication medicine timely
9. Give information the availability, stock out stats of pain medication to palliative
care unit timely.
10. Accept tasks assigned by the palliative care team leaders which is related to
palliative care service

Job description of Spiritual leaders

1. To assess the patient spiritual issues

2. To manage the patient spiritual issues
3. To assess the patient family spiritual issues
4. To document the patient spiritual problems appropriately
5. To train others how to handle spiritual problems
6. Have regular meeting with palliative care team and handling spiritual problem
happen in the team ( involving in care for care giver service)
 7. Accept tasks assigned by the palliative care team leaders which is related to
palliative care service

Job description of Volunteers

1. To help the patient in need

2. To transport and direct the patient to appropriate place
3. To involve in community visit
4. To involve in patient tracing system for delivering palliative care service
5. Accept tasks assigned by the palliative care team leaders which is related to
palliative care service (The team can refer from strategic plan)

3.3 Pain and Palliative Care work force

Pain and palliative care require teamwork and a multi-disciplinary approach. Regular planning clinics are
required to discuss patient cases as well as regular ward rounds with the team. Furthermore, patients can
be seen in outpatient clinics run by pain and palliative care staff.
The hospital human resources development plan is expected to incorporate pain and palliative care
training need.
All clinical staffs working in all service delivery points should get training on pain management and
palliative care service. Since pain is assessed and managed in all service areas, the hospital should assign
facilitators in all departments. Availability of pain and palliative care trained personnel is important to
support other hospital in the hubs and make need based capacity building.
The hospital should establish a pain and palliative care workforce that identifies priority areas of patient
need and establishes procedures for collaboration with other pain and palliative care health care
professionals and cross- referral in the unit. Take the skill mix of professionals into consideration.
Establishes procedures to refer patients to specialized services.
Each palliative care professional is responsible for the following:
 Collaborate with patient and their family and cares
 Work with palliative care team, to form overall goals and plan for patient
 Make referrals to specialized rehabilitation/palliative care professionals and
other clinical staff and community services.
 Collaborate with other health care professionals in teaching, consulting, and
management and research activities
Source document

1. National Palliative Care guidelines (2016) MOH, Ethiopia

2. Hospice Fundamentals, LLC PALLIATIVE CARE HANDBOOK (2019) Jean Acevedo, LHRM,
CPC, CHC, CENTC, AAPC Fellow,
3. World Health Organization (1990) Cancer Pain Relief and Palliative Care. Available at:
http://whqlibdoc.who.int/publications/9241544821.pdf (Accessed: 8 September 2011).
4. World Health Organization (2002) WHO Definition of Palliative Care. Available at:
http://www.who.int/cancer/palliative/definition/en/ (Accessed: 10 November 2010).
5. World Health Organization (2014a) WHO African Region: Ethiopia. Available at:
http://www.who.int/countries/eth/en/ (Accessed: 4 August 2014).
6. World Health Organization (2014b) ‘Strengthening of Palliative Care as a Component of
Integrated Treatment throughout the Life Course’, Executive Board 134th Session, Provisional
Agenda Item 9.4. EB134/28, World Health Organization.
7. World Palliative Care Association (2005) an Advocacy Tool Kit for Hospice and Palliative Care
Organizations. Available at: http://www.wpca.org.uk/advocacy_toolkit_05April (1).pdf
(Accessed: 10 August 2014).
8. Wright, M., Clark, D., Hunt, J. and Lynch, T. (2006) Hospice and Palliative Care in Africa. A
review of developments and challenges. 1st edition. New York: Oxford University Press.
9. Wube, M., Horne, C. J. and Stuer, F. (2010) ‘Building a Palliative Care Program for Ethiopia: the
impact on HIV and AIDS patients and their families’, Journal of Pain and Symptom
Management. 40, (1) pp.6-8.
10. Palliative Home Care and Services provided in a Rural Area – Kerala, India’, Indian Journal of
Palliative Care, 18 (3), pp.213-218
CHAPTER 14
PHARMACY SERVICES AND PHARMACEUTICAL SUPPLY MANAGEMENT

1
Outline

Outline

1. Introduction ............................................................................................................................. 1
2. Operational Standards for Pharmacy Services and Pharmaceutical supply management ....... 2
3. Implementation Guidance ....................................................................................................... 3
3.1. Pharmacy Service and Pharmaceutical Supply Management Organization .................... 3
3.1.3. Resources needed for pharmacy and pharmaceutical supply management services .... 7
a. Personnel .............................................................................................................................. 7
3.2. Drug and Therapeutics Committee .................................................................................. 9
3.3. Pharmaceutical selection, quantification, procurement, warehouse, inventory
management, distribution, and an effective information management system ......................... 17
d. Pharmaceutical emergency supply chain management system ......................................... 21
3.4. Pharmaceutical cold chain and vaccine management .................................................... 25
3.5. Medical Oxygen Supply management ........................................................................... 38
3.6. Pharmaceutical waste management ................................................................................ 42
3.7. Auditable pharmaceutical transactions and services (APTS) and good dispensing
practices. .................................................................................................................................... 43
3.8. Clinical pharmacy services............................................................................................. 51
3.9. Drug Information Services ............................................................................................. 56
3.10. Compounding services ............................................................................................... 57
3.11. Antimicrobial Stewardship Program (ASP) ............................................................... 59
3.12. Narcotic drugs and psychotropic substances rational use, distribution and handling
system. 62
3.13. Monitoring and Evaluation of pharmacy service and supply mana ........................... 65
6. Annexes ................................................................................................................................. 67
Annexes
Annex 1: DTC functionality criteria ............................................................................................. 78
Annex 2: ADR reporting format .................................................................................................. 79
Annex 3: Pharmaceutical Good storage guideline ........................................................................ 81
Annex 4: Bin Card ........................................................................................................................ 84
Annex 5: Internal Facility Report and Resupply Form (IFRR) .................................................... 85
Annex 6: Report and Requisition Form (RRF) ............................................................................. 86
Annex 7: Refrigerator tag temperature recording sheet ................................................................ 87
Annex 8: Procured medical oxygen cylinders checking form during receiving at store to ensure
proper filling ................................................................................................................................. 87
Annex 9: Medical oxygen Internal Reporting and Requesting form (maintained separately for
each ward) ..................................................................................................................................... 88
Annex 10: Medical oxygen monthly consumption tracking report .............................................. 88
Annex 11: Expired and unfit for use product registration form.................................................... 88
Annex 12: Prescription evaluation and intervention register ........................................................ 89
Annex 13: Data collection form for patient knowledge and labelling interview .......................... 90
Annex 14: Data collection form for client satisfaction with dispensing services ........................ 91
Annex 15: In-patient Medication Profile Form ............................................................................ 92
Annex 16: Pharmaceutical Care Progress Note Recording Form ................................................. 93
Annex 17: DIS Summary and Report form .................................................................................. 94
Annex 18: Drug Information Response Form .............................................................................. 96
Annex 19: Drug Information Query Form .................................................................................... 97
Annex 20: Drug information service feedback form .................................................................... 98
Annex 21: List of basic compounding equipment ........................................................................ 99
Annex 22: Compounding Process Recoding Form (Compounding sheet) ................................. 100
Annex 23፡ Compounding Prescription Register Forms .............................................................. 101
Annex 24: Antimicrobial Stewardship program functionality Criteria ...................................... 102
Annex 25: AMS review/Audit form ........................................................................................... 103
Annex 26: Dispensed and administered Narcotic drugs record format ...................................... 105
Annex 27: Dispensed and administered psychotropic drugs record format ............................... 106
Annex 28: Annual report of narcotic drugs ................................................................................ 107
Annex 29: Annual report of Psychotropic substance .................................................................. 108

List of Tables
Table 1: pharmaceutical service positions and corresponding number of professionals .................. 9
Table 2: Criteria to classify pharmaceuticals into ABC category...................................................... 14
Table 3: Selected indicator to assess prescribing, patient care and facility practices ..................... 15
Table 4: Heat sensitive Vaccines ........................................................................................................... 30
Table 5: Freeze sensitive Vaccines ........................................................................................................ 31
Table 6: Pharmacy Service and Supply Management Standard and Verification criteria ............ 73
List of Figures
Figure 1: Hospital pharmacy service and pharmaceutical supply management organogram ....................... 7
Figure 2: Arrangement of vaccines in a refrigerator compartment ............................................................. 32
Figure 3: Vaccine and diluent arrangement in a front-opening kerosene vaccine refrigerator ................... 32
Figure 4: Vaccine and diluent arrangement in a top-opening refrigerator without baskets ........................ 34
Figure 5: Vaccine and diluent arrangement in a top-opening refrigerator with baskets ............................. 34
Figure 6: Vaccine vial monitoring criteria .................................................................................................. 36
Figure 7: Key result areas of APTS ............................................................................................................ 45
Figure 8: Pharmacy patient flow arrangement in APTS implementing health facilities............................. 48

1
Abbreviations and Acronyms
ADE Adverse Drug Event
AMC Average monthly consumption
AMS Antimicrobial Stewardship
APTS Auditable Pharmaceutical Transactions and Services
ASP Antimicrobial Stewardship Program
AWaRe Access, Watch and Restrict
DMAT Disaster Medical Assistance Team
DTP Drug Therapy Problem
DUE Drug Use Evaluation
EFDA Ethiopian Food and Drug Administration
EHSTG Ethiopian Hospital Service Transformation Guideline
EPSS Ethiopian Pharmaceutical Supply and Service
GCP Good Compounding Practice
HFSML Health Facility Specific Medicine List
HSTP Health Sector Transformation Plan
IFRR Internal Facility Report and Resupply
ILR Ice Lined Refrigerator
NPS Narcotic drugs and psychotropic substances
PIS Patient Information Sheet
PMIS Pharmaceutical Management Information system
PMP Patient Medication Profile
PTC Patient Tracking Chart
SSA Stock Status Analysis
VEN Vital, essential, Non-essential
VVM Vaccine Vial Monitor

1
Section 1 Introduction
Pharmaceutical supply chain management and pharmacy service activities are integral parts and
crosscutting activities of the health care system. Managing the pharmaceutical supply chain and
pharmacy service is key to fulfilling basic customer satisfaction and is all about obtaining the
right product in the right quantity and condition at the required time. The ultimate health
outcome is determined by the appropriate selection, quantification, procurement, and rational use
of pharmaceuticals. Pharmacy service and pharmaceutical supply management are essential
components of health care delivery in hospitals. It contributes to improved treatment outcomes
by ensuring the availability and rational use of quality, safe, and effective medicines.
The provision of an effective pharmacy service is also crucial for the early recognition and
prevention of medication errors and adverse drug events, as well as the prevention and
containment of antimicrobial resistance. Effective pharmacy service and pharmaceutical supply
chain management also promote optimal use of meagre resources, thereby improving the quality
of care and resulting in better health outcomes. Accordingly, pharmacy services should provide
assurance that quality and safety are maintained at all stages of service provision and that clients’
satisfaction is given the utmost importance. The pharmacy chapter of the previous versions of
EHRIG and EHSTG has guided hospitals in the implementation of critical operational standards.
It helped hospitals in the delivery of quality services and enabled the Ministry of Health, regional
health bureaus, and hospitals to evaluate their performance using predefined indicators.
Consequently, commendable achievements have been registered in terms of improving pharmacy
service delivery. Currently, the majority of hospitals in the country have achieved many of the
operational standard’s verification criteria set in the last two versions of this document. In the
last five years and recently, new initiatives like the antimicrobial stewardship program, oxygen
supply management, pharmaceutical cold chain management, and other new initiatives have
been implemented in Ethiopian hospitals. Subsequently, it was found necessary to update
operational standards and implementation guidance.
In addition, there was a need to develop robust measurement approaches and applicable
indicators that are in line with the health sector's expectations for the coming years. Therefore,
the standards and guidance set in this chapter are designed to align with and support hospital
pharmaceutical services and supply management systems to meet the demands of the nation's
health sector transformation plan.
Section 2 Operational Standards for Pharmacy Services and Pharmaceutical supply management
1. The hospital pharmacy service and supply management are organized in a way that
facilitates pharmaceutical care and coordination
2. The hospital has a functional Drug and Therapeutics Committee (DTC).
3. The hospital has an effective system for pharmaceutical selection, quantification,
procurement, inventory management and distribution
4. The hospital has a standardized pharmaceutical cold chain management system.
5. The hospital has an effective oxygen supply management system.
6. The hospital conducts continuous segregation, documentation, and safe disposal of
pharmaceutical wastes.
7. The hospital has functional Auditable Pharmaceutical Transactions and Services (APTS)
and executes good dispensing practices at all outlets.
8. The hospital has functional clinical pharmacy services in the inpatient, outpatient, and
emergency departments.
9. The hospital provides drug information services.
10. The hospital has a functional compounding service.
11. The hospital has an Antimicrobial Stewardship Program (ASP).
12.The hospital has a system for rational use, distribution and handling of
narcotic/psychotropic substances
13.The performance of pharmacy service and supply management is regularly monitored
and evaluated.
Sction 3 Implementation Guidance
3.1. Pharmacy Service and Pharmaceutical Supply Management Organization
Pharmacy services should be organized and managed in such a way that ensures patient safety,
convenience, privacy, and satisfaction. The organization and management should also improve
performance and be convenient for practitioners.
3.1.1 Management of pharmacy service and pharmaceutical supply management
Hospital pharmacy should be managed in a manner that facilitates the provision of patient-
centered pharmaceutical services consistent with the standards outlined in this guideline. A head
or director appointed by the hospital management is responsible for overseeing the hospital
pharmacy. The hospital management also assigns unit coordinators. Whereas the pharmacy
director or head assigns team leaders as deemed necessary.
The head or director of the pharmacy department performs the following activities:
- Develops, implements, monitors, and follows the approval of the pharmacy service and
pharmaceutical supply management annual action plan.
- Cascading the pharmacy service and pharmaceutical supply management plan to
coordinators and unit leaders
- Follows developments and trends in health care and makes sure national service
standards and guidelines pertaining to hospital pharmacy service and pharmaceutical
supply management practice are communicated to everyone involved in the provision of
pharmacy services and pharmaceutical supply management.
- Makes sure vaccine and medical oxygen supply management are properly implemented.
- Continuously perform workload analysis, communicate, and follow the hospital
management's instructions for action.
- Participate in hospital committees and meetings representing the pharmacy department.
- Makes sure that new staff are properly oriented and supervised, and skill transfer is
undertaken while staff are rotating to other units or leaving the hospital.
- Designs and follows the implementation of professional development programs for all
staff as appropriate to enhance their knowledge and skills.
- Regularly ensure evaluation of the performance of pharmacy staff and take measures
accordingly.
- Communicates and collaborates with other departments and services throughout the
hospital.
 - Communicates performance reports to the hospital management and relevant government
bureaus and agencies with the approval of the responsible body in charge of leading the
hospital.
- Discharging his or her roles and responsibilities as DTC and ASP secretary
3.1.2. Pharmacy Service and Pharmaceutical Supply Management Organization
Pharmacy service and supply management in the hospital should be organized as an outpatient
pharmacy services unit, an inpatient pharmacy services unit, an emergency pharmacy services
unit, a pharmaceutical supply management unit, a clinical pharmacy services unit, a drug
information services unit, a compounding pharmacy services unit, and other units, depending on
the hospital's service. Each unit should be led by a registered pharmacist and shall be organized
and function as follows:
a. OPD Pharmacy Unit: shall be organized in multiple locations (e.g., general OPD pharmacy,
ART/TB pharmacy, chronic care pharmacy, MCH pharmacy, etc.) depending on the
arrangement of the OPD clinics, proximity, and complexity of the hospital to improve
accessibility and convenience to patients. Patient waiting areas at the OPD pharmacy units
should be fitted with adequate seats and ventilation to ensure patient safety.
Chronic Care Pharmacies: Depending on the hospital’s level and service specialization,
one or more chronic care pharmacies shall be established. All patients who have follow-up in
these pharmacies shall have individual patient medication profile (PMP) records. The
dispensing pharmacist should update the PMP whenever a refill medication are dispensed to
the patient. When a patient presents to the pharmacy for a refill, the pharmacist must assess
the patient for signs of compliance, adherence, effectiveness, and safety of the therapy.
Whenever the need arises, the pharmacist should communicate with the prescriber for any
therapeutic modification.
b. Inpatient pharmacy unit: depending on patient load, number of beds, and accessibility,
there should be an adequate number of inpatient dispensaries and specialty pharmacies
located near the major wards. Pharmacists (preferably clinical pharmacists) should lead these
dispensaries. Inpatient pharmacy services should function under a unit dose dispensing
system and work 24 hours a day, 7 days a week.
c. Emergency Pharmacy Service Unit: This should be organized within or near the
emergency department. The dispensing process should be organized such that medicines
 reach the patient as quickly as possible. Emergency pharmacies should function 24 hours a
day, 7 days a week. The unit also prepares ambulance kits for the hospital.
Besides routine prescription-based dispensing, an emergency crash cart system shall be used
to avoid delays in availing pharmaceuticals to emergency patients, and orders received by
word of mouth or through telephone during an emergency should later be endorsed by the
prescriber and documented in writing before the next shift. The quantity prescribed should be
limited to the emergency period only.
d. Clinical pharmacy services: The hospital pharmacy shall provide clinical pharmacy
services in all units. The service should be well integrated into all clinical departments.
Clinical pharmacy services should function 24 hours a day, 7 days a week. All services
provided in these departments should be recorded, documented, and reported.
e. Compounding Unit: in order to respond to specific patient needs, the hospital pharmacy
should have compounding services on separate premises equipped with the necessary
facilities and materials and meeting all other minimum requirements.
f. Pharmaceutical Supply Management Unit: To ensure uninterrupted supply of
pharmaceuticals, the hospital pharmacy should have a pharmaceutical supply management
unit. The unit shall have separate pharmaceutical stores for medicines, medical equipment,
and supplies, including medical oxygen, chemicals, and lab reagents. A dedicated pharmacist
should coordinate the overall operation of the unit (selection, quantification, procurement,
inventory management, warehousing, and distribution), and each store should be managed by
a separate store manager.
g. Drug Information Service (DIS) Unit: The hospital pharmacy should have a drug
information service unit to effectively provide evidence-based and up-to-date drug
information for health care providers and patients or clients, led by a registered pharmacist.
 Hospital head/CCO

Pharmacy service and pharmaceutical supply management head

Deputy Head/Drug supply management unit Deputy Head /Pharmacy services unit

OPD Ward Clinical

Quantification pharmacy pharmacies Emergency Drug
pharmacy
and Store (internal pharmacy information
service
procurement/D managers ART/TB medicine, service
team
SM Officers pharmacy pediatrics, team
Other surgical,
chronic care gyn/obs,
pharmacies ICU
pharmacies
Compounding etc.
service

Figure 1: Hospital pharmacy service and pharmaceutical supply management organogram

3.1.3. Resources needed for pharmacy and pharmaceutical supply management services
a. Personnel
Based on the volume of services and workload the hospital pharmacy should be staffed with an
appropriate professional mix and number. Hospital pharmacies should have at least the following
positions and professional mix:
- Pharmacy Services and Pharmaceutical Supply Management Head/Director: in charge of the
overall activities of the pharmacy services
- Pharmacy Unit Coordinators: coordinate the overall activity in each unit. When necessary,
there will be team leaders under coordinators.
- Pharmacist: Manages dispensing and related functions at the following service areas:
- OPD pharmacists: They avail and dispense medicines to outpatients and manage assigned
bins in dispensaries. In addition, a chronic care pharmacist provides pharmaceutical care for
patients with chronic diseases.
- Inpatient pharmacists: They avail and dispense medicines to inpatients and manage assigned
bins in dispensaries.
- Clinical pharmacists: Provides pharmaceutical care, document and report their activities.
- Drug Information Pharmacist: provides up-to-date and unbiased drug information for the
healthcare provider, patients and public.
- A compounding pharmacist: Undertakes hospital-based pharmaceutical preparations.
- Pharmaceutical supply management pharmacist: manages the selection, quantification,
procurement, storage, inventory, and distribution of pharmaceuticals.
- Emergency pharmacist: provides pharmaceutical services in the emergency pharmacy unit.
- Pharmacy accountants: Are in charge of aggregating, reporting, and documenting pharmacy
transactions and services.
- Cashiers: receive cash from clients, deposit it in banks, and deliver financial documents to
accountants.
- Porters: Are responsible for loading, unloading, delivering, and arranging pharmaceuticals
under the supervision of the respective unit coordinators of the pharmacy.
- Cleaners are responsible for keeping service delivery premises clean and tidy all the time.
- Patient assistants or guards: Are responsible for keeping order at dispensing outlets so that
patients can be served in an orderly and secure manner.
 b. Workload analysis and human power deployment
The pharmacy head/coordinator has to conduct a workload analysis for each pharmacy unit and
propose an adequate and competent work force to the management or human resources
department of the health facility. Based on the results of the workload analysis and the services
provided, the hospital’s human resources department should deploy the required professionals.
Key assumptions used for workload analysis for service areas are:
 For dispensaries, 1000 prescriptions or encounters (or 1800 counselling episodes) per
pharmacist per month
 For clinical pharmacy services in wards, there are 25, 30, and 35 beds per pharmacist per
day for tertiary, secondary, and primary hospitals, respectively.
 For chronic pharmacies, 30 prescriptions per day per pharmacist
 Other service units shall deploy staff as per their workload and services provided.
Table 1: pharmaceutical service positions and corresponding number of professionals
Position Number
Pharmacy services and supply management One pharmacist
director/ head
Deputy Pharmacy service and supply Two Pharmacists
management/ coordinators
Pharmacy units team leaders One pharmacist per unit
Dispenser: Prescription evaluator/biller Based on workload analysis
Dispenser: Medicine counselor Based on workload analysis
Medicine information pharmacist One pharmacist
Clinical pharmacist (in patient) Based on workload analysis
Compounding pharmacist Based on workload analysis
Pharmaceutical supply management officer: One or more per the size of the hospital
Pharmaceuticals store manager: 2 or more as per the size of the health facilities and store number
Pharmacy accountants Based on workload analysis
Cashiers Workload analysis for each dispensing unit
Porters Ranges from 1 to 5 as per the size of the hospital
Cleaners As per the size of the hospital
Patient assistant/ Guard One per each dispensing unit
Note: Calculations for staff number should consider leaves such as annual, sick, and maternity
leaves.
3.2. Drug and Therapeutics Committee
Each hospital shall establish a functional Drug and Therapeutics Committee (DTC) with
multidisciplinary representative members. The hospital DTC has the responsibility of promoting
safe, rational, and cost-effective use of pharmaceuticals. The hospital DTC functionality can be
evaluated using verification criteria.
a. Membership of DTC
Hospital-level DTCs shall have the following members, as a minimum:
- Chief Clinical Officer (chairperson) - Head/representatives of major clinical
- Head/Director of Pharmacy (Secretary) departments
- One relevant representative from the - Chairman of the hospital quality
pharmacy department improvement team
- Head of laboratory department - Head of Finance Department
- Head of Nursing Service (Matron) - From other services as deemed
necessary
Other non-voting participants can be invited to attend DTC meetings to discuss specific issues
that require their particular expertise. Sub-committees and ad hoc committees of the DTC may
be formed to address specific issues as the need arises (for example, a policy on the use of
antimicrobials, etc.). All DTC members, especially the chair and secretary, should be given
sufficient time for their DTC functions, and this should be included in their job descriptions.
b. DTC meetings
The DTC should meet regularly every two months, or more often as the need arises. The agenda,
supplementary materials, and minutes of the previous meeting should be prepared by the
secretary and distributed to members in sufficient time before the meeting. These documents
should be kept as permanent records of the hospital. All DTC recommendations should be
disseminated to the medical staff and other concerned parties and authorities in the hospital. 75%
of the membership of the committee will constitute a quorum for any meeting, and 50% plus
members support will approve the decision.
c. Roles and responsibilities of the DTC
The DTC should develop a TOR detailing the objectives, scope, meeting frequency, membership
of the DTC, and roles and responsibilities of each member. The DTC is expected to develop and
implement an annual action plan in line with its roles and responsibilities. To effectively carry
out its mandated objectives, the DTC should have the following roles and responsibilities.
1. Advise the medical, pharmacy, and administrative departments on medicine-related issues.
2. Develops the policies and procedures needed to ensure pharmaceutical availability and their
rational use.
o Policies should be developed for drug supply management, disposal, drug information
services, generic substitution, and therapeutic interchange, monitoring and evaluation of
medicine supply and use, interventions to promote rational use of medicines,
pharmaceutical promotion, and use of specific medications such as narcotics and
psychotropic, chemotherapeutic agents, highly expensive medications, etc.
3. The DTC develops and maintains the hospital’s specific list of pharmaceuticals.
o The list should comprise medicines, medical supplies, consumable medical equipment,
and laboratory reagents that are prioritized as vital (V), essential (E), and non-essential
(N).
o All relevant departments of the hospital should take part in the selection and prioritization
of pharmaceuticals needed by the hospital.
o This list shall be developed based on the MOH Master Medicine List and other lists and
National Essential Medicine List.
o Antibiotics shall be classified as "access, watch, and reserve (AWaRe).
o The hospital should use the list for procurement purposes and the procurement should be
monitored using ABC and VEN analysis methods.
o Tertiary hospitals shall have a formulary manual for specific medicines used for their
specialty services.
o The selection of pharmaceuticals for the hospital-specific medicine list or formulary
manual should be based on:
- The local pattern of disease - Level expertise in the hospital
- Standard treatment guidelines - Diagnostic capacity of the
- The recent national master's hospital
medicine list - Global and national updates and
- Health services package given by recommendations
the hospital
 o During the preparation of the drug list or formulary, emphasis should be placed on:
- Medicines descriptions using generic names
- Dosage form and strength in basic units (for example, Amoxicillin 500mg capsule)
- Inclusion of a limited number of drugs to improve drug availability, adherence to
treatment, focused prescribing, and supply management
o The pharmaceutical list should be reviewed and updated at least annually
o The medicine list should be available in clinical departments, the pharmaceutical store,
dispensaries, laboratories, finance, etc. to be used as references.
4. Monitor medicine procurement and inventory management.
o Developing policies to facilitate the pharmaceutical supply management
o Identifying problems and recommend interventions to streamline the supply management
of pharmaceuticals.
5. Promoting the adoption and utilisation of standard treatment guidelines (STG).
o STGs promote the rational use of medicines and provide a benchmark for optimum
treatment for the monitoring and audit of drug use.
o Specialised hospitals may also develop their own STGs based on the availability of the
required expertise, facilities, etc.
6. Identifying and addressing medicine supply and use problems.
o Monitoring the rational use of medicines by conducting medicine use studies to identify
problems.
o The DTC can use a number of qualitative and quantitative methods to investigate
problems with medicine use and supply.
o The DTC should establish policies and procedures for identifying and managing drug use
problems, including, at a minimum:
- Monitoring adverse drug reactions - Drug utilisation monitoring
- Prescription monitoring - Rational use of antimicrobials
o The DTC follows up on the implementation of these activities by setting up a taskforce
composed of relevant departments.
o When problems are identified, the DTC should devise specific interventions to improve
practises. Interventions may be any one or a combination of the following strategies:
- Educational programmes such as in-service training,
 - Managerial interventions such as the use of standard treatment guidelines and
formularies and establishing antimicrobial stewardship programmes
- Regulatory actions such as controlling medicine promotions, etc.
7. Establishing and overseeing the Drug Information Service (DIS).
o Drug information service provides information and advice to health professionals,
patients, and the public.
8. Cooperating and sharing experiences with other hospital committees and regional or national
DTCs.
9. Promoting the monitoring and management of ADEs
o The DTC should have a plan to monitor, assess, report, correct identified problems, and
prevent ADEs to assure that medicines are efficacious, safe, and of high quality.
o To monitor the use of medications in the hospital, the pharmacy department in
collaboration with the DTC should undertake activities periodically using the following
methods.
- Monitoring of prescriptions - Aggregate data methods
- Monitoring of patient charts for - Indicator study methods
medication therapy - Drug use evaluation methods
i. Prescription Monitoring
Prescriptions should be regularly monitored to identify trends and ensure proper prescribing and
dispensing practice in the hospital. This activity should be conduct ed quarterly. The results
should be communicated to the DTC for proper implementation and follow-up. Patients and their
medicine therapy should be monitored for:
- Legality, legibility and completeness - Compliance treatment guidelines
of prescription - Dose and route of administration
- Appropriateness of prescription papers - The appropriate duration of therapy
used - Significant interactions
- Appropriateness of the medication for - Duplication of therapy
the diagnosis
ii. Aggregate methods: ABC-VEN Analysis
ABC and VEN analysis are aggregate data methods that are used to identify medication use
problems. ABC analysis is a method for determining and comparing pharmaceutical costs within
the formulary system. It follows the Pareto principle of "separating the vital few from the trivial
many". ABC analysis is explained in terms of budget consumed and number of drugs in the
budget list as follows:
Table 2: Criteria to classify pharmaceuticals into ABC category
S. N Category % of budget % of Explanation
consumed pharmaceuticals
1. A – pharmaceuticals 70-80% 10-20%  High percentage of funds spent on
large-volume or high-cost items
 Greatest potential for budget
Savings
2. B – Pharmaceuticals 15-20% 10-20%  Moderate cost and moderate
number of items; important items
3. C – Pharmaceuticals 5-10% 60-80%  Small amount of funds spent on
most of the inventory
VEN analysis
VEN analysis is a method that is used to classify pharmaceuticals into vital (V), essential (E), or
nonessential/less essential (N) as per their clinical importance. It should be included in the hospital-
specific medicine list. It is important that the health facility's DTC ensure that pharmaceuticals are
classified by VEN. This categorization should guide the forecasting, procurement, and inventory
management decisions of the health facility. The criteria for prioritizing pharmaceuticals in VEN are as
follows:
Vital (V)
Vital pharmaceuticals are very essential pharmaceuticals that fulfil one or more of the following
criteria:
- Potentially life-saving,
- Patients may die, be harmed, or be disabled due to a lack of these pharmaceuticals.
- It is crucial to provide basic health services, without which it is impossible to deliver the
basic services (in their absence, service may be discontinued).
N.B.: It is mandatory for these pharmaceuticals always be available; any stock out is not
tolerable.
Essential (E)
Essential pharmaceuticals are those that fulfil one or more of the following criteria:
- Effective against less severe but significant illnesses (it is between vital and essential).
- It is important to provide basic health services, without which patients can face difficulty.
- May be somehow substituted.
Essential to the service, without which it is difficult to provide health services.
Nonessential (N)
Non-essential pharmaceuticals are less-essential pharmaceuticals that are:
- Effective for minor illnesses and have a low therapeutic advantage
- Necessary to provide the health service; however, health service delivery will not be
discontinued in the absence of these pharmaceuticals.
Note: Assignment to the non-essential or less essential category does not mean that the
Pharmaceuticals are no longer on the health facility’s pharmaceutical list.
iii. Indicator study methods
In indicator studies, a selected indicator is set, and performance against this indicator is
measured. Indicators can be developed to assess prescribing, patient care, or facility practices.
Table 3 presents possible indicators that could be used for an indicator study.
Table 3: Selected indicator to assess prescribing, patient care and facility practices

Prescribing Indicators Patient Care Indicators Facility Indicators

 Average number of medicines per  Average consultation  Availability of essential
encounter time medicine list or
 % of medicines prescribed by  Average dispensing formulary
generic name times  Availability of key set of
 % of encounters with an  % of medicines actually indicator medicines
antibiotic prescribed dispensed  Availability of standard
 % of encounters with an  % of medicines that are treatment guideline
injection prescribed adequately labeled (STG)
 % of medicines prescribed which  % of patients who
are from the essential medicines know how to take their
list or formulary list medicines

iv. Drug Use Evaluation (DUE) methods

Drug use evaluation studies measure the use of a specific drug and/or adherence to standard
treatment guidelines (STGs). Studies are particularly important to investigate:
- Perceived overuse or underuse of medications,
- Problems identified by indicator studies,
- High numbers of ADRs,
- Excessive amounts of non-formulary medicines used,
 - Use of high-cost medicines when less expensive alternatives exist, and
- Use of excessive numbers of medicines within a therapeutic category
Problems identified by aggregate methods, indicator studies, and DUE studies may be further
investigated using the qualitative methods: in-depth interviews, focus group discussions,
structured observations, and structured questionnaires.
10. Medicine and Vaccine use and safety monitoring
Medication safety is a growing concern in today’s medical practice because patients are getting
harm because of medication errors, ADR, poor quality products, and system problems.
Medication use and safety monitoring include proper dosing, administration, and toxicity
management of oxygen therapy. Therefore, it is crucial to ensure patient safety through the
implementation of safe medication use practices. Each hospital should implement medication
safety program, including ADE monitoring and reporting, medication reconciliation activities,
identifying high-alert medications, medication and vaccine safety self-assessment, and
implementing new and existing national standards and systems.
The detection of side effects and adverse reactions is important on an individual basis to
optimize patient care, prevent harm, and take any necessary action. DTC coordinate this activity,
in cooperation with pharmacy, medical, and nursing staff, and possibly other facilities. This shall
include:
 The identification and immediate reporting of adverse drug reactions to the prescribing
physician and pharmacy,
 The investigation and validation of adverse drug reactions, including the collection of
follow-up information, treatment, and outcome,
 Documentation in the patient’s health care record,
 The regular reporting of adverse drug reactions to the Drug and Therapeutics Committee,
 The regular reporting of adverse drug reactions to EFDA
The pharmacy department shall maintain current information about adverse drug reactions
occurring within the hospital and in the literature. All health care professionals should vigilantly
monitor susceptible individuals for ADR. A standardized form should be used to record and
report ADRs (Annex 2). An online reporting form is also available on the EFDA website. An
ADR focal person should be appointed by the DTC. He or she is responsible for:
  Ensure that all health professionals are involved in detecting, assessing, managing, and
reporting potential ADRs.
 Ensure that ADR report forms are readily available in all clinical areas and that health
professionals are familiar with the form and how to complete it.
 Receive ADR report forms from clinical staff.
 Analyze ADR data and compile reports.
 Provide regular reports to the DTC and hospital management on ADRs in the facility.
 Report all ADRs to the regulatory body.
The DTC should receive regular reports from the ADR focal person and make any necessary
decisions regarding the use of the drug in the facility. Where necessary, the hospital formulary
should be amended to take account of detected ADRs. Suspected ADRs should be investigated
and managed as follows:
1. Assess suspected ADR with respect to patient details, medicine details, and comprehensive
adverse reaction details.
2. Perform a causality assessment.
The ADR should be classified as:
 Certain: a clear temporal association is established between medicine administration and
the reaction; and/or the results of investigations confirm that there is a relationship
between the administration of the medicine and the reaction; and/or the reaction recurs
upon re-exposure to the drugs; and/or the reaction is commonly known to occur with
suspected drug;
 Probable: the reaction is known to occur with the suspected drug, and there is a possible
temporal association between the reaction and medicine administration; and/or the
reaction resolves or improves upon withdrawal of the suspected medicine and other
medicine therapy remains unchanged; and/or an uncommon clinical event occurs in the
absence of other potentially causative factors;
 Possible: an alternative explanation for the reaction exists; and/or more than one
medicine is suspected; and/or recovery follows withdrawal of more than one drug; and/or
the temporal association between the reaction and administration of the medicine is
unclear; or
  Doubtful: another cause is more likely to have accounted for the clinical event, e.g.,
underlying disease.
3. Make recommendations on treatment options, including possible alternative treatments.
4. Document the ADR and provide follow up advice.
All ADRs should be clearly highlighted in the patient’s case notes. Any patient who has
experienced an ADR should receive advice about the drug and reaction, be advised to avoid the
drug in the future, and be given an ‘alert card’ that states the drug involved and the nature of the
reaction. He or she should be advised to show this card at any future clinical consultation to
prevent the same drug from being prescribed again.
The hospital pharmacy section should complete the reporting form, retain the necessary
documentation, and also mail the ADR report to the regulatory authority, EFDA, as per the
guidance provided.
3.3. Pharmaceutical selection, quantification, procurement, warehouse, inventory management,
distribution, and an effective information management system
To ensure uninterrupted supply of safe, effective, and quality pharmaceuticals, the hospital
pharmacy shall have an effective and efficient supply chain management system. This requires
well-organized and functioning pharmaceutical management information systems (PMIS).
Pharmaceutical supply management at hospitals involves the following basic functions:
selection, quantification, procurement, warehouse and inventory management, distribution,
rational use, and information management.
a. Selection
Hospital pharmacies should have a DTC-approved list of medicines, medical supplies,
equipment, chemicals, and reagents categorized into VEN. The pharmaceutical supply
management unit, in consultation with the various departments in the hospital, selects the
required medicines for procurement as per the approved list.
b. Quantification and procurement
The pharmaceutical supply management unit should collect relevant data from past consumption,
morbidity, service delivery, and other relevant sources that are essential for forecasting and
supply planning. Data to be collected from these sources includes:
- Consumption data: quantity of each product dispensed or consumed over the past 12-
month period
 - Services data: number of visits, number of services provided, lab tests conducted,
treatment episodes, or number of patients on treatment over the past 12-month period
- Morbidity data: incidence and prevalence of specific diseases or health conditions (may
be available by population group or through surveillance or research study groups and
extrapolated to estimate national-level incidence and prevalence of specific diseases or
health conditions).
The hospital shall decide on an appropriate method for quantification. The commonly used
methods for existing facilities are consumption and morbidity methods. Based on the supply plan
prepared, hospitals procure pharmaceuticals in a way that ensures the principles of good
pharmaceutical procurement practice and procedures. All hospitals should have standard
operating procedures for pharmaceutical procurement that comply with national standards and
legislation.
Pharmaceutical selection, quantification, and procurement should fulfil the following minimum
standards:
1. Presence of annual pharmaceutical quantification (forecasting and supply plan) approved by
DTC as per the annual plan: This standard is met when
- The hospital has approved a plan for quantification.
- Professionals from all-important units are included in the quantification processes
- There is a quantification report for the current year.
- There is a detailed supply plan for each product that shows when and how much is
needed in each round of procurement.
- Approved by DTC and documented
2. The hospital reconciles the forecast with the available budget: This standard is met when the
total forecasted value is equivalent to the allocated budget. The allocated budget can be from
internal revenue or from treasury.
3. The hospital has SOPs and policies for quantification and procurement. Quantification and
procurement SOPs can be prepared as one SOP or separately. When there is any change, the
SOPs should be amended. The quantification SOP should include at least the following:
- Selection standards
- Methods of quantification to be used in the hospital with respective data sources
- Time line for forecasting and supply planning
 - Professionals to be involved
- Approved by DTC/management
In addition, the procurement management SOP should include at least the following:
- Methods of procurement open tender, direct procurement, long-term agreements, etc.
- Funding strategies
- Approval by DTC or management
- Responsibilities of each stakeholder involved in procurement (finance, supply chain
management, and others)
4. The hospital should assign a focal person who reports to the supply manager and is
responsible for
- Coordination of quantification
- Working as secretary of the quantification committee
- Updating supply planning
- Conducting stock status analysis
5. The hospital procures all pharmaceuticals from the facility-specific medicine list. These
standard measures the number of pharmaceuticals procured from HFSML. All
pharmaceuticals should be procured from HFSML. If new medicine is to be procured, it
should be approved by DTC. Once approved by DTC and a minute is taken, it can be
considered part of HFSML.
6. The hospital performs supplier fill rate analysis regularly: Supplier fill rate is the percentage
of line items filled against the requested quantity. There should be supplier fill rate reports
for each procurement conducted. This standard is met when there is a supplier fill rate report
for at least the last three procurements conducted. The report should contain the percentage
of each product obtained, the percentage of items in full supply (>= 80%), the percentage of
items supplied from 50% to 80 be supplier fill rate reports for each procurement conducted.
This standard is met when there is a supplier fill rate report for at least the last three
procurements conducted. The report should contain the percentage of each product obtained,
the percentage of items in full supply (>= 80%), the percentage of items supplied from 50%
to 80%, and the percentage of items supplied below 50% (categorized as full, sufficient, and
low supply).
7. The hospital should allocate at least 40% of its budget to pharmaceutical procurement. This
standard helps the hospital secure a sustainable supply of pharmaceuticals. It is measured by
calculating the percentage share of budget or funding allocated for pharmaceuticals from the
total health care budget of the hospital. 40% is the minimum standard expected, and it does
not include the budget allocated for capital item procurement (medical equipment budget).

c. Standardized medical store and inventory management system

There should be standard infrastructure, inventory, and warehouse management systems to
ensure a sustainable supply of pharmaceuticals. These should be accompanied by well-organized
and functioning logistics management information systems, regular stock status analysis, and
timely decision-making. In order to say a hospital has a standardized medical store and inventory
management system, it should fulfil the following minimum standards:
1. Fulfils at least 80% of medical store standards. The average percentage of the medical store
standards should be >/= 80%. This standard is measured using the assessment tool annexed
(Annex 3). The assessment tool should be posted in the medical store with an average store
standard.
2. It should have approved store and inventory management. SOP: Hospitals should have a
medical store and inventory management SOP that describes at least:
A. Medical store standards
B. Internal distribution schedules and reports are required.
C. Lists of products to be distributed to each service delivery point
D. Medical store cleaning schedule
E. Responsibilities of personnel involved in medical store management (store manager,
assistants, cleaners, porters)
F. LMIS standards
3. Presence of updated bin cards (Annex 4): The quantity of all pharmaceuticals on the bin card
should be equal to the physical count at all times. To verify this, 10 products will be
randomly selected, and their actual quantity will be compared with the bin card balance. If
the physical quantity for all the products (10 items selected) is equal to the bin card balance,
the hospital’s inventory accuracy is 100%; therefore, the hospital gets a full mark.
 Otherwise, it will be calculated by multiplying the value given for this standard with the
quotient of accurate items divided by 10.
4. Implement IFRR in all dispensing and service delivery units (Annex 5):: This standard is
fulfilled when:
A. The hospital uses standard IFRR to receive reports from all units; check for five
reports submitted.
B. The hospital posted a schedule for IFRR submission; check for the schedule posted
and adhere by checking five reports.
C. All the information required is complete; see at least five random reports from
different units.
5. Presence of all PMIS formats (Bin cards, RRF, IFRR, M-19 H, M-22 H): All formats
required to record pharmaceutical logistics data should always be available. The hospital
should ensure the availability of this format. This standard is fulfilled if all the forms listed
above are available. For IFRR and RRF, the availability of a soft copy can also be
considered if it is in use.
6. Reports should be timely, complete, and accurate. RRF: This standard requires the
availability of an RRF report. Three recent RRF reports will be checked. The reports should
be complete, timely, and accurate (Annex 6):
7. All hospitals should conduct a physical count in the medical store every quarter. The
availability of the physical inventory report for the recent two quarters will be checked.
8. Conducts stock status analysis (SSA) every quarter and ABC/VEN analysis and
reconciliation at least once per year and uses them for decision-making. There should be an
SSA with a possible intervention report for the recent two quarters, an ABC/VEN analysis,
and a reconciliation report for the last budget year.
9. The SCM unit is a member of the DMAT (Disaster Management Assistance Team) team and
has SOPs for managing pharmaceuticals during emergencies and disaster management.
Emergency and disaster management require multidisciplinary teamwork.
d. Pharmaceutical emergency supply chain management system
Over the years, Ethiopia has had multiple epidemics, which have caused huge losses and
continue to affect the population, including the current COVID-19 pandemic. The response to
COVID-19, which saved lives and disabled people, is a recent and highly commended action by
the country. This effort has averted the loss of countless lives and contributed to the continuity of
livelihoods and the economy.
However, the country does not have a strong emergency supply chain management system
(ESCMS) capacity to support all elements of logistic processes, including coordination of
logistics activities, material flow, inventory replenishment, and supply chain management. The
country needs a robust ESC system capacity to support all elements of logistic processes,
including coordination of logistics activities, material flow, inventory replenishment, and supply
chain management.
Emergency supply chain management is a principle of supply chain and logistics operations as
applied to public health emergency preparedness and response, including the important logistic
operations of selection, quantification, procurement, and sourcing of public health emergency
products as part of the overall preparedness plans for public health emergency response. It also
presents the management of storage, distribution, and fleet management for public health
emergency products, as well as waste management and reverse logistic as related to public health
emergency products.
During emergencies, supply chain management must prioritize stabilizing the critical supply
chain of medical goods, reviewing stockpile options, and identifying alternate supply chains for
emergencies when needed. Integrating the needs of supply chains into mitigation, response,
recovery, and supply planning and actions is key to improving supply chain resilience for health
emergencies and ensuring the availability of key goods and services. The emergency supply
chain framework provides a broad overview of the interlinked functions that support a one-health
approach to the development of a plan for the deployment of medical countermeasures during
public health events. It is comprised of three broad areas: people and processes; commodity
planning and procurement warehousing; logistics; and transportation. Stakeholders' capabilities
along different dimensions of a supply chain, such as technical expertise, personnel,
warehousing, and information on the location of stockpiled commodities, funds, transport, cold
chain, and waste management facilities, shall be identified, properly documented, and
communicated to key implementers on a regular basis.
Coordination and collaboration among public health supply chain stakeholders and resource
mobilization, as well as monitoring and evaluation of emergency supply chain performance, are
the cornerstones of implementing effective emergency supply chain management. The goal of
this implementation guideline is to provide supply chain practitioners involved in the
management of public health emergencies with the basic knowledge, skills, and attitude required
for the supply chain management of health emergency products.
Therefore, it is important to strengthen the health ESCM system of Ethiopia to manage all the
health and health-related items necessary to respond to public health emergencies and ensure that
the needed items get to the point of care as quickly and efficiently as possible. So, strengthening
Ethiopia's health ESCM system will greatly enable it to manage all the health and health-related
items necessary to respond to public health emergencies and ensure that the emergency supplies
get to the last mile as quickly and efficiently as possible.
Implementing ESCM at the health facility level mainly focuses on building the capacity of four
key ESCM preparedness and response areas: people and processes, commodity planning,
logistics and transport, and response. It is mainly to strengthen the health facilities approach to
emergency supply chain preparedness and establish the key elements of emergency supply chain
preparedness. It is a plan to develop and strengthen emergency supply chain preparedness in
Ethiopia with the objective of establishing the health ESCM system to manage all the health and
health-related items necessary to respond to public health emergencies and ensure that the
needed items get to the point of care as quickly and efficiently as possible.
The core team for emergency preparedness and response will be able to:
Familiarize yourself with the core components of public health emergency operations
management in relation to emergency supply chain management.
Understand the basic concepts and framework of emergency supply chain management.
Apply the selection, quantification, procurement, distribution, fleet management, and rational use
activities during different stages of health emergency management. Use reverse logistics and
waste management principles for public health emergencies.
Emergency supply chain management at the facility level should consist of activities such as the
management of stakeholders, strategic planning, and assessment efforts to facilitate efficient and
effective responses in collaboration with other stakeholders.
It also has the following importance:
Reducing the loss of life due to a lack of medicines because of non-prepositioned products based
on the vulnerability index.
Increase the availability of life-saving health products for emergencies where needed.
Increase awareness of ESCM needs by the stakeholders and their coordination governance
structure at all administrative levels to increase preparedness for future epidemic or pandemic
responses.
- Used to design systems for humanitarian and emergency SCM, including stockpiling
protocols to ensure responsiveness to health emergencies.
Every hospital should try to implement functional ESCM by:
- Availing a standard operating procedure for disaster supply management
- Updating the list of medicines and supplies for disaster response regularly.
- Presence of a disaster supply management response plan (a quantified list of medicines
and supplies with a budget)
- Assigning a responsible workforce
- Training necessary staff on disaster supply management systems and ESCM manuals
- Pharmaceutical emergency kit management is used to encourage standardization of the
drugs and equipment used in an emergency; to permit swift initial supply from outside; to
rationalize urgent requests and responses; and to promote disaster preparedness by the
provision of a kit that may be kept in readiness as a stock of essential items. The
composition of the kit should be based on epidemiological data, population profiles,
disease patterns, and certain assumptions borne out by emergency experiences using the
country’s emergency list and guidelines on management of specific health emergency
conditions.
The contents of the kits are frequently reviewed and updated to adapt to changing needs based on
experience in emergency situations.
The management of reverse logistics must consider not only transportation but also information
management and storage. To maintain transportation efficiency throughout the entire supply
network, reverse distribution must be carefully coordinated with the predominant downstream
flow of pharmaceuticals. Unused or overstocked emergency products should be redistributed to
nearby health facilities as per the internal resource sharing guidelines. Logistics personnel and
facility heads of the issuer and receiver health facilities are responsible for redistribution.
Redistribution data should be reported to the next higher level for planning and tracking the
utilization of emergency commodities.
Monitoring and evaluation (M&E) is an integral part of the emergency pharmaceutical supply
chain management plan, which involves setting up systems to consistently review how the
emergency supply chain management response is progressing, point out areas that need
improvement, and determine whether the set goals are being met. It provides guidance for the
gathering of timely, accurate, and complete information for organizing, analyzing, reporting,
monitoring, and evaluating performance; promoting continuous improvement in the ESCM
through timely identification; and addressing implementation challenges. Moreover, it also
allows ESCM stakeholders to know the impact of their efforts and advocacy, as it can highlight
program successes and areas of greatest need.
3.4. Pharmaceutical cold chain and vaccine management
The cold chain is a system of storing and transporting vaccines and medicines at recommended
temperatures from the point of manufacture to the point of use. It includes all of the materials,
equipment, and procedures used to maintain vaccines in the required temperature range of +2 oC
to +8 oC until the product is administered to individuals. Products commonly stored in the cold
chain system are vaccines, glaucoma eye drops, aerosol sprays against asthma, insulin
preparations, biological products, and others.
A vaccine is a biological preparation that provides active acquired immunity to a particular
infectious disease. Vaccines are temperature-sensitive and must be maintained at a temperature
between 2 and 8 oC, unless otherwise indicated. Potency is reduced every time a vaccine is
exposed to an improper condition, and it will become ineffective. This includes overexposure to
heat, cold, or light at any step in the cold chain.
a. Cold chain management policy/procedure
The hospital should have policies and procedures to monitor appropriate storage conditions for
vaccines, order and receive vaccines, report or recall damaged vaccines, and develop procedures
to provide orientation to new staff and others who are responsible for cold chain management. It
should have guidelines for safe waste disposal related to vaccines.
Therefore, the hospital should assign a responsible person and ensure the appropriate cold chain
system required for vaccine storage and transportation to maintain its efficacy. The hospital
should have a SOP for proper understanding and implementation of the cold chain system and
fulfil the following basic materials:
- Ice-lined refrigerator or deep freezer
 - Cold boxes or vaccine carriers for transporting or storing vaccines
- Ice packs to keep vaccines cool
- Material to separate ice packs from the vaccines when using cold boxes (e.g.,
shredded paper, cardboard, bubble wrap)
- Digital, electronic, or mercury/maximum thermometer
- Chart for recording daily temperature readings
The responsible person assigned to the cold chain system will:
- Segregate the vaccines according to their optimum temperature categories as freeze-
sensitive, heat-sensitive, and light-sensitive, and store them to avoid any damage to the
products.
- Check vaccine vial monitor status as it is not to be frozen and thawed.
- Prevent accidental unplugging of the refrigerator and connect the refrigerator to a
dedicated electrical circuit or attach it to a functional UPS.
- Position the refrigerator in a cool area, out of direct sunlight or a heat source, and
- Keep the refrigerator at least 10cm away from the wall to allow for adequate
ventilation.
- Ensure that all ice-lined refrigerators are fitted with the correct vaccine storage baskets.
- Check as vaccines are not stored in a fridge door.
- Store the vaccine in the center of the fridge (vaccines are not to touch the
- back or sides of the fridge)
- Record vaccine refrigerator temperatures twice daily, at the start and at the end of the
working day (Annex 7).
- Should keep temperature logs on file for 3 years.
- Should record any maintenance or repair work done on the fridge on the temperature
log.
- Should prevent the ice packs from coming into direct contact with the vaccine product.
- Should update the bin card (vaccine ledger book) for products managed with cold chain
- Ensure the presence of a cold chain management policy or procedure.
- Ensure regular cleaning and the proper functioning of the refrigerator.
- Should quantify the vaccine required and ensure the availability of sufficient cold chain
storage systems.
 - should place freeze-watches or monitors in the coldest part of the fridge in every
vaccine fridge that stores freeze-sensitive vaccines.
b. Cold Chain Management Principles includes:
- Store vaccines in a purpose-built vaccine or medication-specific refrigerator.
- Nominate a staff member responsible for vaccine storage and cold chain management.
- Ensure policies, procedures, and protocols are in place for vaccine management in the
facility.
- Develop procedures for orienting new staff and staff with new roles who are
responsible for cold chain management.
- Ensure essential equipment is readily available for responses to cold chain breaches and
power failures in the facility.
- Report temperatures outside the +2°C to +8°C range (excluding fluctuations up to
+12°C, lasting no longer than 15 minutes).
- Follow the guidelines for using ice packs and gel packs and monitoring vaccines in
coolers and cold boxes as required during power outages.
- Record the vaccine temperatures on the ‘Vaccine Cooler Temperature Chart’ when
storing vaccines in a cooler.
- Perform vaccine storage self-audits at least once a year.
c. Vaccines arrangement in refrigerators
In health facilities, refrigerators are used to store vaccines and diluents. Several types of
refrigerators are available, and the arrangement of items inside them varies according to the type
of refrigerator. Vaccines and diluents are stored in a dedicated refrigerator that is reserved for
this purpose. In general, the arrangement of vaccines in the refrigerator will take appropriate
spacing and placement of the product to maintain a good storage condition for easy utilization
and monitoring of the products, as follows:
- Put measles, BCG, OPV, yellow fever, meningococcal A conjugate, MR, MMR, and/or
any other vaccines not damaged by freezing on the top shelf.
- Put DTP-HepB-Hib, PCV, IPV, Td, HPV, Rotavirus vaccine, HepB, and/or any other
freeze-sensitive vaccines on the middle or lower shelves.
- Always arrange vaccines and diluents in such a way that it allows air circulation freely.
- Arrange the boxes so that there is at least a 2-cm space between stacks.
- Mark the cartons clearly, and make sure the markings are visible when the door or lid is
opened.
- If vaccines or diluents are supplied in individual containers (vials, ampoules, or tubes),
use a plastic tray, plastic box, or other arrangement to store the vaccines in an orderly
fashion.
- If diluents are supplied separately from the vaccine, store them in the refrigerator if
there is adequate space.
- If there is no adequate space, move the diluents to the refrigerator at least 24 hours
before they are needed so they are cooled.
- Place vaccines with VVMs that show the most heat exposure (darker squares) in a
separate container in the refrigerator, clearly marked "Heat-exposed vials—Use first".
- If there are other vaccines of the same type in the refrigerator, the vaccines with the
darkest squares should always be used first, even if the expiration date is later than the
vaccines with the lighter squares.
- If an opened multi-dose vial will be used for the next session, the vials must be placed in
a separate container in the refrigerator that is clearly marked "Opened Vials—Use
First."
- Put water packs or plastic bottles full of colored water in the space below the bottom
shelf, and this helps stabilize the temperature if there is a power cut.
Table 4: Heat sensitive Vaccines
 Table 5: Freeze sensitive Vaccines

DO NOT arrange the vaccines in the health facility refrigerator like this:
- Never store non-vaccine products in vaccine refrigerators.
- Do not open the door or lid unless it is essential to do so.
- Frequent opening raises the temperature inside the refrigerator.
- If there is a freezer compartment, do not use it to store vaccines and diluents.
- Do not keep expired vaccines in the refrigerator.
- Do not keep vaccines with VVMs that have reached their discard point.
- Do not return reconstituted vials and open liquid vaccines without preservatives to the
refrigerator.
- Discard all these items immediately according to your national guidelines.
Figure 2: Arrangement of vaccines in a refrigerator compartment
Specific rules for using front-opening refrigerators
Different types of front-opening vaccine refrigerators are used for storing vaccines. Figure below
show how a kerosene vaccine refrigerator or an electric front-opening refrigerator should be
organized.

Figure 3: Vaccine and diluent arrangement in a front-opening kerosene vaccine

refrigerator
- Note: In upright ice-lined refrigerators, there is very little variation in the temperature inside
the refrigerator compartment, so vaccines and diluents can be safely placed on any of the
shelves. However, in humid climates, there is a risk of condensation. Cartons and vials should
be stored in plastic boxes with tightly fitting lids to reduce the risk of moisture damage. Never
store vaccines below the bottom shelf; this area may be wet because it collects and drains the
condensation from the roof and walls of the compartment.
Figure 4: Vaccine and diluent arrangement in a top-opening refrigerator without baskets

Figure 5: Vaccine and diluent arrangement in a top-opening refrigerator with baskets

 d. Monitoring of vaccine refrigerator temperature
To ensure good storage and distribution practices, effective, well-managed temperature
monitoring and record-keeping procedures are crucial. A standard manual temperature-
recording pad or chart should be available for each and every vaccine refrigerator. Readings
should be taken twice a day (morning and evening), seven days per week, including weekends
and holidays, and for 30 days. Daily readings should be taken from the same temperature-
monitoring device each time. Recording temperatures provides evidence that the refrigerator is
being monitored and regular readings are being taken. These procedures help to ensure that:
 Vaccine quality is maintained throughout the vaccine supply chain.
 Vaccines are not wasted due to exposure to heat or freezing temperatures at fixed storage
locations or during transport.
 Cold chain equipment performs according to recommended standards.
 Recognize and respond to temperature excursions, and take corrective action when problems
occur.
To achieve these outcomes, the hospital should develop suitable policies and standard operating
procedures (SOPs) and provide adequate training, tools, supervision and resources to ensure that
these policies and procedures are properly implemented.
e. Vaccine vial monitors
A vaccine vial monitor (VVM) is a label containing a heat-sensitive material that is placed on a
vaccine vial to register cumulative heat exposure over time. The combined effects of time and
temperature cause the inner square of the VVM to darken gradually and irreversibly. The rate of
color change increases with temperature.
The inner square of the VVM is made of heat-sensitive material that is light in color initially and
becomes darker when exposed to heat. The inner square is initially lighter in color than the outer
circle. It remains so until the temperature and/or duration of heat reach a level that is likely to
degrade the vaccine beyond the acceptable limit. At the discard point, the inner square is the
same color as the outer circle. This indicates that the vial has been exposed to an unacceptable
level of heat and that the vaccine may have degraded beyond the acceptable limit. The inner
square continues to darken as heat exposure continues, until it is much darker than the outer
circle. If the inner square becomes as dark as or darker than the outer circle, the vial must be
discarded. The pharmacist in charge should properly follow VVM and take the necessary action
accordingly.

Figure 6: Vaccine vial monitoring criteria

f. Bin card update
The Bin Card should be kept with the product in the storage area. The staff in charge should
record transaction of vaccines and update bin cards, and maintained for each product. Bin Card
should be used to:
• Record vaccine products received
• Record vaccine products issued
• Record changes in its stock balances
• Track supplies moved through non-routine methods (e.g. Transfers)
• Track losses/adjustments record expiry dates
g. Cleaning and defrosting of refrigerator
Frost formation is a sign of malfunctioning of the equipment, either due to incorrect setting
of the thermostat or incorrect operation of the equipment. Frost increases electricity
consumption and also makes the refrigerator less efficient. The accumulated frost must
be removed, i.e. the equipment must be “defrosted”. This requires technical intervention
as the vaccines are put to risk. It is recommended that the appliance be defrosted every
month or earlier if the frost thickness on the inner wall is more than 5 mm.
Therefore, to defrost the vaccine refrigerator
 • Transfer vaccines to a working refrigerator or cold box with conditioned icepacks
• Turn off the power supply to the refrigerator
• Leave the lid or door open and wait for the ice to melt
• Do not try to remove the ice with a knife or other sharp object
• Doing this can permanently damage the lining
• Clean and dry the inside of the appliance
Turn on the power supply to the refrigerator on again. When the temperature falls to +8°C or
lower (but not less than +2°C), return the vaccines, diluents, and/or cool water packs.
h. Maintaining functionality of refrigerator
• The refrigerators functionality should be monitored and checked regularly
• The refrigerator or freezer door seal should be regularly checked for signs of wear
• Any dust residue should be cleaned from the unit’s coils and motor since it will cause the
unit to work inefficiently
• Make sure all cooling fans both inside and outside the appliance move freely and clear of
all dust
• Check the appliances plug, make sure it is not broken, twisted up, melted or burnt looking
• Be sure the units power cord and all other electrical connections are not worn out
• Make sure all wires are secure and have no insulation stripped with exposed conductors
showing
• If any frost buildup is more than 1/4 inch thick , the refrigerator need to defrosted
following the manufacturers defrost instructions
i. Vaccine distribution
Distribution of vaccine requires the availability of appropriate vaccine cold chain transport
equipment such as cold boxes or vaccine carriers, and ice packs to prevent the damage of vaccine
products due to exposure to unnecessary heat, cold and light.
Cold Box
A cold box is an insulated box used for transportation and emergency storage of vaccines and ice
packs.
 Should be large enough to store vaccines and icepacks during transport
 Used to store vaccines for transfer up to 5 days, if necessary for outreach sessions
  Store vaccines in case of breakdown of ILR or when there is a power cut, as a
contingency measure
 It is also used for storing frozen ice packs, e.g. during emergencies and before campaigns
 Its external surface material needs to be durable and robust
 Lid needs to be tight fitting
 Strong handles for carrying the cold box
 A dedicated cool box should be used for each delivery
Packing a cold box
- Place conditioned ice packs at the bottom and sides of the cold box
- Load the vaccines in cardboard cartons or polythene bags
- Never place freeze-sensitive vaccines in direct contact with the ice packs
- Keep a thermometer in the cold box
- Place two rows of conditioned ice packs above the vaccine vials
- Place a plastic sheet to cover the ice packs kept on top to ensure full holdover time
- Securely close the lid of the cold box
Vaccine carrier
It is an insulated box used for carrying vaccines (16–20 vials) and diluents from the cold-chain
point to session sites and to bring back the open vials from the session sites to the cold-chain.
Vaccine carrier (with 4 conditioned ice packs) maintains the inside temperature between +2°C
and +8°C for 12 hours, if not opened frequently.
Packing a vaccine carrier
- Confirm that there are no cracks in the walls of the vaccine carrier
- Take out the required number of ice packs from the deep freezer and wipe them dry
- Keep them outside for conditioning before placing into the carrier
- Place four conditioned ice packs into the vaccine carrier along the sides
- Wrap vaccine vials and ampoules in thick paper, e.g. plain white paper before putting in a
polythene bag so as to prevent them from touching the ice packs
- Place the plastic bag in the center, away from the ice packs; this will prevent labels from
peeling off from the vials
- Place foam pad on top of the ice packs
- A foam pad is a piece of soft foam that fits on top of the conditioned ice-packs in a cold box
or a vaccine carrier
- If more than one vaccine carrier is being carried, keep the whole range of vaccines required
for the day’s use in each carrier so that only one carrier is opened at a time
Ice packs
Ice packs are plastic containers filled with water. These are hard frozen in the deep freezer.
They are placed inside a vaccine carrier and cold box to improve and maintain the holdover time.
They are also used in ILRs as inside lining to improve and maintain holdover time during
electricity failure. Frozen ice packs must be used with extreme caution and not to be allowed to
come into direct contact with vaccines. Any spaces within the cool box should be filled with
insulating material.
3.5. Medical Oxygen Supply management
Medical oxygen is lifesaving and an essential element of appropriate management for a wide
range of clinical conditions. It can be used for the treatment of multiple acute and chronic cases
related to respiratory illness and other conditions, which include trauma, safe surgery, anesthesia,
and obstetric care. The ability to detect and treat hypoxemia is critical for patient care and the
quality of services, especially for children and neonates. As a life-saving medicine, oxygen
should always be available at all hospitals. Oxygen is vital to combat pneumonia-related
mortality and morbidity in under-five children and for the treatment of many emergencies.
Sustained and adequate availability of oxygen is required to ensure implementation of MOH
initiatives, including the Newborn and Child Survival Strategy, the Maternal and Neonatal
Health (MNH) Road Map, the Saving Lives Through Safe Surgery Initiative, the establishment
of trauma centers, the strengthening of emergency medical services, and the expansion of ICU
services to realize the health sector transformational plan.
Focal person and medical oxygen supply management Policy
A multidisciplinary group is responsible for the safe use of oxygen in the hospital. There are
aspects of these systems that fall under the responsibility of various professionals, including
anesthesiologists, pharmacists, nurses, engineers, maintenance personnel, and gas suppliers. The
hospital should assign a pharmacist from the PSM unit to coordinate oxygen supply and use
activities. The hospital should also have an oxygen supply management policy to guide the
management of medical oxygen within the facility. The policy should indicate the roles and
responsibilities of the focal person and staff involved in oxygen supply management. The policy
should also include issues related to medical oxygen and related devices inclusion in the
medicine and medical device list, quantification and procurement of medical oxygen and medical
devices, handling, storage, distribution within the hospital, related recording documents, and
reporting.
The hospital oxygen supply management policy should include national standard systems in
terms of color coding, sizing, Paraphrase Text and units used.
Quantification and procurement
Proper oxygen delivery service requires the availability of medical oxygen and related oxygen
devices. Medical oxygen supply management should always ensure the availability of medical
oxygen 24/7. To ensure this, the hospital should include medical oxygen in its medicine list as a
vital medicine and quantify and procure it with other pharmaceuticals. The quantification and
procurement should also include consumable oxygen devices and ensure the availability of
oxygen face masks (infant, pediatric, and adult), nasal cannulas (infant, pediatric, and adult),
oxygen T-pieces, oxygen tubing, oxygen cylinders, oxygen concentrators, oxygen trolleys, pulse
oximeters, oxygen regulators, oxygen analyzers, flow meters, pulse oximeters, and other required
devices. The quantification of oxygen requirement should consider the expected number of
patients that require medical oxygen in all departments of the hospital, including emergency,
inpatient, maternal, pediatric, etc. In addition, the quantification of oxygen and its consumables
should be done using the MOH quantification tool prepared for this purpose Oxygen supplies are
available in two different standards: industrial oxygen and medical oxygen. Medical oxygen
supply via cylinder includes the procurement of oxygen cylinders, their transport (both full and
empty), and their refill (Annex 8).
Medical oxygen is prescription medicines. The supply management of oxygen should ensure
the protection of the patients who need medical oxygen from cylinders. Medical oxygen
provision companies that fill/refill medical oxygen cylinders should be registered by EFDA.
These suppliers need to comply with the required standards for medical oxygen. Proper pre-fill
inspections, labeling, and testing should be required. If the hospital is switching oxygen cylinders
or suppliers, then it is susceptible to impure oxygen due to the contaminants entering the
cylinder. Due to the fact that all medical gases are considered medicines which are only available
by prescription, the standards with which they are governed are strictly controlled by EFDA. The
hospital should also establish its own standards on the handling and use of compressed medical
oxygen.
Monitoring patient’s response to Oxygen
Oxygen is expensive, so it should be used only in situations where it is necessary and
discontinued as soon as possible. Oxygen has potential risks if it is not administered safely and
appropriately. Monitoring the patient’s response to oxygen therapy is very important. To ensure
the patient received an adequate concentration of oxygen, an oximeter should be used according
to the manufacturer’s instructions. The content of cylinders should be checked, and how long
they will last should be calculated. This is especially important for cylinders on resuscitation
trolleys and when transferring a patient. It is possible to determine how long cylinders can last
using the formula:
Time until the cylinder is empty = (Tank pressure (200) X cylinder conversion factor)/Flow
rate (LPM)
Sources of Oxygen
The hospital should have a reliable oxygen source (preferably a central oxygen supply). The
hospital should ensure that a source of oxygen is always available. There are three main sources
of oxygen. These are oxygen cylinders, oxygen concentrators, and oxygen plant distribution
systems.
Oxygen Cylinder: An oxygen cylinder is filled with oxygen under high pressure. An oxygen
cylinder does not require electricity; however, it requires a special regulator to control the flow
of oxygen. It is important to ensure that a backup cylinder is available in case the first cylinder
becomes empty.
Oxygen Concentrator: An oxygen concentrator is a medical device that can serve as a reliable
source of quality, medical-grade oxygen for patients. It produces oxygen by extracting oxygen
from the ambient air and separating it from nitrogen.
Oxygen Plant:
Concentrated oxygen refers to oxygen that is a minimum of 90% pure with moisture removed to
a 100-degree Fahrenheit dew point. It can be produced from an oxygen concentrator or from a
plant and delivered in a pressurized cylinder bottle. Oxygen cylinders can be used stand-alone, in
conjunction with, or as backup for other sources of oxygen (e.g., oxygen concentrators). Oxygen
cylinders can be an alternative to oxygen concentrators; although concentrators can produce a
constant flow of oxygen, they do require intensive maintenance and a reliable power supply.
Oxygen cylinders are also found in ambulances for patient transport when oxygen is necessary.
Medical oxygen storage
Medical oxygen cylinders have to be stored in a dry and well-ventilated room. The room must
not contain flammable materials like fuel or paint, and it must always be locked. Different gases
should be stored separately. Mechanical assistance should be used when handling and it
shouldn’t be rolled along the ground. The person responsible for storing medical oxygen
cylinders should ensure that cylinders are stored and used away from sources of ignition.
Smoking and open flames close to gas cylinders are dangerous and are prohibited in and around
this room. Warning signs in the local language should indicate this. When medical oxygen
cylinders are stored,
 Always physically separate full and empty medical gas cylinders, even if they are in the
same enclosure. This can be done by using separate racks, physical barriers, or color-coding
the storage rack.
 Be sure to label the cylinders clearly (open, empty, full, or unopened). Staff should not have
to spend additional time trying to determine whether a cylinder is full, partial, or empty.
Proper labeling from the outset helps to avoid confusion and delay if a full cylinder is
needed quickly; proper labeling could save a life.
 Consider any open cylinders "empty". Though it is perfectly reasonable to use partially
filled cylinders, these should never be stored with full or unopened ones.
 The potential for fire risk must be considered when evaluating medical gas cylinder safety.
The amount of any medical gas, no matter its properties, must be monitored and managed when
stored in or near patient areas. The addition of concentrated oxygen to a fire greatly increases its
intensity and can even support the combustion of materials that normally do not burn.
Medical oxygen management information system (Bin card, IFRR, Monthly consumption
tracking)
The hospital should record the stock status of oxygen using a bin card. Use the oxygen IFRR for
internal facility distribution (Annex 9) and the monthly consumption tracking chart for reporting
medical oxygen consumption every month (Annex 10).
Medical oxygen distribution
Medical oxygen can be stored in cylinders in either compressed or liquefied form. Medical-grade
oxygen could be manufactured on-site by establishing an oxygen plant or oxygen concentrator
where ambient air is extracted, compressed, and fed into a piped network in a health facility. The
hospital could also get filled medical oxygen cylinders from a nearby hospital that has an oxygen
plant. Medical oxygen cylinders could also be provided by licensed manufacturers who meet the
quality controls established by the EFDA.
An oxygen analyzer or meter should be present if oxygen is being sold or where oxygen
concentrators have to be maintained or repaired. Medical oxygen must be extremely pure; it has
to correspond to >99.995%. Be aware of the color coding of cylinders to avoid confusion
between medical oxygen cylinders and other compressed air cylinders (medical and nonmedical).
It is also important to ensure the quality of supply and that the product is not adulterated in the
distribution system by meeting the agreed specifications. When a gas cylinder is to be
transported, the metal protection cap should always be mounted. It protects the valve from
tearing off in case the cylinder falls over. Oxygen cylinders shouldn’t be transported in the
passenger compartment of a vehicle.
3.6. Pharmaceutical waste management
Health commodities wastes are all wastes that are generated in the hospital while using health
commodities during diagnosis, treatment, immunization, compounding, and manufacturing of
health commodities. To protect patients, health workers, supportive staff, the community, and the
environment, handling, transportation, and disposal of health commodities wastes should be
guided by regulatory bodies' health commodities waste disposal guidelines. Each hospital should
establish a health commodities disposal committee comprised of representatives from pharmacy,
finance/audit, and sanitation services to ensure the proper disposal of health commodities wastes
in accordance with the country’s law. The DTC should prepare a SOP, which contains the
schedule, methods, materials, and equipment required for disposal that will be used by the
committee. The SOP should also clearly identify the responsible person for the proper
management of health commodity waste, and the hospital should work out activities to minimize
pharmaceutical waste below 2%.
Hospital pharmacy and cleaning staff should be trained and well informed about the potential
risks of hazardous health commodities and their management.
The following key activities should be performed in health commodity waste management:
  Segregate, count, record, and place separately all expired, damaged, or unfit for use
health commodities from the usable health commodities with registration in standard
format.
 Submit the segregated health commodities data to the management of the hospital to
secure approval for the disposal. It should be accompanied by lists of products to be
disposed of clearly stating trade name and/or generic name, strength (where applicable),
dosage form, pack type and size, quantity, batch number, expiry date, manufacturer,
supplier, country of origin, and product price (Annex 11).
 Sort the expired or unfit-for-use health commodities based on the pharmaceutical dosage
forms.
 Segregate and choose the appropriate disposal method. For those health commodities
wastes that cannot be disposed of at hospital level, the hospital shall submit disposal
applications to central disposal sites, respective suppliers, or licensed disposal firms and
shall report or copy to the appropriate administrative structure. In addition, it also
requests approval for the disposal of medicine waste, except recyclable materials, cartons,
leaflets, and labels, by submitting applications to the appropriate organ.
 The hospital should retain a signed and stamped certificate of disposal from the
authorized body entitled to dispose of the health commodities. Depending on the risk of
health commodity waste and the complexity of the disposal method, the hospital may use
a disposal referral system. If that is the case, disposal service applications to licensed
disposal firms shall be filed.
 Adjust the inventory management system for each disposed health commodity.
 Methods of disposal of health commodities should be based on the directive of the
national regulatory body and supported by proper documentation, including the price of
the products for audit and other legal requirements.
3.7. Auditable pharmaceutical transactions and services (APTS) and good dispensing practices.
APTS is a data driven package of interventions designed to establish accountable, transparent,
and responsible pharmacy practice. It enables health facilities to optimize utilization of
medicines budget, improve access to medicines, and decrease wastages. APTS continuously
monitors the number, mix & performance of pharmacy workforce. It also improves pharmacy
premise design and workflow. Through improving recording and documentation, it generates
reliable and consistent information for decision-making. As a result, APTS improves overall
quality of pharmacy services thereby increasing patient knowledge and satisfaction. Ultimately it
contributes to better health outcomes.
APTS has five result areas: efficient budget utilization, transparent and accountable transactions,
reliable information, effective workforce development and deployment, and improved customer
satisfactions. To achieve these results, hospitals are expected implement selected interventions.
The following list provides guidance on what needs to be done to achieve each of these results.
Presence of dedicated pharmacy accountant and office with computer, shelves, file folders and
standardized premises to keep patient safety, privacy, and satisfaction are some of the five result
and verification criteria to measure APTS functionality.

