FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH

ETHIOPIAN HOSPITAL MANAGEMENT INITIATIVE

ETHIOPIAN HOSPITAL

TRANSFORMATION GUIDELINES

Assessment Handbook, September 2016

Federal Democratic Republic of Ethiopia

Ministry of Health

ETHIOPIAN HOSPITAL

TRANSFORMATION GUIDELINES

Assessment Handbook

Ethiopian Hospital Management Initiative

Version 1.0

Assessment Tool for Operational Standards of the EHTG

CHAPTER 1 HOSPITAL LEADERSHIP, MANAGEMENT AND GOVERNANCE

# Standard Method of evaluation Met Unmet

1. The hospital has a functional governing board that meets

regularly to oversee the service delivery of the hospital.

The board is established in accordance with a relevant

legislation

Meets in accordance with a relevant legislation (every quarter)

Minutes are taken at each meeting and agendas are relevant

2. The hospital has a functional SMT that meets regularly

to manage and execute the overall hospital activities.

Obtain a copy of the hospital’s organogram and check it with

the membership SMT

SMT Meets every week

Check whether minutes are taken at each meeting and agendas

are relevant

ToR is prepared and signed by all members

Standing committees are established (quality committee…)

There is an annual plan cascaded to each unit using the

balanced score card(BSC) framework

The SMT submits regular report to the board and relevant

bodies.

3. Hospital has a well-functioning hospital development

army.

There is a functional health development army established as

per the guideline

Regular hospital-community forums conducted every quarter.

Regular hospital management-staff forums conducted every

month.

Citizen charter is prepared and communicated well to the

clients and community

Verify if timely feedbacks are given for issues raised in the

various meeting sessions

4. The hospital governing board mobilizes resources from

diverse sources and makes sure resources are utilized

effectively and efficiently.

Annual budget of the hospital is approved by the board

Check if there is a plan to mobilize additional resources for the

hospital

Check resources are mobilized based on the plan

Internal and external audit reports are reviewed by the board

and findings and recommendations are attended.

5. There is a system and practice of measuring performance

and results in the hospital.

View the BSC documents and performance expectations/plans

are submitted by each units/ departments and are approved by

SMT

The performance of each units/departments are reviewed and

feedback is provided every month

A system of recognition is established for each

units/departments and health workers who meet established

standards.

Decisions are made based on performance data for quality

improvement

6. The hospital has good ethical practice promotion, ethics

violation reporting and responding mechanism.

The hospital has established a complaints handling system

Verify that the hospital assigns a unit to timely collect, properly

document, and submit reports of violation and takes proper

actions.

Suggestion boxes and logbooks are in place at each services

area, and suggestions are reviewed, analyzed and discussed on

SMT meeting every month.

A functional medical ethical committee is established

CHAPTER 2 LIASON, REFERRAL AND SOCIAL SERVICES

# Standard Method of Evaluation Met Unmet

1. The Hospital has established management structures

and job descriptions which detail roles and

responsibilities for:

Reception service

Liaison and referral service

Social service

Check if the hospital has reception service near at the gate of

the hospital with adequately trained staff, stretcher and

wheelchair

The hospital has established liaison unit

adequate number of social workers are assigned

2. The hospital should provide liaison services 24 hours

in a day and 7 days a week throughout the year.

Interview the head of the unit.

3. The hospital has a written protocol for the admission

and discharge of patients that is known, and adhered to,

by all relevant staff.

Check for hospital specific admission and discharge protocol

Interview staff for their knowledge and adherence

7. The hospital has a regular capacity building program for

governing board members and senior management.

Check if there is both a formal and ongoing orientation

program for the governing body on their role, responsibilities,

and accountabilities, organizational structure, regulations and

directives, guideline, policies, procedures and hospitals’

operation.

New members receive a thorough orientation before attending

their first governing body meeting.

Obtain a minute of a meeting held on self-

assessment.(conducted every six month)

8. The CEO is evaluated every six months, consistent with

FMOH or Regional Legislation to ensure he/she is

meeting operational and strategic plans as established by

the Board and the CEO collectively.

Check whether the CEO is evaluated by the board by obtaining

a copy of performance appraisal

Check whether the appraisal result is submitted to MOH or

their respective RHB/Zonal health office.

TOTAL _____

_

______

4. The hospital has a Referrals Service Directory, listing

facilities which the hospital may refer patients to or

receive patients from, categorized by the type of

clinical services they provide.

Check for availability of revised service directory

5. Criteria for the referral of patients from the hospital to

other health facilities are established, including

standardized referral and feedback forms and necessary

clinical documents to accompany referred patients, in

accordance with the national referral implementation

guidelines.

Check for availability of referral criteria

Check for mechanism to truck referral feed back

Check for mechanism to monitor to referred cases.

6. The hospital has a standardized method for managing

referrals and staff members are familiar with the

referral systems including relevant referral protocols

and forms.

Interview 5 relevant staff on their knowledge on referral

criterions and their practices

7. The hospital promotes and publicizes the referral

system throughout the community in order to ensure

that all constituents are aware of the applicable service

pathway.

Check for if the hospital has a mechanism to promote referral

system (public forum)

8. The hospital has established hospital based social

service which addresses the social care needs of

patients affecting the efficient and effective flow of

patients.

Check if the hospital has social health services for the needy

integrated with the liaison office

Check if the social service has SOPs

TOTAL ____ ______

CHAPTER 3 EMERGENCY MEDICAL SERVICES

# Standard Method of Evaluation Met Unmet

1. The hospital has an emergency department led by an

emergency director / case manager.

View the organizational structure

View job description of the emergency department

2. The hospital has an Emergency Triage, staffed with Asses the availability of drugs and equipment according to

necessary infrastructure, appropriately trained

personnel and equipped with necessary equipment,

drugs and supplies needed to provide quality

emergency medical services.

emergency medical services management chapter

Interview the head of the department about adequacy of staff

Check whether the staffs are trained to conduct emergency

patient triage and emergency care.

3. The hospital has easily accessible Emergency

department with an ambulance parking area.

Check whether the ER unit is labeled properly and visible

from the distance

Confirm that the emergency unit is located near to the gate

View the ambulance parking area and confirm that it is

appropriate for parking

4. The hospital shall establish efficient flow of Patients in

the emergency department.

Confirm that the emergency unity is organized based on the

following areas;

o Patient assistant area at Emergency gate

o Triage area

o Waiting area for non-critical emergency patients

o Examination area

o Isolation room

o Resuscitation area

o Procedure area

o The observation and treatment area(beds for 24hrs)

o Emergency OR or easy access to main OR

5. The Emergency Department or Unit shall use a triage

system of screening and classifying patients to

determine their priority needs and to ration patient care

efficiently.

Observe the triage area

Interview ER staff on how to triage patients

6. The hospital provides emergency medical service 24 View presence of emergency

hours a day and 365 days a year with a 24-hours’

access to diagnostic laboratory, radiology and

pharmacy services.

o Pharmacy

o Laboratory

o Mobile x-ray and ultrasound or 24hrs access

7. There is emergency response plan for both internal and

external disasters with a system to alarm or

communicate personnel and other stake holders.

View emergency response plan

Check the assignment of emergency response coordinator and

ask his duty in case of disaster

8. Emergency department or Unit has policies, protocols,

flowcharts, consultation and treatment guidelines for

running ED/EU.

View presence of policies, protocols, flowcharts, consultation

and treatment guidelines

TOTAL ____ ______

CHAPTER 4 OUTPATIENT SERVICES

# Standard Method of Evaluation Met Unmet

1. The Hospital has established management structures

and job descriptions that detail the roles and

responsibilities of each discipline within

services/departments/units, including reporting

relationships.

Check organogram of the hospital

Assigned director/case team manager with JD

Plan/monthly, quarterly and annual

Report/monthly, quarterly and annual

Quality improvement plan

2. The hospital has well-equipped service specific OPD

rooms with necessary equipment and supplies as per

hospital tier level of care.

Check availability of necessary equipment and supplies

3. The hospital has established outpatient specific

diagnostic laboratory, radiology, and pharmacy service

units.

Functional Outpatient lab

Functional outpatient pharmacy

Functional radiology

Sample collection unit

4. The hospital has an outpatient department waiting area

with adequate lightening, ventilation and multimedia

facilities.

Check availability of adequate waiting area in comparison

with volume of patient

Waiting area is ventilated and lightened

Multimedia service is available (like TV, Radio etc)

Chairs are comfortable

5. The hospital has an OPD staffed with adequate and

appropriately trained personnel and OPD service rooms

are managed by at least a GP and specialty clinics by a

service specific specialist/ sub- specialty clinic by sub

specialist as per hospital tier level of care.

Check clinics arranged as per specialty

Check specialty clinics are run by specialist

Check referred patients seen by next level

professional(General practitioner -Specialist-Sub Specialist

6. Outpatient department (OPD) specific central triage

procedure is established to ensure efficient patient

flow; and seek to reduce patient crowding.

Protocol for managing queue

Registration for appointment

Observation MR, Pharmacy and Examination

7. The hospital has established OPD patient appointment

and queuing management systems.