Figure 7: Key result areas of APTS

a. Efficient Budget Utilization
- Identifying the top diseases in the area and the medicines, supplies, and reagents used to treat
them
- Procurement should be conducted from the hospital medicine list.
- The hospital should measure the waste rate of medicines on a monthly basis.
- Developing an essential medicines list per health facility and identifying medicines by category
(like a master list) and by ABC/VEN matrix reconciliation analysis
- Analysis: consumption to stock ratio (CSR) and stock status analysis (SSA) and using stock
transfer, resource sharing, and reverse logistics to reduce wastage and increase availability.
Result of efficient budget utilization is to improve availability and reduce misappropriations and
wastage rate.
b. Transparent and Accountable Transactions
The process of receiving, issuing, and dispensing pharmaceuticals in hospitals should be
transparent and accountable. Pharmaceuticals are received at the pharmacy store from EPSS and
other sources. The pharmaceuticals received by the store are issued to dispensing outlets. From
the dispensing outlets, medicines are dispensed to patients in cash, for free, or on credit. All
transactions should be conducted using legally approved and pharmaceutical-specific models,
sales tickets, and dispensing registers. The flow of pharmaceuticals from distributers to end users
in the hospital shall include:
Receiving
All pharmaceuticals (medicines, lab reagents, medical supplies, and equipment) should be
received and managed by the hospital Pharmaceuticals Store. Pharmaceuticals need to be
physically inspected before receiving. In physical inspection, the store manager and supply
management officer make sure that the products received are as per the list, quantity ordered and
expected quality. Once pharmaceuticals are received, inventory records are immediately updated.
Pharmaceuticals should be requested using standard format (RRF) from EPSA every two month.
Issuing
Each dispensing unit should have an agreed-upon list of pharmaceuticals, including the
maximum (one month) and minimum (two weeks) quantities to be stocked in the dispensing unit.
The stock list of each dispensing unit should be approved by the pharmacy head. Each
dispensing unit should maintain bin cards for all pharmaceuticals in the unit, with shared
responsibility by bin owners.
Dispensary transactions and billing
The provisions of the Health Care Finance Reform Legislation enable hospitals to raise and
retain revenue. The sale of pharmaceutical products is an important source of hospital income.
Except for exempted health program (immunization, TB, leprosy, ART, and MNCH),
pharmaceuticals can be sold at a price that covers the actual cost of the medicine plus a service
charge. Transparent and uniform procedures should be established for setting the sale price of
each pharmaceutical and for recording sales.
The retail price of each pharmaceutical should come from the store when issuing vouchers
(model 22/health). Each dispensing unit should sell pharmaceuticals at the stated price. All
pharmaceuticals should be dispensed or sold using a standard sales ticket designed for the
purpose and approved by the Federal Ministry of Finance and Economic Development or the
respective regional finance bureaus. The pharmacy professional is responsible for recording each
medicine with full descriptions, uniquely identifying codes, and retail prices on the intended
sales tickets or free registers. The pharmacist also must record all services provided, DTP
identified by prescription evaluators, and counseling made for clients. The pharmacy accountant
summarizes all transactions (financial value, dispensed medicines, and services) on a daily basis
and prepares a report on a monthly basis as per the APTS guidelines. Auditors, in collaboration
with pharmacy professionals and DTC members, should use the document for auditing the above
transactions and improving the service. All activities should be performed using the following
legal framework and tools:
 Enacted legal frameworks, APTS regulations, directives, and guidelines.
 Tools: vouchers (Model 19 health and 22health), sales tickets, and registers; price control
sheets, IFRR, and RRF.
 Bin ownership, role, and responsibility of professionals for controlling medicines and
using physical inventory sheets (before, during, and after) by using the best experience of
IDA (international dispensary association) principles
 Unique identifier (base code) for professionals and auditors
 Auditing tools: beginning, received, issued, transferred, expired, and ending stock
c. Pharmacy Organization, Workflow, Workload Analysis & Deployment
All hospitals should develop detailed job descriptions for all staff in the pharmacy department.
The level of effort for each unit should be measured, and the workload should be calculated.
Based on the workload, hospitals should take subsequent measures.
Figure 8: Pharmacy patient flow arrangement in APTS implementing health facilities
The following assumptions are used for workload analysis for OPD pharmacies:
- For dispensaries, 1000 prescriptions (or 1800 counseling episodes) per pharmacist per month
- For clinical pharmacy services in wards, there are 25, 30, and 35 beds per pharmacist per day
for tertiary, secondary, and primary hospitals, respectively.
- For chronic pharmacies, 30 prescriptions per day per pharmacist
- The accountants’ practical experience showed that 5000 patients per month
- For cashiers, the number of patients served by one cashier at a dispensary is up to 500 per day.
The pharmacy model for chronic patients is designed to serve them in a special counseling room
that has a table height of 0.75 meters and chairs for both pharmacists and patients.
d. Improved Pharmacy Service and Satisfaction of patients and professionals
The eventual success of hospital pharmacy service is to meet client demand and improve their
satisfaction through improved availability of medicines and quality pharmaceutical services.
Dispensing workflow arrangements and providing a one-stop-shopping service enhances client
convenience and reduces waiting time. Regular workload analysis and human resource
deployment enable efficient manpower use and reduce patient waiting times. This and the other
create an environment whereby patients are empowered to properly adhere to prescribed
medicine by improving their knowledge and satisfaction.
a. Improved availability and patient knowledge on the correct dosage will increase
satisfaction.
b. Workflow: Entrance door (Rx evaluator, cashier, counselor) and exit doors
 c. Rx evaluator and biller, cashier, and medicine use counselors; all in one queue, and one-
stop shopping service (in one workplace)
d. Increase care time and reduce waiting time.
e. Very suitable for both patients and professionals.
f. Improve patient satisfaction with good patient knowledge on the correct dosage.
e. Reliable Information for Decision Making
All hospitals should produce reliable information on products, financial values of medicines
transacted, and pharmaceutical services rendered on a monthly basis. The pharmacy report
should be linked to the serial numbers of financial tools for ease of documentation, reference,
and validation. Information concerning the financial values includes the value of medicines sold
in cash, on credit, or for free.
Service-related information includes the total number of patients served per health facility, per
dispenser, per month, segregated by service type, which may include services rendered for
paying, credit, and free patients; outpatients, inpatients, and emergency patients; mothers and
children; patients with chronic illnesses; patients taking medicines for OIs; and so on.
This information should be used for decision-making. Hospitals should also use product
information like consumption-to-stock ratio analyses, availability of medicines for the top ten
diseases, rate of expiration, and affordability to take subsequent measures for improving
services.
 Generate monthly financial reports in cash, credit, or for free.
 Generate a service report that indicates the number of patients served per health facility and
dispenser per month, segregated by service type and unit.
 Generate information on stock and consumption analyses, availability, and affordability of
medicines.
 Use reliable information (referring to the serial number of receiving, issuing, and dispensing
tools) for service and financial reports so that it can be used for decision-making.
f. Good Prescribing and Dispensing Practice
Good Prescribing and dispensing practices provided by health professionals have a crucial role in
promoting rational drug use, ensuring treatment outcomes, and hence saving lives. For better
patient outcomes, the prescriber should identify the patient’s problem, define effective and safe
treatments, select appropriate drugs, dosage, and duration based on national standard treatment
guidelines (STG) or protocols, and then write a clear prescription. The hospital should ensure the
availability and utilization of STG among prescribers. Continuous monitoring and evaluation of
adherence to STG should be done.
On the other hand, good dispensing practice is the delivery of the correct medicines to the right
patient in the required dosage and quantities in a package that maintains acceptable potency and
quality for the specific duration with clear labeling and drug information. In order to provide
quality dispensing services, the dispensing unit has to be equipped with the necessary facilities,
and the premises should allow a logical flow of the dispensing process so that it reduces waiting
time, ensures patient knowledge, convenience, safety, and confidentiality, and ultimately
achieves better patient satisfaction. For these, reference materials like STG/formulary/protocol,
facility-specific medicine lists, and dispensing aids like tablet counters, cutters/scissors, medicine
envelopes, markers, and other labeling materials should be available at all dispensing outlets.
As part of the outpatient pharmacy service, oral solid dosage forms reconstitution services should
be provided. Oral powders for suspension, dispersible tablets, and oral rehydration salts are the
major categories of medications that need reconstitution before administration. It helps to ensure
that a safe and clean solvent is used and minimize errors in reconstituting the medicines to a
negligible level so that adverse effects and treatment failure risks due to under- and over-dosing
from incorrect reconstitution practice by careers and patients at home could be avoided. During
reconstitution, the dispenser should properly demonstrate how to reconstitute powder forms and
dilute dispersible table to the patient or career. After the reconstitution, the first dose should be
administered in the pharmacy with appropriate counseling and labels.
The dispensing process involves stepwise activities. These are: interpretation and evaluation of
prescriptions; selection and manipulation; labeling and packaging; counseling of patients on
appropriate use of medicines; recording of information; and filing of prescriptions.
The dispensing process involves stepwise activities. These are: interpretation and evaluation of
prescriptions; selection and manipulation; labeling and packaging; counseling of patients on
appropriate use of medicines; recording of information; and filing of prescriptions.
Step 1: Receiving, validation, interpretation and checking appropriateness of a prescription
The pharmacy professional receives prescriptions in a professional manner, validates them for
completeness, legality, and legibility, and evaluates any drug therapy problems using the
standard checklist (Annex 12). Then, the pharmacist confirms the appropriateness of the drug
choice, dosage form, strength, dose, frequency, and duration of treatment with the diagnosis. The
pharmacist is also required to identify any medicine interactions, contraindications, ADRs, and
treatment duplications, paying special attention to pregnant mothers and children. He or she also
monitors the utilization of standard prescription paper.
Orders received by word of mouth or through the telephone for emergency cases should later be
endorsed by the prescriber and documented in writing. During receipt of a prescription, the
pharmacist should identify the patient, the prescriber, and the entity responsible for payment (as
applicable). Any problems identified should be discussed, and solutions should be solicited in
consultation with the prescriber, pharmacists, and patient.
Step 2: Billing and recording of transactions
The pharmacy professionals should perform the necessary calculations related to the quantity and
cost of medicines to be dispensed. Medicines dispensed should be recorded and documented as
proof of the transaction between the patient and the pharmacy professional. Prescriptions can
therefore be traced back if any need arises. Billing and recording of transactions (products and
services) should be conducted using standardized records (seriously numbered sales tickets and
registers). For drugs that are not available in the pharmacy, those items should be copied on a
blank prescription and signed by the dispenser with the word ‘copied’ on the prescriber’s
signature space or using a transcription paper copy. On the original prescription, this is retained
by the pharmacy, a “mark should be placed adjacent to those items that have been dispensed and
an “X’ for items that are not dispensed?
In addition to standard documentation practice, in specialty pharmacy outlets such as ART,
chronic care, and other pharmacy outlets, specific service records should be maintained. For
instance, patient information sheets (PIS), patient tracking charts (PTC), and ARV drug
dispensing registers should be properly recorded and updated in the ART pharmacy; similarly, it
will be for chronic and other services.
Step 3: Selection, manipulation or compounding of medicines:
Medicines should be selected carefully with a prescription at hand. The counting of tablets and
capsules should be done on a clean counting tray. Cross-checking the name, strength, and dosage
form of prescribed medicines with the container should be done at least twice to minimize errors
during assembling the medicines. Compounding of extemporaneous preparations should be done
in a separate room with the appropriate staff, equipment, and procedures (see the compounding
section).
Step 4:Packaging and labeling of medicines
The packaging materials for dispensing medicines must maintain the quality and potency of the
medicines. It should be protected from moisture, light, and contamination. All medicines to be
dispensed should be labeled, and the labels should be clear, legible, and indelible. Printed labels
are advisable for patient safety. The label should at least indicate the patient's name, the generic
name of the product or active ingredients (for compounding), strength and dosage form, dose,
frequency, route of administration, and duration of treatment (Annex 13).
Step 5:Provision of medicines with counseling to a patient:
All drugs should be dispensed with adequate and appropriate information and counseling.
Information must be structured to meet the needs of individual patients. Written information
should be provided to supplement verbal communication. Counseling should ensure that the
patient has an adequate understanding of the instructions and any distinct characteristics or
requirements of the medicine. The pharmacist should confirm that the patient has understood at
least the dose, frequency, duration, and route of the dispensed medications (Annex 14).
Step 6: Filing the prescription
Each prescription (signed by the prescriber, evaluators, and counselors) should be filed properly.
3.8.Clinical pharmacy services
Clinical pharmacy services are patient-oriented services developed to promote the rational use of
medicines and, more specifically, to maximize therapeutic benefits, minimize risk, and reduce
cost. Clinical pharmacists are responsible for managing medication therapy in direct patient care
settings (inpatient, outpatient, emergency, and other departments). They assess patients to
identify drug therapy needs and problems, propose care plans, recommend choices, and hence
contribute to therapeutic decisions, thereby improving treatment outcomes. The service should
be well integrated with all clinical departments.
Clinical pharmacy services are provided based on pharmaceutical care principles. The delivery
of pharmaceutical care involves the following logical processes:
 Assess the patient’s medication therapy needs and identify actual and potential drug
therapy problems (DTP).
 Develop a care plan to resolve and/or prevent the DTPs.
 Implement the care plan.
  Evaluate and review the care plan.
a. Assess the patient’s medicine therapy needs and identify actual and potential drug
therapy problems (DTP)
A drug therapy problem is any undesirable event experienced by a patient that involves, or is
suspected to involve, medicine therapy, including medical oxygen, and which interferes with the
achievement of the desired goals of therapy. Through assessment, the pharmacist establishes the
existence of any therapy needs or problems with the drug therapy by interpreting information
collected from patients, careers, medical records, and other healthcare professionals.
b. Develop a care plan to resolve and/or prevent the DTPs
At this step, the pharmacist determines how to manage the patient’s medical conditions
successfully with pharmacotherapy. The pharmacist establishes the goals of therapy by
negotiating and agreeing upon endpoints and a time frame for pharmacotherapies. Then
appropriate interventions are determined to resolve DTPs, achieve goals, and prevent new
problems by considering therapeutic alternatives and selecting patient-specific pharmacotherapy,
patient education, and other nondrug interventions. Finally, a schedule is established for follow-
up evaluation that is clinically appropriate and convenient for the patient. The responsible
clinician should be informed and agree on the plan before implementation. In developing the
care plan, the pharmacist should ensure that the patient is well informed of the process being
undertaken.
c. Implement the care plan
The pharmaceutical care plan is implemented with the patient's agreement and within the context
of the patient's overall care, in cooperation with other members of the health care team.
d. Evaluate and review the care plan
At this step of the pharmaceutical care process, the pharmacist evaluates the effectiveness and
safety of pharmacotherapy and makes a judgment as to the clinical status of the condition being
managed with pharmacotherapy. Patient compliance is also assessed, and new DTPs are
identified, if any. Finally, the next follow-up evaluation is scheduled.
Although all patients benefit, it is necessary to select patients who would benefit most from a
pharmaceutical care plan. Hence, the following group of patients should be considered:
 Those with multiple conditions or drugs
 Those whose age, weight, or clinical state may affect drug PK and PD
  Patients taking medicines known to have a high risk of toxicity
 Patients taking medicines with a narrow therapeutic index
 Patients taking medical oxygen therapy
 Patients taking medicines that may interact
 Patients whose therapy is changed frequently
 Patients who have an advanced disease state and/or develop complications
 Patients who failed to respond to initial therapy and continue to deteriorate
During the provision of clinical pharmacy services in the inpatient setting, the following
activities need to be performed:
Admission medication history taking
Using an in-patient medication profile form (Annex 15), a pharmacist working in a specific ward
will be responsible for taking the admission medication history either together with the admitting
physician or independently. The information collected during the process will be documented in
a patient chart so that it will be an input for subsequent decision-making for the MDT.
Admission medication history includes, but is not limited to:
 Pertinent patient demographics
 Past or current medications (prescription drugs, including medical oxygen, over-the-
counter drugs, herbal medicines, or supplements)
 Any known drug allergy (KDA)
 Adverse drug reactions
 Overall patient adherence to therapy
 Social habits
 Immunization status for a child and pregnancy status for women
Patient monitoring and follow-up
The pharmacist shall be responsible for monitoring the outcome of drug therapy from
effectiveness and toxicity perspectives for admitted patients based upon relevant laboratory data,
radiological findings, physical findings, and subjective findings and documenting it on the
pharmaceutical care progress note recording form (Annex 16) in a patient chart. These include:
 Assess whether the goals of therapy are achieved or not.
 Identify existing or potential adverse reactions and/or treatment failures and
 recommend management approaches.
 Identify drug incompatibilities and interactions with clinical significance and discuss
potential solutions.
 Apply pharmacokinetic dosing principles to the dosing of selected drugs, such as the IV
to PO switch.
Ward rounds, morning sessions and seminars
The pharmacist should actively engage in ward rounds, morning sessions, and seminars to
contribute to patient care decisions. These activities are performed both as part of the
multidisciplinary team (MDT) and as pharmacy-only activities. In pharmacy-only rounds, the
pharmacists are also expected to communicate with patients and provide patient medication
counseling. They will also participate in grand rounds and death reviews.
Medication reconciliation services
Medication reconciliation is the standardized process of obtaining a patient’s best possible
history and comparing it to admission, transfer, or discharge medication orders to prevent errors
of transcription, omission, duplication, interactions, and other medicine-related problems. It
involves documenting discrepancies identified between the medication history and current
medication orders and how these discrepancies were resolved.
All patients should have their medication reconciled as soon as possible after admission or
presentation. If medication reconciliation cannot be completed for all patients, priorities the
patients most likely to obtain maximum benefit. The service should be documented using the
medication reconciliation form (Annex 17).
Drug information provision
As part of the routine clinical pharmacy service provision in the inpatient setup, pharmacists
should provide verbal and/or written drug information timely. If the service is given proactively
or when asked for by the healthcare team, it should be recorded appropriately (Annex 18).
Discharge medication counseling
Pharmacists need to be involved in discharge planning and provide medication counseling to
ensure continuity of care after patients is discharged from the hospital. Using the in-patient
medication profile form, the pharmacist will record discharge medications and counseling
provided. Discharge medication counseling includes, but is not limited to:
 Informing the name of drugs by showing each (if applicable), dose, frequency, and
 specific time of administration, how to administer if a skill is needed, etc.
 Clear benefit and outcome of each drug therapy, expected major side effects from drugs
and what to do in the event of their occurrence, pertinent drug-drug and drug-dietary
interactions, warnings if any, storage conditions, etc.
Documentation of clinical pharmacy services
Clinical pharmacy services should be properly documented in standard formats, and relevant
reports should be produced. Documentation ensures continuity of care, and failure to document
clinical pharmacy activities adversely affects the quality of care provided to the patient. The
formats include:
 Inpatient Medication Profile Form
 Pharmaceutical Care Progress Recording Form
 Medication Reconciliation Form
 Clinical Pharmacy Intervention Daily Summary Form
 Clinical Pharmacy Intervention Monthly Summary and Reporting Form
The first three forms should be part of the patient's permanent medical record (patient chart). All
patients with chronic illnesses who have a follow-up in the hospital should have a patient
medication profile form (PMP) for documentation. The PMP should be retained in the pharmacy
and updated by the dispensing pharmacist whenever drugs are dispensed to the patient.
The PMP can be in hard copy or computerized with hard copy backup and should contain the
following information:
a) Name of the health institution, h) Reason for any changes made in the
b) Patient medical record number patient's regimen
c) The full name, sex, age, and weight i) Name or initials of the prescriber and
of the patient, prescription number
d) The address of the patient j) Dispensing and/or prescription date
e) Diagnoses and concomitant diseases k) Appointment or refill date, and
f) History of adverse drug reactions l) Signature of the dispenser
g) Description of all medicines
PMPs should be filed sequentially by medical record number or alphabetically by patient name
in chronic care pharmacies. When a patient presents to the pharmacy for a refill, the pharmacist
must assess the patient for signs of compliance, effectiveness, and safety of therapy. The
pharmacist should identify areas for therapeutic modification and refer to the prescriber when
appropriate.
Unit dose dispensing in ward pharmacies
Evidence shows that the unit dose dispensing system is the most cost-effective of all pharmacy
distribution systems. Through the establishment of ward pharmacies (at medical, pediatric,
emergency, ICU, gynecology, surgery, etc.), a unit dose dispensing system shall be implemented
to reduce drug wastage, improve drug availability, efficiently use pharmacy and nursing staff,
and promote rational drug use.
A unit dose system is characterized by providing 24-hour supplies in a single dose package in a
ready-to-administrate form, and pharmacy-specific documentation will be retained. In this
system, the pharmacist reviews all medication orders written by the physician (patient chart) and
brought to the ward pharmacy by the nurse. Then the pharmacy professional prepares the
medication needed for a 24-hour period and makes it ready to be taken to patient care areas by
the nurses. Before administering each dose, the nurse compares the medication label on the drug
product with the appropriate medication administration record (MAR). The nurse then
administers the dose to the patient and records the fulfillment of the order on the MAR. The
hospital should also measure the functionality of its clinical pharmacy service.
3.9.Drug Information Services
Due to the vast number of medicines and the information related to them, it would be very
difficult for the health professional to search for all credible sources of information and use them
in routine practice. Hence, access to authoritative, unbiased, and well-referenced drug
information is fundamental for the rational and effective use of drugs.
All hospitals should establish a drug information center (DIC) and provide the service to health
professionals, patients, and the public. The service generally responds to drug information
queries. It also provides education and training to health professionals and/or the public
regarding the appropriate and safe use of medicines. Regular drug information publications, such
as drug alerts, newsletters, monographs, and therapy updates, shall be prepared and distributed to
keep the health care team up-to-date. The hospital shall also provide poison information services.
The DIC should have a dedicated room that has sufficient space and appropriate furniture and
equipment, including a telephone, computer, printer, filing cabinets, and internet access. The
DIC should have a current collection of authoritative national and international reference
materials such as books, journals, guidelines, formularies, and databases. Appropriately skilled
drug information pharmacists who trained in the provision of drug information should staff the
DIC.
The operations of the drug information service should be guided by appropriately formulated
standard operating procedures (SOPs) and guidelines prepared in line with national documents.
The guidelines and SOPs should be established for receiving and answering drug information
queries, developing and distributing educational materials and information publications,
documentation activities, and education and training activities. It also needs to guide monitoring
and evaluation activities, participation in other clinical pharmacy services, supporting DTC
activities, and conducting research. The center is a resource for the DTC's hospital medicine list
and STG preparation and revision. The DIC should be open during normal working hours. The
services provided by the center should be documented in standard formats prepared for this
purpose. The hospital should also measure the functionality of its DIS activities.
Educating patients on the rational use of medicines through different mechanisms is a crucial
activity of the DIC. Patients need to be given appropriate information about the medicines they
use to achieve optimum adherence, which results in better treatment outcomes. Medicine use
education is needed so that people have the skills and knowledge to make informed decisions
about how to use and store medicines and to understand the role of medicines in health care and
their potential benefits and risks. All relevant staff members of the pharmacy department should
be involved in the provision of education for the patient as appropriate. Under the hospital health
education program, the unit should have a weekly breakdown of topics assigned to responsible
pharmacists.
The DIC should develop an annual action plan for each activity, which should be communicated
to the head or director of the pharmacy department. All services provided should be documented,
and a performance report should be sent to the head of the pharmacy department regularly.
3.10.Compounding services
A hospital pharmacy should prepare non-sterile preparations such as prescription-based
ointments, creams, solutions, lotions, pastes, and bulk preparations (e.g., alcohol-based hand
rubs, hydrogen peroxide, alcohol of different strengths, gentian violet), which are not available
commercially but are needed for patient care. Small-scale manufacturing of sterile preparations
such as intravenous fluids, admixtures, and total parental nutrition should also be initiated,
depending on the needs of the hospitals and their feasibility. Both sterile and non-sterile
preparations in the hospital should fulfill efficacy, safety, and quality parameters. In order to
produce quality-assured compounded products, good compounding practice (GCP) should be
implemented. These can be achieved by following the key principles of GCP. These are:
 Personnel are appropriately trained and qualified to perform their assigned duties.
 Compounding raw materials of appropriate identity, purity, and quality should be used,
properly stored, and labeled according to manufacturer recommendations.
 All equipment used in compounding should be cleaned, status labeled, properly handled,
regularly calibrated, and used appropriately.
 The compounding environment should be clean and suitable for its intended purpose.
 A system must be in place to reduce any risk of contamination or cross-contamination.
 A quality control (QC) and assurance system must be in place.
 All aspects of compounding must be appropriately documented.
Besides, standard operating procedures and protocols that guide the preparation of the products
should be prepared. The compounding should also be done by pharmacists who have been
trained in the compounding service. The hospital should ensure the fulfillment of key equipment
used for compounding services (Annex 22) and follow its compounding services using
compounding service functionality criteria.
A proper compounding process should be followed to ensure GCP. The compounding process
includes preparatory work, compounding, a final check, sign-off, and cleanup. The room should
be segregated in such a way to facilitate the compounding process effectively. Accordingly, the
room should be categorized as weighing and measuring, compounding, quality control, and
cleaning areas.
Electrical supply, water supply, lighting, temperature, humidity, and ventilation shall be
appropriate such that they do not adversely affect, directly or indirectly, either the products
during their compounding or storage.
Good documentation practice constitutes an essential part of the quality assurance system and, as
such, should be related to all aspects of GCP. A compounding record should be kept of all
compounding activities. Further guidance and a sample format for recording the compounding
process and compounding prescription register are presented in (Annex 23 & 24), respectively.
3.11. Antimicrobial Stewardship Program (ASP)
The cause of antimicrobial resistance (AMR) is complex and multi-sectorial. Inappropriate use
of antimicrobials is a key contributor. Tackling AMR requires a multi-sectorial response.
Optimizing the use of existing antimicrobial agents through the implementation of antimicrobial
stewardship program in hospital settings is pivotal to overcoming the threat. Antimicrobial
stewardship is defined as a coherent set of actions that promote the responsible use of
antimicrobials. The main objectives of antimicrobial stewardship include optimizing the use of
antimicrobials, promoting behavior change in antimicrobial prescribing and dispensing practices,
improving quality of care and patient outcomes, and saving on unnecessary health care costs.
a. Establishing ASP in hospital setting
The management should give due emphasis to the establishment and functionality of the ASP
program in the hospital setting. Hence, the management should be committed to organizing an
ASP team that will be accountable to the Chief Clinical Director. The management also secures
the required resources (human, financial, and information technology) for ASP implementation.
The ASP team will operate in collaboration with the DTC, IPC, patients’ safety team, and other
hospital initiatives to enable a holistic and coordinated approach to implementing antimicrobial
stewardship program strategies. The hospital should also measure the functionalities of its ASP
activities regularly (Annex 25).

b. Membership of ASP team

The hospital ASP team is multi-disciplinary, and it includes: an infectious diseases’ physician
(preferred if available), an internist, a general practitioner, a clinical pharmacist, a clinically
oriented pharmacist, a pharmacist, a microbiologist, a clinical laboratory technologist, a nurse
representative, a quality control and patient safety representative, an IPC focal or representative, etc.
To operationalize the ASP team, there should be a guiding document (terms of reference or
TOR) that shows the collective and individual contributions and communication to meet the
objectives of the team. The TOR consists of the following at a minimum: background, purpose
of the ASP Team, scope of the team, roles and responsibilities of the team, membership and
governance, members of the team, accountability, and terms of service. The TOR should be
reviewed by each member and secure approval from the hospital management.
The ASP team is chaired by the hospital’s chief clinical director and co-chaired by the hospital
pharmacy head. The roles and responsibilities of the ASP leads (chair, co-chair, or secretary)
should be reflected in their respective job descriptions. Furthermore, all members of the
stewardship team should be officially appointed with a copy of the TOR.
c. Roles and responsibilities of ASP Team
The ASP team is responsible for developing, implementing, and managing the ASP in the
hospital. These include developing and maintaining antimicrobial policies, procedures, clinical
pathways, formulary restriction, and approval processes; overseeing interventions and
educational strategies for clinical staff; and ensuring appropriate monitoring, reporting, and
feedback of AMS processes and indicators to relevant hospital staff as per the guidelines.
d. Establishing/strengthening ASP in hospitals
Establishing and strengthening an antimicrobial stewardship program requires the identification
and prioritization of interventions following a stepwise approach as stipulated in the national
guideline. These include:
1. Undertake a facility AMS situational analysis:
2. Establish a sustainable AMS governance structure based on existing structures:
3. Prioritization of AMS interventions based on situational analysis: Start small, select relevant
and feasible activities (low-hanging fruit) to build motivation, and gradually expand coverage
and types of AMS activities, which may include:
- Review or adapt national policy documents or guidelines for facility use (e.g., develop or
update facility-specific medicine lists that incorporate WHO AWaRe categorization).
- Conduct point prevalence surveys; audit antimicrobial prescriptions; collect and analyses
data; and provide feedback on antimicrobial consumption, adverse drug reactions, or
compliance with guidelines.
- Select some common issues to address and improve antimicrobial prescribing.
- The ASP team undertakes surveillance of antimicrobial resistance.
- Establishing an antimicrobial stewardship program, The ASP, through a multidisciplinary
approach (physicians, pharmacists, nurses, laboratory professionals, the infection prevention
committee, and others as needed), has a responsibility to coordinate efforts to prevent and
contain AMR by instituting policies and implementing various strategies such as infection
prevention, antimicrobial medicine prescribing privileges, and surveillance.
4. Develop an AMS action plan based on the situational analysis and prioritized interventions.
5. Implement AMS interventions.
6. Monitor AMS interventions.
7. Continuous education
e. Implementing Antimicrobial Stewardship Strategies
The two core strategies that provide the foundation of an antimicrobial stewardship program
include prospective audits and feedback to prescribers, and formulary restriction and pre-
authorization.
f. Prospective audit with feedback
A prospective audit with feedback is an intervention that consists of a case-by-case review of
prescribed antimicrobials to safeguard and optimize their use while minimizing unintended
consequences such as AMR and adverse effects. The feedback is delivered directly to the
provider caring for the patient. The prospective audit with feedback can be employed in a variety
of ways depending on the need and available resources and expertise in areas of high and/or poor
quality antimicrobial use and can target and combine a variety of interventions such as:
- Targeting patients who are on antimicrobials as per the AWaRe category, specific infections,
or surgical prophylaxis,
- Dose optimization
- IV-to-Oral switch
- Regimen de-escalation
- Treatment duration
The AMS team should assign a team of experts who properly execute the audit with feedback
interventions using the audit and feedback tool (Annex 26).
g. Formulary restriction and preauthorization
Formulary restriction and preauthorization are restrictive measures. Hospitals should implement
formulary restrictions and preauthorization requirements for specific antimicrobial agents to
reduce microbial resistance. Decisions can be made based on the spectrum of activity, cost, or
associated toxicity. Preauthorization is a strategy to improve antibiotic use by requiring
clinicians to get approval antibiotics before they are prescribed. The use of preauthorization
requirements is commonly implemented as a means to restrict last-resort antibiotics.
The impact of AMS interventions on antimicrobial use and acceptance of the intervention should
be regularly communicated as part of morning sessions, other multidisciplinary meetings, or
management or DTC meetings. The AMS team can do assessments to identify areas for
improvement in antimicrobial prescribing for the whole hospital, a department, or a ward. This
includes antimicrobial consumption and point prevalence surveys using the standard tools
available for this purpose.
h. Measures of Success
Key measures of success that help demonstrate that a facility’s AMS structure is functioning
efficiently include:
- Availability of approved terms of reference (TOR) and reporting processes in place
- AMS plan and implementation
- Evidence of regular AMS committee meetings with documented agendas,
- Implementation of and results from priority activities, including:
- Assessment of antimicrobial prescribing, use, and resistance
- Increased prescribing adherence to standard treatment guidelines
- Based on the AWaRe classification, increased use of Access antimicrobials and streamlined
use of Watch and Reserve products
3.12. Narcotic drugs and psychotropic substances rational use, distribution and handling system.
Narcotic drugs and psychotropic substances (NPS) are classes of medicines with a high potential
for abuse. Addiction to these medicines is a global problem that crosses national, ethnic,
religious, and gender lines. Substances of abuse include substances classified under international
law as controlled drugs, which include narcotic drugs such as opium and its derivatives, cocaine
and its derivatives, cannabis, and psychotropic substances such as depressants, stimulants,
hallucinogens, and tobacco. On the other hand, substances of abuse can be classified into licit,
those substances obtained legally for medical application and research purposes, and illicit, those
substances obtained illegally and used for illegitimate purposes. Ethiopia has put in place control
mechanisms to counter the illicit manufacture, distribution, and use of these medicines.
Accordingly, the procurement, storage, prescribing, distribution, and administration of these
medicines in hospitals should be in line with the following national recommendations:
Prescribing and dispensing of narcotic drugs and psychotropic substances
- The hospital DTC determines the clinical units and types of professionals who can
prescribe these medicines. Hospitals need to ensure that the person who can prescribe
narcotic drugs, psychotropic drugs, and other controlled substances is a registered doctor,
psychiatrist, health officer, or nurse who has obtained a legal professional license and has
a first degree or above.
- The hospital needs to ensure that only a professional designated by the management or
DTC should carry narcotic drugs and psychotropic substances (NPS). These professionals
are responsible for ensuring and monitoring that the drugs are used only for their intended
purpose.
- The authorized prescriber for NPS should use only special legal prescriptions printed for
the purpose, and the prescriptions that bear the name or seal of the hospital should be
used only within the hospital. If the prescriber makes a mistake or changes his or her
mind while writing on the prescription paper, he or she must fold the damaged
prescription paper and leave it in the pad.
- A hospital pharmacy dispenses NPS when the information mentioned in the prescription
is complete,no more than one medication is written on one prescription paper, and 15
days have not passed since the writing of the prescription.
Movement of NPS medicines and prescriptions
- Hospitals should keep narcotic drugs and psychotropic substances, prescription papers,
and related records in a lockable cabinet or a separate room that cannot be easily broken
or moved. The key shall be kept only by an authorized pharmacist.
- The pharmacy department of the hospital should keep receiving and issuing models,
reports, and other records.
- Any used narcotic drugs, psychotropic drugs, and other controlled substances prescribed
by the hospital should be kept by the hospital for five years from the time of use.
- The pharmacy department of the hospital should receive the prescriptions in Model 19
and stamp the prescriptions using the official seal of the hospital. Whereas wards (or
service units) fill out their requests in Model 20, the pharmacy department will issue the
requested prescriptions using Model 22.
- The pharmacy department issues new prescription pads only when nurses in charge of
clinical departments return the used prescription pads. Nurses in charge of clinical
 departments distribute the prescription pads to prescribers at the start of each day and
collect the pads after working hours.
Record management
- Any person who handles narcotic drugs or psychotropic substances is responsible for
keeping a record on the day of the operation in accordance with the form prepared by the
authority and submitting the record when requested by the authority or regional health
regulatory body.
- A hospital should receive purchased or donated narcotic drugs and psychotropic
substances using Model 19 or the legal receipt of the institution, whereas these medicines
should be issued using Model 22 or the institution's legal receipts.
- Records of narcotic drugs and psychotropic substances dispensed to inpatients using
respective prescriptions should be kept on forms NPS/08/A and NPS/08/B (Annex
27&28,), respectively.
- Records of narcotic drugs and psychotropic substances dispensed to outpatients using
respective prescriptions should be kept on forms NPS/08/A and NPS/08/B, respectively.

Reporting
- A hospital is expected to send a report to the regional health bureau about the narcotic
drugs or psychotropic substances they have purchased and used at the end of the year
according to the European calendar in the form NPS/15/A and NPS/15/B (Annex 29 &30),
respectively.
- A hospital under the Ministry of Health must send a report to the authority about the
narcotic or psychotropic drugs they have purchased and used according to the European
calendar at the end of the year in the form NPS/15/A and NPS/15/B, respectively.
- A hospital must compile a report once a year by January 30, stating the number of
prescriptions received, used, and in stock with their serial numbers, and send it to the
authority or regional health regulatory agency in accordance with Form NPS/18.
A hospital, in cases where a narcotic drug or psychotropic substance or a used or unused narcotic
and psychotropic drug prescription paper has been lost, damaged, or stolen, must report the
incident to the authority, regional regulatory agency, or police within 24 hours and keep
information about the notification.
3.13. Monitoring and Evaluation of pharmacy service and supply management
All hospital pharmacy units should establish a routine monitoring and evaluation (M&E) system
for the pharmaceutical supply chain and pharmacy service to enhance efficiency and
effectiveness. To ensure the implementation of the system, the hospital pharmacy unit should
have an officially assigned M&E focal person to follow the routine activities. The focal person is
responsible for following the recording and documentation system, coordinating data collection,
analysis, and interpretation, evaluating and generating quality reports, organizing internal
performance reviews, working with the hospital M&E unit, following action taken, and
promoting data use.
The hospital pharmacy M&E system helps to ensure that the right product is delivered in the
right quantity, in the right condition, and at the right time, improving the quality of pharmacy
service. Proper implementation of the M&E system demonstrates the performance of supply
chain management and pharmacy service, highlights successes, and informs areas that need
improvement.
The hospital pharmacy unit should regularly report the pharmaceutical supply chain and
pharmacy service M&E indicators. The report quality shall be monitored and maintained through
a good recording and documentation system.
To ensure the quality of the report, the assigned focal considers the following data quality
dimensions before submitting the report: These include:
- Completeness: Data for all data elements should have been filled.
- Consistency: Data should be consistent and accurate.
- Timeliness: All reports should be submitted at the appointed time.
The hospital pharmacy unit should conduct a quarterly internal performance review based on the
M&E findings to take the necessary action on the identified gaps and share their successes.
The hospital management utilizes pharmacy M&E findings for data-driven supply decisions and
pharmacy service improvement.
 Annexes
Annex 1: DTC functionality criteria
# Operational Verification Criteria Score
Standard Verification Result
weight
Assigned DTC members by official letter, has approved TOR and 0.75
1 The hospital annual action plan (0.25 for each)
has a Meets regularly at least every two months with documented minutes 0.5
functional Has updated health facility specific Medicine and Medical supplies list 1
Drug and prioritized by VEN(0.5 for each)
Therapeutics Has medicine use policy and procedures (at least one new policy 0.5
Committee developed during the reporting period)
(DTC) The hospital DTC generates ADE/AEFI reports and take action on the 1
finding (0.5 for each)
Conduct supply and medicine use studies (at least one semiannually) and 2.75
ABC/VEN analysis annually
Take actions based on the supply and medicine use study findings 1
Report its performance activities to the management 0.5
Total score 8
Annex 2: ADR reporting format
 Annex 3: Pharmaceutical Good storage guideline
Activities Justification
1. Store pharmaceuticals in a dry, well-lit, well- Extreme heat and exposure to direct sunlight can degrade pharmaceuticals and
ventilated storeroom - away from direct dramatically shorten shelf life. Direct sunlight raises the temperature of the product
sunlight. Temperatures in the storeroom and can reduce its shelf life or may damage the product by other mechanisms.
should not exceed 25oC.
2. Clean and disinfect the storeroom regularly. Pests are less attracted to the storeroom if it is regularly cleaned and disinfected.
Keep food and drink out of the storeroom. The outside of the store should also be kept clean, and any garbage should be
stored in covered containers. Water should not be allowed to stagnate near the
building. Would should be varnished or painted to discourage pests. If possible, a
regular schedule for extermination will also help eliminate pests.
3. Protect storeroom from water and moisture. Moisture can destroy both supplies and their packaging. If the packaging is
damaged, the product is still unacceptable to the patient even when the
pharmaceutical is not damaged.
4. Keep fire safety equipment available, Stopping a fire before it spreads can save expensive supplies and the storage
accessible, and functional, and train facility. The right equipment should be available; water is able to put out paper
employees to use it. fires, but is ineffective on electrical and chemical fires. Place well-maintained fire
extinguishers at suitable positions in the storeroom. If a fire extinguisher is not
available, keep sand or soil in a bucket nearby.
5. Store latex products away from electric Latex products can be damaged if they are directly exposed to fluorescent lights
motors and fluorescent lights. and electric motors. Electric motors and fluorescent lights create the chemical
ozone which can rapidly deteriorate latex products. Keep latex products in paper
boxes and cartons.
6. Maintain cold storage, including a cold chain, Cold storage (2 to 8 degrees Celsius or 36 to 46 degrees Fahrenheit) is essential for
as required. maintaining the shelf life of certain pharmaceuticals. These items are irrevocably
damaged if the cold chain is broken. If electricity is unreliable, the use of
cylindered gas or kerosene-powered refrigeration is recommended. Many drugs
require storage below 25 oC. There may also be products that should be stored at a
temperature below 0oC and hence the required storage condition should be
maintained for these products.
7. Limit storage area access to authorized To prevent theft and pilferage, lock the storeroom and/or limit access to personnel
personnel. Drugs which need an access- other than authorized staff, and track the movement of pharmaceuticals.
controlled environment such as narcotics,
psychotropic, etc should be stored under lock
and key separate from the rest of stock
preferably a locked wire cage within the
storage facility or a lockable cabinet.
8. Stack cartons at least 10 cm off the floor, 30 Pallets keep the products off the floor so they are less susceptible to pests, water
cm away from the wall and other stacks, and and dirt damage. Stack pallets 30 cm away from the walls and each other to
no more than 2.5m high. promote air circulation and to ease movement of stock, cleaning and inspection.
Do not stack cartons more than 2.5m as the weight of the products may crush the
cartons at the bottom. This will reduce potential injury to warehouse personnel. If
cartons are particularly heavy, stack cartons less than 2.5m.
Where feasible, strong well-organized shelving is preferred.
9. Store medical supplies away from Exposure to insecticides and other chemicals may affect the shelf life of
insecticides, chemicals, old files, office pharmaceuticals. Old files and office supplies may get in the way and reduce space
supplies and other materials. for medical supplies or make them less accessible. “De-junking” the storeroom
regularly makes more space for storage.
10. Store flammable products separately from Some medical procedures use flammable products, such as alcohol, cylindered gas,
other products. Take appropriate safety or mineral spirits. Such products should be stored in the coolest possible place,
precautions. away from electrical appliances and other products and near a fire extinguisher.
Storage areas and cabinets should be clearly
marked to indicate that they contain highly
flammable liquids and should display the
international hazard symbol.
Corrosive or oxidant products, laboratory
chemicals and reagents should be stored
away from flammables, ideally in a separate
steel cabinet to prevent leakage.
11. Store pharmaceuticals to facilitate FEFO FEFO (First Expiry, First Out) is a method of managing drugs in a storage facility
procedures and stock management. where the drugs are managed by their expiry date. Drugs that will expire first are
issued first, regardless of when they were received at the health facility.
12. Store drugs in their original shipping cartons. Drugs should not be opened to repackage them. Store supplies in their original
Arrange cartons with arrows pointing up, and shipping cartons. Items should be stored according to manufacturer’s instructions
with identification labels, expiry dates, and on the cartons; this includes paying attention to the direction of the arrows.
manufacturing dates clearly visible. Identification labels make it easier to follow FEFO, and make it easier to select the
right product.
13. Separate unusable pharmaceuticals from Do not dispense expired drugs to the patients. Designate a separate part of the
usable pharmaceuticals and dispose of storeroom for damaged and expired goods.
damaged or expired products immediately.

Annex 4: Bin Card

Hospital Name: _______________________________
Product Name, Strength and Dosage Form: ________________________
Unit of Issue: _________________________________________________
Date Doc. No. Received Quantity Batch Expiry Remark
Received

Issued

Loss/Adj

Balance

(Receiving from or No. Date

or Issued t
Issuing)
Annex 5: Internal Facility Report and Resupply Form (IFRR)
 Annex 6: Report and Requisition Form (RRF)
Report and Requisition Form (RRF)
Name of the health facility Region: Zone: East Shoa Woreda: Adea
Reporting Period From To
(Month/day/year) (Month/day/year)
(Scenario I)Maximum Stock Level: 4 MOS Emergency Order point: 0.5 MOS
Report Part
Requisition Part
Begin
Sl. Unit of ning Ending Balance Maximum Quantity
No. Product Description Issue Balan Quantity Losses/ Calculated Days Out Stock needed to Quantity
ce Received Adjustment In DU In Store Consumption Of Stock Quantity reach Max Ordered
s
F G H
A B C D E = A + B +/- C = 120*F / I= H-E-D
– D+E) (60 – G)

1
2
3
4
Products with shelf life <6 months (S/No, Quantity and Expiry date): Remarks:
 Name Signature Date
Prepared by: ________________________ ______________________________ _________________
Verified by: ________________________ ______________________________ _________________
Approved by: ______________________ _____________________________ ________________
Annex 7: Refrigerator tag temperature recording sheet

Annex 8: Procured medical oxygen cylinders checking form during receiving at store to ensure
proper filling
Date Number of Volume of Properly filled Checked by BME/T Remark
cylinders cylinders Pass/Fail Test
procured procured Name Signature
Annex 9: Medical oxygen Internal Reporting and Requesting form (maintained separately for
each ward)
Requesting Requester Requesting Number of Number of Volumes of Requester
Date name Unit cylinders cylinders cylinders (liters) Signature
requested supplied supplied

Annex 10: Medical oxygen monthly consumption tracking report

Service Medical oxygen Medical Oxygen Medical Medical Remark
units/wards supplied Supplied (in Oxygen oxygen stock
(number of liters) Supplied (in out in days
cylinders) Birr)

Emergency
Inpatient Adult
Inpatient
Pediatric
ICU adult
ICU pediatric
Maternal

Annex 11: Expired and unfit for use product registration form
S.N Description unit quantity Batch.no expired Manufacturer country unit Total
of date of cost cost
Medicines origin
Wastes
 (generic &
brand
name,
strength
and dosage
form)
1.
2.
3.
4.

Annex 12: Prescription evaluation and intervention register

Annex 13: Data collection form for patient knowledge and labelling interview
Annex 14: Data collection form for client satisfaction with dispensing services

Annex 15: In-patient Medication Profile Form

(Follow the instructions when completing this form)
Name of Hospital: ____________________________________ Region: _______________
In-patient Medication Profile Form In-patient Medication Profile Form
In-patient Medication Profile Form In-patient Medication Profile Form

In-patient Medication Profile Form

In-patient Medication Profile Form

In-patient Medication Profile Form
In-patient Medication In-patient Medication Profile Form Start Date Stop Date
Profile Form
In-patient Medication In-patient Medication Profile Form
Profile Form
In-patient Medication In-patient Medication Profile Form
Profile Form
In-patient Medication In-patient Medication Profile Form
Profile Form
In-patient Medication In-patient Medication Profile Form
Profile Form
In-patient Medication In-patient Medication Profile Form
Profile Form
In-patient Medication Profile Form
Annex 16: Pharmaceutical Care Progress Note Recording Form
Form 2: Pharmaceutical Care Progress Note Recording Sheet
(Follow the instructions when completing this form)
Patient Name: ______________________ Card No. ___________________
Annex 17: Medication Reconciliation Form
(Follow the instructions when completing this form)
Hospital __________________________Region________________
Patient name: ____________________________ Age ______ Sex _______Weight _____
Source(s) of medication list
________________________________________________________
Allergic:
_______________________________________________________________________
Reconciliation Adjustments/
Medication Regimen (Drug name, Plan on Plan on Plan On Changes
information Dose, Frequency, admission transfer Discharge made
source Duration) C DC C DC C DC
Pre-admission Medication
Medication
Current

C – Continue, DC - Discontinue
Recorded by: Name _____________________________ Signature ____________ Date ______________
 Annex 17: DIS Summary and Report form
_____________Hospital Drug Information Service (DIS)

P.O. Box: ______, Telephone: ___________, Fax: ___________, E-mail: ____________

Drug Information Query/Response and related activities summary and reporting form

Name of DI pharmacist: Telephone E-mail

Data compilation/reporting eriod Date: Month:

1 Number of DI requests Received: Replied :

Number of Requests health facility patient:
2 Staff from other Health faciility:
coming from staff: other

1 Requesters’ Sex Male: Female:

Specialist GP Health Officer
Requesters’ Qualification/
2 Nurse Pharmacist Druggist
profession
Student Other
II-Background information on query:
Number of queries Walk-in Phone Written form
1
received through: E-mail Fax Letter
Other/ Not
2 Type of queries : Patient specific: Academic:
specified
Therapy Pregnancy ADR

Interaction Pharmaceutical Pharmacology

3 Classification of Query:
Pharmacokinetics Administration Local/Foreign

Availability Other equiv.

 In-house
Reference books Journals
database
Sources of information
4 Peer reviewer Package
used Internet sites
publication inserts

Other DIS Previous response Other

Oral/Verbal Written/print format Telephone call

Provide
Response communicated
5 E-mail Notice board Reference
by:
source
Provide
Provide Internet source Other
Literature
6 Number of requesters who sent feedback

B. Additional activities of DIS

Drug ALERTS Bulletins Newsletters
Number of
1 Therapy Other
publications issued New arrivals/ availability
updates publications
Continuing Medical Eduction/Patient education (CME/PE) events:
The
2 Number of events organized to: hospital Patients/community Others
staff
The
3 Number of attendees/ target audiences: hospital Patients/community Others
staff
Drug Rational
Disease specific
4 Number of topics related to: Specific use
others
Feedback
Received
received
5 Number of ADR/ADE Reports from Sent to FMHACA
From
staff
FMHACA
 DIS’ support to DTC (Formulary management/
6 Drug use reviews/ studies/ DUE/ Designing Facilitate the workshop to conduct DUE on Ceftriaxone
strategy)
organize educational sessions and meetings with prescribers to
DIS’ support to clinical pharmacy/ pharmaceutical
7 sensitize staff on the role of pharmacists in the chronic diseases
care
management

8 Major Challenges/ constraints affecting progress None

9 Actions taken to address challenges/ constraints: None

Report compiled/reported by: Date:

Report reviewed by: Date:

For Office use only

Report sent to home

Report received by: Date:
office on:
Home/ central office-
Report received on: Report compiled and documented on:
Annex 18: Drug Information Response Form
DRUG INFORMATION RESPONSE FORM

Enquiry Reference No.:

Date: Time

To(name of inquirer): Phone No: Email:

Dear

We acknowledge the receipt of your enquiry on drug information dated and documented
under ref. No We are pleased to put forward the required information as follows:

Question/query:

Answer/response:

References:

Additional information/materials and

recommendations provided:

Disclaimer:
The DIS is designed to assist health care providers and other users to provide accurate, up-to-date, reliable and complete

We hope we have served you with this information and in case you need further information/materials, please fill free to

Response completed By: Date: Initials:

Annex 19: Drug Information Query Form
DRUG INFORMATION QUERY FORM
Date:
Time: am/pm am
I-Requester’s contact information: (To be filled by requester or DI pharmacist)

Full Name: Dr. Mr. Mrs. Sr.): Mr

Physical address: Tel No: E-mail: Fax:
Qualification/Profession: GP Specialist Health Officer Patient
Nurse Pharmacist Druggist Student
Other (Please specify )
Method of Contact: Walk-in Phone Written form E-mail
Fax Letter Other (Please specify )

II-Background information on query:

The request is: Patient specific Academic Other
If Patient specific, Please Age Sex wt (kgs) Diagnosis
record patient information that Current Medication:
you feel may be helpful in
answering your request (such
Concurrent medication/s:
as patient’s age, sex, weight,
disease states, laboratory Allergies:
values, medications allergies Other information
etc…). related to Patient:
Request/Question:

Verbal Phone printout E-mail

Preferred method of
written form Fax
Response:

prompt 30-60 min end of day when time permits

Response needed in:

References required: YES NO

Additional Information
required:

Initials of the requester(optional) Date: Time:

For DI pharmacist use only

Enquiry Received on (Date): Time:

Enquiry Received by: Enquiry Reference No. DI001

Response given to requester on (Date): Time:

Response made by:

 Annex 20: Drug information service feedback form
DRUG INFORMATION SERVICE FEEDBACK FORM

Enquiry Reference No.:

Date of enquiry:
Dear enquirer:

We want to hear fro

The _________hospital/H center DIS is seeking your feedback on the information we have provided in response
your enquiry under Dated . We value your
feedback because this helps us to stay in touch with your needs and for the continuous quality improvements of

We invite you to use this form to submit feedback or complaint. Provision of the information requested

1. Was the information received in time? Yes No

2. Was the presentation of the information Yes No
3. Did the information provided meet your Yes No
4. Was the information used? Yes No
5. If your answer to Question No. 4 is
Yes, what was the outcome?
6. If your Answer to Question No. 4 is
No, please describe the reason why the
7. Additional comments and suggestions
on the DIS

Name of Phone No: Email:

enquirer:

We thank you for your time and response

Annex 21: List of basic compounding equipment

S.N Equipment/material Description
1. Working bench Level, smooth, impervious, free of cracks and crevices and non-shedding;
covered with protector sheets of plastic, rubber or absorbable paper when
appropriate
2. Mortar and pestle 250 ml capacity or more; glass type and porcelain type
3. Water distiller Stainless steel of 20 litter capacity or more
4. Water bath Stainless steel of 4 openings or more
5. Electrical hotplate Various Sizes and Features
6. Evaporating dish Stainless steel and porcelain type
7. Spatula Stainless steel/plastic type, flexible and non-flexible, different blade lengths.
8. Gloves disposable, non-sterile
9. Glass rod Different length and thicknesses
10. Wash bottle 250ml capacity, polyethylene
11. Funnel Glass type and plastic type (polyethylene)
12. Beakers Glass type; different capacity
13. Volumetric flask Glass type; different capacity
14. Balances Prescription, torsion, triple beam, electronic; capacities of not less than 300
gm; sensitivity of greater than 0.1 mg.
15. Ointment tile Glass type
16. Micropipettes Glass type; different capacities (less than 1ml); with pipette bulb
17. Pipettes Glass type; different capacities (1ml-100ml); with pipette bulb
18. Cylindrical graduate Glass and plastic type; different capacity
19. Conical graduate Glass and plastic type; different capacity
20. Weighing dishes Plastic, aluminum, stainless steel type
21. Weighing paper Normal paper; grease-proof for semisolids
22. Thermometers Fridge and wall thermometer
23. Scientific calculator Electronic calculator that can show its output in scientific notation
24. Packaging materials Different sizes of plastic or glass bottles
Annex 22: Compounding Process Recoding Form (Compounding sheet)
Name of the dispensary/health institution __________________________________Date
__________________
Batch number/control number_____________________________ Batch quantity _______________

Name or initials of the

Description of ingredients
person in charge
Name Source Batch number Quantity

Description of the steps of the preparation

Beyond use Date: …………………………………….

Yield: …………………………………………….
Loss: ……………………………………………
Reason for loss: ………………………………………………………………………………………….
Prepared by: Name ___________________ Signature_________ date _________
End control before release of the product

Parameters Comment
Approved by: Name ___________________________ Signature______________Date________
Annex 23፡ Compounding Prescription Register Forms
Annex 24: Antimicrobial Stewardship program functionality Criteria
Category Functionality parameter
0 There no ASP team in the facility
There is ASP team having approved ToR with list and responsibilities of
members,
1
Availability of ASP plan addressing ASP guideline

Availability of the national ASP practical guide in hard and soft copies.

Availability of AMR trained professionals,

2 Availability of functioning diagnostic laboratory in the facility,

Presence of institutional base line data.

Conduct regular review meeting with minutes documented,
Availability of audit and feedback system, appropriate de-escalation
(Spectrum), appropriate switch from IV to oral (route de-escalation),
3
Registration of antimicrobial consumption,
Recording of HAIs in the institution

Availability of DUE finding conducted on AMs in the past one year.

 Annex 25: AMS review/Audit form
Name of Hospital:----------------------------------------------------------------
1. Patient demographic and clinical information
Date of Admission: Department: Ward:
Patient name (ID): Age in Yrs: Weight: Sex: Male ☐ or Female ☐
Chart Number: Allergies:
Previous admission history for >2 days with in the last 3 Yes ☐ No ☐
Previous antibiotic use histories within 30 days Yes ☐ No ☐
Immunosuppressed Yes ☐ No ☐
CKD10/ current AKI Yes ☐ No ☐, If yes serum creatinine_
If the patient is a neonate Gestational age (in weeks) ;
birth weight (in kgs):_

4. Initial review of antibiotic treatment

Is indication for Antibiotic treatment Is antibiotic treatment prescribed according Comments
documented? Yes ☐ No ☐ to
recommended guidelines? Yes ☐
Correct dose? Yes ☐ No ☐ Appropriate route? Yes ☐ Treatment duration or review date stated?
☐
No ☐ Yes ☐
2. Current antibiotic prescriptions for the current indication (see below) ☐
Antibiotics prescribed Dose (mg) Route Interval Start date End date (if
3. Indication for antibiotic treatment
Indication11 S. Prophylaxis ☐ Empirical ☐ Definitive ☐
Diagnosis (it Urinary tract Infection ☐ Gastrointestinal Infection ☐ Bloodstream Infection ☐
might be more Pneumonia ☐ CNS/Meningitis ☐ Skin infection ☐ Bone infection ☐

than one)
Other (specify):_
Diagnostic Fever recorded
workups done WBC with differentials
X-ray findings
Cultures Sent before antibiotics ☐ Sent after antibiotics ☐ Not sent ☐
If sent, culture Blood ☐ Sputum ☐ Other (specify):
specimen source Urine ☐ CSF ☐
1.
2.
3.
4.
5.

If yes, what action? Escalate Continue De-‐escalate Stop Change ☐ IV-• oral switch ☐
☐ ☐ ☐ ☐
5.If continue,
Within 72Why
hours
is review of antibiotic
Continuingtreatment by physician/AMS
clinical signs Confirmed infection ☐
of infection team Other (comment):
Is antibiotic treatment Yes ☐ No ☐
antibiotic
If stop, Why is antibiotic ☐
No evidence for Treatment duration Allergy ☐ Other (comment):
treatment beingisstopped?
If Change, Why antibiotic infection ☐
Inappropriate too long ☐
Culture-sensitivity IV to PO ☐ Other (comment):
treatment being
Microbiology Changed?
specimens spectrum ☐ ☐results received?
Microbiology Microbiology results acted upon? ☐
collected? ☐ ☐ Comment:
Date: Date:

6. General
(Review) Date:_ Name/signature (reviewer)
7. Actions based on comments/recommendation/s:
Fully accepted ☐ Partially accepted ☐ Not accepted ☐
If not accepted, Reasons:_

CKD: chronic kidney disease, AKI: acute kidney injury, CSF: cerebrospinal fluid, CNS: central nervous
system, IV: intravenous, PO: per- oral,
Annex 26: Dispensed and administered Narcotic drugs record format
FORM NPS/08/A
Date ------------------------------
DISPENSED AND ADMINISTRED NARCOTIC DRUGS RECORD IN HEALTH INSTITUTION
Name of Health Institution: --------------------------------------------------Serial No. --------------------
Description of Drug---------------------------------------------- Quantity Issued -------------
Ward/Department -----------------------------------------------------------------------------------
Chief pharmacist: Name----------------------------------------------------Signature -----------------------
Head Nurse: Name -------------------------------------------------------- Signature ----------------------

-------------------------------------------------------------------------------------------------
FORM NPS/08/A
Date -------------------------------------
Name of Health Institution: --------------------------------------------- Serial No. -----------------------
The following is an accurate record of -----------------------------------
Total quantity ------------------------------ each used in ward Department
Please fill the following record clearly and neatly.
Date Hour Name of Bed No. Chart No. Nurse Dose
patient

Ward physician: Name ________________ Signature ____________________

Ward Head Nurse: Name __________________ Signature _______________________
Annex 27: Dispensed and administered psychotropic drugs record format
FORM NPS/08/B
Date ------------------------------
DISPENSED AND ADMINISTRED PSYCHOTROPIC SUBSTANCE DRUGS RECORD IN HEALTH INSTITUTION
Name of Health Institution: --------------------------------------------------Serial No. --------------------
Description of Drug---------------------------------------------- Quantity Issued -------------
Ward/Department -----------------------------------------------------------------------------------
Chief pharmacist: Name----------------------------------------------------Signature -----------------------
Head Nurse: Name -------------------------------------------------------- Signature ----------------------

-------------------------------------------------------------------------------------------------

FORM NPS/08/B
Date -------------------------------------
Name of Health Institution: --------------------------------------------- Serial No. -----------------------
The following is an accurate record of -----------------------------------
Total quantity ------------------------------ each used in ward Department
Please fill the following record clearly and neatly.
Date Hour Name of Bed No. Chart No. Nurse Dose
patient

Ward physician: Name ___________________ Signature ___________________

Ward Head Nurse: Name__________________ Signature ___________________
 Annex 28: Annual report of narcotic drugs
FORM NPS/15/A
Name of Reporting Health institution:-------------------------------------- Address: Region---------------------
City/Town ---------------------------------------------P.O. Box------------Tel. -----------------------------
These statistics Relates to the calendar year -----------------------------------------------
Balance at balance at Remark
the Beginning Quantity Purchase d consumptio n the end of
Dosage Form

Narcotic of the Year purchased from during the the year

Strength

Drug during the year

Ser. No.

year

Remark: -Report on the Psychotropic Drug is required annually at the end of December.
 Annex 29: Annual report of Psychotropic substance
FORM NPS/15/A
Name of Reporting Health institution:-------------------------------------- Address: Region-----------
City/Town ---------------------------------------------P.O. Box------------Tel. -----------------------------
These statistics Relates to the calendar year -----------------------------------------------
Balance at balance at Remark
the Quantity Purchase consumptio n the end of
Dosage Form

Psychotropi Beginning purchased d from during the the year

Strength
Ser. No.

c substance of the Year during the year

year

Remark: -Report on the Psychotropic Drug is required annually at the end of December.
 CHAPTER: TEN

Laboratory Service Management

CONTENT

Section 1 Introduction

Section 2 Operational Standards for Human Resource Management and Development

Section 3 Implementation Guidance

Section 4 Implementation checklists

Section 5 Performance Indicators

Section 6 Annexes

Section 7 References
ABBREVIATIONS

ART: Antiretroviral therapy

AFB: Acid Fast Bacilli
QMS: Quality Managements System
CPD: Continuing professional development
DNA: Deoxyribonucleic acid
EPHI: Ethiopian Public Health Institute
EQA: External Quality Assessment
EFDA: Ethiopia Food and Drug Administration Authority
MOH LEO: Ministry of Health Lead Executive Office
HMIS: Health management information system
IQC: Internal Quality Control:
NBBS: National Blood Bank Service
OHSO: Occupational Health and Safety Officer
PCR: Polymerase Chain Reaction
PIHCT: Provider Initiated HIV Counseling and Testing
PPE: Personal Protective Equipment
PT/ EQA: Proficiency Testing/ External Quality Assessment/
QA: Quality Assurance
QC: Quality Control
QI: Quality Improvement
RHB: Regional Health Bureau
SOPs: Standard Operating Procedures
STS: Sample Transfer Service
TAT: Turnaround time
UPS: Uninterrupted Power Supply
SECTION ONE: INTRODUCTION

Laboratory services strengthen the practice of modern medicine by providing information to end
users to accurately assess the status of a patient’s health, make accurate diagnoses, formulate
treatment plans, and monitor the effects of treatment. Laboratories are a major source of health
information for epidemiological and surveillance purposes, and are often the first sites for the
detection of disease outbreaks. To provide such functions laboratory data must be recorded and
reported through the appropriate channels in an accurate and timely manner.

The current laboratory service in Ethiopia is organized in a structure that follows the general health
care delivery system of the country, incorporating specialized, general and primary hospitals in
addition to health centers and health posts. At the apex of this system, there are currently thirteen
Regional Reference Laboratories and a National Reference Laboratory at the Ethiopian Public Health
Institute (EPHI). A detailed description of the responsibilities of laboratories at different tier levels in
Ethiopia is presented in Appendix A.

As part of the Ethiopian laboratory network, hospitals receive specimens for analysis from the lower
level of laboratories and also from the same level of facilities and may refer specimens to a higher
level facility, in accordance with agreed protocols and guidelines. This chapter sets standards and
guidelines to ensure that hospital laboratories provide accurate, reliable and timely test results for
patient care. Effective laboratory management ensures the implementation of standard laboratory
quality management systems to perform agreed tests with minimal ‘down time’ in service provision.
SECTION TWO: OPERATIONAL STANDARDS FOR MEDICAL LABORATORY
SERVICE

1. The hospital has established laboratory management structure and accountability arrangement.
2. The hospital laboratory management shall develop and implement quality management
system and continually quality improvement.
3. The hospital laboratory management has established system for management of documents.
4. The hospital laboratory has established system and practice to monitor the effectiveness of its
customer/Client/ service program.
5. The hospital laboratory has established and implements a proper equipment and supply
management system.
6. The hospital laboratory shall implement a process control system (Pre-analytic, Analytic and
Post-analytic) and documented procedure to identify and manage nonconformities in any
aspect of the quality management system.
7. The hospital laboratory has established incident handling and reporting system
8. The hospital has established Laboratory Information Management System
9. The laboratory shall develop and implements a program to ensure the safety of laboratory
services and facilities.
10. The hospital laboratory shall have backup laboratory service within and between laboratory
11. The hospital laboratories create public-private partnership in the delivery of laboratory
service.
12. The hospital has blood bank service that adhered to appropriate standards of practice
SECTION THREE: IMPLEMENTATION GUIDELINE

3.1 Organization and Management

3.1.1 Management structure
The laboratory shall have its own organizational structure that enables the laboratory to communicate
internally and externally with vendors, other health institutions to create collaboration and partnership
and EQA program providers by working under the organizational umbrella of the hospital. Each
laboratory must have an organizational chart (organogram) that describes the management and
supervisory arrangements in the laboratory.

The hospital laboratory should have functional central, emergency and inpatient laboratories. Both
emergency and inpatient laboratories should provide services 24hrs a day and 365 days a year. The
central laboratory should have a functional overview of all other labs to ensure the provision of
quality services. The laboratory shall have job descriptions that describe responsibilities, authorities
and tasks for all personnel.

3.1.2 Management role

The laboratory shall be managed by an experienced laboratory professional or persons with the
competence in their field and in management. The duties and responsibilities of the laboratory
manager, quality officer and safety officer should be documented.
The laboratory manager (or designate/s) shall:
1. Provide effective leadership of the medical laboratory service, including planning, budgeting
and overall financial management, in accordance with organizational assignment.
2. By representing the hospital, liaise and work effectively with applicable regulatory authority
and accrediting agencies, appropriate administrative officials, the healthcare community, and
the patient population served.
3. Ensure that there are appropriate number of staff with the required education, training and
competence to provide medical laboratory services that meet the needs and requirements of
the users
 4. Ensure the implementation of laboratory quality policy
5. Implement a safe laboratory environment in compliance with good practice and applicable
requirements
6. Develop hospital laboratory specific annual plan and ensure that adequate budget is allocated
7. Ensure the provision of clinical advice with respect to the choice of examinations, use of the
service and interpretation of examination results
8. Provide professional development programs for laboratory staff and opportunities to
participate in scientific and other activities of professional laboratory organizations
9. Define, implement and monitor standards of performance and quality improvement of the
medical laboratory service or services
10. Maintain strong communication/relationship among clinical and non-clinical staff.

3.2 Quality Managements System

The implementation of a quality management system in the hospital laboratory is a crucial step
to ensure ongoing enhancement in quality. One key aspect involves inspecting the certification of
accreditations and assessing the number of accredited scopes. If a laboratory has six or more
scopes accredited, it receives a full score, while those with fewer than six scopes receive an
equivalent score. Additionally, the evaluation includes a review of the laboratory's updated
quality manual and sample management guidelines. The presence of Standard Operating
Procedures (SOPs) for all technical and administrative procedures in all service areas is essential,
along with confirming the availability of updated formats, job aids, and instructions in the
workplace.

Moreover, the assessment delves into the awareness and adherence of laboratory staff to the
SOPs relevant to the tests they are performing. Ensuring that the laboratory has identified quality
gaps and prepared annual quality improvement plans is a critical component. Finally, the
evaluation involves confirming that at least 50% of the laboratory staff have undergone
competence assessments with documented results for their assigned tasks. This comprehensive
approach to quality management aims to establish a framework for continuous improvement and
adherence to best practices in the hospital laboratory.
3.2.1 Committed Managements

Laboratory management shall provide evidence of its commitment to the development and
implementation of the quality management system and continually improve its effectiveness by:
1. communicating to laboratory personnel the importance of meeting the needs and requirements
of users as well as regulatory requirements;
2. establishing the quality policy
3. ensuring that quality objectives and planning are established
4. defining responsibilities, authorities and interrelationships of all personnel
5. establishing communication processes
6. appointing a quality manager
7. conducting management reviews
8. Ensuring availability of adequate resources to enable the proper conduct of pre examination,
examination and post-examination activities.
9. ensuring that all personnel are competent to perform their assigned activities

3.2.3 Competency Assessment

A competency assessment is a mechanism to test new experts' knowledge and skill in connection
to that specific laboratory service that he is allocating to do and when laboratory professional
comes to do a new kind of laboratory test. Competency evaluations might be theoretical exam,
practical exam, or a combination of the two. Each hospital laboratory shall have policy and
procedure how to do competency assessments. This policy and procedure should have the
following
1. Who is qualified to conduct competency evaluations in laboratories?
2. Who was assessed for competency?
3. When competency evaluations are conducted
4. Assessment theoretical, practical or combination
5. Standard to state "pass" and "fail"
Competency evaluations should be conducted after introducing all members about new or updated
work procedure or processes. It can be conducted regularly according to a policy or procedure that has
been established by hospital laboratory. If the laboratory personnel failed the competency test, he or
she should be retrained and retake the exam until they pass, unless they should be sent to another
laboratory test service where they can be useful.

3.3. Documents and Records

3.3.1 Document

Documents provide written information about policies, processes, and procedures and should be
annexed in the laboratory quality manual for each laboratory. Documents are a reflection of the
laboratory’s organization and its quality management. A well-managed laboratory will always have a
strong set of documents to guide its work.

3.3.2 Quality Policy Manual

The laboratory shall prepare a policy manual that gives broad and general direction to the laboratory
quality system defined by the organization and endorsed by hospital management.

3.3.3 Procedure

The laboratory shall also prepare technical and managerial procedures for all processes. A procedure
tells “how to do it”, and shows the step-by-step instructions that laboratory staff should meticulously
follow for each activity. The term standard operating procedure (SOP) is often used to indicate these
detailed instructions on how to do it.

3.3.4 Standard Operating Procedures

Standard Operating Procedures (SOPs) are created for regularly recurring work processes that are
conducted in the laboratory. This is done to ensure that activities are performed consistently and in a
manner that achieves results of the highest quality, and that the laboratory is run as efficiently as
possible. All laboratory staff should participate in the creation of SOPs. Each SOP should be
approved by the Laboratory Manager and Quality officer prior to implementation.
All for specimen management SOPs should include:
I. Action upon receipt of a sample:
Upon receipt the laboratory should check the availability of the requested test in that
laboratory, including the turnaround time for results. If the service is not available, the
laboratory should notify the customer and refer the sample to a different laboratory capable of
performing the request test. If the service is available, the sample must be checked according
to the acceptance and rejection criteria. A specimen can be rejected if:
● It is received without a request form,
● It is unlabeled, incompletely labeled or if the name on the label does not match the
name on the request form
● It is leaking, or broken container
● It is the wrong type of specimen for the requested test
● It was not transported according to requirements or bacterial overgrowth present
● The time since collection is too long (depending on the type of test),
● It is hemolytic (depending on the type of test) or insufficient volume of a specimen.
II. Documentation of sample receipt:
A log book either manual or electronic should be used to record the receipt of samples. This
form should include:
● The name of the patient and identification number
● The source of the specimen
● The name of the submitter, and
● The date of collection.
III. All testing procedures:
All SOPs for individual tests should include:
1. The full test name, including the full name of the methodology used (commonly used
abbreviations should be listed at the beginning of the SOP)
2. The types of reactions, specimens, or organisms involved in the test
3. Guidelines for the storage of specimens to ensure their integrity until testing is
complete
4. The clinical reasoning for performing the test
5. Any calculations and formulas needed to obtain a result
 6. The methodology used, including the limitations of procedures and reagents,
7. Standards by which a sample is accepted or rejected
8. Safety issues related to that particular test
9. The test procedure, including
10. A complete set of instructions
11. Detailed descriptions such as measuring units, etc
12. How to prepare slides, solution, calibrators, control, reagents, stains, etc. for use
13. The criteria for what to do if a test system becomes inoperable
14. A corrective action guideline (when necessary)
15. Interpretation of results, including: Reportable ranges, Critical or panic values
16. Methods of disposal for specimens and other products used,
17. References to relevant and pertinent materials
18. Criteria for the referral of specimens to and from other health facilities, and
19. Transport requirements (e.g. cold chain) if the specimen is to be transferred to another
laboratory.
SOPs should also be available for:
1. Testing algorithms (The procedure for analyzing a sample that has more than one test
request)
2. The maintenance and monitoring of each piece of equipment
3. Sample referrals and transportation
4. Safety procedures and waste management, including proper specimen disposal
5. Quality assurance procedures

3.3.5 Document Revision

Each SOP should be reviewed on a regular basis (usually, annually).The revision status and due date
for next review should be stated on policy.

3.3.6 Document Identification

The laboratory shall have a uniform approach to document identification, format, status and issue
control, and to the procedure for document review and preparation is required for the continued
integrity of the system.
 1. Job aids, or work instructions: are shortened versions of SOPs that can be posted at the bench
for easy reference on performing a procedure. They are meant to supplement, not replace, the
SOPs.
2. Formats: the document was designed as a tool to collect information in the course of all
laboratory activity and converted to record after capturing certain information of the
laboratory activity.

3.3.7 Control of Records

The laboratory shall have a documented procedure for identification, collection, indexing, access,
storage, maintenance, amendment and safe disposal of quality and technical records. Records shall be
created concurrently with performance of each activity that affects the quality of the examination.
Laboratory records can be in any form or type of medium and shall define the time period that
various records pertaining to the quality management system. The length of time that records are
retained may vary; however, reported results shall be retrievable for as long as medically relevant or
as required by regulation.
Legal liability concerns regarding certain types of procedures (e.g. histology examinations, genetic
examinations, pediatric examinations) may require the retention of certain records for much longer
periods than for other records. For some records, especially those stored electronically, the safest
storage may be on secure media and an offsite location. Characteristics of records are that they:
● Need to be easily retrieved or accessed and
● Contain information that is permanent, and does not require updating.
Records shall include, at least, the following:
1. supplier selection and performance, and changes to the approved supplier list;
2. request for examination;
3. records of receipt of samples in the laboratory;
4. information on reagents and materials used for examinations (e.g. lot documentation,
certificates of supplies, package inserts);
5. laboratory workbooks or worksheets;
6. instrument printouts and retained data and information;
7. examination results and reports;
8. instrument maintenance records, including internal and external calibration records;
 9. calibration functions and conversion factors;
10. quality control records;
11. incident records and action taken;
12. accident records and action taken;
13. risk management records;
14. nonconformities identified and immediate or corrective action taken;
15. preventive action taken;
16. complaints and action taken;
17. records of internal and external audits;
18. inter-laboratory comparisons of examination results;
19. records of quality improvement activities;
20. minutes of meetings that record decisions made about the laboratory’s quality management
activities;
21. Records of management reviews.
22. Personnel records; such as educational and professional qualifications; copy of certification or
license, when applicable; previous work experience; job descriptions; introduction of new
staff to the laboratory environment; training in current job tasks; competency assessments;
records of continuing education and achievements; reviews of staff performance; reports of
accidents and exposure to occupational hazards; immunization status, when relevant to
assigned duties.

3.3.8 Archiving documents and Records

The quality officer is responsible for the proper archiving of documents and records. The laboratory
respects the national regulations or legislations concerning the retention time of all records. A copy of
an obsolete document is kept to provide a means for review if the situation arises.

3.4 Customer Service

Each laboratory should develop a system to collect and measure data on how much the laboratory
services and products satisfy the customer (the patients and clinical staff) and should take steps to
address any problems identified. This could be done through suggestion boxes, suggestion books
and/or satisfaction surveys as part of or additional to the overall hospital’s clinical governance and
quality improvement program.

The laboratory should have a mechanism to record complaints from patients, staff and clients. All
complaints and problems reported to the laboratory as well as corrective action taken should be
documented and the handling procedure should be part of the overall hospital’s complaint handling
and management system.

The laboratory need to conduct the need of its customers regularly .The hospital should ensure the
laboratory management produces a list of all tests that are provided by the laboratory based on the
national regulatory guidelines, including the fee per test and turnaround time. The list should be
updated regularly and should be posted in all sample collection areas and readily available to all
clinical staff and patients. The hospital laboratory has at least a minimum test menu based on FDA
standards (Annexed appendix D, E, F).

3.4.1 Laboratory Handbook

A laboratory handbook should be prepared by the laboratory for the benefit of clinical staff ordering
diagnostic tests. The handbook should be distributed to all sample collection and patient examination
areas including wards, emergency room, operating room, labor and delivery, outpatient department
etc.
The laboratory handbook should include:
● A list of all tests with current price available in the laboratory and appropriate turn-around
time for each test.
● A list of tests that may be taken by the laboratory and referred to a higher tier for analysis, and
turn-around time for each
● Important information that should be included in the laboratory handbook:
 Clinical significance of the test
 Basis for reference range
 Critical range notification
 Test interference or procedure limitations
 Any other pertinent test characteristics
  Interpretation
 Contact names and telephone numbers of key personnel
 Name and address of the laboratory
 Hours of operation of the laboratory
 List of tests that can be ordered
 Detailed information on sample collection requirements
 Sample transport requirements, if any
 Expected turnaround times
 Description of how urgent requests are handled—this should include a list of what
kinds of tests are done on an urgent basis, what are the expected turnaround times, and
how to order these tests
 Test ordering procedures
 Sample collection and sample disposal procedures

3.4.2 Advisory service

The laboratory should provide an advisory service for clinical staff to assist with the interpretation of
results and to provide advice on the process of decision making. To achieve this, laboratory staff
should make comments on the result report, either commenting on the interpretation of the results
and/or suggesting additional investigations that might aid the diagnosis. Laboratory personnel should
be available to answer queries from clinical staff about individual test results or the need for further
investigation. Additionally, the laboratory should identify ‘panic results’ (i.e. a result which should be
communicated immediately to the physician for urgent action) for each investigation and processes
by which such results are communicated immediately to the ordering clinician.

3.4.3 Information notification

The hospital laboratory should have a process to update clinical staff and others on areas such as a
start of new tests, discontinuation of tests and if there is a delay in test results etc. through registered
telephone calls or by filling notification format. A list of all tests with current price available in the
laboratory and appropriate turn-around time should be posted in all services areas. There should also
be a forum through which laboratory staff can discuss individual patient care with clinicians when
necessary. Possible mechanisms include:
 1. ‘In house’ education sessions at which all laboratory staff members who attend
workshops/training share this knowledge with their laboratory and other clinical colleagues.
2. Clinical review meetings of all clinical staff (nurses, physicians, X-ray, lab, pharmacy or any
other relevant staff). These meetings should be a forum for presentations and discussion on
general clinical issues. Laboratory staff should participate in these meetings and could use
these meetings to provide clinical advice and update information about laboratory services to
clinical staff.

3.5 Laboratory Equipment and Supply Management

The hospital laboratory has a system for proper laboratory equipment management to create and
ensure the provision of accurate, reliable and timely test results of its minimum standard. The
laboratory should be connected to a back-up power supply (generator) in cases of interruption to the
mains electrical supply. Additionally, the laboratory should have a telephone(s), fax machine,
sufficient computers and printers for administrative purposes and internet connection if possible.
Equipment Life book and Inventory: Every laboratory equipment’s should have a life book and
inventory mechanism of all equipment and instruments that includes:
● Name of manufacturer
● Model and serial number
● Date of purchase or acquisition
● Date of installation
● Purchase cost
● Current location
● Electric power requirement
● Record of contracted maintenance, and
● Record of equipment down time

Manufacturers’ manuals should be attached to, or stored beside, each instrument. Laboratory
equipment should only be used by appropriately trained staff (s). An equipment usage logbook or
form can be completed by laboratory staff to indicate the duration of use and name of the person who
used the equipment.
3.5.1 Laboratory Equipment Maintenance

There should be a predefined program for preventive maintenance, calibration and monitoring of
equipment function. Maintenance information should be properly documented and a maintenance
activity should follow a minimum of manufacturer’s recommendations. The Quality officer (QO) is
responsible to ensure that instruments in the laboratory are maintained properly, daily controls and
calibrators are run, and maintenance logs are kept up to date.

Curative maintenance of laboratory equipment must be performed by trained senior professionals or

engineers (biomedical engineers) as soon as possible to minimize equipment down time and decrease
client waiting time in the facility. The equipment supplier office or bio-medical engineer contact
information must be posted on specific equipment. The record of curative maintenance should be
signed and documented in the equipment life book.

3.5.2 Preventive Maintenance

Periodic maintenance prior to equipment failure will prevent accidental breakdown and increase
performance. Systematic Preventive Maintenance includes adjusting, calibrating, changing parts,
following shut down procedures, and performing general cleaning procedures (such as blowing,
rinsing, wiping, flushing). Cleaning procedures should adhere to Standard Operating Procedures that
apply to each instrument.
The Operator laboratory professional (user) should perform daily, weekly, monthly and/or quarterly
preventive maintenance for each type of equipment in the laboratory. All preventive maintenance
activities should be recorded in a maintenance log for each piece of equipment.
Service engineers from the appropriate company or EPHI should perform semi-annual or annual
preventive maintenance on the larger more complex instruments. A log must be completed with
copies held on site and by the service engineer.

3.5.3 Equipment calibration

There should be a timetable for the calibration and maintenance of each piece of equipment.
Otherwise calibration should be performed:
● Based on the specifications of the manufacturer
● After a complete change of reagents
 ● Where controls show unusual trends
● After major preventive maintenance
● After replacement of critical parts
● When the procedure requires more calibration

3.5.4 Laboratory Reagents and Supplies Management System

Reagents should be stored according to manufacturer’s recommendations. All reagents and other
supplies should be:
● cataloged and stored accordingly to aid retrieval
● reagents and supplies should be dispensed first expiry first out
● properly stored according to manufacturer’s instructions
● discarded when the shelf life is expired
● labeled to indicate identification and, when applicable, significant titre strength or
concentration
● marked with date of preparation or receipt
● marked with the date opened, the date that the reagent was first opened must be written on the
container with a standard plastic laminated form. If reagents are dispensed from intact stock
containers by dilution or any other treatment, the date of preparation as well as the duration
should be written
● the components of reagent kits of different lot numbers should not be interchanged unless
otherwise specified by the preparer
● reagent validation and monitoring should be done prior to use

3.5.5 Inventory control of Reagent and supply

To ensure the smooth operation of a laboratory, the management should be involved in the purchase,
storage, and distribution of laboratory reagents and supplies. If another department, such as finance or
pharmacy, is responsible for purchasing these items, they should consult with the Laboratory
Manager beforehand. To keep track of inventory levels, the laboratory should establish a control
system using either a stock/bin card or an electronic cataloging system. This system should record the
reagent name, supply on hand, and expiration date to allow staff to compare the current stock in the
laboratory and warehouse to avoid unexpected stockouts. Transactions of commodities should be
traceable and auditable, using formats such as the internal facility report and requisition form (IFRR).
Electronic Supply Chain Management (eSCM) systems are essential in laboratories. They help track
and manage inventory levels, monitor the movement of goods, and improve communication with
suppliers and customers. This results in better decision-making, reduced costs, and improved
customer satisfaction. eSCM systems also help reduce errors and delays in the supply chain process,
improving productivity and increasing profitability. They provide organizations with real-time
visibility into their supply chain, which helps identify areas for improvement and optimize processes.