Composition and number of staff

Patient to physician ratio

Equipment’s and supplies

TOTAL ____ ______

CHAPTER 5. INPATIENT SERVICE MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The Hospital has established management structures

and job descriptions that detail the roles and

responsibilities of each discipline within

services/departments/units, including reporting

relationships

Check organogram of the hospital

Assigned director/case team manager with JD

Plan/monthly, quarterly and annual

Report/monthly, quarterly and annual

Quality improvement plan

2. IPD specific admission and discharge procedures are

established to reduce the unnecessary inpatient length

of stay.

Take 10 patient chart and check Discharge and care plan for

each patient

IPD Admission and Discharge Protocol

Hospital access/security for all IPD

Appointment systems for IPD

3. All admitted patients have medical and

nursing/midwifery care plans that describes medical

and nursing/midwifery interventions to address their

needs. The plans are regularly reviewed and updated as

required.

Randomly take 10 charts to check presence complete and

revised history sheet, progress note, discharge summery and

death summery

4. The hospital implements a minimum of daily

multidisciplinary team patient rounds and visit

services.

Check round schedule

Observe round program on the day of visit

Check round team composition

5. The Hospital has IPD service specific facilities as per

hospital tier level.

Mental health

ICU service

Surgical service

6. The hospital has IPD staffed with adequate and

appropriately trained personnel and equipped with

necessary equipment and supplies for Inpatient as per

tier level of care

Composition and number of staff

Patient to physician ratio

Equipment’s and supplies

7. The Hospital has established guidelines for verbal and

written communication about patient care, including

verbal orders and patient handover by discipline and

between disciplines

Communication guideline

Interview 10 staffs about the communication ways between

staffs and coordinators

Shift hand over protocol

8. The Hospital has established procedure for and inter-

professional and departmental consultation and transfer

of patients’ care to ensure continuity of care.

Consultation protocol

9. The Hospital has a policy for accompanying all

patients by appropriately trained health provider/s

during out of IPD diagnostic services and transfer

between wards/departments.

Observe patient transportation

Patient transportation protocol

Interview 10 admitted patients about their experience

TOTAL ____ ______

CHAPTER 6. MEDICAL RECORDS MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. Unique medical record number is assigned to a patient

during his/her first visit of care.

Verify that unique medical record numbers are given to all

patients.

2. The hospital shall have a single unified medical

registration unit for all patients’ registration.

Interview Head of Medical Records Department (or

equivalent) and confirm that only one registration system

exists for ALL patients, including inpatients, outpatients,

emergency patients, and specialty clinic patients.

3. The hospital utilizes paper and computer-based

systems to register and retrieve medical records.

Identify the Master Patient Index

View MR tracking system.

4. The hospital avails and utilizes a standard set of

formats that comprise a complete medical record for

continuum of patient’s care.

Randomly sample 10 inpatient medical records of patients

admitted in the past year, and confirm that each, as a

minimum, contains: physician admission assessment,

progress notes, nursing care plan, discharge summary

5. The hospital shall implement and comply with national

guidelines to manage access to patient’s medical

records.

Interview medical records staff and confirm national

guidelines on handling and confidentiality of medical records

are known by all staff.

6. The hospital performs medical record auditing, data

quality checks, archiving/culling procedures and takes

corrective actions on a regular basis.

View audit reports

Randomly select 10 medical records and check for proper

completion of the forms (at least look for date, utilization of

standard formats, discharge summary for discharged patients,

and name and signature of the physician.

View proper shelving of medical records

View store for keeping medical records that are not active for

more than 5 years

7. The hospital ensures patient’s medical records return

from different service units to medical records unit at

Check the use of tracer card to identify the location of

the end of each service day in accordance with medical

record tracing system.

medical records at all times

View the mechanism of getting all medical records back at

the end of each service day

8. The hospital shall automate health information system

through implementation of integrated electronic

medical record system.

View and confirm implementation of electronic medical

record systems

TOTAL ____ _____

CHAPTER 7. NURSING AND MIDWIFERY CARE SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has established nursing/midwifery service

management structures and job descriptions that detail

the roles and responsibilities of each nursing and

midwifery professional, including reporting

relationships.

Check for nursing representation in the SMT;

Does a system exist to supervise nursing activities?

Has the hospital established management structures that detail

the roles and responsibilities of nursing/midwifery

professionals, including reporting and communication

relationships?

Does the hospital have a nursing/midwifery workforce plan that

addresses nurse/midwifery staffing requirements according to

the standard set for hospitals?

Do the hospitals provide written policies describing the

responsibilities of nurses/midwives on prevention, promotion,

rehabilitative and curative care as well as nursing and

midwifery care process?

Is there a prepared budget and operational yearly plan r

regarding nursing and midwifery practice and has it been

submitted to the SMT?

2. The hospital has a nursing and midwifery workforce

plan that addresses nurse /midwife staffing

requirements and sets minimum nurse /midwife to

Obtain copy of nursing staffing plan and confirm this

establishes nurse to patient ratios for each service area (e.g.

inpatient wards, ER, surgical suite, labour and delivery).

patient ratios in each service area. Confirm the plan identifies mechanisms to reassign nursing

staff or call in extra staff to ensure that minimum nurse to

patient ratios are maintained at all times

3. The hospital has written policies describing the

responsibilities of nurses and midwives for the

nursing/midwifery process including the admission

assessment, planning, implementation and evaluation

of nursing/midwifery care.

Identify written policies that describe the nursing process.

Verify that the following are addressed:

o Nursing admission assessment

o Nursing care planning, implementation and

evaluation

4. All admitted and emergency patients/clients have a

nursing/midwifery care plan that describes holistic

nursing/midwifery interventions to address their needs.

The plan is regularly reviewed and updated as required.

Select a random sample of 10 inpatient records from different

wards. Confirm that each contains a nursing care plan.

5. All hospital nurses/midwives comply with the

professional code of conduct and ethics which governs

their professional practice.

Does the hospital provide a written professional code of conduct

and ethics to all nurses and midwives?

Does the hospital provide complete uniforms for

nurses/midwives and do nurses/midwives comply with the

institutions dress code and all nurses are wearing the specific

uniform?

Are nurses /midwives in complete uniform at all times?

Does the hospital have a system to report illegal, incompetent or

impaired practice?

6. The hospital has established guidelines for verbal and

written communication about patient/client care that

involves nurses/midwives and their patients/clients,

families, other case team professionals of the disciples,

including verbal orders and timely documentation of

accomplished activities.

Does the hospital provide written guidelines regarding verbal

and written communication and documentation?

Do nurses and midwives attend nursing rounds on a regular

basis?

Do nurses and midwives provide safe, effective, efficient, and

patient-centered care to patient/clients?

Do nurses/midwives engage in self-evaluation on a regular

basis?

Do nurses and midwives seek constructive feedback regarding

their own practice?

Does the hospital have a systematic peer review? Regularly,

supervise, mentor and coach the senior nurse to support the

junior nurses?

Do the nurses/midwives have perform one hour rounds?

7. The hospital has standardized procedures for the safe

and proper administration of medications by nurses or

designated clinical staff.

Identify written procedures for process of medication of

administration.

Verify that procedure addresses safety, proper administration,

and administration authority.

Review 10 Medication Administration Records from different

wards and confirm that each is completed correctly with the

signature of the transcriber and of the individual who

administered each medicine dose.

8. The hospital has established nursing/midwifery care

practice audit programme, including the documentation

of completed audits and resulting practice

improvements.

Does the Hospital have a Nursing/midwifery Audit

Committee?

Does the Nursing/midwifery Audit Committee meet regularly

and conduct a nursing/midwifery service audit?

Do Nurses/midwives collect data to monitor the quality of

nursing/midwifery practice?

Do Nurses/midwives participate in critical review and/or

evaluation of policies, procedures, and guidelines to improve

the quality of healthcare?

Do Nurses/midwives collaborate with the inter-professional

team to implement quality improvement plans and

interventions?

Do Nurses/midwives analyze trends in healthcare quality

data?

Do Nurses/midwives incorporate evidence based best

practices to improve health outcomes?

Look for a nursing/midwifery audit report

Look for action plans that address gaps identified by audits

Observe implementation of the action plans

9. The hospital implements regular nursing/midwifery

eight hours’ shift, hourly rounds, and central

medication cabinet or room.

Is the hospital implementing 8 hours shift of nurses/midwifes?

Do the nursing/ midwife staffs conduct hourly patient rounds?

Does the hospital implements central medication management

system to ensure medications are not placed at patient side?

10. The hospital has a centralized nursing/midwifery

station set-up in each ward with adequate space,

equipment and consumables.

Does each unit have the necessary equipment and supplies to

accomplish nursing and midwifery care practice?

Does the unit have equipment for specific minor procedures?

Does the nurse/midwife assess equipment necessary to

accomplish the nursing and midwifery practice related to safety,

effectiveness and availability?

TOTAL ____ ______

CHAPTER 8. MATERNAL, NEONATAL AND CHILD HEALTH SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. 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.

The ANC clinic provides service for pregnant women 8

working hours in a day:

All care providers in ANC clinic are trained on focused

ANC:

ANC services in ANC clinic keep visual and auditory

privacy of Pregnant women:

All ANC service are being provided free of charge:

Investigation results should be given on the same day by

prioritizing pregnant mothers in the laboratory:

Invitation letter for Partners are given with counseling to all

ANC clients to improve partner involvement:

Ensuring the women holds her own medical record summary

at 36 weeks:

Mother infant follow up at ANC clinic until 18 months of

discharge:

There has to be a referral clinic for high risk mother and the

clinic should be run by OBGYN specialist or IESO, open

twice per week and 75% of referred ANC mothers should be

seen by referral clinic for consultation :

2. The hospital should ensure provision of

Comprehensive Emergency Maternal and Newborn

Care (CEmONC) services

Ensure all 10 signal functions are available (see annex) :

Safe surgery check list is used always at least for 75% :

Spinal anesthesia rate should be monitored and should be

more than 75%:

Audit to assess completeness of documentation should be

done every three month: (see MNCH QoC audit assessment

tool):

The rate and indications for C/S should be displayed in white

board every month:

No administrative barrier:

3. The hospital should ensure women and child friendly

services at all MNCH units including pain

management.

Rooms should be well ventilated and temperature of the

room should be good (nether hot nor cold):

There should be screens or curtain to maintain privacy and

has sufficient space to walk around:

The rooms should have a working bath room and toilet with

door that is accessible to laboring mothers that has a hand

washing basin with soap and water for both labour and post-

natal ward:

Family member/support person is allowed to remain with

woman constantly during labour and birth:

Mother is offered oral fluids and light food during labour and

allowed to deliver in their preferred position:

Pain management:

4. The hospital ensures all equipment, essential drugs,

supplies and reference materials are available in

maternity and pediatric units

See MNCH QI assessment tool or annex 1, 2, 4, 5, 6, 7, 8, &

9 on MNCH service chapter on EHSTG.

5. The hospital should ensure the provision of intra-partal

care as per national protocols

Identification and previous obstetric history are properly

documented:

Date and time of admission finding properly recorded:

Basic and essential Laboratory investigation Hgb, blood

group and Rh and HIV test is done routinely during

Intrapartum care:

FHB is monitored at least every 30 minutes and recorded in

the Partograph and chart:

Cervical dilation assessed every 4hrs and documented:

Maternal Blood Pressure measured at least every 2-4 hours

and pulse rate every half hour:

Delivery summary is properly documented:

Safe child birth checklist used consistently:

Oxytocin 10 IU IM given just after delivery of the

baby(AMSTL):

Neonate is given vitamin K 1 mg, TTC eye ointment and

vaccinated with BCG and OPV 0:

6. The hospital should provide comprehensive postnatal

care in the facility as per national standards

Mothers have checked for vaginal bleeding, uterine

contraction, fundal height, temperature and heart rate

routinely immediately after birth every 15min for the first

2hours, if normal hourly during her stay in the hospital:.

Neonates checked for breathing problems, color; pulse rate,

fever, breast feeding and cord tie security:

Mother should be counseled for danger signs for both mother

and neonate and should be documented.

The hospital should ensure provision of family planning

(with focus on long term:

7. The hospital should ensure provision of family

planning (with focus on long term methods) and

comprehensive abortion care services following the

national guideline and policies.

Trained health professional were assigned to provide

counseling on contraception, unintended pregnancy and

abortion;

demonstrate competent skills and the services should be

evidence based:

Comprehensive health and obstetric, gynecologic and

reproductive health history taken and physical examination

done:

Care, support and referral or treatment for the HIV positive

woman and HIV counselling and testing for women who do

not know their status provided:

Prescribe, dispense, furnish or administer a broad range of

contraceptive methods, including IUDs, implants, injectable

emergency contraceptives and women advised about

management of side effects and problems with use of family

planning methods:

Perform vacuum aspiration (manual or electric) for

pregnancies of gestational age up to 12–14 weeks according

to the national guideline.

Medical methods of abortion available for pregnancies of

gestational age up to 9 weeks, or up to 12 weeks if the

woman can stay in the facility until the abortion is complete

according to the national guideline;

Clinical stabilization, provision of antibiotics, and uterine

evacuation provided for women with complications of

abortion;

Referral women who needing unavailable services in the

hospital or HCs.

8. Maternity and pediatric units should undertake CQI

activities by conducting regular review meetings and

audit programmes.

Maternity and pediatric unit should perform audit every

month

Maternity unit should perform MDSR

Client/mom’s satisfaction survey should perform every 3

months

Data should be displayed on White board at ANC, Labour

and delivery and postnatal ward and updated

Community involvement ( Pregnant mother forum,

community forum) at least one activity in 3 months

Regular review meetings (at least every week) to discuss

audit findings

The pediatric department should conduct regular QoC audits

in respective units as to the proper checklist.

Pediatric unit should perform death audit.

9. Hospitals have established separate pediatric OPD,

emergency and triage services.

Observe that the pediatric OPD is separate from adult OPD

Observe that the hospital has established separate pediatric

triage and adjacent emergency treatment area (room) within

pediatric OPD

Check by observation that children are sent directly to the

pediatric triage area upon arrival in the hospital (before

registration)

Confirm that professionals assigned at pediatric triage and

emergency unit are trained in ETAT

Check that emergency box containing all emergency drugs

and equipment is available in the pediatric ER

Check that ETAT guidelines and job aides are available in

the triage area and ER (see Annex 3)

Verify that the equipment and drugs listed in Annex 1 are

available and functional

10. Hospitals have comprehensive Neonatal Care service

that includes NICU, KMC, mother’s room and

isolation rooms.

Check the hospital has established neonatal unit

Confirm the neonatal unit is composed of:

- Neonatal ICU

- Kangaroo mother care (KMC) room

- Mothers’ waiting room

- Isolation room for neonates with communicable

infections

- Procedure/resuscitation room

Confirm that all the equipment, supplies and essential drugs

listed in annex2 are available and functional

Check that infants admitted to the neonatal unit are managed

by a neonatologist (if available),a pediatrician or a

professional with special training on neonatal care (NICU

care)

Check that guidelines and jobs aids listed in Annex 3 are

available for neonatal unit

Confirm that LBW infants (<2000 gr) that are clinically

stable are given KMC starting soon after birth

Confirm from mothers’ and infant charts that prophylactic

antibiotics are given for neonates with documented risk

factors (ROM >18 hr, maternal fever, foul smelling amniotic

fluid)

Check that thermal environment is maintained for the sick

infants:

Young infant is kept dry and well wrapped

Room is kept warm (at least 25oC)

Attention is given to avoid chilling the infant during

examination or investigation

Infants’ temperature is regularly checked to maintain b/n 36-

37oC axillary (36.5-37.5oC core)

11. Hospitals have separate Pediatric Wards composed of

separate critical, general, SAM, isolation and

Check that the hospital has pediatric ward separate from adult

ward

procedure rooms. Check that the pediatric ward is composed of the following

rooms:

- Therapeutic feeding room for children with

complicated SAM

- Pediatric ICU or at least dedicated room for critically

ill children next to the nursing station

- Isolation room for children with communicable

diseases

- Clean, ventilated procedure room with good light

source

Observe that the ward room paintings are child friendly

Confirm the presence of national guidelines and job aids

listed in Annex 3, and supplies and equipment listed in

Annex 6 are available and functional

From patient charts, check the following:

- Children admitted to the wards are evaluated by

physicians (preferably pediatricians) on daily basis (

twice per day for critical children)

- Critically sick children are evaluated by registered

clinical nurses every 4 hours

- Vital signs are measured every 6 hrs for admitted

children (more frequently if ordered by a physician)

- Growth monitoring is performed for all U5 children

admitted to the ward

Admission and discharge notes, vital sign sheets, and

discharge or death summaries are attached to the patient

charts

12. Midwives should implement the midwifery process at

all hospitals for all admitted patients.

Midwives assess and record pertinent data using evidence

based assessment.

Midwives’ assessment data able to reach to proper diagnoses

Midwives ‘care plan is according to the assessment and

diagnosis

Midwives appropriately implemented and executed the care

plan

Midwives re-evaluate and re planed if necessary

Midwives record and document all data in the clients’ chart

TOTAL ____ ______

CHAPTER 9. LABORATORY SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has a clear laboratory management

structure and accountability arrangement with well-

defined roles and responsibilities for the provision of

laboratory services organized into central, emergency

and inpatient laboratory services.

View organization chart.

View central, emergency and inpatient laboratories

Interview senior staff member of Central Laboratory and

confirm that Central Lab has functional overview of all

laboratory services.

2. The hospital laboratory management has established

system for management of documents and records that

are maintained, controlled, reviewed and approved to

ensure the provision of quality laboratory services.

Obtain evidence whether the laboratory have document and

record generation, identification, approval, use, control and

disposal procedure

View the laboratory-produced quality manual, safety manual,

sample management guideline and laboratory handbooks

Confirm the availability of standard operating procedures

for all Technical and Managerial procedures in work place

Confirm the availability of Guidelines, Formats , Job aids

and instructions in work place

3. The hospital laboratory has established system to

monitor the effectiveness of its customer service

programme.

View laboratory handbook in all services areas.

View customer satisfaction survey report.

View presence of suggestion box to collect customers

suggestions

View posted available test menu with current price and

standard TAT to customers.