3.5.6 Reagent and supply storage condition

The reagents and supplies should be stored in appropriate storage areas with better security, adequate
ventilation and monitored appropriate temperature. The storage temperature should be monitored
with standardized and calibrated thermometers. The reagents and chemicals should not be exposed to
direct sunlight. Laboratory reagents and supplies should be stored in a mini-store that is managed by a
person delegated by the laboratory manager.

3.6 Process control

Process control consists of several factors that are important in ensuring the quality of the laboratory
testing processes. These factors include quality control for testing, participating in external quality
assessment programs, appropriate management of the sample, including collection and handling, and
method verification and validation.

3.6.1 Pre-analytical phase

Sample management:
1. The laboratory should prepare a requisition form to provide all detailed information. (Patient
ID, tests requested, time and date of the sample collection, source of the sample, clinical data
and contact information for the health care provider requesting the test).
2. The laboratory should have specimen management guidelines which includes how to handle
incorrectly identified specimens.
3. Each primary sample should have a unique accession number with date and time of receipt.
4. Specimen collection SOP should be there for all sample types.
 5. Urgent requests should be handled with special attention and develop communication
procedure with physicians.
6. The laboratory should have a clear collection, labeling (minimum of two identifiers),
preservation and transport (triple packaging) procedure.
7. There should be a safety practices (leaking or broken containers, contaminated forms, other
biohazards) in the laboratory
8. The laboratory develops a system for evaluating, processing and tracking samples timely.
9. The laboratory results should be approved and assigned by responsible personnel before it
goes out from the laboratory
10. The laboratory should keep a register (log) of all incoming and referred samples. The register
should include date and time of collection; date and time the sample was received in the
laboratory; sample type; patient name and demographics; laboratory assigned identification;
and performed tests.
11. The laboratory should develop an SOP for specimen storage, retention and disposal and
practice according to these SOPs.
12. Referral samples should be registered by the laboratory for tracking and its results should be
written in a log to ensure receipt of results and for further reference.

3.6.2 Analytical phase

Internal Quality Control (IQC) programmed

The goal of IQC is to detect, evaluate, and correct errors due to test system failure, environmental
conditions or operator performance, before patient results are reported. All laboratory tests should
have a quality control mechanism. Quality control processes vary, depending on whether the
laboratory examinations use methods that produce quantitative, qualitative or semi quantitative
results. These examinations differ in the following ways:

Quantitative examinations measure the quantity of an analyte present in the sample, and
measurements need to be accurate and precise. The measurement produces a numeric value as an end-
point, expressed in a particular unit of measurement. The laboratory should follow the following steps
during implementing a quantitative QC:
 ● Establish policies and procedures
● Assign responsibility for monitoring and reviewing
● Train all staff in how to properly follow policies and procedures
● Select good QC material
● Establish control ranges for the selected material
● Develop graphs to plot control values—these are called Levey–Jennings charts
● Establish a system for monitoring control values
● Take immediate corrective action if needed
● Maintain records of QC results and any corrective actions taken.

Qualitative examinations are those that measure the presence or absence of a substance, or evaluate
cellular characteristics such as morphology. The results are not expressed in numerical terms, but in
qualitative terms such as “positive” or “negative”; “reactive” or “non-reactive”; “normal” or
“abnormal”; and “growth” or “no growth”.
● The laboratory should keep records of all QC processes and corrective actions
● When problems occur, investigate, correct, and repeat patient testing

Semi-quantitative examinations are similar to qualitative examinations, in that the results are not
expressed in quantitative terms. The difference is that results of these tests are expressed as an
estimate of how much of the measured substance is present. Results might be expressed in terms such
as “trace amount”, “moderate amount”, or “1+, 2+, or 3+”.

External Quality Assessment (EQA) program

EQA is a method that allows for comparison of a laboratory’s testing to a source outside the
laboratory. This comparison can be made to the performance of a peer group of laboratories or to the
performance of a reference laboratory.
The laboratory should participate in EQA challenges, and this should include EQA for all testing
procedures performed in the laboratory. Currently EPHI coordinates EQA activities at national levels
and provides panels for different laboratory tests in Ethiopia. Laboratory EQA programs are
implemented in the form of:
 ● Proficiency testing—an external provider sends unknown samples for testing to a set of
laboratories, and the results of all laboratories are analyzed, compared and reported to the
laboratories.
● Rechecking or retesting—slides that have been read are rechecked by a reference laboratory;
samples that have been analyzed are retested, allowing for inter-laboratory comparison.
● On-site evaluation—usually done when it is difficult to conduct traditional proficiency testing
or to use the rechecking/retesting method.

The laboratory should ensure that all EQA samples are treated in the same manner as patient samples
tested and this will be supported with an SOP. Procedures should be developed to address:
● Handling of samples—these will need to be logged, processed properly and stored as needed
for future use.
● Analyses of samples—consider whether EQA samples can be tested so that staff does not
recognize them as different from patient samples (blinded testing).
● Appropriate record keeping—Records of all EQA testing reporting should be maintained over
a period of time, so that performance improvement can be measured.
● Investigation of any deficiencies—for any challenges where performance is not acceptable.
● Taking corrective action when performance is not acceptable—the purpose of EQA is to allow
for detection of problems in the laboratory, and to therefore provide an opportunity for
improvement.
● Communication of outcomes to all laboratory staff and to management.
Hospital laboratories must comply with all national EQA requirements. Another method of inter-
laboratory comparison is the exchange of samples among a set of laboratories.

Point of care testing Quality assurance

Laboratory testing quality assurance is important in Ethiopia because it ensures that the results of
tests conducted in laboratories are accurate, reliable, and consistent. Quality assurance measures help
to identify and correct errors in testing processes, ensure that instruments and equipment are
calibrated correctly, and that testing personnel are properly trained and qualified. This ultimately
leads to better decision-making, improved public health outcomes, and increased confidence in the
reliability of laboratory test results.
3.6.5 Post analytical Phase

The laboratory result should be reported on a standard report format that contains laboratory, patient,
sample and other information (name of requester, person authorizing result release, reference range,
etc...) related to the test/is performed. The laboratory request should be cross-checked with results to
ensure all tests have been completed. The result should be reviewed and signed out by the name of
authorized personnel before being released to the requester or patient. The laboratory should also
have a policy and procedure for how it handles samples unsuitable for testing and how all samples are
managed after reporting the result.

3.7 Occurrence/Incidence management and Risk management

3.7.1 Occurrence/Incidence Management:

In healthcare, the occurrence or incidence management program plays a pivotal role in

addressing events that have a negative impact on an organization. These events may affect
personnel, products, equipment, or the environment in which the organization operates. To
ensure continual quality improvement, the laboratory must adopt a proactive approach, which
includes preventive, remedial, and corrective actions. Preventive actions involve a systematic
evaluation of processes and procedures to identify potential error points, requiring planning and
team participation. Remedial actions focus on fixing consequences resulting from errors, such as
notifying concerned parties about erroneous results. Corrective actions delve into addressing the
root cause of errors and implementing steps to prevent their recurrence. The laboratory utilizes
outcomes from internal audits, proficiency testing, customer feedback, and tracking of quality
indicators to improve overall performance. These actions are monitored and documented through
occurrence reports, fostering a culture of continuous learning and improvement.

3.7.2 Risk Management:

Risk management is a crucial aspect of ensuring the stability and resilience of laboratory
operations. The laboratory's risk management policy and procedures provide a structured
framework for identifying, evaluating, and managing risks. A comprehensive risk register
documents all identified risks, assessing their likelihood and potential impact on laboratory
operations. The risk evaluation process involves a systematic assessment of each identified risk
to determine its significance. The laboratory's risk management plan outlines strategies and
actions to manage identified risks effectively. Additionally, the notification process ensures that
the Senior Management Team (SMT) is promptly informed of significant risks, allowing for
timely intervention. Evaluation of the risk management process involves assessing the
appropriateness of risk identification, evaluation, and management, as well as the effectiveness
of SMT notification procedures. This comprehensive approach to risk management contributes to
the overall stability and resilience of laboratory operations, aligning with best practices in the
healthcare industry.

3.8 Laboratory Information Management System (LIMS)

Information management is a system that incorporates all the processes needed for effectively
managing data—both incoming and outgoing patient information. The information management
system may be entirely paper-based, computer-based, or a combination of both.
The laboratory information system shall be strengthened and mainstream into other HMIS and
disease control information systems and have a system to ensure that the laboratory has an effective
information management system in place in order to achieve accessibility, accuracy, timeliness,
security, confidentiality and privacy of patient information. When planning and developing an
information management system, whether it is a manual, paper-based system, or an electronic system,
there are some important elements to consider:
● Unique identifiers for patients and samples
● Standardized test request forms (requisitions)
● Logs and worksheets
● Checking processes to assure accuracy of data recording and transmission
● Protection against loss of data
● Protection of patient confidentiality and privacy
● Effective reporting systems
● Effective and timely communication
● It is important to establish a means to protect against loss of data. For paper based systems,
this will involve using safe materials for recording and storing the records properly. For
computerized systems, scheduled or regular backup processes are very important.
 ● It is of utmost importance to safeguard a patient’s privacy and, in this regard, security
measures must be taken to protect the confidentiality of laboratory data.
● Laboratory directors/managers are responsible for putting policies and procedures in place to
ensure confidentiality of patient information is protected.
● Attention should be given to the reporting mechanism to ensure that it is timely, accurate,
legible and easily understood.
● There shall be a predefined schedule and guideline for proper data back-up.

3.9 Laboratory Safety program

A laboratory safety program is important in order to protect the lives of employees and patients, to
protect laboratory equipment and facilities, and to protect the environment. It is a minimum
requirement for a hospital to have a biosafety level 2 laboratories.

The biosafety level BSL-2 is utilized when working with human blood, body fluids, or tissues where
the presence of an infectious agent is unknown. Accidental percutaneous or mucous membrane
exposure, exposure of non-intact skin, or ingestion of infectious materials are the primary hazards at
BSL-2. It includes work with agents connected with human disease, or pathogenic or infectious
organisms that pose a moderate risk. When performing standard diagnostic procedures or working
with clinical specimens, examples include equine encephalitis viruses and HIV.

● The responsibility for developing a safety program and organizing appropriate safety
measures for the laboratory is assigned to a laboratory safety officer. In smaller laboratories,
the responsibility for laboratory safety may fall to the laboratory manager or even to the
quality officer. The steps for designing a safety management program include:
● Developing a manual to provide written procedures for safety and biosafety in the laboratory;
organizing safety training and exercises that teach staff to be aware of potential hazards and
how to apply safety practices and techniques—training should include information about
universal precautions, infection control, chemical and radiation safety, how to use personal
protective equipment (PPE), how to dispose of hazardous waste, and what to do in case of
emergencies; setting up a process to conduct risk assessments—this process should include
 initial risk assessments, as well as ongoing laboratory safety audits to look for potential safety
problems.
● There must be eyewash, a sink for hand washing, and emergency shower. When working with
infectious agents, use proper PPE, Standard BSL-2 PPE includes a lab coat, gloves, and eye
protection. Other protective equipment may be required like First aid equipment, Fire
extinguishers and fire blankets, appropriate storage and cabinets for flammable and toxic
chemicals and Waste disposal supplies and equipment. (Refer: see EH&S PPE Assessment
Guide and National Hospital IPC manual.
● The safety officer should be assigned with proper job description, Induction, and appropriate
training.
The laboratory shall put in place measures to safeguard against malicious use of chemicals, infectious
agents and other harmful materials. Policies should be put in place that outline the safety practices to
be followed in the laboratory. Standard laboratory safety practices include:
● Limiting or restricting access to the laboratory
● Washing hands after handling infectious or hazardous materials and animals, after removing
gloves, and before leaving the laboratory
● Prohibiting eating, drinking, smoking, handling contact lenses, and applying cosmetics in
work areas
● Prohibiting mouth pipetting
● Using techniques that minimize aerosol or splash production when performing procedures—
biosafety cabinets should be used whenever there is a potential for aerosol or splash creation,
or when high concentrations or large volumes of infectious agents are used
● Preventing inhalation exposure by using chemical fume hoods or other containment devices
for vapors, gasses, aerosols, fumes, dusts or powders
● Properly storing chemicals according to recognized compatibilities—chemicals posing special
hazards or risks should be limited to the minimum quantities required to meet short-term
needs and stored under appropriately safe conditions (i.e. flammables in flammable storage
cabinets)—chemicals should not be stored on the floor or in chemical fume hoods
● Securing compressed gas cylinders at all times
● Decontaminating work surfaces daily
 ● Decontaminating all cultures, stocks and other regulated wastes before disposal via autoclave,
chemical disinfection, incinerator or other approved method
● Implementing and maintaining an insect and rodent control programmed
● Using PPE such as gloves, masks, goggles, face shields and laboratory coats when working in
the laboratory
● Prohibiting sandals and open-toed shoes to be worn while working in the laboratory
● Disposing of chemical, biological and other wastes according to laboratory policies.
● Hospital Laboratory staff who have direct contact with harmful infectious agents should be
vaccinated. For example, they should be vaccinated for Hepatitis B
● Construction and renovation of laboratories shall be in conformity with national standards and
guidelines (Refer FMHACA National Minimum Standard for different Health Facilities).
(Refer: National Hospital IPC Manual on Healthcare Waste Management).

3.10 Backup laboratory services

The Hospital ensures that there is no interruption to laboratory services in the event of: staff shortage,
equipment breakdown, and prolonged power outages, stock outs of reagents and consumables, fire,
natural disasters.
The backup laboratory service improves the provision of the service to deliver results through
avoiding interrupted service. Therefore the Hospital shall have MOU with other nearby facilities
(Regional laboratory) and use backup service whenever their services get interrupted. The Hospital
laboratory should avail backup laboratory equipment and supplies to avoid service interruption.
Where the hospital laboratory uses another laboratory as a backup, the performance of the back-up
laboratory shall be regularly reviewed to ensure quality results.

3.11 Public private partnership

Public private partnerships (PPPs) to strengthen laboratory services

Public-Private Partnerships are defined as a variety of co-operative arrangements between the
government and the private sector in delivering goods or services to the citizens. PPPs provide a
vehicle for coordinating with non-governmental actors to undertake integrated, comprehensive
efforts to meet community needs.
PPPs can be implemented in various areas related to laboratory services, including:
 1. Diagnostic testing: PPPs can be used to provide diagnostic testing services, including
laboratory tests and imaging services. This can help to improve access to these services in
underserved areas or where public sector laboratories are overburdened.
2. Equipment and technology: PPPs can be used to acquire and maintain laboratory equipment
and technology. This can help to ensure that laboratories have access to the latest technology
and equipment, which can improve the quality of laboratory services.
3. Training and capacity building: PPPs can be used to provide training and capacity building for
laboratory staff. This can help to improve the skills of laboratory staff and ensure that they are
able to deliver high-quality laboratory services.
4. Quality assurance: PPPs can be used to establish quality assurance programs for laboratory
services. This can help to ensure that laboratory services are delivered to a high standard and
that patients receive accurate and reliable test results.
5. Laboratory management: PPPs can be used to provide laboratory management services,
including procurement, inventory management, and quality control. This can help to improve
the efficiency and effectiveness of laboratory services and reduce costs.
Overall, PPPs can be implemented in various areas related to laboratory services, depending on the
specific needs and challenges faced by each country or region. By working together, the public and
private sectors can leverage their respective strengths to improve the quality and accessibility of
laboratory services.

3.12 Blood Transfusion Service

Hospital laboratories should establish a mini blood bank and provide a blood transfusion service.
Blood received from the regional blood bank should be stored in regularly monitored refrigerator/s.
Quality assurance measures should be in place to ensure the correct storage temperature is maintained
at all times. Refrigerators or freezers for blood storage should have a back- up electricity supply in
case of mains failure.

3.12.1 Facility and systems requirements

The hospital shall have a transfusion committee and sign an MOU with respective blood bank service
and should have enough space, equipment, to perform compatibility tests and to store blood and
blood products received from the blood bank service.
The minimum area of the hospitals’ blood and blood product store should be 12 meter square. The
size will increase depending on the amount of products the health facility receives from the blood
bank service and should have the following:-
1. Laboratory refrigerator to store whole blood at 2-6oc
2. Deep freezer to store plasma products <-180c
3. Platelet agitator to maintain viability of the platelet product before transfusion
4. Blood warmer
5. Space for compatibility testing
6. Water bath

Documents and Records of blood bank services

The hospital mini blood banks have well created, reviewed, approved and authorized documents that
are helpful for blood transfusion service like policies, process procedures, job aids and forms.
Records
A Facility wristband containing patient’s name and unique Facility ID number must be placed on the
patient prior to specimen collection and must remain on the patient until completion of the
transfusion.
Collection of records of clerical errors and serious adverse effects of transfusion should be in place to
ensure positive identification of specimens, requisition forms, blood and blood components, and
patients.

3.12.2 Blood and Blood Components storage

Whenever possible, temperatures of refrigerators and freezers in which blood and/or blood
components are stored should be fitted with a device that continuously measures and records the
temperature inside the equipment. A maximum and minimum temperature recording thermometer
should be placed in the refrigerator or freezer and the following temperatures should be recorded a
minimum of four times a day (every 6 hours).
These temperatures should be recorded and the maximum and minimum thermometer reading should
be re-set following each reading.
3.12.3 Blood and Blood Components Transportation

The standard transfusion request form prepared by National Blood Bank Services should be filled
appropriately. Blood units are packed in a sealed, temperature-validated transport container according
to SOP for the type of component being issued. Only one patient’s components are packed per
transport container for facilities that do not have appropriate blood storage equipment. For other
facilities, components requiring different storage temperatures should be packed in different transport
containers.
Issue of Blood Components for Transfusion
Facilities are required to perform a final check of records relating to the component at the time of
issue. One of the records to be checked is existing records of the recipient. These records provide the
previous ABO and RhD type of the recipient, which should match the blood group of the unit to be
issued.
Special instances
1. Neonatal transfusion (i.e. for infants under the age of 4 months): To perform neonatal
exchange transfusions, the freshest (less than 7 days old), usually group O RhD negative,
blood is used.
2. ABO group compatible red blood cell-containing components shall be issued, which should
also be ABO compatible with the mother.
3. RhD compatible red blood cell components shall be issued, which should also be compatible
with the mother.

3.12.4 Blood transfused in cases of dire emergency:

The health facility shall have procedures for the issuing of blood and blood components on an
emergency basis when full compatibility testing is not possible. In this instance, the patient’s
physician must weigh the risk of transfusing blood or blood components that have not undergone
compatibility testing, or those for which compatibility testing has not been completed, against the risk
of delaying transfusion until compatibility testing is complete. When a delay in transfusion may be
detrimental to the recipient, blood and blood components that do not meet requirements should only
be released when the following conditions are met:
 1. The recipient of a transfusion whose blood group is not known should receive blood which is
Group O and RhD negative (particularly if the recipient is a female with child bearing
potential).
2. Recipients of a transfusion whose blood group is known should receive ABO and RhD-
compatibility, if there has been time to test a current specimen.

3.12.5 Blood Administration

Hospital is responsible for the administration of blood and blood components shall provide
procedures for the use of all transfusion equipment such as blood warmers and the various filters that
are available. Information should be made available regarding the obtaining of informed consent and
the patient monitoring that is required during transfusion as well as the signs and symptoms indicative
of an adverse transfusion event. Procedures should be available for the recognition, evaluation, and
treatment and reporting of adverse events. Thawing of FFP should be accomplished using a validated
thawing device, specifically designed to thaw frozen plasma. The thawing device should have a
temperature monitoring device.

3.12.6 Adverse transfusion events

The transfusing health facility may want to develop forms to encourage the recognition and assist in
the reporting and management of adverse events related to transfusion, such as transfusion-
transmitted infections and hemolytic transfusion reaction. The health facility should encourage the
reporting of these events. When transmission of an infectious disease is suspected to be the result of
transfusion, the hospital shall report that information to the respective blood bank service.
The hospital is responsible for transfusing blood and blood components shall have appropriately
trained and experienced personnel available to provide advice on the use of blood and blood
components, particularly in the case of transfusion events in which the treating physician may have
limited experience, such as massive transfusions, exchange transfusions, platelet transfusions and the
treatment of hemophilia
1. Laboratory management shall ensure that laboratory services, including appropriate advisory
and interpretative services, meet the needs of patients and those using the laboratory services.
2. The Hospital laboratory shall have documented procedures for the establishment and review
of agreements for providing medical laboratory services
SECTION FOUR: SUMMARY

Laboratories plays significant role in provision of quality health care. Hospital laboratories are
expected to establish and maintain the quality of services they are providing. This chapter covered
list of operational standards that the laboratories are expected to comply and provides detail guidance
on implementation of these operational standards. The operational standards are selected based the
national priority areas for improvement of laboratory services and ISO and WHO recommendations.
The operational standards mainly covered the laboratory management structure, quality management
system, management of documents and records, effective customer service program, Laboratory
equipment management system, supplies management system, process control system, incidence
handling and reporting system, laboratory information management system, laboratory safety
program, laboratory back up services and blood bank services.

Assessment checklist list has also been prepared as a supplement, which can be used for self-
evaluation and national evaluation. The laboratory management is expected to regularly review and
acquaint itself with the guideline, self-evaluate and plan and implement activities that can improve
the quality of services they are providing.
 Implementation Checklist Laboratory Services

CHA PTER 9. LABORATORY SERVICES MANAGEMENT

S.N OPERATIONAL VERIFICATION CRITERIA Weight Score Remark
STANDARDS
1 The hospital has View organization chart, 1
established Check the laboratory has personnel record for 2
laboratory each its staff (Educational qualification,
management Experience, license, JD, training certificates,
structure and COC…)
accountability Check assignment of full time quality and 1
arrangement. safety officers
Check central laboratory controls the 1
emergency and inpatient laboratory services
(minutes, reports.)
View central, emergency and inpatient 1
laboratories functionality
Sub total 6
2 The hospital Inspect certification of accreditations and how 6
laboratory much scopes are accredited. If 6 and more
management has scopes accredited give full point. Below 6 will
develop and have equivalent score
implement quality View the laboratory-produced updated quality 1
management manual, and sample management guidelines.
system to ensure Availability of SOPs for all technical and 1
continually quality administrative procedures in all service areas
improvement at work place
Confirm the availability of updated, Formats , 1
Job aids and instructions in work place
Check each lab, Staff are aware of and follows 1
the SOP for the laboratory tests they are
performing.
Check the laboratory has identified the quality 2
gaps and prepared annual quality improvement
plans.
Confirm at least 50% of lab staff have 2
competence assessment result with the
moment assigned task
Sub total 14
3 The hospital Check SOPs for document preparation 2
 laboratory has Check SOPs for document control (Master 1
established system List documents)
for management of Check absence of obsolete document at work 1
documents. place
Check SOPs for record control 2
View record disposal procedure with practice 2
Sub total 8
4 The hospital Confirm the laboratory handbook is prepared 2
laboratory has and distributed to clinical departments.
established system View customer satisfaction survey report and 2
and practice to implementation of identified gaps
monitor the View presence of suggestion box /book, 1 ·
effectiveness of its summary of reviews and actions taken in the
customer service past quarter.
program. The laboratory has established communication 1
mechanism for panic results. Check list of
panic test results is posted
The laboratory has all types of tests listed in 2
menu based on national standards for the
hospital level.
Sub total 8
5 The hospital Confirm if the laboratory is implementing 1 ·
laboratory has MEMS for its laboratory equipment
established and management
implements a Check record of equipment/method 1
proper equipment verification done.
and supply Check the laboratory has updated equipment 1
management inventory
system. Check a record of preventive and corrective 1
maintenance for all clinical laboratory
equipment as per manufacturer
recommendation (Maintenance log)
Check the implementation of electronic supply 1
chain management system.
Check record of regular calibration of 2
equipment as per the manufacturer’s
recommendation.
Check updated SOPs ( Operational, Preventive 1
maintenance) job aids, forms,… for each
M/Es at each department
 View laboratory has mini store for lab supplies 2 ·
and reagents that should be clean, safe and
well ventilated with regular room temperature
monitoring
View updated Bin cards are used to manage 1
laboratory supplies and reagents (check 5
randomly selected bin to update)
Confirm the use of IFRR for requesting and 1
receiving reagents and supplies from the store
View SOP for reception, storage, acceptance 1
testing and inventory management of reagents
and consumables.
Sub total 13
6 The hospital Pre- examination: 1
laboratory shall View well established and isolated sample
implement a collection area.
process control View sample collection manual ready for use 1
system and in work place.
documented check record of risk identification, evaluation 2
procedure to and management plan and notification to SMT
identify and for a better risk apatite.
manage Examination phase: 2 ·
nonconformities in Obtain records of valid IQC for all tests in
any aspect of regular manner
the quality Confirm whether the laboratory participates in 2
management any recognized EQA (PT scheme) or intra
system. laboratory evaluation and scored ≥80% for
tests included in that scheme.
Check IQC and EQA out comes evaluated 2
regularly with Lab. staffs and SMT with
actions for gaps
Lab. staffs forum with clinical staffs at least 1
quarterly to improve services and Pt, care
Post- Examination: 1
Confirm a system to review results before
release independent of testing personnel
View a TAT established for every test and 1
evaluated regularly
Verify And Check record of point of care 1
testing quality assurance
Sub total 14
7 The hospital View records of occurrences or incidences 2 ·
laboratory has View deviations identified and actions taken 2
established for improvement and prevent recurrence
incident handling
and reporting
system.
Sub total 4
8 The hospital has View written procedure for the laboratory 2
established information management system
Laboratory The hospital established computer based 2
Information laboratory information management system
Management linked with the rest of EMR
System All laboratory personnel are training in of 1
EMR recording and reporting system.
The hospital has external data backup system 1
Sub total 6
9 The laboratory View the laboratory has updated safety manual 1 ·
shall develops and Ensure the laboratory has safety program 2
implements a (check if there is annual safety objectives and
program to ensure plans) and monitored accordingly
the safety of Confirm the following safety equipment and 2
laboratory services supplies are available, inspected and are
and facilities working; first aid kit, fire extinguisher, and
emergency shower, eye wash, PPE etc)
Observe every laboratory staff are using 1
proper PPE while working in the laboratory
Work stations, floor and walls are clean and 1
well maintained.
Observe for restricted access when work is in 1
progress
Sub total 8
10 The hospital Confirm if a system designed for back-up 2 ·
laboratory shall laboratory service
have backup View MOU signed with back up laboratory 1
laboratory service facility.
within and View back-up (water, equipment, electric 2
between hospital power, supply) made ready by the hospital
laboratory
Sub total 5
11 The hospital Observe MOU of Public private partnership 1
laboratories create between
 public-private private and governments laboratory
partnership in the Check MOU contain at least following: list of 1
delivery laboratory service, price, payment mechanism
laboratory service. and schedule, turnaround time, responsibility
on quality of service etc
Check MOU is reviewed based on the 1
schedule.
Sub total 3
12 The hospital has The hospital has separate mini blood bank 2 ·
blood bank service
that adhered to The laboratory has formally assigned qualified 1
appropriate laboratory personnel for blood bank and/or
standards of transfusion services.
practice The blood bank laboratory has developed and 2
updated SOPs and guidelines for its services
Check the laboratory maintains and monitors 1
temperature of storage areas for blood and
components.
The hospital has transfusion committee and 1
focal person. (Check letter of assignment
letter, TOR and annual plan of the committee
members and focal person.)
Check the HTC coordinated a blood collection 1
campaign as per the plan and schedule
Check updated equipment and supplies 1
inventory and check their functionality of each
equipment For mini blood bank
Check the presence of documents and records 1
for blood received ,blood issued and
compatibility test
Check if the laboratory is calculating average 1
daily consumption for each unit of blood and
blood product
Sub total 11
Total 100
Reference
1. International Organization for Standardization. (2012). ISO 15189:2012 Medical
laboratories -- Requirements for quality and competence.
2. International Organization for Standardization. (2022). ISO 15189:2012 Medical
laboratories -- Requirements for quality and competence.
3. CLSI. (2018). Laboratory Quality Control Based on Risk Management. CLSI document
QMS
4. CLSI. (2019). Understanding and Meeting Customer Needs. CLSI document QMS05.
Clinical and Laboratory Standards Institute.
5. CLSI. (2014). Method Validation and Verification for Laboratory Diagnosticians. CLSI
document EP15-A3. 3rd ed. Clinical and Laboratory Standards Institute.
6. Strengthening Laboratory Management Toward Accreditation. (2016). SLMTA Checklist.
Retrieved from https://www.slmta.org/wp-content/uploads/2016/09/SLMTA-Checklist-
English.pdf
7. Ethiopian Food, Medicine, and Healthcare Administration and Control Authority. (2020).
Test Menu. Retrieved from https://www.fmhaca.gov.et/wp-content/uploads/2020/02/TEST-
MENU-1.pdf
8. World Health Organization Regional Office for Africa. (2014). Checklist for Accreditation
of Medical Laboratories in the African Region. Retrieved
from https://www.afro.who.int/sites/default/files/2017-06/WHO AFRO Checklist for
Accreditation of Medical Laboratories in the African Region.pdf
Appendix A: Ministre Organo Gram
 Appendix B: Sample Preventive Maintenance Log

Document No:
NAME OF HOSPTAL NHCL/F5.3-25
Clinical laboratory Copy No: Rev No:
0 0

Sample Preventive Maintenance Log Page No: Effective date:

1 of 54 01 Jan.15

Time and Activity 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Daily

Weekly
Monthly

Initials
Appendix C: Sample Request form for New and Used spare parts of Instrument

Document No:

Organization Arma NAME OF HOSPTAL NHCL/F5.3-25

Clinical laboratory Copy No: Rev No:
0 0

Sample Request form for New and Used spare parts of Instrument Page No: Effective date:
1 of 54 01 Jan.15

Date Department/Instrument name

Items names & New Used Requested by Received by Signature
identification No
Appendix D: National SOP Template

Document No:

Hospital Arma NAME OF HOSPTAL NHCL/F5.3-25

Clinical laboratory Copy No: Rev No:
0 0
Page No: Effective date:
Sample Request form for New and Used spar
parts of Instrument 1 of 54 01 Jan.15

Purpose
 Explains the management of all SOPs. This procedure ensures correct management of
SOPs.
Objective
 This procedure explains the process of SOP management.
Definitions
 SOP(s): Standard Operating Procedure(s)
References
 To be filled in if necessary
Responsibilities
 The Quality Manager is responsible for organizing and supervising SOP management. The
technical or managerial staff is responsible for writing SOPs. The senior staff with technical
(for technical SOPs) or managerial (for managerial SOPs) knowledge reviews the SOPs. The
Laboratory Director / Manager authorize release of SOPs. The Document Controller is
responsible for providing printed copies of SOPs.
Operating mode
Methodology
 Managing Standard Operating Procedure (SOP) documents is a critical responsibility and a
cooperative process between all users of the SOP document set. The SOPs need to be
written, reviewed, authorized, published, distributed, revised and archived.
SOPs type
SOPs provide step-by-step instructions to the laboratory’s staff with respect to performing laboratory
tests (analytical SOP), using a piece of equipment (equipment SOP), or successfully carrying out any
kind of procedure/non-test activity (procedural SOP, e.g. SOP Document Distribution).
Each type of SOP follows the same general format:
 Purpose , Objective, Definitions, References, Responsibilities, Operating mode, Related
documents, Analytical/ Technical SOPs also details for each laboratory test: principle,
sample, equipment, reagents, and quality control.
 Equipment SOP details for each piece of equipment: description, safety, start up,
calibration, validation, maintenance, operation, and troubleshooting.
Creation and editing
SOPs are produced from a template. Each section of the template is completed or deleted if not
applicable. Once a draft of the document is ready, it should be sent to senior staff with
technical (for technical SOPs) or managerial (for managerial SOPs) knowledge for review and
comments.
Review and authorization
1. The appropriate staff and the consultant review the first draft of each SOP and make notes
or comments on the draft. Any necessary revisions of the draft are made by the author(s).
This review and revision process continues until the reviewers accept a final version.
2. Each SOP is then sent to the Laboratory Director / Manager for authorization of release.
Once the SOP is authorized, it is sent to the Document Controller for hardcopies to be
printed. The authorization of the final SOP version is noted by the Laboratory Director /
Manager signature on one dated copy. The author(s) and reviewer(s) also sign this copy.
Publishing
3. Authorized SOPs should have sufficient copies printed for distribution.
4. Signed documents (originals) should be stored in file cabinets.
5. Electronic versions of SOPs should be stored on a secure file server with access
restricted to authorized users.
Distribution
6. Finalized and authorized SOPs are distributed to the staff that requires them for
referral.
7. The Quality Manager will keep track of which staff members need specific SOPs,
and will determine who has actually read and demonstrated comprehension of the
documents as well. (Refer to SOP Document Distribution).
Revision of existing SOPs
1. Each SOP is reviewed every year. The review can result, or not, in modification(s)
of the SOP. The review process is coordinated by the Quality Manager.
2. The decision to modify a laboratory procedure should not be made casually, but
should only be recommended after thorough consideration. The reasons for the
revision and the changes shall be sufficiently documented to ensure that the rationale
for the revision is clear.
3. If possible, changes to existing procedures should be made by the original author(s).
If not, the Quality Manager coordinates the changes with the appropriate staff.
4. After a decision to modify a procedure has been reached, the Quality Manager will
serve as the point of contact responsible for ensuring that the new procedure is
properly reviewed, authorized, and recorded for use.
5. After a SOP has been revised, the following shall be identified on the front page of
the document:
 The date of the revision,
 The person making the revision,
 The changes made (and the reasons for the revision)
Archiving SOP versions
 When a published and distributed document has been revised, the previous version should be
stored in an archive for 2 years and later discarded. This includes both the hardcopy and any
electronic copies of the document.
Related documents
 4.3-01 Document Master List
 4.3-02 Form For Document Distribution List
 4.3-03 Form For Document Change Requesting Memo
 4.3-04 Form For Document Requesting
 4.3-08 Check list for new document formality
 4.3-06 Form for Quality Management System Documents Transportation Log

Prepared by:_____________________ Date:________________ Signiture:____________

Aproved by:_____________________ Date:________________ Signiture:_____________

Appendix D: List of laboratory tests to calculate laboratory test availability in Compressive
Specialized Hospital Laboratory

No Types of laboratory test Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

1 Blood glucose
2 Cholesterol
3 Triglyceride
4 LDL
5 HDL
6 Na+
7 K+
8 Cl-
9 T. Calcium, Iodized Ca
11 PO4
12 ALKP
13 AST
14 ALT
15 d GT
16 Total bilirubine
17 Direct bilirubine
18 Total protein
19 Albumin
20 Urea
21 Creatinine
22 Uric acid
23 LDH
24 CK-MB
25 Troponine
26 CPK,
27 T3
28 T4
29 TSH
30 FSH
31 LH
32 Testosterone
33 Prolactine
34 Stool microscopy
35 Blood Film
36 Occult blood
37 Urinalysis chemical test
38 Urinalysis Microscopy
39 Criptococal Ag test
40 Ascitic fluid
41 Pleural fluid
42 KOH test
43 Fungal culture
44 Haemoglobin
45 Total WBC count
46 Differential white cell count
47 Peripheral blood film
48 ESR
49 Hematocrit
50 Platelet count
51 Bleeding time
52 Reticulocyte count
53 prothrombin time
54 APTT
55 INR
56 Hb electrophoresis
57 Lupus Erythematosus(ANA)
58 H.Pylori Ab
59 H. pylori Ag
60 Troponin
61 HBs Ag
62 HCV
63 Toxoplasma latex
64 ASO
65 RF
66 CD4 count
67 CD pannel
68 RPR
69 TPHA
70 CRP
71 Salmonella Typhi-O
72 Salmonella Typhi-H
73 Proteus-OX19
74 HIV-test
75 Earily Infant Diagnosis for HIV
76 Viral load,
77 Blood Group including RH
78 Compatibility testing
79 Cross match
80 Coombs Test
81 Gram stain
82 Ziehl Neelson stain
83 India Ink,
84 Aerobic Culture and sensitivity
test
85 CA-153
86 CA-125
87 CA-199
88 Iron
89 Transferrin
90 RBC folate
91 UIBC (unsaturated iron binding
capacity)
92 Vitamin B 12
93 Febernogen
94 Folate3
95 Ferrtien
96 CK-MB
97 LDH
98 CPK (creatine phosphokinase)
99 Troponine
100 Lipase
101 Folate3
102 Speram Ananlysis
103 HgbA1C,
104 Arterial Blood gass analysis
105 HB viral load
106 HC vira load
107 Gxp riff assay
108 OGTT
109 SSS (BI/MI, Leshmania, oncho
110 Anearobic bacterial culture and
sensitivity test
Appendix E: List of laboratory tests to calculate laboratory test availability in General Hospital
Laboratory

No Test Name Day1 Day 2 Day 3 Day 4 Day 5

1 Blood glucose
2 GTT
3 Cholesterol
4 Triglyceride
5 LDL
6 HDL
7 Na+
8 K+,
9 Cl-
10 ALKP
11 AST
12 ALT
13 d GT
14 Total bilirubine
15 Direct bilirubine
16 Total protein
17 Albumin
18 BUN
19 Urea
20 Creatinine
21 Uric acid
22 LDH
23 CK-MB
24 Troponine
25 CPK
26 T3
27 T4
28 TSH
29 FSH
30 LH
31 Prolactin
32 Testestrone
33 Stool microscopy
34 Blood film
35 Occult blood
36 Urinalysis chemical test
37 Urinalysis Microscopy
38 CSF analysis
39 Ascitic fluid
40 Pleural fluid
41 KOH
42 Haemoglobin
43 Total WBC count
44 Differential white cell count
45 Peripheral blood film ·
46 ESR
47 Hematocrit
48 Platelet count
49 Bleeding time
50 Reticulocyte count
51 prothrombin time
52 APTT
53 INR
54 H.Pylori
55 Troponin
56 HBs Ag
57 HCV
58 Toxoplasma latex
59 ASO
60 RF
61 RPR
62 TPHA
63 CRP
64 Troponin Qualitative
65 PAS Qualitative
66 Salmonella Typhi-O
67 Salmonella Typhi-H
68 Proteus-OX19
69 HIV-test
70 HCG
71 Blood Group
72 Compatibility testing
73 Cross match
74 Gram stain
75 Ziehl Neelson stain
76 India Ink
77 Culture and sensititivty
78 Spermatozoa
Appendix F: List of laboratory tests to calculate laboratory test availability in Primary Hospital
Laboratory

No Test Name Day1 Day 2 Day 3 Day 4 Day 5

1 Blood glucose
2 ALKP
3 AST
4 ALT
5 GGT
6 Total bilirubine
7 Direct bilirubine
8 Total protein o
9 Albumin
BUN
10 Urea
11 Creatinine
12 Uric acid
13 Stool microscopy
14 Occult Blood Test
15 Blood film
16 Urinalysis chemical test
17 Urinalysis Microscopy
18 CSF analysis
19 Ascitic fluid
20 Pleural fluid
21 KOH
22 Hemoglobin
23 Total WBC count
24 Differential white cell count
25 Peripheral blood film
26 ESR
27 Hematocrit
28 Platelet count
29 H. pylori Ags
30 H.Pylori Abs
31 HBs Ag
32 HCV
33 ASO
34 RF
35 RPR
36 Salmonella Typhi-O
37 Salmonella Typhi-H
38 Proteus-OX19
39 HIV-test
40 HCG
41 Blood Group: Anti-A, Anti-B,
AntiD,
42 Compatibility testing
43 Cross match
44 Gram stain
45 Ziehl Neelson stain
46 Indian Ink
CHAPTER: 16
INFECTION PREVENTION AND CONTROL
Outline
Section 1 Introduction .......................................................................................................................................... 1
Section 2 Operational Standards for Infection Prevention and Control (IPC) ...................................................... 2
Section 3 : Implementation Guidance ...................................................................................................................... 3
3.1 The hospital has functional infection prevention and control (IPC) Program .............................................. 3
3.2. The hospital has adapted evidence based IPC guidelines, SOPs and monitoring tools. .................................. 4
3.3 IPC Education and Training ................................................................................................................................. 5
3.4 Healthcare associated Infections (HAIs) Surveillance......................................................................................... 6
3.5 Multimodal Strategies Implementation ............................................................................................................. 6
3.6 Monitoring, Audit and Feedback ........................................................................................................................ 7
3.7 Built Environment, Materials & Equipment ....................................................................................................... 8
3.8 Hand Hygiene...................................................................................................................................................... 9
3.9 Safe Injection Practices .....................................................................................................................................12
3.10 Healthcare Waste Management.....................................................................................................................13
3.11 Environmental Cleaning..................................................................................................................................17
3.12 Laundry Service...............................................................................................................................................19
3.13 Medical devices decontamination and Processing Instruments and Reusable Items: ..................................20
3.14 Food and Water Safety ...................................................................................................................................26
3.15. Occupational Safety .......................................................................................................................................28
Annex …………………………………………………………………………………………………………………………………………………………………
Abbreviations

ART Anti-Retroviral Therapy

CASH Clean And Safe Healthcare facilities
CDC U.S. Centers for Disease Control and Prevention
CEO Chief Executive Officer
HBV Hepatitis B Virus
HAI Healthcare Acquired Infection
HP Healthcare Personnel
HCV Hepatitis C Virus
HCW HealthCare Waste
HCWM HealthCare Waste Management
HEPA High Efficiency Particulate Air
HIV Human Immunodeficiency Virus
IMAI Integrated Management of Adolescent and Adult Illness
IMNCI Integrated Management of Newborn and Childhood Illnesses
IPC Infection Prevention and Control
IPC Infection Prevention and Patient Safety
MDT Multi-Disciplinary Team
MRSA Methicillin Resistant Staphylococcus Aureus
OSHA Occupational Safety and Health Administration
PEP Post Exposure Prophylaxis
PIHCT Provider Initiated HIV Counselling and Testing
PPE Personal Protective Equipment
STI Sexually Transmitted Infections
TB Tuberculosis
WHO World Health Organization

Tables
Table 1: IPC Checklist
Table 2: IPC Indicators
Section 1 Introduction

Healthcare facilities are entrusted with the responsibility of delivering high-quality services characterized
by safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Central to this mandate is
the imperative to maintain hospital cleanliness and safety, which significantly influences the quality of
care and patient satisfaction. A clean and safe hospital environment fosters comfort and security for
patients, attendants, visitors, staff, students, and the broader community. Given the heightened risk of
infection transmission in healthcare settings, both recipients and providers of care are vulnerable to
acquiring and transmitting infections through various exposures. Healthcare-acquired infections (HAIs)
present a significant challenge, defined as those acquired during healthcare delivery in any setting.
Effective infection prevention and control (IPC) practices are paramount in mitigating the occurrence of
HAIs, including those related to antimicrobial resistance, thereby underscoring a hospital's dedication to
patient and staff well-being.

Furthermore, hospitals must uphold the safety of all individuals by preventing infection acquisition and
transmission, especially amid the prevalence of infectious diseases like Tuberculosis, HIV, HBV, HCV,
and the recent COVID-19 pandemic. The recent development of a national IPC Policy and strategy by the
Federal Ministry of Health marks a pivotal step in enhancing IPC program implementation, ultimately
elevating patient safety and healthcare quality. This initiative strengthens the foundation for proactive
measures aimed at safeguarding employees, patients, and visitors, thereby reaffirming the commitment to
maintaining a safe and conducive healthcare environment.

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Section 2 Operational Standards for Infection Prevention and Control
(IPC)

1. The hospital has functional Infection Prevention and Control (IPC) Program
2. The hospital has adapted evidence based IPC guidelines, SOPs and monitoring tools
3. The hospital has IPC training and education program for its HCWs
4. The hospital has active surveillance for its prioritized HAIs
5. The hospital implements multimodal strategy to improve its prioritized IPC interventions
6. The hospital conducts regular monitoring and audit and provide feedback to ensure
compliance of standardized IPC practice
7. The facility has appropriate built environment, materials and equipment for IPC
8. Hand hygiene practice is implemented and supplies are provided at all service points at all
time
9. Safe injection practices are implemented to minimize risk to clients, staff and surrounding
community
10. The hospital practices safe healthcare waste management
11. The hospital ensures cleanliness of health care environment
12. The hospital avails adequate and functional laundry service
13. The hospital has proper medical devices decontamination and reprocessing mechanism
14. The hospital has a monitoring system to ensure safety of food and water served in the
premises
15. The hospital ensures all preventive and post exposure interventions and procedures are in
place in case of occurrence of occupational risks and hazards

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Section 3: Implementation Guidance

3.1 The hospital has functional infection prevention and control (IPC) Program

The purpose of an IPC program is to prevent HAI and combat AMR. Hospitals should have
functional Infection Prevention and Control (IPC) Program Management and governance. The
national IPC program policy and strategy clearly defined its objectives, functions, and activities.
The activities of the facility-level IPC program should be guided by national strategies. Having a
strong and functional IPC program at the facility level is fundamental for the implementation of
IPC activities and ultimately for improving patient safety and the quality of healthcare delivery.

The Infection prevention and control program at the hospital level should be led by well-trained,
dedicated, and full-time IPC professionals. Hospitals should have a minimum ratio of one full-
time or equivalent infection prevention nurse or doctor per 250 beds. The hospital IPC program
should be supported by an IPC team with dedicated time for IPC. In addition, the hospital IPC
program should have clearly defined objectives and operational plans based on local
epidemiology and priorities. Hospitals should have dedicated budgets to implement their
operations plans. The IPC programs should cover defined activities that at least include:
 Surveillance of HAIs and AMR.
 IPC activities related to patients, visitors and health care workers’ safety and the
prevention of AMR transmission.
 Development or adaptation of guidelines and standardization of effective preventive
practices (standard operating procedures) and their implementation.
 Outbreak prevention and response, including triage, screening, and risk assessment
especially during community outbreaks of communicable disease.
 Health care worker education and practical training.
 Maintaining effective aseptic techniques for health care practices.
 Assessment and feedback of compliance with IPC practices.
 Assurance of continuous procurement of adequate supplies relevant for IPC practices, as
well as functioning WASH services that include water and sanitation facilities and a
health care waste disposal infrastructure.

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  Assurance that patient care activities are undertaken in a clean and hygienic environment
and supported by adequate infrastructures.

3. 2. The hospital has adapted evidence based IPC guidelines, SOPs and monitoring tools.

Hospitals should develop/ adapt guidelines and implement for the purpose of reducing HAI and
AMR. Guidelines should be evidence-based and reference international or national standards.
Early engagement and participation of stakeholders in the development and production of
guidelines is important to achieve consensus and support during the implementation phases.
For correct implementation, health care workers (HCWs) should be trained on IPC guideline
recommendations. Processes must be in place to ensure that HCWs in the facility are educated
and understood these guideline’s recommendations. Adherence with these guidelines should be
monitored by the IPC focal person in conjunction with hospital management.
At a minimum, the hospitals should develop/ adapt the following standard operating procedures
(SOPs):
 Hand hygiene,
 Decontamination and reprocessing of medical devices and patient care equipment ,
 Environmental cleaning,
 Health care waste management,
 Injection safety, HCW protection (for example, post exposure prophylaxis, vaccinations),
 Aseptic techniques
 Triage of infectious patients
 Standard and transmission-based precautions (for example, detailed, specific SOPs for the
prevention of airborne pathogen transmission);
 Aseptic technique for invasive procedures, including surgery;
 Specific SOPs to prevent the most prevalent HAIs based on the local
context/epidemiology;
 Occupational health (specific detailed SOP).

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3.3 IPC Education and Training

The hospital should have IPC education and training for all health care workers to reduce the risk
of HAI and AMR. IPC education and training should be a part of an overall health facility
education strategy, including new employee orientation and the provision of continuous
educational opportunities for existing staff, regardless of level and position (for example, senior
administrative and housekeeping staff). The training and education should cover the following
category of human resources.

IPC focal person and members of IPC team (doctors, nurses and other professionals) should
be trained to achieve an expert level of knowledge covering all areas relevant to IPC, including
patient and health care worker safety and quality improvement. To maintain high-level expertise,
it is important that all IPC personnel undergo regular updates of their competencies.

All health care workers involved in service delivery and patient care: clinical staff should
understand IPC measures embedded within clinical procedures. Healthcare workers should have
access to and trained on the facility level adapted guidelines/ SOPs

Other personnel that support health service delivery: these include cleaners responsible for
the day-to-day cleaning of the facility, auxiliary service staff and administrative and managerial
staff responsible and accountable for the safety and quality of health service delivery, including
the overall implementation of policies and guidelines and the monitoring of national and local
policies. Senior managers should understand the importance of supporting IPC infrastructure and
practices to reduce harm to patient and health care workers and therefore the associated costs.

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3.4 Healthcare associated Infections (HAIs) Surveillance

At hospital level, HAI surveillance should be conducted to guide IPC interventions and detect
outbreaks, with timely feedback of results to health care workers and stakeholders. Regular
reports on the levels of healthcare associated infections within the facility should be made
available to treating clinicians to make them aware of their local resistance profiles.
The HAI surveillance should be conducted based on national Healthcare Associated infection
Surveillance Guideline and customized to the facility according to available resources. The
hospital should put in place enabling structures and supporting resources (for example,
dependable laboratories, medical records, trained staff), for an appropriate method of
surveillance.
Surveillance should provide information for:
 Describing the status of infections associated with health care (that is, incidence and/or
prevalence, type, etiology and, ideally, data on severity and the attributable burden of
disease).
 Identification of the most relevant AMR patterns.
 Identification of high-risk populations, procedures and exposures.
 Existence and functioning of a WASH infrastructure, such as water supply, toilets and
health care waste destruction.
 Early detection of clusters and outbreaks (that is, early warning system).
 Evaluation of the impact of interventions
3.5 Multimodal Strategies Implementation

Hospitals should implement multimodal strategies to improve IPC practices and reduce HAI and
AMR. A multimodal strategy consists of several elements or components (3 or more; usually 5)
implemented in an integrated way to improve an outcome and change behavior. The 5 most
common components include: (i) system change (that is, availability of the appropriate
infrastructure and supplies to enable IPC good practices); (ii) education and training of health
care workers and key players (for example, managers); (iii) monitoring infrastructures, practices,
processes, outcomes, and providing data feedback; (iv) reminders in the workplace or
communications; and (v) culture change with the establishment or strengthening of a safety
climate.

3.6 Monitoring, Audit and Feedback

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The hospital should conduct regular monitoring/ audit and timely feedback of health care
practices according to IPC standards to prevent and control HAI and AMR. Monitoring and
auditing allows assessing the extent to which standards are being met, activities performed
according to requirements, and to identify aspects that may need improvement.
Monitoring, audit and feedback should also include the regular evaluation of facility compliance
with regulations and IPC best practices and standards, and identification of actions that need
reinforcement or a change in strategies, as well as successful experiences.
Feedback should be provided to all audited persons and relevant staff. Sharing the audit results
and providing feedback not only with those being audited, but also with hospital management
and senior administration is a critical step. IPC teams and committees (or quality improvement
team) should also be included as IPC care practices are quality markers for these program.
IPC program should also be periodically evaluated to assess the extent to which the objectives
are met, the goals accomplished, whether the activities are being performed according to
requirements and to identify aspects that may need improvement identified via standardized
audits.

The hospital should prepare/ adapt monitoring and audit tool and performance indicators for
collection and reporting its overall IPC performance.

3.7 Built Environment, Materials & Equipment

Patient care activities should be undertaken in a clean and hygienic environment that facilitates
practices related to the prevention and control of HAI as well as AMR. This includes the
availability of WASH infrastructure and services and the availability of appropriate IPC
materials and equipment. Materials and equipment to perform appropriate hand hygiene should
be readily available at each point of care.

Infrastructure and supplies to implement other standard precautions such as personal protective
equipment, sharps safety management, safe hospital laundry, environmental cleaning, and waste
management should be in place in accordance with the national IPC guideline. The following are
the minimum requirements for the built environment, materials, and equipment for proper IPC
practices:

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  Water should always be available from a source on the premises to perform basic IPC
measures, including hand hygiene, environmental cleaning, laundry, decontamination of
medical devices and health care waste management.

 A minimum of two functional, sanitation facilities should be available for outpatients and
one per 20 beds for inpatient wards;

 Functional hand hygiene facilities should always be available at points of care/toilets and
include soap and water or alcohol-based hand rub (ABHR) at points of care and soap and
water within 5 meters of toilets.

 Sufficient and appropriately labelled bins to allow for health care waste segregation
should be available and used; waste should be treated and disposed of safely via
autoclaving, high temperature incineration, and/or buried in a lined, protected pit.

 The facility should be designed to allow adequate ventilation (natural or mechanical, as

needed) to prevent transmission of pathogens.

 There should be spacing of at least one meter between the edges of beds; and no more
than one patient per bed;

 Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent,
disinfectant, personal protective equipment (PPE) and sterilization) and power/energy
(for example, fuel) should be available for performing all basic IPC measures according
to minimum requirements/SOPs, including all standard precautions, as applicable;
lighting should be available during working hours for providing care

 The facility should have a dedicated space/area for performing the decontamination and
reprocessing of medical devices (that is, a decontamination unit) according to minimum
requirements/SOPs.

 The facility should have adequate single isolation rooms or at least one room for cohort
patients with similar pathogens or syndromes.

3.8 Hand Hygiene

Ensuring Proper Hand Hygiene Practices

Basic principles to be followed concerning hand hygiene

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There are very important basic principles in relation to proper hand hygiene. If these principles
are followed consistently hand hygiene practices can be implemented effectively. Some of the
important basic principles to be followed are:
o Guidelines on hand hygiene have to be followed
o Guidelines on hand hygiene have to be properly disseminated and promoted
o Best practices on hand hygiene have to benchmarked
o Every staff members have to be involved
o The culture of providing positive feedbacks has to be developed
o Necessary supplies have to be availed at service areas
o There has to be a culture of rewarding role models of proper hand washing
o Basic orientation/training has to be given to all hospital staff
Necessary infrastructures for proper hand hygiene
To practice proper hand hygiene among healthcare providers there are basic infrastructures
which must be fulfilled by the hospital as a prerequisite. The basic infrastructures (minimum
requirement) which should be put in place by hospitals for proper hand hygiene are:
o Functional hand washing sinks
o Functional water container (if there is no running tap water)
o Water tanker for reserve water during water supply interruptions
o Functional drainage system
Necessary supplies for proper hand hygiene
There are vital supplies which are needed for proper hand hygiene practices without which
healthcare providers can’t practice hand hygiene. It is expected from hospitals to ensure the
continuous supply of these vital supplies. The vital hand hygiene supplies to be put in place
continuously by hospitals at hand washing area are:
o Continuous supply of water
o Detergents ( bar soap, liquid soap)
o Alcohol based hand rub
o Alcohol solution to prepare alcohol based hand rub
o Disposable paper towels
When to Perform Hand Hygiene (Hand Hygiene Opportunities)
The World Health Organization has five recommended points in time when hand hygiene should
occur in order to prevent transmission of HAIs. These recommendations are called the ―My 5
Moments for Hand Hygiene‖ and focus on the following times:

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  Before making contact with a patient
 Before performing a clean/aseptic task, including touching invasive devices
 After performing a task involving the risk of exposure to a body fluid, including touching
Invasive devices
 After patient contact
 After touching equipment in the patient‘s surrounding areas (WHO 2006a)
Hand Hygiene Promotion
Hospitals have to have a consistent, proper hand hygiene promotion system. Promotional work is
needed to change the attitudes of hospital staff and clients toward proper hand washing. To have
effective promotion work, hospitals have to:
 Prepare and post signs that clearly show hand washing areas at service points.
 Post five Moments of Hand Hygiene posters at visible areas of service points.
 Posters of hand washing techniques posters (including alcohol-based hand rubs) at hand
hygiene stations.
 Select quarterly observed "Hand Washing Days" on which proper hand washing role
models are rewarded.
 Prepare promotional posters using pictures of role models of proper hand washing and
post them in visible areas of the hospital.
 Prepare audiovisual materials for hand washing and display them in waiting areas for
patients
Monitoring hand washing practices in the hospital
The core issue of proper hand hygiene is consistently practicing hand hygiene appropriately. The
other issues discussed above are the means to achieve this important end which is practicing
proper hand hygiene. The hospital establishes systems and develops necessary tools and
procedures to monitor proper hand washing practices.
For effective hand hygiene practices monitoring the hospital:
o Develops hygiene practices monitoring checklist ( in interview and observation form)
o Conducts quarterly assessments using the developed checklists
o Identify strengths and gaps/challenges
o Disseminate the identified strengths and challenges to the staff
o Prepare improvement plan and share the prepared plan to responsible bodies who are
expected to implement the planned action items
o Properly document all monitoring activities

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3.9 Safe Injection Practices

A) Basic principles on injection safety

Hospitals have to adhere to some basic principles to ensure injection safety at their injection and
medication rooms. Hospitals have to follow the following principles:

 Eliminating unnecessary injections is the best way of preventing risks of unsafe injections
 One needle and one syringe for one injection principle has to be followed
 Recapping of needles has to be avoided
 Educating patients and the community at large on pros and cons of medication by
injection is an important intervention
B) Supplies and other inputs needed to ensure injection safety
There are important inputs which are needed to ensure injection safety in hospitals. Hospitals
ensure the availability of the following to make injections in their medication rooms safe:
 Basic orientation/trainings for hospital staff members
 Standard operating procedures of safe injection implementation
 New and sterile injection devices
 Necessary personal protective equipment in medication rooms
 Necessary supplies for antiseptic purposes
 Necessary infrastructure and supplies for proper hand washing
 Sharp containers
 Waste containers for non-sharp wastes
 Equipment and supplies for instrument processing
C) Expected activities from healthcare providers
The following activities are performed by healthcare providers who administer injections to
make those injections safe:

 Properly washing hands before applying necessary PPE

 Utilizing the appropriate PPE
 Giving the right injection medication for the right person, with the right dose and right
time
 Properly utilizing sharp containers and other waste containers
 Disposing medical wastes generated in medication room according to national medical
waste management guidelines

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  Ensuring proper documentation of activities in the service area

NB. For detailed technical information on injection safety, please refer National Medical
Waste Management Guidelines and National IPC Reference Manual.

3.10 Healthcare Waste Management

Health care waste should be dispose in a manner that poses minimal hazard to patients, visitors,
healthcare workers and the community. Infectious waste materials shall be treated properly to
eliminate the potential hazard to human health and environment. Health facilities should ensure
that HCWs are safely managed along the waste stream.
Waste Management Procedures and principles
The management of health care multi-step process involving:

 Waste Minimization
 Segregation
 Handling
 Collection
 Storage
 Transportation
 Treatment and Disposal
NB. For detailed technical information Healthcare waste Management, please refer
National Medical Waste Management Guidelines and the National IPC Reference Manual.
The 3 categories of HCW shall be segregated into color coded containers as follows

Table 1: The 3 HCW Categories

Segregation Color-coded container Non-color coded bins
Category
Non-infectious waste/ Black bin Bins should be labeled non-risk waste
General waste
Infectious waste Yellow bin Bins should be labeled infectious waste
Sharp waste Yellow safety box The box should be labeled biohazard
waste.

3.11 Environmental Cleaning

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Maintaining a clean and safe health facility is essential to provide quality care for patients.
Proper cleaning will reduce the number of microorganisms in patient care areas and will help to
minimize the risk of exposure to infectious agents to patients, families, caregivers, visitors and
hospital staff. Hospitals may provide the housekeeping service through its own staff or, or may
contract out services to an outside vendor. However, regardless of how the service is provided
and by whom, the hospital must ensure that standards are met and the guidance adhered to.
A. Work plan
The housekeeping department should develop operating procedures or work plan on the cleaning
process and schedule for each unit (clinical vs. administrative areas). The procedures are meant
to serve as a guide for hospitals in devising their own cleaning schedule and procedures. Further
detailed guidance can be found in National Reference Manual for Infection Prevention and
Control.
B. Supplies
The hospital should have a regular supply of all necessary cleaning materials. At minimum
hospitals should provide the following:
 Disinfectants and detergents, bleach, powder detergents e.g. Omo
 Mops, cloths for dusting, brooms, soaps , buckets
 Personal protective equipment for cleaning staff and alcohol for hand rub preparation.
The head of the department should plan for and request supplies to meet monthly consumption
needs.

C. Procedures
All patient care areas should be cleaned based on as per the schedule by wet mopping, scrubbing
or dusting and or scrubbing using disinfectant cleaning solutions. Staff should be trained/
oriented on how to prepare cleaning solutions and procedures for preparing the solution should
be posted in an area visible to the cleaning staff.
The hospital should conduct a cleaning audit using audit tool to ensure all patient areas and
toilets are clean properly and regularly. The hospitals should conduct a needs assessment to
identify and ensure availability and functionality of hand wash sinks, toilets and showers.
Availability of adequate water supply at all clinical service units should also be assessed. The
assessment should be done periodically (at a minimum quarterly) to ensure that any new needs
are identified.
3.12 Laundry Service

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Hospitals may provide the laundry service through its own staff or, or may contract out services
to an outside vendor. However, regardless of how the service is provided and by whom, the
hospital must ensure that standards are met and the guidance adhered to. Larger hospitals with a
high volume of work should have large capacity machines that can handle a high volume of
linens and/or an increased number of machines Heavy-duty washers/dryers are recommended for
a large hospital with high patient load.
The hospital should provide leak proof plastic containers with a lid or leak proof plastic bags at
each procedure room to store soiled linens and to prevent spills from soiled linen until they are
transported to the laundry. The laundry should also at a minimum–have two separate carts to
transport clean and soiled linens to and from the laundry as well as storage shelves to store clean
linens before they are returned to the appropriate work area. Waste generated from the laundry
should be decontaminated and have a proper.
It is recommended that each unit/work area should be allotted with a designated shelf to allow
separation of linens by case teams and ensure accurate management of linens. Linens should be
checked regularly for holes and/or threadbare areas. Repairs, replacement or disposal should be
done based on the assessment.
A. Work plan
Each hospital laundry should develop an operating procedure or work plan for laundry services.
The plan would give guidance on the segregation of linen at the ward level, transport of linens to
and from the laundry, cleaning procedures, operation of machines, segregation of linen by the
laundry staff after washing, storing of linen and transport to different case teams/wards,
registration of incoming and outgoing linen and shifts for working hours. There must be hand
washing facility there.
The laundry space should be adequate with separated rooms for soiled and clean linens and has
to have at least three machines (washing, ironing and. drying).
B. Supplies
The laundry should ensure that there is always an available supply of detergent and bleach.
C. Laundry operations
For detailed technical recommendations on Laundry operation and processing of reusable
Textiles and Laundry Services, please refer National IPC Reference Manual Volume 1
Chapter 8.

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3.13 Medical devices decontamination and Processing Instruments and Reusable Items:

Level of Disinfection or Sterilization Required

Decisions regarding the level of processing medical devices and surgical instruments for patient
care should be made based on Spaulding categories. Spaulding classified instruments and patient
care devices into three categories as follows:

Risk category Level of disinfection/sterilization Examples

Critical Sterilization Reusable surgical instruments

Semi-critical High-level disinfection Respiratory instruments, specula used for

vaginal examination, endoscopes
Non-critical Cleaning Blood pressure cuffs, stethoscopes
In all levels of instrument processing, special attention should be given to proper handling of the
instruments and other items to minimize the risk of accidental injury or exposure to blood and
other body fluids of the sterile processing staff and to attain a high quality end result.

NB. Soaking instruments in 0.5% chlorine solution or any other disinfectant before cleaning is
not recommended

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For detailed technical recommendations on Medical devices decontamination and
Processing Instruments and Reusable Items, please refer National IPC Reference Manual
Volume 1 Chapter 7.

3.14 Food and Water Safety

Food safety should be ensured through the provision of adequate, clean facilities for food
preparation and storage. It is imperative that:
 The kitchen should have adequate space, well ventilated, visibly clean and free from
debris, dusts, spillages, etc
 Food safety shall be monitored by Head of Kitchen or other senior manager
 Kitchen staffs maintain personal hygiene and health.

Food purchase and storage

A committee consisting of representatives from the kitchen, environmental hygiene and
procurement unit should be created to oversee the delivery of food items for the kitchen.
Possible committee members could be the kitchen manager, dietician, environmental health
professional, and purchaser.

When food items are delivered to the kitchen, the kitchen manager or delegate should check the
items to ensure that the food delivered is of the desired quality. If the quality of the food is not
acceptable, then the supplier should be informed, “rejected” items returned, and if possible, the
supplier should provide replacements that meet the committee’s specifications.

The food items that are delivered to the kitchen have to be properly stored in a separate clean
area in the kitchen. Food that is perishable and warm should be cooled before storage.

Food handling and preparation

 There should be separate cutting boards for meat products and non-meat products
 Cooking staff should be oriented on safe handling of food
 Cooking should be done at proper temperature and for the appropriate length of time
 All kitchen staff should follow hand hygiene procedures. Hand hygiene should be
practiced at all critical hand washing times. In addition to hand hygiene, kitchen staff
should also maintain their personal hygiene. Facilities for bathing should be made
available to all kitchen staff.

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Water safety
The hospital should have a continuous clean water supply. Water used for special services
(drinking, cooking and for instrument processing) shall be tested for bacteriological and physical
parameters water quality periodically (minimum of quarterly).
Water provided for clients should be treated by either by boiling (20minutes) or using chlorine
(0.001 concentrations).

For detailed technical recommendations on Food and Water Safety, please refer National
IPC Reference Manual Volume 1 Chapter 11.

3.15. Occupational Safety

Hospital staff members may be exposed to different health risks merely due to their work place.
They can be exposed to blood and other body fluids through which infections can be transmitted.
They have a potential to be exposed to different kinds of sharp materials which can transmit
infections and can also cause other health problems. Generally hospital staff members are
exposed to different kinds of occupational health hazards. They can be exposed to infections like
HIV, HBV, HCV etc. or other health hazards like excessive bleeding due to sharp injury.

Hospitals are expected to minimize occupational hazards to their staff members and they have to
ensure occupational safety practices. To minimize the occurrences of occupational hazards and
ensure occupational safety the hospital has to ensure the availability of preventive services in
place. These services can be personal protective equipment, preventive vaccinations and
preventive prophylaxis interventions. The following interventions are provided in hospitals to
minimize occupational hazards to hospital staff members.

Post Exposure Prophylaxis of HIV

To avail PEP services effectively hospitals implement the following:

 Assign one service point for PEP

 Make the PEP focal person member of IPC Committee

 Organize necessary trainings for the assigned focal person on PEP and HIV testing and
counseling

 Assign PEP focal person who can be accessed 24 hrs. a day and 7 days a week

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  Avail supplies and equipment for HIV testing and counseling for exposed individuals
during time of not working time

 Put in place referral linkage system

 Make PEP one attention area of IPC Committee activities

 Place ARV drugs( starting pack ) at PEP service point always and restock it on time to
avoid shortages due to stock out

 Establish documentation system for PEP

 Establish reporting system for PEP activities

 Establish PEP programme monitoring and evaluation system

The hospital management monitors PEP implementation by assessing:

 The availability of all input materials

 The continuous availability of PEP services both at regular and non-regular working
hours

 The adherence of healthcare workers to the national PEP protocol

 Monthly PEP service uptakes

 Activity plans of PEP focal person

 Monthly reports of PEP focal person to hospital management

 Agendas of IPC Committee meetings on PEP

NB. For technical details of PEP please refer to National IPC Reference Manual Volume 1
Chapter 13 & National Comprehensive HIV/AIDS Care & Treatment Guidelines

Preventive interventions for HBV & HCV

Currently there are no public health level prophylactic and treatment interventions in Ethiopian
for Hepatitis B and C virus exposures and infections. What are at hand on these infections are
prevention interventions.

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Hospitals utilize all preventive measures to the maximum to minimize health risks from exposure
to HBV and HCV. The following are the major intervention measures used by hospitals to
minimize risks to their staff members from HBV & HCV exposure:

 Facilitating vaccination of hospital staff members for HBV

 Ensuring all staff members properly utilize necessary PPE when needed

 Ensuring proper waste management system in the facility to minimize sharp injuries

 Orienting staff members on how to deal with blood and other body fluids strictly

 Ensuring availability of effective primary care services for those who have got exposed

Other preventive measures to ensure occupational safety

Hospitals should put in place all preventive measures which are possible and feasible to
minimize occupational risks to their staff members. The following preventive measures are put in
place in hospitals to ensure occupational safety for hospital staff members:

 Train/orient all hospital staff members on basic infection prevention and patient safety

 Ensure the availability and utilization of personal protective equipment at all service
points

 Ensure proper hand washing practices by all staff members of hospitals

 Properly manage medical wastes according to national guidelines

 Properly implement injection safety

 Establish conducive work environment

 Continuously monitor the status of standard precautions at all service point

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Annex
Infection Prevention and Control Program Facility Level Assessment Tool (IPC FLAT)
Updated June 2023
Infection Prevention and Control Program Facility Level Assessment Tool (IPC FLAT)
Updated June 2023

Overview

The IPC assessment tool is designed for use in hospital settings to:
• Evaluate the system and capacity of IPC for safe healthcare services
• Evaluate the compliance of healthcare workers to IPC standards and practices
• Aid development of work plans for improvement
• Monitor the progress of IPC quality improvement activities over time
The tool has two sections that include:
• Section I (Domains 1-8) - Facility IPC Capacity and System: This section addresses high-level IPC
systems and capacities
• Section II (Domains 1-14) - IPC Practices and Compliances to IPC standards by healthcare workers:
This section includes routine IPC practices of healthcare workers considering the IPC standards and
priorities.

This assessment will be conducted by health facilities quarterly (every three months)

The tool is developed using the World Health Organization (WHO) IPC assessment framework and other
regional IPC tools. Due to the technical nature of the questions, assessments must be carried out by IPC
experts with relatively good experience and strong familiarity with IPC requirements and standards. The
second section can be used more frequently as per the needs and available resources of the facility and
assessment can be done using particular IPC domains (e.g. Hand Hygiene compliance) or combination of
domains depending on the priority for monitoring compliance to IPC standards and practices.

Instructions for use

1 Conduct a comprehensive assessment of the facility using the agreed list of

instructions, indicators; record whether each indicator meets (Yes), does not meet
(No), or the not applicable (N/A).
2 Record additional information under Comments (Col I), for example, the reasons
why a particular indicator does not meet the target, important observations or
questions that need further investigation.
3 For each domain (IPC Program, Appropriate Personal Protective Equipment (PPE)
Use etc.), review the score at the bottom. This should calculate automatically
according to the number of indicators that have been assessed.