Refer list of tests and equipment’s in Appendix B

Confirm the laboratory staffs communicated the available

tests to their clients and advisory service given

Confirm the established Complaint monitoring system

Check Suggestion box and/or suggestion book in place

4. The hospital laboratory has and implements a proper

management system for its equipment that includes the

calibration, maintenance and inventory to ensure the

provision of accurate, reliable and timely test results.

Confirm if there is a proper and functional equipment

management system in place

Obtain evidence on equipment management system include

ways of participation on consultation, selection,

specification, installation, calibration, maintenance, retiring

and disposal

5. The hospital has a laboratory supplies management

system.

Ensure that an effective supply chain management system is

in place to select, quantify, transport, store, distribute and

keep records of all reagents and supplies.

Confirm the laboratory have functional inventory system for

resource management

View laboratory has mini store for lab supplies and reagents

View Bin cards are used to manage laboratory supplies and

reagents

View stock status report

6. The hospital laboratory shall implement a process

control system that monitors the processes from pre

analytical to post analytical phases of testing, including

an established internal quality control (IQC) and

participates in external quality assurance (EQA).

Pre-analytical

View well established and isolated sample collection area.

View sample collection manual ready for use in work place.

Analytical phase

Obtain records of valid IQC for all tests in regular manner

Confirm whether the laboratory participates in any

recognized EQA (PT scheme) or intra laboratory evaluation

and scored ≥80% for tests included in that scheme.

Post-Analytical

Confirm a system to review results before release

independent of testing personnel

View a TAT established for every test and evaluated

7. The hospital laboratory has established incident

handling and reporting system which includes errors or

near errors (also called near misses).

view records occurrences or incidence

View identified and registered occurrences or deviations

from standard assessed and put for improvement

8. The hospital has established laboratory management

information system.

View written procedure for the laboratory information

management system

Confirm the system prevents patient data loss or proves

confidentiality, accessibility, accuracy, timeliness, security,

and privacy of patient information.

9. The hospital laboratory should be designed and

organized at least for bio safety level 2 or above and

work environment is clean and well maintained at all

times.

View if The hospital laboratory have enough working space

Ensure a laboratory safety program is in place and

performed accordingly

make sure availability of safety equipments and supplies (

first aid kit, spill kit, fire extinguisher, and emergency

shower, eye wash, PPE etc)

Interview selected lab staff in order to check relevant safety

awareness among staff

Observe for restricted access when work is in progress

Work stations ,floor and walls are easily cleanable,

10. The laboratory shall design a backup laboratory service

through availing back laboratory equipment or and

through backup laboratory facility.

Confirm if a system designed for back-up laboratory service

View lists of backup laboratory facilities

View developed and signed MOU by all responsible bodies

View back-up equipment in case of equipment failure

11. The hospital laboratory has appropriate storage and

stock management systems for blood and blood

products received from blood banks.

View the mini blood bank

Obtain list of transfusion committee members and focal

person with their official letters

Obtain singed MoU b/n hospital and Blood Bank Services

Obtain equipment inventory list and check their functionality

status

View documents and records for blood received ,blood

issued and compatibility test and SOPs

12. The hospital laboratory blood bank service in

collaboration with respective regional blood back

service shall have mobilization of blood donation

strategy through community awareness programs.

Obtain number of awareness creation program in the year

View number of notification letters for awareness creation

session

View the list of potential blood donors in the hospital

identify notification letter written to blood bank service so as

to collect blood for VNBDS in hospital

13. The hospital laboratory blood bank service shall have

appropriate cold chain system for blood and blood

products received from blood bank service until used

by prescribers.

View SOP for cold chain system

Randomly check Temperature control chart

Check the following equipments

a. Blood bank refrigerator 2-6Oc

b. Blood bank deep freezer <-18oC

c. Platelet Agitator 20-24Oc

d. Bench top centrifuge

e. Blood group or Cross match plate

f. Blood group reagents (Anti-A,B and Anti-D

g. Anti-human globulin antisera

h. Biohazard bag

i. Blood warmer

j. Water bath

14. The hospital laboratory blood bank service shall report

blood administration and patient safety information to

respective regional blood banks.

Check blood request forms and see for completeness

Check whether the transfusion committee has a meeting

plans/schedule

Check minutes of blood transfusion committee meeting and

check status and approval

View blood transfusion committee TOR and check for

implementation

Check all documents are controlled

TOTAL ____ ______

CHAPTER 10. PHARMACY SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital provides quality pharmaceutical products

and effective services in its outpatient, inpatient, and

emergency pharmacy service units.

Presence of separate outpatient, inpatient, emergency,

Drug supply management, Drug information and

Compounding pharmacy service provision units.

Presence of separate store for medicines and other

supplies and reagents.

2. The hospital has a functional Drug and Therapeutics

Committee (DTC) that develops and implements

interventions promoting the rational and cost-effective

use of medicines.

Presence of DTC annual plan for the fiscal year

Presence of terms of reference (TOR)

Presence of official letter of assignment for members

Presence of at least 6 signed meeting minutes in the last

12 months

Presence of performance report of DTC activities of the

last fiscal year

3. The hospital has a Medicines Formulary listing all

pharmaceuticals prioritized by VEN that can be used in

the facility. The Formulary is utilized and updated

annually.

Availability of annually updated pharmaceutical list or

formulary

The list is prioritized by VEN

4. The hospital ensures execution of good dispensing

practices at all dispensing outlets.

Dispensing area workflow organized as: Evaluation &

Billing Payment//Processing Counseling

Presence of waiting area with seats in OPD pharmacies

Presence of signed prescriptions by evaluator and

counselor (hint: see randomly selected 10 prescriptions)

Presence of records for identified DTPs and measures

taken

Presence of report on patient knowledge on correct

dosage and satisfaction

5. The hospital implements auditable, transparent and

accountable pharmaceutical transactions and services

(APTS).

Presence of properly recorded and filed prescriptions,

sales tickets and registers at dispensaries

Adequate human resource is deployed in each pharmacy

services units (hint: based on workload analysis: number

of prescriptions and bed size)

Pharmacy premises are arranged so as to keep patient

safety and privacy

Implementation of coding to uniquely identify medicines

Bin ownership is implemented

Presence of monthly reports for products, finance and

services

Presence of audit report (internal)

Wastage rate in monetary value is <2%

Presence of annual report on ABC and VEN analyses

6. The hospital provides clinical pharmacy services at

inpatient, outpatient and emergency departments.

Completed patient medication profile form,

pharmaceutical care progress recording form and

medication reconciliation forms are part of the patient

chart (hint: see randomly selected 10 patient charts at an

inpatient ward)

Ward pharmacy available in each major ward and

functions for 24 hrs.

Unit dose dispensing is implemented at ward pharmacies

(medicines are dispensed only for 24 hrs.)

Regular participation of pharmacists in ward rounds,

morning sessions and seminars (ask a physician and a

nurses in major wards)

7. The hospital provides drug information services to

health care providers, patients and the public.

Presence of properly filled query receiving and

answering forms (see the previous month records)

Presence of recently prepared sample drug

alert/newsletter, therapy update, drug monograph

Presence of updates on stock availability to the hospital

community (ask health care team or see records)

Presence of medicine use education for patients (ask the

appropriate unit)

Has started providing poison information

Presence of survey report on patient satisfaction of

overall pharmacy services

8. The hospital has a functional compounding service. Separate premises for compounding service

Availability of equipment, materials and chemicals

Availability of SOP for all compounding procedures

Recorded documents for all compounded items

9. The hospital has efficient and effective pharmaceutical

logistics management system that reduces the

frequency of stock-outs, wastage, over supply and drug

expiry.

Presence of procurement policy

Presence of annual pharmaceutical quantification and

supply plan

Report that shows percentage of procured items from the

hospital list.

Presence of updated bin card (check randomly selected

10 bin cards)

Good storage practice is being followed

10. The hospital has appropriate paper/computer-based

inventory management system.

Presence of properly recorded and filed Vouchers at store

Availability of paper based or electronic inventory

management tool

Presence of physical inventory report for dispensaries

for stores

Presence of stock status analysis report.

11. The hospital has an established system for regular

monitoring medication use and safety.

Presence of semi-annual prescription monitoring report

Presence of annual DUE Report

Presence of ADE report

Presence of WHO drug use indicator study report

Presence of update on (high alert medications,

error prone abbreviations, look-alike and sound alike

medication list …)

12. The hospital conducts continuous segregation,

documentation and safe disposal of pharmaceutical

wastes

Presence of SOP for disposal for the hospital

Presence of list of disposed products with description

Expired medicines are separately segregated

Presence of certificate for disposed medicines (minutes

during disposal)

TOTAL ____ ______

CHAPTER 11. RADIOLOGICAL AND IMAGING SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has a separate well designed and

equipped radiology unit and qualified personnel

that oversees radiological and imaging services.

Confirm that:

Radiology unit is established with service provided 24/7

The head is a member of SMT and hospital medical

equipment committee

The unit has strategic and annual plan with budgets

approved by SMT

2. The radiology unit has all the necessary layout and

infrastructure, personnel and equipments as per

FMHACA and ERPA standards.