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Hospital General Information

Name of Hospital
and type

Location Region, Zone/Sub city, District/Woreda

Name and Phone No Email

contact of CEO
Name of Medical Phone No Email
Director
IPC Team Phone No Email
Leader/coordinat
or
Date of
Assessment
(MM/DD/YY):

Date of Previous
Assessment
(MM/DD/YY):
Total number 1. Total Number of Health Professionals ________
staff 1.1.Dedicated IPC experts_________
1.2.Total physicians _____________
1.3. Environmental Health ___________________
1.4.Total Nurses all types__________
1.5.Other Health Professionals _______
2. Total Number of Supportive staff _________
2.1.Cleaners/house keeping ______________
2.2.Laundry staff___________________
2.3.Kitchen workers________________
2.4.CSSD staff________________
2.4.Porters and runners________________
2.5.Others __________
3. Total Number of Admin staff________
4. Other staff
5. Total Number of staff _(1+2+3 +4)_________________
Total bed
number
Basic service In-house? Outsourced Remark
1. Food
2. Cleaning
3. Security

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4. Laundry
Name of
Assessors

Section –I: Facility IPC Program Capacity and System

S Domain Criteria Y N N Assessment Comment
N es o / Instructions/Guide
A
1 IPC 1.1. IPC programme supported Check the lists of IPC
Program by an IPC case team comprised team Members and
of IPC-trained professionals. look that they are
certified for IPC training
and letter of
assignment and JD.
1.2. The IPC programme has an Look for the letter of
IPC ToT-trained full-time focal assignments as IPC
person, case Team leader, or Focal person/Case
Director. Team
Leader/Coordinator and
for the ToT certificate.
1.3.Check that the IPC team Ask for the IPC updated
has an evidence-based annual annual plan.
plan.
1.4.The facility has a functional Ask to see a copy of the
IPC committee (with defined TOR and meeting
TOR and regular meetings) minutes and regularity

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 1.5. Leadership shows clear Check budget
commitment and actively allocation specifically
supports the IPC program by for the IPC program and
allocating a budget specifically senior management
for the IPC program. team minutes.
1.6.The IPC programme is Check joint planning/
linked to or integrated with performance report
other vertical or horizontal comprises those
programmes (e.g., AMR, programs and the IPC
Quality & Safety, WASH, team is a committee
immunisation,MCH,TB, member for those
Occupational Health, etc.). programs.
1.7.The IPC program has access Ask availability of
to microbiological laboratory microbiology lab
support (either onsite or services, See MoU, and
offsite) for routine day-to-day communicate evidence
use. with the regional
Laboratory or referal
facility with Private
Microbiology
laboratories.
Domain score Total score for Yes, No
and N/A
Domain percentage score
IPC 2.1. Facility has updated See/look for the
guideline national IPC reference guideline availability
s or guidelines / or adopted
standard 2.2 facility has SOP on
operating Standard precautions for the
procedur following:
es (SOPs) 2.2.1. Hand hygiene Ask and check the
guide/ SOP
2.2.2. Instrument reprocessing Ask and check the
guide/ SOP
2.2.3. Injection safety Ask and check the
guide/ SOP
2.2.4. Waste management Ask and check the
guide/ SOP
2.2.5. Environmental cleaning Ask and check the
guide/ SOP
2.2.6. Personal Protective Ask and check the
Equipment guide/ SOP
2.3 Facility has SOP on
Transmission-based
precautions
2.3.1 Prevention of vascular Ask and check the
catheter-associated guide/ SOP

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 bloodstream infections

2.3.2 Prevention of catheter- Ask and check the

associated urinary tract guide/ SOP
infections
2.3.3 Prevention of Surgical Ask and check the
Site infection (SSI) guide/ SOP
2.3.4 Prevention of healthcare Ask and check the
associated pneumonia (HAP) guide/ SOP
2.3.5 Prevention of healthcare Ask and check the
associated diaharrea guide/ SOP
2.3.6 Prevention and Ask and check the
containement of multidrug- guide/ SOP
resistant (MDR) pathogen
2.3.7 Outbreak preparedness Ask and check the
and response guide/ SOP
2.3.8 Healthcare worker Ask and check the
protection and safety guide/ SOP
2.3.9. Other(s) (List additional Ask and check the
SOPs) including dead body guide/ SOP
handling, laundry, food &
water safety
2.4. All the facility level IPC Check SOPs/guidelines
SOPs/ guidelines are easily are within the reach of
accessed by healthcare HCWs or easily
workers accessible in different
units
Domain score Total score for Yes, No
and N/A
Domain percentage score
3 IPC 3.1 The Facility has an ongoing Ask for dates of the
education development system to most recent training
and train/educate HCWs on IPC (Both on site and off
training site IPC training)
including induction
training and check
training unit's annual
plan
3.2. All Health professionals Check for list of IPC
including students and new trained professionals
staff receive from training record
training/orientation on the
updated IPC guideline.
3.3. Cleaning staff and non- Check for list of IPC
clinical staff directly involved in trained cleaning and
patient care receive IPC other non-clinical staff
training at least per year from training records

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 3.4. Administrative and Check for list of IPC
managerial staff receive trained administrative
general IPC training/orientation and managerial staff
from training records
3.5. IPC training is integrated Check training modules
into clinical practice and in- that incorporated into
service trainings of other IPC training .
specialties (e.g., training on
prevention of Tuberculosis)
3.6. Specific IPC training is in Ask a training
place for inpatients or family guide/programme for
members and incorporated in patients and family
the weekly hospital HE members and check the
program to minimize the schedule of health
potential for HAI. education on IPC.
3.7. Healthcare facility Confirm availability of
maintains records of IPC training record
trained HCWs
Domain score Total score for ‘Y’, ‘N’
and ‘N/A’
Domain percentage score
4 Health 4.1. Facility has adopted the Check the guidance
care- national HAI surveillance
associate guidance Check that applies to
d the facility practices
infection 4.2. Facility has assigned a Ask for letter of
(HAI) dedicated trained (on basic assignment and training
surveillan epidemiology/surveillance) certificate
ce professional for HAI
surveillance activities
4.3. Informatics/IT is available Check availability of the
to conduct surveillance (e.g., required equipment
equipment, mobile and their functionality
technologies or electronic
health records)
4.4. Facility has standard Check in surveillance
surveillance case definitions guideline on use or
according to national or posted on wall
international definitions for a
disease of interest
4.5. Use standardized data Check surveillance SOPs
collection methods (e.g., active or protocols
prospective surveillance)
according to national or
international surveillance
protocols

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 4.6. Responsible personnel Check surveillance
regularly review data quality reports
(e.g., assessment of case report
forms, review of microbiology
results, denominator
determination, etc.)
4.7. Surveillance data are used Ask cases and records
to make tailored facility-based when the surveillance
plans for the implementation data used for
or improvement of IPC interventions
practices
4.8. HAI surveillance is Check this domain only
currently ongoing: (if yes, check for those Hospitals
from the options below) implementing HAI
surveillance
4.8.1. Surgical site infection Check for the existing
(SSI) of SSI surveillance
ongoing
4.8.2. Catheter-associated Check for the existing
urinary tract infections (CAUTI) of CAUTI surveillance
ongoing
4.8.3. Blood stream -associated Check for the existing
bloodstream infections (BSI) of BSI surveillance
ongoing
4.8.4. Clinically-defined Look for clinical
infections (for example, definitions on HAI
definitions based only on surveillance guideline or
clinical signs or symptoms in posted on wall
the absence of microbiological
testing)
4.8.5 Facility regularly (for Check surveillance
example, quarterly/half- reports and feedback
yearly/annually) provides up- notes
to-date surveillance
information to managers,
department heads and front
line HCWs
Domain score Total score for ‘Y’, ‘N’
and ‘N/A’
Domain percentage score
5 Multimod 5. 1 Facility use multimodal Check that applies to
al strategies including any or all of the facility practices
Strategies the following elements
5.1.1 System change to ensure Check for IPC supply
the necessary infrastructure stock monitoring
and continuous availability of records
supplies are in place

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 5.1. 2.Education & training Randomly ask 5
professionals whether
they are trained on
specific IPC measures to
solve IPC gaps
5.1. 3. Monitoring & feedback Check filled monitoring
IPC practice report and
feedback provided
5.1.4. Communication & Check for availability of
reminders reminder poster at
point of use
5.1.5 Safety climate & culture Check for risk
change (If no, specify management
components with multimodal protocol/guidance, risk
strategies) assessments
5.2. Multi-disciplinary team Ask interventions
(organized from different reports or meeting
unit/department) is used to notes
implement IPC multimodal
strategies
5.3. Facility has conducted QI Check for conducted QI
projects on IPC, implemented, project topic on IPC,
and successful change ideas implementation and
were identified that were learning session report
implemented
Domain score Total score for ‘Y’, ‘N’
and ‘N/A’
Domain percentage score
6 Monitori 6.1. Well-defined monitoring Ask monitoring plan
ng/audit plan with clear goals, targets that includes goals and
of IPC and activities are available activity list including
practices tools to collect data in a
and systematic way
feedback 6.2. Locally adapted facility IPC Check for IPC data
data collection tools are collection tools (e.g. IPC
available (if yes, specify in the system/capacity
comments) assessment, facility IPC
practices, and others)
6.3.At least the following
processes and indicators are to
be monitored:
6.3.1. Hand hygiene (HH) Check on
compliance (using the WHO HH monitoring/feedback
observation tool or equivalent) reports (by the time of
audit completion)

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 6.3.2. Transmission-based Check on
precautions and isolation to monitoring/feedback
prevent the spread of infection reports (e.g., multidrug-
resistant organisms
(MDRO), Environmental
cleaning, Disinfection &
sterilization of medical
equipments and waste
management)
6.3 Provide feedback auditing Ask/check meeting
reports (e.g., HH compliance notes or feedback
data) on the state of the IPC reports (by the time of
activities/performance to staff audit completion)
in the areas being audited and
report performance to IPC
committee and facility
managers
6.4. Monitoring data are Ask/Check notes or
reported regularly (at least reports
quarterly to facility managers
Domain score Total score for ‘Y’, ‘N’
and ‘N/A’
Domain percentage score
7 Workload 7.1. Facility assesses Ask assessment report
, staffing appropriate staffing levels at or meeting note on
and bed least annually according to assessment of staffing
occupanc patient workload using national
y standards or WHO tool such as
the WHO workload indicators
of staffing (staff to patient
ratio)
7.2. System in place to act on Ask SOP or protocol for
the results of staffing needs staffing needs
assessments when staffing assessment and staffing
levels are deemed to be too plan
low
7.3. There is adequate spacing Observe randomly for
of >1 meter between patient spacing of beds
beds
7.4. System in place to assess Check facility bed
and respond when adequate occupancy rate report,
bed capacity is exceeded a plan document for
higher bed demands
Domain score
Domain percentage score

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8 Built 8.1. Functional Hand hygiene Check availability and
environm stations are available at the functionality of hand
ent, entrance and at all points of hygiene stations
materials care
and 8.2. Designated isolation areas Check isolation areas
equipme are available for patients with
nt for IPC suspected and confirmed
infectious diseases including
COVID-19, tuberculosis, Ebola
Virus Disease, MDRO & others
as applicable
8.3. Reliable safe drinking Check drinking water is
water are present and available all the time,
accessible for staff, patients ask if water quality test
and families at all times and in is regularly performed
all locations/wards (at least every quarter)
8.4. At least 4 toilets or Observe toilets or
improved latrines are available improved latrines
for outpatient settings or ≥ 1
per 20 users for inpatient
settings
8.5. Facility has sufficient Ask if sufficient power is
energy/power supply available available 24/7. If not,
at day and night for all uses please specify how
(e.g., pumping and boiling frequently there is a
water, sterilization and power outage, check
decontamination, incineration power availability
or alternative treatment
technologies, electronic
medical devices)
8.6. Facility has functioning and Check for availability of
sufficient environmental functional ventilation of
ventilation (natural or any type in patient care
mechanical) available in patient areas
care areas
8.7. Facility has a:
8.7.1.Fenced and functional Check for functionality
burial pit waste dump available and fenced waste
for disposal of non-infectious disposal area
(non-hazardous/general waste)
8.7.2. Municipal pick-up Check for contract
available for disposal of non- agreement with
infectious (non- municipality or waste
hazardous/general waste) transporting facility
8.7.3. Facility has an incinerator Check/ observe its
or alternative treatment availability
technology for the treatment

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of infectious and sharp waste
that is functional and of a
sufficient capacity
8.7.4. Facility has a waste Check/ observe its
water treatment system (for availability
example, septic tank followed
by drainage pit) present on or
off site and functioning reliably
8.7. 5. Facility has dedicated Check/ observe its
decontamination area and/or availability
sterile supply department
(either present on or off site
and operated by a licensed
decontamination management
service) for the
decontamination and
sterilization of medical devices
and other items/equipment
8.8. Disposable items available Check availability during
when necessary (e.g., injection the assessment
safety devices, examination
gloves)
8.9. A designated person is Check for assignments
responsible for managing and of designated person
requesting critical IPC supplies for managing IPC
(provide consumption rate(per supplies and observe
2 weeks) for critical supplies for recent inventory
and performs an inventory of activities and
IPC supplies at least monthly) requisition
records/documents
8.10. PPE stored in a safe Observe how stocks are
location off the floor stored
8.11. Facility has adequate
quantities (enough for at least
one month) of the following
supplies in stock at the time of
the assessment
8.12. PPE For the following PPEs,
check whether there is
sufficient stock and use
for the specific
procedure/work area
8.12.1. Non-sterile gloves Check for the
availability of sufficient
stock
8.12.2. Gowns Check for the
availability of sufficient

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 stock
8.12.3. Aprons Check for the
availability of sufficient
stock
8.12.4. Eye protection (face Check for the
shields or goggles) availability of sufficient
stock
8.12.5. Medical masks Check for the
availability of sufficient
stock
8.12.6. N95, FFP2, or Check for the
equivalent respirators availability of sufficient
stock
8.13. Hand hygiene supplies Check for the
availability of sufficient
stock
8.13.1. Alcohol-based hand rub Check for the
availability of sufficient
stock
8.13.2. Soap Check for the
availability of sufficient
stock
8.13.3. Disposable or reusable Check for the
towels availability of sufficient
stock
8.13.4. Veronica buckets with Check for the
functional taps, lids and basin availability of sufficient
for collecting used stock
handwashing water
* If functional sinks are not
available in registration or
waiting areas
8.14. Cleaning supplies Check for the
availability of sufficient
stock
8.14.1. Neutral detergent, Check for the
liquid or powdered soap availability of sufficient
stock
8.14.2. Cleaning cloths Check for the
availability of sufficient
stock
8.14.2. Mops currently Check for the
available availability of sufficient
stock
8.14.3. Portable buckets (for Check for the
mopping and surface cleaning availability of sufficient
solutions) currently available stock

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 8.14.4. Hospital-grade Check for the
disinfectants (e.g., sodium availability of sufficient
hypochlorite) stock
Domain Score
Domain score percentage
Section-I subtotal Total
Section-I subtotal percentage
score

Section II - IPC Practices and Compliances by Healthcare Workers

S Domain Criteria Y N N Assessment Instructions/Guide Comme

N e o / nt
s A
1 Appropri 1.1. SOPs for PPE use are Check the availability and
ate easily available and accessibility of SOP at least in the
Personal accessible to staff. following sites for routine use:
Protecti OR, Maternity, ICU, NICU, and
ve Labour ward.
Equipme 1.2. HCWs are trained on Ask 3-5 staff randomly whether
nt (PPE) proper PPE use, including training /orientation on the
Use donning and doffing proper use of PPE including
donning & doffing provided to
them.
1.3. Availability of sufficient Check the availability of the
PPE supplies at different following PPEs: Medical masks
service delivery points N95, FFP2, or equivalent
respirator; aprons; eye
protection (face shields, eye
goggles); gowns; sterile gloves;
non-sterile gloves; Heavy-duty
gloves, rubber or plastic boots,
and head caps.
1.4. Appropriate PPE is used Observe at least three HCWs in
during patient care delivery four service areas (e.g.,
emergency, ICU, OR, maternity,
etc.) using the standard PPE
observation checklist.
1.5.PPE is donned and doffed Observe at least four HCWs in
in appropriate steps and four service areas (e.g.,
sequence. Emergency, ICU, OR, Maternity,
etc.) using standard PPE and an
observation checklist

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 1.6. PPE is stored in a safe Observe how the PPE supplies
and accessible location are stored in closed and safe
(keeping it in a clean, location and easily accessible for
designated area away from use at service delivery points.
chemicals, temperature
extremes, etc.).
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
2 Hand 2.1. All hand hygiene stations Observe the availability of HH
Hygiene have alcohol-based hand supplies and check the
(HH) rubs or soap and water. functionality of HH stations
Practice (check at least 5 HH stations at
Complia the service delivery point).
nce 2.2. Hand hygiene posters or Check for the availability of
job aids are available at all posters and observe the five
HH stations. moments of HH for hand
washing steps that are posted.
2.3. The facility conducts HH Check the HH assessment report
audits quarterly using the and audit score (HH audits were
WHO HH observation tool. conducted at least at five
different service delivery points).
2.4. Hand hygiene audit Check for documents showing
report findings are regularly feedback was provided or
analyzed, and feedback is pictures of meetings with
shared with staff and stakeholders on feedback
respective stakeholders. sharing.
2.5. Hand hygiene Check for pictures and an activity
celebration days are report.
conducted quarterly.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
3 Transmis 3.1.The facility has a Observe or look for a labeled
sion- designated isolation room isolated room, and if cohorted
based for the care of patients with patients are placed at least 1
Precauti the same active infection meter apart.
ons who are isolated or cohorted
Adheren in a designated ward or
ce room (who need
transmission based
precautions).
3.2. Hand hygiene facilities Check if ABHR and/or water and
are available in isolation soap are available in the
areas. isolation room.

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3.3. The PPE required for Check if the required PPEs are
transmission-based available for the defined TBP.
precautions is available in • N95 or other respirators
inpatient departments. (airborne)
• Face masks, face shields, or
goggles (droplets)
• Gowns (contact precaution)
• Disposable gloves
• Boots and
• Hazma Suits
3.4. Staff don appropriate Observe the practice of applying
PPE (gloves and other PPE as PPE (interview staff if there is no
indicated) as per the risk patient under TBP). Check if
level. there are designated donning
and doffing areas and observe
donning and doffing practices
before and after patient
transport.
3.5. Transport and Look for signs limiting patient
movement of patients movement. Check if the facility
outside the isolation area are has a SOP for transmission-based
limited to medically precautions and if it entails how
necessary purposes (e.g., patients in isolation are
operation procedures) transported.
3.6. Frequently touched Check cleaning checklists and
surfaces (e.g., bed rails, over- visual observations for
bed tables, bedside cleanliness.
commodes, lavatory surfaces
in patient bathrooms,
doorknobs) and equipment
in the immediate vicinity of
the patient are cleaned and
disinfected twice daily and
when visibly soiled.
3.7. Toilets are cleaned twice Review the checklist and observe
daily and when visibly soiled. for a visibly soiled toilet.
3.8. There is no equipment Observe
or practice in the patient
room that could exacerbate
any environmental
contamination.
3.9. Contaminated, reusable, Ask and observe how bed sheets
non-critical patient-care and patient pajamas works too.
equipment is placed in a
plastic bag for transport to a
soiled utility area for
reprocessing.

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 3.10. The facility has policies Check if:
and a system for triaging • Coughing patients are triaged
coughing patients to prevent separately; • Coughing
airborne or droplet patients should be separated by
transmission at OPDs. at least one meter.
• Coughing patients are given
priority in que
3.11. The facility ensures the Observe patients in waiting area
wearing of facemasks by and TB clinic for wearing of mask
coughing clients and other
symptomatic persons upon
entry to the facility (including
providing facemasks for
coughing patients with no
mask).
3.12. The facility has posted Observe the posted signage and
signs on respiratory hygiene posters.
(covering mouth /nose with
tissues while coughing or
sneezing, perform hand
hygiene after touching
respiratory secretions) for
individuals with symptoms of
respiratory infection
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
4 Instrum 4.1. The facility has a Check for availability of CSSD
ent designated Central with a responsible person
Reproce Sterilization Services assigned with a letter; signage is
ssing Department (CSSD). posted to restrict entry to the
CSSD room; CSSD has a separate
entrance and exit gate for
unidirectional flow of traffic; and
CSSD has a zonal partition to
delimit the placement of
contaminated and sterilized
items.
4.2. Reprocessing of Observe the reprocessing
contaminated medical process, SOP availability, water
instruments follows the availability at the point of use
updated national standard cleaning site, and at least three
(point-of-use cleaning). ---> different wards:-
(thorough cleaning) --->
(high-level disinfection or • Point of care cleaning
sterilization) • Thorough cleaning
• Sterilization

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 4.3. Critical medical devices Check how instruments are
(e.g., forceps, scissors) are sterilized. Check if chemical
sterilized as indicated per sterilizing agents are available
standard (glutaraldehyde (2-4%), peracetic
acid 0.3%, hydrogen peroxide
8.3%, or mixed H2O2).
4.4. The Facility has clear Observe utility rooms in care
separation of clean and units and sterilizing areas in CSR,
contaminated medical Zonning
equipment.
4.5. The facility has a Check the availability of CSR and
dedicated area for cleaning the presence of a unidirectional
and sterilizing medical flow of traffic in CSR.
devices.
4.6. Reprocessed medical Observe storage
equipment (sterilized or HLD)
is safely stored in a
designated and safe area
(free from moisture, dust,
insects, rodents, etc.).
4.7. Sterilization machine Check out the document:
preventive and corrective • Daily preventive maintenance
maintenance and calibration • Corrective maintenance as
are conducted regularly. needed
• Calibration based on
manufacturer instructions
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
5 Environ 5.1. Environmental cleaning Locate the cleaning forms or
mental follow-up monitoring checklists and check if they are
Cleaning systems are available and completed, the frequency of
completed at the time of this completion, and how frequently
assessment. they are completed.
5.2. Cleaning and disinfection Ask for the schedule and check
of wards/rooms occurs twice SOPs.
daily and when visibly
soiled.
5.3.Frequently touched Ask for the schedule and check
surfaces in SOPs and verification by visual
consultation/examination inspection/ fluorescent marker.
areas are cleaned and
disinfected at least twice
daily.
5.4. Walls, windows, ceilings, Check cleaning checklists and
and doors should be spot visual observations for
cleaned with a towel, cleanliness.

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detergent, and water
(specify rooms observed).

5.5. Toilets and latrines Check cleaning checklists and

should be cleaned with a visual observations for
dedicated mop, cloth, or cleanliness; check if cleaning
brush and a disinfectant equipment is stored separately.
solution.
5.6. Instructions on making Observe the poster or
solutions for disinfection are instructions posted.
posted where the solution is
prepared.
5.7. Required cleaning Check for the availability of
supplies (a bucket, mop, cleaning supplies and
cleaning cloths, and equipment; check for the
disinfectant solution, e.g., availability of a cleaning supply
bleach) are all available. stock monitoring tool or
mechanism.
5.8. Rooms are terminally Check cleaning checklists and
cleaned and disinfected after visual observations for
patient discharge, including cleanliness.
floors, sinks, toilets, ceilings,
walls, and any material in the
room (sinks and toilets after
use).
5.9. The drainage system Observe
within and around hospital
building(s), e.g., gutters,
pipes, etc., should be free
from any obstructions, e.g.,
vegetation.
5.10. Cleaning campaigns Check for the availability
should be conducted every schedule, pictures, and report.
month.
5.11. The dedicated utility Check cleaning checklists and
room for the storage of visual observations for
cleaning equipment cleanliness.
5.12. Stairs, steps, and lifts, Observe
internal and external,
including all component
parts, are visibly clean and
well-maintained.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score

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6 Adheren 6.1. Proper HH, using Observe at least three HCWs`
ce with alcohol-based hand rub per ward performing HH.
Injection (ABHR) or soap and water, is
Safety performed prior to
Practices preparing, during the
administration of
medications, and after the
procedure.
6.2.Injections are prepared Observe at least three HCWs per
using aseptic technique in a ward practicing injection
clean area free from procedures.
contamination or contact
with blood, body fluids, or
contaminated equipment.
6.3. Needles and syringes are Observe at least three HCWs per
used for only one patient ward.
(this includes manufactured
prefilled syringes and
cartridge devices such as
insulin pens).
6.4.HCWs dispose of needles Observe at least 3 HCWs doing
appropriately (i.e., needles injection procedures per ward
are discarded after single use and check the availability of a
and are not recapped, bent, safety box in the hand-accessible
or broken prior to disposal in area.
a sharps container).
6.5. The rubber septum on a Observe during the injection
medication vial is disinfected procedure.
with alcohol prior to piercing
6.6. Medication vials are Observe Interview HCP
entered with a new needle
and a new syringe, even
when obtaining additional
doses for the same patient
6.7. Single-dose or single-use Observe Interview HCP
medication vials, ampoules,
and bags or bottles of
intravenous solution are
used for only one patient
6.8. Medication Observe during medication
administration tubing and administration
connectors are used for only
one patient.
6.9. Multi-dose vials are Observe. This is different from
dated when they are first the expiration date printed on
opened and discarded within the vial. (Interview HCP)
28 days, unless the

13-38
 manufacturer specifies a
different (shorter or longer)
date for that opened vial.

6.10.Multi-dose vials are Check if multi-dose vials are used

dedicated to individual for a patient (Interview HCP)
patients whenever possible.
6.11. Multi-dose vials used Observe. If multi-dose vials
for more than one patient enter the immediate patient
are kept in a centralized treatment area, they should be
medication area and do not dedicated for single-patient use
enter the immediate patient and discarded immediately after
treatment area (e.g., use.
operating room, patient
room/cubicle).
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
7 Facility 7.1. The facility has a policy Observe
Design to access hospital premises
and and manage traffic flow.
Patient 7.1.1. Visiting hours for Check and verify
Flow clients, including time for • Facility visitor hour’s protocol
Manage rounds, cleaning , patient • Visitor hours are posted at the
ment meals, and the number of hospital gate.
attendants per patient, are • Visiting hours, round time,
determined. meal delivery time, and the
number of allowed attendants
are posted clearly in each ward.
7.1.2. Triage and Observe the triage services and
appointment systems should appointment system at Liason,
be established in the IPDs, and OPDs and check if the
hospital. block-hour appointment system
is followed.
7.1.3. Patient waiting areas Observe waiting areas, adequate
are well ventilated and not seating based on patient load,
crowded. and natural or artificial
ventilation.
7.1.4. The facility has Observe traffic flow
assigned a dedicated person management at the facility.
to handle traffic flow at all Check if appropriate signage and
service delivery points. physical barriers are used in
restricted areas.
7.1.5. The facility practices Check the OR, ICU, labour ward,
regarding zoning restrictions CSD, Kitcken, etc.
at different high-risk
departments

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 7.2. The hospital compound Observe and check that the
is safe for patients, visitors, waiting areas, garden, cafeteria,
and staff and walkways are free and safe
for patient transport.
7.3. The hospital regulates Check service areas randomly for
the flow of visitors, patients, signage, reminders, and physical
and staff using signs (such as barriers.
authorized personnel only,
reminders, and physical
barriers, e.g., closed doors)
in designated areas.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
8 Processi 8.1.The facility has a Check that the laundry has
ng functional laundry service. separate areas for segregation,
reusable collection of soiling linens,
textiles washing, drying, ironing, and
and storing clean linen.
laundry 8.2. The facility has physically Check cleaned/washed linens
services separated storage areas for observed separately from soiled
cleaned/washed linens and linen.
for soiled linens with
sufficient ventilation and
light.
8.3. Appropriate PPE is Observe laundry staff wearing
utilized by laundry personnel appropriate PPE.
at all times
8.4. The laundry has Observe the availability of water
uninterrupted water by opening the pipe and
availability for 24 hours a checking that the laundry has a
day, 7 days a week. hot water source.
8.5. The laundry has a well- Check the number of functional
maintained sewage system. windows and doors and the
availability of artificial
ventilation. Check that sewage is
not spilled on the floor.
8.6.The laundry has a Observe the availability of
continuous electric supply electricity 24/7 with backup
(24 hours per day, 7 days per source.
week) with a backup source.
8.7. The laundry has Check the number of functional
adequate natural or artificial windows and doors and the
ventilation. availability of artificial
ventilation.
8.8. Hand washing sinks are Observe the presence of a
available in the laundry functional sink with soap.

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 8.9. consistent and sufficient Check for SOPs on disinfectant
supply of detergents and and detergent, and ask the
chemicals for laundry head for a consistent
washing/disinfecting linen. supply.
8.10. Separate physical Observe the containers/trolleys
storage areas and different used for transporting clean,
trolleys and waterproof washed, and dirty/contaminated
containers are used for linens.
transporting clean, washed,
and dirty/contaminated
linens.
8.11. Appropriate waste Observe the availability and
disposal containers are cleanliness of color-coded waste
available in the laundry for containers.
high- and low-risk waste.
8.12. Laundry machines in Observe the functionality of the
the facility are regularly machine and the maintenance
maintained schedule
8.13. The laundry keeps Observe records
records of receiving and
distributing linens.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
9 Food 9.1. Food handlers are Ask food handlers whether they
and educated and trained in food are trained in food handling and
Water safety and good food safety procedures; check their
Safety handling procedures names at the training office and
their certificate.
9.2. The kitchen has a hot Observe whether the kitchen has
water source for washing three compartments and a hot
kitchen utensils, with at least water source.
three compartments for
washing.
9.3.After each use, kitchen Observe the cleaning practice
utensils are cleaned and/or
disinfected (if necessary)
9.4. The facility provide Observe at least 3 food handlers
necessary and suitable PPE wearing appropriate PPE (e.g.,
for kitchen staff aprons, face masks, hair covers)
9.5. Prepared food Observe whether food is
transported to the patient transported using clean and
room using a clean and covered carts
covered cart
9.6.The facility has separate Observe whether raw food
storage areas for perishable storage is separate for
and non-perishable raw perishable and non-perishable
foods. foods.

13-41
9.7. Food handlers undergo Ask for and observe the medical
medical examinations for certificates of food handlers.
foodborne transmittable
infections at least every
three months.
9.8. The kitchen has Observe the availability of sinks
dedicated and adequate (at least one).
sinks with running water and
soap at all times for hand
washing
9.9. The Kitchen is well Check for washable floors, walls,
maintained and has a posted and ceilings free of dirt and
cleaning schedule. debris. Check the posted
cleaning schedule.
9.10. The Kitchen checks and Observe refrigerator
documents the temperatures temperature monitoring
of the refrigerator and cold mechanisms (documentation,
rooms regularly. temperature gauge up to the
requirement), and check the
functionality of the refrigerator.
9.11. The facility has Check waste containers
washable, leak-proof
garbage containers with
tight-fitting lids, and garbage
is collected daily.
9.12. The facility has a Check that water quality is
regular Physicochemical and tested every three months
bacteriological water quality (Check documentation).
monitoring system.
9.13.The kitchen has a policy Observe the policy and check for
to limit the traffic of relevant signage and posters.
unauthorized individuals into
the food preparation area.
9.14. The kitchen cleanliness Check whether there is an
and personal hygiene of the assigned professional to monitor
food handlers are monitored the cleanliness and hygiene of
regularly by a knowledgeable the kitchen and food handlers.
and responsible professional.
9.15.A responsible person or Observe the signed document
team is assigned to ensure and ask the kitchen store head
the quality of food entering
the kitchen. (Meat,
vegetables, and milk).
9.16. There is a system for Check the documentation from
the management of food the kitchen coordinator (Treated
handlers’ illnesses. properly; sick leave was given
and rescreened before return to

13-42
 the work place).

Domain score Total score for ‘Y’, ‘N’ and ‘N/A’

Domain percentage score
1 Waste 10.1. Waste collection Observe that all waste bins are
1 Manage containers for non-infectious clearly marked to indicate the
ment (general), infectious, and type of waste (e.g., colour-
and sharps waste are available at coding or labeling to indicate the
Sharps each clinical area. type of waste) and available at
Disposal each clinical area.
10.2. Waste is correctly Observe the segregation practice
segregated into general, at the point of generation.
infectious waste, and sharps
at the point of generation
10.3. Waste segregation Observe availability of posters
posters (including sharp
containers) are displayed
above all waste bins
10.4. Each waste bin and Observe the dust bins and safety
sharp container is filled less boxes at least at three points of
than its ¾th volume. use.
10.5. No sharps or needles Observe the floor
were observed on the floor
at the time of this
assessment.
10.6. Bins and bags are Ask about and observe waste
transported upright in carts transportation practices to the
or trolleys to a central waste disposal site.
storage site, burial pit, waste
dump, or municipal pick-up
area.
10.7. The facility has a Observe the storage site (e.g.,
designated waste storage temporary storage).
area.
10.8.The facility has a Observe the incinerator plant
designated and fenced
incinerator for both solid
waste and sharps.
10.9. The facility has a Observe the disposal practice
designated waste disposal
area.
10.10.The facility has an Observe the availability of liquid
appropriate liquid waste waste treatment plants.
management system.

13-43
 10.11. Janitors and Check the schedule /attendance
transporters are available 24 sheet.
hours a day, 7 days a week.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
1 Healthca 11.1. The facility has policies Ask for the policy and reporting
1 re and a reporting structure for structure, and check if they are
Workers occupational exposure and available for all wards.
Safety management.
11.2. All HCWs and waste Check vaccination records or
handlers are vaccinated reports. If not all, specify the
against Hepatitis B. percentage of vaccinated staff in
the notes.
11.3. HCWs are aware of Ask for a reporting register or
management procedures form and reporting lines.
following exposure to blood
or body fluids.
11.4. The facility has a plan Ask about the plan and reports
in place for monitoring HCWs for monitoring HCWs.
exposed to patients with
respiratory illnesses,
including TB, COVID-19, and
other infectious diseases.
11.5. Healthcare workers Specify the specific plan in the
receive post-exposure notes
counseling and PEP
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
1 IPC in 12.1.The facility has SOPs for Observe updated SOPs.
2 Mortuar handling dead bodies,
y including those with highly
contagious diseases.
12.2.The facility has a Observe the availability of
functional dead body freezer functional refrigerators.
(refrigerator).
12.3. The staff working in the Observe the document/ask the
mortuary are trained for care providers
dead body management and
care.
12.4. Appropriate PPE is used Check the availability of PPE and
by care providers, relatives, observe whether all wear
or other individuals involved appropriate PPE during the
in the handling of dead handling of dead bodies.
bodies.
12.5. A proper dead body Check the availability of plastic
plastic bag (cadaver pouch) bags

13-44
 should be used when
necessary.
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
1 Outbrea 13.1.The facility has a Check the meeting note, TOR,
3 k functional Outbreak and Letter of Assignment of
Prepare response committee or task Taskforce.
dness force.
and 13.2. Outbreak preparedness Check the plan.
Respons and response plans are in
e place.
13.3. The facility has a SOP Check the availability of the plan.
for managing contact tracing.
13.4. Determined maximum Committee meeting notes and
capacity in the event of a action points
surge (availability of physical
space, human resources,
intensive care capabilities,
ventilator support, etc.) for
an outbreak.
13.5.Developed a plan to Check availability SOP
stop non-essential services
(e.g., elective or non-urgent
procedures) in the event of a
surge.
13.6. Identified additional Check the plan
space that can be used to
expand the number of
patients that can be treated
(assuming adequate human
resources, supplies, etc. are
available).
13.7. Developed a plan to Check the plan in the planning
move non-critical patients document.
elsewhere (e.g., for home-
based care) to increase
capacity in the event of a
surge.
13.8. The facility has clear Check the plan
communication and
reporting mechanisms in the
event of a surge.
13.9. The facility has a Check the inventory report.
procedure for estimating
consumption rates for critical
supplies, including PPE, in
the context of a surge

13-45
 scenario.

Domain score Total score for ‘Y’, ‘N’ and ‘N/A’

Domain percentage score
1 Environ 14.1. The facility has a fence Fences are strong enough to
4 mental that surrounds all the restrict the entrance of Pets and
cleanline hospital grounds and will not other animals. There are at least
ss and allow the entrance of pets two separate gates for the entry
safety and other animals without a and exit of both pedestrians and
functional gate, or at least vehicles. A separate gate for
two gates. staff. Gates are spacious enough
to accommodate emergency
scenarios.
14.2. The hospital's external Observe the hospital external
ground (at least 5–20 m from ground.
the fence) is free from any
hospital or community-
generated waste.
14.3. The hospital has a good Check the availability of green
Internal compound areas with seats and walkways.
appearance (Designated Check their cleanliness and
social green areas or parks tidiness.
with seating facilities) and
tidiness.
14.4. The Hospital has Check the activity report and
established a certification.
system/mechanism for pest
and rodent control
(outsourced or trained and
assigned personnel).
Domain score Total score for ‘Y’, ‘N’ and ‘N/A’
Domain percentage score
Section Grand Total
Section Grand Total
percentage

13-46
Source Documents

1. National Infection Prevention and Control Reference Manual, MoH- Ethiopia third edition;
2023
2. Interim Practical Manual supporting national implementation of the WHO Guidelines on
Core Components of Infection Prevention and Control Programmes. Geneva: World Health
Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP)
data. CIP data are available at http://apps.who.int/iris

13-47
3. Guidelines on core components of infection prevention and control programmes at the
national and acute health care facility level. Geneva: World Health Organization; 2016.
Licence: CC BY-NC-SA 3.0 IGO.
4. Minimum requirements for infection prevention and control. Geneva: World Health
Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.

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13-1
Chapter XX:
TEACHING AND AFFILIATED
HOSPITALS SERVICES MANAGEMENT
Chapter Outline

Section 1 Introduction

Section 2 Operational Standards

Section 3 Implementation Guidance

3.1. Teaching and Affiliated Hospitals' Management and Governance Structure

3.2. Principles of Quality Service, Teaching and Research in Teaching and Affiliated Hospitals

3.3 Students/Interns/Residents' Orientation

3.4 Ward Round and Bedside Student Teaching Related to Patients' Dignity and Quality of Care

3.4.1 Protecting Confidentiality and Dignity

3.4.2 Use of Skills Lab and Simulator Centers

3.4.3 Ward Rounds/Bedside Teaching and Quality of Care

3.4.4 Multidisciplinary Morning Meeting Sessions

3.4.5 Record Keeping

3.5 Community Practice and Field Visits

3.6 Regular Clinical Audit of Patient Care Provided by Students/Interns and Residents

Section 4: Source Documents

Abbreviations

ADD - Academic and Development Director

CAD - Chief Administrative and Development Director

CARD - Chief Academic and Research Director

CCD - Chief Clinical Director

CED - Chief Executive Director

EHSTG - Ethiopian Hospital Service Transformation Guidelines

FMOE - Federal Ministry of Education

FMOH - Federal Ministry of Health

HCF - Health Care Financing

HMIS - Health Management Information System

HSTP - Health Sector Transformation Plan

JD - Job Description

KPI - Key Performance Indicator

M&E - Monitoring and Evaluation

MCC – Motivated, Competent, Compassionate

MDT - Multidisciplinary Team

MoU - Memorandum of Understanding

QI - Quality Improvement

SBFR - Strategic Budget and Fiscal Reform

SMT - Senior Management Team

ToR - Terms of Reference

Section 1 Introduction

Teaching and affiliated hospitals have the potential to provide exceptional care to patients, in
addition to medical education and training for current and future healthcare professionals, as
well as serving as research centers to improve healthcare delivery. However, recent findings
show that care provided at major teaching hospitals results in better patient outcomes across a
wide range of common medical and surgical conditions and severity levels compared to non-
teaching hospitals (Medical et al., 2018).

Managing teaching and affiliated hospital services introduces novel challenges. The delivery of
healthcare and teaching in these hospital settings is complex, involving multifaceted learning
approaches. Bedside teachings and ward rounds have historically formed the foundation of
clinical education for health professionals. Currently, the lack of integration between top
management and shared activities between care delivery, teaching, and research remain key
challenges. Similarly, prolonged bedside and ward teachings combined with inappropriate ward
layouts, overcrowded spaces, and high student-to-bed ratios contribute to these challenges.

To address these challenges, the Ministry of Health has developed and proposed various
guidelines, promoting a model of full organizational integration where patient care, teaching,
and research collectively function under the leadership of a single Chief Executive Director
(CED) and a common governing board. However, the anticipated integration, teamwork,
coordination to ensure proper implementation of patient care, teaching, and research activities
to improve care quality, patient safety, engagement, develop high-performing teams and use
resources efficiently in teaching hospitals, have fallen short of expectations, resulting in poor
performance.

Therefore, this chapter aims to facilitate comprehensive integration of services, education,

research, and community endeavors to ensure quality patient care and optimize the
management efficiency and effectiveness of teaching and affiliated hospitals.
Section 2: Operational Standards

1. The hospital has established a functional management and governance structure

integrating medical education, health services, research, and community health priorities.

(Optional for affiliated hospitals)

2. The teaching and affiliated hospital has established functional management procedures

directing all teaching processes, student attachments, and community field activities.

3. The hospital develops and implements an orientation protocol for

students/interns/residents on hospital and national reforms before clinical attachments.

4. The teaching and affiliated hospital conducts regular clinical audits of patient care

provided by students/interns/residents and develops quality improvement projects based

on audit findings.

5. The teaching and affiliated hospital has established a system to ensure care provided

and student practices maintain patient confidentiality and privacy at all times.

6. The hospital has functional Library, skill labs and simulation centers.

7. The teaching and affiliated hospital has established protocols/policies and procedures for

ward rounds and bedside student teachings to maximize patient benefit.

8. The teaching and affiliated hospital ensures student/intern/resident patient care is

supervised by their respective teachers/hospital-based instructors at all times.

9. The teaching and affiliated hospital has established guidelines, memoranda of

understanding and procedures for affiliating with other teaching institutions, communities

and field activities.

Section 3 Implementation guidance
3.1. Teaching and Affiliated Hospitals’ management and governance structure

The Ministry of Health currently promotes a full organizational integration model where patient
care, teaching and research collectively function under the leadership of a Chief Executive
Director (CED) and a common governing board. Under this model, integration requires a shared
vision, collaborative strategic planning, and transparency between clinical and academic
components within a teaching hospital.

Full organizational integration under unified leadership and governance is advantageous for
several reasons. First and foremost, it facilitates strategic focus. Without such focus and
discipline, patient care, teaching and research activities may pursue divergent interests and
engage in initiatives that benefit one component but do not optimally advance the shared
mission. Secondly, it enables efficient utilization of financial and human resources. Third, it
allows researchers to focus on local health problems so that patients and the community can
benefit from research outcomes.

Teaching and affiliated hospitals should establish a governing board aligned with the FMOH and
FMOE’s “Guidelines for the Management of Federal Hospitals in Ethiopia.”

The teaching Hospital shall have:

 A governing board
 A Chief Executive Director nominated by the board and appointed by the Minister of
Health or relevant university president.
 Chief Directors for Clinical and practical teaching services, Academic and Research
affairs, Administration and Business affairs
 An Executive management committee under the CED and composed of all chief Directors
 A Senior Management team composed of clinical directors and relevant departments
 An academic commission organized based on relevant regulations

Affiliated Hospitals can continue to use their existing structures.

The roles, responsibilities, and procedures for the Chief Executive Director (CED), Chief
Academic and Research Director (CARD), Chief Clinical Director (CCD), Chief Administrative and
Development Director (CADD), Clinical Services Directors, Departments, Student rights and
duties, Consultant Staff, Residents and Interns are detailed in the “Guidelines for the
Management of Federal Hospitals in Ethiopia.” Teaching and affiliated hospitals should adhere
to and implement these guidelines.

3.2 Principles of Quality Service, Teaching and Research in Teaching and Affiliated
Hospitals:

 Complete integration of patient care, medical education and research under one
institution and management produces optimal results.
 Teaching and affiliated hospitals need to be led by boards overseeing the core activities
of the institutions.
 The functions of teaching and affiliated hospitals must be patient- and student-
centered.
 All legislation needs to accommodate the unique aspects of teaching and affiliated
hospitals, with necessary modifications made.
 “Departments” are the basic functional units of teaching and affiliated hospitals for
patient services, medical education and research.
 Teams are the core groups running activities at all levels and need to be empowered.
 Teaching and affiliated hospital boards should be adequately represented in Federal
Hospital boards.
 Teaching and affiliated hospital boards shall include change agents, entrepreneurs,
community and civil society representatives, and be transparent, representative of all
stakeholders.
 All teaching and affiliated hospital appointments will involve participation, transparency
and be merit-based.
  All department members are jointly and individually responsible and accountable for
the three functions of medical care, teaching and research.
 Performance-based evaluation and evidence-based practice are fundamental to
teaching and affiliated hospital activities.
 Physician engagement, participation and leadership at all levels ensure ownership,
responsibility and accountability.
 Developing management and leadership capabilities among staff and trainees is
essential for teaching and affiliated hospital productivity.

3.3. Students/interns/residents’ orientation

All new students/interns/residents should receive an orientation on hospital improvement
initiatives, policies and procedures before any clinical attachment. The orientation should cover
the hospital’s organizational structure, accountability arrangements, policies and procedures to
help new students/interns/residents become acquainted with the overall organization and their
attachment areas and departments. The hospitals have developed an orientation guideline as a
reference for newly enrolled students/interns/residents. The orientation guide should include
updated information on:

 Infection prevention and control

 Patient information documentation and management/EMR use
 Communication with patients and staff
 Patient confidentiality, privacy, safety practices
 Hospital reforms like:
o EHSTG, Clinical audit, designing quality improvement projects
o Clinical Leadership Improvement Program/CLIP/
o SBFR
o HSTP-II
o HCF etc.
o National Quality and Safety Strategy
 Professional codes of conduct and other relevant knowledge and skills.
  Using the hospital knowledge repository
 MCC

All students/interns/residents are expected to comply with relevant hospital policies and
procedures at all times. The hospital should implement established new
student/intern/resident orientation guidelines.

3.4 Ward round and bedside student teaching related patients’ dignity and quality of care

The hospital should develop and implement a written protocol/policy for ward rounds and
bedside teachings to ensure these activities are patient-centered. All healthcare providers
should practice and provide care, teaching and research while maintaining patient dignity,
confidentiality, privacy, and quality care for optimal clinical outcomes. The protocol should also
include information on patient/family/caregiver involvement and access to details about their
care, including assessments, testing, care planning, implementation, and evaluating the
effectiveness of interventions.

3.4.1 Protecting confidentiality and dignity

In addition to medical knowledge and skills, healthcare professionals should demonstrate

psychosocial and humanistic qualities like caring, empathy, humility, compassion, social
responsibility, and sensitivity to cultural beliefs. Respecting patient trust in healthcare implies
adhering to values like acting in the patient's best interests while upholding the highest
standards of medical practice. Confidentiality and dignity are heavily influenced by ward layout
and available space. All ward team members should be aware of the environment when
conducting bedside teachings and rounds. Below are recommended guidelines to ensure
patient confidentiality and dignity:

 Use language that sets the tone for partnership.

 Common courtesy: Ask the patient for permission, introduce teachers/learners, explain the
proposed activity.
 Perform and practice examinations/procedures with appropriate explanation to the patient
and family/caregiver.
 Engage the patient in three-way dialogue with teacher and learners.
 Ask for patient feedback on clinician communication, clinical skills, attitude, and bedside
manner.
 Ask if the patient has questions since sensitive issues may have been raised.
 Ensure students respect patient information confidentiality.
 Use bedside curtains fully drawn before examinations to protect visual privacy. Auditory
privacy must also be respected during discussions.
 Establish policy on student-to-patient ratios to ensure patient comfort and effective student
learning.

3.4.2 Use of Skills Lab and Simulator Centers

Skills labs and simulation centers provide a safe way to acquaint healthcare students, especially
medical and nursing students, with clinical skills before application on actual patients. The
simulation prepares students to acquire skills prior to clinical practice.

3.4.3 Ward rounds/bedside teaching and quality of care

Ward rounds and bedside teachings are integral components of inpatient care, enabling the
clinical team to coordinate ongoing care planning, implementation, and evaluation. Quality
care, positive patient experience, and safety should be central to all ward rounds. Mistakes are
more likely in complex, chaotic teaching hospital wards, but a systematic human factors
approach to identify omissions and mistakes can reduce errors. Establishing, promoting and
sustaining cultural change around ward rounds and bedside teaching requires robust clinical
leadership and commitment from all healthcare professionals. Below are the recommended
guidelines for ward rounds/bedside teachings:

 Maximum ONE hour bedside teaching/ward rounds per patient. Extra time should be
justified and patient permission obtained.
  In the absence of teaching rounds, the ward specialist/medical officer should conduct
DAILY rounds for ALL inpatients.
 Findings, treatment changes, complaints in medical records during rounds should be
documented.
 Ensure implementation of consultant recommendations/treatment regimens from
rounds as detailed in patient notes.
 On-duty medical officer should see ALL inpatients at least ONCE EVERY shift, and as
needed.
 Critically ill patients should be routinely monitored by the on-duty doctor, and seen by
the specialist at least ONCE per shift whenever there is a change in condition.
 Inpatient medication changes should ONLY be made after consulting the on-duty doctor,
apart from documented standing orders.
 Attend immediately to emergencies, discuss critical situations with the on-duty doctor
as early as possible, prioritizing patient stabilization.
 Communicate all referrals and consultations to the on-duty doctor, specialist, and
document in records.
 Ensure accurate, legible documentation.

3.4.4 Multidisciplinary Morning Meeting Sessions

Multidisciplinary morning meetings enable the multidisciplinary team (MDT) -

under/postgraduates, interns, clinicians, nurses, pharmacists, laboratory staff, radiographers,
etc. - to briefly review patient cases before starting routine activities on weekdays, excluding
weekends and holidays. The MDT uses the meetings to discuss care for critically ill patients and
propose alternative effective treatments. The meetings also discuss emerging administrative
issues.

A drawback is that prolonged meetings increase patient waiting times to see physicians, a
major source of complaints and dissatisfaction. Meeting durations should not exceed 30
minutes.
3.4.5 Record keeping

Ward rounds should include holistic patient assessments. Reviews and decisions need proper
documentation for care continuity and to address any medico-legal issues. Records should be
maintained in wards or medical records rooms. All documents should be legible with the name,
designation and signature of the documenter.

 Patient records should be centralized to enable effective communication and teamwork.

 Clearly document all key ward round decisions and actions.

3.5 Community practice and field visits

Community practice and field visits are important teaching and learning activities conducted in
health facilities or the community. When students are placed in other health facilities or
communities, the teaching hospital should sign a memorandum of understanding with the
receiving/host facility and relevant community health authority.

Recommended guidelines include:

a) Students should always be accompanied by their instructors.

b) Orient students on community roles and responsibilities.

c) Provide relevant information on socio-cultural structure, values before deployment. Staff and
students should respect local cultures, values, social structures.

d) Hospital staff and students should not replace regular host facility activities.

3.6 Regular clinical audit of patient care provided by students/interns and residents.

Regular clinical audits of care provided by students/interns and residents are crucial for
teaching and affiliated hospitals to ensure care delivery adheres to standards without
compromising training and teaching activities.

Hospitals should develop a protocol to monitor and evaluate regular clinical audits of
student/intern/resident-provided care. The primary goal of this clinical audit protocol is to
instill a culture of systematic evaluation in teaching and affiliated hospitals and improve care
and learning processes.

The Clinical Audit Implementation Guide manual developed by the Ministry of Health provides
detailed guidance on implementing clinical audits in hospitals.
Section 4: Source Documents

1. Health, M. of (2021) National Clinical Leadership Improvement Program guidlin .

2. Medical Services, D.G. office (2019a) Final-National Clinical Audit Implementation
Guide.
3. Medical Services, D.G. office (2019b) Health Sector Transformation in Quality: A
guideline to support implementation of health service quality improvement activities in
Ethiopian health facilities, First edition.
4. Medical, W. et al. (2018) “Investment in Teaching Hospitals Benefits All: Mortality
Outcomes,” (September). doi:10.1001/jama.2017.5702.2.Burke.
5. Medical, W. et al. (2018) “Investment in Teaching Hospitals Benefits All: Mortality
Outcomes,” (September). doi:10.1001/jama.2017.5702.2.Burke.
6. Sector, H. and Plan, T. (2021) “Hstp ii,” 25(February).
 Healthcare Technology
Management
CHAPTER 18

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Table of content

Contents
Table of content ............................................................................................................................................ 2
List of table.................................................................................................................................................... 3
List of figure .................................................................................................................................................. 3
Abbreviations ................................................................................................................................................ 4
Section 1 Introduction .................................................................................................................................. 5
Section 2 Operational Standards for Medical Equipment Management...................................................... 7
Section 3 Implementation Guidance ............................................................................................................ 8
3.1. Healthcare technology Management Unit/Directorate/Department ............................................... 8
3.2 Medical Device Advisory committee (MDAC) ................................................................................... 10
3.3. Medical Device Management information System (MDMiS). ......................................................... 12
3.4. Medical device maintenance and training workshop ...................................................................... 17
3.5. Oxygen Devices Management ......................................................................................................... 18
3.6. Cold chain management system ...................................................................................................... 20
3.7. Good medical devices and spare parts storage practice ................................................................. 22
3.8. Acquisition/Procurement of medical devices .................................................................................. 23
3.9. Medical devices installation and commissioning practice ............................................................... 28
3.10. Medical Device Maintenance Practice ........................................................................................... 32
3.11. Capacity building for users and Biomedical on proper utilization, safety and maintenance of
medical devices ....................................................................................................................................... 41
3.12. Decommissioning and disposal of medical equipment ................................................................. 44
Section 4 operational standards with implementation checklist ................................................................. 46
Section 5 Indicators..................................................................................................................................... 49
5.1. Percentage of medical equipment Repaired ................................................................................... 49
5.2. Availability of standardized biomedical workshop .......................................................................... 49
5.3. Percentage of medical equipment installation ................................................................................ 50
5.4. Percentage of MDMiS implementation ........................................................................................... 50
5.5. Percentage of Health Facilities with Functional Medical Device Advisory Committee (MDAC) ..... 51
5.6. Percentage of Medical Equipment Functionality............................................................................. 52
Annexes ....................................................................................................................................................... 53
Annex A: Inventory form ......................................................................................................................... 53
Annex B Performance test checklist ....................................................................................................... 54

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 Annex C PPM check list ........................................................................................................................... 54
Annex D Biomedical Equipment Maintenance workshop layout For General and Referral Hospital .... 56
Annex E Sample User Training Verification Form ................................................................................... 56
Annex F - Work Order Form ................................................................................................................. 57
Annex G Corrective Maintenance form .................................................................................................. 58
Annex H Good Practice Checklist for Corrective Maintenance .............................................................. 58
Annex I PPM Log Sheet .......................................................................................................................... 61
Annex J Sample Bin Card for Spare Parts ................................................................................................ 61
Annex L Sample Acceptance Test Log Sheet ........................................................................................... 63
Annex M calibration and testing tools .................................................................................................... 68

List of table
Table 1 Advantages and Disadvantages of Leasing/Leasing Type Arrangements ........................ 27
Table 2 Maintenance related definitions...................................................................................... 37
Table 3 operational standard with implementation checklist...................................................... 48
Table 4 Percentage of medical equipment Repaired..................................................................... 49
Table 5 Availability of standardized biomedical workshop ......................................................... 50
Table 6 Percentage of medical equipment installation ................................................................ 50
Table 7 Percentage of MDMiS implementation ........................................................................... 51
Table 8 Percentage of Health Facilities with Functional Medical Device Advisory Committee
(MDAC) ........................................................................................................................................ 51
Table 9 Percentage of Medical Equipment Functionality............................................................. 52

List of figure
Figure 1 healthcare technology management cycle ........................................................................ 7
Figure 2 organogram for hospital HTMU ..................................................................................... 10
Figure 3 components of maintenance program ............................................................................. 33

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Abbreviations
BME/T – Biomedical Engineer/Technician
CCE – Cold chain equipment
CM – Corrective Maintenance
CMMS – Computerised Maintenance Management System
DiCOM – Digital imaging and Communication in Medicine
EFDA – Ethiopian Food and Drug Administration
EHSTG – Ethiopian Health Sector Transformation Guide
EPSS – Ethiopian Pharmaceutical Supply Service
FMOH – Federal Ministry of Health
HM7 – Health Level 7
HSTP- Health Sector Transformation Program
HTM – Healthcare Technology Management
HTMU - Healthcare Technology Management Unit
IPM – Inspection and Preventive Maintenance
JD – Job Description
LCD – Liquid Crystal Display
MD - Medical device
MDAC – Medical Device Advisory Committee
MDM – Medical Device Management
MDMiS – Medical Device Management Information System
MDDP – Medical Device Development Plan
PM – Preventive Maintenance
PPM – Planned Preventive Maintenance
SOP – Standard Operating Procedure
TOR – Terms of Reference

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Section 1 Introduction

There is recognition that healthcare technology management (HTM), including medical Devices,
are among areas included in the Healthcare Sector Transformation plan (HSTPII and HSTPIII).
Specific areas that require improvement in the coming years include the development of local
innovative healthcare technologies through technology transfer and increased local production
capabilities. In Ethiopia, lack of proper management of Healthcare Technology has limited the
capacity of health institutions to deliver adequate health care. It is estimated that only 75% of
medical equipment found in Addis Ababa public hospitals that are functional and 50% in some
regional hospitals.
The rising number of this non-functional equipment is due to Poor equipment handling and
utilization, frequent power surges, the age of the equipment, the four lack (lack of operator
training, lack of preventive maintenance, lack of spare parts, lack of maintenance capacity), no
medical device policy and minimal knowledge regarding sophisticated equipment, factors which
also contribute to equipment breakdown. Beside all this existing problems because of lack of
representative data on medical device availability and functionality makes it, difficult to deploy
appropriate and skilled professionals.
As healthcare delivery continues to expand and improve in Ethiopia, and an increasing number
of sophisticated high-tech medical devices are being introduced, a system capable of supporting
and managing these medical technologies must be in place. It is very crucial to implement
Medical Devices Management operational standards in the hospitals using its cycle which
includes planning and assessment of needs, procurement, training, operation, maintenance,
decommissioning and disposal. Ensuring the interoperability of the Medical software and the
clinical application should be uses HL7 protocol and DiCOM supported. Additionally, activities
that ensure the successful management of resources and patient related risks in a healthcare
facility need to be implemented.
To improve healthcare technology management across all hospitals, the FMOH has introduced
and implemented EHSTG for the past decade.

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This chapter outlines procedures that a hospital should undertake to appropriately implement the
Healthcare Technology management that allowing for the extension of services while ensuring
the safety of its patients.

Section 2

Operational Standards for Medical Equipment Management

The Hospital has in-house biomedical Engineering department or directorate or unit to oversee
the entire Medical Equipment Management system that has operational plan as well as a
necessary structure and staff.

1. The hospital has organized Healthcare Technology Management (HTM) Structure

2. The hospital has HTM committee (HTMC) from multi-disciplinary team
3. The hospital has a functional HTM information system
4. The hospital has standard medical device maintenance workshop
5. The hospital has medical oxygen devices management system
6. The hospital has cold chain equipment (CCE) management system
7. The hospital has separate medical device and spare part store
8. The hospital has appropriate acquisition system for medical devices
9. The hospital has proper medical devices installation and commissioning practice
10. The hospital has a proper medical device maintenance practice
11. The hospital conducts capacity building for users and BME/T on proper utilization,
safety, and maintenance of medical devices
12. The hospital has a proper decommissioning and disposal system

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Section 3 Implementation Guidance

3.1. Healthcare technology Management Unit/Directorate/Department

Each hospital should establish a Medical Equipment Management Unit/Directorate/Department
that is appropriately staffed and led by trained biomedical personnel, which oversee the entire
health care technology/Medical device Management system with the following activities;

 The HTMU should have internal structure with JD for each Biomedical staffs within
hospitals according to Hospital level.
 The HTMU ensures the hospital recruit biomedical work forces as per the hospital
organogram.
 The HTMU should have Medical Device Strategic and Operational plan for Procurement,
Maintenance and Training of medical device.
 The HTMU ensures the hospital allocate sufficient budget for operational, maintenance
and spare part for Medical devices.
 Assuring quality and safety of patients, operators and Doctors while using medical
device.
 Arrange continuous training for all users by certified trainers on medical device
 The HTMU head should be part of the hospital management team.
 The HTMU should conduct preventive and corrective maintenance for medical device
 The HTMU should follow Medical Equipment after sales contract management as per
procurement agreement.
 The HTMU should develop a written procedure describing the processes for managing
risk, improving safety and quality of utilization
 The HTMU establishes automated and centralized documentation system that tracks all
equipment and spare parts for planning, budgeting, acquisition, reporting and other
purposes.
 The HTMU participates on equipment planning, purchase, installation, maintenance,
troubleshooting, and technical support
 The HTMU works towards national and international service accreditations.

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 Figure healthcare technology management cycle

Healthcare technology management cycle

The Healthcare Technology Management (HTM) cycle involves a systematic approach to
effectively manage and optimize healthcare technology within a healthcare facility. It begins
with the with planning and need assessment with appropriate budgeting and financing which
enable to the identification of technology needs, followed by the process of planning and
procurement to fulfil the necessary devices. Once acquired, the next step involves installation
and commissioning, ensuring proper integration and functionality. Regular maintenance and
calibration ensure the equipment's sustained performance and reliability, while training and
education ensure that healthcare professionals can effectively and safely utilize the technology.
Eventually, the technology may reach the end-of-life stage, where strategies for
decommissioning and disposal are determined. Overall, this cycle ensures a comprehensive and

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efficient approach to managing healthcare technology, ultimately contributing to improved
patient care and outcomes.
Budgeting and financing
Budgeting and financing of medical devices management activities involve planning and
managing the financial aspects of acquiring and maintaining medical equipment. The budgeting
process typically involves estimating the costs of various medical devices, including their
purchase prices, installation expenses, maintenance and repair costs, and ongoing operational
expenses. It's important for healthcare facilities to assess their needs, prioritize their medical
device requirements, and allocate proper resources accordingly.

Organogram for Hospital HTMU/department/directorate/team

CEO/CED

HTMU/D/T

Warehouse Oxygen
Maintenance Managment managment
and training case
Work shop Team/Focal

Imaging and
Radiation Laboratoy Other HTM HTA & MD Data
Case case case Management case OR & ICU case
Team/Focal team/focal team/focal team/focal team/focal

Figure 2 organogram for hospital HTMU

3.2 Healthcare Technology Management Committee (HTMC)

Health technology management committee is a multidisciplinary team that has an advisory role
on medical device management system. Medical device management is not a standalone task and

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needs involvement of multidiscipline within hospital. Each hospital should establish a medical
device advisory committee (HTMC) that has an advisory role in management of medical device
in the facility.

Organization of Healthcare Technology Management Committee

The health technology advisory committee should be organized from clinical, administrative, and
finance, and other relevant hospital departments. The committee will be chaired by the clinical
director of the hospital and the head of HTM will be a secretary. Members will be assigned from
different departments and should comprises, as a minimum:-
 Chief Clinical officer/ Medical director/ Chief executive director/ Chief executive officer
(Chairperson)
 Head/Director of health technology management (Secretary)
 Head of Pharmacy (member)
 Head of laboratory department (member)
 Head of Nursing - midwifery service (Matron) (member)
 Head/representatives of major clinical departments (internal medicine, surgery,
pediatrics, gyn-Obs, etc.) (members)
 Head of finance department (member)
 Head of imaging department
 Representative from medical oxygen management unit (if oxygen plant available)
 Representative from other services as deemed necessary (member)
All members should be assigned with official letter and defined role and responsibilities.
Depending on the equipment being discussed by the HTMC, specialists from the associated
department/case team may also participate. The selection of members of the HTMC should be a
clear and transparent process. The Committee should prepare terms of reference (TOR) that
clearly outline the roles and responsibilities of the committee members and should conduct
regular meeting (at least every two months) and as needed in urgent situations. Meeting minutes
should be documented properly. The committee will prepare action plan and monitor, review,
and report its performance to the management.

The advisory committee should regularly assess the hospital’s medical device management
system performance and take intervention strategies accordingly.

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Role of HTM committee
 Oversee the medical device management system
 Develop a model medical device list
o The hospital should develop and maintain a model medical device list that
comprises types of equipment required by the hospital. The model device list is
prioritized to provide each service.
o National standards for medical equipment for each type of service or hospital
(Primary, General and Specialized), where these exist, should be the minimum
requirements of the model list, but these may be expanded upon as determined by
the multi-disciplinary team.
o The model medical device list should be approved and revised annually by the
advisory committee.
 Monitor the implementation of policies, standards and guidelines developed for effective
medical device management
o Planning and procurement of medical equipment
o donation of medical equipment
o Disposal of medical equipment
o Review incident reports related to medical equipment
 Monitor establishment of a medical equipment inventory system
 Ensure proper utilization of medical device within the health facility
 Conduct medical device utilization, safety, and need assessment and propose intervention
strategy
3.3. Healthcare technology management (HTM) information system
Healthcare technology management (HTM) information system is hardware or software products
intended to transfer, store, convert formats, and display medical device information.
The major category of information about medical device are:
 Medical device Inventory
 Bin and stock card
 Medical device History file,
 Risk classification system
 Spare parts and accessories inventory management

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Medical device inventory
Medical device information recording and archiving begins on the day the device is
commissioned and overhanded to the health facility. Medical device inventory is a list of the
technology on hand, including details of the type and quantity of equipment and the current
operating status, preventive maintenance schedules, Accessories, consumables and spare parts
The inventory provides the basis for effective asset management, including facilitating
scheduling of preventive maintenance and tracking of maintenance, repairs, alerts and recalls.
The inventory can provide financial information to support economic and budget assessments.
The inventory is the foundation needed to organize an effective MDM department. Items such as
equipment history files and logbooks, operating and service manuals, testing and quality
assurance procedures and indicators are created, managed and maintained under the umbrella of
the device inventory. Furthermore, accessories, consumables and spare parts inventories are
directly correlated with the main medical equipment inventory.
 Conduct once and must be continually maintained and updated to reflect the current
status of each Medical equipment.
 Depending on the level of the hospital and its Medical device, different details are
tracked and updated as changes occur
Each hospital should establish an inventory of all medical device following the inclusion and
exclusion criteria described in the Medical Equipment guidelines and definition.
 A small team should be established to set up the initial inventory of medical equipment.
 The team should be led by the Head of Medical device management who is ultimately
responsible to establish and maintain the equipment inventory.
 Medical device maintenance personnel or other staff assigned by hospital management
should also form part of the inventory team.
 Additionally, one or more department/case team representatives should participate in the
inventory of their respective department/case team.
 The inventory team is responsible to visit every department and record every item of
medical equipment.
 A sample Inventory Data Collection Form is presented in annex A.

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  Items that are obsolete, that cannot be repaired or that are not of use to the hospital should
be removed and transferred to a storage area at the time of the inventory and the formal
disposal process should be started.
 An inventory code number should be assigned to each piece of equipment. This can be
done sequentially from number one (1) upwards. Each new item is assigned the next
number, with no regard to type of device, location etc. Alternatively, a ‘speaking
numbers’ inventory system can be used.
 This system indicates the location, the type of equipment and the individual number of
the equipment. With a ‘speaking number’ system each room/department in the hospital is
assigned a location code and each type of equipment is assigned an equipment type code
– for example “T1 99 02” where T1 is Theatre number 1 in the operating suite, 99
indicates the item is suction pump and 02 is the individual number of machine.
 Although the ‘speaking numbers’ inventory system is more complex to establish, it has
the advantage that it is easy to identify the location of each item and to organize the
equipment inventory by each department.
 An inventory database should be established to record and manage all items of
equipment. This can be paper based or computerized, with paper back up. The following
should be documented in the inventory for each item of equipment:
 Information gathered as part of the inventory of medical equipment should be included in
the overall fixed asset inventory of the hospital.
 The inventory should be reviewed and checked annually, with regular updates during the
year when new equipment arrives or is removed from service.
 Additional inventory checks may be conducted at regular time intervals throughout the
year, as determined by the HTMC and hospital management.
 When an item is discarded it should be removed from the Inventory Database. A record
should be kept in a separate file of all discarded equipment for future reference and audit
purposes. All equipment should be labelled with its inventory number preferably using a
water proof Poly Vinyl Chloride (PVC) sticker. Hospital policy should prohibit use of
medical equipment without inventory tags/stickers. This is to ensure that all equipment in
use has undergone ‘acceptance testing’ and receives regular preventive maintenance,
hence minimizing risks to patients and staff from faulty equipment.

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  Uses MEMIS website for computer based medical devices, Spare parts inventory and
Maintenance system
 Upload the develop and maintain Equipment History Files for all Equipment and
uploaded in MEMIS
 Upload the establish SOPs for equipment use, safety, PPM and Troubleshooting
procedures and using MEMIS
 Upload the establish PPM schedules using MEMIS
 Track history file
Items included in an inventory
 The hospital medical device inventory includes medical equipment’s;
 Can be based on function (2-10 pts), risk level (1-5 pts) and maintenance requirement (1-
5 pts) criteria whose formula is given by:-
 𝑫𝒆𝒗𝒊𝒄𝒆 𝒎𝒂𝒏𝒂𝒈𝒆𝒎𝒆𝒏𝒕=𝑭𝒖𝒏𝒄𝒕𝒊𝒐𝒏+𝑹𝒊𝒔𝒌+𝑴𝒂𝒊𝒏𝒕𝒆𝒏𝒂𝒏𝒄𝒆 𝑹𝒆𝒒𝒖𝒊𝒓𝒎𝒆𝒏𝒕
 Items with score <12 are excluded from inventory
 In addition to this include the medical equipment’s by definition.
 Main medical equipment inventory Data included in Hospital medical equipment
inventory information:
o Inventory identification number based on available nomenclature system
o Type of equipment/item
o Brief description of item
o Manufacturer
o Model/part number
o Serial number
o Power requirement
o Physical location within facility
o Condition/operating status
o Operation/service requirements
o Date inventory updated
o Maintenance service provider
o Purchase supplier
o Year of Manufacturing and purchased

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 o Equipment risk classification
o Estimated life span
o Availability of trained user and technicians
o Other information as needed
 Before establishing a medical equipment inventory the MDAC/HTMU should determine
which items should and should not be included in the inventory and medical equipment
management program based on standard inclusion and exclusion criteria. However, the
MDAC/HTMU may decide to exclude smaller, less expensive and easily replaceable
items from the medical equipment inventory and program (for example
sphygmomanometers, stethoscopes, etc.) since the effort required to record, maintain and
repair these smaller items may not be worth the required

Equipment History File

An individual file/folder should be established for each item of equipment. This file should be
held in the equipment maintenance department. The file should contain:
 Inventory Data Collection Form (Appendix xx)
 The address of the manufacturer
 The address of the supplier and local agents
 Details of any maintenance contract and maintenance contractor (if relevant)
 Copy of warranty (if relevant)
 Price paid/Copy of invoice
 Medical device manual or location of the manual
 List of consumables required to run machine and recommended spare parts
 Acceptance test log sheet (Appendix H)
 Medical device Risk Assessment Form (Appendix C)
 SOPs for operation and maintenance of the item
 Planned preventive maintenance schedule
 Corrective maintenance reports (Appendix K)
Operator, service and other relevant manuals for all equipment items should be stored in the
workshop library. Copies should be made and distributed to users and other interested parties as
necessary

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Medical device Risk Classification
As part of establishing an inventory an assessment should be undertaken to classify each item of
equipment as ‘high’, ‘medium’ or ‘low’ risk. This level of risk determines the priority with
which equipment should be repaired and maintained or replaced if no longer operable. For
example if a ‘high risk’ item (such as an anesthesia machine) is broken this should generally be
repaired before a ‘low risk’ item even if the ‘low risk’ item has been broken for longer, except
under special circumstances. Additionally, when implementing the guidance in this chapter (such
as developing standard operating procedures (SOPs), setting maintenance schedules, training
staff in equipment use etc.) the ‘high risk’ items should be dealt with first.
The assessment of risk should be done based on:
 Function of the equipment: For example whether the equipment is used for life support,
routine treatment, diagnosis or monitoring Risk which may associated with equipment
failure
 Preventive maintenance requirements: The frequency with which preventive maintenance
is required to minimize breakdown and ensure safety
 Main area of equipment use: For example use in anesthesia or surgical areas, use in
general care areas etc.
 Likelihood of equipment failure: This is measured as the ‘mean time between failures’
calculated from previous use or service records. A Medical Equipment Risk Assessment
Form should be completed for all items in the equipment inventory. The risk category
should be entered on the Inventory Index Card, and the Risk Assessment Form should be
fled in the medical device history file. Any new item of equipment should be assigned a
‘risk category’ when it is received by the hospital and entered into the inventory.
Spare Parts and accessories Inventory
The medical device maintenance department should maintain a stock of the most commonly
replaceable spare parts for the different types of equipment in the hospital. Items should be kept
in a locked room with a stock control system in place. Spare parts should be stored according to
manufacturer’s instructions and should not be used beyond the expiration date. The inventory of
spare parts should be managed using a ‘stock and bin card’ system.

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3.4. Medical device maintenance and training workshop

The hospital should have a medical devices Training and maintenance workshop separately from
the general maintenance workshop equipped with the necessary testing, calibration, measuring
instruments, maintenance tools, personal protective equipment, computer, printers, reference
books, operator and service manuals, SOPs and internet access needed to carry out the overall
medical devices management services.

Hospitals should establish a medical equipment maintenance workshop based on their level (see
the Appendix D Workshop Minimum standard layout) that consists of the following:
Maintenance workshop including space for:

 Standard medical device and training workshop layout - Hospitals based on their
service level and standard should establish medical device workshop as per the minimum
standard of MOH. The hospital should have all the necessary facility rooms, well
ventilated utilities, easy access for loading and unloading.
 Administration offices - Hospital medical device workshop as of any department in the
hospital shall have administrative office for department head as well as for their staff and
well furnish with the necessary office equipment (furniture, computers, and internet).
 Electrical/Electronic Work Area
 Biomechanical Work Area
 Test, Measuring equipment, Tools, Spare parts - Medical device of the hospital
Workshop shall have standard test, measuring, calibration, and maintenance tools based
on the number of staff available in the workshop. The minimum standard list of medical
device workshop test, calibration, and maintenance tools are annexed M.
 Personal Protective Equipment(PPE) – such as safety shoes, eye goggle, mask, gloves,
rubber sheet/apron and others
 Spare part and consumable mini- Store - Hospital medical device workshop shall have
a mini- store for storing fast moving consumable’s Spare part. This mini- store should
have a shelf to put all items in their proper order and easy to apply a good storage
practice and using bin card.
 Mini- library - Workshop must have a mini- library facility which is help full to access
equipment users and service manuals, maintenance SOPs, reference books
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  Training Room - The hospital medical device should have a well-equipped (with LCD
projector and chair) training room which is appropriate to conduct frequently equipment
users ( clinicians) training on newly arrived equipment and also train a new clinical staffs
about the equipment they are going to use and proper handling
 Duty room - Medical device Workshop should have a duty room for their staffs those
who assigned for night duty activity.
 Rest room (toilet) - Hospital medical device workshop should have a functional and
separate for male and female rest room with shower and change room services

3.5. Medical Oxygen Devices Management

Hospitals that have medical gas systems plan (medical Oxygen plant) and pipeline system they
shall have oxygen device management team under the HTMU. The team may be composed of
biomedical and electromechanical engineer professionals as required.

Medical Oxygen plant

The health facilities should conduct oxygen production quality assurance activities through
periodic check using the proper instrument. It is also important to verify that the quality and
capacity of each oxygen sources/plants production maintained (m3 per hour) as per the
manufacturer’s manual. Furthermore, it is important to ensure the continuous production and
supply. To ensure continuity of production it is advisable to use duplex or triplex pant system
instead of single use.
Consumption & production Record
The health facilities BME/T should record the daily, monthly and annual oxygen consumption to
facilitate proper quantification, budgeting and to ensure access to patient treatment and there by
avoid mortality due to oxygen scarcity.
Availability of testing and measuring devices
To monitor the quality and production capacity of oxygen production plants /devices the
availability of testing and measuring with appropriate oxygen analyzer is mandatory. To
maintain quality of work analyzers needs to be calibrated and documented periodically.
Oxygen Cylinders
The health facilities BME/T team need to ensure the implementation of standard color code and
use medical grade oxygen cylinders. There must be a separate storage compartment for filled and

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empty cylinders. It is also important to have storage space to keep distance between each
cylinder. During transportation and storage, ensure that all cylinders are kept up right position
with safety cup on them. In order to avoid accidents due to oxygen explosion and valve damage
proper care must be taken on loading and un-loading cylinders. Inspection for each cylinder
should be done to identify if there is a damaged valve. The use of proper transportation trolley
should be a usual habit by all oxygen cylinder transporters.
Oxygen cylinder Refilling
During refilling oxygen Cylinders, the BME/T should inspect to ensure whether the cylinder is
properly filled and compressed (appr…150 bar). It is also important to ensure the cleanness of
cylinders every six months and document the certificate. Leak and purity (oxygen concentration
93 ± 3) test have to be performed using relevant instrument or other methods such as soap foam
and so on.
Health facility Medical gas distribution system
Medical Gas Distribution System is a central supply system to supply a medical gas (O2, N2O,
and N2), medical air, and medical vacuum to each ward of hospital safely and conveniently
through a central supply piping from medical gas supply sources. The system has a thorough
going color coordination according to the kind of gas.
Oxygen devices, Consumables & Accessories as per the annexed list
The health facilities should ensure/ confirm the availability of relevant oxygen devices,
consumables, accessories and other relevant equipment’s needed for the production, distribution,
delivery and monitoring of medical gas for safe treatment of patients. (List of oxygen devices are
annexed).
3.6. Cold chain management system

As immunization programs is one of the hospital critical service, Vaccines, some

pharmaceutical, Laboratory reagents and blood products must be kept in appropriate cold chain
system. For this purpose equipment needed to move and store vaccines, reagents, and blood
products at the ideal temperature range. By implementing the following best practices—planning
with program needs in mind; committing to cold chain equipment maintenance; and developing
good recordkeeping, reporting, to maintain a strategic cold chain and lower risk to the vaccine,

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pharmaceuticals, and blood products. To separate cold chain equipment’s based on their
functionality status is very crucial.

The preservation of cold chain products, including vaccines, is indeed vital in the healthcare
industry. Cold chain products are temperature-sensitive and must be stored, managed, and
transported within a limited temperature range to maintain their potency. Temperature
monitoring devices play a crucial role in ensuring that proper storage conditions are maintained
throughout the cold chain. These devices measure and record the temperature of the environment
in which the products are stored or transported. By using temperature monitoring devices, the
risk of spoilage and quality degradation is reduced, regulatory compliance is improved, and
proactive measures can be taken to prevent product loss. It is also important for biomedical
engineers/technicians to calibrate temperature monitoring devices, regularly document
temperature readings, and store vaccines according to the manufacturer's instructions.
Additionally, during the loading and unloading process, vaccines should be carefully packed into
refrigerated containers or trucks to maintain the required temperature range. Vaccines sensitive
to freezing should be stored within a specific temperature range of 2°C to 8°C.

3.7. Good medical devices and spare parts storage practice

The procured medical device and spare parts shall be received by the store manager. Before
receiving established procedure for each incoming items against the relevant documentation
(specification, ordered quantity, required manuals) to ensure that the correct product is delivered.
Once confirmed that these medical device and spare parts fulfill the minimum requirements, the
store manager should receive using Model 19.
If there is any discrepancy, it should be noted and informed to EPSS or the supplier. The
received medical device and spare parts should be stored at separate store from pharmaceutical
store until they are issued to service delivery units of the hospital. The medical device and spare
parts store manager should properly store medical device and spare parts following guidelines/
SOP for good storage practices for medical device and spare parts. The stored items must have
proper management (zoning for medical device, spare part) and labelling of items including the
following information (item name, part number, model).

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The store manager also determines the available warehouse space before ordering medical
device and spare part for the next procurement period according to Storage Guideline/ SOP. Both
manual and electronic-based inventory management system shall be implemented. Effective
inventory management is underpinned by a Medical Equipment Management Information
System (MEMIS). The purpose of MEMIS is to support the management of all medical device
and spare part by collecting, organizing and reporting information to other levels in the system.
Standardized forms for inventory management are described below:
Bin Card: A Bin Card should be prepared for each product in the medical device and spare part
Store. The Bin Card should be kept with each product inside the store. All transactions of the
product to or from the store should be recorded on the Bin Card. The Bin Card should also
include a column for the loss/adjustment of stock and a column for the stock balance. The stock
balance should be updated after each and every transaction or adjustment.
Stock Record Card: The Stock Record Card is similar to the Bin Card but is used to track stock
based on issuing and receiving orders. It should be kept in the Medical Device Management
Unit. The totals on the Stock Record Card should be checked against those on the Bin Card and
the results of the physical count. Any discrepancies should be investigated. A combined
Bin/Stock Card System provides a measure of internal control that helps to minimize leakages of
stock due to theft or loss. Paper based or electronic systems can be used.
3.8. Acquisition/Procurement of medical devices

Any new equipment acquired must be suitable for the hospital’s mission and improve access to
quality healthcare. The HTMU also needs to ensure that equipment operators have the ability
and capacity to absorb, support, and use any technologies procured. Procurement activity is part
of the broader acquisition phase of healthcare technology management, which also includes
planning, need assessment, selection, financing and budgeting.

Purchasing refers to the acquisition of goods or services in return for money or equivalent
payment whereas Procurement is a wider term and refers to the process of obtaining goods and
services in any way, such as through purchase, donation, loan or hire. However, the use of the
terms ‘procurement’ and ‘purchasing’ interchangeably to mean ‘procurement’ is a common and
accepted practice

Planning and need assessment

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Planning and need assessment requires establishment of Multi-disciplinary Team/HTMC, data
gathering and definition of strategic areas, development of list of required devices, quantities and
specifications and specifying of site requirements.

Need assessment is the identification and definition of prioritized requirements with regard to
medical devices. A thorough needs assessment is indeed essential before purchasing medical
equipment. It involves evaluating the potential impact on the performance of medical equipment
users and the delivery of services within the context of the health system's capabilities and
service delivery priorities. This assessment considers factors such as the overall objectives of the
institution, existing facilities and infrastructure, long-term usage plans, and human resources
development. The general approach to conducting a needs assessment is to assess the current
availability of medical equipment in the facility and compare it with what should be available
based on the specific demands and situations of the catchment area or target group. This helps
identify any gaps and determine the necessary medical devices that need to be procured. During
the procurement process of medical devices and technical evaluation, the involvement of
biomedical engineers and related disciplines is crucial. Their expertise ensures the procurement
of quality and appropriate medical devices that meet the requirements of the institution and can
be effectively utilized by the healthcare professionals.

Medical Devices Development Plan

The Medical Device Development Plan (MDDP) is aimed to define goals for acquisition,
maintenance, and replacement of equipment in the short term and long term. It should be
developed taking into consideration the current devices inventory and the ‘model medical device
list’.

The medical devices development plan (MDDP) brings attention to:

● Current stock and condition of equipment: which pieces need to be replaced or

rehabilitated or to be disposed
● Shortfalls in equipment: missing equipment that needs to be purchased
● What action is needed to rehabilitate, replace or purchase equipment
● Short-term (1 year) and long-term (2-5 year) goals to ensure that the hospital has all
necessary equipment for current and future services.

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The MDDP should be developed by the HTMU and approved by hospital management. The plan
is the basis for the annual equipment budget .The Head HTMU is responsible to implement the
plan, with the assistance of other departments where relevant (for example administration and
finance). The HTMU should quantify spare parts and device consumables together with the
equipment.

Medical device Specification

The specification is the most important document for both the purchaser and for the potential
supplier, since it sets out precisely what characteristics are required of the products or services
sought. Often, this is the only chance to detail the selection criteria including requirements for
certain levels of technology, quality, safety, appropriateness, consumable inputs, training, and
technical support. This is especially the case if the hospital is using a tendering process when it is
not legal to introduce additional terms and conditions after the tender bids have been received.
Therefore any preferences made in these areas must be highlighted within the initial
specification.

The HTMU should write medical device specifications, so that whoever is procuring/ providing
the goods can conform to the hospital’s requirements. The specifications provide the detailed
technical description of each type of equipment on the Model Equipment List. HTMU may
require specialists to help with writing such specifications.

Having drawn up Model Equipment Lists and Acquisition policies follows the process of
acquisition. Whether we are carrying out procurement on our own behalf, or have enlisted the
help of an external support agency to do it, purchase orders or requests for tenders/quotations
have to be prepared. A clear specification includes;

 A detailed description of the equipment

 The ‘package of inputs’ needed to keep the equipment going through its lifetime
(including consumables, installation, training and after-sales support)
 The quantities required

Medical device Procurement

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Obtaining equipment is intensive work, both in terms of time and resources. It is therefore
required to consider a number of factors before committing to buying, accepting donations, or
hiring equipment. Before carrying out any equipment procurement (through purchases, donations
or rentals), the hospital should already have

● an up-to-date equipment inventory

● a vision for health service delivery
● purchasing, donations, replacement, and disposal policies
● Model Equipment Lists

Ideally, all procurement should be for those items laid out in the Device Development Plan for
the current year, plus occasional additional items required to cover contingencies (emergencies
and unplanned events).

The acquisition/procurement of medical equipment should be under taken in accordance with the
Ethiopian government/ MOFED/ directives. Once we know the equipment we need, there are
several ways to obtain it:

Choosing purchase methods

Whenever the hospital purchases medical equipment, it is needed to decide the best model of
procurement to use (for example, whether to purchase by ourselves or collectively). It is needed
to decide upon the most appropriate purchasing method and the types of suppliers to approach.
Such planning will enable to make efficient use of resources, and ensure that any equipment
bought is appropriate to the need and is of the right quality. It will also enable to work within the
appropriate timescales. There are various ways of purchasing equipment. It is important to know
the different options available, so that each time the equipment is bought; the most appropriate
options are selected.

 Centralized procurement – procurement takes place centrally, for example at the national
level
 Group procurement – joint procurement by different health facilities, health authorities
(district, regional) or health service provider organizations (public or private)

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  Decentralized procurement – health facilities or health authorities to which authority has
been decentralized procure equipment themselves, or health facilities and health
authorities with independent funds undertake their own procurement.
 Mixed procurement – a combination of centralization and decentralization, whereby
some parts of the procurement process are undertaken centrally and others at district or
facility level.
 Using procurement agents – private companies being hired to handle procurement.