Confirm if

Hospital received Yearly ERPA certification

Adequate number and mix of professionals (radiographer

technicians, radiographer technologists, radiologists etc are

maintained as per FMHACA and / or ERPA standards

Adequate utilities are ensured including 24 hour water and

electricity supply, toilets (gender separate), telephone line,

3. All radiological and imaging equipment users are

appropriately trained on the operation and

maintenance of such equipment with standard

operating procedures readily available to the

service providers.

Confirm if

SOPs are developed and in use for the regular operation and

maintenance of all equipments in the unit

All equipment users are appropriately trained on the

operation and maintenance of medical equipment with

standard operating procedures readily available to the user

Regular orientation and refreshment training is given for all

workers on how to operate the equipments

4. The hospital has established procedures for the

maintenance, calibration, capability, quality

control testing and functionality of all radiological

and imaging equipment.

Confirm if

All new equipment undergoes acceptance testing prior to its

initial use to ensure the equipment is in good operating

condition.

All new Equipment is installed and commissioned in

accordance with the manufacturer’s specifications

There is a schedule for inspection, testing and preventive

maintenance for each piece of equipment as guided by the

manufacturer’s recommendations and that schedule is

appropriately implemented

There is a notification and work order system for the repair

of medical equipment

5. The hospital has and implements written policies,

procedures, protocols and guidelines for the

delivery of all radiological services, interpretations

and timely reporting of results for all patients.

Confirm if SOPs are developed and implemented for the following

activities

Request reviewing

Client communication and consenting

Turnaround time

Patient preparation and positioning

Radiation Safety protocols

Contrast administration

Management of specific situations (pediatric patients,

pregnancy, clients needing sedation, emergency patients and

prioritization protocols)

Quality improvement activities (identification of quality

gaps, action plan development and implementation)

6. The hospital has a paper or computer based system

for recording and reporting of all radiological and

imaging procedures carried out and for archiving

all patients’ results that are periodically audited for

quality assurance, service improvement and

expansion.

Confirm if the hospitals has and implements

Reporting formats and standards

Policies and procedures for recording and reporting

(including remote reporting)

Communication policy with the unit and other clinical

departments

TOTAL ______ ______

CHAPTER 12. REHABILITATIVE AND PALLIATIVE CARE SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital should have a rehabilitation and

palliative care service with necessary equipment,

There is a designated area in the hospital, including area for

rehabilitation and palliative care services

aids and appropriate human resources. Relevant equipment and resources has been procured

Trained rehabilitation, at least a physiotherapist and palliative

care professionals has been recruited and employed

Rehabilitation and palliative care treatment protocol are in place

Rehabilitation service has education programs in place for

patients receiving rehabilitation

2. With regard to rehabilitation, the hospital should

at least provide a physical therapy/physiotherapy

service and if possible, occupational, speech and

Prosthetics Osthotic Technology.

A physiotherapist is available in the hospital

A physiotherapy centre is equipped with the minimum

equipment required

3. With regard to palliative care services, the hospital

should at least provide good pain and symptom

control for both in and out patients.

Essential palliative care drugs mainly consisting of pain

management, are available in the hospital

Pain assessment is established as a fifth vital sign in the hospital.

4. The hospital should have a written standard

operational procedure and patient record

management for all rehabilitative and palliative

care services.

There is written guidelines and SOPs for the assessment,

implementation and evaluation of rehabilitation and palliative

care services

Patient health records identify the patient and document

rehabilitation assessment, goals, intervention and outcomes

5. The hospital should establish a mechanism for

referral and transfer of rehabilitation and palliative

care services through in-patient and outpatient and

in the case of palliative care, linkage to services

that provide home-based care.

Community partners are engaged for patient care in the home

Protocols related to information sharing communication and

confidentiality developed

TOTAL _____ ______

CHAPTER 13. INFECTION PREVENTION AND PATIENT SAFETY

# Standard Method of Evaluation Met Unmet

1. The hospital has strategies and operational plan for

IPPS as well as a management system to monitor

and evaluate the activities.

Interview CEO/medical director to confirm that CASH/IPPS

committee is in place and functional(check updated and printed

TOR of the committee,)

Check regular monthly minutes of the committee

Check the hospital has strategies/ policies

Does the committee have an operational plan on CASH and

IPPS

Check the activities planned are implemented based on the

schedule(check performance reports)

2. Hand hygiene practice is implemented and

facilities are provided at all service points at all

time

Check the presence of hand washing facilities(at minimum with

soap , water and functional faucets ) at all different service

outlets with access to clients and attendants

Check the hospital has continuous water supply at point of use

with backup.

Check hand washing posters are posted at a visible location

Randomly Spot check 5-10 staff from different service points

washing hands/interview about steps and critical hand washing

times.

3. All the necessary commodities and supplies of

IPPS are routinely available and utilized at the

designated service areas.

Check the availability and adequacy of necessary PPE’s at(

labor ward, OR, procedure rooms/minor OR, Laundry,

Housekeeping/waste handlers staff

utilization of PPEs at ( labor ward, OR, procedure rooms/minor

OR, Laundry, TB rooms, housekeeping and waste handling

spots

4. The hospital has ensured that safe surgical

procedures and practices are in place to minimize

risks to clients and providers

Check the usage of WHO surgery safe surgery checklist for 5-10

clients.

Check the presence of standard surgical antiseptics at all

procedure rooms.

Spot check /interview whether safe practices are implemented in

the OR

5. Safe injection practices are implemented to

minimize risk to all surrounding community and

management of adverse event related to injection

are in place.

Check

the presence of client education to avoid unnecessary injections

Spot check /interview whether recapping of used syringes is not

practiced

Check safety boxes are available at right spot, disposed timely

including proper incineration

6. The hospital practices health care waste

management following the national IPPS

guidelines

Observe

Presence of color coded bins

practice of waste segregation,

Presence of primary waste storage area

Presence of well-designed functional incinerator with ash pit

and proper use

Presence of fenced and ventilated placenta pit with tight fitting

cover( if applicable)

Check /interview if safety boxes are disposed safely (quantified,

properly stored and observed) during the incineration.

Proper disposal of liquid wastes check presence of septic tank/

absence of leakage of the sewerage system (waste should not be

discharged without treatment)

If treatment plant is available the quality of discharge should be

acceptable and checked periodically.

7. The hospital ensures the cleanliness and

housekeeping activities

Cleaning audit should be conducted based on the CASH audit

tool schedule

Interventions/solutions are provided to solve the gaps based on

the audit finding(check monthly report collected from

departments/teams

Check/observe the hospital compound cleanliness and

Check /observe service areas are visibly clean and absence of

bad odor and well ventilated

8. The hospital ensures the availability of adequate

and functional toilets, hand washing sinks and

showers

Check

The number of functional toilets are adequate to clients(1 toilet

for20-24 clients

Hand washing facilities are available at all service units

Functional showers at all wards

Proper and separate storage of washed lines

Presence of Hand washing facility

9. The hospital ensures Adequate and functional

laundry service

The facility has adequate laundry space

The hospital has at least two functional washing machines with

ironing

Separate doors for entrance of dirty and clean linen

Separate storage room for clean linen.

Separated cart for clean and soiled linen

Adequate detergents and disinfectants

10. All reusable medical equipment are processed

according to the national IPPS guidelines

Check whether proper decontamination procedures are in place

Check functionality and how they operate autoclave and dry heat

oven or chemicals for sterilization

Check whether proper high level disinfection procedures are in

place

Check whether processed items are properly stored in well-

designed rooms.

11. The hospital has a procedure in place to regulate

traffic flow

Check how the facility handles traffic at procedure rooms as

well as in the premises,

The facility has zoning restriction at OR

Does the Hospital have defined visiting hours, number of

attendants

12. The hospital has a monitoring system to ensure

safety of food and water served in the premises.

Check

the cleanliness of the kitchen

if kitchen staff/food handlers have periodic medical check up

Interview patients/clients to assess that the food served is in

hygienic way and spot check the kitchen utility

If all water sources are lab tested periodically every 3 months.

13. The hospital has a clients’ education system to for

IPPS improvement.

Check

the presence of client education schedule where relevant IPPS

contents is included,

Educational materials and supplies related to IPPS

14. The hospital ensures all the post exposure and

preventive interventions and procedures are in

place in case of occurrence of occupational risks.

Check

If surgical site infections are recorded

If documented action taken to reduce health facility acquired

infections based on observed infection pattern

15. The hospital develops hospital acquired infections

tracking and monitoring system

Check

Recording of surgical site infection and other HAIs

TOTAL ______ ______

CHAPTER 14. FEDERAL AND TEACHING HOSPITAL SERVICES MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has established functional

management and governance structure that

integrates patient care, medical education and

research.

Check the membership and functionality of the governing board

View the organogram of the hospital

View the JD of CED, CARD,CCD,CAD

View minutes of the executive committee, SMT, Strategic and

annual plan

2. The hospital implements an orientation programme

View the orientation guidelines

Interview five students/interns/residents randomly to check if

for students/interns/residents on hospital policies

and procedures prior to clinical attachments.

they have taken the orientation before clinical attachments.

Interview department head and ward head nurses for

students/interns/residents compliance on policies and

procedures

3. The hospital has established system to ensure care

provided and students’ practice maintains patients’

confidentiality and privacy at all times.