Leasing and Renting Medical Equipment

Leasing and renting are terms commonly associated with acquiring the temporary use of a
property or asset, but they have some fundamental differences.

If the hospital do not wish to buy equipment using the capital budget, it may choose some form
of leasing arrangement, which uses funds from the recurrent budget instead. When doing this, it
is necessary to weigh up carefully the costs and benefit and also check whether such
arrangements are legal and approved by national authorities or the central management body.

Renting, on the other hand, typically involves shorter-term agreements, often month-to-month or
on a yearly basis. Renting usually involves paying regular rent to the landlord for the use of a
property or asset. Apartments, houses, and equipment rentals are common examples of renting
arrangements.

In the case, the leasing organization retains ownership of the item and is also responsible for the
maintenance, repair, and updating of the equipment. The lessee (in this case, the hospital) has
possession and use of the equipment until such time as the lease contract runs out.

In summary, the key difference between leasing and renting lies in the duration and flexibility of
the agreement. Leasing usually involves a long-term commitment, while renting tends to be more
short-term and flexible.

Advantages and Disadvantages of Leasing/Leasing Type Arrangements

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Advantages Disadvantages

Provides certainty as costs are known in A fixed obligation is created to pay rental from
advance your recurrent funds

Reduces the need to tie up capital funds in The flexibility to dispose of obsolete
fixed assets equipment before the end of the lease may be
reduced.

Enables the suitability of equipment to be Doesn’t provide ownership.

assessed over a pre-determined trial period

Sometimes enables you to obtain equipment or Agreements are one-sided. When leasing, if
material that is hard to purchase something goes wrong most risks are
transferred to the lessee (for example, loaned
items must be replaced if damaged). Under
leasing type arrangements, although most of
the risk remains with the owner of the
equipment this has to be paid for in the rental
price, and additional costs will be incurred,
depending on the contract terms, if a leased
item is misused or otherwise damaged.

Table 1 Advantages and Disadvantages of Leasing/Leasing Type Arrangements

Medical Device Donation

The hospital should strictly follow National Medical Devices Donation Directive for the receipt
of donated medical devices. The directive describes the conditions under which donated medical
devices will be accepted by the hospital. For example:

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 ● Donated equipment must be in good working order
● Equipment will only be accepted if the item is needed by the hospital and is described in
the Model Devices List and associated annual medical device management plan
● Instruction manuals, in English, should be supplied with the donation
● Supplies, consumables and spare parts for the equipment should be readily available in
Ethiopia. If that is not possible, at least 1 to 2 years of needed consumables and spare
parts should be supplied by the donor with the donated equipment
● Expertise for the maintenance and repair of the equipment should be available in Ethiopia
● The equipment must be compatible with other medical equipment system in the hospital
● The equipment must not require any special storage or operating conditions that the
hospital cannot provide (for example air conditioning, humidity control etc.)
● The donor should provide training in the regular use and preventive maintenance of the
equipment, if relevant, and
● The donor should provide follow up support regarding use of the equipment, where
necessary
● When items are donated the hospital and donor must agree who is responsible for
customs clearance, including approval of the item by the regulatory authority if
necessary.
All equipment donations should be reviewed by HTMU and approved by the hospital
management before acceptance.

3.9. Medical devices installation and commissioning practice

Healthcare and patient management have changed dramatically in recent years and continue to
do so, mainly as a result of the advances in healthcare technology. Healthcare technology plays
an extremely important role in everyday clinical and public health work. Therefore the hospital
senior management in-collaboration with medical device management unit shall in place proper
medical device installation and commissioning procedure/protocol or other guiding documents.

When an order has been placed to purchase a new item of equipment, or a donation has been
accepted, preparations must be made for receipt of the item. Receive equipment on site check
according to given logistics specifications and confirm there is no visible damages. This is to

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ensure quick and efficient installation, commissioning, training, acceptance testing and
eventually placement into service.

Installation of medical devices is “the process of fixing equipment into place” related processes
are the delivery, storage and placement of procured goods in the desired location and should
completed contract awards or purchase orders, specified materials and well defined delivery
requirements.

Pre-installation work involves:

 Preparing the site ready for equipment when it arrives

 Organizing any lifting equipment
 Organizing any warehouse (storage) space
 Confirming installation and commissioning details
 Confirming training details.

Site Preparation - Site preparation is often required to ensure that the location where the new
equipment to be installed is suitable. This may require sufficient room/place, door entry sizes,
elevator capacity, and new connections for electricity, water, drainage, gas or waste piping and
may even require construction work.

Site preparation tasks may include:

 Disposing of the existing item that is to be replaced

 Extending pipelines and supply connections to the site
 Upgrading the type of supply, such as increasing voltage or pipeline diameters
 Providing new surfaces, such as laying concrete or providing new worktops
 Creating the correct installation site, such as digging trenches, building a transformer
house or a compressor building

Lifting Equipment - Large or heavy items will need to be lifted and moved upon arrival. Plans
should be made ahead of time to arrange proper lifting/ moving equipment before the new
equipment arrives.

Warehouse (storage)

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If goods need to be stored before they can be unpacked or installed, space should be made
available for these items before they arrive.

Acceptance testing - Depending on the complexity of the equipment, installation can range from
simply plugging the equipment into an electrical socket to building it into the fabric of the room.
All medical equipment, purchased or donated, should be inspected upon delivery and tested prior
to initial use. This is known as acceptance testing and ensures that delivered medical equipment
is complete, undamaged, in good operating condition, accompanied by manuals and spare parts,
satisfies safety criteria, and meets specifications of the purchase order. A competent individual
must assess the functionality of the equipment to prevent any harm to the operator or patient
upon use. Guidance for unpacking and inspecting equipment is presented within the package.

The main steps in the Acceptance Testing process are described below:

 How complex is the equipment? The more complex the device, the more likely the
manufacturer will need to be involved.
 Do the hospital staffs have the necessary technical skills? If the staff cannot perform
the job, then an outside vendor should be contracted.
 Does the purchase is single item or in bulk? If purchasing in bulk, it is often
worthwhile to contract the manufacturer to perform this process on all the equipment. For
a single unit, the in-house staff may be able to manage with guidance from the
manufacturer.

Commissioning is performing a series of tests and adjustments that will check whether the new
equipment is functioning correctly and safely, and ensuring that any adjustments are made,
before the equipment is accepted.

Preparation for User Training: The details of training should already have been decided when
drawing up the purchase contract or donation acceptance document. During delivery time, any
preparations that need to be made (including preparation of training materials, training space,
equipment, etc.) should be finalized in order to ensure training can commence when the
equipment is delivered.

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Isolate the equipment until it has undergone acceptance testing Once equipment arrives, set it
aside by isolating the equipment in a special holding area and by labeling it as “not for use” to
ensure that the equipment will not be used. The only exception is for large items that may be
delivered to where they will be installed but should still be clearly marked as “not for use” until
the acceptance process is completed.

Undertake acceptance testing and complete Acceptance Test Log Sheet (see Appendix L)

Acceptance testing should include:

 Checking the delivered equipment matches as per the details of the purchasing order
(model, vendor, quantity, technical requirements, etc)
 Checking the equipment is accompanied by operation and service manuals and necessary
paperwork (e.g. warranty, if applicable) as per the purchase order.
 Checking that appropriate spare parts and consumables are included as per the purchase
order
 Installation and commissioning of the equipment. Installation is the process of fixing the
equipment into place. Depending on the complexity of the equipment, this can range
from simply plugging the equipment into an electrical socket to building it into the fabric
of the room. Commissioning is performing a series of tests and adjustments that will
check whether the new equipment is functioning correctly and safely, and ensuring that
any adjustments are made, before the equipment is accepted.

If the equipment passes the safety, calibration and function tests and commissioned then the
hospital can officially accept the equipment and establish equipment history file which includes
Inventory form, Standard Operating Procedure, risk classification and Preventive maintenance
schedule.
Provide training for equipment users and maintainers as appropriate.
This will ideally occur immediately but sometimes, due to availability of trainers (in-house,
vendor, other), training may occur at a later date. In this case the HTMU will have to decide if it
is safe to hand over the equipment before training the staff. Placing the equipment into operation
without training should only be done when the equipment type has been used before and the
staffs are familiar with proper operation. Installation and commissioning should be carried out in

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the presence of the user as well as engineering support team. Demonstration of the device
indicating all its functions should be carried out to the satisfaction of the user and biomedical
engineering team. Training on operation and maintenance should be included in specifications
indicating the type, duration, location (on-site/off-site, local/overseas), target personnel i.e.
doctors, nurses, maintenance personnel, since differing types and levels of training needs to be
provided for each staff category. User training should be provided by an application specialist,
especially training for sophisticated or complex devices.

3.10. Medical Device Maintenance Practice

Medical devices may cause life threatening problem if it is not managed properly. Therefore, it is
important to have a well-planned and managed maintenance practice to ensure medical device
are reliable, safe and available all time when it is needed for diagnostic procedures, therapy,
treatments and monitoring of patients. In addition, such activities lengthen the useful life of the
device and minimize the repair related cost of device.

Medical device maintenance practice is the strategy and the procedure which consists adequate
planning, management and implementation. Planning considers the financial, physical and
human resources required to adequately implement the maintenance activities. Once the program
has been defined, financial, personnel and operational aspects are continually examined and
managed to ensure the program continues uninterrupted and improves as necessary. Ultimately,
proper implementation of the program is key to ensuring optimal equipment functionality.

Medical device maintenance practice can be divided in to corrective maintenance and inspection
and preventive maintenance (IPM) which includes performance testing, functional testing and
calibration after corrective, preventive maintenance and before applying to the patient.

Components of a maintenance program

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 Maintenance

Inspection and
Corrective
Preventive
maintenance
maintenance

Planned functional and

Inspection Preventive performance
maintenance test

Figure 3 components of maintenance program

IPM includes all scheduled activities that ensure equipment functionality and prevent
breakdowns or failures. Performance, calibration and safety inspections are straightforward
procedures that verify proper functionality and safe use of a device. Preventive maintenance
(PM) refers to scheduled activities performed to extend the life of a device and prevent failure
(i.e. by calibration, part replacement, lubrication, cleaning, etc.). Inspection can be conducted as
a stand-alone activity and in conjunction with PM to ensure functionality; this is important as
PM can be fairly invasive in that components are removed, cleaned or replaced. Corrective
maintenance is performed whenever medical equipment breaks down.

Tags and labels: It is good practice to label each piece of medical equipment with a unique
identification number. This number will be used by the users to communicate with the medical
equipment maintenance department so there is no confusion about which specific piece of
equipment is being reported.

Maintenance related definitions:

Name Description
Acceptance testing The initial inspection performed on a piece of medical equipment
prior to it being put into service. When the device first arrives in the
health-care facility, it is checked to ensure it matches the purchase
order, it is functioning as specified, the training for users has been
arranged and it is installed correctly. If a computerized maintenance

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 management system (CMMS) is available, it is registered into the
CMMS.
Corrective maintenance A process used to restore the physical integrity, safety and/or
(CM) performance of a device after failure. Corrective maintenance and
unscheduled maintenance are regarded as equivalent to the term
repair. This document uses these terms interchangeably.
Inspection and IPM refers to all the scheduled activity necessary to ensure a piece of
preventive maintenance medical equipment is functioning correctly and is well maintained.
(IPM) IPM therefore includes inspection and preventive maintenance (PM).
Inspection Inspection refers to scheduled activities necessary to ensure a piece of
medical equipment is functioning correctly. It includes both
performance inspections and safety inspections. These occur in
conjunction with preventive maintenance, corrective maintenance, or
calibration but can also be completed as a stand-alone activity
scheduled at specific intervals.
Calibration Some medical equipment, particularly those with therapeutic energy
output (e.g. defibrillators, electrosurgical units, physical therapy
stimulators, etc.), needs to be calibrated periodically. This means that
energy levels are to be measured and if there is a discrepancy from
the indicated levels, adjustments must be made until the device
functions within specifications. Devices that take measurements (e.g.
electrocardiographs, laboratory equipment, patient scales, pulmonary
function analyzers, etc.) also require periodic calibration to ensure
accuracy compared to known standards.
Performance test These activities are designed to test the operating status of a medical
device. Tests compare the performance of the device to technical
specifications established by the manufacturer in their maintenance or
service manual. These inspections are not meant to extend the life of
equipment, but merely to assess its current condition. Performance
inspections are sometimes referred to as ‘performance assurance
inspections’. Evaluation of the device parameter by comparing

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 measured output and true value by using different analyzers such as
electrical safety analyzer, radiation analyzers, oxygen analyzer,
pressure analyzer, patient simulator, defibrillator analyzers etc.
Failure The condition of not meeting intended performance or safety
requirements, and/or a breach of physical integrity. A failure is
corrected by repair and/or calibration.
Preventive maintenance PM involves maintenance performed to extend the life of the device
(PM) and prevent failure. PM is usually scheduled at specific intervals and
includes specific maintenance activities such as lubrication, cleaning
(e.g. filters) or replacing parts that are expected to wear (e.g.
bearings) or which have a finite life (e.g. tubing). The procedures and
intervals are usually established by the manufacturer. In special cases
the user may change the frequency to accommodate local
environmental conditions. Preventive maintenance is sometimes
referred to as ‘planned maintenance’ or ‘scheduled maintenance’.
This document uses these terms interchangeably. The maintenance
plan and schedule should be developed collaboratively between the
HTMU and the Head of the Department/Case Team where the item is
located. The maintenance plan, schedule and log sheet should be
attached or kept adjacent to the equipment item. A copy of the plan and
schedule should be kept in the Equipment History y File that is held in
the Equipment Maintenance department.
 A description of and guidelines for the tasks to be
conducted including
 Care and cleaning
 Safety procedures
 Functional and performance checks
 Calibration testing
 Preventive maintenance checks
Repair A process used to restore the physical integrity, safety, and/or
performance of a device after a failure. Used interchangeably with

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 corrective maintenance.

Safety inspections These are performed to ensure the device is electrically and
mechanically safe. These inspections may also include checks for
radiation safety or dangerous gas or chemical pollutants. When these
inspections are done, the results are compared to country or regional
standards as well as to manufacturer’s specifications. The frequency
of safety inspections may be different than planned maintenance and
performance inspections, and are usually based on regulatory
requirements.
Work Orders and Whenever an item of equipment is faulty this should be reported
Reports immediately to the medical equipment maintenance department using
a Service Request/Work Order Form. Requests for maintenance to
be under taken by technicians should also be documented on a Work
Order Form. In urgent cases the request for repair can be made by a
telephone call or other verbal means of reporting, however this must
always be backed up with a written request on the Work Order Form. .
Outsourcing of When the HTMU is unable to perform PPM or corrective
Technical Services maintenance of a par titular item of equipment, support from external
maintenance contractors will be required. Work may be outsourced
to the National Scientific Equipment Centre, the manufacturer’s local
agent, the manufacturer, private maintenance companies, individuals
such as electricians or plumbers or the Ethiopian Public Health
Institute for laboratory y equipment. The Ethiopian Biomedical
Engineers/Technicians Association could be a good source for finding
qualified individuals or companies. Support may also be provided by
the relevant Regional Health Bureau.

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Equipment History Medical Equipment History Files for each equipment that consists of
file schedule for Inspection, performance testing, and preventive
maintenance, corrective maintenance, SOP, and inventory data
collection form and risk assessment form.

Table 2 Maintenance related definitions

Prioritization of maintenance work

Prioritize medical device for maintenance is important. Prioritization will be done based on the
following criteria:

 Risk-based prioritization: One method used to prioritize medical equipment IPM is

based on assigning the highest priority to equipment with the highest likelihood of
causing patient injury if it fails.
 Resource-based prioritization: This is a combination with knowledge about the staffing
and resource levels of the particular facility or region, in order to define maintenance
priorities.
 Mission-based prioritization: This methodology is based on the question: Which
devices are most important to us in providing the majority of our patient care? For
example, if the hospital’s priorities were caring for people living with HIV and caring for
pregnant women and their children, the equipment used in this type of care would
become the priority. The second priority after this work is completed would then be those
devices with the highest risk.

CM performance measures

In addition to the measures already mentioned, there are certain measures that may be recorded
to specifically monitor CM performance. For example:

 Mean time between failures. The average time elapsed between failures.
 Repeated failures.
 The number of failures within a specified period of time

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Troubleshooting and repair Identification of a device failure occurs when a device user has
reported a problem with the device. As mentioned earlier, it may also occur when a technician in
the biomedical engineering department finds that a device is not performing as expected during
IPM.

This corrective maintenance may be accomplished at various levels:

 Component level: Component-level troubleshooting and repair isolates the failure to a

single, replaceable component
 Board level: it is common to isolate failures to a particular circuit board and to replace
the entire circuit board rather than a given electronic component.
 Device or system level: In some cases even board-level troubleshooting and repair is too
difficult or time consuming. In such cases it can be more cost-effective to replace the
entire device or subsystem

Work order

Three copies of the Work Order Form should be prepared (using carbon copy paper):

 The first copy should be kept by the user department and filed in a ‘Maintenance Pending
File’. This file is best organized by date submitted, with the most recent request at the
top. The ‘Maintenance Pending File’ should be checked regularly by the Head of
Department/Case Team to ensure that Work Orders are being carried out in a timely
manner. When the work is completed and the item is returned to service the Work Order
Form should be signed by the user (Department/Case Team Head or representative) and
the Work Order Form should be transferred to a ‘Maintenance Completed File’.
 The second two copies of the Work Order Form should be submitted to the HTMU
together with the broken item (if it is feasible to move the item). Whenever a Work Order
is received by HTMU it should be reviewed by the Department Head and the duty should
be assigned to the appropriate individual (or outside service provider). The name of the
person who is assigned to undertake the repair should be written on both copies of the
Work Order Form. In the event that several items required repair at the same time then
‘High priority’ equipment should be repaired before ‘Medium ‘or ‘Low Priority’
equipment.

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  Within the HTMU one copy of the Work Order should be entered into a ‘Work Order
Pending’ File held by the Head of Equipment Maintenance. This file is best organized by
date submitted, with the most recent request at the top. When the work is completed the
Work Order should be transferred to a ‘Work Order Completed’ File and kept as a
permanent record of the work under taken.
The final copy of the Work Order Form should be given to the responsible medical
equipment technician who is assigned to undertake the repair. Upon completion of the
task the final section of the Work Order Form and a Corrective Maintenance Log should
be completed. The item should be returned to the user. The completed Work Order Form
and Corrective Maintenance Log should be filed together in the Equipment History File.

Out-sourcing for technical service

When making the decision to outsource a service, the hospital must consider the task at hand and
the qualifications needed to perform the task. In order to do this, the Medical Device Advisory
Committee should register all potential individuals and companies that they would consider as a
supplier of maintenance services. The HTMU should prepare a list of requirements that each
company should meet in order to be contracted by the hospital and a team of suitable staff
chosen to visit these registered suppliers when possible to ensure that the suppliers meets the
requirements and are qualified to provide the services they offer.

Once the appropriate companies or individuals have been identified and registered, the MEMU
should determine the type of arrangement they would like to have with the par titular
organization. The arrangement used depends on the sophistication of the equipment and the
number of maintenance options available.

The most common arrangements encountered are:

1. Agents’ Maintenance Contracts – typically for sophisticated equipment that is covered by

a warranty for a certain period of time. The contract would be for service post-warranty
and negotiated at the time of equipment purchase.

2. Annual Contracts – for particular types or groups of equipment that can be maintained by
an external company for a period of one year. A formal tendering process should take
place to select the best company to provide these service.

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 3. Annual Standby Registration – these companies or individuals can be called upon as
needed to provide maintenance services for certain equipment although they must submit
tenders at the time a job becomes available

4. One-off Jobs – in this case, the expertise needed may not be on the registered list and the
HTMU must look for individuals or companies that might be able to undertake this one-
time only task.

Having such arrangements allows the hospital to gain from the benefits of bulk purchasing (e.g.
one company can cover many different maintenance jobs), gain from the benefit of fixed period
contracts; ensure that appropriate contractors are chosen and that the quality of work is high.
Therefore, when a repair requiring external support t becomes necessary, the Head of the
biomedical engineering department can refer to the registered list of companies and/or contracts
to outsource the work.

The HTMU should follow national guidelines for the use of outside contractors including:

 Staff from the biomedical engineering directorate/department/unit/case team must

accompany outside consultants at all time
 Contractor must provide feedback on progress of job
 Contractor must sign-out after each service visit
 Contractor will provide a report t at the completion of the service to be placed in the
equipment file

Hospitals may also collaborate together to enter joint service contracts in order to minimize
costs and benefit from bulk purchasing.

Reporting

For IPM and CM activities, the technician typically has a detailed checklist to follow in order to
record the results. Having such a checklist also serves as a reminder of each step in the IPM
process and thus helps avoid skipping or overlooking specific steps. Recording measurements
and documenting the final results (either as ‘pass/fail’ or numeric values) aids in the execution of
future maintenance work, including repairs

39 | P a g e
 Safety

There are various safety aspects to consider when implementing a successful and effective
maintenance program, such as the safety of technical personnel while performing maintenance,
safety of the user following maintenance, and general infection control.

3.11. Capacity building for users and Bio-medicals

Proper utilization of medical device is essential to maintain optimal performance, sustainable

functionality, and quality of care and preserve the safety of patients as well as the staff operating
the devices. Building the capacity of biomedical engineers, technologists, and technicians is
always one of the major activities of the HTMU. This can be realized through regular short -term
training programs, Supplier Company’s training, and formal credit programs in higher education
institutions, local and abroad. All such training programs are accompanied by certifications. The
hospital plans annually at least one-week long in-house refresher training program for its staff.
Participation in such refresher programs is mandatory and is part of the annual performance
evaluation.
Given the differences in the technical characteristics of medical equipment, hospital biomedical
engineers and technicians, or suppliers during new equipment installation and commissioning,
should provide training for all clinical staff working on the devices how to operate and handle
each medical device that they use. The hospital should prepare long and short-term training plan
to capacitate and equip the man-power of biomedical engineers/technicians on all Medical
devices to operate, perform preventive maintenance, corrective maintenance and calibration. The
HTMU is responsible for coordinating and overseeing all user and biomedical
engineers/technicians pre and post training for medical devices, whether in-service or conducted
by suppliers/external parties.
Training should be conducted at various times throughout a staff member’s career:
 Induction training – when staff are newly placed in post, move to a new department or
facility, or to a new location with different responsibilities
 Training at the commissioning of Medical devices – when new MDs first arrives and
installed
 Refresher training – to update and renew skills throughout the working life of staff

40 | P a g e
 User training should cover Guideline, policy, SOP and other related documents
Equipment capabilities and technology
 Purpose and capabilities of device
 Awareness of different models and operational differences
 Awareness of the expected life of medical device and need for replacement
 Knowledge of where/how to access user manuals and receive equipment updates
Operating procedures
 How to connect the device with its accessories
 How to operate the device effectively and safely
 How to link device to patient safely, causing minimal discomfort to patient
 How to set/change controls
Protocol for equipment failure
 How to recognize malfunction (or correct if possible)
 Who to contact to report damage and adverse incidents and to do so promptly
Proper handling and safety procedures
 How to proper handling of the devices
 How to safely shut down/disassemble
 How to clean/decontaminate device and maintain equipment in good operating condition
 Basic safety protocol:
 Always visually inspect equipment before each use.
- Check for signs of damage or incorrect settings
- Make sure all necessary p a r t s are in place
Preventive maintenance procedures
 How to perform basic preventive and routine maintenance (if applicable)
 How to request maintenance work order
 How to keep track of accessories, consumables and reorder when necessary

Biomedical engineer and technicians training should cover:-

 Medical device supply chain management

41 | P a g e
  Health care technology management
 Company, facility, regional and federal level
 Healthcare technology assessment
 Biomedical equipment maintenance workshop tool, calibration devices, and analyzers.
 Trainer (professionally trained expert in use, maintenance, and repair of medical
equipment)
 Training materials specific to the piece of medical equipment
 Adequate space to conduct the training
 Sample equipment and supplies to practice/conduct the training
 Test and calibration instruments to test performance and safety
 Spare parts for maintenance training
 User and service manuals
 Formal method of testing and method of certifying trainees (e.g. give exam and issue
certificate)
 Cold chain equipment
 Medical Oxygen plant and device management
Steps to Develop an Equipment Training Plan
Assess training needs:

The first step in developing a medical devices training program is to identify and assess needs
and gaps. User and biomedical engineering and technicians training needs may be in the areas of
– management, planning, procurement, logistics, basic handling, operation, application, care and
cleaning, safety, user PPM, PPM and repair for maintainers, associated skills. These gaps should
be identified, prioritized, and turned into training objectives for the organization.

Set organizational training objectives:

The ultimate goal is to bridge the knowledge, skill, and attitude gap that has to improve supply
chain management, medical device functionality, utilization, preventive and corrective
maintenance, calibration, safety, and handling at the facility level in order to provide safe,
quality, and effective services.

Create training action plan:

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The next step is to create a comprehensive action plan that includes development of training
manuals, materials and other training elements needed for medical devices training. Resources
and training delivery methods should be detailed in the context of medical devices. While
developing the program, the level of training and participants’ learning styles need to consider
user and biomedical engineers/technician. The hospital should implement a pilot training and
gather feedback to make adjustments well before launching the training to the hospital.

Implement training initiatives:

The implementation phase is where the training program comes to life. The hospital management
needs to decide whether training will be delivered in-house or externally coordinated. The
training implementation should include schedule of training activities and any related resources.
The training is then officially launched, promoted and conducted. During training, participant
progress should be monitored and evaluated to ensure that the program is effective.

Post training monitoring

The hospital should monitor the training continually and evaluate to determine if it was
successful and met training objectives.

The Human Resource Department and HTMU are responsible for keeping records of all user
trainings. Training records should specify the name of the person trained, the trainer, the date of
the training, the medical device for which training was conducted, its manufacturer and model. If
possible, the content of the training should be appended or briefly described in the user training
form. A sample User Training Verification Form is presented in annex E.

Medical Equipment Incident Reporting

Definition of Incident
An incident is an event that causes, or has the potential to cause, unexpected or unwanted effects
involving the health and safety of patients, users or other people.
Incidents in medical devices may arise due to:
 Shortcomings in the design or manufacture of the device itself
 Inadequate instructions for use
 Inadequate servicing and maintenance

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  locally initiated modifications or adjustments
 inappropriate user practice
 Inappropriate management procedures
 inappropriate environment in which a device is used or stored
 selection of the incorrect device for the purpose

The aim of incident reporting is to improve the protection of health and safety of patients, users
and others by reducing the likelihood of the same type of incident being repeated in different
places at different times.
The hospital should establish a process to report and investigate all critical incidents, including
incidents that arise from the use of medical equipment. An Incident Officer should be assigned to
investigate all incidents and to ensure that any required follow up action is implemented. Further
guidance on Incident Reporting and a sample Incident Report Form are presented in Clinical
Governance and Quality Improvement Chapter.
3.12. Decommissioning and disposal of medical equipment

Decommissioning is the process of removing a medical device from service in a health care
facility following a decision to disinvest. Disposal is process of remove medical devices from the
health facility through donation, transfer, sale, destruction, and incineration which undertaken
with local and international standards at minimum risk and financial cost.
Health facilities are obligated to use medical device safely, rationally and efficiently to improve
the healthcare delivery. The hospital should establish Medical Equipment Disposal Committee to
oversee the disposal of all medical equipment that are no longer required medical equipment in
the health facility. Items may be decommissioned and disposed when they are no longer required
by the hospital, cannot be repaired, or have reached the end of their useful lifespan or surplus. A
Functional policy for the decommissioning and disposal of medical devices should be developed
as per national and international standards and regulations by the hospital HTMC and approved
by hospital management.
When medical equipment is decided to decommission and disposal the hospital Biomedical
engineering team perform a technical assessment and verify it for decommissioning and the
hospital HTMC approved the decommissioning and disposal. The equipment should be removed
from service in a safe manner and stored in a secure warehouse until it is disposed of. And
44 | P a g e
remove all data, especially confidential or identifiable data, from the equipment. Following the
committee's decision to dispose, the item should be removed from the hospital inventory and
record should be entered into the Equipment History File to indicate that the item has been
disposed. The medical device History File should then be moved to a separate storage location
for ‘inactive’ equipment items. Further guidance on the disposal of medical devices refer
Ethiopian Food and Drug Authority (EFDA) Guideline for Decommissioning and Disposal of
Medical Devices.

45 | P a g e
46 | P a g e
Source Documents
1. Abington Memorial Hospital Department of Biomedical Engineering, Medical Equipment
Management Program.Abington Memorial Hospital Policy and Procedure for Biomedical
Equipment Class/Risk Classification.
2. Association for the Advancement of Medical Instrumentation. AAMI Equipment
Management Committee. (1999). ANSI/AAMI EQ56: 1999. Recommended practice for a
medical equipment management program. Arlington, VA.
3. The Australian Council on Healthcare Standards.EQuIP Standards, 3rd Edition. Safe Practice
and Environment, pp. 4.
4. Baldinger, P. and Ratterman, W.(2008). Powering Health. Options for Improving Energy
Services at Health Facilities in Ethiopia. Washington DC: United States Agency for International
Aid.
5. Bekele, H. (2008, August). Assessment on Medical Equipment Conditions. Ethiopian Science
and Technology Agency. National Scientific Equipment Centre
6. Egyptian Ministry of Health and Partners for Health Reformplus. (2004, December). Egyptian
Hospital Accreditation Program: Standards. 6. Environmental Safety, pp. 31.
7. Hospital Standards for Accreditation for Afghanistan. Section 5: Administration and
Management. Maintenance of Hospital Facilities and Equipment.
8. Joint Commission International. Joint Commission International Accreditation Standards for
Hospitals, 2nd Edition. Facility Management and Safety. pp. 135, 140-1.
9. Mavalankar, D., Raman, P., Dwivedi, H., Jain, M.L. (2004). Managing Equipment for
Emergency Obstetric Care in Rural Hospitals. International Journal of Gynecology and
Obstetrics. (87): 88-97.
10. Temple-Bird, C., KaurManjit, LenelAndreas,andWilliKawohl. (2005). Guide 1: How to
Organize a System of Healthcare Technology Management. In ‘How to Manage’ Series for
Healthcare Technology. Hertfordshire, UK: TALC.
11. Temple-Bird, C., KaurManjit, LenelAndreas,andWilliKawohl. (2005). Guide 2: How to Plan
and Budget for your Healthcare Technology. In ‘How to Manage’ Series for Healthcare
Technology. Hertfordshire, UK: TALC.
12. Temple-Bird, C., KaurManjit, Lenel Andreas, TrondFagerli, and WilliKawohl. (2005). Guide
3: How to Procure and Commission Your Healthcare Technology. In‘How to Manage’ Series for
Healthcare Technology. Hertfordshire, UK: TALC.
13. Temple-Bird, C., KaurManjit, Lenel Andreas, and WilliKawohl. (2005). Guide 4: How to
operate your healthcare technology effectively and safely. Management Procedures for Health
Facilities and District Authorities. In‘How to Manage’ Series for Healthcare Technology.
Hertfordshire, UK: TALC.

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Annexes
Annex A: Inventory form
Inventory #: __________________________________________________________________
Type of Equipment: ____________________________________________________________
Manufacturer: _________________________________________________________________

Model: ____________________________ Serial no. _______________________________

Country of Origin: ____________________ Year of Manufacture: _______________________

Power Requirement: 220V 110V
Current State/Condition:

Operable and in service

Operable and out of service

Reason out of service;
Needs maintenance
Not repairable
Needs to be discarded? Yes No
Spare parts available? Yes No
If yes, what, how many, and where are they located?__________________________________

Manuals Available:

User manual # of copies _______ Location ________________________

Service manual # of copies _______ Location _____________________
Equipment Users:
Doctors Nurses Lab Technicians Students
Equipment owner (department), if any: ___________________________________________
Contact Person and Telephone numbers: __________________________________________
Current location of equipment: __________________________________________________
Will it move from here? No Yes If so, where? _____________________

Annex B Performance test checklist

Description Set Measured Pass Fail N/A

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 UOM values values Limit/Tolerance
( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )

( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )
( ) ( ) ( )

UOM = UNIT OF MEASUREMENT

Remarks/ Status: ( Performance report)

Test Equipment Used

Test Device : Test Device:
Model : M odel:
Serial No: Serial No:

Annex C PPM check list

Pass
Planned Preventive Maintenance (PPM) Checklist Fail Not Available
Physically
Inspection
Examine for cleanliness and general physical
1. Chassis/Housing condition.
Examine for mount/fastener general physical
2. Mount/Fastener condition.
Examine for caster/breaks general physical
3. Caster/Brakes condition.
4. AC plug Examine AC plug physical condition

5. Line Cord Examine for line cord physical condition.

Examine the strain relief at both ends of the line
6. Strain relief cords.
7. Fuse Check correct value fuse rating is use.
8. Cables Inspect the patient cable and leads and strain relief.
Examine for connectors physical condition and
9. Fitting/Connectors smooth Movement between male female contacts.

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10.Pump Check for pump physical condition.
11. Examine for controls and switches physical condition
Control/Switches. and free movement
12. Indicator/Display Examine for indicator/Display operational
Check audible alarm for indicator/Display
13. Alarm operational

14. Label Check label legibility.

Internal Inspection
15. Cleanliness Clean interior and exterior of the equipment.
16. Lubricate Lubricate paper drive and recorder mechanism.
Check internal battery.(Replace according
17. Battery manufacture requirement )
Performance
18. Lubricate Lubricate paper drive and recorder mechanism.
19. Battery Check main external battery.(Replace if required)
Safety Test &
Performance
Electrical Safety Perform EST as stated and required in IEC
20. Test 60601.01(refer to EST report).
Test according to Hospital Engineering Planned
21 Performance Preventive
Planned Preventive Maintenance (PPM) Results:
No safety relevant defects Defect which require repair and removed from service.
Defects corrected immediately Significant defects, this unit beyond feasible repair.
Remarks/ Status: (Physical Inspection) Notes:

Evidence Attachment: (Physical Defect) If needed for exception of incident.

Evidence Pic 1 Evidence Pic 3

Evidence Pic 2 Evidence Pic 4

Notes:

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Annex D Biomedical Equipment Maintenance workshop layout For General and
Referral Hospital

Annex E Sample User Training Verification Form

Name: _____________________ Position: ___________________________
Department __________________ date employment commenced ____________
Manufacturer/

Date of training
Medical Device

Assessment/
Review date

Comments
Trained By
Supplier

Model

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Annex F - Work Order Form
Note: this is a triplicate form
· 1st sheet is the User File copy

· 2nd sheet is the Maintenance Progress File copy

· 3rd sheet is the Equipment History File copy

SECTION A: To be completed by user

Equipment Type: Inventory Number:

Item Location:

Name of person making request: Date:

Description of Problem:

Troubleshooting performed (if relevant):

SECTION B: To be completed by Head of Equipment Maintenance

Date request received: Work order number:

Priority of task (high/medium or low): Task allocated to:

SECTION C: To be completed by Maintenance Technician

Was item repaired?

Yes No

If Yes, complete Maintenance Report Form. If No, state reason work not Return Item to User.
completed and return Work Order Form to Head of
Equipment returned Equipment Maintenance for to follow up and
completion of Work Order (by assigning an-
Date returned other technician or outsourc- ing):
Name of Maintenance Technician Signature:

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After corrective maintenance is completed the Work Order Form and Corrective Maintenance Log Form
should be filed together in the Equipment History File.

Annex G Corrective Maintenance form

Work order number:
Equipment type Inventory Number

Model Serial No.

Description of equipment failure

Cause of equipment failure (if known)

Part of machine / equipment to be maintained

Corrective action
Time required
Spare parts replaced
1. 2. 3.

4. 5. 6.

Engineer 1 Signature 1 Date

Engineer 2 Signature 2 Date
User comments

Date Signature Date

Annex H Good Practice Checklist for Corrective Maintenance

Step 1 Resist the temptation to dive straight in. Do not immediately open up the machine and
plunge in with a screwdriver.
Step 2 Listen to the equipment users. Talk to the user – they can help you to discover the
symptoms of the fault. Ask the users lots of questions – they often don’t realize how much

53 | P a g e
they know.
Step 3 Look up the equipment’s service history. Each individual piece of equipment should
have a record of its service history. Use this to make yourself aware of the particular
machine’s past fault.
Step 4 Check the main incoming supply. Ensure that the electricity/gas/water supply is
reaching the wall outlet/socket – if it isn’t, check the relevant main circuit breakers/valves/taps
controlling the service supply.
Step 5 Inspect the main incoming connection. Check the plug, connector, and mains/ incoming
lead to see if electricity (or other supply) is reaching the machine.
Step 6 Inspect the machine’s external supply connection point. Check the main external
fuses/taps/regulators for the machine.
Step 7 Refer to the operator’s manual. Familiarize yourself with the instructions on how the
equipment is meant to work.
Step 8 Check the accessories. Ensure that the correct accessories are attached to the correct
inlets
Step 9 Watch the machine in operation. Ask the users to describe what steps they usually take
to put the machine through a normal operational cycle. Watch them do this, and observe what
happens
Step 10 Refer to local sources of advice. Consult the service manual, training resources, PPM
schedules and any other technical personnel. Take note of any possibility of remote
diagnostics where, for complex equipment such as CT scanners, the manufacturer’s computer
may be able to log into the equipment and diagnose the fault.
Step 11 Only at this point, consider opening the machine. Decide whether it is best to take the
machine back to the workshop before opening it.
Step 12 Inspect the machine’s internal supply connection points. Check the main internal
fuses/taps/valves for the machine, and then check the on/off switch.
Step 13 Go through the troubleshooting or fault-finding steps provided in the service manual.
BEWARE: It is very common for maintainers to guess the problem and act on it without
verification. This leads to frustration when the diagnosis turns out to be incorrect. Thus,
always take steps in the following order:

54 | P a g e
1. Determine the problem to a high degree of certainty by testing
- Alter and adjust the equipment as little as possible during this stage
- Never guess a problem or make an alteration that cannot be reversed
- Always record adjustments as the work progresses (for example, on a notepad)
2. Correct the problem
Step 14 Contact more experienced colleagues. Ask the in-house team of another health service
provider (for example at a neighboring public or private hospital), or ask the national service
provider (National Scientific Equipment Center).
Step 15 Ask the manufacturer or their representative for help. Contact them for discussions
and fault-finding by phone, fax or email. Email is the cheapest and often the most effective
way to get in contact with the manufacturer. Try to get some hints, but be sure to clarify
whether you are being charged for this advice.
Step 16 Call in support from the private sector when the work is beyond your capabilities. Call
in the private maintenance contractor, if there is one, for faults that cannot be handled by the
in-house team. Ensure that the hospital management or Medical Equipment Service has the
funds to cover this.
Step 17 If the work is within your capabilities, only at this point consider taking corrective
action. When a fault is found that the in-house team has the skills and authority to pursue,
follow the corrective action or parts replacement steps provided in the service manual.
Step 18 Use the correct materials. Select only the correct maintenance materials and spare
parts relevant to the machine.
Work carefully. Handle the spare parts and maintenance materials carefully so as not to
damage them or the machine
Step 20 Make a record of your work. Fill in the Work Order form to record the problem
reported, fault found, corrective action taken, parts used, time taken, etc.
Step 21 Ensure the equipment is safe to use. Always safety test the equipment with the correct
test equipment before returning it to the users.
Step 22 Repeat step 9. Ensure that the operators can make the equipment function properly
during a normal operational cycle.
Step 23 Reduce the likelihood of problems in the future. Ensure in the future that planned
preventive maintenance (PPM) is carried out on the equipment.

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Annex I PPM Log Sheet
Equipment: Inventory #: Location: Month:

Task 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Daily Tasks
Daily Task 1
Daily Task 2
Daily Task 3
Daily Task 4
Daily Task 5
Weekly Tasks
Weekly Task 1
Weekly Task 2
Monthly Tasks
Monthly Task 1
Monthly Task 2
Quarterly Tasks
Quarterly Task 1
Quarterly Technical PM
Semi-Annual Tasks
Semi-Annual Technical
PM
Annual Tasks
Annual Technical PM

Annex J Sample Bin Card for Spare Parts

Item Description: ___________________ Item Code Number:_________________________
Received from or Issued to
Doc. No. (Receiving or

Quantity
Expiry Date
Issuing)

Batch No.

Remarks
Date

Received

Loss/Adj

Balance
Issued

56 | P a g e
Annex K Site preparation steps for installation of medical equipment
Step Activity
· Study the manufacturer’s site preparation instruction
Review technicalneeds
· Use experience and common sense

· Cut supply connections and remove the existingitem

Remove existing
equipment · Cannibalize the existing item for parts

· Build any special construction required, such as a transformer housing, lead

screening, room extension

Construct or alter building · Make any special modifications necessary, such as enlarging the doorway, or
building a worktop

· Remove any scrap or other items from the room

Undertake the work required to provide (as necessary):

· A new transformer
· A new or upgraded generator

Provide electrical · A single phase or three-phase supply at the site ofinstallation

requirements
· A special circuit breaker
· A special socket outlet
· An electrical circuit with sufficient capacity

Undertake:
Ensure the electricity
· An exercise to ensure that all relevant electricalinstallations are properly
installationis safe
grounded and tested

· Any remedial works as required

Undertake the work required to provide (as necessary):

· Adequate water pressure

· Water treatment
Provide water and
drainage · Increased pipeline diameter
requirements
· Proper drainage
· Appropriate connection points

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 Undertake the work required to provide (as necessary):

· A steam supply at the proposed site

· Increased pipeline diameter
Provide steam sup-
ply requirements · A boiler which can accommodation the increased load

· Appropriate connection points

Undertake the work required to provide (as necessary):
Provide gas supply · Relevant gas supplies at the proposed site
requirements
· Appropriate connection points

Depending on specific guidelines for certain types of equip- ment (as detailed
by the equipment supplier), provide:
Provide extra specific · Bolts in the ceiling for attaching operating lights in the- atres
requirements for
· Trenches for supply lines to dental suites
installing the
equipment · Trenches for waste water for washing machines, etc.
Provide any associated items as necessary for the equip- ment or installation,
Provide any such as:
additional equipment · An uninterruptible power supply (UPS)
needs
· A water pump

Annex L Sample Acceptance Test Log Sheet

Only when this form has been satisfactorily completed should the Registration Box be filled in
by the Head of Medical Equipment Maintenance.

ALLOCATED INVENTORY NUMBER _____________________________________________________________

EQUIPMENT TYPE ________________________________________________________________________________________
DESTINATION LOCATION_______________________________________________________________________________
ACCEPTANCE DATE _____________________________________________________________________________________
MAINTENANCE CONTRACT WITH _____________________________________________________________

HEALTH FACILITY ___________________________________________________________________________________________

NAME OF EQUIPMENT _______________________________________________________________________________________

TYPE/MODEL ________________________________________________________________________________________________

ORDER NUMBER _________________________________ SERIAL NUMBER ____________________________

COST__________________________________ DATE RECEIVED _______________________________________

MANUFACTURER ________________________________ SUPPLIER/AGENT ________________________________________

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ADDRESS _______________________________________ ADDRESS _________________________________________________

PHONE . . . . . . . . . . . . . . . . . . . . . . . PHONE . . . . . . . . . . . . . . . . . . . . . .

DETAILS OF ALL ACCESSORIES, CONSUMABLES, SPARE PARTS AND MANUALS

RECEIVED ARE LISTED ON THE FOLLOWING PAGE OF THIS FORM
ACCEPTANCE CHECKS
1. DELIVERY
Undertaken by______________________________________________________________
Witnessed by: Name ________________________ Position _________________________
Date _________________________
Corrected if
No/not
Yes/done applicable
done

a) Representative of supplier present?

b) Correct number of boxes received?
c) After unloading, visible damage to theboxes?

d) If damaged, has this been stated onthe delivery

Note and senior management informed?

2. UNPACKING (refer to invoices and shipping documents)

Undertaken by: _________________________________________________________________
Witnessed by: Name ______________________ Position ____________________________
.. Date ____________________________
Yes/done No/not Corrected if
done applicable
a) Visible damage to the equipment?
b) Equipment complete as ordered?
c) User/operator manual as ordered?
d) Service/technical manual as ordered?

e) Accessories as ordered?
f) Consumables as ordered?
g) Spare parts as ordered?

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3. ASSEMBLY (refer to manuals)
Yes/done No/not Corrected if
done applicable

a) Are all parts available?

b) Do they fit together?

c) Mains lead with plug included?

d) Do all the accessories fit?

e) Are markings and labels OK?

f) Any damage?

4. INSTALLATION (refer to manuals)

Yes/ No/not Correctedif
done done applicable

a) Was the work carried out satisfactorily?

b) Were technical staff present as learners?

5. COMMISSIONING/TESTING (refer to manuals)

Correctedif
Yes/ No/not
applicable
done done
a) Were electrical, mechanical, gas, radiation safety tests
and performance checks carried out inaccordance with
the test sheets on pages 7 to 9 of this
Form?

...... ...... ......

b) Was the work carried out satisfactorily? ...... ...... ......
c) Were technical staff present as learners? ...... ...... ......
d) Were operators present as learners? ...... ...... ......

6. ACCEPTANCE – to be certified by the Head of Equipment Maintenance only

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 Yes/done No/not Corrected if
done applicable
a) Is the equipment accepted?
b) If rejected, have the shortcoming- been
summarized

on page 10 of this form

c) If so, has a report gone to senior
management and formal complaints
procedures started?

d) Should payment be withheldpending

corrections?
e) Is payment approved?

7. TRAINING
Yes/ done No/not done Corrected if applicable

a) Were the expected training courses given?

b) Were the training courses satisfactory?

c) Were suitable operators present?

d) Were suitable technical staff present?

8. REGISTRATION – to be undertaken by the Head of Medical Equipment Maintenance

Yes/done No/not Corrected if
done applicable
a) If accepted, has an inventory number been allocated?

b) Has the Registration Box on Page1 of this form been

filled in?
c) Has the Stores Controller been provided with the
location for the equipment and all necessary data, so
that the Stores Receiving Procedure canbe followed
and a Goods Received Note completed?

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d) Have the accessories, consumables, spare parts,
and manuals all been issued to the correct holding
authorities?

ACCESSORIES RECEIVED
1. 2.
3. 4.
5. 6.
7. 8.

CONSUMABLES RECEIVED
1. 2.
3. 4.
5. 6.
7. 8.

SPARE PARTS RECEIVED

1. 2.
3. 4.
5. 6.
7. 8.

COMMISSIONING/TESTING PROCEDURES (see manuals)

ELECTRICAL INTEGRITY TESTS
Yes/done No/not Corrected if
done applicable

Mains Connection
a) Are cables and plugs intact?
b) Is cable color code correctly connected?
c) Are connectors intact?
d) Are the fuses correct?
e) Is equipment protection correct?
f) Is voltage setting correct?
g) Is there an earth terminal?

Electrical Measurements with Safety Tester

a) Is protective earth continuity correct?
b) Is insulation resistance correct?
c) Are the leakage currents correct?
d) Is the voltage measurement correct?

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GAS INTEGRITY TESTS
Yes/ No/not Corrected if
done done applicable
a) Are the cylinders full?
b) Are appropriate gauges available?
c) Is there a cylinder key?
d) Is the pressure reading correct?
e) Is the cylinder colour code correct?
f) Are the hoses and fittings correct?
g) Is the system leaking?

RADIATION INTEGRITY TESTS

Yes/ No/not Corrected if
done done applicable
a) Is the kV calibration correct?
b) Is the mAs calibrated correctly?
c) Was the line voltage compensation per-formed?

d) Was the exposure test correct?

e) Were the step wedge test results correct?

f) Were the small and large focus calibrations done?

PERFORMANCE TESTS
Yes/done No/not Corrected if
done applicable
Note: carry out all operational tests as specified by the manufacturer
a) Are the function verification tests correct?

b) Is the equipment calibration acceptable?

Annex M calibration and testing tools

Defibrillator analyzers Ultrasound meters

Electrosurgical analyzers Ventilator Taste
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Infusion pump analyzers Gas Flow Analyzers
NIBP analyzers Temperature / Humidity Calibration
 Annex N criteria for standard biomedical work shop

s.no Standard criteria for biomedical work shop Met Unmet

1 Presence of well-equipped staff office with mini
library (e - library ) at the workshop
2 Presence of mini- store(for spare part and
accessories) in the medical device workshop
3 Presence of maintenance, calibration & testing tools,
appropriate gases (e.g. Acetylene, oxygen) & other
tools
4 Availability of equipped maintenance training
workshop capable of mechanical & electrical
activities
5 Presence of appropriate and adequate space for
loading and unloading of medical devices
6 Rest room
7

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Infrastructure and Asset Management --xx
Chapter outline sections
1. Introduction

2. Operational standards

3. Implementation Guidance

3.1. Organizations

3.1.1. Organization of Hospital Infrastructure and Asset Management Services

3.1.2. Buildings
3.1.3. Landscape and Garden
3.2.Asset Management
3.2.1. Asset Procurement and Delivery
3.3.Utilities and Sewerage
3.3.1. Electricity
3.3.2. Water supply
3.3.3. Sewerage
3.3.4. Plumbing
3.3.5. Boiler/steam supply
3.3.6. Heating, ventilation, and air conditioning (HVAC)
3.3.7. Energy efficiency
3.3.8. Pet, pest, and rodent control
3.4. Vehicle Management
3.4.1. Vehicle Management and Transport Services
3.5.Hospital Security
3.5.1. The Security (Guard) department
3.5.2. Control of entry and exit to and from the hospital
3.5.3. Security plan
3.6.Hospital Safety
3.6.1. Hazardous materials
3.6.2. Fire safety
3.6.3. Other safety measures

2
 3.7.Major Incident Planning and Management
3.7.1. Major Incident Committee
3.7.2. Roles of the Major Incident Commander and Deputy Major Incident Commanders
3.7.3. Incident control room
3.7.4. Command and control arrangements in a major incident
3.7.5. The Major Incident Plan
3.7.6. Management of a Major Incident
3.7.7. Testing the Major Incident Plan
4. Annex
5. Reference

3
 Section 1:- Introduction

Facility and Asset Management is a systematic approach to the governance and realization of
all values for which a group or entity is responsible. It may apply both to tangible assets
(physical objects such as complex processes or manufacturing plants, infrastructure, buildings,
or equipment) and to intangible assets (such as intellectual property and goodwill) is a
systematic process of developing, operating, maintaining, upgrading, and disposing of assets
in the most cost-effective manner (including all costs, risks, and performance attributes).1

Adequate facility and asset management has several benefits, which include Improving patient
care and safety; Allowing staff to quickly and easily locate medical equipment in real-time and
increase staff efficiency; recording assets actual value; ensuring accurate asset usage and
performance data; safety disposes medical waste, and to create efficient use of physical space
and organized equipment storage.2 As well as overseeing cleaning, transportation, landscape
and gardening, hospital security service, and asset management.

1
Wikipedia, the free encyclopedia
2
Asset Management Software

4
Section 2:- Operational Standards

1. The hospital has a functional Basic Service and Asset Management Executive office to plan,
execute, coordinate, and monitor hospital infrastructure and Asset Management activities.

2. The hospital complies with relevant laws, regulations, Guidelines, SOPs

3. The hospital grounds are regularly inspected maintained, for their basic services and ensured
cleanliness for safety of patients, visitors & staff.

4. The hospital has included its infrastructure, asset procurement, and maintenance plan in its
long-term and annual plans
5. The hospital has a maintenance workshop with technical personnel, sufficient space, and
adequate ventilation.
6. The hospital has a transport policy for using and accessing hospital vehicles.
7. The hospital has a safety and security policy.
8. The hospital has a plan for responding to likely incidences in the hospital and other disasters.
9. The hospital stock management system is in place, and disposal is done in compliance with
the relevant laws and guidelines.
10. The hospital conducts an annual inventory.
11. The hospital has allocated a budget for procuring and maintaining medical and non-medical
devices, buildings, vehicles &utilities from retained revenue.

5
Section 3:-Implementation Guidance
3.1 organization

3.1.1. Organization of Hospital Infrastructure and Asset Management Services

Each hospital should have a fictional Basic Services and Asset Management Executive office
to lead and manage infrastructure and asset management activities. The executive office
should have assigned full-time workers to carry out activities based on their job description
effectively. The Basic Services and Asset Management Executive office is responsible for the
following:
 Cleaning and janitorial services
 Vehicle management and transport services
 Landscape and Gardening
 Hospital security services
 Laundry and Kitchen services
 Pets, pest, and rodent control
 Planning, procuring, and maintenance of Asset management.
The Executive office is also responsible for the management of:

 Buildings organization, construction, layout, maintenance/renovation

 Hospital infrastructure Master plan preparation and implementation

 Utilities (electrical, water, incinerator, placenta pit) and sewerage

 Safety (Fire, Hazardous materials, and other environmental safety)

 Major incident planning and response

In addition, each hospital must have an asset management policy and Asset Management strategy to
enhance the efficient use of its resources for the ultimate attainment of improved healthcare services.
For that purpose, any hospital should employ evidence-based planning and budgeting. Asset
management tasks start with identifying the asset need of the hospital. Therefore, each hospital
should conduct a comprehensive need assessment to identify and fulfill its asset needs step-by-step.
To that end, the hospital has to set clear objectives and priorities, as the asset need might not be met
at once due to resource constraints.
The hospital’s Asset Management strategy must be based on the hospital’s set objectives and
priorities. Furthermore, each hospital has to include the asset plan in its long-term and annual plans.

6
In doing so, the most urgent assets have to get precedence over those assets, which can be gradually
fulfilled. The Asset Management plan has to be detailed enough and should include the following:
 Asset set to be acquired
 Utilization
 Maintenance
 Dispose/replace
 The hospital's assets must be appropriately registered when received, utilized, and
disposed of in line with the public asset management rules and regulations.
Furthermore, the hospital’s asset procurement must align with the Government Asset Procurement Guidelines.
3
The assets must be appropriately registered when received, when issued, at the time of use, and finally, be
disposed of in line with the public asset management rules and regulations. The hospital can procure assets
from the treasury or its approved retained revenue budget. It is to be remembered that the procurement of
hospital assets is in the first category of the positive list to be covered with the retained revenue of the
hospitals. 4

3.1.2. Buildings
3.1.2.1.Buildings layout
The buildings are the most fundamental component of a hospital, and their layout and design
contributesignificantly to the smooth operation of patient services and other activities. The use
of buildings should be organized to:

 Minimize the travel distance between frequently used spaces,

 Streamline the movement of patients between care teams/units,

 Allow for patients to be easily visible to staff for supervision purposes,

 Include all the needed clinical and non-clinical areas, avoiding unnecessary
redundancies andmaking efficient use of space,
 Provide an efficient system for the handling of food, storage of supplies, and the
removal ofwaste, and
 Enhance the safety and security of patients, visitors, staff, and hospital assets.

3
Please refer to the Government Procurement Guideline.
4
Please refer to the Revised HCF Implementation Manual.

7
 3.1.2.2.The layout of patient services

The hospital should be organized so that patient services are easily accessible and located
nearby.

The Emergency Department should be easily accessed from the adjacent main road and have a
separate entrance labeled in a way visible from the street.

The Outpatient Department (OPD) should also be easily accessed from the main road and have
enough space and seating for the expected daily arrivals.

The hospital triages (central and emergency) should be clearly labeled and easily accessible.
Inpatient wards should be easily accessible from elevators, ramps, and stairways. Sufficient
seating space should be provided for visitors, caregivers, and guests.
Toilets and showers should be provided for patients. Ideally, these should be located adjacent
to each ward, but if this is not possible, they should be signposted, and a covered walkway
should be used to link the ward to the facilities.
Administrative offices, such as medical records and payment offices, should be in a location
that is easily accessible to patients and visitors and clearly labeled.

All public areas should be kept clear of large objects and clean. Hazards such as wet floors
should be clearly labeled to prevent injury.

Hospitals with more than one story should have elevators or ramps to transport wheelchair- or
bed-bound patients. If elevators are in use, they should provide access to all levels of the
hospital. Elevators should be large enough to accommodate patient beds. Floors should be
labeled at elevator exit points and stair landings for easy identification for guests. Stairs and
corridors should not be used as storage areas and must be kept clear to allow easy access to
patients, staff, and visitors.

Areas restricted only to staff should be clearly marked with "No entry" or "Restricted entry"
signs to prevent unwanted visitors from entering.

8
 3.1.2.3.The layout of staff services

Staff services should be organized to provide easy access and mobility. Toilets should be
available within proximity to all staff working areas. Where necessary, changing rooms with
lockable lockers should be provided to staff without their own office (such as operating theatre,
delivery suite, laundry, kitchen, maintenance staff, and security personnel). Showers should be
provided to workers exposed to dirt, hazardous materials, or body fluids during their duty shift.

Health workers should be provided with adequate space for meals. A canteen or café should be
available for staff to purchase food or beverages. Drinking water should be available at all times.

Staff working ‘on duty’ should have access to duty rooms with beds for resting when not actively
working. Duty rooms should be located near regular work areas and equipped with telephones or
other communication access in case the worker is needed.

Facilities should provide meals/refreshments during duty hours. Health workers, residents, and
visiting students should have access to a study area or library with various educational resources,
including internet access.

3.1.3. Hospital site map

A map of the hospital campus should be displayed at all entry points to the hospital to provide
straightforward, easy navigation for patients and visitors. All hospital buildings should be
clearly labeled, and signs should be used to guide patients or visitors to each service area.

3.1.4. Building maintenance

Buildings are generally the most significant investment in the facility and should be well-
maintained to prolong their lifespan and minimize the need for expensive repairs or
renovation. Inspections of all hospital buildings should be conducted regularly to ensure that
facilities are in good condition and should be performed by professional, certified staff (for
example, masons, painters, carpenters, etc.) with access to appropriate tools, equipment, and
machinery. Preventive maintenance and repairs should be undertaken whenever necessary. In
particular:

 Windows should be replaced when cracked or broken.

 Windows should be able to open to allow for ventilation.

9
  Windows should have a functioning lock to prevent theft or unwanted intruders.

 Doors should be able to open and close quickly.

 Doors should have a functioning lock so doors may be opened as needed.

 The roof should not have any source of leakage into the facility.

 The walls should be repaired as necessary.

 Rain drainage systems should be working correctly and efficiently. Water from
drainage systems should be diverted to a location that eliminates considerable flooding
in locations around the building, and
 Mold growth should be prevented or removed if discovered to prevent building
damage.
 Sagging and broken beds should be fixed.
 Broken patient or visitor chairs, tables, etc., should be repaired as soon as the
problem isreported.
 Regular walkthroughs should be conducted to assess the hospital facilities'conditon.These
should be done at least once a month.

The hospital should ensure that reasonable stocks of building maintenance materials are held at
all times and that these form part of recurrent budgets. Basic building maintenance materials
include cement, paint, metal, wood, glass, etc. A system should be in place that prompts for
re-order when stocks of building maintenance materials run low.
A construction plan for the buildings, including civil engineering drawings, should be
available and kept within the office of the section head and should be updated when
modifications are made.

3.1.4.1.Buildings maintenance workshop

The hospital should have a maintenance workshop with skilled personnel and equipment to
maintain hospital buildings and non-medical equipment. Some maintenance services may be
outsourced if necessary (for example, electrical engineering, etc.). The hospital should also
have skilledpersonnel and equipment to maintain and repair medical equipment (See Chapter
9, Medical Equipment Management). A hospital maintenance workshop should have the
following:

 Appropriate workforce,

10
  Adequate workspace,
 Essential tools,
 Adequate, safe, and secure storage space for tools, equipment, and
hazardous materials,
 Maintenance/repair manuals and literature,
 Protective clothing for maintenance staff (ex., Gloves, overalls/overcoat,
goggles, boots),
 Proper disposal guidelines and methods for maintenance waste, and
 Dedicated disinfection room or area for disinfecting equipment before
maintenance isperformed.
The layout of the workshop can vary according to the size of the maintenance team; the
design should allocate space for:

 Different work areas are designated for different maintenance work,

 Adequate work benches and stools to meet the needs of each work area,
 Storeroom with cabinets and shelves,
 Office space (for workshop manager’s desk and filing space),
 Changing room with toilet, lockers, wash basin, and shower,
 Shaded outdoor area for large maintenance/repair jobs and handling of
hazardous materials,
 Secure outdoor storage area for bottled gases and equipment to be
discarded,
 Vehicle access, and
 Technical library.
A library of reference materials is essential for ongoing staff education and should also be
included in the workshop's design. The library should include operation and service manuals,
general textbooks on engineering and related disciplines, journals, instruction booklets,
updated hazardreports, and other reference material. A sample layout of a workshop for a 300-
bed hospital is presented in Annex A.

11
 3.1.4.2.Workshop tools

The maintenance team should identify essential tools (either by maintenance needs or
technician roles) required to perform their work and procure them based on quality. Poor
tools may break if not strong enough, fail earlier than expected, rub, corrode, or damage other
machine parts. It is recommended that higher-quality tools and test instruments be purchased
for repairs on critical equipment. Lower-quality tools may be acceptable for less critical items,
but the cost of early replacement of such tools should be considered before purchase. Sample
lists of suggested maintenance tools and safety calibration testing instruments are presented in
Appendices B and C.
The maintenance team should have a tool inventory, either paper-based or computerized, that
lists all test and bench instruments and the contents of all tool kits. Tool usage should be
monitored by keeping a tool ledger in which each item is 'signed out' and 'signed in' when
used by a technician. Asample format for a tool’s ledger is presented in Appendix D.

3.1.4.3. Fault reporting and work order

Procedures should be in place, so staff, patients, or visitors can report any problems
identified with the hospital building or facilities so that repair can be undertaken promptly.
The Facility Maintenance Team should be informed of building maintenance needs (e.g., a
broken window or sink). The work request should be submitted in written form to enable
tracking of service requests. Telephone calls or other verbal means of reporting may be
acceptable in times of emergency; however, a service request/work order should be submitted
to provide a written record of the reported fault. A sample Facilities Maintenance Work
Order Form is presented in Appendix E. Follow-up should be conducted on all service
requests to ensure the work has beencompleted. Service requests/work orders should be filed.

3.1.4.4.Planning for new construction or renovation

The services provided by a hospital and the number of patients attending a hospital are rarely
static. To accommodate changes in services or patient load, it may be necessary to undertake
significant renovation of existing buildings, construct new buildings, and/or redesign the
layout and functionsof the hospital.
Adequate planning for new constructions must be carefully performed to ensure good results.

12
Planning is best carried out through a dedicated committee, with members from various
backgrounds, including staff well-versed in the new service. Technical staff with sufficient
knowledge of existing facilities must be included in the planning to interface with already-
existing systems, such as electricity, plumbing, sanitation, etc.

Adequate consideration should be given to the effects of the construction process on existing
services. Factors that may interrupt regular facility operation include noise, vibrations, water
or electricity needs or interruptions, access to large equipment or machinery, storage of
construction materials, facilities for construction staff, excess dust, etc. Construction activities
should be planned tominimize the effect on daily facility operations.

To ensure that any construction or renovation is fit for purpose, it is essential to involve
multiple personnel in the planning process and to follow critical steps as described in Table 1
below.

Table 1:- Steps to be taken for planning construction or renovation

Step Description
One Establish the need for renovation or construction:
 What services will be provided?
 What is the demand and/or population health need for those services?
 Can these services be provided using existing buildings, or is a renovation
or new construction required?
At this stage, stakeholders such as woreda, zonal, regional, or federal health
offices, hospital staff,and the community should be involved.
Two Preparation of a Design Brief.
 The Design Brief is a basic framework for the design of the building or
facility and should provide sufficient detail for construction engineers to
prepare construction plans.

At this stage, stakeholders such as woreda, zonal, regional, or federal health

offices, hospital staff,and the community should be involved.

A “Sample Format and Checklist for a Typical Design Brief” is presented in

Appendix F.

13
 Three Tender announcement and consideration of bids received
 The Design Brief should be put to a competitive tender
 Bids received should be considered by the planning committee
 Explicit criteria should be used to assess or score each bid received.
Criteria could include:
o Cost of construction
o Time to completion
o The closeness of Plan to Design Brief
Four Construction of the building or facility.
Construction activities should be planned to minimize the effect on daily facility
operations.
Five Purchase of all furniture, equipment, and supplies needed for the building or
facility and Appointment and training of all staff

3.1.3. Landscape and Garden

Patient and community perceptions of a hospital and staff satisfaction with their workplace can
be enhanced by clean and pleasant hospital grounds. Buildings should be linked by covered
and paved walkways. Recreation areas should be established, including areas for sitting and
for walking. Grass, trees, and flowers should be planted wherever possible and unique
features such as fountains may be installed as a focal point. Hospital grounds may also be
used to grow crops, vegetables, or fruit in the hospital kitchen.
Hospital grounds should be free from litter, including old equipment or construction materials,
and regularly inspected to ensure a safe and comfortable environment for patients, visitors, and
staff.
Grounds keeping staff should have access to all necessary tools, equipment, and machinery
necessaryto maintain and enhance the hospital ground. These materials should be budgeted to
ensure a consistent supply of materials.

14
 3.2. Asset Management
The hospital should establish a robust Asset Management (AM) system to ensure the
availability, efficient use, and replacement of asset sets.
3.2.1. Asset Procurement and Delivery
 Procuring any asset must comply with the country's public procurement law.
 Once procured, the hospital must ensure that the asset set is delivered to the hospital with
(Model 19)
 The hospital should also deliver any donated asset with Model 19.
 The hospital should establish a database for fixed assets that details the history of the asset
sets, such as the name of the fixed asset set, its manufacturing time, lifespan, and actual or
estimated cost asset.
 The wear and tear of significant hospital assets must be appropriately registered and annually
updated.
 The hospital also needs to ensure assets are stored in the right place and under optimal
temperatures depending on the nature of asset assets.
 The hospital also must ensure that significant assets have been issued to pertinent
departments with Model 22
 The hospital must also compile with the rules and protocols of the government to dispose of
any significant hospital asset.

3.3. Utilities and Sewerage

3.3.1. Electricity

A reliable source of electricity is essential for every hospital. As regular supplies may be
erratic, every healthcare facility must have a backup system, such as a diesel generator.
Suppose a generator is the preferred backup system. In that case, a dedicated individual must
ensure the proper functioning of the generator, including a sufficient supply of diesel, charged
batteries (for start-up), and regular maintenance. Alternatively, solar panels might be a more
cost-effective backup option. Regular inspections of the backup electricity system should be
conducted, with particular attention given to potential causes of malfunction. Hospitals should
have access to a professionally qualified technician with appropriate training, tools, and
equipment to perform maintenance and repair electrical backup installations. Up-to-date plans
and manuals should be kept by each facility to ensure easy access when troubleshooting or
maintaining the equipment.

15
The hospital should ensure that a reasonable stock of spare parts for the backup electrical
system(s) is always held and that these form part of recurrent budgets. A system should be in
place that prompts for re-order when spareparts or diesel stocks run low.

The backup supply can be used to provide power to the entire hospital or may be used to
provide electricity to selected critical areas or critical equipment. Suppose the backup supply
does not provide electricity for the whole facility. In that case, an assessment should be made
to identify those essential areas that must be provided with uninterrupted supply, for example,
the operating room, emergency room, labor and delivery room, patient wards, laboratories,
refrigerators for drugs, reagents, and blood products, etc. The backup system must be able to
maintain all the critical functions identified. Ideally, the backup supply should start
automatically during mains interruption. If this is not possible, a trained individual must be
available on-site to start the generator or alternative power source immediately when a power
failure occurs.

Standard electricity in Ethiopia runs at 220V and 50-60 Hz. However, medical and hospital
equipment originating abroad may require a different operating voltage. For example,
equipment originating from the United States operates on 110V. The donor should be asked to
modify the equipment to operate on a 220V supply if possible. If this is not possible, a step-
down transformer is necessary. Staff must be educated on when to use such step-down
transformers, as plugging the machine into the 220V supply will damage the equipment. Other
large equipment, such as X-ray machines, may require a 3-phase electricity supply, generally
at 380V. Facilities need to prepare accordingly if such electricity is needed. Medical
equipment may be affected by fluctuations in supplied voltage or power loss. Even in facilities
with backup generators, there may be a brief period (20-30 seconds) of electricity loss while
the generator powers up. Any equipment damaged by power fluctuations or interruptions must
have a backup Uninterruptible Power Supply (UPS) that lasts at least 30 minutes, providing
sufficient time for the generator to start up or for the equipment to be switched off safely. The
UPS will also protect the item from a power surge when the main power returns.

Electrical hazards may pose serious fire and shock hazards to patients, staff, and visitors.
Electrical safety should be ensured at all times. Regular inspections should be conducted, and
electrical fire hazards, such as frayed cords and compromised electrical sockets, should be
identified and corrected immediately. Electrical power strips (dividers) should be used
cautiously and inspected regularly.

16
Hospitals should have access to a professionally qualified electrician with appropriate training,
tools, and equipment to perform maintenance and repair of electrical installations. To guarantee
safety, they must:

 Test for grounding,

 Test for circuit connectivity,

 Test for loose connections,

 Perform insulation tests,

 Test switch leaks,

 Test for power,

 Check for the correct rating, and

 Check whether wiring regulations were followed during installation.

Each facility should keep up-to-date plans of electrical installations to ensure easy access when
troubleshooting or maintaining the electrical system.

The hospital must ensure that reasonable stocks of electrical maintenance materials are always
held and that these form part of recurrent budgets. Basic electrical maintenance materials
include wires, sockets, switches, fluorescent light components, fuses, circuit breakers, etc. A
system should be in place that prompts for re-order when stocks of electrical maintenance
materials run low.

3.3.2. Water supply

All hospitals should have access to a safe and reliable water supply. Water in hospitals must be:

 Free of disease-causing organisms and any other hazardous substances,

 Transparent, colorless, odorless, and tasteless,
 Not too highly concentrated with calcium, magnesium, manganese, iron, or carbonates,
 Without any corrosive substances, and
 At a relatively low temperature.

Regular (at least every 6 months) microbiological checks should be conducted on the water
supply. Checks should be conducted on water outlets (faucets) and storage tanks.

17
A backup water supply such as water tanks, a reservoir, or a dedicated well should be available
if the main supply is interrupted. Water tanks should hold sufficient water to supply the
hospital for at least one or three days. Backup supplies should be cleaned regularly and water
checked to ensure the quality and safety of the water being brought to the facility. A mesh
filter can prevent large debris from entering the water supply. Filters must be cleaned
regularly, as they get clogged with dirt or mud.
If, for any reason, the water supply is lost, every effort must be made to ensure that water is
supplied to all essential areas. The cause of the water interruption should be investigated, and
the potential length of the interruption should be estimated. The hospital should prepare a
contingency plan that identifies the areas to which water must be provided in order of priority.
If the interruption is likely prolonged and the backup supply is limited, then only the most
essential services should be provided with water.

The contingency plan should include systems for transporting water throughout the building
and coordinating alternative plans for food preparation and laundry services. When the main
supply is not functioning, staff, patients, and visitors should be reminded to close faucets to
prevent water wastage and flooding when the water supply resumes. If the hospital cannot
continue patient services due to prolonged interruption to the water supply, then arrangements
should be made to transfer patients to other facilities. Such arrangements should be described
in the contingency plan.

Water should be available in all toilets and clinical areas (wards, treatment rooms, outpatient
department, emergency room, laboratory, pharmacy etc). Ideally, piped water and faucets
should be provided in the above areas. If this is not possible covered water containers should
be installed and regularly filled. Such containers may be static or mobile so they can be taken
on ward rounds, etc.

Additionally, all staff should have access to hand washing facilities near their workstation.
Drinking water should be available to patients and staff at all times. Water should be tested
to ensure that it is potable. If water is treated with chlorine, regular chlorination tests should
be performedto ensure the water is safe for drinking.
3.3.3. Sewerage
Proper sewage facilities are essential to any healthcare facility to ensure cleanliness and
minimize the spread of infections. Flushing toilets should be available wherever possible and

18
when adequate water is available 4, ideally adjacent to each ward and clinical area.
Otherwise, pit latrines are recommended. Covered walkways should be used to link hospital
buildings to any external toilet facilities.

Flushable toilets should be inspected regularly to ensure the flushing mechanism is functional
and practical. Drainage systems should be inspected and maintained to eliminate leaks and
system back-ups. Patients, staff, and visitors must be instructed to keep large solid waste out
of the sewage system since these may cause blockages. Signs with written and visual
messages indicating what can and cannot be deposited in the sewage system should be used to
minimize system misuse.

Where available, hospital sewage systems should connect to the municipal sewage system.
Hospital sewage should be pre-treated before entering the municipal system. Where municipal
sewage systems are not available, septic tanks may be used. Hospitals should install biogas
systems where possible to minimize sewage build-up and provide an efficient energy source.
All hospital sewage should be regarded as a hazardous material, and appropriate safety and
infection prevention measures, including personal protective equipment, should be followed
when handling sewage or undertaking repairs on any sewage systems (pipes, drains, toilets,
septic tanks, etc.).

Hospitals should have access to a professional qualified plumber with appropriate training,
tools, and equipment to perform maintenance and repair of sewage installations. Up-to-date
plans of sewage installations should be kept by each facility to ensure easy access when
troubleshooting or maintainingthe sewage system.

4
Federal Ministry of Health. Site Selection Criteria, 1998.

The hospital must ensure that reasonable stocks of sewage maintenance materials are always held
and that these form part of recurrent budgets. Basic sewage maintenance materials include pipes,
elbows, de-clogging snakes, and personal protective equipment for workers (such as boots,
gloves, and face masks). A system should be in place that prompts for re-order when stocks of
sewage maintenance materials run low. The disposal of pharmaceutical and laboratory products
and infectious waste are considered further in Chapter 4 Pharmacy Services, Chapter 5
Laboratory Services, and Chapter 7 Infection Prevention.

19
 3.3.4. Plumbing

Hospital plumbing should be checked regularly to ensure that all components are functional
and there are no leaks in the system. Unnecessary water loss (due to leaks, running toilets,
etc.) can be costly and can cause damage to a building or equipment if left unattended. If
present, water pumps should be regularly checked and maintained per the manufacturer’s
recommendations.

Plumbing hazards may pose various risks to hospital facilities, patients, staff, and visitors.
Hazards include flooding, slippery floors, and water damage. Regular inspections should be
conducted, and possible causes for leakage should be identified and corrected immediately.
Hospitals should have access to a professionally qualified plumber with appropriate training,
tools, and equipment to install, maintain, and repair plumbing installations. The plumber may
be a regular employee of the hospital or may be hired on a contract basis, depending on the
size and needs of the hospital. Each facility should keep up-to-date plans of plumbing
installations to ensure easy access when troubleshooting or maintaining the plumbing system.

The hospital must ensure that reasonable stocks of plumbing maintenance materials are always
held and that these form part of recurrent budgets. Basic plumbing maintenance materials
include pipes, faucets, toilet and sink fixtures, valves, flexible tubing, etc. There should be a
system in place that prompts for re-order when stocks of plumbing maintenance materials run
low.

3.3.5. Boiler/steam supply

The hospital may use a boiler where a regular steam supply is needed. While running,
boilers should be constantly supervised by a dedicated boiler technician. Regular inspections
should be performed to ensure the boiler is running as expected; results of these inspections
should be recorded, and corrective action should be performed immediately. A functional
backup boiler should be available for emergency use when steam from boilers is used to
provide essential services, such as autoclave sterilization. The boiler technician should be
qualified and have access to appropriate tools and equipment to install, maintain, and repair
boilers and associated steam pipe installations. The boiler technician may be a regular
employee of the hospital or may be hired on a contract basis, depending on the size and needs
of the hospital. Up-to-date plans of steam plumbing installations should be kept by each

20
facility to ensure easy access when troubleshooting or maintainingthe steam piping system.

The hospital must ensure that reasonable stocks of boiler and steam plumbing and piping
maintenance materials are held at all times and that these form part of recurrent budgets. This
includes heavy oil or other oil used to fuel the boiler. Basic steam piping maintenance
materials include copper pipes, steam traps, release valves, steam valves, etc. There should be
a system in place that prompts for re-order when stocks of boiler and steam plumbing
maintenance materials run low.

3.3.6. Heating, ventilation, and air conditioning (HVAC)

Hospitals in Ethiopia generally do not require heating systems. If installed, they should be
inspected and maintained regularly to ensure they function correctly and do not pose a hazard.
Where appropriate, carbon monoxide detectors should be used to eliminate the risk of
inhalation. Additionally, “space heaters” or other small heaters must be regularly checked for
damage to eliminate the risk of fire or other hazards.

Air conditioning systems are generally not used in Ethiopian hospitals but may be necessary
under certain conditions. For example, specific medical equipment may require rooms to
remain within a specific room temperature range that may only be achieved through air
conditioning systems. If present, air conditioning systems must be inspected and maintained
regularly to ensure correctoperation.

Adequate ventilation is essential in a hospital environment to help prevent the spread of

infectious diseases and to minimize health risks due to harsh chemicals or other pollutants.
Ventilation is also needed to reduce mold or other fungus growth in areas of high humidity,
such as the kitchen, laundry, and any other areas with steam, water, or sewage pipes running
through. Workshops where welding, soldering, burning, or other smoke-producing activities
occur, or exposure to harsh chemicals (such as paint or epoxies) must also be adequately
ventilated. Natural ventilation (opening windows) can be a low-cost alternative when artificial
ventilation methods are unavailable. This method should not be used if the external
environment is polluted or excessively noisy.

Hospitals should have access to a professionally qualified HVAC technician with appropriate
training, tools, and equipment to perform maintenance and repair of HVAC installations. Up-

21
to-date plans of HVAC installations should be kept by each facility to ensure easy access when
troubleshooting or maintaining the HVAC system.

The hospital must ensure that reasonable stocks of HVAC maintenance materials are always
held and that these form part of recurrent budgets. Basic HVAC maintenance materials
include vent ducts, fans, air filters, etc. A system should be in place that prompts for re-order
when inventory of HVAC maintenance materials runs low.

3.3.7. Energy efficiency

Hospitals should maximize energy efficiency to minimize costs and environmental pollution.
Ways to increase energy efficiency include:

 The use of natural ventilation:

o Open windows (should only be done if the external environment is free of

pollution, smog, industrial gases, and excessive noise). Screens can be installed
to protect from insects while allowing maximum airflow,
o Provide vents in the ceiling and roof to allow hotter air to escape,
 Construct windows to be as tall as possible to let in the maximum amount of natural
light,
 Provide comprehensive roof coverage to protect windows from direct sunlight and
hence keep buildingscool,
 Provide reflective materials on windows to redirect the rays of the sun,

 Plant trees to provide shade to buildings, especially outside windows, in hot climate areas,

 Ensure doors and windows close correctly to maintain internal heat in cold climate areas,

 Use solar panels for heating water, powering lights, etc.,

 Install biogas systems as an alternative source of energy, and
 For new buildings, orient the building to decrease sun exposure or take advantage
of prevailing winds.