View protocols for conducting teaching on patients.

Interview 10 patient from different wards on their privacy,

confidentiality and their involvement on the care process.

Observe patient care areas

check presence of sill labs and simulation centers

4. The hospital has established protocols/policies and

procedures for ward rounds and bedside students’

teaching to maximize patients’ benefit.

Check for presence of protocol

Interview staff for their knowledge on the protocol and

adherence

Check if student to patient ratio is defined

Time spent for bedside and round teachings is defined (

shouldn’t exceed one hour on one patient)

Consultant’s recommendation on bedside/rounds are

implemented

5. The hospital ensures students/interns/residents’

patient care provided is supervised by their

respective teachers/hospital based instructors at all

times.

View posted program listing supervisors/teachers for specific

unit and for specific date.

Beside the students/interns/residents the hospital assigns a staffs

accountable and responsible for all their respective patient care

activities at all times.

6. The hospital has established guidelines,

memoranda of understanding and procedures for

affiliation with other teaching institutions,

communities and field activities.

View the guidelines/MoU for affiliation, community and field

activities

Check for mechanism to monitoring implementations of

guidelines/MoU

TOTAL _____ ______

CHAPTER 15. MEDICAL EQUIPMENT MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has in-house Medical Equipment

Management unit with an operational plan,

required staff and led by a biomedical personnel.

Confirm that hospital has Medical equipment management unit

with the necessary staff

Confirm that the unit is led by a biomedical personnel

2. The Hospital has a Medical Equipment

Management Committee composed of doctors,

nurses, technicians, pharmacists, and

administrative personnel that oversees the medical

equipment management programme.

Review MEC TOR and ensure the following responsibilities are

included: develop and monitor implementation of medical

equipment strategy; oversee establishment of medical equipment

inventory; develop a model medical equipment list; develop and

implement medical equipment policies; determine annual budget

for medical equipment strategy; review incident reports related

to medical equipment.

Verify that MEC membership consists of doctors, nurses,

technicians, pharmacists and administrative personnel.

3. The hospital has an appropriately equipped medical

equipment maintenance workshop.

Check availability of maintenance workshop

Confirm that the workshop is well equipped with the necessary

tools

4. The Hospital has a paper-based and computer-

based or automated inventory management system

that tracks all equipment and spare parts included

in the equipment management programme.

View inventory management system and confirm updated

within past year.

Confirm (by interview with Head of Equipment Maintenance (or

equivalent)) that all medical equipment in the equipment

management program is listed in the inventory.

Confirm (by interview with Head of Equipment Maintenance (or

equivalent)) that the inventory system is used to manage the

stock of spare parts

5. An Equipment History File is maintained for all

medical equipment containing all key documents

for the equipment.

Take a random sample of 10 Equipment History Files and check

that each includes: SOP for equipment use, inventory data

collection form and risk assessment form.

6. The hospital has policies and procedures in place

for acquisition of new medical equipment,

commissioning, decommissioning and disposal of

Obtain copy of policies and procedures for medical equipment

management and verify that they address acquisition,

commissioning, decommissioning, disposal, donations, and

outsourcing technical services.

equipment, the receipt of donations, and

outsourcing technical services for medical

equipment repair and maintenance.

7. All new equipment undergoes acceptance testing

prior to its initial use to ensure the equipment is in

good operating condition, and are installed and

commissioned in accordance with the

manufacturer’s specifications.

Request list of all equipment purchased in the past year.

Randomly select 10 items (or all items if less than 10 were

purchased) and review Equipment Log File. Confirm that this

contains a copy of the Acceptance Test Log Form.

8. All equipment operators and personnel are trained

on proper operation, safety, and maintenance of

medical equipment with standard operating

procedures readily available to the user.

Visit a minimum of 3 different departments/case teams (for

example ER, laboratory, pharmacy, delivery, patient wards etc).

Select two items of medical equipment in each department.

View SOP for each item. Interview staff on duty and confirm

that each one has received training on the use and maintenance

(where relevant) of the item.

9. There is a schedule for inspection, testing and

preventive maintenance for each piece of

equipment as guided by the manufacturer’s

recommendations and that schedule is

appropriately implemented.

For the 10 randomly selected Equipment History Files confirm

that the schedule for Inspection, testing, and maintenance is

present in the equipment history file and confirm that inspection,

testing and maintenance has been conducted as described in the

schedule.

10. There is a notification and work order system for

corrective maintenance and calibration of medical

equipment based on their level of risk.

Identify written protocol for medical equipment work orders.

Review at least 5 copies of notification and work order and

reports.

TOTAL _____ ______

CHAPTER 16. FACILITY MANAGEMENT

# Standard

Method of Evaluation Met Unmet

1 The hospital complies with relevant laws,

regulations, and facility inspection requirements.

Interview CEO to identify any relevant laws, regulations or

inspection requirements and confirm that the hospital complies

with these.

2 Designated hospital staff members are assigned

for facility maintenance and safety functions.

View organization chart.

Confirm on organization chart (or by interview with HR Dept

Head) that the hospital has assigned individuals for the following,

as a minimum: masonry, plumbing, electrical installation,

landscape and garden, sewerage.

3 The hospital grounds are regularly inspected,

maintained, and, when appropriate, improved to

ensure cleanliness of grounds and safety of

patients, visitors and staff.

Interview Facilities Manager (or equivalent). Check

process/schedule for grounds inspection and maintenance.

View patient and staff areas (garden, waiting areas etc). Confirm

that these are tidy, clean and free from hazards (e.g. discarded

equipment or other materials).

4 Potable water is available 24 hours a day, seven

days a week through regular or alternate sources

to meet essential patient care.

Interview CEO or Head of Facilities. Confirm that an alternative

source of water exists (e.g. tank, well). Obtain documentary

evidence that the alternate source/ and or mains source are tested

for safety at a minimum every six months.

5 Electrical services are available 24 hours a day,

seven days a week through regular or alternate

sources to meet essential patient care.

Interview CEO or Head of Facilities. Confirm that an alternative

power source is available. Confirm that this is sufficient to

provide power to essential patient areas including wards,

emergency room, labour and delivery and laboratory.

6 The hospital has a maintenance center with

technical personnel, sufficient space and adequate

ventilation to conduct maintenance and repair

work on the facility operating systems (e.g.,

electrical, water, sanitation, sewerage and

ventilation) and equipment. This includes proper

hand washing facilities, proper disinfection and

cleaning of equipment facilities, a storage area,

and a library.

View maintenance center. Confirm that this has adequate space

and is not crowded. Confirm that the medical equipment service

is separated from the general maintenance area. Confirm that

there are hand-washing facilities, facilities for cleaning and

disinfection, a storage area and a library.

7 The maintenance centre has appropriate tools and

Interview Head of Maintenance Dept. (or equivalent). Confirm

that sufficient tools are available for all maintenance functions

testing equipment to perform repairs, as well as

procedures to ensure the routine calibration of the

testing equipment is performed as required.

and that routine calibration of testing equipment is performed as

required.

8 The hospital conducts regular preventive and

corrective maintenance for all facilities and

operating systems (e.g., electrical, water,

sanitation, sewerage and ventilation) to ensure

patient and staff safety and comfort.

Interview Head of Maintenance Dept. (or equivalent). Confirm

that regular preventive and corrective maintenance is conducted.

View maintenance logs. Confirm that maintenance logs exist for,

as a minimum: electrical systems, water and sewerage.

9 There is a notification and work order system for

facility and operating system (e.g., electrical,

water, sanitation, sewerage and ventilation)

repairs.

Interview Head of Maintenance Dept. (or equivalent). Confirm

that a notification and work order system exists.

View at least 5 recent work order requests and reports.

10 The hospital has a transport policy for the use of

and access to hospital vehicles.

View transport policy.

View logs of two hospital vehicles and confirm that vehicle use

complies with transport policy

11 The hospital has a policy addressing access to the

hospital premises.

View policy.

Visit two wards and confirm that all caregivers are wearing

appropriate ID badges.

Confirm that all staff interviewed in the course of this assessment

are wearing ID badges.

12 The hospital has a fire safety plan that addresses

both the prevention and response to fires. A ‘Fire

and Evacuation Drill’ is conducted at least

annually.

View fire safety plan.

Obtain documented evidence of most recent Fire Drill and

confirm that this was conducted within the past one year.

13 The hospital has a plan for responding to likely

community or hospital emergencies, epidemics

and natural or other disasters.

View response plan.

14 Staff members are trained and knowledgeable

about their roles in the plans for fire safety,

Interview 10 randomly selected staff members from different

Case Teams. Confirm that each one knows what action to take

and their individual responsibility in the event of a fire, security

security, hazardous materials, and emergencies. threat or other emergency.

TOTAL _____ ______

CHAPTER 17. HUMAN RESOURCE MANAGEMENT

# Standard

Method of Evaluation Met Unmet

1. The hospital has a Human Resources

Management Directorate/Department/ Support

Process staffed by individuals who possess

management knowledge, skills and experience

dealing with individual personnel matters and

teams.

Identify designated staff members of the HR case team

Check experience of case team members and confirm that

personnel staff have requisite skills (training and personnel

management experience).