22
 3.3.8. Pet, pest, and rodent control
Rodents and insects can spread disease and cause damage to buildings and equipment, for
example, by chewing electrical wires and soft tubing. Pests and rodents can be minimized by
keeping the facility clean and free from waste materials. The following steps help to eliminate
pets androdents and are particularly important in storage areas:

 Design or modify storerooms to facilitate cleaning and prevent moisture.

 Regularly clean floors and shelves.

 Do not store or leave food uncovered/unsealed in any storage areas.

 Keep the interior of the building as dry as possible.

 Properly varnish or paint wooden furniture as needed.

 Use pallets and shelving; do not keep products directly on the floor.

 Regularly inspect and clean the outside premises of the storage facility, especially
areas where garbage is stored. Make sure that garbage and other wastes are stored in
covered containers.
 Check for still or stagnant pools of water in and around the premises, and ensure there
areno buckets, old tires, or items holding water.
 Treat wood frame facilities with water sealant, as required.

 The fine wire mesh should protect the facility from birds or bats and cover any open
space between the roof and the ceiling.
 To protect the facility from flying pests, keep all doors and windows closed or put fine
wire mesh on all windows to ensure no holes in the ceiling, walls, or floors.
 Using Insect Electrocuting Light Bulb (hanging electric grids that attract flying insects
via a bright fluorescent or ultraviolet light) may be the appropriate solution if available
at a reasonable price.
 Using noisemakers and keeping the outside of the facility clear of long grasses and
bushes can protect the facility from the different snake species.
 All patient bed sheets and blankets should be washed and ironed regularly to eliminate
flees or similar insects. Mattresses, pillows, and other items that do not get laundered
should be disinfected with appropriate chemicals regularly, especially before the bed
is occupied bya new patient.
 Animals in Health care may have direct contact (Bites), Direct or indirect contact,

23
 Fecal-oral, and Droplet vector born. This may cause selected diseases transmission
like Rabies, Staphylococcus aureus infection, Giardiasis (Giardia duodenalis), and
Ticks (dogs passively carry ticks to humans; disease not transmitted directly from dog
to human).
 The role of animals in transmitting zoonotic pathogens and cross-transmitting human
pathogens in these settings may affect the Service provider and the clients. So it is
mandatory to use standardized infection prevention and control measures to prevent
animal-to-human transmission in Hospital settings.
 Inspections should be performed regularly to detect the presence of rats, rodents, or
other pests, paying particular attention to store rooms and the kitchen. Proper
extermination methods should be undertaken when pests are suspected. Extermination
techniques should be performed by local rules. Patients and staff should be
temporarily removed from areas if there is a risk of exposure to toxic chemicals or
substances.

3.4. Vehicle Management

3.4.1. Vehicle Management and Transport Services

Hospitals may have one or more vehicles, including ambulances, depending on the size and
location of the facility. Such vehicles should be organized within a transport department of
drivers and department heads. All drivers must have valid driving licenses for the vehicle type
and be sufficiently trained to undertake essential repairs (for example, burst tires, overheating,
etc.). All vehicles should be equipped with at least one spare tire and preferably two for
vehicles used in remote locations, and these should be checked regularly to ensure they are
intact and filled with air. All vehicles should be fitted with functioning seat belts in both front
and back seats, which should be used by drivers and passengers at all times. All vehicles must
be insured against accident and theft.

Routine services should be undertaken for each vehicle by the manufacturer’s

recommendations. Routine and repair services should only be undertaken by a qualified
mechanic.

A logbook describing the mileage undertaken and maintenance record should be kept for each
vehicle.

24
A transport policy should be established that specifies the following:

 The appropriate use of ambulances and regular vehicles,

 The process by which vehicles are issued for use,

 Control of vehicle keys,

 Storage of vehicles,

 Fuel consumption policy,

 Use of seatbelts,

 Use of mobile telephone by the driver,

 Use of alcohol, chat, or other substances by the driver,

 Action to be taken in the event of an accident or breakdown, and

 Action to be taken in the event of misuse of the vehicle.

3.5. Hospital Security

3.5.1. The Security (Guard) department
Security for the staff, patients, property, and information located within the hospital is critical.
Potential security threats include theft – by an employee or visitor and threats against patients
or staff.

Security personnel play a vital role in ensuring the hospital is welcoming and accessible and a
safe environment for patients, visitors, and staff. Security personnel need a thorough
knowledge of the premises to protect buildings and valuable equipment. Security personnel
should know when and how to diffuse potentially difficult situations and should be able to
react appropriately in an emergency.

A head of security should be appointed to manage all security officers. The security
department should provide 24-hour coverage, with security officers stationed at all hospital
entry and exit points. The security staff also should conduct regular rounds of the premises.
Security staff shouldbe issued with appropriate communication devices, such as walkie-talkies
or mobile telephones to ensure communication in an emergency. If firearms are to be held
by security staff, then appropriate training must be given to ensure their appropriate use. The
local police department may provide such training on request. There should always be a
security focal person on the premises who will be the first point of contact in a security

25
incident (such as a fire or theft) and will be in charge of deploying guards to the incident area
to diffuse the situation. Security personnel should be fit and in good health and issued
uniforms and ID badges to be identified as security staff easily.
3.5.2. Control of entry and exit to and from the hospital

The hospital should have a policy to control access to the hospital addressing the areas outlined
below.
Access to the hospital should be limited to staff, patients, caregivers, and visitors with
legitimate business.

All staff should wear ID badges which they must present upon entry to the facility. In
addition, staff should wear uniforms appropriate for their positions at all times within the
hospital. A policy should be established for the number of caregivers permitted for each
patient (for example, one caregiver per patient except for critical and pediatric cases). The
policy should be displayed in the hospital and explained to all patients and caregivers
whenever a patient is admitted. Caregiver ID badges should be issued for caregivers,
indicating the ward and bed number of the patient they are attending. (For further information
on 'traffic control,' please see Section 3.4.5 of Chapter 7, Infection Prevention).

Fixed visiting hours should be established and displayed at all hospital entry points and within
each ward. These should be strictly enforced. The number of visitors to each bed should be
limited to prevent crowding. Visitor ID badges should be issued for patient visitors,
indicating the ward and bed number of the patient they are visiting.

All other visitors to the hospital attending for other purposes, such as providing supplies, and
administrative or supervisory functions, should also be issued visitor ID badges.

Patients attending the outpatient department or emergency room should be directed to the
appropriate department and not enter ward areas unless attending for clinical assessment or
treatment. All staff, mainly security personnel, should ensure that patients, caregivers, and
visitors remain within the area where they have legitimate business and do not wander
around other clinical areasor hospital premises unnecessarily.

Staff, visitors, patients, and vehicles should be searched when they enter the premises to detect
dangerous weapons or other security threats, and a search should be undertaken of all
individuals and vehicles on exit from the premises to prevent theft.

26
Visitor and caregiver ID cards should be returned to security personnel when the individual
leaves the premises.
3.5.3. Security plan
A security assessment should be undertaken at least once a year to identify security
vulnerabilities, including the location of essential or expensive equipment or supplies. A
security plan should be designed based on the findings of this assessment. The security plan
should address areas such as:
 Control of access points, entry and exit to premises,

 Security rounds,
 Action to be taken in the event of security threat,
 Use of communication devices,
 Use of firearms (if permitted),
 Control of assets entering or leaving premises, and
 Induction and training of new security personnel.

3.6. Hospital Safety

3.6.1. Hazardous materials
Exposure to hazardous chemicals can produce a wide range of adverse health effects. The
likelihood of an adverse health effect occurring and the severity of the effect is dependent on
the toxicity of the chemical, the route of exposure, and the nature and extent of exposure to
that substance.

Toxic chemicals often produce injuries at the site at which they come into contact with the
body. Forexample, irritant gases, such as chlorine and ammonia, can produce a localized toxic
effect in the respiratory tract; corrosive acids and bases can damage the skin. In addition, a
toxic chemical may be absorbed into the bloodstream and distributed to other body parts.
These chemicals may then produce systemic effects. There are three main routes of chemical
exposure: inhalation, skin contact, and ingestion.

27
Table 2. Recommended protection against some chemical hazards

Chemical Exposure Routes Symptoms First Aid Personal

Protection
Glutaraldehyde Inhalation, skin Irritation of eyes, Eye: irrigate Wear eye- protection,
(commonly used as absorption, skin, respiratory immediately. Skin: protective clothing,
ahigh level ingestion, skin system; dermatitis; Water flush gloves, and a mask
disinfectants and/or and/or eye contact cough, asthma; immediately Good ventilation
sterilizers for some nausea, vomiting Breathing: Respiratory and easy access to
medical equipment supportSwallow: Medical water
that does not resist attention
heat)
immediately

Ammonia Inhalation, Irritation of eyes, Eye: irrigate immediately Wear eye- protection,
(used in the ingestion, skin nose, throat; Skin: Water flush protective clothing,
laboratory and and/or eye contact dyspnoea, immediately. gloves, and a mask
some cleaning wheezing, chest Breathing: Good ventilation
solutions) pain; pulmonary Respiratory support and easy access to
oedema; skin burns water
Swallow: Medical
attention immediately

Formalin or Inhalation, skin, Irritation of eyes, Eye: irrigate immediately Wear eye- protection,
formaldehyde and/or eye contact nose, throat, Skin: Water flush protective clothing,
(commonly used as respiratory system; immediately. gloves, and a mask
a high-level lacrimation; cough; Breathing: Good ventilation
disinfectant or wheezing Respiratory support and easy access to
sterilizer for some water
medical equipment
that do not resist
heat)
Chlorine Inhalation, skin, Burning eyes, nose, Eye: irrigate immediately Wear eye- protection,
(used for and/or eye contact mouth; lacrimation, Skin: Water flush protective clothing,
decontamination, rhinorrhea; cough; immediately. gloves, and a mask
cleaning, and chocking; nausea, Breathing: Good ventilation
disinfection) vomiting; headache, Respiratory support and easy access to
dizziness; syncope; water
pulmonary oedema,
pneumonitis;
dermatitis
Mercury Inhalation, Burning eyes, nose, Eye: irrigate immediately Wear eye- protection,
ingestion, skin mouth, skin Skin: Water flush protective clothing,
and/or eye contact irritation; damage to immediately gloves, and a mask
the nervous system Good ventilation
and easy access to
water

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 Source: Adapted from NIOSH Pocket Guide to Chemical Hazards. Draft Workplace Safety &
Health Guidelines for Health
Workers (2007).

Material safety data sheets (MSDSs) should be available for all chemicals found at the
hospital. These should include information about the substance, safe handling, precautions,
first aid, etc. MSDSs should be held at all sites where hazardous materials are stored or
utilized, and a complete set of all MSDSs should be held by personnel in the materials
management/central supply department and hospital management. An example of MSDS is
presented in Appendix G.

The hospital should ensure that reasonable stocks of personal protective equipment are held at
all times and that these form part of recurrent budgets. Essential personal protective
equipment includes gloves, masks, eye protection, protective clothing, etc. A system should
be in place that prompts for re-order when stocks of personal protective equipment run low
(For further information on personal protective equipment, please refer to section 3.2.2 of
Chapter 7, Infection Prevention).

3.6.2. Fire safety

A fire in a health facility risks patients' and providers' safety, health, and lives. Hospitals
should have a fire safety plan that addresses the prevention of and response to fires.
A. Fire prevention
The following safety measures minimize the risk of fire:
 Electrical safety: All appliances, instruments, and installations should be tested before use
to determine compliance with grounding, current leakage, and other device safety
requirements. A routine maintenance program should be enforced to ensure that all
electrical receptacles, plugs, wires, and connectors are safe. An earth leakage (grounding)
system should be used, and startand stop switches must be identified.
 Flammable storage: Specifically designated areas for storage of flammables (e.g., diesel,
alcohol, oxygen) should be identified. These items should be stored properl y and
located in restricted areas protected from sources of excessive heat, fire, or electrical
discharge and away from patient care areas. Minimum quantities of flammables should be
kept at workstations.

29
 Smoking/open flame restrictions: The facility should adopt strict rules governing
smoking within the hospital, which should be made known to hospital personnel, patients,
and visitors. These rules should include at least the following: smoking must be prohibited
within the facility and in any room or compartment where flammable liquid, combustible
gas, or oxygen is being used or stored and in any other hazardous hospital area. These
areas must be posted with clear ''NO SMOKING'' signs. Open fires (e.g., waste burning,
kitchens) must not be allowed near explosive storage areas. All open fires should be
monitored until wholly extinguished.
 Fire inspections: In localities where fire departments exist, health facilities should request
an annual inspection by the local fire department that includes verification of fire
prevention measures and response readiness assessment (access to the building, current
floor plan, storage places of flammable and explosive gases, sources of water, firefighting
equipment, patient rooms, exits, and evacuation plans).
B. Response to a fire
The action taken in response to a fire can minimize injury and the damage caused to
buildings andequipment. Fire response measures should include the following:
 Fire warning system: Ideally, every building should have a fire alarm system installed
(automatic and/or manually activated) to allow the early identification of fires. If this is
not possible, a large handbell may be used as an alert signal.
 Emergency notification: The facility should have a fire emergency notification
system for the local fire department using the most direct, fast, and reliable
communication.
 Firefighting equipment: All buildings should have portable extinguishers appropriate to
the different hazards, properly tagged, and easily accessible in all building areas.
Extinguishers should be periodically checked according to regulations to ensure they are
operable. If hydrants and hoses exist within the facility, they should be conveniently
distributed throughout the building to allow water to reach all potential fire points
effectively. Hydrants and hoses should also be regularly checked to ensure functionality.
 Water sources: Adequate water sources must be available in the facility for fire control.
If the public water supply system is non-existent or unreliable, water supply should be
guaranteed by elevated tanks or electric pumps. In the latter case, an emergency energy
source should be available.
 Access to the building: Access to the building for firefighters should be marked and

30
 freeof obstacles. Established routes must allow access to all parts of the building.
 Evacuation: All facilities must have evacuation plans for patients and staff. Evacuation
routes can be horizontal or vertical. Evacuation routes must be marked, built of fire-
resistant materials if possible, free of obstacles, well-lit, and ventilated to avoid smoke
accumulation. They must not pass through or be close to explosive storage areas.
Evacuation routes should direct patients and staff to a safe place outside of the building or
to a designated safe area in the building (behind fire doors if they exist). Elevators must
not be used for vertical evacuation. Evacuation should be done systematically by first
moving all patients and personnel closest to the danger. Doors into patient rooms should
not be locked when the patient is alone. Exit doors should be easily opened from the
inside.

Referrals: After a fire, it may be necessary to relocate patients to other facilities. Health
facilities must have an emergency referral plan that includes all health services, public or
private, in their geographical area, including the identification of transportation means.
All employees should be trained in fire prevention and response and familiar with the fire
safety plan. Training should include the operation of firefighting equipment, evacuation,
and the specific responsibilities of each staff member. Update training should be
conducted at least annually.
A' Fire and Evacuation Drill' should be conducted annually to test the fire and safety plan
and ensure that staff is familiar with their responsibilities. These drills should be planned
and implemented to:
 Ensure that all personnel on all shifts are trained to perform assigned duties in case of a fire,

 Ensure that all personnel on all shifts are familiar with the use and operation of the fire-
fightingequipment in the hospital,
 Enable hospital management to evaluate the effectiveness of the plan,

 Check the feasibility of a prompt and orderly discharge or transfer of patients already in
thehospital who can be safely moved without jeopardy,
 Verify security measures to keep unauthorized persons out of the emergency area.

3.6.3. Other safety measures

All hazards (such as wet floors, spills, broken glass, etc.) should be clearly labeled to
prevent injury. All public areas should be kept clean and free of large objects. Stairwells and

31
corridors should be kept clear and not used as storage areas. When cleaning is conducted, only
half of the area of corridors and stairwells should be wet cleaned at a time to have a dry and
safe path available for use. Further occupational health and safety guidance is presented in
Section 3.13 of Chapter 11, Human Resource Management.

3.7. Major Incident Planning and Management

A significant incident is any event whose impact cannot be handled within routine service
arrangements. This may arise when:

 The numbers or type of casualties overwhelm or threaten to overwhelm r o u t i n e

services, andspecial arrangements are needed to deal with them; or
 An incident poses a serious threat to the health of the community; or

 There is the potential for the hospital itself to suffer severe internal disruption.

Major incident planning aims to ensure that the hospital can respond to major incidents of any
scale in a way that delivers optimum care and assistance to victims, minimizes the
consequential disruption to healthcare services, and brings about a speedy return to normal
activity levels. Box A outlines ways in which a major incident may present. It is the nature of
major incidents that they are unpredictable, and each will present a unique set of challenges.
The task is not toanticipate each major incident in detail but to have a set of expertise available
and to have developed a set of core processes to handle the uncertainty and unpredictability of
whatever happens.

Box A: Presentation of a Major Incident

Major incidents may present in several ways:

 The big bang

 The rising tide
 The cloud on the horizon
 Headline news
 Internal incidents
 Deliberate release of chimerical or biological materials
A. The 'Big Bang'- A major health service incident is classically triggered by a sudden
primary transport or industrial accident. In this case, the police service or emergency
room may be the first to be aware of and respond to the incident.

32
 B. 'Rising Tide'- This problem creeps up gradually, as occurs with an infectious disease
epidemic. There is no clear starting point for the major incident, and the point at which
an outbreak becomes ‘major’ may only be apparent retrospectively.
C. ‘Cloud on the horizon
An incident in one place may affect others following the incident, for example, a
major incident in another health facility or an epidemic arising elsewhere.

D. ‘Headline news’-A wave of public or media alarm over a health issue as a reaction to a
perceived threat may create a major incident for the health service even if fears prove
unfounded. For example, a perceived risk of bird flu or swine flu may cause mass
attendance at the facility, even if the risk to the population is minimal. It is the urgent
need to manage information that creates the major incident. If well handled, it may not
become a major incident; if mishandled, it probably will.
E. ‘Internal incidents’-The hospital itself may be affected by fire, breakdown of utilities,
major equipment failure, hospital-acquired infection, hazardous material spill, etc. If
such incidents are mishandled, the morale of staff and public confidence in the facility
may be eroded in the long term.

F. ‘Deliberate release of chemical or biological materials

The hospital's role in such incidents is to deal with emergency cases that present to the
facility. The overall response to such incidents requires close coordination between the
hospital and government agencies such as police, military, and woreda/zonal/regional
health bureaus.
The essentials of major incident planning are:

 establishing a Major Incident Committee,

 establishing an Incident Control Room,

 preparing a Major Incident Plan (MIP),

 establishing appropriate command and control arrangements,

 implementing the MIP through training, exercising, and testing, and

 I am validating the MIP through a system of regular reviews and updates.

33
 3.7.1. Major Incident Committee

All hospitals should have a Major Incident Committee (MIC) responsible for supervising and
coordinating emergency planning. The MIC should be led by a Major Incident Commander.
Major Incident planning leads should be identified in all clinical and non-clinical case
teams/departments, andeach should be a member of the MIC.

Roles of the MIC include:

 To consider all possible types of major incidents that could affect the local population,

 To undertake a risk analysis of the facility and identify risks that should be
addressed in the Major Incident Plan. A sample Facility Risk Analysis Template is
presented in Appendix H,
 To produce and update annually the Major Incident Plan (see below),

 To determine membership and terms of reference of the Incident Response Team,

 To develop Action Cards that describe the responsibilities and reporting

arrangements of allkey personnel in the event of a major incident,
 To establish an emergency communication system including both internal
communication andexternal communication with external parties,
 To ensure staff receive training in emergency preparedness,

 To conduct emergency drills and tabletop exercises to test the Major Incident Plan, and

 To evaluate the response to any major incidents and take action to address any
problems identified.

3.7.2. Roles of the Major Incident Commander and Deputy Major Incident
Commanders
All hospitals should have a Major Incident Commander, who should be the Chair of the MIC.
This role could be filled by the CEO, the Head of Finance and Procurement, or another
individual with an excellent working knowledge of the facility, staff, and services provided.
The Major Incident Commander authorizes MIP activation and communication to all hospital
personnel. Other MIC members may be assigned as Deputy Major Incident Commanders who
can authorize activation of the MIP if the Major Incident Commander is unavailable. The
Major Incident Commander and Deputies must operate a rota system with 24-hour coverage

34
each day, 365 days a year, and this duty schedule should be available to all staff. Ideally, a
dedicated mobile telephone number or pager should be carried by the duty Major Incident
Commander or Deputy known to external agencies and hospital staff so that the duty
Commander may be contacted directly and immediately in the event of a major incident.
The Major Incident Commander or Deputy is also responsible for deactivating the MIP after a
proper emergency assessment.

3.7.3. Incident control room

All hospitals should have an Incident Control Room (ICR) activated as a post to manage
emergency/disaster response activities. This may be an existing office or meeting room that
can be used as the ICR in an emergency. Keys for the ICR should be kept with the Major
Incident Commander or the Deputy on duty. The ICR serves as the assembly point where
duties are assigned and personnel report activities in the event of a major incident. The ICR
should contain the following:
 Desks and chairs

 Telephone

 Fax

 Stationary

 Action Cards

 Copies of the Major Incident Plan

3.7.4. Command and control arrangements in a major incident

An Incident Response Team (IRT) should be formed in a Major Incident. The IRT should
gather in the Incident Response Room, where all activities will be coordinated.

Members of the IRT should include:

 Major Incident Command Officer

 Major Incident Command Deputies

 Chief Executive Officer

 Director of Facility Services (or equivalent)

 Director of Human Resources

35
  Director of Outpatient Services

 Director of Inpatient Services

 Director of Emergency Services

 Chief Nursing Officer (or equivalent)

 Liaison and Referral Officer

 Others, as determined by the facility

Sample terms of reference of an IRT are presented in Box B.

Box B Terms of Reference of Incident Response Team

 To oversee the response to the incident, issuing Action Cards and receiving
update reports from key personnel
 To make an initial assessment of the situation and determine the critical
organizations with which to establish communication
 To put in place adequate measures to ensure communications with
the appropriate organizations during the incident
 To put in place adequate measures to ensure communication with
relatives and the community during the incident
 To assess the internal resources required to deal with the incident and to
ensure that these are put in place (for example, calling additional staff onto
duty, mobilizing medical supplies)
 To seek expert advice where the expertise does not exist within the
hospital (for example,from Public Health Laboratory Service)
 To prepare staff for the execution of the response plan and to monitor implementation.
 To prepare a plan for the long-term follow-up of the incident if necessary
 To prepare, if necessary, regular press statements or other means of public communication
 To decide when the incident should be declared over and inform any
necessary external agencies that this has been done
 To organize the re-entry of staff, patients, and visitors
 To identify and complete appropriate reports of any damage that occurred
to buildings or equipment
 To carry out a debriefing, including a review of the Major Incident Plan and

36
 recommendations for modification
 To prepare a report for the Hospital Governing Board and other agencies on the incident

The membership, contact details, and terms of reference of the IRT should be described in the
Major Incident Plan (see section 3.9.5 below).

In addition to the IRT, the MIP should describe command and control arrangements showing
who is accountable to whom in the event of a major incident. The command and control
arrangements can be supported by ‘Action Cards’ that specify the responsibilities of each
individual in the event of a Major Incident and state who that individual should report (see
section 3.9.6 below). Sample Major Incident Action Cards are presented in Appendix I.

All staff should be familiar with the command-and-control arrangements and their particular
responsibilities and reporting arrangements described in their Action Card.

3.7.5. The Major Incident Plan

All hospitals should have a Major Incident Plan approved by the Senior Management Team.
The MIP should be distributed to all staff, and copies should be readily available in all case
teams/departments. The MIP should be updated annually.
The MIP should include:
 Basic hospital information, e.g., location of facility, number of beds, services provided

 An outline plan of the hospital identifying:

o Emergency room areas

o Patient flow plan
All fire extinguishers and fire alarms
o Exit routes (doors, windows, stairways, etc.)
o Assembly points
o Emergency supply storage

 Contact information for:

o Key facility personnel (for example, MIC and IRT members, hospital
management, caseteam leaders, and medical staff)

o External agencies (for example, police, fire brigade, water and electricity

37
 suppliers,woreda/zonal/regional health offices, FmoH, and local media)

 Clear alerting and activating procedures for the MIP

 The essential functions and critical personnel needed to continue health facility
operations in caseof an emergency
 A communications cascade by which all key personnel will be contacted

 Precise arrangements for establishing an Incident Response Team

 Clear statements on the roles/responsibilities of essential staff/functions

 Action cards for key personnel involved in a Major Incident that describe staff
roles/responsibilities and reporting arrangements (see section 3.9.6 below)
 Department/Case Team specific action plans and checklists that establish the different
courses of action for each department in an emergency
 Clear identification of resources required for the response and how these will be
accessed (for example, emergency drug store)
 A plan outlining coordination with all suppliers/providers to deliver needed supplies
during an emergency (for example, food, drugs, water, electricity, laundry services,
additional personnel, etc.)
 A communications plan with all local emergency agencies. All local emergency
agencies should have a copy of the hospital's MIP.
 Evacuation protocol includes:

o All possible evacuation routes and assembly points for staff, patients, and
visitors to convene. This emergency should be marked throughout the facility.
o Description of situations requiring evacuation such as:
 Fire/Smoke

 Hazardous fumes and/or hazardous material spill

 Area contamination by toxic agents

 Radiation

 Loss of critical support services (this could simply require a partial

evacuationof patients from one department to another)

 Explosion

 Police action

38
  Armed/dangerous visitor

 Natural disasters (ex., flooding, earthquakes)

 Fire safety plan

 Arrangements for creating additional space/capacity within the hospital

 Arrangements with other healthcare providers for an alternative care site for patients if
the facility exceeds its capacity
 Communication plan to manage communication and information for families of
casualties and other visitors. A communications Centre should be established to
provide information about casualties' status. The center should collect visitors' names
and patient associations to help stafflocate visitors needing to be escorted to the patient.

3.7.6. Management of a Major Incident

The steps to be taken in the management of a major incident include the following:

1. Incident alert: Any staff member may identify a potential incident and should notify
their case team/department head immediately or the Major Incident Commander,
depending on the situation's nature and the event's time. An external event may come
to the attention of staff in the emergency room via the local police, fire service, or
health bureaus. Such external agencies should be instructed to notify the Hospital
Major Incident Commander immediately should a potential major incident occur.
2. Assessment of the situation by Major Incident Commander. The Major Incident
Commander should complete an Incident Alert Log (Appendix J) and decide if the MIP
is to be activated.
3. Activate communications cascade (Appendix K). The Major Incident Commander
should contact the Incident Response Team, who is responsible for contacting directly
or arranging for the contact of all key personnel as described in the Communications
Cascade.
4. Establish Incident Response Room and Incident Response Team. The Incident
Response Room should be opened by the Major Incident Commander, and all members
of the IRT should report there immediately or as soon as they reach the facility. The
Major Incident Commander shall brief team members on the situation.
5. Assign Action Cards: All essential post holders/managers should have a card that
briefly details the actions they should take in an emergency. The cards should be

39
 laminated and carried by each individual at all times. Copies should be kept in the
Incident Response Room and included in the MIP.
6. Proceed as instructed in the action cards

7. Manage Incident

8. Step down when an incident is over

Management of a Major incident

Inform Major Incident Commander or Deputy

Incident alert: Internal event (e.g., Incident alert: External event (e.g.,
fire,chemical spill) roadaccident, disease epidemic)

The department staff provides Emergency Rooms or external agencies

an initialresponse such as the police provide an initial
response.

Assess situation. Compete Incident Alert Log

Activate communications cascade

Review responses and revise

IncidentManagement Plans
accordingly.
Establish Incident Control Room and
Incident Control Team

Take action cards

Proceed as instructed

Manage incident

Step down when an incident is over.

40
 3.7.7. Testing the Major Incident Plan

All staff should be trained in major incident preparedness, including personal roles and
responsibilitiesin the case of a major incident.
The MIP should be tested at least once every year, and modifications made to the plan based
on lessons learned from the drill. The drill can be either a simulated exercise involving mock
victims or a 'desk top' exercise involving establishing the IRT, activating the cascade system,
issuing action cards,and testing each department/case team's response. A MIP Drill Plan and
Drill Evaluation Form are presented in Appendices L and M. The Drill Evaluation should be
carried out by one or more observers.

Source Documents

1. Agency for Healthcare Research and Quality. Emergency Management Principles and
Practices for Health Care Systems: Unit 3 – Healthcare System Emergency Response and
Recovery. Retrieved from:-http://www.ahrq.gov/research/hospdrills/predrill.htm;
http://www.ahrq.gov/research/hospdrills/triage.htm;
http://www.ahrq.gov/research/hospdrills/tx.htm.

2. California Hospital Association. (2008, Nov 20). Hospital Emergency Management

ProgramChecklist.

3. Carr, R.F. The National Institute of Building Sciences – Whole Building Design Guide:
Hospital.Retrieved from: http://wbdg.org/design/hospital.php.

4. Claude Moore Health Sciences Library. (Revised August 2008). Emergency

Preparedness andResponse Plan.

5. Federal Democratic Republic of Ethiopia Ministry of Health. Planning and Project

Department. Architectural and Engineering Team. (1998, May). Site Selection Criteria.
Addis Ababa, Ethiopia.

6. Griffith, J. R. and. White, K. R. The Well-Managed Healthcare Organization: Sixth Edition.

7. Ministry of Finance and Economic Development. (2007, December). Government

Owned FixedAssets Management Manual.

41
8. Ugandan Ministry of Health. Prepared by Necochea, E. and Bossemeyer, D. Jhpiego. (2007).
Ugandan Ministry of Health Draft Workplace Safety and Health Guidelines for Health
Workers.

9. Mississippi Depart of Health: Office of Emergency Planning and Response. Hospital

EmergencyPreparedness Planning Template (August 2005).

10. Mississippi Department of Health: Office of Emergency Planning and Response. (2005, April)
Clinical Emergency Planning Template.

11. National Association of Community Health Centers. Retrieved from:

http://www.nachc.com/EM-Planning. cfm.

12. New York Centers for Terrorism Preparedness and Planning. (2006 March). Draft
HospitalEvacuation Protocol.

13. New York Centers for Terrorism Preparedness and Planning. (2006 July).
Draft MassCasualty/Trauma Event Protocol.

14. Quality Improvement Support Services. Departmental Emergency Preparedness Plan.

15. U.S. Department of Health and Human Services: Agency for Healthcare Research and
Quality. Retrieved from: http://www.ahrq.gov/research/hospdrills/introduction.htm.

16. United Nations Development Programme, India. Guidelines for Hospital Emergency
PreparednessPlanning. GOE-UNDP DRM Programme (2002-2008).

17. Washington University in St. Louis: Disaster and Business Continuity Planning Committee.
Department Emergency Guides.

18. Wisconsin Department of Health Services. Hospital Disaster Plan.

Retrieved from:
http://dhs.wisconsin.gov/rl_DSL/Hospital/HospitalDisastrPlng.htm.

42
19. World Health Organization-Regional Office for the Western Pacific. "District Health
Facilities- Guidelines for Development and Operations. Risks, Emergencies, and
Disasters," Planning andDesign. WHO Regional Publications. Western Pacific Series No.
22. 1998. Retrieved from: http://www.wpro.who.int/internet/files/pub/297/part1_1.6.pdf.

20. Yale-New Haven Health System. Disaster Critique Follow-up and Resolution Form.

21. Yale-New Haven Hospital. (2009). Emergency Management Plan.

43
 CHAPTER 20

Human Resource Management and Development

 Outline
Section 1 Introduction
Section 2 Operational Standards for Human Resource Management and Development
Section 3 Implementation Guidance
Section 4 Annexes
Section 5 References
Section 1 Introduction
The most important asset of a hospital is the people who work there. Employees, whether they are the hospital’s
technical or admin wing staff, all individually and as a group, are responsible for and have valuable
contribution in carrying out the hospital’s duty to care for patients. A well-performing health workforce is one
that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given
available resources and circumstances (i.e. there are sufficient in number, with required mix, fairly distributed;
they are competent, compassionate, caring, responsive and productive).
The main objective of the Human Resource management and Development Department/Directorate(HRMD)
function is to ensure that the facility attracts, develops, retains, and motivates qualified employees who are
critical for achieving the organization’s objectives of delivering high quality and safe patient care by creating
conducive working environment for the staff (Capacity building on different initiatives including MCC,QI
concepts, strong support and monitoring at all level with regular feedback, engagement of clinicians in L/P,
performance based evaluation and recognition).
The HRMD Directorate/Department does this by designing organizational structure that shows clear vertical
and horizontal communications, and roles and responsibilities, establishing policies and procedures for the
work environment and the effective management and development of employee workplace issues to the mutual
benefit of the individual employee , the hospital and the clients.

The benefits of a well-functioning HRMD system include:

 Develop hospital-based HR development plan which address professional mix, education level category
 Continuous professional development CPD through ongoing training (onsite, short- and long-term
training to maximize employee performance, skills and knowledge, satisfaction
 Implement scope-based practices and assess competency
 Create conducive learning platform for the hospital staff (face to face, online courses, etc.)
 Prepare Skill lab/simulation centre for staff capacity building
 The hospital should clearly define and create awareness on employee roles and responsibilities
 Improved relationships between employees and management,
 Efficient use of HR to improved effectiveness and productivity.
 Regularly monitor staff adherence to rules and regulations, Ethics, performance with improvement plan
and level of staff satisfaction
 Set a recognition mechanism for individual and service areas based on well-defined recognition
mechanism.
This chapter sets standards and provides guidance for the establishment of a human resource functions that
contributes to the advancement of the vision, mission and guiding principles of the hospital.
Section 2 Operational Standards for Human Resource Management and Development
1. The hospital has a Human Resources Management Directorate/Department/ which lead and
manage the HR management and development of the hospital
2. The hospital has a human resource development plan.
3. The hospital established a transparent and accountable system of staff acquisition
4. The hospital has the number and professional mix in accordance with the regional/national
standards.
5. The HRMD Directorate/Department maintains each personnel file and fully implement HRIS
6. The Human Resource Directorate/Department creates conducive work environment to motivate
health work force.
7. The hospital strengthens a system to have Motivated, Competent, and Compassionate (MCC)
human resource for the hospital.
8. The hospital has a performance evaluation management system and reward policies to formally
and objectively evaluate all the employees.
9. The hospital has occupational health and safety policies, plan, and procedures
10. The hospital’s HRMD directorate/department enhances Productivity and working hours
management of the hospital
11. HRM&D directorate/department prepares an Employee Handbook that contains policies and
procedures to help ensure consistency in service delivery.
12. The hospital regularly conducts a staff job satisfaction survey and exit interview.
Section 3 Implementation Guidance
3.1 Human Resource Department

The Human Resource Management and Development (HRMD) Directorate/Department/ Support

Process is responsible for the planning, recruitment, placement, performance appraisal,
development, motivation and retention of employees, and for establishing policies and
procedures to manage employee/employer relations. The HR Directorate/Department/ Support
Process should be led by a competent individual who possesses management skills and
experience dealing with HR issues. He/she should be a member of the hospital’s Senior
Management Team (SMT). Additional HR staff includes recruitment and promotion, training
and development, employee services and benefits, occupational safety and health, and HRIS.

The HR Directorate/Department/ Support Process should have sufficient space to store personnel
files securely, and should have an area/room where confidential discussions can be held between
the HR Head and individual employees should the need arise.
3.2 Human Resource Policies

The HR Directorate/Department/ Support Process is responsible to establish policies to manage

employee activities and employee/employer relationships. Once developed, these policies
should be communicated to all employees to ensure they are aware of the policies that guide their
workday. Policies should be collated into an ‘Employee Hand Book that is distributed to all
existing and new staff. Preferably the Employee Hand Book should be in a ring binder format to
allow for the addition of new policies or insertion of revised policies as the need arises. The
Employee Hand Book should be revised and updated regularly (for example every 3 years).

Policies should address the following areas:

A) Recruitment, Promotion and Transfer Procedures
1) Recruitment: vacancy announcement, screening of applicants
2) Job applicant interviews
3) Reference checks
4) Employment offers
5) New staff induction/Orientation
6) Promotion, secondments and transfers
B) Remuneration/ Compensation, Benefits and Reward
1) Salary scales
2) Salary review policy
3) Paydays
4) Duty/Overtime
5) Salary increment/adjustment
6) Severance pay/lay off/retrenched
7) Services and Benefits
7.1 Types of available benefits
7.2 Eligibility
 7.3 Medical and disability payments
7.4 Private wing opportunities
7.5 Staff canteens
7.6 Private wing opportunities
7.7 Transport facilities
C) Occupational health and safety
1) Medical assessment and immunizations
2) Safety risks and protection measures
3) Work-related injuries and compensation policies

D) Work schedule
1) Work days and working hours
2) Overtime and duty work
3) Annual leave, unused leave (carry over)
4) Sick leave
5) Maternity, paternity leave
6) Nuptial leave
7) Exam leave
8) Special leave (with or without pay)

E) Performance Appraisal procedures

1) Performance appraisal process

2) Performance improvement plans
 3) Uses of performance evaluation results
4) Recognition/award schemes

F) Training and Development

G) Continuing Professional Development
H) Disciplinary and Grievance procedures
I) Termination of employment (exit interview)
J) Staff Code of Conduct
1) Employee Code of Conduct (see Appendix B)
2) Employee rights and responsibilities (See Appendix C)
3) Timekeeping
4) Dress code (ID badges and uniform to be worn at all times)
5) Smoking policy (not permitted on hospital premises)
6) Use of alcohol, chat or other substances (not permitted in hospital premises, employee
should not be under the influence when attending for duty)

7) Mobile phone use (no personal calls while on duty or with patients)
8) Photography, video camera, audio-recording (not permitted without permission of
management and patient)

9) Gift policy (personal gifts should not be accepted from patients or caregivers since this
could be interpreted as an attempt to gain preferential favour. If a patient wishes to offer a
gift he/she should be encouraged to make a donation for the benefit of the whole hospital
or staff, e.g. a financial or equipment donation after care has been completed.)
3.3 Human Resource Acquisition Plan

Human resource acquisition planning enables the hospital to forecast its human resource needs,
to acquire human resources in the right number and type, and to develop and properly utilize
available resources.
All hospitals should have a human resource acquisition plan which is the foundation for the
recruitment and placement of staff both in the short term and long term. The human resource
acquisition plan should give due consideration to skill mix, competence and staff adequacy, and
should be developed taking into consideration the hospital’s ‘Essential Services Package’ (See
Section 3.6 of Chapter 1 Hospital Leadership and Governance), WHO and FMHACA standards.

Steps to develop a human resource acquisition plan:

Step 1: Define the Essential Services Package (See Section 3.6 of Chapter 1 Hospital Leadership
and Governance).

Step 2: Estimate patient load based on past trends of utilization and, for new services, estimated
need for the service

Step 3 Identify any plans to ‘outsource’ non-clinical services and/or to clinical service areas

Step 4: Determine ‘ideal’ skill mix and minimum staff to patient ratios or minimum staff
numbers in each service area

Step 5: Compare current staff pattern with ‘ideal’ staff pattern and identify the gaps

Step 7: Describe actions to address the gaps, for example:

 Training of current staff

 Transfer/reassignment/lay-offs of existing staff to better match ‘ideal workforce’

 Recruitment of new staff: number, type

 Revision of organizational structure, if necessary

Step 8: Estimate budget for implementation of the HR acquisition plan. Budget should include
salaries, and all corresponding benefits and allowances.

A sample data collection tools that can be used develop the human resource acquisition plan are
presented in Appendix A.

Figure 1: Human Resource Planning Model

SUPPLY ANALYSIS

 Workforce analysis and trends

 Employee knowledge, skills, SOLUTION ANALYSIS
abilities GAP ANALYSIS
 Planning workforce
 Workforce demographics  Comparison of current transition
 Current Workload Analysis workforce skills with  Employee development
future needs and re-training
 Analysis of how workforce  Changes in staffing
DEMAND ANALYSIS demographics will change patterns
 Identification of areas in
 Workforce knowledge, skills, which management action
abilities to meet project need will be needed to reach
 Staffing patterns
 Anticipated program and

Source: Adapted from: ww.hhs.gov/ohr/workforce/wfpmodel.gif.

The human resource acquisition plan and budget should be approved by the hospital SMT and
should be updated annually. The human resource acquisition plan should be the foundation for
the hire of new staff or transfer of a staff member from one service area to another. New
employees may be hired to fill gaps in the workforce or to fill vacancies that arise due to
employee resignation or retirement.

3.4 Workload Indicators of Staffing Need (WISN)

Hospitals can use Workload Indicators of Staffing Need (WISN) to determine their staff
requirements. The WISN method is a human resource management tool that calculates a
staff
requirement based on workload for a particular staff category and type of health facility. This
tool can be applied nationally, regionally, or only for a single health facility or even a unit/ward
at a hospital, provided relevant service statistics are available.

The steps of the WISN method are:

i. Determining the priority cadre(s) and work unit/service area(s) for applying the WISN
method.
ii. Estimating available working time, defined as the time a health worker has available in
one year to do their work, given authorized and unauthorized absences for leave,
sickness, and so on.
iii. Defining workload components, consisting of both health service activities and those
supporting these activities (such as recording, reporting, and management meetings).
iv. Setting activity standards, defined as the time necessary to perform an activity to
acceptable professional standards in the local circumstances.
v. Establishing standard workloads (that is, the amount of work within a health service
component that one health worker can do in a year).
vi. Calculating allowance factors in order to take account of the staff requirement of support
activities performed by all or some of the staff for which there are no service statistics.
vii. Determining staff requirements based on WISN by calculating the total staff required to
cover both health service activities and activities supporting the services.
viii. Analyzing and interpreting the WISN results.

An analysis of WISN results provides two different measures: (1) the difference between current
and required number of staff, and (2) the WISN ratio (current staff divided by required staff).
The WISN ratio is a proxy measure for the daily workload pressure on the staff. Examining both
the gap or excess in staffing and the WISN ratio is important in determining how to improve
staffing equity; a staffing gap of the same size has a much bigger impact on workload stress in a
health facility with only a few staff than in one with a large staff.

Illustrations of the Steps of WISN Method

Step I. Determining Priority Cadre(s)

1. List all work units/ service areas and the main staff categories working in the hospital

2. Determine which staff categories/ cadres have most difficult staffing problems cadres
3. Decide which staff category (or categories) should have highest priority 17-9

4. If sufficient resources are available, incorporate the second and the third highest priorities
in the WISN process
 Step II: Estimating Available Working Time

Available working time (AWT): The time a health worker has available in one year to do his or
her work, taking into account authorized and unauthorized absences.

S. Category Average Weeks Average days in Average Hours

N. in
one year in one year
one year
1 Working weeks, days and 52 260 2080
hours in one year
2 Annual leave 3.6 25 200
3 Sick leave 2.1 15 120
4 Public holidays 1.7 12 96
6 Other leaves (training, personal 2. 15 120
1
leave)
7 Maternity leave 1.4 10 80
8 Weeks, days & hrs. not Worked 11 67 616
in one year
9 Available Working 41 193 1544
Weeks, Days & Hours in one
year

*Available working days per year = 52 weeks in a year – (public holidays + annual leave + sick
leave + other leave). This applies for doctors, nurses and midwives and other health workforces.
*Available working hours per year = available working days per year x number of working hours
in a day.
Step III: Defining workload components
Workload Components:

1. Health service activities: Performed by all members of the staff category & Regular statistics are collected
on them
2. Support activities: Performed by all members of the cadre, but regular statistics are not collected on them
3. Additional activities: Performed only by certain (not all) members of the cadre Regular statistics are not
collected on them
 The workload components that the hospital define should be the most important activities in a
health workers daily schedule. Each component has its own, separate demand for time. For
example, antenatal care and deliveries are two different workload components of a health centre
midwife. Each requires a certain portion of the midwife’s time, because she cannot provide
antenatal care while attending to a delivery. This is why each important workload component
must be listed separately.

Table: Example of Defining Workload Components

Staff category: Midwife in x Hospital

Workload group Workload component
Health service activities of all midwives Antenatal care
Postnatal care (including care of a newborn)
Deliveries
Family planning
Support activities of all midwives Recording and reporting

Meetings
Additional activities of certain midwives Supervision of midwifery students
Attending continuing education sessions
General administration

Step 4: Setting activity standards

Types of Activity Standards:

1. Service Standards: A service standard is an activity standard for health service activities
2. Allowance Standards: Performed by all members of the cadre, but regular statistics are not
collected on them
 Service standards and allowance standards must be considered separately, because they will be
used differently in calculating the final staff requirement based on WISN.

4.1 How to Calculate Service Standards for health service activities

A service standard is an activity standard for health service activities, this can be expressed in
two ways, as a unit time or as rate of working.
A) Unit time: This is the average time that a health worker needs to perform the activity

E.g. Service standards for antenatal care by a health centre midwife can be shown as
“10 minutes per pregnant woman”
B) Rate of Working: This is the average number of activities completed within a defined
time period.
E.g. Service standards for antenatal care by a health centre midwife can be expressed as
“18 pregnant women seen during a three-hour antenatal clinic”

Example of setting service standards

Staff Category: Midwife in X Hospital

Health service activity Unit time or rate of working
Antenatal care 20 minutes per client
Postnatal care (including care of newborns) 6 clients in a 4-hour postnatal clinic
Deliveries 8 hours per client
Family planning 30 minutes per client

4.2 Allowance standards for support activities and additional activities

An allowance standard is an activity standard for support and additional activities. There are two
types of allowance standards: Category allowance standards (CAS) and individual allowance
standards (IAS)

A) Category allowance standards: are determined for support activities that all members of a
staff category perform.
E.g. all midwifes in a hospital spend time in recording and reporting
 B) Individual allowance standards (IAS) are set for additional activities that only certain
cadre members perform.
E.g. only two hospital midwives spend time supervising midwifery students.

Category Allowance Standards can be expressed either as actual working time or as a percentage
of working time. For example, an allowance standard for “recording and reporting” can be
shown either as “one hour per working day” or as“14% of working time.

Individual Allowance Standards: to calculate how much time the additional activities of certain
staff members require.
 Write down the number of staff members who perform each activity and the time it
takes them.
 Multiply the number of staff members by the time the activity requires in one year

 Do this for each workload component.

 Add the results together to calculate the total individual allowance standard (IAS) in a
year.
Step 5: Establishing standard workloads

Example of standard workload calculation

Staff Category: Midwife

Available Work Time (AWT) in a Year:
1544
Health Service Activity Unit Time or Rate of Standard Work Load

Working
Antenatal care 20 minutes per client 4632 clients (1544 x 3)
(equivalent to 3 clients per
hour, or 60 / 20)
Postnatal care 6 clients in a four-hour postnatal 2316 clients (1544 x 1.5)
(includingcare of clinic (equivalent to
newborns) 1.5 clients per hour, or 6 / 4)
Deliveries 8 hours per client 193 clients (1544 / 8)
Family planning 30 minutes per client 3088 clients (1544 x 2)
(equivalent to 2 clients per
hour, or 60 / 30)

A standard workload is the amount of work within a health service workload component that one
health worker can do in a year. The formula to calculate a standard workload depends on
whether the service standard is expressed as unit time or as rate of working.

Use this formula when the service standard is shown as unit time:

Standard workload = AWT in a year divided by unit time

Use this formula when the service standard is expressed as rate of working:

Standard workload = AWT in a year multiplied by rate of working.Step

6: Calculating allowance factors
Having established standard workloads will help the hospital management to know how much
work a health worker can do in a year within all health service activities. These are the workload
components for which routine statistics are collected and available annually. But health workers
are also required to undertake other important activities for which routine data are not collected.
These are the support and additional activities of health workers. The following calculation
shows how to take account of the time that such activities take.
To take into account the two types of allowance standards calculated in step 4 (Category
allowance standards & Individual allowance standards) the hospital management need to convert
the allowance standards into allowance factors as follows.
The category allowance factor (CAF) is a multiplier that is used to calculate the total number of
health workers required for both health service and support activities.
CAF= 1/[1-(Total CAS/100)]

The individual allowance factor (IAF) is the staff requirement to cover additional activities of
certain cadre members of activity group. The IAF shows how many full-time equivalent staff
members (or what proportion of such a staff member time) are needed to cover the time
commitment of certain cadre members to additional activities. The IAF is not a multiplier.
Instead, it is added to the total required number of staff members in the final WISN step.

IAF = annual total individual allowance standard (IAS) divided by the available
Working time (AWT)
Step7. Determining staff requirements based on WISN

To determine how many health workers are required to cope with all the workload components
of your WISN cadre(s) we need the annual service statistics for the previous year. We need these
data for each health service activity for which a standard workload is calculated. The total
required number of staffs must be calculated separately for the three different workload groups

Health service activities: Divide a health facility’s annual workload for each workload
component (from annual service statistics) by its respective standard workload. This gives the
number of health workers that is required for the activity in this health facility. By Adding the
requirements of all workload components together we will get is the total staff requirement for
all health service activities.
Support activities: done by all members of the staff category can be calculated by multiplying
the staff requirement of health service activities by the category allowance factor. This gives the
number of health workers required for all health service activities and support activities.
Additional activities of certain cadre members: Add the individual allowance factor to the
above staff requirement.

Components of workload Activity standards Standard workload

Outpatients 10 minutes/patient 11,232 patients/year

Home visits 12 minutes/visit 9,360 homes/year
Category allowance

Standard
Travelling 1.5 hours/day 18.75 per cent
Individual allowance

Standard
Administration, 1 CHW 15 per cent 15 per cent

Step 8: Analyzing and interpreting WISN results

The WISN results are analyzed in two ways. The first analysis looks at the difference between
the current and required number of staff. The second analysis examines the ratio of these two
numbers. The two analyses will help to examine different aspects of the staffing situation in a
given facility
Difference: By comparing the difference between current and required staffing levels, we can
identify the health facilities that are relatively understaffed or overstaffed.
3.5 Employee Job Description

Job description is a short statement that includes information about an employee’s assigned
duties or responsibilities. It details the position’s objectives, the skills, training and education
necessary to perform the position. These statements define the performance standards or
obligation of the employee to the health facility. For the health facility, a job description defines
the type of employee desired for the position and what is expected of the employee. It provides
the facility with guidance for hiring, salary structure, performance appraisal and supervision.

A job description should be developed for every position in the hospital. Template job
descriptions may be available from the FMOH or Regional Health Bureaus (RHBs). However,
each hospital should adapt these job descriptions to reflect the hospital’s needs and to define the
duties and responsibilities of the position. Job descriptions should be developed in collaboration
with the Human Resources Department and head of the department/case team in which the
position is located. The job description should be explained to each new employee when he/she
commences employment and he/she should sign on the job description to indicate their
understanding of and agreement with the duties and responsibilities therein.

Two copies of the job description should be prepared. The first copy should be kept by the post
holder and the second copy should be filed in his/her personnel file.

The job description should be kept under review and amended if the need arises, for example if
duties or supervisory responsibilities are added to or removed from the post. At the time of
Performance Based Evaluation (PBE), the employee and supervisor should consider whether the
job description is still an accurate description of the post and should amend if necessary.

If an employee is promoted or transferred to another position then a new job description should
be given and signed for the new position. The date on the new job description will indicate the
date at which the employee changed position.

A job description should contain the following components:

Job Title: The title of the position

Reporting to: The position of the immediate supervisor to whom the post

holder will report

Department: The department within which the position is located

Full-time, part-time, contract, consultancy, temporary

Employment type:
position, or otherwise.

Job Summary: Provides a 2-3 sentence description of the job

Essential Duties and A detailed explanation of the position’s tasks

Responsibilities:

Supervisory
responsibilities: Statement that outlines which staff will be supervised by the
post holder, and the specific tasks associated with
supervision (e.g. conduct PBE etc)
Educational
The minimum educational requirement for the position
Qualifications

Certificates, Licenses, All minimum required credentials and equivalents should be

Registrations: outlined here.

Experience The minimum work experience required for the position

Other required skills Any other required skills/competence. For example language
skills, IT skills, mathematical or statistical skills; reasoning
skills (such as ability to define problems, collect data,
establish facts, and draw valid conclusions) planning and
organization skills etc

Physical Demands If the position requires heavy lifting, high level of physical
activity, or exposure to natural elements such as outdoors in
weather conditions, it should be noted here.
Description of job site This contains specific information about the work
and work environment environment, including a description of surrounding areas,
building layout, and other information relevant to the work
atmosphere including environmental hazards.

Occupational Exposure If the employee will be exposed to a known risk for an

extended period of time, it should be noted on the job
description.

Salary and Benefits The specific salary or salary range. This information may or
may not be included in the job description. Instead, a
hospital may use a job-grade system, which rates each job
and assigns a job grade number that correlates to a wage
range.
Employee Name and
Signature

Date

A sample Job Description for the position of Laboratory Technologist is presented in Appendix
D.

3.6 Recruitment
Recruitment involves searching for and attracting prospective employees, either from outside or
inside of the hospital. The Federal and Regional Civil Service Proclamations and Directives
establish criteria for recruitment as follows:

The candidate should have no prior criminal record,

No one terminated for a disciplinary offence can be rehired by a public facility within
five years,

Preferential consideration should be given to female candidates, candidates with

disabilities, and members of nationalities/ethnicities comparatively less represented in the
 hospital, having equal or not more than 3% score (if the difference is 3%) to other
candidates, and

Candidates should not be discriminated against on the grounds of ethnic origin, religion,
political outlook, disability, sex, HIV/AIDS status or any other grounds.

3.6.1 Recruiting and Staff Request Procedures

To fill a vacant position the Head of the requesting department or work unit and the HR
Department should follow the following steps.
 Departments/work units fill staff request/recruitment form and submit to HR
Directorate/Department/Support Process.
 HR Management Directorate/Department/Support Process check the availability of
approved and budgeted position/s
 HR and requesting department review the qualification requirements of the vacant
position/s
 The job description for the post should be reviewed by the requesting department/work
unit and the HR Department to confirm that it is still suitable for the position.
Amendments should be made if necessary.
 HR Management Directorate/Department/Support Process advertise the vacant position/s
A sample Personnel Recruiting and Posting Request Form is presented in Appendix E.

3.6.2 Vacancy Announcement

A job announcement should be made for any vacancies that arise stating as a minimum:
 name and address of the hospital

 place of work and department

 position, grade and salary

 number of vacant positions to be filled

  minimum qualification requirements for the position

 knowledge, skills, competence and other essential requirements

 specification of documents that should be submitted

 nature of the work including travel, duty or overtime requirements if relevant

 application closing date and time

 Place where candidates can get more information about the position and from where they
can collect an application form.

Ethiopian Federal Civil Service Directives specify that for positions up to grade VIII and below
hospitals can advertise external recruitment in their premises or notice boards. However, the
hospital can advertise these vacant positions through the mass media to attract adequate pool of
applicants. For grade IX and above positions the vacancy position announcement should always
be posted externally through mass media outlets such as newspapers, television, internet etc.
(NB: internal candidates may still apply but will be screened and assessed against the same
criteria as external candidates).

A sample Vacancy Notice Form is presented in Appendix F.

3.6.3 Application process

A standardized application form should be completed by all applicants for the position. The form
should include candidate’s personal information, education, language proficiency, training, work
history, and licenses (if required). A sample Application Form is presented in Appendix G.

3.6.4 Selection process

A selection team should be established to shortlist candidates. The procedures may have slight
differences between regions but according to the federal recruitment and promotion directives
the selection team members include:

 Head of the directorate/department/ Case Team where the post will be located (Chair)
 HR directorate/department/support process Head or Representative

 HR Professional assigned by HR directorate/department/support process (Secretary)

The selection team should screen all applications and to assess whether candidates fulfil essential
and desirable qualifications and experience that are described in the vacancy announcement.
Candidates that best meet the criteria should be invited for interview and or written
exam/practical test.

NB: Federal Civil Service Directives specify that at least three candidates must compete for a
vacancy before a final candidate is selected unless the hospital can evidence that the level of
professional skills and training required are scarce in the market, in which case, less than three
candidates may be allowed to enter into competition. It may be necessary to advertise the
position for a second time, or more widely, if there are insufficient applicants following the first
vacancy announcement.

3.6.5 Competitive Assessment

Short listed candidates should be assessed against each other by interview. The hospital may also
conduct a written examination or practical test for positions that require technical knowledge and
skills.

Interviews should be conducted by the selection team. The role of each interviewer should vary.
For example, the immediate supervisor should evaluate the candidate’s technical knowledge
while the HR representative should investigate more general skills and behaviours.

The following techniques may be useful for the interviewers when conducting an interview:

 Be familiar with the job description,

 Ask the applicant questions that draw information from him/her

 Describe hypothetical situations that might occur on the job and ask how they would handle
them
 Use how, what, why and when questions as open ended questions that elicit answers that
reveal the candidate’s interests, attitudes and approach to work
 Describe the job, and

 Answer any questions the applicant may have

A scoring system and comparative assessment form may be used to compare candidates and to
select the top applicant. A sample Candidate Assessment Form is given in Appendix H.
All candidates should be notified of the outcome of their interviews/written exams/practical test
by the HR Department in as short a time as possible, ideally no more than 5-10 days following
interview/written exams/practical test. At the time of interview candidates should be informed
both how and when they will be notified their results.

3.6.6 Reference Checking

Prior to employment the credentials and employment history of the selected candidate should be
verified. The candidate should submit original ESLCE/certificate/diploma/degree documents (as
appropriate) for verification by the HR department. Photocopies of the original(s) should be
taken and filed in the employee file. A minimum of two professional work references should be
obtained. References can be verified by telephone or in writing. A standardized form should be
used to obtain references. A sample Reference Check Form is given in Appendix I.

3.6.7 Appointment and Probation

Prior to appointment the candidate should submit a medical certificate (except HIV test) to
demonstrate his/her fitness for service. The assessment for the medical certificate can be done
either at the hiring Hospital or at another health facility. The medical certificate should include a
history of any current or previous illnesses and a full physical examination. The candidate should
also provide written testimony from policy to prove that he/she does not have a criminal record.
A clearance letter from the previous employer should also be submitted.

The first six months of employment of any new employee will be a probationary period. A
probation period appointment letter should be issued to the selected candidate. This letter should
stipulate, at minimum, the following:

 employee name

 position and department/case team where located

 position identification number

 salary and benefits

 job grade

 starting date
  employment status: temporary or permanent

 full time or part time position

A copy of the job description should be included with the letter.

At the end of the six months a performance evaluation should be conducted. If the performance
of the employee in probation period is satisfactory, a letter of permanent employment should be
issued. If the evaluation is unsatisfactory, the employee should be instructed on his/her
shortcomings and provided with training/orientation as necessary. The probation period can be
extended for a further three months. If the work performance remains unsatisfactory the
employment can be terminated.

3.6.8 Promotion

In accordance with federal and regional directives, hospitals should consider employees for
promotion. The hospital should post an internal vacancy announcement for each post that may be
filled by promotion of an internal candidate. The vacancy notice should describe the post and
essential education, work experience, knowledge and skills required. A ‘promotion selection
team’ should be established to review all applicants for promotion. The procedures may have
slight differences between regions but according to the federal recruitment and promotion
directives the team should be comprised of;

1. Head of the directorate/department/ Case Team where the post will be located (Chair)

2. HR directorate/department/support process Head or Representative

3. HR Professional assigned by HR directorate/department/support process (Secretary)

The following criteria should be considered when assessing a candidate(s) for promotion:

1. Permanent employee who has completed his/her probation period

2. Should fulfil the essential qualification requirements for the vacant position
3. Must have attained a satisfactory or above performance evaluation result in 2 subsequent
performance appraisal.
 4. Must not be under any current rigorous disciplinary measure (for example demotion or
salary suspension)
5. Should be no less than 3 months before retirement age.

Health Professionals career promotion should follow the health professionals career ladder and
qualification requirement procedures.

3.6.9 Transfers

An employee may be transferred from one position to another of similar grade and salary when
the need arises. Employees may be transferred when:

1. An emergency situation arises and there is a need to fill any gaps in a service. This is a
temporary transfer and should not last more than a year
2. An employee has been deemed unfit to carry the functions of his current post by a
medical authority
3. The current position of an employee has been abolished

An employee may also be transferred from one government institution to another when needed
and upon agreement of the employee, recipient and sender institutions. The transfer of the
employee should be to a position of equal grade and salary as their current position.

3.7 Orientation

3.7.1 New Hire Orientation/Induction

New-hire orientation training should be provided to all new employees (see Table 1 below). The
orientation provides information about the hospital’s mission, vision and values – and helps build
the employee’s sense of identification with the organization. The orientation enables the new
employee to become familiar with the entire organization as well as his/her own work area and
department. The orientation should include an overview of the job expectations and performance
skills needed to perform the job functions and an explanation of reporting structures and
mechanisms. The Employee Code of Conduct and Statement of Employee Rights and
Responsibilities should be introduced to the worker at this stage (see Appendices B and C).
Training should also be provided on any equipment or specific documents/forms that are used in
the position.
A copy of the Employee Hand Book should be given to the employee when his/her employment
begins and he/she should be given opportunity to raise questions or discuss this with his/her
supervisor or the HR Directorate/Department/Support Process during the time of orientation.

Table 1 New Hire Orientation

Hospital-  Overview of the hospital

wide o Mission, vision and core values of the facility
information
o Services offered

o Organizational structure

o Hospital layout

 General overview of each department’s functions

 HR policies, including benefits

 Safety guidelines (e.g., standard precautions, fire safety, and

disaster preparedness plan)
 Performance Appraisal Procedures

 Employee Code of Conduct

 Employee Rights and Responsibilities

Job specific  Specific responsibilities of their job (job description)

 Performance expectations

 Reporting mechanisms

3.7.2 In-service/Refresher Orientation

In addition to orientation for new employees, the HR Case Team should also provide recurring
orientations to all staff in order to:

 orient existing staff who may not have received new hire orientations

 introduce new HR policies and procedures to staff

  provide employees with a forum to discuss issues with the HR department

Hospitals should provide updated orientations to all staff at least once a year. The training should
be on site, and preferably should not exceed one day in duration. The orientation should cover
both general HR policies and department specific policies and hence may be provided on a Case
Team by Case Team basis. It may be necessary to provide the orientation on more than one
occasion to ensure that all staff can participate.
3.8 Salary and benefits

An important component of Human Resources for the hospital is effective remuneration

administration. While the hospital may be required to work within government-directed
protocols and/or regulations for salaries and fringe benefits, the compensation system will
directly affect the organization’s ability to attract and retain quailed employees.

3.8.1 Compensation system factors

Equity in pay between jobs is the foundation of a sound compensation system. This involves
consideration of three factors:

1. Internal equity: How does the pay of various jobs compare? What should a nurse
earn compared to a dietary worker or physician? To achieve internal equity, job
requirements must be identified and their complexity evaluated. This evaluation can
be reduced to a numerical factor or rating, so that jobs can be compared.

2. External equity: How does the hospital’s pay for jobs compare with that at a
competing organization? As supply and demand affects the marketplace for workers,
external equity becomes more important. Shortages of a certain type of staff can
create “wage wars.”

3. Philosophy: How does the hospital see itself as an employer – one that targets its
wages at the midpoint of the market so that it stays competitive in the marketplace or
one that targets its wages near the top of the market so it can attract the best
candidates?

3.8.2 Benefits

In addition to the basic salary, employees may be provided with additional benefits as
determined by hospital management. Benefits may be in the form of medical benefits, pension,
housing, vehicles, vacations, holidays, or sick time. These forms of compensation add to the
overall cost of labour for the hospital, so decisions regarding fringe benefits must be evaluated to
maximize employee satisfaction and minimize costs.
Some benefits will be common to all employees (e.g. medical benefit). In addition to these
universal benefits, hospitals should seek to develop and implement a benefit system that:

 Motivates staff to improve performance,

 Incentivizes staff to remain with the hospital, and

 Attracts new employees to the hospital.

Benefits that hospitals may consider include:

1) Medical benefit

2) Pension

3) ‘Top up’ allowance: This is particularly useful to attract skilled employees to remote
locations where the living conditions are less convenient than in larger towns.

4) Housing allowance: as above.

5) Transport allowance: as above

6) Duty allowance: Payments made for employees who work evening or night hours

7) Risk and Hazard allowance: A specified amount of money to be paid to employees whose
positions expose them to risks. For example, an incinerator operator or X-ray technician.

8) Telephone allowance: allowance given to employees (senior positions) for work related calls
made outside of working hours or when using personal telephone.

9) Travel allowance: allowance given to employees who use a non-hospital vehicle for transport
to work-related activity.

10) Uniforms allowance: provision of uniforms to employees in accordance with the Federal
 Civil Service directive

11) Bereavement allowance: payment given to the family if an employee dies.

12) Training opportunities/allowance: The hospital should ensure that all workers have the skills,
knowledge and competence to perform their required duties and should provide all necessary
trainings to ensure that essential job functions can be fulfilled. However in addition to this,
hospitals may give opportunities for staff to participate in additional ‘career development’
trainings that will enhance their opportunities for promotion within the hospital, or enhance
their chance to obtain a higher position within another organization in the course of time.
Training may be provided ‘in house’ or by an external agency (either on-site or off-site).

13) Participation in private wing activities: Staff who provide services in a private wing are
entitled to a share of the profit made by the service. The opportunity to participate in private
wing activities may be offered preferentially to candidates with good work performance and
acts an incentive for employees to improve their performance. (For more information about
private wing establishment and activities please see Chapter 10 Financial Management).

14) Access to recreational services such as:

a. Cafeteria

b. Break room (equipped with a television and other recreational equipment)

c. Green area

d. Library (equipped with books and computers with internet connectivity)

e. Quiet rooms for prayer (multi-purpose prayer room)

15) Rewards for high performers (see section 3.10.4 Employee Recognition)

3.9 Performance Management

Performance management is an on-going process focused on reinforcing high performance or
improving substandard performance to enhance the knowledge, skills and behaviors of all
employees in order to achieve organizational goals. Performance management has three main
components: supportive supervision, performance-based evaluation and performance
improvement.
3.9.1 Supportive Supervision
Supportive supervision is a continuous and participatory process, where a supervisor or manager
accepts shared responsibility for an employee’s professional development in order to get the best
possible performance from the employee. Performance can be enhanced through managers
working directly with their staff to set clear goals, standards and expectations. This includes
mentoring staff, providing constructive feedback and open and two-way communication.

The intended result of supportive supervision is that employees develop a supportive link with
their supervisors, marked by open communication to address concerns and share ideas. There
should be a process for mentoring and coaching staff, including developing performance plans in
advance so that there is clarity in terms of job/performance expectations; a feedback mechanism
on performance; and support for staff through training or skill development, as needed. In order
to achieve this, the hospital should prepare a supervision policy, which clearly spells out
procedures, rules, responsibilities and authority of managers.
3.9.2 Performance Based Evaluation
Performance-based evaluation (PBE) is the practice of periodic review and evaluation of an
individual’s or team’s performance against specified goals or expectations. The first step in
performance evaluation is to determine the performance objectives of each employee. The goals
and expectations may be described in an individual’s job description. Alternatively, goals and
expectations may be described in an alternative performance framework - for example the
‘Balanced Scorecard’ (see Chapter 13 Monitoring and Reporting) - and an individual or team
may undergo evaluation against these criteria. The advantage of the Balanced Scorecard
approach is that the hospital’s vision, mission and plans can be cascaded down to
department/team level and subsequently to the level of the individual, ensuring that individual
and team actions contribute to the overall goals of the hospital. Whichever performance criteria
are used, there must be a clear understanding from the outset between the supervisor and
individual/team on the specific goals and expectations that the employee(s) will be evaluated
against. In PBE the supervisor assesses how well the individual is fulfilling the roles and
responsibilities outlined in his/her performance plan (i.e. job description, and/or BSC) and
whether remedial action is necessary. A sample job description and related PBE framework are
presented in Appendices D and J.

Performance evaluation should be conducted by the immediate supervisor of each employee.

PBE should be conducted at the end of the probation period and semi-annually thereafter, or
more frequently if poor performance is identified and corrective action is necessary.

To be effective, PBE must be linked to both positive reinforcement (recognition, benefits or

rewards) for good performance and to performance improvement processes when areas of poor
performance are identified.

Positive reinforcement

Employees who obtain a satisfactory or above satisfactory result on performance evaluation are
entitled to a periodic salary increment as specified in Federal/Regional Civil Service Legislation.
Additionally, hospitals should devise rewards for good performance such as ‘Employee of the
Month’ recognition, or opportunities for further training or participation in Private Wing
activities for those employees who demonstrate good performance. For further discussion on
staff motivation and benefits see Section 3.10 below.
3.9.3 Performance Improvement Process (PIP)
The Performance Improvement Process is designed to identify, communicate, and intervene
when job performance is below expected standards. Performance improvement interventions
should be initiated as soon as it becomes apparent that an employee is not meeting expected
performance standards. Supervisors should not wait until the end of the review period to
communicate the need to improve performance if the need to improve is identified earlier in the
period.

Performance improvement should begin with coaching/counselling or specific training to address

identified gaps, and should proceed to more formal oral or written warnings if performance does
not improve as a result. Finally, where performance does not improve despite remedial action, it
may be necessary to terminate the employment of the individual. The duration of each step of the
Performance Improvement Process (Coaching/Counselling, Oral Warning, and Written Warning)
will vary depending on the performance issue and on the employee's progress. Normally, each
step would last from 30 to 90 days. No matter what the stated duration of the step, additional
action may be taken before the stated end of the step if the performance continues to decline
noticeably or the employee does not make a good faith effort to meet expectations. By acting
promptly and decisively, the organization can avoid long-term problems.

Coaching and Counseling

In many cases, informal coaching and counseling will be all that is necessary to facilitate
improved performance. The objective of coaching is to help the employee recognize – and solve
– the problem early on. When a problem occurs or begins to develop regarding work
performance, the supervisor should discuss the situation with the employee before it becomes
serious. During such a discussion, the supervisor should explain exactly what the performance
expectation is and specifically how the employee is failing to meet it. Once the employee agrees
(or at least understands) that he or she is accountable for meeting expectations, the employee and
supervisor should jointly explore steps the employee might take to ensure he or she meets
expectations in the future. Ideally, the employee and supervisor will agree on the approach that
will be taken to solve the problem. If agreement cannot be reached, it is the supervisor’s
responsibility to ensure that the employee understands what he or she must do to solve the
problem and the consequences for the employee if the problem is not resolved. The supervisor
also needs to tell the employee how and when he or she will follow up to provide additional
feedback on progress against the agreement.

If the employee’s performance does not improve with coaching/counseling or it is apparent that
the employee is not sufficiently trying to improve his/her performance then it may be necessary
to take Disciplinary Action as described in Section 3.10.5 below.

In all cases of poor performance, the supervisor should consult with the HR Department and
other senior management as necessary for advice and decision making about any actions
necessary.

All PBE results and any Performance Improvement measures should be documented in the
employee personnel file for follow up and future reference.

A sample Performance Improvement Process Form is presented in Appendix K.

3.10 Training and development

Federal Legislation stipulates that all public hospital employees are entitled to training to
improve his/her capability, or prepare him/her for increased responsibility based on career
development. Staff training includes both short and long-term training and educational
opportunities.

Staff training benefits the hospital by:

Creating a pool of readily available and adequate replacements for personnel who may
leave or move up in the organization
Ensuring adequate human resources for expansion into new programs

Enhancing the hospital's ability to adopt and use advances in technology because of a
sufficiently knowledgeable staff
Improving staff morale which in turn enhances performance and reduces employee
turnover
Attracting staff to the facility

Reducing the need for supervision

Plans for staff training should be included in the human resource development plan. Training
plans should take into consideration the needs of the organization as a whole and the needs of
individual workers. The HR department should conduct a training needs assessment to identify:

Knowledge, Skills and attitude gaps

Performance gaps at institution, work unit and individual levels

Who needs to be trained? (All staff, selected departments/case teams?)

What types of trainings should be offered to staff?

The hospital’s training plan should also include an estimate of cost and budget needs. The HR
department should communicate budget needs to the SMT to ensure that budget is secured for
planned training needs. The frequency of training programs should be based on the level of need
and the level of importance to improving performance or quality of care. For example, infection
prevention and nursing process trainings could be conducted at least 2-3 times a year, as both are
key areas relating to patient outcomes. In addition to trainings that improve employees’ technical
skills, the hospital should also organize trainings to develop the management skills of employees.

All trainings can be provided either ‘in house’ or through external trainings. Clear selection
criteria should be set to determine who is selected to attend a specific training. This will ensure
transparency of the process and allow for equity in the distribution of trainings among staff.

As part of staff development each hospital should have a core set of trainings that are provided to
staff on a regular basis. For example, trainings should be provided to all staff on fire safety, the
major incident plan, occupational health and safety risks and infection prevention practices.

The main objective of training is to instil a new or renewed behaviour or practice to a specific
area of work. Therefore, trainings do not end when the training modules conclude but rather
when the impact of the training is assessed and the desired outcome is achieved. All trainings
should be evaluated to assess whether the desired outcomes (knowledge or skills have been
achieved) and their impact on employee performance. If the objectives have not been attained
additional training, using different methods may be necessary.

Staff development (medium- and long-term trainings/education) should be based on workforce

plan. Staff development plans are aimed at creating pool of leadership successors and competent
manpower for key positions.

3.11 Continuing Professional Development (CPD)

FMHACA’s Continuing Professional Development (CPD) Guideline for Health Professionals

define Continuing Professional Development (CPD) ‘as a range of learning activities through
which health professionals maintain and develop throughout their career to ensure that they
retain their capacity to practice safely, effectively and legally within their evolving scope of
practice’. This definition emphasizes the need for health professionals to maintain, update and
enhance their knowledge, skills and attitude in order to adequately deliver quality health care.
Health professionals need to cope up with the changing disease pattern in which diseases that
had been eradicated are now reemerging, as well as an increase on non-communicable diseases.
CPD helps to maintain professional competence in an environment of numerous challenges,
rapid organizational changes, information technology, increasing public expectation and demand
for quality and greater accountability.

CPD is an ethical obligation for all health professionals to ensure their professional practice is
up- to- date and can contribute to improving patient outcomes and quality of care. It is also a
mandatory for health professionals practicing in Ethiopia. Health professionals should
accumulate the mandatory credit hours or certificates of training attendance for relicensing their
profession every five years.

According to the FMHACA’s Continuing Professional Development (CPD) Guideline for Health
Professionals, some of the features of CPD applicable to the context of hospitals are:

Continuing professional development refers to all activities health professionals

undertake formally so as to maintain, update and develop their knowledge, skills and
attitudes in response to the health service needs of the public
Continuing professional development denotes to the period of education and training of
health professionals commencing after completion of basic or post graduate health
professional training

Continuing professional development is a broad concept referring to the continuing

development of the multi-faceted competencies inherent in health services covering wider
domains of professionalism needed for high quality professional performance. It aims to
maintain and develop competencies of individual health professionals essential for
meeting the changing needs of patients and the health service system and responding to
the new challenges of scientific development
Continuing professional development must serve the purpose of enhancing the
professional development (what is relevant to current practice and the future profession)
of health professionals
 Continuing professional development should occur when; 1) there is a clear need, 2)
learning is based on the identified need, and 3) there is follow up to reinforce the learning
is accomplished
The challenges or barriers of accessing CPD trainings and activities are costs, time, lack of
motivation or incentives and geographical distances. Hospitals need to recognize the
importance of CPD and enable all health professionals to undertake CPD suitable to their
needs and interests by identifying and tackling the barriers for accessing CPD. Hospitals
should:

Looking at barriers and incentives to following CPD, the need for systemic and
organizational support to professionals, in terms of allocating time for CPD in workplace and
staff planning and in ensuring costs of CPD are not prohibitive, is identified as shared
responsibility, in which employers, professional organizations and the ministries of health
have a role to play, alongside the professional. It is also recommended to make use of
flexible learning tools and ensure CPD is relevant to health professionals’ daily practice, so
as to improve access and motivation.

1. Undertake CPD need assessment for their workforce and communicate the result to
training or accreditation institutions
2. Allocate CPD time in workplace and staff planning, and avail CPD activities to their
employees CPD activities
3. Make use of flexible learning tools and ensure CPD is relevant to health professionals’
daily practice, so as to improve access and motivation.
4. Ensure costs are not prohibitive for accessing CPD by taking shared responsibilities with
other stakeholder in soliciting fund for their employees’ CPD activities
3.12 Employee Relations

The HR Directorate/Department/Support Process should strive to establish employer-employee

relationships that contribute to satisfactory productivity, motivation and morale. Employee
relations are directed toward preventing and resolving problems involving individuals that arise
out of or affect work situations. The hospital should create conducive work environment and
conduct periodic work climate assessment, and develop work climate improvement plans.
The hospital should provide services for staff including toilets, showers, safe drinking water, a
canteen and library facilities. For further discussion on staff services please see Section 3.2.1 of
Chapter 8 Facilities Management.

3.12.1 Employee Code of Conduct and Professional Ethics

Each hospital should devise a set of standards that governs employee conduct and ethics. The
standards should include what is expected from the employee in their work, their interactions
with patients, caregivers, visitor and other staff. These standards/principles should be made
known to all employees and packaged in a code of conduct. A sample of code of conduct is
presented in Appendix B. Outlined below are core areas that should be covered in an employee
code of conduct and ethics.

Guidelines for employees to follow when offered gifts: Employees should refuse any gifts,
favours or hospitality that might be interpreted as an attempt to gain preferential treatment, not
ask for or accept loans from anyone under their care or anyone close to them and must establish
and actively maintain clear boundaries at all times with patients, their families and caregivers.

Patient care: Patients have the right to fair and equal access to care from all staff, according to
their needs. All employees should care for all patients equally and without prejudice to age,
gender, and economic, social, political, ethnicity, religious or other status and irrespective of
personal circumstances. They should demonstrate a personal and professional commitment to
equality and diversity in caring for patients and ensure that their professional judgment is not
influenced by any commercial or preferential considerations.

Confidentiality: All patients have the right to expect that any information they disclose in the
course if their care is confidential between themselves and their treatment team. Hospitals should
ensure that there is a written hospital information management policy which sets out how the
hospital ensures that information held by the hospital on patients, their families and staff is
handled confidentially.

Respect for persons: Health care practitioners should respect patients as persons, and
acknowledge their intrinsic worth, dignity, and sense of value.
Best interests or well-being: Health care practitioners should not harm or act against the best
interests of patients, even when the interests of the latter conflict with their own self-interest.
Health care practitioners should also act in the best interests of patients even when the interests
of the latter conflict with their own personal self-interest.
Compassion: Health care practitioners should be sensitive to, and empathize with, the individual
and social needs of their patients and seek to create mechanisms for providing comfort and
support where appropriate and possible.
Integrity: Health care practitioners should incorporate these core ethical values and standards as
the foundation for their character and practice as responsible health care professionals.
Tolerance: Health care practitioners should respect the rights of people to have different ethical
beliefs as these may arise from deeply held personal, religious or cultural convictions.
Dress Code and Identification: The Hospital should have guidelines which clearly and strictly
define dress codes for all employees. Such guidelines should explicitly list each article of
clothing, the colour, and condition which is acceptable in hospital settings. The hospital should
have colour-coded system– one which clearly and easily allows patients to distinguish between
staff. The hospital should also have a policy to ensure that all staff wear their identification
badges at all times.

Community: Health care practitioners should strive to contribute to the betterment of society in
accordance with their professional abilities and standing in the community.

Professional competence and self-improvement: Health care practitioners should

continuallyendeavour to attain the highest level of knowledge and skills required within their
area of practice.

3.12.2 Employee Motivation

Employees who are motivated tend to work harder and stay longer with their employer. To
“motivate” is to stimulate the employee’s enthusiasm and factors that harness their driving force.
What motivates employees? Each hospital employee brings his/her own personal goals and what
they hope to gain. These might include:
 1) To get a good job and keep it

2) To earn money and help support the family

3) To advance professionally

4) To improve their financial situation

5) To have a job that is pleasant, secure, and offers opportunity for improvement

6) To have fair and consistent supervision – free from discrimination or harassment

7) To receive recognition, praise or other rewards for a job well done

8) To help people and contribute to society

9) To work in a good work environment and

3.12.3 Job satisfaction

Job satisfaction is another component of employee relations. Job satisfaction depends on the
employee’s evaluation of the job and the environment surrounding it. The employee evaluates
their actual experience in the job – remuneration, supervision and the work conditions – when
assessing their job satisfaction.

1) Remuneration: Ideally, the compensation for the job should be deemed equitable by
the employees. If, instead, the employee believes the wages paid are substandard in
the market, then the hospital is at risk for unwanted turnover, low staffing ratios,
higher overtime costs and lower productivity by employees.
2) Supervision: Supervision of the employee should be fair and consistent, following
established policies and procedures that are applied consistently across the
organization. The supervisor communicates clearly to the employee the expectations
for the job and any necessary performance improvements that must be undertaken to
 meet expectations.
3) Work conditions: Work conditions relates to the climate in which the work takes place

– do supervisors and co-workers have mutual respect, are there positive interactions,
shared problem solving, investment in improving quality outcomes and an interest in
 employee work life quality? Hospitals should provide a safe and comfortable working
environment for staff, including accessible toilets, showers and changing facilities
(where relevant). Staff should also have access to refreshments and meals, to a library
with internet access and to private recreational areas (such as garden or canteen).

3.12.4 Employee Recognition

Staff motivation and performance may be enhanced by a recognition/reward scheme that
acknowledges outstanding individuals or teams.
Employee recognition can be in the form of a certificate or letter from hospital management to
the individual/team, or through an ‘Employee of the Month’ program where the hospital
identifies employees who evidence the hospital’s vision, mission and core principles in their
everyday work. Recognition can also be coupled with a reward (for example additional vacation
days, gift, or financial reward). Ideally recognition should be public, for example announcements
could be made in the hospital bulletin or posted on the hospital notice board etc. In addition, the
hospital can also organize all staff gatherings to recognize the contribution of the entire hospital
workforce.

The hospital should set clear criteria for the selection of staff for recognition or reward. The
selection and reward process should be transparent and made known to all staff. Any recognition
should be filed in the employee file as evidence of good performance and should be referenced
when evaluating an individual for further opportunities for advancement and benefits, such as
training opportunities.

3.12.5 Health Workforce Productivity

Hospitals should ensure that their health workers perform well and deliver effective, quality
health services to the communities they serve. In addition to developing long-term strategies for
increased motivation and retention of health workers hospitals should also strengthen the
productivity and performance of the workforce so as to getthe best possible results and the highest
impact with existing resources. Hospitals expect to conduct workforce productivity
measurement, identify the underlying causes for health workforce productivity problems and
potential intervention areas for health workforceproductivity improvements.
 1. How to Measure Health Workforce productivity

Health workforce productivity measures the amount of health services produced

by health workers in a given period of time. While the issue of productivity applies
to all levels of the health system, (i.e., national, regional, zone/Woreda, and facility
levels) health workforce productivity can often be best analyzed and understood at the
facility level.

Health workforce productivity is calculated by taking the ratio of the service delivery
outputs produced over the human resource inputs used. The calculation assumes that
all other health systems inputs are constant among the facilities whose health
workforce productivity is being measured.

The denominator, or the human resource inputs in the productivity ratio, is the
health workers’ salary, which represents the time and effort of the health workers
who contribute to health services deliveries in which the productivity ratio
measures.

Health workforce productivity can be improved either by increasing outputs for a

given number of inputs or by reducing the use of inputs for a given level of
outputs. Productivity analysis can help inform if the level of outputs is acceptable
given the present input use. If productivity is low, the analysis can help managers
and supervisors identify what they can do to enhance productivity at their health
facilities.

Some examples of service delivery areas and the indicators commonly used to represent
the numerator, or service delivery outputs, in the productivity ratio include the
following:

Health Service Area Out Put Indicator Weight

Outpatient care Number of outpatient

Consultations
Inpatient care Number of inpatient days
Antenatal care (ANC) Number of ANC consultations
Labor and delivery care Number of institutional
deliveries
Family planning (FP) Number of FP consultations
Child immunizations Number of
immunizations

Administered

(Source: Vujicic, Addai, and Bosomprah 2009,)

To calculate total health workforce productivity, the single health service outputs are
combined into an aggregate output measure. Total service provision is not simply the
sum of the individual services because not all the services are of equal value in terms of
time, effort, and impact. Therefore, weights are assigned to each health service. It is
recommend using service weights that represent the relative human resources costs of
producing the services.

Several different categories of health workers contribute to the provision of health

services. The decision of which of the health workers to include in the input calculation
should be guided by the set of health services included in the output calculation. All
categories of staff that contribute to the provision of the
relevant health services should be included in the input calculation. Therefore,
typically, it will be appropriate to include all categories of staff except in rare cases
when the service unit is very narrow (e.g., surgical ward). Staffing categories should
be defined according to the categories used in the unit of analysis. In general, these
will include: Medical, Nursing, Specialties (e.g., surgery), Laboratory, Pharmacy,
Diagnostics, Support Staff, and Administration.

Generally, hospitals can apply the following steps to generate a measure of workforce
productivity
Step 1 – Define the Service Unit

Measuring the Aggregate Facility-level health workforce productivity would be of great interest
to compare the productivity level of all hospitals. In addition to the aggregate health workforce
productivity the facility may decide to measure Special Service Area Productivity Level.
Step 2 – Define the Categories of Health Services to Include as Outputs in the Numerator

In practice, two of the broadest indicators of health care services commonly used to measure
aggregate workforce productivity are inpatient days (IPD) and outpatient visits (OPD). These are
often used because they are comprehensive measures of health care service delivery and are
relatively easy to construct from HMIS databases. In order to measure departmental level/
special service productivity, the availability of data on the utilization of that specific service
shall be considered.
Step 3 – Determine a Method of Aggregating Different Categories of Health Services into a
Composite Service Indicator
A simple method of aggregating health services into a single Composite Service Indicator (CSI)
is to take a weighted sum of the volume of various categories of services produced in a service
unit:

Composite Service Indicator= Summation of the volume of service Z in service unit Yx Weight assigned to
service Z

Step 4 – Define the Categories of Human Resources to Include as Inputs in the Denominator
Several different categories of health workers contribute to the provision of health services. All
categories of staff that contribute to the provision of the relevant health services should be
included in the input calculation. Therefore, typically, it will be appropriate to include all
categories of staff except in rare cases when the service unit is very narrow (e.g. surgical ward).
Staffing categories should be defined according to the categories used in the unit of analysis. In
general, these will include: Medical, Nursing, Specialties (e.g. surgery), Laboratory, Pharmacy,
Diagnostics, Support Staff, and Administration.
Data Sources and analysis

The data need to measures aggregate productivity as well as especial service productivity shall
be extracted from the routine health management information system. The data for this consist of
clinical service data (i.e. outpatient visits, inpatient days), public health service data (i.e.
antenatal care, supervised delivery, and immunization), and human resource data (i.e. staffing,
and wages).
There are several approaches in selecting weights, again with implicit value judgments. Different
weighting schemes have a large impact on the composite service indicator measure of service
output as well as composite staffing indicator measure of service input. Specifically, the relative
performance of facilities will be affected by the choice of weights. Thus, both weighting scheme
shall be drawn through a consultative process involving, clinicians, hospital managers, Quality
team, and M&E professionals.

3.12.6 Discipline Management

In cases where an employee demonstrates behavior that is unacceptable or in conflict with the
hospital’s Code of Conduct, or where an employee persistently performs poorly despite
opportunities for improvement, it may be necessary to take disciplinary action. Disciplinary
measures should be governed by two principles:

 the employee must be clearly informed by his/her immediate supervisor as to the source of
dissatisfaction, and
 Except in limited circumstances (such as serious professional misconduct or corruption)
the employee should be given the opportunity to correct the problem. A Disciplinary
Committee should be established to investigate all disciplinary charges and to determine
 the appropriate disciplinary measure. The Committee should be chaired by the HR
Department Head. Additional membership should be determined by the hospital CEO.
Each hospital should establish a Policy for Discipline Management that describes the
behaviour or performance issues for which should be brought to the discipline committee,
the range of disciplinary measures, the process by which disciplinary action is taken and
the appeals process by which an employee may appeal against any disciplinary measures.
The Policy should be included in the Employee Handbook.
Civil Service Regulations stipulate six types of disciplinary measures:
1. Oral warning
2. Written warning
3. Fine up to one month’s salary
4. Fine up to three month’s salary
5. Downgrading of position for up to two years
6. Dismissal
The first three categories are considered as ‘simple disciplinary penalties’ while the latter three
categories are considered as ‘rigorous disciplinary penalties’. Examples of behaviour that might
result in a ‘rigorous disciplinary penalty’ are presented in Appendix L. Evidence of rigorous
penalties should remain in the employee record for 5 years while simple penalties should remain
in the employee file for 2 years.

In general, disciplinary action should not come as a surprise to the employee and any concerns

with an employee 17-45

Guidance for Supervisors

It can be very difficult to advise an employee that you have concerns with his/her behavior or
performance. However, to enable the employee to improve it is essential to be honest, frank
and precise about the problem and to be clear about your future expectations of the
employee. Vagueness and generalities, or glossing over the situation, are likely to leave the
employee uneasy and feeling that something is wrong but unable to correct his/her behavior
or performance. Criticism should be related to work related matters only. Wherever possible,
guidance on how to improve should also be given.
performance or behavior should be addressed at an early stage to avoid the need for ‘rigorous’
disciplinary measures. It is the responsibility of the employee’s immediate supervisor to explain
to the employee those areas in which he/she is expected to improve, to make suggestions about
how to improve, and to allow time for the employee to make improvements. It is usually only in
instances of serious misconduct that the more severe penalties, including termination of
employment, should be considered.

3.12.7 Grievance Management

A grievance is a concern, problem or complaint that an employee has about his/her job, for
example his/her employment terms and conditions, work environment, contractual or statutory
rights or the way he/she is being treated at work.

Grievances can often be avoided by good communication between employees and senior
managers such that problems are identified and corrective action taken at an early stage.
Grievances are more likely when employees feel that their views are not being heard or their
concerns are not being addressed. Grievances are more likely to be settled when employees
perceive that the process is transparent, fair and without retribution for the employee.
Each hospital should establish a Grievance Policy that describes the steps that could be taken by
an employee should he/she have any concerns or complaints about the work environment or their
work situation. A Grievance Committee should be established that is responsible to investigate
employee complaints about, and make recommendations in relation to:

 Interpretation and implementation of laws and directives

 Protection of rights and benefits

 Occupational health and safety

 Placement and promotion

 Performance appraisal

 Undue influence exerted by supervisors

 Disciplinary measures

 Other issues related to conditions of service

The Grievance Committee should be chaired by the Head of the HR Department, with other
members determined by the CEO.
Any employee with a complaint about their work situation should first try to resolve the issue
with their immediate supervisor. If this is not possible a Grievance Form should be completed
and submitted to the Grievance Committee. A sample Grievance Form is presented in Appendix
M. All grievances should be responded to promptly and a written response should be given to the
complainant following the investigation. A copy of the Grievance Form and written response
should be kept in the employee file.
All grievances should be kept confidential unless required to disclose to senior management or
higher authorities (based on severity).
The HR Department should maintain an anonymous record of Grievances received and should
monitor these on a monthly basis, identifying any trends or common themes that might require
further investigation or action by senior hospital management.

3.12.8 Staff Survey

Each hospital should regularly (for example biannually) conduct a staff survey to assess staff
satisfaction with the workplace and suggestions for improvement. Summary results should be
presented to the SMT and Governing Board.

3.13 HR Audit

A Human Resources Audit is a comprehensive method (or means) to review current human
resources policies, procedures, documentation and systems to identify needs for improvement
and enhancement of the HR function as well as to assess compliance with ever-changing rules
and regulations. An Audit involves systematically reviewing all aspects of human resources,
usually in a checklist fashion. The purpose of an HR Audit is to recognize strengths and identify
any needs for improvement in the human resources function. A properly executed Audit will
reveal problem areas and provide recommendations and suggestions for the remedy of these
problems. The hospital is expected to conduct periodic(annually) HR Audit by establishing an
HR Audit committee comprising people from Internal Audit, Legal Service and HR Department.
The areas to be covered by the HR Audit include;
Hiring, promotion and transfer processes
 Compensation and benefits

Performance evaluation process

Medium- and long-term training opportunity processes

Job descriptions

Employee orientations

Safety trainings

Disciple and employee grievance handling processes

Personnel files

Termination process and exit interviews

3.14 Termination of employment

A worker’s employment may end through retirement, resignation, termination by the employer
or death. Whenever an employee leaves the workplace an exit interview should be conducted to
gather information about the employee’s experience and any lessons that could be learned for
future employees. A sample Exit Interview Form is presented in Appendix N. The exit interview
should be reviewed by the Head of HR to identify areas for follow up action, and thereafter
should be filed in the employee’s Personnel Record.
3.15 Personnel Records
For organizational and legal purposes, hospitals should maintain and regularly update a file on
each employee that includes information such as credentials for hiring, ongoing performance
evaluations, and any documentation concerning performance improvement action. Hospitals may
need to share employee data between departments – Nursing and Human Resources, for example
– and files are an ideal way to facilitate this function. Employee files are also the repository of
documents defining the mutual understanding between the employee and employer concerning
workplace policies and performance expectations.

3.15.1 Organization of Personnel Records

Employee Records should be filed by employee name. Within each individual file, papers should
be organized by category - Hiring Documents, New Hire Orientation, Education and Trainings,
Performance Management, Exit of Employment, Other. Within each category, documents should
be organized by date.
Standardized Forms should be used for all documents maintained in each Personnel File, for
example application form, performance evaluation, disciplinary action etc. All forms should
include the following basic information:
 Employee name, position/job title,

 Date of action(s) taken

 What action is being taken, and

 Signatures of all involved, signed when the form is completed.

3.15.2 What to maintain in the Personnel Record

All-important job-related documents should go in the file, including:

1) Hiring documents:

a) job description for the position,

b) job application and/or resume,

c) offer of employment,

d) references checked in the hiring process,

e) any contract, written agreement, receipt, or acknowledgment between the employee and
the employer (such as an employment contract, or an agreement relating to a hospital-
provided car), and
f) Payroll/wage information.

2) New employee orientation:

a) receipt or signed acknowledgment of having received the employee handbook,

b) forms relating to employee benefits,

c) forms providing next of kin and emergency contacts,

d) forms related to beneficiary designation and

 e) Documentation of completion of new hire orientation.

3) Growth and development: Any document that evidences an employee’s advancement in

skills or knowledge should be kept here, for example
 a) Record/certificate of all trainings completed

b) Copies of educational program completion (certificates, diplomas or degrees)

4) Performance management and improvement documents:

a) all performance evaluation documents

b) awards or citations for excellent performance

c) recognition letters from patients or caregivers regarding the employee

d) complaints from customers and/or co-workers

e) disciplinary documents

5) Exit of employment: This should contain any documents relating to the worker's
departure from the hospital including:
a) Exit interview

b) Documentation of return of all hospital-issued property or items

6) Other forms that should be maintained in the employee file include:

a) Leave forms (including annual leave, maternity, paternity and sick leave)

b) Health examination forms/fitness for duty verification

c) Disciplinary action

d) Grievances filed

e) Any change or update to employee information

3.15.3 Keeping the Personnel Record Up to Date

The HR Department should periodically review each employee's personnel file to ensure that all
information remains accurate, up to date and complete. For example this could be done when the
employee’s evaluation is conducted. Questions to consider include:

1. Does the file reflect all of the employee's raises, promotions, and commendations?

2. Is there a current copy of the employee’s job description that reflects changes made to
 the original job description?
3. Does the file contain every written evaluation of the employee?

4. Does the file show every warning or other performance improvement/disciplinary

action taken against the employee?
 5. If the employee was on a performance improvement plan, a probationary or training
period, or other temporary status, has it ended? Has the file been updated to reflect
the employee's current status?
6. If the employee hand book has been updated since the employee started working for
the hospital, does the file contain a receipt or acknowledgment for the most recent
version?
7. Does the file contain current versions of every contract or other agreement between
the hospital and the employee?

3.15.4 Computerized Personnel Records

Hospitals may choose to install a computerized database to manage selected human resource
information for example employee hire date, transfers, promotions, benefits, annual leave
requests and approval etc. Computerized systems provide easy retrieval of information for audit
and planning purposes (for example calculation of vacancy rates, staff turnover rates, average
performance evaluation scores etc). However, if a computerized system is installed a complete
paper-based personnel file should still be maintained for every employee.

3.15.5 Confidentiality of Personnel Records

Employee records are private and confidential. All employees should have access to their own
employee record, but they cannot add to their employee record without authorization of the HR
Department Head. Employees are not authorized to remove anything from their personnel file,
nor should employees be able to access records other than his/her own. If an employee wants to
look at their personnel file, they should first get permission from the Head of the HR department.
The employee should look at the file in the presence of a representative from the HR department.

3.16 Occupational Health and Safety

Each hospital should assign an Occupational Health and Safety Officer (OHSO) who is
accountable to the HR Department head or HR team leader.
Responsibilities of the OHSO include:

1. To meet with all new employees and review the following:

a. Medical certificate submitted– see section 3.13.2 below
 b. Immunization status – see section 3.13.3 below

2. Conducts site visits to identify, in collaboration with case team staff, workplace risks and
actions to be taken to address those risks, as well as personal protective equipment needs.
(see section 3.13.1 below)
3. In collaboration with the hospital Incident Officer to investigate reports of employee
accidents or injuries in the workplace. (See section 3.1.1 of Chapter 19 Quality Management
and Patient Safety.
4. Facilitate access to treatment for employee’s who have been injured in the work place.

Maintaining a safe work environment for hospital employees is essential for the provision of
quality care and for promoting staff satisfaction.

Both the hospital and employees play a role in ensuring occupational health and safety. The
hospital should:

 ensure that the work place does not cause hazards to the health and safety of employees

 provide workers with protective materials and equipment needed to protect them from
potential hazards
 provide training/orientation to workers which includes safety risks, risk minimization
methods and occupational health and safety services available.

It is also the responsibility of all workers to observe safety rules and procedures, as issued by the
facility. Employees once trained and provided with necessary information, should properly use
safety devices and materials, and report any problems or defects of materials/equipment, as well
as report any situation which they feel presents a hazard at the facility.

3.16.1 Risk Assessment

In order to provide appropriate occupational health and safety services, the hospital should assess
the safety risks that might occur. When assessing safety risks areas that should be considered
include but are not limited to:

 Needle stick
  Slips, trips and falls

 Manual handing

 Violence and aggression (from patients and/or other staff)

 Hazardous substances (chemicals, drugs etc)

 Harassment (from patients and/or other staff)

 Stress

Safety risks can be identified through workplace inspections and reviewing reports of workplace
accidents and injuries. Hospitals should establish processes to regularly assess and take steps to
minimize risk arising in the workplace. Some potential risks and possible solutions for those
risks are described in Table 2 below. Further guidance on risk assessment is presented in Section
3.1.1 of Chapter 19 Quality Management and Patient Safety.

Additionally, hospitals should establish a process for reporting and investigating workplace
injuries or accidents. An Incident Officer should be assigned to receive reports of all incidents
that involve patient or worker safety. He/she should inform the OHSO and jointly investigate
with the OHSO any incidents that involve injury to a hospital employee. The OHSO should
keep a register of all occupational incidents. A sample register is presented in Appendix O.

Table 2 Examples of Risks and Suggested Solutions

Potential Hazard Example Potential Solution

Lifting, Dressing, bathing, Minimizing manual lifting of patients in all
handling, feeding, and toileting cases and eliminating lifting when possible.
transferring
patients
Needlestick Injections, inserting IVs Provide workers with auto disable syringes.
injuries etc Establish syringe usage and disposal procedures
and ensure that staff are trained on injection
 safety procedures.

Transferri Transferring Place equipment on a rolling device, if possible,

ng equipment like IV to allow for easier transport, or have wheels
equipmen poles, wheelchairs, attached to the equipment. Push rather than pull
t oxygen canisters, equipment when possible. Keep arms close to
respiratory equipment, your body and push with your whole body not
x- ray machines, or just your arms. Assure that passageways are
multiple
items at the same time
 unobstructed. Attach handles to equipment to
help with the transfer process. Get help moving
heavy or bulky equipment or equipment that you
can't see over. Don't transport multiple items
alone; for example, if moving a patient in a
wheelchair as well as an IV pole and/or other
equipment get help, don't overexert yourself.
Reaching into Washing dishes, Placing an object such as a plastic basin in the
deep sinks or laundry, or working in bottom of the sink to raise the surface up while
containers maintenance areas and washing items in the sink or remove objects to be
using a deep sink washed into a smaller container on the counter
for scrubbing or soaking and then replace back
in the sink for final rinse.
Source: Adapted from the US Department of Labor, Occupational Safety and Health
Administration, Health Care Wide Hazards Module.

3.16.2 Medical screenings and Health Promotion

All employees should undergo a health screening prior to employment at the hospital. The
health screening can either be done at the hiring hospital or at another health facility. The
candidate should submit a medical certificate (except HIV results) prior to employment to show
fitness for service. The medical certificate should include a history of current and previous
illnesses and a full physical examination.

The OHSO should review the medical certificate of each new employee to identify any special
needs of the employee in relation to the workplace or work duties.

Any employee who has completed his/her probationary period is eligible to receive medical
services at any government medical facility, free of cost. Through the OHSO the hospital should
provide health promotion and disease prevention services for employees and prompt access to
medical assessment for workers who have any symptoms of illness. In particular the OHSO
should educate employees about signs and symptoms of common diseases (such as TB or
malaria) and encourage workers to seek early medical advice should they have signs and
symptoms of these diseases. This is especially important for those diseases that may be
transmitted to co-workers or patients (e.g. TB, hepatitis). Health promotion programs dealing
with issues such as smoking, substance abuse, stress, and reproductive health at the workplace
should be made available to staff.

Voluntary counselling and testing for HIV should be encouraged and made available to all
workers.

3.16.3 Immunizations

Many health care workers are at risk for exposure to and possible transmission of vaccine-
preventable diseases such as TB, hepatitis B, influenza, measles, mumps, rubella, and varicella.
Maintenance of immunity is an essential part of prevention and infection control programs for
health care workers.

The OHSO should review the immunization history of each new hospital employee. For those
whose vaccination status is incomplete, the hospital should provide all routine childhood
immunizations, in accordance with the current national immunization policy. Additionally,
‘booster’ doses should be provided if necessary (e.g. tetanus booster).

The OHSO must assess the need for vaccination on an individual employee basis, taking into
consideration any co-morbidities and/or pregnancy status. Some vaccines are contraindicated in
cases of pregnant workers (varicella, MMR) and workers with HIV infection (varicella), or
AIDS.

3.16.4 Workplace Injuries

As specified in Federal Legislation, any worker who incurs accident, injury or disease as a direct
result of their employment is entitled to receive free general and special medical treatment and
surgical care expenses; hospital and pharmaceutical care expenses; an all necessary prosthetic or
orthopaedic expenses. Additionally, employees are entitled to injury leave with pay, or will be
provided with benefits should s/he be (due to a permanent disability) unable to return to work.

Hospitals should seek to reinstate workers who suffer an accident or injury by making
adjustments to accommodate the injury/disability. Examples include:
 Rearrangement of working hours

 Modified tasks and jobs, including modifications in the case of HIV-positive workers who
may be at risk (e.g. avoiding exposing them to infectious TB patients, particularly MDR TB)
or pose a risk to patients by virtue of their performing invasive procedures (this precaution
may also apply to workers with other infections such hepatitis B)
 Adapted working equipment and environment

 Provision of rest periods and adequate refreshment facilities

 Granting time-off for medical appointments

 Flexible sick leave

 Part-time work and flexible return-to-work arrangements

3.16.5 Occupational Health and Safety Trainings

The hospital should conduct promotional activities to raise the awareness and strengthen
decision-making skills of workers related to infectious exposures and other hazards.

Basic information on infectious exposures and other hazards must be provided to every new
health worker within the first week of employment as part of the new employee orientation.
Refresher orientation sessions can also be provided to other staff annually. Facilities must have
appropriate written informational materials through which updated information on infectious
exposures and other hazards is communicated.

The information provided should include:

 identification of potential hazards and infectious and other exposures in the health
workplace
 provide information about infection transmission mechanisms and how to reduce the risk
of such transmission
 instruct workers on the utilization of safe work practices and standard precautions

 workplace health and safety services

 workers’ responsibilities regarding workplace safety and health
 promote the implementation of periodic health screening for health
workers including the promotion of voluntary counseling and testing for
HIV/AIDS
 provide information on the signs and symptoms of the most frequent
illnesses at the workplace, including TB, HIV, malaria, hypertension, and
diabetes and instruct workers to report promptly for evaluation should
these develop
 disseminate health workers’ rights and responsibilities with regard to
workplace safety and health, including the right to confidentiality (See
Statement of Workers’RightsandResponsibilities,inAppendix
Section 6 Annexes
1. HRMD Implementation Manual
2. HRMD Training Module
3. Staff competency assessment score tool
4. Staff satisfaction score tool
Section 7 Reference
1. HSTP II
2. HRD Strategy
3. Health Service Delivery and Administration Legal Framework
4. National regulatory standards for HR by hospitals level
Chapter 21: Managing Health Financing

1
Chapter outline
1. Introduction

2. Operational standards

3. Implementation Guidance
3.1.The hospital has a functional finance structure with trained finance personnel and
technology.
3.2.The hospital has a strategic and operational financial plan in alignment with its
overall plan.
3.3.The hospital increases internal revenue collection and its allocation for quality
improvement.
3.4.The hospital establishes systems and practices for improving its resource utilization.
3.5.The hospital has put in place a reimbursement mechanism for HI and other services
given on credit basis.
3.6.The hospital has established a system to implement outsourcing of services
3.7.The hospital has opened up a private wing in accordance with the provisions of the
federal or regional regulation
3.8.The hospital fully complies with the government finance rules and regulations

2
Section 1: Introduction
Health Financing Concept
According to the World Health Organization (WHO), healthcare financing is one the functions of
the health system that deals with how resources are mobilized, pooled and health services are
purchased. It refers to the “function of a health system which is concerned with the mobilization,
accumulation, and allocation of money to cover the health needs of the people, individually and
collectively, in the health system. The purpose of health financing is to make funding available,
as well as to set the right financial incentives to providers, to ensure that all individuals have
access to effective public health and personal health care” (WHO 2000).

Without the necessary funds, no health workforce would be employed, no medicines would be
available, and no health promotion, prevention or rehabilitation would occur. Hence, Health
Financing is far more than generating funds- it drives other health system components to provide
improved and sustained health services.

Health Financing Reforms in Ethiopia

The Ethiopian health delivery system and financing mechanisms have been evolving over time.
In 1998, the Government of Ethiopia approved a comprehensive healthcare financing strategy
with primary policy objectives of:

 Increasing resources to the health sector.

 Enhancing efficiency in the use of available resources.
 Improving the quality and coverage of health services.
 Ensuring equity and promoting sustainability.

The government has also lunched Health Insurance System to improve financial protection
through risk pooling and foster prepayment, improve quality of healthcare services, and raise
revenues to accelerate progress towards Universal Health Coverage (UHC)

The healthcare financing strategy in Ethiopia aims to contribute to the realization of progress
towards universal health coverage by enhancing risk protection mechanisms and protecting all
indigents. Additionally, the strategy seeks to increase domestic sources and to gradually reduce
aid dependency. It also emphasizes the importance of investing in essential health services in a

3
sustained manner that is allocating adequate resources to ensure the availability and accessibility
of key healthcare services to improve the overall health outcomes.
Every hospital has a critical role in effectively implementing health financing reforms. As some
health financing components, such as the health facility governing board, have stand-alone
chapters independently, the fee-waiver system component is being replaced by health insurance
programs; and the fee revision component is majorly beyond the mandates of the hospital, the
chapter guides the remaining health financing components, namely, revenue retention and
utilization, Private Wing, Outsourcing, Exempted Health Services, and Health Insurance as well
as compliance of the hospitals to the government financial rules and regulations to ensure
financial sustainability for sustained improvement of the health outcome.

Section 2: Operational Standards for Health Financing

1. The hospital has a functional finance structure with trained finance personnel and
technology.
2. The hospital has a strategic and annual financial plan in alignment with the hospital’s overall
plan.
3. The hospital increases retained revenue collection and its allocation for quality improvement.
4. The hospital establishes systems and practices for improving its resource utilization.
5. The hospital has put in place a reimbursement mechanism for HI and other services given on
credit basis.
6. The hospital has established a system to implement outsourcing of services
7. The hospital has opened up a private wing to the provisions and requirements of the federal
or regional regulation
8. The hospital fully complies with government finance rules and regulations

4
Section 3: Implementation Guidance

3.1. The hospital has a functional finance structure equipped with trained finance
personnel and technology
Every hospital should have a functional finance structure approved by the civil service
commission. The finance directorate of the hospital is a member of the management committee.
The finance structure needs to be equipped with skilled finance personnel who can effectively
run the hospital's financial activities. Though the number of staff may vary from hospital to
hospital depending on the level of a hospital, the presence of the Finance Directorate, senior and
junior accountants, cashiers, and daily cash collectors is mandatory for the proper execution of
financial activities.

Hospital Organizational structure of finance support process:

Each hospital should establish a finances support process with, a minimum of the following
personnel:
 Finance Head

 Senior finance officer

 Finance officers

 Assistant finance officer/ Cashier

 Daily Cash Collector/s

 Archive staff
The finance support process contributes to the provision improved service in several ways:
 Increasing revenue,

 Reducing unnecessary costs and assisting in ensuring that all resources are used
appropriately, efficiently, and effectively, and

 improving the quality of services and in providing decision-makers by providing them

with timely, accurate, and reliable program and financial information.

5
Duties and responsibilities of the key finance personnel will be as per job descriptions elaborated
by the human resource unit of the hospital.

Besides, the hospital's finance department must have relevant financial laws, regulations,
directives, implementation manuals, vouchers, and financial formats printed by the Ministry of
Finance or Finance Bureau or its finance structure. Every hospital should also have a safe box(s)
to help ensure its financial security.

Furthermore, the hospital should provide periodic financial training on financial management,
Budgeting, and Reimbursement for its finance staff to improve the staff's skills and knowledge
and continuously improve the hospital's financial operation.

3.2. The Hospital has a strategic and Operational Financial Plan in alignment with its
overall plan

Hospitals must have financial strategic and operation plan that aligned with the overall
development plan of the hospital. Hospitals should also prepare evidence-based planning by
taking into account key considerations such as make expenditure projection by identifying
expenditures financed from treasury and retained revenue, community priority needs, etc.;
national/regional health sector plans and initiatives, reforms, map resources during plan
preparation to avoid duplications.
Evidence-based planning has been implemented in a decentralized fiscal setting to ensure
resources are invested in high-impact, low-cost interventions to enhance effectiveness and
efficiency. Efforts have also been exerted to encourage private partners to establish healthcare
facilities equipped with high-end technologies and enhance local production of medical
technologies and products.
With the growing demands to improve health care quality, coverage, and outcomes, health sector
decision-makers not only face the challenge of allocating resources to the highest priorities but
also of ensuring that those resources are put to good use, deliver "value for money," and achieve
the intended outcomes or impact. For that reason improving a hospital's budgeting ability and
control of the flow of finances is extremely important.

6
The hospitals’ financial plan needs to be based on the needs of all the departments of the hospital
and the initial proposal is prepared by the finance directorate and then reviewed by the
management committee and submitted to the governing board for approval. The hospital board
is required to critically review the budget proposal submitted to it by the Management
Committee. In reviewing the financial plan, the governing board is expected to have clear
information on the budget allocated for the hospital from the government treasury and from the
internal revenue sources. Furthermore, the Governing board should know the amount of the
retained revenue allocated for quality improvement activities. By successfully implementing
performance-based program budgeting capabilities, hospitals are to be attained greater financial
control to effectively utilize resources, and maintain spending limits related to expected targets
and results. Improved financial flows and procurement processes within a hospital also create
greater efficiency and use of human resource. Hospital budgets should be prepared, approved,
and appropriated following procedures established by BOFED/MOFED. Procedures for
planning and budgeting are necessary to ensure that financial resources within the hospital are
spent with proper accountability and promptly according to expenditure guidelines established
by the BOFED/MOFED.

Plan and Budget Preparation:

The budget plan preparation is done in a decentralized setting and the budget cycle has
three stages:
• Budget planning
• Budget preparation and request
• Procedures for budget approval and to complete the budget cycle
A budget estimates is the maximum level of resources (financial, human, material, time)
available to spend to achieve desired set of outcomes. Decentralized planning and budgeting
pass through the following stages; a) Budget planning (preparing work plans, review of work
plans, estimation of revenue, allocation of revenue, estimation of capital and recurrent budget,
budget call, budget request), b) budget preparation, c) budget hearing and recommendation, d)
budget consolidation, e) budget approval, f) budget appropriation, g) budget notification, h)
budget allocation, and I) budget implementation, monitoring and reporting. These stages are

7
described below. ( further details of each stage can be found in the Budget Preparation and
Management Manual.)

Budget Planning:
A. Preparation of work plans: The Hospital Management, with the active participation of the
staff, prepares a work program considering overall health sector objectives, catchment area
activities, improvement of service quality, and envisaged projects. The annual plans should
include the requirements for outsourcing non-clinical services, procurement of goods and
services etc. The finance bodies (MOFED/BOFED) issue guidelines regarding the direction and
priorities that public bodies should incorporate in their annual work plans. Although health
facilities are not public bodies, this guidance equally applies to them.

B. review of work plans: After getting the approval of their respective) Boards, Hospitals
submit their work plans to FMOH/RHB for review. Federal Ministry of Health/Regional Health
Bureaus consolidates the work plans and submits them to finance bodies at their respective
levels. The work plans include both recurrent and capital components. Past performances are
taken into consideration during the review of work plans.

Planning and Budgeting for Retained Revenue:

As part of the budget planning process, the hospital should estimate the retained revenue it
anticipates collecting from different sources in the coming year. Health facilities shall forecast
the amount of retained revenues they expect to collect from different sources in the budget year
(from July eight to July seven), including expected changes in user fees, expected improvement
in the quality of health services, and the resulting inflow of patients, etc.
Retained revenue can be estimated based on past revenue collection trends made from each
source of revenue item-Total, number of visitors, and collected revenue from each item of
revenue (examination/card, drugs, x-rays, lab tests, etc.), Estimated number of service seekers
and average collections, and changes in the amount of user fee and expected facility visitors.
The retained revenue estimate should be included in the budget proposal.

8
 Note: Expenditure of retained revenue should be budgeted separately from expenditures made
from other revenue sources.
All revenue must be appropriated before use. The hospital should declare any unutilized
retained revenue at the end of every fiscal year to be proclaimed and utilized with the collections
of the following budget year and the appropriated block budget. Sources of retained revenue
include:
 Block budget appropriated by the government
 Fees collected from health care and diagnostic services
 Sale of drugs and medical supplies
 Revenue collected from third parties.
 Fees collected from consultancy, trainings and research activities
 Income from non-medical services and goods
 Direct aid in cash and in kind
Government source: main sources of revenue for health facilities includes what they get from
WOFED/BOFED/MOFED in the form of budget allocations from government treasury and
foreign sources. There is no direct allocation for primary hospitals from
WOFED/BOFED/MOFED. Instead, they are notified of their ceilings based on what WOFED
/BOFED allocates to the health sector.
Budget adjustments: There are two types of budget adjustments permitted by law:
a) Budget transfers-- moving budgeted funds from one item of expenditure to another (in so far
as it is permissible by the law) after the annual budget process is finalized.
b) Supplementary budget-- adding an increment to the authorized budget with approval of
OFED/BOFED and appropriation by the respective council. Finance bodies notify the public by
Form Ma/BeMa6 (for recurrent) and Ka/BeMa6 (for capital).
For budget transfers from government subsidies, the Hospital Manager must seek the approval of
BOFED/MOFED before the funds have been spent, using The request should be made using
Form BeMA1 and should specify from which item(s) in the approved initial budget funds will be
taken and for what new expenditure categories they will be used.
The Hospital Management must approve budget transfers from retained revenues for Hospitals.
Transferring and using the budget for those categorized as 'negative list'

9
Budget Execution: Budget execution refers to the activities undertaken to utilize the appropriated
budget for the intended purposes. Hospitals and Health Centers shall submit a monthly
disbursement request to the respective finance office, either by filling out the required form or by
writing a letter to BOFED/MOFED according to the existing procedures provided by MOFED/
BOFED.
Monitoring and evaluation: The budgets are monitored and evaluated through monthly and
quarterly execution reports, audits, supervision, etc.

Financial management

Financial management means planning, organizing, directing, and controlling financial activities
such as the utilization of funds of an organization. Finding adequate resources to finance health
systems has become a real challenge for countries worldwide. This challenge is exacerbated in
developing countries that need more funds to meet their populations' essential health. Increasing
public resources for health—or more precisely, expanding "fiscal space" for health—does not
necessarily need to come from more significant tax revenue or larger budgets. Often, it is not the
amount of health spending but the efficiency with which those funds are used that matters most.
Efficiency improvements in the health sector, even slight efficiency, can yield considerable cost
savings and even facilitate the expansion of services for the community. Public Financial
Management (PFM) is about ensuring that public money is used well and is made to stretch as
far as possible. It provides leaders and managers with information to make decisions and know
if they use resources effectively. Managing finances in the public sector is about much more
than accountancy – it is integral to bringing services to people.
Accounting Practices:
Accounting is concerned with recording, analyzing, and interpreting financial data. Hospitals
require qualified financial officers to provide information for the regular evaluation of business
performance and for periodic appraisal of the business's 'value' or 'net worth.' Accounting
information is necessary to prepare business plans, analyze business efficiency and costs of
services, and make policy decisions. Detailed guidance on accounting systems for hospitals is
provided in the financial management Manual of the relevant Government bodies, with
additional guidance in the Healthcare Finance Reform Implementation Manual. Each hospital

10
should follow an Accounting Manual which establishes all policies and procedures relating to
financial management. The hospital's financial practices should comply with the accounting
system as described in the manual, using approved, standardized vouchers and forms. The
following section gives a brief overview of significant accounting practices for hospitals by the
procedures established in the financial management Manual.

Cash Collection Procedures

General issues:
 The Health Care and Finance Legislation makes the following stipulations:
 Hospitals should only charge payments at the user fee or bypass fee set by the
 respective government authority
 Bilingual fee posters should be placed next to each departmental reception desk, in all
waiting areas, and
 At all cash points; the hospitals are highly encouraged to indicate the estimated fee for
illiterate patients.
 Each poster should show the fees & exemptions and should advise patients to obtain & keep
 Receipts for all payments,
 Collection points should be readily accessible for all patient services
 Cash should be collected only by personnel who the hospital authorizes,
 Except in emergency cases, the services fees should be collected after the treatment has been
ordered and its availability confirmed, but before the treatment is administered,
 In emergency cases, treatment should be administered when needed, and the question of
payment should be handled when the emergency is under control
 Revenue can be collected as cash, cheque, or bank transfer. When a cheque is received, the
following issues should be considered:
 Cheques must be made payable to the health facility;
 Personal or company cheques must be certified by the drawer's bank;
 Government agency cheques are acceptable without certification;
 No employee has the authority to cash any cheque made payable to the health facility;
 Post-dated cheques shall not be accepted as revenue, and

11
  Bank transfers must be evidenced by a bank deposit slip or bank advice

Cash Receipt Vouchers

Cash Collectors should collect payments from clients/patients and others by issuing a Cash
Receipt Voucher. The Cash Receipt Voucher should be used to acknowledge and evidence the
receipt of cash, cheques, the direct deposit of cash into the bank, and bank transfers. Only pre-
printed sequentially prenumbered official Receipt Vouchers issued by BOFED (MOFED for
Federal Hospitals) should be used. The Cash Receipt Vouchers should be distributed as follows:
 Original copy to the payer as an acknowledgment of the cash receipt;
 Second copy to the main Cashier; and
 Third copy is retained in the pad
Daily, each Cash Collector should submit all cash receipt vouchers and cash collected to the
principal Cashier/assistant finance officer.
Summary Receipt Voucher
The principal Cashier/assistant finance officer uses the Summary Receipt Voucher to summarize
the cash collected and cash vouchers received from each Cash Collector. Upon receipt of the
cash receipt vouchers, the main Cashier should summarize these on a pre-numbered Summary
Receipt Voucher. The Summary Receipt Voucher is prepared in triplicate:
 Original copy is given to the daily Cash Collector when the collected cash is remitted;
 Second copy is sent to the financial officer, attaching the Receipt Vouchers & deposit
slips;
 Third copy is kept in the pad.
Receipt Voucher Summary by Revenue Code.
The Receipt Voucher Summary by Revenue Code is a spreadsheet prepared by daily Cash
Collectors to summarize receipt vouchers by revenue account code. Daily, each Cash Collector
should complete a Receipt Voucher Summary by Revenue Code and submit this to the main
Cashier with the issued receipt vouchers and cash collected. The total amount shown on the

12
Receipt Voucher Summary by Revenue Code should be checked with the total amount shown on
the Summary Receipt Voucher to ensure that the two amounts are the same.
A copy of the Receipt Voucher Summary by Revenue Code should be submitted to the financial
officer together with the Summary Receipt Voucher and supporting Receipt Vouchers.
Deposit Receipt Voucher
This is used to acknowledge and evidence the receipt of cash or cheques as a deposit/advance
payment from inpatients. The Deposit Receipt Voucher should be prepared by the Cash
Collector and submitted to the main Cashier with the funds deposited.
The daily Cash Collector should summarize all deposit payments in a Deposit Cash Book.
At the end of the patient's stay, the total service charge should be calculated as follows:
A. If the service charge equals the deposited amount, then a Cash Receipt Voucher should
be prepared. A copy should be given to the payee, and the second copy should be
attached to the Deposit Receipt Voucher and submitted to the financial officer.
B. If the service charge is greater than the deposit, then the payee should pay the difference,
and a Cash Receipt Voucher should be prepared for the total sum, with a copy given to
the payee and a second copy attached to the Deposit Receipt Voucher and submitted to
the financial officer.
C. If the service charge is less than the deposited amount, a Cash Receipt Voucher should be
prepared for the total service charge. The balance should be remitted to the payee using a
Payment Voucher. A copy of the Cash Receipt Voucher and Payment Voucher should be
attached to the Deposit Receipt Voucher and submitted to the financial officer.

Cash Register

A Cash Register should be established to record the cash collected daily and the sum deposited in
the bank. The Cash Register should be completed by the main Cashier.

Collections from Credit Services

Hospitals may provide services on a credit basis. A Credit Agreement should be entered
between the hospital and each Institution which would like to subscribe to health services on a
credit basis. The Credit Agreement should describe the reimbursement collection procedure and
13
schedule. Credit should be granted for a maximum period of three months. Institutions with a
Credit Agreement with the hospital may deposit money in the hospital's account in advance.
That sum can be replenished whenever it is used up. The hospital financial officer should prepare
a monthly report for the Hospital Management with details of credit granted, credit repaid, and
balance outstanding.
Handling Cash
In monetary terms, 'cash' refers to currency, cheques, drafts, cash payment orders, and bank
remittances. Cash in hand should be kept in a locked safe box under the responsibility of the
main Cashier or the daily Cash Collector. The cash safe box must be used only for those assets
belonging to the hospital. Personal property should not be kept in the cash safe box.
Wherever a cash safe box has double or triple keys, the reserve keys should be safely kept in a
sealed envelope. The sealed envelope should be signed by the Cashier, the Auditor, the financial
officer, and the Finance Head of the Hospital. When the Cashier requires the reserve key, the
sealed envelope should be opened with two or three signatory persons.
Cheque books
When checkbooks are received from the bank, the Cashier should make sure that the leaves of
the checkbooks are correct and that each leaf in the cheque is stamped. A Register should be
used to record all new checkbooks received and checkbooks issued. Partly used checkbooks
should be kept with the financial officer.
Deposit Procedures
All cash and cheques received should be deposited into the hospital bank account on the date of
collection or the next working day if it is not possible to deposit on the same day. The amount of
cash 18-25 kept overnight in the safe box should be, at most, the limits set by BOFED. Daily
collections should not be mixed up with petty cash funds when revenue is deposited; the Cashier
should obtain two copies of the deposit slip – one should be submitted to the financial officer,
and the other should remain with the Cashier as evidence. In direct deposits by a third party, the
financial officer should collect copies of deposit slips from the bank.

14
Bank Accounts

Hospital bank accounts can only be opened or closed with the approval of BOFED/MOFED.
Hospital management should assign, in writing, three named individuals as signatories of each
bank account. The bank and BOFED/MOFED should be notified of any signatory changes.
Each hospital should have a particular bank account specifically for retained revenue. Health
facilities' retained revenue bank account shall be allowed at the end of the financial year. To
open the bank account, the hospital should apply in writing to BOFED/MOFED.
The hospital should establish a bankbook or bank register record for each bank account that
shows the movement of funds, indicating the beginning balance, deposits, withdrawals, and
ending balance at any given time. Every month the Finance officer should prepare Bank
Reconciliation for every bank account and pass any necessary correcting entries. Correcting
entries must be evidenced by the Finance officer's signature and verified by separate persons by
the government Budget and Accounts Manual.
Petty Cash
Petty cash is a fund from which small cash payments can be made. Petty cash funds should be
authorized by the CEO and established under the custody of cashiers. Depending on the size of
the hospital, the CEO may approve more than one petty cash fund.
The CEO, in consultation with the Finance Head and Finance officer, should determine the
magnitude of the petty cash fund. Generally, this should not exceed ETB 30,000.
The number and magnitude of petty cash funds should be approved from /BOFED/MOFED. A
change in the size of the petty cash fund within a limit of ETB 30,000 can be made with the
approval of the CEO. However, if a change in the size of the petty cash fund exceeds Birr
30,000, approval of the BOFED/MOFED is required.
The petty cash fund should be kept separately from other collections and funds.
Petty cash funds should be replenished when the remaining cash reaches a minimum level. The
Cashier should submit all paid petty cash vouchers and a request form for replenishment to the
Finance officer. The Finance officer should verify the vouchers and sum requested and should
18-26 prepare a Payment Voucher and cheque for the total expended amount in the name of the
Cashier. This cheque should be handed over to the Cashier against their signature on the
Payment Voucher.

15
A petty cash book should be established to track the cash balance for each petty cash fund. At
the end of every month, a cash count should be conducted by someone other than the Cashier,
with a third employee as a witness. Additional 'surprise' cash counts may be conducted. At the
end of the budget year, the remaining balance of petty cash funds should be deposited into the
appropriate bank account.
Disbursement Procedures
The Finance Head should prepare a cash flow program each month and quarter detailing income
and expenditure for each significant budget heading. This should be submitted to the CEO for
review and approval. A sample Format for Cash Flow Forecast is presented in Appendix.
Requests for disbursement (payments) should be made to the hospital Finance officer, who will
prepare a payment voucher and submit it and supporting documents to the Head of Finance. The
Head of Finance should review and approve the disbursement, considering the available funds,
providing the payment amount is within the limits of BOFED/MOFED.
The Finance officer will prepare a cheque and submit it for signature. For cash disbursements,
the approved voucher should be submitted to the Cashier who will effect payment. Withdrawals
from the bank should be recorded sequentially in the transaction register. Facilities should
present disbursement requests to respective BOFED/MOFED for operating expenses of all
eligible expenditures from the government block grant. Requests for monthly salary will also
follow appropriate BOFED/MOFED guidelines.
Recording/Accounting
The accounting system of Hospitals should follow the Federal/regional government accounting
system and should utilize the printed payment voucher for expenses as a detailed financial
management Manual. The following are some of the recording procedures that need to be
followed:
A. The hospital shall establish registers for cash collected, and the Cashier shall enter
daily cash collections into the Cash Receipts Register Book.
B. The Finance officer shall prepare a Daily Cash Receipt Summary.
C. The Cashier shall keep a record of all cash received and deposited in the bank and
record it in a Cash Transaction Register Book as described in the Accounts Manual.
The Finance officer will prepare a cash receipt summary at the end of the day.

16
 D. The Finance officer shall record all cash received and deposited in the bank accounts
and records it in the Cash Receipts Registration Book. The Receipt A voucher is the
source document to record a receipt of cash in the Cash Receipts Register Book.
E. When the services provided or delivered for a particular purpose are entered into
transaction register at health facilities, debit payable account, and credit cash at bank
by utilized amounts.
F. When a health facility utilizes the fund appropriated to it, it will debit the related
expenditure account and credit its bank account.
G. Outstanding bills at the end of the financial year are paid within the grace the period
by federal/regional financial proclamations, regulations and financial management
manual.
H. Health facilities shall make monthly reconciliations of accounting records with
related statements.
I. As each month ends, a reconciliation statement of the balances of the Health facility
ledger and bank statements should be prepared for all bank accounts. Reconciling
items should be shown in sufficient detail and should be cleared timely.

Reporting

Each hospital shall maintain books of accounts and formats. This will provide complete and
adequate monthly information on how funds allocated have been utilized as prescribed in the
regional financial proclamation and regulation and shall report to the respective Health and
Finance Office at all levels. RHB, zone health office, Woreda Health office , in collaboration
with the respective Finance office, will assist Hospitals in establishing proper systems for
accounting and in submitting disbursement requests and reporting.

3.3 The hospital increases internal revenue collection and its allocation for quality
improvement
Ethiopia has a tradition of paying for health services dates back to the introduction of the modern
health service delivery system. Ethiopia follows a consolidated revenue collection and
budgeting system in which all public institutions are supposed to channel their collected revenue

17
to the central treasury and receive operational funding through a government budget. Similarly,
in the health sector, health facilities used to channel all revenue they have been generating to the
treasury. This caused a lack of sense of ownership by health facility staff.
On the other hand, health facilities faced a severe shortage of resources to cover their operational
costs, and, in most cases, their non-salary operational budget was depleted by the end of the first
quarter, making it difficult to provide quality health services. In response to this challenge, a
healthcare financing strategy was prepared and approved by the Council of Ministers, which
allows, among other things, the retention and utilization of revenue by health facilities following
the approval of the strategy. The federal and respective regional laws were approved, which
mandate health facilities to retain and use their revenue for improving the quality of health
services. Sources of retained revenue of hospitals include:
 Fees collected from health care and diagnostic services, as well as beds and other services
related to medical treatment,

 Sale of drugs and medical supplies,

 Revenue collected from third parties in connection with waiver and health insurance
schemes,

 Fees collected from consultancy, teaching-learning activities, training, and research

activities,

 Income from non-medical services and goods such as lease of facilities and other similar
activities,

 Direct aid in cash and in-kind obtained from domestic and outside sources, and

 Other similar revenue sources.

Utilization of Revenues
Positive Lists
To ensure hospitals should use retained revenue judiciously to improve the quality of healthcare
services, activities for which RRU should be used are identified as positive lists while activities
that should not be undertaken by RRU are listed as negative lists to guide implementation.
Whereas retained revenue can generally be used for set activities which positively impact quality
of healthcare services such as:
 Improve the services provided under the referral system,

18
  Improve the supply of drugs, medical equipment, and supplies,
 Conduct procurement and carry out construction works to improve the health care
services of the hospital,
 Develop health care information systems and manuals and improve procedures,
 Conduct on-the-job training programs and other similar health-related problem-solving
research so as to improve the efficiency of employees,
 Strengthen health education activities and undertake disease control and preventive
activities,
 Undertake other similar revenue utilization activities in line with the objectives
designated by the hospital management committee.
positive lists can be further divided into three categories based on their level of importance to
quality improvement. Hospitals therefore can set priorities based on their needs. The general
categorization is:
First level priorities
• For purchase of drugs, medical equipment and supplies.
• To develop health facility infrastructure,
• Activities that improve cleanness of the health facilities
• For purchase of generator
• First level priorities
• For purchase of drugs, medical equipment and supplies.
• To develop health facility infrastructure,
• Activities that improve cleanness of the health facilities
• For purchase of generator
Second level priorities
• To finance activities required to improve health management information system (HMIS)
• To finance construction of additional rooms/wards to improve services to patients
• To finance activities that improve financial and pharmaceutical management of health
facility

19
Third level priorities
• To finance training cost on computer operation skill, office administration, procurement
management, etc.
• Purchase and transportation of office furniture
• Vehicle purchase such as ambulance and transportation for health facility staff, etc.
Negative List
Retained revenue should not be used for activities which include:
 Any kind of foreign trip and training,
 Long-term domestic training program of more than three months,
 Any kind of subsidy given to a third party,
 Revenue utilization other than those activities designed to meet the objectives therein, nor
 There is no approved budget for any expenditure code in the positive list.
(Please refer to the revised HCF implementation Manuals of MOH for detailed information)

3.4. The hospital establishes a system and practice for improving its resource utilization

Ensuring adequate resources to finance health systems has become a real challenge for countries
worldwide. This challenge is exacerbated in developing countries that lack sufficient funds to
meet their populations' essential health services. Increasing public resources for health—or more
precisely, expanding "fiscal space" for health—does not necessarily need to come from more
significant tax revenue or larger budgets. Often, it is not only the magnitude health spending but
the efficiency with which those funds are used that matters most. Efficiency improvements in
the health sector, even in small amounts, can yield considerable cost savings and even facilitate
the expansion of services for the community.
Public hospitals are mandated to retain and use internal revenue from different sources, including
consultation fees, sales of drugs, and different non-medical income-generating activities.

The hospital’s health financial system strictly follows government financial rules and
regulations. That means the hospital should fully adhere to the public financial system in
generating, managing cash, and utilizing financial resources. For instance, the hospital should
use receipt vouchers printed by the Ministry of Finance or Finance Bureau. The hospital should

20
also not utilize retained revenue before appropriation even though it has revenue collected at
hand. Therefore, utilizing retained revenue before it is appropriated is strictly prohibited, as
doing so would breach the government's financial rules and regulations.

In line with the above, the hospital governing board needs to monitor the hospital's adherence to
the government's financial rules and regulations. In this connection, the governing board is
expected to give direction for the hospital to strengthen its financial management system.
Public Financial Management (PFM) means planning, organizing, directing, and controlling
financial activities such as the utilization of funds of an organization. It is about ensuring that
public money is used well and is made to stretch as far as possible. It provides leaders and
managers with information to make decisions and know if they use resources effectively.
Managing finances in the public hospital is much more than accountancy – it is integral to
bringing health services to people.

3.5. The hospital has put in place a reimbursement mechanism for HI and other services
provided on credit
Health Insurance (HI) is a formal arrangement where insured persons are protected from the cost
of medical services that are covered by the insurance plan. Health Insurance provides for the
unforeseen medical bills that would otherwise be a burden on the hard-earned savings of
individuals/HHs. It is an agreement between an insurance scheme/company and the individual
or groups where the insurer agrees to pay some or all medical expenses in exchange for a
monthly or annual contribution/premium payment. HI can cover a range of medical services,
including hospitalization, doctor visits, medication, and medical procedures. With health
insurance, a person can access quality health services from healthcare providers without
worrying about the financial impact of medical expenses. In other words; HI is a formal
arrangement where insured persons are protected from the cost of medical services covered by
the insurance plan. Health Insurance covers unforeseen medical bills that would otherwise
burden hard-earned savings.
Types of Health Insurance

SHI: a mandatory, non-for-profit Health Insurance program for formal sector employees and
financed by earmarked payroll/pension contributions (from employees and employers).

21
CBHI: Not-for-profit insurance scheme aimed primarily at the informal sector and formed on the
basis of a collective pooling of health risks, and in which the members participate in its
management.
Private HI: refers to insurance schemes that are financed through individual (group) private
health premiums, which are often voluntary, and risk rated and funds managed by ‘For-profit’
insurance companies
The government of Ethiopia has launched two types of health insurance programs, namely,
Social Health Insurance (SHI) and Community Based Health Insurance (CBHI), with objectives
of alleviating financial barriers, mobilizing additional resources to the health sector, encouraging
community participation, and ultimately improving health service utilization and health status of
the population.
Social health insurance covers the population engaged in the formal sector, including civil
servants, NGO employees, private sector employees, pensioners, and police forces while the
CBHI program is designed to address populations engaged in the informal sector- i.e., the rural
population, self-employed and people engaged in petty trade in urban settings.
Hospital is one of the critical stakeholders that have a significant role in the successful
implementation of the programs. They are expected to provide quality health services included
in the benefit package. The benefit package covers outpatient and inpatient services, delivery
services, surgical services, and provision of generic drugs included in the health insurance drug
list and diagnostic services at the hospital level. Insurance beneficiaries should not pay any out-
of-pocket payment when accessing care, apart from the copayment and bypass fee, if any.
Not all services may be covered by the benefit package, and some services such as diagnosis and
treatment abroad, cosmetics surgeries, and dialysis, except acute renal failure, in vitro
fertilization, organ transplantation, hip replacement, traffic accidents, etc., excluded for various
reasons.
Services included in the benefits package, including supply of drugs, laboratory, and diagnostic
services per the terms and procedures indicated in the contractual agreement, the hospital should
submit timely, complete, and accurate payment requests using agreed-upon formats and follows
up on the reimbursement.
Whereas user fees were majorly paid by patients and clients for the hospital at a point of service
for long, this trend has been changing, especially with the commencement of the CBHI program.

22
Furthermore, these days public hospitals are covering the cost of Exempted Health Services,
which have to be covered from the government budget and/or from donner funding in financial
and non-financial form/in-kind, expecting the reimbursement of the costs they incurred for the
exempted health services.
Nevertheless, the hospitals are depleting their internal revenue, which must be allocated to
prioritized high-quality impacting activities such as the purchase of drugs, medical equipment &
utility payments, as they are not reimbursed by the government partners or the treasury budget.
Implementing health insurance programs requires active involvement of different stakeholders
with their distinct roles and responsibilities.
For that reason, hospitals should hospital keep records of all services provided to eligible health
insurance beneficiaries and related financial information as appropriate, and the information
must be compiled into reports. These include: -
 service utilization reports,
 cost of services provided
 hospital fee schedules issued by the authorized body,
 standard treatment guidelines, and
 contract documents.
Apart from HMIS data capturing and reporting formats, the hospital utilizes formats
developed by health insurance schemes/service purchaser to record and document health
insurance activities.

Exempted Health Services

Exempted health services refer to those services that are rendered free of charge to all
irrespective of the level of income, because they are of public health nature that widely affects
the general public and improves the health-seeking behavior of society. Exempted services are
generally those of a public health nature, such as:
 Immunization of mothers and children against eight child illnesses;
 Prenatal, delivery, and postnatal services
 Family planning services in health care units;
 HIV Voluntary Counseling and Testing (VCT);

23
  Diagnosis, treatment, and follow-up of TB;
 Leprosy management
 Epidemic follow-up and control;
 Obstetric Fistula management
 Immunization and treatment of health professionals to reduce risk related to occupational
hazards
 Other services are to be provided free of charge for future endorsement by the
government.

Federal Ministry of Health and each Regional Government will approve the list of exempted
services for Federal and Regional Hospitals, respectively. Each hospital should provide
exempted services by the relevant Legislation and display a list of exempted services at
appropriate locations throughout the hospital to inform patients, staff, and the public.
The budget for exempted health services should be covered by the treasury budget and/or by
development partners. However, most hospitals are forced to cover the cost of exempted health
services from their retained revenue, which depletes internal resources dedicated to improving
the general quality of health services. The cost of the services should be financed from the
appropriated government budget or from donations. For that to happen, the hospital must
strengthen its data capturing system, especially data on the cost of exempted health services, to
reimburse the cost expended on exempted health services from their internal revenue.

Overview of Provider Payment Mechanisms

The ways providers are organized and paid is central to the structure of any health insurance
system. The payment mechanisms used to reimburse providers have essential effects on system-
wide costs and efficiency. Some payment mechanisms encourage the over-provision of services,
while others run the risk of causing providers to restrict the provision of services that are
necessary. The provider payment system influences the quantity of services provided and rate of
user fees.

24
The provider payment mechanism used by the health insurance system must be evaluated against
its effects on the quality of health care service, cost containment, and administrative simplicity.
The widely used provider's payment systems are:
Fee-For-Service: Fee-for-service payment systems can be completely open but are often based
on an established fee schedule. The drawback of this payment mechanism is that hospitals can
maximize their income under a fee-for-service reimbursement scheme by increasing the number
of services provided or by reducing quality of service's.

Diagnosis-Related Groups (DRG)/ Case Payment: The most widely-known case classification
system is the "diagnosis-related groups" (DRG) system, which classifies conditions into
approximately 470 diagnostic groups. DRG or case-based payment systems are most commonly
used to pay hospitals for inpatient treatment. Hospitals must examine the resources used
(operating theatre, supplies, technology, drugs, medical staff, and bed days) to treat a patient
with a given diagnosis. Because a fixed fee is received per case, the hospital faces incentives to
minimize costs and to increase income. On the other hand, providers also face incentives to code
the diagnosis into a more generously reimbursed diagnostic group. This tendency, called "DRG
creep," requires an elaborate monitoring system to control. As the health insurance authority has
no prior experience with the DRG payment mechanism and also since sufficient data has to be
available to define the DRGs, the social health insurance system may initially use a less
complicated form of case payment mechanism known as Departmental Based Grouping (DBG)
for all inpatient services.

Capitation payment: Capitation payments are made to health plans that receive a fixed monthly
payment per member to provide a defined benefits package. The health insurance may contract
health centers and hospitals to provide part of the benefits package and may pay those provider
groups by capitation payment. If designed and appropriately implemented, capitation payment
systems have many desirable qualities. For a capitation payment system to be effective, there
must be a large base of enrollees to spread the financial risk. With few enrollees and a
comprehensive package, few very sick enrollees could bankrupt the provider. It is essential for
members to have the opportunity to choose among competing capitated plans. Competition to

25
attract members should cause quality to increase, and the pressure to provide a defined package
of benefits for a fixed premium should result in controlled costs.
Because capitation payment is for a range of benefits, providers and health insurance schemes
have incentives to rethink the structure and organization of the delivery system. Capitation
payments encourage a systemic focus compared to fee-for-service payment, which encourages a
focus on individual procedures or diagnoses. Administrative costs of capitation payment
methods are low compared with fee-for-service reimbursement systems.

3.6. The hospital has established a system to implement outsourcing of services

Outsourcing is the agreement between a health facility as a purchaser and a third–party provider
of services as a vendor, under which the vendor provides to the health facility certain defined
services formerly performed by the health facility itself. It has the potential to become a core
business strategy for health facilities. By leveraging the contractors' core abilities, the health
facilities can maximize their options to, for example, expand additional services by gaining
access to the state–of–the–art technologies without investing directly in the development of such
technologies. Thus, by allowing the contractor to deal with services that are the core
competency of that contractor, the health facilities can focus their efforts on their core clinical
competencies.
Box B. Rationale for Outsourcing:

 improve quality
 Help hospitals to focus their efforts on core clinical competencies.
 Access specialized skills/expertise that are not available in the facilities.
 Cost reduction and/or
 Gain efficiency and effectiveness

Outsourcing allows health facilities to leverage the contractor's knowledge of services and
abilities. It provides health facilities with access to individuals with specialized skills who might

26
otherwise be expensive and difficult for the facilities to hire/attract. Although the current practice
focuses on outsourcing non-clinical services, there is a strong need for outsourcing selected
clinical services such as Radiology and Imaging. It is to be noted that hospitals have to pay
particular attention to undertaking preparatory activities, including conducting feasibility
assessments and preparing clear bid documents before they outsource services.
Through outsourcing, hospitals can gain access to the experience of the contractor, which may,
through its provision of the outsourced services, improve the work pattern or processes of the
facilities. This may, in turn, improve the quality of services provided by the facilities. It allows
health facilities to benefit from the ability of the contractors to provide these services at rates that
reflect economies of scale.
The international experience shows that, while outsourcing of clinical services, public facilities
have faced challenges in the proposal design, decision-making, implementation, and monitoring
stages. Some challenges at the designing stage include changing priorities, setting unrealistic
expectations, neglecting to realize the cost of outsourcing, and failing to strategize an exit
procedure. Similarly, the challenges encountered during the implementation phase were
permitting the outsourced service to get out of control and pressures from the internal
constituent. It has also been reported that there were weak monitoring mechanisms, poor
capacity to monitor contracts at each level, and poorly defined monitoring indicators. To resolve
these challenges, they took several actions, including creating an enabling political environment,
designing legal frameworks and strategies, building the facility's capacity to manage to
outsource, and establishing independent sources of monitoring information. The Federal Ministry
of Health (FMOH) recognizes the potential of the private for-profit and private not-for-profit in
expanding health development.
3.7 The hospital has opened a private wing in accordance with the Provisions of the federal
or regional regulation

Ethiopian public hospitals cannot meet increasing financial demands solely using the budgeted
funds allocated by the government. This has deteriorated the quality of services provided in
public hospitals, decreased staff motivation and morale, and increased the movement of health
workers from public to private hospitals in Ethiopia and abroad. This brain drain has been
exacerbated under the free-market economy that Ethiopia currently follows, which promotes the

27
attractiveness of the private sector. The health policy of Ethiopia encourages hospitals to look
for new sources of revenue to supplement the grants they receive from the government to
expand, organize, support, and strengthen the services they provide. Furthermore, the policy
encourages upper-income people to pay for healthcare services and, thus, help to support those
who do not have the financial capacity to gain equitable access.
Therefore, the hospital may establish a private wing to motivate the health workforce and retain
senior health professionals by enabling them to earn additional income by working in the wing
during off hours, weekends, and holidays. The establishment of the private wing also lessons
overcrowding and enhances the provision of services in the regular service as the private wing
provides alternatives for clients who choose to be served by their preferred health professionals
and at their preferred time.
A private wing is an official arrangement for public hospitals where clinical services are
provided based on a service fee. Hospitals may establish a private wing to benefit patients, staff,
and the hospital (see Box C). Fees charged to patients in the private wing should be set based on
cost recovery and higher than those charged in the regular hospital.
Income raised by the private wing should be shared between the hospital and the professionals
providing the private wing services. The income distribution should be approved by the
Governing Board based on the federal and respective regional guidelines. The hospital should
receive its share from the private wing income.

28
Box C Benefits of a private wing

Benefits for the patient include:

 A higher level of amenities and customer service
 A cleaner, more comfortable, and secure environment
 More convenient appointment times
 Personal choice of doctors
Benefits for the staff include:
 A better work environment
 Caring for people with an increased level of patient satisfaction
 For eligible employees, a potential to increase earning
Benefits for the Hospital include:
 Help to retain qualified staff
 Increase revenue for institutional improvement – upgraded equipment, computer
system,
 Clinical services, additional investment in staff training, etc
 Establish and role model a higher standard of non-clinical services throughout the
facility
Improve patient satisfaction
Improve reputation

Care should be taken to establish a pirate wing. The establishment of the private wing must be
based on national/regional regulations and implementation guidelines. Yet, preparatory activities
must be undertaken, and a comprehensive plan must be prepared to guide the establishment and
implementation of the private wing. The preparatory activities include:
 Conducting a feasibility analysis and gathering information, among other things, on the
need for private room services,
 Willingness of the hospital staff
 Availability of working space
 Establishment of the technical committee

29
  Preparation of the private wing guideline
 Review and approval of the establishment proposal by the board.
The hospital management should ensure that the opening of a private wing does not negatively
affect the quality and regular operations of the general hospital services and should ensure that
the quality of clinical care provided in the private wing is no different from the quality of care
provided to other patients.
The hospital management should ensure that the opening of a private wing does not negatively
affect the quality and regular operations of the hospital services and should ensure that the
quality of clinical care provided in the private wing is no different from the quality of services
provided during regular working hours.
Step 1
Public Private Partnerships in Hospitals (PPPH)

Public Private Partnership (PPP) is an arrangement between the public and private sectors that
aims to join forces to meet public needs through the most appropriate allocation of resources,
risks, and rewards.
The country's current stage of health development calls for engaging the private sector in Public
Private Partnership in Health (PPPH), particularly in providing secondary and tertiary level
health services, manufacturing indigenous health products, alleviating human resource
constraints, and nurturing the existing PPPH. With the objective to encourage the private sector
for high-end diagnostic services (laboratory and imaging services), high-end clinical services
such as hemodialysis, radiotherapy, neurosurgery and rehabilitation medical services, and other
unmet need driven PPP projects in the premises of the public health facilities; To guide
outsourcing of non-clinical services, as appropriate (management service, building, and
equipment maintenance to the private operators; guide the existing partnership to fully
complement government public health programs regarding coverage, standardization, ensuring
transparency and accountability, service quality, public safety, and sustainability.
Currently, some hospitals have contract with the private sector for clinical services - diagnostic
services. The existing PPPH has contributed significantly to improving the efficiency and
quality of service delivery, availing the private sector expertise, building the health professionals'
capacity, and creating a conducive environment for private sector collaboration.

30
The expansion of Non-Communicable Diseases (NCD) and the growth of the citizens' income
put more pressure on the demand for high-tech diagnostic and imaging services. Under the
existing condition, many public hospitals cannot meet this increasing demand due to financial
and technical reasons. For that reason, many patients are compelled to travel abroad for medical
treatment or get treatment in quite a few private facilities where some of these technologies are
available, and the user fees are too expensive to afford for many of them. Evidence from
international experience suggests that these gaps are met through public facilities that can
mediate by outsourcing clinical services. There are several reasons why many countries
outsourced the clinical services previously provided at public hospitals as indicated under
outsourcing improving access, quality, and efficiency to engage the private sector in the health
service delivery system, leveraging the advanced medical technology available in the private
sector, and reducing the cost of foreign treatment were significant reasons for outsourcing
clinical services.

3.8. The hospital fully complies with the government finance rules and regulations

Ensuring full adherence of the hospital's operations to the government rules, regulations, and
standards is one of the primary responsibilities of the Hospital Governing Board (HGB) and
management committee (MC). Hence, the hospital governing board should provide due attention
to ensuring the management and use of the public finance and assets as per the government rules
and regulations, use different mechanisms to validate the rules, and ensure the regulations are
fully implemented in the hospital. And undertaking financial, pharmaceuticals, and financial
enteral and external audits are among the mechanisms employed to ascertain full adherence of
the hospital. Hence, the hospital board needs to give guidance and support for the
implementation of the following audits: Internal financial audit regularly to guard against
breaches of the hospital's finance rules and make on-spot corrections.
Internal drugs and supply audit for mini stores every quarter and annually for leading stores
Annual external audit on financial performance, assets, and pharmaceuticals
Notably, the HGB and MC should review the internal and external audit findings and make
corrective actions for future improvement without delay.

31
The audit is derived from a Latin word meaning "He hears." In ancient times, the accounts of an
estate, domain, or manor were checked by having them called out to those in authority by those
who had compiled them. Currently, auditing can be defined as the process by which a
competent, independent person accumulates and evaluates evidence about quantifiable
information related to a specific economic entity to determine and report on the degree of
correspondence between the quantifiable information and established criteria.

Types of audits

Auditing can be grouped into four types: -

1. Financial audit: involves verification of financial data to express an opinion on their
validity and reliability
2. Compliance audit: involves verifying adherence to policies, plans, procedures, laws, and
regulations
3. Value for money (performance) audit: is a forward-looking evaluation of operations to
identify areas in which economy, efficiency, and effectiveness (the three E's) may be
improved or to evaluate compliance with and the adequacy of operational policies, plans,
and procedures. It involves the evaluation of inputs, processes, and outputs. Other names
that describe this type of audit include Operational, Management, and Three E.
4. Environmental audit: is an audit that confirms the degree of compliance with both
internally and externally determined emission and pollution standards.

Pre audits and Post audits

Auditing takes two forms, especially in government offices, commonly called "pre-audit" and
"post-audit." Pre-audit is the examination of transactions before payment. It is the more
traditional audit function. Post-audit represents an after-the-fact examination and is more recent
in origin.
Scope and concept of pre-audit
The pre-audit, perhaps more accurately described as a prepayment audit, is generally an integral
part of the central accounting and payment process. The primary objectives of pre-audit are to

32
ensure that; Expenditures are not unreasonable or extravagant; sufficient funds are available to
enable payment of the invoice, and there has been compliance with government proclamations,
regulations, directives, and procedural and budgetary requirements. It may include an
examination of contracts before approval and encumbrance, scrutiny of all invoices, and all
payrolls before payment.

Scope of post audit

The scope of post-audit may be grouped into two general categories:
 Financial accountability and legality – the verification of accounting records and review
of internal controls;
 Value for money – the examination of the efficiency, effectiveness, and economy of
operations, including the broad examination of the extent to which objectives are
accomplished.

These categories tend to overlap, but they help demonstrate the changing auditing concepts. The
primary limitation of the post-audit is that it concentrates on detecting irregularities rather than
preventing their occurrence. Each hospital should appoint an Internal Auditor responsible for
conducting regular internal audits as described in the government Internal Audit Manual.

The hospital accounts should be closed on the last day of the financial year. The external audit
should be conducted by external auditors from the Office of the Auditor General (Federal or
regional Audit office) or other authorized private auditors, approved by the Governing Board,
within six months of closing the accounts. The audit should consider the recording and
bookkeeping system and the hospital's annual retained revenue and expenditure. Audit reports
should be submitted to the CEO, who will present them to the Governing Board for taking
corrective actions.

33
Annexes

Box A Decentralized planning and budgeting

Decentralized budgeting and planning decentralization transfers authority and responsibility for public
functions from the central government to lower-level tiers. It involves the transfer of authority for
decision-making to local governments on expenditure assignment, i.e., performing public functions,
including the provision of services, and revenue assignment, i.e., generating own revenues and having
independent authority in making investment decisions. Fiscal decentralization is a core component of
decentralization. It refers to the situation where lower levels of government are entitled to collect and
spend their revenues and share some revenue with a higher level of government authority. The
principle of fiscal decentralization suggests that assigning expenditure responsibilities and decision-
making powers to the lower levels of government can substantially improve a state's ability to identify
and address its citizens' needs effectively. In light of this, the government has introduced fiscal
decentralization and essential planning and budgeting procedures. The purpose of planning and
budgeting is to ensure that financial resources at the facility level are spent with proper accountability
promptly according to expenditure guidelines established by the MOFED/BOFED.

Source: Implementation Manual for Health Care Finance Reform. FMOH, 1995

34
Box B: Components of Health Financing

 Revenue retention and utilization, which is mainly aimed at increasing health sector
resources to be dedicated to improving the quality of healthcare

 Facility Governing Board -is the legitimate authority to provide strategic leadership for
the attainment of the overall objectives of the hospital.

 Private wing -helps to provide an alternative health service for those who can afford to
pay and to retain senior health professionals in public health facilities.

 Outsourcing of non-clinical services -contract out selected non-clinical services for the
third party to enhance efficiency. It helps health professionals to focus on their core
business and to provide an enhanced service.

 Exempted Health Services-provision of selected health services for all eligibles for free
irrespective of ability to pay.

 The fee waiver system aims to improve equitable health services provision by providing
exceptional support for citizens who cannot afford health services. Currently, this
component is majorly being implemented under Health Insurance programs.

 User fee revision – refers to the periodic revision of user fees, considering the
population's ability and willingness to pay.

 Community-Based Health Insurance aims to remove catastrophic out-of-pocket health

expenditures and improve health service utilization of citizens engaged in the informal
sector without exposing them to financial hardship.

 Social Health Insurance aims to remove catastrophic out-of-pocket health expenditure

and improve health service utilization of citizens engaged in the formal sector without

35
References

1. The Federal Democratic Republic of Ethiopia. (1988). Health Care Financing Strategy, Addis
Ababa.

2. The Federal Democratic Republic of Ethiopia. (2006, January). User's Guide for
Procurement of Goods (For National Competitive Bidding).

3. Federal Democratic Republic of Ethiopia. (2006, January). User's Guide for Standard
Bidding Document for the Procurement of Works (For International Competitive Bidding).

4. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

(1998 E.C.). Internal Auditor Standard, Ethical Conduct Guidance, and Internal Auditing
Manual. Addis Ababa: Ministry of Finance and Economic Development.

5. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

Procurement Manual.

6. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

Federal Government of Ethiopia Accounting System Volume I Accounting for Modified Cash

Transaction Version 1.1. Addis Ababa: Ministry of Finance and Economic Development.

7. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

Federal Government of Ethiopia Accounting System Volume II Chart 7 Accounting Version

8. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

Federal Government of Ethiopia Accounting system Volume III Accounting for Other Assets
and Liabilities version 1.1. Addis Ababa: Ministry of Finance and Economic Development.

10. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.
(2007, 12 January).
11. Revised Federal Budget Manual (Draft). Addis Ababa: Ministry of Finance and Economic
Development.
12. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.

36
(2005, 05 July). Federal, Public Government Procurement Directive. Addis Ababa: Ministry of
Finance and Economic Development.

13. Federal Democratic Republic of Ethiopia Ministry of Health. (2005, 14 November).

Implementation Manual for Healthcare Financing Reforms Final Document (Revised).
14. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic Development.
(2007, December). Government Owned Fixed Assets Management Manual. Addis Ababa:
Ministry of Finance and Economic Development.
15. Office of Public Management NSW Premier's Department SYDNEY NSW 2000.
16. Proclamation No. 57/1996. Federal Government of Ethiopia Financial Administration Addis

Ababa: Federal Negarit Gazeta.

17. Proclamation No. 430/2005: Determining Procedures of Public Procurement and Establishing
its Supervisory Agency. (2005, 12 January). Addis Ababa: Federal Negarit Gazeta.
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Administration Proclamation. (2009, 09 September). Addis Ababa: Federal Negarit Gazeta.