2. The Human Resources Directorate/Department/

Support Process maintains a personnel file for

each and every hospital employee.

Interview Head of HR Case Team. Confirm that the hospital has

personnel files for all grades of employees

Take a random sample of 10 personnel files from different case

teams/departments and ensure that they contain at a minimum:

personal contact information, appointment letter, employee job

description, medical certificate and performance evaluation.

3. The hospital establishes and institutionalizes

Human Resources Information Management

Systems (HRIS) that enhance the HR

management functions.

Confirm implementation of HRIS through viewing

Check information are up to date

4. The Human Resource Head (or equivalent) is a

member of the hospital Senior Management

Team.

Obtain list of SMT members from CEO and confirm that Head of

HR Case Team is a member.

5. The hospital has a human resource development

plan that addresses staff numbers, skill mix and

staff training and development.

Review a copy of the human resource development plan.

Ensure that it addresses staff numbers, skill mix and staff training

and development.

6. Each employee’s responsibilities are defined in a

See standard 11.2 above. Confirm that the 10 randomly selected

files contain a signed employee job description.

current job description, which has been signed by

the employee and filed in the personnel file.

7. The hospital has policies and procedures for

recruitment and hiring of staff.

Identify written policies for recruiting and hiring staff.

8. The Human Resource Directorate/Department/

Support Process provides services to employees

to ensure satisfactory productivity, motivation,

and morale as evidenced by effective policies and

procedures for personnel retention, compensation

and benefits, training and development and

employee recognition.

Identify documented policies that support employee motivation

and retention including as a minimum: policy for compensation

and benefits, training and development and employee recognition.

9. Human Resource policies are documented in an

Employee Hand Book that is distributed to all

staff and updated, at a minimum, every 3 years.

The employee hand book contains policies and

procedures that define employee/employer

relations, the rights and obligations of employees/

employer, employee services and benefits,

promotion and employee development

procedures.

Obtain a copy of the hospital’s Employee Manual

Ensure that it contains Hospital personnel policies and procedures

such as working hours, leave, benefits.

Ensure that it has been updated and is current (within 3yr renewal

window).

Verify that it has been disseminated among staff by interviewing

a random sample of 10 staff and asking them if they have a copy

of the employee manual.

10. The hospital has a Code of Conduct and

Professional Ethics that is known, and adhered to,

by staff.

Obtain a copy of employee code of conduct.

See 11.8 above: interview 10 random staff members from

different Case Teams and ask if they are familiar with the Code

of Conduct and ask each to describe (in general terms) the areas

covered in the Code of Conduct. Confirm that each has a general

understanding of the principles and main provisions of the Code

of Conduct.

11. The hospital has a performance management

process and reward policies in which all

employees are formally evaluated at least semi-

annual, higher performers are recognized and

See Standard 11.2 above. Confirm that the 10 randomly sampled

files contain a performance evaluation conducted within the past

year (with the exception of new employees who are currently in

their probation period). Where relevant, confirm that there is a

documented action plan for any staff member with poor

rewarded, and action plans for improvement are

documented.

performance.

12. The hospital regularly conducts a staff job

satisfaction survey and exit interview to assess

staff opinions about their workplace.

View results of last staff survey.

View the documented exit interview report

Confirm that survey conducted within last 6 months.

View summary results with recommendations sent to hospital

Senior Management Team and Governing Board.

13. The hospital ensures employees wear ID badges

and appropriate uniforms at all times.

Observation. Confirm that each staff member interviewed or

observed in the course of the assessment is wearing an ID badge

and uniform

14. The hospital has occupational health and safety

policies and procedures to identify and address

health and safety risks to staff.

Obtain a copy of occupational health and safety policies and

procedures.

TOTAL _____ ______

CHAPTER 18. HEALTH FINANCING AND ASSET MANAGEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has established finance, procurement

and asset management structure, personnel per unit

cost and an operational plan , approved by the

Senior Management Team that details:

The process of submitting procurement

requests

The responsible body/person for approval

of procurement requests

The means of procuring

Responsible person(s) for procurement

activities

The hospital is a cost unit, staffed as the guideline described

Does the hospital has an operational plan

Check the activities planned are implemented based on the

schedule and monthly and quarterly report submitted for SMT

A five year plan for major capital

purchases

2. Bilingual service fee schedule posters are

displayed beside each departmental reception desk,

in all waiting areas and at all cash points. Each

poster shows the fees and advises patients to obtain

and keep receipts for all payments.

Visit different departments (OPD, ER, and inpatient wards and

cash collection points) and confirm that bilingual service fee

schedule posters are clearly displayed.

Confirm that the poster shows fees and

advises that patients should to keep receipts for all payments.

3. The hospital provides exempted services in

accordance with the relevant Federal/Regional

Legislation and displays a list of exempted services

at appropriate locations through the hospital for the

information of patients, staff and the public.

Obtain relevant Federal/Regional Health Care Finance Reform

Directive.

Obtain list of all exempted services that are provided by the

hospital.

Confirm that the list displayed at appropriate place in the hospital

and matches the list in the federal/Regional Directive.

4. The hospital provides all services indicated in

health insurance benefit package in accordance

with the agreement and should be displayed at

appropriate locations through the hospital for

information for the patients, staff and the public.

Get the contractual document

Take sample patient records and visit each department and

confirm whether the services indicated in the benefit package are

properly provided to beneficiaries.

Check proportion of services provided within the hospital or in

facilities with insourcing contracts

Check out of pocket payment s by beneficiaries and compare with

compliments.

5. The hospital submits timely payment

requests/claims /reimbursements for services to the

Health Insurance Agency and fee waiver

beneficiaries in accordance with established

standards and formats.

Ensure that claim request formats are appropriate and are

available both in hard and soft copy

Confirm that claim documents are properly prepared and timely

submitted to insurance schemes

Confirm that all visits by health insurance beneficiaries are

properly recorded and documented

6. The hospital keeps records of services provided to

Confirm that financial records of health insurance, fee waiver and

exempted service beneficiaries properly (separately) kept and

eligible health insurance, fee waiver and exempted

service beneficiaries and related financial

information as appropriate and, reported to the

relevant body

documented

View most recent two quarters reports submitted to concerned

bodies

Take list of samples beneficiaries and confirm that whether the

beneficiaries are included in the list of eligible health insurance,

fee waiver and exempted service beneficiaries

7. The hospital ensures a private wing service is

established in accordance with the required federal

/regional directives and approved by the Hospital

Governing Board.

Establishment of private wing services was approved by the

board

The private wing services fees are approved by the board

Staff performance at private wing is equivalent with the regular

hours

check for mechanisms of reimbursing supplies of the hospitals

that are utilized for private wing services

8. In a hospital where services are outsourced,

procedures are in place to monitor the contract and

services provided and contractual agreements

comply with relevant government directives.

Confirm that an assessment of the feasibility of outsourcing

services has been undertaken and project plan developed.

Confirm Contractual agreement procedures have been developed

that define the outsourcing process and what services are

outsourced

view the most recent performance reports of outsourced service

9. The hospital establishes multi-year budgeting and

expenditure which link to programs and priorities

of each department and fiscal information is

channeled through various medium of

communication.

Confirm that Existence of hospital strategies with multi-year

Costing of recurrent and capital expenditure.

Verify that there is a linkage between capital budgets and forward

expenditure estimate by reviewing multiyear budget Document.

Expenditures are linked to technical programs, MOH Priorities,

and expected results.

Capital budgets are consistently selected on the basis of relevant

hospital strategies and recurrent cost implications in accordance

with hospital budget allocations and included in forward budget

estimates for the hospital.

Obtain Annual budget documentation (a complete set of

documents can be obtained by the public through appropriate

means when it is approved by GB.

Confirm that In-year budget execution reports (the reports are

routinely made available to the public through appropriate

means within one month of their completion).

External audit reports (all reports on consolidated operations are

made available to the public through appropriate means within

six months of completed audit).

Contract awards (award of all contracts with value above approx.

ETB 100,000 equiv) are published at least quarterly through

appropriate means).

10. The hospital stock management ranging from

identifying the need for a property to materials and

supplies in order to receive, use and dispose

complies with the relevant guidelines and

disaggregated by each department.

View annual procurement plan that is approved by the hospital

leadership.

Use of competitive procurement methods(When contracts are

awarded by methods other than open competition, they are

justified in accordance with the legal requirements)

View reports and confirm assets are included in annual inventory

11. The hospital stock management ranging from

identifying the need for a property to materials and

supplies in order to receive, use and dispose

complies with the relevant guidelines and

disaggregated by each departments

There is effective internal controls comprise the comprehensive

set of rules and procedures that serve to reduce the risk of

mistakes and fraud and safeguard assets.

Verify Degree of compliance with rules for processing, recording,

use and disposal of stokes with relevant guidelines.

12. The Hospital accounting system should produce

and access periodic reports to the relevant bodies

at all levels.

View last 3 month financial report and confirm that each

provides details of credit granted, credit repaid and balance

outstanding

Routine data collection or accounting systems provide reliable

information on all types of resources received in cash and in-kind

by departments across the hospital. The information is

compiled into reports at least quarterly

Verify that regular, timely, and accurate information on actual

budget performance is produced at least quarterly and used for

decision by SMT and GB.