19. South Nations Nationalities and People's Regional Government and Health Bureau. (2006,
May). Implementation Manual for Healthcare Financing Reforms

37
Chapter Outline

Section 1: Introduction
Section 2: Operational standards
Section 3 Implementation Guidance
3.1 Organizational structure for
3.1.1 Roles and responsibilities of

3.2 Clinical audit

3.3 Quality improvement projects
3.3.1 Quality improvement models
3.3.2 Implementing improvement cycle
3.3.3 Measuring change, communicating findings, documenting and recognizing achievements
3.3.4 Conclusion - Quality Improvement Project
3.4 Clinical Risk Management
3.5 Patient Focused Care
3.6 Benchmarking and experience sharing platforms
Source Documents/References
Appendices
Abbreviations
ANC - Antenatal Care
CEO - Chief Executive Director/Officer
CED - Chief Executive Director
EHAQ - Ethiopian Hospital Alliance for Quality
ER - Emergency Room
FMOH - Federal Ministry of Health
GB - Governing Board
GP - General Practitioner
HMIS - Health Management Information System
HO - Health Officer
HSQ - Health Service Quality
IPD - Inpatient Department
MPH - Master of Public Health
OPD - Out Patient Department
PDSA - Plan, Do, Study, Act
PPE - Personal Protective Equipment
QI - Quality Improvement
RHB - Regional Health Bureau
SMT - Senior Management Team
TB - Tuberculosis
TOR - Terms of Reference
WHO - World Health Organization PDSA Plan, Do, Study, Act
QI Quality Improvement
RHB Regional Health Bureau
WHO World Health Organization
Section 1 Introduction
As per the national quality and safety strategy of Ethiopia, quality is defined as comprehensive
and integrated care that is measurably safe, effective, people-centered, and uniformly delivered
in a timely manner that is affordable to the Ethiopian population and appropriately utilizes
resources and services efficiently. It encompasses seven generally accepted dimensions:

Table 1: Quality Dimensions

Quality dimensions Definitions

Avoiding injuries to patients from the care that is intended to help them; the
Safe WHO defines “patient safety” as the prevention of errors and adverse effects
to patients associated with healthcare.
The care is based on evidence-based knowledge and evidence-based
Effective
guidelines.
It must consider the people’s needs, preferences and values while delivering
health care, characterized by respect and dignity of the users. People-
People-centered
centeredness shifts the power from the health care system
and providers to patients/users of the system.
Reducing waits and sometimes harmful delays for both those who receive
Timely
and provide care.
Efficient Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Providing care that does not vary in quality because of personal
Equitable characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
Care provided to the patients is coordinated across the health care platform
Integrated and
individual providers.

Quality management in healthcare needs three core components (Juran Trilogy): Quality Planning, Quality Control and
Quality Improvement. Quality care is achieved not by one aspect. As part of the health system, information about quality
care can be drawn from integration of structure, process and outcomes. SMT and GB should ensure that health service
quality is in place and should monitor their effectiveness. All staff should participate in health service quality activities
specific to their work area.

Quality improvement (QI) is a continuous process whereby organizations iteratively test and measure changes in work
routines, set and achieve ambitious aims, shift whole system performance, and spread best practices rapidly for uptake at
a larger scale to address specific issues set to improve. The content in these operational standards is organized to include
health service quality organizations, all quality dimensions, clinical audits and regulatory accreditation concepts.
Section 2: Operational Standards

1. The hospital has an established Health Service Quality Directorate/Office.

2. The hospital has functional Health Service Quality council/committee
3. The hospital coordinates health service reform activities and integrates into the existing system.
4. The hospital has established a system to manage health care delivery related risks.
5. The hospital has functional clinical audit program
6. The hospital actively participates in collaborative learning and experience sharing platforms.
7. There is regular Hospital to health center support system
8. The hospital develops a system to insure patient preference and value.
9. The hospital regularly conducts patient satisfaction surveys.
10. The hospital has established a health literacy desk.
11. The hospital identifies priority problems in service delivery areas and implements QI projects.
12. The hospital ensures equitable service delivery.
13. The hospital establishes a system to ensure timeliness of care.
14. The hospital establishes a system to control efficiency of healthcare delivery.
 Section 3 Implementation Guidance
3.1 Organizational structure for Health Service Quality

A Health Service Quality Directorate/Office requires a clear and standard structure and framework. The structure
includes the organization's human, physical, and financial resources, such as buildings, staff, equipment, plan and
policies. These structures and serve to:

 Encourage the participation of all staff in continuous Health Service Quality processes.
 Assign responsibility for Health Service Quality processes.
 Ensure activities proceed as planned per the annual plan.
 Maximize quality, effectiveness and efficiency of services.

The hospital should establish a Health Service Quality Directorate/Office reporting to the Chief Executive
Director/Officer (CEO/CED) or relevant body based on hospital level. This unit should be led by an assigned senior
physician, general practitioner, or holder of a Master of Public Health degree or other equivalent professional. This
person will be the Health Service Quality Director/Head. The director/head should be selected using the following
criteria:

 Good clinical leadership capability

 Excellent clinical skills
 Excellent analytic and research skills
 Commitment
 Good understanding of systems thinking and systems change
 Good data-use culture
 Innovative/ creative and able to offer solutions
 Team player

Each clinical department should establish its own QI team, led by the department/case team head, to undertake HSQ
activities. Department heads are responsible for ensuring quality activities occur and reporting them to the HSQ
Directorate/Office. Each department should regularly audit its performance.

3.1.1 Roles and responsibilities of Health

As outlined above, hospitals should establish an HSQ Directorate/Office to oversee all hospital QI functions. The HSQ
Directorate/Office should comprise a director/head and Quality Officers. It should be multidisciplinary, with members
from different clinical and administrative backgrounds. The HSQ Directorate/Office head should be a member of the
hospital senior management team and accountable to the CEO/CED. The HSQ director and officers should serve full-
time in their HSQ roles.
CEO/CED. The HSQ director and Directorate/Officers should be full time in their role for HSQ activities.

HSQ Unit Roles include:

a) Develop the HSQ strategy and present to the Senior Management Team for approval,
b) Develop an HSQ strategy implementation plan and monitor execution,
c) Ensure HSQ activities relate to the hospital's vision and mission, aligned with strategic and annual plans,
d) Coordinate all HSQ activities,
e) Promote and support staff participation in HSQ activities,
f) Receive and analyze feedback from patients, staff and visitors,
g) Receive clinical audit reports and maintain records of all clinical audit activities,
h) Review selected hospital deaths as part of death audit committee,
i) Work closely with the HMIS Office to monitor performance
j) Conduct peer review in response to specific quality and safety concerns and take appropriate action and follow-up
when deficiencies are identified,
k) Build capacity of hospital staff on QI activities and findings.

This unit should collaborate closely with the Medical Director as activities are closely related.

Departmental Quality Improvement team/taskforce

Irrespective of the workload, the hospital should establish a departmental/case team level QI team/taskforce to undertake
some of the above functions. Each departmental QI team should be chaired by the department/case team director/head
that provides regular update reports to the HSQ office.

3.2 Clinical Audit and Death Audit

A. Clinical Audit
Clinical audit is defined as a quality improvement process seeking to improve patient care and outcomes through
systematic review of care against explicit criteria and implementation of change. It involves assessing structure, process,
and outcomes against agreed standards and introducing changes based on identified gaps with further monitoring to
ascertain improvements.

Hospitals should establish and implement a clinical audit program with identifiable service areas. Clinical audit involves
5 main steps:

i. Audit planning
for successful clinical audit, adequate preparation is very important. Planning involves three essential
components:
  Identifying stakeholders - those involved in the audited activity including service providers and users. Including
the unit head will be beneficial.
 Identifying the audit topic - it is necessary to decide the topic in advance. With several topics, the team should
prioritize resources efficiently.
 Planning the audit field work - the audit objective should be clearly understood by all stakeholders, required
skills and personnel identified, appropriate training and briefing conducted on roles, and a comprehensive
proposal developed with adequate resources and timetable.

ii. Develop standards/criteria for clinical care in the selected area

Standards/criteria may include:
 National or international drug treatment guidelines,
 National or international diagnostic and treatment guidelines,
 ‘Best practice evidence’ from literature reviews
 National clinical audit guideline as a reference.

iii. Assess current practice against standards

This can be done through retrospective or prospective case note review, direct observation, surveys or
interviews.

iv. Take action to address identified deficits in clinical care (Conduct QI activities)
If the audit identifies suboptimal care, reasons should be investigated using qualitative methods like those in
Table 1. Investigation should involve relevant stakeholders to address the problem comprehensively. Findings
should inform recommendations for practice change.

Table 2. Summary of qualitative study methods

METHOD ADVANTAGES DISADVANTAGES

Focus Group Discussion  Inexpensive  Groups may not represent

 < 2-hour recorded discussion  Quick the larger population

 6–10 non-random respondents  Easy to organize  Successful outcome depends heavily

 2–4 discussions for each  Identifies range of on moderator skills

significant target population beliefs  Recorders may inhibit participants.
 Moderator leads discussion
Respondents have similar
characteristics e.g. age, gender,
social status
 Discussion topics pre-defined
 Informal, relaxed, ambient
  Reveals beliefs, opinions and
motives

In-depth Interviews  Can reveal significant  May generate difficult to manage of

 One-to-one extended interview but unsoughtdata data
 Questions are pre-  Time-consuming and expensive
determined butopen-ended  Bias due to respondent pleasing
 Often covers up to 30 topics interviewer

Corrective measures will vary but may involve staff training, providing aide-memoires, developing and implementing
guidelines, or ensuring availability of appropriate drugs or diagnostics.

v. Re-assess practices against standards (Sustain improvements)

The audit should be repeated after corrective interventions to measure impact and identify if further action is needed.

Clinical audit enables participation of all clinical staff in QI activities and is an ideal mechanism for multidisciplinary
teams or department staff to improve performance collaboratively. Ideally all clinical staff should participate in at least
one clinical audit project annually and findings should be shared across the hospital. All staff should be encouraged to
identify potential audits based on observed clinical activity and outcomes. Similarly, hospital management may
recommend an audit in response to reported outcome measures. For example, a high or increasing postoperative
infection rate may prompt an audit of prophylactic antibiotic use for surgeries, to identify adherence to guidelines.

The HSQ Directorate/Office should receive all Clinical Audit Reports and maintain a record of audits undertaken.
Participation in clinical audit could be a performance measure for staff undergoing evaluation, or when assessing
department contributions to hospital strategic plans.

If possible, the hospital should appoint a clinical audit officer to support activities, including helping design protocols
and tools, data entry and analysis alongside clinical staff. If this is not feasible, hospital management should ensure
necessary equipment and supplies are available to audit staff.
The HSQ Directorate/Office should ensure clinical audits occur in the hospital. The Governing Board may include
completed audits as an indicator on the Balanced Scorecard for monitoring performance.

B. Death Audit

The death audit committee, led by the Chief Clinical Officer (CCO), should consist of members from the quality unit
and other relevant departments. The audits should be conducted regularly, with deaths being audited at the departmental
level. Additionally, it is essential to prioritize the audit of all maternal deaths, given their unique considerations and the
need for specialized care. By following these guidelines, healthcare organizations can effectively identify areas for
improvement and implement necessary changes to enhance patient safety and healthcare outcomes.

3.3. Quality Improvement Projects

Quality improvement projects in healthcare are systematic, data-driven initiatives to enhance efficiency, effectiveness,
and safety of care delivery processes, ultimately improving patient outcomes and satisfaction. They involve identifying
areas for improvement, implementing evidence-based interventions, continuously monitoring and evaluating results to
ensure sustained progress.

3.3.1 Quality improvement models

The two selected QI Models to be used in the Ethiopian healthcare are:

1. Kaizen: Engine driving improvement or entry point of all QI activities

2. Model for Improvement: Vehicle that provides structure for improvement

KAIZEN

 Focuses on improving efficiency and lowering costs.

 Key feature is big results from small changes accumulated over time.

Implementation steps
5S establishes an ideal workplace for continuous improvement. It is a philosophy and way of organizing and managing
workspace and workflow to improve work efficiency. 5S shall be conducted systematically with staff participation.
 Figure 1: Kaizen/5S

1. Sort: remove unused stuff from working area by:

• Categorizing and color code the items.

• Developing inventory list of categorized items.

• Storing “may be needed” items.

• Regularly sorting of unused items.
• Developing a culture of returning items where they belong.

2. Set in order: organize necessary items in proper order for easy serviceprovision:
• Labeling/numbering cabinets
• Keeping items in respective areas and labeling them
• Directional arrows to services areas.
• Labeling service rooms.
• Updating equipment/stock inventories.

Note: Rules and regulations must be written and known to all staff

3. Shine: maintain high cleanness standards:

• Routine cleaning and mass cleaning campaigns
 • Clean behind and under furniture/equipment
• Clean and attractive environment appreciated by clients

4. Standardize: the first three components set the stage for to developand implement
standard operating procedures to maintain good work environment.
• Set up the sort, set and shine as a norm in all sections
• Work instructions
• Standard operating procedures (SOPs)

• Standards and regulations for administrative and technical staff

5. Sustain: train and maintain discipline of engaged staff through consistent 5S practice:
• Train and maintain staff discipline
• Apply regular self-assessment.

THE MODEL FOR IMPROVEMENT

The model of improvement asks three fundamental questions:

• What are we trying to accomplish?
• What change can we make that will result in improvement?
• How will we know a change is an improvement?

What are we trying to accomplish?

This encourages clear aim-setting. The aim should be:
• Specific – described clearly and precisely, identifying beneficiaries and achievements
• Measurable – progress can be tracked using data
• Ambitious - may not know how to achieve initially but shouldn't limit bold targets if
aligned with customer needs/expectations and achievable
• Relevant – meaningful to others if requiring resources or support
• Time-bound – clear timeframe for achievement

“What change can we make that will result in improvement?”

This prompts thinking about changes that may help achieve the aim - change ideas. Change is required for improvement,
but not all changes result in improvement. Many techniques and tools can identify successful changes like:

• Benchmarking against better performers to identify differences

• Consulting experts to determine best practices
• Using root cause analysis tools like 5 whys and fishbone diagrams
• Applying creativity tools such as provocations and random words to think
innovatively
• Checking lists of change concepts to generate ideas
• Mapping key process steps to identify potential improvements

“How will we know the change is an improvement?”

Measurement question means finding a way to demonstrate the aim is achieved - the outcome measure. Before making
changes, the current outcome measure provides a baseline. Observing what happens to the outcome measure with
different changes then shows if there is improvement correlated to the intervention. A process measure related to the
change provides insight into how well it is being implemented.

Combined with the Plan-Do-Study-Act (PDSA) test cycle, the Model for Improvement is the foundational framework
for successful improvement activities.
 Figure 2: The PDSA Cycle, a model for Quality Improvement

Plan – Do – Study – Act cycle (Deming cycle)

Step 1: Plan
• Plan the test, including data collection.
• State the test objective.
• Make predictions about what will happen and why.
• Develop a test plan. (Who? What? When? Where? What data to collect?)
Step 2: Do
• Try the test on a small scale.
• Carry out the test.
• Document problems and unexpected observations.
• Begin data analysis.

Step 3: Study
• Refine the change based on learning.
• Compare data to predictions.
• Summarize learning.

Step 4: Act
• Refine the change, based on what was learned from the test.
• Determine modifications needed.
• Prepare next test plan.

PRINCIPLES OF IMPROVEMENT
Fundamental to the success of any improvement effort is the understanding that improvement requires change -
altering how work is done to produce visible, positive differences relative to goals with lasting impact. Not all changes
result in improvement, some just reset things. Doing more of the same does not necessarily bring change.

TYPES OF CHANGES

Reactive change: needed to maintain current performance

Fundamental change: required to create new performance systems through redesign and
fundamentally altering how the system works.

Fundamental changes that result in improvement

• Alter how work or activities are done
• Produce visible, positive difference relative to historical norms

• Have lasting impact

Improvement is characterized by being faster, easier, more efficient, effective, less expensive,
safer, cleaner, etc. The extent relates directly to the nature of implemented changes.

DRIVERS OF IMPROVEMENT IN HEALTH CARE

The drivers of Improvement are:

• Will: Desire to change current state to better state.
• Ideas: Developing ideas to improve processes and outcomes.
• Execution: Applying QI theories, tools and techniques enabling idea implementation.

Figure 3: Drivers of quality improvement in health care

QUALITY PLANNING AND MONITORING

Successful quality improvement programs include four key elements:

1. The Problem
• In-depth understanding of the problem
• System-wide buy-in for the initiative and targeted problem
2. The Goal
• Targeted improvements based on a return on investment (ROI) and cost-benefit analyses
• Key questions when defining goals:
o How does this tie into strategic improvement objectives?
o What will have the biggest patient impact?
o What areas have largest variation?
o What will have the biggest cost impact?
 3. The Aim

 Breaks up goal achievement into manageable pieces.

4. The Measures

 Measuring baselines and actuals

 Determining if and how the improvement correlates to the intervention

3.3.2 Implementing improvement cycle

Health center performance and quality need continuous improvement. The cycle involves:

Step 6 – Monitor
action plan
Step 1 – Review
progress and performance and
expected quality
achievements

Step 5 – Prepare Step 2 –

detailed action plan Identify and
to implement prioritize
intervention
problems

Step 4 – Select Step 3 – Conduct

interventions root-cause analysis
addressing root-
causes
 Figure 4: Quality improvement implementation cycle

Identify the problems and prioritize

From the indicator and issue review in Step 1, list problems needing improvement. Select a
manageable number as monthly priorities. Improving all areas simultaneously may not be
possible, so the facility should choose priority areas for the timeframe before taking
improvement actions.

First priority should be problems solved with few resources, followed by more complex,
expensive ones. However, more difficult areas may need addressing first if impact is
significant. Performances related to national & regional priority areas (TB, Malaria, HIV,
Maternal and Child health) should be priority considerations.

Conduct root-cause analysis of the problem

Understanding the causes helps develop appropriate interventions. Targeting changes to

causes enables sustainable improvement versus superficial solutions. Fishbone analysis and
flowcharting are common techniques for identifying root causes.

Fishbone analysis steps

1. Place the problem to be analyzed and improved in a box at the end of a horizontal arrow
2. Categorize major cause areas (policy, process, people, environment, infrastructure) and
connect them to the backbone with diagonal arrows
3. To find secondary, tertiary, etc causes ask "why did this happen?" under each category
4. Repeat until reaching the root cause

Figure 5 illustrates a fishbone diagram analyzing causes of “Low skilled birth attendance in our area”
Figure 5: Fishbone analysis of root causes in quality problems

Flow chart steps

1. Decide beginning and end points of the process to chart
2. Identify process steps
3. Link steps with directional arrows. May also use symbols:

Begin or End

Step

Decision

Flow Lines

Connectors

Delays
Select interventions that address the root-cause
Following root cause analysis, design an intervention addressing the root cause directly for sustainable
problem-solving versus superficial fixes. When selecting interventions, consider cost and
implementation feasibility.

Prepare detailed action plan, implement the intervention, monitor the progress and
expected achievements
Here, the team prepares an action plan to implement selected interventions and collect relevant
monitoring data using the PDSA cycle. The team should discuss implementation status and evaluate if
the intervention is leading to improvement or requires continuation, modification, or discontinuation.
The cycle then continues.

3.3.3 Measuring change, communicating findings, documenting and recognizing

achievements
Along with implementing quality improvement strategies, the care quality level needs continuous
measurement against set goals to track changes. Findings from quality measurement, after analysis,
provide advocacy tools to take further improvement actions - mobilizing resources, creating
competitiveness among providers, and increasing user awareness.

3.3.4 Conclusion - Quality Improvement Project

The above steps may result in a quality improvement project to address specific facility deficiencies
through a strategic approach. The QI project process involves: quality assessment comparing
performance to expectations/standards/goals; identifying gaps and root causes; designing and
implementing best interventions within available resources; and continuous monitoring and evaluation
of outcomes.

3.4 Clinical Risk Management

Risk is the likelihood, from low to high, of somebody or something experiencing harm from an
unwanted event or incident, multiplied by the severity of potential harm. Clinical risk management is
an approach to improving the quality and safety of care by emphasizing identifying circumstances
putting staff/patients at risk of harm and acting to control those risks.

Risk management involves assessing the environment for potential patient and staff risks, then taking
action to minimize identified risks. The risk management process seeks to answer four related
questions:

How bad?

Is there a need for

What can go
action?
wrong?

How often?

Figure 6: Risk management

Risk management proactively reduces identified risks to an acceptable level by creating a culture
founded upon assessment and prevention culture, rather than reaction and remedy. Risk assessment
examines:
Hazards – situations with potential for cause harm; and
Risks - defined as the probability a specific adverse event will occur in a timeframe or because of a
situation.

Risk assessment involves 5 steps:

Step 1 Identify hazards (what could go wrong) - Consider past incidents and near misses. Walk
around and discuss with patients and staff. Map/describe the assessed activity. A
multidisciplinary team may be needed.

Step 2 Decide who may be harmed and how (what can go wrong, who is exposed)

Step 3 Evaluate risks (severity, likelihood) and precautions needed - Use a risk matrix like Table
3.

Step 4 Record findings, proposed actions and responsible persons

Step 5 Review and update the risk assessment as needed

Table 3 Risk Assessment Matrix

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood

Low risk (green) – quick, easy measures should be implemented

immediately and furtheraction planned when resources permit.

Moderate risk (yellow) – actions should be implemented as soon as

possible, but no laterthan one year.

High risk (orange) – actions should be implemented as soon as possible,

but no later thansix months.
Extreme risk (red) – action should be taken immediately.

Hospitals should establish systems for regular risk assessment from healthcare provision and delivery,
ensuring steps are taken to minimize risk. Each department should regularly (quarterly) conduct risk
assessment and identify risk minimization actions. The whole team should be involved in an open,
learning environment. Areas for consideration include, but are not limited to:

Physical environment – clean, safe, hazard-free?

 Emergency exits clearly labeled and unobstructed?
 Infection prevention policies and procedures adequately implemented?
 Hazardous materials safely and securely stored?
Equipment in good working order with maintenance minimizing errors and breakdowns?
 Medication administration policies implemented to reduce errors?
 Laboratory policies ensuring correct samples from patients, accurate timely results?
 Clinical guidelines adhered to for evidence-based practice?
A ‘Safety Walk-Round’ is another Risk Management approach. A leadership/quality team visits areas
asking frontline staff about events, contributing factors, near misses, potential problems and solutions.
Issues are then prioritized for the department to develop solutions. This often embeds solutions in the
descriptions, enabling prompt care and safety improvements. It can lead to culture change as frontline
concerns are addressed through ongoing hazard observation and discussion with leadership. Safety
Walk-Rounds are a low-cost way to identify frontline staff concerns and make needed changes without
additional resources.

3.5. Patient focused care

Patient-centered care includes care quality - the compassion, dignity and respect shown. Every patient
wants to be treated as an individual and has rights to courtesy, privacy and confidentiality, and full
information about their condition, investigations and treatments. Patient-centered care involves
planning and delivering quality care in partnership between staff, patients and caregivers. Effective care
balances:
Consideration
Talking and Listening

Hospitals should adopt a Patient Rights and Responsibilities Statement readily available to patients like
posting in outpatient/inpatient areas. All staff should be aware of the Statement to treat patients
accordingly.

Patient-centered care also includes quality of hotel services like housekeeping, food services, etc. The
hospital should ensure high standards of these services within the budget by outsourcing to improve
quality and cost-efficiency.

Patient-centered care is improved by analyzing patient satisfaction. Hospital management and

Governing Board should monitor patient perspectives on care through Patient Satisfaction Surveys.
Appendices F and G contain validated Inpatient and Outpatient Satisfaction Surveys. Surveys should be
conducted quarterly with summary results reported to the Board, analyzed, and acted upon through
detailed action plans or linked to QI projects. Results can be included in the hospital’s Balanced
Scorecard. Additionally, staff attitudes and relationships with patients and caregivers should be a
component of performance evaluation. (refer Human Resource Management chapter).
Patient and public involvement in healthcare planning and implementation
Services should be tailored to population needs and expectations. Patient and public perspectives help
identify what works and doesn't in service delivery. Before involvement, important considerations are:
 What information is needed,
 Why their views are needed,
 How their views will be used, and
What patients/services will gain from this involvement.

Involvement can occur through:

Informing: where people passively receive information,
Consulting: where the users of a service are asked to give information or advice, or
Partnership: involving the public in decision-making.

The involvement level will influence who is involved and the approach. For example, informing the
public about diarrhea management may use posters at the hospital/community or lectures. Establishing
a new child clinic may involve focus groups, surveys or public meetings. Each situation requires
tailored involvement for the purpose. Using multiple approaches gives more people chances to
participate. All approaches have strengths/weaknesses and may overlap.

Health Literacy Desk

Health literacy is understanding and using health information to make informed care decisions.
Hospital health literacy desks significantly help clients learn about their health and make informed care
decisions.

Hospitals should establish a Health Literacy Desk coordinated by an assigned health education focal
point, with additional professionals as needed based on hospital tier. The unit should maintain a register
with patient details like name, address, diagnosis, information provided, contact number, etc.
Preferably, leaflets/posters should be in local languages. Audiovisual materials are also recommended.

3.6. Benchmarking and experience sharing platforms

In 2012 GC, Ethiopia launched the Ethiopian Hospital Alliance for Quality (EHAQ) clustering
hospitals nationwide. Purposes include learning, experience sharing, support, mentoring, resource
sharing and synergy towards improvement.
EHAQ hospitals are evaluated against requirements through self-then external assessment by trained
auditors authorized by the Ministry/Regional Health Bureau. The audit tools introduced in each EHAQ
cycle can be used for training, mentoring and supportive supervision. The national EHAQ audit team
supports hospitals and conducts audits and recognition. EHAQ provides a learning opportunity for
continuous healthcare quality improvement and an ideal mechanism for efficient and effective resource
management.

Additionally, as part of the health system, hospitals should support health centers technically,
materially, and with human resources to improve quality of care.
Source Documents
1. Federal Ministry of Health, Ethiopia. National quality strategy review document; 2021-2025.
2. Department of Health. (2000). An Organisation with a Memory. London, England: Her Majesty’s
Stationary Office.
3. Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring. The Definition of
Quality and Approaches to its Assessment. Vol. I.Ann Arbor, MI: HealthAdministration Press.
4. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). Health Management
Information System/Monitoring and Evaluation. Strategic Plan for the Ethiopian Health Sector.
Addis Ababa, Ethiopia.
5. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector. Addis Ababa,
Ethiopia.
6. Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Population. New England Journal of Medicine, 2009; 360:491-9.
7. Institute of Medicine. (1999). To Err is Human. Building a Safer Health System. Washington, DC:
National Academy Press.
8. NHS Quality Improvement Scotland. (2005). National Standards. Clinical Governance and Risk
Management: Achieving Safe, Effective, Patient-Focused Care and Services.
9. Standards Australia and Standards New Zealand. (2004). AS/NZS 4360:2004. Risk Management.
Sydney, NSW. ISBN 0 7337 5904 1.
10. World Health Organization. World Alliance for Patient Safety. (2005). WHO Draft Guidelines for
Adverse Event Reporting and Learning Systems. From information toaction. . Retrieved
from:http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf.
11. World Health Organization. Patient Safety, World Alliance for Safer Healthcare.(2009).
Implementation Manual Safe Surgery Checklist 2009. Retrieved
from:http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf.
12. World Health Organization. (2009) WHO Guidelines for Safe Surgery 2009: SafeSurgery Saves
Lives. Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf.
Appendices
Appendix A Sample Risk Assessment Template

Date of Risk Assessment: dd/mm/yy

Case Team/Service Area: Example- Operating Theatres

Participants who took part in Risk Assessment: (list names and positions)

Risk Assessment Matrix:

Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence

Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood
Hazard identified Consequence(negligibl Likelihood(rare, Category(green, Action to be Responsible Date for
e, minor, moderate, unlikely, possible, yellow, orange, taken person completion of
major, catastrophic) likely, almost red) action
certain)

1. Old broken equipment in Moderate Likely ORANGE Remove Head of Case Within one week
corridor and potential that equipment to Team(name) by dd/mm/yy
patients or staff may trip and maintenance
fall, or injure themselves on department
the items

2.No sharp boxes available Major Likely RED Install sharp Senior Within two days
and potential to cause boxes Nurse(name) by dd/mm/yy
needle-stick injury to staff or
patients

3.Interrupted electrical Catastrophic Possible RED Back-up CEO As soon as

supply potential for failure generator to be possible, no later
of lights, anaesthesia installed than 3 months
machine during surgical dd/mm/yy
procedure and hence patient
harm

4.Shortage of nursing staff Catastrophic Possible ORANGE Add more Case Team Head Within three
to monitor patients in nursing staff to and Head of months, i.e. by
‘recovery’ area and potential department or Human Resource dd/mm/yy
harm due to poor monitoring change skill mix Department
and clinical care of existing staff

5.Lack of pre-surgical Major Possible ORANGE Prepare pre- Senior Within two
checklist and potential for surgical checklist Surgeon(name) months, i.e. by
cancelled surgery because and train ward dd/mm/yy
patient not prepared staff in its use
adequately
Appendix B Sample Statement of Patients’ Rights and Responsibilities

Your Rights and Responsibilities as a Hospital Patient

We consider you a partner in your hospital care. When you are well-informed, participate in
treatment decisions, and communicate openly with your doctor, nurse and other hospital staff,
you help make your care as effective as possible. This hospital encourages respect for the
personal preferences and values of each individual.

While you are a patient in our hospital, your rights include the following:

1. You have the right to considerate, respectful and safe care.

2. You have the right to be well informed about your illness, possible treatments,
likelyoutcomes and unexpected outcomes and to discuss this information with your
doctor.
3. You have the right to know the names and roles of people treating you.
4. You have the right to consent to or refuse a treatment, as permitted by law,
throughout your hospital stay. If you refuse a recommended treatment, you will receive
other neededand available care.
5. You have the right to have an advance directive, such as a living will or health care
proxy. These documents express your choices about your future care or name someone
todecide if you cannot speak for yourself. If you have a written advance directive, you
should provide a copy to the hospital, your family, and your doctor.
6. You have the right to privacy. The hospital, your doctor and others caring for you will
protect your privacy as much as possible.
7. You have the right to expect that treatment records are confidential unless you have
givenpermission to release information or reporting is required or permitted by law.
When the hospital releases records to others, such as lawyers or insurers, it emphasizes
that the records are confidential.
8. You have the right to review your medical records and to have the information
explained,except when restricted by law.
9. You have the right to expect that the hospital will give you necessary health services to
the best of its ability. Treatment, referral, or transfer may be recommended. If transfer
is recommended or requested, you will be informed of risks, benefits, and alternatives.
Youwill not be transferred until the other institution agrees to accept you.
10. You have the right to know if this hospital has relationships with outside parties that
mayinfluence your treatment and care. These relationships may be with educational
institutions, other health care providers, or insurers.
11. You have the right to consent or decline to take part in research affecting your care.
Ifyou choose not to take part, you will receive the most effective care the hospital
otherwise provides.
 12. You have the right to be told of realistic care alternatives when hospital care is no
longerappropriate.
13. You have the right to know about hospital rules that affect you and your treatment
and about charges and payment methods. You have the right to know about hospital
resources, such as social and religious services, or ethics committees, that can help
youresolve problems and questions about your hospital stay and care.
14. You have the right to have an autopsy done by a physician who is not affiliated with
thishospital and/or to have it done at an unaffiliated institution. Any person authorized
to give consent for an autopsy will receive this information before signing the consent
or giving consent by telephone.
15. You have the right to be free from all forms of abuse or harassment.

You have responsibilities as a patient.

1. You are responsible for providing information about your health, including past
illnesses,hospital stays, and use of medicine. You are responsible for asking questions
when you do not understand information or instructions. If you believe you can’t follow
through with your treatment, you are responsible for telling your doctor.

2. This hospital works to provide care efficiently and fairly to all patients and the
community. You and your visitors are responsible for being considerate of the needs
ofother patients, staff, and the hospital.

3. You are responsible for providing information for insurance and for working with
thehospital to arrange payment, when needed.

4. Your health depends not just on your hospital care but, in the long term, on the
decisions you make in your daily life. You are responsible for recognizing the effect of
life-style onyour personal health.

5. A hospital serves many purposes. Hospitals work to improve people’s health; treat people
with injury and disease; educate doctors, health professionals, patients, and community
members; and improve understanding of health and disease. In carrying out these
activities, this institution works to respect your values and dignity.

You have the right to be free from restraints of any form (physical or chemical) and/or seclusion
that are not medically necessary.
A restraint can only be used if needed to improve your well-being and when less restrictive
interventions have been determined to be ineffective. A restraint may be used to ensure your
safety and/or that of others.

There must be an order for restraints, and that order should never be written as standing or as
needed. This order must:

 be followed by consultation with the treating physician as soon as possible if not

ordered by the treating physician
 be in accordance with a written modification to the plan of care
 be implemented in the least restrictive manner possible
 be in accordance with safe and appropriate restraining techniques
 end at the earliest possible time

Your condition must be continually assessed, monitored and revaluated.

Staff involved must have ongoing restraint education and training.

Seclusion is the involuntary confinement of a person where the person is physically prevented
from leaving. A physician or other Licensed Medical Practitioner (LMP) must see and evaluate
the need for the restraint or seclusion within one hour after its initiation.

Time limits exist for which orders for restraint or seclusion are valid, depending upon your age.
After the order expires, the physician or LMP must see and assess you before issuing a new
order.

A restraint and seclusion may not be used simultaneously, except in certain situations.

For more information about your rights regarding restraint or seclusion, please contact
………………. (Hospital state the contact person and details here).

Complaints and Grievances

We would like to resolve any concern you might have as soon as possible. Please first discuss it
with the staff looking after you; you may also request to speak to the nurse in charge, assistant
manager or manager. If you are not satisfied with the results, you may contact the …… (Hospital
to specify here).
Appendix C Sample Patient Satisfaction Survey Tools

Outpatient Assessment of Health Care (O-PAHC) Survey

Survey No. Health Facility Name:

Age Ethiopian Date (DD/MM/YYYY):

Male 1 Female 2
Morning/Afternoon Department:

Strongly
Strongly Disagree Disagree Agree
Agree
1. During this visit, nurses treated me with
1 2 3 4
courtesy and respect.
2. During this visit, nurses listened carefully to me. 1 2 3 4

3. During this visit, nurses explained things in a

1 2 3 4
way I could understand.
4. During this visit, doctors/health officers treated
1 2 3 4
me with courtesy and respect.
5. During this visit, doctors/health officers listened
1 2 3 4
carefully to me.
6. During visit, doctors/health officers explained
1 2 3 4
things in a way I could understand.
7. I could distinguish between doctors/health
1 Yes 2 No
officers and nurses.
8. The outpatient department was clean. 1 2 3 4

9. The bathrooms/latrines were clean (leave blank

1 2 3 4
if not applicable).
10. I was prescribed new medication at this visit. 1 Yes 2 No, Skip Q11, 12, & 13
11 The staff told me what the medication was for. 1 Yes 2 No
12 The staff described the medications possible
1 Yes 2 No
side effects in a way I could understand.
13 All the medications I needed were available at
1 Yes 2 No
the drug dispensary here.
14 Someone discussed with me what symptoms to
1 Yes 2 No
look out for after I left the health facility.
15. It was easy for me to find my way around the
1 Yes 2 No
facility.

16. On a scale of 0-10 (0 being the worst facility, 

10 being the best facility), how would you rate this 0 1 2 3 4 5 6 7 8 9 10
health facility?
Worst… ................................................................................... Best
17. I would recommend this outpatient 1 2 3 4
department/clinic to my friends and family. Definitely no Probably no Probably yes Definitely yes
18. I had to pay for this outpatient visit. 1 Yes 2 No, Skip Q19
19. I consider this outpatient visit too expensive. 1 Yes 2 No
Inpatient Assessment of Health Care (I-PAHC) Survey

Survey # Health Facility Name Department Ward:

Ethiopian Date (DD/MM/YYYY): Age:

Male 1 Female 2

Never Sometimes Usually Always

1. During this health facility stay, how often did nurses treat you
1 2 3 4
with courtesy and respect?
2. During this health facility stay, how often did nurses listen
1 2 3 4
carefully to you?
3. During this health facility stay, how often did nurses explain
1 2 3 4
things in a way you could understand?
4. During this health facility stay, how often did doctors/health
1 2 3 4
officers treat you with courtesy and respect?
5. During this health facility stay, how often did doctors/health
1 2 3 4
officers listen carefully to you?
6. During this health facility stay, how often did doctors/health
1 2 3 4
officers explain things in a way you could understand?
7. I could distinguish between doctors/health officers and nurses. 1 2 3 4
8. During this health facility stay, how often was the room you
1 2 3 4
were sleeping in kept clean?
9. During this health facility stay, how often was the area around
1 2 3 4
you quiet at night?
10. During this health facility stay, how often did you have
1 2 3 4
enough personal privacy?
11. During this health facility stay, did you experience any pain? 1 Yes 2 No, Skip 12 & 13
12. During this health facility stay, how often was your pain well
1 2 3 4
controlled?
13. During this health facility stay, how often did staff do
1 2 3 4
everything they could to help you with your pain?
14. During this health facility stay, were you given any
1 Yes 2 No, Skip 15 & 16
medication that you had not taken before?
15. Before giving you any new medication, how often did staff
1 2 3 4
tell you what the medicine was for?
16. Before giving you any new medication, how often did staff
1 2 3 4
describe possible side effects in a way you could understand?
17. Did anyone discuss with you what symptoms to look out for
1 Yes 2No
after you left the health facility?
18. Was it easy to find your way around the health facility? 1 Yes 2 No


0 1 2 3 4 5 6 7 8 9
19. On a scale of 0-10 (0 being the worst facility, 10 being the 10
best facility), how would you rate this health facility? Worst
facility .................................................. Best
facility
1 2 3 4
20. Would you recommend this health facility to your friends and
Definitely Probably Probably Definitely
family?
no no yes yes
21. Did you have to pay for this health facility stay? 1Yes 2 No, Skip Q22

22. Do you consider this health facility stay too expensive? 1 Yes 2 No
Appendix D Sample Complaints Management Procedure

Introduction

Any hospital complaint management process tries to answer the following questions:

 How easy is it for patients to make complaints?

 Are patients’ complaints analyzed systematically?
 Do changes occur to the way patients are cared for and treated as a result?
 How are staff trained and supported in patient (customer) care? Communication
skills?Confidentiality issues? Complaints handling?
 Is there recognized customer care practice e.g. codes of conduct?
It is important that all hospitals have an effective complaint management process (referred to as
‘the complaints system’ in this guide) in place for identifying, receiving, handling and
responding appropriately to complaints and comments patients/service users or persons acting on
their behalf make in relation to a service/s or care received.

Even hospitals in high income countries do receive complaints from their service users and
complaints are a fact of hospitals’ business- from minor staff behavioral issues to serious
accusations of incompetence or misconduct.

Patient/client feedback comes in three forms: compliments, comments and complaints. All three
are worth recording as they act as pointers to what’s going right or wrong within your hospital.

Everybody hears and remembers compliments-although they sometimes seem rarer than
comments and complaints! However, even the negative comments worth your attention too as
they can be useful early warnings of dissatisfaction or a weakness in the hospital delivery service
system. Ignoring a negative comment may lead to a full-blown complaint and take up much of
your time and energy.

It is important to remember that whoever receives a complaint is the patient’s or client’s first
point of contact. You will win points both for yourself and the hospital if you seem genuinely
concerned and interested in helping to resolve the matter

This guide is designed to help all hospital staff deal with complaints as quickly and effectively as
possible. It is split into two parts: Section I is for front line staff and contains general tips for all
hospital staff dealing with complaints; Section II deals with general advice for those responsible
for hospital policies and procedures. We hope this guide will help you in handling complaints
from the unhappy patients/clients/service users.
Section I: Dos and don’ts in handling complaintsWhat is a
complaint?

A complaint is a clear expression of dissatisfaction with a given hospital service and it may be:

 A verbal comment serious enough to demand a direct response

 A letter from a client/patient
 A letter on behalf of a patient/client
The must dos at hospital level

For the purposes of assessing, preventing or reducing the impact of unsafe or inappropriate
hospital care, the hospital must:

 Bring the complaints system to the attention of service users and persons acting on
theirbehalf in a suitable manner and format(including notice/leaflets);
 Provide support to service users and persons acting on their behalf on how to bring
acomplaint or make a comment, where such assistance is necessary;
 Ensure that any complaint made is fully investigated and ,so far as reasonably
practicable, resolved to the satisfaction of the service user and person acting on
theirbehalf and;
 Take appropriate steps to coordinate a response to a complaint where that complaint
relates to care or treatment provided to a service user, and share or notify the
appropriateregulatory body where patient safety has been compromised through
professional misconduct/incompetence/negligence.

Top tips for those handling hospital complaintsListening to a

complaint

The most important thing is to make sure the complainant feel you’re really listening, if you can
take the time and space to listen properly first time around when a client/patient/family
member/friend complaints to you in person or by phone. It will save a lot of extra time and
trouble later on! Here are some useful tips to bear in mind:
 Stay calm
 Take the client/patient/complainant to a private , seated area or take their call in a
quietzone
 Thank the client or complainant for bringing the matter to your attention
 Ask them to tell you the full story from the beginning, just listen and keep listening-
don’tinterrupt or argue
  Empathize-but it is generally better to avoid phrases such as “I know how you
feel”(youcan’t)
 Pick up on key words, e.g., ‘You must have been very worried about x (etc.…)”
 Take notes- and check that the complainant agrees with what you’ve written
 Summarize for the complainant what has been said to make sure you
haven’tmisunderstood or missed anything.

Say sorry and mean it

Once you’ve listened carefully, express regret that the complainant is dissatisfied. This is often
all the complainant needs, but it must sound genuine. So…
 Be sincere- the person you’re talking to will detect and resent an automatic response
 Remember, an expression of regret will make the complainant feel heard and
understood.It doesn’t mean you are admitting liability-it simply means you are
acknowledging the upset and are ‘sorry that something has happened’, not ‘ sorry it
was caused by anyone’s fault’
 Try not to make apologies on behalf of someone else-or let someone else apologize
foryou. The complainant may feel put off and could end up unhappier than before!
 Get the complainant on your side by saying things like, ‘How can we solve the problem?’

Explain quickly and clearly

A prompt and thorough explanation can work wonders too. Here are some key points that might
help,most of which apply to written explanations too:

 Focus on the key issues the complainant is concerned about- and ask in what order
they’dlike you to cover them
 Use clear language and explain any health jargon
 Encourage the complainant to ask questions throughout
 Check they have understood, e.g., ‘I’m not sure I’ve put that clearly. Did that
makesense?’
 Ask the complainant if your explanation has answered their concerns
 Reassure them that the matter will be dealt with promptly and that you’ll keep
theminformed of progress
 To identity the specific issues of a complaint, it may be helpful to ask
theclient/patient/relative to put something in writing
 Never blame other members of staff.
What to do next?

Refer any clinical problems to the hospital medical director or equivalent for university hospitals
as soon as possible

 Ask the complainant what they’d like you to do at this stage and if possible do it
 If the complaint is now satisfied, record the complaint and how you resolved it and send
acopy to the CG&QI Unit.

What if the complainant isn’t satisfied?

 If the complainant isn’t satisfied, ask if they wish to take the complaint further
and explain the ‘Hospital’s Complaints Procedure’. Give them a copy of the
hospital’scomplaints’ leaflet
 Agree a plan within the hospital of what action will be taken by whom and by when
 Look at the root causes of the problem and see if there are any changes you could
maketo stop it happening again, e.g.:
- Bringing a policy on what to say when a patient’s appointment has been cancelled
- Putting up a notice in the waiting areas inviting patients and visitors to make
commentson a new change in service, etc.
- Displaying information sheets or TV programs on standard treatments or procedures.
 Tell the complainant which member of the hospital service/case team is going to
dealwith the complaint and by when.

How to respond in writing

First send out an immediate, brief letter of acknowledgment (see appendix G for a sample
acknowledgement letter) when you receive a written complaint from a complainant. This should
inform the complaint who is going to deal with the complaint and by when.

Remember to respond within 24 hours on receipt of a written complaint and within 28 days to
provide a full response in writing after a full investigation has been carried out.
Appendix E: A sample hospital’s acknowledgement letter to a complaint

[Complainant name]
[Address 1]
[Address 2]
[Address 3]
[

[Date]

Dear [Salutation]

RE:

Thank you for the information you have shared with us about < service name> that we received
on <date>.

The first step is for <name and position of hospital staff> to look at what you have told us. We
will then write to you within <insert date/working days> to inform you about how we will
respond to this information.

A leaflet is enclosed that gives you information about what the Hospital’s Complaint Procedure.

<Additional closing information if appropriate>

Yours sincerely

<Name>
<Job Title>

Encl: Hospital’s Complaint Procedure

Appendix F Hospital’s Complaint Procedure

Most issues can be resolved without you having to make a formal complaint. Try having an
informal chat with your doctor or a member of staff first.

A formal complaint takes time and minor issues are resolved quicker if you just speak to a
person on site. For example, if you are worried about something during your hospital outpatient
appointment talk to one of the nurses or the team leader.

The Federal Ministry of Health calls this informal process 'local resolution' and urges everyone
to see if things can be solved there and then before they escalate to a real problem.

However, if despite everything this doesn’t solve your problem, or even if it does but you would
still like to make a formal complaint, you should follow the ‘Hospital’s Complaints Procedure’
as described below.

Giving feedback and comments

Not all issues have to end up with a complaint. Sometimes it is enough to give feedback or leave
a comment. All hospitals do welcome feedback as it will help improve the quality of their
services.

You can give feedback about the hospital service or staff in person or in writing and the hospital
may respond to your comments.

Stage one: Thinking of making a complaint

If you don't feel like you can solve issues informally then you should make a formal complaint to
the hospital directly. If you cannot make a complaint yourself, then you can ask someone else to
do it for you.

Every hospital has a complaints procedure. To find out about it, ask a member of staff, look
onthe hospital’s noticeboards or website, or contact the “Clinical Governance and Quality
Improvement Unit” for more information. Each hospital has this unit.

What to consider before making a complaint

If you decide to make a complaint it's important to consider what you want to happen. For
example:
 Are you content with an apology?
 Do you want action to be taken against a member of staff?
 Do you want a change to the system?
Whatever action you're seeking, make this clear. Before you make your complaint, make a note
of:

 The relevant events;

  Dates
 Times
 Names and conversations, and include all necessary details.
Your notes will also help you to remember all the details in the future. Processing a complaint
can take a while, and you might be asked to verify some information at a later stage.

Whether you decide to complain orally or in writing, try to make your explanations as short and
clear as possible. Focus on the main issues, and leave out irrelevant details.

If you can, talk through what you want to say with someone else, or ask them to read what
you've written before you send it.

If you complain in writing, keep a copy of everything you give to the hospital, and make a note
of when you sent it.

Who can help you make a complaint?

Making a complaint can be daunting, but help is available. Ask a hospital staff to show you
where the “Clinical Governance and Quality Improvement Unit” is and they will offer
confidential advice, support and information on health-related matters to patients, their families
and their carers.

What happens if you are not happy with the hospital response or reply to your written complaint?

If you have already complained to the Case Team Leader/Department Leader/Service Head of
the hospital and you are still unhappy with their response, then contact the hospital manager
(address to be included here). You should provide as much information as possible to allow your
CEO to investigate your complaint, such as:
 Your name and contact details
 A clear description of your complaint and any relevant times and dates
 Details of any relevant hospital staff or services
 Any relevant correspondence, if
applicableWhen should I complain?

As soon as possible. Complaints should normally be made within 12 months of the date of the
event that you're complaining about, or as soon as the matter first came to your attention.
The time limit can sometimes be extended (so long as it's still possible to investigate the
complaint). An extension might be possible, for instance in situations where it would have been
difficult for you to complain earlier, for example, when you were grieving or undergoing trauma.

If you made your complaint to the hospital manager you will receive the findings of the
investigation together with an appropriate apology and the changes or learning that have taken
place as a result of the investigation.
Stage two: I am not happy with the outcome of my complaint

If you are unhappy with the outcome of your complaint you can refer the matter to the
HealthService Ombudsman, who is independent of the healthcare system and the address
is:

………
………

Include the following details in your complaint:

 Your name, address and telephone number
 Name and contact details of anyone helping you with the complaint
 Name and contact details of the hospital you wish to complain about
 The factual details of your complaint (listing the main events and when they
happened)
 Why you think your previous complaint wasn’t resolved to your satisfaction,
and howthis has caused you injustice
 Details of the complaints you've already made to the hospital and the outcome
of theirinvestigations
 Copies of any relevant documents (it's usually helpful to number these and provide
a list)Keep copies of everything you post, and make a note of when you send it. The Health
Service Ombudsman’s decision is final but this does not take away your human rights to
pursue a civil law suit.

How long will it take to complete an enquiry?

We will aim to complete our enquiry within 20 working days. If we are not able to do
this, wewill keep you informed of what is happening.

Contact details
Our contact details are –

<Hospital’s contact details>

 CHAPTER 23

HOSPITAL PERFORMANCE MONITORING AND REPORTING

1
Section 1 Introduction
Information Revolution is crosscutting agenda described in Health Sector Transformation Plan II
(HSTP II), which mainly deals with improving culture of data use at all levels of the health
system; to digitalize priority Health Information System (HIS) to improve access and quality of
service, to improve HIS governance.

Health Information System refers to system that captures, stores, manages or transmits
information related to the health of individuals or the activities of organizations, which will
improve health care management decisions at all levels of the health system (WHO, 2017).
Health Information System provides the underpinnings for decision making and improves health
care management decisions at all levels of the health system. The components of HIS are Data
production, compilation, analysis, synthesis, communication and use. Health Information system
serves multiple users and data from different sources are used for multiple purposes at different
levels of the health system.

A well-functioning health information system is one that ensures the production, analysis,
dissemination and use of reliable and timely information on health determinants, health systems
performance and health status. Availability and use of quality information on health
determinants, health systems performance and health status.

Hospital management and Governing Boards play a pivotal role in ensuring the effective
monitoring and reporting of hospital performance. Monitoring, defined as the systematic and
continual collection, analysis, interpretation, and use of data on key aspects of an intervention
and its expected results, serves as a fundamental process in healthcare management. Regular
tracking and reporting of performance are essential to ensure that activities are executed as
planned, contributing to the achievement of national health sector targets and objectives.

The objectives of monitoring encompass various critical aspects:

1. Ensuring Planned Implementation: To verify that activities are progressing as intended

and on schedule, ensuring the faithful execution of annual plans.
2. Maximizing Service Quality, Effectiveness, and Efficiency: To enhance the quality,
effectiveness, and efficiency of healthcare services provided by the hospital.
3. Ensuring Financial Viability: To monitor and ensure the financial viability of the
hospital, contributing to its sustainability.
4. Contribution to National Targets: To guarantee that the hospital aligns its efforts with
national health sector targets and objectives.

2
This chapter emphasizes the role of the Health Management Information System (HMIS) as a
valuable tool for internal monitoring of hospital performance. It highlights the HMIS's
significance in providing data for hospital management and external oversight by Regional
Health Bureaus (RHBs) and the Federal Ministry of Health (FMOH). Furthermore, the chapter
underscores the pivotal role of the hospital Governing Board in monitoring performance. It
introduces a tool and a set of indicators, the Balanced Scorecard, designed to aid Governing
Boards in effectively fulfilling their monitoring responsibilities. This integrated approach aims to
optimize hospital performance, promote transparency, and contribute to the broader goals of the
national health sector.

3
Section 2: Operational Standards for Monitoring and Reporting

1. The hospital has established Performances Monitoring and Reporting Structure

2. The hospital has a functional Performances Monitoring Committee
3. The Hospitals has daily EMR data monitoring system or equivalent dashboard to track
key clinical and administrative data.
4. The hospital conducts integrated -interdepartmental performance assessment
5. The hospital has regular mechanism to ensure data quality
6. The hospital submits standard complete monthly, quarterly and annual reports to the
relevant higher office within the agreed timelines.
7. The hospital has regular data driven decision making practice
8. Hospital regularly perform HMIS and KPIs capacity building for staff
9. The hospital SMT and GB regularly evaluate HMIS and KPI reports

4
Section 3: Implementation Guidance

3.1 Hospital Monitoring and Reporting with HMIS:

Health Management Information System (HMIS) is the routine collection, aggregation, analysis,
presentation and utilization of health and health related data for evidence based decisions for
health workers, managers, policy makers and others.
Purposes of HMIS
 Availing accurate, timely and complete data to support decision making at each level of
the health system
 Strengthening the use of locally generated data for evidence based decision making

Components of HMIS

1. Information management

Data collection: Recording of health data using individual and family folder, registers, tally
and reporting formats

Data processing: is a process of cleaning, entering and aggregation of data.

Data analysis and presentation: is a process of interpretation and comparison of generated

information in the form of sentence, tables and graphs.

2. Using information for management purposes

Problem identification: identifying problems using key indicators

Prioritizing problems and decision making: Problems identified should be prioritized and
decide what types of actions need to be taken.

Action taking: Implementing the agreed action.

Result monitoring: Assessing the desired result has been achieved.

Establishment of HMIS Unit: Hospitals undertaking the critical task of systematic monitoring
and reporting should first establish a dedicated Health Management Information System (HMIS)
unit. This unit serves as the nerve center for the collection, analysis, and reporting of essential
healthcare data. The establishment of this unit demonstrates a commitment to harnessing the
power of data for performance enhancement.

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Assignment of HMIS Focal Officer: An equally vital step involves the appointment of an
HMIS focal officer equipped with a clearly defined Job Description (JD). This designated
individual should not only serve as a pivotal member of the Senior Management Team (SMT)
but also be directly accountable to the hospital's Chief Executive Officer (CEO) or Chief
Executive Director (CED). This strategic positioning ensures seamless integration with top-level
leadership.

Infrastructure and Resources: The infrastructure supporting the HMIS unit is critical for its
effective functioning. This includes ensuring the presence of a dedicated or integrated room,
equipped with necessary office furniture, computers, printers, UPS systems, and reliable internet
access. These resources are fundamental to facilitating the seamless operation of the HMIS unit.

Regular Weekly Meetings and Planning: To maintain a structured and proactive approach to
performance monitoring, hospitals should instigate regular weekly meetings among case team
members. These meetings serve as a platform to discuss ongoing monitoring activities and
ensure alignment with the hospital's annual, quarterly, and monthly plans.

HMIS Indicators Implementation: For a successful HMIS implementation, it is imperative to

familiarize hospital staff with the 122 indicators outlined in the system. These indicators span
various categories, including Access to Health Services, Quality of Health Services, and Human
Capital. Furthermore, staff should undergo comprehensive training to ensure proficiency in
HMIS procedures and reporting formats.

By following this comprehensive guide, hospitals can not only establish a robust HMIS
infrastructure but also integrate it into their monitoring and reporting mechanisms. This approach
sets the stage for data-driven decision-making, continuous improvement, and enhanced
healthcare delivery.

3.2 Performance Monitoring Committee (PMC)

A critical component of hospital governance and performance oversight is the establishment of a

functional Performance Monitoring Committee (PMC). The PMC plays a vital role in
systematically monitoring and addressing the hospital's performance to ensure it aligns with set
standards and objectives. To assess the effectiveness of the PMC, several key elements should be

6
considered. Firstly, the presence of an assignment letter and Terms of Reference (TOR) is
crucial, as it defines the committee's responsibilities and scope of activities. These foundational
documents serve as a guiding framework for the PMC's role in monitoring the hospital's
performance.

Additionally, the examination of minutes from consecutive monthly Performance Review Team
(PRT) meetings over the last three months provides insight into the committee's ongoing
activities. These minutes reveal discussions, decisions, and actions taken by the PMC in response
to identified performance issues. A well-documented activity plan demonstrates the committee's
proactive approach to addressing performance challenges, while evidence of implemented
corrective measures signifies the committee's commitment to driving positive changes within the
hospital. In essence, a robust PMC, supported by clear documentation and effective actions,
contributes significantly to the hospital's continuous improvement and adherence to quality
standards.

3.3 Electronic Medical Record (EMR)

Implementing an Electronic Medical Record (EMR) system in hospitals holds paramount

importance in enhancing healthcare delivery, patient safety, and overall operational efficiency.
EMR systems enable real-time data monitoring, ensuring that clinical and administrative
information is readily accessible and up-to-date. This not only streamlines the healthcare
workflow but also contributes to improved patient care through accurate and timely information.
Monitoring and reporting within a hospital become more efficient with the integration of an
EMR system, allowing for quick identification of trends, performance metrics, and areas that
require attention or improvement.

The guiding document for implementing an EMR system in hospitals includes a comprehensive
data monitoring protocol. This protocol outlines the procedures and standards for monitoring and
reporting clinical and administrative data using the EMR system. Access privileges, especially
self-reporting capabilities, are critical aspects to examine, ensuring that relevant personnel have
the appropriate access rights. Verification of the presence of a dashboard dedicated to monitoring
daily service area and administrative data is also crucial. Lastly, collaborative meetings involving
the Medical Record Unit, Hospital Service Quality, and Performance Monitoring and Reporting

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Unit create a platform for aligning goals, sharing insights, and collectively leveraging the
benefits of the EMR system for enhanced hospital performance.

In essence, the implementation of an EMR system with a robust monitoring and reporting
infrastructure not only modernizes healthcare practices but also fosters a data-driven approach to
hospital management, ultimately leading to improved patient outcomes and operational
excellence.

3.4 Integrated Departmental Performance Assessment

The hospital's commitment to conducting integrated-interdepartmental performance assessments

reflects a proactive approach to ensuring comprehensive and cohesive healthcare services. To
assess the effectiveness of this initiative, it is essential to review three copies of integrated-
interdepartmental assessment reports. These reports serve as a tangible representation of the
hospital's commitment to evaluating its overall performance. During the examination, particular
attention should be paid to verifying whether the assessment reports contain HMIS indicators, as
well as any additional local indicators determined by hospital management. This ensures that the
assessment process aligns with both national standards and the hospital's specific objectives,
capturing a holistic view of performance.

Equally important is the examination of the action measures taken on identified gaps within the
assessment reports. The implementation of strategic actions in response to identified weaknesses
or gaps demonstrates the hospital's dedication to continuous improvement. The effectiveness of
these action measures directly contributes to the hospital's ability to address challenges promptly
and enhance its overall performance. Therefore, assessing the integration of HMIS indicators,
local indicators, and the subsequent action measures is pivotal in gauging the hospital's
commitment to achieving excellence through performance assessments

3.5 Ensuring Data Quality in Hospital Management

Ensuring the quality of data is fundamental to a hospital's commitment to accuracy and reliability
in healthcare information. The regular conduct of Data Quality Assurance (DQA) and Lot
Quality Assurance Sample (LQAS) on a monthly basis serves as a robust mechanism to validate
the accuracy and consistency of the collected data. This commitment to data quality should be

8
evident in the minutes of Performance Monitoring Team (PMT) meetings, highlighting its
integration into the hospital's monitoring and evaluation framework.

During the evaluation, it is crucial to confirm that the LQAS percentage consistently exceeds
85%, indicating a high level of accuracy and reliability in the reported data. This benchmark
serves as a crucial indicator for acceptable data quality, ensuring that the hospital's information is
trustworthy for decision-making processes. Investigating the availability of a protocol for the
triangulation of selected data and corresponding triangulation reports illustrates the hospital's
systematic approach to cross-validating data from different sources, enhancing overall data
quality assurance practices. Additionally, regular supportive supervision of the HMIS
unit/department affirms the hospital's commitment to providing continuous guidance and
oversight to maintain high standards of data quality.

Dimensions of Data Quality and Importance:

Data quality is the state of completeness, validity, consistency, timeliness, accuracy, integrity,
and confidentiality that makes the data appropriate for specific use. Accurate and reliable data
are essential for making informed, evidence-based decisions and modifying healthcare delivery.
Inaccurate data can lead to erroneous understanding and inappropriate decisions, hindering
service improvement. The dimensions of data quality assessment include accuracy, timeliness,
completeness, precision, integrity, reliability, and confidentiality. These dimensions ensure that
data are measured consistently, are timely, complete, precise, and secure, providing a holistic
view of service delivery in the hospital.

Types of Data Quality Assurance Tools and Methodology:

Various data quality assurance tools are available, with Lot Quality Assurance (LQAS), Routine
Data Quality Assurance (RDQA), and Performance of Routine Information System Management
(PRISM) being common. Hospitals are recommended to conduct Lot Quality Assurance (LQAS)
for data quality assurance, with the performance monitoring team, HMIS focal or team, and the
CG&QI team jointly involved in this activity. LQAS, originating as a low-cost quality
assessment methodology, has been applied to assess the quality of health services, including data
quality. The methodology involves estimating the level of quality based on a small sample size,

9
ensuring the accuracy and reliability of monthly data reports and subsequent decision-making
processes.

Steps to do Lot Quality Assurance Sample (LQAS):

The Lot Quality Assurance Sample (LQAS) process for estimating the quality of HMIS data
involves several key steps:

1. Identification of Data Elements: Begin by randomly selecting 12 data elements from

different sections of the monthly report form. This random selection ensures a
representative sample, offering an equal opportunity for all data elements to be assessed

2. Data Accuracy Check Sheet: Create a data accuracy check sheet with three columns. In
the first column, record the selected data elements. In the second column, note the figures
from the monthly report form related to these data elements.

Table 1 Data Accuracy Check Sheet

Week for which data accuracy is checked______________
Randomly Selected Data Elements from the monthly Figures from Figures Do figures, from
reporting form the Monthly counted from columns 2 & 3
report form registers Match?
(2) &tallies (3) YES NO
1. Disease cases for a single disease / age / gender group
2. OPD attendance for a single age / gender group
3. Family planning monthly report section
4. Maternal health monthly report section
5. Child health
6. EPI monthly report section
7. Logistics
8. TB (if service provided)
9. HIV/AIDS (if service provided)
TOTAL

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3. Verification from Registers: Retrieve the registers or tally sheets containing the selected data
elements. Count the actual entries in the register or tally for each specific data element and record
these figures in the third column of the check sheet.
4. Comparison and Verification: Compare the figures from the monthly report form (column 2) with
the figures from the registers (column 3). If the numbers match, mark "YES" in the fourth column;
if they don't match, mark "NO."
5. Calculation of Totals: Count the total number of "YES" and "NO" marks. Ensure that the sum of
both totals equals the sample size of 12, verifying the consistency of the comparison process

Table 2: LQAS Decision

Interpretation: the interpretation of the "Yes" column in the Lot Quality Assurance Sample
(LQAS) table is crucial for understanding the accuracy level of Health Management Information
System (HMIS) data. The total number of "Yes" marks directly corresponds to the percentage of
data accuracy, as indicated in the LQAS table. For instance, if the total number of "Yes" marks is
2, it implies that the accuracy level is within the range of 30-35%. Similarly, if the total number
of "Yes" marks is 7, the accuracy level falls within the range of 65-70%.

Setting achievable targets for data accuracy becomes instrumental in monitoring progress over
time. By establishing goals for improvement within a specified period, organizations can track
the monthly increase in correct match numbers, as demonstrated in the LQAS table. The
relationship between the correct match number and the monthly improvement reflects the
ongoing enhancement in the level of data accuracy.

Furthermore, achieving a data accuracy level of 95% is considered a high standard and signifies
a commendable level of precision. Sustaining this high level of accuracy is essential,
emphasizing the need for continuous efforts to maintain the integrity and reliability of HMIS
data.

11
It's essential to note that, given a sample size of 12 data elements, the data accuracy ranges
within a +15% margin. For example, if the data accuracy is 30%, the acceptable range extends
from 15% to 45%. This acknowledgment underscores the need for a nuanced understanding of
the data accuracy level, considering the inherent variability within the defined margin.

3.6 HMIS data registration, aggregation and reporting

The Federal Ministry of Health (FMOH) has developed standardized registers, tally sheets,
abstract and reporting formats. An integrated data collection and reporting system provides the
foundation for harmonizing the requirements of information consumers need within and outside
the FMOH. It creates the basis for the harmonization concept (one report).
Used to compile and compare health information in an integrated comparable fashion nationally
and internationally. Hospitals are expected to report disease according to Ethiopian Simplified
Version of International Classification of Diseases, now 11th revision (ESV ICD 11). These
enables standardization and integration of health data specially disease reports. it also Provides
the basis for compiling national mortality and morbidity statistics. The health sector play a key
role in providing statistical information on key health variables to the civil registry and national
statistics office

Ethiopia is among countries to legalize community- and facility-level birth and death notification
and cause of death reporting, under the proclamation number 720/2012 and 1049/2017 of the
Federal Negarit Gazette. These proclamations gives the responsibility to the health sector to
notify birth and death, and cause of death that happen both in the health facilities and
community.

According to the proclamation, if the event happen in the health facility, the physician who
attained the birth and death is responsible to give notification paper for the family who is
responsible to register the event. If the event happen outside the health facility, the lower health
administrative level is responsible to fill birth and death notification paper and give the copy to
respective keble civil registration office. It is also expected that the health sector to print and
distribute birth and death notification materials and follow the performance routinely.

These registries and reporting formats should be correctly filed in order to have quality data at all
levels of the health system. Inappropriate use of the registries will lead to erroneous data entry,
aggregation into reporting formats and poor data quality, unhelpful for planning, decision
making and process improvement. Therefore, correct and appropriate use of the registers and
reporting formats is crucial in maintaining data integrity and quality. The HMIS is designed to
generate different types of reports that can capture important data elements required to monitor
and evaluate health programs in Ethiopia.

Types of reports by period: Weekly, Monthly, Quarterly, Annual

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  Last date of report time for frontline (data owner) is 22
 Last date of report time for HMIS focal through DHIS2 is 26

Types of reports by content:

 OPD disease IPD morbidity and mortality

 Service PHEM

3.7 Promoting Data-Driven Decision-Making in Hospitals

Ensuring the hospital's commitment to data-driven decision-making is pivotal for informed and
effective healthcare management. Several key indicators can be assessed to verify the adoption
of this practice:

1. Regular Trend Analysis:

o Check for the availability of regular trend analyses at each service delivery area
within the hospital. This involves scrutinizing whether the hospital conducts
systematic assessments of trends in various healthcare metrics. Such analyses
provide valuable insights into the performance and effectiveness of different
services over time.
2. Encouragement of Evidence Generation:
o Investigate whether there is a mechanism in place to encourage evidence
generation, particularly through gap-oriented research. This entails assessing the
hospital's commitment to fostering research activities that aim to fill knowledge
gaps and address specific challenges in healthcare delivery.
3. Institutional Quality Improvement (QI) Projects:
o Verify if the hospital has devised institutional Quality Improvement (QI) projects
based on data findings. This involves examining whether the hospital actively
identifies areas for improvement through data analysis and subsequently
implements structured QI initiatives to enhance overall healthcare quality and
outcomes.
4. Linkage of Annual Plan to Historical Performance Data:
o Check for the linkage of the hospital's annual plan to facility-specific historical
performance data. This involves assessing whether the hospital's strategic

13
 planning takes into account historical data on performance metrics. This linkage
ensures that the annual plan is informed by past experiences and is aligned with
continuous improvement goals.

In summary, the hospital's commitment to data-driven decision-making can be confirmed by

evaluating the presence of regular trend analyses, mechanisms for evidence generation,
institutional QI projects based on data, and the linkage of the annual plan to historical
performance data. These practices collectively contribute to a culture of continuous improvement
and informed decision-making in healthcare management.

3.8 Ensuring Staff Orientation on HMIS and KPIs in Hospitals

To guarantee that hospital staff are well-versed in Health Management Information System
(HMIS) and Key Performance Indicators (KPIs), several key verification steps can be taken:

1. Staff Awareness of KPIs:

o Check and verify with selected staff regarding their awareness of Key
Performance Indicators (KPIs). This involves assessing whether the hospital staff,
especially those directly involved in service delivery, is knowledgeable about the
specific KPIs relevant to their roles.
2. Availability of Data Owners:
o Check for the availability of designated data owners from each case team or
service area. Data owners are individuals responsible for overseeing and
managing the data related to specific performance indicators. Their presence
ensures accountability and accurate data management.
3. Indicator Determination by Case Teams/Departments:
o Verify whether case teams or departments within the hospital are actively
involved in determining indicators relevant to their areas. The utilization of a
process improvement model can be assessed to ensure that teams are engaged in
selecting, monitoring, and improving performance indicators based on their
unique responsibilities.
4. Review of Reports/Minutes:

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 o View reports and minutes of case team meetings to assess the utilization of
performance data. This involves scrutinizing documented evidence of how case
teams or departments are using performance data during their meetings for
decision-making, improvement planning, and overall performance management.

By conducting these verification steps, the hospital can ensure that staff orientation on HMIS and
KPIs is comprehensive and effective. This, in turn, contributes to a data-driven culture within the
hospital, where staff are not only aware of key indicators but also actively engaged in utilizing
data for continuous improvement in healthcare services.

3.9 Performance evaluation

Effective collaboration between the hospital's Performance Monitoring and Reporting (PMR)
unit and the Governing Board (GB) through the CEO is crucial for informed decision-making
and strategic planning. Regular presentations of core and selected Health Management
Information System (HMIS) and Key Performance Indicators (KPIs) ensure that the Governing
Board is well-informed about the hospital's overall performance. Monthly reports to the hospital
Senior Management Team (SMT) contribute to continuous monitoring and allow for timely
interventions. Furthermore, the presentation of core indicators in a 'user-friendly' manner as a
Balanced Scorecard (BSC) to the Governing Board on a quarterly basis enhances transparency
and facilitates the understanding of complex data. This strategic alignment fosters a shared
understanding of hospital performance, promotes accountability, and empowers the Governing
Board to make well-informed decisions that positively impact patient care and organizational
efficiency.

The implementation of this collaborative reporting process involves establishing a systematic

approach for the PMR unit to present comprehensive HMIS and KPI reports to the hospital SMT
on a monthly basis. This requires a well-defined communication channel and reporting schedule.
Additionally, the identification and presentation of core indicators in a Balanced Scorecard
format for the Governing Board demand careful consideration of the indicators' relevance and
significance. The PMR unit should ensure that the presentation is tailored to the Governing
Board's needs, providing a clear snapshot of performance trends. This may involve the use of
visual aids, concise summaries, and comparisons against benchmarks. Regular training sessions

15
for the PMR unit and relevant hospital staff can enhance the effectiveness of this reporting
mechanism, ensuring that data is not only accurate but also communicated in a manner that
facilitates strategic decision-making at the governance level.

3.9.1 Role of the Governing Board to monitor hospital performance

The hospital Governing Board is responsible to direct and supervise the overall activities of the
hospital, to provide proper financial oversight, to ensure adequate resources for hospital
operations, and to ensure that the hospital provides services to the highest possible standard in an
environment that is safe for patients, staff and visitors.
As described in Chapter 1 Hospital Leadership, Management and Governance the Governing
Board Fulfils these functions by establishing corporate strategies, plans and policies and by
overseeing the performance of the CEO who is responsible for implementation of these.
The Governing Board cannot and should not monitor day-to-day activities of the hospital.
Similarly, it is not feasible for the Governing Board to review and monitor the full set of HMIS
Indicators for the hospital. None-the-less, the Board must have sufficient information to assure
itself that the hospital is performing to a high standard and that proper mechanisms are in place
to deliver safe, efficient and high quality services. One means to achieve this is to monitor a core
set of indicators of hospital performance.

Ideally, the number of indicators should be small and should be presented in a ‘user friendly’
format that aids understanding. The Balanced Scorecard is a tool that can be used by Governing
Boards to achieve this.

3.9.2 The Balanced Scorecard

The Balanced Scorecard (BSC) is a planning, monitoring and evaluation tool that considers
performance in four key areas:
 Customer perspective
 Finance perspective
 Internal processes
 Learning and growth of the organization
The BSC is recommended by the FMOH as a management and measurement tool for all levels of
the health sector. The use of the BSC as a monitoring tool assists Governing Boards to oversee
the performance of the hospital. The indicators within the BSC provide only a summary of
hospital performance. The Governing Board should review each BSC report, identifying areas of
16
good performance and areas of concern and should discuss these with the CEO, seeking
clarification or further information where necessary.
Governing Boards should determine selected indicators within each of the four key areas and
should receive quarterly reports from hospital management on these indicators. (NB Patient
surveys may be conducted on a bi-annual basis, but all other indicators within the BSC should be
reported to the Governing Board as a minimum every quarter). A sample BSC for a hospital
Governing Board is presented in Figure 1 below. In the figure, the additional domain of ‘safety
and quality’ has been added to highlight the importance of patient safety and quality of services
provided. A definition of each indicator presented in Figure 1 is given in Appendix D. An
assessment tool measuring the attainment of the Operational Standards of the Ethiopian Hospital
Transformation Guidelines is presented in tool is presented in the Assessment Handbook.
The BSC can also act as a tool to orient staff to the objectives of the hospital and strengthen staff
engagement with hospital improvement efforts. To achieve this, hospital staff should be oriented
to the BSC and in particular should be familiar with the BSC indicators that will be reviewed by
the Governing Board. The Governing Board may choose to consult with hospital staff when
defining the core set of indicators that will be monitored on the BSC. Staff should understand the
purpose of each indicator and method of data collection in order to strengthen the completeness
and accuracy of the data.
Additionally, each Case Team/Department should set its own objectives (in consultation with
Senior Management) and should monitor its own performance using defined indicators. In this
way, the activities of each Case Team can be aligned with the objectives of the hospital and each
Case Team can be encouraged to improve its own performance.
Hospital management should ensure that there is a monitoring process for all HMIS indicators
but it is not necessary for the Governing Board to review each and every HMIS indicator.
Additionally, the BSC contains indicators that are not part of the HMIS data set but that would
be useful to the Governing Board to effectively govern the hospital.

3.5 Integrated Health Information platform

Integrated health information platform is about enabling data visualization, reporting and
charting across multiple information sources so that data might be used for planning,
identification and prioritization of problems, performance monitoring, and providing feedback
reports to support transformative and sustainable evidence-based decision making.

17
No single source can provide sufficient information for monitoring service delivery. Thus, a
service delivery monitoring system relies on multiple sources of data brought together for
analysis and decision-making. Data from routine health facility reporting systems needs to be
supplemented with data from health facility assessments, etc. In addition, data generated through
facility assessments should be complemented or cross-checked with data from other sources,
such as the databases of health workers, infrastructures, equipment, and procurement, which are
often available in various departments of the hospital. This can serve as complementary or
benchmarking material for data on service delivery generated through the routine HMIS.
Health information is often not available to those who are best placed to use it to improve
performance of the health system. Hence, data visibility refers to analysing the health and health-
related data and making accessible different data presentation techniques from display charts in
the health institutions to stakeholders and mass media.
Major Activities that should be exercised to bring data comparability and synthesis practice
across multiple information sources are:
 Improve advanced analytical skill (in depth analysis, data mining)
 Conduct regular self-assessment (PMT establishment & functionality)
 Enhance accountability scorecard system and Pool health and health-related
 Strengthen the decision support system and Improve data triangulation mechanisms
 Implement an integrated platform
 Develop data access protocols for users

18
Annex
Appendix A- HMIS indicators by level and frequency of collection

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Appendix B HMIS / M&E Implementation Roles and Responsibilities at
Hospitals
1. Obtain sanction for HMIS, Hospital Information System (HIS), and card room posts and hire
staff.
 Optimal
a) HMIS / HIS
a. One person/ 150 patients/clients/ day
b. Professional background: Diploma in HMIS or Medical Records or Statistics
c. Card room: 5 minimum + 1/100 patients/clients/ day
b) Required to begin implementation
a. Minimum 1 full time HMIS professional person.
b. Card room: 5 minimum
2. Establish an HMIS implementation team.
a) Composed of Medical Director (team leader), Medical Administrator, Matron, HMIS staff,
and at least one Disease Prevention and Control and Family Health specialist (MD, HO, or
senior nurse).
b) Prepare Hospital HMIS implementation plan. In the plan, care should be taken to ensure that
all reengineering and personnel requirements are fulfilled before training begins at the
Hospital.
c) Monitor execution of implementation plan and provide guidance and support as necessary.
d) Assist woreda / sub city, regional and FMOH training teams in training and follow-up
supervision.
e) Provide orientation / sensitization to other public sector and civil society organizations as
required.
3. Training.
a) Assist woreda / sub city, regional, and FMOH training team to train all hospital staff.
b) Provide post-training follow-up supervision, in collaboration with regional and federal
training teams, to ensure that training is put into practice.
4. Resource mobilization for all.
a. HMIS and medical statistics staff and their office furnishings, including ICT, if any,
and an HMIS storage area including space for archives and storage of stationery.
b. Budget for hospital HMIS work – stationery, office supplies, and, if appropriate, ICT
consumables (paper, ink cartridges, CDs, etc) and ICT maintenance.

31
 c. Estimate costs, if any, for reengineering card room for integrated medical records
folder and fast track. Estimate costs for additional card room staff needed, if any.
Higher level hospitals request funds from RHB; district hospitals from woreda.
5. Establish a performance monitoring team, as specified in HMIS Information Use Guidelines.
Include HMIS implementation progress on regular management agenda during preparation
phase and monthly / quarterly performance monitoring when the HMIS has been installed.
Conduct meetings with other groups as specified in Harmonization manual.
6. Specific responsibilities of HMIS officer.
a. In collaboration with clinical staff, supervise recording of client/patient information
on cards and registers according to standard.
b. Perform monthly data quality checks
c. Ensure that HMIS reports are completed in a timely fashion
d. Provide tables and charts as needed for performance monitoring team
e. Ensure that display charts, worksheets, and performance monitoring team meeting
minutes are maintained.
f. Establish mechanism for ensuring a supply of HMIS reporting and recording formats.

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Appendix C – Sample BSC for Governing Board and Emergency Room

33
Reference

1. Federal Democratic Republic of Ethiopia Ministry of Health (2008, July). Business Process
Reengineering: Policy, Planning and Monitoring & Evaluation Core Process
2. Federal Democratic Republic of Ethiopia Ministry of Health (2008, January). HMIS/M&E.
Strategic Plan for Ethiopian Health Sector
3. Federal Democratic Republic of Ethiopia Ministry of Health (2008, January). HMIS/M&E.
Indicator Definitions. HMIS/M&E Technical Standards Area 1.
4. Federal Democratic Republic of Ethiopia Ministry of Health (2007, May). HMIS/M&E.
Disease Classification for National Reporting. Technical Standards Area 2.
5. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS
Procedures Manual: Data Recording and Reporting Procedures. HMIS/M&E Technical
Standards Area 3. HMIS/M&E.
6. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Information Use Guidelines and Display Tools. HMIS/M&E Technical Standards Area 4.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
8. Federal Democratic Republic of Ethiopia Ministry of Health (2009, June). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector. FMOH.

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