13. Internal audit on quarterly basis and external audit

at least once in a year conducted and reports are

reviewed by the senior management and

Governing Board.

Internal audit is operational for the hospital and generally meets

professional standards. It is focused on systemic issues.

Reports adhere to a fixed schedule and are distributed to the

SMT, GB, and relevant bodies.

Action by management on internal audit findings is prompt and

comprehensive.

TOTAL _____ ______

CHAPTER 19. CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT

# Standard Method of Evaluation Met Unmet

1. The hospital has a Clinical Governance and

Quality Improvement Unit that is led by an

assigned Senior Physician or General Practitioner.

Interview head of the CG&QI unit and check the organogram of

the Hospital

Ensure that the Head is a motivated senior Physician or a General

Practitioner

View TOR and list of members of Quality Committee.

Check the minutes of the Quality Committee to ensure whether

regular meetings are being conducted and the content of meetings

Receive a copy of the unit’s annual plan

2. The hospital should develop a clinical governance

and quality improvement strategy and an operation

plan that addresses the key components of quality.

View Clinical Governance and Quality Improvement strategy.

Ensure that the strategy includes:

o Safety and risk management

o Clinical effectiveness

o Professional competence

o Patient focused care

o Patient and public involvement

o Benchmarking

Confirm (by interview with Unit Head or documentary evidence)

that reports on implementation of CG&QI strategy are received

by Senior Management Team from the CG&QI unit.

3. Procedures are established to monitor clinical

practices and standards through services’ specific

process and outcome measures to enable the

hospital to address any problems identified.

Interview chair of CG&QI unit head and ask for list of clinical

outcome measures that are monitored regularly.

Ask CG&QI unit head to show the most recent results of at least 3

clinical outcome measures.

Determine (by interview with CG&QI unit head) that appropriate

action was taken in response to the outcome measures.

Check and confirm with selected staff from various service areas

whether they are aware of clinical outcome measures in their

respective service areas

Check that the hospital has a continuous quality improvement

systems that is used to provide safe and quality service

4. The hospital implements a regular clinical audit

program in each service area. Such program

encourages the participation of all clinical staff and

includes the implementation of a quality

improvement plan derived from audits.

Get documented reports of clinical audits.

Check and ensure that all relevant clinical service areas are

audited.

Check the composition audit team. The audit report should

demonstrate that all relevant service unit staff and service users

(when mandatory) are involved.

Check whether re-audits are conducted to close gaps identified

during previous audits. Determine if there is an improvement.

5. Procedures are established to assess and minimize

risk arising from the provision and delivery of

health care. A system is also in place for reporting

and analyzing incidents, errors and near misses

View risk assessments of inpatient, outpatient and ER case teams

and other departments.

Check date of risk assessment and confirm that it was conducted

within the previous 1 year.

Check to ensure that appropriate system for gathering, recording

and evaluating quality and safety of care is available

Confirm that the hospital has an Incident Officer who has a job

description that outlines his/her duties in relation to Incident

Investigation and management.

View two recent Incident Reports (if any) and confirm that the

reported incidents were investigated and any necessary follow up

action documented by the Incident Officer.

Confirm that the hospital has a system to identify, analyze and

monitor risks, adverse events, incidents, errors and near misses.

6. The hospital adopts a statement of patient rights

and responsibilities, which is posted in public

places in the hospital.

View statement of patient rights and responsibilities.

Visit patient service areas (as a minimum OPD, ER and inpatient

wards) and confirm that statement is clearly displayed.

7. The hospital continuously and systematically

reviews and improves all aspects of its activities

that directly affect patient safety and apply best

practice in assessing and managing risks to

patients, staff and others.

View patient Involvement strategy.

Confirm (by interview with CEO or Chair of QC) that at least two

of the following activities have been conducted within the past 6

months:

o Suggestion boxes in patient service areas

o Complaints procedures

o Public meetings

o Establishment of patient groups

o Activities to engage marginalized groups

8. The hospital monitors patients’ experiences with

care through patient and satisfaction surveys

conducted on a quarterly basis.

View results of last patient satisfaction survey.

Confirm that survey conducted within last 6 months.

Check and confirm that actions were taken as a results of patient

satisfaction survey

9. The hospital implements a strategy for the

involvement of patients and the public in service

design and delivery including procedures to be

followed when engaging with patients and the

public.

View minute document of the Hospital’s Public Forum

Confirm that public forums or town hall meetings are conducted

at least every quarter.

Check whether the hospital informs the public through

o Patient information leaflets

o Poster displays in hospital or community

o Publications in local press

o Presentations at public meetings

Check and confirm suggestion box is used in the hospital and that

suggestions are compiled, analyzed and acted up on.

Confirm Community representation on hospital Governing Board

10. The hospital develops and implements a strategy to

provide patient focused care which incorporates,

compassion, respect and dignity for patients,

effective communication, better hotel services and

involvement of patients in the care delivery.

View hospital Compassionate, Respectful and Caring Healthcare

Professional Strategy

View and confirm whether the strategy covers issues about

respect and dignity, effective communication, better hotel

services (housekeeping, nursing care, balanced diet (food)

services, laundry services)

Randomly ask and confirm patients and care givers in ward if

patients concerns are taken into account and they are involved in

the care delivery.

11. The hospital participates in benchmarking

activities to learn from and share good practice

with other hospitals.

Confirm (by interview with CEO or other documented evidence)

that hospital participates in benchmarking activities. For example

regular attendance at regional hospital/RHB meetings;

participation in hospital cluster activities etc.

Check and confirm that the hospital attends EHAQ Cluster

meetings

Check and confirm with selected hospital staff that they are aware of

EHAQ Change Package

TOTAL _____ ______

CHAPTER 20. MONITORING AND REPORTING

Std # Standard Method of Evaluation Met Unmet

1. The hospital has an HMIS Monitoring Team (or

equivalent) which collaborates with the CG&QIU

in reviewing the HMIS indicators and takes action

to address any areas of concern.

Interview CEO. Confirm that HMIS/KPI Performance Monitoring

Team (or equivalent) is in place.

View TOR of HMIS/KPI Monitoring Team to confirm that role

includes review of indicators.

View minutes of last 3 HMIS/KPI performance monitoring team

meetings to confirm that HMIS/KPI indicators are reviewed and

action taken as a result.

2. The hospital conducts a self-assessment of its own

performance at a minimum every quarter, using

HMIS indicators and any additional local

indicators determined by hospital management.

View copy of last 3 self-assessment meetings. Confirm that

frequency was monthly.

Check with relevant staff whether there is an action plan as a result

of the self-assessment.

Check whether there is an implementation plan in place to

implement those action plans

3. The hospital submits monthly, quarterly and

annual HMIS reports to the relevant higher office

within the agreed timelines.

View HMIS/KPI reports for last year. Confirm that monthly,

quarterly and annual reports were submitted as per schedule.

Check whether the report submitted is accurate and timely

4. The correspondence between data reported on

HMIS forms and data recorded in registers and

patient / client records, as measured by Data

Quality Assurance (DQA) and Lot Quality

Assurance Sample (LQAS) is ≥85%.

View LQAS result on last 3 HMIS/KPI reports.

Confirm LQAS is > 85%.

5. In collaboration with the Governing Board through

the CEO, the Clinical Governance and Quality

Improvement Unit have established performance

indicators for the hospital that are described in

hospital performance reports presented by the CEO

to the Governing Board as a minimum every

quarter.

View last 3HMIS and KPI reports submitted to Governing Board.

Confirm that frequency of HMIS and KPI reports to Governing

Board was quarterly as a minimum.

6. Indicators included in the hospital performance

monitoring system are a combination of

national/regional indicators and other local

indicators as determined by the Governing Board.

View list of KPI indicators and confirm that some are national

indicators (HMIS) while others are local indicators set by the RHB

7. Hospital staff receive orientation on all

performance indicators and case

teams/departments determine indicators and

monitor their own performance using the process

improvement model.

Check and verify with selected staff about their awareness of

KPI’s.

Check availability of data owners from each case team/service

area.

View reports/minutes of case team on performance data utilization.

TOTAL _____ ______

Summary Table

Chapter Number of Standards

Met

% of Standards

Unmet

Hospital Leadership, Management and Governance (8

standards)

Liaison, Referral and Social Services (8 standards)

Emergency Medical Services (8 standards)

Outpatient Services (7 standards)

Inpatient Services (9 standards)

Medical Records Management (8 standards)

Nursing and Midwifery Care Services (10standards)

Maternal, Neonatal and Child Health Services (12

standards)

Laboratory Services (14 standards)

Pharmacy Services (12 standards)

Radiological and Imaging Service Management (6

standards)

Rehabilitative and Palliative Care (5 standards)

Infection Prevention and Patient Safety (15 standards)

Federal and Teaching Hospitals Management (6

standards)

Medical Equipment Management (10 standards)

Facility Management (14 standards)

Human Resource Management (14 standards)

Health Financing and Asset Management (13 standards)

Clinical Governance and Quality Improvement (11

standards)

Monitoring and Reporting (7 standards)

Total (197 standards)

Name of Hospital: Region:

Date of assessment: Name of lead assessor:

Signature:

Contact telephone: Contact email: