Hospital Reform Implementation Guidelines - All

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH

NATIONAL HOSPITAL REFORM IMPLEMENTATION

GUIDELINES
Ethiopian Hospital Management Initiative

January 2010
NATIONAL HOSPITAL REFORM IMPLEMENTATION GUIDELINES
FMOH
Federal Democratic Republic of Ethiopia
Ministry of Health
National Hospital Reform Implementation

Guidelines
Ethiopian Hospital Management Initiative

January 2010
Version 1.0
i
Foreword
Ethiopias Federal Ministry of Health (FMOH) has been leading a sector-wide reform effort
aimed at significantly improving the quality and accessibility of services at all levels of the
countrys decentralized health system. As part of this reform, health facilities throughout the
country have been streamlining their operational processes and building their capacities with
a view to making their services more effective and efficient. Recognizing the importance of
strengthening management capabilities, the FMOH has given priority to building the
management capacities of hospitals, including through the pioneering Ethiopian Hospital
Management Initiative (EHMI). Launched in 2006 in collaboration with the Clinton
Foundation and Yale University (USA), EHMI has introduced a comprehensive blueprint of
standards for the optimal management of hospitals and made considerable progress in
establishing health management as a profession in Ethiopia. The training of hospital CEOs
through a new Hospital Administration Masters degree program started at Jimma University
will soon be expanded to the Addis Ababa University.
The ongoing hospital reform is reorganizing hospital services into emergency services and
non-emergency care delivery and further streamlining outpatient and inpatient services. Each
of these service categories are being staffed by case teams with a well-rounded skill-mix,
including medical doctors, nurses, pharmacy personnel, laboratory personnel, runners and
other support staff. The aim is to ensure that patients obtain the comprehensive quality health
services they require, in line with the principle of one-stop-shopping.
This handbook contains a common set of guidelines to help hospital managers and health
providers in steering the consistent implementation of these reformed processes in hospitals
throughout the country. These National Hospital Reform Implementation Guidelines focus
on selected management functions, including hospital governance, service quality, patient
flow, medical records, pharmacy and laboratory services, infection prevention, nursing care,
human resources, facility and equipment management, finance management, as well as
monitoring and reporting. The Guidelines also incorporate recent lessons from the
operationalization of the hospital management blueprint, as well as the core principles of the
system-wide business process re-engineering conducted as part of the health sector reform.
While primarily intended as a reference for hospital personnel, it is hoped that managers and
practitioners across all levels of the national health system will also find this handbook
useful. It is also expected that the guidelines will continuously evolve as new evidence
emerges regarding improved management practices and procedures better-tailored to the
particular needs and circumstances of different facilities.
I would like to take this opportunity to express our profound appreciation to all partners that
have participated in the production of this important handbook. Special thanks go to our
colleagues at the Clinton Foundation for their substantial contributions and support
throughout the development of these guidelines as well as their dedicated efforts in support of
our health reform efforts in so many other capacities.
Hon. Minister Tedros Adhanom Ghebreyesus (PhD)

Minister of Health, Federal Democratic Republic of Ethiopia
ii
Acknowledgements
The Federal Democratic Republic of Ethiopia Ministry of Health would like to acknowledge
the following individuals and their organizations for their participation in technical working
groups and for their contribution to the development of this document.
Hospital Leadership and Governance and Quality Management

Assefa Alem (Dr.) EngenderHealth
Bahredin Mohammed (Dr.) St. Peters Specialized Hospital
Abdu Nurhussien (Dr.) Jhpiego
Tenagne Setargie (Dr.) ALERT Hospital
Ato Solomon W/Amanuel Ethiopian Nurse Midwives Association
Lia Tadesse (Dr.) St. Paul Hospital
Nardos Fikru (Dr.) St. Peters Specialized Hospital
Sr. Meskerem Abebaw Amanuel Mental Health Hospital
Tenaye Demissie Amanuel Mental Health Hospital
Ato Alemu Hailemariam Addis Ababa Regional Health Bureau
Tsehaysina G/eyesus (Dr.) Amanuel Mental Health Hospital
Patient Flow
Abebaw Derso (Chair) Yekatit 12 Hospital
Berhanu Tekle (Dr.) Johns Hopkins University- TSEHAI
Mohammed Haji Hyder (Dr.) Amanuel Mental Health Hospital
Mezemir Ketema ALERT Hospital
Ismael Hassen (Dr.) Tigray Regional Health Bureau
Workineh Getahun Management Sciences for Health/SPS
Melaku Samuel (Dr.) Ethiopian Public Health Association
Gezashign Denekew Yekatit 12 Hospital
Gebremedhin Gebreegiziabher Abi Adi Hospital
Halima Mohamed Tikur Anbessa Specialized Hospital
Samuel Tefera Tikur Anbessa Specialized Hospital
Birkti Birhane Zewditu Hospital
Addis Alemu (Dr.) ICAP
Edmealem Ejigu Management Sciences for Health/SPS
Ashagre Tilahun Ethiopian Nurses Association
Girma Desta (Dr.) Federal Ministry of Health
Abraham Asnake (Dr.) Ras Desta Damtew Memorial Hospital
Mersha Mengesha Ras Desta Damtew Memorial Hospital
Alem Agedew Hayat Hospital
Medical Record Management

Asrade Abate (Chair) Tulane University/ Federal Ministry of Health - Plan
and Programming Department
Kedir Yimer (Dr.) Johns Hopkins University- TSEHAI
Paulos Nigussie Ethiopian Medical Laboratory Association
iii
Kinfe Haile Amanuel Mental Health Hospital
Mulugeta Tamene Debre Markos Hospital
Tsedale Tilahun Zewditu Hospital
Birhanu Alemayehu Dilla Hospital
Shigute Wolde Menelik II Hospital
Mohamed Dilbi Federal Ministry of Health
Ayele Zewdu Dil Chora Hospital
Yared Kifle EngenderHealth
Pharmacy Services
Hailu Tadeg Management Sciences for Health/SPS
Edmealem Ejigu Management Sciences for Health/SPS
Elias Geremew Management Sciences for Health/SPS
Ayalew Adinew Management Sciences for Health/SPS
Negussu Mekonnen (Dr.) Management Sciences for Health/SPS
Laike T/Medhin Management Sciences for Health/SPS
Yosef Wakwoya Management Sciences for Health/SPS
Yedilken Kebede Management Sciences for Health/SPS
Elizabeth W/Mariam Management Sciences for Health/SPS
Workineh Getahun Management Sciences for Health/SPS
Zenash Tessema Management Sciences for Health/SPS
Tenaw Andualem Management Sciences for Health/SPS
Edgegayehu Hailu Management Sciences for Health/SPS
Getachew Ayalew Management Sciences for Health/SPS
Tesfaye Seifu Ethiopian Pharmaceutical Association
Raey Yohannes DACA
Mesfin Goji Jhpiego
Shimelis Endailalu SCMS
Gashaw Shiferaw SCMS
Meseret Zerihun USAID/DELIVER
Jeff Sanderson USAID/DELIVER
Sami Tewfik USAID/DELIVER
Atkure Defar ALERT Hospital
Tewodros Lemessa Ras Desta Damtew Memorial Hospital
Nathan Assefa Kenema Pharmacies Enterprise
Laboratory Services
Samuel Kinde AAU School of Medical Laboratory Science
Bihil Sharezedin Johns Hopkins University- TSEHAI
Dereje Abate St. Peters Specialized Hospital/Ethiopian Medical
Laboratory Association
Jin Bae Clinton Foundation
Tina Falle Clinton Foundation
iv
Nursing Care Standards
Berhane Gebrekidan (Chair) Ethiopian Nurses Association
Feleke Mulatu Ethiopian Nurse Midwives Association
Senait Bitew/Abebe Shume Jhpiego
Meseret G/Tsadik Amanuel Mental Health Hospital
Tadelech Fantu Black Lion Hospital
Teferi Fenta St. Paul Hospital
Zeleke W/Giorgies Menelik II Hospital
Gezashign Denekew Yekatit 12 Hospital
Mehretie Jemberie Zewditu Hospital
Kassahun Chekole Debre Markos Hospital
Imana Teferra Ambo Hospital
Mengesha Chanyalew Debre Birhan Hospital
Almaz Siraj Federal Ministry of Health
Meskerem Asnake Bishoftu Hospital
Abu Tesfaye Shashemene Hospital
Lisanework Girma ALERT Hospital
Infection Prevention and Control

Haregewoin Kiflom Tigray Regional Health Bureau
Yayeneabeba Tadesse Ethiopian Nurses Association
Muhidin Abdo (Dr.) EngenderHealth
Hailu Yeneneh (Dr.) The Carter Center/EPHTI
Solomon Tassew JSI/MMIS
Negash Seyoum (Dr.) Jhpiego
Yodit Kidanemariam Jhpiego
Abebe Shume Jhpiego
Asefaw Abera St. Paul Hospital
Tesfaye Deressa Menelik II Hospital
Zeleke Yimechew Debre Markos Hospital
Fitsum Desalegn Debre Birhan Hospital
Tesfaye Alemu Nekemte Hospital
Ali Mohammed Shashemene Hospital
Leuleseged Yohannes (Dr.) Federal Ministry of Health,
Medical Services Directorate
Shewaminale Yohannes Federal Ministry of Health,
Fahmi Mohammed (Dr.) World Health Organization, Africa Regional Office
Daniel Atnafu (Dr.) Johns Hopkins University- TSEHAI
Sr. Ejigayehu Sahle St. Paul Hospital
Zemichael Mekonen ALERT Hospital
Assefa Bulcha The Carter Center
v
Facilities Management
Tania OConnor Johns Hopkins University/Black Lion Hospital
Saran Ellis Jhpiego
Abdurahman Ali Ethiopian Nurses Association
Berhanu G/Michael (Dr.) ALERT/People to People
Bethel Girma (Dr.) Federal Ministry of Health / People to People
Medical Equipment
Tania OConnor (Chair) Johns Hopkins University/
Black Lion Hospital
Gizachew Anteneh Ethiopian Health and Nutrition Research Institute
Zelalem Eshetu (Dr.) ORBIS International
Yohannes Jorge (Dr.) Black Lion Hospital/ People to People
Jennifer Barragan Clinton Foundation
Paulos Nigussie Ethiopian Medical Laboratory Association
Berhanu Gizaw (Dr.) Addis Abeba University
Negash Seyoum (Dr.) Jhpiego
Gizachew Abdeta (Dr.) Federal Ministry of Health
Tiemtu G/Selassie Abi Adi Hospital
Gebreegziabher Getahun Dil Chora Hospital
Hailu Bekele National Scientific Equipment Center (NSEC)
Demeru Yeshitla Ethiopian Biomedical and Laboratory Equipment
Engineers Association /NSEC
Tadele Gebre Federal Ministry of Health, Public Health
Infrastructure Directorate
Financial and Asset Management

Alemtsehai G/medhin Tikur Anbessa Specialized Hospital
Alemtsehay Worku St. Paul Hospital
Tekola Mekonnen MCM Hospital
Kim Byung Soo MCM Hospital
Tsige Tadesse Ministry of Finance and Economic Development
Esubelew Demissie Health Sector Finance Reform/Abt Associates
Human Resource Management

Bineyam Taye Addis Ababa University
Girma Azene (Dr.) Tulane University
Tesfaye Mamo Tikur Anbessa Specialized Hospital
Assefa Alem (Dr.) EngenderHealth
Abraham Zeleke Amanuel Mental Health Hospital
Fekadeselassie Wami Federal Civil Service Agency
Berihun Yehdego Federal Civil Service Agency
vi
Additional contributors:
Federal Democratic Republic of Ethiopia Ministry of Health,

Dr. Yibeltal Assefa, Dr. Abraham Endeshaw, Mahlet Asayehegne, Abebaw Derso, Dr.
Abiyou Kifle, Megerssa Negassa, Sophie Boreshe, Shewaminale Yohannes, and Dr.
Mulugeta Workalemahu.
Clinton Health Access Initiative

Dr. Yigeremu Abebe, Michael Van der Ven, Dr. Ruth Lawson, Salem Fisseha, Rebecca
Zewdie, David Conteh, Stephen Batts, Habtamu Tezera, Haile Ayana, Lillian Kidane,
Charles Ivy, Zelalem Haile, Mengesha Kassew, Solomon Gebreyesus, Kassaye Tekie and
Ismael Ali.
Yale University
Prof. Elizabeth Bradley, Jeannie Mantopoulos, Denise Walsh, Rachelle Alpern, Tashonna
Webster, Khadija Gurnah, Emily Cherlin, Cindy Czaplinksi, Martha Dale, Louise-Marie
Dembry, Sosena Kebede, Erika Linnander, Laura Rowe, Rex Wong and Josh Pashman.
The printing of this document was made possible by the financial contribution of the World
Health Organization, Africa Regional Office. We thank them for their generous support.
vii
Contents
Chapter 1. Hospital Leadership and Governance
Chapter 2. Patient Flow
Chapter 3. Medical Record Management
Chapter 4. Pharmacy Services
Chapter 5. Laboratory Services
Chapter 6. Nursing Care Standards
Chapter 7. Infection Prevention and Control
Chapter 8. Facilities Management
Chapter 9. Medical Equipment Management
Chapter 10. Financial and Asset Management
Chapter 11. Human Resource Management
Chapter 12. Quality Management
Chapter 13. Monitoring and Reporting
viii
Hospital Leadership and Governance
Page 1 of 36
Table of Contents Page
Section 1 Introduction 4
Section 2 Operational Standards for Hospital Leadership and Governance 4
Section 3 Implementation Guidance 5
3.1 Practical tools of leadership and management 5
3.2 Governing Board 14

3.2.1 Responsibilities of Governing Board
3.2.2 Membership of Governing Board
3.2.3 Officers of the Governing Board
3.2.4 Procedures of Board meetings
3.2.5 Governing Board standing committees
3.3 Chief Executive Officer 24

3.3.1 Selection and appointment of the CEO
3.3.2 Roles and responsibilities of the CEO
3.3.3 Accountability and evaluation of the CEO
3.3.4 Relationship between CEO and Governing Board Chairperson
3.4 Hospital Senior Management Team 27

3.4.1 Responsibilities of the Senior Management Team
3.4.2 Membership of the Senior Management Team
3.4.3 Appointment of Senior Management Team Members
3.4.4 Duties and responsibilities of Management Committee Members
3.4.5 Procedures of Management Committee Meetings
3.4.6 Subcommittees of the Senior Management Team
3.5 Strategic and annual planning 31
3.6 Essential service package 33
Section 4 Implementation Checklist and Indicators 33
4.1 Assessment tool for Operational Standards 33

4.2 Implementation Checklist 34
4.3 Indicators 34
Source Documents 35
Appendices
Appendix A Sample Hospital Mission, Vision and Values Statements
Chapter 1 Hospital Leadership and Governance Page 2 of 36

Appendix B Sample content of Governing Board training programme
Appendix C Sample Self assessment checklist for Governing Board
Appendix D Guidelines/etiquette for effective committees and meetings
Appendix E FMOH, Hospital Annual Plan for EFY 2002 (Planning Template)
Tables
Table 1 Hospital Leadership and Governance Checklist
Table 2 Hospital Leadership and Governance Indicators
Figures
Figure 1 Common mistakes and suggestions for problem statements
Figure 2 Relating the problem statement, objective and target
Figure 3 Sample fishbone diagram
Figure 4 Problem ranking matrix
Figure 5 Sample flow chart
Figure 6 Sample histogram
Figure 7 Sample options appraisal
Figure 8 Sample GANTT chart
Figure 9 Strategic and annual planning at all levels
Box A Monitoring and Evaluation

Box B The Seven Deadly Sins of Poor Hospital Governance
Abbreviations
BOFED Bureau of Finance and Economic Development
CEO Chief Executive Officer
FMOH Federal Ministry of Health
HSDP Health Sector Development Programme
MOFED Ministry of Finance and Economic Development
RHB Regional Health Bureau
SMT Senior Management Team

Section 1 Introduction
Hospital leadership and governance arrangements are essential to ensure effective and
efficient hospital services that contribute to the health and wellbeing of the population served.
Hospital leaders require a unique set of skills to both manage their organization and to liaise
with external agencies and the local community. Hospital leaders must be able to lead their
organizations through change, identifying and solving any challenges that arise.
The Federal Government of Ethiopia through the Health Care and Financing Strategy has
established the legislative framework for enhanced hospital autonomy with authority
decentralized to hospitals in areas such as strategy, planning and budget development. To
achieve this, hospitals should be governed by a Governing Board that is responsible to
appoint the CEO who in turn leads on all hospital operations and functions.
Governance can be defined as the system by which an organization directs, controls and
monitors its functions and its interactions with stakeholders1.
Effective hospital governance requires:

Clear national standards for services and treatments
Clear objectives for hospital services, articulated through strategic and annual plans
Local delivery of high quality healthcare, and
Effective monitoring of progress.
This chapter describes structures and mechanisms through which the above functions can be
achieved.
Section 2 Operational Standards for Hospital Leadership and

Governance
1. The Hospital Governing Board is developed using clear and transparent systems and
processes and includes a representative sample of community members.
2. An assigned Board Chairperson leads and manages Board activities.
3. The Board selects the Chief Executive Officer (CEO), who leads on all Hospital
operations and functions.
4. The Board approves an annual strategic plan for the Hospital to achieve its goal of
improving its communitys health and welfare.
5. The Board has open communication via effective and regular meetings and written
minutes of meetings, which are reviewed and approved by vote of the Board members.
1
Clinical Governance and Risk Management: Achieving safe, effective, patient-focused care and services. NHS
Quality Improvement Scotland, October 2005.

6. The CEO is evaluated annually, 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.
Section 3 Implementation Guidance

3.1 Practical tools of leadership and management
Common tools in effective management include problem solving and change management.
Although there are many approaches to both problem solving and change management, some
common elements are apparent. These can be summarized in the 8 steps of Scientific
Method of Problem Solving which is described below.
Step 1 Define the problem,

Step 2 Set the overall objective,
Step 3 Conduct a root cause analysis,
Step 4 Generate alternative interventions,
Step 5 Perform comparative analyses of alternatives,
Step 6 Select the best intervention and address its limitations,
Step 7 Develop an implementation plan and implement, and
Step 8 Develop an evaluation plan and evaluate.
To successfully move from one step to the next, leaders can rely on a number of useful
management tools including:
Root cause analysis, including fishbone diagramming, flow charting, and histograms,
Options appraisal using evaluative criteria, and
GANTT chart.
Each step, together with the associated management tools, is described in detail below.
Step 1: Define the problem

As leaders we are often very familiar with the challenges and problems that face our
organizations. The first step to solving a problem is to define the problem (the problem
statement) in a way that allows us to find solutions. Defining the problem requires
substantial analysis of the current situation and how it differs from the desired situation. The
defined problem reflects the priority of the organization in a particular area and sets the path
for management interventions to address the selected problem. Therefore, the problem
statement should be defined after careful consideration.
To devise a good problem statement the following should be considered:

1. Focus on a single problem: The challenges that many leaders face are complex, but it is
important to identify one single problem to work on, rather than getting lost in a tangle of
multiple problems.
2. Address problems that are feasibly solved: Selecting a problem that is impossible to
solve will result in frustration and no clear progress.
3. Keep it short: Simply state, The problem is Long, complex problem statements can
be confusing and may result in a lack of a shared understanding of the problem.
4. Find statements that are shared widely by key constituents: In order to gain support for
your solutions, key players must all believe that this problem exists and is important.
5. Do NOT include solutions themselves: This first step simply states the problem.
Subsequent steps focus on identifying solutions. Good leaders often may have a solution
in mind, but a clear strategy starts with the problem, and next focuses on generating
multiple solutions.
Figure 1 below shows some common mistakes in defining the problem and gives suggestions
for improvement.
Figure 1 Common Mistakes and Suggestions for Problem Statements
Weak Problem Statement Suggestions for Improvement Strong Problem Statement

We need more regular Focus on a problem, rather than the Stock-outs of essential drugs are
delivery of supplies. solution. In this case, why is a more common in our pharmacy.
regular delivery important?
Due to understaffing, Focus on the problem, rather than the Nurses feel overworked.
nurses are overworked. causes of the problem when defining
the problem statement.
Our budgets are too small Focus on a single problem. There is not sufficient revenue to
and we run out of cover costs.
pharmaceuticals in the
middle of the year and no
one pays their bills, and
our medical director is
leaving soon, along with 4
doctors.
Step 2: Set the overall objective

The overall objective should be phrased to address or solve the problem. The objective
identifies where the organization wants to be regarding the specific problem. In this sense, the
defining of the problem (i.e., reflecting the current state) and the setting of the objective (i.e.,
the desired state) is a central part of strategic management. The objective is the goal that your
team will focus all of its efforts toward achieving, so it is important that it is clearly defined.
Good overall objectives address the problem you have defined in the problem statement and
have measurable targets.

Figure 2 Relating the Problem Statement, Objective and Target
Relating the problem statement, objective and target

Problem Statement Stock-outs are common
Overall Objective Reduce the frequency of stock-outs by 50%
in the next quarter
Measurable Target Number of stock-outs per quarter
Step 3: Conduct a Root Cause Analysis

Your overall objective has been defined, but how can you best reach your goal? A root cause
analysis will help identify the factors that cause the problem. Like peeling away the layers of
an onion, finding the root cause requires careful analysis of multiple layers. Several
management tools can help leaders find the root causes of the problem, including:
1) Fishbone diagram,
2) Flow charting, and
3) Histograms.
Fishbone Diagram
A fishbone diagram helps leaders identify multiple causes of a single problem. The diagram
takes its name from its shape, which resembles the skeleton of a fish as shown in Figure 3.
Figure 3 Sample Fishbone Diagram
As shown in the diagram, the problem statement is placed at the head of the fish. Causes of
this problem are grouped into 4 categories:

1) People: Are staff behaviours or characteristics contributing to the problem?
2) Process/policy: What procedures or policies contribute to the problem?
3) Equipment: Is there any equipment, including supplies, that contribute to the problem?
4) Environment: Does the immediate environment (i.e., the building or compound), or the
broader environment (i.e., the community, town, or nation) contribute to the problem?
As you identify factors that contribute to the problem, place them on the appropriate
fishbone. For each factor that you identify, ask, What leads to that factor? For example,
in the diagram above, the laundry machines were identified as an important factor in the lack
of sanitation. This is an equipment issue, and Laundry Machines Broken was placed on the
equipment fishbone. The laundry machines were broken because of 2 factors: lack of parts
and a budget shortfall. Both of these were added to the diagram.
Fishbone diagramming is useful for a number of reasons:
1) Allows for open session: Involves everyone in an open session. Using a chalkboard or
other display to brainstorm allows everyone to contribute their ideas, no matter how big
or small.
2) Ideas are generated quickly: Generates an abundance of diverse ideas quickly. Because
there are many bones, there is room for many ideas.
3) Group understanding develops: Helps group members understand and appreciate others
perspectives. Some participants will be more focused on the environmental factors while
others will focus on factors related to people. The diagram makes room for all of these
perspectives.
4) Alternative approaches emerge: Helps generate alternative approaches. Identifying
multiple factors will lead to multiple possible solutions.
One drawback to the fishbone diagram is that this tool cannot display the importance or
commonality of a particular issue. To address this weakness, managers may wish to use a
problem ranking matrix.
Ranking Matrix of Root Causes

A Ranking Matrix helps determine which causes are the most important to address given
limited resources. A sample Problem Ranking Matrix is presented in Figure 4.

Figure 4 Problem Ranking Matrix
In this figure, there are 2 sets of rankings used to determine the importance of a factor: risk
and cost-benefit.
Risk: Risk (indicated by the blue text) is a measure of how much the factor affects the
problem. Risk is a function of frequency (on the x-axis) and severity (on the y-axis).
Consider the example of the broken laundry machines. A breakdown occurs only
occasionally (frequency), but has a critical impact on the sanitation of the hospital (severity),
resulting in a score of 4.
Cost-benefit: Cost-Benefit (indicated by black text) is a measure of how difficult or costly it

is to fix the problem (on the y-axis), as compared to the level of benefit or improvement that
is expected (on the x-axis). Repairing the broken washing machines is relatively easy to do
(cost) and will result in great benefit, resulting in a score of 4.
Therefore the total score for repairing broken laundry machines is 8 (4 + 4).
Flow Charting
Sometimes managers find it necessary to identify problems within larger processes or
systems. The flow chart is a diagram that puts the process into pictures so that problems can
be seen.
Flow charts are useful because they:

1) Describe complex processes in manageable steps that can be improved,
2) Illustrate breakdowns in the process, including parallel processes, extra steps, or
incomplete feedback loops (an incomplete feedback loop is when the communication
loop is not closed, i.e., the conversation ends without a clear assignment of action steps
for specific people to accomplish in a specific time period),
Page 9 of 36
3) Show how ones own actions influence downstream events,
4) Foster a team that owns the whole process, not simply individuals focused only on
fragments, and
5) Help generate alternative approaches.
While a flow chart is useful for identifying breakdowns in the process, this tool does not tell
how often breakdowns occur.
Figure 5 indicates a sample flow chart for medication ordering. Notice that the start and end
points are indicated by circles, and each step in the process is shown in a rectangle. If there is
a decision point, or question, that must be asked along the way, this is indicated by a diamond
shape.
Figure 5 Sample flow chart

Histogram
A histogram is a useful tool for quantifying the frequency of common causes of the problem.
By quantifying the frequency, managers can focus on the biggest issues first. The histogram
below shows reasons that in-patients do not receive required drugs:
Figure 6 Sample Histogram
70
% of problems
60
50
40
30
20
10
0
Pharm is out Order not MD order not MD order Pharm lost
of drug brought to transcribed missing order
pharm
Histogram analysis provides a useful representation of data that allows managers to prioritize.
This analysis also helps generate alternative approaches and provides a tool for showing
progress. One drawback is that this analysis shows the frequency of the problem without
indicating possible solutions.
Step 4: Generate alternative interventions

To the point above, the problem solving process has focused on identifying all of the factors
that contribute to a problem, including the root causes, or underlying factors. After
identification of the problems cause(s), the next step is to start generating solutions. By
generating multiple alternatives for solving the problem, the chances of reaching a solution
are increased. Effective leaders are creative in developing these alternatives.
Good alternatives are:

Clearly described,
Comprehensive, but not too many (try to identify 2 to 4 solutions),
Feasible to implement, and
Mutually exclusive, so you can compare and choose one of the options:
o Do A and do not do B,
o Do B and do not do A, or
o Do both A and B
Step 5: Perform comparative analysis of alternatives

When a few alternative interventions have been generated, the most promising intervention
must be identified. Comparing these alternatives can be challenging, as some members of the
group may prefer one alternative, while other members may champion a different alternative.
An Options Appraisal allows for a side-by-side comparison of the strategic alternatives using
evaluative criteria to select the best option. Consider the following options for addressing
low productivity:
Page 11 of 36
Problem Productivity is inadequate
Option 1 Increase staffing
Option 2 Increase pay among existing staff
Option 3 Increase supervision of existing staff
In order to compare these 3 options, the group must agree on a set of evaluative criteria.
Evaluative criteria are factors that are important to the group and the organization. For
example, they may include effect of the problem, expense, political feasibility, or time to
implement. The Options Appraisal can be qualitative or quantitative as shown in Figure 7.
Figure 7 Sample Options Appraisals
Qualitative Options Appraisal

Impact on Annual Political Time
Productivity Expense Feasibility Required
1: Increase Staff Good High Low 3 Months
2: Increase Pay Unclear High Very Low 1 Year
3: Improve Supervision Good Low High 1 Month
Quantitative Options Appraisal

Impact on Annual Political Time Total
Productivity Expense Feasibility Required Score
1: Increase Staff 5 1 2 4 12
2: Increase Pay 3 1 1 1 6
3: Improve Supervision 4 4 4 4 16
Note: Each option ranked on a score of 1-5 with 5 being the best, or strongest, option. In this case, if
each evaluative criteria is weighted equally, improve supervision is the best option with a total score
of 16.
Estimating the values within the matrix is not a perfect science. A sensitivity analysis allows
managers to determine whether the final decision, or best option, would change if some of the
estimates inside the matrix were changed, or if the estimates were slightly wrong. In other
words, how much can each estimate change without changing the selection of the best
strategy?
Often, managers only estimate the impact of interventions and not the other factors. An
options appraisal and the sensitivity analysis allows managers to think through whether being
slightly wrong would change the choice of the best option.
Step 6: Select the best intervention

Based on the results of the competitive analysis, select the best intervention.
Step 7: Develop implementation plan and implement

Once you have selected the best intervention, the Implementation Plan is the strategy that you
will use to turn your ideas into reality.

1) Identify specific tasks: Identify tasks to be completed to meet specific objectives,
including who is responsible for each step, what resources are needed, and conditions
necessary for success.
2) Develop timeline using a GANTT chart: The GANTT Chart is a tool for defining the
tasks, timeline and persons responsible for accomplishing the project objectives. When
developing the GANTT chart, key persons responsible should be involved in the process
of defining the target dates and their role(s) for each task. This step will ensure their
support and commitment. The GANTT chart should be reviewed on a regular basis (e.g.,
weekly, monthly, quarterly) and adjusted and revised to reflect changes in the
environment to ensure progress towards objectives (see Figure 8).
Figure 8 Sample GANTT Chart

Person
Task Description Responsible 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1 Development of Methodology
1.1 Workshop on user needs
1.2 Draft of methodology
1.3 Evaluation of methodology
2 Specifications of Integrated System

2.1 Inventory of resources in selected regions
2.2 Review of existing facilities
2.3 Specify technical developments
2.4 Impact analysis of different scenarios
2.5 Prepare detailed business plans
3 Feasibility studies for each region

3.1 Review existing practices
3.2 Review technologies
3.3 Sensitivity analysis of scenarios
3.4 Report on most suitable options
4 Project Management and Coordination

4.1 Dissemination of information: Workshops
Step 8: Monitor process and outcomes

Part of problem solving is monitoring your impact or success.
Box A Monitoring and Evaluation
Monitoring is the systematic and continuous collection of information over time to measure
progress or change of an activity or objective, using pre-defined indicators of progress
and/or impact of an intervention.
Evaluation is the process by which one determines if the program achieved its overall and
specific objectives; it usually is an assessment at one point in time to determine the impact
of the project.

A monitoring plan provides a set of indicators that will be monitored regularly to show the
impact of the management interventions. Indicators should be selected that reflect both
processes and outcomes. Process indicators measure interim impacts, such as the number of
staff trained or the percent of drugs properly unpacked and put away properly. Outcome
indicators measure the ultimate objectives such as patient waiting time or stock outs or
patient satisfaction. A good evaluation system has both types of indicators. In addition, the
system should identify how each indicator will be measured, and ideally, what the target is
for performance (i.e., waiting time will be less than one hour for 90 percent of patients;
satisfaction scores will increase by 25%, etc.).
The management team can use information generated from monitoring and evaluation to
assess if interventions are working as expected and identify where further work is needed to
improve performance in desired areas.
3.2 Governing Board
A well functioning Governing Board, that includes representatives from the hospitals
community, can have a significant impact on the quality and efficiency of the hospital and its
daily performance.
The establishment of a Governing Board builds in two essential characteristics of good

hospitals:
Autonomy to do what is necessary to provide good care and
Accountability to those served for the results of that care.
Governing Boards must be committed to creating and maintaining a strong bond between the
hospital and the community it serves and to maintaining a good working relationship with
higher authorities such as Woreda, Zonal, Regional and Federal Health Finance and other
relevant Government Offices.
The following sections set out the basic principles related to the establishment,
responsibilities and operating mechanisms of Governing Boards. More detailed information
on the specific powers and duties of Governing Boards within each region are described in
the Health Service Delivery and Administration Proclamations, Regulations and Directives of
each Region.
3.2.1 Responsibilities of Governing Board
Specific responsibilities of the Governing Board include:
A) Determine the organization's mission, vision and values

It is the Governing Board's responsibility to create and regularly review a statement of
mission and vision that articulates the organization's goals and values.

A Mission statement can be defined as purpose, reason for being or simply who we are and
what we do.
A Vision statement can be defined as an image of the future we seek to create.
Sample Hospital Vision and Mission and Value Statements are given in Appendix A.
All strategies, plans and policies of the Hospital should be in accordance with the mission,
vision and values set by the Governing Board.
B) Establish corporate policies

The Governing Board should ensure that corporate policies (such as policies for staff
recruitment and retention, for income generation and expenditure, for quality assurance etc)
are available to govern the operations of the facility.
C) Ensure effective organizational planning

Governing Boards must actively participate in an overall organizational planning process.
This includes examining and approving the strategic and annual plans of the hospital, and
ensuring that such plans are in accordance with the mission, vision and values of the hospital
and are aligned with local, regional and national health sector priorities and targets.
D) Direct and supervise the overall activities of the hospital

Governing Boards must monitor progress towards the goals and targets of the strategic and
annual plans. If the hospital is not on track to meet its stated plans the Governing Board must
identify the reasons why and should assist the CEO and hospital management team to identify
and implement solutions.
Further guidance on the role of the Governing Board to monitor hospital performance,
including a sample monitoring tool and indicators (the Balanced Scorecard) is presented in
Chapter 13 Monitoring and Reporting.
E) Provide proper financial oversight

The Governing Board must review and approve the hospitals annual budget, and implement
proper financial controls to follow up on its utilization and ensure that the hospital operates
within its budget. This includes implementation of revenue retention and utilization as per the
Federal or Regional financial rules and regulations. Additional responsibilities include
ensuring that internal and external financial audits are carried out as required by legislation.
The Governing Board should regularly review audit reports and ensure that action is taken on
any recommendations made.
F) Ensure adequate resources

The Governing Board must identify what constitutes adequate resources for the organization
and ensure the effective means to access these resources. Where necessary, the Board and
staff must devise strategies and the means to improve revenues. Such mechanisms could

include fee revision, outsourcing of activities or the establishment of private wings in
accordance with the Regional financial rules and regulations.
G) Oversee fee waiver and exemption systems

Governing Boards must ensure the provision of health services to fee waived patients without
discrimination, and must ensure the provision of exempted services as described in the
Regional financial rules and regulations. Boards must ensure the reimbursement of fee waiver
expenses from the appropriate Fee Waiver Certificate issuing authorities.
H) Oversee quality management activities

The Governing Board must ensure that hospital services are provided to the highest possible
standard. The Board should ensure that systems are in place for monitoring and evaluating
the quality and outcome of patient care, customer services and use of resources. The Board
should ensure there are appropriate mechanisms and activities to minimize risk, to identify
and correct problems, and to identify opportunities to improve patient care and services.
I) Select the Chief Executive Officer (General Manager)

Governing Boards must ensure that the most qualified individual is appointed to the position
of Chief Executive Officer (CEO), following the processes set out in Federal or Regional
Directives. The CEO should be qualified by education and experience appropriate to the
position. The authority and duties of the CEO must be defined and documented by the
Governing Board or appointing authority.
J) Support, monitor, and assess the performance of the CEO

The Governing Board should ensure that the performance of the CEO is assessed at least
annually by the Board or appointing authority. Should the CEO fail to meet the expectations
of the Governing Board, his/her employment should be terminated, following the processes
described by Federal or Regional Directives.
K) Provide orientation for new Board members and ensure ongoing education for
existing members
All Governing Boards should participate in ongoing education to assist members to carry out
their role in the hospital. For newly appointed board members, there should be a planned
orientation program that ensures members understand their responsibilities. Appendix B
presents areas that should be included in a training/orientation programme for Governing
Board members.
L) Review effectiveness of its own performance

The Governing Board should periodically and comprehensively evaluate its own
performance, taking into consideration areas such as:
Regularity of and attendance at Board meetings
Board vacancy rate (% of Board positions that have been filled)
Knowledge, skills and awareness of Board members on hospital operations, finance,
on key issues affecting the hospital and any national, regional and local health
priorities

Approval of the strategic and annual plans by set deadline
The relationship between the governing board, CEO and hospital Senior Management
Team
The relationship between the hospital and communities served by the hospital
Engagement with the wider health economy such as woreda, zonal and regional health
departments and any local health partnerships
A self assessment checklist for a Governing Board is presented in Appendix C.
M) Ensure legal and ethical integrity and maintain accountability

The Governing Board is responsible for ensuring adherence to legal standards and ethical
norms. It ensures that activities of the hospital are carried out with transparency and
accountability and that all required reports are submitted to higher authorities (e.g. RHB,
BOFED, FMOH, MOFED) in accordance with government requirements.
N) Ensure community involvement in hospital service planning and delivery

The Governing Board should ensure that mechanisms are established to enhance the
involvement of patients and the public in the planning and delivery of hospital services and to
maintain close consultation with community leadership.
O) Enhance the organization's public standing

The Governing Board should clearly articulate the hospital's mission, vision, values
accomplishments and goals to the public and garner support from the community.
3.2.2 Membership of Governing Board
A strong governing board is comprised of members who:

act on behalf of the community as a whole;
are interested and committed to serve as a board member;
have a variety of expertise as a collective whole, including finance, administration,
public health, government bureaucracy, legal and marketing;
maintain high ethical principles, integrity and competence;
deliver results while using resources wisely;
give management the full authority to run the hospital and do not micro-manage the
hospital leaders;
commit the time required for meetings, dialogue, etc;
subscribe to the principles of accountability for themselves and others;
prioritize the benefits of the hospital rather than personal benefits;
are participatory in planning, decision-making, and activities; and
declare any conflicts of interest and excuse themselves from any decisions that have
immediate benefit for themselves, their families or their business interests.

A) Appointment of Board Members
Rules and procedures for the appointment of Governing Board members are described within
Federal and Regional Proclamations, Regulations and Directives. In general, Specialized,
General and District Hospital Board members are nominated by Zonal or Urban
Administrations and appointed by the respective RHB, or by the FMOH for Federal hospitals.
Boards are comprised of between 5 to 7 members, or as specified in Federal and Regional
Directives.
Governing Board members should be residents of the area where the hospital is established.
Additional factors to be taken into consideration when appointing board members include:
Due consideration to gender and professional mix;
Community representation;
Professional efficiency, time and experience that will enable the Board member to
contribute to the improvement of the health sector
B) Tenure of Board membership

The tenure of service of Board members should be between 3-5 years, and Board members
may serve a maximum of two terms, as determined by Federal and Regional Directives.
C) Revocation of Board membership

The membership of any Board member should be revoked when:
a) The Board member has no interest to continue membership. In such circumstances the
Board member should give one to two months advance notice (as determined by Federal
and Regional Directives) in writing to the Board Chairperson and RHB Head or Minister
of Health;
b) The Board member changes residence address or leaves the office he/she represented;
c) In the case of peoples or employees representative if the Board member loses the faith
of his/her constituency and a request is made by the constituency to replace him/her; or
d) The Board member has failed to fulfil the duties of his/her membership. This includes
considerations such as:
i. Repeated absence from Board meetings without sufficient reason
ii. Proven corruption such as earning benefits in the health facility other than the
legally permitted benefits or other corrupt practice
iii. Repeated failure to follow up on actions agreed by the Board
iv. Breach of confidentiality
In such cases, the Board should reach consensus that membership should be revoked and
should make this recommendation to the RHB Head or Minister for Health who will reach a
final decision on the matter.
If a Board member leaves office during his/her period of tenure the remaining Board
members should select one or more possible replacements and nominate the candidate(s) to
the RHB or FMOH to make the final appointment.
Page 18 of 36
D) Duties and responsibilities of Board members
Board members have a duty to:
a) Attend ordinary and extraordinary meetings, respecting the time;
b) Accept and implement a decision passed by the majority;
c) Prepare for each meeting by reading agendas, minutes of the previous meeting and other
documents distributed for consideration;
d) Follow up on any actions agreed by the Board in a timely manner; and
e) Maintain confidentiality on all matters discussed by the Board.
E) Board accountability
Board members have individual and joint responsibility for the decisions they pass and are
responsible individually and jointly for any damage caused to the hospital due to their failure
to accomplish the duty entrusted to them. In the event a Board member solely opposes a
decision or an agenda for discussion, he/she may explain the reason for his/her unique
opposition and make it noted on the minutes. He/she shall not be responsible for any damage
occurred due to this decision or agenda item.
Governing Boards are accountable to their respective RHB or the FMOH and should meet all
expectations that the RHB or FMOH places on the Board.
F) Allowance for Board members

Reimbursement of expenses for Board members and allowances for Board duties should be
provided as established by Federal and Regional Directives.
3.2.3 Officers of the Governing Board
The Governing Board should appoint three to five Officers, who form the Executive
Committee of the Board.
Officers of the Board include:

a) The Chairperson
b) The Vice-Chairperson
c) The Secretary
Additional Officers, such as immediate past Chairperson may be appointed as necessary.
3.2.3.1 Roles of the Chairperson of a Governing Board
The Governing Board should be lead by a Chairperson, who is appointed by the RHB or
FMOH from among the Board members. The main responsibilities of the Chairperson are to:
A) Preside over the Board

The Chairperson should chair Board meetings and direct the overall functioning of the Board.
The Chairperson should take the lead in clarifying the goals of the Governing Board. This
helps to build a cohesive group and clarify expectations, while focusing the Governing
Boards attention to the connection between its own performance and the success of the
hospital.
B) Convene and facilitate board meetings and set meeting agendas
The Chairperson should ensure that regular Board meetings take place in compliance with the
periods prescribed in Federal or Regional Directives and should convene extraordinary
meetings in compliance with these Directives. The Chairperson must ensure that meetings are
conducted in a professional manner and are constructive for both the hospital and the
individual Governing Board members. The Chairperson therefore must oversee the
development of a well-thought out agenda and supporting materials. The agenda should be a
collaborative effort with the CEO. The Chairperson should expect members to arrive at
meetings fully prepared to participate in Governing Board meetings. It is important that the
Chairperson knows how to clarify, summarize and move Governing Board members to a
decision, as well as set aside some time at the end of the meeting for feedback on how the
meeting went.
C) Manage Governing Board structure

The Chairperson should create, in collaboration with the CEO, a structure that supports the
mission and work of the Governing Board. Where appropriate he/she should establish
standing committees to undertake specific functions of the Board. The Chairperson should
ensure that any such committees are working as they should.
In addition to the above, an effective Chairperson will:
1. Understand the organization

The Chairperson must have an expert understanding of the hospitals history, mission, current
role, finances, programs and services, and staff. He/she must also be knowledgeable of any
external forces that affect the hospitals inner workings, making certain to execute any health
policies as required by the appropriate government body.
2. Know his/her own responsibilities and authority as Chairperson

By understanding his/her own responsibilities, the Chairperson serves as a model for other
Governing Board members to follow. The Chairpersons real authority and influence rests in
how he/she develops and manages relationships with the rest of the Governing Board and
staff.
3. Create a safe environment for decision making

The Chairperson should take the lead in establishing the tone for shared decision making by
inviting participation, encouraging varying points of view and promoting an open and honest
exchange of ideas about issues.
4. Build a working culture

The Chairperson should encourage a participatory working culture that focuses on collective
responsibility and accomplishment.
5. Cultivate future leadership

It is essential that the Chairperson is capable of cultivating and nurturing Governing Board
members who have expertise and personal qualities that the hospital needs. He/she must be

able to prepare Governing Board members for future leadership, which requires encouraging
periodic self-assessment in order to highlight Governing Board members strengths and
leadership possibilities.
6. Communicate with the Governing Board through an effective information system

Providing information about hospital operations is an essential responsibility of the
Governing Board Chairperson and CEO. Materials for Governing Board and committee
meetings should be distributed in advance of the meeting to allow time for review by
members. Establishing a reliable system to distribute information at other times is also
important, for regular, interim updates and in the event of unexpected matters that demand
Governing Board attention.
7. Maintain a productive relationship with the CEO and the appropriate government
body
Maintaining productive relationships with both the CEO of the hospital, plus the appropriate
government body, are extremely important. It requires clarity of roles, trust, honesty and
frequent communication.
3.2.3.2 Roles of the Vice Chairperson of the Governing Board
The Vice Chairperson is appointed from among Board members and acts on behalf of the
Chairperson in the Chairpersons absence.
3.2.3.3 Roles of the Secretary of the Governing Board
The Secretary of the Governing Board is appointed from among Board members. This
position could be filled by the hospital CEO. The Secretary is responsible for taking minutes
of Board meetings. Minutes should be reviewed and approved by the Chairperson before
distribution to Board members.
3.2.4 Procedures of Board meetings
The main purpose of Board meetings is to ensure effective governance of the hospital. This
includes developing, debating and approving strategic and annual plans, monitoring
implementation, discussing and approving corporate policies and addressing any legal and
ethical issues that arise. Board meetings are also an opportunity to provide structured
education sessions for Board members on emerging issues concerning the hospital and/or the
community it serves.
(NB: General guidance/etiquette to ensure that any type of committee or meetings function
effectively are presented in Appendix D.)
A) Frequency of Board meetings

It is recommended that during the first year of establishment the Governing Board meets once
every month to become familiar with its own responsibilities, with the hospital and the health
sector in general. Thereafter the Board should develops a schedule whereby the Board meets
no less than the frequency set out in Federal or Regional Directives. Extra-ordinary meetings

may be convened should a matter of particular importance arise. Such meetings will be
convened upon the decision of the Chairperson, or if called for by a minimum of one-third of
Board members.
B) Agenda items
The agenda should be set jointly by the Board Chairperson and Hospital CEO. All Board
members should be invited to nominate agenda items for consideration by the Chairperson
and CEO. The agenda and any documents for discussion at the meeting should be distributed
to Board members at least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the Board:
a) Approval of previous meeting minutes;
b) Committee reports;
c) CEOs report providing an overview of hospital operations, discussion of pressing
issues and immediate concerns;
d) Old business issues unresolved from last meeting;
e) New business any issues Governing Board members want to raise; and
f) Next steps plans for taking action on decisions reached by the Board, with the
assignment of follow up responsibilities to individuals as appropriate.
C) Decision making
Decisions by the Board should be made by majority vote. In the case of a tie the Chairperson
has the deciding vote. Voting may only take place when a full quorum of Board members is
present. A vote passed by less than a full quorum is invalid. The criteria for a full quorum
vary from Region to Region (from 50% + 1 of Board members to 2/3rd of Board members)
and are described in Federal and Regional Directives. The CEO is an ex officio Board
member and hence has no vote on the Governing Board.
3.2.5 Governing Board standing committees
The Governing Board should assign standing committees to carry out specific functions of
the Board and report on their activities to the full Board. As a minimum the following
standing committees should be established:
a) Executive committee
b) Finance committee
c) Audit committee
Other standing committees may be established on a temporary or permanent basis as the need
arises (for example a CEO selection committee, strategic planning committee, quality
assurance committee or a committee to address an emerging clinical matter).
When selecting members for each committee the following principles should be followed:
a) Committee members should be selected from the current Board members
b) Selection should be transparent and fair, without favouritism of any kind
c) The Governing Board Chairperson should be a member of all committees

d) Each committee should have its own chairperson who will preside over the actions of the
committee
e) Hospital staff, representatives of appropriate external bodies (e.g. MoFED or Woreda
Health Office) or prominent members of the community with an active interest in the
hospital and appropriate professional expertise (eg. an accountant for the Finance
committee) may be appointed as non-voting members to support the functions of the
committee
A) Executive Committee
The Executive Committee should be chaired by the Governing Board Chairperson and should
be comprised of Officers of the Board and all key Governing Board committee chairpersons.
The Committee acts on behalf of the full Governing Board in their absence and is responsible
for reporting to the full Governing Board on such actions.
B) Finance Committee
The Finance Committee oversees the hospitals financial planning and ongoing financial
operations to ensure the viability of the hospital. This includes monitoring that adequate
funds are available for the organizations financial plan, safeguarding hospital assets, and
ensuring that the hospital has adequate fiscal policies. Moreover, the Finance Committee
must anticipate financial problems by reviewing hospital financial information provided at
regular intervals. The Finance Committee should be comprised of selected Governing Board
members, the hospital Finance Head and possibly representatives from the Regional or
Woreda Bureaus of Finance and Economic Development and business leaders from the local
community. Other than those individuals who are members of the hospital Governing Board,
all finance committee members have no voting rights.
C) Audit Committee
The Audit Committee should make sure that all required financial audits are conducted and
that reports are presented to appropriate bodies. The committee should be chaired by the
Treasurer of the Governing Board and comprised of selected Governing Board members, the
hospital internal auditor, the Finance Head and possibly representatives from the Regional or
Woreda Bureaus of Finance and Economic Development or a respected local accountant with
knowledge of bookkeeping and auditing. Other than those individuals who are members of
the hospital Governing Board, all audit committee members have no voting rights.
Box B The Seven Deadly Sins of Poor Hospital Governance
1. Lack of mission, vision, strategies and community participation/involvement.

2. Resisting change and failure to make strategic investments
3. Making do with irrelevant, useless information
4. Lack of hospital board and management alignment
5. Hiring unqualified or ineffective leaders
6. Failure to spend meeting time on strategic priorities

3.3 Chief Executive Officer
3.3.1 Selection and Appointment of the CEO
Each hospital should be managed by a CEO (General Manager) who is appointed by the
Governing Board or appointing authority following the processes set out in Federal or
Regional Directives.
A qualified CEO should have a diverse set of leadership and management skills, as well as
considerable healthcare/hospital experience as either a clinician or management professional.
He/she must be capable of working with diverse groups, such as the Governing Board,
various community groups, government officials and hospital staff, patients and families.
He/she should be able to think strategically to provide vision and direction to the hospital
with special attention to professional development. An individual with an entrepreneurial
spirit and who is fiscally responsible will be valuable to the organization. He/she should be a
results oriented leader with an eye for understanding how to improve patient quality of care.
3.3.2 Roles and responsibilities of CEO
The CEO is the highest ranking management officer in the hospital and as such, directs and
administers the activities of the Hospital in accordance with instructions and plans developed
by the Governing Board. The CEO must ensure that decisions of the Governing Board are
implemented effectively and efficiently throughout the hospital and must ensure the efficient
planning and utilization of all hospital resources in order to achieve the organizations goals.
This entails the management of human resources, supplies, revenues, and physical and capital
assets based on detailed plans developed for all aspects of the hospitals operations (see Box
C).
Box C Summary of the Role of a hospital CEO
The Chief Executive provides executive leadership to the Hospital and has corporate
responsibility for setting the strategic direction, formulating policies, monitoring performance
and contributing to the decision making process with fellow Board Members to ensure the future
stability and success of the Hospital, whilst providing the best possible care within available
resources.
CEO responsibilities should be described in a Job Description that clarifies the expectations
of performance and boundaries of his/her responsibilities. Areas of responsibility include:
A) Governing Board development, communication and relationships

The CEO should work closely with the Governing Board to ensure that they, and any
Standing Committees, are assisted and provided with relevant information to enable them to
perform their functions effectively and efficiently. The CEO is an ex officio, non-voting
member of the Governing Board. The CEO should inform the board in a timely manner of
any issues of concern or risks that affect or may affect the hospital. The CEO should work

with the Board to provide or facilitate trainings of Governing Board members to ensure that
Board members are adequately skilled for their role.
B) Planning, monitoring and evaluation of hospital operations

The CEO should prepare hospital strategic and annual plans and submit these to the Board
and all necessary higher authorities for approval. The CEO is responsible to effectively
implement these plans and achieve strategic plan goals. Strategic and annual plans should
include all hospital improvement initiatives.
The CEO should submit to the Board regular performance and financial reports of the
hospital, showing progress towards the goals of the strategic and annual plans, and in
particular highlighting any areas of concern.
The CEO should also ensure that any reporting requirements of higher authorities (such as
Woreda, Zonal or Regional Health & Finance Departments) are submitted in a timely
manner.
C) Fiscal
The CEO should prepare and submit to the Board the budget of the hospital for approval.
After approval the CEO should maintain the hospital budget within agreed upon parameters,
effecting payments in accordance with the approved budget and plans. In partnership with the
Governing Board, the CEO is also responsible for designing various mechanisms to increase
hospital revenue such as:
outsourcing non clinical services to improve the overall quality of care,
establishing, organizing, and controlling private wing health services, and
revising fee and revenue collection and utilization procedures.
The CEO should ensure that financial audits are performed in accordance with government
requirements and submitted to the Board for approval, and subsequently to the appropriate
higher authority in a timely manner.
The CEO should ensure that any recommendations made by internal or external financial
audits are acted upon appropriately.
D) Development of hospital management committee and other structures
Each hospital should have an organisation chart that describes the organisation of hospital
functions and personnel, including reporting structures. The organisation chart should be
developed by the CEO and approved by the Governing Board.
A skilled CEO finds other capable staff members with whom to share the workload. The
CEO may delegate part of his/her powers and duties to the employees of the hospital to the
extent necessary for the efficient performance of its activities.

The CEO is responsible to establish an effective Senior Management Team to oversee day to
day hospital operations. He/she may also establish additional committees as the need arises
(examples are given in Section 3.4.6 below). The CEO should ensure that each committee has
clearly defined membership and responsibilities, and should ensure that each committee
fulfils its functions.
E) Personnel management and development

The CEO should ensure the recruitment and retention of a qualified workforce that enables
the hospital to discharge its activities. The CEO should ensure that an Employee Manual and
incentive schemes are developed and submitted to the Board, and should implement these
upon approval. The CEO should strive to empower and advance the professional capacity of
hospital staff.
F) Quality of care
The CEO should establish mechanisms to measure the quality of care and establish programs
to continuously strive for improved levels of quality. The CEO should ensure that patients
rights are respected by all staff. Further guidance on Quality Management is presented in
Chapter 12 Quality Management.
G) Regulations compliance
The CEO should oversee compliance with all relevant regulations from government bodies.
Such regulations may include safety regulations, employment regulations, finance and audit
regulations among others.
H) Management of hospital buildings, campuses and physical assets

The CEO should establish and meet goals for the maintenance and improvement of hospital
buildings and campuses and all physical assets including medical equipment and vehicles.
I) Public Relations: community, governmental and professional audiences

The CEO is the chief spokesperson for the hospitals various audiences and should represent
the hospital in its dealings with third parties. The CEO should strive to enhance the reputation
of the hospital by strengthening relationships with the community, government and
professional audiences.
J) Professional development
The CEO should keep current with emerging issues and technologies and ensure that staff
members are also kept current in these areas through training, access to resources, and related
opportunities.
K) Leadership
The CEO should establish and increase leadership presence within the hospital and the local
community, as well as in its district, provincial and national communities.

3.3.3 Accountability and evaluation of the CEO
The CEO is accountable to the Hospital Governing Board, and is the only staff member under
the direct supervision of the Board. Evaluations of the CEOs performance should be
conducted at least annually by the Board or appointing authority. Evaluation criteria should
be based on the job description of the CEO. Annual performance expectations should be
spelled out at the beginning of each year in discussion between the Governing Board
Chairperson, or appropriate member of the appointing authority, and the CEO.
If the Governing Board is concerned about the CEOs performance at any time it should use
the evaluation criteria to address these concerns. The discussion can lead to goals for
performance improvement in the future. If these concerns have been addressed in the past and
no improvements have been made, the discussion may ultimately lead to the termination of
employment of the CEO following the process described by Federal or Regional Directives.
3.3.4 Relationship between CEO and Governing Board Chairperson
The relationship between the CEO and the Governing Board Chairperson must be managed
well by both individuals in order for the overall operations of the hospital to be conducted at
their best. It is mostly the responsibility of the CEO to ensure that this relationship remains
professional, courteous, and informative and defines the leadership of the organization.
While Governing Board Chairpersons may come and go, as an appointed volunteer with
defined terms of service, the CEO is the hired professional who will hopefully work
alongside and maintain the organization through Governing Board Chairperson successions.
The final authority overseeing the hospital is the Governing Board, and as such, the CEO
serves at the pleasure of the Governing Board and its Chairperson.
Attending to the needs and dictates of the Governing Board Chairperson is the duty of the
CEO, and this hierarchical relationship can be made constructive and successful if the two
individuals understand each others strengths, weaknesses, management/governance styles,
responsibilities of their office and each others personalities. The CEO must elicit support
from the Chairperson on matters of importance to the hospital and the community it serves,
so that together the Chair and the CEO can be successful in designing strategies that the
Governing Board members can endorse and that the CEO can implement within the hospital.
3.4 Hospital Senior Management Team
Each hospital should have a Senior Management Team (SMT) that supports the CEO to
oversee the day to day operations of the hospital. The SMT provides information and advice
to the CEO, and serves as a forum to share decision making when appropriate, thus
strengthening the transparency and accountability of hospital leadership.
The SMT is accountable to and chaired by the hospital CEO.

Terms of Reference for the SMT should be defined including: a description of the
membership of the SMT, the roles and responsibilities of the SMT, frequency of meetings,
voting rules and a statement of confidentiality. Each SMT member should sign a copy of the
TOR indicating his/her acceptance.
3.4.1 Responsibilities of Senior Management Team
The main purpose of the SMT is to assist the CEO and as such many of the functions of the
Management Committee are similar to that of the CEO.
Specific responsibilities include:
A) Assist the CEO to prepare hospital strategic and annual plans for submission to the
Governing Board.
B) Provide reports to the CEO on implementation of strategic and annual plans, according to
each committee members area of responsibility.
C) Identify areas of concern in the achievement of hospital plans, and assist the CEO to find
solutions.
D) Ensure that activities of the hospital are carried out with transparency and accountability
and that all required reports are submitted to higher authorities (e.g. RHB, BOFED,
FMOH, MOFED) in accordance with government requirements.
E) Ensure the hospital complies with all relevant government regulations.
F) Provide financial oversight, advising the CEO on mechanisms to generate income and
minimize expenses.
G) Ensure proper implementation of fee waiver mechanisms and reimbursement.
H) Ensure proper management of hospital buildings, estate, equipment and supplies.
I) Resolve departmental or case team problems or disputes when these are beyond the
ability of the department head or case team director.
J) Ensure high quality clinical services by establishing and implementing mechanisms to
measure and improve the quality of care.
K) Support workforce recruitment and retention, protecting the health and wellbeing of
hospital staff, and creating opportunities for staff development including leadership
opportunities.
L) Communicate relevant Governing Board, CEO and Management Committee decisions
with subordinate employees.
M) Establishes mechanisms to involve patients and the public in the planning and delivery of
hospital services and to maintain close consultation with community leadership.
N) Work to enhance the organization's public standing and strengthen relationships with
community, government and professional audiences.
3.4.2 Membership of Senior Management Team
The SMT should be comprised of senior hospital leaders such as department or case team
heads, senior clinical staff and key administrative personnel. It is also recommended that a
staff representative, nominated by staff members on a rotating basis, is a member of the SMT.
The exact membership will be determined by the organization structure of the hospital but
should include the following personnel (or individuals with similar responsibilities):
1. Hospital CEO (Chairperson of SMT)
2. Finance Head
3. Director of Human Resources
4. Chief Medical Officer (or equivalent)
5. Senior Nurse Representative
6. Senior Laboratory Representative
7. Senior Pharmacy Representative
8. Chair of Hospital Quality Committee (or equivalent)
9. Staff representative
Hospital staff or representatives of appropriate external bodies may be invited to attend SMT
meetings as non-voting members, to provide reports, information or advice to the SMT as the
need arises.
3.4.3 Appointment of Senior Management Team Members
The CEO should determine the membership of the SMT, taking into consideration the
organization structure of the hospital and key leadership positions. He/she should
recommend the proposed membership to the Governing Board for approval. After approval,
specific individuals will automatically be appointed by virtue of their position within the
hospital. When a committee member leaves the office which he/she represented he/she will
be replaced on the SMT by the next person assigned to that post.
The main exception to this rule is the staff representative, who should be elected by majority
vote of hospital employees. This member should serve on the SMT for a time limited period
as determined by the Governing Board (generally one year) and should then be replaced by
another elected representative.
3.4.4 Duties and responsibilities of Senior Management Team Members
Similar to Board members, SMT members have a duty to:

a) Attend ordinary and extraordinary meetings, respecting the time;
b) Accept and implement a decision passed by the majority;
c) Prepare for each meeting by reading agendas, minutes of the previous meeting and other
documents distributed for consideration;
d) Follow up on any actions agreed by the SMT in a timely manner; and
e) Maintain confidentiality on all matters discussed by the SMT.
3.4.5 Procedures of Senior Management Team meetings
A) Frequency and timing of SMT meetings
SMT meetings should be held at least monthly or more often as the need arises. Extra-
ordinary meetings may be called by the CEO at any time.

As far as possible SMT meetings should be held during regular working hours, and
committee members should have dedicated time within their work schedule to attend and
prepare for committee meetings.
B) Agenda items for SMT meetings
The agenda should be set by the Hospital CEO. All SMT members should be invited to
nominate agenda items for consideration by the CEO. The agenda and any documents for
discussion at the meeting should be distributed to SMT members at least one week in
advance of the meeting.
The following should be regular standing items on each and every agenda of the SMT:
a) Approval of previous meeting minutes;
b) CEOs report providing an overview of hospital operations, discussion of pressing
issues and immediate concerns;
c) Reports from each SMT member providing an overview of their department/function and
any pressing issues and immediate concerns
d) Old business issues unresolved from last meeting;
e) New business any issues SMT members want to raise; and
f) Next steps plans for taking action on decisions reached by the Committee, with the
assignment of follow up responsibilities to individuals as appropriate.
C) Decision making
Ultimately, the CEO is responsible for all hospital operations and as such has the authority to
reach decisions on hospital management matters. However, he/she may decide to determine
specific issues by a vote of the SMT. In such circumstances decisions of the SMT should be
made by majority vote. In the case of a tie the CEO has the deciding vote.
3.4.6 Subcommittees of the SMT
The SMT may establish a number of subcommittees to carry out specific duties related to
hospital management. Examples include:
A) Quality Committee
This committee is responsible to establish and monitor implementation of a quality
management strategy for the hospital. Further discussion on the roles and responsibilities of
the Quality Committee are presented in Section 3.2.1 of Chapter 12 Quality Management.
B) Drug and Therapeutic Committee

A Drug and Therapeutic Committee serves to promote the safe, rational and cost-effective
use of medicines within the facility. Further guidance on the establishment and functions of a
DTC are presented in Section 3.1 of Chapter 4 Pharmacy Services.
C) Infection Prevention and Control Committee

An Infection Prevention and Control Committee serves to establish and monitor all infection
prevention policies and procedures in the hospital. Further guidance on the establishment and

functions of an Infection Prevention and Control Committee are presented in Section 3.1 of
Chapter 7 Infection Prevention.
D) Medical Equipment Committee

The Medical Equipment Committee serves to oversee all medical equipment maintenance in
the facility, including development of a medical equipment strategy, equipment inventory
control, procurement plan and preventive and corrective maintenance. Further information
on Medical Equipment Committee can be found in Section 3.1 of Chapter 9 Medical
Equipment Management.
E) Major Incident Committee

The Major Incident Committee is responsible to supervise and co-ordinate emergency
planning. For further information on the membership and roles of a Major Incident
Committee please see Section 3.8.1 of Chapter 8 Facilities Management.
F) Disciplinary Committee
The Disciplinary Committee serves to investigate all employee disciplinary charges and to
determine the appropriate disciplinary measure. Further information on the membership and
responsibilities of the Disciplinary Committee can be found in Section 3.10.5 of Chapter 11
Human Resource Management.
3.5 Strategic and Annual Planning
Strategic planning is the process of determining what an organization intends to be in the

future and how it will get there. The Annual Plan shows how the broader objectives, priorities
and targets of the strategic plan will be translated into practical activities. Each hospital
should have strategic and annual plans that are developed taking into consideration the
mission, vision and values of the organization and aligned with national, regional and local
priorities.
Strategic plans should cover a 5 year period and should be ambitious towards reaching the
desired outcome. The annual plan should align with this, providing greater operational detail
on a year by year basis, tied to the annual budget. The Health Sector Development
Programme (HSDP) and the Regional/Zonal/Woreda Strategic Plans are the source
documents for hospital strategic plans and targets.
Detailed annual plans should have the following features:
Scope: should reflect all activities and budgets, including those implemented by the
public sector, donor agencies, NGOs and communities
Resource and source of finance: estimation of the total amount of resources available
from all sources (government, specific donors, internal revenue, NGOs etc).
Implementation schedule: a list of major activities, a quarterly/monthly implementation
schedule and the responsible body for the implementation of each activity

Monitoring framework: for assessing progress during implementation. This includes
key performance indicators, baseline data, annual targets, information sources and
collection mechanisms, as well as reporting and feedback mechanisms.
Annual plans should be developed in two stages. The core plan is about achieving national
targets; the detailed plan is the core plan plus other activities of local importance.
Figure 9 shows how the planning process works in practice. Hospitals should first review
Federal, Regional, Zonal and Woreda indicative plans, based on which the hospital should
develop its owns strategic and annual indicative plan. This is then passed back up the chain
for review and approval, with higher bodies amending their own strategic or annual plans to
take account of lower level plans, or advising amendments to lower level plans where
necessary. This top down, bottom up approach will lead to integration of plans at all levels.
The FMOH has established an Annual Planning Template for hospitals that describes the core
indicators for each year, based on HSDP and national targets. The Planning Template for
EFY 2002 is presented in Appendix E. This template may change from year to year in
accordance with national priorities.
In addition to the planning template of the FMOH, hospitals should also follow the processes
established by MOFED/BOFED for budget allocation. This involves preparation of an annual
plan and budget using the MOFED/BOFED template and submission of this to the
appropriate authority. Further details on the budget allocation process are presented in
Chapter 10 Financial and Asset Management.

Figure 9 Strategic and Annual Planning at all Levels
3.6 Essential Service Package
Each hospital should develop an Essential Service Package that describes the core functions
and clinical services provided by the hospital. The Essential Service Package is the
foundation for the Human Resource Development Plan (see Section 3.2 of Chapter 11
Human Resource Management) and for the Model Medical Equipment List and Equipment
Development Plan (See Sections 3.5 and 3.6 of Chapter 9 Medical Equipment Management).
The Essential Services Package should be developed based on the hospital vision, mission
and strategic and annual plans.
Section 4 Implementation Checklist and Indicators

4.1 Assessment Tool for Operational Standards
In order to determine if the Operational Standards of Hospital Leadership and Governance

have been met by the hospital an assessment tool has been developed which describes criteria

for the attainment of a Standard and a method of assessment. This tool can be used by
hospital management or by an external body such as the RHB or FMOH to measure
attainment of each Operational Standard. The tool is presented in Appendix E of Chapter 13
Monitoring and Reporting.
4.2 Implementation Checklist
The following Table can be used as a tool to record whether the main recommendations
outlined above have been implemented by the hospital. The Table does not measure
attainment of each Operational Standard but rather provides a checklist to record
implementation activities.
Table 1. Hospital Leadership and Governance Checklist

Yes No
1. A Governing Board has been established
2. Terms of Reference for the Board are defined
3. The Board meets at a minimum every quarter
4. Board members participate in ongoing education
5. There is a planned orientation programme for new Board members
6. The hospital has a Statement of Vision, Mission and Values that has
been approved by the Governing Board
7. All staff have been oriented to the Hospital Vision, Mission and Values
8. A CEO has been appointed
9. The CEO has signed a job description that outlines his/her duties to lead
the hospital
10. The CEO is evaluated annually
11. A Senior Management Team has been established. Membership of the
SMT has been approved by the Governing Board
12. Terms of Reference for the SMT are defined
13. The SMT meets as a minimum every two weeks
14. The hospital has a strategic plan that has been approved by the
Governing Board
15. The hospital has an annual plan that has been approved by the
Governing Board
16. All staff have been oriented to the hospital strategic and annual plans
17. An Essential Service Package has been defined for the hospital
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.

Table 2 Hospital Governance and Leadership Indicators
Indicator Formula Frequency Comments
1. Number of Board meetings in Total number of board Quarterly
reporting period meetings in the reporting
period
2. a) Number of Board meetings a) Total number of board Quarterly
cancelled or deferred meetings cancelled or
b) Proportion of scheduled deferred in the reporting
Board meetings cancelled or period
deferred b) Total number of board
meetings cancelled or
deferred in the reporting
period total number of
scheduled Board meetings
x 100
3. Average attendance rate at Board number of attendees [total Quarterly
meetings number of Board members x
number of meetings] x 100
4. Number of Senior Management Total number of SMT Quarterly
Team meetings held meetings held in the reporting
period
5. a) Number of SMT meetings a) Total number of SMT Quarterly
cancelled or deferred meetings cancelled or
b) Proportion of scheduled deferred in the reporting
SMT meetings cancelled or period
deferred b) Total number of SMT
meetings cancelled or
deferred in the reporting
period total number of
scheduled SMT meetings
x 100
6. Average attendance rate at SMT number of attendees Quarterly
meetings [number of SMT members x
number of meetings] x 100
Source Documents
1. Addis Ababa City Administration Health Bureau. (2009, January). Directive No. 1/2001
issued to provide for the execution of Addis Ababa City Government Health Services
Provision and Health Institutions Administration and Management Regulation No.
26/2001. Addis Ababa: Addis Ababa City Government.
2. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 117/ 2005.
3. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 39/ 2006.
4. Department of Health. (1999, March). Clinical Governance, Quality in the New NHS.
London: Department of Health.

5. Department of Health. (2009, January). The NHS Constitution for England. London:
Department of Health.
6. Federal Democratic Republic of Ethiopia Ministry of Health. (2007). The Health Sector
Development Program Harmonization Manual.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, July). Policy,
Business Process Reengineering: Policy, Planning and Monitoring & Evaluation Core
Process.
8. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January).
HMIS/M&E. Strategic Plan for Ethiopian Health Sector.
HMIS/M&E. Indicator Definitions. HMIS/M&E Technical Standards Area 1.
10. Federal Democratic Republic of Ethiopia Ministry of Health. (2007, May). HMIS/M&E.
Disease Classification for National Reporting. Technical Standards Area 2.
HMIS/M&E. HMIS Procedures Manual: Data Recording and Reporting Procedures.
HMIS/M&E Technical Standards Area 3.
HMIS/M&E. Information Use Guidelines and Display Tools. HMIS/M&E Technical
Standards Area 4.
13. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August).
Performance Monitoring and Quality Improvement Guideline for the Ethiopian Health
Sector.
14. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, June). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
15. Federal Democratic Republic of Ethiopia Ministry of Health. Data Collection Guide for
Healthcare Quality Assessment.
16. NHS Quality Improvement Scotland. (2005, October). Clinical Governance and Risk
Management: Achieving safe, effective, patient-focused care and services.
17. Oromia Regional Government Administrative Council. (2005). Oromia Regional State
Health Service Delivery and Administration Regulation No. 56/ 2005.
18. Tigray National Regional Government Council. (1999 EC). Bylaw for the Provision,
Management and Administration of Health Services in Tigray National Regional
Government Number 42/1999.

Appendices
Chapter 1 Hospital Leadership and Governance

Appendix A Sample Hospital Mission, Vision and Values
Statements
A Mission can be defined as purpose, reason for being or simply who we are and what we
do.
A Vision can be defined as an image of the future we seek to create.
Mission statement
The mission of [ ] Hospital is to provide all patients quality, accessible and cost effective
health care.
Vision Statement
[ ] Hospital strives to be the premier hospital in Ethiopia, recognized nationwide for the
quality of care provided.
We aspire to:
provide an excellent standard of service
deliver patient care in a way that inspires public confidence
expand our skills and knowledge to serve our clients
continually build up our services to meet our clients needs
be cost effective and financially secure
be recognized as an employer of choice in the Ethiopian health system
Underlying principles governing [ ] Hospital

1. [ ] Hospital provides a comprehensive service, available to all.
2. Access to [ ] Hospital is based on clinical need, not an individuals ability to pay.
3. [ ] Hospital aspires to the highest standards of excellence and professionalism.
4. Services provided by [ ] Hospital must reflect the needs and preferences of patients,
their families and their caregivers.
5. [ ] Hospital works across organizational boundaries and in partnership with other
organizations in the interest of patients, local communities and the wider population.
6. [ ] Hospital is committed to providing best value for money and the most effective, fair
and sustainable use of finite resources.
7. [ ] Hospital is accountable to the public, communities and patients that it serves.
Values of [ ] Hospital
Respect and dignity. We value each person as an individual, respect their aspirations and
commitments in life, and seek to understand their priorities, needs, abilities and limits. We
take what others have to say seriously. We are honest about our point of view and what we
can and cannot do.
Commitment to quality of care. We insist on quality and striving to get the basics right
every time: safety, confidentiality, professional and managerial integrity, accountability,
dependable service and good communication. We welcome feedback, learn from our
mistakes and build on our successes.
Chapter 1 Hospital Leadership and Governance Appendix A: Page 1 of 2

Compassion. We respond with humanity and kindness to each persons pain, distress,
anxiety or need. We search for the things we can do, however small, to give comfort and
relieve suffering. We find time for those we serve and work alongside. We do not wait to be
asked, because we care.
Improving lives. We strive to improve health and well-being and peoples experiences of our
hospital. We value excellence and professionalism wherever we find it in the everyday
things that make peoples lives better as much as in clinical practice, service improvements
and innovation.
Working together for patients. We put patients first in everything we do, by reaching out to
staff, patients, caregivers, families, communities, and professionals outside the hospital. We
put the needs of patients and communities before organizational boundaries.
Everyone counts. We use our resources for the benefit of the whole community, and make
sure nobody is excluded or left behind. We accept that some people need more help, that
difficult decisions have to be taken and that when we waste resources we waste others
opportunities. We recognize that we all have a part to play in making ourselves and our
communities healthier.
Adapted from The NHS Constitution for England. DoH, London, Jan 2009.
Chapter 1 Hospital Leadership and Governance Appendix A: Page 2 of 2

Appendix B Sample content of Governing Board training
programme
Governance:
What is hospital governance?
What are RHB expectations of Governing Boards?
Roles and responsibilities of Governing Board
Jurisdiction and Power of Hospital Governing Board
Leadership and Code of Conduct for Governing Board Members
Role of Chairman, Members and CEO
Disclosure of Gifts and Loans
Register of Interests
Conflict of Interest
Meeting Agendas and Rules
8 Deadly Sins of Hospital Governance
Policies, Guidelines and Protocols
Hospital Committees
Complaints Management
Adopting the Code of Conduct
Public Interest vs. Private Interest
Dealing with Material Personal Interest and Conflict of Interest
Dealing with Official Misconduct
Performance monitoring:
So you think your hospital is doing in a good job. How do you know?
Hospital Reporting System to Board
Benchmarking
Patient and community involvement:

Patients Rights and Responsibilities
Involving the community
Business and Financial Management:

Planning Cycle
Hospital Corporate Plan
Hospital Operational Business Plan
Annual Budget
Annual Report
Revenue and Expenditure
Raising Revenue
Commercial activities
Hospital enterprises
Private Wing
Fees and Charges
Grants and Subsidies
Borrowings
Developer Contributions/Infrastructure Charges
Chapter 1 Hospital Leadership and Governance Appendix B: Page 1 of 2
Planning and Development
Planning and Development
Land Use Planning
Masterplan Development
Planning for Prosperous Hospital
Building
Local Health Economy and Health Priorities

Catchment population
Population demographics
National priorities and targets (Health Sector Development Program)
Other
WHO Six Building Blocks of a Health System
Worldwide trends in hospital development
Twinning
Universal principles for hospital reform
Chapter 1 Hospital Leadership and Governance Appendix B: Page 2 of 2

Appendix C Sample Self Assessment Checklist for Governing
Board
1. Legal Structure of the Hospital and Background Information

a. Is there documentation relating to the role and Yes/No
reporting responsibilities and appointment of
the Governing Board (GB) and its members If yes, list and provide copies of documentation
available:
b. Are there any special issues or challenges Describe:
facing the hospital (i.e. member
communication, resources, stability)
c. Date of most recent governance review State date:
2. Role of Governing Board and Accountabilities
a. Role of the corporation List and provide copies of objects/purpose,
mission, vision, values, strategic directions etc
b. Date of last strategic plan and date of next State dates:

review of strategic plan
c. Is there a formal statement of corporate Yes/No
accountability? If yes, what is the date of the
last review? If yes, state date:
3. The Boards Governance Role
a. Define the role of the Board Define:
b. Has the board expressly adopted a statement Yes/No

of the Boards role? If yes, date of last review
If yes, date:
Provide copies of statement if available

c. Is there an annual Board work plan? Yes/No
If yes, provide copy

d. Provide an outline of how the Board performs Describe:
its responsibilities for the following areas of
Board performance:
Strategic planning
Oversight of management (CEO)
Quality and risk identification and
management
Financial oversight
Board Governance including board size and
composition, committee mandates and
composition, Officers, meeting effectiveness
Communications and accountability with
stakeholders
4. Duties. Obligations and Expectations of Individual Board Members
a. Is there a formal policy with respect to Board Describe:
members duties? How are Board members
made aware of their duties and obligations? Provide copy of policy is available
b. Is there a Board Code of Conduct that Yes/No
describes the rules of fiduciary conduct (avoid
conflict of interest, corporate obedience If yes, provide copy.
solidarity, board speaks with one voice
confidentiality, loyalty)?
c. Describe expectations regarding the level of Describe:
attendance and participation at Board and
Chapter 1 Hospital Leadership and Governance Appendix C: Page 1 of 3
Committee meetings. How are these
expectations communicated?
d. Describe participation in Board and Describe:
individual Board member evaluation (self-
evaluation and/or peer review)
5. Board Governance Policies
a. Has a formal Board Governance Policy Yes/No
Manual been prepared? What is the date of
the last review? If Yes state date of last review:
Provide copy of available

b. Describe the process for updating Board Describe:
policies
6. Board Composition and Recruitment

a. Identify the number of elected/appointed/ex- Describe and list:
officio directors. List ex-officio officers by
office
b. Is there a process to identify the skills Yes/No
required of Board members?
If yes, describe
c. Is a Board profile or skills matrix of the Yes/No
current Board maintained?
If yes, provide copy
d. How are prospective Board nominees Describe:
identified? Is a roster of eligible candidates
maintained?
e. How are prospective candidates advised with Describe:
respect to the role and expectations of Board
members?
f. How are prospective candidates evaluated? Describe:
g. Who makes the recommendation of approved Describe:

candidates?
h. What is the term of office of Board members Describe:
(initial, renewal and maximum terms)?
i. What is the term of office of Committee Describe:
Chairs (initial, renewal and maximum terms)?
j. What is the term of office of Board Officers Describe and identify Officers:
(initial, renewal and maximum terms)?
Identify Officers
7. Officers of the Board
a. Is there a clear process to select officers and Yes/No
committee chairs Describe:
b. Are position descriptions prepared and Yes/No
periodically reviewed?
If yes, describe and give copies if available
8. Board Committees
a. Do all Committees have written Yes/No
mandates/TORs
If yes, provide copies
b. Are Committee mandates/TORs reviewed Yes/No
periodically?
Describe:
c. How are Committees established? Describe:
d. How are Committee reports dealt with by the Describe:

Board?
e. Is the Audit Committee comprised of Describe:
independent directors?
f. Is there an Executive Committee? What is its Yes/No
role? Describe decision making role.
If Yes describe:
9. Board Orientation, Education and Evaluation
a. Is Board orientation mandatory? How is Yes/No
orientation conducted?
Describe and provide index of orientation
manual if available
b. Is there a written manual for new Board Yes/No
members?
If yes, provide index
g. Is there a clear process for Board members to Yes/No
participate in external education programs?
If yes, describe process:
h. How is Board education conducted? Describe:
i. What is the frequency of continuing education Describe:

for Board members?
j. Is an annual Board retreat held? Yes/No
If yes, state date of last retreat, attendance and

agenda
k. Is there an annual evaluation of the Yes/No
performance of individual Board members
and the Board as a whole? If yes, provide copy of the evaluation tool and
describe process for providing feedback and
action on results
10. Board Governance Policies
a. Is Board work aligned with the annual Board Describe and provide sample Board agendas?
goals and work plan?
b. Are decision items separated from Yes/No
information items?
c. Is specific time allocated for agenda items Yes/No
and is time adhered to?
d. What is the process to bring forward Board Describe:
Committees recommendations and reports?
e. Are meetings regularly evaluated? Yes/No
If yes, provide copy of evaluation tool

f. Are Board meetings open? Is there a policy Yes/No
for public attendance at Board meetings?
If yes, describe and provide copy of policy
g. Is there a clear policy that allows the Board to Yes/No
obtain independent advice (legal or financial
or other)> If yes, provide copy of policy
11. Members
a. Describe the following: Describe as listed:
Board members composition and
qualification
Term
Termination
Role
Voting rights

Appendix D Guidelines/etiquette for effective committees and
meetings
When a new committee/group is established it is important to:
1) Determine group membership:

Consider which departments/people are most involve and should be on team
Include all points of view, including conflicting ones
2) Assign a Chair and Secretary
3) Establish Terms of Reference for the group including:

Function/duties of the committee
Description of outputs expected
Realistic timeline for completion of project (if relevant)
Statement of who the group/committee is accountable to (if relevant)
Frequency of meetings
4) Set schedule for meetings, ideally at a fixed frequency, day and time. (For example, the first
Monday of every month at 4pm; or every Wednesday at 3pm). A fixed schedule makes it easier
for committee members to plan their schedule and remember to attend the meetings.
For each meeting:
5) The Secretary and Chair should circulate an agenda, the minutes of the previous meeting, and
papers for discussion in advance of the meeting. These should be circulated to all committee
members in advance (ideally one week before the meeting).
6) All committee members should review the agenda, minutes and items for discussion BEFORE the
meeting so that they have full information for discussion at the meeting. If the meeting is spent
reviewing items for the first time then much time will be wasted and the meeting will be
unproductive.
7) Begin and end the meeting ON TIME. Do not wait more than a few minutes for members who are
late.
8) Be concise and stay on topic. If the agenda is long, a time limit should be set for each agenda
item.
9) Begin the meeting by reviewing the minutes of the previous meeting and obtaining an update
report on any action points that were assigned from the previous meeting.
10) For each item on the agenda agree any action points that need to be followed up after the meeting.
For each action assign a specific individual to complete the task and a deadline for completion
(for example prior to next meeting, or within one month etc)
11) Prepare minutes of each meeting. These should include a summary of discussions and all action
points should be clearly stated with the name of the responsible individual.
Chapter 1 Hospital Leadership and Governance Appendix D: Page 1 of 2

Appendix E FMOH, Hospital Annual Plan for EFY 2002
(Planning Template)
FEDERAL MINISTRY OF HEALTH
HOSPITAL ANNUAL PLAN FOR EFY 2002
Hospital Name
Zone
Region
Date (DD/MM/YY): _____/_____/_______
Chapter 1 Hospital Leadership and Governance Appendix E: Page 1 of 8

1. PROFILE
1.1. Type of hospital:
1.2. Catchment population:
1.3. Employees in the Hospital:

a) Number of Employees:
Technical Supportive Total
S.No Type (profession) Currently providing service

1 Specialist
2 General practitioner
3 Health Officer
4 B.Sc. Nurse
5 Midwives (All type)
6 Nurses (diploma all type)
7 Nurses (certificate all
type)
8 Lab (all type)
9 Pharmacy (all type)
10 X-ray (all type)
11 Others
2. BACKGROUND INFORMATION:
2.1. Major health problems seen in the hospital (top diseases and health problems):
2.2. Major achievements in EFY 2001 implementation period & financial resources
utilization:

2.3. Challenges/problems encountered in the EFY 2001implementation period:

3. OBJECTIVES
3.1. SPECIFIC OBJECTIVES, INDICATORS AND TARGET FOR THE EFY 2002:
S.N Objective Description Indicator Eligible Description Eligible Baseline Target

in In % In number %
number number
Resources (Human and Logistics)
1. Decrease attrition rate of Proportion of Specialists leaving Total number of Specialists at
Specialists in the hospitals the beginning of the year
2. Decrease attrition rate of Proportion of General Practitioners Total number of General
General Practitioners in the leaving Practitioners at the beginning of
hospitals the year
3. Ensure essential drug availability Proportion of months in the time period Total number of months in the
in health centers under consideration for which given given period of time *Total
tracer drug was available when needed. number of tracer drugs
4. Decrease Average stock out The number of days in which a tracer Total number of tracer drugs
duration drug was not available averaged over all
tracer drugs
Disease Prevention and Control
5. Decrease Inpatient Mortality Patient deaths before discharge per 100 Total Number of Admissions
Rate patients admitted
6. Decrease institutional maternal Proportion of maternal deaths from all Total number of deliveries in the
death deliveries attended in the hospital hospital
7. Decrease institutional very early Proportion of deaths within the 24 hours Total number of live births
neonatal death of life from total births attended in the attended in the hospital
hospital
9. Cataract Surgical rate Number of cataracts that were operated
10. Increase safe abortion service Number of safe abortion services
provided as far as the law permits

TB/Leprosy
11. Increase detection of new Number of Smear Positive TB cases
sputum smear-positive TB cases detected
12. Increase TB treatment success Percentage of cohort of new smear Total number of new smear-
Rate Positive TB cases registered in a specific positive TB cases registered in
period that successfully completed the same period
treatment
13. Increase TB Cure rate Percentage of a cohort of new Smear- Total number of new smear-
positive TB cases registered in specified positive TB cases registered in
period that was cured as demonstrated by the same period
bacteriologic evidence
14. Test newly diagnosed TB Proportion of newly diagnosed TB Total number of new TB cases
patients for HIV patients tested for HIV enrolled in the same period
15. Increase detection of new Number of new cases of Multi bacillary
leprosy cases leprosy, never treated before and
registered during the specified period of
time
16. Increase leprosy treatment Proportion of newly registered multi Total number of new multi
completion rate bacillary cases completed their treatment bacillary cases registered in the
same period
HIV/AIDS
17. Increase number of individuals Number of individuals who received VCT
counseled and tested for HIV services
[VCT]
18. Increase PIHCT Pre-test Number of individuals who received HIV All OPD and family planning
counseling Pre-test counseling that was initiated by a visits
provider
19. Increase PIHCT Testing rate Proportion of individuals counseled who Number of individuals who
received HIV testing that was initiated by received HIV Pre-test
a provider counseling that was initiated by
a provider

20. Increase number of pregnant Proportion of pregnant women counseled Total number of ANC clients in
women counseled and tested for & Tested for PMTCT the facility
HIV
21. Reduce mother to child Proportion of HIV+ pregnant women Total number of HIV+ ANC
transmission of HIV received ARVs for prophylaxis client mothers in the facility
22. Proportion of deliveries of HIV+ women The total number of HIV+
that receive a full course of ARV women who deliver during a
prophylaxis given time period
23. Proportion of infant born from HIV+ Total number of infant born
mother averted from HIV infection from HIV+ mother
24. Increase number of People Cumulative number of People Living
enrolled in HIV Care [Pre-ART] With HIV/AIDS (PLWHA) ever enrolled
in HIV care
25. Increase number of People Cumulative number of People Living
receiving ART With HIV/AIDS (PLWHA) ever started
on ART
26. Number of PLWHA currently receiving Number of People (15 to 49
ART years) with HIV in the facility
who are eligible for ART
27. Number of children (under 15
Number of eligible children receiving
years) with HIV in the facility
ART
who are eligible for ART
28. Number of eligible HIV+ pregnant Number of HIV+ pregnant
women receiving ART mothers in the facility who are
eligible for ART
29. Increase TB screening among Proportion of HIV positive clients Total number of HIV positive
HIV positive People screened for TB clients in the facility
Health Systems (Health service Utilization, management and Monitoring and Evaluation)
30. Increase out patient [OPD] Average number of out patient visit[ Population in the catchment area
attendance per capita including first and repeat visits] per
person per year
31. Increase bed occupancy rate Average percentage of occupied beds Number of beds available times
[BOR] during the period under review number of days in the period

32. Decrease average length of stay Average length of stay [in days] of Number of inpatient discharges
[ALOS] patients in an inpatient facility during a
given period of time
33. Increase number of supportive Number of supportive supervision visits Total number of planned
supervision conducted reported by respective health institutions supportive supervision visits for
respective health institutions
34. Improve performance Number of performance monitoring Total number of planned
monitoring conducted in the hospital performance monitoring
(Monthly performance
monitoring)
35. Ensure timeliness of routine Number of routine health and Total number of expected
health and administrative reports administrative reports timely sent to the reports
respective health institutions
36. Ensure routine data quality Proportion of correspondence between Total number of sample taken
data reported and data recorded in
registers and patient/client records, as
measured by a Lot Quality Assurance
Sample [LQAS]
37 Expand CEmONC Establish/strengthen CEmONC services
4. MAJOR ACTIVITIES FOR THE EFY 2002
S.N Activity Description Unit Qt 1st Q 2nd Q 3rd Q 4th Q

5. BUDGET FOR THE EFY 2002
Total Required Budget For EFY

S.N. Items of Expenditure
2002
1 6100 Personnel services

2 6200 Goods & Services
Government
6300 Fixed Assets &
3 source
Construction
4 6400 Other Payments
Non-
5 Other sources
Governmental
6 TOTAL
6. CONCLUSION
Planning team:
1. Name: Position:
2. Name: Position:
3. Name: Position:
4. Name: Position:
5. Name: Position:

Patient Flow
Page 1 of 42
Section 2 Operational Standards for Patient Flow 4
3.1 Patient Reception Services 5
3.2 Hospital Layout 6
3.3 Emergency Services 6

3.3.1 Emergency Services Layout
3.3.2 Emergency Services Management and Organization
3.3.3 Emergency Triage and Treatment
3.3.4 Emergency Case Management
3.4 Outpatient Services 13

3.4.1 Outpatient Services Layout
3.4.2 Outpatient Services Management and Organization
3.4.3 Central Triage
3.4.4 Outpatient Case Management
3.5 Inpatient Services 21

3.5.1 Inpatient Services Layout
3.5.2 Inpatient Services Management and Organization
3.5.3 Inpatient Case Management
3.6 Delivery Services 27

3.6.1 Delivery Services Layout
3.6.2 Delivery Services Management and Organization
3.6.3 Delivery Services Case Management
3.7 Liaison and Referral Service 30

3.7.1 Bed Management
3.7.2 Elective Admission Process
3.7.3 Emergency Admission Process
3.7.4 Referral Service
3.7.5 Availability of Liaison and Referral Service
3.7.6 Promotion of the Referral Network

Page 2 of 42
4.3 Indicators 40
Source Documents 42
Appendices
Appendix A WHO Paediatric Emergency Triage and Treatment (ETAT) Guidelines
Appendix B Sample Adult Triage and Treatment Guidelines
Appendix C List of Possible Day Surgery Procedures
Tables
Table 1 Human Resource Needs for Emergency Services
Table 2 Equipment and Supply Needs for Emergency Services
Table 3 Equipment and Supply Needs for Outpatient Services
Table 4 Patient Flow Checklist
Table 5 Patient Flow Indicators
Figures
Figure 1 Reception service responsibilities
Figure 2 Typical pathway for patients attending Emergency Services
Figure 3 Sample layout of outpatient department
Figure 4 Contents of a sample appointment book
Figure 5 Typical pathway for outpatients
Figure 6 Typical pathway for inpatient admission
Figure 7 Typical pathway for delivering mother
Boxes
Box A Operating Theatre
Box B Intensive Care Unit
Box C Transit Lounge
Box D Referral Network and Emergency Command Centre
Abbreviations
CEO Chief Executive Officer OPD Outpatient Department
ETAT Emergency Triage and Treatment OR Operating Room
FMOH Federal Ministry of Health PA Public Announcement
ICU Intensive Care Unit WHO World Health Organization
Chapter 2 Patient Flow Page 3 of 42

Patient flow in a hospital setting refers to the processes and procedures needed to ensure the
efficient flow of patients between services. Patient flow requires various inputs including
human resources, infrastructure, equipment, protocols and pathways. Properly designed and
implemented patient flow will reduce patient waiting times, increase provider efficiency and
staff/client satisfaction as well as improve overall quality of care. This chapter details the
inputs required to ensure well-organized patient flow and describes the flow of services from
the patients first encounter with the reception service at the entrance of the hospital until the
patient exits the hospital. Four main service processes are described in the chapter:
emergency, outpatient, inpatient and delivery services. Triage, liaison, admission and
discharge and referral processes are also outlined.
Section 2 Operational Standards for Patient Flow

1. Procedures are established to ensure efficient patient flow; such procedures are specific to
emergency, outpatient, and inpatient settings and seek to reduce patient crowding.
2. The Hospital has an Emergency Triage, staffed with appropriately trained personnel and
equipped with necessary equipment and supplies.
3. The Hospital has a Central Triage, staffed with appropriately trained personnel and
equipped with necessary equipment and supplies.
4. All patients (except labouring mothers, patients with an appointment for an outpatient
clinic or admission and private wing patients) undergo triage.
5. Outpatient appointment systems are in place for all disciplines provided by the hospital.
6. Appointment systems are in place for elective inpatient admissions in all disciplines that
are provided by the hospital.
7. The Hospital has a Liaison and Referral Service that:

a. Manages bed occupancy,
b. Facilitates emergency and non-emergency (elective) admissions, and
c. Receives referrals from, and makes referrals to, other facilities in the referral
network.
8. The Hospital has a written protocol for the admission and discharge of patients that is
known, and adhered to, by all relevant staff.
9. 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.

10. 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.
11. The hospital has a standardized method for managing referrals.
12. Hospital staff members are familiar with the referral systems including relevant referral
protocols and forms.
13. 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.

3.1 Patient Reception Services
A patients experience at a hospital is often impacted by their first encounter. Therefore, it is

critical that a patients reception at the gate is a positive experience.
Reception personnel should be stationed close to the main gate to direct patients or visitors to
the appropriate location in the facility. Reception staff should be easily identifiable (by
uniform or identification badges). The reception staff should be knowledgeable of the
services provided by the hospital, the staff who provide services (case team leaders etc.), and
the layout of the hospital. Wheelchairs and stretchers should be available to transport patients
to appropriate areas when needed.
Reception staff should ascertain the following from each patient and direct the patient
accordingly (see Figure 1 below).
1. Is the patient an emergency?

2. Is the patient a labouring mother?
3. Does the patient have an appointment for a follow-up clinic?
4. Does the patient have an appointment for admission?
5. Is the patient a private patient?

Figure 1 Reception Service Responsibilities
3.2 Hospital Layout
Patient flow can be improved by an appropriate arrangement of services (hospital layout)

supported by well-placed signs to indicate all service areas. Services should be organized in
way that:
Minimizes patient travel time between services; and
Reduces the likelihood of patients getting lost when going from place to place.
A site map should be displayed at the hospital entrance. Signboards should be used
throughout the facility to direct patients, caregivers and visitors to the appropriate service
areas.
Hospitals should also consider establishing a colour coded system to direct patients who may
not be literate. For example, blue signs could indicate all outpatient services and red signs
could indicate emergency services, etc. The use of drawings and photographs may also be
useful in directing patients. For further guidance on the layout of patient services please see
Section 3.2.1 of Chapter 8 Facilities Management.
3.3 Emergency Services
3.3.1 Emergency Services Layout
The Emergency Services should be organized so that the Emergency Services entrance can
be easily accessed by ambulances and patients. This means that the entrance to the

Emergency Services should be clearly labelled in a way that is visible from the street. The
Emergency Services should have the following:
Ambulance parking space
Triage area
Resuscitation room(s)
Examination room(s)
Procedure room(s)
Laboratory sample collection and testing facilities
Ambulatory imaging facilities
Pharmacy dispensary
Nursing station
Short stay beds
Waiting area
Cashier window(s)
Administration room(s)
Toilet and bathroom
Duty room(s)
Direct telephone line
Additionally, an operating room should be readily accessible to the Emergency Services Case
Team. If the workload is high, there should be a specific operating theatre for Emergency
Services only. However, the general operating theatre may be used if the workload is less, in
which case emergency cases should always be given priority over elective/cold surgical
cases.
3.3.2 Emergency Case Team Management and Organization
The Emergency Case Team should be overseen by a Director of Emergency Services. He/she
is responsible for all activities conducted in Emergency Services including:
Patient triage,
Case management, and
Laboratory, pharmacy and diagnostic services.
The Director of Emergency Services is responsible for managing all department staff and
should ensure that sufficient equipment and supplies are available for the patient load.
3.3.3 Emergency Triage and Treatment
A) Emergency Triage and Treatment Pathway

Patients entering the hospital through the separate Emergency Department entrance, from the
reception desk or those referred to the Emergency Department from Central Triage (see
section 3.4.3 below) should undergo Emergency Triage. If further investigations and/or
treatments are required following triage, these should be provided by the Emergency Case

Team. Patients that are not classified as emergency cases should be referred to Central
Triage.
B) Emergency Triage and Treatment Activity

Triage can be defined as the sorting of patients into priority groups according to their need
and the resources available. The aim of triage is to give priority treatment to those with the
most critical conditions, thus minimizing delay, saving lives, and making the most efficient
use of available resources. During emergency triage any problems identified with critical
body functions (airways, breathing or circulation) should be treated immediately. For this
reason emergency triage may be better described as Emergency Triage and Treatment
(ETAT).
Ideally, adult and paediatric ETAT areas and triage staff for emergency patients should be
separate. However, if the workload is low a single triage may serve both adult and paediatric
patients in the emergency department. In this case, paediatric patients should be given
priority over adults in the event that more than one patient requires ETAT at the same time.
The ETAT service should be provided 24 hrs a day, 365 days a year. Adult and Paediatric
Triage Protocols should be developed and implemented. Protocols should be posted on the
walls of triage areas as an aide memoire for triage staff.
The WHO has developed detailed ETAT guidelines for paediatric cases. These are presented
in Appendix A and should be adopted by all hospitals.
The WHO is currently developing ETAT guidelines for adults. When finalized, these should
also be adopted by hospitals. In the meantime, hospitals should develop their own triage
protocols following the basic steps outlined in Appendix B.
Following the initial triage and treatment to stabilize vital functions, patients should be
assigned to the Case Management Team for further investigations, treatment and follow up.
The Triage Officer should prioritize cases, determining which patients need the immediate
attention of the Case Management Team, which patients are priority cases, and which are
less urgent (for example a patient with a minor wound whose vital signs are intact). The
Triage Officer should also identify non-emergency patients and refer such patients to
Central (outpatient) Triage.
During triage and case management of adult and paediatric cases, runners- should handle
relevant administrative processes (such as patient registration, retrieving the patients medical
record, making payments etc). For further information on the process of registration see
Chapter 3 Medical Records Management.
C) Emergency Triage and Treatment Human Resource Requirements

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

runner. If the workload is high the hospital may appoint more than one Emergency Triage
Officer, Nurse and Runner.
D) Emergency Triage and Treatment Equipment and Supply Requirements

The emergency triage should be equipped with the following items as a minimum. Each
hospital should conduct its own assessment to determine the quantity of each item and any
other necessary items in addition to the following:
Desk
Chairs
Examination bed
Thermometer
Adult Stethoscope
Paediatric Stethoscope
Adult sphygmomanometer
Paediatric sphygmomanometer
Light source
Tourniquet
Pulse oximeter
ECG
Defibrillator
Oxygen
Oral and nasopharyngeal airways- adult/paediatric size
Ambu bags- adult/paediatric size
Suction
Intubation sets
Foley catheters
Chest drain sets
Dry dressings/ bandages
Casting materials
Finger prick glucotest & finger prick haemoglobin
Urine dipsticks & urine pregnancy tests
Weight scale- adult/paediatric- hanging, tape measures
Screens, partitions or separate rooms
Walkers, wheelchairs, stretchers
Gloves, face masks & other personal protective equipment
Emergency drug supply (See Chapter 4 Pharmacy Services; Appendix H for a list of
recommended drugs).
E) Emergency Triage and Treatment Training Requirements

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

3.3.4 Emergency Case Management
A) Emergency Case Management Pathway
Patients enter the emergency case management pathway upon referral from the Emergency
Triage Officer. Appropriate care is then initiated by the emergency physician and based on
the outcome the patient is either admitted, discharged (with or without a follow up
appointment) or referred (see Figure 2 below).
Figure 2. Typical Pathway for Patients Attending Emergency Services
A: Inpatient service flow D: Discharge service flow DR: Delivery service flow: DI: Diagnostic Imaging Service
flow E: Epidemic notification flow ER: Emergency Service flow F: Pharmacy service flow L: Laboratory
service flow O: Outpatient service flow R: Registration service.
Source: Federal Democratic Republic of Ethiopia Minsitry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report

B) Emergency Case Management Activity
The emergency physician on duty should take a full history and examine the patient and
arrange for any investigations required.
Laboratory samples should be obtained within the emergency department and analyzed either
within the department or at the central laboratory, depending on the test requested.
As a minimum the following tests should be provided in the Emergency Department:

Haemoglobin,
Haematocrit,
Blood film,
Blood group and cross match,
Total cell count,
Random blood sugar,
Urinalysis,
Stool examination, and
Pregnancy test.
More complex tests may be performed in the Central Laboratory. If the sample is to be tested
in the central laboratory then a runner should take the specimen to the laboratory and collect
the result.
If radiology tests are required these too should be conducted in the Emergency Department
using a portable X-Ray. If this is not possible a runner should transport the patient to the X-
Ray department where the test will be conducted. Results should be taken back to the
Emergency Department by a runner.
If medication is required, a prescription should be issued by the emergency physician and

should be dispensed by the emergency room dispensary.
A cashier service should be available within the emergency department for the payment of all
emergency room treatments, investigations, drugs and consumables. Runners should assist
the patient and/or caregiver with making payment.
Patients who require short term treatments (such as IV fluid administration, a loading dose of
IV antibiotics etc) may be transferred to a bed in the Emergency Services and kept for a
maximum of 24 hours. Any patient who requires treatment for a longer period of time should
be admitted to an inpatient ward.
Following assessment, investigation and treatment the patient may be discharged home,
referred for a follow up appointment at the outpatient services admitted to an inpatient ward
or referred to another facility.

If an outpatient follow up appointment is necessary this should be arranged by the Liaison
Officer and an appointment card should be given to the patient before he/she leaves the
emergency department (see section 3.4.3 below).
If the patient is to be admitted to the hospital the Liaison Officer will check the availability of
a bed and arrange for the patient to be transferred to the appropriate ward, escorted by a
runner with his/her medical record (see section 3.7.3 below).
If a bed or the service required is not available at the hospital, the Liaison Officer will contact
other facilities or the Regional Emergency Command Centre (if available) to identify a
hospital with the capacity to provide care to the patient and will facilitate referral following
agreed protocols (see section 3.7.4 below). If the service is not available in another facility
the patient must be kept in the hospital to receive treatment.
C) Emergency Case Management Human Resource Needs

A case team comprised of clinical and support staff will provide emergency services. Table 1
describes the minimum human resource needs of the Emergency Case Team.
NB: some of the personnel described in Table 1 below (such as Specialists, Social Worker)
may also be part of the Inpatient Case Team, however they should be readily available to
provide support/consultation to the Emergency Case Team whenever required. The
Emergency Case Team should have ready access to the Liaison and Referrals Service (see
section 3.7 below).
Table 1. Human Resource Needs for Emergency Services

Clinical Non Clinical
General Practitioner/Health Officer Data clerk
Professional/Clinical Nurse Runner
Pharmacist/Druggist Porter
Lab Technologist/Technician Cashier
Imaging Personnel Cleaner
Specialists (eg Internal Medicine, Paediatrics, Security
Surgery, Gynaecology etc) Social Worker
D) Emergency Case Management Equipment and Supply Needs

Each triage and treatment room should be equipped with equipment and supplies needed to
provide care. Table 2 presents a list (not exhaustive) of items that should be available in the
emergency department for patient treatment and care. Each hospital should conduct its own
assessment to determine other items in addition to those described in Table 2 below.

Table 2. Equipment and Supply Needs for Emergency Services
Equipment and Furniture Supplies
Stretcher Emergency Drugs
Wheel chair Cleansing agents/chemicals
Office furniture Antiseptics/Disinfectants
Screen Dressing materials
Diagnostic kits Stationary
Resuscitation tools adult/paediatric Personal Protective Equipment
Examination beds
Short stay beds
Refridgerator
Weighing scale
IV stand
Procedure kits
Lab equipment
Mobile X ray
Ultrasound
Monitoring machines
Electrocardiogram
Oxygen cylinder with accessories
High power mobile lamps
Telephone
Computer
Wall clock
3.4 Outpatient Services
3.4.1 Outpatient Services Layout
Outpatient services consist of

a) central triage
b) clinical assessment, sample collection and treatment rooms
c) pharmacy dispensing unit and cashier
d) laboratory team, with cashier
e) imaging diagnostic team, with cashier
Outpatient Services should be organized in a manner that reduces the amount of time that it
takes a patient to travel from one service location to another. Although each facility has a
different layout and plan, clinical services should be organized as close to one another as
possible. A possible layout of outpatient services is presented in Figure 3 below.

Figure 3 Sample Layout of Outpatient Services
C1 C2 Sample C3 C4
Collection
Outpatient Case Teams

Gate
Receptionist
Central Triage Case Team Client Waiting Area

Runners
Laboratory sample collection Imaging diagnostic team Pharmacy dispensing unit

team (with cashier) (with cashier) (with cashier)
The central triage is the first point of patient contact in outpatient services. The central triage
infrastructure should include a shaded waiting area, registration and medical record storage,
cashier and, clinical assessment areas. There should be separate assessment areas for adult
and paediatric cases. Following central triage, patients should be directed immediately to a
case team, or to a shaded waiting area where they will wait until it is their turn to be seen by
their assigned case team.
3.4.2 Outpatient Services Management and Organization
Outpatient Services will be overseen by the Director of Outpatient Services. He/she is

responsible for all activities conducted in the Department including:
Patient triage;
Case management; and
Laboratory, pharmacy and diagnostic services.
3.4.3 Central Triage
A) Central Triage Pathway

Patients will be directed to Central Triage from the reception service (or Emergency
Department). Within Central Triage the patient will undergo a triage assessment and all
relevant administrative processes (registration, medical record retrieval, payment etc) will be
conducted. (For further information on the process of registration see Chapter 3 Medical
Records Management). The triage assessment will assign each patient to an appropriate case
team (outpatient case team or emergency case team). The patient will then be directed to the
relevant case team and his/her medical record will be delivered to the case team by a runner.
B) Central Triage Activity

Central Triage should be open during regular working hours. All patients should undergo
Central Triage EXCEPT:
Emergency cases (should immediately attend emergency department),

Labouring mothers (should immediately attend delivery unit),
Those with an appointment (should immediately go to relevant case team), and
Private patients (should immediately go to private wing).
The first step in Central Triage activity is to assess and treat emergency signs, following the
adult and paediatric ETAT protocols described in Appendices A and B. The Triage Officer
should identify patients who would be more appropriately treated by the emergency case
team and, after stabilizing vital signs, should transfer these patients to the emergency case
team. If the patient does not have an emergency condition, the Triage Officer should then
determine the nature and urgency of the clients medical problem and determine the
appropriate service/case team required by the patient. If the service is not available in the
hospital then a referral should be made to another facility (see section 3.7.4 below). If the
service is available the patient should be transferred to the appropriate case team or given an
appointment for the next available date.
When scheduling appointments for the same, or a future date, staff should take all relevant
patient information into account, including:
The severity of the condition;
Distance travelled by patient;
Financial status of patient (for example financial difficulties that could prevent the
patient returning to the hospital at a future date taking into consideration transport
and/or hotel costs); and
Social circumstances of patient (for example loss of income due to absence from
work, childcare needs of dependent children etc).
The criteria by which a patient is given priority for treatment should be written and visible to
patients and staff to ensure transparency in the process.
If the patient can receive services on the same day he/she will complete all necessary
registration and payment requirements in the Central Triage and then be directed to the
relevant outpatient case team.
If the appointment is scheduled for a future date, the patient should be given an appointment
card and advised to report to the appropriate case team on the date of their appointment,
without undergoing Central Triage again. A sample Appointment Card is presented in
Appendix A, item 3 of Chapter 3 Medical Records Management.
Appointment system
Outpatient appointment systems should be established for both general outpatients and for all
specialist services provided by the hospital.
To achieve this Appointment Books should be established for each general and specialist case
team. Each Appointment Book should have a defined number of slots that are kept free for
urgent patients who undergo triage and require treatment on the same day.

Figure 4 below presents the Contents of a Sample Appointment Book for a Case Team that
can manage 15 same day treatment patients and 10 booked appointments on a single day.
Figure 4 Contents of Sample Appointment Book
Date:
Appointment Patient name Medical New or follow- For new CaseTeam
number record number up appointments,
source of
appointment (eg
Central Triage or
referred from
elsewhere)
Urgent cases, requiring same day treatment (these appointment slots should not be filled
in advance)
1
2
3 etc
15
Non urgent cases. These appointment slots can be booked in advance
16
17 etc
25
Appointments can be made following Central or Emergency Triage. During regular working
hours the Appointment Books should be maintained by the Central Triage Case Team. A
clerical staff member of the Central Triage Case Team should complete the Appointment
Book and issue Appointment Cards following the instructions of the Triage Officer. Patients
should then be directed as follows:
a) Patient to be seen on the same day: Registration and payment completed. Patients
Medical Record created or retrieved, and passed to assigned case team. Patient directed to
outpatient department waiting area.
b) Patient to be seen on future date: Appointment book completed by clerical staff member
and Appointment Card given to patient following the instructions of the Triage Officer. A
runner should assist patients from the Emergency Case Team to book follow-up
appointments if necessary. On the day of the appointment the patient should be directed
straight to the relevant case team without undergoing Central Triage.
Appointments may also be booked by other facilities through the Liaison and Referral
Service (see section 3.7.2 below)
During non-regular hours the Appointment Books should be held by the duty Liaison and
Referral Officer, who should complete the Appointment Book and issue an Appointment

Card to any patient who attends the Emergency Services during non-regular hours and who
requires outpatient follow-up.
At the start of each day runners from the respective Case Teams should ensure that the
Medical Records for all patients who have an appointment for that date are available in the
Case Team first thing in the morning.
The appointment system should be kept under review to ensure efficiency. For example if a
Case Team regularly finishes the workload early in the day, before the end of regular working
hours then the number of appointments should be increased, whereas if the Case Team
regularly fails to complete the workload during regular working hours, or patient transit time
(from arrival to completion of the episode of care) is long, then the number of appointments
may need to be reduced.
C) Central Triage Human Resource Requirements

The Central Triage Case Team consists of both clinical and non-clinical staff. Paediatric and
adult triage should be conducted separately, with separate Triage Case Teams and rooms for
adult and paediatric cases.
Ideally, triage should be carried out by a General Practitioner. However, depending on the
availability of human resources a Health Officer or BSc Nurse could conduct triage for
patients attending the outpatient department.
Non-clinical members of the Central Triage case team include runners, cashiers, registrars/
clerks and cleaners. The runners are responsible to facilitate the registration of patients and to
transport patients as needed.
The Central Triage Case Team should have ready access to the Liaison and Referrals Service
(see Section 3.7.5 below).
D) Central Triage Equipment and Supply Requirements

The Central Triage should have sufficient equipment and supplies for the patient workload.
The following is a list of the minimum items that should be available for Central Triage:
Office furniture
Examination bed x 2 (one for adult and one for paediatric cases)
Thermometer x 2
Adult stethoscope
Paediatric stethoscope
Adult sphygmomanometer (automatic or manual)
Paediatric sphygmomanometer (automatic or manual)
Adult weight scale
Paediatric weight scale/balance
Resuscitation tools

Electrocardiogram (ECG)
Pulse oximetry
Wheelchair
Stretcher
Screens, partitions or separate rooms
Gloves, face masks and other personal protective equipment
Wall clock(s)
Microphone/PA system
D) Central Triage Training Requirements

All Central Triage clinical staff should be trained to conduct triage, following the established
triage protocols. Staff should also be trained on customer service.
3.4.4 Outpatient Case Management
A) Outpatient pathway
Outpatient services should be organized as Case Teams. There should be General Case
Teams and Specialist Case Teams for all specialist services provided by the hospital. Patients
enter the outpatient case management pathway from Central Triage or directly from the
reception service if they have a pre-booked appointment. Appropriate care is then initiated by
the Case Team and based on the outcome the patient is either admitted, discharged (with or
without a further appointment) or referred.

Figure 5. Typical Pathway for Outpatients
B) Outpatient activity
The outpatient case team will take a history and examine the patient. If laboratory tests are
required samples should be collected from the patient within the outpatient department.
Ideally, samples should be collected in the initial consultation suite by a nurse or
phlebotomist, and a runner is responsible to take the sample to the laboratory testing area and
to assist the patient to make payment. If it is not possible to take a sample in the initial
consultation room then there should be a specific sample collection and payment area within
the OPD that is easily accessible to all OPD patients and has sufficient staff to prevent delay.
Runners should transport samples from the collection area to the testing laboratory and
should take all results back to the clinical case team.

The Diagnostic Imaging department should be located in close proximity to OPD and any
patient who requires imaging services should be directed there, with the assistance of a
runner, if necessary.
The results of all investigations should be taken by a runner back to the patients case team as
soon as they are available. The patient will then be reviewed by the case team and the results
of any investigations and treatment options should be explained and discussed with the
patient.
If the patient needs consultation with another Specialist this should, as far as possible, take
place on the same day. A consultation request form should be completed and this should be
given to the appropriate Specialist together with the patients Medical Record. A sample
Consultation Request Form is presented in Appendix B, item 6 Chapter 3 Medical Records
Management.
If medication is required the patient should be directed to the pharmacy dispensing unit from
where he/she will make payment (if necessary) and obtain the necessary drugs and
appropriate counselling.
Any minor procedures that are required (such as dressings change or injections) should be
carried out in the outpatient department.
If the patient needs to be admitted to hospital the case team will contact the Liaison and
Referral Service to arrange admission (emergency or elective).
C) Outpatient case team human resource needs

The hospitals outpatient services should be organized in clinical case teams according to the
clinical services provided by the hospital. Each case team should have a clinician (specialist,
physician or health officer) plus a nurse. Additionally, there should be sufficient staff to run a
pharmacy dispensing unit (pharmacy case team), to collect samples for laboratory testing and
to undertake diagnostic imaging.
Non-clinical staff required within the OPD include: runners, cashiers, cleaners and security
personnel.
The Outpatient Case Team should have ready access to the Liaison and Referrals Service (see
section 3.7.5 below).
D) Outpatient case team equipment and supply needs

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

Table 3. Equipment and Supply Needs for Outpatient Services
Equipment and Furniture Supplies
Examination bed Patient forms:
Chairs and tables History and examination sheets
Stretcher Consultation request form
Wheel chair Referral form
Stethoscope Laboratory, X ray request form
Sphygmomanometer (automated or manual) Prescription pads
Otoscope Sample collection supplies
Opthalmoscope Dressing supplies
Thermometer Personal protective equipment
Weight scale
Measuring tape
Screen for patient examination
Steam sterilizer
Minor procedure kits
Computer
3.5 Inpatient Services
3.5.1 Inpatient Services Layout
Patient wards should be located in close proximity to the emergency and outpatient
departments and should be easily accessible from elevators, ramps or stairways. Each ward
should have a functioning set of toilets, sinks and showers. There should be sufficient seating
for caregivers and visitors. If mixed-sex wards are used there should be separate areas/rooms
for male and female patients. Similarly, if adult and paediatric cases are mixed there should
be separate areas/rooms for paediatrics. All wards should have a case team station and
patients should be allocated beds such that the most critical patients are closest to the case
team station. Wards should be laid out to facilitate the collection of laboratory samples from
patients (ie sufficient space around beds for blood collection, bed screens or curtains to
maintain privacy during wound examination and swab collection, etc). Each ward should
have a procedure room where minor procedures can be performed and where simple
diagnostic tests (such as urinalysis) can be carried out.
Laboratory and pharmacy dispensary services should also be readily accessible to the
inpatient wards.
3.5.2 Inpatient Services Management and Organization
The Director of Inpatient Services should oversee all inpatient activities. Clinical and support
staff should be organized into Case Teams by type of Speciality (eg Surgery, Internal
Medicine, Paediatrics, Obstetrics and Gynaecology). Case Teams should be comprised of
specialists, general practitioners, health officers, nurses, runners, cleaners etc. Each Case
Team should be led by a Case Team Leader. Pharmacy and laboratory personnel should also
form part of inpatient services and should provide support and advice to the Clinical Case

teams on individual patient care as the need arises (see Chapter 4 Pharmacy Services and
Chapter 5 Laboratory Services for more information).
3.5.3 Inpatient Case Management
A) Admission process
All admissions should be arranged through the Liaison Service following the process
described in Sections 3.7.2 and 3.7.3 below.
The Hospital should have a written protocol for the admission of patients that includes all
steps to be taken in the admission process including how to arrange admission, and the
activities to be undertaken when the patient arrives on the ward. This should be known by,
and adhered to by all relevant staff.
Upon arrival on the ward the patient should be received by a nurse who will initiate the ward
admission process, including orientation to the facilities (such as toilet and showers),
instructions for care-givers etc.
The patient should be assessed by a medical doctor upon arrival on the ward and a History
and Physical Examination Assessment should be completed. This should include the
immediate management plan for the patient. A sample History and Physical Examination
Assessment Form is presented in Appendix B, item 4 Chapter 3 Medical Records
Management.
Additionally, a Nursing Assessment should be completed within 24 hours of admission and a

Nursing Care Plan Developed. For further information on the Nursing Process, including
sample formats, see Chapter 6 Nursing Care Standards.

Figure 6. Typical Pathway for Inpatient Admission.
B) Inpatient activity
After the initial assessment by the physician, the patient should be reviewed regularly (at
least once a day) by the relevant Case Team and all clinical contact should be documented in
the Medical Record using a hospital Progress Sheet (see Appendix B, Chapter 3 Medical
Records Management).
Any required investigations should be ordered on the relevant request forms. Laboratory
specimens should be collected from the patient while on the ward. If the patient requires an
X-Ray or ultrasound investigations he/she should be directed to the relevant department,
transported to the department using a wheelchair or stretcher and accompanied by a runner or
clinical staff member if necessary.

Medications should be administered and documented using standardized formats.
Samples of all Medical Record Forms, including Investigation Order and Report Forms,
Medication Administration Record etc, are presented in Appendix B of Chapter 3 Medical
Records Management.
As part of inpatient services particular attention should be given to the the organization of
operating theatre activities, Box A presents recommendation on operating theatre
management and layout.
Box A Operating Theatre
Management: The Operating Theatre should be under the team leader (or equivalent) of
surgical services who is accountable to the Inpatient Services Director.
Layout: For a successful outcome of the operation in terms of healing the wound,
decreasing blood loss and controlling pain, the OR should be a place that is comfortable
and unobstructed by the movement of other staff. It should have a table that is strong
enough to hold the patient and is easy to clean.
The Operating Theatre should have basic services of water, light and medical gasses and an
adequate place to store instrument. The number of OR tables depends on the number of
beds of the hospital. There should be one OR table for every 25 surgical beds. Ideally, the
Operating Theatre should be located on the floor as the surgical ward and should be
connected to the ward by the simplest possible route. Preferably the Operating Theatre
should adjoin the sterilization units, delivery suites and intensive care unit.
The following service areas are needed in an operating theatre suite:

1. Reception and office area
2. Transfer area: large enough to transfer a patient from bed to trolley
3. Holding bay: to allow supervision of patients waiting for the OR
4. Staff changing room
5. Operating theatre
6. Scrub room
7. Trolley parking
8. Recovery room
Equipment and Staff: should be provided as per the national standard for general and
specialized hospitals.

The intensive care unit of a hospital should also be given attention. Box B presents
recommendation on ICU management.
Box B. Intensive Care Unit (ICU)

The ICU, also called critical care unit, is a specialized unit in a hospital that provides
intensive care medicine. Many hospitals have also designated areas for intensive care for
certain specialties. Examples include; neonatal, medical, surgical, cardiac etc. The ICU is
for critically ill patients who need constant medical attention and highly specialized
equipment, to control bleeding, support breathing, control toxemia and prevent shock.
Patients come from the recovery room of the operation theatre, from wards, or from
emergency or outpatient units.
Management: The management of the intensive care unit should be under the team leader
of the respective specialty who is accountable to the Inpatient Director or equivalent.
The layout of intensive care unit depends on the type of intensive care unit that a hospital
has.
However, the following points are applicable:

The ICU should be adjacent to the operating theatre and recovery unit.
The number of beds should be approximately 1-2% of the total number of beds of
the hospital.
Preferably, the ICU should have a controlled environment with medical gasses
and power sources.
Equipment and Staff should be provided as per the national standard for general and
specialized hospitals.
C) Discharge Process
The hospital should establish a written protocol for the discharge of patients stating all the
steps to be followed when arranging discharge, including preparation of a discharge summary
and handling of the medical record after discharge. In particular, when a patient is ready for
discharge he/she should be counselled by a member of the Case Team. This should include:
An explanation of the patients diagnosis, investigation results and treatments given
An explanation of any medications that the patient should continue to take upon
discharge
Any necessary follow up arrangements
A discussion of any warning signs that the patient should be aware of and for which
he/she should seek medical attention
The decision for discharge should be made by a physician who should complete a discharge
summary for the patient. A copy of the discharge summary should be given to the patient and
a second copy filed in the Medical Record. If a patient was referred from another facility the

discharging physician should also complete the feedback section of the Referral Paper. A
Sample Discharge Summary is presented in Appendix B, item 21 of Chapter 3 Medical
Records Management.
D) Patient death
If a patient dies in the hospital the death should be confirmed by a physician. A death
summary should be completed and should be documented in the patients medical record. A
sample Death Summary is presented in Appendix B of Chapter 3 Medical Records
Management. If it is necessary to confirm the cause of death a post mortem examination
form should be completed and the body should be transferred to the pathology case team for
post mortem examination. A sample Post Mortem Request Form is presented in Appendix B,
item 22 of Chapter 3 Medical Records Management. When all necessary medical
examinations are complete the body should be stored in the hospital morgue until collection
by the patients relatives or other responsible person. If the patient does not have a next of
kin, the local authority is responsible for collecting the body.
All unexpected deaths should be reported to, and investigated by, the hospital Mortality
Committee. For further information on roles of the Mortality Committee see Section 3.3.2 of
Chapter 12 Quality Management.
E) Inpatient Service Human Resource Requirements

Inpatient services should be provided by Case Teams comprised of:
Specialist (s)
General practitioner(s)
Nurses
Porters/runners
Cleaners
Laboratory and Pharmacy staff should also be assigned to each Case Team. It may not be
necessary for Laboratory and Pharmacy personnel to attend every ward round or case team
meeting. However the frequency with which Laboratory and Pharmacy personnel meet with
the case team and/or participate in ward rounds should be sufficient to ensure that each can
provide appropriate advice to the case team on individual patient care when needed (see
Chapter 4 Pharmacy Services and Chapter 5 Laboratory Services).
F) Inpatient Service Equipment and Supply Requirements

The minimum equipment and supplies for patient wards include:
beds, mattress, pillows, linens and blankets
chairs, tables, and bed side tables
bed screens
emergency trolley with resuscitation equipment and emergency drugs
oxygen
suction machine

stethoscope(s)
sphygmomanometer(s)
thermometer(s)
tendon hammer
weight scale
pulse oximeter
IV stands
trolleys, wheelchairs and stretchers
dressing sets
minor procedure sets according to the type of ward/case team
personal protective equipment
3.6 Delivery Services
3.6.1 Delivery Services Layout
The Delivery Service is comprised of the antenatal and postnatal ward(s), delivery suite
(labour and delivery rooms) and the neonatal unit. An operating room(s) should be readily
accessible. Ideally, there should be a specific operating theatre(s) for the delivery suite but if
this is not possible the general operating theatre should be located nearby and obstetric cases
should be given priority over other surgical cases to minimize delay and prevent avoidable
maternal and perinatal deaths.
Ideally the delivery suite should be located on the ground floor and should be easily
accessible to stretchers, wheelchairs and ambulances. The antenatal, postnatal and neonatal
wards should be located adjacent to, or nearby the delivery suite. The delivery suite should be
organized sequentially as follows: pre-delivery assessment, observation room(s), delivery
room(s) equipped with equipment for neonatal resuscitation, and post-delivery room(s). The
delivery suite should also be equipped with patient toilets, sinks and showers. The delivery
suite should have a nurses station, staff changing facilities and a store.
There should be an emergency drug supply within the delivery suite for all essential
maternity and neonatal drugs.
3.6.2 Delivery Services Management and Organization
The Maternity Services will be led by the Director of Inpatient Services. He/she is
responsible to oversee all activities and ensure sufficient manpower, equipment and supplies
for safe delivery services.

3.6.3 Delivery Services Case Management
A) Delivery Services Pathway

Labouring mothers should be directed immediately to the delivery suite by the reception
service. Assistance may be provided by a runner, using a wheelchair or stretcher if necessary.
Within the delivery suite the patient will be assessed by the Midwife in Charge. At the same
time all relevant administrative processes (registration, medical record retrieval, payment etc)
will be conducted with the assistance of a runner. The patient will be admitted, discharged or
referred to another facility according to her status and the availability of the necessary service
in the receiving facility.
Figure 7. Typical Pathway for Delivering Mothers
A: Inpatient service flow D: Discharge service flow DR: Delivery service flow: DI: Diagnostic Imaging Service flow E:
Epidemic notification flow ER: Emergency Service flow F: Pharmacy service flow L: Laboratory service flow O:
Outpatient service flow R: Registration service. Source: Adapted from Federal Democratic Republic of Ethiopia Minsitry of
Health. (2008). Curative, Rehabilitative and Treatment Sub-Business Process. The New General and Specialized Hospital
Business Process Study Report.

B) Delivery Services Activities
Upon arrival in the delivery suite the labouring mother should be assessed for signs of, and
the stage, of labour. An assessment of foetal wellbeing (using foetoscope, doppler or
cardiotocograph) should also be conducted.
If the mother is in labour a partograph should be commenced and labour and delivery
managed accordingly.
If laboratory investigations are required the sample should be collected in the delivery suite
and taken to the testing area by a runner. Payment should be facilitated by a runner.
Normal and complicated deliveries should be managed in the delivery suite including:
Assisted vaginal delivery, preferably with vacuum
Manual removal of placenta
Blood transfusion
Neonatal resuscitation.
If Caesarean section is required the patient should be transferred immediately to the operating
theatre where surgery should be performed without delay (ideally within 30 minutes from the
time at which the decision to operate was made).
After normal delivery the mother and neonate should remain in the hospital for 6 hours and
may then be discharged if both are in a stable condition.
If there is an obstetric complication that cannot be managed by the hospital then the patient
should be referred to another facility by the Liaison and Referral Service, following the
process described in section 3.7.4 below.
Before discharge all patients should be advised to attend for postnatal care. Those with
uncomplicated, normal deliveries should be advised to receive postnatal care at a primary
healthcare unit (health post or health centre). Those with complications (such as Caesarean
Section, eclampsia, haemorrhage etc) may be advised to return to the hospital for postnatal
care, and an appointment should be given before discharge (see Section 3.7.3 below).
C) Delivery service human resource requirements

The delivery service case team is comprised of clinical and support staff as follows:
Obstetrician(s)
General physician (s)
Paediatrician(s)
Anaesthetist(s)
Midwife Nurses
Porter/runner
Cleaners etc
D) Delivery Suite Equipment and Supply Requirements

The minimum equipment and supplies for the delivery service include:
Beds, mattresses, pillows, blankets, linens etc
Chairs, bed side tables/lockers
Bed screens
Delivery beds
Examination couches
Thermometer(s)
Sphygmomanometer(s)
Tendon hammer(s)
Stethoscope(s)
Foetoscope(s) or Foetal Doppler
Adult weight scale
Neonatal weight scale
Oxygen (cylinder with flow meter or oxygen concentrator) with face mask and
connectors
Suction machine and tubes
Ambu-bag and airways
IV stands
Vacuum extractor (preferably with silastic cups of various sizes)
Procedure kits:
o Delivery set
o Episiotomy set
o Perineal suture set
o Manual Vacuum Aspiration Set
o Craniotomy set
Personal protective equipment
Neonatal cots
Neonatal heater/baby warmer(s)
Neonatal incubator (s)
Stretchers and wheelchair
Patient trolley(s)
Emergency drugs
Wall clock
3.7 Liaison and Referral Service
Each hospital should establish a Liaison and Referral Service that is responsible to:
1. Manage hospital bed occupancy (bed management)
2. Facilitate emergency and non-emergency (elective) admissions
3. Provide social service support to the Emergency, Inpatient and Outpatient Case
Teams
4. Manage the referral service, specifically:
Coordinate the overall referral activities within the health facility

Record and report the referral activities to facility management
Compile, analyze and interpret data to improve the referral service
Take part in the quality assurance programs of the referral system by participating
in regular review meetings within and outside the health facility
Perform supportive supervision
Ensure feedback is sent back to the referring health facility
The Liaison and Referral Service is staffed by Liaison Officers. Each hospital should
determine the number of Liaison Officers required based on the caseload. If the number of
admissions and/or referrals is high, then at least one Liaison Officer should be assigned to the
Outpatient Case Team and another to the Emergency Case Team. However if the number of
admissions and/or referrals is low then a single Liaison Officer could be responsible for all
Liaison and Referral Services, providing he/she is readily accessible to each Case Team by
telephone, pager or via a runner.
Additionally, the Liaison and Referral Service should include at least one social worker.
Social work assessment, advice and any necessary follow up is particularly important for
emergency and paediatric cases, and should also be provided for any patient where social
work assessment is requested by the relevant clinical case team.
The Liaison and Referral Service should establish and regularly update a Hospital Service
Directory which includes:
information about services provided by the hospital,
contact information for key services (such as emergency, outpatient, inpatient, and
delivery case teams, laboratory, radiology services etc), and.
a map indicating the layout of hospital services.
Copies of the Service Directory should be distributed to Emergency, Outpatient and Inpatient
Case Teams in addition to hospital managers.
3.7.1 Bed Management

The aim of bed management is to make maximum use of hospital beds, ensuring high bed
occupancy, high patient turnover and minimum waiting times for elective admission.
Bed management is also a critical function of Major Incident Planning and Management (See
Section 3.8.5 of Chapter 8 Facilities Management.
Steps to achieve the above include:
a) Reduce length of stay

No patient should remain in hospital any longer than is necessary. Patients are often not
discharged when ready because:
Ward rounds are irregular or infrequent and there is no one to authorize discharge,
Required investigations or procedures are not carried out in a timely manner,

There is a delay in arranging necessary follow up appointments, discharge or referral
papers, or
The hospital does not provide administrative or cashier functions to handle discharges
24 hours a day, 365 days a year.
A pro-active approach should be taken to minimized length of stay. Discharge planning

should begin at the point of admission of each and every patient when the admitting
physician should outline a plan of action, including investigations and procedures for the
patient. Ward rounds should be conducted daily and the case team should ensure that each
day the treatment plan is being followed or modified as required. On each ward round case
teams should consider the possible discharge date for each patient and should plan
accordingly, ensuring that all necessary investigations and procedures are carried out
promptly, referral papers are prepared etc.
Patients should be discharged every day of the week and hence ward rounds should be
conducted daily to authorize discharge and all necessary administrative/payment functions
required for discharge should be available on each and every day.
b) Make greater use of day surgery

Many surgical procedures can be carried out as day cases. Each hospital should establish a
list of procedures that may be performed as day surgery. An example is given in Appendix C.
Day surgery requires a pre-operative assessment at which the patient is assessed for
suitability as a day surgical case and appropriate pre-operative instructions (for example the
need to fast prior to general anaesthesia, medication use etc) are given to the patient. When
considering a patient for day surgery the following should be considered:
The type of procedure
The general health of the patient (for example patients with cardiac or respiratory
disease are generally not suitable as day cases)
Medications taken by patient (for example those on anticoagulant treatment may not
be suitable for day surgery)
The social circumstances of the patient (for example patients who do not have a
responsible adult to care for them at home, or who must travel a long distance to reach
home after surgery may not be suitable for day surgery)
Each hospital should strive to increase the proportion of day surgery carried out. The Director
of Inpatient Services should monitor the proportion of surgery that is carried out as day
surgery and report this to the Chief Clinical Officer on a regular basis (eg monthly). The
proportion of all surgery that is carried out as Day Surgery could also be included as one of
the indicators that is included within the Balanced Scorecard and regularly monitored by the
Governing Board (see Chapter 13 Monitoring and Reporting)
c) Manage the admission process

All admissions should be co-ordinated through the Liaison and Referral Service. Priority
should be given to emergency cases.

Effective management of the admission process requires knowledge of:
1. The total number of beds
2. The number of occupied beds at the midnight census (bed occupancy)
3. The number of beds that are due to be vacated or could be vacated that day
4. The number of reserved beds for elective admissions that day, the urgency of and reason
for admission, and length of time on the waiting list for that patient.
Each night, at midnight, every ward or inpatient case team should count the number of
occupied beds. This number should be reported to the Liaison and Referral Service at the start
of the working day. Each ward/case team should also determine the number of patients due to
be discharged that day, and this number should also be reported to the Liaison and Referral
Service.
At the same time, the Liaison and Referral Service should keep a record of the number of
elective admissions to each ward/case team expected for the day.
The number of available beds available in each Case Team can be calculated on a daily basis
as follows:
Number of available beds

= total number of beds minus number of occupied beds plus number of expected
discharges minus number of elective admissions.
The above calculation should be done on a daily basis for each ward/case team and for the
hospital as a whole.
3.7.2 Elective Admission Process

Elective admissions may be booked by the Outpatient Case Team or Emergency Case Team.
When a patient requires elective admission a clinical member of the relevant Case Team
should contact the Liaison Service providing, as a minimum, the following information:
Patient name and medical record number,
Summary of clinical history and reason for admission,
Case team to which patient should be admitted (for example surgical case team,
internal medicine case team etc), and
Urgency of admission.
The Liaison and Referral Service should book the admission date and bed and give an
appointment card to the patient.
On the day of admission the patient should report to the Liaison Officer and from there he/she
will be assisted to make any necessary payment or registration and will be directed to the
relevant Inpatient Case Team/Ward.

On a daily basis the Liaison Officer should inform each Inpatient Case Team of any planned
admissions for the following day to ensure that the required service is available and allow the
Case Team to make all necessary preparations for the admission.
3.7.3 Emergency Admission Process
If the patient is to be admitted as an emergency a clinical member of the relevant Case Team
should contact the Liaison Service providing, as a minimum, the following information:
Patient name and medical record number,
Summary of clinical history and reason for admission,
Case team to which patient should be admitted (for example surgical case team,
internal medicine case team etc), and
Urgency of admission.
When a request for admission is made the Liaison Officer should follow the steps below:
1. Is a bed immediately available in the relevant inpatient case team/ward?
If yes admit patient.
The Liaison Officer should inform the Case Team Leader of the admission and the patient
should be transferred to the ward and any necessary administrative tasks carried out with
the assistance of a runner.
2. Is there any patient in the relevant case team/ward due to be discharged that day?
If yes confirm that patient will be discharged. Identify and address any factors that are
delaying discharge. Consider moving patient to Transit Lounge (if available) or another
waiting area. In this way the bed can be freed and the new patient can be admitted.
Box C Transit Lounge
A Transit Lounge is an area where patients can wait for either admission or
discharge. Similar to an airport, the Transit Lounge is a holding area for patients
who are either on their way into or out of the inpatient wards.
Patients who are due for discharge but who are awaiting administrative tasks (such
as awaiting medication, referral papers for bill payment) can be asked to wait in the
Transit Lounge for completion of these activities. In this way their bed becomes
empty and is available for another admission.
Similarly, a patient who is being admitted to the hospital may be asked to wait in the
Transit Lounge until his/her bed is prepared.
The Transit Lounge should ideally be located within Inpatient Services at a place
that is easily accessible to all inpatient wards.

3. Is a bed available within another case team/ward?
If yes discuss with Director of Inpatient Services, and if appropriate, admit patient to
that bed and inform the Leader of the Inpatient Case Team that is responsible for the
patient where the patient is located. Ensure that the patient is transferred to correct case
team bed/ward as soon as a bed there becomes available.
4. Is there an elective admission that could be cancelled to make a bed available for the
patient?
As far as possible, planned admissions should not be cancelled. However depending on
the priority it may be necessary to do so. Factors to be considered are:
The clinical urgency of both the planned admission and the emergency patient
requiring admission
The time on waiting list, distance travelled and other pertinent social circumstances of
the elective case
The availability of a bed in another facility for the emergency patient requiring
admission, and the distance to reach that facility
If a bed can be made available by any of the steps above then the patient should be admitted.
If a bed is not available, or if the required service is not available at the hospital then the
patient should be referred to another facility (see section 3.7.4 below).
3.7.4 Referral Service
Each hospital should establish a Referral Protocol that outlines the criteria for making a
referral to another facility and the process to be followed when making a referral, including
use of the Referral and Feedback Form and any necessary clinical documents that should
accompany the referred patient. The protocol should be known and adhered to by all relevant
staff.
Each hospital should establish a Referrals Service Directory that lists facilities to/from which
patients can be referred or received and the services available at each facility (the Referral
Network). The contact details of each facility in the Referral Network should be documented.
The criteria for receiving/referring patients to each facility should also be documented and
agreed between all facilities participating in the Network. Standardized Referral and
Feedback formats should be used by all facilities participating in the Network.
A sample Referral and Feedback Form is presented in Appendix B, item 24 of Chapter 3

Medical Records Management. For further guidance please also refer to the National
Guideline for Implementation of a Patient Referral System.

Box D Referral Network and Emergency Command Centre
A Referral Network is a group of facilities that, in aggregate, provide comprehensive

health care services in a defined geographical area. The Referral Network is comprised of
both Referring and Receiving Units.
Each member of the Referral Network should have a Directory of Services and
Organizations within the network, including contact information.
A standardized referral format should be used by each member of the Referral Network.
Ideally, the Referral Network should be developed by the Regional Health Bureau and
should include a functioning transport system, with a Unit responsible to co-ordinate and
oversee referral activities.
Regions may also establish an Emergency Command Centre to direct emergency patients
to an appropriate facility for treatment. If a Command Centre exists then each hospital
Liaison and Referral Service should provide regular updates to the Command Centre on
the number of beds available in the hospital. If an emergency case arrives at the hospital,
but cannot be handled by the hospital Emergency Service, or if no bed is available, then
the Liaison and Referral Officer may contact the Emergency Command Centre to identify
an alternative hospital to which the patient should be referred.
A hospital can be both a Receiving Unit for patients referred from other facilities and a
Referring Unit to refer patients to another facility.
Referrals can be made for both outpatient services and for inpatient admissions.
a) The hospital as a Receiving Unit

The Liaison and Referral Service should maintain a Directory of all services that are available
in the facility and should have an assigned telephone number and/or fax number that can be
called by other facilities when making a referral request. This telephone/fax number should
be circulated to other facilities in the Referral Network.
i) Receiving inpatient referrals

At the start of each working day the number of beds available in the facility should be
ascertained by the Liaison and Referral Service (see section 3.7.1 above). When another
facility phones/faxes the service to request an emergency admission the Liaison Officer
can check bed and service availability, and if appropriate, agree to accept the referral. The
Liaison Officer should then inform the Reception Service and the relevant Case Team
(Emergency or Inpatient) so that the patient can be directed straight to the Case
Team/Ward on arrival.
If the referral is non-urgent, an elective admission date can be given and the Referring
Unit should be instructed to pass this information onto the patient, advising him/her to
present to the Liaison Officer on the assigned date. As described under section 3.7.2
above, the Liaison and Referral Service should include these patients in the elective
admission list that is presented to the Inpatient Case Teams on a daily basis.
ii) Receiving outpatient referrals
If a telephone/fax request for an outpatient appointment is made, the Liaison Officer
should obtain all relevant patient details and confirm that the referral is appropriate. The
Liaison Officer should then book an appointment in the Appointment Book of the
relevant Outpatient Case Team (see section 3.4.3 above) and give this appointment date
to the Referring Unit, instructing the Referrer to pass this information onto the patient and
to advise him/her to present at the Outpatient Department on the assigned date.
Patients who have been given appointments in this way should be directed by the
reception service straight to the inpatient ward or to the Outpatient Case Team (without
undergoing Central Triage).
iii) Receiving patients who are referred without a pre-booked appointment

If a patient attends the hospital with a referral paper but without a pre-booked
appointment, then he/she must first be directed to Central Triage where the
appropriateness and urgency of the case will be determined and subsequent Case
Management conducted.
iv) Providing feedback on referrals

The Feedback section of the referral paper should be completed by a physician. This
should include a summary of the patient history, examination, investigation results,
treatments given, future management plan/advise and any follow up appointments (if
relevant). A copy should be given to the patient, a second copy should be faxed (or sent
by alternative means) to the referring unit, and a third copy should be kept in the patients
medical record.
b) The hospital as a Referring Unit

All referrals from the hospital should be handled by the Liaison and Referral Service.
Referrals may be necessary if:

The service required is not available in the facility, or
A bed is not available in the facility.
To make a referral, a clinical member of the patients Case Team should contact the Liaison
and Referral Service and provide information on the case. The Liaison and Referral Service
will advise whether a referral is necessary. If referral is necessary the Case Team member
should complete the relevant clinical sections of the Referral and Feedback Form and give
this to the Liaison Officer. The Liaison Officer should contact the most appropriate facility in
the network (in accordance with policies established in the Referral Network Directory) and
request the referral. If the patient is an emergency case and an Emergency Command Centre
exists then the Liaison Officer should contact the Emergency Command Centre in the first
instance. Once the referral has been agreed the Liaison Officer should complete the relevant
administrative details on the Referral and Feedback Form. A copy of the Form should be kept
in the patients Medical Record and a copy should be given to the patient. Ideally, the Form
should also be faxed to the Receiving Unit. The Liaison Officer should ensure that the patient

has any necessary transport to reach the Receiving Unit, making use of a hospital vehicle if
necessary.
If the required service and/or bed is not available in another facility then the hospital should
keep the patient and provide treatment as necessary until the patient can be discharged or
until the service and/or bed becomes available in another facility.
c) Follow up and audit of received and referred patients

The Liaison and Referral Service should keep a Register of all referrals received by and made
from the facility. As a Receiving Unit the hospital should ensure that a summary of the
patient attendance is prepared and sent back to the Referring Unit. As a Referring Unit the
hospital should establish a mechanism to track all referrals and ensure that Feedback Forms
are received for all patients who were referred by the facility. If Feedback Forms do not
arrive when expected, the Liaison Officer should follow up with the Receiving Unit to check
that the patient attended and to request a copy of the Feedback Form.
The Liaison and Referral Service should prepare regular (eg quarterly) reports on referral
activities including:
1. The number of referrals accepted for outpatient appointments (by speciality if

appropriate)
2. The number of referrals accepted for inpatient admissions (by speciality if
appropriate)
3. The number of referrals made for outpatient appointments at another facility (by
speciality if appropriate)
4. The number of referrals made for inpatient admission at another facility (by speciality
if appropriate)
5. A breakdown, by facility name, or referrals received and referrals made
The number of referrals received and made by the hospital, as a proportion of all attendances,
could be included as indicators in the Balanced Scorecard and monitored regularly by the
Governing Board (see Chapter 13 Monitoring and Reporting).
3.7.5 Availability of Liaison and Referral Service
The Liaison and Referral Service should be available 24 hours a day, 365 days a year.
Possible options to achieve this include:
1. If the caseload is high there should be a Liaison Officer on shift within the Emergency
Department providing 24 hour cover, 365 days a year; or
2. If the caseload is low, the Emergency Case Team could handle admissions and referrals
during out of hours periods. To achieve this, at the end of each working day the Liaison
Service should provide information to the Emergency Department indicating the number
and location of beds available in the hospital. A member of the Emergency Case Team on
shift during each out of hours period should be assigned as Deputy Liaison Officer for
the duration of that shift. He/she is responsible to facilitate emergency admissions to the
available beds and to arrange emergency referrals (following hospital protocols) if a bed
is not available. If an outpatient appointment is necessary this can be arranged by the
Deputy Liaison Officer by booking the appointment in the Appointment Book of the
relevant Outpatient Case Team.
If the second option is selected then the Liaison and Referral Service should collect a record
of patients admitted or referred from the Emergency Department at the start of each working
day.
3.7.6 Promotion of Referral Network
The hospital should collaborate with other facilities in the network and the Regional Health
Bureau to promote, monitor and evaluate the referral system. In particular, the hospital should
promote and publicize the referral system through the community in order to ensure that all
constituents are aware of the applicable service pathway. For further guidance on
mechanisms to inform and involve the community see Section 3.1.5 of Chapter 12 Quality
Management.

In order to determine if the Operational Standards of Patient Flow have been met by the
hospital an assessment tool has been developed which describes criteria for the attainment of
a Standard and a method of assessment. This tool can be used by hospital management or by
an external body such as the RHB or FMOH to measure attainment of each Operational
Standard. The tool is presented in Appendix E of Chapter 13 Monitoring and Reporting.
implementation activites.
Table 4. Patient Flow Checklist

Yes No
1. There is an emergency triage.
2. There is a central triage.
3. There are personnel trained in triage processes working in both the central
and emergency triages.
4. Emergency and central triages are equipped with necessary supplies and
equipment.
5. Outpatient appointment system is in place.
6. There is an appointment system for elective inpatient admission.
7. A Liaison and Referral officer has been assigned.
8. There is a written protocol for admission and discharge of patients.
9. There is a written protocol for the referral of patients (receiving into the
hospital and referring outside of the hospital).
10. There is a referral directory listing that facilities that hospitals can recieve
patients from or refer patients to.
11. Bed occupancy information is gathered and reported.
4.3 Indicators
effectiveness/outcomes of implementation of the above recommendations.
Table 5. Patient Flow Indicators

S/N Indicators Formula Frequency Comments
1. The number of new and repeat Quarterly HMIS
outpatient visits (including indicator
emergencies and specialized clinics
such as ART, VCT) during reporting
Total OPD attendances period
2. Number of ER attendances Total number of ER attendances Quarterly
3. a) Number of emergency a) Total number of ER inpatient Quarterly

inpatient admissions admissions
b) % of total admissions b) Total number of ER inpatient
admissions/total number of
admissions *100
4. a) Number of elective a) Total number of elective Quarterly

inpatient admissions inpatient admissions
b) % of total admissions b) Total number of elective
inpatient admissions/total
number of admissions *100
5. Number of major surgeries Total number of major surgeries/ Quarterly HMIS

per surgeon total number of surgeons indicator
6. Total length of stay in days (sum Quarterly HMIS

total of each daily patient indicator
Inpatient days per doctor census)/number of physicians

total of each daily patient indicator
Inpatient days per nurse census)/number of nurses

Inpatient days per other total of each daily patient indicator
clinical staff census)/number of other clinical staff
9. Number of doctors/Average number Quarterly HMIS

Doctors per bed of beds indicator
10. Number of nurses/Average number Quarterly HMIS

Nurses per bed of beds indicator
11. Number of other clinical staff/ Quarterly HMIS

Other clinical staff per bed Average number of beds indicator
12. Number of OPD visits per Number of outpatient visits/(number Quarterly HMIS

practitioner per day of OPD practitioners *22*number of indicator
months in period)
13. ER wait time to triage triage wait time/number of Quarterly HMIS

[Average time from arrival at attendances indicator
the emergency department to
initiation of triage
(minutes);]
14. OP wait time to triage triage wait time/number of Quarterly HMIS

[Average time from arrival at attendances indicator
the outpatient department to
initiation of triage (minutes)]
15. time from beginning of OPD Quarterly HMIS

consultation to discharge from the indicator
facility (following completion of
investigations and purchase of any
necessary drugs)/ number of
OP consulation transit time attendances

total of each daily inpatient census) indicator
during reporting period /[number of
beds available * number of days in
Bed Occupancy rate reporting period]
17. Total number of discharges Quarterly HMIS

(including transfer outs and indicator
deaths)/average number of beds in
Bed Turnover rate reporting period

total of each daily patient census) indicator
Average length of stay during reporting period /[total
(ALOS) discahrges + transfer outs and deaths]
19. Delay for elective medical number of days on waiting Quarterly

inpatient admission list/number of patients
20. Delay for elective surgical number of days on waiting Quarterly

inpatient admission list/number of patients
21. number of days in hospital Quarterly

Delay from inpatient awaiting surgery/number of elective
admission to surgery surgical admissions
22. a) Number of referrals a) The total number of OPD, ER or Quarterly

made to other facilities admitted patients who were
b) Referral rate (referrals referred to another facility with a
made to other facilities) referral paper
b) The total number of OPD, ER or
admitted patients who were
referred to another facility with a
referral paper / total OPD visits,
ER visits and inpatient
admissions*100
23. a) Number of referrals a) The total number of OPD visits, Quarterly

accepted from other ER visits and inpatient
admissions who were referred
health facilities from another facility with a
b) Proportion of all referral paper
attendances that were b) The total number of OPD visits,
referred from another ER visits and inpatient
facility admissions who were referred
from another facility with a
referral paper / total OPD visits,
ER visits and inpatient
admissions*100
24. % of inpatients indicating The number of inpatients that Biannual Survey tool
that it was it easy to find responded yes to the question on the presented in
their way around the health patient survey Was it easy to find Appendix F
facility. your way around the health of Chapter 12
facility?/total number of Quality
respondents *100 Management
25. % of outpatients indicating The number of outpatients that Biannual Survey tool
that it was easy to find their responded yes to the question on the presented in
way around the health patient survey Was it easy to find Appendix F
facility your way around the health of Chapter 12
facility?/total number of Quality Mgt
respondents*100
Source documents
1. Federal Democratic Republic of Ethiopia Minsitry of Health. (2008). Curative,

Rehabilitative and Treatment Sub-Business Process. The New General and Specialized
Hospital Business Process Study Report. Addis Ababa, Ethiopia.
2. Federal Democratic Republic of Ethiopia Minsitry of Health. (2009, November).

Guideline for Implementation of a Patient Referral System. Addis Ababa.
3. Federal Democratic Republic of Ethiopia Minsitry of Health. (2008, October). Patient

Flow: A Manual Prepared for Heads of Hospitals and Service Providers. Addis Ababa,
Ethiopia
4. WHO. (2005). Pocket Book of Hospital Care For Children. Guidelines for the
Management of Common Illnesses with Limited Resources. Geneva: World Health
Organization.
5. WHO. (2005). Emergency Treatment and Triage: Participant Manual. Geneva: World
Health Organization.

Appendices
Chapter 2 Patient Flow

Appendix A WHO Paediatric Emergency Triage and Treatment
(ETAT) Guidelines
Chapter 2 Patient Flow Appendix A: Page 1 of 10

Appendix B: Sample Adult Emergency Triage and Treatment
Protocol
Note: The following is a guide only. Each hospital should develop a detailed ETAT protocol
for the triage and emergency treatment of adult patients.
The triage and treatment of adult patients should be conducted in the following order, with all
necessary action taken at each step of the assessment:
A = airway: if obstructed OPEN THE AIRWAY

clear foreign body or secretions +/-
insert oral or nasopharyngeal airway +/-
intubate +/-
perform tracheostomy.
give oxygen
B = breathing: if absent, irregular or shallow BEGIN ARTICIFICIAL VENTILATION

bag and mask, with oxygen +/-
intubate
look for signs of impaired respiration such as pneumothorax, flail chest etc
o insert chest drain or perform other corrective action as necessary
C = circulation:
a) heart beat absent RESTORE CARDIAC FUNCTION:
begin CPR
connect to ECG
give cardiac drugs or defibrillate as appropriate
b) if pulse weak or irregular
connect to ECG
treat any arrhythmia found with appropriate drugs
c) if haemorrahge control bleeding
wound pressure
insert IV lines (2, large bore cannulae)
give IV fluids
D = disability: After the patients airway, breathing and circulation have been stabilized a
full assessment should be undertaken, examining the body from head to toe looking for signs
of injury or disease.
Chapter 2 Patient Flow Appendix B: Page 1 of 1

Appendix C List of Possible Day Surgery Procedures
Hernia Repair
Umbilical
Femoral
Inguinal
Incisional
Epigastric
Mass/Cyst
Excision
Breast
Submandibular
Other (Bakers Cyst, Uncomplicated lipoma)
Urological
Surgery
Varicocele Ligation
Hydrocele Ligation
Uretheral Dilatation
Rectal Surgery
Hemorrhoidectomy
Fistula-en-Ano correction
Thyroid Surgery
Small Cyst/Nodule excision
ENT Surgery
Nasal Polyp removal
Soft Palate surgery
Orthopaedics
External Fixation
Wire Removal and Plating Procedures
Miscellaneous
Varicose Vein Stripping
Genital Warts Removal
Abscess Drainage
Biopsy
Chapter 2 Patient Flow Appendix C: Page 1 of 1

Medical Record Management
Page 1 of 27
Section 2 Operational Standards for Medical Record Management 5
3.1 Retrieval of Existing MRN or Generation of New MRN 6
3.1.1 Master Patient Index
3.1.2 Patient registration
3.1.3 Starting a Medical Record for a new patient
3.1.4 Service Card
3.1.5 Storage of Medical Records
3.1.6 Retrieving existing Medical Record for a returning patient
3.1.7 Appointment Card
3.2 Documenting Patient Information 11
3.2.1 Purpose of clinical documentation
3.2.2 How and when to document
3.2.3 General rules in clinical documentation
3.2.4 Standardized documentation and forms
3.2.5 Key components of clinical documentation and Medical Record forms
3.2.6 Correcting medical record data
3.3 Handling of Medical Records 18
3.3.1 Tracking the location of Medical Records
3.3.2 Who should handle Medical Records?
3.3.3 Archiving Medical Records
3.3.4 Medical Records at discharge
3.3.5 Destruction of inactive Medical Records
3.3.6 Removal of Medical Records from hospital
3.3.7 Confidentiality
3.4 Basic requirements for establishing a Medical Record Management System 21
3.5 Human Resources for the Medical Records Department 23
3.6 Medico-legal Issues and Procedures 24
4.3 Indicators 27
Source Documents 27
Appendices
Appendix A Template of forms used in Medical Records Department
Chapter 3 Medical Records Management Page 2 of 27

Item 1 Master Patient Index Card
Item 2 Service Card
Item 3 Appointment Card
Item 4 Hospital Tracer Card
Appendix B Template of forms that are included in a Medical Record

Item 1 Demographic Sheet
Item 2 Summary Sheet
Item 3 Admission and discharge card
Item 4 History and physical examination assessment
Item 5 Progress notes
Item 6 Consultation request form
Item 7 Consent form
Item 8 Physician order sheet
Item 9 Haematology Order and Report Form
Item 10 Clinical Chemistry Order and Report Form
Item 11 Serology Order and Report Form
Item 12 Microbiology Order and Report Form
Item 13 Stool Analysis Order and Report Form
Item 14 Urine Test Order and Report Form
Item 15 Radiology/Ultrasound Order and Report Form
Item 16 Pathology Order and Report Form
Item 17 Routine Observation Sheet
Item 18 Medication Administration Record
Item 19 IV Fluid and Additive Administration Record
Item 20 Fluid Balance Chart
Item 21 Discharge Summary
Item 22 Post mortem Request
Item 23 Death Report
Item 24 Referral and Feedback form
Tables
Table 1 Items Required for a Medical Record Management System

Table 2 Optional Items for a Medical Record Management System
Table 3 Medical Record Management Checklist
Table 4 Medical Record Management Indicators
Figures
Figure 1 Flow of data from registration to return of the medical record
Abbreviations
DOB Date of Birth
HMIS Health Management Information System
MPI Master Patient Index
MR Medical Record
MRD Medical Records Department
MRN Medical Record Number

The medical record (MR) is the central documentation of the patients visit to a health care
facility. A well-managed MR system is critical to providing efficient and high quality patient
care. The primary purpose of the MR is to act as an immediate record available at all times,
documenting the patients presenting symptoms and the subsequent care and treatment. MR
management systems are designed to improve a patients health status by maintaining a MR
that encompasses all aspects of a comprehensive health program. In addition, the MR
function supports the surveillance and audit of hospital activities. The system must include a
readily available, complete, and accurate MR on all individuals evaluated and treated in the
hospital. A well-designed MR management system facilitates the exchange of medical
information among all health care professionals (physicians, nurses, technicians) who provide
health care to the patient.
Key aspects of MR management include: 1) retrieval of existing medical record number

(MRN) or generation of new MRN as needed, 2) documenting of patient MR information,
and 3) handling of MRs.
This chapter describes standards and guidelines for the effective management of a MR
system.
Section 2 Operational Standards for Medical Records Management

1. The Hospital utilizes a Master Patient Index with a single, unique Medical Record
Number for each patient.
2. The Hospital utilizes a single, unified registration system for all patients, including in-
patients, out-patients, emergency patients, and specialty clinics.
3. The Hospital utilizes a paper-based or computer-based system to track where the medical
record is located at all times.
4. The Hospital utilizes a uniform set of forms that comprise a complete medical record for
the duration of a patients care.
5. The Hospital has medical records management guidelines for proper handling and
confidentiality of medical records.
6. The Hospital has orientation and training programs for all medical records personnel to
ensure awareness of and competency in medical record management procedures.

3.1 Retrieval of Existing MRN or Generation of New MRN
When a patient arrives at a hospital seeking care and treatment, the hospitals first interaction
with the patient is to identify his/her status as an emergency or routine case and to identify if
the patient is a new patient (i.e., has never been given a MRN before at the facility) or a
returning patient (i.e., has a MRN at the facility from a previous visit).
Each patient should have one MRN for all visits to the health facility. The MRN is generated
during the registration process at the first visit a patient has to the health facility.
Subsequently, the same MRN will be used for all other visits, including outpatient, inpatient,
and emergency visits.
The Master Patient Index (MPI), is a database of patient names, contact information,
registration dates, and the MRN for each patient ever treated at the health facility. The MPI is
an essential element of retrieving existing and generating new MRNs.
3.1.1 Master Patient Index
Each health facility should have a Master Patient Index (MPI). The MPI can be paper-based
or computer-based (with paper based back up). A paper-based MPI relies on the use of an
individual index card. Each MPI card should include the following information:
Patients first name
Patients father name
Patients grandfather name (if available)
Date of Birth (DOB)/Age
Sex (Male/Female)
Address
MRN
Date of registration
Phone number
A template Patient Index Card for use in Ethiopian health facilities is presented in Appendix
A, Item 1.
The index cards should be filed alphabetically by first name. When the hospital learns that a
patient has changed his/her name, a cross-index file should be made to identify the initial
record with the previous name. The MRN of the original registration should be recorded on
the cross-index card.
If a patient changes any other contact details (such as address or telephone number) a new
MPI card can be prepared to replace the original. The patient name, MRN, date of registration
and any other unchanged information should be transcribed exactly as written on the original
onto the new card. The old card should be scored through with the signature of the individual
preparing the new card. The new card should be stapled to the top of the old card and both

should be filed together so that the updated information is readily available without losing
any prior information. In a computer based MPI the contact details can be amended directly
in the appropriate computer fields.
Manual Paper-Based System: Vertical file cabinets for filing index cards may be purchased
for hospitals that use a paper-based MPI. The paper-based MPI should be monitored by the
MR Department, at a minimum, every quarter to ensure that the MPI is filed correctly. Each
facility must establish a procedure for this activity. Sub-headings may be added in the
alphabetized system for common names (Me for Meskerems, Mo for Mohammeds, etc).
Computer-Based System: The use of a computerized MPI permits faster retrieval of

patients MRNs. Health Management Information System (HMIS)s electronic medical
record system which is being rolled out across Ethiopian Hospitals includes a computerized
MPI component. However, a paper-based card file should also be maintained in case of
computer technical failure/downtime. Interruptions in the system can be caused by a variety
of factors, including electrical outages or hardware/software problems. Therefore, hospitals
should maintain a back-up, paper-based system in order to ensure no interruption in MRN
retrieval.
If a computer based system is used in addition to a manual system, similar procedures should
be followed for both MR management systems to ensure optimal patient care. Both systems
are effective when implemented and used correctly.
3.1.2 Patient Registration
Patient registration is the process of documenting the patients visit to the facility and
assigning a MRN, which is the patients MRN forever at that facility. When the patient
arrives at registration, the clerk should ask the patients name (first, fathers first name and
grandfathers name) and then look for an existing MRN in the paper-based MPI (i.e., set of
index cards) or in the computerized MPI. This should be done whether the patient reports that
he/she has been to the hospital before or not.
If there is an existing MRN for that patient, the registration clerk should facilitate the retrieval
of the existing MR stored in the record room. A runner/transitor should retrieve the patients
MR and then take the MR to the area where the patient is to be treated.
If no previous MPI card or MRN can be found, the registration clerk should generate a new
MRN. New MRNs should be issued in straight numeric sequence, without skipping any
numbers. Each MRN should be assigned to one and only one patient. Reissuing a MRN to
another patient should never occur. Registration staff should both create an index card for the
paper-based MPI and enter the new patient in the computerized MPI if there is a
computerized MPI.
All patients regardless of which service they will access should be registered at one
central registration site.

3.1.3 Starting a Medical Record for a new patient
After the MRN is generated (i.e., the next number in the sequence is assigned to the selected
patient), an individual hospital-approved folder should be assigned to the patient. Any patient
information generated by hospital staff during the period of care will be kept in this folder. A
paper fastener or the equivalent should be used to keep all pre-approved clinical
documents/forms in the folder. The MRN should be clearly displayed on the folder as a form
of identification.
3.1.4 Service Card
Each new patient registered for outpatient or inpatient services should be issued a service
card. This card is a small pocket-sized card used as an identification card for each patient
which should be shown to the MR staff whenever the patient attends the hospital. Selected
registration information should be recorded on the card. Contents of the patient service card
include:
1. Name of the Facility

2. Date of Registration
3. Medical Record Number
4. Name of client
5. DOB or age at registration
6. Sex
7. Clients address
A template Service Card for use in Ethiopian health facilities is presented in Appendix A,
Item 2.
3.1.5 Storage of Medical Records
All active MRs should be filed in a single, centralized file room, i.e., the Medical Records
Department or Card Room. MRs should be filed numerically according to MRN. If more
than one room is needed for file storage, files should be stored numerically (ie MRN 1,000-
5,000 in one room 1; MRN 5,001 10,000 in room 2). Hospitals should audit the files
periodically (quarterly or as per hospital policy) to ensure correct filing. All patient files
should be stored together, using one MPI, including those from specialized clinics (eg ART,
EPI etc). If separate record numbers and/or filing systems exist the hospital should integrate
these within a single system.
3.1.6 Retrieving existing Medical Record for a returning patient
1. Use the MRN to find the MR.
If the patient knows his/her MR number or brings his Service Card then the MR number can
be used to find the patients MR. The MR is filed numerically in the MR room and hence can
be easily retrieved from the shelf.
2. Retrieving a MR by name

If the patient does not remember their MRN or does not have their service card, then MPI can
be used to search for the patient information. The patients index card is filed alphabetically
by first name in the MPI. When the Index Card is located the MR number can be read from
the card and used to retrieve the MR.
3.1.7 Appointment Card
An appointment card should be given to the patient stating the date and time of planned
outpatient visits or admission. A template appointment card is presented in Appendix A, Item
3.
Figure 1 below shows the flow of medical record from generation until return of the medical
record to the medical record room.

Figure 1. Flow of data from registration to return of the medical record
MRD
Client seeking
Healthcare;
MR Opened
MPI
Search by
Indexed
MR listed and dispatched
Clinic
Ward
Outpatient
Inpatient
data data
REGISTERS REGISTERS
Pathology, Consultations,
X-ray, Operation,
Biochemistry, Anesthesia,
ECG data Physiotherapy
Data REGISTERS
REGISTERS
Client completed
MRD
MR assembled and completed
MR Filed
-----------
-
Source: HMIS Medical Records Training Manual, June 2008

3.2 Documenting Patient Information
3.2.1 Purpose of clinical documentation
MR documentation is essential to ensure quality of care for every patient. All information
regarding the patient and his/her course of care at the hospital should be recorded in the MR.
This includes his/her presenting symptoms and medical history, any diagnostic test orders
and results, all documentation from care providers and consultants, interventions,
medications, therapy, and information and instructions at discharge. Any subsequent return
visits to the hospital should be recorded in the same MR.
The MR provides each clinician responsible for patient care with access to a record of the
patients health status, medical history, investigation procedures (lab tests, etc.), treatments
and outcomes.
3.2.2 How and when to document
Each clinical event, intervention, instruction or observation should be documented by the

health care professional responsible for administering each clinical event, intervention,
instruction or observation, as soon as possible after the occurrence. MRs of discharged
patients should have all documentation completed by the discharging physician before the
patient is discharged from the hospital and the record should then be returned to the card
room.
All entries should be dated and authenticated with full signatures. Professional designation
(i.e. MD, RN, etc.) should also be included.
MR information includes: the patients presenting symptoms and history; any diagnostic test
orders and results; all documentation from care providers and consultants; interventions,
medications, therapy, etc., provided to the patient; and information and instructions at
discharge. This information is to be filed in one folder divided in separate sections for each
visit/admission in chronological order.
If the patient has a chronic disease and regularly attends a Specialized Clinic (e.g. HIV, TB
etc) then a separate section may be created in the MR folder to record all visits to the
Specialized Clinic.
3.2.3 General rules in clinical documentation
The patient's name and MRN should appear on each page.

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

information and co-signed by the person giving the verbal order within 2 working
days of the verbal order.
3.2.4 Standardized documentation and forms
Only approved and standard clinical forms (approved by government agencies or hospital
management) should be used in the MR. A standardized format should be used throughout
the hospitals forms to facilitate the entry, review, and retrieval of information.
The following criteria can be applied to ensure standardization.

All forms should be of the same size, usually A4.
Key identifiers such as the name of the form, patients name and medical record
number should be located in the same place on all medical record and clinical
documentation forms.
3.2.5 Key components of clinical documentation and Medical Record forms
The MR should contain the following components, filed in the following order:
Demographic sheet
Summary sheet of all visit dates (including inpatient, outpatient, and emergency care)
For each inpatient admission:
Admission Card
History and Physical Examination Assessment
Progress notes
Consultation request form (if relevant)
Consent form (if relevant)
Physician order sheet
Laboratory order and report form(s)
Radiology order and report form(s)
Pathology order and report form(s)
Pharmaceutical care plan (if relevant)
Nursing Process Forms
a) Nursing admission assessment form
b) Nursing problem statement list
c) Nursing care plan
d) Nursing patient progress report
Routine observation chart
Medication administration record
IV fluid and additive administration record
Fluid balance chart
Discharge summary
Post mortem request and report (if relevant)

Death summary (if relevant)
Referral form(s)
NB: While the patient is in hospital some of the above forms (e.g. Nursing Care Plan,
Routine Observation Chart, Medication Administration Record, IV fluid and Additive
Administration Record) may be kept in a clip folder by the patients bedside or at the nurses
station for ease of reference. When the patient is discharged these forms should all be entered
into the MR before the MR is returned to the Medical Record Room.
For each outpatient attendance:

Progress notes
Laboratory order and report form(s)
Radiology order and report form(s)
Pathology order and report form(s)
Referral form(s)
Samples of the Nursing Process Forms are presented in Chapter 6 Nursing Care Standards
and the pharmaceutical care plan is described in Chapter 4 Pharmacy Services. Templates of
all other forms listed above are presented in Appendix B, Items 1 to 24.
Other forms that could be included in the MR if relevant include, but are not limited to:
Emergency room record
Immunization and growth monitoring records, for paediatrics
Obstetrical care
Family planning visits
Anesthesia and operation report
Forms included in a Medical Record include:
1. Demographic sheet
Function: A page recording all patient demographic and contact information for all
clinicians to reference (patient name, date of registration, date of birth/age, sex, address,
emergency contact information).
Location: Front of MR.
Work process: When the patient is first registered a demographic sheet will be put in the
patients MR.
2. Summary sheet of all visit dates
Function: To capture patient visits to the facility.

Location: Front of medical record

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

Function: To record patient history and physical examination assessment findings.
Location: MR
Work process: When a patient is admitted as an in-patient a full history and physical
examination should be conducted by the attending physician.
4. Progress notes
Function: To record clinical findings and progress.
Location: MR
Work process: When patient is seen by a clinician, the information obtained will be recorded
with date, clinical details, and signature of the attending clinician.
5. Consultation request sheet

Function: When a different specialty opinion is sought, the form serves as a communication
tool for the different consulting parties.
Location: MR as a permanent record.
Work process: When any consultation is needed, the original physician will put the request
in the physicians order sheet and sign a consultation request. Nurses or appropriate case
team member will contact the consulting specialist to see the patient. The consulting
specialist should record the result/opinion on the consultation request.
6. Consent forms
Function: The consent form outlines the risks associated with a particular procedure. A
signed consent form indicates that the patient (or designated proxy) has been informed of the
risks and has authorized the procedure.
Location: MR
Work process: Before any procedure that has associated risks, the patient should be counseled
regarding all risks and alternative options for treatment and asked to sign a consent form to
indicate his/her agreement to the procedure. Consent should be obtained by the person who
will perform the procedure.
7. Physician order sheet

Function: All physicians will write orders on this form, including diet, nursing care,
medication, and investigation procedures (lab, imaging, consultation, etc.).
Location: MR.
Work process: When patient is admitted to a ward, a physician order form will be put in the
MR. A physician will write his/her orders on this form and other individual request forms
(i.e., medication prescription, lab order form, consultation request form, etc.).

8. Laboratory order and report result forms
Function: Informs laboratory of any individual patients lab investigation order and allows
lab result to be recorded on these forms.
Location: MR.
Work process:
Inpatient: When any lab test is ordered, the ordering physician will sign a lab order and
report form. The lab order will be sent to lab. Lab will collect the sample and conduct
corresponding test(s) upon receiving the order. The test results will be recorded on the lab
order form as well as in the log book in the laboratory department. The completed lab order
will then be sent back to the ward and kept in the MR.
Outpatient: When any lab test is ordered, the ordering physician will sign a lab order. The
lab order will be given to the patient. For most tests, a sample will be collected by case team
member and sent to the lab. For other tests the patient takes the lab order to the laboratory for
the corresponding test(s). The test results will be recorded on the order form as well as in the
log book in the laboratory department. The completed lab order will then be sent back to the
ordering clinic/physician and kept in the MR. If the patient goes to an external lab for test; the
completed lab order will be brought to the physician by the patient upon next follow up visit,
to be filed in the MR.
9. Radiology order and report form

Function: Informs diagnostic imaging department of any individual patients imaging
investigation order and allows result to be recorded on this form.
Location: MR as a permanent record.
Work process:
In-patient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be sent to diagnostic imaging department. The radiology
technician will schedule a test appointment upon receiving the order form. The test results
will be recorded on the order form by the radiologist, as well as in the log book in the
diagnostic imaging department. The completed radiology request and film will then be sent
back to the ward and kept in the MR.
Out-patient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be given to the patient. The patient takes the radiology
request to a diagnostic imaging department for the corresponding test(s). The test results will
be recorded on the order form, as well as in the log book in the diagnostic imaging
department. The completed radiology request will then be sent back to the ordering
clinic/physician and kept in the MR. If the patient goes to an external imaging clinic for test,
the completed radiology request and film will be brought back to the physician by the patient
upon next follow up visit, to be filed in the MR.
Emergency: When any imaging test is ordered, the ordering physician will sign a radiology
request. If a mobile diagnostic imaging machine is available, the test will be done in the

emergency room. The test results will be recorded on the order form. If mobile unit is not
available, steps outlined for outpatients above should be followed.
10. Pathology order and report form

Function: Official record for the pathology request/results
Location: MR
Work process: When a pathology sample is collected (e.g. fluid aspirate, tissue biopsy) the
ordering physician will complete a Pathology Request Form. The sample and form will be
taken to the pathology department for analysis. If the required service is not available in the
hospital the sample and request form should be taken to the central laboratory where they will
be stored and then transferred to the appropriate facility, in accordance with hospital policy
for sample referral.
11. Nursing Process Forms
a) Nursing admission assessment form
b) Nursing problem statement list
c) Nursing care plan
d) Nursing patient progress report
Function: To describe the nursing assessment, care plan and outcome of nursing care of an
admitted inpatient.
Location: Bed-side clip board during the patients stay, but must ultimately be included in
the patients MR as a permanent record.
Work process: When a patient is admitted a nurse completes a nursing assessment and care
plan within 24 hours. The outcomes of nursing care are documented on the problem list, care
plan and progress report during the course of the patients admission.
Further discussion on the Nursing Process is presented in Chapter 6 Nursing Care Standards.
12. Routine Observation Chart

Function: To record the vital signs of each specific patient during the hospital stay.
the patients MR as a permanent record.
Work process: When vital sign measurements are needed, the observation sheet will be put in
the bed-side clip board. The nurse will record all vital sign measurements on this form. When
one sheet is finished, a new blank sheet will be put on top of the finished sheet. When the
patient is discharged, all the forms will be put in the MR.
13. Medication Administration Record

Function: To record all medications ordered and administered to a patient.
the patients MR as part of the permanent record.

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

Function: The record should detail all specific infusions, including rate of drops and duration
of infusions while the patient is confined.
Work process: When medication or IV fluid is ordered for an in-patient the name of the IV
fluid and rate of infusion should be documented on the IV fluid administration record. The
name and dosage of any additives should also be documented. When the IV infusion is given,
the start time and end time of the each bag of fluid should be documented and signed by the
responsible nurse.
15. Fluid Balance Chart

Function: To record all fluid inputs and outputs for patients at risk of fluid overload or
dehydration.
Work process: All fluid inputs both oral and intravenous, and all outputs including urine and
other outputs such as blood loss should be documented on the chart by the nurse. At the end
of every 24 hours the balance is calculated as total input minus total output.
16. Discharge summary

Function: An instruction sheet to summarize all needed information for the patient upon
discharge.
Location: One copy in the MR and one copy to patient.
Work process: Discharging physician will fill out the discharge summary that includes a
summary of the patients diagnosis, treatment and investigations and any instructions
following discharge (for example medications, wound care, diet, activity and follow-up
appointments). The form will be kept in the MR for hospital record and a copy will be given
to the patient to take home.
17. Death summary sheet (if relevant)
Function: In the event that a patient dies, to document patients health records, care received
and cause of death.
Location: MR
Work process: After death the attending physician should complete a death summary. If a
post mortem examination is required the death summary should be completed AFTER the
results of the post-mortem examination are known.

18. Referral and Feedback Form (if relevant)
Function: To document patient history at the hospital and to provide reason for referral
Location: One copy in the MR and one copy to patient.
Work process: If it is necessary to refer a patient to another facility the attending clinician
should complete a referral request, indicating the reason for referral, summary of the patient
history and examination and the results of any investigations conducted.
3.2.6 Correcting Medical Record Data
If any data contained within a MR require correction, the following rules should apply:
No erasure or other obliteration should be made.
Incorrect data should be lined out with a single line.
The date of correction, the signature and profession of the person making the
correction, the correct information, and the reason for the correction should be added.
3.3 Handling of Medical Records
A comprehensive MR management system encompasses the handling the MR from time of

patient registration, during active care delivery, through patient discharge, and ongoing
filing/storage of the MR, until removal/destruction of old MRs from storage. The flow of
MRs/charts is important to ensure a balance between availability of clinical information and
patient confidentiality. A well-designed system minimizes the loss of MRs.
3.3.1 Tracking the location of Medical Records
A MR location tracking system should be established in order to find MRs. The system
varies depending on whether or not a paper-based or computerized patient registration system
is used. Manual Paper-Based System: A check in/out log book should be used by Medical
Record Room staff. Entries on the log should include the following information:
MRN Date checked out Signature of person checking out MR taken to Date returned
On a daily basis, assigned MR staff should refer to the log book and ensure that all MRs are
returned to the card room. The only exception is for admitted inpatients whose treatment is
ongoing. This step is important, as it prevents loss and misuse of MRs. In addition, when a
MR is removed, one can put in its place a tracer card, which is a card the size of the MR, on
which is written the patient name, the MRN, where the MR is going, and the date it was
removed from the file. This can help track where records are outside the Medical Records
Room. When not in use the tracer card should be stored in the back of the MR. A sample
tracer card is included in Appendix A, Item 4.

Computer-Based System: In a computerized patient registration system, a MR tracking
feature should allow for an easy and effective method to locate MRs.
3.3.2 Who should handle Medical Records?
Only authorized personnel should have access to MRs, and only on a need to know basis.
The Medical Records Department should only be accessed by selected employees who have
been designed by hospital management to handle MRs and who have received MR training.
When other hospital employees need access to MRs, a request should be made to the MR
staff. Patients should never handle MRs without staff assistance.
Hospitals should develop strict procedures based on these principles and ensure that all staff
members are properly informed and trained for adherence.
3.3.3 Archiving Medical Records
Inactive files (i.e., MRs with no clinical activities for a pre-defined period of time (i.e., 2
years) may be archived by MR staff in order to regain shelving space. Individual hospitals
should establish an archiving policy.
When archiving, these files should be numerically stored in a separate area, according to their
MRNs. The corresponding MPI index card of the patient should be labeled archived.
NEVER create another file numbering system for archived files.
If archived files needed to be retrieved, the same MR retrieving mechanism should be used.
3.3.4 Medical Records at Discharge
The MR of discharged or deceased patients should be returned to the Medical Record Case
Team within 24 hours of discharge. The Medical Record Case Team should review the MR to
see if all forms have been properly signed, particularly the discharge summary. If they are not
signed, the MR Department should alert the physician on record or case team leader to
complete and sign the discharge summary.
3.3.5 Destruction of Inactive Medical Records
The FMOH Hospitals Patients/Clients/Records Retention Schedule guideline details the

length of time a MR is retained in inactive status. In general, a facility is required to retain a
MR for up to 10 years after the patients last episode of care at that facility. After the pre-
defined retention period, the MR should be destroyed by burning, shredding or another
method that is certain to maintain the patients confidentiality. Destruction of the medical
record should also be supervised by the head of the MR department.
If medical records are destroyed the following key information should be maintained
permanently:
patient's full name and date of birth;
admission and discharge dates;
name of the attending doctor(s);

diseases treated and operations performed; and
a discharge summary for each admission if more than one
A note should be included with the retained documents stating that the records have been
destroyed according to the retention policy.
The MR Department should establish a folder to collate the information above for all MRs
that are destroyed.
3.3.6 Removal of Medical Records from the Hospital
MRs should be removed from the facility only upon an order from a federal or regional
jurisdiction. The hospital should establish its own policy regarding MR removal, and should
comply with federal and regional health policies.
If a patient seeks health care from another hospital and has consented to the release of his/her
clinical information to the new hospital, only a photocopy should be given to the requesting
hospital. The original MR should never be transferred out of the hospital.
3.3.7 Confidentiality
MRs should be maintained in the strictest confidence, as they contain personal and private
information about patients, including their health status, personal family and contact
information. MRs should be stored in a secure area, and there should be clear policies
regarding confidentiality and the release of patient information.
The content of a MR should only be used for providing patient care or in the course of
supporting patient care activities(for example evaluation of services, clinical audit etc.).
Access to the content of MRs should be granted only to personnel who are undertaking the
above activities. Other supporting staff who are granted access to MRs but are not involved in
delivering patient care (e.g., porters, runners) should not read and/or disclose the content of
the records.
All employees should sign a Code of Conduct that includes a statement regarding the
confidentiality of patient information. (See Section 3.10.1 of Chapter 11 Human Resource
Management).

3.4 Basic requirements for Establishing a Medical Record
Management System
Table 1 describes the items required for a well-functioning MR management system.
Table 1 Items Required for a Medical Record Management System

Required Item Ideal Setting Possible
Substitute
1) Space
Central Filing Central files for MRs should be adjacent to the registration -
Space* area with barriers necessary to impede or prevent access by
unauthorized personnel. Filing space should be provided for
at least 3 7 years accumulation of records.
Work space for Work stations set up according to nature of work, ideally in Any adequate
registration triage areas or as close as possible work space
Office for MR staff Office for use by MR staff for sorting MRs, keeping records
awaiting completion and filing, making out slip cards,
stamping free patient papers and other documents, etc.
Archive space Separate archive room that is easily accessible by MR staff. Designated
shelves for
archiving
purposes
Supply / storage Separate room that is clean and can be used for storing Any space in
room forms, supplies, etc. the MR
Department can
be used for
storage
2) Equipment
Photocopier Necessary for immediately producing copies of records for Any means of
transfer files or legal reasons producing
copies
Word processor for Computer Work

report and legal processor/type
documents writer
Printer - -
MPI file cabinets Vertical file cabinets for filing index cards Long index
card boxes

Required Item Ideal Setting Possible
Substitute
Shelves for filing Open unit shelves permit increased visibility and faster Drawer unit
handling of records, and they require less floor space. cabinets
Aisles should be at least 36 inches wide. Each filing
unit should be labeled with the medical record
numbers of the medical records filed in that filing unit;
and each filing shelf should be labeled with the range
of numbers of medical records filed on that particular
shelf. Guides should be placed at regular intervals.
3) Supplies
MPI Files Paper-based MPI Paper-based

index cards
Binders for filing Durable binders Folders

statistical reports
MR folders Durable folders with dividers to separate sections of Durable

documents and fasteners to hold loose papers. The file folders with
folders used with open shelf filing must have side fasteners
tabs/visible spines for viewing MRN for identification.
Stationeries Complete sets of stationary at various locations within One complete

the Department set in the dept
Clip boards for in- For temporarily providing easy access to observation -
patients charts, medication administration records, etc. during
in-patient stay. The clipboards should be tied to each
bed.
Durable binders (2 For holding the contents of MR during in-patient care, Folders
rings/3 rings) for to provide easy access and frequent addition of new
in-patients sheets. Preferably with dividers to separate each
section.

Table 2 Optional Items for an Medical Record Management System
Optional Item Details
1) Space
Offices For use by Medical Records Department staff
2) Equipment
Shredder Used for destroying copies of documents no longer necessary
Carts Used for transporting MRs from one location to another
Safety ladder / Step Used by staff to obtain MRs located on upper shelves within card / archive
stool rooms
Computer Used if an electronic registration system is used
3) Supplies
Rubber stamps / Rubber stamps imprinted with a year on it, in a chronological order may be
Year stickers purchased if folders are pre-printed.
Year stickers may be an alternative method. Both can be used for labeling
files.
* Central Filing Space
It is critical that plenty of space is available for filing medical records, and that the file area is
clean, tidy and has good light. Medical records are a health record from birth to death; hence,
a lot of space will be required to store medical records.
In the majority of cases, healthcare institutions in Ethiopia possess a one room Medical
Record Department. Depending on the availability of rooms and expected annual load of
patients per the facility, preparations should be made to allocate enough space for the storage
of MRs. Incomplete medical records should be kept in a separate location in the department
rather than integrated with those completed medical records. An incomplete record area
facilitates ease in retrieval for completing records. When there is not enough room in the
MRD to store all medical records for the defined retention period, it is necessary to locate
alternative storage. Optimally the storage should be in the facility to facilitate retrieval. When
an alternative storage space is needed, the space selected must be secure and must protect the
records from damage, loss or destruction.
3.5 Human Resources for the Medical Records Department
All personnel that work in the Medical Records Department should be qualified to conduct
their jobs, which require reading, keyboarding, and organizational skills. Depending on the
size of the facility and volume of patients, the number of personnel working in the Medical

Records Department will vary. However, there should be enough staff to cover the following
duties, particularly during the prime hours:
Patient registration
Authorization of free and credit services
Development and maintenance of the MPI
Retrieving and filing MRs
Delivering files to various locations of the hospital
Recording chart location
Collection of MRs from individual service units
Checking and ensuring completion of MRs after discharge or death
Filing reports generated by the Medical Records Department
Handling of medico-legal issues relating to the release of patient information and
other legal issues.
All MR personnel should undergo MR orientation and subsequent annual training on all
Departmental policies.
3.6 Medico-legal Issues and Procedures
As the central documentation of the patients visit to a health care facility, a patients medical
record is considered the property of the healthcare facility. The personal data contained in the
medical record is considered confidential communication and the property of the patient. As
such there are certain measures that must be taken to ensure the security of patient records
while also complying with requests for release of patient data for medico-legal cases.
3.6.1 Patient Consent for Release of Records
Unless the patient has given written consent to release information from his or her medical
record, the information contained in it can only be released to a court by subpoena or a court
order. No information concerning a patient should be released to another person without the
written consent of the patient or the patient's legal guardian. If a patient is under the age of 14
years or otherwise subject to a guardianship order, any consent for access to information
should be given in writing by the patient's parents or legal guardian. If the patient lacks the
capacity to provide genuine consent then the written consent must be obtained from the
person's legal guardian. In the case of a patient who has died, the written consent to access
information from the patient's medical record should be provided by the next of kin shown on
the medical records.
3.6.2 Procedures for Releasing Patient Data
Information contained in a medical record may be accessed for a number of medicolegal

issues. Listed below are types cases for which medical records may be requested.
Insurance Cases

Worker's Compensation
Personal Injury Claims
Malpractice Claims
Will Cases
Criminal Cases
Mental Competency
When a request for a medical record is received from a lawyer, the request should be
registered and date of receipt of request recorded by the healthcare facility administration and
forwarded to the MR Administrator for processing. The MR Department should confirm that
the patient has given consent for the release of information.
The information requested is identified and the attending doctor asked to write a report. In
many health care facilities a pre-designed form may be use or if a discharge summary is
already in the medical record, it is checked and if it includes all the requested information a
copy is made.
If the actual medical record is needed, the lawyer must produce a court order of subpoena to
enable the release of the medical record.
3.6.3 Responding to Subpoena or Court Order Request
If a subpoena or court order is served it must be obeyed. On receipt of a subpoena the clerk
records the date and time the subpoena was received and records in a log book the date and
time the medical record is due in court. The Clerk should notify the attending doctor and
healthcare facility administration that a subpoena has been received for the release of the
medical record to court.
The Clerk should locate the medical record and create a tracer card to indicate that the MR
has been removed. The Clerk should check that all necessary information, as specified in the
subpoena, is in the medical record and that it is complete. In some countries the original
medical record is not sent to court. If a photocopy is permissible as evidence in court all
forms are photocopied and numbered and the photocopy sent in place of the original. If a
copy is made a note needs to be recorded in the medical record indicating that a copy exists
and will need to be destroyed on return from court. Some healthcare facilitys send the
original and keep a photocopy on file. When the original medical record is returned to file the
copy is removed from file and destroyed.
The medical record is placed in a large envelope addressed to the clerk of the court (or
specified person) with the receipt attached to the front. The tracer on file is changed to
indicate that the medical record was sent to the court and the date it was sent. The medical
record should be forwarded under adequate security to the clerk of the court named in the
subpoena and the signed receipt obtained from the person accepting delivery. Adequate
security should involve hand delivery of the medical record from the healthcare facility or

health centre direct to the clerk of the court by an employee of the healthcare facility or
health centre or by a courier service.
On return from court the medical record is checked to ensure that all pages (forms) are
present. The file is returned to its appropriate place and the tracer removed. As mentioned
previously if a photocopy has been made it must be checked as for the original and then
destroyed.
More detailed guidance on the policies concerning medico-legal issues and procedures can be
found in the Federal Ministry of Health HMIS Medical Records Training Manual, 2008,
chapter 3, Pp. 34-40.

In order to determine if the Operational Standards of Medical Records Management have

been met by the hospital an assessment tool has been developed which describes criteria for
the attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of
each Operational Standard. The tool is presented in Appendix E of Chapter 13 Monitoring
and Reporting.
Table 3. Medical Record Management Checklist

Yes No
1. There is one registration unit for all services offered at the hospital.
2. There is a Master Patient Index.
3. A patient record numbering system exists in which each patient is given a
unique medical record number.
4. Forms are printed and available to document inpatient and outpatient care
given at the hospital.
5. Patient record confidentiality and handling are defined in medical records
guidelines. ..
6. Medical records staff are given skilled in medical records management.
7. Trainings and/or orientations are given to medical records staff on medical
records management

4.3 Indicators
Table 4. Medical Record Management Indicators

S/N Indicators Formula Frequency Comments
1. % of medical records Randomly sample 50 MRNs from the Quarterly
lost MPI and check to see if the medical
record (MR) is in the medical records
room. A MR is considered lost if it is
not found in the card room and there is
no tracer card indicating where the
medical record can be found. Calculate
the total number of cards not
found/50*100
2. % of inpatient medical Total number of inpatient medical Quarterly
records with completed records with a discharge summary/total
discharge summary number of inpatient medical
records*100
3. Number of complaints Total number of complaints against the Quarterly
received against against Medical Records
Medical Records Department/Case Team
Department/Case Team
4. a) Number of a) Total number of MR complaints Quarterly
complaints upheld upheld
b) % of complaints b) Total number of MR complaints

upheld upheld/Total number of MR
complaints filed*100
Source Documents
1. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, June). Health

Management Information System (HMIS). Medical Records Training Manual.
2. Federal Democratic Republic of Ethiopia. (2007). Hospitals Patients /Clients Records

Retention Schedule.
3. World Health Organization. (2002). Medical Records Manual: A Guide for Developing
Countries. Revised and updated 2006. Manila: Regional Office for the Western Pacific.

Appendices
Chapter 3 Medical Records Management

Appendix A. Template of Medical Records Department Forms
Item 1: Master Patient Index Card
"[Name of Facility]"
Master Patient Index Card
IU "` l` }Su<u k
Medical Record Number: Date Of Registration(DD/MM/YY)
eU v eU
Patients Name: Fathers Name:
eU
Grand Fathers Name: Sex: F M
M: k ` /U T@
Date Of Birth Day Month Year Age:
^h MM [ kuK?
Address: Region Woreda Kebele
u? l`
Gott: House Number:
Item 2: Service card (Front & Back)
MKA Sm "`
SERVICE IDENTIFICATION CARD
[/K-}T _____________________
? `~ eU ____________________________ Woreda/Subcity
Facility Name
kuK? _______________________________
u? `~ }Su<u k ________________ Kebele
Date Of Registration
u? l` __________________________
IU "` l` __________________________ House No.
Medical Record Number
eU _________________ T ____ ___

Name Age Sex
Item3:Appointmentcard(Front&Back)
A
DATE Appointment with service
APPOINTMENT CARD
? `~ eU ____________________________
Facility Name
eU ________________________________________
Name
IU "` l` __________________________
Medical Record Number
Chapter 3 Medical Records Management Appendix A: Page 1 of 2

Item 4: Hospital Tracer Card
Tracer card
Facility Name: ________________________________________________

MRN #: ________________________________________________
Patients Name: ________________________________________________
# Department/Person MR is sent to Receivers Signature Date
Chapter 3 Medical Records Management Appendix A: Page 2 of 2

Appendix B: Template of forms that are included in a Medical Record
Item 1: Hospital Patient Information Demographic Sheet
PATIENT INFORMATION
MRN: Patients name: Sex: Registration date:
F M / /
Phone no.:
( )
City/Town: Woreda: Kebele: House no:
Emergency contact information:
Contacts Name:_______________________________
Telephone Number:____________________________
Chapter 3 Medical Records Management Appendix B: Page 1 of 28

Item 2: Hospital Summary Sheet of all Visit Dates
INTEGRATED FOLDER SUMMARY SHEET

(One line per visit not for clinical notes)
MRN #: ________________________________________________
Patients Name: ________________________________________________
Date Diagnosis / Complication

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

* Write the department providing service: IPD, OPD, ANC, FP, EPI, etc
** OPD / IPD Service write diagnosis
FP, ANC, PNC write complication, if any
EPI write antigen given

Item 3: Admission and Discharge Card (Front)
JeM N=dw Tem l

_________________________HOSPITAL CASH SHEET NO __________________
QSU Sku "`
ADMISSION CARD
IU "` l`
Medical Record Number (MRN) __________________
eU v eU
Name _________________________________ Fathers Name _______________________
eU
Grand Fathers Name _____________________ Sex ___________________
^h MM [/K-}T
Address: Region _________________ Woreda/Subcity _______________
kuK?
Gott ___________________ Kebele_______________________
u? l`
House Number___________
K< l` M l`
Ward No. _______________________________________ Bed No. ____________
c=v QSS< G<@
Admission Diagnosis __________________________________________________________
}[< QSS<
Discharge Diagnosis ___________________________________________________________
JeM c= u[< G<@
Condition on discharge
ISS< /}iKA V K?L ? ` }M
Improved Dead Referred
N=U n < u n H@
Left against Medical Advice Absconded
JeM vu k }kuK< N=U `T
Date of admission _________________ Signature of Admitting Dr. _________________________
u k cu}< N=U
Date of Discharge _________________ Discharged by ___________________________________
S M L `e `T KSv~ S M L `e `T KS<~
Sign. Of Ward Nurse for Admission ____________ Sign. Of Ward Nurse for Discharge _________
_}\ `T KSv~ (eL> J) KS<~ (eL> J)
Directors Sign. For Admission (if required) _____________For Discharge (if required) ___________
=/w` X
Birr Cts.
}u k w k w`
Number of days admitted __________________ Amount per day in birr ________________
?e_ U`S^ N=dw
For X-Ray Examination _______________________________________________________
S> N=dw
For Medicine ______________________________________________________________
*^c= N=dw
For Operation _____________________________________________________________
Lx^` N=dw
For Laboratory ____________________________________________________________
M M MKA N=dw
For Various Services ________________________________________________________
}
Total Payment
uS ekV }K
Deposited
_e^\ `T
Signature of Registrar
}SLi
_____________________ Amount to be Reimbursed
}T]
Amount to be paid
N=Xw g<U `T
Signed by The Chief Accountant ____________________________

Item 3: Admission and Discharge Card (Back side)
KQU< H>Xw }m
FINANCIAL RESPONSIBILITY
w eU
Name of Individual Responsible for Bill ____________________________________________________
Y^ x eM l`
Occupation _____________________________________ Tel. ________________________
kuK? [/K-}T u? l` eM l`
Kebele ____________ Woreda/Subcity ____________ House No. _________ Tel. __________
U< JeM S<

Relationship _______________________ Brought to Hospital by __________________________
eT@ L }K< L }k< w uS<K< SM L Kw u`T [KG<::
I, the above named person, accept full responsibility for payment of the charges incurred during this period of
Hospitalization.
`T
Signature
__________________________

Item 4: History and Physical Examination Assessment
History and Physical Examination Assessment
Name: Ward:
MRN: Bed Number:
Date of Admission:
Presenting Complaint:
History of Presenting Complaint:
Past Medical History:
Drug History:
Family History:
Personal/Social History:
PHYSICAL EXAMINATION
General Appearance:
Vital Signs: Temp: BP: Pulse: Resp:
HEENT:
Glands:
Chest:
CVS:
Abdomen:
Genito-Urinary:
Musculo-Skeletal:

Skin:
Central Nervous System:
Motor:
Sensory:
IMPRESSION:
DIFFERENTIAL DIAGNOSIS:
PLAN OF ACTION (investigations, treatments and medication ordered):
Name of physician: Signature:
Date of assessment: Time of assessment:

/ /

Item 5: Hospital Progress Note
HOSPITAL PROGRESS NOTE

Name: OPD
MRN: IPDWard:BedNumber:
Date&
ProgressNote
Time


Item 6: Consultation Request Form
CONSULTATION REQUEST FORM
Patient Name: ___________________________ OPD

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

Reason for consultation:
Consultation report:
Consulting Physician Name: Signature:
Specialty: Date:
/ /

Item 7: Consent Form
CONSENT FORM
MRN #: ________________________________________________
Patients Name: ________________________________________________
1. Name of proposed procedure or course of treatment (include brief explanation of medical terms are not clear):
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Statement of health professional (to be completed by health professional with appropriate knowledge of
proposed procedure):
I have explained the procedure to the patient. In particular I have explained:
The intended benefits:

___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Serious or frequently occurring risks:

___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Any extra procedures which may become necessary during the procedure:
Blood transfusion
Other procedure (please specify) ________________________________________________
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments
(including no treatment) and any particular concerns of this patient.
This procedure will involve:
General and/or regional anesthesia Local anesthesia Sedation
3. For females of reproductive age (if relevant):
During the operation it may be necessary to take an X-ray to assist the surgeon with the procedure. It is important that X-
Rays should be avoided if there is a possibility of pregnancy.
Date of Last Menstrual Period: ____________________________
Is there a possibility of the patient being pregnant? Yes No
If yes, can this procedure be deferred or does the clinical urgency override the risk to the pregnancy?
Yes, the procedure should be deferred No, the procedure must be performed
Signed:_______________________________ Date: ____________________________

Name: _______________________________ Job title: _________________________
Do ask if you have further concerns. We are here to help you. You have the right to change your mind at any
time, including after you sign this form. You may ask for a relative or a friend or a nurse to be present whilst
the procedure is being explained and consent obtained.
Please tick boxes to indicate that you have understood and agreed to the statements below:
I agree to the procedure or course of treatment described on this form
I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person
will however have appropriate experience.
I agree that any procedure in addition to those described on this form will only be carried out if it is necessary to
save my life or to prevent serious harm to my health
I have been told about additional procedures that may become necessary during my treatment. I have listed below
any procedures which I do not wish to be carried out without further discussion.
I acknowledge that the nature and purpose of the foregoing procedures and the risks associated with the procedure
have been explained to me and I have been given the opportunity to ask questions.
Patients signature: ____________________________ Date: ________________________

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

Item 8: Physician Order Sheet
PHYSICIAN ORDER SHEET

Name: Ward
MRN: BedNumber:
Transcriber Dateand
Physician
Date Time Order signature Timeorder Signature
Signature
(ifrelevant) completed


Item 9: Haematology Order and Report Form
HAEMATOLOGY ORDER AND REPORT FORM

Name: OPD
MRN: IPD Ward: Bed Number:
Age: Sex:
Clinical history:
Test ordered Result Reference

Total CBC ________ cells/mm3 ________ cells/mm3
Differential
Neutrophil ________ % ________ %
Lymphocyte ________ % ________ %
Eosinophil ________ % ________ %
Basophil ________ % ________ %
Monophil ________ % ________ %
Haemoglobin ________ G/dL ________ G/dL
Haematocrit ________ % ________ %
MCV ________ Fl ________ Fl
MCH ________ Pg ________ Pg
MCHC ________ Pg ________ Pg
RBC ________ cells/mm3 ________
Platelet Count ________ x 103 ________ x 103
ESR ________ mm/hr ________ mm/hr
Bleeding time ________ ________
Clot retraction ________ ________
Coagulation time ________ ________
Prothrombin time ________ ________
P.T.T. ________ ________
Fibrinogen ________ ________
Coombs test ________ ________
CD4 (absolute) ________ Cell/ul ________ Cell/ul
Other (describe):
______________________
Ordered by: __________________ Sample collected by: ___________
Date of order: __________________ Date of collection: ____________
Time of order __________________ Time of collection: ____________
Lab tech comments:
Name of lab tech: __________________ Signature: __________________

Date of analysis: __________________ Time of completion: _________________
Result checked/approved by: _______________________________________________________

Item 10: Clinical Chemistry Order and Report Form
CLINICAL CHEMISTRY ORDER AND REPORT FORM
Name: OPD
Age: Sex:
Clinical history:
Test ordered Result Reference

SGOT ________ IU/L ________ IU/L
SGPT ________ IU/L ________ IU/L
ALP ________ IU/L ________ IU/L
AST ________ IU/L ________ IU/L
Sodium ________ MEQ/dL ________ MEQ/dL
Potassium ________ MEQ/dL ________ MEQ/dL
Calcium ________ mg/dl ________ mg/dl
Creatinine ________ mg/dl ________ mg/dl
Bilirubin direct ________ mg/dl ________ mg/dl
Bilirubin total ________ mg/dl ________ mg/dl
Blood urea nitrogen ________ mg/dl ________ mg/dl
Total Protein ________ G/dL ________ G/dL
Albumin ________ G/dL ________ G/dL
Uric Acid ________ ________
Fasting Blood Glucose ________ mg/dL ________ mg/dL
Random Blood Glucose ________ mg/dL ________ mg/dL
Amylase ________ U/L ________ U/L
Triglycerides ________ mg/dL ________ mg/dL
Cholesterol ________ mg/dL ________ mg/dL
Other (describe):
_________________________
Sample collected by:

Ordered by: __________________ ___________
Time of collection:
Time of order __________________ ____________
Lab tech comments:


Item 11: Serology Order and Report Form
SEROLOGY ORDER AND REPORT

Name: OPD
Age: Sex:
Clinical history:
Test ordered Result

HIV serology rapid test _________________
HIV serology by EIA _________________
Cryptococcal Ag _________________
Hepatitis B _________________
Hepatitis C _________________
TPPA/TPHA/RPR _________________
Syphilis _________________
HCG
Other (describe): _________________
______________________ _________________

Lab tech comments:


Item 12: Microbiology Order and Report Form
MICROBIOLOGY ORDER AND REPORT FORM

Name: OPD
Age: Sex:
Clinical history:
Sample type/site:
Test ordered Result

AFB smear _________________
India Ink Stain _________________
Gram Stain _________________
Microbiology smear _________________
C+S _________________
Wet mount - direct
microscopy _________________
Other (describe): _________________
VDRL _________________
Skin scraping _________________
Skin snip _________________
Other (describe below):
_________________ _________________
Sample collected by:

Ordered by: __________________ ___________
Lab tech comments:


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

Name: OPD
Age: Sex:
Clinical history:
Result
Consistency _________________
Occult blood _________________
Cells _________________
Ova or parasite _________________
Other _________________

Lab tech comments:
_________________ Signature
Name of lab tech: _ : __________________
_________________
Date of analysis: _ Time of completion: _________________

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

Name: OPD
Age: Sex:
Clinical history:
Result
Colour _________________
Appearance _________________
Protein _________________
Glucose _________________
pH _________________
Blood _________________
Ketones _________________
Bilirubin _________________
Pregnancy test (HCG) _________________
Other(describe below):
_________________ _________________
Lab tech comments:


Item 15: Radiology/Ultrasound Order and Report Form
RADIOLOGY/ULTRASOUND ORDER AND REPORT FORM

Name: OPD
Age: Sex:
Investigation (s) requested:
Summaryofclinicalhistory,relevantclinicalfindingsandinvestigationresults:
Requestingphysician: Signature:
Dateofrequest: Timeofrequest:
Report:Tobecompletedbytrainedradiologist/ultrasonographerifavailable.
Nameofreporter:___________________________Signature__________________________________
Designation/Position:________________________Dateofreport:______________________________
NB:TheXrayfilmorUltrasoundpicturesshouldalsobesenttotherequestingphysicianforreviewand
interpretationifnoradiologist/ultrasonographerisavailable.


Item 16: Pathology Order and Report Form
PATHOLOGY ORDER AND REPORT FORM

Name: OPD
Age: Sex: Datespecimencollected:

Specimen type and site:
Timespecimencollected:
Investigation(s)requested:
Summaryofclinicalhistory,relevantclinicalfindingsandinvestigationresults:
Requestingphysician: Signature:
Dateofrequest: Timeofrequest:
Report:
Nameofreporter:___________________________Signature__________________________________
Designation/Position:________________________Dateofreport:______________________________

Item 17: Routine Observation Sheet
Name:____________________
MRN: ____________________
Ward: _________Bed: ______
Date
Time
>41
41
40
TEMPERATURE
X 39
38
37
36
35
<35
>200
Pulse 200
z
190
180
170
160
Systolic BP 150
140
130
PULSE and BP
120
110
100
Diastolic BP 90
80
70
60
50
40
<40
Respiration / min
O2 Saturation %
Fetal Heart Rate
Blood Sugar
Dip- Protein
stick Blood
Urine Sugar
Ketones
_ Circum. Of head
(cm)
_ Circum. Of arm
(cm)
Bowel
Weight (kg)
Remarks:
Staff Initial:

Item 18: Medication Administration Record
Name:____________________
MRN: ____________________
Ward: _________Bed: ______
Diagnosis: Allergy:
Medications Date Date Date Date Date Date Date Date
Time to give Signature of
# Date (Name, dose,
one time each line Transcriber Given by Given by Given by Given by Given by Given by Given by Given by
route, freq)

Item 19: IV fluid and Additive Administration Record
Name:____________________
MRN: ____________________
Ward: _________Bed: ______
Diagnosis: Allergy:
Mixed,
Discontinue Date of Time of checked, Time
# Date IV Fluid (Name, Volume, Rate) Additives date start start given by completed Completed by

Item 20: Fluid Balance Chart

FLUID BALANCE CHART

Please Complete or Affix Label
MRN: Ward:
Name Bed No.:
Date:
Previous days balance (+ or -)
INTAKE OUTPUT
Total Fluid
Intra- Intra- Total Others Balance
Time Oral Urine Total Output (ml/24hr)
Venous Venous Intake
01.00
02.00
03.00
04.00
05.00
06.00
07.00
08.00
09.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
19.00
20.00
21.00
22.00
23.00
24.00
Sub
Total
TOTAL + OR - TOTAL
Print Name:
Signature:
Date and time completion:

Item 21: Hospital Discharge Summary Sheet
HOSPITAL DISCHARGE SUMMARY SHEET

Name: MRN:
Ward: Date of admission:
Bed number: Date of discharge:
Hospital Course:
Diagnosis/Diagnoses:
Diagnostic procedures and laboratory findings:
Condition on discharge:
Cured Improved No change Worse Left against medical advice
Instructions for home:
Diet:
Activity:
Specific care needs:
Sick leave recommended (if relevant):

Medications:
Drug: Dosage: Frequency:
1.
2.
3.
4.
Follow up care:
Appointment date: Place: To be seen by:
1.
2.
Form completed by:
Designation/Position: Patient/Care giver name:
Signature: Signature:
Date: Date:
One copy of form should be given to the patient or caregiver and a second copy should be filed in the patients Medical
Record.

Item 22: Post Mortem Request Form
POST MORTEM REQUEST FORM

Section A: Identification
MRN: Name of deceased:
Age: Date of Death: / /
Sex:
Occupation:
Address:-
Region: Zone: Woreda/Sub-city: Kebele: House No.: Tel:
Brief history of the deceased:
Physical examination findings:
Possible cause(s) of death:
Reason for Referral:

Referring Institution:
Requesting Physician:
Name: Signature: Date: / /
*Responsible professional must fill and send the following note to requesting institution

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

Item 23: Death Report
DEATH REPORT
Health Facility: Region: City:
Deceased Name: Age (Year): Sex:
F M
Date of admission: Date / Month / Year Time Hrs : Min
Date of death : Date / Month / Year Time Hrs : Min
Cause Of Death Approximate Interval Between Onset And Death
I. Disease or condition leading to death*: -
Due to (as consequence or )
a)
b)
Antecedent cause: Morbid conditions, if any, giving rise to the above
cause, stating: - Due to ( as a consequence or)
c)
d)
* This does not mean the mode of dying, e.g. heart failure, respiratory failure. it means the disease, injury or complication
that caused death.
II. Other significant conditions contributing to the death, but not related to the disease or condition causing it
Management/Treatment given :
Consider Collecting the following Information

III. If the deceased is a female, was she
Not pregnant
Pregnant at the time of death (Approximate gestation age ______ (WKS))
During labor ( stage of labour ______________)
unknown pregnancy status
IV. If the deceased is a newborn:
Still birth Death after birth Weight: . . . . . . . . . g Not Known

Reported by (Dr./ Mr/Ms): Profession :
Signature: Date : / /
Approved by: Medical Director:

Item 24: Sample Referral and Feedback Form
Section 1: Patient Details (to be completed by Referral Unit)

Name:
MRN:
Date of birth/Age: Next of kin name:
Address: Next of kin address:
Telephone number: Next of kin telephone number:
Section 2: Administrative Details (to be completed by Referral Unit)
Name of Referring Unit: Name of Receiving Unit:
Name of Liaison Officer: Name of Liaison Officer:
Contact Telephone Number: Contact Telephone Number:
Date referral made: Date referral received (to be completed by Receiving
Unit):
Section 3:Referring Clinician Information (to be completed by Referral Unit)
Name of Referring Clinician: Name of Consultant (if relevant):
Profession/Qualifications: Address:
Registration number: Telephone number:
Address:
Telephone number:
Signature:
Section 4: Clinical Information (to be completed by Referral Unit)
Reason for referral:
Basic history and statement of the problem:
Physical examination findings:
Results of investigations performed:
Treatments given:
Current medication:
Social/psychological factors:
Known allergies:
Any other relevant information:
Section 5: Feedback information (to be completed by Receiving Unit)
Summary of history:
Physical examination:
Investigation results:
Diagnosis:
Treatment given:
Management plan/advise:
Follow up appointment date (if given):
Any other relevant information:
Section 6: Receiving Clinician Information (to be completed by Receiving Unit)
Name of Receiving Clinician: Name of Consultant (if relevant)
Profession/Qualifications: Address:
Registration number: Telephone number:
Address:
Telephone number:
Signature:

Pharmacy Services
Page 1 of 51
Section 2 Operational Standards for Pharmacy Services 7
3.1 Drug and Therapeutic Committee 8

3.1.1 Membership of the DTC
3.1.2 Procedures of the DTC
3.1.3 Roles and Responsibilities of the DTC
3.2 Hospital Pharmaceuctical Services 10

3.2.1 Clinical Pharmaceutical Services
3.2.2 Organization and Management of Pharmaceutical Services
3.2.3 Dispensing and Medication Use Counselling
3.2.4 Compounding of Non-sterile Extemporaneous Preparations
3.2.5 Patient Medication Profile Card
3.2.6 Pharmaceutical Care Plan
3.2.7 Emergency Pharmacy Services
3.3 Drug Information Service 18
3.4 Monitoring of Drug Use Problems 19

3.4.1 Monitoring and reporting of adverse drug reactions
3.4.2 Prescription monitoring
3.4.3 Drug Utilization Monitoring
3.5 Drug Supply Management 24

3.5.1 Selection
3.5.2 Quantification
3.5.3 Procurement
3.5.4 Stores Management
3.5.5 Inventory Management
3.5.6 Distribution
3.6 Pharmaceutical Waste Management 41
3.7 Pharmacy Billing 44
3.8 Premises, Equipment and Facilities 44

Chapter 4 Pharmacy Services Page 2 of 54
4.3 Indicators 46
Source Documents 48
Appendices
Appendix A ABC method for Reviewing Hospital Formulary
Appendix B Sample Prescription Registration Book
Appendix C List of Equipment and Materials for Compounding in Hospitals
Appendix D Compounding Guidelines
Appendix E Format for Recording of the Compounding Process (Compounding Sheet)
Appendix F Compounding Prescription Registration Book
Appendix G Patient Medication Profile Card
Appendix H Sample List of Emergency Drugs
Appendix I Sample Contents of Drug Information Centre Library
Appendix J Sample Adverse Drug Reaction Reporting Form
Appendix K Sample Bin Card
Appendix L Sample Stock Record Card
Appendix M Internal Facility Report, Issue and Receipt Voucher
Appendix N Facility Combined Report and Requisition Form
Appendix O Record for Returning Unusable Commodities
Appendix P Consumption Summary Sheet
Appendix Q Losses/Adjustment Tracking Sheet
Tables
Table 1 Selected indicators to assess prescribing, patient care and facility practices
Table 2 Comparison of Quantification Methods
Table 3 Guidelines for Storage of Pharmaceuticals and Health Commodities
Table 4 Pharmacy Services Checklist
Table 5 Pharmacy Services Indicators
Boxes
Box A Selected National Reform Programmes that Impact on Pharmaceutical
Services
Box B VEN Analysis

Box C Quantification Steps Using the Consumption Method

Box D Quantification Steps using the Morbidity Method
Box E Temperature & Humidity Control for Pharmaceutical Products
Box F Pharmaceuticals Requiring Cold Storage
Box G Preparation for Physical Inventory
Abbreviations
ADR Adverse drug reaction
AR Analytic reagent
DACA Drug Administration and Control Authority
DSM Drug supply management
DTC Drug and Therapeutics Committee
FCC Food chemical codex
FEFO First expiry, First out
FMHACA Food, Medicine and Healthcare Administration Control Authority
LILO Last in, Last out
PFSA Pharmaceuticals Fund and Supply Agency
PMP Patient medication profile card
STGs Standard treatment guidelines

Pharmaceutical Services are an essential component of hospital care. Effective
pharmaceutical services promote the safe, rational and cost-effective use of drugs thus
maximizing health gain and minimizing risk to patients. A well-organized pharmaceutical
service ensures the continuous availability of all pharmaceuticals that are required for patient
care. At the same time, an effective pharmaceutical service should be able to respond to
sudden increases in drug demand, ensuring that adequate supplies are available to deal with
any emergencies that arise.
Within the Ethiopian Health Service a number of reforms are currently taking place that
affect hospital pharmaceutical services. Such reforms include Business Process Re-
engineering for hospitals, strengthening of the Pharmaceutical Supply Chain, Financial
Reform and the creation of a new regulatory body for pharmaceuticals and services [the
Food, Medicines and Healthcare Administration and Control Authority (FMHACA)]. A brief
summary of these reforms and the implications for hospital pharmaceutical services are
presented in Box A.
The standards and guidance set in this chapter are designed to align with and support hospital
pharmaceutical services to meet the demands of these national reform programs.

Box A Selected National Reform Programmes that Impact on Pharmaceutical Services
A) Business Process Re-engineering for Hospitals:

Aim: To enhance the patient experience, ensuring the smooth flow of patients between services
and minimize patient waiting times.
Process: Hospital Services will be organized into 3 main case teams: Outpatient Case Team,
Inpatient Case Team and Emergency Case Team. Each Case Team will be led by a Service
Director (Director of Outpatient Services, Director of Inpatient Services and Director of
Emergency Services). Pharmaceutical (and Laboratory) services should be organized into these
Case Teams. The relevant Service Director has overall accountability for pharmaceutical services
within his/her Case Team.
B) Pharmaceuticals Logistics Master Plan

Aim: To ensure the uninterrupted supply of essential, quality and cost-effective pharmaceuticals at
all health facilities.
Process: The Pharmaceutical Fund and Supply Agency (PFSA) has been created to co-ordinate
national drug supply, drug storage and delivery to facilities. Public hospitals should preferentially
purchase pharmaceuticals from PFSA. Standardized order and reporting formats have been
developed and these should be used by hospital pharmaceutical services.
C) Food, Medicines and Healthcare Administration and Control Authority (formerly DACA)
Aim: To ensure public safety by setting standards and a regulatory framework for:
Health service delivery (premises, services, personnel)
Pharmaceuticals, and
Food Safety
Process: The FMHACA has the authority to regulate all pharmaceuticals, and including suppliers.
FMHACA will set a national drug list and will also set minimum standards for hospital premises
and services. Hospital Pharmaceutical Services should only purchase pharmaceuticals that are
included in the national drug list, and should only purchase from suppliers that are licensed by
FMHACA.
D) Financial Reform
Aim: To enhance hospital autonomy, efficiency and accountability thus promoting service
improvements and maximizing health gain.
Process: Hospital governing boards have been created and Chief Executive Officers appointed to
manage facility operations. Hospitals have the authority to raise and retain revenue, which can be
used to improve services. Hospitals may raise income from a variety of sources including the sale
of pharmaceuticals and the establishment of private wings. All patients are expected to pay for
medical care with the exception of those receiving exempt services (as set out in Federal and
Regional Legislation) and those with fee waiver certificates. Additionally, social and
community health insurance schemes are being developed. Hospitals must have mechanisms to
record all pharmaceuticals that are dispensed under fee waived and insurance schemes so that
reimbursement can be claimed from the appropriate body.

Section 2 Operational Standards for PharmacyServices
1. The hospital has a Drug and Therapeutics Committee (DTC) which implements measures
to promote the rational and cost-effective use of medicines.
2. The hospital has a Medicines Formulary listing all pharmaceuticals that can be used in the
facility. The Formulary is reviewed and updated annually.
3. The hospital has outpatient, inpatient, emergency pharmacies and a central medical store
each directed by a registered pharmacist.
4. The hospital ensures that all types of drug transactions and patient-medication related
information are properly recorded and documented.
5. The hospital has Standard Operating Procedures (SOPs) for all compounding procedures
carried out.
6. The hospital provides access to drug information to both health care providers and
patients in order to optimize drug use.
7. The hospital has policies and procedures for identifying and managing drug use problems,
including: monitoring adverse drug reactions, prescription monitoring and drug utllization
monitoring.
8. The hospital has a drug procurement policy approved by the DTC that describes methods
of quantification, priorization, drug selection, supplier selection and ordering of
pharmaceutical supplies and is in line with national guidance.
9. The hospital has a paper-based or computer-based inventory management system to

reduce the frequency of stock-outs, wastage, over supply and drug expiry.
10. The hospital conducts a physical inventory of all pharmaceuticals in the store and each
dispensing unit at a minimum once a year.
11. The hospital ensures proper and safe disposal of pharmaceutical wastes and expired
drugs.
12. The hospital has adequate personnel, equipment, premises and facilities required to store
pharmaceutical supplies and carry out compounding, dispensing, and counseling services.

3.1 Drug and Therapeutics Committee
Each hospital should establish a Drug and Therapeutics Committee (DTC) to promote the
safe, rational and cost-effective use of medicines.
3.1.1 Membership of DTC
The DTC should be multidisciplinary including, as a minimum:

Clinical Services Director, or equivalent (Chairperson)
Senior Pharmacist (Secretary)
A representative from each Case Team
A representative clinician from each major specialty ( internal medicine, surgery,
paediatrics, obstetrics and gynaecology etc)
Senior nurse representative
Representative from hospital finance department
Representative from other services as deemed necessary
All DTC members, especially the chair and secretary, should be given sufficient time for their
DTC functions, and this should be included in their job descriptions.
Other non-voting, non-executive members may be invited to attend DTC meetings to discuss
issues that require their particular expertise.
3.1.2 Procedures of DTC meetings
The DTC should meet at a minimum every two months, or more often as the need arises.
Minutes should be kept of all DTC meetings. The agenda, supplementary materials and
minutes of the previous meeting should be prepared by the secretary and distributed to
members for review in sufficient time before the meeting. These documents should be kept as
permanent records of the hospital and should be circulated to hospital senior management and
all clinical Case Teams. All DTC recommendations should be disseminated to the medical
staff and other concerned parties and authorities in the hospital. The DTC should cooperate
and share experiences with other hospital committees and regional or national DTCs.
Sub-committees of the DTC may be formed to address specific issues as the need arises (for
example a policy on the use of antimicrobials etc).
3.1.3 Roles and responsibilities of the DTC
1. To develop and maintain the hospital formulary

All hospitals should have a Hospital Formulary listing all pharmaceuticals that can be used in
the facility.
A participatory process should be followed to develop the Formulary involving clinical,

laboratory, diagnostic imaging and finance personnel.

The selection of pharmaceuticals for the Formulary should be based on:
the national drug list (List of Drugs for Ethiopia)
the Federal Ministry of Healths Essential Health Services package,
the National Standard Treatment Guidelines (STGs)
the local pattern of disease
During preparation of the formulary emphasis should be placed on:

drug description using generic names
dosage form, strength and package size in basic units (for example: Amoxycillin
500mg, capsule, 100 per pack)
inclusion of a limited number of drugs to improve drug availability, adherence to
treatment, focused prescribing, and to simplify supply management
The Formulary should be reviewed and updated at least annually. The ABC method described
in Appendix A is a useful tool for reviewing the drugs within a Hospital Formulary.
2. To develop standard clinical/treatment guidelines

Standard clinical/treatment guidelines (STGs) promote rational drug use and provide a
benchmark of optimum treatment for the monitoring and audit of drug use. The DTC should
implement national STGs for use in their own hospital. Hospitals should develop their own
STGs for common clinical conditions that are not covered by national STGs. A participatory
process should be followed to develop STGs involving clinical, laboratory and diagnostic
imaging personnel.
3. To develop policies and guidelines for managing formulary and non-formulary items
Such policies and guidelines include:
Policies/guidelines for the selection, quantification, procurement and distribution of
pharmaceuticals Policies/guidelines for generic substitution and therapeutic
interchange
Policies/guidelines on the use of specific medications for example narcotics,
chemotherapeutic agents, highly expensive medications etc
4. To establish mechanisms to identify and address drug use problems

The DTC should establish a policy and procedures for identifying and managing drug use
problems including, as a minimum:
Monitoring adverse drug reactions (see Section 3.4.1)
Prescription monitoring (See Section 3.4.2)
Drug utilization monitoring (See Section 3.4.3)
Antimicrobial prescribing and use
Additionally, if resources are available the surveillance of antimicrobial resistance may also
be undertaken.

Strategies should be established to correct any drug related problems identified. Such
interventions may include:
Educational programs and in-service training,
Use of standard treatment guidelines and formularies,
Prescribing restrictions, etc
5. To establish and oversee the Drug Information Service

Each hospital should establish a drug information service that provides information and
advice to health professionals, patients and the public. For further discussion please see
Section 3.3 below.
6. To develop an annual action plan

The DTC should prepare an annual action plan, describing the main tasks to be undertaken in
the year with corresponding budget requirements to cover areas such as trainings, printing
etc.
3.2 Hospital Pharmaceutical Services
3.2.1 Clinical Pharmacy Services
Clinical pharmacy services are patient-oriented services developed to promote the rational
use of medicines and, more specifically, to maximize therapeutic benefits (optimize treatment
outcomes), minimize risk, reduce cost, and support patient choice and decisions there by
ensuring the safe, effective and economic use of drug treatment in individual patients. To
achieve this, clinical pharmacists should get information on medication histories, perform
medication reviews, attend ward rounds, provide recommendations on drug selection and
follow-up, and provide counseling to patients and health care providers. Clinical pharmacists
will therefore have the following functions:
Provide advice to doctors, nurses and other health care workers on the clinical use of
medicines, economic drug utilization and safety
Offer direct patient care services through, for example, medication history-taking,
medicines education and advice
Offer hospital managers, including clinical managers, appropriate advice and support
that enables them to make informed decision with respect to medicines policy,
procedures and guidelines designed to ensure safety, effectiveness and economy in
medicines use
3.2.2 Organization and Management of Pharmaceutical Services
Pharmacy services should be provided as part of the Inpatient Case Team, Outpatient Case
Team and Emergency Room Case Team. (See section 3.2.7 for further guidance on
emergency pharmaceutical services). Each of these three services should have a dispensing
unit, patient counselling areas and cashier services. Each Case Team should have one or

more pharmacists who provide specific advice and support to the Case Team when needed.
The pharmacy personnel should promote the rational and safe use of drugs and should ensure
that all medication prescribed by the Case Team is included within the hospital Drug
Formulary and is in accordance with Standard Treatment Guidelines. Any discrepancies
should be discussed with the prescriber. Occasionally it is necessary to prescribe non-
formulary medication and/or to deviate from treatment guidelines. Such circumstances should
be discussed between the pharmacist and Case Team/prescriber and should be documented in
the patients medical record. Additionally, as part of the Case Team the pharmacist should
identify which patients would benefit from an individual Pharmaceutical Care Plan (see
Section 3.2.6).
The relevant pharmacy personnel may attend Case Team meetings, ward rounds or outpatient
clinics (especially for patients with chronic diseases). It will not be necessary for the
pharmacy personnel to attend every case team meeting, ward round or clinical consultation.
However the frequency with which the pharmacy personnel meets with the case team and/or
participates in client contacts must be sufficient to ensure that the pharmacist has a full
appreciation of the clinical context in which advice on the use of medications is given.
Pharmacy personnel should counsel patients in relation to drugs prescribed and should ensure
the detection and reporting of adverse drug reactions among patients managed by their
respective Case Team. The Service Director (Inpatient Service Director etc) is accountable
for pharmaceutical services and personnel within his/her Case Team.
Pharmaceutical staff can also provide health education to patients in the OPD, on wards or
through community outreach.
3.2.3 Dispensing and Medication Use Counselling
Dispensing involves six main steps:

1. The interpretation and evaluation of a prescription
2. The selection, manipulation or compounding of the medicine
3. The labelling and supply of the medicine in an appropriate container
4. The provision of information and instructions to a patient
5. Recording the transaction
6. Filing the prescription
All steps in the dispensing process may be performed by a pharmacist. All steps, with the
exception of the interpretation and evaluation of a prescription, may also be performed by
pharmacist's assistants (druggists/pharmacy technicians) under the supervision of a
pharmacist. All dispensing procedures, whether performed by a pharmacist, pharmacy
technician/ druggist, must be carefully checked for accuracy and completeness by a
responsible pharmacist.

Step 1 The interpretation and evaluation of a prescription
Dispensers must make sure that prescriptions are legible, legal, complete and correct. Orders
received by word of mouth or through telephone should later be endorsed by the prescriber
and be documented in writing. Receipt of the prescription and confirmation of the integrity of
the communication should follow standard procedures for:
a) Identifying the patient, the prescriber and the entity responsible for payment (as
applicable);
b) Ensuring the legality/authenticity of the prescription;
c) Interpreting the type of treatment and the prescriber's intentions;
d) Identifying the medicine, and checking the pharmaceutical/ dosage form, strength,
appropriate dosage, presentation, method of administration and duration of treatment;
e) Informing the patient of the benefits and implications of the substitution for a branded
medicine of an interchangeable multi-source medicine.
f) Helping the patient to resolve the problem when the prescription cannot be dispensed;
The pharmacist should assess the prescription to ensure the optimal use of the medicine with
respect to:
a) therapeutic aspects
i. the safety of the medicine,
ii. possible contra-indications,
iii. drug/drug interactions,
iv. drug/food interaction,
v. drug/disease interactions, and
vi. treatment duplications.
b) appropriateness for the individual and the indication for which the medication is
prescribed.
c) cost of medicine and availability of cheaper alternatives.
Any problems identified should be discussed with the prescriber and a solution should be
worked out in consultation with the prescriber and patient.
Step 2 The selection, manipulation or compounding of the medicine

Patient-ready packs/pre-packed medicines may be used if available. Counting should be done
on a clean counting tray. If necessary, compounding of extemporaneous preparations may be
necessary. This should be carried out following Standard Operating Procedures in a
designated compounding room (see section 3.2.2 below).
Step 3 The labelling and supply of the medicine in an appropriate container

The containers used for dispensing must be appropriate for the product dispensed. All
containers intended for medicinal products must be protected and kept free from
contamination.

All medicines to be dispensed should be labelled and the labels should be unambiguous,
clear, legible and indelible. If possible lettering should be printed. The following information
must be indicated on the label:
the generic name of the product or each active ingredient, where applicable
the strength, dose, frequency of administration and total quantity
expiry date
prescribers name
the name of the person for whom the drugs are dispensed
the directions for use
the name and business address of the dispenser
date of dispensing and
special precautions as applicable
Step 4 The provision of information and instructions to a patient

All drugs should be dispensed with adequate and appropriate information and counselling.
Information must be structured to meet the needs of individual patients and questions and
answers should be used to check the patients understanding. Written information should be
provided to supplement verbal communication as appropriate. Counselling should ensure
that the patient has an unequivocal understanding of the instructions for use, and any distinct
characteristics or requirements of the medicine. Counselling should cover matters that will
enhance or optimize medicine therapy and should include:
Name and description of the medicine used
Intended use of the medicine and expected action
Dosage form, dose, route of administration
duration of therapy with emphasis given to completing the entire course, eg
antibiotics
expected time to see a response of the medication and instructions on what to do if the
medicine appears not to have the desired effect
the time the drug should be taken in relation to other drugs, food, life style
interactions etc
clear instructions on measurement and administration of medicine (for example
liquid, aerosol, topical preparations or suppositories). If necessary a demonstration
such as opening and closing containers or using an aerosol may be necessary
Techniques for self-monitoring of medication therapy
Action to be taken in the event of a dose not being taken
explanation of harmless effects of the medication such as urine discoloration
Common severe side or adverse effects or interactions and therapeutic interactions
that may be encountered, including their avoidance and the action that required if they
occur
storage instructions

advice regarding keeping medicines out of reach and sight of children, and
clarification on the consequences of sharing medication or keeping extra doses at
home
Prescription repeat information
Step 5 Recording the transaction

Prescriptions should be recorded and documented as proof of transaction between the patient
and the pharmacy professional. Prescriptions can therefore be traced back if any need arises.
All dispensing units should have a standardized Prescription Registration Book (PRB) for
recording every pharmaceutical issued to a patient. A computerized dispensing and
registration system may also be used, but should always be supported by paper back up. An
example PRB is presented in Appendix B. The registration book should be completed at the
time of dispensing or at the close of the working day.
The prescription registration book should be used both when prescriptions are retained in the
pharmacy and when they are returned to the patient.
For a prescription which is returned to a patient because all the items in the original
prescription could not be filled, the drugs that have been dispensed from the pharmacy should
be copied on a blank prescription and the prescription should be filed appropriately. On the
original prescription, which is retained by the patient, the word dispensed should be
stamped adjacent to those items which have been dispensed.
For prescriptions which are to be refilled on a later date, the dispensing information should be
entered into the registration book before returning the prescription to the patient. The official
seal of the pharmacy, name and signature of the dispenser, the date of dispensing and the next
refill date should be written on the back of the prescription.
Step 6 Prescription filing

Each prescription should be signed and accountability accepted by the pharmacist or other
authorized person for the correctness of the dispensing of the medicine and confirming that
the medicine was supplied.
1. At the close of each day all dispensed prescriptions should be organized into normal or
special (eg. Narcotic drugs) prescriptions and filed
2. Prescriptions should be filed sequentially by day in a single container/carton for each
month. The container should be labelled with the month and year
3. Containers should be arranged on a monthly basis
4. Normal prescriptions should be filed securely for two years and special prescriptions for
5 years
Prescriptions, patient and medication related records and information should be documented
and kept in a secure place that is easily accessible only to the authorized personnel.

3.2.4 Compounding of Non-sterile Extemporaneous Preparations
Compounding involves the preparation, mixing, assembling, packaging, and labelling of a

drug or device in accordance with a licensed practitioner's prescription. This may include the
reconstitution or manipulation of commercial products. Compounding should only be
undertaken by capable, qualified and authorized personnel who have been trained for the type
of compounding conducted.
Standard Operating Procedures (SOPs) should be established for all compounding procedures
carried out by the pharmacy department. An SOP should include:
The name, strength and dosage form of the preparation compounded
all ingredients and the quantities needed
equipment needed for preparation
mixing instructions including:
o order of mixing
o mixing temperature
o duration of mixing
beyond-use date
the packaging or container to be used for dispensing
storage requirements
labelling instructions
quality control procedures (eg measurement of the degree of weight variation between
capsules; checking the adequacy of mixing, odour, colour, consistency, clarity or pH
of preparation as appropriate)
A list of equipment and materials for compounding is presented in Appendix C. Further

details on the compounding process are described in Appendix D.
A Compounding Record should be kept of all compounding activities. The record should list:
the name and strength of the compounded preparation
the formulation record reference for the preparation
the sources and lot numbers of ingredients
the total number of dosage units compounded
the name of the person(s) who prepared and approved the preparation
the date of preparation
the assigned beyond-use date
the prescription number
the results of quality control procedures (eg the weight range of filled capsules)
Sample Format for Recording of the Compounding Process (Compounding Sheet) and
Compounding Prescription Registration Book are presented in Appendix E and F,
respectively.

To ensure the safety and quality of compounded preparations SOPs should be strictly
followed, and the compounder should check and recheck each step of the preparation process
to guarantee that each weight or measurement is correct as stated in the SOP. Specific quality
control measures for each procedure should be described in the SOP.
3.2.5 Patient Medication Profile Card
All patients with a chronic illness should have a patient medication profile card (PMP). The
PMP should be updated by the dispensing pharmacist whenever drugs are dispensed to the
patient.
The PMP can be in hard copy or computerized with hard copy back up and should contain the
following information:
a) Name of the health institution
b) Patient medical record number
c) The full name, sex, age and weight of the patient
d) The address of the patient and next of kin (if appropriate)
e) Principle diagnosis/diagnoses and any concomitant diseases
f) History of adverse drug reactions
g) A list of all medicines (prescription as well as non-prescription) used by the patient
h) Reason for any changes made in the regimen of the patient
i) Name or initial of prescriber and prescription number
j) Dispensing and / or prescription date
k) Appointment / Refill date
l) Signature of the dispenser
PMPs should be filed sequentially by medical record number or alphabetically by patient

name in the dispensing unit.
When a patient presents to the pharmacy for a refill the pharmacist must assess the patient for
signs of compliance, effectiveness and safety of the therapy. The pharmacist should identify
areas for therapeutic modification and should refer to the prescriber when appropriate.
A sample PMP is presented in Appendix G.
3.2.6 Pharmaceutical Care Plan
A pharmaceutical care plan should be considered for selected inpatients and outpatients
including:
Those with multiple conditions/diseases
Those whose age, weight or clinical state may affect drug absorption or disposition,
alter dosage requirements or predispose the patient to adverse reactions or drug
toxicity
Patients taking medicines known to have a high risk of toxicity and a narrow
therapeutic index
Patients taking medicines which may interact
Patients taking an investigational medicine
Patients whose therapy is changed frequently
Patients receiving IV therapy
The pharmaceutical care plan defines treatment goals, determines appropriate interventions
and helps to assess whether the patients needs have been met. It also defines responsibilities
for the pharmacist and patient.
The first step in developing a pharmaceutical care plan is to assess the patient, with particular
attention to:
General health and activity status
Past medical history
Medication history
Social history
Diet and exercise history
History of present illness
Economic situation (self-pay, insured or fee waived status)
Information on the above can be obtained directly from the patient or carers, from the
patients medical record or from other clinical staff (nurses or physicians).
The plan should address each of the patients diseases or conditions, taking into consideration
the cost and/or complexity of therapy and patient adherence. The plan should be developed in
consultation with the patient and the Case Team or clinician responsible for the care of the
patient. In developing the plan the pharmacy staff member should ensure that the patient is
well informed on:
the various pros and cons (cost, side effects etc) of the treatment options
instances where one option may be more beneficial based on the pharmacy staff
members professional judgment
The disease and the therapy/medications described in the plan
The essential elements of the plan, including the patients responsibilities
The pharmacist is responsible for monitoring the patients progress in achieving the outcomes
specified in the pharmaceutical care plan. Progress should be documented in the care plan
and any necessary changes to the plan should be coordinated with the patient and his/her
other healthcare providers as appropriate.
A final evaluation should be undertaken by the pharmacist to determine whether the actions
and interventions of the care plan have achieved the desired outcomes. This can be done in
person or by follow-up telephone contact depending on the circumstances.

3.2.7 Emergency Pharmacy Services
According to the current health sector reforms, emergency pharmacy service is one of the
basic health care services to be provided under the emergency service unit of a hospital.
Emergency pharmacy service should be directed by a registered pharmacist who is

accountable to the emergency unit of the hospital. Services should be available 24 hours a
day.
The responsible pharmacist shall take the duty to coordinate and prepare emergency
pharmaceuticals list (A sample list is provided in Appendix H) and ambulance kits for the
hospital and he/she has to exert all the necessary efforts to ensure continuous availability of
pharmaceuticals for the emergency unit and hospital ambulances.
Orders received by word of mouth or through telephone during an emergency should later be
endorsed by the prescriber and be documented in writing within 48 hours of the order. The
quantity prescribed should be limited to emergency period only.
The emergency pharmacy, in addition to supply of pharmaceuticals, shall ensure safe and
correct use of medications as medication error is significantly high in this service area.
3.3 Drug Information Services
All hospitals should provide a drug information service for health professionals, patients and
members of the public. The service generally responds to patient-oriented drug problems
received from clinical staff or patients. However the drug information service can also
provide education and training to health professionals and/or the public regarding appropriate
and safe drug use.
A drug information centre (DIC) should be established in each hospital. The Center should
have sufficient space with appropriate furniture and equipment including a dedicated
telephone with answering machine, filing cabinets, printer and computer, preferably with
internet access. The DIC should contain a current collection of reference materials such as
books, journals, drug profiles, formularies and manufacturers information. A list of possible
resource materials is presented in Appendix I.
The DIC should be open during normal pharmacy hours and should be staffed by
appropriately skilled personnel who are trained in the provision of drug information.
To guide operations of the unit, SOPs should be established for:

receiving, researching, answering, referencing, logging and storing medicine
information queries
consulting specialists or other DICs for handling enquiries that are beyond the
expertise of the unit

a patient counselling service
reporting adverse drug reactions (see Section 3.4.1)
A filing system should be in place for information such as drug profiles, manufacturers
literature, drug protocols, drug trial protocols, and hospital policies. The system should be
indexed and organized systematically. Information should be regularly updated and all
contents should be reviewed annually.
3.4 Monitoring of Drug Use Problems
The hospital should develop and implement a policy for monitoring drug use and to identify
drug use problems that includes, as a minimum:
Monitoring adverse drug reactions
Monitoring of prescriptions
Drug utilization monitoring
o Indicator study methods
o Aggregate data methods
o Drug use evaluation methods
The policy should assign responsible personnel for each of the activities, and should specify
the frequency with which studies are conducted and the process by which findings/reports are
presented to the DTC.
3.4.1 Monitoring and reporting of adverse drug reactions
The side effects or adverse reactions to medicines may range from relatively mild to, in rare
cases, serious and life threatening. The detection of side effects and adverse reactions is
important on an individual basis to optimize patient care and prevent harm. Additionally, the
detection of ADRs is an important element of post market surveillance, by which health
providers report ADRs to the appropriate higher authority so that problems not detected in the
pre-marketing phase of drug use may be detected and any necessary action taken.
Vigilance is required to detect ADRs. Individuals susceptible to an ADR include:

those with multiple diseases
those on multiple drug therapy
geriatric or paediatric patients
those receiving medicines that are known to be associated with serious adverse effects
those receiving drugs with a low therapeutic index or potential for multiple
interactions
those with organ impairment that may alter drug pharmacokinetics
those who have had a previous ADR

A standardized form should be used to record and report ADRs. This should include:
Patient name, sex, age, medical record number
Clinical diagnosis
Current medication
History of previous ADR if any
Details of adverse reaction
Causality assessment
Recommendations given
A sample is presented in Appendix J.
An ADR focal person should be appointed by the DTC. He/she is responsible to:
Ensure that all health professionals are involved in detecting, assessing, managing and
reporting potential ADRs
Ensure that ADR report forms are readily available in all clinical areas and that health
professionals are familiar with the form and how to complete it
Receive ADR report forms from clinical staff
Investigate potential ADRs
Analyze ADR data and compile reports
Provide regular reports to the DTC/and Hospital Management on ADRs in the facility
Report all ADRs to the Regulatory Body
The DTC should receive regular reports from the ADR focal person and make any necessary
decisions regarding the use of the drug in the facility. Where necessary the hospital formulary
should be amended to take account of detected ADRs.
Suspected ADRS should be investigated and managed as follows:

1. Assess suspected ADR with respect to:
a) Patient details: age, gender, organ function, height, weight; diagnosis and other
relevant co-morbidities prior to reaction; previous exposure to suspected drug(s) or
related drug(s).
b) Medicine details: non-prescription drugs, alternative treatments, recently ceased
medicines; name, dose, route of administration, manufacturer, batch; date and time
commenced; date and time discontinued (if applicable); indication.
c) Comprehensive adverse reaction details: description of the reaction; time of onset
and duration of reaction; complications and sequelae; treatment and outcome of
treatment; relevant investigation results or autopsy report.
2. Perform causality assessment to assess likelihood of the drug causing the observed
reaction.

A literature review may be undertaken to assess the likelihood that a suspected ADR was
caused by a particular drug and/or the advice of other health professionals may be sought.
The ADR should be classified as:

Certain: a clear temporal association is established between medicine administration
and the reaction; and/or the results of investigations confirm that there is a
relationship between the administration of the medicine and the reaction; and/or the
reaction recurs upon re-exposure to the drug; and/or the reaction is commonly known
to occur with suspected drug;
Probable: the reaction is known to occur with the suspected drug, and there is a
possible temporal association between the reaction and medicine administration;
and/or the reaction resolves or improves upon withdrawal of the suspected medicine
and other medicine therapy remains unchanged; and/or an uncommon clinical event
occurs in the absence of other potentially causative factors;
Possible: an alternative explanation for the reaction exists; and/or more than one
medicine is suspected; and/or recovery follows withdrawal of more than one drug;
and/or the temporal association between the reaction and administration of the
medicine is unclear; or
Doubtful: another cause is more likely to have accounted for the clinical event, e.g.
underlying disease.
3. Make recommendations on treatment options, including possible alternative treatments

taking into consideration:
the likelihood of the suspected drug(s) having caused the reaction
the clinical significance of the reaction
the condition of the patient
the requirement for therapy
the risks and benefits associated with continuing therapy
the relative efficacy and safety of other therapeutic options
the prophylactic use of other medicines to prevent future adverse reactions.
4. Document the ADR and provide follow up advice:

All ADRs should be clearly highlighted in the patients case notes. Any patient who has
experienced an ADR should receive advice about the drug and reaction, should be advised to
avoid the drug in the future and should be given an alert card that states the drug involved
and nature of the reaction. He/she should be advised to show this card at any future clinical
consultation to prevent the same drug being prescribed again.
The ADR reporting form provided by the regulatory authority should be completed and
returned as per the guidance provided.

3.4.2 Prescription Monitoring
Prescriptions issued by each Case Team should be regularly monitored to identify problems
or opportunities for optimizing treatment. The monitoring schedule should be set at a
frequency suitable for the patient mix and prescribing practice of the Case Team. The DTC
should establish a policy that outlines the responsible person (s), the process of and frequency
with which prescription monitoring will be conducted for each Case Team.
Patients and their medicine therapy should be monitored for:

Legality, legibility and completeness of prescription
Relative efficacy of the medication for the clinical indication
Compliance with the hospital formulary or applicable treatment guidelines
The appropriate dose and route of administration
The appropriate duration of therapy
Possible altered kinetics of drug absorption, distribution, metabolism or excretion
which may affect therapy
Significant drug interactions
Possible drug/disease incompatibilities
Drug/laboratory test interference
Duplication of pharmacologically similar drugs
Adverse drug reactions (ADRs) or drug toxicity
Problems relating to intravenous administration, including potential incompatibilities,
medicine stability, volume of intravenous fluid for medicine administration and rate
of administration
Administration errors and omissions
Patient compliance
Potential problems identified should be discussed with the prescriber, with advice given on
alternative treatments. A pharmaceutical care plan may be developed to resolve any
problems identified (see Section 3.2.6).
3.4.3 Drug Utilization Monitoring
The purpose of drug utilization monitoring is to assess the overall drug utilization pattern of
the hospital and identify problem areas for intervention and the impact of interventions. Two
main methods may be used:
Indicator study methods (prescribing, patient care and facility indicators); and
Drug use evaluation (DUE) methods.
a) Indicator study methods:

In Indicator studies a selected indicator is set and performance against this indicator is
measured. Indicators can be developed to assess prescribing, patient care or facility practices.
Table 1 presents possible indicators that could be used for an Indicator Study.

Table 1. Selected indicators to assess prescribing, patient care and facility practices
Prescribing Indicators Patient Care Indicators Facility Indicators
Average number of medicines Average consultation time Availability of
per encounter Average dispensing times essential medicine
% of medicines prescribed by list or formulary
% of medicines actually
generic name dispensed Availability of key
% of encounters with an set of indicator
% of medicines that are
antibiotic prescribed medicines
adequately labeled
% of encounters with an Availability of
% of patients who know how
injection prescribed standard treatment
to take their medicines
guideline (STG)
% of medicines prescribed
which are from the essential
medicines list or formulary list
Steps to be taken when conducted an indicator use study include:

Determine objectives of study
Define indicators and data collection procedures
Determine study design and sampling methods
Pilot test
Train data collectors
Collect data as per the time line
Compile and analyze data
Prepare report and recommendations based on findings of study
Present report and recommendations to DTC and relevant hospital staff
Implement recommendations arising from study, repeat study to assess impact.
b) Drug Use Evaluation (DUE) methods
Drug Use Evaluation studies can be undertaken to measure the use of a specific drug and/or
adherence to standard treatment guidelines (STGs). DUE studies are particularly important to
investigate:
Perceived overuse or underuse of medications
Problems identified by indicator studies
High numbers of ADRs
Excessive amounts of non-formulary medicines used
Use of high-costs medicines when less expensive alternatives exist
Use of excessive numbers of medicines within a therapeutic category
Steps to be undertaken in conducting a DUE study include:

Step 1: Define appropriate medicine use (for example medicine use described in national or
local STGs)
Step 2: Audit actual prescribing practice against the set criteria
Step 3: Analyze data, prepare report and recommendations based on findings
Step 4: Present report and recommendations to DTC and relevant staff
Step 5: Implement recommendations arising from study, repeat study to assess impact
Problems identified by Indicator Study or DUE studies may be further investigated using
qualitative methods further described in Chapter 12: Quality Management; section 3.2.1.
3.5 Drug Supply Management
Effective drug supply management ensures the uninterrupted availability of quality,

approved, safe and effective pharmaceuticals. Drug supply management involves six basic
functions: selection, quantification, procurement, storage, distribution and use. The Hospital
should have a pharmacist for overall drug supply management, a pharmacy technician for
store manager and a data clerk to enter data.
3.5.1 Selection
All hospitals should have a Hospital Formulary that lists all pharmaceuticals that can be used
in the hospital. The Formulary should be approved by the DTC and be based on the List of
Drugs for Ethiopia/ National Formulary. The Formulary is the basis for drug selection and
procurement.
3.5.2 Quantification
After the Formulary is prepared, the quantity of each product required by the hospital for a
given period of time should be determined. To guide this process, a Quantification Policy
should be developed and approved by the DTC. The Quantification Policy should indicate:
The methodology to be used for quantification
Techniques for cost analysis and prioritization for periods when funds are insufficient
(see Box B)
The annual schedule for quantification

Box B VEN Analysis
If funds are limited, VEN analysis is a method to prioritize for medicine purchase. This
analysis is used to identify high-priority medicines for procurement and low-priority
medicines that the DTC should analyze carefully for deletion from the formulary.
VEN stands for:
V = Vital: Potentially lifesaving and crucial to providing basic health services
E = Essential: Effective against less severe but significant illness, not vital
N = Non essential: Effective for minor illnesses but have high cost and low therapeutic
advantage
Steps for conducting a VEN analysis are as follows:
Step 1. Classify all medicine on the list as V, E, or N
Step 2. Analyze the N items. Where possible, reduce quantities to purchase or

eliminate them.
Step 3. Identify and limit therapeutic duplications.
Step 4. Reconsider proposed purchase quantities.
Step 5. Find additional funds if needed or possible.
Any quantification method should aide in :

Setting the maximum, minimum and reorder stock levels
Identifying what to quantify (develop drug list)
Considering the impact of lead time
Adjusting for service growth and losses due to wastage and theft
Estimating total procurement cost
Adjusting and reconciling final quantities
Two main methods for quantification are:

consumption methods;
morbidity methods;
Table 2. Comparison of Quantification Methods

Method Uses Essential Data Limitations
First choice for Reliable inventory Must have accurate
procurement forecasts, records consumption data
Consumption given reliable data Records of supplier Can perpetuate
Most reliable predictor of lead time irrational use
future consumption Projected drug costs

Estimating need in new Data on population and Morbidity data not
programs or disaster patient attendances available for all diseases
assistance Actual or projected Standard treatments
Morbidity Comparing use with incidence of health may not really be used
theoretical needs problems
Developing and Standard treatments
justifying budgets (ideal, actual)
Projected drug costs
Every quantification method should address at least the following:

Plan/schedule for quantification
Review of the minimum, maximum, and order interval set for each pharmaceutical
(primarily for products supplied by private suppliers).
Identify which pharmaceuticals are to be quantified
Consider the impact of procurement lead time
Adjust for service growth (program effort) and estimated losses due to wastage and/or
theft
Estimate total procurement quantities and cost
Adjust and reconcile final quantities and cost according to funding and other factors
3.5.2.1 Consumption Method
The Consumption Method is the most reliable predictor of future consumption therefore this
method is the preferred option for quantifying the requirements for pharmaceuticals. Since
the Consumption Method relies on accurate records of past drug consumption each hospital
should have a reliable system to track drugs from the store to each dispensing unit and to the
patient. Daily drug consumption at different outlets of the hospital should be recorded,
compiled and analyzed for the appropriate supply and use of pharmaceuticals.
This Consumption Method is most suitable when there is:

a representative pattern of morbidity and patient attendances
an acceptable pattern of rational prescribing
adequate and uninterrupted drug supply
complete and accurate data on stock-on-hand and issues/consumption, and
data on waste and losses

Box C Quantification Steps Using the Consumption Method
Step 1: Prepare list of pharmaceuticals to be quantified

Step 2: Determine the period of time to be reviewed for consumption
Step 3: Enter consumption data for each pharmaceutical
Step 4: Calculate average monthly consumption
Step 5:Calculate the quantity of each drug required for the next procurement period
Step 6: Adjust for expected changes in consumption patterns
Step 7: Adjust for safety stock requirements and estimated losses
Step 8: Estimate costs for each pharmaceutical and total costs
Step 9: Compare total costs with budget and make adjustments
3.5.2.2 Morbidity method
This method uses morbidity data to determine the quantity of pharmaceuticals required. It
may be the most appropriate method of quantifying drug requirements when:
consumption data are incomplete or not available
prescribing patterns are not cost effective
budget is unlikely to be sufficient to meet estimated requirements, and
health facilities or services are new
Box D Quantification Steps using the Morbidity Method
Step 1: Specify the list of health problems

Step 2: Establish standard or average treatments for each health problem
Step 3: Establish the list of drugs to be quantified
Step 4: Collect morbidity data for each problem
Step 5: Calculate the number of treatment episodes for each health problem
Step 6: Calculate the quantity of drugs for each health problem
Step 7: Combine the estimates for each drug from the various health problems into a
master procurement list
Step 8: Adjust quantities to cover other health problems
Step 9: Adjust for current stock position and expected losses
Step 10: Estimate costs for each drug and total cost
Step 11: Compare total costs with budget and make adjustments
The Chief Clinical Officer should review and approve all forecasts/quantifications prior to
procurement.
3.5.3 Procurement
A designated pharmacist (drug supply management officer) should be responsible for the
pharmaceutical aspects of the purchase of all pharmaceuticals. A Procurement Policy,

approved by the DTC should be established. General principles and procedures that should be
addressed in the procurement policy include:
procurement by generic name
procurement limited to products specified in the Hospital Formulary
procurement in bulk
procurement based on quantification and available funds
flexibility to respond to emergency situations
compatibility with the regional and national laws
product quality assurance
o The pharmacist must not purchase any medicinal product where the
pharmacist has any reason to doubt its safety, quality or efficacy.
o The pharmacist must ensure that both the supplier and the source of any
medicine purchased are reputable and registered by the regulatory body.
supplier selection: PFSA or private
contract terms (delivery time, payment terms etc)
batch recall of pharmaceuticals, when necessary
audit and monitoring of the procurement process
Additionally, the Procurement Policy should:

a) indicate how an order should be placed to the PFSA/
b) indicate procedures for procuring pharmaceuticals that are not available through
PFSA.
The responsible pharmacist is accountable for:

adherence to delivery schedules, contract or purchasing agreements
the maintenance of up-to-date price records to ensure that the most favorable prices
are obtained
establishing and maintaining adequate records of purchases for inventory control and
satisfaction of legal requirements.
establishment and maintenance of a system for reporting errors and withdrawing
defective products
Order placement and receiving of pharmaceuticals should be made using official and serially
numbered vouchers. There must be only a small number of authorized signatories. Telephone
orders must be confirmed in writing immediately.
3.5.3.1 Procurement through PFSA
Hospitals should procure preferentially through PFSA. A contract agreement should be

entered between PFSA and the hospital that describes, as a minimum:
routine ordering and reporting processes
emergency ordering
payment terms

processes for handling discrepancies, damages and losses
stock related information to be delivered to PFSA
supply status related information to be delivered to hospitals
For most essential pharmaceuticals, the hospital should adopt the national system for
resupply (formats, inventory control procedures, delivery schedules, etc.), in cooperation with
the Pharmaceutical Fund and Supply Agency.
3.5.3.2 Procurement through Private Suppliers
If pharmacueticals are not available to through PFSA, they should be purchased from private
suppliers. Purchases should only be made from private suppliers that are registered with
FMHACA. To improve efficiency and minimize costs one year contracts are preferred, with
quarterly or bi-monthly deliveries.
3.5.4 Stores Management
Storage is the safekeeping of pharmaceuticals to protect the shelf life of products and avoid
damage, expiry, and theft.
A pharmacist must be assigned for the overall management of pharmaceuticals for the
hospital and including oversight of the medical store and a data clerk. A designated pharmacy
technician should be responsible for the storage of all pharmaceuticals.
All drugs and medical supplies should be stored in a designated area with security measures
to restrict access to authorized personnel only. All pharmaceuticals from suppliers should be
delivered directly to the central medical store where they will be registered, stored and issued
to dispensing units.
Since drugs and medical supplies may be damaged by improper storage it is essential that the
central medical store has adequate control of sanitation, temperature, light, ventilation and
humidity. Box E describes measures to ensure adequate temperature and humidity control.
Guidelines for the storage of pharmaceuticals are presented in Table 3 and Box F.
All storage areas, including those in the various dispensing units, should be inspected
regularly to ensure that:
Pharmaceuticals are stored and handled in accordance with the pharmaceutical
manufacturers requirements and regulatory standards.
Proper storage conditions are maintained for all pharmaceuticals requiring special
conditions, such as cold storage, high security (controlled substances), radio-
pharmaceuticals, and medical gases.
Expired or obsolete pharmaceuticals are stored separately.
Stock levels are adequate to ensure a continuous supply of ready-to-use
pharmaceuticals at all times, especially the essential drugs as defined by the latest
edition of the formulary.

Flammable substances are stored separately and in an appropriate manner.
Disinfectants, chemicals, and preparations for external use are stored separately from
pharmaceuticals.
Box E Temperature & Humidity Control for Pharmaceutical Products
1. The store should be designed store to moderate internal temperatures. The use of trees for
shade and shelter, correct building orientation for natural lighting and ventilation, and
appropriate building materials can moderate internal temperature.
2. Ceilings should be at least 3m high to allow adequate ventilation.
3. The following procedures can be implemented to moderate the temperature inside the store.
In hot, dry climates, good construction and night time ventilation can maintain
daytime temperatures several degrees below ambient. In hot, humid climates,
effective cross-ventilation is required.
In cold climate areas the storage buildings should be well insulated.
4. Moisture sensitive products should be stored at a relative humidity less than 60%. For this
purpose:-
It is advisable to open the windows or air vents of the store room to allow air
circulation. Ensure that all windows have screens to keep out insects and birds
before opening.
Put boxes on pallets and ensure that there is sufficient space between the pallets and
the walls of the store room for proper air circulation.
Never open a new container unless necessary.
Use ceiling mounted ventilator or standing fans as appropriate.
Installing Air Conditioners (AC) when the need arises.
Depending on the climate condition and the financial capacity of the hospital,
installation of a dehumidifier can also be considered.
5. Some drugs are photosensitive and can be damaged if exposed to direct sunlight. To protect
products from sunlight:
Shade the windows or use curtains, if they are in direct sunlight.
Keep products intact in cartons.
Maintain trees on the premises around the facility to help provide shade.
6. Heat affects many products. Ointments and creams that can easily melt and heat can cause
degradation. The above stated points about sunlight and humidity control will also help
protect such products from heat. It is important to have a thermometer in various parts of the
pharmacy/store to monitor temperature.

Table 3. Guidelines for Storage of Pharmaceuticals
Activities Justification
1. Store pharmaceuticals in a dry, well- Extreme heat and exposure to direct sunlight can degrade
lit, well- ventilated storeroom - away pharmaceuticals and dramatically shorten shelf life. Direct sunlight
from direct sunlight. Temperatures in raises the temperature of the product and can reduce its shelf life or
the storeroom should not exceed may damage the product by other mechanisms.
25oC.
2. Clean and disinfect the storeroom Pests are less attracted to the storeroom if it is regularly cleaned and
regularly. Keep food and drink out disinfected. The outside of the store should also be kept clean, and
of the storeroom. any garbage should be stored in covered containers. Water should
not be allowed to stagnate near the building.
Would should be varnished or painted to discourage pests. If
possible, a regular schedule for extermination will also help
eliminate pests.
3. Protect storeroom from water and Moisture can destroy both supplies and their packaging. If the
moisture. packaging is damaged, the product is still unacceptable to the patient
even when the pharmaceutical is not damaged.
4. Keep fire safety equipment available, Stopping a fire before it spreads can save expensive supplies and the
accessible, and functional, and train storage facility. The right equipment should be available; water is
employees to use it. able to put out paper fires, but is ineffective on electrical and
chemical fires. Place well-maintained fire extinguishers at suitable
positions in the storeroom. If a fire extinguisher is not available, keep
sand or soil in a bucket nearby.
5. Store latex products away from Latex products can be damaged if they are directly exposed to
electric motors and fluorescent fluorescent lights and electric motors. Electric motors and
lights. fluorescent lights create the chemical ozone which can rapidly
deteriorate latex products. Keep latex products in paper boxes and
cartons.
6. Maintain cold storage, including a Cold storage (2 to 8 degrees Celsius or 36 to 46 degrees Fahrenheit)
cold chain, as required. is essential for maintaining the shelf life of certain pharmaceuticals.
These items are irrevocably damaged if the cold chain is broken. If
electricity is unreliable, the use of cylindered gas or kerosene-
powered refrigeration is recommended. Many drugs require storage
below 25 oC. There may also be products that should be stored at a
temperature below 0oC and hence the required storage condition
should be maintained for these products.
7. Limit storage area access to To prevent theft and pilferage, lock the storeroom and/or limit access
authorized personnel. Drugs which to personnel other than authorized staff, and track the movement of
need an access-controlled pharmaceuticals.
environment such as narcotics,
psychotropic, etc should be stored
under lock and key separate from the
rest of stock preferably a locked wire
cage within the storage facility or a
lockable cabinet.

8. Stack cartons at least 10 cm off the Pallets keep the products off the floor so they are less susceptible to
floor, 30 cm away from the wall and pests, water and dirt damage. Stack pallets 30 cm away from the
other stacks, and no more than 2.5m walls and each other to promote air circulation and to ease movement
high. of stock, cleaning and inspection.
Do not stack cartons more than 2.5m as the weight of the products
may crush the cartons at the bottom. This will reduce potential injury
to warehouse personnel. If cartons are particularly heavy, stack
cartons less than 2.5m.
Where feasible, strong well-organized shelving is preferred.
9. Store medical supplies away from Exposure to insecticides and other chemicals may affect the shelf life
insecticides, chemicals, old files, of pharmaceuticals. Old files and office supplies may get in the way
office supplies and other materials. and reduce space for medical supplies or make them less accessible.
De-junking the storeroom regularly makes more space for storage.
10. Store flammable products separately Some medical procedures use flammable products, such as alcohol,
from other products. Take cylindered gas, or mineral spirits. Such products should be stored in
appropriate safety precautions. the coolest possible place, away from electrical appliances and other
Storage areas and cabinets should be products and near a fire extinguisher.
clearly marked to indicate that they
contain highly flammable liquids and
should display the international
hazard symbol.
Corrosive or oxidant products,
laboratory chemicals and reagents
should be stored away from
flammables, ideally in a separate
steel cabinet to prevent leakage.
11. Store pharmaceuticals to facilitate FEFO (First Expiry, First Out) is a method of managing drugs in a
FEFO procedures and stock storage facility where the drugs are managed by their expiry date.
management. Drugs that will expire first are issued first, regardless of when they
were received at the health facility.
12. Store drugs in their original shipping Drugs should not be opened to repackage them. Store supplies in
cartons. Arrange cartons with arrows their original shipping cartons. Items should be stored according to
pointing up, and with identification manufacturers instructions on the cartons; this includes paying
labels, expiry dates, and attention to the direction of the arrows.
manufacturing dates clearly visible. Identification labels make it easier to follow FEFO, and make it
easier to select the right product.
13. Separate unusable pharmaceuticals Do not dispense expired drugs to the patients. Designate a separate
from usable pharmaceuticals and part of the storeroom for damaged and expired goods.
dispose of damaged or expired
products without delay.

Box F Pharmaceuticals Requiring Cold Storage
Thermo-labile medicines must be kept in a refrigerator.

The refrigerator should only be used for storing pharmaceuticals.
The refrigerator should not be overloaded and stock should be kept in an orderly manner.
The door of the refrigerator should close tightly.
Uninterrupted power supply must be ensured.
The temperature of the refrigerator should be maintained between 2oC and 8oC.
The temperature of the refrigerator must be monitored and charted twice daily.
A WHO approved dial thermometer or alcohol or mercury thermometer should be used. The
thermometer must be hung from the middle shelf of the refrigerator.
If the power is off for any length of time, the refrigerator should not be opened until the power
supply is restored.
The cold chain must be maintained when the refrigerator is cleaned. Cooler boxes should be
used to maintain the cold chain.
The following procedures should be followed when the refrigerator is cleaned:
i) The inside of the refrigerator should be cleaned with an appropriate cleansing solution
and wiped dry.
ii) The door gasket should be cleaned, especially along the bottom edge on upright units.
iii) The freezing compartment should be defrosted if there is more than 10 mm of ice on
the evaporator.
iv) The condenser coil on the back of the refrigerator should be cleaned and dust removed
from the compressor.
3.5.5 Inventory Management
For most essential pharmaceuticals, the hospital should adopt the national system for
pharmaceutical management and resupply (formats, recording, reporting, ordering, inventory
control procedures, delivery schedules, etc.) in cooperation with the Pharmaceutical Fund and
Supply Agency (PFSA).
All pharmaceuticals handled in the hospital should be stored and dispensed following the
standard coding system. Until a national coding system is set by PFSA, hospitals should
devise their own method. Pharmaceuticals must be organized utilizing a system that allows
for easy identification of all pharmaceuticals, which ensures the safety of all pharmacy team
staff, and which utilizes:
First Expiry First Out principles
Alphabetical, pharmacological, pharmaceutical orders, or high/low usage systems,
or a logical combination of one or more of these methods
Flood method/system
3.5.5.1 Stock and Shelf Numbering
A Stock Number System is used to facilitate the inventory management process through
creating a systematic arrangement of all stocks in the central medical store. In case of
computerization, it helps to have a fast item tracking system for each type of product
category. Each item should have a unique stock number as an identifier. There are many
ways of creating a stock number. In a complex and very large facility, a typical stock number
may be structured as twelve alphanumeric characters. However, in our settings, eight
alphanumeric characters can be adequate. For instance, GI-100-001 can be used as a stock
number for a drug in gastrointestinal tract category.
Inventory coding should be done in accordance with the following procedures.

Take product category alphabets from the national drug list of Ethiopia. Example, GI
for drugs used to treat gastrointestinal problems.
Take sub-category number from the national drug list of Ethiopia. Example:
o 100 for Antacid agents
o 200 for Anti-ulcer agents
List all the drugs under each sub-category alphabetically using generic name and
provide three digit numbers. Example:
Products under sub-category antacid agents (100) Products under sub-category anti-
ulcer agents (200)
1. 001 for Aluminium hydroxide + Magnesium trisilicate 1. 001 for Cimetidine 400mg tablet
susspension 310mg+620mg in 5ml 2. 002 for Ranitidine 300mg tablet
2. 002 for Aluminium hydroxide mixture 320mg/5ml
3. 003 for Aluminium hydroxide suspension 360mg/5ml
Sample Template for Developing Eight Digit Stock Numbers

Product Category Sub-Category Product Item Stock Number
Aluminium hydroxide + GI-100-001
Magnesium trisilicate susspension
310mg+620mg in 5ml (001)
Antacid Agents Aluminium hydroxide mixture GI-100-002
Gastrointestinal (GI) (100) 320mg/5ml (002)
Aluminium hydroxide suspension GI-100-003
360mg/5ml (003)
Antulcer Agents Cemitidine 400mg tablet (001) GI-200-001
(200) Ranitidine 300mg tablet (002) GI-200-002
Note:
1. Incases when a product has been registered in more than one sub-category,
give code using the category where it appears first in the latest national drug
list of Ethiopia
2. In situations where a new drug is added to the formulary list assign its stock
number as described above by disregarding the alphabetic order.
Establishing Shelf Numbers: the pharmacy personnel should follow procedures listed below
in order to assign shelf numbers in the central medical store.
Apply six digit numeric characters for shelf numbering i.e 100-001. The first three
digits represent the rows and the next three digits represent the columns

The first box of the first row from the top takes a shelf number 100 and the first box
of the first column from the top takes a shelf number 001 and its number at the end
becomes 100-001
Accordingly, all boxes inside the store shelve will have unique shelf number. A
practical shelve template with shelf number is presented below.
These numbers should be indicated on bin cards for each drug.
Template for numbering stock shelves
100-001 100-002 100-003 100-004 100-005
200-001 200-002 200-003 200-004 200-005
300-001 300-002 300-003 300-004 300-005
3.5.5.2 Inventory Control System
The purpose of an inventory control system is to maintain appropriate stock levels to meet the
needs of patients. A well designed inventory control system informs personnel when and how
much of a commodity to order and helps to reduce shortages, oversupply, and expiry of
commodities.
Effective inventory management is underpinned by a Logistics Management Information

System (LMIS). An LMIS is a computerized database for inventory management that records
all drug transactions and connects all levels of the supply chain.
The purpose of LMIS is to support the management of all pharmaceuticals by collecting,

organizing and reporting information to other levels in the system.
Three essential data items that must be captured by the LMIS are:
1. Stock on Hand: Quantities of usable stock available at a given point in time
2. Consumption Data: The quantity of health commodities used during a time period or
reporting period (or a proxy of consumption calculated from issues data)
3. Losses/Adjustments: Losses are the quantities removed from stock for any reason other
than the provision of services to patients or the transfer of commodities to another facility
(e.g. expiry, loss, theft, or damage). Losses are recorded as negative (-) numbers.
Adjustments are quantities of a product received from any source other a regular supplier,
or issued to another facility outside the regular procedures. An adjustment may also be a

correction due to an error in mathematics. An adjustment may be a negative (-) or positive
(+) number.
An effective inventory control system has 3 key elements:
1. The maximum months of stock is the largest amount of each pharmaceutical a facility
should hold in the store at any one time. If a facility has more than the maximum for a
commodity, it is overstocked and risks having commodities expire before they are used.
2. The minimum months of stock is the approximate level of the stock on hand at the time
of the expected arrival of the next delivery from the supplier.
3. The emergency order point is the level where the risk of stocking out is likely, but there
is still time to receive an emergency delivery to avoid the stock-out.
To help maintain adequate stock levels, the maximum months of stock, minimum months of
stock and an emergency order point will be regularly established within the new national
system. These levels are largely determined by the order interval (length of time from order
to order) and the safety stock requirements.
For commodities procured from private suppliers, it may be necessary to set different
minimums and maximums to reflect different delivery schedules.
Standardized forms for inventory management are described below:
1. Bin Card (See Appendix K)
A Bin Card should be prepared for each product in the Pharmaceutical Store. The Bin Card
should be kept with the product inside the store. All transactions of the product to or from
the store should be recorded on the Bin Card. The Bin Card should also include a column for
the loss/adjustment of stock and a column for the stock balance. The stock balance should be
updated after each and every transaction or adjustment.
2. Stock Record Card (See Appendix L)
The Stock Card is similar to the Bin Card but is used to track stock based on issuing and
receiving orders. The Stock Card should be kept in the Store Managers Office. Whenever
Stock Cards are updated the totals should be checked against those on the Bin Card and any
discrepancies should be investigated.
A combined Bin/Stock Card System provides a measure of internal control that helps to
minimize leakages of stock due to theft or loss.
Paper based or electronic Stock Cards can be used. If an electronic system is installed there
should be regular back up of data.

3. Internal Facility Report, Issue and Receipt Voucher (IFRIR) (See Appendix M):
The IFRIR Voucher is used to report the internal transfer of items between the hospital
pharmaceutical store and Dispensing Units. The IFRIR also calculates the quantity of each
item that should be provided to the Dispensing Unit to reach maximum stock levels. A copy
of the IFRIR is given in Appendix H.
4. Facility Combined Report and Requisition Form (FCRRF) (See Appendix N)
The FCRRF is used to order health commodities from PFSA. Orders should be placed every
second month. The quantity to be ordered is calculated as follows:
Quantity requested = quantity issued from the store room in the previous reporting period x 2
minus stock on hand.
An example FCRRF is presented in Appendix I. All requisitions/orders shall carry a unique

order number so that they can be official documents (replacing MOFED Models 19 to 22). If
an order is placed to PFSA by telephone this should immediately be confirmed in writing.
5. Record for Returning Unusable Commodities (RRUC) (See Appendix O):
The RRUC form is used to track the transfer of supplies back to PFSA. The form should be
submitted to PFSA every second month.
The recommended inventory control system for the new national system is a Forced Ordering
Maximum/ Minimum inventory control system. This means that all facilities are required to
report on a fixed schedule, and PFSA is expected to supply on a fixed schedule. Facilties will
place orders to return their stock levels to the maximum determined for each pharmaceutical.
All products are resupplied each time a report and order is completed/sent to PFSA. In
emergencies, an emergency order can be placed.
3.5.5.3 Physical Inventory (Physical Count)
A Physical Inventory (also called Physical Count) is an actual count of each commodity in
stock at any given time. A Physical Inventory should be done regularly in the store and each
dispensing unit, at a minimum of once per year. If the facilty decides the Physical Inventory
could be done every two months to coincide with PFSAs planned delivery schedule. Bin
Cards and Stock Record Cards should be updated at the end of each physical count.
Each facility should establish an SOP providing details on how the Physical Inventory should
be conducted.Box G below provides is a checklist that can be used prior to initiating a
physical inventory:

Box G Preparation for Physical Inventory
Set a date for the physical count. Select the physical count team. Participants should be selected
from the facility.
Do not issue pharmaceuticals during the physical count or count receipts on the day of the
physical count, except in an emergency. Receipts during the physical count will be recorded on
the Bin Cards and the Stock Record Cards the following day and counted in the next physical
count.
Make sure that the Bin Cards and the Stock Record Cards for the pharmaceuticals are updated
to the day of the physical count. If the Bin Cards and the Stock Record Cards are not
completed, complete them.
Prepare the store, making sure all cartons are neatly stacked and partial cartons are clearly
visible.
Reorganize pharmaceuticals by FEFO before counting. Mark expiry dates clearly, with large,
dark numbers, on each box or carton. This step should have been taken during routine receipt
and management of supplies.
Visually inspect pharmaceuticals as you organize them for counting.
Separate any expired or damaged supplies.
Be sure to have the Bin Cards and the Stock Record Cards for each pharmaceutical to be
counted.
Register all drugs in full description (name, dosage form, strength, brand, code number, and
unit price and expiry date) in the inventory sheet.
Crosscheck the list in the inventory sheet against drugs on the shelves
3.5.5.4 Receiving
Receiving is an important input to proper inventory management, as commodities must be

assessed and accepted (quality), paid for (cash or credit), and installed into the inventory of
the store. Key priorities in the receiving process include:
Visual inspection of the boxes to be received (to check quality and possible damage)
Matching of the quantities issues/delivered by the supplier with the voucher/shipping
documents and the actual amounts received/delivered.
Documentation of the amounts received for each item.
Managing the financial aspects of the receiving transaction.
Placement of the new commodities into the inventory using the stock cards / computer
and the bin cards (according to the hospitals policies and procedures).
For PFSA Products:

Products ordered from PFSA using the FCRRF will be delivered to hospitals every second
month. At the time of delivery, PFSA trucks will wait while the products are counted and
assessed in order to obtain proof of delivery and to take note of any discrepancies with the
shipment.
Pharmaceuticals will be delivered with an Issue Voucher from PFSA which includes a
column for receiving at the facility, or a copy of the original FCRRF.

For Non - PFSA Products:
All Purchase Orders with suppliers other than PFSA should include an agreed delivery
schedule. At the time of delivery, the truck should wait while products are counted and
assessed in order to obtain proof of delivery and to take note of any discrepancies with the
shipment.
3.5.5.5 Facility Financial Issues
PFSA or other suppliers should be paid for the delivery of health commodities using one of
three different options:
Advance: Pharamceutical budget allocations are made to PFSA on an annual basis by
the health facility. As pharmaceuticals are ordered from and delivered by PFSA, the
cost is deducted from the facilitys account.
Cash and Carry: PFSA will be paid for the commodities at the time of delivery to the
facility. Most hospitals are expected to use this method of payment.
Credit: As far as possible hospitals should avoid obtaining pharmaceutical supplies
on credit. Sufficient budget should be allocated (using raised revenue if necessary) to
purchase pharmaceutical supplies. Hospitals may, with the approval of
MOFED/BOFED, decide to operate a separate bank account for pharmaceutical
supplies to ensure that funds are available and are not used for other purposes. If any
supplies are obtained on credit then payment should be made as soon as funds become
available.
3.5.6 Distribution
Pharmaceuticals should be managed centrally by the hospital Central Medical Store. All
products should be received into the hospital Central Medical Store, and most of commodities
should be stored there until they are issued to the various dispensing units within the facility.
The distribution of pharmaceuticals within a hospital (from the store to any of the various
dispensing units) should be directed by a pharmacist.
Pharmacy Dispensing Units should be established within Outpatient Services, Inpatient

Services and Emergency Services. Pharmaceutical supplies will also be distributed to the
hospital laboratories (outpatient, inpatient and emergency) and radiology unit.
Each dispensing unit should have an agreed list of stock items including the maximum
quantity to be stored in the dispensing unit. Stock levels in the cabinet/storage area of each
dispensing unit should be kept to a minimum, preferably less than one month. The stock list
of each Dispensing Unit should be determined by the relevant Service Director (Inpatient,
Outpatient, Emergency Services etc) and should be approved by the DTC. Each Dispensing
Unit should maintain Bin Cards for all pharmaceuticals in the unit.
SOPs, approved by the DTC, should be established for:

Obtaining supplies from the Central Medical Store

Action to be taken in the case of incomplete documentation or other queries
Return of expired, damaged, leftover and empty packs from the dispensing units to
the Central Store
The Central Medical Store manager should establish a resupply schedule for each of the
dispensing units, generally between one week to one month. Each dispensing unit should
have a designated day to receive its resupply (for example every Monday for weekly supply
or the first Monday of every month for monthly supply). On that day, the dispensing unit staff
should complete their part of the Internal Facility Report, Issue and Receipt Voucher (see
Appendix M). The Central Medical Store Manager will use this information to determine the
resupply quantities needed to serve clients until the next scheduled resupply day. For
example, every Monday (on a weekly basis), the MCH service provider reports data to the
Central Medical Store, and the store resupplies enough product to serve clients until the next
week (the dispensing unit will also keep a small safety stock). This system ensures that the
dispensing units are not overworked with pharmaceutical management responsibilities, and
the quantities issued to the dispensing units from the Central medical store reflect actual
consumption by clients. It also spreads out the workload of the store across the week.
3.5.6.1 Resupply Options
Low volume dispensing units (for example MCH, TB/Leprosy etc): Dispensing units that
dispense a low volume of drugs may use Bin Cards to record drug transactions. Such units
should have a cabinet of drugs that is stocked with sufficient supplies for the reporting and
resupply period (weekly, every two weeks or monthly). At the start of each day drugs can be
taken from the cabinet and placed in the consultation rooms where patients are seen. Drugs
are dispensed to patients directly from the consultation room. At the end of the day any
unused drugs are returned to the cabinet. All transactions from and to the cabinet should
be recorded on the Bin Card. Losses and Adjustments should also be recorded on the Bin
Card when they are made/discovered. At the end of the reporting period the dispensing unit
should complete its part of the Internal Facility Report and Resupply Form using information
contained on the Bin Cards.
High volume dispensing units (for example OPD/IPD/Emergency pharmacy dispensaries):

Dispensing units that dispense a high volume of drugs should establish a Prescription
Registration Book (PRB) that records every pharmaceutical issued to a patient. An example
PRB is presented in Appendix B. At the end of the reporting period the consumption data
should be aggregated from the PRB using a Consumption Summary Sheet (see Appendix P).
The Dispensing Unit should also complete a Losses/Adjustment Tracking Sheet (Appendix
Q) for the reporting period. This data, together with stock-on-hand balances from the
previous reporting period should be used to complete the Dispensing Unit part of the Internal
Facility Report and Resupply Form.
The Store Manager/Pharmacy Head should ensure that adequate control and monitoring
procedures are in place for all commodities kept by the dispensing units within the hospital.
He/she should occasionally visit and verify the stock-on-hand in the dispensing unit before
issuing. The Store Manager/Pharmacy Head has the right to delay issuing to a particular
dispensing unit if proper procedures have not been followed; however, problems should be
resolved immediately so as not to risk stock-outs in that dispensing unit.
3.6 Pharmaceutical Waste Management
Pharmaceuticals which are eligible for disposal include the following:

All expired/damaged pharmaceuticals
All unsealed syrups or eye drops(expired or unexpired)
All cold chain products not stored as per manufacturers recommendations (e.g.:
insulin, hormones, gamma globulins and vaccines)
All bulk or loose tablets and capsules with containers which are not sealed, properly
labelled or within broken blister pack.
All unsealed or damaged tubes of creams, ointments, lotions and related products.
Each hospital should establish a pharmaceutical disposal committee comprised of

representatives from pharmacy, finance/audit, and sanitation services to ensure the proper
disposal of pharmaceutical wastes in accordance with the country laws.
Each hospital should establish an SOP for the management of pharmaceutical waste. The
SOP should include the schedule, methods, materials and equipment required for disposal and
the responsible person. The SOP should be approved by the hospital DTC. Disposal of
pharmaceutical wastes should be supported by proper documentation, including the price of
the products, for audit and other legal requirements.
Basic steps to be adhered for the disposal of pharmaceutical wastes are:

Step 1: Pharmaceuticals that are expired/damaged or unfit for use should be counted,
recorded and placed segregated from the other pharmaceuticals in the hospitals.
Step 2: List of pharmaceuticals expired or unfit for use should be submitted to the
responsible body for disposal.
Step 3: The pharmaceuticals should be sorted out based on the pharmaceutical dosage
form and chosen disposal method.
Step 4: The pharmaceuticals should be disposed of in accordance with the appropriate
method and in the presence of delegates from the responsible body.
Step 5: Signed and stamped certificate of disposal format should be issued by the
authorized body entitled to dispose the drugs.
Step 6: Adjustments for each disposed drug should be made in the available
inventory management system.
Pharmaceutical waste should be sorted by optimal disposal method and prepared for disposal
with supportive documents. Hospital pharmacy and cleaning staff should be trained / well
informed about the potential risks of hazardous pharmaceutical wastes and their management.
Cleaners and others handling hazardous pharmaceutical wastes should wear protective
devices like apron, plastic shoes, gloves, head gears, eye glasses, and goggles.

The following disposal methods can be applied:
General Disposal Methods:

Return to donor or manufacturer: Whenever practical, the possibility of returning
unusable drugs for safe disposal by the manufacturer/donor should be explored;
particularly for drugs which present disposal problems, such as anti-neoplastics.
Waste immobilization/encapsulation: This involves immobilizing pharmaceutical
wastes in a solid block within a plastic or steel drum filled to 75% capacity. The
remaining space should be filled and sealed with cement or cement/lime mixture and
water in proportions 15:15:5 by weight. The sealed drums are then placed at the base
of a land fill and are covered with fresh municipal solid waste.
Landfill: Place the expired or unfit for use pharmaceuticals directly into a land
disposal and cover it with municipal waste to prevent scavenging. It should be noted
that discarding in open, uncontrolled dumps with insufficient isolation from water
courses can lead to pollution.
Sewer: Some liquid pharmaceuticals, e.g. syrups and intravenous fluids, can be
diluted with water and flushed into the sewers in small quantities over a period of
time without serious public health or environmental effect. Fast flowing water courses
may likewise be used to flush small quantities of well-diluted liquid pharmaceuticals
or antiseptics. In this case, disposal should be done in consultation with the hospital
sanitarian/environmental health specialist.
Traces of pharmaceuticals and other chemicals from the compounding and sterile preparation
(if applicable) can be discharged directly into the sewerage system; however, the construction
of a small underground neutralization pit to periodically check the pH of the effluent before
discharging to the nearby municipal drainage system, in consultation with the appropriate
regulatory bodies, is recommended.
Burning in open containers: Pharmaceuticals should not be disposed by burning at
low temperature in open containers, as toxic pollutants may be released into the air.
Paper and cardboard packaging, if they are not to be recycled, may be burnt but
polyvinyl chloride must not be. It is strongly recommended that only very small
quantities must be disposed in this way.
Incineration: Expired solid form of pharmaceuticals are burned using a two chamber
incinerator that operates at a minimum temperature of 8500 C.
Product specific disposal methods:

1. Solids, semisolids and powders:
Medium temperature incineration should be applied for solid forms.
If there is no incinerator, encapsulation of the drugs before discharge to a land fill is
necessary
o Solids, semisolids and powders should be removed from their outer packages but
should remain in their packaging
o The disposed drugs then should be covered by municipal waste immediately to
prevent scavenging.

Pharmaceuticals classed as biodegradable organic material in the solid or semisolid
form such as vitamins, can also be disposed of in a landfill.
2. Liquids
Pharmaceuticals that can be classified as readily biodegradable organic materials such
as liquid vitamins can be diluted and flushed into a sewer. Harmless solutions of
different concentrations of certain salts, amino acids, lipids or glucose may also be
disposed of in sewers.
Small quantities of other liquid pharmaceuticals which are not controlled drugs,
antineoplastics or anti-infective can also be flushed into sewers.
3. Ampoules
These should be crushed on a hard impermeable surface (e.g. concrete or in a metal
drum) and the crushed glass should be swept up, placed in a container, sealed and
disposed of in a land fill.
Ampoules should not be burnt or incinerated as they will explode, possibly causing
injury to operators and damage to the incinerator by melting and clogging.
4. Anti-infectives
Anti-infective drugs should not be discarded in an untreated form. Generally they are
best incinerated and if this is not possible they can be encapsulated.
Liquid anti-infective may be diluted in water, left for two weeks and disposed to the
sewer.
Controlled substances should be rendered unusable, by encapsulation or inertization,
and then dispersed among the municipal solid waste in a land fill or incinerated.
5. Antineoplastics
These drugs should be segregated from other pharmaceuticals and kept separately in
clearly marked containers.
They should be returned to the supplier if contract supports; otherwise, they should be
destroyed in a high temperature incinerator of at least 1200 C.
Antineoplastics should never be disposed of in a land fill without encapsulation or
inertization. They should never be disposed into sewers and water courses.
Work teams handling these drugs should avoid crushing cartons or removing the
product from its packages.
6. Aerosol canisters
Disposable aerosol canisters and inhalers should not be burnt or incinerated, as high
temperatures may cause them to explode, possibly causing injury to operators and /or
damage to the incinerator.
Provided they do not contain poisonous substances, they should be disposed of in a
landfill dispersed among municipal solid wastes.
Disposal of radiographic waste

7. Waste types not to be incinerated
Pressurized gas containers
Large amounts of reactive chemical waste.
Silver salts and photographic or radiographic wastes.
Halogenated plastic such as polyvinyl chloride (PVC), which is mostly used for I.V.
fluids container.
Waste with high mercury or cadmium content; such as broken thermometers, used
batteries, and lead-lined wooden panels.
Sealed ampoules or ampoules containing heavy metals.
For further guidance on waste management, including management of hazardous material

spills refer to Chapter 7 Infection Prevention.
3.7 Pharmacy Billing
The provisions of Health Care Finance Reform Legislation enable hospitals to raise and
retain revenue. The sale of pharmaceutical products is an important source of hospital
income. With the exception of exempted health programs (immunization, TB, ART and the
like) pharmaceuticals can be sold at a price that covers the actual cost of the medicine plus a
service charge. Clear and uniform procedures should be established for setting the sale price
of each commodity and for recording sales transactions.
The sale price of each pharmaceutical should be entered on the IFRIR form by the Central
medical store. Each dispensing unit should sell pharmaceuticals at the stated price. All
pharmaceuticals should be dispensed/sold using a standard sales ticket designed for the
purpose.
3.8. Premises, Equipment and Facilities
The hospital should have sufficient space for the storage, compounding, counselling and
dispensing of drugs and for the conduct of related administrative activities. A dispensing unit,
counselling area, cashier services (with or without compounding facilities) should be
established in each main service area (Inpatient Services, Outpatient Services and Emergency
Services). The pharmaceutical products and quantities of each that are maintained in each
dispensing unit should be approved by the hospital Drug and Therapeutic Committee (see
section 3.3 of Chapter 2 Patient Flow for the minimum contents of the Emergency Services
Dispensing Unit).
Counselling areas should be arranged to ensure reasonable privacy and minimize background
noise.
All areas where pharmaceutical services are provided (for example dispensing units, central
medical store etc) should be clearly labelled. Access should be controlled to ensure that only
authorized personnel enter the premises and that only designated personnel have access to
keys. A procedure should be established to ensure access to pharmacy premises in an
emergency situation.
All equipment used for compounding, distribution and administration of medication should
be regularly calibrated and maintained according to manufacturers requirements. The need
for continuous electrical supply should be determined and all critical items of equipment (for
example refrigerators) should be protected by individual UPS devices and should be
connected to the hospital back-up power supply (generator or alternative). All compounding
and dispensing rooms should have a sink with hot and cold running water. There should be
sufficient computers within each service area for the functions carried out. Ideally,
telephones should also be available within each services area.
The main medical store should be accessible to vehicles to allow the easy delivery of
supplies. Where possible, the central medical store should be located by itself on a separate
area to enhance security and minimize human and vehicle congestion.

In order to determine if the Operational Standards for Pharmacy Services have been met by
the hospital an assessment tool has been developed which describes criteria for the attainment
of a Standard and a method of assessment. This tool can be used by hospital management or
by an external body such as the RHB or FMOH to measure attainment of each Operational
Table 4. Pharmacy Services Checklist

Yes No
1. A Drug and Therapeutics Committee has been established.
2. Terms of reference for the Drug and Therapeutics Committee are defined.
3. A Medicines Formulary is created and is shared with staff.
4. Pharmacy services are integrated in the emergency, outpatient and inpatient
case teams.
5. There are SOPs to describe different compounding procedures.
6. A Drug Information Centre is established to provide drug information to
staff and patients alike.

7. Procedures are established to receive, investigate adverse drug reactions.
8. Procedures are established to monitor prescriptions and drug utilization
9. There is a drug procurement policy.
10. An inventory management system to manage drug supply and distribution
is established.
11. There is process to dispose of expired drugs.
12. Adequate personnel to provide pharmacy services are in place.
13. Facilities and equipment needed to provide pharmacy services are in place.
4.3 Indicators
Table 5. Pharmacy Services Indicators

S/N Indicators Formula Frequency Comment
s
1. Percentage availability of tracer drugs x months available Quarterly HMIS
x100
tracer drugs at hospital drug tracer drugs x total number of months in time period
store
2. Average stock out duration of stock out days of tracer drugs throughout Quarterly HMIS
for tracer drugs at drug store reporting period/total number of tracer drugs
3. Actual drug expenditure as Actual expenditure on drugs /total budget Quarterly
% of budget allocated to allocated to drugs *100
drugs
4. Drug expenditure from Actual expenditure on drugs from PFSA /total Quarterly
PFSA as proportion of total expenditure on drugs x 100
drug expenditure
5. Inventory accuracy rate Total number of items where stock record count Quarterly
equals physical stock count /total number of
items counted * 100
6. Inventory turnover rate Total value of items distributed /Total value of Quarterly
stock available during the period * 100
7. Percentage of prescriptions Total number of compounding completed per Quarterly
compounded per month month /total number of prescriptions per month
8. a) Number of ADR a) Total number of ADR reported to ADR Quarterly
reported to ADR Focal focal person within the reporting period
Person
b) % of prescriptions b) Number of ADR reported to ADR focal
issued person within the reporting period /total
number of prescription issued within the
reporting period *100
9. a) Number of ADRs a) Total number of ADR classified as Quarterly
classified as certain or certain or probable following
probable following investigation
investigation
b) % of ADRs classified as b) Total number of ADR classified as
certain or probable certain or probable following
following investigation investigation / total number of ADR
reported during reporting period *100

10. a) Number of ADR a) Total number of ADRs reported to DACA Quarterly
reported to DACA
b) % of ADRs reported to b) Total number of ADRs reported to DACA

ADR Focal Person within reporting period/ Total number of
ADR reported to ADR focal person within
the reporting period
11. a) Number of prescriptions a) Total number of prescriptions that contain Quarterly
that contain a non- a non-formulary item written during
formulary item reporting period;
b) As % of all b) Total number of prescriptions that contain

prescriptions a non-formulary item written during
reporting period/ Total number of
prescriptions written during reporting
period*100
12. Number of drug information Total number of drug information request filled Quarterly
requests filled
13. a) Expired drug stock
value
a) (number of expired drugs x price of that drug) Quarterly
b) (number of expired drugs*price of that

b) % of total inventory
value drug)/ (drugs in inventory at time of
evaluation*price of drug at time of
evaluation)
14. a) Value of items lost; a) of number of pharmaceuticals lost * Quarterly
items lost is defined as price of pharmaceutical
pharmaceuticals
expired, damaged, and
lost in the reporting
period
b) % of total inventory b) of number of pharmaceuticals lost *
value price/ pharmaceuticals in inventory at
time of evaluation * price
15. Proportion of drug budget Proportion of budget allocated to drugs/total Quarterly HMIS
out of the total recurrent recurrent budget * 100
budget
16. Attrition rate of pharmacy Number of pharmacy staff leaving/total number Quarterly HMIS
staff of pharmacy staff at beginning of reporting
period * 100
17. a) Cumulative number of a) Total number of pharmacy staff trained Quarterly HMIS
pharmacy staff who from beginning of year until end of
have undergone reporting period
inservice training
b) Cumulative proportion b) Cumulative number of staff who received
of pharmacy staff who training/total number of staff at beginning
have received in service of period *100
training
18. a) Cumulative number of a) Total number of pharmacy staff who have Quarterly
pharmacy staff who unergone perfomance evaluation from
have unergone beginning of year until end of reporting
perfomance evaluation period
b) Cumulative proportion b) Cumulative number of staff who who have

of pharmacy staff who unergone perfomance evaluation /total
have unergone number of staff at beginning of period
perfomance evaluation *100

19. In patient satisfaction survey Total number of inpatients who respond Biannual Survey
: always or usually to the questions listed/ Total tool
% of respondents who number of inpatients respondents.. presented
answer always or usually in
to the following questions Appendix
Before giving you any new F of
medication, how often did Chapter
staff describe possible side 12 Quality
effects in a way you could Managem
understand? ent
20. Out patient satisfaction Total number of outpatients who respond yes Biannual Survey
survey : to the questions listed / Total number of tool
% of respondents who outpatients respondents.. presented
answer yes to the in
following questions The Appendix
staff described the F of
medications possible side Chapter
effects in a way I could 12 Quality
understand? Managem
ent
Source Documents
1. American Society of Health System Pharmacists. (2007). ASHP Statement on the Role of
Health-System Pharmacists in Public Health, Medication Therapy and Patient Care:
Specific Practice AreasStatement. Retrieved from:
http://www.ashp.org/DocLibrary/BestPractices/SpecificStPubHlth.aspx.
2. Breland, B.D. (2000). Strategies for the Prevention of Medication Errors. Hospital
Pharmacy Report; 14(8):56-65.
3. Clark, C. (2002). Overview of Clinical Pharmacy Services in Northern Ireland,

Department of Health, Social Services and Public Safety.
4. Counseling and Additional Instructions for Dispensed Medicines. (2006). In: Australian
Pharmaceutical Formulary and Handbook, 20th Edition, Pharmaceutical Society of
Australia, Canberra.
5. Dispensing Practice Guidelines. (2006). In: Australian Pharmaceutical Formulary and

Handbook, 20th Edition, Canberra: Pharmaceutical Society of Australia.
6. Drug Administration and Control Authority of Ethiopia. (2002). Standards for the
Establishment and Practice of Pharmaceutical Compounding Laboratory. Addis Ababa,
Ethiopia.
7. Drug Administration and Control Authority of Ethiopia. (2005). Good Dispensing

Practice Manual.

8. Drug Administration and Control Authority of Ethiopia. (2008). Guidelines for Adverse
Drug Reaction (ADR) Monitoring, 2nd Edition. Addis Ababa: Drug Administration and
Control Authority of Ethiopia.
9. Deepak, V. and Bradley C. (2006). Development of a Pharmacy Care Plan and Patient
Problem Solving. In: Remington, the Science and Practice of Pharmacy, 21st Edition,
Lippincott Williams & Wilkins.
10. Environmental Pollution Control Proclamation No. 300/2002, Ethiopia, 2002.
11. Ethiopian Democratic Republic Federal Ministry of Health and Drug Administration and
Control Authority of Ethiopia in Collaboration with Management Sciences for
Health/Strengthening Pharmaceutical Systems. (2008). Standard Operating Procedures
Manual for Patient Focused Pharmacy Services (Draft).
12. Good Compounding Practice (1075). (2009). In: The United States Pharmacopoeia 32,
The USP Conventions Inc., Rockville, MD, USP 2009.
13. Hutchinson, S.L. and Graham, D. (1998). Specialized Services from a Hospital Pharmacy,
In Winfield, A.J. and. Richard, R.M.E (Eds.), Pharmaceutical Practice, 2nd Edition.
Churchill Livingstone.
14. John Snow, Inc./DELIVER in collaboration with the World Health Organization. (2003).
Guidelines for the Storage of Essential Medicines and Other Health Commodities,
Arlington, VA: John Snow, Inc./DELIVER, for the U.S. Agency for International
Development.
15. Joint Formulary Committee. (2008). British National Formulary. [No.. 55] ed. London:
British Medical Association and Royal Pharmaceutical Society of Great Britain.
16. Moody M.M. (1998). Dispensing Techniques (Compounding and Good Practice). In:
Winfield, A.J. and. Richard, R.M.E (Eds.), Pharmaceutical Practice, 2nd Edition,
Churchill Livingstone.
17. Management Sciences for Health. (1996). Manual for the Development and Maintenance
of Hospital Drug Formularies, Management Sciences for Health, Rational
Pharmaceutical Management Project, Russia Rational Pharmaceutical Management
Project. Retrieved from: http://www.msh.org.
18. Management Sciences for Health in Collaboration with World Health Organization.
(1997). Managing Drug Supply, The Selection, Procurement, Distribution and Use of
Pharmaceuticals. Action Program on Essential Drugs, Kumarian Press.
19. Model Standards for Self Audit in Community Pharmacy in England. (1994). The
Dispensing Process, Department of Pharmacy Policy and Practice, Keele University.

20. Moody M.M. (1998). Health Promotion and Health Education, In Winfield, A.J. and.
Richard, R.M.E (Eds.), Pharmaceutical Practice, 2nd Edition. Churchill Livingstone.
21. Nicholas G, Popovich. Fundamentals of Pharmacy Practice In Gennaro, A.R. (Ed),

Remington, The Science and Practice of Pharmacy, 21st Edition, Lippincott Williams &
Wilkins, 2006.
22. Pharmaceutical Compounding Non Sterile Preparations 795. (2009). In The United
States Pharmacopoeia 32, The USP Conventions Inc. Rockville, MD, USP 2009.
23. Proclamation No.649/2009: A Proclamation to provide for the Establishment of a Drug

Fund and the Pharmaceutical Supply Agency. (2007, 04 September) Addis Ababa:
Federal Negarit Gazetta.
24. Robert, L.T. and Richard, J.B., Specialization in Pharmacy Practice, in: Remington, The
Science and Practice of Pharmacy, 21st Edition, Lippincott Williams & Wilkins, 2006.
25. The Society of Hospital Pharmacists of Australia. (2005). Standards of Practice for
Clinical Pharmacy; J Pharm Pract Res; 35(2):122-46.
26. The Society of Hospital Pharmacists of Australia. (1994). Practice Guidelines for
Outpatient Services, Aust J Hosp Phar; 24(5):421-3.
27. The Society of Hospital Pharmacists of Australia. (2005). Standards of Practice for the
Safe Handling of Cytotoxic Drugs in Pharmacy Departments, J Pharm Pract Res;
35(1):44-52.
28. South African Pharmacy Council. (2004). Good Pharmacy Practice in South Africa.
Good Pharmacy Practice Manual, 2nd Edition.
29. Stability Considerations in Dispensing Practice. 1191. (2009). In: The United States
Pharmacopoeia (USP), 32, The USP Conventions Inc. Rockville, MD, USP 2009.
30. Walker, R. (2000), Pharmaceutical public health: the end of pharmaceutical care? The
Pharmaceutical Journal, 264 (7085):340-341.
31. World Health Orgnaization, Essential Drugs and Medicines Policy Department. (2003).
Drug and Therapeutics Committees, A practical guide, WHO/EDM/PAR/2004.1, CH
1211 Geneva 27. Retrieved from: http://www.who.int/Medicines.
32. World Health Organization, Department of Medicines Policy and Standards. (2006).
Developing Pharmacy Practice, A Focus on Patient Care Hand Book. Geneva,
Switzerland: World Health Organization. In collaboration with International
Pharmaceutical Federation, The Hague, The Netherlands.

33. World Health Organization. (1996). Good Pharmacy Practice (GPP) in Community and
Hospital Pharmacy Settings. Geneva: World Health Organization.
34. World Health Organization. (1999). Guidelines for Safe Disposal of Unwanted
Pharmaceuticals in and after Emergencies. WHO/HTP/EDM/99.2.
35. World Health Organization. (2000). Guideline for Safety monitoring of medicinal
products, The UPPSALA monitoring center. Geneva: World Health Organization.

Appendices
Chapter 4 Pharmacy Services

Appendix A: ABC Method for Reviewing Hospital Formulary
ABC analysis is a method for determining and comparing pharmaceutical costs within the
formulary system. It follows the Pareto principle separating the vital few from the trivial
many. ABC Analysis can be explained in terms of budget consumed and number of drugs in
the budget list as follows:
Category Percentage of Budget Share Percentage of Drugs

A Drugs 70-80% 10-20%
B Drugs 15-20% 10-20%
C Drugs 5-10% 60-80%
A medicines:
High percentage of funds spent on large-volume or high-cost items
Greatest potential for savings
Greatest potential for identifying expensive medicines that are overused
B medicines:
Moderate cost and moderate number of items; important items
C medicines:
Small amount of funds spent on the majority of the inventory
Applications of ABC analysis:

Measures the degree to which actual consumption reflects public health needs and
morbidity
Reduces inventory levels and costs by arranging for more frequent purchase or
delivery of smaller quantities of class A items
Seeks major cost reductions by finding lower prices on class A items
Reduces inventory of items that have limited use in the system, but costs the system
large amounts of money
Provides information for choosing the most cost-effective alternatives and finding
opportunities for therapeutic substitution
Gathers information for pharmacoeconomic analysis
Chapter 4 Pharmacy Services Appendix A: Page 1 of 2

Steps in performing ABC analysis:
Step 1. List all items purchased and enter the unit cost.
Step 2. Enter consumption quantities for each item.
Step 3. Calculate the value of consumption for each item.
Step 4. Sort the list in descending order by total value.
Step 5. Calculate the percentage of total value represented by each item.
Step 6. Calculate the cumulative percentage of total value for each item.
Step 7. Choose cutoff points for A, B, and C.
Note: The results of ABC should be reconciled with that of VEN.
Chapter 4 Pharmacy Services Appendix A: Page 2 of 2

Appendix B Sample Prescription Registration Book (PRB)
Prescription No.
Name or
Patient Information Description of Drug Dispensed Initial of
Dispenser
Total
Qty
Name Medical Qty (Page/
of Record Dosage in Day)in
S.N. Date Patient Sex Age Weight No. Diagnosis Drug Name Strength Form BU BU
Minor UTI
XXX F 42 65 2222 Infection Amoxicillin 500mg Capsule 30 60
Paracetamol 500mg Tablet 10 10
YYY M 40 55 111 Upper RTI Amoxicillin 500mg Capsule 30 _
Ibuprofen 200mg Capsule 20 20
Chapter 4 Pharmacy Services Appendix B: Page 1 of 1

Appendix C: List of Equipment and Materials for Compounding in Hospitals
SN Equipment/material Description
1. Working bench Level, smooth, impervious, free of cracks and crevices and non-
shedding; covered with protector sheets of plastic, rubber or
2. Mortar and pestle 250 ml capacity or more; glass type and porcelain type
3. Water distiller Stainless steel of 20 litre capacity or more
4. Water bath Stainless steel of 4 openings or more
5. Electrical hotplate Various Sizes and Features
6. Evaporating dish Stainless steel (glazed inside) and porcelain type; with/without
handling
7. Spatula Stainless steel and plastic type, flexible and non-flexible, different
blade lengths.
8. Gloves disposable, non-sterile
9. Glass rod Different length and thicknesses
10. Wash bottle 250ml capacity, polyethylene
11. Funnel Glass type and plastic type (polyethylene)
12. Beakers Glass type; different capacity
13. Volumetric flask Glass type; different capacity
14. Balances Prescription, torsion, triple beam, electronic; capacities of not less
than 300 gm; sensitivity of not less than 0.1 mg.
15. Ointment tile Glass type
16. Micropipettes Glass type; different capacities (less than 1ml); with pipette bulb
17. Pipettes Glass type; different capacities (1ml-100ml); with pipette bulb
18. Cylindrical graduate Glass and plastic type; different capacity
19. Conical graduate Glass and plastic type; different capacity
20. Weighing dishes Plastic, aluminium, stainless steel type
21. Weighing paper Normal paper; grease-proof for semisolids
22. Thermometers Fridge and wall thermometer
23. Scientific calculator
Chapter 4 Pharmacy Services Appendix C: Page 1 of 1

Appendix D Compounding Guidelines
A. General Procedures for Compounding

1. Receive, validate and interpret the prescription as per the Standard Operating Procedures
(SOP) for dispensing
2. Ensure that the compounding area, equipments and containers are ready for the process
and dont compromise the quality of the final product
3. Calculate the quantity of each ingredient accurately
4. Weigh and measure the ingredients necessary for compounding of the product as per the
procedures for weighing and measuring, respectively
5. Compound the preparation following the appropriate procedure
6. Transfer to the final container, if it is not prepared in the final container, and make up to
volume, if necessary
7. Close the container and shake well as appropriate
8. Assign beyond-use date for the preparation
9. Prepare and attach a proper label on the product container
10. Clean all the equipments used for the compounding process and return to their original
place
11. Clean the working table
12. Record the compounding process on the Compounding Sheet
13. Dispense the product to the patient with proper counselling
14. Record the prescription on the Compounding Prescription Registration Book
B. Procedures for Weighing

1. Select a balance with appropriate capacity and sensitivity.
2. If weighing a solid material which requires being size reduced (ground) or sieved,
always ensure that this is carried out before weighing.
3. Ensure that the balance is clean, dry and working properly
4. Put the balance on a level, non-vibrating and clean table
5. Adjust the balance, put the container for the material to be weighed and weigh it (to
deduct from the final total weight) or use auto-zero to cancel its weight. Grease-proof
papers should be used for weighing of semisolids.
6. Read carefully the label of the material to be weighed (check name, strength, expiry
date)
7. Check the appearance and any sign of stability problems.
8. Add the material to be weighed on to the container using spatula until the correct weight
is obtained, close the container and return to the original place
9. Carefully remove the weighed material and transfer to the suitable container
10. Clean the balance and its accessories.
11. Return the balance and its accessories to the original place
Chapter 4 Pharmacy Services Appendix D: Page 1 of 4

C. Procedures for Measuring Liquids
1. Make sure the availability of appropriate graduated measure (cylindrical graduate,
conical graduate, pipette, syringe, and dropper) depending on the viscosity and quantity
of the liquid to be weighed.
2. Select a clean and dry graduated measure of appropriate size.
3. Read the label of the liquid carefully (check name, strength, expiry date)
4. Check the appearance and any sign of stability problems.
5. Pour the liquid into the measure until the desired volume is obtained.
6. In case of measuring more than one liquid, hold the cap of the container in your hand,
preferably between the fourth finger and the palm of the hand, so that the possibility of
exchange of closures ending up with cross-contamination is minimized.
7. Transfer the liquid from the measure.
8. Allow to drain for sufficient time. Viscous liquids need more time as compared to
aqueous, alcoholic and hydroalcholic liquids which can drain within 30 seconds.
9. Clean the measure and replace to its original place.
10. Clean the working table.
D. Procedures for Preparing Solutions

1. Select the appropriate container
2. Use freshly boiled and cooled purified water (if water is part of the formulation).
3. Calibrate (tare) the bottle, when accurate transfer of the preparation to the final container
is difficult.
4. Weigh and measure the ingredients accurately
5. Dissolve the ingredients in the appropriate solvent.
6. Volatile components should be added at the end of the process and after cooling (if heat
is to be used).
7. Transfer to the final container, if it is not prepared in the final container, and make up to
volume by using the solvent.
8. Close the bottle and shake well
9. Prepare and attach a label
10. Clean all the equipments used for the compounding process and return to their original
place
12. Fill the compounding Sheet
13. Dispense the product to the patient with proper counseling
14. Record the prescription on the Compounding Prescription Registration Book

1.Stability and Beyond-use Dating
a. Compounding pharmacists should avoid ingredients and conditions that could result
in excessive physical deterioration or chemical decomposition of drug preparations,
especially when compounding.
b. The beyond-use date is the date after which a compounded preparation is not to be
used and is determined from the date the preparation is compounded. Because
compounded preparations are intended for administration immediately or following
short-term storage, their beyond-use dates is assigned based on criteria different from
those applied to assigning expiration dates to manufactured drug products.
c. Compounders should consult and apply drug-specific and general stability
documentation and literature when available, and should consider the nature of the
drug and its degradation mechanism, the container in which it is packaged, the
expected storage conditions, and the intended duration of therapy when assigning a
beyond-use date.
d. At all steps in the compounding, dispensing, and storage process, the compounder
should observe the compounded drug preparation for signs of instability. However,
excessive chemical degradation and other drug concentration loss due to reactions
may be invisible more often than they are visible.
e. In the absence of stability information that is applicable to a specific drug and
preparation, the following maximum beyond-use dates are recommended for non-
sterile compounded drug preparations that are packaged in tight, light-resistant
containers and stored at controlled room temperature unless otherwise indicated.
For Non-aqueous Liquids and Solid Formulations:

Where the Manufactured Drug Product is the Source of Active Ingredient The beyond-use
date is not later than 25% of the time remaining until the products expiration date or 6
months, whichever is earlier.
Where a USP or BP Substance is the Source of Active Ingredient The beyond-use date is
not later than 6 months.
For Water-Containing Formulations (prepared from ingredients in solid form):
The beyond-use date is not later than 14days for liquid preparations when stored at cold
temperatures between 2 and 8 (36 and 46 F).
For All Other Formulations:
The beyond-use date is not later than the intended duration of therapy or 30 days, whichever
is earlier. These beyond-use date limits may be exceeded when there is supporting valid
scientific stability information that is directly applicable to the specific preparation (i.e., the
same drug concentration range, pH, recipients, vehicle, water content, etc.).

2.Labeling
Compounded products must be labeled according to regulatory requirements. In addition,
labels of these products should also include names of any preservatives used. This
information may be useful for avoiding sensitivity reactions in susceptible individuals and for
explaining differences in flavor where the preservatives vary.
When non-pharmacopoeia products are prepared, the labels should document the complete
list of ingredients and their amounts/proportions for future reference by other pharmacists
and health professionals.
The pharmacist should examine the product for correct labeling after completion of the
compounding process. Labels on compounded products for individual patient should have a
minimum of the following information:
Patient's name
Name of the compounder
Name and address of the compounding institution
A complete list of ingredients and preparation name
Strength
Quantity of each ingredients
Directions for use
Date of preparation
Beyond-use date
Storage condition
Batch number
3.Packaging
Compounded preparations should be packaged in containers meeting standard requirements.
The container used depends on the physical and chemical properties of the compounded
preparation. Containerdrug interaction should be considered with substances such as
phenolic compounds and sorptive materials (e.g., polypeptides and proteins). The containers
and container closures should also be made of clean materials that are neither reactive,
additive, nor absorptive. The containers and closures shall be of suitable material so as not to
alter the quality, strength, or purity of the compounded drug.

Appendix E: Format for Recording of the Compounding Process (Compounding
Sheet)
Name of the dispensary/health institution __________________________________

Date __________________________
Batch number/control number_____________________________ Batch quantity _______
Name or initials of
Description of ingredients
the person in charge
Name Source Batch Quantity
number
Description of the steps of the preparation
Beyond use Date: .

Yield: .
Loss:
Reason for loss: .

Prepared by: Name ________________________ Signature_________ date _________
End control before release of the product

Parameters Comment
Approved by: Name ___________________________ Signature______________Date________
Chapter 4 Pharmacy Services Appendix E: Page 1 of 1

Appendix F: Compounding Prescription Registration Book
Patient identifiers Description of the preparation

S Diagnosis Name or
dispensed
Qty
number
Control
Ingredients
Sex
Age
Wt.(kg)
N Name of the Patient (ICD) Code Initials of the
Card No Name & strength Quantity
No dispenser
Chapter 4 Pharmacy Services Appendix F: Page 1 of 1

Appendix G: Patient Medication Profile Card
PATIENT MEDICATION PROFILE CARD
Name of Health Institution: _________________________________
Patient Information Clinical Information
Card No: ____________ Type of Chronic Illness: _____________________________________
Name: _________________________ Current Status: On active treatment Transferred-out Lost for Follow-up Deceased
Sex: Male Age: _____ years History of ADR or Side Effects Concomitant Diseases Reason for Change in Regimen or other
Female remarks
Wt. on Start: ___ Date Description Date Description Date Description
Date Started: Kg
________
Patient Source:
Inpatient Outpatient
Patients: Support Persons:
Address
__________ __________
Drug Dispensing Information

Date Reason Prescriber Drugs Dispensed Other Date of Signatur
Weight in Kg
In/Outpatient (I/O)
for Visit Drugs Next e

Drug One Drug Two Drug Three Visit
Start
Refill
Initial
Presc. No.
Drug Drug Drug

Strength
Brand
Quantity
Strength
Brand
Quantity
Strength
Brand
Quantity
Name Name Name
Chapter 4 Pharmacy Services Appendix G: Page 1 of 1

Appendix H: Sample List of Emergency Drugs
Sample List of Emergency Drugs

S. Name of the Drug Dosage Form and Strength
1. Acetylcystene Powder
2. Activated Charcoal Powder 25G, 50G, Suspension
3. Adrenaline (Epinephrine) Injection, 1mg/ml, 1:1000 solution
4. Acetazolamide Tablet, 250mg
5. Aminophylline Injection, 25mg/ml in 10-ml ampoule
6. Atenolol Injection, 5mg /ml
7. Atropine Sulphate Injection, 0.6mg in 1-ml ampoule
8. Adenosine Injection, 3mg/ml
9. BAL (Dimercaprol) Injection, 50mg/ml
10. Calcium Gluconate Injection, 10%
11. Chlorpromazine Injection, 25mg/ml in 2-ml vial
12. Dexamethasone Injection, 4mg/ml in 2ml ampoule
13. Digoxin Injection, 0.25mg/ml in 2ml ampoule
14. Diazepam Injection, 5mg/ml in 2ml vial
15. Dobutamine Injection, 12.5mg/ml in 20ml ampoule
16. Dopamine Injection, 40mg/ml in 5ml ampoule
17. Frusemide Injection, 10mg/ml in 2ml ampoule
18. Glyceryl Trinitrate Sublingual tablet, 0.5mg
19. Heparin Injection, 5000 Units/vial
20. Haloperidol Injection, 5mg/ml in 1ml ampoule
21. Hysocine n-butylbromide Injection, 20mg/ml in 1ml ampoule
22. Hydrocortisone Powder for Injection, 100mg
23. Insulin (Soluble) Injection,40IU/ml in 10ml vial
24. Ipecauanha Syrup
25. Isoprenaline Injection, 20mcg/ml
26. Isosorbide dinitrate Subligual tablet, 5mg
5%Dextrose, 540ml
10%Dextrose, 540ml
27. Intravenous Fluids (IV fluids) 5%Dextrose with sodium chloride, 540ml
Ringer lactate, 540ml
0.9% Sodium Chloride, 540ml
28. Ipratopium Bromide Aerosol Inhalation
29. Ketamine Injection, 10mg/ml, 50mg/ml in 10 ml vial
30. Lignocaine Injection, 1%, 25 in 30 ml vial; Gel 2%;
31. Lignocaine(Xylocard) Injection, 21.3mg/ml in 50ml vial
32. Mannitol Injection, 20% in 300ml vial
33. Magnesium Sulphate Injection, 50%, 10ml (5gm ampoule)
34. Methyl-ergometrine Injection 0.2mg/ml in 1 ml ampoule
35. Metoclopramide Injection, 5mg/ml in 2ml ampoule
36. Morphine Injection, 10mg/ml in 2-ml ampoule
37. Naloxone Injection, 0.4mg/ml in 1 ml ampoule
38. Noradernaline(norepinephrine) Injection,1mg/ml in 1 ml ampoule
39. Nitroprusside Injection - 50mg
40. Nifedipine Capsule, 5mg
Chapter 4 Pharmacy Services Appendix H: Page 1 of 2

41. Oxygen
42. Oxytocin Injection, 5units /ml in 1ml ampoule
43. Paracetamol Injection, 150mg/ml in 2ml ampoule
44. Pethidine Injection, 50mg/ml in 1 and 2 ml ampoule
45. Pheniramine maleate Injection, 22.75 mg/ml in 2ml ampoule
46. Phenobarbitone Injection, 200mg/ml in 1ml ampuole
47. Phenytoin sodium Injection, 50mg/ml in 5 ml ampuole
48. Pilocarpine Eye drop, 2%, 4%
49. Polygeline with Electrolytes IV solution, 3.5%
50. Polyvenum Antisnake venum Injection
51. Propanolol Injection, 1 mg / ml
52. Phytomenadione (Vit K) Injection 10mg/ml
53. Potassium Chloride Injection,150mg/ml in 10ml ampoule
54. Pralidoxime (PAM) Injection,25mg/ml in 20ml ampoule
55. Protamine Sulphate Injection, 10mg/ml in 10ml ampoule
56. Quinine Sulphate Tablet, 200mg
57. Ranitidine Injection, 25mg/ml in 2ml ampoule
58. Salbutamol Respiratory solution, 5mg/ml in 15ml vial
59. Silver sulphadiazine cream 1%
60. Sodium bi-carbonate Injection, 75mg/ml in 10ml ampoule
61. Sodium Stibogluconate Injection, 100mg/ml
62. Streptokinase Injection,1.5million IU
63. Tetanus Toxoide Injection, 0.5ml
64. Thiopentone Injection,0.5gm 1gm per ampoule
65. Verapamil (Isoptin) Injection, 2.5mg/ml in 2ml ampoule
66. Suxamethonium (Succinylcholine Injection 50mg/ml - 2ml ampuole or 10ml
67. Ephidrine Injection 30mg/ml - 1ml ampoule
68. Hydrallazine Injection, 20mg/ml vial
69. Paraldehyde injection, 5ml
70. 25% Dextrose Injection
71. Amiodarone Injection 50mg/ml, tablet 100mg
72. Ipratopium Bromide (Respiratory Nebulizer
Chapter 4 Pharmacy Services Appendix H: Page 2 of 2

Appendix I Suggested Contents of Drug Information Centre Library
Martindale : The extra Pharmacopoeia. Reynolds JEF, ed.

MIMS Monthly
AHFS Drug Information. McEvoy GK, ed.
USP DI. Vol 1: Drug Information for the Health Care Provider
USP DI. Vol 2: Advice for the Patient
Drug Interactions. Stockley IH. or Drug Interactions and Updates. Hansten PD, Horn JR.
or Drug Interaction Facts. Tatro DS, ed.
Handbook of Injectable Drugs. Trissel, ed. Or Guide to Parenteral Admixtures. King JC
Poisoning and Overdose. Olson KR, ed.
Meylers Side Effects of Drugs. Dukes MNG, ed.
Samford Guidelines for the Use of Antibiotics
Goodman and Gilmans The Pharmacological Basis of Therapeutics. Gilman AG,
Goodman LS, Rall TW, Murad F, eds.
BNF
Harrisons Principles of Internal Medicine. Braunwald E, Isselbacher KJ, Petersdorf RG,
et al or
Oxford textbook of Medicine. Weatherall DJ, Ledingham JGG, Warrell DA, eds.
Medical Dictionary
Pharmaceutical journals
National treatment guidelines
National drug list
Free online journals if available
Chapter 4 Pharmacy Services Appendix I: Page 1 of 1

Appendix J Sample Adverse Drug Reaction Reporting Form
Chapter 4 Pharmacy Services Appendix J: Page 1 of 2

Chapter 4 Pharmacy Services Appendix J: Page 2 of 2
Appendix K Sample Bin Card
Name of Health Facility:
Product Name, Strength and Dosage Form
Unit of Issue:
Doc. No.
Received
(Receiving Quantity Batch Expiry
Date from or Remarks
or No. Date
Issued to
Issuing) Received Issued Loss/Adj Balance
Chapter 4 Pharmacy Services Appendix K: Page 1 of 1

Appendix L Sample Stock Record Card
Name of Health Facility:
Product Name, Strength and Dosage

Form:
Unit of Issue: Location:
Maximum Stock Emergency Order

Level: Point:
Doc. No. Received Price

Quantity Expiry
Date (Receiving from or Unit Price Remarks
Date
or Issuing Issued to
Received Issued Loss/Adj Balance Birr Cent
Chapter 4 Pharmacy Services Appendix L: Page 1 of 1

Appendix M Internal Facility Report, Issue and Receipt Voucher (IFRIR)
Name of Dispensing Unit: Reporting Period From: To:
Maximum Level (ML):______________

COMPLETED BY UNIT COMPLETED BY STORE
Quantity
Stock on Stock on Estimated Maximum
Expired/ Average Needed to
Hand at Hand at Qty. Consumption Quantity Quantity
Ser. Damaged/ Consumptio Reach Item Price
Item Start of End of Trans. E = A-B-C+/- G=F* Supplied
No. Lost n Max.
Period Period D ML
H=GB
A B C D E F G H I J
1
2
3
4
5
6
Reported by: Issued by: Approved by: Received by:
Signature: Signature: Signature: Signature:
Date: Date: Date: Date:
Chapter 4 Pharmacy Services Appendix M: Page 1 of 1

Appendix N Facility Combined Report and Requisition Form (FCRRF)
Health Region: Zone: Woreda:

Facility:
Reporting Period: From: To:

(month/day/year) (month/day/year)
Report Part Requisition Part
Product Unit of Beginning Ending Days Maximum

SN Product Description Quantity Losses/ Calculated Quantity
Code Issue Balance in Balance in Out of Stock
Received Adjustments Consumption Ordered
Store Store Stock Quantity
F= G= H=
A B C D E
A + B +/- C D F*2 G-D
1
2
3
4
5
6
7
8
9
Remarks:
Completed by: Signature: Date:
Approved by: Signature: Date:
Chapter 4 Pharmacy Services Appendix N: Page 1 of 1

Appendix O Record for Returning Unusable Commodities (RRUC)
Date:
To:
(Name of Health Centre or PFSA Hub)
Facility returning commodities:

Region: Woreda: Kebele:
Reason for
Quantity
Item Description Unit Return/Non-
Returned
Use
Sending Certification:
Completed by: Signature: Date:
Remarks:
Carrier Certification:
Carried by: Signature: Date:
Remarks:
Receiving Facility Certification:

Received by: Signature: Date:
Remarks:
Chapter 4 Pharmacy Services Appendix O: Page 1 of 1

Appendix P Consumption Summary Sheet
Consumption Summary Sheet (CSS) for Dispensaries (Only)

S.N. Description Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Total
1 xxxxxx 0
2 yyyyyyy 0
3 zzzzzzzz 0
4 aaaaaaaaaa 0
5 bbbbbbbbb 0
6 bbbbbbbbb 0
7 bbbbbbbbb 0
8 bbbbbbbbb 0
9 bbbbbbbbb 0
10 bbbbbbbbb 0
Day Day Day Day Day Day Day Day Day

S.N. Description 11 12 13 14 15 16 17 18 19 Day 20 Total
1 xxxxxx 0
2 yyyyyyy 0
3 zzzzzzzz 0
4 aaaaaaaaaa 0
5 bbbbbbbbb 0
6 bbbbbbbbb 0
7 bbbbbbbbb 0
8 bbbbbbbbb 0
9 bbbbbbbbb 0
10 bbbbbbbbb 0
Chapter 4 Pharmacy Services Appendix P: Page 2 of 2

Appendix Q Losses / Adjustments Tracking Sheet for Dispensaries (Only)
Qty Transferred (+ve/-ve)

S.N. Description Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Total Remark
1 Xxxxxx
2 Yyyyyyy
3 Zzzzzzzz
4 Aaaaaaaaaa
5 Bbbbbbbbb
6 Bbbbbbbbb
7 Bbbbbbbbb
8 Bbbbbbbbb
9 Bbbbbbbbb
10 Bbbbbbbbb
Qty Lost/Damage (+ve/-ve)
S.N. Description Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Total Remark
1 Xxxxxx
2 yyyyyyy
3 zzzzzzzz
4 aaaaaaaaaa
5 bbbbbbbbb
6 bbbbbbbbb
7 bbbbbbbbb
8 bbbbbbbbb
9 bbbbbbbbb
10 bbbbbbbbb
Chapter 4 Pharmacy Services Appendix Q: Page 1 of 1

Laboratory Services
Page 1 of 28
Section 2 Operational Standards for Laboratory Services 5

3.1 Customer Services 6
3.1.1 Tests available
3.1.2 User manual
3.1.3 Clinical advice service
3.1.4 Information sharing
3.1.5 Service and satisfaction
3.2 Tests to be provided by a Hospital Laboratory 8
3.3 Blood Transfusion Service 9
3.4 Laboratory Equipment Management 9
3.4.1 Equipment required in a hospital laboratory
3.4.2 Procurement of equipment
3.4.3 Inventory control
3.4.4 Equipment maintenance
3.5 Control of Laboratory Reagents and Supplies 13
3.5.1 Reagent and supply inventory control
3.6 Standard Operating Procedures 14
3.7 Referrals and Transportation of Laboratory Samples 16
3.8 Organisation of the Laboratory Working Environment 16
3.9 Laboratory Safety 18
3.10 Information Management 20
3.10.1 Document management
3.10.2 Record management
3.11 Quality Assurance 22

3.11.1 External quality assurance
3.11.2 Internal quality assurance
3.12 Laboratory Staff Management 24

4.3 Indicators 26
Chapter 5 Laboratory Services Page 2 of 29

Source Documents 28
Appendices
Appendix A The Laboratory Network: Responsibilities of Laboratories at Different Tier
Levels in Ethiopia
Appendix B Sample Preventive Maintenance Log
Appendix C Sample Corrective Maintenance Log
Appendix D Sample SOP for Haemoglobin Estimation
Appendix E National SOP Template
Appendix F Sample Laboratory Risk Assessment Form
Appendix G List of Notifiable Diseases
Tables
Table 1 Laboratory Services Checklist
Table 2 Laboratory Services Inidcators
Abbreviations
AFB Acid Fast Bacilli
ALT Alkaline Transferase
BPR Business Process Re-engineering
DNA Deoxyribonucleic acid Acid
EHNRI Ethiopian Health and Nutrition Research Institute
EQA External Quality Assessment
FMHACA Food Medicine and Healthcare Administration and Control Authority
OHSO Occupational Health and Safety Officer
PCR Polymerase Chain Reaction
PIHCT Provider Initiated HIV Counselling and Testing
PMTCT Prevention of Mother to Child HIV Transmission
PPE Personal Protective Equipment
PT/ EQA ProficiencyTesting/ External Quality Assessment/
QA Quality Assurance
QC Quality Control
QI Quality Improvement

RPR Rapid Plasma Reagin
SOPs Standard Operating Procedures
STS Sample Transfer Service
TPHA Treponema Pallidum Haemagglutination
TPPA Treponema Pallidum Particle Agglutination
UPS Uninterrupted Power Supply

Laboratory services underpin the practice of modern medicine by providing information to
clinicians to accurately assess the status of a patients health, make accurate diagnoses,
formulate treatment plans, and monitor the effects of treatment. Laboratories are a major
source of health information for epidemiological and surveillance purposes and laboratories
are often the first sites for the detection of disease outbreaks. To provide such functions
laboratory data must be recorded and reported through the appropriate channels in an
accurate and in a timely manner.
The current laboratory service in Ethiopia is organized in a structure that follows the general
health care delivery system of the country, incorporating specialized, general and primary
hospitals in addition to health centres and health posts. At the apex of this system, there are
currently eight Regional Laboratories and a National Reference Laboratory at the Ethiopian
Health and Nutrition Research Institute (EHNRI). A detailed description of the
responsibilities of laboratories at different tier levels in Ethiopia is presented in Appendix A.
As part of the Ethiopian laboratory network, hospitals may receive specimens for analysis
from lower level facilities and may refer specimens to a higher level facility, in accordance
with agreed protocols and guidelines.
This chapter sets standards and guidelines to ensure that hospital laboratories provide
accurate and timely test results for individual patient care, using the referral network where
appropriate, and in addition provide data for the surveillance of population health and well
being. Effective laboratory management ensures that equipment and supplies are available at
all times to perform agreed tests with minimal down time in service provision.
Section 2 Operational Standards for Laboratory Services

1. A current list of laboratory tests provided by the facility and the price of each test is
accessible to all clinical staff and patients.
2. Laboratory management ensures that advice on examinations and the interpretation of test
results is available to meet the needs and requirements of customers.
3. Hospital management ensures that the Hospital laboratory has the necessary space,
working environment, reagents, consumables, analyzers and associated equipment needed
to conduct the required repertoire of tests.
4. Laboratory staff members monitor stocks of testing reagents and other consumables so
that supplies are ordered early and in sufficient quantity to prevent stock-outs or
oversupply.
5. The Hospital Laboratory has available and follows standard operating procedures for:
a. Specimen management
b. All testing procedures
c. Testing algorithms

d. Safety procedures and waste management
e. The maintenance and monitoring of each piece of equipment
f. Quality assurance procedures
6. The Hospital has policies and procedures in place for sample collection, transport and
disposal.
7. The central laboratory has functional overview of all hospital laboratories (e.g.
emergency room laboratory, inpatient laboratory etc).
8. The laboratory work environment is organized and clean at all times, with safety
procedures for handling of specimens and waste material to ensure patient and staff
protection from unnecessary risks at all times.
9. The laboratory has a health and safety manual with procedures that include: action in the
event of a fire, action in the event of a major spillage of dangerous chemicals or clinical
material; action in the event of an inoculation accident; reporting and monitoring of
accidents and incidents; disinfection processes; decontamination of equipment; chemical
handling; storage and disposal of waste.
10. Laboratory management establishes a policy for the management of data and information
that includes:
safety
access (including level of access)
confidentiality and data protection
backup system
storage, archive and retrieval
data destruction
11. The laboratory has and implements a quality assurance policy that covers all aspects of
laboratory functions.

3.1 Customer Services
3.1.1 Tests available
The Laboratory Manager, in collaboration with the Finance Department, should produce a list
of all tests that are provided by the laboratory, including the fee per test. The list should be
updated on an annual basis (or more often as required) and should be posted in all sample
collection areas and readily available to all clinical staff and patients.

3.1.2 User manual
A user manual should be prepared by each laboratory for the benefit of clinical staff ordering
diagnostic tests. The user manual should be distributed to all sample collection areas including
wards, emergency room, operating room, labour and delivery, outpatient department etc.
The user manual should include:

A list of all tests available at the laboratory and average turn-around time for each
A list of tests that may be taken by the laboratory and referred to a higher tier for analysis, and
turn-around time for each
For each test:
o Basis for reference range
o Critical range notification
o Test interference or procedure limitations
o Sensitivity
o Specificity
o Accuracy
o Precision
o Any other pertinent test characteristics
o Interpretation
Test ordering procedures
Copy of test order form. Sample test order forms are presented in Appendix B of Chapter
3 Medical Records Management.
Sample collection and sample disposal procedures
3.1.3 Clinical advice service
The laboratory should provide a service to clinical staff to assist with the interpretation of
results and to advise on the need for additional tests. To achieve this laboratory staff may
make comments on the result report form, either commenting on the interpretation of the
results and/or suggesting additional investigations that might aid the diagnosis. Laboratory
personnel should be available to answer queries from clinical staff about individual test
results or the need for further investigation. Additionally, the laboratory should establish
panic results (i.e. a result which should be communicated immediately to the physician for
urgent action) for each investigation and processes by which such results are communicated
immediately to the ordering clinician.
3.1.4 Information sharing
The hospital should have a process to update clinical staff on areas such as new tests,
interpreting laboratory results etc. There should also be a forum through which laboratory
staff can discuss individual patient care with clinicians when necessary. Possible mechanisms
include:
a) In house education sessions at which all laboratory staff members who attend
workshops/trainings share this knowledge with their laboratory and other clinical colleagues.

b) Clinical review meetings of all clinical staff (nurses, physicians, X-ray, lab, pharmacy) or
of each clinical case team. These meetings should be a forum for presentations and discussion
on general clinical issues. Laboratory staff should participate in these meetings and could use
these meetings to provide clinical advice/update information about laboratory services to
clinical staff.
3.1.5 Service and satisfaction
Each lab should develop a system to collect and measure data on how much the laboratory
services and products satisfy the patients and clinical staff and should take steps to address
any problems identified. This could be done through suggestion boxes or satisfaction surveys.
The laboratory should have a mechanism to record complaints from staff and clients. All
complaints and problems reported to the laboratory as well as corrective action taken should
be documented.
For further discussion on ways to ensure a patient centred service please see Sections 3.1.4
and 3.1.5 of Chapter 12 Quality Management.
3.2 Tests to be provided by a Hospital Laboratory
The following diagnostic tests should be provided by primary and district hospital
laboratories (Level II Laboratories):
Haematology
CBC with Automated Differential
CBC Manual
Blood film
CSF Cell Counts
CD4 (absolute)
Type and Cross-match
Clinical Chemistry
Chemistry Panel
o Liver function tests (ALT, bilirubin)
o Serum electrolytes
o Renal function tests (creatinine, urea, nitrogen)
o Lipid profile
o Serum amylase
o Glucose
Whole Blood Lactate
Microbiology
AFB Smear
India Ink Stain

Gram Stain
Microbiology culture and sensitivity
Wet Mounts Direct Microscopy
Serology
HIV Serology Rapid Test
Cryptococcal Antigen Test
Hepatitis B
Hepatitis C
TPPA/ TPHA/ RPR
Parasitology
Malaria Rapid Test
Malaria smear microscopy (Blood Film)
Stool examination: Direct microscopy and concentration techniques
Urine tests
Urine Dipstick with Microscopy
Urine Pregnancy Rapid Test
Tertiary referral hospitals (Level III laboratories) should provide the following tests and
services:
All tests performed at Levels I and II
Viral load (by PCR, DNA or other methods)
Microbiology culture, identification and susceptibilities
Blood cultures
Complete chemistry panel
AFB smear
AFB culture, identification and susceptibility (first-line drugs)
Nucleic acid PCR test (Example: HIV DNA PCR)
3.3 Blood Transfusion Service
Hospital laboratories should establish a blood bank and provide a blood transfusion service.
Blood donations should be screened for pathogens - as a minimum HIV, syphilis, Hepatitis B
and C. Blood should be stored securely and quality assurance measures should be in place to
ensure the correct temperature for storage at all times. Refrigerators or freezers for blood
storage should have an alternative power supply as a backup in case of mains failure.
3.4 Laboratory Equipment Management
Detailed guidance on the management of medical equipment is provided in Chapter 6

Nursing Care Standards. The following sections provide an overview of the management of
laboratory equipment. For more detailed guidance please see Chapter 9 Medical Equipment
Management.

3.4.1 Equipment required in a hospital laboratory
To perform the tests described in section 3.2 above hospital laboratories must, as a minimum,
have the following equipment:
Centrifuge
40C lab refrigerator, 240V
Biological Safety Cabinet Type 1 or Type 2
Tachometer (to verify speed of centrifuge)
3D bi-directional rotator 240V, 50/60Hz
Blood tube rocker/rotator
Refrigerator with freezer compartment, -200 to -400C
Water distiller, complete with wall bracket and tubing
560C Water bath, 15L, 240V, 50/60Hz
Test tube agglutination viewer
Binocular microscope
Dry heat sterilizer
Autoclave
Vortex mixer
Automated haematology analyzer
Automated chemistry analyzer
Coagulation analyser
CD4 analyzer
Cold box and ice pack
Water distiller
Thermometers for fridge, freezer and water bath
Micropipettes with different volumes
UPS
The laboratory should be connected to a back-up power supply (generator) in cases of

interruption to the mains electrical supply.
Additionally, the laboratory should have a telephone(s), fax machine, sufficient computers
and printers for administrative purposes and internet connection if possible.
3.4.2 Procurement of equipment
A senior laboratory technician should be a member of the Medical Equipment Committee

that is responsible to approve the procurement of all medical equipment including laboratory
equipment.
Prior to ordering or accepting equipment there must be a check to ensure that the laboratory
has adequate room size and access for the equipment, together with an adequate electrical
system, plumbing and ventilation, as required.

For all new equipment there must be an agreement with the vendor for installation,
calibration, maintenance, trouble shooting, reagent supply, service and repair and training of
staff for a specified time period. All new equipment should be supplied with a user manual.
All procurement decisions must factor in reagent supply. There should be a sustainable
supply of reagents, and as far as possible required reagents should be integrated across
systems.
All donated equipment must be assessed by laboratory management before acceptance. This
assessment should include the need for the item and any maintenance and reagent
requirements to ensure that any necessary spare parts or reagents are readily available in the
country.
3.4.3 Inventory control
Every lab should have an inventory of all equipment and instruments that includes:
Name of manufacturer,
Model and serial number,
Date of purchase or acquisition,
Purchase cost,
Current location,
Record of contracted maintenance, and
Record of equipment breakdowns.
Manufacturers manuals should be attached to, or stored beside, each instrument. Laboratory
equipment should only be used by appropriately trained staff. An equipment usage log book
or form can be completed by laboratory staff to indicate the duration of use and name of the
person who used the equipment.
3.4.4 Equipment Maintenance
There should be a program for preventive maintenance, calibration and monitoring of

equipment function that is documented and at a minimum follows manufacturers
recommendations. The Quality Assurance (QA) Officer (see section 3.11) is responsible to
ensure that instruments in the laboratory are maintained properly, daily controls and
calibrators are run, and maintenance logs are kept up to date.
There should be a timetable for the calibration and maintenance of each piece of equipment.
Calibration should be performed every six months if specific instructions are absent.
Otherwise calibration should be performed:

Based on the specifications of the manufacturer
After a complete change of reagents
Where controls show unusual trends
After major preventive maintenance
After replacement of critical parts

When the procedure requires more calibration
There should be close follow up of instruments functional abilities such as temperature of

refrigerators, incubators, rotation of centrifuges etc. Log books or standard forms should be
stored near or attached to the instrument and should be completed on a regular basis by the
laboratory staff. Each instrument should have a named individual responsible for these
checks who is assigned by the Laboratory Manager. The QA officer is responsible to review
the log books or forms to ensure that the required checks have been done.
All preventive maintenance should be documented in a computer/log book and kept in each
laboratory. All records of corrective actions taken, repair and services should be documented
and kept in the laboratory and in the maintenance dept of the hospital. For instruments that
are not functioning properly an ' OUT OF ORDER' label should be attached on an easily
visible part of the instrument body until corrective maintenance is done. Instrument down
time should be recorded.
Good maintenance practices minimize instrument repair costs and limit instrument downtime
and workflow interruptions. There are two types of maintenance: planned preventive
maintenance and corrective maintenance. For each item of equipment a log should be kept of
all maintenance activities.
Only individuals who have taken appropriate training on the specific piece of equipment
should undertake maintenance activities. For some equipment this will require a certified
service engineer.
a) Preventive Maintenance
Periodic maintenance prior to equipment failure will prevent accidental breakdown and
increase performance. Systematic Preventive Maintenance includes adjusting, calibrating,
changing parts, following shut down procedures, and performing general cleaning procedures
(such as blowing, rinsing, wiping, flushing). Cleaning procedures should adhere to Standard
Operating Procedures that apply to each instrument.
The Operator (user) should perform daily, weekly, monthly and/or quarterly preventive
maintenance for each type of equipment in the laboratory. All preventive maintenance
activities should be recorded in a maintenance log for each piece of equipment. A sample
Preventive Maintenance Log is presented in Appendix B.
Service engineers from the appropriate company or EHNRI should perform semi-annual or
annual preventive maintenance on the larger more complex instruments. A log must be
completed with copies held on site and by the service engineer.
b) Corrective Maintenance
Corrective maintenance involves equipment repair and replacement of parts. Instrument
operators can perform simple corrective maintenance such as replacing blown out fuses and
removing blockage from the fluidics system by using troubleshooting charts from instrument

user manuals. However, most corrective maintenance must be performed by a qualified
service engineer. All corrective maintenance activities should be recorded in a maintenance
log for each piece of equipment. A sample Corrective Maintenance Log is presented in
Appendix C.
No engineers, aside from those sent by the supplier, can perform corrective maintenance on
instruments still under warranty.
3.5 Control of Laboratory Reagents and Supplies
Laboratories require reagents, controls and supplies for:

Clinical chemistry,
Haematological tests,
Microbiological tests,
Serology,
Parasitology, and
Others.
In the procurement of reagents, the supplier should provide a certificate of suitability of the
reagents for the intended test. Laboratories should only purchase reagents that have been
approved by the Food Medicine and Healthcare Administration and Control Authority
(FMHACA). Reagents should be stored according to manufacturers recommendations.
All reagents and other supplies should be:

catalogued and stored accordingly to aid retrieval,
properly stored according to manufacturers instructions,
discarded when the shelf life is expired,
labelled to indicate identification and, when applicable, significant titre strength or
concentration,
marked with date of preparation or receipt
marked with the date opened:
The date that the reagent was first opened must be written on the container with a
standard plastic laminated form. If reagents are dispensed from intact stock
containers by dilution or any other treatment, the date of preparation as well as the
duration of should be written,
the components of reagent kits of different lot numbers should not be interchanged
unless otherwise specified by the preparer.
Reagent validation and monitoring should be done prior to use.
3.5.1 Reagent and supply inventory control
Laboratory management should have control over the purchase, storage and distribution of
laboratory reagents and supplies. If another department (for example finance or pharmacy) is
responsible for the purchase of laboratory reagents and supplies this should be done in

consultation with the Laboratory Manager and there should be a system through which the
Laboratory Manager can order stock when necessary.
The laboratory should establish a control system to catalogue the purchasing and supply of
reagents and supplies. This can be done through a log book or an electronic cataloguing
system. Reagent name, supply on hand and expiration date of reagents and supplies should
be recorded in the log book or electronic system. This will allow laboratory staff to compare
the current stock in the laboratory and in the warehouse to avoid unpredicted stock out.
Laboratory reagents and supplies should be stored in a mini-store that is managed by the
Laboratory Manager.
3.6 Standard Operating Procedures
Standard Operating Procedures (SOPs) are created for regularly recurring work processes that
are conducted in the laboratory. This is done to ensure that activities are performed
consistently and in a manner that achieves results of the highest quality, and that the
laboratory is run as efficiently as possible. All laboratory staff should participate in the
creation of SOPs. Each SOP should be approved by the Laboratory Manager and Quality
Assurance Officer prior to implementation.
SOPs should be available for:

1. Specimen management
All SOPs for specimen management should include:

a) Action upon receipt of a sample:
Upon receipt each laboratory should check the availability of the requested test in that
laboratory, including the turnaround time for results. If the service is not available, the
laboratory should notify the customer and refer the sample to a different laboratory capable of
performing the request test (see section 3.7). If the service is available, the sample must be
checked according to the acceptance and rejection criteria. A specimen can be rejected if:
it is received without a request form,
it is unlabeled, incompletely labelled or if the name on the label does not match the
name on the request form,
it is leaking,
it is in a broken container,
it is the wrong type of specimen for the requested test,
it was not transported according to requirements,
the time since collection is too long(depending on the type of test),
it is haemolytic (depending on the type of test),
there is insufficient volume of a specimen, or
there is bacterial overgrowth present.

b) Documentation of sample receipt:
A log book should be used to record the receipt of samples. This should include:
the name of the patient and identification number,
the source of the specimen,
the name of the submitter, and
the date of collection.
2. All testing procedures:
All SOPs for individual tests should include:

a) The full test name, including the full name of the methodology used (commonly used
abbreviations should be listed at the beginning of the SOP),
b) The types of reactions, specimens, or organisms involved in the test,
c) Guidelines for the storage of specimens to ensure their integrity until testing is complete,
d) The clinical reasoning for performing the test,
e) Any calculations and formulas needed to obtain a result,
f) The methodology used, including the limitations of procedures and reagents,
g) Standards by which a sample is accepted or rejected,
h) Safety issues related to that particular test,
i) The test procedure, including:
A complete set of instructions
Detailed descriptions such as measuring units, etc.
How to prepare slides, solution, calibrators, control, reagents, stains, etc. for use
j) The criteria for what to do if a test system becomes inoperable,
k) A corrective action guideline (when necessary),
l) Interpretation of results, including:
Reportable ranges
Critical or panic values
m) Methods of disposal for specimens and other products used,
n) References to relevant and pertinent materials,
o) Criteria for the referral of specimens to and from other health facilities, and
p) Transport requirements (e.g. cold chain) if the specimen is to be transferred to another
laboratory.
A sample SOP for haemoglobin estimation is presented in Appendix D.
a) SOPs should also be available for:

b) Testing algorithms (The procedure for analyzing a sample that has more than one test
request)
c) The maintenance and monitoring of each piece of equipment (see section 3.4)
d) Sample referrals and transportation (see section 3.7)
e) Safety procedures and waste management, including proper specimen disposal (see
section 3.9)
f) Quality assurance procedures (see section 3.11)

Each SOP should be reviewed on a regular basis (for example annually). The revision level
and due date for the next review should be stated on each SOP. The national SOP template,
developed by EHNRI is presented in Appendix E.
3.7 Referrals and Transportation of Laboratory Samples
Within hospitals, support staff (runners) should be used to transport samples and results
between the laboratory and clinical areas. The transport between the hospital and external
facilities is handled by the Sample Transfer Service (STS). The STS is a system that outlines
the process of referring and transporting laboratory samples in a coordinated, timely, and
effective manner. The quality of laboratory results is dependent upon the quality of the
specimen received. Therefore, the STS is designed to minimize the time from when the
specimen is collected to when it is delivered.
There should be an assigned contact person to oversee the referral and transport process and a
trained courier (preferably a non-technical staff member) for the transportation of samples.
Transport should be arranged in accordance with the SOP of each test taking into account any
special requirements (e.g. maintenance of the cold chain). All relevant personnel (runners,
couriers, laboratory staff and clinicians) should be trained in the collection, preservation and
transport of specimens as appropriate.
The hospital should establish linkages with other facilities for the receipt and referral of
samples. There should be a policy, agreed between relevant facilities, that specifies:
The lower level facilities from which samples may be received,
The type of samples and tests that will be conducted for lower level facilities,
The turnaround time for each test and process by which results will be reported back
to the referring facility,
The higher level facility(s) to which samples may be referred,
The type of samples and tests that will be conducted at the higher level facility(s), and
The turnaround time for each test and process by which results will be reported back
to the hospital.
Laboratory samples may also be received from external private health facilities. The hospital
may decide to charge a higher fee for the testing of these samples.
A system should be established to track referred and received samples to ensure that no
samples or results are lost and to keep a record of test results.
3.8 Organisation of Laboratory Working Environment
The physical structure of the laboratory should be of an appropriate size, location, and layout
to ensure safety to staff, patients, and others. A diagram of the layout of the laboratory
department should be clearly displayed on the wall of the central laboratory.

The laboratory space should be sufficient to accommodate:
Patient registration and sample collection (if the laboratory takes samples),
Administration and clerical functions,
Technical functions,
Instrument storage, and
Refrigerators and other storage space for reagents and supplies.
All ART laboratory equipment should be integrated with the central laboratory such that
laboratory equipment for HIV patients (e.g. chemistry and haematology analyzers) are also
available for the use of non HIV patients.
Ideally, laboratory samples should be collected from patients within the service area where
they are receiving clinical care (e.g. in OPD, in ER, on the ward etc). The sample and test
request form should be taken to the laboratory by a support staff member (runner). A
process should be in place to ensure that all necessary testing equipment (e.g. tourniquet,
blood collection tubes etc) and sample request forms are always available in all testing areas.
For further discussion on the organization of Laboratory Services and sample collection,
including BPR recommendations, see Chapter 2 Patient Flow.
If it is necessary to collect samples within the laboratory department then there must be a
covered waiting area for patients, a patient reception and a sample collection room.
The laboratory test area should be well lit, have good ventilation and a minimum of two sinks
one for washing hands and the second for laboratory purposes. The central laboratory work
space should be organized by the type of department/test performed (i.e. haematology,
clinical chemistry, microbiology etc).
Sturdy, built-in benches with levelled tops and covered with a surface that can be disinfected
(such as formica) or painted with oil based paint should be present. Benches should be at
least 0.9m high and 0.5m wide. There should be an adequate number of lab stools. These
should be at least 0.6m high to enable staff to sit while performing lab work. Stainless steel
or plastic stools are preferable for the ease of cleaning and disinfection.
Laboratory floors should be made of materials that are resistant to acids, alkalis and salts (e.g.
not wood). Alternatively the floors may be plated or painted with such materials. Ceilings
should be of materials that can easily be cleaned and disinfected and should provide a
continuous seal to prevent contaminants from seeping through. Internal and external walls
should be maintained in good condition.
A mini-store for reagents and supplies should be located within the laboratory department.
There should be sufficient power outlets for all electrical equipment within the laboratory and
the use of extension cords should be minimized. Laboratory equipment, including
refridgerators, should be protected by Uniterrupted Power Supply (UPS) devices. Essential
equipment should be connected to the backup power supply in the event of power failure.

Access to the laboratory should be restricted to authorized personnel. Laboratory buildings
should be secured with window locks or burglar bars, door and cupboard locks as necessary.
Keys should be held by authorized personnel only.
3.9 Laboratory Safety
Within the laboratory there should be someone responsible to oversee health and safety
activities. The Laboratory Manager could fill this position if necessary. Responsibilities
include:
1. To conduct regular risk assessments of laboratory premises
2. To maintain a safe working environment
3. To ensure adequate safety equipment is available at all times
4. To ensure the safe disposal of laboratory waste
5. To prepare the laboratory health and safety manual
6. To prepare the department-specific Major Incident Plan
7. To train laboratory staff on health and safety procedures
8. To establish mechanisms to report laboratory accidents or injuries
9. To ensure that remedial action is taken in response to any accidents or injuries
1. Risk assessment
A regular risk assessment of laboratory premises should be conducted at a minimum every
quarter. A standard assessment tool should be used. A sample Laboratory Risk Assessment
Form is presented in Appendix F. Based on the findings of the risk assessment appropriate
steps should be taken to minimize risk.
Copies of all risk assessments and a description of remedial action taken should be
maintained in the laboratory.
2. Laboratory environment
Laboratories should be adequately signed to indicate:
Entrances to areas where bio-hazardous materials are kept,
Fire exits and fire extinguishers,
First aid kit,
Eye wash station, and
Safety shower.
Bio-hazardous materials should be stored in secure and clearly demarcated.
Walkways, doors and fire escape routes should be unobstructed at all times and all areas of
the laboratory should be adequately lit.
General safety rules, such as standard precautions, should be laminated and posted in an open
and visible space within the laboratory.

3. Safety equipment
a) Personal Protective Equipment (PPE): this should be available in sufficient quantities for
the use of laboratory staff and visitors at all times. PPE includes:
a. Goggles, gloves, coats and face shields
b. Cryogenic/heat resistant gloves
b) First Aid Kit: there should be a first aid kit in each laboratory testing area. This should be
checked and restocked weekly.
c) Eye wash station: there should be an eye wash station in each laboratory testing area. The
water should be changed weekly or after each use.
d) Safety shower: there should be a safety shower available to all laboratory staff in the
event of chemical exposure. This should be tested weekly.
4. Waste disposal
Laboratory waste should be regarded as hazardous and disposed of accordingly. Further
guidance on waste management, including the management of spills of hazardous materials is
presented in Section 3.4.1.1 of Chapter 7 Infection Prevention.
All staff who handle laboratory waste (including those undertaking repairs of drainage
systems) should follow standard infection prevention measures and wear PPE. (For further
guidance on the use of PPE please see Section 3.2.2 of Chapter 7 Infection Prevention).
5. Laboratory Health and Safety Manual

The laboratory should have a health and safety manual that:
a) Establishes general safety principles such as:
i. The implementation of Standard Precautions for infection prevention (see
section 3.2 of Chapter 7 Infection Prevention.
ii. The use of personal protective equipment and proper attire (e.g. close-toed
shoes, clothing that minimized skin exposure, hair tied back etc)
iii. Prohibition of eating, drinking or smoking in the laboratory
iv. The use of equipment by appropriately trained personnel only
v. Decontamination of equipment
b) Establishes procedures for the storage of and access to hazardous materials
c) Establishes procedures for the disposal of laboratory waste
d) Describes action to be taken in the event of an accident or injury such as fire, chemical
spill, inoculation accident etc
e) Reporting and monitoring of accidents and incidents
f) Contains emergency telephone contact numbers including the hospital Incident
Commander (see Section 3.8 of Chapter 8 Facilities Management), senior hospital
management and external agencies such as the fire brigade.
6. Major Incident Plan

The laboratory should have a copy of the hospital Major Incident Plan (see Section 3.8.5 of
Chapter 8 Facilities Management). A department specific plan should be in place that
describes the role of the laboratory and laboratory personnel in the event of a major incident.

7. Training of laboratory staff
All laboratory staff should be trained on each of the areas covered in the health and safety
manual and on the hospital Major Incident Plan, including each staff members role in a
major incident.
8. Report of accidents or injuries

A standard report form should be used to record all accidents and incidents including spills of
chemical or bio-hazardous materials, accidental needle stick injury etc. Reports should be
submitted to the Incident Officer (refer to Chapter 12 Quality Management; section 3.1.1).
The Incident Officer should investigate the incident in collaboration with the Laboratory
Manager and take any necessary action.
3.10 Information Management
Complete and thorough information management is key to improving the efficiency and
quality of laboratory services. In addition, an organized information management system
allows for easy coordination between sites and helps reduce costs.
3.10.1 Document management
The following documents should be present in the laboratory:

SOP manual
Quality assurance manual
Health and safety manual
Approved laboratory test request and report forms (Samples are presented in
Appendix B, Chapter 3 Medical Records Management)
Laboratory registration books
Daily test record form
Specimen referral form
Report form (monthly, quarterly)
Stock inventory form
Fridge/Freezer charts
Equipment Maintenance Logs
QA Charts and External QA Records
Error logs
Accident Logs
These documents should be organized through an established system of document and record
handling, which includes:
Document Identification and version control
Master File

o The master file should contain a copy of every version of every document,
thereby serving as an archive of all previous versions of the document,
including the current version.
Master Index
o The master index should have a list of all the documents currently in use.
o It should contain the document name, number, version designation, effective
date, and document location.
o The master index should be changed every time a new version of a document
is released.
o The master index allows staff to ensure that they are using the appropriate
version of a document.
Document Distribution
o The master file and master index should list the locations of all copies of a
particular document.
Document Review
o To ensure that the latest versions of all documents are being used the Quality
Assurance Officer should be responsible for overseeing the entire system,
monitoring version identification, revision control, the master file, the master
index, and the distribution of documents.
o A review should be performed annually in order to ensure that all documents
and procedures are up to date.
3.10.2 Record management
I. Recording and Reporting Results for Individual Patients

a. Clinical service area
1. The Patient comes to the clinical service area (emergency, outpatient and inpatient
case teams etc) and a request form is written.
2. A sample is drawn.
b. Laboratory
1. Sample Reception Area
- The request form and sample are both received
- The quality of the sample is checked
- The data on the request form is checked
- The sample is entered into the logbook and assigned a lab code
2. Testing Lab
- The sample is prepared and tested
- The results are checked and validated
- The results form is completed
- The results form is checked
- The results are archived
c. Clinical service area
Result Data Management
- The results are received and placed in patients file
- The patient file is given to the responsible healthcare provider (e.g.
nurse, physician)

- The responsible healthcare worker tells the results to the patient
Hospitals should aim to install electronic data management systems through which laboratory
tests can be ordered and results reported to the relevant clinical team. Such systems should
be protected by passwords or other security mechanisms to control levels of access. When
electronic systems are installed there should always be a paper back-up in place.
EHNRI is currently experimenting with an electronic nation-wide data network that will
eventually be implemented in every regional laboratory, all hospital laboratories in Addis
Ababa, and all major hospital laboratories across Ethiopia. Any internal systems developed
or installed within hospitals must be compatible with any external systems developed.
II. Use of data for epidemiological purposes

Laboratory management should monitor investigations requested and test results to identify
any notifiable disease or trends that might indicate a disease outbreak. All notifiable diseases
and clusters of selected diseases should be reported to the higher authority (Woreda or
Regional Health Office) using a Standard Form provided by EHNRI and in accordance with
national guidelines. A list of current notifiable diseases is presented in Appendix G. The
Clinical Service Director should also be informed of the occurrence of any notifiable diseases
or potential disease outbreaks to determine if further action is required by the hospital.
3.11 Quality Assurance
Quality Assurance (QA) is a process of actions and tests designed to ensure that specific
standards are adhered to and that laboratory testing is as accurate and efficient as possible.
QA begins when the laboratory test is first requested, and ends at the point where the test
results are returned to the patients folder. When problems are identified, they should be
documented and corrected in an appropriate manner.
Quality assurance should be undertaken for all tests performed by the laboratory. Both
internal and external quality assurance processes can be applied. Internal QA is when the
hospital itself undertakes QA activities. External QA is when an external body (such as the
Regional Laboratory, EHNRI) performs QA testing of the laboratory.
A full time laboratory quality assurance officer should be assigned to oversee all laboratory
QA activities. This includes the QA of all tests undertaken outside the laboratory (for
example PIHCT, PMTCT). The QA Officer will be responsible to oversee all internal QA
activities and to liaise with, facilitate and maintain records of all external QA activities.
3.11.1 External QA
Currently EHNRI co-ordinates external QA activities for CD4, haematology, chemistry, HIV
rapid test, malaria smear and AFB smear microscopy in all public hospital laboratories in
Ethiopia.

EHNRI is also providing Digital PT EQA services covering panels for clinical chemistry,
haematology, serology, microbiology and parasitology tests for assessing the overall
performance of laboratories.
Laboratory EQA programs are implemented in the form of:

Proficiency panel testing
A number of proficiency panels are sent to a laboratory by the regional
laboratories or EHNRI
Analysis tests are performed
Results are compared between labs
Blind re-checking
A random selection of samples are collected from the routine work
load and sent to a laboratory
Any errors detected reflect the reality of everyday performance in that
lab
On-site assessments
In due course external QA processes will be developed for other laboratory tests. Hospitals
must comply with all national external QA requirements.
Additionally hospitals may establish external QA mechanisms with other accredited agencies
or may develop inter-institutional QA processes.
3.11.2 Internal QA
Internal laboratory QA involves the following steps:
Pre-analytical
Ensuring the correct sample is taken from the correct patient
Ensuring sample request forms contain all relevant information
Ensuring samples are transported appropriately
Ensuring samples are stored appropriately prior to analysis
Analytical
Ensuring that requested laboratory tests are performed in a timely manner and
recorded
Ensuring samples are prepared appropriately and tests conducted in accordance with
SOPs
Ensuring test results are accurate (i.e. fall within an appropriate range)
Includes the regular monitoring of test results from the use of controls.
o Control samples, either prepared or purchased, are analyzed with test samples
to evaluate any bias in the test methods precision or results. The control
samples should be treated in the same manner as the test samples.
o All laboratories should establish an official QA procedure which includes:
Identification of the control being used

Instructions for the preparation and handling of controls
Frequency with which controls are run
How the accepted limits for controls are established
New limits must be determined for each new lot/shipment of
control substance
The corrective actions taken when results do not fall within the pre-
determined range
How QA data is to be documented and stored
All control results and remedial actions should be recorded.
QA data has to include a QA number, standard QA answer sheet, test
result, date of testing and name of the laboratory analyst who took the
test.
What should occur if no controls are available
The laboratory is responsible to check each new shipment of reagents, discs, stains,
antisera and identification systems for positive, negative, or graded reactivity when
either being prepared or opened.
The laboratory must test staining materials for intended reactivity each day in order to
ensure accuracy of results.
The laboratory must test fluorescent stains for positive and negative reactivity each
time of use.
o Any abnormal results should be documented, reviewed, and corrected in a
timely manner.
Post-analytical
Ensuring the correct result is received by the referring clinician in a timely manner
Ensuring the correct result is recorded in the patient medical record
Finally, QA processes must ensure that only qualified and trained personnel complete the
above steps and that any problems identified by the QA system result in appropriate action.
All QA processes, results found, and any corrective action should be appropriately
documented.
3.12 Laboratory Staff Management
Key elements of a successful laboratory staff management plan include:

Identification of duties performed and staff needed to perform those duties
Assignment of duties and responsibilities to each staff person (job description)
Creation of a rotation schedule
Implementation of effective retention strategies for laboratory staff
o Routine guidance
o A good working environment
A clean, well-organized laboratory
Provision of all necessary materials and equipment for testing
Ensuring that all of these are in working order

o Diversity of tasks to ensure against a monotonous schedule
This also ensures that laboratory personnel are trained in multiple
different areas
o The availability of formal training and peer-to-peer knowledge sharing
There should be established mechanisms by which all staff who
receive external training can share the information learned with their
colleagues
o Standardized wages/per diems
o A fair and non-biased system for recognition and rewards
o Clear and open communication channels, opportunities to address complaints,
and responsive action
Career paths that allow the opportunities for progression and career advancement,
including further training and research. Priority for career advancement should be
given to those with longer lengths of service and good performance evaluations
Regular staff meetings
Staff performance reviews
In addition to technical staff the laboratory should have sufficient clerical staff for
registration of samples, documentation of lab results and archiving of materials.
Further guidance on the above is presented in Chapter 11 Human Resource Management.

In order to determine if the Operational Standards of Laboratory Services have been met by
Table 1. Laboratory Services Checklist

Yes No
1. There is a list of laboratory tests offered including the price of each test that is
current.
2. Information is provided on the interpretation of test results or tests to staff and

patients alike.
3. There are adequate personnel to provide laboratory services.
4. Facilities and equipment needed to provide laboratory services are in place.
5. Reagents and other supplies needed to provide laboratory services are available.
6. Laboratory services are integrated in the emergency, outpatient and inpatient case
teams
7. There is a central laboratory with functional overview of all hospital laboratories.
8. There is a monitoring system to manage reagent and other consumables supply.
9. There is an SOP for specimen management.
10. There are SOPs for all testing procedures.
11. There is an SOP for testing algorithms.
12. There is an SOP for waste management
13. There are SOPs for maintenance and monitoring (of each item of equipment).
14. There is an SOP for quality assurance.
15. There are policies and procedures or sample collection, transport and disposal.
16. There is a health and safety manual that defines safety procedures.
17. There is a data management system.
18. Quality assurance procedures are developed and implemented.
4.3 Indicators
Table 2. Laboratory Services Indicators

Indicator Formula Frequency Comment
1. Total number of samples received Total number of samples received Quarterly
by laboratory services by laboratory services (inpatient,
outpatient and emergency) during
2. a) Number of samples rejected a) Total number of samples Quarterly
b) Proportion of laboratory rejected by laboratory
samples rejected services (inpatient, outpatient
and emergency) during the
reporting period)
b) Total number of samples
rejected by laboratory
services (inpatient, outpatient
and emergency) Total
number of samples received
(inpatient, outpatient and
emergency) x 100
3. a) Number of samples referred a) Total number of samples Quarterly
into laboratory services from referred into laboratory

another facility services from another facility
b) Proportion of laboratory during the reporting period
samples that were referred by b) Number of samples referred
another facility into laboratory services
total number of laboratory
samples x 100
4. a) Number of samples referred a) Total number of samples Quarterly
by laboratory services to referred to another facility
another facility laboratory services during the
b) Proportion of laboratory reporting period
samples that were referred to b) Number of samples that were
another facility referred to another facility
total number of laboratory
samples x 100
5. Average turnaround time per turnaround time for each Quarterly
laboratory discipline (chemistry, discipline number of tests
haematology, urine, stool etc) conducted in that discipline
6. Test availability [tests x days available] Quarterly
[tests x total number of days in
time period] x 100
7. Average number of tests per Total number of tests conducted Quarterly
laboratory employee per day [number of laboratory staff x
number of working days in
reporting period]
8. Attrition rate laboratory staff Number of laboratory staff who Quarterly HMIS
left during reporting period total
number of laboratory staff at
beginning of reporting period x
100
9. Cumulative proportion of Total number of laboratory staff Quarterly HMIS
laboratory staff who received in who received in service training
service training from beginning of year to end of
reporting period number of staff
at beginning of year x 100
10. Cumulative proportion of Total number of laboratory staff Quarterly
laboratory staff who underwent who underwent performance
performance evaluation evaluation from beginning of year
to end of reporting period
number of laboratory staff at
beginning of year * 100
11. Number of complaints received Total number of complaints Quarterly
against laboratory services against laboratory services
12. a) Number of complaints against a) Total number of complaints Quarterly
laboratory services upheld against the laboratory upheld
b) Proportion of complaints b) Number of complaints upheld
against laboratory services number of complaints
upheld received x 100

Source Documents
1. CDC, WHO, ASCP, USAID, SCMS, Bill & Melinda Gates Foundation, Clinton
Foundation & The Global Fund. (2008, January). Maputo Consensus Report.
Consultation on Technical and Operational Recommendations for Clinical Laboratory
Testing Harmonization and Standardization. Maputo, Mozambique.
2. Ethiopian Health and Nutrition Research Institute. (2008, December). Ethiopian Health
and Nutrition Research Institute Master Plan for the Public Health Laboratory System in
Ethiopia, Second Edition (2009 2013). Addis Ababa, Ethiopia.
3. Ethiopian Health and Nutrition Research Institute. (2008, August). Ethiopia: National
Guidelines for In-Service Laboratory Training. Addis Ababa, Ethiopia.
4. Ethiopian Health and Nutrition Research Institute. (2008). National Health and Safety
Guidelines for Public Health Laboratories in Ethiopia. Addis Ababa, Ethiopia.
5. Ethiopian Health and Nutrition Institute. (2006, September). Public Health Laboratory
System of Ethiopia: National Policy Guidelines (Draft 2) Manual on Communication
Between EHNRI, Regions, and Other Stakeholders Regarding HIV/AIDS Laboratory
System Operations. EHNRI, Dept of Regional Laboratory Support.
6. Ethiopian Health and Nutrition Research Institute. (2008, August). Quality Manual for
EHNRI Laboratories. Addis Ababa, Ethiopia.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Manual

for Public Health Laboratory Services. Addis Ababa, Ethiopia.
8. Federal Democratic Republic of Ethiopia Ministry of Health . (2009, April). National

Notifiable Diseases and Conditions Reporting Rule and General Control Measures for
the Control of Public Health Threats. Ethiopian Public Health Institute. Addis Ababa,
Ethiopia.
9. SNNP, RHB, RHL and JHU-Tsehai. (2007, April). Standard Operating Procedure for
Laboratory Sample Transfer Service at Health Centers. Addis Ababa, Ethiopia.
10. USAID. (2006). Assessment Tool for Laboratory Services (ATLAS).

Appendices
Chapter 5 Laboratory Services

Appendix A The Laboratory Network: Responsibilities of Laboratories at
Different Tier Levels in Ethiopia
A tiered laboratory network is an integrated system of laboratories organized in alignment

with the public health delivery network in a country. There should be four levels of
laboratories in the national network:
1. Level I-Primary: Health post and health center laboratories that primarily serve
outpatients.
2. Level II- Secondary: Laboratories in intermediate referral facilities (e.g., district

hospitals).
3. Level III-Tertiary: Laboratories in a regional referral hospital that may be part of a

regional or provincial health bureau.
4. Level IV-National Reference Laboratory: The national public health reference

laboratory for the country.
The tiered levels of a laboratory system and the testing performed at each level may vary
depending on the population served (e.g., infants, adults), physical infrastructure, electricity,
water, road conditions, and the availability of trained technical personnel in-country.
Level I Laboratories
Level I laboratories would consist of health post or health center laboratories that would
primarily serve outpatients. Essential infrastructure, such as clean water, refrigeration and
electricity, may or may not be available. These laboratories would serve as peripheral
branches of Level II laboratories, which would be the center or hub. Health posts may refer
specimens to health center laboratories. Diploma level staff at Level I laboratories would be
very limited, with usually no more than one trained laboratory assistant or nurse providing
services. The laboratory would offer diagnostic and monitoring services for HIV/AIDS, TB
and malaria. If essential infrastructure were lacking, then the on-site test menu would be
restricted to manual tests. Sites with reliable power and water would perform certain
automated chemistry tests required for antiretroviral therapy (ART) monitoring. Same day
performance and delivery of results must be available while the patient is present for
immediate counseling, treatment and regimen modification.
When required testing exceeds the scope of services available from Level I facilities, the
parent Level II laboratories would provide a range of consultant services, including receipt
of referral specimens and patients.
Level II Laboratories
Level II laboratories would consist of district hospitals or primary hospital laboratories that
perform tests beyond the capabilities of Level I facilities. Health posts may refer specimens
to Health Center Laboratories under Level I. Serving inpatients; these laboratories would
have dedicated laboratory space, formally trained personnel, UPS systems, and a consistent
source of reagent grade water. The laboratory would be staffed by a minimum of three
formally trained technologists or technicians. One staff member who has managerial skills
would serve as the senior or supervisory technologist.
Chapter 5 Laboratory Services Appendix A: Page 1 of 4

The Level II laboratories would have more extensive test menus for diagnoses and treatment.
Consolidating testing at the district level for certain tests provides necessary volumes for
automated equipment platforms. The Level II laboratories would coordinate the services of
Level I laboratories in the district as well as serve as reagent and supply reservoir/back-up
repositories for these laboratories. In addition, Level II laboratories would provide the
following consultant services and support for Level I laboratories:
Managerial oversight of an outreach program of peripheral primary laboratories

(World Health Organization [WHO], 2003a)
Referral laboratory services with a more extensive test menu
On-site quality assessment visits
Assistance with resolving technical problems
Data management support with a strong paper-based laboratory information system

(should be part of a national system of data collection by the Ministry of Health
[MOH])
Development and implementation of quality assurance (QA) activities (including,

but not limited to, QC, QI and EQA/PT)
Periodic review of QC
Information and training for adequate specimen collection
Coordination of EQA
Collection of data for assessment of quality indicators
Approval and annual review of SOPs and policies to ensure alignment with current
practices
Assistance with development of SOPs and safety procedures
Staff development/training, performance management, competency assessment, and

retraining
Coordination of courier/transport services
Assistance with results reporting and record retention
Equipment maintenance and service support including review of maintenance logs
Follow-up on laboratory incident and accident reports
Assessment of safety management practices
Level III Laboratories
Level III laboratories would consist of laboratories in tertiary referral facilities such as
regional or provincial hospitals. These laboratories would perform a complete menu of
testing for HIV/AIDS, TB and malaria as well as testing for many other diseases. Level III
laboratories would complete the more sophisticated tests that Level II laboratories were not
able to perform. These facilities must have dedicated laboratory space that would include a
separate microbiology space, a Biosafety Level 3 designated area, and UPS systems. Reagent
grade water would also be required. Formally trained, diploma level technologists who are
able to meet workload demands would staff Level III laboratories. One technologist who has
managerial skills would serve as the laboratory supervisor. Level III laboratories would act as
laboratory resource groups for the facilities in their regions.
In addition, Level III laboratories would provide the following services:
A more comprehensive test menu than that provided at Level II laboratories
Coordinate laboratory services and information management with other Level III
laboratories
Perform assessments of laboratories in the region; evaluate the QA data from

laboratories in the region
Coordinate surveillance data collection from lower levels in an effort to obtain

country-wide statistics
May collect and report inter-laboratory comparisons and EQA data for the region
Develop training programs and coordination of continuing education
Assure adequate requisition and reporting mechanisms as well as record retention

procedures
Standardize units, methodologies and reference ranges based on national reference

laboratory recommendations
Determine the amount of patient history/clinical presentation required for tests

referred to other levels
Provide logistical and management support to their service areas
Level IV Laboratories (National Reference Laboratories)
Level IV national reference laboratories are recommended to strengthen laboratory capacity

for diseases of public health concern. Ideally, they would provide linkages with clinical trials
and other public health laboratories, forming integrated laboratory networks. Senior program
employees, laboratory management and senior laboratory technologists/scientists would staff
these laboratories. Level IV laboratories would possess the infrastructure, equipment,
information systems, and logistical capabilities of sophisticated reference laboratories. In
some countries lacking a unique national reference laboratory, Level III laboratories may
serve as national reference laboratories.
Level IV National Reference Laboratories would:
Perform all testing performed at the other levels

Perform molecular and esoteric testing beyond the technical capabilities of Level III
laboratories (e.g., nucleic acid assays, HIV drug resistance studies, TB drug
susceptibility studies)
Develop laboratory standards and processes for laboratory accreditation
Develop monitoring and evaluation activities for laboratories
Serve as the national coordinator for HIV, TB, and malaria laboratory programs
Maintain national database of equipment and maintenance in country
Participate in international EQA programs and develop/oversee national EQA

programs
Provide input on national laboratory policy development
Determine what information needs to be supplied with the test result to better
interpret the test
Provide courier and logistics management support for the regions
Develop and implement testing algorithms and reflex protocols for laboratory
utilization
Establish standards for quality management and assist with policy and procedure
development
Provide assistance with reference range validations and development of national

reference ranges specific to equipment/methods used
Coordinate the collection of surveillance data to obtain and monitor country-wide

statistics
Introduce and implement new technologies, appropriate for each level, to reflect
current best practices
Select and evaluate diagnostic tests
Define sensitivity and specificity requirements in order to select methods that would
be evaluated with a method validation plan

Appendix B Sample Preventive Maintenance Log
Equipment Type Inventory Number
Model Serial No.
Preventive maintenance performed:

1.
2.
3.
4.
Spare parts changed and other materials used:

No. Item Quantity
User comments
Date Signature Date
Service engineer comments and required follow-up
Preventive maintenance performed by
Signature Date
Chapter 5 Laboratory Services Appendix B: Page 1 of 1

Appendix C Sample Corrective Maintenance Log
Equipment type Inventory Number
Model Serial No.
Description of equipment failure
Cause of equipment failure (if known)
Part of machine / equipment to be maintained
Corrective action
Time required
Spare parts replaced
1. 2. 3.
4. 5. 6.
Engineer 1 Signature 1 Date
User comments
Date Signature Date
Chapter 5 Laboratory Services Appendix C: Page 1 of 1

Appendix D Sample SOP for Haemoglobin Estimation
Purpose:
The measurement of haemoglobin is useful for the detection of anemia, its severity, and the
patients response to treatment as well as the quality of a donors blood before donation.
Method
Cyanmethemoglobin method. This involves the use of Drabkins solution, which contains
Potassium ferricyanide and potassium cyanide.
Principle
When whole blood is diluted 1 in 201 in Drabkins solution, it is hemolysed and the
hemoglobin is oxidized to methemoglobin by the ferricyanide. The methemoglobin formed
is converted to stable hemiglobicyanide by the cyanide. The absorbance of the HiCN
solution is read at 540 nm and compared with that of a reference HiCN standard solution.
Sample
Whole blood mixed with EDTA or capillary blood.
Reagents
1) Drabkins solution
2) Potassium ferricyanide (hexacyanoferrate III)
3) Potassium cyanide
4) Potassium dihydrogen phosphate
5) Non-ionic detergent (e.g. Nonidet)
6) Distilled or deionized water.
This solution must be stored in an opaque brown glass container or plain glass with silver
foil wrapped around it. It is pale, yellow and clear and should be discarded if turbid.
Equipment
Spectrophotometer with 540nm wavelength
Procedure
1) Measure out 0.02ml of capillary or venous blood well mixed with EDTA and dispense into
4ml of Drabkins solution.
2) Stopper the tube, mix well and let stand for 4 5mins away from sunlight.
3) Using the 540 nm wavelength in the spectrophotometer, zero with Drabkins fluid and read
the absorbance of test solution.
4) Read off the hemoglobin value from the calibration graph already prepared.
Chapter 5 Laboratory Services Appendix D: Page 1 of 2

Note. Daily control tests are necessary to ensure that the Drabkins solution and
spectrophometer are functioning adequately. This can be done using a control hemolysate,
preserved whole blood control or use of HiCN reference standard. Also the Drabkins
solution can be visibly examined for turbidity or measured against a water blank at 540 nm at
which the Drabkins should give a 300 reading.
Calculation
This is done by directly reading off the value from the already prepared graph.
Avoiding errors
a) Ensure that the blood collected is well mixed
b) The Drabkins solution used must be clear and without any signs of turbidity and at
room temperature before use.
c) The volume of blood collected in the pipette must be exactly 0.02ml.
d) Ensure that the cuvette surfaces are clean and dry without finger prints.
e) Avoid using unmatched or scratched cuvettes or chipped pipettes.
f) Do not allow air bubble in the solution.
Normal values
Men 14 16 g/dl
Women 12 14 g/dl
Children 11 13 g/dl
Chapter 5 Laboratory Services Appendix D: Page 2 of 2

Appendix E National SOP Template
Department of Infectious and Non Infectious Diseases

Ethiopian Health and Nutrition Research Institute
Addis Ababa
TITLE: Revision Date:
Document Number: 01 Status:
Section: Documents and Records Page:
Purpose
Abbreviations
Reagents
Materials
Reagents preparation:
Reagents stability and storage:
Supplies
Sample Sample type Amount required Transport and Stability

Storage
Limitations:
Special Safety
Precautions
Use table if necessary

Maintenance Step Action
1
2
3
Prepared by: Authority:
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic version prior to use.
Chapter 5 Laboratory Services Appendix E: Page 1 of 2

Department of Infectious and Non Infectious Diseases
Ethiopian Health and Nutrition Research Institute
Addis Ababa
TITLE: Revision Date:

Document Number: Status:
Section: Documents and Records Page:
Quality Control Level Stability Frequency Preparation

Control (y/n)
Control preparation:
Note:
Step Action
Procedure
Calculation
Result
Interpretation
Expected
Values
Principle
Clinical Utility
Reference
Prepared by: Authority:
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and

should be checked against the electronic version prior to use.
Chapter 5 Laboratory Services Appendix E: Page 2 of 2

Appendix F Sample Laboratory Risk Assessment Form
Laboratory/ Department: ________________________________________________________
Name of Institution: ____________________________________________________________
Inspected by: _______________________________ Month/Year: _____________________
ITEM YES NO
1. LABORATORY SIGNS
a. Entrance to biohazardous areas clearly marked
b. Emergency contacts listed (First-Aid, Fire etc.)
c. Emergency signs posted (Fire exit. Eye wash station etc.)
d. Emergency telephone numbers (Fire, ambulance etc.)
2. SAFETY EQUIPMENT
a. Safety manual present/ read by all
b. Material Safety Data Sheets (MSDS) available
c. Safety Shower
1. Unobstructed and labeled
2. Tested within past one month
d. Eye wash station present
1. Unobstructed and labeled
2. Water changed weekly
e. First-Aid Kit available and labeled
1. Fully stocked
3. PROTECTIVE CLOTHING
a. PPE present (goggles, gloves, coats, face shield etc)
b. Visitor coats and safety glasses available
c. Proper heat resistant/cryogenic gloves available
d. Appropriate personal clothing and footwear
4. HAZARDS
a. Walkways, doors and fire escape routes unobstructed
b. Adequate lighting in all areas
c. Work benches and floors cleaned daily
d. Storage areas accessible, clean and dry
5. SPILL PROCEDURE
a. Spill kits available (biological/chemical/radioactive)
b. Clearly posted with instruction for use
c. Chemical spills documentation present
6. ELECTRICAL
a. Power distribution board clearly labeled
b. Extension cords only for temporary use
Chapter 5 Laboratory Services Appendix F: Page 1 of 5
c. Multiplugs used only on computers
d. Surge protection (UPS) present
e. Electrical cords not frayed
f. Electrical plugs in good condition
g. Earth leakage system in good working condition
7. GAS CYLINDERS
a. Properly and individually chained to the wall
b. Labeled empty or full
c. Labeled as to cylinder contents
d. Safety caps on cylinders not presently in use
e. No smoking & Danger of explosion signs present
8. REFRIGERATORS/FREEZERS
a. No Food or Drink signs posted on doors
9. CHEMICAL STORAGE
a. Chemicals stored by reactive class (flammables, acids etc)
b. Incompatible chemicals physically separated
c. Chemicals properly labeled
d. Chemicals dated on receipt and when opened
e. Inspected monthly for leakage, cracked stoppers, etc.
f. Storage areas labeled with hazard stickers
g. Acids/corrosives/solvents stored in compatible trays
h. No chemicals stored on bench tops/in fume hoods/under sinks
i. Flammable liquid storage cabinet present and labeled
j. List of chemicals available present with MSDS
10. FIRE EQUIPMENT

a. Fire extinguishers present, clearly labeled in working order
b. Fire blankets present and clearly labeled
c. Fire hose present, clearly labeled, and in working order
d. Fire alarm system present
e. All equipment serviced within the last year
11. BIOHAZARD WASTE

a. Appropriate containers available and clearly marked
b. Containers sealed and stored correctly before disposal
c. Regular disposal system in place & records kept
12. BIOHAZARD CABINETS/EXTRACTION HOODS

a. In good working condition
b. Inspected and serviced within last year
c. Smoke test done regularly (minimum once a week)
d. Cleaned daily

13. SAFETY PROCEDURES & DOCUMENTATION
a. In-house training up to date
b. Risk assessment procedures up to date
c. Medical surveillance records up to date
d. Fire drill practiced
e. Safety meetings held regularly & records kept
f. Injury on-duty reports up to date
g. Standard operating procedures up to date
14. AUTOCLAVE
a. In good working condition
b. Inspected and serviced within the last year
c. Pressure tested within the last two years
d. Log book for daily temperature and pressure recording
And quality control indicators present
15. ACCOMODATION
a. Building adequate
b. Receiving office adequate
c. Staff facilities adequate
d. Laboratory space adequate
e. Bench space adequate
f. Other rooms (Phlebotomy, Office, night duty, etc.)
16. LABORATORY EQUIPMENT

a. Clean and in good working order
b. Properly guarded
c. Proper electrical connections
d. Staff adequately trained in use
17. VENTILATION & NOISE

a. Temperature control systems adequate
b. Dust and fumes minimized
c. Noise level acceptable
General observations:___________________________________________________________
_______________________________________________________________
_______________________________________________________________
Action to be taken:_____________________________________________________________
________________________________________________________________
________________________________________________________________
Signed by: _________________________________________________
Laboratory Manager: ________________________________________
Date: _____________________________________________________
Appendix G List of Notifiable Diseases
The FMOH declares the following conditions to be of concern to the public health and
reportable as required by law:
a. Acute Flaccid Paralysis (AFP)/Polio
b. Avian Human Influenza
c. Cholera
d. Dysentery
e. Measles
f. Malaria
g. Meningococcal meningitis
h. Neonatal Tetanus
i. Plague
j. Relapsing fever
k. Rift Valley Fever (RVF)
l. SARS
m. Smallpox
n. Typhoid Fever
o. Typhus
p. Viral Hemorrhagic Fever
q. Yellow Fever
r. Any unusual occurrence of infectious or communicable disease or any unusual or
increased occurrence of any illness that may indicate public health hazard, including any
single case or multiple cases of a newly recognized, emergent or re-emergent disease or
disease-producing agent, including newly identified multi-drug resistant bacteria or a
novel influenza strain such as a pandemic influenza strain.
s. Any outbreak, epidemic, or unusual or increased occurrence of any illness that may
indicate an outbreak or epidemic. This includes suspected or confirmed outbreaks of
foodborne disease, waterborne disease, disease caused by antimicrobial resistant
organisms, any infection that may indicate a bioterrorism event, or of any infection that
may indicated a public health hazard.
In addition to the reportable conditions the FMOH requires the following reportable emergency
illnesses or health conditions to be of concern to the public health and reporting
i. Clusters of Respiratory illness (including upper or lower respiratory tract infections,
difficulty breathing and Adult Respiratory Distress Syndrome);
ii. Clusters of Gastrointestinal illness (including vomiting, diarrhea, abdominal pain, or any
other gastrointestinal distress);
iii. Influenza-like constitutional symptoms and signs;
iv. Clusters Neurologic symptoms or signs indicating the possibility of meningitis,
encephalitis, or unexplained acute encephalopathy or delirium;
v. Cluster of Rash illness;
vi. Haemorrhagic illness;
vii. Botulism-like syndrome;
viii. Sepsis or unexplained shock;
ix. Febrile illness (illness with fever, chills or rigors);
x. Non traumatic coma or sudden death; and
Chapter 5 Laboratory Services Appendix G: Page 1 of 2
Reports should be submitted to the Woreda Health Office, Regional Health Bureau or Federal
Ministry of Health using a Standard Report Form.
Source: National Notifiable Diseases and Conditions Reporting Rule and General Control
Measures for the Control of Public Health Threats. FMOH, Ethiopian Public Health Institute.
April 2009.
Chapter 5 Laboratory Services Appendix G: Page 2 of 2

Nursing Care Standards
Page 1 of 25
Section 2 Operational Standards for Nursing Care 4
3.1 Organisation of and Support for the Nursing Function 5

3.1.1 Job Descriptions
3.1.2 Teamwork
3.1.3 Clinical Supervision and Delegation
3.1.4 Nursing Workforce Plan
3.1.5 Provision of Resources
3.2 Nursing Process 7

3.2.1 Nursing Admission Assessment
3.2.2 Nursing Diagnosis/Problem Identification
3.2.3 Nursing Care Plan
3.2.4 Implementation of Nursing Care Plan
3.2.5 Evaluation of the Nursing Care Plan
3.3 Communication 13
3.3.1 Written Communication
3.3.2 Verbal Communication
3.3.3 Physician Orders
3.4 Medicines Management 17

4.3 Indicators 21
Source Documents 21
Appendices
Appendix A Sample Nursing Admission Assessment Form
Appendix B Sample Nursing Problem Statement List
Appendix C North American Association of Nurses Approved Nursing Diagnoses
Appendix D Sample Nursing Care Plan
Appendix E Sample Nursing Patient Progress Report
Appendix F Sample Patient Caregiver Contract
Chapter 6 Nursing Care Standards Page 2 of 24

Tables
Table 1 Nursing Care Standards Checklist
Table 2 Nursing Care Standards Indicators

Nursing is a profession that entails the humanistic blend of scientific knowledge and the art
of holistic practice to address the basic human need of achieving health and wellness. Nurses
work collaboratively with patients, their families, and other health care professionals to
develop and implement a plan of care. They coordinate the patients care and treatment
provided by a professional health care team, while frequently acting as a patient advocate.
Nursing practice covers assessment, diagnosis, planning, intervention and evaluation in:
a) The promotion and maintenance of health,
b) The management of illness, injury or infirmity, and
c) The restoration of optimal function, or palliative care.
Nursing practice also includes research and education in relation to the above activities.
Good professional nursing care ensures that patients:

receive high quality, safe and effective care delivered by competent nurses,
are treated as a person with respect, honesty and dignity,
are safe and comfortable confident in the care environment, and
are informed and have a say in the care they receive.
This chapter establishes nursing practice standards, which all hospitals should fully
implement to ensure proper nursing care.
Section 2 Operational Standards for Nursing Care

1. The Hospital has established management structures and job descriptions that detail the
roles and responsibilities of each nursing professional, including reporting relationships.
2. The hospital has a nursing workforce plan that addresses nurse staffing requirements and
sets minimum nurse to patient ratios in each service area.
3. The hospital has written policies describing the responsibilities of nurses for the nursing
process including the admission assessment, planning, implementation and evaluation of
nursing care.
4. All admitted patients have a nursing care plan that describes holistic nursing interventions
to address their needs. The plan is regularly reviewed and updated as required.
5. The Hospital has established guidelines for verbal and written communication about
patient care that involves nurses, including verbal orders.
6. The Hospital has standardised procedures for the safe and proper administration of
medications by nurses or designated clinical staff.

3.1 Organization of and Support for the Nursing Function
Nurses play a pivotal role in any hospital. Encompassing the largest workforce in a hospital,
nurses act as direct caregivers who serve a hospital twenty-four hours a day, seven days a
week. This gives nurses a unique perspective on both patient care and hospital operations.
Given the complexities of hospital management and the direct relationship between hospital
operations and patient care, nursing responsibilities have expanded to include a greater
managerial role. This includes assuming an increased role in hospital leadership and
contributing to effective decision-making within the overall hospital structure, as well as
within case teams, wards/units or departments.
3.1.1 Job descriptions
Nurses play many roles within a hospital. They may work as part of inpatient, outpatient or
emergency case teams, they may lead specialist clinics and may provide health education to
patients and the community both within the hospital and at outreach sites. Given the different
roles of nursing staff within a hospital it is essential that each hospital develops clear job
descriptions for the various nursing posts which will guide nurses in their day to day work
and form the basis for performance evaluation/appraisal of the nurse in his/her duties (see
Section 3.8 of Chapter 11 Human Resource Management).
3.1.2 Team work
Nursing practice requires teamwork, an on-going interaction between members of the

multidisciplinary team, the patients, patients relatives and hospital managers. In working
with colleagues and hospital management, the nurse must:
collaborate with the patient and their care givers
work with colleagues in the formulation of overall goals, plans and decisions related
to patients
work with other members of the multidisciplinary team in caring for patients
consult with other health care providers on patient care, as appropriate
make referrals, including provisions for continuity of care, as appropriate
collaborate with other disciplines in teaching, consultation, management, and research
activities as opportunities arise
It is essential that within a case team, ward/unit or department there exists a clear
management structure that delineates the ultimate roles and responsibilities within the given
team and clinical setting, determining who has clear authority over certain decision-making
processes.
3.1.3 Clinical Supervision and Delegation
Clinical supervision is a formal process of professional support and learning which enables
individual practitioners to develop knowledge and competence, assume responsibility for

their own practice and enhance consumer protection and safety of care in complex clinical
situations. In all work settings nurses should receive adequate support and supervision to
ensure that they have the opportunity to gain professional knowledge and expand their skills.
Nurses may delegate nursing procedures to junior nurses/health assistants and/or to student
nurses. Before delegating the nurse must ensure that anyone they delegate to is able to carry
out the instructions, and the nurse must provide adequate supervision to ensure that the
outcome of any delegated task meets required standards.
3.1.4 Nursing Workforce Plan
Shortages of appropriate nursing staff or inappropriate distribution of available staff

adversely affects the quality of patient care. Inappropriate workforce planning has been
shown to increase staff dissatisfaction and nurse turnover, increase patient mortality, increase
hospital-acquired infections, and increase the risk of needle-stick injuries.1
The hospital should establish a nursing workforce plan that:

establishes minimum nurse to patient ratios for each inpatient ward/service, taking the
skill mix of staff into consideration,
identifies priority areas where the nurse count must at all times meet the minimum
ratio requirements (for example intensive care/high dependency units, post operative
recovery, emergency department, labour and delivery etc), and
establishes procedures for transferring nurses across clinical settings, or calling in
extra nurses from home in order to maintain minimum nurse to patient ratios,
especially in the priority areas.
Determining the minimum nurse staffing level is a complex process. Factors to be considered
include:
the severity of the clinical condition of patients,
the intensity of nursing care needed, for example the frequency of nursing
interventions such as observations, medication administration, wound care, stoma
care, bathing etc,
the number of admissions and discharges,
the availability of technology (patient monitors, beepers etc),
the skill mix of staff, and
the availability of and responsibilities of patient care givers.
There should be a minimum of a registered professional nurse in-charge of each ward/unit
who has a diploma or bachelor degree education and relevant knowledge, skills and
experience to manage a ward/unit and the nursing staff therein. The nurse-in charge, together
with hospital management should determine the minimum nurse to patient ratio for the unit.
The ratio should be kept under review and amended as necessary.
1
Needlemann, Jack; Buerhaus, Peter; Mattke, Soeren; Steward, Maureen; Zelevinsky, Katya; Nurse-Staffing Levels and the
Quality of Care in Hospitals, N Engl J Med. 2002; 346 (22): 1715 1722

The nursing workforce plan should also consider the role of nurses in outpatient and
specialist clinics and the nursing contribution to hospital management and governance
structures (such as quality committees, infection prevention committees etc).
3.1.5 Provision of Resources
Hospitals should ensure that nurses have access to and are trained on how to use resources
(including equipment and consumables) correctly and cost-effectively. Nurses are responsible
for forecasting stock-outs of nursing formats and other consumables on the ward, and should
inform the appropriate party of the need for additional resources to prevent stock out.
3.2 Nursing Process

The nursing process is an organized, systematic and holistic approach to nursing through
which nursing care provision is organized to achieve patient centered care. The nursing
process involves Assessment, Diagnosis, Planning, Implementation and Evaluation of care
(ADPIE). This should be done in collaboration with the patient and/or caregiver(s).
In working with patients, the nurse must:

listen to the people in his/her care and respond to their concerns and preferences,
support people in caring for themselves to improve and maintain their health,
recognize and respect the contribution that people make to their own care and
wellbeing,
make arrangements to meet people's language and communication needs, and
share with people, in a way they can understand, the information they want or need to
know about their health.
Characteristics of the Nursing process include the following:

Problem-oriented,
Goal-oriented,
Orderly, planned, systematic,
Open to accepting new information during its application,
Interpersonal and
Permits creativity among nurses and clients.
3.2.1 Nursing Admission Assessment
A nursing assessment collects and documents critical data regarding a patients health,
psychological and social status. This assessment remains accessible to the entire health care
team during the course of a patients stay in order to assist the team in determining proper
patient care and treatment.
In the nursing assessment, the nurse gathers and examines both Subjective and Objective data.

1. Subjective data are what the patient/client actually states (e.g. "I'm tired"). These are
his/her feelings and perceptions.
2. Objective data are concrete, observable information such as:

vital signs
laboratory studies
changes in physical appearance.
NB: SS=Subjective data are Stated.

OO = Objective data are Observed.
Examples:
Subjective data Objective data:
"I feel sick. Blood pressure of 110/70 mmHg.
"I have a stabbing pain in my side." Rash on right arm
"I wish I were home." Walks with a limp
"I feel like nobody likes me." Ate all of his breakfast
Urinated 150 ml clear urine
A) Procedure of Nursing Admission Assessment
1. Patient arrival: Upon the patients arrival to the unit, place him/ her in a bed and
orient him/ her to the given surroundings. Be certain to provide directions to the toilet
and wash facilities, how to call for assistance and any other pertinent information
about the hospital units routine operations.
2. When patient is settled into bed: After settling the patient into bed, take the patients
blood pressure, pulse, temperature and respirations. Record this information on both
the
(1) Admission Assessment (See Appendix A of this Chapter) and (2) Routine
Observation Sheet (See Appendix B item 17; Chapter 3 Medical Records
Management).
3. Complete nursing assessment: Within 24 hours of the patients arrival, the nursing
admission assessment should be completed and filed in the patients medical record.
Data should be collected from the patient as a first priority. If the patient is not able
to participate, then the information should be collected from a family member or a
guardian. The Physician History and Physical Examination Assessment may also be
used as a source of information (see Chapter 3 Medical Records Management,
Appendix B: Item 4).

B) Admission assessment
A nursing admission assessment complements the physician assessment by focusing on the
patients environmental, psychological and social conditions. The nursing assessment gives
particular attention to the patients activities of daily living such as sight, hearing, speech
and language, mobility, independence and self care.
A sample Nursing Admission Assessment Form is presented in Appendix A.
3.2.2 Nursing Diagnosis/ Problem Identification
The purpose of nursing diagnosis is to identify problems or needs that require nursing input.
The nursing diagnosis differs from the physicians diagnosis as illustrated in Box A.
Box A Physician vs Nursing Diagnosis
Physician diagnosis is disease focused, for example:
Ato Yidnek has pain and swelling in all his joints. Diagnostic studies indicate that he has
rheumatoid arthritis. Anti-inflammatory drugs will be prescribed to treat the rheumatoid
arthritis
Nursing diagnosis is holistic, considering both the problem and its effect on the patient and
family, for example:
Ato Yidnek has pain and swelling in all his joints making it difficult to feed and dress himself.
He states that he feels worthless when he cannot even feed himself.
The nursing diagnosis forms the basis for providing nursing care. Factors to consider when
making a nursing diagnosis include:
self care limitations or impaired functioning related to mental and emotional distress
or mental retardation;
deficits in the functioning of significant biological, emotional and cognitive systems;
emotional stress or crisis components of health problems, pain and disability;
self-concept changes, developmental issues, and life process changes;
problems related to emotions such as anxiety, aggression, sadness, loneliness, and
grief;
alterations in thinking, perceiving, symbolising, communicating and decision making;
difficulties in relating to others;
behaviours and mental states that indicate the patient is a danger to self or others or
has a severe disability;
interpersonal, socio/ethnic/cultural, spiritual or environmental circumstances or events
which have an affect on the mental and emotional well being of the patient family or
community; and
symptom management, side effects associated with medications and other aspects of
the treatment regimen.

The nursing diagnosis/diagnoses should be written as a three-part statement(s) which
includes:
1. The problem (P)
2. Its cause or etiology (E)
3. Signs and symptoms (S)
The PES format describes the problem and its etiology, together with data (signs and
symptoms) that validate the chosen diagnosis. To write a diagnostic statement for an actual
nursing diagnosis, link the problem and its cause by using related to then add as
manifested by or as evidenced by and state the major signs and symptoms that validate the
diagnosis.
Example 1:
Problem Etiology (cause) Symptom/Sign
ineffective airway clearance related to incisional pain as manifested by poor cough effort
Example 2
Problem Etiology(cause) Symptom/Sign
impaired communication related to inability to speak Amharic as manifested by inability to

follow instructions in Amharic and verbalisation of requests in English.
Nurses may also note that a patient has certain risk factors that put him/her at risk of a
particular nursing diagnosis. These risk factors and the related potential nursing diagnosis
should be documented so that the nursing care plan can include actions to prevent the
problem. For example: at risk of impaired skin integrity due to patients age, weight,
immobility and confinement to bed. The nursing care plan would then include action to
prevent irritated or broken skin such as regular turning, massage etc).
A sample Nursing Problem Statement List is presented in Appendix B.
Appendix C presents the North American Association of Nurses Approved Nursing

Diagnoses (NANDA).
3.2.3 Nursing Care Plan
The Nursing Care Plan is designed to provide consistency in care and treatment to a patient
by documenting all aspects of the patients nursing care regime. The goal of any plan of care
is to aid the patients return to his/her best state of health, to help him/her maintain
independence and to ensure a smooth transition to home. The Nursing Care Plan should be

based on the nursing assessment and nursing diagnoses, and should be individualized,
tailored to the patients health problems or psychotherapeutic and physiological needs. The
nursing care plan guides each nurse to intervene in a manner congruent with patient needs
and goals and provides outcome criteria for measurement of progress.
In implementing nursing care plans, nurses should use a wide range of interventions designed
to promote, maintain, and restore mental and physical health. Nursing interventions should
be:
based on current knowledge and principles of relevant treatment modalities,
selected based on the needs and/or desires of the patient,
selected according the nurses level of practice, education, and certification,
implemented within the established plan of care,
performed in a safe, ethical and appropriate manner,
adapted to changing patient needs and situations, and
reviewed in order to understand the progress or lack of progress toward identified
goals.
The following aspects of nursing care should be considered when developing and
implementing a nursing care plan:
1. Therapeutic relationship
The development of a therapeutic relationship between the nurse and the patient promotes
patient engagement and motivation for self-care. It contributes to patient cooperation with
nursing and treatment regimes.
2. Counselling
The counselling role is part of nursing practice and reinforces healthy behaviour and
interaction patterns, helps the patient to modify or discontinue unhealthy ones and promotes
the patients personal and social integration.
3. Promoting self-care activities
The nurse needs to ensure that:

the self-care interventions assist the patient in meeting his/her unique needs and
assuming personal responsibility for activities of daily living,
the self-care activities of daily living are appropriate for the patients age,
developmental level, gender, sexual orientation, ethnic/social/cultural background,
and education,
self-care interventions are aimed at maintaining and improving the patients
functional status, and
patients are referred to community/extended family/social support network resources,
as necessary.

4. Psychobiological interventions
Psychobiological interventions provide the foundation for the treatment regimen and nurses
are in an excellent position to support the use of such interventions. Nurses should explore
patients feelings and concerns related to:
illness and diagnosis
prescribed medication
hospitalization
5. Health education
Patients need to understand their medical as well as their nursing diagnosis, assessments,
interventions and their side effects, and they must develop, as much as possible, self-
sufficiency in caring for themselves.
6. Assigning a named nurse
A named nurse is responsible to arrange and co-ordinate all the needed health care services
at all of the necessary points of service, and acts as the main point of contact between the
patient/caregivers and the healthcare team. Assigning a named nurse is particularly helpful
for patients with multiple problems or with a long length of hospital stay.
In writing the nursing care plan, the nurse should think about:
Who is it for? (the patient and other members of nursing team)
What are the short term and long term goals?
How can you determine that you have reached the goals? (measurable)
How will the patient know he/she has achieved the goals? (realistic)
Who is involved in the delivery of the care? (The patient (and family), yourself, the
nursing team, medical staff, multidisciplinary team, labs, investigations, procedures
etc)
How quickly is the problem likely to change?
How soon will you need to re-evaluate the plan?
How many problems are there?
Which order of priority?
The nursing care plan should also:

act as an educational programme related to the patients health problems, treatment,
and self-care activities
indicate responsibilities of the nurse and the patient, and other case team members if
relevant
give direction for patient-care activities that can be delegated by the nurse to other
care providers
provide for appropriate referral and case management to ensure continuity of care
establish a process for discharge planning

employ a systematic strategy to monitor the patients health status and to evaluate and
revise the care plan.
A sample nursing care plan is presented in Appendix D.
3.2.4 Implementation of Nursing Care Plan
The nursing care plan should be presented to the multidisciplinary case team for discussion
and affirmation on the appropriateness of the planned interventions. The nursing care plan
should be implemented by all nurses who care for a particular patient. Hence all nursing staff
should be familiar with the care plan for each patient and should ensure that the activities
described in the nursing care plan are carried out during each nursing shift.
Implementation of the nursing care plan should be documented in a Nursing Patient Progress
Report (Appendix E).
On the Progress Report nurses document the administration of prescribed care and treatment,
the patients response to that care and treatment, the patients emotional adjustment, health
education given to the patient, and any other related patient care information. Nurses chart a
progress report at the end of each shift worked.
3.2.5 Evaluation of the Nursing Care Plan
Nursing care is a dynamic process involving change in the consumers health status over
time, giving rise to the need for new data, different diagnoses, and modifications in the plan
of care.
As new problems arise they should be entered onto the Problem Index List and related goals
and activities to address the problem should be entered onto the Nursing Care Plan.
Similarly, if a problem resolves this should be recorded on the Problem Index List to indicate
that goals and activities related to that particular problem are no longer necessary.
The nursing care plan should be regularly reviewed and modified as necessary. The following
questions should be considered:
1. Have the goals of the nursing care plan been achieved?
2. If not, why not? Were the goals realistic? Was the patient committed to the goals?
Was there enough time to achieve the goals? Did other problems arise that impeded
progress? Were interventions consistently performed as prescribed?
3. Have any new problems developed that have not been addressed?
4. Could more have been achieved than originally hoped for? Should new goals be set?
3.3 Communication
Every hospital should establish clear guidelines for both verbal and written forms of
communication that involve nurses.

a) Written communication: This includes the written documentation of all findings, progress,
care and treatment provided to the patient by the medical team, including the nurses. A
written record permits immediate access to all information related to the patients care
and facilitates the exchange of information between all members of the case team.
b) Verbal communication: For nurses, this entails the act of reporting and conversing with
other members of the health care team regarding the patients progress and status.
3.3.1 Written Communication: Medical Record Documentation
The following items are used by nurses to document a patients course of treatment. It is the
nurses responsibility to ensure that a patients medical record is complete, containing all the
necessary forms in the proper sequence. The forms are intended to guide the entire medical
team and to become a permanent record maintained in the patients medical record.
1) Clinical forms: Nurses must record patient data and findings on clinical forms that
include:
Routine Observation Sheet
Intravenous Fluid Administration Record,
Fluid Balance Chart
Medication Administration Record
Samples of the above forms are presented in Chapter 3: Medical Records Management,
Appendix B.
It is the nurses responsibility to chart on the appropriate form and to make sure that the
information is timely and accurate.
2) Nursing Process Forms: As described in Section3.2 above, nurses should record all
steps in the nursing process on the appropriate forms:
Nursing Admission Assessment Form (Appendix A)
Nursing Problem Statement List (Appendix B)
Nursing Care Plan (Appendix D)
Nursing Patient Progress Report (Appendix E)
3.3.2 Verbal Communication
1) Reporting to Physicians: Whenever a patients status changes, the physician should

be informed. The status should be reported in an objective manner, allowing for the
physicians recommendation(s). Any physicians order should then be documented in
the medical record by the nurse as a verbal order. Verbal orders from a physician to a
nurse must be told to 2 nurses simultaneously in order to ensure that instructions are
clearly understood and verifiable. The transcribed order should be signed by the
physician within 24 hours.

2) Nurse-to-Nurse Report: During a shift change, the off-going nurse should verbally
report to the on-coming nurse concerning the status of each patient using a standard
format. The report consists of a general synopsis of the patient, any significant events
during the shift, as well as a progress report of the work completed. Updates should
be provided on IV administration, tests done or pending, abnormal laboratory
findings, and general patient progress.
Follow the format below for performing nurse-to-nurse shift report.

Patient name
Patient age
Reason for Seeking Care/Chief complaint
Patient diagnosis: present all current diagnoses
Current IVs
Tests completed or pending
Abnormal lab findings: do not report normal findings
Events during the shift: synopsis of what occurred during the shift
Patient progress: description of patients response to any treatment or
events that occurred during the nurses shift, including the patients
progression towards discharge
3) Nurse to Junior Nurse/Health Assistant/Student Report: At the start of each shift, the
nurse is responsible for reporting to the junior nurse/health assistant/student regarding
patient(s) under his/her care. Specific care information related to bathing, ambulating,
eating, toileting, and other similar concerns should be discussed. A written checklist
of tasks to be completed should be given to the junior nurse/health assistant/student.
Use the following format for performing a nurse to junior nurse/health assistant/student
report. It is important that the assigned tasks are specific to ensure that the junior
nurse/health assistant/student is able to accomplish them during their shift.
a) Vital Signs: Describe the frequency required for assessing a patients vital signs.
Is it necessary to assess them:
Once a shift,
Twice a shift,
Every hour, or
Other unique needs.
b) Bathing: Describe the level of assistance the patient requires for bathing and
changing linens. Is the level:
Complete assistance during both bath and bed linen changing,
Required assistance when bringing bathing materials to the patient who must
remain in the bed while linens are changed,

Required assistance when bringing bathing materials to the patient who is
capable of getting out of the bed while the linens are changed, or
No assistance necessary because the patient is independent during bathing and
the patient is capable of getting out of bed while the linens are changed.
c) Activity: Describe the activity level of the patient as follows:

Bed rest: how often does the patient need to be turned?
Out of bed (OOB) walking: is the patient OOB at will or does he/she need
assistance? If assistance is required, please inform the aide of the frequency of
OOB.
Out of bed (OOB) to chair: what is the level of assistance required to get OOB
to a chair? If assistance is required, please inform the aide of the frequency
that this should occur and for how long.
d) Toileting: Describe the level and type of assistance the patient requires to perform
the following (if applicable):
Out of bed to the bathroom,
Offer the bedpan to the patient every ________ (amount of time),
Patient uses the urinal,
Patient has a Foley catheter, and/or
All patient output should be recorded and communicated.
e) Diet: Describe the patients type of diet and the assistance they require:
Set up the food only,
Set up and cut the food,
Feed the patient, and/or
Record all input.
f) Safety: Describe how often the aide needs to make rounds on the patient.
4) Patient Education: It is important to educate the patient, his/her spouse/partner, and

his/her family about the illness and course of treatment being provided as a preventative
and/or curative measure. It informs and empowers the patient, thus improving his/her
ability to achieve a higher level of wellness and ability to manage specific needs.
Efforts to educate the patient should be realistic, relevant and provide time for patient
practice and opportunity to seek clarification.
Patient education should also incorporate family members and other caregivers who often
play strong role in facilitating patient care in coordination with medical staff. One suggestion
to improve the family and staff relationship is through the use of a Patient Caregiver
Contract, whereby the relationship is formalized between families/caregivers and medical
staff (A sample Patient Caregiver Contract is presented in Appendix F). This allows patient
families to act as aides and provide certain services (feeding, bathing, ambulating, bringing

fresh sheets and food, etc.) within guidelines that are acceptable to medical staff. Such a
formalized process can greatly improve the patients quality of care. It is also important to
ensure that such a contract is fully understood by both the patient and caregiver prior to
signing.
3.3.3 Physician Orders
Physicians provide both written and verbal forms of communication in order to direct a
patients care. It is the nurses responsibility to ensure that a physicians orders and plan for a
patients care are put into action.
Physicians orders should be recorded by the physician on a Physician Order Sheet (See
Chapter 3 Medical Records Management, Appendix B, item 8). When the order is carried out
this should be documented on the order sheet, including the date and time that the order was
carried out, and the signature of the person confirming that the order has been completed.
All physician orders, even verbal orders, must be documented.
Any/all verbal orders from a physician must be given to two (2) nurses simultaneously in
order to ensure verbal instructions are clearly understood and verifiable. The physician
should be clear about which nurse (of the two) is to implement his/her verbal orders. Once
received, the order is immediately transcribed into the Physician Order Sheet by the
implementing nurse. The nurse who is writing the order completes the transcription by
writing verbal order given by (the name of the physician)/the nurses signature. All verbal
orders are to be reviewed and co-signed by the physician within twenty-four (24) hours.
3.4 Medicines Management

It is the nurses responsibility to safely administer the medications to a patient as ordered by
the physician. Nurses should be aware of the desired outcome, dosage, preparation and side
effects of each prescribed medication.
Procedure
1) Physician Order: A physicians order is required for the administration of all
medications. There are several types of orders:
Standing order: To be carried out as specified until it is canceled by
another order (including PRN orders).
Single order: To be carried out only once, as directed.
Stat order: To be carried out immediately.
Verbal order: An order that has been communicated through the phone or
verbally. These orders are reserved for times when the physician is unable
to reach the patients medical record. Verbal orders can only be taken by a
nurse, who must immediately transcribe the verbal order into the Physician

Order Sheet. Verbal orders from a physician to a nurse must be told to 2
nurses simultaneously in order to ensure that instructions are clearly
understood and verifiable. All verbal orders must be co-signed by the
physician within 24 hours.
Physician orders need to include the following information when they are transcribed into the
Physician Order Sheet in order to be considered complete. Orders are not to be carried out
unless all of these elements are present. If an element is missing, the physician who issued
the order should be called to complete the order.
Date and time: When the order was written.
Full name of the medication: Either the chemical or generic name can be
used without abbreviations.
Dosage: Specify the amount of medicine to be given. Abbreviations are
discouraged.
Concentration: If the medication is to be diluted in IV fluid, the amount
and type of diluent/s ordered.
Duration: If the medication is to be given over a period of time, such as
IV administrations, the duration of the infusion ordered should be recorded
by the physician. Nurses should then translate and document the duration
of infusion into number of (micro) drops per minute.
Time and frequency: The time of day and how often a medication is to be
given, as ordered by the physician. The nurse who transcribes the order
will identify the specific time that the medication is to be given by
following a standardized schedule.
Route: For medications that can be given in several ways, the route of
administration needs to be clearly written.
Physician Signature: Is to be clearly written immediately following the
order.
2) Transcribing the Order: Medication orders are transcribed by the nurse from the
physician order sheet to the Medication Administration Record The nurse will
document that the order has been transcribed by putting a signature next to the
order.
The nurse is responsible for questioning the physician regarding any medication order or
element of an order that is in his/her judgment an error. The perceived error may be in the
drug ordered, dosage, route, time and/or frequency to be given.
3) Administration of Medications: The following steps should be followed by the

nurse when administering medications. Two processes are outlined which differ
based on whether the medication is stored at the patients bedside or in a central
cabinet. There are three distinct steps to administering medications: preparation,
administration and documentation. Each step requires safety checks to ensure that
the right drug is given to the right patient.

Medications at the Bedside
The nurse brings the Medication Administration Record to the patients
bedside.
The nurse checks the prescribed medication from the patients bedside to
the Medication Administration Record three times to ensure that it is the
proper medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
Medications in a Cabinet
The nurse brings the Medication Administration Record to the cabinet.
The nurse checks the prescribed medication from the cabinet to
Medication Administration Record three times to ensure that it is the
proper medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
Medications should be prepared one patient at a time. Each medication for
a single patient should be organized into a group for that individual
patient, prior to dispensing medications for another patient.
When medications are to be given to more than one patient, the medication
cup/container should be clearly marked with each bed number.
Before administering medication, the nurse should cross-reference the bed
number (on cup/container) with the bed number and name listed on the
Medication Administration Record.
4) Administration:
The nurse who prepares the medication should always be the nurse who
administers the medication.
During administration, medications should never be out of the sight of the
administering nurse.
It is the nurses responsibility to confirm that they are giving the correct
drug to the correct patient. When the nurse arrives at the patients bedside,
the nurse must confirm using two methods that the patient is properly
identified.
Check the name on the Medication Administration Record with the
patients posted name.
Ask the patient to repeat their name.
Once the correct patient is verified, administer the medication. If it is an
oral medication do not leave it for the patient to take later. The nurse
needs to observe all medications being taken to assure that the medication
has been adequately administered.

If a patient refuses a medication, the physician should be notified and it
should be clearly documented in the medical record.
5) Documentation: Immediately following the administration of a patients

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

In order to determine if the Operational Standards of Nursing care standards have been met
by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
and Reporting.

Table 1. Nursing Care Standards Checklist

Yes No
1. There is a system for coordinating and managing nursing staff.
2. Job descriptions for nursing positions have been developed.
3. A nursing workforce plan has been developed.
4. The hospitals nurse staff requirements are defined in the nursing
workforce plan.
5. Nurse to patient ratios for each service area are defined in the nursing
workforce plan.
6. There is a written policy for the nursing process.
7. Nurses complete nursing admission assessments for inpatients.
8. Nurses complete a nursing care plan for inpatients.
9. There are written guidelines for nursing verbal and written communication.
10. There are written guidelines for medication administration.

4.3 Indicators
Table 2. Nursing Care Standards Indicators

1. Number of pressure Quarterly HMIS
sores/number of
Pressure sore incident rate admissions*100
2. Total number of nurses Quarterly HMIS
leaving/total number of nurses
at beginning of reporting period
Attrition rate of nursing staff * 100
3. a) Cumulative number of a) Total number of nursing staff Quarterly HMIS
nursing staff who received with in-service training from the
in service training beginning of year to the end of
reporting period
b) % of staff who received in
service training b) Cumulative number of staff
who received training/ Total
number of nurses at beginning
of year * 100
4. In patient satisfaction survey : Total number of inpatients who Biannual Survey tool
% of respondents who answer respond always or usually to presented in
always or usually to the the questions listed/ Total Appendix F
following questions: number of inpatients of Chapter
a) During this health respondents*100 12 Quality
facility stay, how often Manageme
did nurses treat you nt
with courtesy and
respect?
b) During this health
facility stay, how often
did nurses listen
carefully to you?
c) During this health
facility stay, how often
did nurses explain
things in a way you
could understand?
Source Documents
1. Aiken, LH et al (2002). Hospital Nurse Staffing and patient Mortality, Nurse Burnout and
Job Dissatisfaction. Journal of American Medical Administration. 288(16):1987-93.
2. Arnold, E. and Boggs, K. (1999). Interpersonal relationships: Professional

communication skills for nurses. 3rd Edition. Philadelphia: W.W. Saunders.
3. Audit Commission. (2001). Acute Hospital Portfolio- Ward staffing. London: Audit
Commission.
4. Buchan, J. (2004). A Certain Ratio? Minimum Staffing Ratios in Nursing. London: Royal
College of Nurses.

5. Clarke, Sean P.; Sloane, Douglas M.; Aiken, Linda H.; Effects of Hospital Staffing and
Organizational Climate on Needlestick Injuries to Nurses. American Journal of Public
Health, 2002; 92 (7): 1115 1119
6. College of Registered Nurses of Nova Scotia. (2004). Standards of Nursing Practice.

Halifax: College of Registered Nurses of Nova Scotia.
7. Cook, D, and Sportsman, S. (2005). DSHS Nursing Standards of Care and Nursing
Standards of Professional Performance.: Texas Department of State Health Services.
8. Department of Health. (1993). A Vision for the Future. London: HMSO.
9. Department of Health. (1997). The New NHS: Modern, Dependable. London: The
Stationery Office.
10. Department of Health. (2000). National Minimum Standards. London: The Stationery
Office.
11. Department of Health. (2001). Good practice in consent implementation guide: consent to
examination or treatment. Retrieved from:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_4005762 on 02/03/09.
12. Dougherty, L, and Lister, S. (Eds) (2008) The Royal Marsden Hospital Manual of
Clinical Nursing Procedures. 7th Edition. Oxford (UK): Wiley-Blackwell.
13. Department of Health. (2003). Building on the best: choice, responsiveness and equality
in the NHS. London: The Stationery Office.
14. FEPI (2009) Code of Ethics and Conduct for European Nursing: Protecting the public and
ensuring patient safety. European Council of Nursing Regulators. Retrieved from:
http://www.fepi.org/userfiles/file/FEPI_Code_of_Ethics_and_Conducts_170908.pdf. on
02/03/09.
15. International Council of Nurses. (2009). Nursing Matters. Nursing:Patient Ratios
16. Heaven, C.M and Maguire, P. (1996). Training hospice nurses to elicit patient concerns.
Journal of Advanced Nursing. 23, 280-286.
17. Kennedy, I. (2001). Learning from Bristol: the Report of the Public Inquiry into
childrens heart surgery at the Bristol Royal Infirmary. London: The Stationery Office.
18. Needlemann, J., Buerhaus, P., Mattke, S., Steward, M., Zelevinsky, K. (2002). Nurse-
Staffing Levels and the Quality of Care in Hospitals, N Engl J Med. 2002; 346 (22): 1715
1722.

19. Nursing and Midwifery Council. (2004). Standards of proficiency for pre-registration
nursing education: Protecting the public through professional standards. London:
Nursing and Midwifery Council:
20. Nursing and Midwifery Council. (2008). The Code: Standards of conduct, performance
and ethics for nurses and midwives. http://www.nmc-
uk.org/aArticle.aspx?ArticleID=3056
21. Roper, W., Logan, W., and Tierney, A. (1990). The elements of nursing based on a model
of living. 3rd edition. London: Churchill Livingston.
22. Royal College of Nursing. (2003.) Clinical Supervision in the workplace: Guidance for
occupational health nurses. London: Royal College of Nurses.
23. Royal College of Nursing. (2008).Dignity: at the heart of everything we do campaign.

London: Royal College of Nurses.
24. Royal College of Nursing. (2003). Guidance for nurse staffing in critical care. London:
Royal College of Nurses.
25. Royal College of Nursing. (2006). Policy Guidance 15/2006: Setting Appropriate Ward
Nurse Staffing Levels in NHS Acute Trusts. London: Royal College of Nurses.
26. Rush, S., Fergy, S. and Wells, D. (1996). Professional Development. Care Planning:
Knowledge for practice. Nursing Times. 92(38)1-4.
27. Scally, G. and Donaldson, LJ, (1998). Clinical governance and the drive for quality
improvement in the new NHS in England. British Medical Journal. 317(7150) 4 July
pp.61-65.
28. World Health Organization. (2003), Nursing and Midwifery Workforce Management.
Analysis of Country Assessments. SEARO Technical Publication No.26. New Delhi:
WHO Regional Office for Southeast Asia
http://www.searo.who.int/LinkFiles/Publications_Analysis_Cntry_Asses_11Sep.pdf
29. World Health Organization Release. (15 August 2003).

http://www.who.int/mediacentre/releases/pr80/en/print.htm
30. Parish, C. (2002). Minimum effort: The introduction of minimum nurse-to-patient ratios
can have maximum effect on recruitment and morale, in nursing standard, Vol. 16, No 42
FURTHER READING
1. Bowman, G.S., Thompson, D., and Suttin, T. (1983). Nurses attitudes towards the
nursing process. Journal of Advanced Nursing. 8(2) p.125129.

2. Braden, S. (1998). Evaluating nursing interventions: A theory driven approach. London:
Sage Publications.
3. Cohen, E., Gesta, T. (2001). Nursing case management from essential to advanced
practice application. 3rd edition. USA: Mosby.
4. Faulkner, A. (2000). Nursing: The reflective approach to adult practice. 2nd Edition.
Cheltenham: Bailliere Tindall.
5. Joint Commission International. (2002). Joint Commission International Accreditation

Standards for Hospitals. Second Edition. Illinois: Joint Commission on Accreditation of
Healthcare Organizations.
6. New Jersey Department of Health and Senior Services. (2005). Hospital Licensing
Standards. N.J.A.C. Title 8: Chapter 43 G. Trenton, New Jersey: NJDOHSS.

Appendices
Chapter 6 Nursing Care Standards

Appendix A Sample Nursing Admission Assessment Form
Nursing Admission Assessment Form

Please Complete or Affix Label HOSPITAL
Name: Fathers Name:
Address: City: Sub city:
Kebele: House no. Ward: _____________________________________
Bed No.: ___________________________________
MRN: Age:
Tel. No.:
Personal Details
Male Female Nationality: Ethnic group:
Mr / Mrs / Miss / Ms / Other Language:
Marital Status: Religion:
Disabled: Yes No Occupation:
Please detail any existing disability that the patient may have, Previous Occupation if Retired:
including learning disability and incorporate into nursing care
and treatment plan.
Next of kin
1. Name: 2. Name:
Relationship: Relationship:
Address: Tel No.: Address: Tel No.:
City: Sub city: City: Sub city:
Kebele: House no. Kebele: House no.
Practitioners
Admission Date: Time:
Admitted / Transferred from:
Consultant/Case Team Leader:

Named Nurse:
Reason for Admission / Referral:
Presenting Symptoms:
Medical Diagnosis / Surgical Procedure:
Relevant Medical History
Please detail any existing disability that the patient may have, include learning disability and incorporate into Nursing Care and
Treatment Plan.
Chapter 6 Nursing Care Standards Appendix A: Page 1 of 7

Perception
Patients understanding of the reason of admission:
Family or next of kins understanding of the reason for admission:
Medication Patient is Currently Taking (incl. over the count)

Drug name Dose Freq. Drug name Dose Freq.
Known Allergies
Special diet required:

Yes No
NAME OF ACCEPTING/RECEIVING NURSE: _________________ DATE: ___________ TIME: ___________
SIGNATURE AND DESIGNATION OF ADMITTING NURSE: _________________________________________
DATE: ___________ TIME: ___________
Countersign if applicable:
Investigation / Procedures at the Admission
Date Investigations / Procedures Specimens Signature Results

Environmental & Social Assessment
Home Environment
Owner Number of occupants: Adults: _________________
Tenant Children (<= 15 yrs): ______
No Permanent Home
Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Toilet Facilities Electrical Supply
Pit latrine (Single household) Flush toilet Does the household have mains electricity? Yes No
Pit latrine (Shared/Communal) None of above Does the household have solar power? Yes No
Water Supply
Household piped water
Communal/Shared piped water Distance from household: _____________ km
Collected rainwater to household
Collected rainwater communal/shared source Distance from household: _____________ km
Household well
Communal/Shared well Distance from household: _____________ km
River source Distance from household: _____________ km
Other _______________________________________________________________________
Discharge Arrangements and Other Social Details
Lives alone? Yes No Comments: _________________________________________

Employee? Yes No Comments: _________________________________________
Self employee? Yes No Comments: _________________________________________
Dependents? Yes No Comments: ________________________________________
Is patient independent? Yes No If no, please state who helps with the following &
the number of times per week:
Cooking: __________ Washing / Dressing: ___________
Shopping: _________ Cleaning: ____________________
Other: ____________ Other: ______________________
Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Patient Assessment for Activity of Living
1. Maintaining a safe environment
Orientated to Person: Yes No
Orientated to Place: Yes No History of Confusion: Yes No Epilepsy: Yes No
Orientated to Time: Yes No Glasgow Coma Scale ______________ Dizziness: Yes No
Appears Rational: Yes No History of Falls: Yes No
Additional Information:
2. Breathing
Respiratory aids used: Yes No Chronic Obstructive Pulmonary Disease: Yes No

At risk of obstruction: Yes No Breathless: at rest: Yes No
Asthma: Yes No on exertion: Yes No
Dry cough: Yes No orthopnea: Yes No
Productive cough: Yes No
Current smoker: Yes No Advice given to stop: Yes No

Ex-smoker: if yes, stop date: ______ Yes No Date advice given: ______________
Comments:
3. Circulation
Pulse regular: Yes No Comments: _________________________________________________
Oedema present: Yes No Comments: _________________________________________________
Pedal pulses present: Left Right (Tick if present)
Blood pressure at time of
admission: _________________________
Hypo/Hypertensive: Yes No
Other comments:

Communication 4. Sight
Blind: Yes No L R
Partially sighted: Yes No
Wears glasses Yes No
Wears contact lenses: Yes No Glasses/lenses with patient: Yes No
Has cataracts Yes No L R
Other comments:
Communication 5. Hearing
Hearing impairment: Yes No Profoundly deaf: Yes No L R
Hearing aid with patient: L R Lip-reads: Yes No
Hearing aid in working order: Yes No Sign language: Yes No
L R
If no, action taken:
Yes No
Other comments:
Communication 6. Speech and language

Native Language: _____________ Laryngectomy: Yes No
Speaks Amharic: Yes No Tracheostomy: Yes No
Understands Amharic: Yes No Communication aids given: Yes No
Other comments (special needs e.g. : dyslexia & learning difficulties)::
7. Eating and drinking

Diet Required:
Nil by mouth: Yes No
Difficulty swallowing: Yes No P.E.G/N.G. feed: Yes No
Difficulty chewing: Yes No Fluids only: Yes No
Wears dentures: Yes No Pureed diet: Yes No
Dentures with patient: Yes No Soft diet: Yes No
Vegetarian/vegan: Yes No
Consumes alcohol: Yes No Halal (Muslim): Yes No
How many units per day: _________________ Fasting: Yes No
Diabetic diet: Yes No
1. Ask the patient: Have you lost weight recently? Yes No
Salt free: Yes No
2. Have you had any change in appetite or food intake? Yes No
3. Is a special diet required? Yes No How controlled: ____________
Other comments: Supplements: Yes No
Please specify: _____________

8. Personal Hygiene and Dressing
Condition of Skin:
Condition of Hair/Scalp:
Condition of Mouth:
Other comments:
9. Elimination-Urine 10. Elimination-Bowels

Usual habits:
Urine elimination problem?: Yes No
Colostomy present?: Yes No
Catheter: Yes No Diarrhea: Yes No
Type: Size: Frequency:
Date of insertion:
Dysuria: Frequency: Constipation: Yes No
Urgency: Urinalysis: Incontinence: Yes No
Stress incontinence: Yes No
How is incontinence being managed?
11. Mobility
Is the patient able to walk on his/her own? Yes No If No, restricted by:
Aids used: Yes No If yes, specify Supervision required:

Comments:
12. Psychological Care

Altered body image: Yes No If No, restricted by:
Anxiety and Emotional requirements:
Other:

13. Spiritual/Dying
Religion: see Personal Details Anxieties/Issues:
Would patient like to see:
Cultural/Religious Representative: Yes No
Please state if yes:
14. Sleeping
Usual pattern:
Sleep interrupted by: Required night sedation:

Pain:
Anxiety:
Nocturia: No. of pillows used:
Other: Able to lie flat: Yes No
15. Cardiovascular Risk Factors
Risk Factor: Advice given:
Smoking: Yes No Smoking cessation
Overweight: Yes No Low fat diet, reduce alcohol intake, and increase physical
activity.
Hypertension: B/P > 140/90 Yes No Weight loss, reduce salt intake, stress management, and stop
smoking.
Importance of good B/P control and compliance with
medication.
Diabetes: Yes No Importance of good diabetic control, regular attendance at
clinic.
Raised Cholesterol: Yes No Diet and exercise.
Serum cholesterol level: ________ Date: _________ Low cholesterol diet, use of statins.
Comments: Comments:
Name of Assessing Nurse: ____________________________________ Date: ___________ Time: _____________

Signature and Designation of Assessing Nurse: ___________________ Date: ___________ Time: _____________
Countersign if applicable: ____________________________________

Appendix B Sample Nursing Problem Index List
Nursing Problem Index List

Name: Fathers Name:
Ward: _____________________________________
Kebele: House no. Bed No.: ___________________________________
MRN: Age:
Tel. No.:
Date Date
Signature
Identified Resolved Signature and
No Problem and
and and Designation
Designation
Time Time
Chapter 6 Nursing Care Standards Appendix B: Page 1 of 2

Date Date
Signature
Identified Resolved Signature and
No Problem and
and and Designation
Designation
Time Time
Chapter 6 Nursing Care Standards Appendix B: Page 2 of 2

Appendix C - 20092011 North American Association of Nurses Approved Nursing
Diagnoses
Activity/Rest Constipation, perceived Allergy Response, risk for latex

Activity Intolerance Constipation, risk for Body Temperature, risk for imbalanced
Activity Intolerance, Risk for Diarrhea Contamination
Activity Planning, ineffective Motility, dysfunctional gastrointestinal Contamination, risk for
Disuse Syndrome, risk for Motility, risk for dysfunctional gastrointestinal Death Syndrome, risk for sudden infant
Diversional Activity, Deficient Urinary Elimination, impaired Environmental Interpretation Syndrome, impaired
Fatigue Urinary Elimination, readiness for enhanced Falls, risk for
Insomnia Urinary Incontinence, functional Health Maintenance, ineffective
Lifestyle, sedentary Urinary Incontinence, overflow Home Maintenance, impaired
Mobility: Bed, Impaired Urinary Incontinence, reflex Hyperthermia
Mobility: Wheelchair, Impaired Urinary Incontinence, risk for urge Hypotherma
Sleep, Readiness for Enhanced Urinary Incontinence, stress Immunization Status, readiness for enhanced
Sleep Deprivation [Urinary Incontinence, total-retired 2009] Infection, risk for
Sleep Pattern Disturbed Urinary Incontinence, urge Injury, risk for
Transfer Ability, Impaired Urinary Retention [acute/chronic] Injury, risk for perioperative positioning
Jaundice, neonatal
Circulation Food/Fluid Maternal/Fetal Dyad, risk for disturbed
Autonomic Dysreflexia Breastfeeding, effective Mobility, impaired physical
Autonomic Dysreflexia, risk for Breastfeeding, ineffective Poisoning, risk for
Bleeding, risk for Breastfeeding, interrupted Protection, ineffective
Cardiac Output, decreased Dentition, impaired Self-Mutilation
Intracranial Adaptive Capacity, decreased Electrolyte Imbalance, risk for Self-Mutilation, risk for
Perfusion, ineffective peripheral tissue Failure to Thrive, adult Skin Integrity, impaired
Perfusion, risk for decreased cardiac tissue Feeding Pattern, ineffective infant Skin Integrity, risk for impaired
Perfusion, risk for ineffective cerebral tissue Fluid Balance, readiness for enhanced Suffocation, risk for
Perfusion, risk for ineffective gastrointestinal [Fluid Volume, deficient hyper/hypotonic] Suicide, risk for
Perfusion, risk for ineffective renal Fluid Volume, deficient [isotonic] Surgical Recovery, delayed
Shock, risk for Fluid Volume, excess Thermoregulation, ineffective
Fluid Volume, risk for deficient Tissue Integrity, impaired
Ego Integrity Fluid Volume, risk for imbalanced Trauma, risk for
Anxiety [specify level] Glucose, risk for unstable blood Trauma, risk for vascular
Anxiety, death Liver Function, risk for impaired Violence, [actual/] risk for other-directed
Behaviour, risk-prone health Nausea Violence, [actual/] risk for self-directed
Body image, disturbed Nutrition: less than body requirements, imbalanced Wandering [specify sporadic or continual]
Conflict, decisional (specify) Nutrition: more than body requirements, imbalanced
Coping, defensive Nutrition: risk for more than body requirements, Sexuality
Coping, ineffective imbalanced Child-bearing Process, readiness for enhanced
Coping, readiness for enhanced Nutrition, readiness for enhanced Sexual Dysfunction
Decision making, readiness for enhanced Oral Mucous Membrane, impaired Sexuality Pattern, ineffective
Denial, ineffective Swallowing, impaired
Dignity, risk for compromised human Social Interaction
Distress, moral Hygiene Attachment, risk for impaired
Energy field, disturbed Self-care, readiness for enhanced Caregiver Role Strain
Fear Self-care Deficit, bathing Caregiver Role Strain, risk for
Grieving Self-care Deficit, dressing Communication, impaired verbal
Grieving, complicated Self-care Deficit, feeding Communication, readiness for enhanced
Grieving, risk for complicated Self-care Deficit, toileting Conflict, parental role
Hope, readiness for enhanced Neglect, self Coping, ineffective community
Hopelessness Coping, readiness for enhanced community
Identity, disturbed personal Neurosensory Coping, compromised family
Post-Trauma Syndrome Confusion, acute Coping, disabled family
Post-Trauma Syndrome, risk for Confusion, risk for acute Coping, readiness for enhanced family
Power, readiness for enhanced Confusion, chronic Family Processes, dysfunctional
Powerlessness Infant Behavior, disorganized Family Processes, interrupted
Powerlessness, risk for Infant Behavior, readiness for enhanced organized Family Processes, readiness for enhanced
Rape-Trauma Syndrome Infant Behavior, risk for disorganized Loneliness, risk for
Relationships, readiness for enhanced Memory, impaired Parenting, impaired
Religiosity, impaired Neglect unilateral Parenting, readiness for enhanced
Religiosity, ready for enhanced Peripheral Neurovascular Dysfunction, risk for Parenting, risk for impaired
Religiosity, risk for impaired Sensory Perception, disturbed (specify: visual, Role Performance, ineffective
Relocation Stress Syndrome auditory, kinaesthetic, gustatory, tactile, olfactory) Social Interaction, impaired
Relocation Stress Syndrome, risk for Stress Overload Social Isolation
Resilience, impaired individual
Resilience, readiness for enhanced Pain/Discomfort Teaching/Learning
Resilience, risk for compromised Comfort, impaired Development, risk for delayed
Self-concept, readiness for enhanced Comfort, readiness for enhanced Growth, risk for disproportionate
Self-esteem, chronic low Pain, acute Growth and Development, delayed
Self-esteem, situational low Pain, chronic Health Behaviour
Self-esteem, risk for situational low Health Management, ineffective self
Sorrow, chronic Respiration Knowledge, deficient (specify)
Spiritual Distress Airway Clearance, ineffective Knowledge (specify), readiness for enhanced
Spiritual Distress, risk for Aspiration, risk for Noncompliance [Adherence, ineffective] (specify)
Spiritual Well-being, readiness for enhanced Breathing Pattern, ineffective Therapeutic Regimen Management, ineffective
Gas exchange, impaired Therapeutic Regimen Management ineffective family
Elimination Ventilation, impaired spontaneous Therapeutic Regimen Management, readiness for enhanced
Bowel Incontinence Ventilatory Weaning Response, dysfunctional
Constipation
Safety
Allergy Response, latex
Chapter 6 Nursing Care Standards Appendix C: Page 1 of 1

Appendix D Sample Nursing Care Plan
Nursing Care Plan

Name: Fathers Name:
Ward: _____________________________________
MRN: Age:
Tel. No.:
Nursing Care Plan
Date
Problem Nursing assessment of identified Signature and
and Intervention/Action
No problem and goal Designation
Time
Chapter 6 Nursing Care Standards Appendix D: Page 1 of 2

Nursing Care Plan
Date
Problem Nursing assessment of identified Signature and
and Intervention/Action
No problem and goal Designation
Time
Chapter 6 Nursing Care Standards Appendix D: Page 2 of 2

Appendix E Sample Nursing Patient Progress Report
Nursing Patient Progress Report

Name: Father Name:
Address:- City: Sub city:
Ward: _____________________________________
MRN: Age:
Tel. No.:
Nursing Patient Progress Report / Evaluation
Date
and Review
Problem Signature and
Time Patient Progress Report / Evaluation Date and
No Designation
Problem Time
Identified
Chapter 6 Nursing Care Standards Appendix E: Page 1 of 2

Nursing Patient Progress Report / Evaluation
Date Review
Problem Signature and
and Patient Progress Report / Evaluation Date and
No Designation
Time Time
Chapter 6 Nursing Care Standards Appendix E: Page 2 of 2

Appendix F: Patient Caregiver Contract
MRN: _______________________________________
WARD: _____________ BED: ______________
I. Patient Information
Patients name:_________________________________
Date: _________________________________ Age: ___________ Sex: ________
Reason for Admission:
________________________________________________________________
II. Visitor Information

Name(s) of all visitors:
1) _______________________________ Relationship to patient:
_______________________
_______________________
_______________________
_______________________
II. Official Caregiver Information

Name(s) of all patient family member(s), close relative(s) or friend(s) who is/are responsible for
patient care. Cannot exceed 2 individuals per patient.
1) ______________________________ Relationship to patient:
________________________
2) ______________________________ Relationship to patient:
________________________
III. Hospital Visiting Hours and Regulations:

Official Caregivers: 24 hours a day
Visitors: 1:30 2:30 (ET) / 7:30am 8:30am (GT)
5:30 7:30 (ET) / 11:30am 1:30pm (GT)
11 2 (ET) / 5:00pm 8pm (GT)
Official and Non-official Caregiver Regulations:

In the best interest of all patients, staff and visitors, a maximum of TWO visitors are permitted to see
a patient at any one time (children under 8 years old not included; however all children must be
accompanied by an adult). Caregivers and visitors are not permitted to damage and/or take possession
of hospital property or equipment. Official caregivers will be held responsible in the event that
hospital property or equipment is damaged or stolen. Visitors and official caregivers will be removed
from the ward immediately if they interfere with the medical and non-medical staffs ability to
perform their jobs, or if they threaten the security of the staff, patients or visitors.
IV. Role of Official Caregivers:

1) To work with ward medical and non-medical staff (cleaners, hospital administrators) in a
cooperative and respectful manner
Chapter 6 Nursing Care Standards Appendix F: Page 1 of 2

2) To undergo a brief orientation to the ward upon patient admission (including basic infection
prevention training and introduction to facilities available for caregiver use)
3) To supply ordered medication (if paying patient)
4) To change patient bed sheets
5) To change patient bedpan in designated area
6) To use toilet and shower properly and clean messes made by self or patient
7) To dispose of liquid and solid waste separately and in provided containers
8) To cooperate with cleaning staff in order to maintain cleanliness of the patients room and
ward hallways
9) To exchange time in the ward and duties ONLY with other official caregivers
10) To assist in minimizing visitors during regular visiting hours in order to avoid overcrowding
and spread of infection
11) To inform medical staff and/or ward security guard of the patients medical problems which
are encountered in the ward
12) To assume responsibility for hospital fee upon patient discharge, if patient does NOT have a
free paper from his/her kebele
IV. Role of Visitors:

1) To allow ward medical and non-medical staff (cleaners, hospital administrators) to perform
their duties in cooperative, respectful manner
2) To undergo a brief orientation to the ward upon patient admission (including basic infection
prevention training and introduction to facilities available for caregiver use)
3) To follow visiting hour guidelines
4) To respect the property of all staff, patients, and visitors
5) To conduct appropriate behaviour in the hospital, so as not to disturb the peace and security of
all patients, hospital staff, and visitors
6) Should a disagreement occur, to file a formal written complaint to the head of the department
ward, rather than to create a direct confrontation
7) To assume responsibility for hospital fee upon patient discharge, if patient does NOT have a
free paper from his/her kebele.
I, the undersigned, agree to fulfill the above mentioned responsibilities and regulations as an official
caregiver, in order to ensure the best possible care for the aforementioned patient(s). I understand that
failure to comply with these responsibilities and regulations will result in my ejection from the ward. I
also understand that the failure of non-official caregivers to comply with visiting hours and
regulations will result in their ejection from the ward.
1) Print Caregiver Name: ____________________________________________________________

Signed: ________________________________________________________________________
2) Print Caregiver Name: ____________________________________________________________

Signed: ________________________________________________________________________
3) Ward Staff Witness: ______________________________________________________________

Signed: _______________________________________________________________________
Chapter 6 Nursing Care Standards Appendix F: Page 2 of 2

Infection Prevention and Control
Page 1 of 54
Section 2 Operational Standards for Infection Prevention and Control 6

3.1 Management of Infection Prevention Activities 6
3.1.1 IPC Committees Scope of Work
3.1.2 Infection Prevention Plan
3.2 Standard Precautions 9

3.2.1 Hand Hygiene
3.2.2 Personal Protective Equipment
3.2.3 Infection Prevention in the Surgical Unit
3.2.4 Infection Prevention in the Laboratory
3.3 Transmission based precautions 18

3.3.1 Contact precautions
3.3.2 Droplet precautions
3.3.3 Airborne precautions
3.3.4 Cohorting
3.3.5 Special precautions for TB infected patients
3.4 Environmental Hygiene 22

3.4.1 Waste management
3.4.2 Linen processing
3.4.3 Housekeeping
3.4.4 Instrument processing
3.4.5 Traffic Flow
3.4.6 Kitchen
3.5 Worker Safety 37

3.5.1 Injection safety
3.5.2 HIV post exposure prophylaxis
3.6 Equipment, Supplies and Infrastructure 42
3.7 Monitoring and surveillance 44

3.7.1 Monitoring
3.7.2 Surveillance of nosocomial infections
3.7.3 Using the data
3.8 Infection Prevention Training 47

3.8.1 Educating patients, caregivers, and other visitors regarding IP policies
Chapter 7 Infection Prevention and Control Page 2 of 54

4.3 Indicators 49
Source Documents 50
Appendices
Appendix A Handwashing Techniques
Appendix B. Summary of Procedures for Handling and Disposal of Healthcare Waste
Appendix C. Suggested Cleaning Guidelines for Hospital Environments
Appendix D. Post-exposure prophylaxis forms: Post Exposure Prophylaxis Decision
Making Tool (from draft National PEP Guideline)
Appendix E Post-exposure prophylaxis forms: Sample Post Exposure Prophylaxis Patient
Tracking Form
Appendix F Post-exposure prophylaxis forms: Sample Occupational Blood and Needle
Stick Exposures Recording Form
Appendix H Monitoring and surveillance forms: Sample Hand Hygiene Monitoring Form
Appendix G Monitoring and surveillance forms: Sample of a Minimum Data Collection
Form for HCAI Prevalence Assessment
Appendix H Monitoring and surveillance forms: Sample Infection Prevention Checklist to
Assess each Case Team
Tables
Table 1 Personal Protective Equipment: Types
Table 2 Personal Protective Equipment: Uses
Table 3 Personal Protective Equipment: Cleaning and Disposal
Table 4 Needs Assessment for Infection Prevention Supplies and Equipment
Table 5 Infection Prevention Checklist
Table 6 Infection Prevention Indicators
Figures
Figure 1 Segregation of health care waste by waste type
Figure 2 Instrument processing steps
Boxes
Box A Personal protective equipment for cleaning staff
Box B Inputs required for PEP service

Abbreviations
ART Antiretroviral therapy
CEO Chief executive officer
CDC U.S. Centers for Disease Control and Prevention
HBV Hepatitis B virus
HCAI Health care acquired infection
HCP Healthcare personnel
HCV Hepatitis C virus
HCW Healthcare waste
HCWM Healthcare waste management
HEPA High efficiency particulate air
HIV Human immunodeficiency virus
IMAI Integrated Management of Adolescent and Adult Illness
IMNCI Integrated Management of Newborn and Childhood Illnesses
IP Infection prevention
IPC Infection prevention and control
MDT Multidisciplinary team
MRSA Methicillin Resistant Staphylococcus Aureus
OSHA Occupational Safety and Health Administration
PEP Post exposure prophylaxis
PPE Personal protective equipment
PIHCT Provider Initiated HIV Counseling and Testing
STI Sexually transmitted infections
TB Tuberculosis
WHO World Health Organization

The potential for the transmission of infections in the health care setting is high. Both those
receiving and providing care in a hospital are at risk of acquiring and transmitting infections
through exposure to blood, body fluids or contaminated materials.
The term most commonly used to describe the type of infection acquired in a healthcare
setting is healthcare acquired infections (HCAIs). Healthcare acquired infections are defined
as infections that are acquired in any healthcare setting by a patient who was admitted for a
reason other than that infection. The patient population is often sick, immunocompromised
and more susceptible to infections and is also more likely to transmit infections to others.
Healthcare workers may be exposed to infection through the provision of care. Invasive
clinical procedures and the use of instruments and sharps expose healthcare workers to
needlestick injuries and in turn to potentially infectious agents.
Although minimal data is available on the prevalance of HCAIs in Ethiopian hospitals, in

developing countries with health systems and resources similar to Ethiopia, studies have
shown HCAI rates as high as 40%1.
Establishing an infection prevention program with the aim of stopping the transmission of
infectious agents is the only way to reduce the occurrence of HCAIs, and demonstrates a
hospitals commitment to the well-being of patients and staff by minimizing the likelihood of
HCAIs and assuring a clean and safe environment. Moreover hospitals must ensure that the
safety of employees, patients and visitors is upheld by preventing the acquisition and
transmission of infections. The prevalence of infectious diseases such as tuberculosis, Human
immunodeficiency virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) and other
infectious diseases in Ethiopia heightens the urgency for hospitals to implement a
comprehensive infection prevention program which includes:
Effective management
Staff engagement and involvement
Provision of necessary equipment and supplies
Monitoring and surveillance and
Training
Implementing an infection prevention and control program will a) help improve the quality of
patient care and b) save valuable resources in the long-term.
This chapter outlines the key components of a comprehensive hospital infection prevention
program.
1
Admasu, K. Assessment of Infection Prevention Practices in Hospitals in Addis Ababa, 2008.
Section 2 Operational Standards for Infection Prevention
1. Hospital Management supports improvement efforts in infection prevention by ensuring

that operational and technical capacity, financial and human resources required to adhere
to infection prevention guidelines are available.
2. A designated group and/or individual(s) are in place to effectively implement and monitor
infection prevention and control activities.
3. The Hospital has an operational plan for the implementation of infection prevention
activities. The plan follows national guidelines and includes guidance on infection
prevention practice, procedures and materials.
4. Standard practices that prevent, control and reduce risk of hospital acquired infections are
in place.
5. The Hospital has an adequate plan to address transmission based precautions for staff,
patients, caregivers and visitors.
6. The Hospital ensures that equipment, supplies and facilities/infrastructure necessary for
infection prevention and control are available.
7. All hospital staff are trained using standard infection prevention training materials.
8. The hospital provides health education to patients, caregivers and visitors, as appropriate,
on infection and prevention and control practices.

3.1 Management of Infection Prevention Activities
Effective management is essential to creating an effective infection prevention and control

(IPC) program. There are two tiers of management of an IPC program: direct management of
IPC activities by a designated individual(s); as well as senior level management from the
Chief Executive Officer (CEO), Senior Management Team and the Governing Board.
Hospitals should have a designated person or persons to oversee day to day infection
prevention activities. Their roles and responsibilities in relation to IP activities should be
described in their job description and each should be allocated sufficient time in their work
schedule to fulfill their IP duties. Resources permitting, it is recommended that one person is
designated to coordinate overall infection prevention (IP) activities as his/her primary
responsibility. This person could be a nursing staff member, environmental health worker or
any other staff member who has been trained in infection prevention and control principles.

In addition to a full-time IP designate, the hospital should also have an Infection Prevention
and Control Committee charged with overall coordination and monitoring of the hospitals
infection prevention and control work. The committee should be multi-disciplinary and
representative of the hospital staff and should have no more than 5-8 members. Committee
members should be individuals who are interested and engaged in infection prevention work
and are able to direct hospital staff to implement the IPC program and incorporate IPC
strategies into their daily work responsibilities.
Hospital staff from key areas should be represented on the IP committee. Representatives
from the following areas should be considered for membership on the hospitals infection
prevention committee:
Inpatient, outpatient and emergency case teams
Environmental Health
Nursing
Medical
Housekeeping
Administration (CEO, or another senior manager)
Pharmacy
Laboratory
Laundry
Kitchen
Instrument processing unit
Occupational health and safety
Quality Management (e.g. Incident officer)
In addition to the above members, it is advisable to include a representative from the hospital
finance unit (head of hospital finance, accounting). It is critical that those who can commit
funds and who can assure that funds are allocated to support IP functions (purchase of critical
supplies, such as soap, antiseptics, disinfectants, personal protective equipment, etc.) are
involved with or aware of the infection prevention committees work. Having the appropriate
people participate in the committee can empower individuals to take ownership of the
program and can assist in assuring the long-term sustainability of the program.
Senior level management should support the IPC committees efforts by:
Monitoring the IPC committees overall activities
Ensuring that equipment and supplies needed for IPC activities are available
Reviewing committee reports (eg. on healthcare facility acquired infections
prevalence) and acting on actionable items
Encouraging staff adherence to and involvement in IPC activities
This core group of hospital leaders can guide the infection prevention program by identifying
areas of critical need, prioritizing areas to focus the program, and committing funds to make
the program successful.

3.1.1 IPC Committees Scope of Work
The infection prevention and control committee and infection prevention designate(s) are
responsible for coordination of the hospitals overall infection prevention activities as well as
development of an operational plan for infection prevention activities.
If there a person selected to work on infection prevention and control (IPC) activities full
time, his/her responsibilities should be clearly delineated in a job description. The committee
should also have a TOR that outlines the roles and responsibilities of all members. The TOR
should include the frequency of meetings as well as the process for recording and reporting
information. It is recommended that the committee meets regularly, at least once a month.
The team should select a chairperson who will be responsible for coordinating the IP
committees activities (calling meetings, disseminating minutes etc) and a secretary to record
meeting minutes. The committees main responsibilities are to:
1. Define the hospitals annual infection prevention and control plan

2. Monitor and evaluate the performance of the infection prevention program by
assessing implementation of plan and adherence to practice
3. Establish a program for the surveillance of HCAIs
4. Review HCAI surveillance data
5. Report findings on HCAI surveillance performance of the infection prevention (IP)
program to management and other staff and identify areas for intervention.
6. Ensure, in collaboration with relevant staff, appropriate staff training in infection
prevention guidelines.
7. Ensure, in collaboration with relevant staff, the consistent and adequate supply of
personal protective equipment and other infection prevention supplies and equipment.
8. Creating a sense of individual responsibility for IP amongst all staff
3.1.2 Infection Prevention Plan
A number of national guidelines exist which outline infection prevention policies and practice
including the Federal Ministry of Healths Infection Prevention Guidelines for Healthcare
Facilities in Ethiopia. These documents should serve as a resource to hospital staff,
particularly staff engaged in infection prevention activities. However, the successful
implementation of an IP program requires an operational plan that defines how the national
guidelines will be implemented at hospital level.
The IP plan should define the infection prevention policies of the hospital, how those policies
will be implemented and by whom.
The plan should outline all of the activities to be included in the hospitals infection
prevention program. At a minimum the plan should address the hospitals policies and
procedures for:
Standard precautions
Transmission based precautions
Equipment and supplies for IP activities, including personal protective equipment

Monitoring and evaluation of IP activities
IP training
3.2 Standard Precautions
Standard precautions are a set of recommendations to minimize the spread of infections in a

health care setting. Healthcare workers should apply the principles of standard precautions
with each encounter with a patient. Consider every person, patient or staff, as potentially
infectious or susceptible to infection.
Most HCAIs can be prevented through readily available and relatively inexpensive strategies.
The elements of standards precautions include implementation of recommended practices
regarding:
Hand hygiene
Personal protective equipment
Safe work practices (such as safe injection practice, safe practice in the operating
room)
Safe house keeping
Disposal of health care waste management
Processing of instruments and linens
3.2.1 Hand Hygiene
Hand hygiene is one of the most important measures for infection prevention. Studies have
shown that effective and consistent hand hygiene practice among hospital staff can
significantly reduce the occurrence of HCAIs. Hand hygiene generally refers to hand
washing, hand antisepsis (with alcohol based hand rub) and surgical hand scrub. Hand
hygiene should be practiced by all healthcare providers before and after contact with a
patient/client regardless of their health status. Steps of hand hygiene (hand washing and hand
antisepsis) should be posted close to every sink and steps of surgical hand scrub near
scrubbers sink (See appendix A for a sample hand washing poster). To achieve the greatest
compliance in hand hygiene all staff should be trained in proper hand hygiene techniques as
part of infection prevention training program and hand hygiene facilities (such as functioning
sinks, soap and water) should be in place in all patient care areas. The hospital should provide
a consistent supply of clean water for all patient care areas. This can be achieved by short
term provision of water using containers with improvised sinks (buckets with faucets fixed to
it) and /or temporary storage tankers or long term provision of water from reliable supply
designed for the hospital.
The hospital should also provide plain soap, in the form of bar or liquid, antiseptic soap,
and/or alcohol and glycerin (for preparation waterless antiseptic hand rub) for all patient care
areas on a regular basis. If bar soap is used, provision of small bars and draining soap racks is
recommended to prevent accumulation of contaminated liquid which harbors
microorganisms. When the soap dispensers are reused they should be thoroughly cleaned

before refilling; adding soap to a partially empty soap dispenser is not recommended as it
leads to bacterial contamination of the soap. The major and minor operation rooms should be
provided with plain soap, antiseptic soap, 2-4% chlorohexidine and 7.5-10% povidone iodine,
alcohol, non-contaminated glycerin, and nail cleaners/soft brushes for surgical hand scrubs.
In procedure areas it is advisable to install faucets with foot controls or faucets that can be
closed by elbow to minimize contamination after hand washing. Disposable paper towels
should be placed close to the faucets for easy access after washing hands. If it is not possible
to supply disposable towels, every health care provider should have a pair of personal towels
for everyday use to dry hands after washing. These personal towels should be washed and
dried every day. Using common towels should be avoided as this is associated with cross
contamination.
In addition to staff training, the hospital should ensure that hand hygiene is included in the
health education program of patients and caregivers.
3.2.2 Personal Protective Equipment
Personal protective equipment (PPE) can be defined as specialized clothing or equipment

worn by an employee for protection against infectious materials.2 PPE protects the
healthcare worker by creating a barrier between the person and any potentially infectious
substance. Personal protective equipment includes: gloves, gowns, aprons, masks/respirators,
protective eyewear (face shield, goggles), caps, protective shoes.
Hospitals should make certain that there is a sufficient supply of all personal protective
equipment for all hospital staff. Regular supply should be provided when there is increased
demand or need for replacement of worn out items. The hospital should monitor staff use of
all personal protective equipment to ensure consistent utilization.
Table 1 outlines the different types of personal protective equipment that are commonly used
in a hospital setting.
Table 1. Personal Protective Equipment: Types

Personal Protective Equipment Type
Gloves Heavy duty gloves
Surgical gloves
Examination gloves (latex or nitrile)
Other types (ex. those worn by cleaning and laundry staff)
Protective Eyewear Eye shield
Goggle
Visors
Masks Dust mask
Surgical
Respirators
Other type of face mask
Aprons Plastic apron
2
CDC, Guidance for the selection and use of personal protective equipment in healthcare settings.
Other types
Protective shoes Boots
Nurse shoes
Other protective shoes
Caps
Face shield

Each personal protective has a different use and application. Table 2 presents a summary of the types
of PPE, when each should be worn and by whom.

Table 2. Personal Protective Equipment: Uses

Type of PPE Who should wear PPE? What is Protected? When PPE should be worn
Gloves Medical, nursing staff Hands When there is direct contact with exposed wounds, blood, body
Surgical (normal and elbow (including students) fluids, or any type of lesion.
length) Porters
Examination Runners/transitors When drawing blood or handling medical instruments involved with
Nitrile invasive procedures (catheters, IV insertion, probes, etc.).
Latex Cleaning, laundry staff
During surgical procedures
Heavy duty
When handling waste items or others contaminated surface
When cleaning patient areas.

Protective eyewear Medical, nursing staff Eyes When splattering of blood or body fluids to the face is possible,
(including students)
Porters When handling biohazardous, soiled linens,
Runners/transitors
When performing waste collection for hazardous or non-hazardous
Cleaning, laundry staff waste.
as needed
Masks Medical, nursing staff Mouth, nose To protect mucous membranes of mouth and nose when splattering
Surgical mask (including students) of blood, body fluids, secretions or excretions is possible
Porters
Runners/transitors
Cleaning, laundry staff

as needed
Particulate respirators Medical, nursing staff, Mouth and nose When entering the room of airborne infectious agents such as TB
cleaning staff entering
Page 12 of 54
isolation rooms
Face shields Medical, nursing staff Face, mouth, nose and To protect mucous membranes of eyes when splattering of blood,
(including students) eyes body fluids, secretions or excretions is likely
Plastic aprons Medical, nursing staff Skin, clothing To protect skin and clothing when splattering of blood, body fluids,
Gowns (including students) secretions or excretions is likely
Porters
Runners/transitors
Cleaning, kitchen and
laundry staff as needed
Protective shoes Medical, nursing staff Shoes To protect feet when there is the likelihood of the splattering of
(including students) blood, body fluids, secretions or excretions
Porters To protect from sharps injury

Runners/transitors
Caps Medical, nursing staff Hair To protect hair when there is the likelihood of the splattering of
(including students) blood, body fluids, secretions or excretions
Porters To reduce spread of microorganisms from healthcare personnel to
Runners/transitors patient or food

Synthetic long sleeve aprons, goggles and masks should be provided to all staff involved with conducting invasive procedures. Synthetic long sleeve
aprons, goggles and masks should be consistently used when splashes are anticipated.

3.2.2.1 Selecting the Appropriate PPE
When selecting what PPE should be worn, the health care worker should assess:
I. Type of exposure anticipated
a. Spray or contact - The health care worker should assess the type and volume of body
fluid or blood that he/she may potentially encounter in caring for the patient and
select appropriate PPE accordingly.
b. Type of isolation precaution (airborne, contact or droplet) - The health care worker
should also consider the level or type of isolation precaution that the patient is on
II. Durability and appropriateness for the task
III. Correct fit of the PPE
3.2.2.2 Cleaning and disposal of PPE
Reusable PPE should be cleaned following standard cleaning procedures (see Section 3.4.4).
Table 3. Personal Protective Equipment: Cleaning and Disposal Methods

Equipment Standard procedure
Apron If reusable: clean with detergent and water, dry, disinfect with 70% alcohol
If disposable: discard in appropriate waste container according to the health
care facility waste management guidelines
N 95 or standard surgical Discard in appropriate waste bag according to the health care facility
mask guidelines
(Use disposable mask only)
Eye protector/goggles/face If reusable: clean with detergent and water, dry, and disinfect with 70 %
shield alcohol or soak in 1% hypochlorite solution for 20 minutes and rinse and dry.
If disposable: discard in appropriate waste bag according to the health care
facility guidelines
Gown If reusable: launder as per the health care facility guidelines for soiled linen
For example: launder in hot water (70 - 80 C) if possible OR Soak in clean
water with bleaching powder 0.5% for 30 minutes Wash again with detergent
and water to remove the bleach. Dry in a clothes drier or in the sun
Cap If reusable: launder as per the health care facility guidelines for soiled linen
(Use of disposable cap is For example: launder in hot water (70 - 80 C) if possible OR Soak in clean
recommended) water with bleaching powder 0.5% for 30 minutes Wash again with detergent
and water to remove the bleach. Caps should be dried in a clothes drier or in
the sun.
If disposable: discard in appropriate waste bag Seal the bag

Gloves If gloves are disposable it is advisable to decontaminate (by washing) before
(Use disposable gloves disposal.
only)
Gloves should be changed and disposed of properly after contact with every
patient or contaminated item.
Surgical gloves can be reused after reprocessing using sterilization or high
level disinfection (HLD) techniques. Surgical gloves should not be
reprocessed more than three times.
Gloves are not reusable if the glove has been torn, punctured, or broken.
Housekeeping staff should wash the exterior of their utility gloves after
cleaning each patient area/room to prevent the spread of infectious agents.
Gloves should be discarded in the appropriate waste container according to the
waste management guidelines
Source: Adapted from Practical Guidelines for Infection Control in Health Care Facilities, WHO , 2003.
3.2.3 Infection Prevention in the Surgical Unit
The surgical unit is inherently a high risk area. Providers are exposed to blood and injuries
from the use of sharp instruments used to perform surgeries. Patients are also at risk of
acquiring infections as a result of the procedures performed. Standard precautions described
above must be adhered to by all surgical unit staff. Described below are additional safe
practices to minimize the risk to patients and staff in the surgical unit.
A. Organization of the Surgical Unit
The surgical unit should have well delineated areas: unrestricted, transition, semi-restricted
and restricted areas. All three areas should be clearly marked.
The unrestricted area is the area at the entrance and is isolated from other areas of the
surgical unit. Staff, patients and materials are supplied to the surgical unit through this entry
point.
The transition zone is where staff dressing rooms and lockers are located. Staff change into
their surgical attire in this area. Only authorized staff should enter this area.
The semi restricted area includes preoperative and recovery rooms, storage space for sterile
and high-level disinfected items, and corridors leading to the restricted area. Support
activities (e.g., instrument processing and storage) for the operating room can occur here.
Traffic in this area should be limited to authorized staff and patients at all times. Clean,
closed shoes should be worn by staff to protect against fluids and dropped items (ex. sharps).
Staff working in this area should wear surgical attire and a cap. The area should be separated
by doors limiting access to the restricted area of the surgical unit.
The restricted area consists of the operating room(s) and scrub sink areas. Never store
instruments and other items in the operating room.
Limit traffic to authorized staff and patients at all times.
Keep the door closed at all times, except during movement of staff, patients, supplies
and equipment.

Scrubbed staff must wear full surgical attire and cover head and facial hair with a cap
and mask.
Staff should wear clean, closed shoes that will protect their feet from fluids and
dropped items.
Masks are required when sterile supplies are open and scrubbed staff are operating.
Patients entering the surgical unit should wear clean gowns or be covered with clean
linen, and have their hair covered.
The Unit should have a constant and adequate supply of all surgical antiseptics of proper
concentrations and personal protective equipment. The staff should be regularly inspected for
the proper use of personal protective equipment and surgical antiseptics.
There should be appropriate facilities for surgical hand scrub: antiseptic soap, clean water,
soft brush or sponges (not hard brushes), and 60-90% alcohol and glycerin. It is advisable to
post steps of surgical hand scrub near the scrubbers sink and instruct the staff to adhere to
the recommended hand scrub techniques.
Waste containers for sharps, contaminated and non-contaminated wastes should be in place
and regularly checked for proper use. All the decontamination containers and bleach should
be in place for the processing of contaminated items.
B. Surgical Antisepsis
The majority of post operative wound infections can be prevented through the use of surgical
antisepsis procedures which include:
Hand hygiene (as described in section 3.2.1)
Surgical hand scrub and gloving of the surgical team
Applying an antiseptic agent to the surgical site
Surgical Hand scrub

The hospital should have a regular supply of antiseptics for hand hygiene and skin
preparation for surgery. All types of antiseptics should be regularly supplied to all procedure
rooms. This includes, but is not limited to, alcohol (ethyl or isopropyl) 70%, chlorohexidine2-
4%, iodine preparation 3%, iodophors 7.5-10%. Hospital staff should be monitored for the
proper use of each antiseptic solution.
Antiseptics should be poured into a small, reusable container for daily use. Gauze or cotton
wool should not be stored in antiseptics. Antiseptic solutions should not be filled on top of
the existing solution in the dispensers. Containers/dispensers with antiseptic solutions should
be emptied and washed with soap and water every time before refilling. There should be an
established routine schedule for preparing new solutions and cleaning containers. Reusable
containers should be labeled with the date each time they are washed, dried, and refilled.
Concentrated antiseptic solutions should be stored in a cool, dark area.

Surgical site preparation
Microorganisms (usually bacteria or sometimes fungi) normally found on the patients skin
can lead to postoperative wound infections. Conducting pre-operative antisepsis can help
reduce risk of infection.
Before the operation, the patients skin (at the incision site) should be washed with soap and
water and cleansed with an antiseptic agent in order to minimize the number of
microorganisms on the skin or mucous membrane. Do not shave hair at the operative site (if
necessary, trim hair close to skin surface immediately before surgery).
C. Safer Operations
Before each operation, the surgical team performing the surgery should review how sharps
will be handled during the operation. This will help minimize the number of sharps injuries.
The team should try to use the least dangerous instrument or device that will effectively
accomplish the task, while at the same time minimizing the risks to the patient and surgical
team.
Hand-free technique of passing surgical instruments should be used. Instrument should be

placed in a sterile or highly disinfected kidney basin, or other small container to pass from
one staff to another during the operation. Scalpel blades can be dulled when placed in a metal
container. Placing a sterile cloth in the bottom of a metal container or using a plastic
container can protect against the dulling of a blades. The surgeon should be verbally alerted
before transferring a sharp instrument saying sharps.
Regular inspection should be done to ensure consistent implementation of the safe

(recommended) practices.
Further guidance is presented is presented in Appendix B (WHO Surgical Safety Checklist)

of Chapter 12 Quality Management.
3.2.4 Infection Prevention in the Laboratory
Laboratory workers are exposed to blood, body fluids and other potentially infectious
materials through the course of their work. In order to reduce the risk of occupationally-
acquired infections laboratory workers must adhere to standard precautions described above.
In addition, laboratory staff should:

always wear new examination gloves when handling blood, body fluids and/or
specimens containing pathogenic microorganisms
not eat, drink or smoke in the laboratory
not store food in refrigerators used for clinical and research specimens
not mouth pipette, but use the appropriate mechanical device
never open the centrifuge while it is in motion
always cover the end of blood collection tubes with cloth or paper towel, or point
them away from anyones face when opening

decontaminate work surface with 0.5% chlorine solution daily or when contaminated
with a spill
wear protective face shield, masks or goggles if splashes and/or sprays of blood, body
fluids or fluids containing infectious agents are possible
wear heavy duty or utility gloves when cleaning laboratory glassware
use puncture-resistant, leak proof containers for sharps
place infectious waste materials in appropriate waste container (see section 3.4.1.1 on
waste management )
Further guidance on safety practices for the laboratory staff can be found in Chapter 5
Laboratory Services; section 3.9.
3.3 Transmission based precautions
Transmission-based precautions are sets of extra precautions that need to be employed when
routes of the transmission are not interrupted though use of Standard Precautions alone. Each
of these precautions should be used in conjunction with Standard Precautions.
The hospital should provide private rooms for patients with airborne, droplet or contact
transmissions of microorganisms. All providers entering private rooms should be trained or at
least well oriented about all types of precautions to apply.
Specific precautions for each type of exposure are outlined below.
3.3.1 Contact precautions
Contact precautions are intended to reduce the risk of transmission through direct and
indirect contact with an infectious patient. Direct contact transmission includes skin to skin
contact and the physical transfer of pathogens from an infectious patient. This includes
contact during bathing, turning, and other patient care activities. Indirect contact means that
the infectious patient has contaminated an object in their environment and then the object
comes into contact with a potential host. Contact precautions should be used when a patient is
known to have a specific disease that is easily transmitted by direct or indirect contact.
Illnesses that require contact precautions include but are not limited to the following:
Acute diarrhea in an incontinent or diapered patient
Diarrhea in adult with recent antibiotic use
Bronchitis or croup in infants and young children
History of infection with multi drug resistant organisms (except TB)
Abscess or draining wound that cannot be covered
Patient Placement
Private room

Door may be left open
If private room is not available, place patient in room with patient having active
infection with the same microorganism, but with no other infection (cohorting)
Precautions
Exercise strict barrier precautions for any type of contact with the patient and their
surrounding environment.
Disposable gloves must be worn by all hospital staff that enter the room/patient area.
All PPE must be disposed of properly when contact with the patient is finished. If
disposable gloves are not available then gloves and gowns must be placed for washing
and appropriate disinfection.
Hand washing using antiseptic soap must occur after removing gloves and other PPE.
Medical equipment must not be shared between patients. If it is to be shared, then any
equipment that comes into contact with a new patient must be disinfected. When
cleaning, all surfaces within the vicinity of the patient must be cleaned on a daily
basis. This should include cleaning bed rails, patient over-the-bed tables, night
stands, floors, patient sinks, doorknobs, and other item that may have come into direct
contact with the patient.
After an infectious patient leaves or is discharged, all surfaces and linens must be
properly cleaned and disinfected.
All stationary and portable medical equipment must be cleaned. Examples include
thermometers, cardiac monitors, respiratory equipment, wheelchairs, and stretchers.
Patient Transport
Limit transport of patient for essential purposes only
During transport, ensure precautions are maintained to minimize risk of transmission
of organisms
3.3.2 Droplet precautions
Droplet precautions are intended to reduce the transmission of infectious pathogens from
contact with an infectious person to the mucous membranes of the nose or mouth of a healthy
individual. Infectious droplets can come from an infected person who coughs, sneezes, talks,
or breathes heavily. Droplets travel up to 1 metre in distance. Thus, droplet precautions
require the use of masks within 1 metre of the infected patient.
Patient Placement
Private room
Door may be left open
infection with the same disease, but with no other infection (cohorting)
If neither option is available, maintain separation of at least 1 metre (3 feet) or more
between patients
Respiratory Protection

A mask must be worn by all hospital staff who come within 1 meter (3 feet) of
patient
Patient Transport
Limit transport of patient for essential purposes only
During transport, patient must wear surgical mask
Notify area/unit receiving patient in advance
3.3.3 Airborne precautions
Airborne precautions are additional precautions needed for infectious patients whose
pathogens are spread by an airborne route. Typically, this applies to most patients who are
known to have respiratory infections and measles.
The following are procedure specifications for airborne precautions:
Patient Placement
Private room
Door closed at all times
Respiratory Protection
Masks must be worn by all hospital staff entering the room/ patient area.
o If TB is known or suspected, a particulate respirator mask should be worn, if
available.
o If chicken pox or measles:
Immune personsno mask is required
Susceptible personsshould not enter the room
o Mask should be removed after leaving the room and placed in a plastic bag or
Room air exhausted to the outside (negative air pressure) using fan or other filtration
system
infection with the same disease, but with no other infection (cohorting)
Nursing staff should be held responsible for screening visitors who are allowed to
enter the patient area/room. Persons who are susceptible (not immune or vaccinated)
should not enter the room or be assigned to the care of a patient known to be infected
with the respective disease. However, if visitation is allowed, then the visitor is
required to abide by all infection prevention guidelines and airborne precautions.
Patient Transport
If the patient must leave the unit for diagnostic procedures, then all medical personnel
involved in the medical care of the patient should be notified before the patient leaves
the medical ward. This enables the medical technician and all staff to prepare and
wear appropriate equipment.
Before patient transport, the transporter should place a clean sheet over the wheelchair
or stretcher.

For patient transport, the patient should wear a facial mask to prevent the spread of
airborne pathogens.
3.3.4 Cohorting
The hospital should provide private rooms for patients with airborne droplet or contact
transmissions of microorganisms. If single rooms are not available, or if there is a shortage of
single rooms, patients infected or colonized by the same organism can be cohorted (sharing
of room/s).
When cohorting is used during outbreaks, these room/s should be in a well-defined area (a
designated room or designated ward), which can be clearly segregated from other patient care
areas in the health care facility used for non-infected/colonized patients.
3.3.5 Special precautions for Tuberculosis infected patients
The prevention of Tuberculosis (TB) begins with stopping hospital-acquired TB infections

from patient-to-patient and patient-to-staff contact. Active TB is easily transmitted from
person to person through the airborne route. TB remains a formidable threat in global health,
as one third of the world is infected. Ethiopia is one of the 22 high TB burden countries
which together produce 20% of the worlds TB cases.3 Prevention of TB transmission within
the hospital setting is important to upholding high standards for patient safety and minimizing
the spread of TB in the population. Strict airborne precautions are critical when caring for TB
patients, as airborne droplets of TB patients can remain suspended in the air for longer
periods of time than other airborne pathogens.
Precautions should be made for:

A patient with a positive sputum smear for mycobacteria
A patient with a chest x-ray with findings of TB
A patient who reports:
o Having a cough of over 2 weeks and
o presents with an infiltrate x-ray and
o reports with any one of the following:
known exposure to TB
known recent exposure to TB +PPD
known immunosuppressive state (HIV+, transplant patient, etc.)
alcohol abuse or injection drug use
past or current homelessness or incarceration
history of high fever, weight loss, and night sweats.
The following are special procedure specifications for preventing TB infections:

If a patient is suspected, but not yet confirmed to have TB, precautions should be
employed until confirmed to be negative.
3
http://www.theglobalfund.org/grantdocuments/6ETHT_1317_0_full.pdf
N-95 and HEPA masks should be worn whenever coming into patient area if
available (Note: Such masks are expensive and not readily available in Ethiopia,
but if they become so they should be worn.)
Before entering patient area/room, hospital staff should make sure that the masks
are fit-tested to ensure they are secure
For patient areas that have several patients, the N-95/HEPA masks do not need to
changed UNLESS the patient is known to have MDR-TB
Hand hygiene needs to be performed before and after contact with the mask and
patient
Patients should be advised to use a tissue when coughing or sneezing, even when
no one else is in the room. This is because the droplets of TB patients remain in the
air for an extended period of time.
If a patient must exit the room for a medical procedure, the patient should be fitted
with a tight fitting surgical mask or a N-95 mask, if possible. A HEPA mask cannot
be used.
Visitors must exercise similar precautions as medical staff. Visitors should use a N-
95 mask if possible or a tight fitting surgical mask if one is not available.
Any visitors that have been known to have close contact with the patient prior to
admission should be tested for TB if possible and advised about symptoms that
could occur.
When cohorting is used during outbreaks these room/s should be in a well-defined
area (a designated room or designated ward), which can be clearly segregated from
other patient care areas in the health care facility used for non-infected/colonized
patients.
3.4 Environmental Hygiene
3.4.1 Waste Management
By some estimates, nearly 80% - 85% of waste generated in healthcare establishments is

municipal waste and 20%-15% is infectious waste. However, in most health care facilities in
Ethiopia waste is not segregated according to proper segregation methods and it is difficult to
quantify the type and amount of waste produced. A varying proportion of healthcare waste
(HCW) requires special attention, including sharps (e.g. needles, razors, scalpels etc.),
pathological waste, other potentially infectious waste, pharmaceutical waste, biological
waste, and hazardous chemical waste. In addition, all waste generated under certain
circumstances, such as in isolation wards and microbiological laboratories, requires special
attention.
Healthcare facilities produce waste that is potentially harmful to public health and the
environment. Healthcare workers, patients, waste handlers, waste pickers, and the general
public are exposed to health risks from infectious waste (particularly sharps), chemicals, and
other special HCW. Improper disposal of special HCW, including open dumping and

uncontrolled burning, increases the risk of spreading infections and of exposure to toxic
emissions from incomplete combustion. Proper management of HCW through an integrated,
effective waste management system can minimize the risks both within and outside
healthcare facilities.
3.4.1.1 Waste Management Procedures
Waste management is a multi-step process involving:

Waste Minimization
Segregation
Handling
Collection
Storage
Transportation
Treatment and Disposal
Waste Minimization
In a proper HCW management system, the first step is waste reduction or minimization. It
helps to ensure good sanitation of the health facility and the safety of workers and
communities by reducing the quantity of wastes generated. Waste minimization also reduces
the environmental impact by decreasing air pollution and the landfill capacity needed for
disposal. Significant reduction of waste generated in health care facilities may be encouraged
by implementing:
source reduction such as by avoiding or reducing unnecessary injections
improved waste reuse/recycling practice,
good management and work control practices (rational use of different reagents,
medical equipments and materials, etc )
proper waste segregation system
Segregation
Segregation denotes the separation of waste into a range of classes according to its character.
Waste separation reduces the quantity of waste that requires specialized treatment and care.
Generally, facility waste is classified into 3 categories of waste: non-infectious, sharps waste
and infectious waste.
Non-infectious waste is waste that is non-hazardous and under normal circumstances poses
no health risk. It includes paper, packaging, left-over foods, boxes, glass, plastic, etc.
Sharps waste includes sharp materials and equipment that are disposed after being used. For
example, used syringes, needles, lancets, blades, scalpels, broken glass, etc.
Infectious waste is a waste material that has, in part or in whole, been in contact with blood
and/or body fluids. Due to the presence of blood and body fluids, such wastes are regarded to
be infectious waste and can potentially transmit microorganisms to susceptible people. It
includes contaminated gauze, dressings, cultures, IV lines, used gloves, anatomical wastes,
placenta, tissues and the like.
Segregation must:
take place immediately and at the source where the waste is generated; waste must
never be re-sorted.
ensure that proper segregation techniques are used and that infectious HCW is not
mixed with noninfectious waste.
The 3 categories of HCW shall be segregated into color coded containers as follows:
Segregation Category Color-coded container Non-color coded bins
Non-infectious waste/ Black bin Bins should be labeled non-
General waste risk waste
Infectious waste Yellow bin Bins should be labeled
infectious waste
Sharp waste Yellow safety box The box should be labeled
biohazard waste.
Note that in the absence of color coded bins, it is possible to in place waste segregation
system using labeled waste bins with an infectious and non-infectious symbol or text on the
side of the bins. However, such bins should not be used for liquid waste.
To maximize efficiency and safety, these three waste categories must be handled and
disposed of separately throughout the main steps of: segregation, collection, handling,
storage, transport, treatment, and disposal.
Location of segregation containers

Safety boxes.
o A safety box should always be located within arms reach of any place where
an injection is given. Safety boxes may be transported on a trolley with
injection equipment in patient wards.
o Safety boxes should not be placed in high traffic areas (ex. corridors outside
patient rooms or procedure rooms) where people could bump into them or be
stuck by someone carrying sharps to be disposed of.
o Dont place containers on the floor or anywhere where they could be knocked
over or easily reached by a child.
Infectious waste bins.
o Yellow infectious waste bins should be located in all rooms where infectious
waste in generated.
o Infectious waste bins should not be located in public areas.
Non-infectious waste garbage bins.
o Black garbage bins should be located in all rooms where waste may be
generated.
o Garbage bins should be located in all public areas.

Figure 1. Segregation of health care waste by waste type
Source: Path, 2005.
Handling
When handling waste, waste management staff should wear protective clothing at all times.
Wearing PPE reduces risk from sharps and protects against exposure to blood and other
bodily fluids, and splashes from chemicals. PPE that is recommended to be worn when
handling waste includes:
Dust mask
Face shield
Heavy duty, gloves
Plastic apron
Clothes that cover the body
Heavy duty, boots
Head cover
Goggle
See also Box A.
Handling sharps
Place the syringe in a safety box immediately after use
Do not recap, bend, or remove needles from syringe.

Handling safety boxes
Safety boxes must be fully and properly assembled before use.
Safety boxes must be sealed and collected when they are full.
Safety boxes must never be emptied or opened.
Put sharps containers as close to the point of use as possible and practical, ideally
within arms reach.
Mark or label safety boxes so that people will not unknowingly use them as a garbage
container or for discarding other items.
Dont shake a safety box to settle its contents and make room for more sharps.
Handling infectious waste bins

Infectious waste bins should be covered before collection,
Bins should be cleaned and disinfected by using 0.5% chlorine solution for 10
minutes after emptying
Collection
Schedule
At a minimum, the infectious waste bins should be collected each day.
Safety boxes should be collected when full or daily.
Garbage bins should be collected each day.
No infectious bag or bin should be collected unless it is labeled with its point of
production and content.
Rotating bins
A rotating bin system must be used if bins are collected during patient hours. When a
bin or safety box is collected, an empty bin or safety box must immediately be put in
its place. This practice is not necessary if bins are collected when the facility is
closed, however emptied bins and new safety boxes must be in place when the facility
opens.
Storage
Each hospital should have a specially designated room for waste storage.
The room should be used only for storage of safety boxes and infectious waste until
final disposal.
Infectious waste should not be stored for more than two days before being treated or
disposed of.
Safety boxes may be stored for up to one week before incineration or transport. The
frequency of incineration should be based on the amount of sharps waste produced
and on incinerator capacity.
The storage room should be totally enclosed and locked.

The storage room should be inaccessible to the public, animals, rodents, birds and
insects.
There should be good lighting and ventilation of storage room.
Transport
On-site transport
A trolley, bin, or wheel barrow may be used for transporting safety boxes and bins
The collected waste should not be left even temporarily anywhere other than at the
designated storage room
Containers should be covered with lids during storage and transport
Carts should be used for transporting bags of infectious waste within the facility
Transport to Off-site Disposal

The waste should be placed in rigid, leak-proof containers before being loaded
Containers should be covered with lids during transportation
When transporting plastic bags of infectious waste, care should be taken to
prevent tearing the bags
Vehicles used for transporting infectious waste should be disinfected (0.5%
chlorine solution) prior to use for any other purpose
The vehicles should carry adequate supply of plastic bags, standard protective
clothing, cleaning tools and disinfectants to clean and disinfect in case of any
spillage
Records should be kept to document all transport of medical waste
Disposal
Options listed in decreasing order of preference.

Sharps waste:
o Incineration using either properly built brick incinerator or another incinerator
o Transport to off-site incinerators, if there is centralized treatment service
o On-site burial
Infectious waste:
o On-site burial
o On site incineration provided that the incinerator is standard incinerator and
capable of destroying such wastes
Non-risk waste:
o Collection by municipal truck for landfill disposal
o On-site secured burning

Incineration
All incinerators should be inspected and maintained by an environmental health professional

on a regular basis, and report of the inspection should be provided to hospital management.
Incineration must follow standard operating procedures, including proper loading, preheating,
and control, according to the design of the incinerator. Dangerous materials must not be
incinerated, including: PVC plastics, mercury thermometers, batteries, x-ray materials,
aerosol cans, glass vials. Incinerator operators must remove ash from the ash chamber and
grate before using the incinerator. Ash should be put in an ash pit or waste pit.
Operator
Incinerator operators must wear protective equipment when loading and operating the
incinerator. Proper equipment includes heavy duty gloves, boots, apron, and goggles.
Protective equipment should be made of materials that do not easily burn or melt.
Burial of infectious waste
Burial pits must be properly constructed and protected. Pits must be above the water table
(the bottom of the pit should at least be 1.5 meter away from the ground water table) and
fenced to prevent access by animals and the community. Non-risk waste must not be dumped
into infectious waste burial pits.
Waste Spills
Despite the implementation of preventive measures, waste spills can occur. Outlined below
are procedures to manage waste spills according to type. Further guidance on managing
pharmaceutical waste spills is given in Chapter 4 Pharmacy Services.
All those managing waste spills should wear personal protective equipment such as protective
gloves, goggles and masks.
A) Infectious Waste Spills

A bleach (Sodium Hypochlorite) solution should be poured over waste and be allowed to
stand for 15 minutes. After the allotted time has passed, using a dustpan and broom, the
waste should be carefully brushed off the ground and into an infectious waste bag or bin.
Ensure no waste remains in the broom. After waste has been removed, cover the area with
bleach solution.
B) Sharps Waste Spills

A bleach (Sodium Hypochlorite) solution should be poured over waste and allowed to stand
for 15 minutes. After the allotted time has passed, using a dustpan and broom, the waste
should be carefully brushed off the ground and into a puncture proof container. Do not allow
hands to contact sharps. Ensure no sharps fragments remain in the broom. After waste has
been removed, cover the area with bleach solution.

C) Managing spills of broken thermometer and blood pressure equipment
Those handling spills of broken thermometer and blood pressure equipment should wear
examination gloves on both hands. All droplets of mercury should be collected with a spoon
(or similar utensil), and placed in a small, closed container for disposal or reuse. Wash or
clean the area with a bleach (chlorine) solution. When process is complete, examination
gloves that were used should be removed carefully and hands washed properly.
Please see Appendix B for a summary of procedures for handling and disposal of healthcare
waste.
3.4.2 Linen Processing
The laundry plays a key role in the function of the hospital and in preventing the spread of
infection. The unit is responsible for transporting linens from wards and other patient areas
to the laundry, laundering the linens and returning items to respective areas. These
procedures ensure the provision of clean linens and clothing for patients and staff alike.
Hospitals may provide the laundry service through its own staff or, or may contract out
services to an outside vendor. However, regardless of how the service is provided and by
whom, the hospital must ensure that standards are met and the guidance adhered to.
The hospital laundry should be equipped with a washing machine, dryer (where possible) and
ironing machine. However, each hospital should first quantify the volume of work done by
the laundry (average number of linens processed by the laundry per day) in order to
accurately assess the number and type of machines that should be purchased. Larger hospitals
with a high volume of work should have large capacity machines that can handle a high
volume of linens and/or an increased number of machines Heavy-duty washers/dryers are
recommended for a large hospital with high patient load.
The hospital should provide leak proof plastic containers with a lid or leak proof plastic bags
at each procedure room to store soiled linens and to prevent spills from soiled linen until they
are transported to the laundry. The laundry should also at a minimum have two separate
carts to transport clean and soiled linens to and from the laundry as well as storage shelves to
store clean linens before they are returned to the appropriate work area. The hospital should
ensure that there is a separate folding and storage room from areas where soiled linen is
presorted.
It is recommended that each unit/work area should be allotted with a designated shelf to
allow separation of linens by case teams and ensure accurate management of linens. Linens
should be checked regularly for holes and/or threadbare areas. Repairs, replacement or
disposal should be done based on the assessment.
Work plan
Each hospital laundry should develop an operating procedure or work plan for laundry
services. The plan would give guidance on the segregation of linen at the ward level,
transport of linens to and from the laundry, cleaning procedures, operation of machines,

segregation of linen by the laundry staff after washing, storing of linen and transport to
different case teams/wards, registration of incoming and outgoing linen and shifts for
working hours.
Supplies
The laundry should ensure that there is always an available supply of detergent and bleach.
Procedures
Linens with visible contamination by blood, body fluids, secretions and excretions are
categorized as soiled" or "contaminated. Other used linen is termed used. These two
categories should be segregated and treated separately. Linen should be handled with
minimum agitation to avoid aerosolisation of pathogenic microorganisms.
Soiled/contaminated linens should be placed in leak proof bags or containers to avoid any
spills or drips of blood, body fluids, secretions or excretions during transportation. Linen
from an isolation room should not be sorted, shaken, or handled excessively. As a general
rule all linens used in a procedure should be considered infectious, even if there is no visible
contamination.
Linens should be disinfected by using hot water and/or bleach. Heavily soiled linen should
be washed separately from non-soiled linens. Staff handling linens should ensure that they
wear personal protective equipment such as boots, heavy-duty gloves, eye protection, aprons
and masks to protect against splashes.
Wash linen (sheets, cotton blankets) in hot water and detergent, rinse and dry preferably in a
dryer or in the sun. Wash wool blankets in warm water and dry in the sun, or in dryers at cool
temperatures. Check all items for cleanliness and rewash if needed.
Linens being supplied to the operating rooms/theatres and high-risk areas, e.g. burns units
should first be autoclaved.
Mattresses and pillows with plastic covers should be wiped over with a detergent. Mattresses
without plastic covers should be steam cleaned (if available) if they have been contaminated
with body fluids. Pillows should be laundered using standard procedures described above.4
Staff should be trained and/or oriented on the laundering process.
Safety
Below are some hazards that laundry staff may face:
Exposure to blood, body fluids, and other excretions
Exposure to sharps and other materials
Contact with chemicals
Noise exposure
Slips/Trips/Falls
4
WHO, Practical Guidelines for Infection Control in Healthcare Facilities, 2003.

The hospital should ensure that appropriate measures are put in place to protect staff from
these and other hazards. For example, the floor should be kept clear of water, and personal
protective equipment should be provided to protect laundry staff against exposure to
contaminated materials. Laundry staff at minimum should have plastic aprons, heavy duty
gloves, masks, protective eyewear (such as goggles) and protective shoes. Other protective
equipment should be provided as necessary. Staff should also be monitored to ensure the
proper use of personal protective equipment.
3.4.3 Housekeeping
Maintaining a clean environment is essential to providing quality care for patients. Proper
cleaning will reduce the number of microorganisms in patient care areas and will help to
minimize the risk of exposure to infectious agents to patients, families, caregivers, visitors
and hospital staff. Hospitals may provide the housekeeping service through its own staff or,
or may contract out services to an outside vendor. However, regardless of how the service is
provided and by whom, the hospital must ensure that standards are met and the guidance
adhered to.
Work plan
The housekeeping department should develop operating procedures or work plan on the
cleaning process and schedule for each unit (clinical vs. administrative areas). Appendix C
presents guidelines for cleaning procedures and schedule for the outpatient and inpatient
units. The provided procedures are meant to serve as a guide for hospitals in devising their
own cleaning schedule and procedures. Further detailed guidance can be found in Infection
Prevention Guidelines for Healthcare Facilities in Ethiopia.
Supplies
The hospital should have a regular supply of all necessary cleaning materials. At a minimum
each Hospital should provide the following:
Disinfectants and detergents, bleach, powder detergents e.g. omo
Mops, cloths for dusting, brooms, soaps , buckets
Personal protective equipments for cleaning staff and alcohol for hand rub
preparation.
The head of the department should plan for and request supplies to meet monthly
consumption needs.
Procedures
Administrative and office areas with no patient contact require normal domestic cleaning
including sweeping, dusting and washing floors and windows with detergent.
All patient care areas should be cleaned by wet mopping, scrubbing or dusting and or
scrubbing using disinfectant cleaning solutions. The cleaning solution should be prepared
according to the guidance outlined in the Infection Prevention Guidelines for Healthcare

Facilities in Ethiopia. Staff should be trained/oriented on how to prepare cleaning solutions
and procedures for preparing the solution should be posted in an area visible to the cleaning
staff.
The pattern of cleaning should be from least soiled area to most soiled and from high to lows
areas. Any areas visibly contaminated with blood or body fluids should be cleaned
immediately. Dry sweeping is not recommended.
Isolation rooms and other areas that have patients with known transmissible infections should
be cleaned with a detergent/disinfectant solution at least daily.
All patient care areas, including horizontal surfaces and all toilet areas should be cleaned
twice a day.
Safety
The hospital should provide cleaning staff with personal protective equipment appropriate for
the work. For example, all cleaning staff should have plastic aprons, heavy duty gloves,
masks and protective shoes. Staff likely to be exposed to substances that may splash or
splatter should also be supplied with goggles. Other protective equipment should be provided
as necessary.
Box 1 below provides a graphic of representation of what should be worn by cleaning staff.
Box A. Personal protective equipment for cleaning staff.
Wearing PPE reduces risk from sharp, germs,

exposure to blood and other bodily fluids, and
splashes from chemicals.
Staff handling waste should wear the following:

Dust mask
Face shield
Heavy duty, gloves
Plastic apron
Clothes that cover the body
Heavy duty, boots
Head cover
Goggle
Other cleaning staff should wear PPE as appropriate

to their exposure.
SOURCE: Adapted from PATH, July 2006.
Staff should also be monitored to ensure the proper use of personal protective equipment and
cleaning supplies.

3.4.4 Instrument processing
There are four main steps in instrument processing as outlined in Figure 2 below:
decontamination, cleaning, sterilization or high-level disinfection and storage.
Figure 2: Instrument processing steps
Decontaminate
Clean
Sterilization High-level
Chemical disinfection (HLD)
High-pressure Chemical
steam Steaming
Dry heat Boiling
Dry/cool and store
Based on guidance given in Infection Prevention Guidelines for Healthcare Facilities in

Ethiopia, the hospital should have clear procedures on how instrument processing should be
done. Instrument processing protocols should be posted in procedure rooms and all staff
responsible for instrument processing should be trained/oriented on the process. In addition,
all staff responsible for decontamination should be trained on how to prepare 0.5% and 0.1%
chlorine solutions from different concentrations of bleach. Instructions for preparing chlorine
solutions should be posted in the procedure rooms and staff instructed to follow the outlined
procedures.
Each hospital should have a consistent supply of bleach (with a visible labeling of the
concentration of chlorine), brushes (preferably tooth brushes), three plastic containers (one
for each step in the process washing with soap (detergent) and water, cleaning with 0.5%
chlorine solution, and rinsing) and personal protective equipment for each procedure room.
The person in charge of the procedure room should plan for and request bleach, detergent and
related supplies to meet monthly consumption needs to ensure that supply is not interrupted.
Stop watches should be provided for each procedure room to ensure compliance to timing for
each step in the decontamination and/or cleaning process.

The hospital should have functioning autoclaves and dry heat ovens for sterilization of
medical equipments. There should also be a supply of 2-4% glutaraldehyde or 8%
formaldehyde for chemical sterilization of plastic items. Steamer pans and boilers should be
in place for high level disinfection purposes. The persons operating the autoclaves and dry
heat ovens should adhere to machine operation instructions. In addition, all staff should be
trained on the use of the machines. The hospital should regularly monitor the effectiveness of
sterilizers using specified indicators. Mechanical, chemical and biological indicators can be
used. Mechanical indicators are most commonly used. This would include checking
adherence to recommended time, temperature and pressure. Chemical indicators are often
used as supplement to mechanical indicators. Although biological indicators (using bacteria)
are considered to be the best method for monitoring the effectiveness of sterilizers, Ethiopian
hospitals may not currently have the capacity to implement this.
All sterile items should be stored in an area and manner to protect the packs or containers
from contaminants such as dust, dirt, moisture, animals, and insects. The storage area of
sterile items for the hospital is best located next to or connected to the place where
sterilization occurs. The space should be in an area separate, enclosed, with limited access
and should be used only to store sterile and patient care supplies.
Persons responsible for instrument processing should be regularly supervised to ensure their
adherence to protocols, proper performance and consistent use of personal protective
equipments during the procedure.
3.4.5 Traffic Flow
Proper management of patient care areas flow of patients and visitors in the hospital is
integral to maintaining high standards of infection prevention. Overcrowding can help the
spread of infections among patients, staff, and visitors. Organization of the patient and
visitor population will not only prevent the unnecessary transmission of disease, but also will
allow the hospital to operate in an efficient manner. Clinical and supportive staff must be
able to perform their tasks in a hospital environment where distractions are minimized.
Furthermore, standards need to be established so that the duties and roles of both staff and
patients visitors are clearly delineated and understood by all parties involved with patient
care. With appropriate patient and visitor control, the hospital can provide quality care in a
clean and safe environment.
Each hospital should strive to control the organization of all patient areas and public spaces.
The hospital layout should be organized in a way that promotes the efficient movement of
traffic throughout the hospital. As much as possible services should be organized close to one
another to minimize patient transit time. Hospitals should ensure that waiting areas have
ample space and provide a secure, shaded area in which patients can wait for care. Further
guidance on hospital layout can be found in Chapter 2 Patient Flow and Chapter 8 Facilities
Management.

Patients and visitors should not be allowed to enter into areas of the hospital where they are
not receiving a service (for example outpatients should not enter inpatient wards, visitors to
inpatients should not go to OPD etc).
Caregiver and visitor control: Putting visitor controls in place serves to prevent confusion
and disputes that may arise between visitors and hospital staff, thus enabling more efficient
hospital operations. The use of visitation hours and placing limits on the total number of
non-hospital staff entering a patient ward area at a given time are both effective methods for
controlling caregiver and visitor access. Visiting hours should be established with
consideration for when health providers conduct the morning and evening rounds, cleaning
staff conducts daily duties, and hospital has meal times. The Hospital should establish a
system to regulate the number of visitors and caregivers allotted for each patient. Limits
should be set on the number of visitors and caregivers allowed to be with a patient at any
given time. ID badges or identification cards should be issued to visitors and/or caregivers to
assist hospital staff in monitoring patient rooms. To ensure that there is clear communication
between a caregiver and the nursing staff, it is suggested that each caregiver sign a contract
(see Chapter 6 Nursing Care Standards, Appendix F for a sample patient caregiver contract,
which delineates the caregivers role in the care of the patient). The contract holds caregivers
accountable for their duties and their conduct within the hospital ward. Furthermore, it
prevents disputes between staff and visitor when a potential conflict arises. Contracts should
outline caregivers responsibilities such as proper visiting hours and leaving the ward to
permit cleaning and nursing staff to perform their duties.
3.4.6 Food Safety
The provision of nutritious, good-tasting and sanitary food is an essential part of patient care.
Meals provided to patients can lessen the need for drugs and other interventions and hasten a
patients recovery shortening their hospital stay. Food borne outbreaks are not uncommon at
hospitals thus measures should be taken to minimize the likelihood of food borne illnesses.
Food safety should be ensured through the provision of adequate, clean facilities for food
preparation and storage.
It is imperative that:
The kitchen is kept clean and free from bacteria
Quality of produce and meats is reviewed and maintained
Quality and taste of food is monitored by Head of Kitchen or other senior manager
Kitchen staff maintain personal hygiene and health
Food purchase and storage

A committee consisting of representatives from the kitchen, environmental hygiene and
procurement unit should be created to oversee the delivery of food items for the kitchen.
Possible committee members could be the kitchen manager, dietician, sanitarian, and
purchaser.

Each time food items are delivered to the kitchen the kitchen manager or delegate should
check the items to ensure that that the food that is delivered is of the desired quality. If the
quality of the food is not acceptable, then the supplier should be informed, rejected items
returned, and if possible, the supplier should provide replacements that meet the committees
specifications.
The food items that are delivered to the kitchen have to be properly stored in a separate clean
area in the kitchen. Food that is perishable and warm should be cooled before storage.
Food handling and preparation

There should be separate cutting boards for meat products and non-meat products
Cooking staff should be oriented on safe handling of food
Cooking should be done at proper temperature and for the appropriate length of time
All kitchen staff should follow hand hygiene procedures outlined in section 3.2.1.
Hand hygiene should be practiced both before and after handling food. In addition to
hand hygiene, kitchen staff should also maintain their personal hygiene. Facilities for
bathing should be made available to all kitchen staff.
Cleaning
The kitchen should be cleaned at the end of each day. Waste should be disposed of regularly
(see waste management section). Special attention should be given to food preparation areas
and cooking equipment and utensils.
Safety
Kitchen staff should have access to face masks, hair covers, and plastic aprons at a minimum.
Other personal protective equipment should be supplied as necessary.
To ensure patient safety and minimize the risk of infection transmission, kitchen staff should
regularly be tested for communicable diseases. Staff should be tested at least every three
months for diseases that can be transmitted through unsafe handling of food; for example
typhoid fever. Any kitchen staff identified as having an active infection should be removed
from food handling and preparation until 24-48 hours after symptoms have resolved.
Below are some hazards that kitchen staff can face:

Ergonomics (repetitive motions, reaching/lifting etc)
Kitchen equipment (hot surfaces, electrical shocks, use of sharp objects etc)
Fire (improper storage of flammable items, poor cleaning etc)
Hazardous chemicals (pesticides, disinfectants etc)
Machine guarding
Food borne disease
Slips/falls
Electrical safety
Infectious materials

Protective measures should be in place to minimize accidents incurred due to the above listed
hazards.
Quality Assurance
Food temperature should be checked. Hygienic and aseptic conditions should always be
checked by the dietician.
The guidelines outlined above apply to any food services provided by the hospital. Hospitals
may provide the service directly, or may contract out services to an outside vendor.
Regardless of how the hospital provides the service, the hospital must ensure that standards
are met and the guidance adhered to.
3.5 Worker safety
In addition to the procedures outlined above, the hospital should ensure that mechanisms are
in place to identify and address occupational health and safety risks to staff. The hospital
should also ensure that staff can access services in the event that they are exposed to
infectious agents.
For more detailed guidance on Occupational Health and Safety refer to Chapter 11 Human
Resources Management; section 3.13 on Occupational Health and Safety. For more guidance
on Hospital Safety please refer to Chapter 8 Facilities Management; section 3.8.
3.5.1 Injection safety
The use of injection materials in the hospital setting exposes healthcare personnel to needle
stick injuries and potentially to infectious materials. The WHO estimates that contaminated
injections caused annually 21 million HBV infections, two million of HCV infections and
260,000 HIV infections. These infections led to 49,000, 24,000 and 210,000 deaths
respectively. 40% of global burden of HBV and HCV among health workers is attributable
to occupational exposure.5 It is imperative that hospitals establish an injection safety plan as
part of an infection prevention and control program.
The injection safety plan should include the hospitals procedures to address the following
areas:
Needle and syringe usage and disposal:
o Every injection is given using a single sterile syringe and needle combination
o Syringes are not reused
o No recapping, manual detaching or manipulation of used needles
o After each use, the needle and syringe are safely disposed of in a puncture
proof container (See section 3.4.1.1 on waste management)
5
WHO, Technical Guidance for Global Fund HIV Proposals, 2008.
http://www.who.int/hiv/pub/toolkits/Injection%20safety.pdf

Provision of injection materials such as auto-disable syringes and disposable syringes
that are of the recommended quality and sterility of the syringes (within expiry date,
WHO/UNICEF certified brand)
Needle stick injuries:
o There is a reporting and tracking mechanism for needlestick injuries
o HIV Post exposure prophylaxis plan (see below)
3.5.2 HIV Post exposure Prophylaxis
The risk of HIV infection after a needle stick injury or other exposure to HIV-infected blood
is estimated to be 0.3% (3 in 1000 or 1 in 300). However, several cases of seroconversion
among healthcare workers exposed to HIV via mucous membrane or non-intact skin have
been documented. Implementation of standard precautions (as described in section 3.2) will
significantly reduce occupational exposure of hospital staff (both healthcare workers and
support staff) to HIV and other blood borne pathogens. In the event that healthcare personnel
(HCP) are exposed, hospitals should have a PEP program in place to identify, assess staff
needing PEP and provide care and treatment.
NB: The following guidelines only address the management of occupational exposure among
healthcare workers. In addition to PEP for occupational exposures, hospitals should provide
PEP services for non-occupational exposure to HIV, such as sexual assault. The
recommendations provided in this section are based on the draft national PEP protocol. The
protocol has not yet been approved but the recommendations provided here can serve as a
guide for hospitals until the national PEP protocol is finalized.
3.5.2.1 Components of a PEP Program
All hospital staff should be aware of standard IP practices to minimize exposure, as well as
where and to whom an occupational exposure should be reported (refer to section 3.13,
Chapter 11 Human Resources Management; for more guidance on occupational health and
safety services).
PEP services can be offered within case teams or through the hospitals ART clinic.
Regardless of where PEP services are provided, the hospital should ensure that there are an
adequate number of staff members that have had PEP training or participated in trainings that
include PEP (e.g. Basic ART, IMAI/IMNCI, and STI/PEP). In addition, the hospital should
ensure the provision of the equipment and supplies necessary for PEP outlined in Box B.

Box B Inputs Required for PEP Service
All Service Outlets

The required IP supplies and hospital infrastructureas described in other sections of this chapter--
must be made available in every service outlet
PEP Outlets
PEP drugs:
o Zidovudine (AZT) or Stavudine (d4T) or Tenofovir (TDF)
o Lamuvudine (3TC)
o Kaletra (Lpr/r) or Efavirenz : one pack in each service outlet area
Rapid HIV test kits
PEP protocols
PEP decision-making tool (wall charts)
PIHCT guideline
PIHCT protocols
Standard patient education materials on HIV, PIHCT, and ART
National IP guideline
Condoms
Penile models
Intra-facility referral forms
ART Clinic
In addition to the items mentioned above for PEP service outlets, the PEP register should be
available in the ART clinic and preferably this should be the primary place of operation for
the PEP focal person.
The availability of PEP services in the health facility should be made known to all staff.
Details of the services that are offered (location, who to contact etc) should be posted in areas
visible to all staff. In addition, availability of PEP services should be included as part of the
hospitals new hire orientation, in service orientation, or in trainings offered through the
hospitals occupational health and safety services or infection prevention training.
3.5.2.2 PEP Procedures
If an occupational exposure occurs, the following procedures for PEP should be followed:
Step 1
Treat exposure:
Use soap and water to wash areas exposed to potentially infectious fluids as soon as
possible
Flush exposed mucous membranes with water
Flush exposed eyes with water or saline solution

Step 2
Report exposures: Report and document the exposure. The incident should be reported to the
healthcare personnels immediate supervisor or case team leader. The supervisor or other
appropriate person should complete an Occupational Blood and Needle Stick Exposures
Recording form presented in Appendix F. The occurrence of the incident should also be
reported to the hospital Incident Officer and Occupational Health and Safety Officer.
Step 3
Determine the level of risk: It is important to determine risk of HIV transmission to the HCP
associated with the HCPs exposure. A number of criteria that should be used to determine
the level of risk are described in detail in thePEP decision-making tool presented in Appendix
D. This tool should also be used to determine the need for PEP, to decide if PEP is indicated
and whether or not a 2-drug or 3-drug regimen is required.
If the exposure occurs during working hours, the case team leader (where the exposure
happened) can treat the exposure site, assess the source patient status, determine the exposure
code.
After working hours (nights, weekends, & holidays): The exposed HCP should report to the
Emergency Case Team for exposure risk assessment. The physician or nurse should complete
the Occupational Blood and Needle Stick Exposures Recording form (Appendix F) and should
utilize the PEP decision-making tool to determine if PEP is indicated.
If PEP is not indicated, the Emergency case team personnel will advise the HCP
accordingly and the exposure case is considered closed at this point.
If PEP is indicated outside regular working hours then the HCP should be given a PEP
starter pack. PEP starter packs should contain sufficient drugs for three days
medication and should be available in the Emergency pharmacy. The HCP should be
instructed to report to the ART clinic on the next working day for further management
and investigations.
Step 4
Counseling and Testing: All healthcare personnel who have been exposed and have PEP
indication should be provided with HIV counseling and testing. Counseling and testing can
either be provided by a trained member of the case team where the exposure occurred If the
testing process is completed during non-working hours, the case team leader should prescribe
the PEP regimen for 2-3 days (for those with PEP indication). Otherwise he/she will refer the
patient to the ART clinic.
Step 5
Provide PEP treatment: Begin appropriate drug and PEP treatment.
Exposed individuals who test negative for HIV, should receive comprehensive
counseling on PEP and receive follow-up care according to the standard PEP
protocol, including the completion of the one month treatment and subsequent HIV

tests at 3 and 6 months post-exposure.
Individuals who test positive for HIV should be enrolled in chronic HIV care and
receive standard HIV/ART services.
A sample Post Exposure Prophylaxis Patient Tracking Form (from draft National PEP
Guideline) is presented in Appendix E. This form should be used to track HCPs over the
course of their treatment.
Step 6
Follow-up testing: Follow-up with laboratory testing at 3-months and 6-months post-
exposure.
Step 7
Maintain records: Keep records of all exposed staff with the intent to maintain
confidentiality.
3.5.2.1 Management of PEP Services
To ensure that PEP services are implemented according to the standard protocol, hospitals
should assign a PEP focal person. This role could be held by the Occupational Health and
Safety officer (see section 3.13 of Chapter 11 Human Resource Management). He/she should
regularly (at least weekly) monitor the availability of inputs (as listed in Box B above) and
supplies necessary to provide PEP services, the quality of PEP services, the efficiency of
referral linkages for patients who started PEP during non-regular hours and the completeness
of PEP registries. The PEP focal person should be an active member of the hospital ART
multi-disciplinary team (MDT) and IP committees and participate in meetings with the MDT
and IP committees at least monthly. The PEP focal person should also prepare reports for the
IP committee and Senior Managment Team (SMT) on PEP services. The report should
include:
The number of occupational and non-occupational exposures (categorized by type)
reported in the hospital
The age, sex, and occupation (including case team) of workers reporting an exposure
The number of patients that started PEP treatment
The number of patients that completed the PEP treatment
The number of patients that received 3 or 6 month post-exposure HIV testing
The data generated from the PEP outlets should be used by case teams and senior
management to identify ways of improving PEP and ART services in the hospital as well as
ways to prevent the occurrence of occupational exposures among HCP.
3.5.2.3 Monitoring and Evaluation of PEP Services
Hospital management should monitor the implementation of PEP services by checking the
availability of the inputs, following the process and the output of the PEP service (as defined
below) first at baseline and every 4-6 months thereafter.

The hospital management should monitor the process of the PEP program implementation by
assessing:
The availability of all input materials
The continuous availability of PEP services both at regular and non-regular working
hours
The adherence of healthcare workers to the national PEP protocol
The presence of regular (monthly) IPC committee meetings
The minutes of hospital IPC committees
Reporting system for the IPC committees to the hospital management
The implementation of operational (action) plans developed for PEP following IPC
committee meetings
3.6 Equipment, Supplies and Infrastructure
The IPC Committee should conduct a needs assessment to identify:

current stock of supplies (personal protective equipment and cleaning supplies such as
gloves, soap, towels, linens, alcohol, etc)
availability and functionality of sinks, toilets
availability and functionality of incinerator and other waste disposal equipment
availability and functionality of laundry equipment
availability and functionality of ventilation systems
availability and quality of water supply
The assessment should be done periodically (at a minimum annually) to ensure that any new
needs are identified. Conducting an evaluation not only permits the IPC committee and
hospital management to estimate needed supplies and equipment for implementing IPC
policies, but allows staff to identify their own needs. Hospital management can also use
information from the evaluation to properly plan and budget for purchase/maintenance of
IPC-related supplies and equipment.
The need for IPC supplies and equipment can be assessed on a department/service area basis
as outlined in Table 4 below:
Table 4. IP Supplies and Equipment Needs Assessment

Case Team Hazard PPE need
Laundry Blood contaminated linens Gloves
Apron
Boots
Masks etc.
Operating room Blood splash Apron
Goggles
Face shield

IP supplies should be purchased regularly to ensure that there is an adequate supply available.
If IP supplies are purchased through a bidding process, clear specifications should be given to
the bidding committee or unit responsible for purchasing the IP supplies that outline the
desired quality and type of materials to be purchased.
In addition to assessing supply needs, the IPC committee should also assess infrastructural
needs required to support infection prevention activities. The IPC committee should assess
the availability, functionality as well as quantify the cost of repair/replacement. The
assessment could include plumbing and sewage, sinks, incinerator for waste disposal and
laundry equipment.
The key infrastructural needs are outlined in brief below. For more detailed guidance please
refer to the Chapter 8 Facilities Management.
Buildings
The design and layout of the hospital building can impact the effectiveness of infection
prevention practice. Increasingly architects of hospitals design facilities to improve traffic
flow and minimize risk of infections. When additions or new constructions are planned, the
IP committee should be consulted to provide input (with respect to infection prevention) on
the design of the facility.
Water, sewage and plumbing

The hospital should ensure that safe water is available 24 hours a day. Provisions should be in
place to ensure that when water outages/shortages occur that water supply is not interrupted.
Tankers or other water storage containers should be in place. They should be cleaned
regularly and the quality of water should be sampled periodically to check for contamination.
Sinks, toilets
It is important that all wards within a hospital have properly functioning sink and toilet
facilities. At a minimum, there should be a sink in each patient care area. Facilities should
be accessible to patients, staff and visitors. Larger wards or those with more than one
entrance are recommended to have a minimum of two sinks with plumbing. There should
also be a functional sink at each patient area, clinical room, and nursing station. Investments
must also be made to ensure existing sinks work properly and preventive maintenance is
done. Repairs should be scheduled as necessary. Sinks and toilets should be cleaned and
disinfected regularly.
Electricity
The hospital should ensure that electricity is available 24 hours a day. In particular, procedure
rooms and operating rooms should have adequate lighting. A generator or other energy
supply should be available for use when power supply is interrupted.
Ventilation
Proper ventilation of patient care areas can reduce trapping of air, promote air circulation and
help to minimize the transmission of infections.

General patient care areas should be well ventilated. In the absence of HEPA filters and
mechanical filtration systems, windows should be opened to allow for ventilation of rooms. A
study conducted in Peru showed that hospitals which had high ceilings and large windows
and used natural ventilation minimized the risk of airborne transmission of infections such as
tuberculosis.6 Natural ventilation can be a low cost intervention that can minimize the spread
of infection.
Lay out of patient beds

Patient rooms should be organized in a way that will reduce transmission risk. In wards with
an open layout, spacing between beds should be 1-2 meters.
3.7 Monitoring and Surveillance
An IPC program must include routine monitoring and surveillance. The hospital must assess
the success of its infection prevention program by measuring adherence to IP guidelines as
well as identifying and tracking HCAIs quarterly, at a minimum.
3.7.1 Monitoring
Hospitals should measure the effectiveness of all components of the IP program including
inputs, processes and outcomes:
For example:
Inputs: IP inputs would include equipment and supplies for hospital staff. Input data can be
used to assess the availability, quantity and quality of supplies and equipment needed for IP
practice. In addition, data can be used to conduct cost analysis.
Process and Outcomes: This data can be used to assess the safety and effectiveness of a
hospitals operations and can be collected through the following methods:
Performance indicators: The IP Committee must develop and monitor performance
indicators to assess the progress of the IP program. Targets should be set for each
indicator based on improvements using a percentage scale. For example, a key target
may be a 50% improvement in the number of staff observed using proper infection
prevention techniques within a given day; or rate of healthcare facility acquired
infection. This will allow the IP committee to work towards continual improvements,
rather than reaching a particular benchmark.
Qualitative methods for assessing quality include clinical vignettes and consultation
observation. Clinical vignettes involve providing staff with hypothetical cases and
recording their response on how they would handle the given cases. Consultation
observations involve observing staff as they interact with patients and adhere to
national IPC guidelines.
Surveys: Often used to collect data on facility procedures, for example, hand hygiene
procedures being used by facility staff (please see Appendix G). A checklist can also
6
Escombe et al, 2007
be used to assess adherence to IP guidelines (please see Appendix I). Surveys are
more common as they can be used to collect a large amount of data at once and is
easier to implement than continuous reporting.
Observation: The IPC Committee also can conduct unannounced site visits to various
case teams on a monthly basis. These site visits would ostensibly be carried out to
determine what is working and what is not. This approach could provide a strong
incentive for the case teams to maintain a high level of IP practices. It would also act
as an indicator which the IP Committee could use to determine the efficacy of the IP
program and implement changes where necessary.
3.7.2 Surveillance of Nosocomial Infections
Monitoring and measuring healthcare acquired infections can provide valuable information
on the effectiveness of the hospitals infection prevention program. Tracking the number of
HCAIs or rate of HCAI allows hospitals to assess quality of care and patient safety. In
addition, data can reveal areas for improvement or gaps in practice that need to be revised or
strengthened. HCAIs be included as one of the indicators in the Balanced Scorecard that is
monitored regularly by the Governing Board (See Chapter 13 Monitoring and Reporting).
In devising a surveillance program the IP committee should consider the following:

Patients and units to be monitored
Type of infections and relevant information to be collected
Frequency and duration of monitoring
Methods of data collection
Methods for data analysis, feedback and dissemination
Methods to ensure confidentiality of information
The methods to be used and staff responsible for coordinating and conducting surveillance
should be clearly outlined in the hospitals HCAI surveillance protocol. In addition, staff
involved in coordinating or collecting HCAI data should include someone trained/oriented in
IP practice and knowledgeable in data collection and analysis techniques.
Either prevalence or incidence of HCAIs can be tracked. Prevalence studies would be

conducted at one point in time and would measure infections that exist on the day the survey
is done. Incidence surveys measure number of infections that occur in patients over a defined
period of time. For an incidence survey, patients would be tracked throughout the course of
their stay in the hospital and the incidence of an infection would be recorded. This method is
most effective when conducted for specific infections (surgical site infections) or in specific
units (surgical unit or ICU).
Conducting surveillance of HCAIs can be a time consuming and costly undertaking.

Therefore when resources are limited, facilities can choose to focus on specific units or
specific types of infections. For example, the hospital HCAI surveillance can begin with
tracking surgical site infections and/or surveillance of particular invasive procedures such as
endoscopy. Various strategies and the methodologies that should be used are outlined in

detail in the WHO document: Prevention of Hospital Acquired Infections: A Practical Guide
WHO/CDS/CSR/EPH/2002.12. For further guidance on setting up a HCAI surveillance
protocol please reference this document. In addition, a sample data collection for monitoring
HCAIs is presented in the Appendix H).
3.7.3 Using the data
The results of the surveillance studies should be compiled by a member of the IP committee
in a written report on a regular basis. The report should include details of the study including:
time frame, the department(s) included, the number of patients seen by the department(s)
within the time frame, number of HCAI detected, and rate of HCAI. The report should also
include analysis of the potential causes of the HCAIs, problems identified and recommended
solutions. The report should be submitted to the IPC Committee and Senior Management
Team for action or resolution.
Data can be used to show the savings in cost that preventing HCAIs can bring. In order to
show the benefits of reducing HCAIs, simple calculations can be done based on the following
assumptions:
1) Assume a hospital acquired infection rate of 20% of the patients admitted: (Note that
the literature states that HCAIs can be as high as 40%).
2) Average daily admission of seventeen patients. (Approximate number for a 250 bed
hospital.)
3) Assume three additional nights stay in-hospital resulting from HCAIs.[20]
Calculation based on previous assumptions:

In one month of 30 days, we would expect approximately 510 admissions. 102 those patients
would contract an HCAI per month. These 102 patients would result in an additional 306
days of admission and care.
Over the course of a full year, the total number of avoidable in-hospital days could be as high
as 3,672. The staff time and resources needed to treat these avoidable in-hospital days
becomes a very significant drain on already overcrowded hospitals with limited resources. In
fact, if the hospital can implement a very aggressive and effective IP program a greater
number of in-hospital days can be avoided as follows:
Percentage Reduction Avoided In-Hospital

In HCAI Rates Days per Year
10% 1,836
20% 3,672
30% 5,508
40% 7,344
Implementing an effective IP program that can reduce the rate of HAIs will increase both
staff time and resources used by the hospital to implement better infection prevention
practices and thus further reduce the rate of HCAIs.

In addition, information that is gathered through surveillance can be used to reward
individuals or case teams that are performing well. As an added incentive, a Case Team of
the Month certificate or award could be presented to those units who have significantly
lowered the HCAIs in their case teams or have implemented innovative changes that could be
used as models for other case teams to follow within the hospital. Recognition and reward
can go a long way in motivating staff and creating a sense of ownership for their work.
3.8 Infection Prevention Training
Successful adoption of infection prevention standards requires periodic Infection Prevention

training for all staff. In order to effectively implement IP practices, staff must first be
informed and educated on current IP principles.
The Infection Prevention team should assess training needs of the staff and provide required
training in collaboration with the human resources department. Trainings should include
general information on IP practice and principles as well as practical skills training. Trainings
for all staff should include general IP principles but should also be tailored and appropriate to
staff job functions. Hospitals can contact partner organizations to provide standardized IP
trainings for staffthrough either on site or off site trainings. In addition, orientation on IP
can be provided on site by hospital staff. Materials should be adapted from standard training
materials and trainers should be trained in IP. Hospitals should provide periodic re-training or
orientation for staff and review the impact of trainings. Further IP information can be given to
staff through awareness programs and campaigns.
A motivated and invested hospital workforce is essential to ensuring the sustainability of IP

policies. As such, successful adoption of infection prevention standards requires that
Infection Prevention trainings not only educate hospital staff on IP policies, but also motivate
the staff to adhere to the IP guidelines. Staff ownership can be cultivated by:
Involving staff by asking their input on IP policies
Assigning a staff member of each case team a role in coordinating and monitoring
staff on infection prevention policies
Providing orientation and sensitization on the importance of IP
The following are additional recommendations on what elements should be included in a

comprehensive IP training to support implementation of an IP program.
Establish the importance of IP with staff: To facilitate staff investment in implementing IP
policies, the IP committee should ensure that all staff understand that the IP policies they are
being trained in:
Prevent the spread of unnecessary infections,
Improve the quality of patient care,
Promote a safe environment for both patients and staff, and
Ensure that patients have a clean environment so that recovery and length of stay

is at an ideal standard.
Use appropriate training techniques: It is necessary that infection prevention policies are
clearly understood by all hospital staff. This can be accomplished by using group-based
training and demonstrative techniques to ensure that all staff, including low-literate staff, are
sufficiently informed on IP practices.
Foster Staff Motivation: To maximize the benefits of infection prevention training, the
following items are suggested to maintain a motivated staff:
Senior management, physicians, and case team leaders should be role-models in
following infection prevention guidelines. They show due diligence in adhering to
infection prevention policies
Make and award certificates of achievement following the IP training
Suggest that letters of recommendation be written and placed on file for staff after
good performance evaluations are achieved
Publicly recognize staff as individuals or in case teams that exemplify excellence in
infection prevention practice. For example, a wall of recognition or employee of
the month award can be used to create positive reinforcement for staff
Distribute IP guidelines throughout hospital: Once training has been completed, materials
relating to IP guidelines should be posted in both public and private spaces throughout the
hospital. The IP guidelines should be strategically located in places where IP must be
practiced, for example, hand hygiene posters should be posted in all hospital bathrooms as a
reminder to staff to wash their hands.
3.8.1 Educating patients, caregivers, and other visitors regarding IP policies
Family members/caregivers are integral in the health delivery process, as they may assist in
the care of the patient while he/she is hospitalized. Therefore it is critical to ensure that
family members and other caregivers are informed and educated on IP policies. Since
caregivers and visitors are not trained hospital staff, special attention is needed in educating
all visitors on appropriate IP policies.
Involve the nursing staff in training patients and visitors. The nursing staff are responsible
for educating patients and visitors about IP practices within the hospital. Nurses should be
held accountable for effectively communicating proper IP policies to both patients and
visitors. Since some patients may be illiterate, it is necessary that representatives from the
nursing staff recite the roles and responsibilities to all patients and visitors who enter the site.
Educate patients and visitors on IP policies using illustrative pamphlets. The nursing staff
can educate patients and visitors in either a group or an individual basis. The hospital should
have pamphlets and/ or brochures that highlight the IP practices that the patients, caregivers
and visitors are expected to abide by. For example, educational pamphlets should address
hand hygiene procedures and visiting hours. Brochures, pamphlets, or other educational
materials should be illustrative in nature. This enables all visitors and patients regardless

of education or literacy levelto quickly grasp the concepts of IP policies. Wherever
possible, posters detailing IP practices also should be posted in patient care areas.

In order to determine if the Operational Standards for Infection Prevention have been met by
Table 5. Infection Prevention Checklist

Yes No
1. An Infection Prevention Committee has been established.
2. Terms of reference for the Infection Prevention Committee are defined.
3. An operational plan that defines the hospitals infection prevention
activities has been developed.
4. Monitoring of infection prevention activities is conducted and reported to
the senior management team.
5. Healthcare acquired infections are tracked.
6. Standard precaution practices are defined and in place.
7. Transmission based precaution practices are defined and in place.
8. Equipment needed to provide infection prevention activities are available.
9. Supplies needed to provide infection prevention activities are available.
10. Trainings and orientations on infection prevention are provided to staff.
11. Health education on infection prevention is given to patients and
caregivers.
4.3 Indicators

Table 6 Infection Prevention Indicators
1. Total number of patients with an Quarterly
infection arising >48 hours after
admission during reporting period
/total number of admissions during
Healthcare acquired infection rate reporting period *100
2. a) Number of occupational exposures a) Total number of occupational Quarterly
reported in the hospital, exposures during reporting
categorized by type of exposure period, categorized by type of
exposure
b) Number of on-occupational b) Total number of non-
exposures reported in the hospital, occupational exposures during
categorized by type of exposure reporting period, categorized
by type
3. Quarterly
Total number of people started on
The number of people that started PEP PEP treatment during the reporting
treatment period
4. Total number of people that Quarterly
completed PEP treatment during
the reporting period/
Total number of people who
should have completed PEP
% of people that completed the PEP treatment during the reporting
treatment period*100
5. a) Number of days when incinerator a) Total number of days that the Quarterly
was not working incinerator was not working
during the reporting period
b) % of total days b) Total number of days that the
incinerator was not working
during the reporting
period/total number of days in
reporting period *100
6. Inpatient satisfaction survey: % of Total number of inpatients who Quarterly

respondents who answered always or respond always or usually to the
usually to the question During this listed question/ Total number of
health facility stay, how often was the inpatients respondents*100
room you were sleeping in kept clean?
7. Total number of outpatients who
Outpatient satisfaction survey: % of respond agree or strongly agree
respondents who answered agree or to the listed questions/ Total
strongly agree to the question The number of outpatients
outpatient department was clean respondents*100
Source Documents
1. Admasu, K. (2008). Assessment of Infection Prevention Practices in Hospitals in Addis

Ababa. MPH Thesis. University of Gondar.
2. Bennett, C., and Rockwell, K. (1995). Targeting Outcomes of Programs (TOP): An

Integrated Approach to Planning and Evaluation. Retrieved October 2008 from:
http://deal.unl.edu/TOP/.
3. Colton, D, (1997). The Design of Evaluations for Continuous Quality Improvement.

Eval.Health Prof. 20.3:265-85.
4. Centers for Disease Control and Prevention. Guidance for the selection and use of
personal protective equipment in healthcare settings. Retrieved on December 12, 2006
from www.cdc.gov/ncidod/dhqp/pdf/ppe/PPEslides6-29-04.pdf.
5. Centers for Disease Control and Prevention. (2001). Guidelines for the Management of
Occupational Exposures to HBV, HCV, and HIV and Recommendation for Postexposure
Prophylaxis. Atlanta: CDC.
6. Department of Health Republic of South Africa. (2007, April). The Draft National
Infection Prevention and Control Policy for TB, MDRTB, XDRTB. Retrieved from
www.doh.gov.za/docs/policy/tb/part1.pdf on March 3, 2009.
7. Escombe, A.R., Oeser, C.C., Gilman, R.H., Navincopa, M., Ticona, E., Pan, W.,
Martnez, C., Chacaltana, J., Rodrguez, R., Moore, D.A., Friedland, J.S., Evans, C.A.
(2007, February) Natural ventilation for the prevention of airborne contagion. PLoS Med;
4(2):e68.
8. Fort A, (2000). Measuring Provider Performance: Challenges and Definitions. Prime II

Better practices. Retrieved October 2008 from
http://www.prime2.org/prime2/pdf/measuring_perf.pdf#search=%22prime%20ii%20mea
suring%20provider%20performance%22.
9. Federal HIV/AIDS Prevention and Control Office. Federal Ministry of Health, Ethiopia.
(2007, October) Comprehensive HIV Performance Standards for Ethiopia. Draft.
10. Federal Ministry of Health, Ethiopia. 2005. Infection Prevention Guidelines for
Healthcare Facilities in Ethiopia.
11. Federal Ministry of Health, Ethiopia. (2009, March). Healthcare Waste Management
Guidelines- Ethiopia. Facility Guideline and Standard Operating Procedures for
Hospitals. Draft.
12. The Global Fund Sixth Call for Proposals Tuberculosis and Prevention and Control.
Retrieved on October 14, 2009 from
http://www.theglobalfund.org/grantdocuments/6ETHT_1317_0_full.pdf
13. Gold, J., Tomkins, M., Melling P., Bates, N. (2004, May). Guidance Note on Health
Care Worker Safety from HIV and other Blood Borne Infections. Washington DC, USA:
The International Bank for Reconstruction and Development/The World Bank.
14. Graves, N., Weinhold, D., Tong, E., Birrell, F., Doidge, S., Ramritu, P., et al. (2007).
Effect of Healthcare-Acquired Infection on Length of Hospital Stay and Cost. Infection
Control and Hospital Epidemiology. 2007 March;28(3):280-92

15. Hulscher, M. E. et al., (2003). Process Evaluation on Quality Improvement Interventions.
Qual.Saf Health Care 12.1: 40-46.
16. Joint Commission International. (2002). Joint Commission International Accreditation

Standards for Hospitals. Second edition. Illinois: Joint Commission Accreditation of
Health Care Organizations.
17. Kak, N., Burkhalter, B., & M. Cooper, (2001). Measuring the Competence of Healthcare
Providers. QA Operations Research Issue Paper: Quality Assurance Project. Retrieved
October 2008 from http://www.qaproject.org/pubs/PDFs/comptence.pdf.
18. Koll, B., Raucher, B., Nadig, R. HIV Exposure Prophylaxis: 1996-1998. (2000).
American Journal of Infection Control 28(1).
19. Johannessen, L.M., Dijkman, M., Bartone, C., Hanrahan, D., Boyer, M.G., Chandra, C.
(2000, May). Health Care Waste Management Guidance Note. HNP Discussion Note.
Washington DC, USA: The International Bank for Reconstruction and Development/The
World Bank.
20. Management Sciences for Health. (1998). Performance Management Tool. Health and
Family Planning Managers Toolkit. Retrieved October 2008 from
http://erc.msh.org/newpages/english/toolkit/pmt.pdf
21. Measure Evaluation: http://www.cpc.unc.edu/measure
22. McDavid J. and Hawthorn, L., (2006) Program Evaluation and Performance
Measurement. Thousand Oaks, CA: Sage Publications.
23. Morbidity and Mortality Weekly Report. (2005). Updated U.S. Public Health Service
guidelines for the management of occupational exposures to HIV & recommendations for
PEP. 2005;54(RR-9).
24. PATH. (2005, October). Training Health Workers in the Management of Sharps Waste
Retrieved from: www.path.org/files/TS_sharps_waste_training_pp41-86.pdf on May
15, 2007.
25. PATH. (2006, July). Waste Handlers.
26. Rossi P., Lipsey M., and H. Freeman, (2004). Evaluation: A Systematic Approach.
Thousand Oaks, CA: Sage Publications.
27. Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection
Control Practice Advisory Committee. (2007, June). Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Retrieved
from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
28. Teitjen, L., Bossemeyer, D., McIntosh, N. (2003). Infection Prevention Guidelines for
Healthcare Facilities with Limited Resources. Baltimore: JHPIEGO Corporation.

29. USAID: Human Resources for Health: http://www.hrhresourcecenter.org/
30. USAID. USAID Infectious Disease. Retrieved on November 11, 2009 from
http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/africa/ethiopia_pr
ofile.html.
31. United States Government Accountability Office. Report to the Chairman, Committee on
Oversight and Government Reform, House of Representatives. Healthcare Associated
Infections in Hospitals. Leadership Needed from HHS to Prioritize Prevention Practices
and Improve Data on These Infections. March 2008.
32. United States Department of Health and Human Services. (2001). Guidelines for the
Management of Occupational Exposures to HBV, HCV, and HIV and Recommendation
for Postexposure Prophylaxis. Atlanta: Centers for Disease Control and Prevention.
33. United States Department of Health and Human Services, ed. (2003). Guidelines for
Environmental Infection Control in Health-Care Facilities. Atlanta: Centers for Disease
Control and Prevention.
34. Wagner, C. et al. (1999). A Measuring Instrument for Evaluation of Quality Systems.
Int.J.Qual.Health Care 11.2: 119-30.
35. Weiss, C. (1998). Evaluation: Methods for Studying Programs and Policies. Upper
Saddle River, NJ: Prentice Hall.
36. W.K Kellogg Foundation. (2004). W.K. Kellogg Foundation Evaluation Handbook.
37. W.K Kellogg Foundation:

http://www.wkkf.org/default.aspx?tabid=75&CID=281&NID=61&LanguageID=0
38. World Bank. (2008). Are You Being Served? New Tools for Measuring Service Delivery.
Washington, DC: The International Bank for Reconstruction and Development /The
World Bank.
39. World Bank: http://www.worldbank.org/ieg/ecd/me_tools_and_approaches.html
40. World Health Organization African Region: Ethiopia. Injection Safety. Retrieved on
October 12, 2009 from
http://www.who.int/countries/eth/areas/immunization/injection_safety.
41. World Health Organization. (2002, January). Guidelines on Prevention and Control of
Hospital Acquired Infections. New Delhi: Regional Office for South-East Asia
42. World Health Organization. Hospital Hygiene and Infection Control. Retrieved on March
3, 2009 from www.who.int/water_sanitation_health/medicalwaste/148to158.pdf.

43. World Health Organization. (2004). Practical Guidelines for Infection Control in Health
Care Facilities. World Health Organization Regional Office for Western Pacific, Manila,
Regional Office for South-East Asia, New Delhi SEARO Regional Publication No. 41
WPRO Regional Publication. Retrieved from
http://www.searo.who.int/LinkFiles/Publications_PracticalguidelinSEAROpub-41.pdfon
March 3, 2009.
44. World Health Organization. (2003, 8 December). Practical Guidelines for Infection
Control in Healthcare Facilities. Geneva: World Health Organization.
45. World Health Organization, ed. (2002). Guidelines on Prevention and Control of Hospital
Associated Infections. New Delhi: Regional Office for South-East Asia.
46. World Health Organization, ed. (2002) Prevention of Hospital-Acquired Infections: A

Practical Guide- WHO/CDS/CSR/EPH/2002.12. Second ed. Malta: Department of
Communicable Disease. Surveillance and Response.
47. World Health Organization, ed. (2004). Safe Piped Water: Managing Microbial Water
Quality in Piped Distribution Systems. London: IWA Publishing.
48. World Health Organization. (2006 ). Health Aspects of Plumbing. Geneva: WHO Press.
49. World Health Organization. (2008 ). Technical Guidance for Global Fund HIV proposals.
Broad area: Prevention. Service Delivery area: Injection Safety and related infection
control. Retrieved from: http://www.who.int/hiv/pub/toolkits/Injection%20safety.pdf on
12 October 2009.
50. Yuan, C.T., Dembry, L.M., Higa, B., Fu, M., Bradley, E.H. (2009). Perceptions of Hand
Hygiene Practices in China. Journal of Hospital Infection (71) 157-162.
51. Recommendations of the Advisory Group of Infections Subgroup on Surveillance of

Antimicrobial Resistance and Hospital Acquired Infections (HAI). A Framework for
National Surveillance of Hospital Acquired Infections in Scotland.
52. Draft Infection Prevention Operational Guidelines (WHO/FMoH). (2008) unpublished.

Appendices
Chapter 7 Infection Prevention and Control

Appendix A: Handwashing Techniques
SOURCE: WHO. 2005. Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. WHO:
Geneva
Chapter 7 Infection Prevention and Control Appendix A: Page 1 of 1

Appendix B: Summary of Procedures for Handling and Disposal of Health Care Waste
Type of Waste Procedures

General waste is immediately placed in the general waste bin (black) by the
General waste person generating it.
Waste handler collects general waste daily, using a wheelbarrow/cart
designated for general waste.
If offsite disposal is available, the waste is stored until the scheduled collection
day.
On days when the incinerator is being operated, the general waste is taken
directly to the incinerator or to burial pit.
If the incinerator is not operating on that day, the waste handler stores general
waste in a covered, secure location until final disposal. (Waste should not be
stored for more than 2 days).
Incinerator operator destroys general waste according to schedule.
Incinerator operator removes ash and disposes of it in an ash pit. (Remove ash
only after the incinerator has cooled down completely)
Food waste is immediately placed in the designated bin.
Food Waste Waste handler collects and disposes of food waste immediately after meal
times.
If offsite disposal is practiced, food waste should only be stored for up to 1
day.
If no on-site disposal, waste handler buries food waste daily. It is highly
recommended that food waste should be composted. (When burying, strictly
follow the guidelines on burying waste)
Health care provider immediately places infectious waste in the infectious
Infectious waste waste bin with liner bag. (yellow)
Waste handlers collects waste every day or when the liner bag is full using a
wheelbarrow/cart designated for infectious waste
On days when the incinerator is being operated, the infectious waste is taken
directly to the incinerator or it shall be disposed using burial technique.
If the incinerator is not operating on that day, the waste handler stores
infectious waste in a covered secure location until final disposal. (Infectious
waste should be disposed of within 2 days, but placenta and anatomical waste
should be disposed on daily basis).
Incinerator operator destroys infectious waste according to schedule.
Incinerator operator removes ash and disposes of it in an ash pit
Injection provider immediately places used syringe in a safety box
Sharps Injection provider closes safety box when its th full and obtains new safety
box,
Waste handler collects filled safety boxes for storage in a secure covered, dry
location awaiting final disposal.
Waste handler transports safety boxes to incineration site using a
wheelbarrow/cart designated for infectious waste.
Incinerator operator destroys safety boxes according to schedule. (Safety
boxes should be destroyed within one week).
Incinerator operator removes ash and disposes of it in an ash pit
Chapter 7 Infection Prevention and Control Appendix B: Page 1 of 1

Appendix C: Suggested Cleaning Guidelines for Hospital Environments
Item/Area Method Minimum Frequency
Outpatient Waiting Use clean cloths and change frequently Daily; pay attention to chairs
area during cleaning; disinfectant solution and tables and other surfaces
preferred (follow contact time). Wet in frequent contact with
mop floor (detergent is adequate). hands.
Exam Use clean cloths for each room; change Between patients unless
room/area cloths frequently when doing a large surfaces are covered (then
area; disinfectant solution preferred daily) or immediately when
(follow contact time). Wet mop floor contaminated with
(detergent is adequate unless blood/body fluids. Pay
contaminated with blood/body fluids attention to exam table,
then use a disinfectant). chairs, and tables.
Hand Use disinfectant to clean sink, water Daily

washing tap, and faucet handles. Re-supply
sinks soap, clean towels.
Bathrooms Use dilute bleach or other disinfectant Daily; more often as needed
to clean toilet, sink, water tap, faucet
handles, and door knobs. Wet mop
floor with a disinfectant solution. Re-
supply soap, clean towels.
Corridors Wet mop floors; detergent/water Daily

solution is adequate. Change bucket
solution and mop head frequently.
Linen Soiled linen should be minimally Daily, more often as needed.

handled in such a way to avoid
aerosolization; bagged, stored
separately until delivered to laundry.
Trash Empty daily, more often as needed.
Chapter 7 Infection Prevention and Control Appendix C: Page 1 of 2

Item/Area Method Minimum
Frequency
Inpatient Open Use clean cloth; disinfectant (appropriate contact Daily; area around a
wards time); clean all horizontal surfaces including bed patient when
rails, tables, chairs; clean door knobs, light discharged before
switches/plates. Wet mop floors; detergent/water next patient put in the
solution is adequate. Change bucket solution and bed.
mop head frequently.
Individual Use clean cloth; disinfectant (appropriate contact Daily and at

patient time); clean all horizontal surfaces including bed discharge
rooms rails, table, chairs; clean door knobs, light
switches/plates. Wet mop floors; detergent/water
solution is adequate. Change bucket solution and
mop head frequently.
Bathrooms Use dilute bleach or other disinfectant to clean Every shift if shared;
toilet, sink, water tap, faucet handles, door knobs, daily if not shared.
showers/tubs. Re-supply soap, clean towels. Tubs should be
cleaned in between
each patient.
Hand Use a disinfectant to clean sink, water tap, faucet Every shift
washing handles. Re-supply soap, clean towels.
sinks
Corridors Wet mop floors; detergent/water solution is Daily
adequate. Change bucket solution and mop head
frequently.
Linen Soiled linen should be minimally handled in such Daily, more often as
a way to avoid aerosolization; bagged, stored needed.
separately until delivered to laundry.
Trash Empty daily, more often as needed.
Chapter 7 Infection Prevention and Control Appendix C: Page 2 of 2

Appendix D. Post-exposure Prophylaxis Forms: Decision Making Tool
1. Determine the Status Code (SC)

Risk assessment of the source patient choose SC1, SC2, or SC unknown
2. Determine the Exposure Code (EC)

Risk assessment of the exposure choose EC 1, EC 2, or EC 3
Decision tree to evaluate need for PEP.
Source patient
HIV - HIV + Unknown/ unwilling to be tested*
High background Low background

risk risk
No PEP No PEP
PEP
*CDC recommendation: usually PEP unnecessary; consider use if source patient is high
risk.
** If HCW is HIV +, he/she would not take PEP, but should be referred to ART clinic for
continued care. If HIV status of HCW unknown or previously negative (-), PEP may/may
not be indicated depending on the risk assessment.
Chapter 7 Infection Prevention and Control Appendix D: Page 1 of 3

Determining HIV status code of the source (SC)
HIV Negative No PEP
Asymptomatic / Viral load < 1500 copies/mL = HIV SC1
HIV Positive
Symptomatic HIV infection, AIDS, Acute seroconversion, patient on

antiretroviral therapy, Viral load > 1500 copies/mL = HIV SC2
HIV status unknown or source unknown = HIV SC unknown
Determining the exposure code (EC)

Exposure on mucous membrane or broken skin

Estimate volume

Few drops, short duration = EC1
Several drops/ long duration/ major blood splash = EC2
Exposure on intact skin No PEP
Percutaneous exposure Determine severity Solid, superficial injury = EC2
Hollow needle deep puncture = EC3
Recommended HIV post exposure prophylaxis for percutaneous injuries

Exposure code
Status code EC 2 EC 3
SC 1 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
SC 2 Recommend expanded 3-drug PEP Recommend expanded 3-drug PEP

SC unknown Generally, no PEP warranted; however, Generally, no PEP warranted;
consider basic 2-drug PEP for source however consider basic 2-drug PEP
with HIV risk factors. for source with HIV risk factors
HIV-Negative No PEP warranted No PEP warranted.
Recommended HIV post exposure prophylaxis for mucous membrane exposures and
nonintact skin exposures
Exposure code
Status code EC 1 EC 2
Consider basic 2-drug PEP Recommend basic 2-drug PEP
SC 1
SC 2 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
Generally, no PEP warranted. If PEP is Generally, no PEP warranted;

SC unknown offered & administered and the source however consider basic 2-drug PEP
is later determined to be HIV-negative, for source with HIV risk factors.
PEP should be discontinued.
HIV-Negative No PEP warranted No PEP warranted.
Adapted from Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to
HIV and Recommendations for Post exposure Prophylaxis. MMWR Recomm Rep 2005; 54 (No RR-9): 1-17 &
MMWR 1998; 47(No. RR-7): 1-33.
Chapter 7 Infection Prevention and Control Appendix D: Page 2 of 3
Appendix E: Post-exposure Prophylaxis Forms: Sample Patient Tracking Form
Patient tracking form for patients who started PEP drugs (from draft National PEP guidelines)
Type of exposure Appointment date: dd/mm/ yr Address

Occupational(HF Non 2 weeks 3 months 6 months Region, Woreda, Telephone
Name of patient and department) Occupational Kebele, House .No
Chapter 7 Infection Prevention and Control Appendix E: Page 1 of 1

Appendix F: Post-exposure Prophylaxis Forms: Sample Occupational Blood and
Needle Stick Exposures Recording Form
Note: This form is for recording exposures only

Date:____________________
1) Name: ____________________________
2) Telephone #:________________________
3) Age: ________
4) Sex: ________
5) Date, time & location of exposure: ___________________________________
6) Type of injury? *Please circle appropriate letter

a) Hollow needle deep prick
b) Hollow needle superficial prick
c) Solid needle deep prick
d) Solid needle scratch
e) Splash to the conjunctivae
f) Splash to the oral cavity
g) Splash to intact skin
h) Splash to broken skin (specify:________________________________)
i) Bite
7) Substance involved? *Please circle appropriate letter

a) Blood
b) Amniotic fluid
c) CSF
d) Body cavity fluids (specify:___________________________________)
e) Vaginal secretions
8) Did the body cavity fluid contain visible blood? *Please circle appropriate letter
a) Yes
b) No
c) Not aware
9) Circumstance of injury? *Please circle appropriate letter

a) Trying to secure intravenous line
b) Needle stick injury during surgery (specify:________________________)
c) Needle stick while disposing of waste
d) Amniotic fluid splash during delivery
e) Splash with body cavity fluids during procedure (specify:_____________)
f) Other (specify:_________________________________________________)
10) Is HIV status of HCP already known? *Please circle appropriate letter
a) Yes (the HCP is HIV +)
b) Yes (the HCP is HIV -)
c) No (HIV status is unknown)
11) HIV status of the source case? *Please circle appropriate letter
a) Positive
b) Negative
c) Unknown
12) Clinical stage of confirmed HIV infection in the source case? *Please circle
Chapter 7 Infection Prevention and Control Appendix F: Page 1 of 2
appropriate letter
a) Asymptomatic
b) Mild symptoms not requiring hospitalization (specify)
c) Admitted with OI to the hospital but not seriously sick
d) Seriously sick (terminally ill)
e) Altered state of consciousness
13) If the exposure has occurred to the mucous membrane, how do you estimate the
volume of blood or body cavity fluid? *Please circle appropriate letter
a) Few drops and once only
b) Few drops but repeatedly
c) Major blood splash
d) Several drops and repeatedly
e) Unable to estimate
14) Assessor (ER physician or ART clinic personnel): after completing the questions
above, please reference decision tree & report if exposed should initiate PEP?
*Please circle appropriate letter
a) Should initiate PEP
b) PEP NOT indicated
15) If PEP is indicated, is the HCP agreeable to starting PEP treatment? *Please
circle appropriate letter
a) Not ready
b) Ready to initiate
16) Previously known medical problems or medications being taken by the HCP?
17) If female HCP, record LMP and if there is a risk of pregnancy?
________________ _____________________ ________________

Name of Assessor Signature of Assessor Date
Chapter 7 Infection Prevention and Control Appendix F: Page 2 of 2

Appendix G: Monitoring and Surveillance Forms: Sample: Hand Hygiene monitoring
form
Hand Hygiene Feedback Form

Staff Member __________________________ Date: ________________
To improve handwashing practices and to ensure that our patients are free from acquiring infections
during their hospital stay, I want share with you my recent observations
Present
Date &
Absent
Providing General Medical Services

Shift
NA
Performed hand hygiene before contact with each patient, disinfected with
either water and soap, an alcohol-based gel, or rubbing hands with alcohol
soaked cotton balls.
Patient was on transmission-based precautions; appropriate PPE donned.
Patient was on transmission-based precautions; PPE was removed and
discarded in the room, or closest waste receptacle, when exiting.
After contact with a patient, equipment that may have been in contact with a
patient (bedpan, commode, Foley bag), or the handling of contaminated items
such as linens, diapers, wash cloths, and wastes, hand hygiene is performed
immediately after service is completed.
If experienced contact with a patients blood or other bodily fluids, then hands
washed with soap and water. Disinfection with alcohol-based gels or alcohol-
soaked cotton swabs will not suffice.
For patients on transmission-based precautions, all visitors were attired w/
appropriate PPE.
Performed hand hygiene, if gloves were donned. Performed before seeing next
patient and/or leaving patient area.
Invasive Procedures
Before seeing a patient, gathered needed equipment first and then performed
hand hygiene.
Performed hand hygiene before contact with each patient, preferably before
entering the room or patient area
Donned gloves before performing any procedures
Donned gowns in situations that posed potential for the splattering of blood or
body fluid onto clothing
Donned masks, glasses/goggles, or face shields in situations where there was
potential of mucous membrane exposure of the face to blood or body fluids.
discarded in the room, or nearest waste receptacle, when procedure is finished.
Adhered to safe disposal or sterilization of medical equipment guidelines
Ensured the gloves were removed and discarded within the room, or nearest
waste receptacle, when interaction with patient is finished.
Medication Administration
Once meds dispensed nurse proceeded directly to patient room/area. Hand
hygiene performed before contact with each patient.
Needed to perform additional tasks before entering patient room/area. Hand
hygiene performed just before contact with each patient.
discarded in the room, or nearest waste receptacle, before seeing next patient
or exiting patient area.
Chapter 7 Infection Prevention and Control Appendix G: Page 1 of 2
Hand hygiene performed before seeing next patient or exiting patient area.
For patients on transmission-based precautions, visitor attired w/ appropriate
PPE.
Passing Meal Trays
Performed hand hygiene before entering first room to pass food tray (not on
transmission-based precautions).
Delivered tray, then consistently performed hand hygiene when exiting each
room.
Was interrupted during tray passing after exiting the room to do another task.
Performed hand hygiene before passing the next tray.
discarded in the room when exiting.
Patient was on transmission-based precautions: Trays passed last.
Phlebotomy
Specimen obtained according to policy (Gloves donned, arm band checked,
venous access assessed, tourniquet applied, skin prepped w/ alcohol, blood
drawn, sharps disposed in sharps container)
Specimen labeled & placed in plastic bag, placed on cart outside room.
Gloves removed & placed in waste basket in room.
Repeat hand hygiene
Patient was on transmission-based precautions; specimens obtained last.
Hand hygiene=wash with soap and water or alcohol hand rub
Hand hygiene Sinks (ward and other areas) Soap

Alcohol based hand rub
Personal Towels
Paper Towels
Chapter 7 Infection Prevention and Control Appendix G: Page 2 of 2

Appendix H Monitoring and Surveillance Forms: Sample Example of a Minimum Data
Collection Form for HCAI Prevalence Study
Example of a minimum data collection form for prevalence study

Date (dd/mm/yy) ______________________
Hospital ______________________
Unit ______________________
Unit specialty ______________________
Patient
Patient identification ______________________
Age (years) ______________________
Gender male female
Date of admission in the hospital (dd/mm/yy) _____________________
Patient exposure
Surgical procedure (during the last month) Yes No
Urinary catheter Yes No
Mechanical ventilation Yes No
Intravascular catheter Yes No
Antibiotic Yes No
If yes, prescription for
Prophylaxis Therapy Other/unknown
Nosocomial infection Yes No

If yes, fill the following items
Surgical site infection Yes No
Urinary tract infection Yes No
Bloodstream infection Yes No
Pneumonia Yes No
Other respiratory infection Yes No
Line-related infection Yes No
Other nosocomial infection Yes No

Chapter 7 Infection Prevention and Control Appendix H: Page 1 of 3
Example of a data collection form for surgical site infection surveillance
Date (dd/mm/yy) ______________________
Hospital ______________________
Unit ______________________
Unit specialty ______________________
Patient
Patient identification _______________________
Age (years) _______________________
Gender Male Female
Date of admission in the hospital (dd/mm/yy) ______________________
Date of discharge (from the unit) (dd/mm/yy) ________________________
Operation
Date of operation (dd/mm/yy) ________________________
Main procedure (code) ________________________
Wound class Clean Contaminated

Clean/contaminated
Dirty/infected
ASA score 1 2 3 4 5
Duration of operation (minutes) __________________________
Urgent Yes No
Prosthesis/implant Yes No
Multiple procedures Yes No
Coeliosurgery Yes No
Antibiotics
Antimicrobial prophylaxis Yes No
Starting date (dd/mm/yy) __________________________
Duration (days) __________________________

Surgical site infection
Surgical site infection Yes No
Date of infection (dd/mm/yy) ___________________________
Infection site Superficial Deep Organ/space
Microorganism 1 __________________________
Microorganism 2 __________________________
Date of last contact (dd/mm/yy) __________________________
Source: Excerpted from: PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A

PRACTICAL GUIDE WHO/CDS/CSR/EPH/2002.12

Appendix I. Monitoring and Surveillance Forms: Sample Infection Prevention Checklist to Assess each Case Team/ Unit
Case Team or Unit _____________________________

Date of Assessment ______________________________
OBSERVATION RESPONSE (circle one) (N/A= Not applicable)

Hand Hygiene (Provider)
Hands are thoroughly washed immediately:

1. Before and after each patient contact? ... Yes No N/A
2. Before handling and putting on gloves? .. Yes No N/A
3. After handing objects which might be contaminated? . Yes No N/A
4. After contact with blood or mucous membranes? ..... Yes No N/A
5. After removing gloves? ... Yes No N/A
6. Is soap or antiseptic hand rub available at sinks and toilets? . Yes No N/A
7. Is there antiseptic hand rub available for use before and after contact with each patient contact? . Yes No N/A
Environmental Hygiene
8. Sheets and blankets are clean and changed regularly.. Yes No N/A
9. Patients are wearing clean pajamas or gowns Yes No N/A
10. Mosquito nets (if necessary) are being used and are clean.. Yes No N/A
11. Staff are separating and disposing of ward waste properly
Yes No N/A
Linens Processing
12. Soiled linens are handled, stored and transported properly Yes No N/A
13. Is there a separate room for sorting soiled linens ... Yes No N/A
14. Is there a separate room for sorting clean linens.. Yes No N/A
15. Is there a separate room for storing clean linens..
Yes No N/A
16. Are separate carts designated and used for transporting contaminated/soiled linens and clean linens
Yes No N/A
Housekeeping
17. Are sinks in patient care areas clean, disinfected, tidy and functioning? Yes No N/A
18. Are ceilings, walls and floors in patient care areas clean? . Yes No N/A
19. Is lighting adequate in patient care areas? .. Yes No N/A
20. Are patient rooms well ventilated? Yes No N/A
Transmission based precautions

21. Are isolation rooms available for highly contagious patients? ... Yes No N/A
Chapter 7 Infection Prevention and Control Appendix I: Page 1 of 3

Waste Disposal
22. The hospital has an operating incinerator? Yes No N/A
23. Are separate (preferably color coded) bins/containers used for segregating waste into infectious, non-
infectious and sharps waste? ...................................................... Yes No N/A
24. Are infectious and sharps waste disposed by burning or burying?
Yes No N/A
25. The hospital has a properly constructed placenta pit ...
Yes No N/A
Observation of Single-use Needles, Scalpel Blades and other Sharp Objects
26. Needles, scalpel blades and other sharp objects are disposed of immediately after use Yes No N/A
27. Needles, scalpel blades and other sharp objects are disposed of in a puncture resistant container Yes No N/A
28. All sharps containers are removed when they are full and taken to the incinerator or the approved
waste burial site .....
Yes No N/A
Decontamination and Cleaning

29. Blood spills are cleaned by flooding with a disinfectant and then wiped up Yes No N/A
30. Instruments are decontaminated in a 0.5% chlorine solution immediately after use for 10 minutes Yes No N/A
31. Instruments are thoroughly cleaned, rinsed and dry before sterilization or HLD use of labeled plastic
buckets for decontamination..........
Yes No N/A
Sterilization
32. What method of sterilization is used?
- High-pressure steam (if YES, go to # 2) .... Yes No N/A
- Dry heat (if YES, go to #3) ....... Yes No N/A
33. When steam sterilizing, is the high pressure steamer operating.

- At 1210C ( 250 oF ) . Yes No N/A
- 2
At a pressure of 106 KPa, 15 Ib /in . Yes No N/A
- For at least 20 minutes for unwrapped items; 30 minutes for wrapped .. Yes No N/A
34. When using dry heat, are the instruments kept:

- At 170oC ( 340oF) for sharps, . Yes No N/A
- At the required temperature ( 170o ) for at least 1 hour, or Yes No N/A
- At 160oC for 2 hours ...... Yes No N/A

High Level Disinfection
35. What method of high-level disinfection is used?
-Boiling (if YES, go to # 40) ..... Yes No N/A
-Steaming (if YES, go to # 41) ..... Yes No N/A
-Chemical disinfectants ( if YES, go to # 42 ). .. Yes No N/A
36. When boiling, are the instruments:

- Boiled for at least 20 minutes once boiling begins, and .. Yes No N/A
- Nothing is added after timing begins . Yes No N/A
37. When steaming, are the instruments:

- Steamed for at least 20 minutes once boiling begins, and.. Yes No N/A
- Nothing is added after timing begins ........ .. Yes No N/A
38. when chemical high-level disinfectants are used:

-is an appropriate chemical used . Yes No N/A
-are items completely submerged ... Yes No N/A
-are instruments soaked for at least 20 minutes ... Yes No N/A
-are instruments rinsed with sterile/boiled water ... Yes No N/A
Workers Health and Safety

1. Has training on occupational hazards and safety measures been given in the last year? Yes No N/A
2. Personal protective clothing and equipment is available (i.e. goggles, boots, aprons etc) Yes No N/A
3. Is PIHCT/VCT service available 24 hours a day? ..... Yes No N/A
4. Is there a Post Exposure Prophylaxis (PEP) protocol in place and posted for all staff to see? Yes No N/A
5. Does the hospital provide immunizations for common communicable diseases? Yes No N/A
Case Team Leader Evaluator
Name ___________________________ Name _________________________
Signature ________________________ Signature ______________________

Facilities Management
Page 1 of 36
Section 2 Operational Standards for Facilities Management 5
3.1 Organization of Facilities Management Function 6
3.2 Buildings 6
3.2.1 Buildings layout
3.2.2 Hospital site map
3.2.3 Building maintenance
3.2.4 Planning for new construction or renovation
3.3 Landscape and Garden 12
3.4 Utilities and Sewerage 12

3.4.1 Electricity
3.4.2 Water supply
3.4.3 Sewerage
3.4.4 Plumbing
3.4.5 Boiler/steam supply
3.4.6 Heating, ventilation and air conditioning (HVAC)
3.4.7 Energy Efficiency
3.4.8 Pest and rodent control
3.5 Vehicle and Transport Services 19
3.6 Hospital Security 19

3.6.1 The Security (Guard) Department
3.6.2 Control of entry and exit to and from the hospital
3.6.3 Security plan
3.7 Hospital Safety 21

3.7.1 Hazardous materials
3.7.2 Fire safety
3.7.3 Other safety measures
3.8 Major Incident Planning and Management 25

3.8.1 Major Incident Committee
3.8.2 Roles of the Incident Commander and Deputy Incident Commanders
3.8.3 Incident control room
3.8.4 Command and control arrangements in a major incident
3.8.5 The Major Incident Plan
3.8.6 Management of a Major Incident
3.8.7 Testing the Major Incident Plan
Chapter 8 Facilities Management Page 2 of 36

4.3 Indicators 34
Source Documents 35
Appendices
Appendix A Typical Layout for a Workshop of 100 Bed Hospital
Appendix B Sample Maintenance Tools List
Appendix C Sample List of Safety and Calibration Testing Instruments
Appendix D Sample Format for the Tools Ledger
Appendix E Sample Facilities Maintenance Work Order Form
Appendix F Sample Format and Checklist for a Typical Design Brief
Appendix G Sample Material Safety Data Sheet
Appendix H Sample Facility Risk Analysis Template
Appendix I Sample Major Incident Action Cards
Appendix J Sample Incident Alert Log
Appendix K Sample Major Incident Plan Communications Cascade
Appendix L Sample Major Incident Drill Plan
Appendix M Sample Major Incident Plan Drill Evaluation Form
Tables
Table 1 Steps to be taken for planning construction or renovation
Table 2 Recommended protection against some chemical hazards
Table 3 Facilities Management Checklist
Table 4 Facilities Management Indicators
Boxes
Box A Presentation of a Major Incident
Box B Terms of Reference of Incident Response Team
Abbreviations
HVAC Heating, Ventilation, Air Conditioning
ICR Incident Control Room

IRT Incident Response Team
MIC Major Incident Committee
MIP Major Incident Plan
MSDS Material Safety Data Sheet
OPD Outpatient Department
UPS Uniterrupted Power Supply

The management of hospital buildings, grounds and utilities is essential to ensure that the
facility is maintained and in good condition, providing a safe environment for patients,
visitors and staff and guaranteeing that clinical services are provided without interruption.
Effective facilities management also includes planning for both internal and external
emergencies to ensure that the hospital is adequately prepared to deal with such events and
minimize their impact.
Section 2 Operational Standards for Facilities Management

1. The Hospital complies with relevant laws, regulations, and facility inspection
requirements.
2. Designated Hospital staff members are assigned for facility maintenance functions.
3. The Hospital grounds are regularly inspected, maintained, and, when appropriate,
improved to ensure cleanliness of grounds and safety of patients, visitors and staff.
4. Potable water is available 24 hours a day, seven days a week through regular or alternate
sources to meet essential patient care.
5. Electrical services are available 24 hours a day, seven days a week through regular or
alternate sources to meet essential patient care.
6. The hospital has an maintenance centre 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.
7. The centre has appropriate tools and testing equipment to perform repairs, as well as
procedures to ensure the routine calibration of the 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.
9. There is a notification and work order system for facility and operating system (e.g.,
electrical, water, sanitation, sewerage and ventilation) repairs.
10. The Hospital has a transport policy for the use of and access to hospital vehicles.

11. The Hospital has a policy addressing access to the hospital premises.
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.
13. The Hospital has a plan for responding to likely community or hospital emergencies,
epidemics and natural or other disasters.
14. Staff members are trained and knowledgeable about their roles in the plans for fire safety,
security, hazardous materials, and emergencies.

3.1 Organization of Facilities Management Services
Each hospital should have a Finance and Property Case Team, led by the Director of Finance
(see Chapter 10 Finance and Asset Management). The facilities management function resides
within this case team. Given the importance of facilities management, each hospital should
assign a Facilities Manager (or equivalent) who is accountable to the Director of Finance.
The FacilitiesManager should be supported by assigned personnel, sufficient to fulfil the
functions described below.
The Facilities Manager, together with support staff, is responsible for:

Buildings organization, layout, maintenance and construction
Landscape and garden
Utilities and sewerage
Vehicle and transport services
Security
Safety
Major incident planning and response
3.2 Buildings
3.2.1 Buildings layout
The buildings are the most fundamental component of a hospital and their layout and design
contribute significantly to the smooth operation of patient services and other activities. The
use of buildings should be organized to:
Minimize the travel distance between frequently used spaces,
Streamline the movement of patients between departments,
Allow for patients to be easily visible by staff for supervision purposes,

Include all the needed clinical and non-clinical areas, avoiding unnecessary
redundancies and making efficient use of space,
Provide an efficient system for the handling of food, storage of supplies and the
removal of waste, and
Enhance the safety and security of patients, visitors, staff and hospital assets.
3.2.1.1 Layout of patient services
The hospital should be organized such that patient services are easily accessible and located
in close proximity to each other.
The Emergency Department should be easily accessed from the adjacent main road and
should have a separate entrance that is labelled in a way that is visible from the street.
The Outpatient Department (OPD) should also be easily accessed from the main road and
should have enough space and seating available for the expected number of daily arrivals.
The Hospital triages (both central and emergency) should be clearly labelled and easily
accessible.
Inpatient wards should be easily accessible from elevators, ramps and stairways. Sufficient
seating space should be provided for visitors, caregivers and other guests. Toilets and
showers should be provided for patients. Ideally these should be located adjacent to each
ward, but if this is not possible then they should be clearly signposted and a covered walkway
used to link the ward to the facilities.
Administrative offices, such as medical records and payment offices should be in a location
that is easily accessible to patients and visitors, and should be clearly labelled.
All public areas should be kept clear of large objects and clean. Hazards such as wet floors,
etc. should be clearly labelled to prevent injury.
Hospitals with more than one story should have either elevators or ramps in order to transport
wheelchair- or bed-bound patients. If elevators are in use, they should provide access to all
levels of the hospital. Elevators should be large enough to accommodate patient beds. Floors
should be labelled for easy identification for guests at elevator exit points and stair landings.
Stairs and corridors should not be used as storage areas, and must be kept clear to allow for
easy access to patients, staff and visitors.
Areas that are restricted to staff only should be clearly marked with No entry or Restricted
entry signs to prevent unwanted visitors from entering.
3.2.1.2 Layout of staff services
Staff services should be organized in a way to provide easy access and mobility. Toilets
should be available within close proximity to all staff working areas. Where necessary,
changing rooms with lockable lockers should be provided to staff without their own office
(such as operating theatre, delivery suite, laundry, kitchen & maintenance staff as well as

security personnel). Showers should be provided to workers who are exposed to dirt,
hazardous materials or body fluids during their duty shift.
Workers should be provided with adequate space for meals. A canteen or caf should be
available for staff to purchase food or beverages. Drinking water should be available at all
times.
Staff working on duty should have access to duty rooms with beds for resting when not
actively working. Duty rooms should be located near regular work areas and should be
equipped with telephones or other communication access in case the worker is needed.
Facilities should be available for staff on duty to obtain meals/refreshments during duty
hours.
Health workers, residents and visiting students should have access to a study area or library
equipped with various educational resources including internet access.
3.2.2 Hospital site map
A map of the hospital campus should be displayed at all entry points to the hospital to
provide clear, easy navigation for patients and visitors. All hospital buildings should be
clearly labeled and signs should be used to guide patients or visitors to each department.
3.2.3 Building maintenance
Buildings are generally the largest investment in the facility and should be well- maintained
to prolong their lifespan and minimize the need for expensive repairs or renovation.
Inspections of all hospital buildings should be conducted on a regular basis to ensure that
facilities are in good condition, and should be performed by professional, certified staff (for
example masons, painters, carpenters, etc.) with access to appropriate tools, equipment and
machinery. Preventive maintenance and repairs should be undertaken whenever necessary.
In particular:
Windows should be replaced when cracked or broken,
Windows should be able to open to allow for ventilation,
Windows should have a functioning lock to prevent theft or unwanted intruders,
Doors should be able to easily open and close,
Doors should have a functioning lock so that doors may be locked and opened as
needed,
The roof should not have any source of leakage into the facility,
Walls should be repaired as necessary,
Rain drainage systems should be working properly and efficiently. Water from
drainage systems should be diverted to a location that eliminates large flooding in
locations around the building, and
Mould growth should be prevented, or removed if discovered to prevent damage to
the buildings.
Sagging and broken beds should be fixed

Broken patient or visitor chairs, tables, etc should be repaired as soon as the problem
is reported
Regular walk through should be conducted to assess the condition of all the hospital
facilities. These should be done at least once a month.
The hospital should ensure that reasonable stocks of building maintenance materials are held
at all times, and that these form part of recurrent budgets. Basic building maintenance
materials include cement, paint, metal, wood, glass, etc. There should be a system in place
that prompts for re-order when stocks of building maintenance materials run low.
A full construction plan for the buildings, including civil engineering drawings should be
available and kept within the office of the Facilities Manager and should be updated when
modifications are made.
3.2.3.1 Buildings maintenance workshop
The hospital should have a maintenance workshop with skilled personnel and equipment for
the maintenance of hospital buildings and non medical equipment. Some maintenance
services may be outsourced if necessary (for example electrical engineering etc). The hospital
should also have skilled personnel and equipment for the maintenance and repair of medical
equipment (See Chapter 9 Medical Equipment Management). A hospital maintenance
workshop should have:
Appropriate manpower
Adequate work space
Essential tools
Adequate, safe, and secure storage space for tools, equipment, and hazardous
materials
Maintenance/repair manuals and literature
Protective clothing for maintenance staff (ex. gloves, overalls/overcoat, goggles,
boots)
Proper disposal guidelines and methods for maintenance waste
Dedicated disinfection room or area for disinfecting equipment before maintenance is
performed
Although the layout of the workshop can vary according to the size of the maintenance team,
the design should allocate space for:
Different work areas designated for different maintenance work
Adequate work benches and stools to meet needs of each work area
Store room with cabinets and shelves
Office space (for workshop managers desk and filing space)
Changing room with toilet, lockers, wash basin, and shower
Shaded outdoor area for large maintenance/repair jobs and handling of hazardous
materials
Secure outdoor storage area for bottled gases and equipment to be discarded
Vehicle access

Technical library
A library of reference materials is extremely important for ongoing staff education and
should also be included in the design of the workshop. The library should include operation
and service manuals, general textbooks on engineering and related disciplines, journals,
instruction booklets, updated hazard reports, and other reference material.
A sample layout of a workshop for a 100-bed hospital is presented in Appendix A.
3.2.3.2 Workshop tools
The maintenance team should identify essential tools (either by maintenance needs or
technician roles) required to perform their work and procure them based on quality. Poor
tools may break if they are not strong enough, they may fail earlier than expected, or they
may rub, corrode, or in some way damage other parts of the machine. It is recommended that
higher quality tools and test instruments be purchased for repairs on critical equipment.
Lower quality tools may be acceptable for less critical items, but the cost of early
replacement of such tools should be considered prior to purchase. Sample lists of suggested
maintenance tools and safety calibration testing instruments are presented in Appendices B
and C.
The maintenance team should have a tool inventory, either paper-based or computerized, that
lists all test and bench instruments and the contents of all tool kits. Tool usage should be
monitored by keeping a tool ledger in which each item is signed out and signed in when
used by a technician. A sample format for a tools ledger is presented in Appendix D.
3.2.3.3 Fault reporting and work order
Procedures should be in place through which staff, patients or visitors can report any
problems identified with the hospital building or facilities such that repair can be undertaken
promptly.
The Facility Maintenance Team should be informed of any building maintenance needs (eg. a
broken window or sink etc). The work request should be submitted in written form to enable
tracking of service requests. Telephone calls or other verbal means of reporting may be
acceptable in times of emergency; however, a service request/work order should be submitted
promptly in order to provide a written record of the reported fault. A sample Facilities
Maintenance Work Order Form is presented in Appendix E. Follow-up should be conducted
of all service requests to ensure that the work has been completed. Service requests/work
orders should be filed.
3.2.4 Planning for new construction or renovation
The services provided by a hospital and the number of patients attending a hospital are rarely
static. To accommodate changes in services or patient load it may be necessary to undertake
significant renovation of existing buildings, to construct new buildings and/or to redesign the
layout and functions of the hospital.

Adequate planning for new constructions must be carefully performed to ensure good results.
Planning is best carried out through a dedicated committee, with members from a range of
backgrounds including staff well-versed in the new service to be provided. Technical staff
with sufficient knowledge of existing facilities must be included in the planning in order to
interface with already-existing systems, such as electricity, plumbing, sanitation, etc.
Adequate consideration should be given to the effects of the construction process on existing
services. Factors to consider that may interrupt normal facility operation include noise,
vibrations, water or electricity needs or interruptions, access to large equipment or
machinery, storage of construction materials, facilities for construction staff, excess dust etc.
Construction activities should be planned to minimize the effect on daily facility operations.
To ensure that any construction or renovation is fit for purpose it is important to involve
multiple personnel in the planning process and to follow key steps as described in Table 1
below.
Table 1 Steps to be taken for planning construction or renovation

Step Description
One Establish the need for renovation or construction:

What services will be provided?
What is the demand and/or population health need for those services?
Can these services be provided using existing buildings or is renovation or new
construction required?
Stakeholders such as woreda, zonal, regional or federal health offices, hospital staff
and the community should be involved at this stage.
Two Preparation of a Design Brief.
The Design Brief is a basic framework for the design of the building or facility
and should provide sufficient detail for construction engineers to prepare
construction plans.
Stakeholders such as woreda, zonal, regional or federal health offices, hospital staff
and the community should be involved at this stage.
A Sample Format and Checklist for a Typical Design Brief is presented in

Appendix F.
Three Tender announcement and consideration of bids received
The Design Brief should be put to competitive tender
Bids received should be considered by the planning committee
Explicit criteria should be used to assess or score each bid received. Criteria
could include:
o Cost of construction
o Time to completion
o Closeness of plan to Design Brief
Four Construction of the building or facility.
As far as possible construction activities should be planned to minimize the effect
on daily facility operations.
Five Purchase of all furniture, equipment, and supplies needed for the building or facility
Appointment and training of all staff

3.3 Landscape and Garden
Patient and community perceptions of a hospital and staff satisfaction with their workplace
can be enhanced by clean and pleasant hospital grounds. Buildings should be linked by
covered and paved walkways, where possible. Recreation areas should be established
including areas for sitting and for walking. Grass, trees and flowers should be planted
wherever possible and special features such as fountains may be installed as a focal point.
Hospital grounds may also be used to grow crops, vegetables or fruit that may be used by the
hospital kitchen.
Hospital grounds should be free from litter, including old equipment or construction
materials, and should be regularly inspected to ensure a safe and comfortable environment for
patients, visitors and staff.
Grounds keeping staff should have access to all necessary tools, equipment and machinery
necessary to maintain and enhance the hospital ground. These materials should be budgeted
for to ensure that there is a consistent supply of materials.
3.4 Utilities and Sewerage
3.4.1 Electricity
A reliable source of electricity is essential for every hospital. As regular supplies may be
erratic, every healthcare facility must have a backup system in place, such as a diesel
generator. If a generator is the preferred backup system, there must be a dedicated individual
in charge of ensuring proper functioning of the generator, including sufficient supply of
diesel, charged batteries (for start-up), and regular maintenance. Alternatively, solar panels
might be a more cost-effective backup option. Regular inspections of the back-up electricity
system should be conducted, with particular attention given to potential causes of
malfunction. Hospitals should have access to a professional qualified technician with
appropriate training, tools and equipment to perform maintenance and repair of electrical
back-up installations. Up-to-date plans and manuals should be kept by each facility to ensure
easy access when troubleshooting or maintaining the equipment.
The hospital should ensure that a reasonable stock of spare parts (including a sufficient
supply of diesel for a generator) for the back-up electrical system(s) is held at all times, and
that these form part of recurrent budgets. There should be a system in place that prompts for
re-order when stocks of spare parts or diesel run low.
The back-up supply can be used to provide power to the entire hospital, or may be used to
provide electricity to selected critical areas or critical equipment. If the back-up supply does
not provide electricity for the whole facility an assessment should be made to identify those
essential areas that must be provided with uninterrupted supply, for example the operating
room, emergency room, labour and delivery room, patient wards, laboratories, refrigerators
for drugs, reagents and blood products etc. The back-up system must have sufficient capacity
to maintain all the critical functions identified. Ideally, the back-up supply should start

automatically in the event of mains interruption. If this is not possible, then a trained
individual must be available on site at all times to start the generator or alternative source of
power immediately when power failure occurs.
Standard electricity in Ethiopia runs at 220V and 50-60 Hz. However medical and hospital
equipment originating from abroad may require a different operating voltage. For example,
equipment originating from the United States operates on 110V. If possible the donor should
be asked to modify the equipment so that it operates on 220V supply. If this is not possible a
step-down transformer is necessary. Staff must be educated on when to use such step-down
transformers, as plugging the machine into the 220V supply will damage the equipment.
Other large equipment such as X ray machines may require a 3-phase electricity supply,
generally operating at 380V. Facilities need to prepare accordingly if such electricity is
needed. Medical equipment may be affected by fluctuations in supplied voltage or power
loss. Even in facilities that have backup generators, there may be a brief period (20-30
seconds) of electricity loss while the generator powers up. Any item of equipment that could
be damaged by power fluctuations or interruptions must have a back up Universal Power
Supply (UPS) that lasts for at least 30 minutes, providing sufficient time for the generator to
start up or for the equipment to be switched off safely. The UPS will also protect the item
from a power surge when the mains power returns.
Electrical hazards may pose serious fire risks, as well as shock hazards to patients, staff and
visitors. Electrical safety should be ensured at all times. Regular inspections should be
conducted, and electrical fire hazards, such as frayed cords and compromised electrical
sockets, should be identified and corrected immediately. Electrical power strips (dividers)
should be used with caution and should be inspected regularly.
Hospitals should have access to a professional qualified electrician with appropriate training,
tools and equipment to perform maintenance and repair of electrical installations. To
guarantee safety they must:
Test for grounding
Test for circuit connectivity
Test for loose connections
Perform insulation tests
Test switch leaks
Test for power
Check for the correct rating
Check whether wiring regulations were followed during installation
Up-to-date plans of electrical installations should be kept by each facility to ensure easy
access when troubleshooting or maintaining the electrical system.
The hospital must ensure that reasonable stocks of electrical maintenance materials are held
at all times, and that these form part of recurrent budgets. Basic electrical maintenance
materials include wires, sockets, switches, fluorescent light components, fuses, circuit

breakers, etc. There should be a system in place that prompts for re-order when stocks of
electrical maintenance materials run low.
3.4.2 Water supply
All hospitals should have access to a safe and reliable water supply. Water in hospitals must
be:
Free of disease-causing organisms and any other hazardous substances,
Clear, colourless, odourless, and tasteless,
Not too highly concentrated with calcium, magnesium, manganese, iron, or
carbonates,
Without any corrosive substances, and
At a relatively low temperature.
Regular (at a minimum every 6 months) microbiological checks should be conducted of the
water supply. Checks should be conducted on water outlets (faucets) and on any storage
tanks.
A backup water supply such as water tanks, a reservoir or dedicated well should be available
in case the main supply is interrupted. Water tanks should hold sufficient water to supply the
hospital for at least one day and preferably for three days. Backup supplies should be cleaned
regularly and water checked to ensure the quality and safety of the water being brought to the
facility. A mesh filter can be used to prevent large debris from entering the water supply.
Filters must be cleaned on a regular basis, as they tend to get clogged with dirt or mud.
If for any reason water supply is lost, every effort must be made to ensure that water is
supplied to all essential areas. The cause of the water interruption should be investigated and
the potential length of the interruption estimated. The hospital should prepare a contingency
plan that identifies the areas to which water must be provided in order of priority. If the
interruption is likely to be of long duration and the backup supply is limited then only the
most essential services should be provided with water. The contingency plan should include
systems for transporting water throughout the building and coordinating alternative plans for
activities such as food preparation and laundry services. When the mains supply is not
functioning, staff, patients and visitors should be reminded to close faucets to prevent water
wastage and flooding when the water supply resumes. If the hospital is not able to continue
patient services due to prolonged interruption to the water supply then arrangements should
be made to transfer patients to other facilities. Such arrangements should be described in the
contingency plan.
Water should be available in all toilets and clinical areas (wards, treatment rooms, outpatient
department, emergency room, laboratory, pharmacy etc). Ideally, piped water and faucets
should be provided in each of the above areas. If this is not possible covered water containers
should be installed and regularly filled. Such containers may be static or may be mobile such
that they can be taken on ward rounds etc.

Additionally, all staff should have access to hand washing facilities close to their work
station.
Drinking water should be available to patients and staff at all times. Water should be tested to
ensure that it is potable. If water is treated with chlorine then regular chlorination tests should
be performed to ensure that the water is safe for drinking.
3.4.3 Sewerage
Proper sewage facilities are essential to any healthcare facility to ensure cleanliness and
minimize the spread of infections. Flushing toilets should be available wherever possible and
when an adequate amount of water is available1, ideally adjacent to each ward and clinical
area. Otherwise, pit latrines are recommended. Covered walkways should be used to link
hospital buildings to any external toilet facilities.
Flushable toilets should be inspected on a regular basis to ensure that the flushing mechanism
is functional and effective. Drainage systems should be inspected and maintained to
eliminate leaks and system back-ups. Patients, staff and visitors must be instructed to keep
large solid waste out of the sewage system since these may cause blockages. Signs with
written and visual messages indicating what can and cannot be deposited in the sewage
system should be used to minimize misuse of the system.
Where available, hospital sewage systems should connect to the municipal sewage system.
Hospital sewage should be pre-treated before entering the municipal system. Where
municipal sewage systems are not available septic tanks may be used. Where possible,
hospitals should install biogas systems to minimize the build-up of sewage and provide an
efficient energy source. All hospital sewage should be regarded as a hazardous material and
appropriate safety and infection prevention measures, including the use of personal protective
equipment, should be followed when handling sewage or undertaking repairs on any sewage
systems (pipes, drains, toilets, septic tanks etc).
Hospitals should have access to a professional qualified plumber with appropriate training,
tools and equipment to perform maintenance and repair of sewage installations. Up-to-date
plans of sewage installations should be kept by each facility to ensure easy access when
troubleshooting or maintaining the sewage system.
The hospital must ensure that reasonable stocks of sewage maintenance materials are held at
all times, and that these form part of recurrent budgets. Basic sewage maintenance materials
include pipes, elbows, de-clogging snakes, personal protective equipment for workers (such
as boots, gloves, face masks), etc. There should be a system in place that prompts for re-
order when stocks of sewage maintenance materials run low.
The disposal of pharmaceutical and laboratory products and infectious waste are considered
further in Chapter 4 Pharmacy Services, Chapter 5 Laboratory Services and Chapter 7:
Infection Prevention.
1
Federal Ministry of Health. Site Selection Criteria ,1998.

3.4.4 Plumbing
Hospital plumbing should be checked on a regular basis to ensure that all components are
functional and there are no leaks in the system. Unnecessary water loss (due to leaks, running
toilets etc) can be costly and can cause damage to a building or equipment if left unattended.
Water pumps, if present, should be regularly checked and maintained in accordance with the
manufacturers recommendations.
Plumbing hazards may pose various risks to hospital facilities as well as to patients, staff and
visitors. Hazards include flooding, slippery floors and water damage. Regular inspections
should be conducted, and possible causes for leakage should be identified and corrected
immediately. Hospitals should have access to a professional qualified plumber with
appropriate training, tools and equipment to perform installation, maintenance and repair of
plumbing installations. The plumber may be a regular employee of the hospital or may be
hired on a contract basis depending on the size and needs of the hospital. Up-to-date plans of
plumbing installations should be kept by each facility to ensure easy access when
troubleshooting or maintaining the plumbing system.
The hospital must ensure that reasonable stocks of plumbing maintenance materials are held
at all times, and that these form part of recurrent budgets. Basic plumbing maintenance
materials include pipes, faucets, toilet & sink fixtures, valves, flexible tubing, etc. There
should be a system in place that prompts for re-order when stocks of plumbing maintenance
materials run low.
3.4.5 Boiler/steam supply
Where a regular supply of steam is needed, the hospital may use a boiler. While running,
boilers should be under constant supervision by a dedicated boiler technician. Regular
inspections should be performed to ensure the boiler is running as expected; results of these
inspections should be recorded and corrective action should be performed immediately.
Where steam from boilers is used to provide essential services, such as autoclave
sterilization, a functional backup boiler should be available for emergency use. The boiler
technician should be appropriately qualified and have access to appropriate tools and
equipment to perform installation, maintenance and repair of boilers and associated steam
pipe installations. The boiler technician may be a regular employee of the hospital or may be
hired on a contract basis depending on the size and needs of the hospital. Up-to-date plans of
steam plumbing installations should be kept by each facility to ensure easy access when
troubleshooting or maintaining the steam piping system.
The hospital must ensure that reasonable stocks of boiler and steam plumbing & piping
maintenance materials are held at all times, and that these form part of recurrent budgets.
This includes heavy oil or other oil used to fuel the boiler. Basic steam piping maintenance
materials include copper pipes, steam traps, release valves, steam valves, etc. There should
be a system in place that prompts for re-order when stocks of boiler and steam plumbing
maintenance materials run low.

3.4.6 Heating, ventilation and air conditioning (HVAC)
Hospitals in Ethiopia generally do not require heating systems. If they are installed they
should be inspected and maintained on a regular basis to ensure they are functioning correctly
and do not pose a hazard. Where appropriate, carbon monoxide detectors should be used to
eliminate the risk of inhalation. Additionally, space heaters or other small heaters must be
regularly checked for damage to eliminate the risk of fire or other hazards.
Air conditioning systems are generally not used in Ethiopian hospitals, but may be necessary
under certain conditions. For example, certain medical equipment may require rooms to
remain within a specific range of room temperature that may only be achieved through air
conditioning systems. If present, air conditioning systems must be inspected and maintained
on a regular basis to ensure correct operation.
Adequate ventilation is essential in a hospital environment to help prevent the spread of

infectious diseases and to minimize health risks due to harsh chemicals or other pollutants.
Ventilation is also needed to reduce mould or other fungus growth in areas of high humidity
such as the kitchen, laundry and any other areas with steam, water or sewage pipes running
through. Workshops where welding, soldering, burning or other smoke-producing activities
take place, or where there is exposure to harsh chemicals (such as paint or epoxies) must also
be adequately ventilated. When artificial ventilation methods are not available natural
ventilation (opening windows) can serve a low cost alternative ventilation method. This
method should not be used if the external environment is polluted or is excessively noisy.
Hospitals should have access to a professional qualified HVAC technician with appropriate
training, tools and equipment to perform maintenance and repair of HVAC installations. Up-
to-date plans of HVAC installations should be kept by each facility to ensure easy access
when troubleshooting or maintaining the HVAC system.
The hospital must ensure that reasonable stocks of HVAC maintenance materials are held at
all times, and that these form part of recurrent budgets. Basic HVAC maintenance materials
include vent ducts, fans, air filters, etc. There should be a system in place that prompts for re-
order when stocks of HVAC maintenance materials run low.
3.4.7 Energy efficiency
To minimize costs and environmental pollution hospitals should aim to maximize energy
efficiency. Ways to increase energy efficiency include:
The use of natural ventilation:
o Open windows (should only be done if the external environment is free of
pollution, smog, industrial gases, and excessive noise). Screens can be
installed to protect from insects while allowing maximum air flow,
o Provide vents in the ceiling and roof to allow hotter air to escape,
Construct windows to be as tall as possible in order to let in the maximum amount of
natural light,
Provide wide roof coverage to protect windows from direct sunlight and hence keep
buildings cool,

Provide reflective materials on windows to redirect the rays of the sun,
Plant trees to provide shade to buildings, especially outside windows, in hot climate
areas,
Ensure doors and windows close properly to maintain internal heat in cold climate
areas,
Use solar panels for heating water, powering lights etc ,
Install biogas systems as an alternative source of energy , and
For new buildings, orient the building to decrease the amount of sun exposure or to
take advantage of prevailing winds.
3.4.8 Pest and rodent control
Rodents and insects can spread disease and cause damage to buildings and equipment, for
example by chewing electrical wires and soft tubing. Thepresence of pests and rodents can be
minimized by keeping the facility clean and free from waste materials. The following steps
help to eliminate pets and rodents and are particularly important in storage areas:
Design or modify storerooms to facilitate cleaning and prevent moisture.
Regularly clean floors and shelves.
Do not store or leave food uncovered/unsealed in any storage areas.
Keep the interior of the building as dry as possible.
Properly varnish or paint wooden furniture as needed.
Use pallet and shelving and do not keep products directly on the floor.
Regularly inspect and clean the outside premises of the storage facility, especially
areas where garbage is stored. Make sure that garbage and other wastes are stored in
covered containers.
Check for still or stagnant pools of water in and around the premises, and be sure that
there are no buckets, old tires, or items holding water.
Treat wood frame facilities with water sealant, as required.
To protect the facility from birds or bats, any open space between the roof and the
ceilingshould be covered with fine wire mesh.
To protect the facility from flying pests keep all doors and windows closed or put fine
wire mesh on all windows and make sure that there are noholes in the ceiling, walls or
floors.
The use of Insect Electrocuting Light Bulb (hanging electric grids that attract flying
insects via a bright fluorescent or ultraviolet light) may be the appropriate solution, if
available at reasonable price.
The use of noisemakers and keeping the outside of the facility clear of long grasses
and bushes can protect the facility from the different snake species.
To eliminate flees or similar insects all patient bed sheets and blankets should be
washed and ironed regularly. Mattresses, pillows, and other items that do not get
laundered should be disinfected with appropriate chemicals regularly, especially prior
to the bed being occupied by a new patient.

Inspections shouldbe performed on a regular basis to detect the presence of rats, rodents or
other pests, paying particular attention to store rooms and kitchen. Proper extermination
methods should be undertaken when pests are suspected. Extermination techniques should be
performed in accordance with local rules. Patients and staff should be temporarily removed
from areas if there is a risk of exposure to toxic chemicals or substances.
3.5 Vehicle and Transport Services
Hospitals may have one or more vehicles, including ambulances, depending on the size and
location of the facility. Such vehicles should be organized within a transport department,
consisting of drivers and department head. All drivers must have valid driving licenses for the
type of vehicle used and must be sufficiently trained to undertake basic repairs (for example
burst tyres, overheating etc). All vehicles should be equipped with at least one spare tyre and
preferably two for vehicles used in remote locations, and these should be checked on a
regular basis to ensure they are intact and filled with air. All vehicles should be fitted with
functioning seat belts in both front and back seats and these should be used by drivers and
passengers at all times. All vehicles must be insured against accident and theft.
Routine services should be undertaken for each vehicle in accordance with manufacturers
recommendations. Routine and repair services should only be undertaken by a qualified
mechanic.
A log book should be kept for each vehicle that describes the mileage undertaken and
maintenance record for the vehicle.
A transport policy should be established that specifies:

The appropriate use of ambulances and regular vehicles,
The process by which vehicles are issued for use,
Control of vehicle keys,
Storage of vehicles,
Fuel consumption policy,
Use of seatbelts,
Use of mobile telephone by driver,
Use of alcohol, chat or other substances by driver,
Action to be taken in the event of an accident or breakdown, and
Action to be taken in the event of misuse of the vehicle.
3.6 Hospital Security
3.6.1 The Security (guard) department
Security for the staff, patients, property, and information located within the hospital is
critical. Potential security threats include theft by an employee or visitor, and threats
against patients or staff.

Security personnel play a vital role in ensuring that the hospital is welcoming and accessible
but also a safe environment for patients, visitors and staff. Security personnel need a thorough
knowledge of the premises in order to protect buildings and valuable equipment. Security
personnel should know when and how to diffuse potentially difficult situations and should be
able to react appropriately in an emergency.
A head of security should be appointed to manage all security officers. The security
department should provide 24 hour coverage, with security officers stationed at all entry and
exit points of the hospital. The security staff also should conduct regular rounds of the
premises. Security staff should be issued with appropriate communication devices such as
walkie-talkies or mobile telephones to ensure communication in the event of an emergency. If
firearms are to be held by security staff then appropriate training must be given to ensure
their appropriate use. The local police department may provide such training on request.
There should always be a security focal person on the premises who will be the first point of
contact in a security incident (such as a fire or theft) and will be in charge of deploying
guards to the incident area to diffuse the situation. Security personnel should be fit and in
good health and should be issued with uniforms and ID badges so that they can easily be
identified as security staff.
3.6.2 Control of entry and exit to and from the hospital
The hospital should have a policy to control access to the hospital addressing the areas
outlined below.
Access to the hospital should be limited to staff, patients, caregivers and visitors with
legitimate business.
All staff should wear staff ID badges which they must present on entry to the facility. In
addition, staff should were uniforms appropriate for their positions at all times within the
hospital. A policy should be established for the number of caregivers permitted for each
patient (for example one caregiver per patient with the possible exception of critical cases and
paediatric cases). The policy should be clearly displayed in the hospital and should be
explained to all patients and caregivers whenever a patient is admitted. Caregiver ID badges
should be issued for caregivers, indicating the ward and bed number of the patient they are
attending. (For further information on traffic control please see Section 3.4.5 of Chapter 7
Infection Prevention).
Fixed visiting hours should be established and should be displayed at all entry points to the
hospital and within each ward. These should be strictly enforced. The number of visitors to
each bed should be limited to prevent crowding. Visitor ID badges should be issued for
patient visitors, indicating the ward and bed number of the patient they are visiting.
All other visitors to the hospital attending for other purposes such as providing supplies,
administrative or supervisory functions should also be issued with Visitor ID badges.
Patients attending the outpatient department or emergency room should be directed to the
appropriate department and should not enter ward areas unless attending for clinical
assessment or treatment. All staff, and particularly security personnel, should ensure that

patients, caregivers and visitors remain within the area in which they have legitimate business
and do not wander around other clinical areas or hospital premises unnecessarily.
Staff, visitors, patients and vehicles should be searched when they enter the premises to
detect dangerous weapons or other security threats, and a search should be undertaken of all
individuals and vehicles on exit from the premises to prevent theft.
Visitor and caregiver ID cards should be returned to security personnel when the individual
leaves the premises.
3.6.3 Security plan
A security assessment should be undertaken at least once a year to identify security

vulnerabilities, including the location of important or expensive equipment or supplies. A
security plan should be designed based on the findings of this assessment. The security plan
should address areas such as:
Control of access points, entry and exit to premises,
Security rounds,
Action to be taken in event of security threat,
Use of communication devices,
Use of firearms (if permitted),
Control of assets entering or leaving premises, and
Induction and training of new security personnel.
3.7 Hospital Safety
3.7.1 Hazardous materials
Exposure to hazardous chemicals can produce a wide range of adverse health effects. The
likelihood of an adverse health effect occurring, and the severity of the effect are dependent
on the toxicity of the chemical, route of exposure, and the nature and extent of exposure to
that substance.
Toxic chemicals often produce injuries at the site at which they come into contact with the
body. For example, irritant gases, such as chlorine and ammonia, can produce a localized
toxic effect in the respiratory tract; corrosive acids and bases can produce damage to the skin.
In addition, a toxic chemical may be absorbed into the blood stream and distributed to other
parts of the body. These chemicals may then produce systemic effects. There are three main
routes of chemical exposure: inhalation, skin contact, and ingestion.

Table 2 Recommended protection against some chemical hazards
Chemical Exposure Routes Symptoms First Aid Personal
Protection
Glutaraldehyde Inhalation, skin Irritation of eyes, Eye: irrigate Wear eye-
(commonly used absorption, skin, respiratory immediately protection,
as high level ingestion, skin system; dermatitis; Skin: Water flush protective clothing,
disinfectants and/or eye contact cough, asthma; immediately gloves, and mask
and/or sterilizer nausea, vomiting Breathing: Good ventilation
for some Respiratory and easy access to
medical support water
equipment that Swallow: Medical
do not resist attention
heat) immediately
Ammonia Inhalation, Irritation of eyes, Eye: irrigate Wear eye-
(used in ingestion, skin nose, throat; immediately protection,
laboratory and and/or eye contact dyspnoea, wheezing, Skin: Water flush protective clothing,
some cleaning chest pain; immediately gloves, and mask
solutions) pulmonary oedema; Breathing: Good ventilation
skin burns Respiratory and easy access to
support water
Swallow: Medical
attention
immediately
Formalin or Inhalation, skin Irritation of eyes, Eye: irrigate Wear eye-
fomaldehyde and/or eye contact nose, throat, immediately protection,
(commonly used respiratory system; Skin: Water flush protective clothing,
as high level lacrimation; cough; immediately gloves, and mask
disinfectant or wheezing Breathing: Good ventilation
sterilizer for Respiratory and easy access to
some medical support water
equipment that
do not resist
heat)
Chlorine Inhalation, skin Burning eyes, nose, Eye: irrigate Wear eye-
(used for and/or eye contact mouth; lacrimation, immediately protection,
decontamination, rhinorrhoea; cough; Skin: Water flush protective clothing,
cleaning, and chocking; nausea, immediately gloves, and mask
disinfection) vomiting; headache, Breathing: Good ventilation
dizziness; syncope; Respiratory and easy access to
pulmonary oedema, support water
pneumonitis;
dermatitis
Mercury Inhalation, Burning eyes, nose, Eye: irrigate Wear eye-
ingestion, skin mouth, skin immediately protection,
and/or eye contact irritation; damage to Skin: Water flush protective clothing,
nervous system immediately gloves, and mask
Good ventilation
and easy access to
water
Source: Adapted from NIOSH Pocket Guide to Chemical Hazards Source:Draft Workplace Safety & Health
Guidelines for Health Workers (2007)

Material safety data sheets (MSDSs) should be available for all chemicals found at the
hospital. These should include information about the substance, safe handling, precautions,
first aid, etc. MSDSs should be held at all sites where hazardous materials are stored or
utilized, and a full set of all MSDSs should be held by personnel in the materials
management/central supply department and by hospital management. An example MSDS is
presented in Appendix G.
The hospital should ensure that reasonable stocks of personal protective equipment are held
at all times, and that these form part of recurrent budgets. Basic personal protective
equipment includes gloves, masks, eye protection, protective clothing, etc. There should be a
system in place that prompts for re-order when stocks of personal protective equipment run
low (For further information on personal protective equipment please see Section 3.2.2 of
Chapter 7 Infection Prevention).
3.7.2 Fire safety
A fire in a health facility risks the safety, health, and lives of patients and providers. Hospitals
should have a fire safety plan that addresses both the prevention of and response to fires.
a) Fire prevention
The following safety measures minimize the risk of fire:
Electrical safety: All appliances, instruments and installations should be tested before
use to determine compliance with grounding, current leakage and other device safety
requirements. A program of routine maintenance should be enforced to ensure that all
electrical receptacles and plugs, wires and connectors are safe. An earth leakage
(grounding) system should be used and start and stop switches must be clearly identified.
Flammable storage: Specifically designated areas for storage of flammables (e.g. diesel,
alcohol, oxygen) should be identified. These items should be stored in proper conditions
and located in restricted areas protected from sources of excessive heat, fire, or electrical
discharge and away from patient care areas. Minimum quantities of flammables should be
kept at work stations.
Smoking/open flame restrictions: The facility should adopt strict rules governing
smoking within the hospital which should be made known to hospital personnel, patients
and visitors. These rules should include at least the following: smoking must be
prohibited within the facility and in any room or compartment where flammable liquid,
combustible gas or oxygen is being used or stored and in any other hazardous area of the
hospital. These areas must be posted with clear NO SMOKING signs. Open fires (e.g.
waste burning, kitchens) must not be allowed near flammable storage areas. All open fires
should be monitored until completely extinguished.
Fire inspections: In localities where fire departments exist, health facilities should
request an annual inspection by the local fire department that includes verification of fire
prevention measures and response readiness assessment (access to the building, current
floor plan, storage places of flammable and explosive gases, sources of water, fire
fighting equipment, patient rooms, exits and evacuation plans).

b) Response to a fire
Action take in response to a fire can minimize injury and the damage caused to buildings and
equipment. Fire response measures should include:
Fire warning system: Ideally every building should have a fire alarm system installed
(automatic and/or manually activated) to allow the early identification of fires. If this is
not possible a large hand-bell may be used as an alert signal.
Emergency notification: The facility should have a fire emergency notification system to
the local fire department using the most direct, fast, and reliable communication means.
Fire fighting equipment: All buildings should have portable extinguishers appropriate to
the different types of hazards, properly tagged and, easily accessible in all areas of the
building. Extinguishers should be periodically checked according to regulations to ensure
that they are operable. If water hydrants and hoses exist within the facility, they should be
conveniently distributed and located throughout the building to allow water to effectively
reach all potential fire points. Water hydrants and hoses should also be regularly checked
to ensure functionality.
Sources of water: Adequate sources of water must be available in the facility for fire
control purposes. In case the public water supply system is nonexistent or unreliable,
water supply should be guaranteed by elevated tanks or electric pumps. In the latter case,
an emergency energy source should be available.
Access to the building: Access to the building for firefighters should be clearly marked
and free of obstacles. Established routes must allow access to all parts of the building.
Evacuation: All facilities must have evacuation plans for patients and staff. Evacuation
routes can be horizontal or vertical. Evacuation routes must be clearly marked, built of
fire resistant materials if possible, free of obstacles, well-lit and ventilated to avoid smoke
accumulation, and must not pass through or be close to flammable storage areas.
Evacuation routes should direct patients and staff to a safe place outside of the building or
to a designated safe area in the building (behind fire doors if they exist). Elevators must
not be used for vertical evacuation. Evacuation should be done in a systematic fashion by
moving all patients and personnel who are closest to the danger first. Doors into patient
rooms should not be locked when the patient is alone in the room. Exit doors should be
easily opened from the inside.
Referrals: After a fire, it may be necessary to relocate patients to other facilities. Health
facilities must have an emergency referral plan that includes all health services, public or
private, in their geographical area, including the identification of transportation means.
All employees should be trained in fire prevention and response and should be familiar with
the fire safety plan. Training should include the operation of fire fighting equipment,
evacuation, and the specific responsibilities of each staff member. Update training should be
conducted at least annually.
To test the fire and safety plan, and ensure that staff are familiar with their responsibilities, a
Fire and Evacuation Drill should be conducted at least annually. These drills should be
planned and implemented so as to:

Ensure that all personnel on all shifts are trained to perform assigned duties in case of a
fire,
Ensure that all personnel on all shifts are familiar with the use and operation of the fire-
fighting equipment in the hospital,
Enable hospital management to evaluate the effectiveness of the plan,
Check the feasibility of a prompt and orderly discharge or transfer of patients already in
the hospital who can be safely moved without jeopardy,
Verify security measures to keep unauthorized persons out of the emergency area.
3.7.3 Other safety measures
To prevent injury all hazards (such as wet floors, spills, broken glass etc) should be clearly
labelled. All public areas should be kept clean and free of large objects. Stairwells and
corridors should be kept clear and should not be used as storage areas. When cleaning is
conducted only half of the area of corridors and stairwells should be wet cleaned at a time to
always have a dry and safe path available for use. Further guidance on occupational health
and safety is presented in Section 3.13 of Chapter 11 Human Resource Management.
3.8 Major Incident Planning and Management
A major incident is any event whose impact cannot be handled within routine service
arrangements. This may arise when:
The numbers or type of casualties overwhelm or threaten to overwhelm normal services

and special arrangements are needed to deal with them; or
An incident poses a serious threat to the health of the community; or
There is the potential for the hospital itself to suffer serious internal disruption.
The aim of major incident planning is to ensure that the hospital is capable of responding to
major incidents of any scale in a way that delivers optimum care and assistance to victims,
that minimizes the consequential disruption to healthcare services and that brings about a
speedy return to normal levels of activity. Box A outlines ways in which a major incident
may present. It is the nature of major incidents that they are unpredictable and each will
present a unique set of challenges. The task is not to anticipate each major incident in detail,
but rather to have a set of expertise available and to have developed a set of core processes to
handle the uncertainty and unpredictability of whatever happens.

Box A: Presentation of a Major Incident
Major incidents may present in several ways:
The big bang

The rising tide
The cloud on the horizon
Headline news
Internal incidents
Deliberate release of chimerical or biological materials
a) The Big Bang
A health service major incident is classically triggered by a sudden major transport or industrial
accident. In this case the police service or emergency room may be the first to be aware of and
respond to the incident.
b) Rising Tide
This problem creeps up gradually such as occurs with an infectious disease epidemic. There is
no clear starting point for the major incident and the point at which an outbreak becomes
major may only be clear in retrospect.
c) Cloud on the horizon
An incident in one place may affect others following the incident, for example a major incident
in another health facility or epidemic arising elsewhere.
d) Headline news
A wave of public or media alarm over a health issue as a reaction to a perceived threat may
create a major incident for the health service even if fears prove unfounded. For example, a
perceived risk of bird flu or swine flu may cause mass attendance at the facility even if the risk
to the population is minimal. It is the urgent need to manage information that creates the major
incident. If well handled, it may not become a major incident at all; if mishandled it probably
will.
e) Internal incidents
The hospital itself may be affected by fire, breakdown of utilities, major equipment failure,
hospital acquired infection, hazardous material spill etc. If such incidents are mishandled the
morale of staff and public confidence in the facility may be eroded in the long term.
f) Deliberate release of chemical or biological materials
The hospital role in such incidents is to deal with emergency cases that present to the facility.
The overall response to such incidents requires close co-ordination between the hospital and
government agencies such as police, military, woreda/zonal/regional health bureaus.

The essentials of major incident planning are:
establishing a Major Incident Committee,
establishing an Incident Control Room,
preparing a Major Incident Plan (MIP),
establishing appropriate command and control arrangements,
implementing the MIP through training, exercising and testing, and
validating the MIP through a system of regular review and update.
3.8.1 Major Incident Committee
All hospitals should have a Major Incident Committee (MIC) that is responsible to supervise
and co-ordinate emergency planning. The MIC should be led by a Major Incident
Commander. Major Incident planning leads should be identified in all clinical and non-
clinical case teams/departments and each should be a member of the MIC.
Roles of the MIC include:

To consider all possible types of major incidents that could affect the local population,
To undertake risk analysis of the facility and identify risks that should be addressed in
the Major Incident Plan. A sample Facility Risk Analysis Template is presented in
Appendix H,
To produce and update annually the Major Incident Plan (see below),
To determine membership and terms of reference of the Incident Response Team,
To develop Action Cards that describe the responsibilities and reporting arrangements
of all key personnel in the event of a major incident,
To establish an emergency communication system including both internal
communication and external communication with external parties,
To ensure staff receive training in emergency preparedness,
To conduct emergency drills and table top exercises to test the Major Incident Plan,
and
To evaluate the response to any major incidents that occur and take action to address
any problems identified.
3.8.2 Roles of the Major Incident Commander and Deputy Major Incident
Commanders
All hospitals should have a Major Incident Commander who should be the Chair of the MIC.
This role could be filled by the CEO, the Head of Finance and Procurement or another
individual with a good working knowledge of the facility, staff and services provided. The
Major Incident Commander authorizes MIP activation and communication to all hospital
personnel. Other MIC members may be assigned as Deputy Major Incident Commanders
who can authorize activation of the MIP if the Major Incident Commander is not available.
The Major Incident Commander and Deputies must operate a rota system such that there is
24 hour cover each day, 365 days a year and this duty schedule should be available to all

staff. Ideally, there should be a dedicated mobile telephone number or pager carried by the
duty Major Incident Commander or Deputy, that is known to external agencies as well as
hospital staff, so that the duty Commander may be contacted directly and immediately in the
event of a major incident.
The Major Incident Commander or Deputy is also responsible for deactivating the MIP after
a proper assessment of the emergency situation has been taken.
3.8.3 Incident control room
All hospitals should have an Incident Control Room (ICR) that is activated as a post to
manage emergency/disaster response activities. This may be an existing office or meeting
room that can be used as the ICR in the event of an emergency. Keys for the ICR should be
kept with the Major Incident Commander or the Deputy on duty. The ICR serves as the
assembly point where duties are assigned and personnel report activities in the event of a
major incident. The ICR should contain:
Desks and chairs
Telephone
Fax
Stationary
Action Cards
Copies of the Major Incident Plan
3.8.4 Command and control arrangements in a major incident
In the event of a Major Incident an Incident Response Team (IRT) should be formed. The
IRT should gather in the Incident Response Room from where all activities will be co-
ordinated.
Members of the IRT should include:
Major Incident Command Officer

Major Incident Command Deputies
Chief Executive Officer
Director of Facility Services (or equivalent)
Director of Human Resources
Director of Outpatient Services
Director of Inpatient Services
Director of Emergency Services
Chief Nursing Officer (or equivalent)
Liaison and Referral Officer
Others as determined by the facility
Sample terms of reference of an IRT are presented in Box B.

Box B Terms of Reference of Incident Response Team
To oversee the response to the Incident, issuing Action Cards and receiving update reports
from key personnel
To make an initial assessment of the situation and determine the key organizations with which
to establish communication
To put in place adequate measures to ensure communications with the appropriate
organizations during the incident
To put in place adequate measures to ensure communication with relatives and the community
during the incident
To assess the internal resources required to deal with the incident and to ensure that these are
put in place (for example calling additional staff onto duty, mobilizing medical supplies)
To seek expert advice where the expertise does not exist within the hospital (for example from
Public Health Laboratory Service)
To prepare staff for the execution of the response plan and to monitor implementation
To prepare a plan for the long term follow up of the incident if necessary
To prepare, if necessary, regular press statements or other means of public communication
To decide when the incident should be declared over and inform any necessary external
agencies that this has been done
To organize the re-entry of staff, patients and visitors
To identify and complete appropriate reports of any damage that occurred to buildings or
equipment
To carry out a debriefing including a review of the Major Incident Plan and recommendations
for modification
To prepare a report for the Hospital Governing Board and other agencies on the incident
The membership, contact details and terms of reference of the IRT should be described in the
Major Incident Plan (see section 3.9.5 below).
In addition to the IRT, the MIP should describe command and control arrangements showing
who is accountable to whom in the event of a major incident. The command and control
arrangements can be supported by Action Cards that specify the responsibilities of each
individual in the event of a Major Incident and state who that individual should report to (see
section 3.9.6 below). Sample Major Incident Action Cards are presented in Appendix I.
All staff should be familiar with the command and control arrangements and with their own
particular responsibilities and reporting arrangements as described in their Action Card.
3.8.5 The Major Incident Plan
All hospitals should have a Major Incident Plan that is approved by the Senior Management
Team. The MIP should be distributed to all staff and copies should be readily available in all
case teams/departments at all times. The MIP should be updated annually.
The MIP should include:

Basic hospital information, eg location of facility, number of beds, services provided
An outline plan of the hospital identifying:
o Emergency room areas
o Patient flow plan
o All fire extinguishers and fire alarms
o Exit routes (doors, windows, stairways etc)
o Assembly points
o Emergency supply storage
Contact information for:
o Key facility personnel (for example MIC and IRT members, hospital
management, case team leaders, medical staff)
o External agencies (for example police, fire brigade, water and electricity
suppliers, woreda/zonal/regional health offices, FMoH, local media)
Clear alerting and activating procedures for the MIP
The basic functions and critical personnel needed to continue health facility
operations in case of an emergency
A communications cascade by which all key personnel will be contacted
Clear arrangements for establishing an Incident Response Team
Clear statements on the roles/responsibilities of key staff/functions
Action cards for key personnel involved in a Major Incident that describe staff
roles/responsibilities and reporting arrangements (see section 3.9.6 below)
Department/Case Team specific action plans and checklists that establish the
different courses of action for each department in an emergency
Clear identification of resources required for the response and how these will be
accessed (for example emergency drug store)
Plan outlining coordination with all suppliers/providers for the delivery of needed
supplies during an emergency (for example food, drugs, water, electricity, laundry
services, additional personnel, etc)
A communications plan with all local emergency agencies. All local emergency
agencies should have a copy of the hospitals MIP
Evacuation protocol including:
o All possible evacuation routes and assembly points for staff, patients and
visitors to convene. These emergency exists should be clearly marked
throughout the facility
o Description of situations requiring evacuation such as:
Fire/Smoke
Hazardous fumes and/or hazardous material spill
Area contamination by toxic agents
Radiation

Loss of critical support services (this could simply require a partial
evacuation of patients from one department to another)
Explosion
Police action
Armed/dangerous visitor
Natural disaster (ex. Flooding,earthquakes)
Fire safety plan
Arrangements for creating additional space/capacity within the hospital
Arrangements with other healthcare providers for an alternative care site for patients
if facility exceeds its capacity
Communication plan to manage communication and information for families of
casualties and other visitors. A communications centre should be established to
provide information about casualties status. The centre should collect visitors names
and patient association to help staff locate visitors that may need to be escorted to the
patient.
3.8.6 Management of a Major Incident
The steps to be taken in the management of a major incident include the following:
1. Incident alert: Any staff member may identify a potential incident and should notify their
case team/department head immediately or the Major Incident Commander, depending on
the nature of the situation and time of the event. An external event may come to the
attention of staff in the emergency room, via the local police, fire service or health
bureaus. Such external agencies should be instructed to notify the Hospital Major Incident
Commander at the earliest opportunity should a potential major incident occur.
2. Assessment of situation by Major Incident Commander. The Major Incident Commander
should complete an Incident Alert Log (Appendix J) and decide if the MIP is to be
activated.
3. Activate communications cascade (Appendix K). The Major Incident Commander should
contact the Incident Response Team who in turn are responsible to contact directly, or
arrange for the contact of all key personnel as described in the Communications Cascade.
4. Establish Incident Response Room and Incident Response Team. The Incident Response
Room should be opened by the Major Incident Commander and all members of the IRT
should report there immediately or as soon as they reach the facility. The Major Incident
Commander shall brief team members on the situation.
5. Assign Action Cards: All key post holders/managers should have a card which briefly
details the actions they should take in an emergency. The cards should be laminated and
carried by each individual at all times. Copies should be kept in the Incident Response
Room and should be included in the MIP.
6. Proceed as instructed in action cards
7. Manage Incident
8. Step down when incident is over

Management of a Major Incident
Incident alert: Internal event (eg Incident alert: External event (eg
fire, chemical spill) road accident, disease epidemic)
Department staff provide initial Emergency Room or external

response agency such as police provide
initial response
Inform Major Incident

Commander or Deputy
Assess situation. Compete

Incident Alert Log
Activate communications cascade
Establish Incident Control Room

and Incident Control Team
Take action cards
Proceed as instructed
Manage incident
Step down when incident is over
Review response and revise

Incident Management Plans
accordingly

3.8.7 Testing the Major Incident Plan
All staff should be trained in major incident preparedness, including personal roles and
responsibilities in the case of a major incident.
The MIP should be tested at least once every year and modification made to the plan based
on lessons learned from the drill. The drill can be either a simulated exercise involving mock
victims or a desk top exercise involving establishment of the IRT, activation of the cascade
system, issuing action cards and testing of each department/case teams response. A MIP
Drill Plan and Drill Evaluation Form are presented in Appendices L and M. The Drill
Evaluation should be carried out by one or more observers.

In order to determine if the Operational Standards of Facilities Management have been met
by the hospital an assessment tool has been developed which describes criteria for the
and Reporting.
Table 3. Facilities Management Checklist

Yes No
1. Regulations that are relevant for facilities are known to and adhered to by
the hospital.
2. There are staff and supplies designated for facilities management.
3. Water is available 24 hours a day, 7 days a week.
4. Electricity is available 24 hours a day, 7 days a week
5. There is a maintenance centre.
6. The maintenance centre has adequate personnel who are trained.
7. Facilities and equipment needed to provide maintenance services are in
place.
8. A maintenance notification and work order system has been established.
9. Preventive maintenance of equipment and facilities is provided.

10. Corrective maintenance of equipment and facilities is provided.
11. There is a transport policy.
12. There is a procedure to control access to the premises.
13. There is a fire safety plan.
14. There is a major incident plan.
15. Trainings on fire safety, security, hazardous materials and major incident
plan are provided to staff.
4.3 Indicators
Table 4. Facilities Management Indicators

1. Number of work orders received

Total number of work Quarterly
orders received
2. Average time to completion of work
order time to completion/ Quarterly
Total number of work
orders received
3. Number of incidents reported to
Incident Officer involving a building Total number of incidents Quarterly
or operating system (eg electricity, reported to Incident
water, sewage etc) Officer involving a
building or operating
system (eg electricity,
water, sewage etc)
4. Outpatient satisfaction survey: Total number of Biannual
outpatients who respond
% of respondents who answer yes to yes to the listed
the question It was easy for me to questions/ Total number
find my way around the facility of outpatients
respondents*100
5. Inpatient satisfaction survey: Total number of Biannual

inpatients who respond
% of respondents who answer yes to yes to the listed
the question It was easy for me to questions/ Total number
find my way around the facility of inpatients
respondents*100.

Source Documents
1. Agency for Healthcare Research and Quality. Emergency Management Principles and
Practices for Health Care Systems: Unit 3 Healthcare System Emergency Response
and Recovery. Retrieve from:
http://www.ahrq.gov/research/hospdrills/predrill.htm;
http://www.ahrq.gov/research/hospdrills/triage.htm;
http://www.ahrq.gov/research/hospdrills/tx.htm
2. California Hospital Association. (2008, Nov 20). Hospital Emergency Management

Program Checklist
3. Carr, R.F. The National Institute of Building Sciences Whole Building Design Guide:
Hospital. Retrieved from: http://wbdg.org/design/hospital.php.
4. Claude Moore Health Sciences Library. (Revised August 2008). Emergency

Preparedness and Response Plan
5. Federal Democratic Republic of Ethiopia Ministry of Health. Planning and Project

Department. Architectural and Engineering Team. (1998, May). Site Selection Criteria.
Addis Ababa, Ethiopia
6. Griffith, J. R. and. White, K. R. The Well-Managed Healthcare Organization: Sixth

Edition.
7. Ministry of Finance and Economic Development. (2007, December). Government Owned

Fixed Assets Management Manual.
8. Ugandan Ministry of Health. Prepared by Necochea, E. and Bossemeyer, D,. Jhpiego.

(2007) Ugandan Ministry of Health Draft Workplace Safety and Health Guidelines for
Health Workers.
9. Mississippi Depart of Health: Office of Emergency Planning and Response. Hospital

Emergency Preparedness Planning Template (August 2005).
10. Mississippi Department of Health: Office of Emergency Planning and Response. (2005,
April) Clinical Emergency Planning Template.
11. National Association of Community Health Centers. Retrieved from:

http://www.nachc.com/EM-Planning.cfm.
12. New York Centers for Terrorism Preparedness and Planning. (2006 March). Draft
Hospital Evacuation Protocol.
13. New York Centers for Terrorism Preparedness and Planning. (2006 July). Draft Mass
Casualty/Trauma Event Protocol
14. Quality Improvement Support Services. Departmental Emergency Preparedness Plan

15. U.S. Department of Health and Human Services: Agency for Healthcare Research and
Quality. Retrieved from: http://www.ahrq.gov/research/hospdrills/introduction.htm
16. United Nations Development Programme, India. Guidelines for Hospital Emergency
Preparedness Planning. GOE-UNDP DRM Programme (2002- 2008).
17. Washington University in St. Louis: Disaster and Business Continuity Planning
Committee. Department Emergency Guides.
18. Wisconsin Department of Health Services. Hospital Disaster Plan. Retrieved from:
http://dhs.wisconsin.gov/rl_DSL/Hospital/HospitalDisastrPlng.htm
19. World Health Organization-Regional Office for the Western Pacific. District Health
Facilities-Guidelines for Development and Operations. Risks, Emergencies, and
Disasters, Planning and Design. WHO Regional Publications. Western Pacific Series
No. 22. 1998. Retrieved from:
http://www.wpro.who.int/internet/files/pub/297/part1_1.6.pdf
20. Yale New Haven Health System. Disaster Critique Follow-up and Resolution Form
21. Yale-New Haven Hospital. (2009). Emergency Management Plan

Appendices
Chapter 8 Facilities Management

Appendix A Typical Layout of a Workshop for a 100-Bed Hospital
Chapter 8 Facilities Management Appendix A: Page 1 of 1

Appendix B Sample Maintenance Tools List
The tool lists provided here are examples of the type of needs required by different sorts of
maintenance staff. However, hospitals will need to personalize them to their own requirements.
The lists here describe metric tools. If you have older equipment to maintain, you will also need the
imperial version of:
- allen keys
- feeler gauges
- spanners (open)
- spanners (ring)
- spanners (socket)
- wrenches (box).
Chapter 8 Facilities Management Appendix B: Page 1 of 8

Appendix C Sample List of Safety and Calibration Testing Instruments
Type of Work Instrument Skill Level

Electrical insulation tester (megger meter) Basic
mains socket wiring tester
phase tester
continuity tester Specialist
three-phase tester
Electronic multimeter Basic
bench-top power supply Specialist
counter/timer
function generator
oscilloscope
Medical equipment ammeter and earth break box (instead of MES Basic
tester)
electronic thermometer
standard mercury BP apparatus
defibrillator analyzer/tester Specialist
ECG simulator
electro-surgical unit (ESU) analyzer
medical electrical safety (MES) tester/analyzer 1,
2
non-invasive BP monitor tester
oxygen analyzer
oxygen flow meter monitor
patient simulator, multi-parameter, two-channel
pH meter standards
phosphorescent strip
pressure/vacuum meter
spectrophotometer standards
X-ray line resistance meter
X-ray mAs meter
X-ray phantoms
gas analyzer Advanced specialist
ultrasound therapy unit output (precision) test very expensive and only
balance required in the largest
ventilator tester workshops
Note:
1. The medical electrical safety (MES) tester/analyzer should include an IEC 60101-1 test load
2. A portable appliance tester (PAT) could possibly be used instead of an MES something is better than
nothing. However, it cannot necessarily go down to the correct sensitivity for medical equipment or check for
patient probe leakage. Use of a PAT requires specialist advice in order to be aware of its limitations.
Chapter 8 Facilities Management Appendix D: Page 1 of 1

Appendix D Sample Format for the Tools Ledger
A Tools Ledger can be designed to ensure that it is possible to always know where tools are
and who has them, even when staff work off site (for example, at staff accommodation), or
on outreach trips over a period of days.
We suggest that the Tools Ledger be a book rather than pieces of paper which are filed, since
sheets of paper detailing who signed for a tool can easily go missing. For larger teams and
workshops which have separate sections for different maintenance disciplines (carpentry,
electrical, plumbing, medical, etc), a Tools Ledger can be kept for each discipline. This
makes it easier to keep track of tools under the responsibility of different work teams.
The Tools Ledger book should be divided in two. This way it can be a record of the
issuing of tools as well as a checklist inventory of the tools for that maintenance
section. The two halves work as follows:
The front of the book is used as a Tools Issue Register with a double-page spread to
record the use of tools daily (or weekly, depending on the level of security chosen). An
example of how it can be laid out is shown below.
The back of the book contains a list of all the tools owned by that maintenance section
(the bench tools, the contents of the various hand-tool kits, and the test instruments), to
act as an inventory of the tools. Against this list there are weekly (or monthly) columns,
where ticks are placed if the tools are present at the end of week (or month) check.
This is an example of a possible layout for the double-page spread within an A4 book which
can act as the Tools Issue Register, with an example included of the type of entries. Large
teams could set up a book for each different maintenance discipline.
Chapter 8 Facilities Management Appendix D: Page 1 of 1

Appendix E Sample Facilities Maintenance Work Order Form
SECTION A: To be completed by user
Name of person making request: Date:
Description and location of problem:
Troubleshooting performed (if relevant):
SECTION B: To be completed by Head of Equipment Maintenance
Date request received: Priority of task (high/medium or low):
Task allocated to:
SECTION C: To be completed by Maintenance Technician
Was repair completed?
Yes No
If No, state reason work not completed and return Work Order Form to Head of
Maintenance:
Chapter 8: Facilities Management Appendix E: Page 1 of 1

Appendix F Sample Format and Checklist for a Typical Design Brief
(1) Introduction
(a) Background, project initiative
(b) Project funding, source
(c) Others
(2) Site information
(a) Physical description: bearings, boundaries, topography, surface area
(b) Land use in adjoining areas
(c) Any limitations of the site that would affect planning
(d) Maps of vicinity and landmarks or centres
(e) Existing utilities
(g) Rainfall and data on weather and temperatures
(3) Policies for hospital operation: concepts on a general level, with implications at specific
levels, such as:
- patient movement
- staff movement
- delivery of supplies
- disposal of used goods
- laundry services
- food services
- domestic services
- security
- engineering services
- fire protection
- emergency alarm systems
(4) Zoning: grouping of departments according to zoning principles
(5) Departmental requirements:
(a) Description of functions and facilities
- procedures, operational policies
- schedule of accommodation
Chapter 8: Facilities Management Appendix F: Page 1 of 3
- list of rooms
- suggested area; critical dimensions, if any
(b) Qualitative parameters
(i) location, relationship to other rooms, services and departments
(ii) use
- function of or activities carried out in room
- space requirements for activities, when critical
- numbers of staff and/or patients using room at one time
- wheeled traffic
- goods or materials
- special uses and work flow,
- occupancy or time in use
(iii) constraints
- privacy
- supervision
- security
- separation
- fire protection
(iv) environment
- wind direction
- lighting, natural and artificial
- heat, humidity, sterility
- cold, room heating
- sound (acceptable noise levels)
- ventilation
(v) fittings, fixtures and equipment (fixed and movable)
(vi) loads on services
- electrical
- heating

- ventilation and air-conditioning
- hot water
(c) Functional relationships and physical proximities
(d) Flexibility and future expansion: possibility of future growth, with schedule
(6) Cost of project, other financial aspects (in terms of capital and recurring costs)
(a) financing scheme
(b) cost limitations for each aspect of the project (working budget)
(c) priorities for phasing, if necessary
(d) expected flow of funding with time

Appendix G Sample Material Safety Data Sheet
Glutaraldehyde Solution, 50% MSDS
Section 1: Chemical Product

Product name:
Glutaraldehyde 50%
Synonym:
Glutaraldehyde Solution, 50%; Petanedial; Glutaric Dialdehyde, 50% in water
Section 2: Composition and information on Ingredients

Composition:
Name % by weight
Glutaraldehyde 50
Water 50
Toxicological Data on Ingredients: Glutaraldehyde: ORAL (LD50); Acute: 134mg/kg [Rat]. 100mg/kg
[Mouse] > 5840 mg/kg [Mouse]. VAPOR (LC50): Acute: 480mg/m 4 hours [Rat].
Chapter 8 Facilities Management Appendix G: Page 1 of 5

Appendix H Sample Facility Risk Analysis Template
Please score Probability, Severity, and Preparedness through a numbering system:
1 = Low/Not Very
2 = Moderate/Adequate
3 = High/Very
*For Probability and Severity, 1 is the best score, indicating that this event is not very
probable/not very severe.
*For Preparedness, 3 is the best score, indicating that the facility is very prepared in the case
of this event
Naturally Occurring Events:
Probability Severity Preparedness
Severe
Thunderstorm
Earthquake
Extreme
Temperatures
Drought
Flood (External)
Wild Fire (External)
Landslide
Dam Inundation
Epidemic
Other
Technologic Events:
Electrical Failure
Generator Failure
Transportation Failure
Fuel Shortage
Chapter 8 Facilities Management Appendix H: Page 1 of 3

Water Failure
Sewer Failure
Steam Failure
Fire Alarm Failure
Communications Failure
Medical Gas Failure
Medical Vacuum Failure
HVAC* Failure
Information Systems
Failure
Fire (Internal)
Flood (Internal)
Hazmat** Exposure
Supply Shortage
Structural Damage
Other
*HVAC = Heating, Ventilating, and Air Conditioning** Hazmat = Hazardous Material
Human Related Events:
Mass Casualty
Incident (Trauma)
Mass Casualty
Incident
(Medical/Infectious)
Terrorism
Terrorism
(Biological)
Infant Abduction
Hostage Situation
Civil Disturbance

Bomb Threat
Other
Events Involving Hazardous Materials:
Mass Casualty Hazmat Incident
Small Casualty Hazmat Incident
Chemical Exposure (External)
Small/Medium Sized Internal

Spill
Large Internal Spill
Terrorism (Chemical)
Terrorism (Radiologic)
Radiologic Exposure (Internal)
Radiologic Exposure (External)
Other

Appendix I Sample Major Incident Action Cards
Major Incident Action Card AC1
Position: Chief Executive Officer
Department: Administration
Reporting to: n/a
Station: Incident Response Room
Responsibilities:
To provide strategic management of the incident

To establish communication with relevant local, regional and national agencies to
ensure adequate resources and co-operation from other organizations
To liaise with the media and prepare any press statements that have to be released
Position: Incident Commander
Department: Incident Response Team
Reporting to: Chief Executive Officer
Station: Incident Response Room
Responsibilities:
To obtain details of the incident using the Incident Alert Log and assess the
situation
To authorize activation of MIP
To activate the communications cascade and establish the Incident Response
Team
To open the Incident Response Room
To assess the situation with relevant staff members
To assign Action Cards
To receive update reports from key personnel
To regularly reassess situation
To decide when incident can be declared over and de-activation of the MIP
Chapter 8 Facilities Management Appendix I: Page 1 of 3

Position: Director of Emergency Services
Department: Emergency Service Case Team
Reporting to: Incident Commander
Station: Emergency Department
Responsibilities:
To call in emergency case team staff in sufficient numbers to care for attending
patients
The reception, registration, triage and immediate care of all patients from the
incident
To ensure there are sufficient drugs and medical supplies for the patient load
Position: Director of Inpatient Services
Department: Inpatient Case Team
Station: Inpatient wards
Responsibilities:
To call in inpatient case team staff in sufficient numbers to care for attending
patients
The management of all patients admitted from the incident, following initial
triage and emergency treatment
To ensure there are sufficient drugs and medical supplies for the patient load
To ensure adequate beds are available for the patient load by the discharge of non
critical cases, cancelling elective surgery etc
To provide regular updates to the Incident Commander on the patient load and
clinical response

Position: Liaison and Referrals Officer
Department: Liaison and Referral Service
Station: Inpatient wards
Responsibilities:
In collaboration with the Director of Inpatient services to ensure adequate beds

are available for the patient load by the discharge of non critical cases, cancelling
elective surgery etc
To liaise with other healthcare facilities for the transfer of patients if the hospital
exceeds its capacity
To provide regular updates to the Incident Commander on bed availability and
patient transfer arrangements
Position: Pharmaceutical Service Major Incident Lead
Department: Outpatient Case Team or Inpatient Case Team
Station: Central Pharmacy/Emergency Store
Responsibilities:
To avail all necessary drugs and medical supplies for the patient load and ensure
these are distributed to all necessary areas including emergency services and
inpatient wards
To provide regular updates to the Incident Commander on stock levels and the
need for additional supplies from alternate sources

Appendix J Sample Incident Alert Log
Name of informant
Designation
Department or Organization
Contact Number Telephone Pager (if relevant)
Call received Date Time
Nature of incident
Date/time of incident Date Time
Location of incident
Current hazards
Potential hazards
Casualties Estimated number Severity Type
Action taken already
Other hospitals/health services

involved
Should hospital Major Yes No

Incident Plan be activated?
Name of Incident Commander:
Signature of Incident Commander:
Chapter 8 Facilities Management Appendix J: Page 1 of 1

Appendix K Major Incident Plan Communications Cascade
Chapter 8: Facilities Management Appendix K: Page 1 of 1

Appendix L: Sample Major Incident Plan Drill
To be filled out by the Incident Commander
What will the disaster scenario include? (Check all that apply)
[ ] Biological [ ] Chemical [ ] Fire [ ] Incendiary device/explosive
[ ] Natural disaster (e.g., earthquake) [ ] Radiation [ ] Structural collapse
[ ] Transportation accident [ ] Internal hospital system failure (specify):
[ ] Other (specify): _______________________________________________________
Proposed date of drill:
Day(s): ________________ Month: ________________ Year: ________________
Estimated start time of drill: _____________________ AM / PM (Circle one)
Expected length of drill:
number of hours: ___________________ number of days: ___________________
Will the disaster drill be announced to the staff prior to the beginning of the drill? (Check
one)
O Yes O No O Unclear
What are your objectives/goals for the disaster drill?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
How many mock victims will be included in the drill? (Enter approximate number):
__________
If there will be mock victims, how will they be physically identified? (Check all that apply)
[ ] Bar coding [ ] Clothing (shirts, caps, etc.) [ ] Victim tracking cards
[ ] Wrist bands [ ] NA [ ] Other (specify): _____________________
Chapter 8 Facilities Management Appendix L: Page 1 of 4

Will the mock victims include people with medical training (i.e., "smart" casualties) who will
assist in assessment of care received? (Check one)
O Yes O No O Unclear O NA If Yes, how many? ____________
Where will the event that initiates the drill take place? (Check one)
O In hospital. Specify where in the hospital: ____________________________________
O Out of hospital. Specify proximity to hospital: (Check all that apply)
[ ] < 1 Km
[ ] 1 - 5 Km
[ ] 6 - 10 Km
[ ] > 10 Km
How will the notification to initiate the drill occur? (Check all that apply)
[ ] By another hospital [ ] By first victim arrival
[ ] By health department [ ] By government agency (e.g., Federal or State emergency

agency)
[ ] Other (specify): _______________________________________________________
Which hospital personnel (not including victims or observers) from the following staff groups
will actively participate in the drill activities? (Check all that apply)
[ ] Administration [ ] Central supply [ ] Emergency department medical staff
[ ] Emergency medical transport service [ ] Engineering and physical plant
[ ] Infection prevention and control [ ] Intensive care unit [ ] Laboratory [ ]

Medicine
[ ] Nursing [ ] OBG [ ] Paediatrics [ ] Pharmacy [ ] Psychiatry
[ ] Radiology [ ] Security/safety [ ] Surgery [ ] Hospital-wide
[ ] Other (specify):
_____________________________________________________________________
[ ] Other (specify):
_____________________________________________________________________
Approximate total number of hospital personnel (not including victims or observers)

participating? ________
Which activities will be included in the drill? (Check all that apply)
[ ] Materials and supplies received

[ ] Simulated clinical procedures performed
[ ] Triage of victims
[ ] Victim decontamination
[ ] Victim transport in the emergency department only
[ ] Victim transport throughout hospital
[ ] Other specify): _______________________________________________________
Will activities occur in active patient care areas? (Check one)
O Yes O No O Unclear
What other organizations/agencies will be involved in the drill? (Check all that apply)
[ ] Ambulance system
[ ] Community
[ ] Fire
[ ] Media
[ ] Police
[ ] Hospital/health systems(s) (specify): ____________________________________
[ ] State agency(ies) (specify): ___________________________________________
[ ] Federal agency (specify): _____________________________________________
[ ] Military (specify): ____________________________________________________
[ ] Other (specify): ______________________________________________________
Does the hospital already have established emergency procedures with any of these outside
organizations/agencies? Please list:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Which zones do you plan to evaluate during the disaster drill? (Check all that apply)
[ ] Decontamination
[ ] Incident command
[ ] Treatment
[ ] Triage
[ ] Other specify): _____________________________________

Which specific activities in the disaster drill are most important to evaluate? (Check all that
apply)
[ ] Biological illness exposure

[ ] Communications
[ ] Equipment and supplies
[ ] Information flow
[ ] Patient documentation and tracking
[ ] Patient flow
[ ] Personnel
[ ] Personal protective equipment (PPE) and safety
[ ] Radiation exposure
[ ] Rotation of staff
[ ] Security
[ ] Time points
[ ] Zone disruption
[ ] Zone location and boundaries (zone description)
[ ] Zone operations
Who will function as drill observers (evaluators)? (Check all that apply)
[ ] Administration staff
[ ] Designated hospital clinical staff
[ ] External clinical staff
[ ] Other designated hospital staff
[ ] Other external experts identified
[ ] Other external experts requested
[ ] Other specify): _______________________________________
Approximately how many observers are you planning to use (minimum one per active zone)
(Enter number): _____________________
Name of lead observer: ____________________________________________________
Additional Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Appendix M Sample Major Incident Plan Drill Evaluation Form
Drill Evaluation Form (To be filled out by the main observer of the drill).
Observer: ______________________________________________________________
Date: ____/____/____
Observer title: ___________________________________________________________
Hospital: _______________________________________________________________
Period of time of evaluation:
_____________ AM / PM (Circle one) to _____________ AM / PM (Circle one)
Time the drill began: _____________ AM / PM (Circle one)
Time the emergency plan was initiated: _____________ AM / PM (Circle one)
Time the facility was ready to accept victims (if applicable): _____________ AM / PM
(Circle one)
Were all incoming victims registered and given a unique identification? (if applicable)
(Check one) O Yes O No
Additional Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Was the emergency plan readily available for use? (Check one) O Yes O No
What method(s) of communication was used?

__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Chapter 8: Facilities Management Appendix M: Page 1 of 2

Was it effective and efficient?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Were significant delays experienced in any area (ex. Transport service, pharmaceutical
service, supplies, etc.)? Please explain:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Did all interactions with outside organizations/agencies go smoothly and efficiently? Any
observed problems?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
If either the entire healthcare facility or just one zone was required to be either fully or
partially evacuated, were there any problems?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Was all appropriate Personal Protect Equipment (PPE) issued to staff/patients/visitors?

(Check one) O Yes O No
Was the appropriate action taken after the drill was over (ex. The re-entry of staff, patients,
and visitors)? Did it go smoothly and efficiently?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Chapter 8: Facilities Management Appendix M: Page 2 of 2

Medical Equipment Management
Page 1 of 31
Section 2 Operational Standards for Medical Equipment Management 6
3.1 Medical Equipment Committee 7
3.2 Medical Equipment Strategy 8
3.3 Medical Equipment Inventory 8
3.3.1 Equipment Risk Classification
3.3.2 Spare Parts Inventory
3.4 Equipment History File 12
3.5 Model Medical Equipment List 13
3.6 Equipment Development Plan 13
3.7 Procurement of Medical Equipment 14
3.8 Equipment Donation 14
3.9 Preparing for Equipment Delivery and Commissioning 15
3.10 Acceptance Testing and Installation 17
3.11 Standard Operating Procedures 18
3.12 Maintenance 18
3.13 Disposal 22
3.14 Training in equipment use and maintenance 22
3.15 Budgeting for Medical Equipment Management 25
3.16 Medical Equipment Incident Reporting 26
3.17 Medical Equipment Maintenance Department 27

4.3 Indicators 29
Source Documents 30
Appendices
Appendix A Sample Inventory Data Collection Form
Chapter9 Medical Equipment Management Page 2 of 31

Appendix B Typical Equipment Lifespan
Appendix C Sample Medical Equipment Risk Assessment Form
Appendix D Sample Bin Record Card for Spare Parts
Appendix E Sample Stock Record Card for Spare Parts
Appendix F Common Site Preparation Steps for Installation of Medical Equipment
Appendix G Guidance for Unpacking and Inspecting Equipment Orders
Appendix H Sample Acceptance Test Log Sheet
Appendix I Sample Planned Preventive Maintenance Log Sheet
Appendix J Good Practice Checklist for Corrective Maintenance
Appendix K Sample Corrective Maintenance Report
Appendix L Sample Work Order Form
Appendix M Sample User Training Verification Form
Appendix N Principles Behind Replacement Cost Calculation
Tables
Table 1 Sample Template for Equipment Development Plan
Table 2 Steps to Develop an Equipment Training Plan
Table 3 Medical Equipment Management Checklist
Table 4 Medical Equipment Management Indicators
Figures
Figure 1 The Medical Equipment Management Cycle
Figure 2 The Hidden Costs of Medical Equipment Management
Boxes
Box A Definition of Medical Equipment
Abbreviations
EDP Equipment Development Plan
FAMU Fiexed Asset Management Unit

MEC Medical Equipment Committee
PPM Planned Preventive Maintenance
SOP Standard Operating Procedure
TOR Terms of Reference

In Ethiopia, the lack of proper management of medical equipment has limited the capacity of
health institutions to deliver adequate health care. It is estimated that only about 61% of
medical equipment found in Ethiopian public hospitals and other health facilities is functional
at any one time.1 Poor equipment handling and utilization, frequent power surges, the age of
the equipment, lack of operator training, lack of preventive maintenance, lack of spare parts,
lack of maintenance capacity, and minimal knowledge regarding sophisticated equipment are
factors that contribute to equipment breakdowns.
As healthcare delivery continues to expand and improve in Ethiopia, and an increasing

number of sophisticated medical equipment is introduced, a system capable of supporting and
managing the medical technology must be in place. Medical Equipment Management defines
the organization and coordination of activities that ensure the successful management of
equipment related to patient care in a healthcare facility. The medical equipment
management cycle (see Figure 1) includes planning and assessment of needs, procurement,
training, operation, maintenance, decommissioning and disposal of the item.
Figure 1 The Medical Equipment Management Cycle
Source: Bird, Caroline, et al. How to Manage Series for Healthcare Technology, Guide 1: How to
Organize a System of Healthcare Technology Management. Hertfordshire, UK: TALC, 2005.
This chapter outlines procedures that a hospital should undertake to appropriately manage its
medical equipment, allowing for the extension of services while ensuring the safety of its
patients.
1
National Scientific Equipment Centre.

Section 2 Operational Standards for Medical Equipment
Management
1. The Hospital has a Medical Equipment Committee composed of doctors, nurses,
technicians, pharmacists, and administrative personnel that oversees the medical
equipment management program.
2. The Hospital has a paper-based or computer-based inventory management system that

tracks all equipment included in the equipment management program.
3. The Hospital has a paper-based or computer-based spare parts inventory management

system. The system is used for ensuring that there is an adequate supply of spare parts on
hand.
4. An Equipment History File is maintained for all medical equipment, containing all key
documents for the equipment.
5. The Hospital has policies and procedures in place for acquisition of new medical
equipment, commissioning, decommissioning and disposal of equipment, the receipt of
donations, and outsourcing technical services for medical equipment repair and
maintenance.
6. All new equipment undergoes acceptance testing prior to its initial use to ensure the
equipment is in good operating condition. Equipment is installed and commissioned in
accordance with the manufacturers specifications.
7. All equipment users are appropriately trained on the operation and maintenance of
medical equipment with standard operating procedures readily available to the user.
8. There is a schedule for inspection, testing and preventive maintenance for each piece of
equipment as guided by the manufacturers recommendations and that schedule is
appropriately implemented.
9. There is a notification and work order system for the repair of medical equipment.

3.1 Medical Equipment Committee
Each hospital should establish a Medical Equipment Committee (MEC) to oversee the
management of medical equipment in the facility.
The MEC should be a representative body composed of hospital management, doctors,

nurses, pharmacists, laboratory technicians, biomedical technicians and/or engineers and
administrative personnel. Depending on the equipment being discussed by the MEC,
specialists from the associated department/case team should also participate on an ad hoc
basis. The selection of members of the MEC should be a clear and transparent process. The
Committee should establish Terms of Reference (TOR) that clearly outline the roles and
responsibilities of the committee members and should meet on a regular basis as defined in
the TOR and as-needed in emergency situations.
The MEC is responsible to:
a) develop and monitor implementation of a medical equipment strategy
b) oversee establishment of a medical equipment inventory
c) develop a model medical equipment list
d) establish and monitor the implementation of policies for:
i. procurement of medical equipment
ii. donation of medical equipment
iii. acceptance testing and installation of medical equipment
iv. maintenance of medical equipment, including a list of external suppliers of

maintenance services
v. disposal of medical equipment
vi. training of hospital staff for the use of medical equipment
e) determine the annual budget for implementation of the medical equipment strategy
f) review incident reports related to medical equipment
NB: Guidance issued by the Federal Ministry of Finance and Economic Development
instructs public bodies to establish a Fixed Asset Management Unit (FAMU) for the
management of fixed assets. Further discussion on the roles and responsibilities of the FAMU
is presented in Section 3.10 of Chapter 10 Financial and Asset Management. Since medical
equipment is of crucial importance to a hospital it is advisable that each hospital, in addition
to the FAMU, establishes a specialized MEC to oversee the management of medical
equipment as described below. The MEC should be a sub-committee of the FAMU and the
Chair of the MEC should be a member of the FAMU. Alternatively, if the hospital is small,

the FAMU may take responsibility for the management of medical equipment without the
establishment of a separate MEC. In such circumstances it is important that the FAMU
includes members with sufficient technical expertise to provide oversight of the management
of medical equipment.
3.2 Medical Equipment Strategy
Each hospital should establish a Medical Equipment Strategy that addresses the following
areas:
medical equipment inventory establishment and management

inclusion and exclusion criteria for medical equipment to be included in the medical
equipment management program
medical equipment maintenance
medical equipment procurement and disposal
planning and budgeting for medical equipment management
medical equipment training
functions of the medical equipment maintenance department
3.3 Medical Equipment Inventory
An inventory is a list of types of equipment with useful information for each piece of
equipment. A useful inventory tells you:
What you own (type/sorts)

How much of it there is (quantity)
Where it is (location)
What condition it is in (status)
How far it is in its lifecycle (age/expected life)
Before establishing a medical equipment inventory the MEC should determine which items
should and should not be included in the inventory and medical equipment management
program. This should be based on the definition of medical equipment that is presented in
Box A. However, the MEC may decide to exclude smaller, less expensive and easily
replaceable items from the medical equipment inventory and program (for example
sphygmomanometers, stethoscopes, etc) since the effort required to record, maintain and
repair these smaller items may not be worth the required manpower and financial resources.
The Medical Equipment Strategy should give a clear definition of medical equipment that
should be included in the medical equipment inventory and program, and should also state
exclusion criteria for items that should not be included.

Box A Definition of Medical Equipment
Medical equipment can be defined as any instrument, apparatus, implement, machine,

appliance, implant, in vitro reagent or calibrator, software, material or other similar or related
article that is used for:
Diagnosis, prevention, monitoring, treatment or alleviation of disease or injury,

Investigation, replacement, modification, or support of the anatomy or of a physiological
process,
Supporting or sustaining life,
Control of conception,
Disinfection of medical devices,
Providing information for medical or diagnostic purposes by means of in vitro examination
of specimens derived from the human body,
and which does not achieve its primary intended action in or on the human body by
pharmacological, immunological or metabolic means.
Source: GHTF/SG1/N29R16:2005, Global Harmonization Task Force, 2005.
Each hospital should establish an inventory of all medical equipment (following the inclusion
and exclusion criteria described in the Medical Equipment Strategy). A small team should be
established to set up the initial inventory of medical equipment. The team should be lead by
the Head of Medical Equipment Maintenance who is ultimately responsible to establish and
maintain the equipment inventory. Additional equipment maintenance personnel or other
staff assigned by hospital management should also form part of the inventory team.
Additionally, one or more department/case team representatives should participate in the
inventory of their respective department/case team.
The inventory team is responsible to visit every department and record every item of medical
equipment. A sample Inventory Data Collection Form is presented in Appendix A.
Items that are obsolete, that cannot be repaired or that are not of use to the hospital should be
removed and transferred to a storage area at the time of the inventory and the formal disposal
process should be started (see section 3.13 below).
An inventory code number should be assigned to each piece of equipment. This can be done
sequentially from number 1 upwards. Each new item is assigned the next number, with no
regard to type of equipment, location etc.
Alternatively, a speaking numbers inventory system can be used. This system indicates the
location, the type of equipment and the individual number of the equipment. With a speaking
number system each room/department in the hospital is assigned a location code and each
type of equipment is assigned an equipment type code for example T1 99 02 where T1 is

Theatre number 1 in the operating suite, 99 indicates the item is suction pump and 02 is the
individual number of machine.
Although the speaking numbers inventory system is more complex to establish, it has the
advantage that it is easy to identify the location of each item and to organise the equipment
inventory by each department.
An inventory database should be established to record and manage all items of equipment.
This can be paper based or computerized, with paper back up. The following should be
documented in the Inventory for each item of equipment:
Description or type of the equipment
Location of equipment (department/section/room)
Inventory code number
Name of manufacturer
Model name and/or number
Manufacturers serial number
Year manufactured or purchased
Equipment risk classification (see section 3.3.1 below)
Estimated total equipment lifespan*
Current status/condition
*Knowledge of the estimated lifespan of equipment is useful for planning and budgeting
purposes. The estimated lifespan of common hospital equipment items is presented in
Appendix B.
Information gathered as part of the inventory of medical equipment should be included in the
overall fixed asset inventory of the hospital. Further guidance on the fixed asset inventory
process is provided in Chapter 10 Financial and Asset Management.
The inventory should be reviewed and checked annually, with regular updates during the year
when new equipment arrives or is removed from service. Additional inventory checks may
be conducted at regular time intervals throughout the year, as determined by the MEC and
hospital management.
When an item is discarded it should be removed from the Inventory Database. A record
should be kept in a separate file of all discarded equipment for future reference and audit
purposes.
All equipment should be labelled with its inventory number preferably using a water proof
PVC sticker.
Hospital policy should prohibit use of medical equipment without inventory tags/stickers.
This is to ensure that all equipment in use has undergone acceptance testing and receives
regular preventive maintenance, hence minimizing risks to patients and staff from faulty
equipment.

3.3.1 Equipment Risk Classification
As part of establishing an inventory an assessment should be undertaken to classify each item

of equipment as high, medium or low risk. This level of risk determines the priority with
which equipment should be repaired and maintained or replaced if no longer operable. For
example if a high risk item (such as an anaesthesia machine) is broken this should generally
be repaired before a low risk item even if the low risk item has been broken for longer,
except under special circumstances.
Additionally, when implementing the guidance in this chapter (such as developing standard
operating procedures (SOPs), setting maintenance schedules, training staff in equipment use
etc) the high risk items should be dealt with first.
The assessment of risk should be based on:

Function of the equipment: For example whether the equipment is used for life
support, routine treatment, diagnosis or monitoring
Risk associated with equipment failure
Preventive maintenance requirements: The frequency with which preventive
maintenance is required to minimize breakdown and ensure safety
Main area of equipment use: For example use in anaesthesia or surgical areas, use in
general care areas etc
Likelihood of equipment failure: This is measured as the mean time between failures
calculated from previous use or service records
Appendix C presents a Sample Medical Equipment Risk Assessment Form for assigning the
risk category to medical equipment.
A Medical Equipment Risk Assessment Form should be completed for all items in the
equipment inventory. The risk category should be entered on the Inventory Index Card, and
the Risk Assessment Form should be filed in the Equipment History File (see Section 3.4
below). Any new item of equipment should be assigned a risk category when it is received
by the hospital and entered into the inventory.
3.3.2 Spare Parts Inventory
The equipment maintenance department should maintain a stock of the most commonly
replaceable spare parts for the different types of equipment in the hospital. Items should be
kept in a locked room with a stock control system in place. Spare parts should be stored
according to manufacturers instructions and should not be used beyond the expiration date.
The inventory of spare parts should be managed using a stock and bin card system.
Bin Card:
A Bin Card should be prepared for each spare part stored in the maintenance department. The
Bin Card should be kept with the product inside the store. All transactions of the product to
or from the store should be recorded on the Bin Card. The Bin Card should also include a

column for the loss/adjustment of stock and a column for the stock balance. The stock
balance should be updated after each and every transaction or adjustment.
Stock Card:
The Stock Card is similar to the Bin Card but is used to track stock based on issuing and
receiving orders. The Stock Card should be maintained by the Head of the Maintenance
Department. Whenever Stock Cards are updated the totals should be checked against those on
the Bin Card and any discrepancies should be investigated.
A combined Bin/Stock Card System provides a measure of internal control that helps to
minimize leakages of stock due to theft or loss.
Paper based or electronic Stock Cards can be used. If an electronic system is installed there
should be regular back up of data.
Sample Bin and Stock Record Cards are presented in Appendices D and E.
3.4 Equipment History File
An individual file/folder should be established for each item of equipment. This file should
be held in the equipment maintenance department. The file should contain:
Inventory Data Collection Form (Appendix A)
The address of the manufacturer
The address of the supplier and local agents
Details of any maintenance contract and maintenance contractor (if relevant)
Copy of warranty (if relevant)
Price paid/Copy of invoice
List of consumables required to run machine and recommended spare parts
Acceptance test log sheet (Appendix H)
Medical Equipment Risk Assessment Form (Appendix C)
SOPs for operation and maintenance of the item
Planned preventive maintenance schedule
Corrective maintenance reports (Appendix K)
Operator, service and other relevant manuals for all equipment items should be stored in the
workshop library. Copies should be made and distributed to users and other interested parties
as necessary.

3.5 Model Medical Equipment List
Each hospital should establish a model medical equipment list that describes the ideal
number and types of equipment required by the hospital. A multi-disciplinary team brought
together from across all the departments/case teams should develop an outline of the
Essential Service Package for the hospital that describes the core functions and services
provided. This Essential Service Package will determine the corresponding Model Equipment
List of all items that are necessary to provide each service. Each discipline will decide the
type of equipment required to provide the healthcare interventions described in the Essential
Service Package. National standards for medical equipment for each type of service or
hospital (Primary, General and Specialized), where these exist, should be the minimum
requirements of the Model Equipment List, but these may be expanded upon as determined
by the multi-disciplinary team. Further guidance on the development of the Essential Service
Package is presented in Section 3.6 of Chapter 1 Hospital Governance and Leadership.
The Model Medical Equipment List should be approved by the MEC.
3.6 Equipment Development Plan
The Equipment Development Plan (EDP) is a plan to define goals for acquisition,
maintenance, and replacement of equipment in the short term and long term. The equipment
development plan should be developed taking into consideration the current equipment
inventory and the model equipment list.
The EDP brings attention to:
Current stock and condition of equipment: which pieces need to be replaced or

rehabilitated, which pieces need to be disposed
Shortfalls in equipment: missing equipment that needs to be purchased
What action is needed to rehabilitate, replace or purchase equipment
Short-term (1 year) and long-term (2-5 year) goals to ensure that the hospital has all
necessary equipment for current and future services
The EDP should be developed by the MEC and approved by hospital management. The
EDP is the basis for the annual equipment budget (see Section 3.15 below). The Head of
Equipment Maintenance is responsible to implement the EDP, with the assistance of other
departments where relevant (for example administration and finance). He/she should present
quarterly reports to the MEC on the status of implementation of the EDP.
The EDP should be updated annually.
A sample template for an EDP is presented in Table 1 below.

Table 1 Sample Template for Equipment Development Plan
Department/Room:
Equipment Condition Short Term Action Short Longer Term Long
term cost Action term cost
(type and For example (1year) estimate estimates
inventory age and (2-5 years)
number) expected life; For example: repair
working needed; replacement For example:
condition needed; user training replacement needed;
(good, fair, needed; first time first time purchase
poor, needs purchase needed needed
repair,
damaged
beyond repair,
obsolete)
A. Existing equipment
a.
b.
c. etc
B. Additional equipment required (based on Model Equipment List)
a.
b.
c. etc
3.7 Procurement of Medical Equipment
Each hospital should have a policy for the procurement of goods and services. The
procurement of medical equipment should be undertaken in accordance with this policy.
When purchasing new equipment enough spare parts and accessories to last at least 2 years
should also be purchased.
Further guidance on the procurement process and development of a procurement policy is

presented in Section 3.10 of Chapter 10 Financial and Asset Management.
3.8 Equipment Donation
The MEC should establish a policy for the receipt of donated medical equipment. The policy
should describe the conditions under which a donated item will be accepted by the hospital.
For example:
Donated equipment must be in good working order
Equipment will only be accepted if the item is needed by the hospital and is described
in the Model Equipment List and associated Equipment Development Plan
Instruction manuals, in English, should be supplied with the donation

Supplies, consumables and spare parts for the equipment should be readily available
in Ethiopia. If that is not possible, at least 1 to 2 years of needed consumables and
spare parts should be supplied by the donor with the donated equipment
Expertise for the maintenance and repair of the equipment should be available in
Ethiopia
The equipment must be compatible with other medical equipment in the hospital
The equipment must not require any special storage or operating conditions that the
hospital cannot provide (for example air conditioning, humidity control etc)
The donor should provide training in the regular use and preventive maintenance of
the equipment, if relevant, and
The donor should provide follow up support regarding use of the equipment, where
necessary
When items are donated the hospital and donor must agree who is responsible for customs
clearance, including approval of the item by the regulatory authority if necessary.
The MEC should establish a list of desired equipment that is based on the Model Equipment
List and associated Equipment Development Plan. The list of desired items and donation
policy should be given to all individuals/organizations that are willing to make a donation to
the hospital.
All equipment donations should be reviewed and approved by the MEC before acceptance.
3.9 Preparing for Equipment Delivery and Commissioning
When an order has been placed to purchase a new item of equipment, or a donation has been
accepted, preparations must be made for receipt of the item. This is to ensure quick and
efficient installation, commissioning, training, and eventually placement into service. Pre-
installation work involves the following:
A) Site Preparation
Site preparation is often required to ensure that the location where the new equipment is to be
installed is suitable. This may require new connections for electricity, water, drainage, gas or
waste and may even require construction work.
Preliminary considerations to think about include:

Is there sufficient access to the room/space (door entry sizes, elevator capacity)?
Is the room/space large enough?
Is the position and layout of the room/space suitable?
Are the required work surfaces and service supply points available?
Is the environment adequate for the purpose? (Is it dust-free? Away from running
water? Air conditioned, if necessary?)
Site preparation tasks may include:

Disposing of the existing item that is to be replaced

Extending pipelines and supply connections to the site
Upgrading the type of supply, such as increasing voltage or pipeline diameters
Providing new surfaces, such as laying concrete or providing new worktops
Creating the correct installation site, such as digging trenches, building a transformer
house or a compressor building
Appendix F presents a list of Common Site Preparation Steps to follow when preparing a site
to receive a new piece of equipment.
B) Organizing Lifting Equipment

Large or heavy items will need to be lifted and moved upon arrival. Plans should be made
ahead of time to arrange proper lifting/moving equipment before the new equipment arrives.
C) Organizing Warehouse Space

If goods need to be stored before they can be unpacked or installed, space should be made
available for these items before they arrive.
D) Preparation for acceptance testing and installation

Any preparations that need to be made for acceptance testing and installation, including
ensuring that appropriately trained personnel to do the testing are available, gathering or
acquiring materials, working/storage space and/or test instruments should be done before the
item arrives.
E) Preparation for User Training

The details of training should already have been decided when drawing up the purchase
contract or donation acceptance document. During delivery time, any preparations that need
to be made (including preparation of training materials, training space, equipment, etc.)
should be finalized in order to ensure training can commence when the equipment is
delivered.
3.10 Acceptance Testing and Installation
All medical equipment, purchased or donated, should be inspected upon delivery and tested
prior to initial use. This is known as acceptance testing and ensures that delivered medical
equipment is complete, undamaged, in good operating condition, accompanied by manuals
and spare parts, satisfies safety criteria, and meets specifications of the purchase order. A
competent individual must assess the functionality of the equipment to prevent any harm to
the operator or patient upon use. Guidance for unpacking and inspecting equipment is
presented in Appendix G.
The main steps in the Acceptance Testing process are described below:
1) Determine what personnel should be involved by asking the following:

How complex is the equipment? The more complex the device, the more likely the
manufacturer will need to be involved.

Do the hospital staff have the necessary technical skills? If the staff cannot perform
the job, then an outside vendor should be contracted.
Are you buying a single item or in bulk? If purchasing in bulk, it is often worthwhile
to contract the manufacturer to perform this process on all the equipment. For a single
unit, the in-house staff may be able to manage with guidance from the manufacturer.
2) Isolate the equipment until it has undergone acceptance testing

Once equipment arrives, set it aside by isolating the equipment in a special holding area and
by labelling it as not for use to ensure that the equipment will not be used. The only
exception is for large items that may be delivered to where they will be installed but should
still be clearly marked as not for use until the acceptance process is completed.
3) Undertake acceptance testing and complete Acceptance Test Log Sheet (see Appendix H)
Acceptance testing should include:
A check that the delivered equipment matches the details of the purchasing order
(model, vendor, quantity, technical requirements, etc)
A check that the equipment is accompanied by operation and service manuals and
necessary paperwork (e.g. warranty, if applicable)
A check that appropriate spare parts and consumables are included (if applicable)
Assembly of the equipment if necessary
Installation and commissioning of the equipment. Installation is the process of fixing
the equipment into place. Depending on the complexity of the equipment, this can
range from simply plugging the equipment into an electrical socket to building it into
the fabric of the room. Commissioning is performing a series of tests and adjustments
that will check whether the new equipment is functioning correctly and safely, and
ensuring that any adjustments are made, before the equipment is accepted.
4) Accept the equipment and Establish Equipment History File

If the equipment passes the safety, calibration and function tests then the hospital can
officially accept the equipment. An Acceptance Test Log Sheet (Appendix H) should be
completed and signed and filed in the Equipment History File.
5) Enter equipment into the equipment inventory

After the item has undergone acceptance testing it should be entered into the hospital
inventory. The assigned inventory number should be marked onto the item of equipment.
6) Prepare Standards Operating Procedures and assign Planned Preventive Maintenance

Schedule (See sections 3.11 and 3.12 below)
7) Provide training for equipment users and maintainers as appropriate.

This will ideally occur immediately but sometimes, due to availability of trainers (in-house,
vendor, other), training may occur at a later date. In this case the MEC will have to decide if
it is safe to hand over the equipment before training the staff. Placing the equipment into

operation without training should only be done when the equipment type has been used
before and the staff are familiar with proper operation.
8) Handover equipment to appropriate department/users.
9) Make final payment for item

Final payment should be made after the item has undergone acceptance testing and all agreed
services (e.g. installation or training) have been provided.
Payment should be withheld if the equipment does not pass the acceptance test or the services
provided are unsatisfactory. In such circumstances the MEC must work with the supplier to
rectify the situation as quickly as possible.
3.11 Standard Operating Procedures
To ensure that equipment is used correctly and safely Standard Operating Procedures (SOPs)
should be developed and attached to each item of equipment. The SOP should be a simple
how-to guide that describes how to use the equipment, instructions for care of the
equipment, and basic safety and troubleshooting procedures. The SOP should be based on the
manufacturers user manual (if available). SOPs should be kept attached or adjacent to the
item and a copy should be included in the Equipment History File that is stored in the
Medical Equipment Maintenance Department.
All staff, including maintenance technicians, should be trained to follow the SOPs and should
follow infection prevention procedures when handling medical equipment. (For further
guidance on infection prevention measures see Chapter 7 Infection Prevention).
3.12 Maintenance
a) Planned Preventative Maintenance
All medical equipment should be inspected and tested prior to use (acceptance testing) and
thereafter should undergo regular planned preventative maintenance (PPM) to ensure that the
equipment is working properly and to prolong its expected lifetime. Safety and calibration
testing should also be performed regularly to ensure the equipment is safe to use and is
operating within expected specifications (or to adjust if it is not).
Preventing equipment failure is more efficient than repairing equipment after breakdown
occurs. PPM should be carried out by both equipment users (for simple, easy, everyday
tasks) as well as biomedical technicians from the maintenance department (for more complex
tasks requiring special skills and/or tools). For some equipment PPM should only be carried
out by certified service engineers.
SOPs for each item of equipment should include instructions on simple PPM and
troubleshooting that can be performed by users of the item.

For each item of equipment there should be a plan for preventive maintenance, safety and
calibration testing that is documented and at a minimum follows manufacturers
recommendations. If the manufacturers manual is not available then inspection, testing and
preventive maintenance should be conducted at a minimum every six months.
The preventive maintenance plan should include:

A description of and guidelines for the tasks to be conducted including:
o Care and cleaning
o Safety procedures
o Functional and performance checks
o Calibration testing
o Preventive maintenance checks
A statement on who is expected to perform each of the above tasks
The frequency with which each of the tasks should be conducted
For each item of equipment a timetable/schedule for each of the tasks above should be
established together with a log file to document all maintenance activities. The maintenance
plan and schedule should be developed collaboratively between the Medical Equipment
Maintenance Department and the Head of the Department/Case Team where the item is
located. The maintenance plan, schedule and log sheet should be attached or kept adjacent to
the equipment item. A copy of the plan and schedule should be kept in the Equipment History
File that is held in the Equipment Maintenance Department.
A sample Preventive Maintenance Log Sheet is presented in Appendix I.
The Head of the Equipment Maintenance Department should establish a system to check all
Maintenance Log Sheets to ensure that all PPM tasks are conducted in accordance with the
schedule for each item of equipment, and should address any instances where PPM is not
conducted in accordance with the schedule.
B) Corrective Maintenance
Corrective maintenance involves equipment repair and replacement of parts. Instrument

operators can follow SOPs to perform simple corrective maintenance such as replacing blown
out fuses or simple troubleshooting. However, most corrective maintenance must be
performed by a qualified technician. A Good Practice Checklist for corrective maintenance
technicians is presented in Appendix J.
Whenever corrective maintenance is performed a Corrective Maintenance Report should be

completed and stored in the Equipment History File. A sample Corrective Maintenance
Report is presented in Appendix K.
NB: Only engineers that are sent by the supplier can perform corrective maintenance on
instruments still under warranty.

If a large piece of equipment requires major rehabilitation an assessment should be done to
determine whether it is worthwhile repairing the item or whether it would be better to
purchase a new one. Generally, if purchasing separately all the parts that make up a piece of
equipment it would cost 3-4 times the price of the equipment. Rehabilitation may be cheaper
in the short term, but if this only adds a short additional lifespan to the item or if it is
continually necessary to replace different parts, then it may be more cost effective to
purchase a new item.
C) Work Orders and Reports
Whenever an item of equipment is faulty this should be reported immediately to the medical
equipment maintenance department using a Service Request/Work Order Form. Requests for
PPM to be undertaken by technicians should also be documented on a Work Order Form. In
urgent cases the request for repair can be made by a telephone call or other verbal means of
reporting, however this must always be backed up with a written request on the Work Order
Form. A sample Work Order Form is presented in Appendix L.
Three copies of the Work Order Form should be prepared (using carbon copy paper):
The first copy should be kept by the user department and filed in a Maintenance
Pending File. This file is best organized by date submitted, with the most recent
request at the top. The Maintenance Pending File should be checked regularly by
the Head of Department/Case Team to ensure that Work Orders are being carried
out in a timely manner. When the work is completed and the item is returned to
service the Work Order Form should be signed by the user (Department/Case
Team Head or representative) and the Work Order Form should be transferred to a
Maintenance Completed File.
The second two copies of the Work Order Form should be submitted to the Equipment
Maintenance Department together with the broken item (if it is feasible to move the item).
Whenever a Work Order is received by the Equipment Maintenance Department this should
be reviewed by the Department Head and the duty should be assigned to the appropriate
individual (or outside service provider). The name of the person who is assigned to undertake
the repair should be written on both copies of the Work Order Form. In the event that several
items required repair at the same time then High priority equipment should be repaired
before Medium or Low Priority equipment.
Within the Equipment Maintenance Department one copy of the Work Order
should be entered into a Work Order Pending File held by the Head of
Equipment Maintenance. This file is best organized by date submitted, with the
most recent request at the top. When the work is completed the Work Order
should be transferred to a Work Order Completed File and kept as a permanent
record of the work undertaken.
The final copy of the Work Order Form should be given to the responsible
medical equipment technician who is assigned to undertake the repair. Upon
completion of the task the final section of the Work Order Form and a Corrective
Maintenance Log should be completed. The item should be returned to the user.

The completed Work Order Form and Corrective Maintenance Log should be
filed together in the Equipment History File.
D) Outsourcing of Technical Services
When the equipment maintenance department is unable to perform PPM or corrective

maintenance of a particular item of equipment, support from external maintenance
contractors will be required. Work may be outsourced to the National Scientific Equipment
Centre, the manufacturers local agent, the manufacturer, private maintenance companies,
individuals such as electricians or plumbers or the Ethiopian Health and Nutrition Research
Institute for laboratory equipment. The Ethiopian Biomedical and Laboratory Equipment
Engineers Association could be a good source for finding qualified individuals or companies.
Support may also be provided by the relevant Regional Health Bureau.
When making the decision to outsource a service, the hospital must consider the task at hand
and the qualifications needed to perform the task. In order to do this, the Medical Equipment
Committee should register all potential individuals and companies that they would consider
as a supplier of maintenance services. The MEC should prepare a list of requirements that
each company should meet in order to be contracted by the hospital and a team of suitable
staff chosen to visit these registered suppliers when possible to ensure that the suppliers
meets the requirements and are qualified to provide the services they offer.
Once the appropriate companies or individuals have been identified and registered, the MEC
should determine the type of arrangement they would like to have with the particular
organization. The arrangement used depends on the sophistication of the equipment and the
number of maintenance options available. The most common arrangements encountered are:
1. Agents Maintenance Contracts typically for sophisticated equipment that is covered

by a warranty for a certain period of time. The contract would be for service post-
warranty and negotiated at the time of equipment purchase.
2. Annual Contracts for particular types or groups of equipment that can be maintained
by an external company for a period of one year. A formal tendering process should
take place to select the best company to provide these services.
3. Annual Standby Registration these companies or individuals can be called upon as
needed to provide maintenance services for certain equipment although they must
submit tenders at the time a job becomes available
4. One-off Jobs in this case, the expertise needed may not be on the registered list and
the MEC must look for individuals or companies that might be able to undertake this
one-time only task.
Having such arrangements allows the hospital to gain from the benefits of bulk purchasing
(e.g. one company can cover many different maintenance jobs), gain from the benefit of fixed
period contracts; ensure that appropriate contractors are chosen and that the quality of work is
high. Therefore, when a repair requiring external support becomes necessary, the Head of the
Equipment Maintenance Department can refer to the registered list of companies and/or
contracts to outsource the work.

The MEC should develop a policy for the use of outside contractors including:
Staff from the maintenance department must accompany outside consultants at all
times
Contractor must provide feedback on progress of job
Contractor must sign-out after each service visit
Contractor will provide a report at the completion of the service to be placed in the
equipment file
Hospitals may also collaborate together to enter joint service contracts in order to minimize
costs and benefit from bulk purchasing.
3.13 Disposal of Medical Equipment
The hospital should establish a Disposal Committee to oversee the disposal of all fixed assets
that are no longer required by the hospital, including medical equipment. Items may be
disposed when they are no longer required by the hospital, cannot be repaired, or have
reached the end of their useful lifespan (see Appendix B). A policy for the disposal of fixed
assets should be established by the hospital and approved by hospital management.
Whenever an item of medical equipment is disposed it should be removed from the hospital
inventory and a record should be entered into the Equipment History File to indicate that the
item has been disposed. The Equipment History File should then be moved to a separate
storage location for inactive equipment items.
Further guidance on the disposal of hospital assets, including medical equipment is presented
in Section 3.10.8 of Chapter 10 Financial and Asset Management.
3.14 Training in equipment use and maintenance
Proper use of medical equipment is essential to maintain optimal performance of medical

devices and preserve the safety of patients as well as the staff operating the devices. Given
the variation in technical characteristics of medical equipment, all clinical staff should be
trained to operate each medical device that they use. The MEC is responsible for overseeing
all user training for medical devices, whether in-service or conducted by suppliers/external
parties.
Training should be conducted at various times throughout a staff members career:
Induction training when staff are newly placed in post, move to a new department or
facility, or to a new location with different responsibilities
Training at the commissioning of equipment when new equipment first arrives
Refresher training to update and renew skills throughout the working life of staff

User training should cover:
Equipment capabilities
o Purpose and capabilities of device
o Awareness of different models and operational differences
o Awareness of the expected life of medical device and need for replacement
o Knowledge of where/how to access user manuals and receive equipment
updates
Operating procedures
o How to assemble the device and connect accessories
o How to operate the device effectively and safely
How to link device to patient safely, causing minimal discomfort to
patient
o How to set/change controls
Protocol for equipment failure
o How to recognize malfunction (or correct if possible)
o Who to contact to report damage and adverse incidents and to do so promptly
Emergency and safety procedures
o How to safely shut down/dissemble
o How to clean/decontaminate device and maintain equipment in good operating
condition
o Basic safety protocol:
Always visually inspect equipment before each use. Check for signs of
damage or incorrect settings. Make sure all necessary parts are in place
Do not use equipment unless properly trained
Ask senior staff or other trained personnel when in need of assistance
Maintenance procedures
o How to perform basic, routine maintenance (if applicable)
o How to request equipment maintenance (work order)
o How to keep track of consumables and reorder when necessary
The MEC should establish an Equipment Training Plan that describes the training needs of
hospital staff for the use of medical equipment. Table 2 describes the steps to develop an
Equipment Training Plan.
Table 2 Steps to Develop an Equipment Training Plan

Process Activity
The MEC (or its training sub-group):
Identify existing needs Refers to:

Any record the Maintenance Manager made when analyzing the
Equipment Inventory that training was required
Any prompts, triggers or requests for training reported/submitted

Identify new needs Study the Equipment Development Plan (EDP) and identify the training
required to handle:
Planned equipment replacements
Planned new equipment purchases/donations or additional services
Problems with equipment operation, maintenance or management
Determine the range of Consider:
training that will satisfy The eight different areas for equipment-related skill development: basic
the needs handling, operation, application, care and cleaning, safety, user PPM, PPM
and repair for maintainers, associated skills (procurement, stock control,
financial management, etc.)
The three types of training required at different times in the working life of
staff (induction, at commissioning and refresher training)
Determine the source that Consider:
will provide the needs The various sources of training which provide the option for on-the-job or
external courses
Any initiatives organized and provided by the central health service
provider organization and donor programs
Prioritize across the needs Prioritize the short-term and long-term actions
Prepare an overall Cover all aspects listed above for equipment-related skill development.
Equipment Training Plan
Training can be provided either on site or off site. When purchasing new medical equipment,
the hospital can request that suppliers provide in-service training for equipment use,
maintenance, and repair. The Hospital can also send staff to the manufacturer. The MEC
should assess the quality of the manufacturers user training to ensure it is practical and
provides adequate training for equipment use. The hospital can also send staff to be trained at
other facilities where employees are already trained and using the particular item of medical
equipment. The Hospital can hold in-service trainings if it has staff that are professionally
trained to operate and repair the specified medical equipment and has other needed resources
to conduct the training (see below).
For in-service trainings the hospital should provide:
Trainer (professionally trained expert in use, maintenance, and repair of medical
equipment)
Training materials specific to the piece of medical equipment
Adequate space to conduct the training
Sample equipment and supplies to practice/conduct the training
Test and calibration instruments to test performance and safety
Spare parts for maintenance training
User and service manuals
Formal method of testing and method of certifying trainees (ex. give exam and issue
certificate)

The Human Resource Department is responsible for keeping records of all user trainings.
Training records should specify the name of the person trained, the trainer, the date of the
training, the medical device for which training was conducted, its manufacturer, and model.
If possible, the content of the training should be appended or briefly described in the user
training form. A sample User Training Verification Form is presented in Appendix M.
3.15 Budgeting for Medical Equipment Management
To effectively manage all medical equipment careful planning and budgeting is essential. As
illustrated in Figure 2 below, there are a variety of costs to medical equipment. It is essential
that entirety of costs for all medical equipmentexisting and planned purchasesare
considered when planning and budgeting.
Figure 2 The Hidden Costs of Medical Equipment Management
The first step in preparing a budget for the management of medical equipment is to determine
the value of existing stock. This is known as the Stock Value Estimate. This should indicate
the up-to-date replacement cost of all items in the Equipment Inventory. The up-to-date
replacement value can be estimated from purchase contracts, supplier information, data from
service contracts, manufacturers websites etc.
With the above information it is possible to calculate an annual equipment budget. This
should be based on the Equipment Development Plan and should include:
Replacement costs for current equipment

Maintenance and repair costs
Costs for new purchases for expansion of services
Installation costs of new equipment

Training costs
a) Replacement costs for current equipment
An annual replacement budget covers equipment likely to reach the end of its usefulness by
the end of the year. A quick estimate of an annual replacement budget can be made using the
Stock Value Estimate as follows:
Annual replacement budget = Stock Value Estimate/ average lifetime of all equipment
Further guidance on the calculation of replacement costs is presented in Appendix N.
b) Maintenance and repair costs
As an approximation, maintenance and repair costs for medical equipment are generally
between 5-6% of the new stock value. Hence the Stock Value Estimate can also be used to
estimate the budget required for maintenance and repair.
c) Costs for new purchases for expansion of services
The Equipment Development Plan guides the purchase of new equipment for the hospital.
The cost of items that are due to be purchased in the Financial Year should be calculated and
included in the Medical Equipment Budget.
d) Installation costs of new equipment
As described in Section 3.10 above, there may be costs associated with the installation of new
items such as renovation, installation of plumbing etc. The equipment development plan
should include a description of any installation work that is required. These costs should be
estimated and included in the budget.
e) Training costs
The equipment training plan is the basis for the estimate of training costs associated with
medical equipment use and maintenance.
3.15.1 Budget Submission
The equipment management budget that is prepared by the MEC should be submitted to the
CEO for inclusion in the hospitals annual budget plan. The CEO should allocate items to
capital or recurrent budget lines as appropriate.
3.16 Medical Equipment Incident Reporting
The hospital should establish a process to report and investigate all critical incidents,
including incidents that arise from the use of medical equipment. An Incident Officer should
be assigned to investigate all incidents and to ensure that any required follow up action is
implemented. Further guidance on Incident Reporting and a sample Incident Report Form are
presented in Section 3.1.1 of Chapter 12 Quality Management.

3.17 Medical Equipment Maintenance Department
Each hospital should establish a medical equipment maintenance department that is

responsible to:
a) Establish and maintain the medical equipment inventory
b) Develop and maintain Equipment History Files for all equipment
c) Establish SOPs for equipment use, safety, PPM and troubleshooting procedures
d) Establish PPM schedules
e) Conduct repair of equipment or outsource to an appropriate body when necessary
f) Conduct acceptance testing and installation of new equipment
g) Provide staff in-service training on the correct and safe use of equipment and basic
troubleshooting and preventive maintenance measures
h) Track equipment inventory, service history, and work orders
The number and skill mix of staff within the medical equipment maintenance department will
depend on the size of the hospital. Larger hospitals should employ skilled biomedical
technicians who are able to undertake corrective maintenance on both small and larger, more
complex equipment. However for smaller hospitals it may be more cost effective for the
equipment maintenance department to perform simple preventive and corrective maintenance
only, and to outsource larger and more complex maintenance work to an external company.
A well-balanced mix of in-house and external service providers is technically and financially
sound, particularly in settings with limited resources. Even the smallest biomedical
maintenance departments should oversee the condition and operation of all medical
equipment, be the contact point for all equipment and maintenance matters, be responsible for
finding the correct solution (calling in technical support from external service providers) and
possibly undertake PPM and repair themselves (if properly trained).
The Head of Medical Equipment Maintenance should conduct weekly work-planning

meetings to assess, prioritize and assign outstanding jobs based on the Work Order File.
The Medical Equipment Maintenance staff should have a workshop in which to carry out
maintenance and repair activities. Workshops provide the workspace for maintenance and
repair procedures, serve as security and storage areas for tools and supplies, and equipment-
related reference materials. Depending on the size of the hospital and the number of
maintenance staff available, hospitals may have a single Maintenance Workshop for the
maintenance of all facility assets (buildings, plumbing, sewage, medical and non medical
equipment), or there may be a designated Medical Equipment Maintenance Workshop that is
separate from the General Maintenance Workshop.
If a single workshop is used then the area for medical equipment repair must be sectioned off
from the rest of the workshop and must be kept clean and free from dust.
Further guidance on the tools required, the organisation and layout of a maintenance
workshop is presented in Section 3.2.3 of Chapter 8 Facilities Management.

In order to determine if the Operational Standards for Medical Equipment Management have
and Reporting.
Table 3. Medical Equipment Management Checklist

Yes No
1. A Medical Equipment Committee has been established.
2. Terms of reference for the Medical Equipment Committee are defined.
3. An inventory management system to manage medical equipment has been
established.
4. An inventory management system to manage spare parts of medical
equipment has been established.
5. An Equipment History File system has been established.
6. There are policies and procedures for medical equipment acquisition.
7. There are policies and procedures for medical equipment commissioning
and decommissioning.
8. There are policies and procedures for medical equipment donations.
9. There are policies and procedures for medical equipment disposal.
10. There are policies and procedures for outsourcing of medical equipment
servicing.
11. A maintenance notification and work order system has been established.
12. Preventive maintenance of medical equipment is scheduled and conducted.
13. Inspection and testing of medical equipment is scheduled and conducted.
14. All new equipment undergoes acceptance testing.

4.3 Indicators
Table 4. Medical Equipment Management Indicators

1. Percentage of medical equipment Total number of medical equipment Quarterly

identified on model medical identified on model equipment list
equipment list that is in use at the that is in use at the hospital/ Total
hospital number of medical equipment
identified on model equipment list
*100
2. Total number of medical equipment Quarterly

that is functional/ total number of
% functional medical equipment medical equipment *100
3. a) Number of donated medical a)Total number of donated medical Quarterly

equipment equipment
b) % of donated items that are b) total number of donated medical

functional equipment that is functional/total
number of donated medical
equipment*100
4. a) Number of work orders a) Total number of work orders Quarterly

received received for repair of medical
equipment
b) Number work orders b) Total number of medical

completed equipment work orders
completed
c) % of work orders completed c) total number of medical

equipment work orders
completed/ Total number of
work orders received for repair
of medical equipment
5. of time taken to complete work Quarterly

Average time to completion of order/ total number of work orders
work order completed
6. Actual expenditure on medical Actual expenditure on medical Quarterly

equipment as % of budget equipment /total budget allocated
allocated to medical equipment to medical equipment *100
7. Number of incident reports Total number of incident reports Quarterly

related to medical equipment received related to medical
malfunction equipment malfunction

Source Documents
1. Abington Memorial Hospital Department of Biomedical Engineering, Medical Equipment

Management Program. Abington Memorial Hospital Policy and Procedure for Biomedical
Equipment Class/Risk Classification.
2. Association for the Advancement of Medical Instrumentation. AAMI Equipment

Management Committee. (1999). ANSI/AAMI EQ56: 1999. Recommended practice for a
medical equipment management program. Arlington, VA.
3. The Australian Council on Healthcare Standards. EQuIP Standards, 3rd Edition. Safe
Practice and Environment, pp. 4.
4. Baldinger, P. and Ratterman, W. (2008). Powering Health. Options for Improving Energy
Services at Health Facilities in Ethiopia. Washington DC: United States Agency for
International Aid.
5. Bekele, H. (2008, August). Assessment on Medical Equipment Conditions. Ethiopian

Science and Technology Agency. National Scientific Equipment Center.
6. Egyptian Ministry of Health and Partners for Health Reformplus. (2004, December).
Egyptian Hospital Accreditation Program: Standards. 6. Environmental Safety, pp. 31.
7. Hospital Standards for Accreditation for Afghanistan. Section 5: Administration and

Management. Maintenance of Hospital Facilities and Equipment.
8. Joint Commission International. Joint Commission International Accreditation Standards

for Hospitals, 2nd Edition. Facility Management and Safety. pp. 135, 140-1.
9. Mavalankar, D., Raman, P., Dwivedi, H., Jain, M.L. (2004). Managing Equipment for
Emergency Obstetric Care in Rural Hospitals. International Journal of Gynecology and
Obstetrics. (87): 88-97
10. Temple-Bird, C., Kaur Manjit, Lenel Andreas,and Willi Kawohl. (2005). Guide 1: How
to Organize a System of Healthcare Technology Management. In How to Manage Series
for Healthcare Technology. Hertfordshire, UK: TALC.
11. Temple-Bird, C., Kaur Manjit, Lenel Andreas, Trond Fagerli,and Willi Kawohl. (2005).
Guide 3: How to Procure and Commission Your Healthcare Technology. In How to
Manage Series for Healthcare Technology. Hertfordshire, UK: TALC.
12. Temple-Bird, C., Kaur Manjit, Lenel Andreas, and Willi Kawohl. (2005). Guide 4: How
to operate your healthcare technology effectively and safely. Management Procedures for
Health Facilities and District Authorities. InHow to Manage Series for Healthcare
Technology. Hertfordshire, UK: TALC.
13. Temple-Bird, C., Kaur Manjit, Lenel Andreas, and Willi Kawohl. (2005). Guide 5. How
to organize the maintenance of your healthcare technology. Management Procedures for

Health Facilities and District Authorities. In How to Manage Series for Healthcare
Technology. Hertfordshire, UK: TALC.
14. Wang, B. (2003). A Framework for Health Equipment Management in Developing

Countries. Business Briefing: In Hospital Engineering & Facilities Management.
International Federation of Hospital Engineering. Retrieved from:
http://www.abeclin.org.br/comissoes_arquivos/A%20Framework%20for%20Health%20E
quipment%20Management%20in%20Developing%20Countries.pdf
15. World Health Organization Regional Office for the Western Pacific. (1998). Section
2.6.Training of Technicians for Medical Equipment Maintenance. In District Health
Facilities: Guidelines for Development and Operations. WHO Regional Publications,
Western Pacific Series No. 22. Retreived from:
www.wpro.who.int/internet/files/pub/297/part1_2.6.pdf
16. World Health Organization. (1998). District Health Facilities Guidelines for
Development and Operations. Part 1, section 2.4 Management of Medical Equipment
pgs.150-154. WHO Regional Publications, Western Pacific Series No. 22, pp 150-3.
17. World Health Organization. (2000). Guidelines for Health Care Equipment Donations.
WHO/ARA/97.3. Geneva: World Health Organization.
18. Doncaster and Basset Law Hospitals. NHS Foundation Trust. Medical Equipment
Training for Trust Staff. Volume 3. Retrieved from:
http://www.dbh.nhs.uk/Library/Corporate_Policies/CORP%20RISK%202%20v.3%20-
%20Medical%20Equip%20Training%20for%20Staff.pdf.

19. Duke University Clinical Engineering Policy CE-020. (2007, January). Retrieved from:
http://clinicalengineering.duhs.duke.edu/wysiwyg/downloads/CE020-
Equipment_Management_Program.pdf.

Appendices
Chapter 9 Medical Equipment Management

Appendix A Sample Inventory Data Collection Form
Inventory # ________________________
Type of Equipment: __________________________________
Manufacturer: _____________________________
Model: ____________________________ Serial #: ___________________________
Country of Origin: ____________________ Year of Manufacture: __________
Power Requirement: 220V 110V
Current State/Condition: Operable and in service
Operable and out of service
Reason out of service: ______________________
Needs maintenance
Not repairable
Needs to be discarded? Yes No
Spare parts available? Yes No
If yes, what, how many, and where are they located? __________________________
________________________________________________________________________
Manuals Available: User manual # of copies _______ Location ____________
Service manual # of copies _______ Location ____________
Other (specify) # of copies _______ Location ____________
Equipment Users: Doctors Nurses Lab Technicians
Chapter 9 Medical Equipment Management Appendix A: Page 1 of 2

Students Residents Other (specify) _______________________________
Equipment owner (department), if any: _____________________________________
Contact Person & phone: _________________________________________________
Current location of equipment: ____________________________________________
Will it move from here? No Yes If so, where? ______________________
Other notes (use back of paper if more room is needed:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Chapter 9 Medical Equipment Management Appendix A: Page 2 of 2

Appendix B Typical Equipment Lifespan
The following is a list of typical equipment lifetimes developed by the American Hospital
Association. The list reflects how equipment lasts within the United States healthcare
system, whether it was manufactured in the U.S. or abroad. While this may not be directly
applicable to the Ethiopian context, it is useful to have and use as a reference.
DiagnosticandTreatmentDepartments
Chapter 9 Medical Equipment Management Appendix B: Page 1 of 6

Nursing Departments
Nursing departments consist of cardiac care, chemical dependency, intensive care,

medical/surgical care, neonatal intensive care, nursery, paediatrics, paediatric developmental
disabilities, and psychiatric units.


Appendix C Sample Medical Equipment Risk Assessment Form
All medical equipment should be assessed to determine the risk associated with equipment
use and failure. This guides the priority that should be assigned to each item for maintenance
and repair and replacement when the item can no longer be repaired.
Step 1 Assign a score to each item of equipment
Each item of equipment should be scored in each of 5 categories:
Category A Equipment function
Category B Risk associated with equipment failure
Category C Preventive maintenance requirements
Category D Main area of equipment use
Category E Likelihood of equipment failure (mean time between failures)
Note: Category E, the mean time between failures can be calculated based on equipment
service and incident history. If this is not known then an estimate should be made.
Step 2 Calculate Total Score and Risk Category
The most important categories in the assessment are (A) Equipment Function and (B) Risk
Associated with Equipment Use. Because these are the most important categories these are
given greater weight when the total score is calculated. Hence the total score is calculated as
follows:
Total score = A + B + (C+D+E)/3
The total score will range from 3 to 20.
Medical equipment should be categorized as follows:
High risk (score 18 20):
Equipment should be tested at least twice per year and should be given highest priority for
repair and routine testing and calibration.
Chapter 9 Medical Equipment Management Appendix C: Page 1 of 4

Medium risk (score 15 17):
Equipment should be tested at least annually and should be repaired or undergo routine
testing and calibration after this has been done for high priority equipment.
Low risk (score 12 -14):
Equipment should be tested at least annually and should be repaired or undergo routine
testing and calibration after this has been done for high and medium risk equipment.
Hazard surveillance (<12):
Equipment in this category should undergo annual inspection.

Equipment Type: Inventory Number:
Name and signature of assessor: Date of assessment:
Assessment Criteria Score (circle as appropriate)
A. Equipment Function
Therapeutic life support 10
Therapeutic surgical or intensive care 9
Therapeutic physical therapy or treatment 8
Diagnostic surgical or intensive care monitoring 7
Diagnostic other physiological monitoring 6
Analytical laboratory analytical 5
Analytical laboratory accessories 4
Analytical computer and related 3
Miscellaneous patient related 2
Miscellaneous non patient related 1
B. Risk associated with equipment failure
Potential patient death 5
Potential patient injury 4
Inappropriate therapy or misdiagnosis 3
Equipment damage 2
No significant identified risk 1
C. Preventive maintenance requirement
Monthly 5
Quarterly 4
Semi-annually 3
Annually 2
Not required 1
D. Likelihood of failure (mean time between failures)
Less than three months 5

Approximately 4 6 months 4
Approximately 7 months to 1 year 3
Approximately 1 to 3 years 2
Approximately > 3 years 1
E. Main area of equipment use
Anaesthesia/Surgical care locations 5
Critical/Intensive care locations 4
Labs/Exam areas 3
General care areas 2
Non patient areas 1
Total Score = A + B + (C+D+E)/3
Inventory Classification Result (tick appropriate box below)
High risk (score 18 to 20)
Medium risk (score 15 to 17)
Low risk (score 12 to 14)
Hazard surveillance (<12)

Appendix D Sample Bin Record Card for Spare Parts
Item Description: Item Code Number:
Doc. No.
Received Quantity
(Receiving Batch Expiry
Date from or Remarks
or No. Date
Issued to
Issuing) Received Issued Loss/Adj Balance
Chapter 9 Medical Equipment Management Appendix D: Page 1 of 1

Appendix E Sample Stock Record Card for Spare Parts
Item Description: Item Code Number:
Unit pack size: Maximum stock level:
Minimum reorder level: Lead time:
Order quantity:
Price
Doc. No. Received Quantity Expiry
Date (Receiving from or Unit Price Remarks
Date
or Issuing Issued to
Received Issued Loss/Adj Balance Birr Cent
Chapter 9 Medical Equipment Management Appendix E: Page 1 of 1

Appendix F Common Site Preparation Steps for Installation of Medical Equipment
Step Activity
Review technical needs Study the manufacturers site preparation instructions
Use experience and common sense
Remove existing Cut supply connections and remove the existing item
equipment Cannibalize the existing item for parts
Construct or alter building Build any special construction required, such as a transformer
housing, lead screening, room extension
Make any special modifications necessary, such as enlarging the
doorway, or building a worktop
Remove any scrap or other items from the room
Provide electrical Undertake the work required to provide (as necessary):
requirements A new transformer
A new or upgraded generator
A single phase or three-phase supply at the site of installation
A special circuit breaker
A special socket outlet
An electrical circuit with sufficient capacity
Ensure the electricity Undertake:
installation is safe An exercise to ensure that all relevant electrical installations are
properly grounded and tested
Any remedial works as required
Provide water and Undertake the work required to provide (as necessary):
drainage requirements Adequate water pressure
Water treatment
Increased pipeline diameter
Proper drainage
Appropriate connection points
Provide steam supply Undertake the work required to provide (as necessary):
requirements A steam supply at the proposed site
Increased pipeline diameter
A boiler which can accommodation the increased load
Provide gas supply Undertake the work required to provide (as necessary):
requirements Relevant gas supplies at the proposed site
Provide extra specific Depending on specific guidelines for certain types of equipment (as
requirements for installing detailed by the equipment supplier), provide:
the equipment Bolts in the ceiling for attaching operating lights in theatres
Trenches for supply lines to dental suites
Trenches for waste water for washing machines, e tc.
Provide any additional Provide any associated items as necessary for the equipment or
equipment needs installation, such as:
An uninterruptible power supply (UPS)
A water pump
Chapter 9 Medical Equipment Management Appendix F: Page 1 of 1

Appendix G Guidance for Unpacking and Inspecting Equipment Orders
Checks Activity
systematically open one crate at a time

check the boxes/packages inside each crate for possible
damage
systematically open one package at a time and note what
you find on the relevant documents (see Appendix H)
For damage
keep all packaging, supports, labels and booklets, as you
may have to re-pack the equipment to return it for repairs.
unpack the equipment carefully
ensure that the equipment and its associated supplies do not
appear to be damaged
if anything appears damaged, take a photograph if possible,
and notify the supplier
check that the delivery matches the packing list(s)

Against documentation check that the contents comply with the specifications in the
purchase order in other words, check the type and model
of all equipment and supplies
check that the quantities are according to the purchase order
ensure that the voltage shown on the packing list (or on the
packing case) for electrical equipment is compatible with
your power supply
Technical requirements check that the equipment data plate matches your order and
the packing case/list and, for electrical equipment, that the
voltage stated is correct
for electrical equipment, ensure the mains lead and battery
charger, where applicable, is included
check that all the necessary consumables, accessories and

spare parts have arrived as per the purchase contract
keep these equipment-related supplies together in a dry, cool
and safe place until you can issue some and register the rest
into the Stores system
The package
check that the operating manual, service manual (including
a wiring/circuit diagram), and any assembly and installation
instructions have arrived as per the purchase contract
keep the manuals together in a dry, cool and safe place until
you can make copies and issue/store them
notify the supplier if any documentation is missing or seems
unacceptable (e.g. in another language than requested)
Chapter 9 Medical Equipment Management Appendix G: Page 1 of 2

sign and date all relevant documents (such as the packing
list and your order) to show that the contents of the delivery
was correct
retain these documents for use in the rest of the Acceptance
Process, and for later submission to the supplier/issuing
Administrative requirements store at the end of handover and submission to the Finance
Officer for payment
record any discrepancies between the documents and the
delivery contents on the documents themselves and on the
Fault Report form
use the complaints procedures to investigate any
discrepancies
complete the relevant sections of the Acceptance Test
Logsheet (see Appendix H)
Chapter 9 Medical Equipment Management Appendix G: Page 2 of 2

Appendix H Sample Acceptance Test Log Sheet
Only when this form has been satisfactorily completed should the Registration Box be filled in by the
Head of Medical Equipment Maintenance.
REGISTRATION BOX
ALLOCATED INVENTORY NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EQUIPMENT TYPE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DESTINATION LOCATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACCEPTANCE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WARRANTY EXPIRY DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MAINTENANCE CONTRACT WITH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEALTH FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NAME OF EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TYPE/MODEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORDER NUMBER . . . . . . . . . . . . . . . . . . . . . . SERIAL NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . .
COST. . . . . . . . . . . . . . . . . . . . . . . . . DATE RECEIVED . . . . . . . . . . . . . . . . . . . . . . . . . .
MANUFACTURER . . . . . . . . . . . . . . . . . . . . . SUPPLIER/AGENT . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................... ...........................................
...............................................................................
.................................... ...........................................
PHONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PHONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DETAILS OF ALL ACCESSORIES, CONSUMABLES, SPARE PARTS AND MANUALS RECEIVED ARE
LISTED ON PAGE SIX OF THIS FORM.
Chapter 9 Medical Equipment Management Appendix H: Page 3 of 19

Page 1
ACCEPTANCE CHECKS
1. DELIVERY
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witnessed by: Name . . . . . . . . . . . . . . . . . . . Position . . . . . . . . . . . . . . . . . . . . . Date . . . . . .
Yes/done No/not Corrected if

done applicable
a) Representative of supplier present? ...... ...... ......
b) Correct number of boxes received? ...... ...... ......
c) After unloading, visible damage to the boxes? ...... ...... ......
d) If damaged, has this been stated on the delivery

note and senior management informed? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
2. UNPACKING (refer to invoices and shipping documents)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Visible damage to the equipment? ...... ...... ......
b) Equipment complete as ordered? ...... ...... ......
c) User/operator manual as ordered? ...... ...... ......
d) Service/technical manual as ordered? ...... ...... ......
e) Accessories as ordered? ...... ...... ......
f) Consumables as ordered? ...... ...... ......
g) Spare parts as ordered? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................

Page 2
3. ASSEMBLY (refer to manuals)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Are all parts available? ...... ...... ......
b) Do they fit together? ...... ...... ......
c) Mains lead with plug included? ...... ...... ......
d) Do all the accessories fit? ...... ...... ......
e) Are markings and labels OK? ...... ...... ......
f) Any damage? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
..................................................................................
4. INSTALLATION (refer to manuals)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Was the work carried out satisfactorily? ...... ...... ......
b) Were technical staff present as learners? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................

Page 3
5. COMMISSIONING/TESTING
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Were electrical, mechanical, gas, radiation safety tests
and performance checks carried out in accordance with
the test sheets on pages 7 to 9 of this form? ...... ...... ......
b) Was the work carried out satisfactorily? ...... ...... ......
c) Were technical staff present as learners? ...... ...... ......
d) Were operators present as learners? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
6. ACCEPTANCE to be certified by the Head of Equipment Maintenance only

done applicable
a) Is the equipment accepted? ...... ...... ......
b) If rejected, have the shortcomings been summarized
on page 10 of this form ...... ...... ......
c) If so, has a report gone to senior management
and formal complaints procedures started? ...... ...... ......
d) Should payment be withheld pending corrections? ...... ...... ......
e) Is payment approved? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................

Page 4
7. TRAINING
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Were the expected training courses given? ...... ...... ......
b) Were the training courses satisfactory? ...... ...... ......
c) Were suitable operators present? ...... ...... ......
d) Were suitable technical staff present? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
8. REGISTRATION to be undertaken by the Head of Medical Equipment Maintenance

done applicable
a) If accepted, has an inventory number been allocated? ...... ...... ......
b) Has the Registration Box on Page 1 of this form been filled in? ...... ...... ......
c) Has the Stores Controller been provided with the location
for the equipment and all necessary data, so that the
Stores Receiving Procedure can be followed and a
Goods Received Note completed? ...... ...... ......
d) Have the accessories, consumables, spare parts, and manuals
all been issued to the correct holding authorities? ...... ...... ......
NAME. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NOW PLACE THIS FORM AS THE FIRST RECORD IN THE EQUIPMENT FILE/SERVICE HISTORY
Page 5
Describe and quantify all items received, and complete a Register of New Stocks form:
ACCESSORIES RECEIVED
1. 2.
3. 4.
5. 6.
7. 8.
CONSUMABLES RECEIVED
1. 2.
3. 4.
5. 6.
7. 8.
SPARE PARTS RECEIVED
1. 2.
3. 4.
5. 6.
7. 8.
MANUALS RECEIVED
1. 2.
3. 4.

Page 6
COMMISSIONING/TESTING PROCEDURES (see manuals and relevant technical standards)
i. ELECTRICAL INTEGRITY TESTS
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Classification (applies to medical equipment only) Fill as

applicable
a) Class I - II - III? ......
b) Type B - BF - CF? ......
c) Type AP - APG? ......

done applicable
Mains Connection
a) Are cables and plugs intact? ...... ...... ......
b) Is cable color code correctly connected? ...... ...... ......
c) Are connectors intact? ...... ...... ......
d) Are the fuses correct? ...... ...... ......
e) Is equipment protection correct? ...... ...... ......
f) Is voltage setting correct? ...... ...... ......
g) Is there an earth terminal? ...... ...... ......
Electrical Measurements with Safety Tester
a) Is protective earth continuity correct? ...... ...... ......
b) Is insulation resistance correct? ...... ...... ......
c) Are the leakage currents correct? ...... ...... ......
d) Is the voltage measurement correct? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
..................................................................................
Page 7
ii. MECHANICAL INTEGRITY TESTS
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Are knobs and switches intact? ...... ...... ......
b) Do the wheels/castors move? ...... ...... ......
c) Are the handles intact? ...... ...... ......
d) Are the mechanical movements okay? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
iii. GAS INTEGRITY TESTS
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Are the cylinders full? ...... ...... ......
b) Are appropriate gauges available? ...... ...... ......
c) Is there a cylinder key? ...... ...... ......
d) Is the pressure reading correct? ...... ...... ......
e) Is the cylinder color code correct? ...... ...... ......
f) Are the hoses and fittings correct? ...... ...... ......
g) Is the system leaking? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
..................................................................................

Page 8
iv. RADIATION INTEGRITY TESTS
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
a) Is the kV calibration correct? ...... ...... ......
b) Is the mAs calibrated correctly? ...... ...... ......
c) Was the line voltage compensation performed? ...... ...... ......
d) Was the exposure test correct? ...... ...... ......
e) Were the step wedge test results correct? ...... ...... ......
f) Were the small and large focus calibrations done? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
v. PERFORMANCE TESTS (see manuals for manufacturers recommendations)
Undertaken by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

done applicable
Note: carry out all operational tests as specified by the manufacturer
a) Are the function verification tests correct? ...... ...... ......
b) Is the equipment calibration acceptable? ...... ...... ......
Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................................................................
..................................................................................
..................................................................................

Page 9
FAULT REPORT (describe any shortcomings with the equipment or services provided)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . .
.........................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .
..........................................................................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..................................
NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SIGNATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chapter 9 Medical Equipment Management Appendix J: Page 1 of 3

Appendix I Sample Planned Preventive Maintenance Log Sheet
Equipment: Inventory #: Location: Month:

Task 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Daily Tasks
Daily Task 1
Daily Task 2
Daily Task 3
Daily Task 4
Daily Task 5
Weekly Tasks
Weekly Task 1
Weekly Task 2
Monthly Tasks
Monthly Task
1
Monthly Task
2
Quarterly Tasks
Quarterly Task
1
Quarterly
Technical PM
Semi-Annual Tasks
Semi-Annual
Technical PM
Annual Tasks
Annual
Technical PM

Appendix J Good Practice Checklist for Corrective Maintenance
Step 1
Resist the temptation to dive straight in. Do not immediately open up the machine and plunge in with a
screwdriver.
Step 2
Listen to the equipment users. Talk to the user they can help you to discover the symptoms of the fault.
Ask the users lots of questions they often dont realize how much they know.
Step 3
Look up the equipments service history. Each individual piece of equipment should have a record of its
service history. Use this to make yourself aware of the particular machines past fault.
Step 4
Check the main incoming supply. Ensure that the electricity/gas/water supply is reaching the wall
outlet/socket if it isnt, check the relevant main circuit breakers/valves/taps controlling the service
supply.
Step 5
Inspect the main incoming connection. Check the plug, connector, and mains/incoming lead to see if
electricity (or other supply) is reaching the machine.
Step 6
Inspect the machines external supply connection point. Check the main external fuses/taps/regulators
for the machine.
Step 7
Refer to the operators manual. Familiarize yourself with the instructions on how the equipment is
meant to work.
Step 8
Check the accessories. Ensure that the correct accessories are attached to the correct inlets.
Step 9
Watch the machine in operation. Ask the users to describe what steps they usually take to put the
machine through a normal operational cycle. Watch them do this, and observe what happens.
Step 10
Refer to local sources of advice. Consult the service manual, training resources, PPM schedules and any
other technical personnel. Take note of any possibility of remote diagnostics where, for complex
equipment such as CT scanners, the manufacturers computer may be able to log into the equipment and
diagnose the fault.
Step 11
Only at this point, consider opening the machine. Decide whether it is best to take the machine back to
the workshop before opening it.
Step 12
Inspect the machines internal supply connection points. Check the main internal fuses/taps/valves for
the machine, then check the on/off switch.

Step 13
Go through the troubleshooting or fault-finding steps provided in the service manual. BEWARE: It
is very common for maintainers to guess the problem and act on it without verification. This leads to
frustration when the diagnosis turns out to be incorrect. Thus, always take steps in the following order:
1. Determine the problem to a high degree of certainty by testing
Alter and adjust the equipment as little as possible during this stage
Never guess a problem or make an alteration that cannot be reversed
Always record adjustments as the work progresses (for example, on a notepad)
2. Correct the problem.
Step 14
Contact more experienced colleagues. Ask the in-house team of another health service provider (for
example at a neighboring public or private hospital), or ask the national service provider (National
Scientific Equipment Center).
Step 15
Ask the manufacturer or their representative for help. Contact them for discussions and fault-finding
by phone, fax or email. Email is the cheapest and often the most effective way to get in contact with the
manufacturer. Try to get some hints, but be sure to clarify whether you are being charged for this advice.
Step 16
Call in support from the private sector when the work is beyond your capabilities. Call in the private
maintenance contractor, if there is one, for faults that cannot be handled by the in-house team. Ensure that
the hospital management or HTM Service has the funds to cover this.
Step 17
If the work is within your capabilities, only at this point consider taking corrective action. When a
fault is found that the in-house team has the skills and authority to pursue, follow the corrective action or
parts replacement steps provided in the service manual.
Step 18
Use the correct materials. Select only the correct maintenance materials and spare parts relevant to the
machine.
Step 19
Work carefully. Handle the spare parts and maintenance materials carefully so as not to damage them or
the machine.
Step 20
Make a record of your work. Fill in the Work Order form to record the problem reported, fault found,
corrective action taken, parts used, time taken, etc.
Step 21
Ensure the equipment is safe to use. Always safety test the equipment with the correct test equipment
before returning it to the users.
Step 22
Repeat step 9. Ensure that the operators can make the equipment function properly during a normal
operational cycle.
Step 23
Reduce the likelihood of problems in the future. Ensure in the future that planned preventive
maintenance (PPM) is carried out on the equipment.

Appendix K Sample Corrective Maintenance Report
Work order number:
Equipment type Inventory Number
Model Serial No.
Description of equipment failure
Cause of equipment failure (if known)
Part of machine / equipment to be maintained
Corrective action
Time required
Spare parts replaced
1. 2. 3.
4. 5. 6.
User comments
Date Signature Date
Chapter 9 Medical Equipment Management Appendix K: Page 1 of 1

Appendix L Sample Work Order Form
Note: this is a triplicate form
1st sheet is the User File copy

2nd sheet is the Maintenance Progress File copy
3rd sheet is the Equipment History File copy
SECTION A: To be completed by user
Equipment Type: Inventory Number:
Item Location:
Name of person making request: Date:
Description of Problem:
Troubleshooting performed (if relevant):
SECTION B: To be completed by Head of Equipment Maintenance
Date request received: Work order number:
Priority of task (high/medium or low): Task allocated to:
SECTION C: To be completed by Maintenance Technician
Chapter 9 Medical Equipment Management Appendix L: Page 1 of 2

Was item repaired?
Yes No
If Yes, complete Maintenance Report Form. If No, state reason work not completed and
return Work Order Form to Head of
Return Item to User. Equipment Maintenance for follow up and
completion of Work Order (by assigning
another technician or outsourcing):
Equipment returned
to___________________
Date returned
__________________________
Name of Maintenance Technician _________________________
Signature: ____________________________________________
After corrective maintenance is completed the Work Order Form and Corrective
Maintenance Log Form should be filed together in the Equipment History File.
Chapter 9 Medical Equipment Management Appendix L: Page 2 of 2

Appendix M Sample User Training Verification Form
Name: Position:
Department/ward: Date employment commenced:
Medical Manufacturer/ Trained Date of Assessment/r

Model Comments
Device Supplier By training eview date
Chapter 9 Medical Equipment Management Appendix M: Page 1 of 1

Appendix N Principles behind Replacement Cost Calculations
A. Basic Principle
Assuming Your equipment stock value is, for example, US$2,500,000 (Note:
This is not based on what is purchased each year, but upon the value of
all the items already owned.)
And All the equipment only had a life of one year
Then US$2,500,000 would be needed each year to replace equipment
B. Taking Equipment Life Into Account
But If the life of the equipment is, in fact, five years
Assume The equipment will not all reach the end of its life at the same time
Then The replacement budget can be spread over the lifetime of the
equipment, as follows:
Replacement budget each year = value of stock

lifetime
For example: Replacement budget per annum = $2,500,000/5 = $500,000 p.a.
C. Averaging Across All Stock
In fact, stock will actually be made up of different types of equipment with different
lifetimes some 5 years, some 10, some 15, etc. Based on such lifetimes, an average
lifetime is often taken to be 10 years. Thus, a rough estimate of the replacement budget
will need to be 10% of the equipment stock value each year:
Replacement budget each year = total stock value

average lifetime
For example: Replacement budget per annum = $2,500,000/10 = $250,000 p.a.
Chapter 9 Medical Equipment Management Appendix N: Page 1 of 1

Financial and Asset Management
Page 1 of 45
Section 2 Operational Standards for Financial and Asset Management 7
3.1 Hospital Governance 8
3.2 Hospital Budget Planning 8
3.3 Finance and Property Case Team 10
3.4 Revenue retention and utilization 10

3.4.1 Utilization of Revenues
3.4.2 Planning and budgeting for retained revenue
3.5 Fee Waiver 12
3.6 Exempted Health Services 13
3.7 User fee setting and revision 13
3.8 Private Wing 14

3.8.1 Steps to establish a private wing
3.8.2 Monitoring and evaluation of private wing
3.9 Outsourcing of non clinical services 20

3.9.1 Establishment of an outsourced service
3.10 Asset Management 25

3.10.1 Fixed Asset Management Unit
3.10.2 Procurement of fixed assets
3.10.3 Open bidding method of procurement
3.10.4 Purchase and receipt of fixed assets
3.10.5 Register of fixed assets
3.10.6 Insurance for fixed assets
3.10.7 Accounting for fixed assets
3.10.8 Disposal of fixed assets
3.11 Accounting Practices For Hospitals 34

3.11.1 Purposes of accounting
3.11.2 Cash collection procedures
3.11.3 Collections from credit services
Chapter 10 Financial and Asset Management Page 2 of 45

3.11.4 Handling cash
3.11.5 Payroll accounting
3.11.6 Disbursement Procedures
3.11.7 Reporting Procedures
3.11.8 Auditing

4.3 Indicators 41
Source Documents 44
Appendices
Appendix A Duties and responsibilities of key finance personnel
Appendix B Sample MOU for Fee Waiver
Appendix C Sample Fee Waiver Beneficiary Register
Appendix D Sample Department Fee Waiver Expense Registration Form
Appendix E Sample Bill for Reimbursement of Fee Waiver
Appendix F Sample of fee calculation for public patients
Appendix G Fee setting for private wing services
Appendix H Sample Cash Receipt Voucher
Appendix I Sample Summary Receipt Voucher
Appendix J Sample Receipt Voucher Summary by Revenue Code
Appendix K Sample Deposit Receipt Voucher
Appendix L Sample Deposit Cash Book
Appendix M Sample Payment Voucher
Appendix N Sample Cash Register
Appendix O Sample Credit Agreement
Appendix P Sample Petty Cashbook
Appendix Q Sample Cash Flow Forecast
Appendix R Sample report for receivables management
Tables
Table 1 Financial and Asset Management Checklist
Table 2 Financial and Asset Management Indicators
Abbreviations

FAMU Fixed Asset Management Unit
GOFAMM Government Owned Fixed Assets Management Manual
HIV Human immuno deficiency virus
IT Information Technology
MOU Memorandum of Understanding
SWOT Strengths, Weaknesses, Opportunities, Threats
TAG Technical Advisory Group
TB Tuberculosis
WOFED Woreda Office of Finance and Economic Development

The primary goal of the health policy of the Federal Democratic Republic of Ethiopia is to
increase access to and coverage of health services, ensuring equity and improving the quality
of healthcare provided. A lack of adequate resources, both financial and non-financial, is
recognized as one of the most important factors limiting improved access to and quality of
the health care system. Hospitals consume a large part of the healthcare budget hence
measures to improve hospital efficiency and mobilize resources can play a substantial role in
maximizing health gain.
Historically, public hospitals in Ethiopia received an annual block budget from the Ministry
or Bureau of Finance and Economic Development (BOFED/MOFED). This budget was used
to cover both capital and revenue expenses. Hospitals were expected to charge patient fees
for services provided. However, this income was returned to BOFED/MOFED at the end of
financial year. Hence there was little incentive for hospitals to maximize income, improve
efficiency nor to improve accounting practices.
To alleviate chronic under-financing of the health sector and mobilize the required resources,
the Federal Ministry of Health (FMOH) of Ethiopian developed the Health Care and
Financing Strategy which was approved by the Council of Ministers in 1998 EC. Principle
components include development of the legal and regulatory provisions related to fiscal
decentralization (see Box A). Specifically, these include provisions for:
The establishment of Hospital Governing Boards, accountable to the Bureau/Zonal
Health Desk according to the level of the hospital;
Appointment of the General Manager (Chief Executive Officer CEO);
Local retention and use of facility user fee revenue;
Fee waiver and exemption systems;
Establishment of health insurance schemes;
Outsourcing of non-clinical health services; and
Management and operation of private wings in public hospitals.

Box A Decentralized budget and planning
Decentralization is the transfer of authority and responsibility for public functions from the
central government to lower level tiers. It involves the transfer of authority for decision making to
local governments on expenditure assignment, i.e., performing of public functions including
provision of services, and revenue assignment, i.e, generate own revenues and have independent
authority to make investment decisions.
Fiscal decentralization is a core component of decentralization and refers to the situation where
lower levels of government are entitled to collect and spend revenues of their own and also share
some revenue with a higher level of government. The principle of fiscal decentralization suggests
that assigning expenditure responsibilities and decision-making powers to the lower levels of
government can substantially improve a states ability to effectively identify and address its
citizens needs.
In light of this the government has introduced fiscal decentralization together with basic planning
and budgeting procedures. The purpose of planning and budgeting is to ensure that financial
resources at the facility level are spent with proper accountability in a timely manner according to
expenditure guidelines established by the MOFED/BOFED.
Source: Implementation Manual for Health Care Finance Reform. FMOH, 1995.
To establish the legislative framework for the Health Care and Financing Strategy,
Proclamations and Regulations are issued at Federal and Regional levels on Health Service
Delivery Administration and Management. The broad provisions of the legislative framework
are common to all Regions, although there are some minor differences from Region to
Region, particularly in the Directives governing implementation. Hospitals should be familiar
with and should comply with their own Regional Regulations and Directives when
implementing finance reform activities.
As public bodies, government hospitals should comply with the accounting practices,
budgeting and reporting mechanisms established by BOFED/MOFED.
This chapter describes key activities to support hospital implementation of the Health Care
and Financing Reform Programme. The chapter also describes processes for the management
of hospital assets and gives an overview of accounting practices for hospitals.

Section 2 Operational Standards for Financial and Asset
Management
1. Bilingual fee posters are displayed beside each departmental reception desk, in all waiting
areas and at all cash points. Each poster shows the fees and exemptions and advises
patients to obtain and keep receipts for all payments.
2. The hospital Accountant prepares a monthly report for the Senior ManagementTeam with
details of credit granted, credit repaid and balance outstanding.
3. The hospital has an asset procurement 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
A five year plan for major capital purchases
4. Monthly reconciliation is undertaken for every hospital bank account and any donor
grants.
5. Monthly and quarterly reports on revenue, expenditures, receivables, payables, trial

balance, the status of budget utilization and others including the hospitals operating
margin are prepared by the Finance Department and submitted to the hospital
management and Governing Board.
6. Internal and external audit of hospital accounts is conducted as a minimum annually and
audit reports are reviewed by the Governing Board.
7. The hospital has a Memorandum of Understanding with Waiver Certificate Granting

Authorities providing details on the type of service and mode of payment.
8. The hospital provides exempted services in accordance with the relevant Regional
Legislation and displays a list of exempted services at appropriate locations through the
hospital for the information of patients, staff and the public.
9. In hospitals where a private wing is established, the operations of the private wing are
governed by policies and procedures that are approved by the Governing Board.
10. In cases where non-clinical services are outsourced, procedures are in place to monitor
the contract and services provided.
11. There is a current hospital accounting manual which establishes all policies and
procedures relating to financial management in the hospital.

3.1 Hospital Governance
Central to the Health Care and Financing Strategy is the enhancement of hospital autonomy,
with authority decentralized to the hospital in areas such as strategy, planning and budget
development.
To achieve this, hospitals should be governed by a Governing Board that is responsible to

appoint the Chief Executive Officer (CEO), who in turn leads on all hospital operations and
functions. The Governing Board should oversee the operation of the hospital, approve short,
medium and long term plans and budget, and examine and decide on all matters that are
presented to it by the CEO.
The basic principles relating to the establishment, responsibilities and operating mechanisms
of Governing Boards, the role and responsibilities of CEOs, and hospital planning processes
are discussed in Chapter 1 Hospital Leadership and Governance.
3.2 Hospital Budget Planning
Hospital budgets should be prepared, approved and appropriated following procedures

established by BOFED/MOFED. Procedures for planning and budgeting are necessary to
ensure that financial resources within the hospital are spent with proper accountability and in
a timely manner according to expenditure guidelines established by the BOFED/MOFED.
The main steps in this process are:
Preparation of work plans: Hospital management, with the active participation of the staff,
should prepare work programs following guidelines issued by BOFED/MOFED.
Preparation of budget: Each hospital should estimate annual (from July eight up to July
seven) budgetary resources from different sources including:
the amount of retained revenue they expect to collect from different sources
block grants from government source (both government treasury and foreign)
other sources (eg NGO)
The resources should then be allocated between recurrent expenditure and capital
expenditure, in alignment with the work plan.
The annual work plan and budget should be approved by the Governing Board.
Budget call: This is a notification by BOFED/MOFED to public bodies to prepare a budget

request for their expenditure.

Review of work plans and budget: Regional Hospitals should submit their work plans and
budget to their RHB and Federal Hospitals should submit to the FMOH for review. Each
RHB should consolidate all work plans and submit them to the Regional BOFED. The
FMOH should submit to MOFED.
Budget Approval, Appropriation, Notification and Execution: Once the budget has been
submitted, BOFED will review and make recommendations for revision if necessary, and will
then consolidate all budget submissions. The consolidated budget is submitted to the
Regional Cabinet for approval and then presented, with or without adjustment, to the
Regional Council for appropriation. After appropriation the RHB will be notified of the
budget which it is authorized to use. The RHB will, in turn, notify the hospital of its
appropriated budget.
Thereafter the hospital may utilize the funds.
Budget Execution: Each month the hospital should submit a monthly disbursement request
to BOFED/MOFED. Funds will then be transferred to the hospital bank account.
Reporting: Each Hospital should maintain a book of accounts and formats as prescribed in
the Regional financial proclamation and regulation. Monthly reports should be submitted to
the RHB and BOFED/MOFED.
Budget Adjustment: There are two types of budget adjustment permitted by law:
Budget transfers in which funds are transferred from one line item to another. Budget
transfers from government subsidies should be approved by BOFED/MOFED before the
funds are spent. The CEO should inform BOFED/MOFED from which item(s) in the
original approved budget funds will be taken and for what new expenditure categories they
will be used. Budget transfers from retained revenue should be approved by the Governing
Board. BOFED/MOFED do not need to give approval in such cases.
Supplementary budget - this is an increase to the authorized budget. Any supplementary

budget must be approved by BOFED/MOFED and appropriated by the respective Council.
Standardized, approved formats for budget submission, disbursement requests, the book of
accounts and accounting formats are contained within the MOFED Revised Federal Budget
Manual.

3.3 Finance and Property Case Team
Each hospital should establish a Finance and Property Case Team with, as a minimum, the
following administrative and financial personnel:
Finance Head
Accountant
Cashier
Daily Cash Collector/s
Internal Auditor
Archive staff
Statistician
Facilities Manager
Procurement Officer
Storekeeper
The Finance Case Team Contributes to the hospital sustainability in a number of key ways:
Increasing revenue,
Reducing unnecessary costs and assisting in ensuring that all resources are used
appropriately, efficiently and effectively, and
Improving the quality of services and providing decision makers with timely, accurate
and useful programme and financial information.
Duties and responsibilities of key finance personnel are presented in Appendix A.
The management of hospital property is also a function of this case team. Further guidance
on Facilities Management is given in Chapter 8 Facilities Management.
3.4 Revenue Retention and Utilization
Sources of revenue of hospitals include:

Block budget appropriated by the government;
Fees collected from health care and diagnostic services as well as beds and other
services related to medical treatment,
Sale of drugs and medical supplies,
Revenue collected from third parties in connection with waiver and health insurance
schemes,
Fees collected from consultancy, trainings and research activities,
Income from non-medical services and goods such as lease of facilities and other
similar activities,
Direct aid in cash and in kind obtained from domestic and outside sources; and
Other similar revenue sources.

3.4.1 Utilization of Revenues
Positive Lists
Hospitals may use the retained revenue to meet the manpower and equipment requirements
and to improve the quality of health services. Specifically, retained revenue may be used to:
Improve the services provided under the referral system,
Improve the supply of drugs, medical equipment and supplies,
Conduct procurement and carryout construction works to improve the health care
services of the hospital,
Develop health care information systems and manuals and to improve procedures,
Conduct on the job training programmes and other similar health related problem
solving research so as to improve the efficiency of employees,
Strengthen health education activities and undertake disease control and preventive
activities,
Undertake other similar revenue utilization activities in line with the objectives
designated by the hospital management committee, and
Motivate staffs and reduce staff turnover.
Negative Lists
Retained revenue should NOT be used for:

Any kind of foreign trip and training,
Long term domestic training programs more than three months,
Any kind of subsidy given to a third party,
Payments for hiring consultants,
Revenue utilization other than those activities designed to meet the objectives therein,
nor
For any expenditure code in the positive list for which there is no approved budget.
3.4.2 Planning and Budgeting for Retained Revenue
As part of the budget planning process the hospital should estimate the amount of retained
revenue it anticipates collecting from different sources in the coming year.
Retained revenue can be estimated on the basis of:

Trend of past year(s) collections from each source revenue item,
Total number of visitors and collected revenue from each item of revenue
(examination/card, x-rays, drugs, lab tests, etc),
Estimated number of service seekers and average collections, and
Change in the amount of user fee and expected facility visitors.

The retained revenue estimate should be included in the budget proposal. Note: Expenditure
of retained revenue should be budgeted separately from expenditures made from other
revenue sources.
All revenue must be appropriated before use. Any unutilized retained revenue should be
declared by the hospital at the end of every fiscal year, so that it can be proclaimed and
utilized together with the collections of the following budget year and the appropriated block
budget.
3.5 Fee Waiver
A fee waiver is a right conferred to a household or individual that entitles the

household/individual to obtain health services in certain health facilities at no direct charge or
at reduced price. Beneficiaries are identified and issued with a fee waiver certificate by a
Waiver Certificate Granting Authority (generally Woreda or City Administration).
Hospitals should enter into a Memorandum of Understanding (MOU) with Waiver Certificate
Granting Authorities. This should provide details on the type of service and mode of
payment. A sample MOU is presented in Appendix B.
The hospital should maintain a record of expenses incurred for services provided to fee
waiver beneficiaries. A sample Fee Waiver Beneficiary Register is presented in Appendix C.
The Register should be filled by the Accountant, using source information from the patients
medical record, lab order forms, prescription etc.
Additionally, each Department should maintain a Departmental Fee Waiver Expense

Registration Form to record services provided to fee waiver beneficiaries (Appendix D). This
form will provide information for the hospital Accountant to assist completion of the Fee
Waiver Beneficiary Register.
Every quarter the hospital should submit a request to the Waiver Certificate Granting
Authority for reimbursement of expenses incurred for services provided to fee waiver
patients. A sample Bill for Reimbursement of Fee Waiver is presented in Appendix E.
Upon receipt of the bill, the Waiver Certificate Issuing Authority should verify the request
and instruct the Woreda Office of Finance and Economic Development (WOFED) to make
the payment to the health facility.
NB: The hospital should make all fee waiver reimbursement requests to the Woreda in which
the hospital is located. For patients who reside outside that Woreda, reimbursement
procedures should be established in a tripartite arrangement between the hospital, the Woreda
in which the hospital is located and the Woreda (s) in which the fee waiver beneficiaries
reside. Regional agreements should also be reached for reimbursement of certificate holders
from different Regions.

3.6 Exempted Health Services
Exempted health services should be provided free of charge to all patients, irrespective of the
patients income. Exempted services are generally those of a public health nature such as:
TB services
HIV services
leprosy services
family planning services in primary health care units
prenatal, delivery and postnatal services in primary health care units
immunization services
fistula management
epidemic follow up and control
occupational health services for health professionals.
Each Regional Government will approve the list of exempted services for that Region. Each
hospital should provide exempted services in accordance with the relevant Regional
Legislation and should display a list of exempted services at appropriate locations through the
hospital for the information of patients, staff and the public.
The hospital should finance the costs of exempted services from the appropriated government
budget or donations. The hospital should maintain records of exempted services provided and
submit monthly, quarterly and annual reports to the RHB.
3.7 User Fee Setting and Revision
Historically user fees at government hospitals have varied from Region to Region and from
hospital to hospital and have remained unchanged for a long time. Fees collected by hospital
were remitted to the treasury and hospitals had no right to use the fees, hence there were no
incentives for hospitals to collect fees appropriately.
Under the Financial Reform Legislation patient fees may now be collected by hospitals and
held by the hospitals as retained revenue. However, patient fees should be collected on a cost-
sharing principle and hence not all costs of providing health services should go into the
calculation of user fees. In setting or revising fees what should be considered is charging the
user any additional cost (marginal cost) of providing the service. These additional costs are
for example costs of drugs, laboratory reagent, cost of any disposable material used to treat
the patient, and consumables such as food, bed services, etc. Examples of items that might
not be included in fee calculation are costs of buildings, durable assets and staff salary.
However a certain percentage may be added to the user fee to replace these costs bit by bit in
the long run.
The process of fee setting is governed by Regional Proclamations, Regulations and Directives
and varies slightly from Region to Region. However the basic principles, common to all
Regions are as follows:
hospital management can initiate the process for user fee revision,

the proposed fee structure should be submitted to the RHB,
the RHB should review, considering the ability and willingness to pay of users,
the RHB should submit the proposal to the Regional Cabinet, and
the Regional Council should make the final decision.
User fees may be revised every 5 years.
Hospitals should keep record of expenses and prices to enable fee-setting authorities to
periodically revise and set fees. These reports should be part of the management reports
submitted by the facilities.
Further guidance on the fee setting process for public (non-private) patients is presented in
Appendix F.
(NB: In contrast to the above, for private wing patients fees should be set on a cost recover
basis as described below).
3.8 Private wing
Hospitals may establish a private wing for the benefit of patients, staff and the hospital (see
Box B). Fees charged to patients in the private wing should be set on the basis of cost
recovery and should be higher than those charged in the regular hospital.
Income raised by the private wing should be shared between the hospital and the
professionals providing the private wing services. The income distribution should be
approved by the Governing Board. The hospital should receive a share of at least 15% of the
private wing income.
The hospital management should ensure that the opening of a private wing does not
negatively affect the quality and regular operations of the general hospital services, and
should ensure that the quality of medical care provided in the private wing is no different
from quality of care provided to other patients..
Outpatient private wing client services should be provided out of the normal government
working hours including holidays, Sunday and Saturday full day. In patient services should
be provided during regular working hours and out of hours.

Box B Benefits of a private wing
Benefits for the patient include:

A higher level of amenities and customer service
A cleaner, more comfortable and secure environment
More convenient appointment times
Personal choice of doctors
Benefits for the staff include:

A better work environment
Caring for people with an increased level of patient satisfaction
For eligible employees, a potential to increase earning
Benefits for the Hospital include:

Help to retain qualified staff
Increase revenue for institutional improvement upgraded equipment, computer system,
new clinical services, additional investment in staff training, etc
Establish and role model a higher standard of non-clinical services throughout the facility
Improve patient satisfaction
Improve reputation
3.8.1 Steps to establish a private wing
Step 1 Establish a Technical Advisory Group (TAG)
A TAG should be established to carry out the business, facility and operational planning for
the private wing. The Chair and members of the TAG should be nominated by the CEO and
approved by the Governing Board. The Chairperson and members should be elected based on
their experience and competence with project planning, time available for the project and
credibility amongst stakeholders, and should include representatives from hospital financial
services, nursing administration, medical staff leadership and facility management.
Step 2 Establish goals of private wing
The TAG should establish the goals of the private wing, taking into account the perspective
of patients, staff and the hospital (see Box B above).
Step 3 Select the Service Delivery Model
The TAG should select the Private Wing service delivery mode taking into consideration the
following factors:
Is the hospital facility able to accommodate a private inpatient unit with some
renovation of existing space, or is new construction required?
If new construction is required, are funds available?

Are doctors available to support an inpatient private unit? If yes, are they generalists
or specialists?
Does the RHB support both inpatient and outpatient models?
Will the hospital be able to meet the demands of private patients relating to choice of
meals, TV/internet access, laundry, etc?
There are three possible service delivery models:
Model One: The private wing is a separate inpatient unit where private pay patients are
admitted for care, or
Model Two: The private wing is an out-patient service that utilizes existing ambulatory care
space, radiology equipment and laboratory equipment during non-peak operation hours, or
Model Three: The private wing is both an in-patient and out-patient service program.
NB: If inpatient beds are provide then the number of beds to be set aside for the inpatients of
the private wing should not exceed 10% of the total number of beds that are available in the
hospital.
Step 4 Define the clinical program
The TAG should determine the clinical focus for the private wing and services to be provided
based upon:
historical admission patterns,
existing private hospital services in the area,
community demographics, and
information gathered from informal focus groups of patients, doctors, business and
community leaders.
Types of services that may be provided include:

medical or surgical services or both,
adult or paediatric services or both,
maternity services,
outpatient or inpatient services or both.
As a minimum, medical and diagnostic services should be provided. However, the Governing
Board may expand the type of services provided at any time.
Step 5 Determine doctors reimbursement
The doctors contract should clearly state that his or her private wing practice will not
negatively impact his or her routine work (non-private wing) in the hospital. Reimbursement

to physicians may be made on a volume basis, on a time basis or a combination of both
depending upon the type of service.
Step 6 Determine the staff reimbursement model
The composition of staff required to run or support the private wing should be determined
based on the types of services provided. If it is necessary to recruit and retain staff,
employees working on the private wing may receive a share of the profit. However this is not
always necessary. For example nursing staff may chose to work in an environment where
nurse-to-patient ratios are significantly lower and hence may not require a higher salary to
work in the private wing.
Step 7 Selection of doctors and other staff
The TAG should develop criteria for the selection of staff to participate in the private wing
initiative. Selection criteria may include:
doctors whose training and specialty meet the requirements of the clinical program
seniority
the interest and motivation of the staff member
clinical competence as determined by objective quality assurance measure
better performance evaluation results for their regular service
performance evaluation result that they score when they are assigned to the private
section.
Step 8 Conduct a SWOT analysis
The TAG should assess the internal and external factors (strengths, weaknesses, opportunities
and threats) that will contribute to the success or failure of a private wing. Based on the
SWOT analysis the TAG should decide whether a private wing has the potential to be
successful. If the TAG decides that a private wing is feasible then a Business Plan should be
prepared.
Step 9 Develop a Business Plan
A business plan is a logical, detailed presentation of information about the project. The
business plan should include:
Executive Summary: defining the private wing project and summarizing major risk and
strategies for risk mitigation.
Market Analysis: this includes a description of the specific target market, its willingness to
pay and analysis of competitors (current or anticipated in the future).

Market Plan: this describes the strategy for reaching the target market. It should address the
following:
Product: describe the service including what extra value the patient gets when paying for the
private wing
Price: explain the pricing strategy (see Box C and Appendix G)
Box C Private wing tariff
The tariff for the private wing should be set taking into consideration:
The total cost incurred to deliver the service;
The fees charged by other private health institutions for the same service;
The financial capacity of the customers;
Prices mandated by government regulation; and
Ensuring sufficient funds to distribute to private wing staff and boost motivation.
Further considerations are discussed in Appendix G.
Place: describe how you will make your product known to potential customers
Promotion: describe all activities to promote the service (local press, public events etc)
Management and Personnel Plan: this identifies key management appointments, staffing
configuration and protocols for working with other hospital operating units.
Operation Plan: this includes a description of the physical facility, equipment, supply chain
and other assets required for operating the service.
Financial Plan: this describes how much the venture will cost, where the funds will come
from, and what type of income it is expected to generate.
The Business Plan should be presented to the hospital CEO and Governing Board for review.
If approved, the TAG should then develop a Facility Plan (NB: often this is developed
concurrently with developing the Business Plan since capital expenses to establish a private
wing may be significant and should be included in the Business Plan).
Step 10 Develop a Facility Plan
The development of a Facility Plan follows four steps:
Describe the Functional Program: this defines the purpose, scope and function of the project.
Areas to be addressed include:

the services to be provided, including detail such as specialities, number and
organization of beds (private, semi-private), types of diagnostic or invasive
procedures provided, etc,
the organization and staffing requirements, including support services such as food,
laundry, housekeeping, provision and storage of patient supplies, and
the anticipated workload, which will determine the size of unit necessary.
Develop a Space Plan: this should be prepared by an architect based on the functional
program. Based on the Space Plan a first budget estimate should be made, taking into
consideration the construction and equipment costs. If necessary the TAG may determine
design/cost trade-offs if the preliminary cost estimate is too high.
Prepare a Schematic Design: This shows the general layout of the spaces to maximize
efficiency.
Complete Design Development drawings: These are technical architectural, electrical,

mechanical and plumbing drawings and based on these a refined cost estimate is prepared. At
this stage further design/cost trade-offs may be necessary.
Step 11 Develop Policies and Procedures for Program Operations
The private wing should be overseen by a Private Wing Manager who is appointed by the
Governing Board and accountable to the CEO. Detailed policies and procedures for operating
the private wing should be developed that address:
Human resources: criteria for selecting hospital staff to be assigned to the private
wing should be developed,
Financial management: registration, billing, cash collection and accounting processes
should be established to ensure that the financial results of the private wing are
tracked as a separate program entity,
The interface between private and main hospital services. For each service (clinical,
ancillary and hotel services) consideration should be given to how integrated or
segregated the private service is from the main hospital operations,
Laboratory and X-ray services should be arranged to jointly serve both the regular and
the private wing health services in such a way that doesnt harm the regular service,
Schedules should be set for the use of the operation theatre, sterilization room and
other services that have limited supplies to ensure that their use by the private service
does not negatively affect their regular service provision,
Hotel services (such as food, linen, laundry, accommodation) should be of a higher
standard in the private wing. A decision needs to be made whether each service can be
provided by the main hospital departments or whether separate services should be
established for the private wing, and
Quality assurance: a private wing quality assurance program should be established
including: patient satisfaction survey; infection control monitoring; incident report
tracking and medical records review to ensure adherence to clinical protocols.

3.8.2 Monitoring and Evaluation of private wing
The Private Wing Manager should oversee the monitoring and evaluation of the private wing.
Indicators that could be used and reported on a monthly basis to the CEO and the Governing
Board include:
The number of health professionals that are serving in the private wing out of the total
professionals of the health institution;
The average number of patients who are monthly served by the private wing of the
health institution;
Attrition rate of specialties: the number of health specialists that desert the health
institutions as compared and expressed in percentage with the previous specialist
attrition rate;
Attrition rate of general practitioners: the number of general practitioners that desert
the health institutions as compared and expressed in percentage with the previous
general practitioners attrition rate;
Private wing income as a % of total hospital income,
The proportion that is employed to improve quality of the service rendered by the
hospital out of the total earnings of the private wing;
The percentage of patients satisfied by the treatment service provided to them by the
private wing health service (a validated patient satisfaction survey is presented in
Appendix F of Chapter 12 Quality Management).
3.9 Outsourcing of non clinical services
Outsourcing is the transfer of a business function or the management of business function to

an external service provider.
The main purposes of outsourcing are to:

Minimize costs
Access technical or management expertise not available within the hospital
Improve the quality of non clinical services and hence increase patient satisfaction
Free hospital managers to focus on core functions such as clinical services and quality
of care
3.9.1 Establishment of an outsourced service
Step 1 Select study team
A study team should be established to assess the feasibility of outsourcing non-clinical

services. The team should be comprised of hospital personnel with expertise in managing
non-clinical services, procurement, contracting (legal), accounting and nursing
administration. The team leader and team members should be nominated by the CEO and
approved by the Governing Board.

Step 2 Determine which services should be studied for outsourcing
The study team should decide, based on the hospitals strategic goals, current problems with
service delivery, and knowledge of the business environment of the community, which non-
clinical services should be selected to study for outsourcing feasibility.
Possibilities include:
Housekeeping/Cleaning services,
Laundry and linen service,
Food preparation and supply,
Security services,
Plant operation and fixed assets maintenance,
IT services,
Printing services,
Transportation, and
Others, as determined by the Governing Board.
Step 3 Conduct a pre-bid study
A pre-bid study should be conducted for services that could be outsourced. The study should
include:
Executive summary to highlight the key findings of the study
Market capabilities: for each service that is considered for outsourcing the following
questions should be addressed:
Who are the vendors in the market that provide the service?
How many vendors are working in the market?
What experience does each company have?
Do the companies have experience in a hospital setting and/or experience in Ethiopia?
How do other customers rate the services provided by each company (availability,
timeliness, effectiveness, efficiency etc)?
Cost of service provision: The current cost of providing the services should be calculated.
This should include the cost of equipment (including maintenance and repair), materials,
supplies and staff costs.
Risk identification: Outsourcing non-clinical services has risk. These should be identified by
the study team and considered in the pre-bid study.
Risks include:

Poor contract documentation: the hospital must have good legal and technical help to
prepare a contract that ensures clear specifications for the service to be provided,
performance measures and penalties for lack of performance.
Lack of management experience: Hospital management must have sufficient expertise
and time to effectively manage contracts for outsourced services.
Loss of control: what will happen if the company fails to perform adequately? How
can continuity of services be ensured?
Labour unrest: is the hospital able to manage employee unrest during the time of
transition?
Policy issues:
Cost vs quality: the study team must determine the appropriate balance between the
cost and quality of services. International companies: would the hospital consider
outsourcing to an international company if local capable companies do not exist?
Group purchasing: If the hospital cannot find a company that is willing to contract
with the hospital alone is the hospital willing to join with other hospitals to enter a
group contract for an outsourced service?
Recommended approach to outsourcing:

a) single (umbrella) versus multiple contracts: A single company may be contracted to
manage multiple services in the hospital or different companies may be offered contracts to
manage a single service each. The advantage of a single contract is that it is easier to manage
than multiple contracts (in terms of monitoring activities, making payment etc). But on the
other hand a single company may not have the capacity nor expertise to manage multiple
departments and hence multiple contracts may be necessary.
b) hospital versus company employees: When services are outsourced the hospital must
consider what will happen to the hospital staff currently providing that service. There are
several alternatives:
staff remain as hospital employees working in the same department,
staff remain as hospital employees but are reassigned to a different (non-outsourced)
department,
staff are employed by the company that provides the outsourced service, or
staff employment is terminated.
Hospital employees are civil servants and as such whichever option from the above is
selected the hospital must comply with the Civil Service Regulations. Hospital staff should be
kept informed of the plans for outsourcing, the benefits to the hospital of outsourcing the
service and should be involved in the discussions about their future status.
Step 4 Issue a tender for outsourced services
The pre-bid study should be reviewed by the CEO who should decide if enough qualified
bidders exist to issue a tender for outsourcing a specific service.

Step 5 Prepare offer to bid document
If it is decided that there are enough qualified bidders then the hospital should prepare a
tender (offer to bid) for each outsourced service.
The offer to bid should contain:

a general description of the hospital and information about the operating context,
detailed description of the service required,
contractual conditions. For example:
o term of contract
o insurance requirements
o payment procedures
o dispute settlement and termination provisions
o variations to the scope of the work
o protection from assignment of work or sub-contracting
o confidentiality of information and documents
the selection criteria. For example:
o fit and quality of service design proposed by tenderer
o quality assurance proposals
o demonstrated track record in the service or related area
o financial stability of the firm and/or the the principals
o calibre of the key people proposed to be involved
o total cost of service provision
instructions for bidders on how to submit the bid and deadline for submission
description of proposed performance management arrangements
Step 6 Bid opening and evaluation
A Tender Committee should be established to review and evaluate bids. Bids that are
received on time should be opened together in the presence of the Tender Committee.
A detailed assessment should be made of each bid, covering five broad areas:
the capability of the tenderers,
the technical aspects of the proposals,
the contractual aspects;
the financial and commercial aspects, and
the longer term factors.
The capability assessment should include the experience of the firm and the capability and
qualifications of the key personnel who will be operating the contract, including the
management and supervisor back up, and the capability of the contractor to work within
relevant policy frameworks of Government. Reference checks should be undertaken.

The technical assessment establishes whether the tender exactly meets the requirements set
out in the specification. For example, where the contractor's own plant, equipment and site
are proposed to be used, their capacity to meet the workload should be verified. Any
modifications proposed in the bid should be checked for acceptability.
The contractual assessment appraises the acceptability of any contractual qualifications or

variations stated in the offer, particularly where these propose variations to schedules of
delivery or quality. The cost and other effects of any acceptable qualifications will need to be
taken into account.
The financial assessment includes identification of all relevant costs and calculation of annual
costs and/or net present values of the competing bids. The initial (once only) costs, the on-
going costs associated with maintaining the service and the costs of handing the service over
at the expiry of the contract should be identified and calculated.
From a longer term perspective, various assumptions will need to be made about future costs
and workload. An analysis should be undertaken which varies the main assumptions made to
assess whether the apparently advantageous bid remains the correct choice under plausible
alternative conditions.
The implications of contractor failure and the risk of being locked into one provider should
be considered. Where plant and equipment is involved, the likely state of plant and
equipment at the time of renewal and the need to plan ahead for capital replacement may
require consideration.
Step 7 Contract agreement
After the preferred bidder has been selected a contract agreement should be entered between
the hospital and the company. Most contractors have standard business terms and conditions
of service. The provisions should be examined for acceptability by the hospitals
management.
Step 8 Hospital management of outsourced services
After the contract has been entered, the hospital CEO should ensure that there is adequate
monitoring of the contract and the standard of services provided.
The contract company should assign a manager to run the outsourced service department. The
manager is accountable to both the hospital CEO and the Company CEO/Director. The
contract department manager should be recognised as an integral member of the hospital
management team and should work in partnership with other hospital managers to achieve
the hospitals mission.
The hospital CEO should ensure that:

He/she meets regularly with the department manager(s) of outsourced services,

Annual performance appraisal is undertaken of the department manager. This should
be conducted jointly by the hospital CEO and the contractor company,
He/she (or a representative) conducts regular scheduled and unscheduled inspections
of the contracted service, and
Regular audit is undertaken of the contractors budget reports, standard conditions of
service provision as provided in the contract, supply and equipment inventories.
Step 9 Re-bid contracted services
The contracted service should be regularly re-bid to ensure that the hospital continues to
obtain value for money and the highest possible service. Although service contracts vary
between one year and up to 5 years, it is usual for most contracts to be a minimum of 2 years
with an option to extend.
3.10 Asset Management
The Council of Ministers Financial Regulations No 17/1997 categorises government assets

into two main categories - fixed assets and supplies.
A fixed asset is a tangible asset costing Birr 200 or more that is in operational use and that
has a useful economic life of more than one year, such as furniture, computers, equipment,
vehicles, buildings.1
Supplies are all other items owned by the government such as stationary, cleaning supplies,
gloves, syringes etc.
The management of assets includes procurement, inventory, storage, maintenance and

disposal of assets. Effective asset management ensures that assets are purchased to meet the
needs of the hospital, that assets are maintained in good working order and are disposed of
promptly when no longer required or when the end of the useful lifespan has been reached.
The management of hospital assets is governed by National Legislation as set out in

Proclamations, Regulations and Directives related to the procurement, inventory control and
disposal of assets. The MOFED has also published the Government Owned Fixed Asset
Management Manual (GOFAMM) to provide guidance on the management of assets.
Additionally, in 2009 the Procurement Agency (www.ppa.mofed.gov.et) was established.
The main role of the Procurement Agency is to ensure the application of fair, competitive,
transparent, non-discriminatory and value for money procurement by public bodies. One
specific function of the Procurement Agency is to prepare, update and issue authorized
versions of the standard bidding documents, procedural forms and any other documents
pertaining to procurement and property administration.
1 FDRE Ministry of Finance and Economic Development. Government Owned Fixed Assests Management
Manual. December 2007, p.8

Hospitals should comply with Legislative requirements and with all guidance and forms
issued by the Procurement Agency when managing hospital assets.
The guidance below focuses primarily on the management of fixed assets such as medical
and non-medical equipment (e.g. generators, vehicles etc) and is consistent with current
Legislative requirements. Additional guidance on Facilities Management (including buildings
and non-medical equipment) is presented in Chapter 8 Facilities Management,. Additional
guidance on Medical Equipment Management is presented in Chapters 5, 9; Laboratory
Services and Medical Equipment Management respectively. Guidance on the management of
pharmaceuticals is presented in Chapter 4 Pharmacy Services.
3.10.1 Fixed asset management unit (FAMU):
Each hospital should assign a unit responsible for the management of fixed assets. Full
responsibilities of the FAMU are described in the GOFAMM manual and include:
To establish the fixed asset register,
To undertake an annual physical count of all fixed assets and reconcile with the
register,
To ensure that all fixed assets are put to appropriate use,
To calculate depreciation on fixed assets, and
To identify items for disposal.
Hospitals should also establish a Medical Equipment Committee (MEC) to oversee the
management of medical equipment, since this equipment is highly specialized and its
effective management requires technical expertise (e.g. clinical knowledge) that may not be
necessary for the management of other assets. The MEC should be a subcommittee of the
FAMU and the Chair of the MEC should be a member of the FAMU. Further guidance on the
establishment and responsibilities of the MEC is presented in Chapter 9 Medical Equipment
Management. Alternatively, if the hospital is small, the FAMU may take responsibility for
the management of medical equipment without the establishment of a separate MEC. In such
circumstances it is important that the FAMU includes members with sufficient technical
expertise to provide oversight of the management of all medical equipment.
3.10.2 Procurement of fixed assets
A) Procurement Plan
Each hospital should prepare a 5 year plan for the purchase of major capital. A detailed
annual procurement plan should be prepared showing the procurement for the budget year.
The costs of procurement should be included in the annual budget. The procurement plan and
budget should consider the entire costs related to the purchase including transport, site
preparation, installation, staff training, support, supply of consumables, spare parts etc. The
procurement plan should be developed taking into consideration the Medical Equipment
Development Plan (see Section 3.6 of Chapter 9 Medical Equipment Management), the
hospital annual plan and specific departmental needs.

Hospitals should also budget for the regular maintenance of fixed assets, and for the
emergency purchase of any essential assets that it might be necessary to replace unexpectedly
during the financial year (for example if equipment is broken and cannot be repaired, or if an
item is stolen).
In general, the following guidance gives an estimate of the annual budget required for
maintenance and fixed asset replacement costs:
For medical equipment, each year 5-6% of the new stock value is required.
For buildings, each year 1-2% of the new construction cost is required.
For service supplies and plant, each year 3-4% of purchase and installation costs is
required
B) Procurement Policy
All hospitals should have a procurement policy detailing:

The process of submitting procurement requests
The responsible body/person for approval of procurement requests
Responsible person(s) for purchasing activities
C) Considerations for procurement
When fixed assets, and in particular medical equipment is purchased the following
considerations should be made:
Is the item appropriate to the hospital setting? Consider:
o Environmental factors such as power and water supply, altitude, humidity,
heat, dust etc
o Physical space required and interface with required utilities
Is it of good quality and safety?
Is it affordable and cost-effective? Consider:
o Cost and quality
o Cost-effectiveness when considering lifecycle costs: transportation,
installation, training, repair, spare parts, disposables, reagents, etc.
o Costs to get and keep equipment functioning
Is it easily used and maintained? Consider:
o Skills and training required
o Maintenance and support services available
o Guarantees and warranties
o Consumables accessories and spare parts availability and ease of procurement

D) Methods of procurement
Federal Legislation stipulates that the preferred method of procurement is open bidding
which is described further below. Other options that may be considered when open bidding is
not suitable include:
Request for proposals
Two stage tendering
Restricted tendering
Request for quotation
Direct procurement
Full guidance on these additional methods, including conditions on their use, is provided in
the Federal, Public Government Procurement Directive.
3.10.3 Open bidding method of procurement
The main steps in the open bidding method of procurement are:

Advertisement/Announcement of Invitation to Bid
Preparation and provision of bidding documents
Submission and receipt of bids
Opening of bids
Examination and evaluation of bids
Notification of award and signing of contract
Step 1 Advertisement/ Announcement of Invitation to Bid
Invitations to bid should be advertised at least once in a national newspaper. The hospital
may additionally advertise the bid on national radio or television.
The Invitation to Bid should contain:

The name and address of the public body
A brief description of the goods, works or services to be procured
The place and deadline for the submission of bids
The place and time for opening of bids, along with an announcement that bidder or
their representatives are allowed to attend at the opening of bids
Step 2 Preparation and provision of bidding documents
The bidding documents should contain sufficient information to enable competition among
bidders on the basis of complete, neutral and objective terms.
The bidding documents should contain:

Instructions for the preparation and submission of bids,

Information about the final date for receipt of bids, the address to which bids must be
sent, the date, hour and place of opening,
Bid submission forms and, where applicable, forms of bid security to be provided,
The number of copies to be submitted with the original bid,
The general and specific conditions of the contract,
Specification of requirements including:
o Characteristics of the goods such as quality, performance, safety and where
necessary dimensions, symbols, terminology, packing, marking and labelling
o Additional requirements such as:
Provision of warranty
Service contract
Provision of staff training
Provision of spare part, accessories and/or consumables
Upgradeability
Delivery, installation and commissioning
Confounding factors in the hospital that may impact on the equipment (for example
generator power that may be interrupted, rainy or dusty seasons, availability of air
conditioning etc),
The quantity required,
Time limit for delivery or completion of the task as appropriate,
Evidence to be provided by bidder to demonstrate its qualifications as well as its fiscal
and legal standing,
The period during which the bid remains in force,
The criteria and the points given to each criterion for evaluation of bids and award of
the contract,
A reservation to the effect that the public body may reject all bids at any time prior to
the notification of award, and
The price adjustments that may be made during contract implementation and the
conditions and manner under which such price adjustments can be made.
Bid documents should be made available to candidates either for free, or at a price not
exceeding the cost of reproduction and delivery of the document to candidates.
Hospitals should use the Standard Bidding Document approved by the Procurement
Agency/MOFED which comprises:
Preface
Section 1 Instructions to Bidders (ITB)
Section 2 Bid Data Sheet (BDS)
Section 3 Evaluation and Qualification Criteria (EQC)
Section 4 Bidding Forms
Section 5 Eligible Countries
Section 6 Statement of Requirements
Section 7 General Conditions of Contract (GCC)
Section 8 Special Conditions of Contract (SCC)

Section 9 Contract Forms
Step 3 Submission and Receipt of Bids
Bids should be submitted in writing, signed and in a sealed envelope. Bids that are received
after the closing date and time should be rejected.
Step 4 Opening of Bids
Bidders, or their representative may attend the opening of bids if they so desire. Bids should
be opened at the time stipulated in the bidding document. The name of the bidder and the
total amount of each bid, discounts offered and any such information as the hospital deems
necessary to let the bidders know their relative rank should be read out loud and recorded and
a copy of the record should be made available to any bidder on request.
Step 5 Examination and Evaluation of Bids
A Tender Committee should be established to evaluate bids. The Tender Committee should
be comprised of technical and administrative staff. In particular, the Tender Committee
should have sufficient technical expertise to examine the technical aspects of the bids.
The technical evaluation is crucial to ensure that the items submitted in the bid documents
meet the needs and requirements of the hospital. Thus, bids should not be accepted solely on
cost (i.e. the cheapest items), but should be evaluated to ensure they meet the specifications
and requirements in the Bidding Document. If items do not meet specifications, they should
be eliminated from consideration.
Offers should be judged against the following criteria to ensure that decisions are based on
the best value for the money, rather than simply the items purchase price:
Compliance with requirements in the purchase document
Technical nature of the offer - including services such as installation, training,
maintenance and repair, provision of spare parts and consumables where relevant
Compatibility/standardization with existing hospital equipment. For example, if the
item is a model that already exists in the hospital cost savings could be made in the
long run on spare parts, consumables and maintenance, even if another option meets
the technical requirements and appears less expensive in the short term
Financial nature of the offer
Supplier qualification criteria
The bid that meets the technical requirements at the lowest price should be selected. The
hospital should prepare an evaluation report, containing a summary of the examination and
evaluation of bids.

Step 6 Notification of award and signing of contract
The successful bidder should be informed that its bid has been successful. A contract should
be entered and signed by the hospital and thesuccessful bidder. The unsuccessful bidders
should also be informed as to whom the successful bidder is, and if requested, the
unsuccessful bidders should be informed why they have lost the bid.
3.10.4 Purchase and receipt of fixed assets
After the contract is signed the item should be purchased and delivered as described in the
contract agreement. The hospital should prepare for delivery of the item. This could include
site preparation, installation of electricity or plumbing if required and staff training for
equipment use.
All items should be received into a Central Store where the item will be registered and from
where it will be issued to the site of use. The only exception is for extremely large items
where it is unfeasible to keep in storage, or for items where the vendor is contracted to install
the item and to check that it is working correctly. In these circumstances it may be necessary
to deliver the item directly to the site of use. None-the-less all items should be registered
appropriately and a custodian assigned as described below.
Approved, standardized forms for the receipt and issue of fixed assets should be used.
3.10.5 Register of fixed assets
The hospital should establish a register of fixed assets that contains information on the date
of purchase, description, quantity and cost of each item. A custodian should be assigned for
each fixed asset. In general the custodian should be an individual who regularly uses the fixed
asset or who is in charge of the department/unit where the item is held. The name of the
custodians and the locations of the fixed assets under their custody should be recorded in the
register of fixed assets.
An inventory check to physically verify the inventory against records should be undertaken
annually, following the procedures described in the GOFAMM manual. Key steps are
outlined below:
Decide on date of count

Inform internal audit department,
Organize a team of counters, checkers and supervisors. Each team should consist of at
least three people. The teams should include at least one person capable of identifying
the type and condition of the assets, and

Provide each team with clear written instructions about how the inventory should be done
as well as all of the forms that will be needed including Fixed Assets Count Sheet, Fixed
Assets Registration Card and Fixed Assets with User Control Card. Copies of these forms
can be found in the GOFAMM manual.
The inventory team is responsible for visiting every department and cataloguing every item.
Items stored in cabinets, closets, store rooms, etc, should be checked during this inventory.
For facilities containing large amounts of unused and/or permanently damaged equipment or
other items, the initial inventory activity is a great opportunity to clean up the facility,
removing any item that is obsolete, un-repairable, inappropriate, or, for any other reason, not
of use in the hospital. These items should be physically removed from the ward or other
location within the hospital and the formal disposal process should be started.
Once the inventory information is collected, it may be organized in many ways. A

computerized inventory database or other computerized method is the easiest way to organize
such information, but a card index or similar paper-based system is also possible. Depending
on the desired information, information may be sorted in many ways, such as by product,
location, manufacturer, use/function, age, inventory code number.
If an inventory of medical equipment has already been conducted it is not necessary to repeat
this process, the information gathered can be included within the overall fixed assets
inventory. Further guidance is given in Chapter 9 Medical Equipment Management.
3.10.6 Insurance for fixed assets
The Council of Ministers Finance Regulations No 17/1997, Article No 62 provides that the
Heads and employees of public bodies are responsible for the protection and preservation of
public property. One of the protection methods for fixed assets is purchasing appropriate
insurance policy against unforeseen calamities.
The CEO and the FAMU should assess for which of the assets the hospital should buy
insurance cover. Once purchased, the policy should be renewed every year in advance of its
expiry date.
3.10.7 Accounting for fixed assets
All fixed assets should be valued and recorded in the hospital accounting records. The cost at
which fixed assests are valued should be the historical cost, ie the cost incurred at the time the
fixed asset was purchase or constructed. While this is available for new purchases, it may not
be known for all assets in the hospital, particularly items that were donated or are old. The
GOFAMM manual provides guidance on assigning a value to fixed assets in such
circumstances.
After the initial valuation hospitals should depreciate all items of property, plant and
equipment until the item is derecognized. Depreciation is defined as a systematic allocation

of the depreciable amount of an asset over its useful life. There are various methods of
depreciation. The simplest of all is the Straight-line method of depreciation. Straight-line
method of depreciation assumes that the usefulness of the asset is the same over the entire life
of the asset.
The following depreciation rates should be used for depreciating Government Owned Fixed
Assets.
Vehicle and other vehicular transport 20%
Plant and machinery 12.5%
Buildings residential 5%
Buildings non residential 5%
Infrastructure 5%
Furnishings and fixtures 10%
Office equipments 10%
Books 25%
3.10.8 Disposal of fixed assets
Fixed assets may be disposed when the item becomes unserviceable, obsolete, surplus or
abandoned. Government regulations describe three approved methods of disposal:
Transfer to other public bodies
Disposal by sale
Sale by public auction
Sale through public tender
Sale as scrap
Discarding
Whichever method is followed, the description and amount received from all items that are
disposed of should be entered in the hospital acccounts and the hospital fixed asset register
should be amended accordingly.
A Disposal Committee should be established as an advisory body to hospital management.

The Commitee should be comprised of Heads from appropriate Departments/Units such as
procurement, finance, legal etc. The Committee should review all recommendations from the
FAMU for the disposal of fixed assets, including the method of disposal, and should follow
up on any disposals that are approved by hospital management.
Full guidance on disposal procedures is provided in the GOFAMM manual.

3.11 Accounting Practices for Hospitals
3.11.1 Purposes of accounting
Accounting is concerned with the recording, analyzing and interpreting of financial data.
Hospitals require qualified accountants to provide information for the regular evaluation of
business performance and for periodic appraisal of the value or net worth of the business.
Accounting information is necessary for the preparation of business plans, analysis of
business efficiency and costs of services and policy decision-making.
Detailed guidance on accounting systems for hospitals are provided in the Budget Manual of
the relevant Regional Government with additional guidance provided in the Regional
Implementation Manual for Healthcare Finance Reform.
Each hospital should develop an Accounting Manual which establishes all policies and
procedures relating to financial management in the hospital. The manual should follow the
Regional/Federal accounting system as described in the Budget Manual, using approved,
standardized vouchers and forms.
The following section gives a brief overview of accounting practices for hospitals in
accordance with the procedures established in the Budget Manual.
3.11.2 Cash Collection Procedures
General issues:
The Health Care and Finance Legislation makes the following stipulations:
hospitals should only charge payments at the user fee or bypass fee set by the Health
Bureau or the Regional Council,
bilingual fee posters should be put up next to each departmental reception desk, in all
waiting areas and at all cash points. Each poster should show the fees and exemptions
and should advise patients to obtain and keep receipts for all payments,
collection points should be readily accessible for all patient services (for further
guidance see Chapter 2 Patient Flow),
cash should be collected only by personnel who are authorized by the CEO,
except in emergency cases the fees should be collected after the treatment has been
ordered by the clinicians and its availability confirmed, but before the treatment is
administered,
in emergency cases treatment should be administered when needed and the question
of payment should be handled when the emergency is under control (for further
guidance see Chapter 2 Patient Flow),
revenue can be collected as cash, cheques or bank transfer. Where a cheque is
received the following issues should be considered:
o Cheques must be made payable to the health facility;
o Personal or company cheques must be certified by the drawer's bank;
o Government agency cheques are acceptable without certification;

o No employee has the authority to cash any cheque made payable to the health
facility; and
o Post-dated cheques shall not be accepted as revenue, and
Bank transfers must be evidenced by a bank deposit slip or bank advice.
Cash Receipt Vouchers
Cash Collectors should collect payments from clients/patients and others by issuing a Cash
Receipt Voucher. The Cash Receipt Voucher should be used to acknowledge and evidence
the receipt of cash, cheques, the direct deposit of cash into the bank and bank transfers. Only
pre-printed sequentially pre-numbered official Receipt Vouchers issued by BOFED (MOFED
for Federal Hospitals) should be used. A sample Cash Receipt Voucher is presented in
Appendix H.
The Cash Receipt Vouchers should be distributed as follows:

Original copy to the payer as acknowledgment of the cash receipt;
Second copy to the main Cashier; and
Third copy is retained in the pad.
On a daily basis each Cash Collector should submit all cash receipt vouchers and cash
collected to the main Cashier.
Summary Receipt Voucher
The Summary Receipt Voucher is used by the main Cashier to summarize the cash collected
and cash vouchers received from each Cash Collector. Upon receipt of the cash receipt
vouchers the main Cashier should summarize these on a pre-numbered Summary Receipt
Voucher.
The Summary Receipt Voucher is prepared in triplicate:

original copy is given to the daily Cash Collector as a receipt when the collected cash
is remitted;
second copy is sent to the Accountant attaching the Receipt Vouchers and deposit
slips; and
third copy is kept in the pad.
A sample Summary Receipt Voucher is presented in Appendix I.
Receipt Voucher Summary by Revenue Code
The Receipt Voucher Summary by Revenue Code is a spreadsheet prepared by daily Cash
Collectors to summarize receipt vouchers by revenue account code. On a daily basis each
Cash Collector should complete a Receipt Voucher Summary by Revenue Code and submit
this to the main Cashier together with the issued receipt vouchers and cash collected. The

total amount shown on the Receipt Voucher Summary by Revenue Code should be checked
with total amount shown on the Summary Receipt Voucher to ensure that the two amounts
are the same.
A copy of the Receipt Voucher Summary by Revenue Code should be submitted to the
Accountant together with the Summary Receipt Voucher and supporting Receipt Vouchers.
A sample Receipt Voucher Summary by Revenue Code is presented in Appendix J.
Deposit Receipt Voucher
This is used to acknowledge and evidence the receipt of cash or cheques as a deposit/advance
payment from inpatients. The Deposit Receipt Voucher should be prepared by the Cash
Collector and submitted to the main Cashier together with the funds deposited. A sample
Deposit Receipt Voucher is presented in Appendix K.
The daily Cash Collector should summarize all deposit payments in a Deposit Cash Book (see
Appendix L).
At the end of the patient stay the total service charge should be calculated:
a) If the service charge is equal to the deposited amount then a Cash Receipt Voucher
(Appendix H) should be prepared. A copy should be given to the payee and the second
copy attached to the Deposit Receipt Voucher and submitted to the Accountant.
b) If the service charge is greater than the deposit then the payee should pay the difference
and a Cash Receipt Voucher should be prepared for the total sum, with a copy given to
the payee and a second copy attached to the Deposit Receipt Voucher and submitted to
the Accountant.
c) If the service charge is less than the deposited amount then a Cash Receipt Voucher
should be prepared for the total service charge. The balance should be remitted to the
payee using a Payment Voucher (Appendix M). A copy of both the Cash Receipt Voucher
and Payment Voucher should be attached to the Deposit Receipt Voucher and submitted
to the Accountant.
Cash Register
A Cash Register should be established to record the cash collected each day and the sum
deposited in the bank. The Cash Register should be completed by the main Cashier. A
sample Cash Register is presented in Appendix N.
3.11.3 Collections from Credit Services
Hospitals may provide services on credit basis. A Credit Agreement should be entered
between the hospital and each Institution which would like to subscribe health services on

credit basis. The Credit Agreement should describe the reimbursement collection process and
schedule.
A sample Credit Agreement is presented in Appendix O.
Credit should be granted for a maximum period of three months. Institutions that have a
Credit Agreement with the hospital may deposit a sum of money at the hospitals account in
advance. That sum can be replenished whenever it is used up.
The hospital Accountant should prepare a monthly report for the Hospital Management with
details of credit granted, credit repaid and balance outstanding.
3.11.4 Handling Cash
In monetary terms cash refers to currency, cheques, drafts, cash payment orders and bank
remittances.
A) Cash in hand
Cash in hand should be kept in locked safe box under the responsibility of the main Cashier
or the daily Cash Collector. The cash safe box must be used only for those assets belonging
to the Hospital. Personal properties should not be kept in the cash safe box.
Wherever a cash safe box has double or triple keys, the reserve keys should be safely kept in
a sealed envelope. The sealed envelope should be signed by the Cashier, the Auditor,
Accountant and Finance Head of the Hospital. When the Cashier requires the reserve key, the
sealed envelope should be opened with the presence of two or three signatory persons.
B) Chequebooks
When chequebooks are received from the bank the Cashier should make sure that the leaves
of the chequebooks are correct and that each leaf in the cheque is stamped. A Register should
be used to record all new chequebooks received and chequebooks issued. Partly used
chequebooks should be kept with the Accountant.
C) Deposit Procedures
All cash and cheques received should be deposited into the hospital bank account on the date
of collection or the next working day if it is not possible to deposit on the same day. If the
bank is far from the facility then cash should be kept in a safe box and deposited no less
frequently than once a week. If for any reason this is not practical then any different
mechanism should be approved by BOFED/MOFED.
When revenue is deposited, the Cashier should obtain two copies of the deposit slip one
should be submitted to the Accountant and the other should remain with the Cashier as
evidence. In case of direct deposits by the third party, the Accountant should collect copies
of deposit slips from the bank.

D) Bank Accounts
Hospital bank accounts can only be opened or closed with the approval of BOFED/MOFED.
Hospital management should assign, in writing, three named individuals as signatories of
each bank account. The bank and BOFED/MOFED should be notified of any changes in the
signatories.
Each hospital should have a bank account specifically for retained revenue. To open the bank
account the hospital should apply in writing to BOFED/MOFED.
The hospital should establish a bankbook or bank register record for each bank account, that
shows the movement of funds indicating the beginning balance, deposits, withdrawals and
ending balance at any given time.
Every month the Accountant should prepare Bank Reconciliation for every bank account and
should pass any necessary correcting entries. Correcting entries must be evidenced by the
signature of Accountant and also verified by separate persons, in accordance with the
government Budget and Accounts Manual.
E) Petty Cash Fund

Petty cash is a fund from which small cash payments can be made. Petty cash funds should be
authorized by the CEO and established under the custody of cashiers. Depending on the size
of the hospital the CEO may approve more than one petty cash fund. The CEO, in
consultation with the Finance Head and Accountant should determine the magnitude of the
petty cash fund.
Generally this should not exceed ETB 15,000. Approval for the number and magnitude of
petty cash funds should be obtained from /BOFED/MOFED. A change in the size of the petty
cash fund within a limit of ETB 15,000 can be made by the approval of the CEO. However if
a change in the size of the petty cash fund exceeds Birr 15,000 approval of the
BOFED/MOFED is required.
The petty cash fund should be maintained and kept separately from other collections and
funds.
Petty cash funds should be replenished when the amount of the cash remaining reaches a
minimum level. The Cashier should submit all paid petty cash vouchers and a request form
for replenishment to the Accountant. The Accountant should verify the vouchers and sum
requested and should prepare a Payment Voucher and cheque for the total expended amount
in the name of the Cashier. This cheque should be handed over to the Cashier against his/her
signature on the Payment Voucher.
A petty cash book should be established for each petty cash fund to track the balance of cash
on hand (Appendix P).

At the end of every month a cash count should be conducted by a person other than the
Cashier with a third employee as a witness. Additional surprise cash counts may be
conducted. At the end of the budget year the remaining balance of petty cash fund should be
deposited into the appropriate bank account.
3.11.5 Payroll Accounting
All employees of hospital expect and are entitled to receive their remuneration at regular
intervals following the close of each payroll period. Regardless of the number of employees
and the difficulties in computing the amounts to be paid, the payroll system must be designed
to process the necessary data quickly and assure payment of the correct amount to each
employee.
The payroll system must also provide adequate safeguards against unauthorized payments to
employees and other misappropriations of funds
Various government laws require employers to keep accurate payroll records and to prepare
reports and submit to the appropriate governmental units. The law also require employers to
remit the amounts withheld from its employees and for taxes imposed on itself. These records
must be kept for specified periods of time and be available for inspection by those
responsible for enforcement of the laws. Besides, payroll data may be useful in negotiations
with labor unions, in settling employee grievances, and in determining rights to vacations,
sick leaves, and retirement pensions.
Accounting for payroll in hospitals is particularly important because:

Payroll often represents the largest expense that a company incurs.
Both federal and state governments require that detailed payroll records be kept and
Employees are sensitive to payroll errors or irregularities. To maintain good employee
morale payroll must be paid on a timely and accurate basis.
3.11.6 Disbursement Procedures
Each month and quarter the Finance Head should prepare a cash flow program detailing
income and expenditure for each major budget heading. This should be submitted to the
CEO for review and approval. A sample Format for Cash Flow Forecast is presented in
Appendix Q.
Requests for disbursement (payments) should be made to the hospital Accountant who will
prepare a payment voucher and submit, together with supporting documents, to the Head of
Finance. The Head of Finance should review and approve the disbursement, taking into
consideration funds available, providing the amount of payment is within the limits set by
BOFED/MOFED.
After approval the Accountant will prepare a cheque and submit for signature by assigned
signatories. For cash disbursements the approved voucher should be submitted to the Cashier
who will effect payment.

Facilities should present disbursement requests to respective BOFED/MOFED for operating
expenses of all eligible expenditure from the government block grant. Requests for monthly
salary will also follow appropriate BOFED/MOFED guidelines.
3.11.7 Reporting Procedures
The hospital Accountant should prepare monthly and quarterly reports on revenue,
expenditures, receivables, payables, trial balance, the status of budget utilization and others.
Reports should be submitted to the hospital management and Governing Board.
Each identified hospital cost or profit centre should have a monthly revenue and expenditure
report.
A sample report for receivables management is presented in Appendix R.
3.11.8 Auditing
Each hospital should appoint an Internal Auditor who is responsible to conduct regular
internal audit as described in the government Internal Audit Manual.
The accounts of the hospital should be closed on the last day of the financial year. External
audit should be conducted by external auditors from the Office of the Auditor General
(Federal or regional Audit office) or other authorized private auditors, approved by the
Governing Board, within six months of the closing of the accounts. The audit should consider
the recording and bookkeeping system and the annual retained revenue and expenditure of
the hospital. Audit reports should be submitted to the CEO who in turn will present to the
Governing Board.
The Health Bureau and BOFED/MOFED have the right to access and investigate all
accounting records of health facilities as surprise audit or regular audit.
In order to determine if the Operational Standards for Financial and Asset Management have
and Reporting.

Table 1. Financial and Asset Management Checklist

Yes No
1. There are bilingual fee posters in each service area.
2. There is a procurement policy.
3. There is an accounting manual.
4. The Finance Case Team prepares monthly reports that are reviewed by the
Senior Management Team (SMT).
5. The Finance Case Team prepares and sends monthly reports to
appropriate bodies.
6. Reconciliation of bank accounts is done.
7. Internal and external audits are conducted; reports are reviewed by the
SMT.
8. MOUs with Waiver Certificate Granting Authorities are in place.
9. Exempted services are provided and information about services is posted
in appropriate places in the hospital.
10. The hospital has a private wing and policies and procedures for how
private wing services are to be provided.
11. Policies and procedures have been developed that define the outsourcing
process and what services are outsourced.
12. An assessment of the feasibility of outsourcing non-clinical hospital
services has been undertaken.
4.3 Indicators
Table 2 Financial and Asset Management Indicators

Indicators Formula Frequency Comment
1. Revenue Mix
i) Revenue from gov. Quarterly
a) Government allocation (% of total allocation (ETB)
revenue) ii) Revenue from gov. Quarterly
allocation/total revenue *100
b) Internal revenue generated (% of i) Internal revenue generated Quarterly
total revenue) (ETB)

ii) Internal revenue Quarterly
generated/total revenue *100
i) Private wing revenue Quarterly
i) Private wing income (% of total (ETB)
revenue) ii) Revenue from private Quarterly
wing/total revenue *100
i) Insurance payment revenue Quarterly
ii) Insurance payments (% of total (ETB)
revenue) ii) Revenue from insurance Quarterly
payments/total revenue *100
i) Non insurance patient fee Quarterly
revenue (ETB)
iii) Non-insurance patient fees (% of
total revenue) ii) Revenue from non- Quarterly
insurance patient fees/total
revenue *100
Quarterly
i) Other revenue (ETB)
iv) Other internal revenue generated
(% of total revenue) ii) Revenue from other Quarterly
sources/total revenue*100
2. Budget utilization
a) Ratio of health budget utilization Budget utilized/government Quarterly HMIS
to allocation allocated budget*100
Amount of recurrent Quarterly HMIS
b) Proportion of hospital recurrent expenditure on
expenditure spent on administration administration/total recurrent
expenditure*100
Total expenditure on Quarterly
c) Salary expenses as % of total
salaries/total hospital
expenses
recurrent expenditure *100
3. Efficiency
Quarterly
Total recurrent
expenditure/[number of
a) Cost per patient-day equivalent
inpatient days + (OPD
visits/4)]
4. Customer service
i) Number of patient Quarterly
attendances provided with
exempted service
a) Number (%) if persons provided
with exempt services ii) Number of patient Quarterly
attendances provided with
exempt services /Total
number of attendances *100)
i) Number of 'fee waiver' Quarterly
patient attendances
b) Number (%) of persons provided
with 'fee waiver' service Number of 'fee waiver' Quarterly
patient attendances /Total
number of attendances *100)
5. Financial stability
[total operating revenue - Quarterly
a) Operating margin (the % of
total operating
operating revenue remaining after all
expenses]/total operating
operating expenses are paid)
revenue*100
Amount of waived fees Quarterly HMIS
b) Proportion of reimbursed amount
reimbursed/Total amount of
out of the patient total fees waived
waived fees*100

6. Private wing
i) Number of attendances at Quarterly
private wing
a) Number of private wing
ii) Number of attendances at Quarterly
attendances (% of total)
private wing/total number of
OPD attendances*100
Biannual Survey tool
presented in
b) Private wing patients overall rating Patient survey. Average Appendix F of
of private wing rating on a score of 0-10 Chapter 12
Quality
Management
Patient survey. % of Biannual Survey tool
respondents answering 'yes' presented in
c) Private wing patients willingness or 'definitely yes' to the Appendix F of
to recommend private wing question "Would you Chapter 12
recommend this facility to Quality
your family/friends'? Management
i) Number of health Quarterly
professionals serving in
private wing
d) Number of health professionals
ii) Number of health Quarterly
serving in private wing (% of total)
professionals serving in
private wing/total health
professionals*100
Number of physicians Quarterly
e) Attrition rate of general leaving/total number of
practitioners physicians at beginning of
reporting period * 100
Number of specialists Quarterly
leaving/total number of
f) Attrition rate of specialists
specialists at beginning of
reporting period*100
7) In patient satisfaction survey : Total number of inpatients Biannual Survey tool
% of respondents who answer yes who respond yes to the presented in
to the following questions Do you question listed/ Total number Appendix F of
consider this health facility stay too of inpatients Chapter 12
expensive? respondents.*100 Quality
Management
8) Out patient satisfaction survey : Total number of outpatients Biannual Survey tool
% of respondents who answer yes who respond always or presented in
to the following questions I consider usually to the questions Appendix F of
this outpatient visit too expensive? listed/ Total number of Chapter 12
outpatients respondents.*100 Quality
Management

Source Documents
1. Chart of Accounts, Budget Preparation and presentation for the Federal Government
Version 2.1 (Number of page 234)
2. The Council of Ministers Financial Regulation No 17/1997.
3. Federal Democratic Republic of Ethiopia. (2006, January). Users Guide for Procurement
of Goods (For National Competitive Bidding).
4. Federal Democratic Republic of Ethiopia. (2006, January). Users Guide for Standard
Bidding Document for the Procurement of Works (For International Competitive
Bidding).
5. Federal Democratic Republic of Ethiopia Ministry of Finance and Economic

Development. (1998 EC). Internal Auditor Standard, Ethical Conduct Guidance and
Internal Auditing Manual. Addis Ababa: Ministry of Finance and Economic
Development.

Development. Procurement Manual.

Development. Federal Government of Ethiopia Accounting system Volume I Accounting
for Modified Cash Transaction Version 1.1. Addis Ababa: Ministry of Finance and
Economic Development.

Development. Federal Government of Ethiopia Accounting system volume II Chart 7
Accounting Version 1.1. Addis Ababa: Ministry of Finance and Economic Development.

Development. Federal Government of Ethiopia Accounting system Volume III Accounting
for other Assets and liabilities version 1.1. Addis Ababa: Ministry of Finance and
Economic Development.

Development. (2007, January 12). Revised Federal Budget Manual (Draft).Addis Ababa:
Ministry of Finance and Economic Development.

Development. (2005, July 5). Federal, Public Government Procurement Directive. Addis
Ababa: Ministry of Finance and Economic Development.

12. Federal Democratic Republic of Ethiopia Ministry of Health. (2005, November 14).
Implementation Manual for Healthcare Financing Reforms Final Document (Revised).

Development. (2007, December). Government Owned Fixed Assets Management Manual.
Addis Ababa: Ministry of Finance and Economic Development.
14. Grace period Payments Directive, number 13/1993(Amharic Version).
15. Government Disbursement and Cash Management Directive number 19/1996 (Amharic
Version).
16. Guidelines for Competitive Tendering and Contracting Out Services
17. Office of Public Management NSW Premier's Department SYDNEY NSW 2000
18. Opening and administering Government Bank Accounts Directive, number 16/1996
(Amharic Version).
19. Procurement directive (Amharic Version).
20. Proclamation No. 57/1996. Federal Government of Ethiopia Financial Administration

Addis Ababa: Federal Negarit Gazetta.
21. Proclamation No. 430/2005: Determining Procedures of Public Procurement and

Establishing its Supervisory Agency. (2005, January 12). Addis Ababa: Federal Negarit
Gazetta.
22. Proclamation No.553/2007: The Ethiopian Federal Government Procurement and

Property Administration Proclamation. (2009, 09 September). Addis Ababa: Federal
Negarit Gazetta.
23. Refundable amounts to Central Treasury Directive, number 18/1996 (Amharic Version).
24. South Nations Nationalities and Peoples Regional Government and Health Bureau.
(2006, May). Implementation Manual for Healthcare Financing Reforms.
25. Write-off Directive, number 11/1992 (Amharic Version)

Appendices
Chapter 10 Financial and Asset Management

Appendix A Duties and Responsibilities of Key Finance Personnel
Finance Head
a. Plans, manages and controls the accounting functions in the hospital and manages the
work of Accountants and cashiers. Maintains the current Hospital Accounting Manual.
b. Manages the hospital cash at Bank and accounts and cash in safe
c. Monitors level of cash in safe, Suspense Payment Vouchers and cash in bank
d. Signs cheques and all vouchers in accordance with the financial delegations approved by
the CEO and the Governing Board.
e. Ensures that the work of accounts are up to date, the monthly reports are produced
accurately and delivered to concerned authorities/institutions on a timely basis
f. Ensures that financial formats, registers and ledgers are available to execute the accounts
work
g. Cheques and verifies:
o The hands budget/ledger cards to all source of funds and prepared source
documents and enters transaction on Transaction Register
o The posting of the entries from the Transaction Register to the General Ledger,
Budget/Expenditure subsidiary Ledger Card and Subsidiary Ledger Cards
o All accounting records are maintained up to date
o All monthly reports and bank reconciliation statements
The Accountant
a. Prepares a cash receipt voucher in triplicate for every receipt of cash or cheques in the
name of the Hospital and maintains receipt vouchers
b. Keeps the cheque book and prepares cheques
c. Prepares source documents for retained revenue and government budget
d. Maintains Budget/Expenditure Subsidiary Ledger Cards
e. Prepares appropriate monthly reports for all sources of finance (donors fund, retained
revenue and government budget)
f. Prepares bank reconciliation statements for all bank accounts maintained by the hospital
for retained revenue and government budget accounts
g. Maintains vouchers and cheque books of accounts of the hospital
h. Keeps all financial documents after registration in chronological order
i. Provides financial documents to auditors (both internal and external) when required
Chapter 10 Financial and Asset Management Appendix A: Page 1 of 3

Cashier
a. Collects the hospital cash receipts, cheques, and draft and cash payment orders by issuing
an official pre-printed receipt voucher for the sums received revenue
b. Collects or receives the cash from other revenue collectors or assistant cashiers and
deposits into the bank
c. Withdraws cash from the bank when endorsed by the assigned signatories
d. Handles the petty cash at the health facility level where authorized by appropriate
officials
e. Handles the cash in safe and suspense payment vouchers
f. Pays employees salary and operating expenses
g. Issues cash receipts voucher to cash collectors
h. Prepares summary receipt voucher and distribute to cash collector and Accountant
i. Keeps unused cheque in locked safe box
j. Keeps all original documents of bid bond performance guarantees, cheques and payment
orders.
k. Collects new chequebooks from the bank when authorized by the CEO.
l. Transfers source documents to the Accountant after filling and signing Financial
Document Transitory Forms (Model 42).
Daily Cash Collector(s)
a. Collects or receives cash from clients/patients and others by issuing an official pre-printed
receipt voucher for the sums received
b. Remits collected cash daily to the main cashier
c. Prepares daily cash collection/receipts summary by revenue code
Internal Auditor
a. Advises the head of the health facility on the effectiveness of the internal control systems
within the facility and assists in establishing an efficient, effective control system.
b. Ensures that all health facility resources are used only for the proper and approved
purposes, and that they are used in the most economical, efficient and effective way
through conducting internal audit at specific intervals, and submits reports to the head of
the health facility and a copy to respective Finance Office.

c. Ensures compliance of the facility management with established policies, procedures,
laws and regulations, including behavioral and ethical expectations.
d. Safeguards the Health facilitys assets from losses of all kinds, including those arising
from fraud, irregularity or corruption.
e. Monitors the achievement of the health facilitys objectives and assess and identifies the
risks in achieving the objectives.
f. Ensures the integrity and reliability of the health facilitys financial information, accounts
and data including internal and external reporting and accountability processes.
Other staff
Hospitals shall have other staffs that are necessary to carry out their day-to-day activities.
These other staffs include procurement officer, storekeeper, archive staffs and statistician.

Appendix B Sample Memorandum of Understanding for Fee Waiver
Memorandum of Understanding
Between
"Fee Waiver Issuing Authority" and "[name] Health Institution"
Regarding
Financing of Health Services Rendered to Fee Waiver Certificate Holders
WHEREAS the resources mobilized and allocated for health sector in Ethiopia are by far less than the
required level of basic health service delivery;
WHEREAS the Federal Council of Ministers endorsed a health care and financing strategy, which is
serving as a basis for formulating various health finance reform measures in the country;
WHEREAS the main aims of the strategy are to increase efficiency in the use of available resources
and promote sustainability of health care financing to improve coverage, equity and quality of health
services;
WHEREAS some of the changes suggested by the Strategy were, among other things, allowing
facilities to retain user fees, rationalize and tighten rules for fee waivers, and steps to revise user fees;
WHEREAS no one should be excluded from use of health services because of increased user feed;
WHEREAS no health service shall be completely free and some one has to pay for it;
Now, therefore, the two parties have entered into this Memorandum of Agreement dated ----------------
--------------- for Financing of Health Services Rendered to Fee Waiver Certificate Holders residing in
------------------Woreda/Kebele.
1. Purpose and framework of the agreement
The overall purpose of the agreement is to ensure equity and efficiency in Health Service delivery by
the health institution. It is drawn within the framework of expanding equitable and quality basic
health service delivery system and provide efficient and sustainable health services.
2. Scope of agreement
This agreement is applicable to health service rendered by health facilities for free to holders of fee
waiver certificate issued by the fee waiver issuing authority, which has entered into this agreement. It
applies to all types of health services provided by the health institution.
3. Obligations of the two parties
3.1. Duties of the health institution
The health institution has the following duties and responsibilities:
Chapter 10 Financial and Asset Management Appendix B: Page 1 of 3

a) Render all types of health services within its capacity to all persons demanding and deserving
those services without making any distinction between waived and paying patients;
b) Ensure that the poor are able to utilize health services rendered by the health institution;
c) Record services rendered to fee waiver certificate holders in a format provided for this purpose
and submits periodic reports, in line with the established norms for reporting, to the next higher
level of authority;
d) Request reimbursement for services rendered freely at the end of each quarter of the budget year;
e) Shall not provide unnecessary services and shall not charge higher fees for services given to
waiver certificate holders than to the paying patients;
f) Post the fee payable and the conditions under which health services are provided free of charge
and conduct educational programmes to make the public aware of this fact;
g) Collect and deposit payments made in reimbursement of costs incurred for health services
provided to patients entitled to waiver;
3.2. Duties of fee waiver certificate issuing authority
a) Certificate granting authorities have full obligation to reimburse the fees that the health facilities
would have received had the service would not have been rendered freely to certificate holders.
b) Verifies and disburses payments received from health facilities within one week of the receipt of
request for disbursement by the health institution;
c) Submits list of fee waiver certificate holders and copies of each of the fee-waiver certificates
issued to the health institution;
d) Make payments to referral health facilities for services given to fee-waiver certificate holder
through referral letters issued by the health institution, which has signed this agreement.
e) Ensure that those issued with fee waiver certificates are indeed those who deserve it.
f) Allocate budget to cover for the fee-waiver certificates issued by it.
4. Duration/ Tem of this Agreement
This agreement is valid for one budget year, starting from Jul 1 to June 30 of the next Ethiopian Fiscal
Year.
5. Monitoring and evaluation of this agreement
The two parties shall convene and discuss the implementation of this agreement twice per year: one at
the end of the first six months and one at the end of the budget year.
In witness whereof, the parties hereto execute this agreement
Fee waiver certificate issuing authority

Health Institution [NAME] [NAME]
Name of signatory: _________________ Name of Signatory --------------------------

Title ----------------------------------------
Title: ----------------------------------------
Date: ---------------------------------------- Date ___________________________

Witnesses
1. Name:___________________________________________________________________
Address:___________________________________________________________________
2. Name: __________________________________________________________________
Address: __________________________________________________________________
3. Name: _________________________________________________________________
Address __________________________________________________________________

Appendix C Sample Fee Waiver Beneficiary Register

Date of Category Cost of services provided

Waiver ID Medical
No service Full name Age Sex Occupation Address (Inpatient
certificate # number card #
rendered /Outpatient) To
Woreda Kebele House # Exam. Lab test Drugs Others Total
Chapter 10 Financial and Asset Management Appendix C: Page 1 of 1

Appendix D Sample Departmental Fee Waiver Expense Registration Form
______________ Regional Government ______________ Woreda ______________ Hospital/Health Center
Fee Waived Patient Charge Form

No Date Name of Waived Patient Card Number Type of Service Provided Fee Charged in Name and Signature
Birr of Accountant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Total
Chapter 10 Financial and Asset Management Appendix D: Page 1 of 1

Appendix E Sample Bill for Reimbursement of Fee Waiver
From: [Name of Health Facility]
To: [Name of Reimbursing Institution]
No Name of Fee-Waiver Woreda Kebele Date Service Total Requested Name and
Patient card Number is provided Reimbursement signature of the
beneficiary
Total
_______________________________ _______________________________
Prepared by [Name and Signature] Approved by [Name and Signature]
Accountant Finance Officer
Note: The Bill is prepared in three copies. 1st and 2nd copy will be sent to the waiver certificate issuing
authority (retains 1st copy and sends 2nd copy to WOFED for payment), 3rd copy is retained in the
Health Facility for record.
Chapter 10 Financial and Asset Management Appendix E: Page 1 of 1

Appendix F Sample of fee calculation for public patients
The Health Care Reform and Financing strategy stipulates that user fees should be set on a cost
sharing basis. Accordingly, some expenditure items may not go into the calculation. For practical
considerations it is useful to limit the user fees to costs that can easily be attributed to a given service
for example:
medical examination (card) fee
laboratory tests
X ray
drugs
consumables such as gloves and syringes
Example to Set Examination (card) fee
In setting the examination fee the elements that should be considered are direct and indirect costs of
printing the card and a certain percentage of the salary of medical personnel who are deployed to
provide medical examinations.
a. Total cost of printing cards (paid to printing house) plus total transportation plus loading and
unloading cost divided by the total number of cards printed = the average cost of printing a card,
which is unit cost of a card that should go into the calculation of examination fee.
b. A given % of costs of total salary of medical personnel (to be determined by an appropriate

authority)
c. Add the above a+b to arrive at Examination/Card Fee to be charged
Example to Set the Cost of Drugs
To set the cost of drugs one should consider the purchase price of drugs from the distributor,
transportation cost, loading and unloading cost and other direct costs. After considering all the costs
the total cost divided by the by the number of tins, pills, capsules, bottles, etc will give the unit cost of
the drug.
a. Direct purchase price of the drug
b. Transportation and associated costs such as loading and unloading to be divided equally among
all types of drugs procured
c. Per diem associated and other costs related with procurements will be divided among the types of
the drugs
d. Profit to be calculated as a given percent of purchase price to be decided by appropriate authority
e. The Price of a Particular unit of drug = Purchase price + Transportation cost + loading and
unloading cost + Per Diem and other related costs DIVIDED by the number of units (number of
tin, pills, capsules, bottles, etc) PLUS a certain %, say 25% to calculate PROFIT of the Health
facility.
Chapter 10 Financial and Asset Management Appendix F: Page 1 of 3

Example to Set Laboratory Test Fees
To determine the cost of lab tests, we need to have information on the purchase price of reagents, the
number of tests that we can make with a unit of reagent and the total cost of laboratory equipment.
a. Add total purchase price + transportation cost + per diem and any other direct cost related to the
acquisition of the reagent and DIVIDE the sum by total reagent units to arrive at the cost of a unit
reagent.
b. Estimate or get data from past experience on the number of tests that can be conducted using one
unit/volume of reagent to arrive at cost of a given reagent per test
c. Determine % of profit to be calculated per test (to be decided by appropriate authority)
d. Then Laboratory test fee = Cost of one unit reagent DIVIDED by NUMBER of Tests that we can
make by a unit of reagent TIMES a given % equals laboratory fee to be charged for that particular
test.
Example to Set X-Ray Fee
To calculate and determine X-Ray fee we have to consider the cost of x-ray film the cost of
processing materials (chemicals) of the film, other direct and estimated indirect costs of the x-ray lab.
a. Divide total cost of packs of x-ray film by number of pieces to get the unit cost
b. Take total cost of processing materials (chemicals) and divide by the number of films that the
material can process to arrive at cost of chemicals for processing per unit.
c. Divide total transportation and per diem costs for acquiring the films by the number of films
d. Add a+b+c
e. Calculate a given percent for profit on (d) above [to be determined by the appropriate authority]
f. Add d+e to get estimated fee per x-ray.
Example to Set Bed Fee
Hospitals might have different class of beds. Based on the class the fee structure also differs.
The bed fee can be estimated by considering the cost of housekeeping, (which can be calculated by
taking into account the detergents per month, number of beds or bed sheets) purchase price of bed
sheets and blankets, wage of cleaners, or, by taking the cost of acquiring the materials and by
calculating outsourcing cost per unit of bed into account. To set fee for bed per day:
a. Estimate cost of bed sheets and blankets (calculate the duration of service in terms of days and
divide the cost by number of days); take the quotient you get to calculate the bed fee
b. Consider cost of detergents for washing the bed sheets and blankets (take total cost of detergents
used per month and divide by the total number of bed sheets)
c. Take wage of cleaners/ janitors (divide monthly salary by number of bed rooms); and take some
%, say 5% of the unit wage cost for the calculation of bed fee

d. Or instead of (b) and (c), take outsourcing cost for housekeeping divided by the number of bed
rooms
e. Add some %age to cover part of the fixed costs and/ or profit on (a + b + c), or on (a + d)
f. Add (a + b + c)+(e), OR, add (a + d + e) to set fee per bed
Daily Inpatient Fees
The daily inpatient fee is meant to cover bed, food, theatre, and drug and doctor fees. Laboratory and
x-ray fees also should be collected from inpatients according to the number and type of investigations
performed.
Outpatient Fees
An outpatient treatment fee is chargeable for each treatment received by the patient. The health
facility manager is responsible for having the most recent list of chargeable treatments and the correct
fee. This list should be distributed to all relevant staff at the facility and posted in waiting areas.
Non-Ethiopians
Since hospitals are subsidized from government treasury, tax payers resource or the public fund,
foreigners are required to pay double for all fees. Note that the cost of health services for refugees are
often covered though agreements with United Nations or other agencies responsible for refugee
assistance. Billing arrangements should be investigated.
No treatment-no fee.
If treatment is not provided because the treatment is not available, e.g. drugs, then there is no charge.
If the patient purchases materials privately the treatment fee should not be charged for applying the
treatment.

Appendix G Fee Setting for Private Wing Services
Private wing fees should be calculated on a cost recover basis, plus a mark up to ensure the hospital
gains profit from the private wing. Fees should be arrived at by the logical process of first making a
detailed study of all the costs involved. Costs should include direct and indirect costs plus a suitable
provision for asset depreciation.
The following factors should be considered when determining the cost of services:
1. Direct costs: recurring operating expenses for the service provided. For example in the case of
Radiology Department the cost of films, injections, chemicals stationery and printing, maintenance,
repairs and spares, electricity and fuel charges, salaries and wages and other related expenditure has to
be considered.
2. Costs of equipment used during treatment: the cost of an asset should be allocated over the
assets useful life.
3. Salary costs: this includes the salary and benefits for staff directly involved in providing the
service plus a share of the salary and benefit costs of support staff such as guards, cleaners,
housekeeping etc.
4. Total capital cost of the private wing: this includes the cost of procurement of capital assets for
the hospital such as land, building, machinery, equipment etc.
5. The overall expenses for the running of the private wing: In addition to basic production costs,
the hospital has many day to day expenses e.g. electricity, water, fuel for generator, communication
costs.
The above costs can be used to determine costs of the service through a top down costing method as
described below.
Top Down Costing
The top down process of allocating costs depicted below starts with spending on broad types of
inputs, such as electricity, maintenance of buildings, catering, drugs, salaries, etc. This expenditure
is then reallocated to patient treatment services: wards, operating theatre, pharmacy, etc. This
reallocation may be direct, such as wages for the number of nurses normally staffing a particular
ward; or indirect, for example operating theatres may be allocated a proportion of the cost of hospital
cleaning corresponding to their share of total hospital area.
These costs, once allocated to patient treatment services, are then reallocated to specialties:
paediatrics, general medicine, general surgery, etc. Again, this reallocation may be direct, for example
when a ward houses patients in only one specialty, or indirect, where the proportion of operating
theatre time booked by a specialty is used to determine the share of operating theatre costs
apportioned to that specialty (see Figure 1).
Chapter 10 Financial and Asset Management Appendix G: Page 1 of 3

Figure 1 Top Down Costing
For non-surgical specialties the cost per patient bed day is calculated by dividing the total specialty
cost by the number of bed days occupied by patients admitted under that specialty.
The calculation of costs for patients undergoing surgery or other procedures is not based on bed days
alone, but includes costs related to the procedure, such as theatre use. An illustrative example is
provided in Table 1, where allowance is made for theatre time and prostheses in calculating the cost
of a Primary hip replacement (Epstein and Mason, 2006).
Table 1: Theatre time and prostheses in calculating the cost of a Primary hip replacement
In addition to the cost of service provision, other factors to be taken into consideration when setting
fees include:
1. The standard of general facilities and services provided to the patients of a particular class:
Private wing facilities may offer a different level of accommodation (single room, double room etc)
and may offer single or shared toilet and shower facilities, television, menus, telephone and internet
services etc. A higher fee should be set for higher classes of accommodation.
2. Skill required in the procedure and system
High performing and talented medical, nursing, allied health and non-medical staff are not easy to
find. Once found, retaining them is even more essential for effective and efficient functioning. The

high price paid to acquire and retain excellence is included in the form of fees for different services
rendered in the private wing.
3. Charges for similar services in other hospitals in the same area
Consideration should be given to the fees set by other hospitals in the same area for similar services
although fees can be adjusted to meet the financial needs of the hospital in general. Fees in rural
hospitals are usually lower than urban areas.
4. Image of the medical professionals attached to the hospital
If physicians at the hospital have a good name and reputation the hospital is likely to attract more
patients. The hospitals job is to market the physician and hospital services as a joint venture.
Renowned and reputable physicians, especially specialists, could be a justification for a higher fee
structure.
5. Paying capacity of the patient
The fee structure should be based on the ability to pay of the local community. Patients may be
deterred from seeking services if the cost of treatment is too high.
6. Analysis of the local current market
Hospitals should be competitive with the local health care market. If fees are set too high clients will
seek an alternative provider. Alternatively, if fees are significantly lower than other providers the
hospital may be missing an opportunity to gain income.
Source:
Epstein D and Mason A. Costs and prices for inpatient care in England: Mirror twins or distant
cousins? Health Care Management Science, 2006. Vol 9 (3): 1386.

Appendix H Sample Receipt Voucher
No. ____
Date ____
Name of Health Facility

__________________________________________________________________________________
Received From
__________________________________________________________________________________
Address:
___________________________________________________________________________
Mode of Collection
__________________________________________________________________________________
Amount in Figures __________________________________________________________________
Amount in words (Birr) ______________________________________________________________
Purpose ___________________________________________________________________________
Revenue Category Account Code Debit Credit
Total
_____________________ ______________________
Prepared by Name and Signature Received by Name and Signature
Original- to payer, Second Copy to Accounts, Third Copy in Pad
Chapter 10 Financial and Asset Management Appendix H: Page 1 of 1

Appendix I Sample Summary Receipt Voucher
No _____
Date _____
Name of Health Facility ________________________________________________________
Received From:__________________________________________________________
Receipt Voucher Series _________________ To _________________________
Receipt Voucher Serial Nos. ________________ To _________________________
Receipt Voucher Serial Nos. _________________ To _________________________
Receipt Voucher Serial Nos. ________________ To __________________________
Amount in Figures ________________________________________________________
Amount in words (Birr) __________________________________________________
Revenue Account Code Debit Credit

1435 Health Services
1436 Sales of Medicines and Medical Supplies
1437 Medical Examinations and Treatments
Total
_______________________________ _____________________________
Prepared by: Name and Signature Cashier: Name and Signature
Original- Accounts Section; Second Copy to Cashier, Third Copy in pad
Chapter 10 Financial and Asset Management Appendix I: Page 1 of 1

Appendix J Sample Receipt Voucher Summary by Revenue Code

Name of the Facility __________________________________________
Year_____________ Month ___________ Day ______________
Name of Cashier/cash collector _________________________________

Date of Receipt
Revenue Revenue Code Revenue Revenue Revenue Code Revenue Code Revenue Code Revenue
Code Code Code Code
Voucher No
Voucher
Receipt
Amount Amount Amount Amount Amount Amount Amount Amount

Received Received Received Received Received Received Received Received
TOTAL
Prepared by: _____________________________________________
Chapter 10 Financial and Asset Management Appendix J: Page 1 of 1

Appendix K Sample Deposit Receipt Voucher

Model 85.1 Serial No ___
Date ______
HOSPITAL DEPOSIT RECEIPT VOUCHER
Name of Hospital
Patient's Full Name
Address ___________ ____________ ____________ __________ ______________

Region Zone Woreda Kebele House No.
Grade _____ Room No. ______ Card No. ________
Amount in Figure_________________________________ Deposited by ____________________________
Amount in Words (Birr)
Purpose
For Accounts use only

Budget Category Account code Debit Credit
Total
Prepared by Name and Signature Received by Name and Signature
Original -to Accounts, Second copy in Pad
Chapter 10 Financial and Asset Management Appendix K: Page 1 of 1

Appendix L Sample Deposit Cashbook
Model 93 Serial No.
Date
DEPOSIT CASHBOOK
Name of Public Body Page
Reference Reference
Type No.
Date Name of Cashier Name of Depositor Payments Opening balance b/f Balance
Total
Original to Accounts, Second copy in Pad
Chapter 10 Financial and Asset Management Appendix L: Page 1 of 1

Appendix M Sample Payment Voucher

ME/HE 7/1
[NAME OF REGION] Serial No_____

BUREAU OF FINANCE AND ECONOMIC DEVELOPMENT Date__________
PAYMENT VOUCHER
Name: _______________________________________________________________________________________________
Paid to: _____________________________________________________________________________________________

Address: _____________ ___________________ ___________________ _____________ ________________
Region Zone Woreda Kebele House No.
Check Check No. ____________________
Bank Transfer Ref. No. ______________________
Cash
Amount in Figures _______________________________
Amount in Words (Birr) ________________________________________________________________________________

_______________________________________________________________________________
Purpose ______________________________________________________________________________
_______________________________________________________________________________
For Accounts Use Only
Budget Category Account Code Debit Credit
Total
_________________________________________ __________________________________________________
Prepared By: Name and Signature Budget Approval: Name and Signature
__________________________________________ ____________________________________________________
_________________________________________ _____________________________________________________
Checked By: Name and Signature Authorized By: Name and Signature
I acknowledge that I have received the amount shown above (Name and Signature)
Original to Accounts; Second copy in Pad
Chapter 10 Financial and Asset Management Appendix M: Page 1 of 1

Appendix N Sample Cash Register
Name of Health Facility ___________________________________ Page________

___________________________________ _______________________________
Name of Cashier ____________________________________ Month _______ Year _______
Date Description Receipt No. Receipts amount Bank Remaining

Deposit balance in safe
amount
Opening Balance (B/F)
Balance C/F
Chapter 10 Financial and Asset Management Appendix N: Page 1 of 1

Appendix O Sample Credit Agreement
The [NAME OF HEALTH FACILITY], hereafter called [HEALTH FACILITY], and [NAME OF
THE SIGNATORY], hereafter called "the subscriber" have entered into this agreement as of [date]
[month] [year] in [PLACE]
A. Telephone number of the Subscriber -------------------------------

B. Address of the Subscriber (Location: Region/Zone/Woreda) ---------------------
C. Name and signature of higher official of the Subscriber ---------------------------
Areas of agreement
The health facility shall be obliged to provide all medical services on credit, unless otherwise it is
expressly stated that the services, which includes [LIST THEM HERE], cannot be provided on credit.
1 The customer shall receive medical treatment if admitted as an emergency case or if s/he presents
a referral letter;
2 No medical service is granted to a person demanding medical service unless s/he produces a
medical form especially prepared for this purpose, which is signed by officials, whose sample
signatures are already deposited with the health facility;
3 The letter/referral authorizing the bearer to receive medical services on credit shall be valid for a
single episode of illness;
4 If a person receiving medical treatment is laid off from work while receiving medical services
from the health facility, the Subscriber shall have an obligation to notify the health facility to
discontinue provision of medical service on credit. The Subscriber, however, shall be obliged to
settle the total value of medical services provided to the employee of the Subscriber before
notification;
5 The Subscriber shall be obliged to go to the credit services section of the health facility and
collect invoices on or before the 5th day of the every month and settle within 15 days the total
value of medical services granted to all of its employees on credit. After making the payments,
the Subscriber should make sure that the payment is recorded by appropriate section of the health
facility. No further request for medical services on credit shall be entertained if the Subscriber
fails to make the payments for services granted on credit basis as per the terms of this agreement.
6 The health facility shall have the authority to terminate this agreement without further notice if
the Subscriber fails to honor the terms of this agreement and fails to settle its bills. The health
facility shall have the authority to claim unsettled bill at a court of law.
7 The persons who have received medical services upon credit based on credit agreement should
ask for a medical certificate immediately after s/he received the services. The Subscriber shall
have no right whatsoever to ask for medical certificate at a latter date. If, for some reason, the
Subscriber doubts the genuineness of medical certificates, it shall have the right to demand
clarifications by writing official letter to the health facility.
8 This agreement shall be valid for a period of one year;
Chapter 10 Financial and Asset Management Appendix O: Page 1 of 2

9 If the Subscriber who entered into this agreement with the health facility is transferred to another
location, sold, changed, becomes bankrupt, closed, dissolved, etc., it shall have the obligation to
settle its bills beforehand and request for termination of this agreement. Transferring the
obligation to a third party shall not be allowed and hence not acceptable.
10 If the Subscriber fails to act in accordance with the terms an conditions indicated above, the
health facility shall have the authority to terminate this agreement without any further notice. The
health facility shall have the right to claim any unsettled bills in a court of law if the Subscriber
fails to pay the total value of medical services granted to the employees of the Subscriber on
credit basis.
11 We, the undersigned, representing our respective institutions have correctly understood all the
terms and conditions indicated above from 1-10 have entered into this agreement.
On behalf of the health facility: On behalf of the Subscriber
_________________________ ______________________________
Name and Signature Name and Signature
[OFFICIAL STAMP ] [OFFICIAL STAMP]
Witnesses:
1 Name _______________________ Signature ________________________
2. Name _______________________ Signature ________________________
3. Name _______________________ Signature ________________________
Copy:
(As appropriate)
Chapter 10 Financial and Asset Management Appendix O: Page 2 of 2

Appendix P Sample Petty Cashbook

Name of Public Body Page __________
Year
Name of Cashier __________________________ Month __________
Cash Payment
Date Description Cheque No
Voucher Receipts Payments Balance
Opening balance B/F
Balance B/F

Chapter 10 Financial and Asset Management Appendix P: Page 1 of 1

Appendix Q Sample Cash Flow Forecast
Name of Health Institution:

Month XXX XXX 2006
Birr '000s
May June July Total
Week 1 Week 2 Week3 Week 4 Week 5
Code Major Budget Headings 3rd-7th 10th-14th 17th-21st 24th-28th 31st Total Total Total (3 Mths)
1100 Tax on Income, Profit & Capital Gains

1410 20 Administrative Fees & Charges
1435 Health Services
1436 Sales of Medicines and Medical Supplies
1437 Medical Examinations and Treatments
1500 Capital Revenue
TOTAL INCOME
6100 Personnel Services
Emoluments
Allowances / Benefits
Pension Contributions
6200 Goods & Services
Goods & Supplies
Maintenance & Repair
Contracted Services
Training Services
6300 Fixed Assets & Construction
Fixed Assets
Construction
6410 Subsidies, Investment & Grant Payments
TOTAL EXPENDITURE
NET CASH FLOW
Chapter 10 Financial and Asset Management Appendix Q: Page 1 of 1

Appendix R Sample Report for Receivables Reporting and Control
Beginning Receivables
New Receivables
Accruals
TOTAL Receivables
LESS
Collections
Adjustments
Write Offs
Ending Receivables
Collections as a % of :
Total Receivables
Beginning and New
Collections+Adjustments+ Write Offs as a % of:

Total Receivables
Beginning and New
Write-Offs as a % of:
Total Receivables
Beginning & New Collections
Delinquencies
1-90 days
91 180 days
Over 181 days
Total Delinquent
Delinquencies as a % of Total Receivables:

1-90 days
91-180 days
Over 181 days
Total Delinquent
Chapter 10 Financial and Asset Management Appendix R: Page 1 of 1

HUMAN RESOURCE MANAGEMENT
Page 1 of 37
Section 2 Operational Standards for Human Resource Management 6
3.1 Human Resource Department 6
3.2 Human Resource Development Plan 7
3.3 Human Resource Policies 8
3.4 Employee Job Description 10
3.5 Recruitment 12
3.5.1 Personnel Recruiting and Posting Request Form
3.5.2 Vacancy announcement
3.5.3 Application process
3.5.4 Selection process
3.5.5 Competitive assessment
3.5.6 Reference checking
3.5.7 Appointment and probation
3.5.8 Promotion
3.5.9 Transfers
3.6 Orientation 16
3.6.1 New Hire Orientation
3.6.2 In service orientation
3.7 Salary and Benefits 17
3.7.1 Compensation system factors
3.7.2 Benefits
3.8 Performance Management 19
3.8.1 Supportive supervision
3.8.2 Performance Based Evaluation
3.8.3 Performance Improvement Process
3.9 Training and Development 21
3.10 Employee Relations 22

3.10.1 Employee Code of Conduct
3.10.2 Employee Motivation
3.10.3 Job Satisfaction
3.10.4 Employee Recognition
3.10.5 Discipline Management
3.10.6 Grievance Management
3.10.7 Staff Survey
3.11 Termination of Employment 27
3.12 Personnel Records 27
3.12.1 Organization of Personnel Records
Chapter 11 Human Resources Management Page 2 of 37

3.12.2 What to maintain in the Personnel Record
3.12.3 Keeping the Personnel Record up to date
3.12.4 Computerized Personnel Records
3.12.5 Confidentiality of Personnel Records
3.13 Occupational Health and Safety 29
3.13.1 Risk Assessment
3.13.2 Medical Screenings and Health Promotion
3.13.3 Immunizations
3.13.4 Workplace injuries
3.13.5 Occupational Health and Safety Training
4.3 Indicators 34
Source Documents 36
Appendices
Appendix A Tools to aide in the creating the Hospitals Human Resource Development
Plan
Appendix B Sample Employee Code of Conduct
Appendix C Statement of Employee Rights and Responsibilities
Appendix D Sample Job Description for Laboratory Technologist position
Appendix E Sample Personnel Recruiting and Posting Request
Appendix F Sample Vacancy Notice Form
Appendix G Sample Employment Application Form
Appendix H Sample Candidate Assessment Form
Appendix I Sample Reference Check Form
Appendix J Sample Performance Based Evaluation for Laboratory Technologist position
Appendix K Sample Performance Improvement Process Form
Appendix L Behaviours that merit rigorous disciplinary penalties
Appendix M Sample Grievance Form
Appendix N Sample Exit Interview Form
Appendix O Occupational Incident Register

Tables
Table 1 New Hire Orientation
Table 2 Examples of risk and suggested solutions
Table 3 Human Resources Management Checklist
Table 4 Human Resources Management Indicators
Figures
Figure 1 Human Resource Planning Model
Abbreviations
BSC Balanced Scorecard
HR Human Resource
PBE Performance Based Evaluation

The most important asset of a hospital is the people who work there. Employees, whether
they are the hospitals security guards, lab technicians, nurses or physicians, are responsible
for carrying out the hospitals duty to care for patients. A well-performing health workforce
is one that works in ways that are responsive, fair and efficient to achieve the best health
outcomes possible, given available resources and circumstances (i.e. there are sufficient staff,
fairly distributed; they are competent, responsive and productive).
The main objective of the Human Resource (HR) function is to ensure that the facility
attracts, develops, retains, and motivates qualified employees who are critical for achieving
the organizations objectives of delivering high quality and safe patient care.
The HR Department does this by establishing policies and procedures for the work
environment and the effective management of employee workplace issues, establishing a
performance management system for workers and ensuring that supervisors use these tools to
the mutual benefit of both the individual employee and the hospital.
The benefits of a well-functioning HR management system include:

Systematic planning to support the hospital mission and objectives,
Increased capacity for the hospital to achieve its goals,
Clearer definition of employee and management responsibilities,
Improved relationships between employees and management,
Maximization of employee performance, skills and knowledge, satisfaction,and
Cost savings through improved efficiency and productivity.
This chapter sets standards and provides guidance for the establishment of a human resource
function that contributes to the advancement of the vision, mission and guiding principles of
the hospital.

Section 2 Operational Standards for Human Resource
Management
1. The hospital has a Human Resources Case Team staffed by individuals who possess
management skills and experience dealing with individual personnel matters.
2. The Human Resources Case team maintains a personnel file for each and every hospital
employee.
3. The Human Resource Head (or equivalent) is a member of the hospital Senior
Management Team.
4. The hospital has a human resource development plan that addresses staff numbers, skill
mix and staff training and development.
5. Each employees responsibilities are defined in a current job description, which has been
signed by the employee and filed in the personnel file.
6. The Hospital has policies and procedures for recruiting and hiring staff.
7. The Human Resource Case Team 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.
8. Human Resource policies are documented in an Employee Manual that is distributed to

all staff and updated, at a minimum, every 3 years. The employee manual contains
policies and procedures that define employee/employer relations.
9. The hospital has a Code of Conduct that is known, and adhered to, by staff.
10. The hospital has a performance management process in which all employees are formally
evaluated at least annually and action plans for improvement are documented.
11. The hospital regularly conducts a staff survey to assess staff perspectives on the
workplace. Summary results are presented to the Senior Management Team and
Governing Board.
12. ID badges and appropriate uniforms are worn by employees at all times.
13. The hospital has occupational health and safety policies and procedures to identify and
address health and safety risks to staff.

3.1 Human Resource Department
The Human Resource (HR) Case Team is responsible for the recruitment and retention of
employees and for establishing policies and procedures to manage employee/employer
relations. The HR Case Team should be led by a competent individual who possesses
management skills and experience dealing with personnel matters. He/she should be a

member of the hospitals Senior Management Team (SMT). Additional HR staff include
administrative and clerical personnel.
The HR Case Team should have sufficient space to store personnel files securely, and should
have an area/room where confidential discussions can be held between the HR Head and
individual employees should the need arise.
3.2 Human Resource Development Plan

Human resource planning enables the hospital to forecast its human resource needs, to
acquire human resources in the right number and type, and to develop and properly utilize
available resources.
All hospitals should have a human resource development plan which is the foundation for the
recruitment and training of staff both in the short term and long term. The human resource
plan should give due consideration to skill mix and staff development and should be
developed taking into consideration the hospitals Essential Services Package (See Section
3.6 of Chapter 1 Hospital Leadership and Governance).
Steps to develop a human resource development plan:
Step 1: Define the Essential Services Package (See Section 3.6 of Chapter 1 Hospital
Leadership and Governance).
Step 2: Estimate patient load based on past trends of utilization and, for new services,
estimated need for the service
Step 3 Identify any plans to outsource non clinical services and/or to close clinical service
areas
Step 4: Determine ideal skill mix and minimum staff to patient ratios or minimum staff
numbers in each service area
Step 5: Compare current staff pattern with ideal staff pattern and identify the gaps
Step 7: Describe actions to address the gaps, for example:

Training of current staff
Transfer/reassignment/lay-offs of existing staff to better match ideal workforce
Recruitment of new staff: number, type
Revision of organizational structure, if necessary
Step 8: Estimate budget for implementation of the HR development plan. Budget should
include salaries, and all corresponding benefits and allowances.
A sample data collection tools that can be used develop the human resource development
plan are presented in Appendix A.

Figure 1: Human Resource Planning Model
SUPPLY ANALYSIS
Workforce analysis and trends
Employee knowledge, skills,
abilities GAP ANALYSIS SOLUTION ANALYSIS
Workforce demographics Comparison of current Planning workforce
Current Workload Analysis workforce skills with transition
future needs Employee development
Analysis of how workforce and re-training
demographics will change Changes in staffing
Identification of areas in patterns
DEMAND ANALYSIS which management action Determine budget needs
Workforce knowledge, skills, will be needed to reach
abilities to meet project need workforce objectives
Staffing patterns
Anticipated program and
workload changes
Source: Adapted from: ww.hhs.gov/ohr/workforce/wfpmodel.gif.
The human resource development plan and budget should be approved by the hospital SMT
and should be updated annually. The human resource development plan should be the
foundation for the hire of new staff or transfer of a staff member from one service area to
another. New employees may be hired to fill gaps in the workforce or to fill vacancies that
arise due to employee resignation or retirement.
3.3 Human Resource Policies

The HR Case Team is responsible to establish policies to manage employee activities and
employee/employer relationships. Once developed, these policies should be communicated
to all employees to ensure they are aware of the policies that guide their workday. Policies
should be collated into an Employee Manual that is distributed to all staff and new
employees. Preferably the Employee Manual should be in a ring binder format to allow for
the addition of new policies or insertion of revised policies as the need arises. The Employee
Manual should be revised and updated regularly (for example every 3 years).
Policies should address the following areas:
A) Work schedule
1) Work day hours

2) Overtime and duty work
3) Lunch periods
4) Breaks
5) Annual leave, unused leave (carry over)
6) Sick leave
7) Maternity, paternity leave

8) Grievance leave
9) Nuptial leave
10) Exam leave
11) Special leave (with or without pay)
12) Leave of absence.
B) Hiring and placement procedures
1) Recruitment: vacancy announcement, screening of applicants

2) Job applicant interviews
3) Reference checks
4) Employment offers
5) New Hire Orientation
6) Promotion, secondments and transfers
C) Employee behaviour and conduct
1) Employee Code of Conduct (see Appendix B)
2) Employee rights and responsibilities (See Appendix C)
3) Timekeeping
4) Dress code (ID badges and uniform to be worn at all times)
5) Smoking policy (not permitted on hospital premises)
6) Use of alcohol, chat or other substances (not permitted in hospital premises, employee
should not be under the influence when attending for duty)
7) Mobile phone use (no personal calls while on duty or with patients)
8) Photography, video camera, audio-recording (not permitted without permission of
management and patient)
9) Gift policy (personal gifts should not be accepted from patients or caregivers since
this could be interpreted as an attempt to gain preferential favour. If a patient wishes
to offer a gift he/she should be encouraged to make a donation for the benefit of the
whole hospital or staff, eg a financial or equipment donation after care has been
completed.)
D) Remuneration
1) Paydays
2) Overtime
3) Salary scales
4) Salary review policy
5) Salary increment due to promotion

6) Severance pay
7) Medical and disability payments
F) Benefits
1) Eligibility
2) Types of available benefits
G) Occupational health and safety
1) Medical assessment and immunizations

2) Safety risks and protection measures
3) Work-related injuries
H) Performance evaluation procedures
1) Performance evaluation process

2) Performance improvement plans
3) Uses of performance evaluation results
I) Disciplinary and Grievance procedures
J) Education and Training
K) Other
1) Recognition/award schemes
2) Private wing opportunities
3) Termination of employment (exit interview)
3.4 Employee Job Description

Job descriptions are short statements that include information about an employees assigned
duties or responsibilities. They detail the positions objectives, the skills, training and
education necessary to perform the position, and compensation and benefits provided. These
statements define the obligation of the employee to the health facility. For the health facility,
a job description defines the type of employee desired for the position and what is expected
of the employee. It provides the facility with guidance for hiring, salary structure,
performance evaluation and supervision.
A job description should contain the following components:
Job Title: The title of the position

Reporting to: The position of the immediate supervisor to whom the post
holder will report
Department: The department within which the position is located

Employment type: Full-time, part-time, contract, consultancy, temporary
position, or otherwise.
Job Summary: Provides a 2-3 sentence description of the job
Essential Duties and A detailed explanation of the positions tasks
Responsibilities:
Supervisory Statement that outlines which staff will be supervised by the

responsibilities: post holder, and the specific tasks associated with
supervision (eg conduct PBE etc)
Educational The minimum educational requirement for the position
Qualifications
Certificates, Licenses, All minimum required credentials and equivalents should be
Registrations: outlined here.
Experience The minimum work experience required for the position
Other required skills Any other required skills/competence. For example language
skills, IT skills, mathematical or statistical skills; reasoning
skills (such as ability to define problems, collect data,
establish facts, and draw valid conclusions) planning and
organization skills etc
Physical Demands If the position requires heavy lifting, high level of physical
activity, or exposure to natural elements such as outdoors in
weather conditions, it should be noted here.
Description of job site This contains specific information about the work
and work environment environment, including a description of surrounding areas,
building layout, and other information relevant to the work
atmosphere including environmental hazards.
Occupational Exposure If the employee will be exposed to a known risk for an

extended period of time, it should be noted on the job
description.
Salary and Benefits The specific salary or salary range. This information may or
may not be included in the job description. Instead, a
hospital may use a job-grade system, which rates each job
and assigns a job grade number that correlates to a wage
range.
Employee Name and
Signature
Date
A job description should be created for every position in the hospital. Template job
descriptions may be available from the FMOH or Regional Health Bureaus (RHBs).
However, each hospital should adapt these job descriptions to reflect the hospitals needs and
to define the responsibilities of the position. Job descriptions should be developed
collaboratively with the Human Resources Department and head of the department/case team
in which the position is located. The job description should be explained to each new

employee when he/she commences employment and he/she should sign the job description to
indicate their understanding of and agreement with the duties and responsibilities therein.
Two copies of the job description should be prepared. The first copy should be kept by the
post holder and the second copy should be filed in his/her personnel file.
The job description should be kept under review and amended if the need arises, for example
if duties or supervisory responsibilities are added to or removed from the post. At the time of
Performance Based Evaluation (PBE), the employee and supervisor should consider whether
the job description is still an accurate description of the post and should amend if necessary.
If an employee is promoted or transferred to another position then a new job description

should be signed for the new position. The date on the new job description will indicate the
date at which the employee changed position.
A sample Job Description for the position of Laboratory Technologist is presented in

Appendix D.
3.5 Recruitment
Recruitment involves searching for and attracting prospective employees, either from outside
or inside of the hospital. The Ethiopian Civil Service Proclamation and Directives establish
criteria for recruitment as follows:
The candidate should have no prior criminal record,
No one terminated for a disciplinary offence can be rehired by a public facility within
five years,
Preferential consideration should be given to female candidates, candidates with

disabilities, and members of nationalities/ethnicities comparatively less represented in
the hospital, having equal or close score to other candidates, and
candidates should not be discriminated against on the grounds of ethnic origin,

religion, political outlook, disability, sex, HIV/AIDS status or any other grounds.
3.5.1 Personnel Recruiting and Posting Request Form
If a post becomes vacant and the Head of the Case Team wishes to fill the post then he/she
should complete a Personnel Recruiting and Posting Request and submit this to the HR
Department. The job description for the post should be reviewed by the Case Team and the
HR Department to confirm that it is still suitable for the position. Amendments should be
made if necessary.
A sample Personnel Recruiting and Posting Request Form is presented in Appendix E.
3.5.2 Vacancy Announcement
A job announcement should be made for any vacancies that arise stating as a minimum:

name and address of the hospital
position, grade and salary
number of vacant positions to be filled
minimum requirements for qualification for the position
knowledge, skills, competence and other essential requirements
specification of documents that should be submitted
nature of the work including travel, duty or overtime requirements if relevant
application closing date and time
place where candidates can get more information about the position and from where
they can collect an application form and job description.
For select job grades, hospitals can internally post a job vacancy within the hospital prior to
informing the public. Ethiopian Federal Civil Service Directives specify that for positions up
to grade VIII and below hospitals can advertise internally. If unsuccessful, and for positions
that require education grade IX above then the vacancy announcement should always be
posted externally through mass media outlets such as newspapers, television, internet etc.
(NB: internal candidates may still apply but will be screened and assessed against the same
criteria as external candidates).
A sample Vacancy Notice Form is presented in Appendix F.
3.5.3 Application process
A standardized application form should be completed by all applicants for the position. The
form should include candidates personal information, education, language proficiency,
training, work history, and licenses (if required). A sample Application Form is presented in
Appendix G.
3.5.4 Selection process
A selection team should be established to shortlist candidates. Team members include:
Head of the Case Team where the post will be located (Chair)
HR Case Team Head or Representative
Professional assigned by HR Case Team (Secretary)
The selection team should screen all applications to assess each candidates fit for the
position based on the essential and desirable qualifications and experience that are described
in the job description. Candidates that best meet the criteria should be invited for interview.
NB: Federal Civil Service Directives specify that at least three candidates must compete for a
vacancy before a final candidate is selected unless the hospital can evidence that the level of
professional skills and training required are scarce in the market, in which case, less than
three candidates may be allowed to enter into competition. It may be necessary to advertise
the position for a second time, or more widely, if there are insufficient applicants following
the first vacancy announcement.

3.5.5 Competitive Assessment
Short listed candidates should be assessed against each other by interview. The hospital may
also conduct a written examination or practical test for positions that require technical
knowledge and skills.
Interviews should be conducted by the selection team. The role of each interviewer should
vary. For example, the immediate supervisor should evaluate the candidates technical
knowledge while the HR representative should investigate more general skills and
behaviours.
The following techniques may be useful for the interviewers when conducting an interview:
Be familiar with the job description,

Ask the applicant questions that draw information from him/her
Describe hypothetical situations that might occur on the job and ask how they would
handle them
Use how, what, why and when questions as open ended questions that elicit answers that
reveal the candidates interests, attitudes and approach to work
Describe the job, and
Answer any questions the applicant may have
A scoring system and comparative assessment form may be used to compare candidates and
to select the top applicant. A sample Candidate Assessment Form is given in Appendix H.
All candidates should be notified of the outcome of their application by the HR Department
in as short a time as possible, ideally no more than 5-10 days following interview. At the time
of interview candidates should be informed both how and when they will know the outcome
of their interview.
3.5.6 Reference Checking
Prior to employment the credentials and employment history of the selected candidate should
be verified. The candidate should submit original ESLCE/certificate/diploma/degree
documents (as appropriate) for verification by the HR department. Photocopies of the
original(s) should be taken and filed in the employee file. A minimum of two professional
work references should be obtained. References can be verified by telephone or in writing. A
standardized form should be used to obtain references. A sample Reference Check Form is
given in Appendix I.
3.5.7 Appointment and Probation
Prior to appointment the candidate should submit a medical certificate (except HIV test) to
demonstrate his/her fitness for service. The assessment for the medical certifcate can be done
either at the hiring Hospital or at another health facility. The medical certificate should
include a history of any current or previous illnesses and a full physical examination. The
candidate should also provide written testimony to prove that he/she does not have a criminal
record. A clearance letter from the previous employer should also be submitted.
The first six months of employment of any new employee will be a probationary period. A
probation period appointment letter should be issued to the selected candidate. This letter
should stipulate, at minimum, the following:

employee name
position and department/case team where located
position identification number
start date
employment status: temporary or permanent
salary and benefits
full time or part time position
A copy of the job description should be included with the letter if this has not previously been
given to the candidate.
At the end of the six months a performance evaluation should be conducted. If the quality of
work is satisfactory, a letter of permanent employment should be issued. If the evaluation is
unsatisfactory, the employee should be instructed on his/her shortcomings and provided with
training/orientation as necessary. The probation period can be extended for a further three
months. If the work performance remains unsatisfactory the employment can be terminated.
3.5.8 Promotion
In accordance with federal and regional directives, hospitals should consider employees for
promotion. The hospital should post an internal vacancy announcement for each post that
may be filled by promotion of an internal candidate. The vacancy notice should describe the
post and essential education, work experience, knowledge and skills required. A promotion
selection team should be established to review all applicants for promotion. The team should
be comprised of:
1. Head of Case Team where the post will be located (Chair)
2. HR Head or Representative
3. Professional assigned by HR (Secretary)
The following criteria should be considered when assessing a candidate(s) for promotion:
1. Permanent employee who has completed his/her probation period

2. Non temporary employee or non contract employee
3. Should have the essential qualification requirements for the vacant position
4. Must have attained a satisfactory or above performance evaluation result in 3
subsequent evaluations
5. Must not be under any current disciplinary measure (for example demotion or salary
suspension)
6. Should be no less than 3 months before retirement age.
An employee who has completed a training program and/or higher education may also be
eligible for promotion. The procedures outlined above are not needed in these cases.
3.5.9 Transfers
An employee may be transferred from one position to another of similar grade and salary
when the need arises. Employees may be transferred when:

1. An emergency situations arises and there is a need to fill any gaps a gap in service.
This is a temporary transfer and should not last more than a year
2. An employee has been deemed unfit to carry the functions of his current post by a
medical authority
3. The current position of an employee has been abolished
An employee may also be transfered from one government institution to another when
needed and upon agreement of the employee, recipient and sender institutions. The transfer of
the employee should be to a position of equal grade and salary as their current position.
3.6 Orientation
3.6.1 New Hire Orientation
New-hire orientation training should be provided to all new employees (see Table 1 below).
The orientation provides information about the hospitals mission, vision and values and
helps build the employees sense of identification with the organization. The orientation
enables the new employee to become familiar with the entire organization as well as their
own work area and department. The orientation should include an overview of the job
expectations and performance skills needed to perform the job functions and an explanation
of reporting structures and mechanisms. The Employee Code of Conduct and Statement of
Employee Rights and Responsibilities should be introduced to the worker at this stage (see
Appendices B and C). Training should also be provided on any equipment or specific
documents/forms that are used in the position.
A copy of the Employee Manual should be given to the employee when his/her employment
begins and he/she should be given opportunity to raise questions or discuss this with his/her
supervisor or the HR Case Team during the time of orientation.
Table 1 New Hire Orientation

Hospital-wide Overview of the hospital
information o Mission, vision and core values of the facility
o Services offered
o Organizational structure
o Hospital layout
General overview of each departments functions
Personnel policies, including benefits
Safety guidelines (eg standard precautions, fire safety, and disaster preparedness
plan)
Performance Evaluation Procedures
Employee Code of Conduct
Employee Rights and Responsibilities
Job specific Specific responsibilities of their job (job description)
Performance expectations
Reporting mechanisms
Training and qualifications required
3.6.2 In-service orientation
In addition to orientation for new employees, the HR Case Team should also provide
recurring orientations to all staff in order to:
orient existing staff who may not have received new hire orientations
introduce new HR policies and procedures to staff

provide employees with a forum to discuss issues with the HR department
Hospitals should provide updated orientations to all staff at least once a year. The training
should be on site, and preferably should not exceed one day in duration. The orientation
should cover both general HR policies and department specific policies and hence may be
provided on a Case Team by Case Team basis. It may be necessary to provide the orientation
on more than one occasion to ensure that all staff can participate.
3.7 Salary and benefits

An important component of Human Resources for the hospital is effective remuneration
administration. While the hospital may be required to work within government-directed
protocols and/or regulations for salaries and fringe benefits, the compensation system will
directly affect the organizations ability to attract and retain quailed employees.
3.7.1 Compensation system factors
Equity in pay between jobs is the foundation of a sound compensation system. This involves
consideration of three factors:
1. Internal equity: How does the pay of various jobs compare? What should a nurse
earn compared to a dietary worker or physician? To achieve internal equity, job
requirements must be identified and their complexity evaluated. This evaluation
can be reduced to a numerical factor or rating, so that jobs can be compared.
2. External equity: How does the hospitals pay for jobs compare with that at a
competing organization? As supply and demand affects the marketplace for
workers, external equity becomes more important. Shortages of a certain type of
staff can create wage wars.
3. Philosophy: How does the hospital see itself as an employer one that targets its
wages at the midpoint of the market so that it stays competitive in the marketplace
or one that targets its wages near the top of the market so it can attract the best
candidates?
3.7.2 Benefits
In addition to the basic salary, employees may be provided with additional benefits as
determined by hospital management. Benefits may be in the form of medical benefits,
pension, housing, vehicles, vacations, holidays, or sick time. These forms of compensation
add to the overall cost of labour for the hospital, so decisions regarding fringe benefits must
be evaluated to maximize employee satisfaction and minimize costs.
Some benefits will be common to all employees (eg medical benefit). In addition to these
universal benefits, hospitals should seek to develop and implement a benefit system that:
Motivates staff to improve performance,
Incentivizes staff to remain with the hospital, and
Attracts new employees to the hospital.

Benefits that hospitals may consider include:
1) Medical benefit
2) Pension
3) Top up allowance: This is particularly useful to attract skilled employees to remote

locations where the living conditions are less convenient than in larger towns.
4) Housing allowance: as above.
5) Transport allowance: as above
6) Duty allowance: Payments made for employees who work evening or night hours
7) Risk and Hazard allowance: A specified amount of money to be paid to employees whose
positions expose them to risks. For example, an incinerator operator or X-ray technician.
8) Telephone allowance: allowance given to employees (senior positions) for work related
calls made out side of working hours or when using personal telephone.
9) Travel allowance: allowance given to employees who use a non-hospital vehicle for
transport to work-related activity.
10) Uniforms allowance: provision of uniforms to employees in accordance with the Federal
Civil Service directive
11) Bereavement allowance: payment given to the family if an employee dies.
12) Training opportunities/allowance: The hospital should ensure that all workers have the
skills, knowledge and competence to perform their required duties and should provide all
necessary trainings to ensure that essential job functions can be fulfilled. However in
addition to this, hospitals may give opportunities for staff to participate in additional
career development trainings that will enhance their opportunities for promotion within
the hospital, or enhance their chance to obtain a higher position within another
organization in the course of time. Training may be provided in house or by an external
agency (either on-site or off-site).
13) Participation in private wing activities: Staff who provide services in a private wing are
entitled to a share of the profit made by the service. The opportunity to participate in
private wing activities may be offered preferentially to candidates with good work
performance and acts an incentive for employees to improve their performance. (For
more information about private wing establishment and activities please see Chapter 10
Financial Management).
14) Access to recreational services such as:

a. Cafeteria
b. Break room (equipped with a television and other recreational equipment)
c. Green area
d. Library (equipped with books and computers with internet connectivity)
e. Quiet rooms for prayer (multi-purpose prayer room)

15) Rewards for high performers (see section 3.10.4 Employee Recognition)
Benefits that are given to an employee on the basis of his/her position or that are universal for
all staff (for example medical benefit) should be stated in the job description for the position
and in the offer of employment letter.
3.8 Performance Management

Performance management is an on-going process focused on reinforcing high performance or
improving substandard performance to enhance the knowledge, skills and behaviours of all
employees in order to achieve organizational goals. Performance management has three main
components: supportive supervision, performance based evaluation and performance
improvement.
3.8.1 Supportive Supervision
Supportive supervision is a continuous and participatory process, where a supervisor or

manager accepts shared responsibility for an employees professional development in order
to get the best possible performance from the employee. Performance can be enhanced
through managers working directly with their staff to set clear goals, standards and
expectations. This includes mentoring staff, providing constructive feedback and open and
two-way communication.
The intended result of supportive supervision is that employees develop a supportive link
with their supervisors, marked by open communication to address concerns and share ideas.
There should be a process for mentoring and coaching staff, including developing
performance plans in advance so that there is clarity in terms of job/performance
expectations; a feedback mechanism on performance; and support for staff through training
or skill development, as needed. In order to achieve this, the facility should prepare a
supervision policy, which clearly spells out procedures, rules, responsibilities and authority of
managers.
3.8.2 Performance Based Evaluation
Performance-based evaluation (PBE) is the practice of periodic review and evaluation of an

individuals or teams performance against specified goals or expectations. The first step in
performance evaluation is to determine the performance objectives of each employee. The
goals and expectations may be described in an individuals job description. Alternatively,
goals and expectations may be described in an alternative performance framework - for
example the Balanced Scorecard (see Chapter 13 Monitoring and Reporting) - and an
individual or team may undergo evaluation against these criteria. The advantage of the
Balanced Scorecard approach is that the hospitals vision, mission and plans can be cascaded
down to department/team level and subsequently to the level of the individual, ensuring that
individual and team actions contribute to the overall goals of the hospital. Whichever
performance criteria are used, there must be a clear understanding from the outset between
the supervisor and individual/team on the specific goals and expectations that the
employee(s) will be evaluated against. In PBE the supervisor assesses how well the
individual is fulfilling the roles and responsibilities outlined in his/her performance plan (ie

job description, and/or BSC) and whether remedial action is necessary. A sample job
description and related PBE framework are presented in Appendices D and J.
Performance evaluation should be conducted by the immediate supervisor of each employee.

PBE should be conducted at the end of the probation period and annually thereafter, or more
frequently if poor performance is identified and corrective action is necessary.
To be effective, PBE must be linked to both positive reinforcement (recognition, benefits or

rewards) for good performance and to performance improvement processes when areas of
poor performance are indentified.
Positive reinforcement
Employees who obtain a satisfactory or above satisfactory result on performance evaluation

are entitled to a periodic salary increment as specified in Federal/Regional Civil Service
Legislation. Additionally, hospitals should devise rewards for good performance such as
Employee of the Month recognition, or opportunities for further training or participation in
Private Wing activities for those employees who demonstrate good performance. For further
discussion on staff motivation and benefits see Section 3.10 below.
3.8.3 Performance Improvement Process (PIP)
The Performance Improvement Process is designed to identify, communicate, and intervene

when job performance is below expected standards. Performance improvement interventions
should be initiated as soon as it becomes apparent that an employee is not meeting expected
performance standards. Supervisors should not wait until the end of the review period to
communicate the need to improve performance if the need to improve is identified earlier in
the period.
Performance improvement should begin with coaching/counselling or specific training to

address identified gaps, and should proceed to more formal oral or written warnings if
performance does not improve as a result. Finally, where performance does not improve
despite remedial action, it may be necessary to terminate the employment of the individual.
The duration of each step of the Performance Improvement Process (Coaching/Counselling,
Oral Warning, Written Warning) will vary depending on the performance issue and on the
employee's progress. Normally, each step would last from 30 to 90 days. No matter what the
stated duration of the step, additional action may be taken before the stated end of the step if
the performance continues to decline noticeably or the employee does not make a good faith
effort to meet expectations. By acting promptly and decisively, the organization can avoid
long-term problems.
Coaching and Counselling
In many cases, informal coaching and counselling will be all that is necessary to facilitate
improved performance. The objective of coaching is to help the employee recognize and
solve the problem early on. When a problem occurs or begins to develop regarding work
performance, the supervisor should discuss the situation with the employee before it becomes
serious. During such a discussion, the supervisor should explain exactly what the
performance expectation is and specifically how the employee is failing to meet it. Once the
employee agrees (or at least understands) that he or she is accountable for meeting

expectations, the employee and supervisor should jointly explore steps the employee might
take to ensure he or she meets expectations in the future. Ideally, the employee and
supervisor will agree on the approach that will be taken to solve the problem. If agreement
cannot be reached, it is the supervisors responsibility to ensure that the employee
understands what he or she must do to solve the problem and the consequences for the
employee if the problem is not resolved. The supervisor also needs to tell the employee how
and when he or she will follow up to provide additional feedback on progress against the
agreement.
If the employees performance does not improve with coaching/counselling or it is apparent

that the employee is not sufficiently trying to improve his/her performance then it may be
necessary to take Disciplinary Action as described in Section 3.10.5 below.
In all cases of poor performance the supervisor should consult with the HR Department and
other senior management as necessary for advice and decision making about any actions
necessary.
All PBE results and any Performance Improvement measures should be documented in the
employee personnel file for follow up and future reference.
A sample Performance Improvement Process Form is presented in Appendix K.
3.9 Training and development

Federal Legislation stipulates that all public hospital employees are entitled to training to
improve his/her capability, or prepare him/her for increased responsibility based on career
development. Staff training includes both short and long-term training or educational
opportunities.
Staff training benefits the hospital by:

Creating a pool of readily available and adequate replacements for personnel who
may leave or move up in the organization
Ensuring adequate human resources for expansion into new programs
Enhancing the hospital's ability to adopt and use advances in technology because of a
sufficiently knowledgeable staff
Improving staff morale which in turn enhances performance and reduces employee
turnover
Attracting staff to the facility
Reducing the need for supervision
Plans for staff training should be included in the human resource development plan. Training
plans should take into consideration the needs of the organization as a whole and the needs of
individual workers. The HR department should conduct a training needs assessment to
identify:
Who needs to be trained? (all staff, selected departments/case teams?)
What types of trainings should be offered to staff?

The hospitals training plan should also include an estimate of cost and budget needs. The HR
department should communicate budget needs to the SMT to ensure that budget is secured for
planned training needs. The frequency of training programs should be based on the level of
need and the level of importance to improving performance or quality of care. For example,
infection prevention and nursing process trainings could be conducted at least 2-3 times a
year, as both are key areas relating to patient outcomes. In addition to trainings that improve
employees technical skills, the hospital should also organize trainings to develop the
management skills of employees.
All trainings can be provided either in house or through external trainings. Clear selection
criteria should be set to determine who is selected to attend a specific training. This will
ensure transparency of the process and allow for equity in the distribution of trainings among
staff.
As part of staff development each hospital should have a core set of trainings that are
provided to staff on a regular basis. For example, trainings should be provided to all staff on
fire safety, the major incident plan, occupational health and safety risks and infection
prevention practices.
The main objective of training is to instill a new or renewed behaviour or practice to a

specific area of work. Therefore, trainings do not end when the training modules conclude but
rather when the impact of the training is assessed and the desired outcome is achieved. All
trainings should be evaluated to assess whether the desired outcomes (knowledge or skills
have been achieved) and their impact on employee performance. If the objectives have not
been attained additional training, using different methods may be necessary.
3.10 Employee Relations

The HR Case Team should strive to establish employer-employee relationships that
contribute to satisfactory productivity, motivation and morale. Employee relations are
directed toward preventing and resolving problems involving individuals that arise out of or
affect work situations.
The hospital should provide services for staff including toilets, showers, safe drinking water,
canteen and library facilities. For further discussion on staff services please see Section 3.2.1
of Chapter 8 Facilities Management.
3.10.1 Employee Code of Conduct
Each hospital should devise a set of standards that governs employee conduct. The standards
should include what is expected from the employee in their work, their interactions with
patients, caregivers, visitor and other staff. These standards/principles should be made
known to all employees and packaged in a code of conduct. A sample of code of conduct is
presented in Appendix B. Outlined below are core areas that should be covered in an
employee code of conduct.
Guidelines for employees to follow when offered gifts: Employees should refuse any gifts,
favours or hospitality that might be interpreted as an attempt to gain preferential treatment,

not ask for or accept loans from anyone under their care or anyone close to them and must
establish and actively maintain clear boundaries at all times with patients, their families and
caregivers.
Patient care: Patients have the right to fair and equal access to care from all staff, according
to their needs. All employees should care for all patients equally and without prejudice to
age, gender, and economic, social, political, ethnicity, religious or other status and
irrespective of personal circumstances. They should demonstrate a personal and professional
commitment to equality and diversity in caring for patients and ensure that their professional
judgment is not influenced by any commercial or preferential considerations.
Confidentiality: All patients have the right to expect that any information they disclose in
the course if their care is confidential between themselves and their treatment team. Hospitals
should ensure that there is a written hospital information management policy which sets out
how the hospital ensures that information held by the hospital on patients, their families and
staff is handled confidentially.
Dress Code and Identification: The Hospital should have guidelines which clearly and
strictly define dress codes for all employees. Such guidelines should explicitly list each
article of clothing, the colour, and condition which is acceptable in hospital settings. The
hospital should have colour-coded system one which clearly and easily allows patients to
distinguish between staff. The hospital should also have a policy to ensure that all staff wear
their identification badges at all times.
3.10.2 Employee motivation
Employees who are motivated tend to work harder and stay longer with their employer. To
motivate is to stimulate the employees enthusiasm and factors that harness their driving
force. What motivates employees? Each hospital employee brings his/her own personal goals
and what they hope to gain. These might include:
1) To get a good job and keep it
2) To earn money and help support the family
3) To advance professionally
4) To improve their financial situation
5) To have a job that is pleasant, secure, and offers opportunity for improvement
6) To have fair and consistent supervision free from discrimination or harassment
7) To receive recognition, praise or other rewards for a job well done
8) To help people and contribute to society
9) To work in a good work environment and
3.10.3 Job satisfaction
Job satisfaction is another component of employee relations. Job satisfaction depends on the
employees evaluation of the job and the environment surrounding it. The employee
evaluates their actual experience in the job remuneration, supervision and the work
conditions when assessing their job satisfaction.
1) Remuneration: Ideally, the compensation for the job should be deemed equitable by
the employees. If, instead, the employee believes the wages paid are substandard
in the market, then the hospital is at risk for unwanted turnover, low staffing
ratios, higher overtime costs and lower productivity by employees.
2) Supervision: Supervision of the employee should be fair and consistent, following

established policies and procedures that are applied consistently across the
organization. The supervisor communicates clearly to the employee the
expectations for the job and any necessary performance improvements that must
be undertaken to meet expectations.
3) Work conditions: Work conditions relates to the climate in which the work takes
place do supervisors and co-workers have mutual respect, are there positive
interactions, shared problem solving, investment in improving quality outcomes
and an interest in employee work life quality? Hospitals should provide a safe and
comfortable working environment for staff, including accessible toilets, showers
and changing facilities (where relevant). Staff should also have access to
refreshments and meals, to a library with internet access and to private
recreational areas (such as garden or canteen).
3.10.4 Employee Recognition
Staff motivation and performance may be enhanced by a recognition/reward scheme that

acknowledges outstanding individuals or teams.
Employee recognition can be in the form of a certificate or letter from hospital management
to the individual/team, or through an Employee of the Month program where the hospital
identifies employees who evidence the hospitals vision, mission and core principles in their
everyday work. Recognition can also be coupled with a reward (for example additional
vacation days, gift, or financial reward). Ideally recognition should be public, for example
announcements could be made in the hospital bulletin or posted on the hospital notice board
etc. In addition, the hospital can also organize all staff gatherings to recognize the
contribution of the entire hospital workforce.
The hospital should set clear criteria for the selection of staff for recognition or reward. The
selection and reward process should be transparent and made known to all staff. Any
recognition should be filed in the employee file as evidence of good performance and should
be referenced when evaluating an individual for further opportunities for advancement and
benefits, such as training opportunities.
3.10.5 Discipline Management
In cases where an employee demonstrates behaviour that is unacceptable or in conflict with

the hospitals Code of Conduct, or where an employee persistently performs poorly despite
opportunities for improvement, it may be necessary to take disciplinary action. Disciplinary
measures should be governed by two principles:

the employee must be clearly informed by his/her immediate supervisor as to the
source of dissatisfaction, and
except in limited circumstances (such as serious professional misconduct or

corruption) the employee should be given the opportunity to correct the problem. A
Disciplinary Committee should be established to investigate all disciplinary charges
and to determine the appropriate disciplinary measure. The Committee should be
chaired by the HR Case Team Head. Additional membership should be determined by
the hospital CEO. Each hospital should establish a Policy for Discipline Management
that describes the behaviour or performance issues for which should be brought to the
discipline committee, the range of disciplinary measures, the process by which
disciplinary action is taken and the appeals process by which an employee may appeal
against any disciplinary measures. The Policy should be included in the Employee
Handbook.
Civil Service Regulations stipulate six types of disciplinary measures:
1. Oral warning
2. Written warning
3. Fine up to one months salary
4. Fine up to three months salary
5. Downgrading of position for up to two years
6. Dismissal
The first three categories are considered as simple disciplinary penalties while the latter
three categories are considered as rigorous disciplinary penalties. Examples of behaviour
that might result in a rigorous disciplinary penalty are presented in Appendix L. Evidence
of rigorous penalties should remain in the employee record for 5 years while simple penalties
should remain in the employee file for 2 years.
In general, disciplinary action should not come as a surprise to the employee and any
concerns with an employees performance or behaviour should be addressed at an early stage
to avoid the need for rigorous disciplinary measures. It is the responsibility of the
employees immediate supervisor to explain to the employee those areas in which he/she is
expected to improve, to make suggestions about how to improve, and to allow time for the
employee to make improvements. It is usually only in instances of serious misconduct that
the more severe penalties, including termination of employment, should be considered.

Guidance for Supervisors
It can be very difficult to advise an employee that you have concerns with his/her behaviour or
performance. However, to enable the employee to improve it is essential to be honest, frank
and precise about the problem and to be clear about your future expectations of the employee.
Vagueness and generalities, or glossing over the situation, are likely to leave the employee
uneasy and feeling that something is wrong but unable to correct his/her behaviour or
performance. Criticism should be related to work related matters only. Wherever possible,
guidance on how to improve should also be given.
3.10.6 Grievance Management
A grievance is a concern, problem or complaint that an employee has about his/her job, for
example his/her employment terms and conditions, work environment, contractual or
statutory rights or the way he/she is being treated at work.
Grievances can often be avoided by good communication between employees and senior
managers such that problems are identified and corrective action taken at an early stage.
Grievances are more likely when employees feel that their views are not being heard or their
concerns are not being addressed. Grievances are more likely to be settled when employees
perceive that the process is transparent, fair and without retribution for the employee.
Each hospital should establish a Grievance Policy that describes the steps that could be taken
by an employee should he/she have any concerns or complaints about the work environment
or their work situation. A Grievance Committee should be established that is responsible to
investigate employee complaints about, and make recommendations in relation to:
Interpretation and implementation of laws and directives
Protection of rights and benefits
Occupational health and safety
Placement and promotion
Performance appraisal
Undue influence exerted by supervisors
Disciplinary measures
Other issues related to conditions of service
The Grievance Committee should be chaired by the Head of the HR Case Team, with other
members determined by the CEO.
Any employee with a complaint about their work situation should first try to resolve the issue
with their immediate supervisor. If this is not possible a Grievance Form should be completed
and submitted to the Grievance Committee. A sample Grievance Form is presented in
Appendix M. All grievances should be responded to promptly and a written response should
be given to the complainant following the investigation. A copy of the Grievance Form and
written response should be kept in the employee file.
All grievances should be kept confidential unless required to disclose to senior management
or higher authorities (based on severity).

The HR Case Team should maintain an anonymous record of Grievances received and should
monitor these on a monthly basis, identifying any trends or common themes that might
require further investigation or action by senior hospital management.
3.10.7 Staff Survey
Each hospital should regularly (for example biannually) conduct a staff survey to assess staff
satisfaction with the workplace and suggestions for improvement. Summary results should be
presented to the SMT and Governing Board.
3.11 Termination of employment
A workers employment may end through retirement, resignation, termination by the

employer or death. Whenever an employee leaves the workplace an exit interview should be
conducted to gather information about the employees experience and any lessons that could
be learned for future employees. A sample Exit Interview Form is presented in Appendix N.
The exit interview should be reviewed by the Head of HR to identify areas for follow up
action, and thereafter should be filed in the employees Personnel Record.
3.12 Personnel Records

For organizational and legal purposes, hospitals should maintain and regularly update a file
on each employee that includes information such as credentials for hiring, ongoing
performance evaluations, and any documentation concerning performance improvement
action. Hospitals may need to share employee data between departments Nursing and
Human Resources, for example and files are an ideal way to facilitate this function.
Employee files are also the repository of documents defining the mutual understanding
between the employee and employer concerning workplace policies and performance
expectations.
3.12.1 Organization of Personnel Records
Employee Records should be filed by employee name. Within each individual file, papers
should be organized by category - Hiring Documents, New Hire Orientation, Education and
Trainings, Performance Management, Exit of Employment, Other. Within each category,
documents should be organized by date.
Standardized Forms should be used for all documents maintained in each Personnel File, for
example application form, performance evaluation, disciplinary action etc. All forms should
include the following basic information:
Employee name, position/job title,
Date of action(s) taken
What action is being taken, and
Signatures of all involved, signed when the form is completed.
3.12.2 What to maintain in the Personnel Record
All important job-related documents should go in the file, including:

1) Hiring documents:
a) job description for the position,
b) job application and/or resume,
c) offer of employment,
d) references checked in the hiring process,
e) any contract, written agreement, receipt, or acknowledgment between the
employee and the employer (such as an employment contract, or an agreement
relating to a hospital-provided car), and
f) payroll/wage information.
2) New employee orientation:

a) receipt or signed acknowledgment of having received the employee handbook,
b) forms relating to employee benefits,
c) forms providing next of kin and emergency contacts,
d) forms related to beneficiary designation and
e) documentation of completion of new hire orientation.
3) Growth and development: Any document that evidences an employees advancement

in skills or knowledge should be kept here, for example
a) Record/certificate of all trainings completed
b) Copies of educational program completion (certificates, diplomas or degrees)
4) Performance management and improvement documents:

a) all performance evaluation documents
b) awards or citations for excellent performance
c) recognition letters from patients or caregivers regarding the employee
d) complaints from customers and/or co-workers
e) disciplinary documents
5) Exit of employment: This should contain any documents relating to the worker's
departure from the hospital including:
a) Exit interview
b) Documentation of return of all hospital-issued property or items
6) Other forms that should be maintained in the employee file include:

a) Leave forms (including annual leave, maternity, paternity and sick leave)
b) Health examination forms/fitness for duty verification
c) Disciplinary action
d) Grievances filed
e) Any change or update to employee information
3.12.3 Keeping the Personnel Record Up to Date
The HR Department should periodically review each employee's personnel file to ensure that
all information remains accurate, up to date and complete. For example this could be done
when the employees evaluation is conducted. Questions to consider include:
1. Does the file reflect all of the employee's raises, promotions, and commendations?
2. Is there a current copy of the employees job description that reflects changes
made to the original job description?
3. Does the file contain every written evaluation of the employee?
4. Does the file show every warning or other performance improvement/disciplinary
action taken against the employee?
5. If the hospital policies provide that written warnings or other records of discipline
will be removed from an employee's file after a certain period, have they been
removed?
6. If the employee was on a performance improvement plan, a probationary or
training period, or other temporary status, has it ended? Has the file been updated
to reflect the employee's current status?
7. If the employee handbook has been updated since the employee started working
for the hospital, does the file contain a receipt or acknowledgment for the most
recent version?
8. Does the file contain current versions of every contract or other agreement
between the hospital and the employee?
3.12.4 Computerized Personnel Records
Hospitals may choose to install a computerized database to manage selected human resource
information for example employee hire date, transfers, promotions, benefits, annual leave
requests and approval etc. Computerized systems provide easy retrieval of information for
audit and planning purposes (for example calculation of vacancy rates, staff turnover rates,
average performance evaluation scores etc). However, if a computerized system is installed a
complete paper based personnel file should still be maintained for every employee.
3.12.5 Confidentiality of Personnel Records
Employee records are private and confidential. All employees should have access to their
own employee record, but they cannot add to their employee record without authorization of
the HR Department Head. Employees are not authorized to remove anything from their
personnel file, nor should employees be able to access records other than his/her own. If an
employee wants to review their personnel file they should first get permission from Senior
Management and the Head of the HR department. The employee should review the file in the
presence of a representative from the HR department.
3.13 Occupational Health and Safety

Each hospital should assign an Occupational Health and Safety Officer (OHSO) who is
accountable to the HR Case Team leader. For larger hospitals the OHSO should be full time
in this role. For smaller hospitals the OHSO may continue with other duties, but should have
OHSO functions clearly identified in his/her job description and should have designed time
assigned each week for OHS issues. The OHSO should be a health professional (nurse, health
officer or physician).
Responsibilities of the OHSO include:

1. To meet with all new employees and review the following:
a. Medical certificate submitted see section 3.13.2 below
b. Immunization status see section 3.13.3 below
2. Conducts site visits to identify, in collaboration with case team staff, workplace risks and
actions to be taken to address those risks, as well as personal protective equipment needs.
(see section 3.13.1 below )
3. In collaboration with the hospital Incident Officer to investigate reports of employee
accidents or injuries in the workplace. (See section 3.1.1 of Chapter 12 Quality
Management.
4. Facilitate access to treatment for employees who have been injured in the work place.
Maintaining a safe work environment for hospital employees is essential for the provision of
quality care and for promoting staff satisfaction.
Both the hospital and employees play a role in ensuring occupational health and safety. The
hospital should:
ensure that the work place does not cause hazards to the health and safety of
employees
provide workers with protective materials and equipment needed to protect them
from potential hazards
provide training/orientation to workers which includes safety risks, risk minimization
methods and occupational health and safety services available
It is also the responsibility of all workers to observe safety rules and procedures, as issued by
the facility. Employees, once trained and provided with necessary information, should
properly use safety devices and materials, and report any problems or defects of
materials/equipment, as well as report any situation which they feel presents a hazard at the
facility.
3.13.1 Risk Assessment
In order to provide appropriate occupational health and safety services, the hospital should
assess the safety risks that might occur. When assessing safety risks areas that should be
considered include but are not limited to:
Needlesticks
Slips, trips and falls
Manual handing
Violence and aggression (from patients and/or other staff)
Hazardous substances (chemicals, drugs etc)
Harassment (from patients and/or other staff)
Stress
Safety risks can be identified through workplace inspections and reviewing reports of
workplace accidents and injuries. Hospitals should establish processes to regularly assess and
take steps to minimize risk arising in the workplace. Some potential risks and possible
solutions for those risks are described in Table 2 below. Further guidance on risk assessment
is presented in Section 3.1.1 of Chapter 12 Quality Management.

Additionally, hospitals should establish a process for reporting and investigating workplace
injuries or accidents. An Incident Officer should be assigned to receive reports of all
incidents that involve patient or worker safety. He/she should inform the OHSO and jointly
investigate with the OHSO any incidents that involve injury to a hospital employee. The
OHSO should keep a register of all occupational incidents. A sample register is presented in
Appendix O.
Table 2 Examples of Risks and Suggested Solutions

Potential Hazard Example Potential Solution
Lifting, handling, Dressing, bathing, feeding, Minimizing manual lifting of patients in all
transferring patients and toileting cases and eliminating lifting when possible.
Needlestick injuries Injections, inserting IVs etc Provide workers with auto disable syringes .
Establish syringe usage and disposal procedures
and ensure that staff are trained on injection
safety procedures.
Transferring Transferring equipment like Place equipment on a rolling device if possible
equipment IV poles, wheelchairs, to allow for easier transport, or have wheels
oxygen canisters, attached to the equipment. Push rather than pull
respiratory equipment, x- equipment when possible. Keep arms close to
ray machines, or multiple your body and push with your whole body not
items at the same time just your arms. Assure that passageways are
unobstructed. Attach handles to equipment to
help with the transfer process. Get help moving
heavy or bulky equipment or equipment that
you can't see over. Don't transport multiple
items alone for example if moving a patient in a
wheelchair as well as an IV pole and/or other
equipment get help, don't overexert yourself.
Reaching into deep Washing dishes, laundry, or Placing an object such as a plastic basin in the
sinks or containers working in maintenance bottom of the sink to raise the surface up while
areas and using a deep sink washing items in the sink or remove objects to
be washed into a smaller container on the
counter for scrubbing or soaking and then
replace back in the sink for final rinse.
Source: Adapted from the US Department of Labor, Occupational Safety and Health Administration, Health Care Wide
Hazards Module.
3.13.2 Medical screenings and Health Promotion
All employees should undergo a health screening prior to employment at the hospital. The
health screening can either be done at the hiring hospital or at another health facility. The
candidate should submit a medical certificate (except HIV results) prior to employment to
show fitness for service. The medical certificate should include a history of current and
previous illnesses and a full physical examination.
The OHSO should review the medical certificate of each neew employee to identify any
special needs of the employee in relation to the workplace or work duties.
Any employee who has completed his/her probationary period is eligible to receive medical
services at any government medical facility, free of cost. Through the OHSO the hospital
should provide health promotion and disease prevention services for employees and prompt
access to medical assessment for workers who have any symptoms of illness. In particular the
OHSO should educate employees about signs and symptoms of common diseases (such as
TB or malaria) and encourage workers to seek early medical advice should they have signs

and symptoms of these diseases. This is especially important for those diseases that may be
transmitted to co-workers or patients (eg TB, hepatitis). Health promotion programs dealing
with issues such as smoking, substance abuse, stress, and reproductive health at the
workplace should be made available to satff.
Voluntary counselling and testing for HIV should be encouraged and made available to all
workers.
3.13.3 Immunizations
Many health care workers are at risk for exposure to and possible transmission of vaccine-
preventable diseases such as TB, hepatitis B, influenza, measles, mumps, rubella, and
varicella. Maintenance of immunity is an essential part of prevention and infection control
programs for health care workers.
The OHSO should review the immunization history of each new hospital employee. For those
whose vaccination status is incomplete, the hospital should provide all routine childhood
immunizations, in accordance with the current national immunization policy. Additionally,
booster doses should be provided if necessary (eg tetanus booster).
The OHSO must assess the need for vaccination on an individual employee basis, taking into
consideration any co-morbidities and/or pregnancy status. Some vaccines are contraindicated
in cases of pregnant workers (varicella, MMR) and workers with HIV infection (varicella), or
AIDS.
3.13.4 Workplace Injuries
As specified in Federal Legislation, any worker who incurs accident, injury or disease as a
direct result of their employment is entitled to receive free general and special medical
treatment and surgical care expenses; hospital and pharmaceutical care expenses; an all
necessary prosthetic or orthopedic expenses. Additionally, employees are entitled to injury
leave with pay, or will be provided with benefits should s/he be (due to a permanent
disability) unable to return to work.
Hospitals should seek to reinstate workers who suffer an accident or injury by making
adjustments to accommodate the injury/disability. Examples include:
Rearrangement of working hours
Modified tasks and jobs, including modifications in the case of HIV-positive workers
who may be at risk (e.g. avoiding exposing them to infectious TB patients, particularly
MDR TB) or pose a risk to patients by virtue of their performing invasive procedures
(this precaution may also apply to workers with other infections such hepatitis B)
Adapted working equipment and environment
Provision of rest periods and adequate refreshment facilities
Granting time-off for medical appointments
Flexible sick leave
Part-time work and flexible return-to-work arrangements

3.13.5 Occupational Health and Safety Trainings
The hospital should conduct promotional activities to raise the awareness and strengthen
decision-making skills of workers related to infectious exposures and other hazards.
Basic information on infectious exposures and other hazards must be provided to every new
health worker within the first week of employment as part of the new employee orientation.
Refresher orientation sessions can also be provided to other staff annually. Facilities must
have appropriate written informational materials through which updated information on
infectious exposures and other hazards is communicated.
The information provided should include:

identification of potential hazards and infectious and other exposures in the health
workplace
provide information about infection transmission mechanisms and how to reduce the
risk of such transmission
instruct workers on the utilization of safe work practices and standard precautions
workplace health and safety services
workers responsibilities regarding workplace safety and health
promote the implementation of periodic health screening for health workers including
the promotion of voluntary counselling and testing for HIV/AIDS
provide information on the signs and symptoms of the most frequent illnesses at the
workplace, including TB, HIV, malaria, hypertension, and diabetes and instruct
workers to report promptly for evaluation should these develop
disseminate health workers rights and responsibilities with regard to workplace
safety and health, including the right to confidentiality (See Statement of Workers
Rights and Responsibilities, in Appendix C)

In order to determine if the Operational Standards of Human Resource Management have
and Reporting.

Table 3 Human Resources Management Checklist

Yes No
1. Personnel are assigned to provide human resources management services.

2. Each employee has a personnel file that is maintained by the Human
resource case team.
3. The Human Resource head is represented on the Senior Management
Team.
4. A Human Resource Development plan has been developed.
5. Job descriptions have been developed for each position at the hospital.
6. Policies and procedures for staff recruitment and hiring have been
developed and implemented.
7. Policies and procedures for performance evaluation have been developed
and implemented.
8. Policies and procedures for compensation and benefits have been
developed and implemented.
9. Policies and procedures for training and development have been developed
and implemented.
10. Staff survey is conducted regularly.
11. Policies and procedures for employee recognition have been developed and
implemented.
12. Policies and procedures for occupational health and safety services have
been developed and implemented.
13. Policies that define when and what type of identification badges and
uniforms are worn by staff have been developed and implemented.
4.3 Indicators
Table 4 Human Resources Management Indicators
Human Resources Management Indicators

Total number of posts filled
% of posts filled as per the total number of posts as HMIS
1. Quarterly
regional standard indicator
per regional standard x 100
a)Total number of doctors at

end of reporting period
a) Total number of doctors
b) Total number of doctors HMIS
2. Quarterly
who left during reporting indicator
b) Attrition rate
period /total number of
physicians at beginning of
a) Total number of health a) Total number of health
officers officers at end of reporting
period
HMIS
b) Attrition rate b)Total number of health Quarterly
3. indicator
officers who left during
reporting period/total
number of health officers at
beginning of reporting

period * 100
a) Total number of nurses a) Total number of nurses at
end of reporting period
b) Attrition rate b) Total number of nurses
HMIS
4. who left during reporting Quarterly
indicator
period /total number of
nurses at beginning of
a) Total number of other a) Total number of other
clinical staff clinical staff at end of
reporting period
b) Attrition rate- b)Total number of other HMIS

5. Quarterly
clinical staff who left during indicator
number of other clinical
staff at beginning of
a) Total number of - non a) Total number of non
clinical staff clinical staff at end of
reporting period
b) Attrition rate b)Total number of non HMIS

6. Quarterly
clinical staff who left during indicator
number of non clinical staff
at beginning of reporting
period * 100
Total number of staff who
underwent performance
Cumulative number (%) of staff evaluation from beginning
7. who underwent performance of year to end of reporting Quarterly
evaluation period total number of
staff at beginning of year *
100
a) Number of staff with a) Total number of staff
performance that is less than with performance that is less
satisfactory than satisfactory
b) Proportion of employees b) Total number of staff

8. Quarterly
with less than satisfactory with performance that is less
performance than satisfactory/ Total
number of staff who
underwent performance
evaluation*100
a) Total number of staff
a) Cumulative number of staff with in-service training
who received in service from beginning of year to
training end of reporting period
HMIS
9. b) Cumulative number of Quarterly
indicator
b) % of staff who received in staff who received
service training training/total number of
staff at beginning of period
*100
a) Number of new staff who a) Total number of new staff
received new hire who received a new hire
orientation during reporting orientation
period
10. Quarterly
b) % of new staff who received b) Total number of new
new hire orientation staff who received a new
hire orientation / total
number of new staff *100
Total number of grievances
11. Number of grievances received Quarterly
recorded by the HR

department
Total number of
Number of occupational injuries
12. occupational injuries Quarterly
reported
reported
Total number of working
13. Number of functional computers Quarterly
computers
Source Documents
1. Accel Team. (2006). Employee Motivation. Motivation in the Workplace - Theory and
Practice. Retrieved November 27, 2006 from http://www.accel-
team.com/human_resources/hrm_04.html.
2. African Services Committee. (2004, February). Work Plan and Performance Evaluation
Report.
3. Davis, W., Haacker, R., Townsend, J. (2004). The Principles of Health Care
Administration. Second ed. Bossier City, LA: Professional Printing and Publishing.
4. Department of Health and Human Services. HHS Workforce Planning Model. Retrieved
October 30, 2009 from www.hhs.gov/ohr/workforce/wfpmodel.gif.
5. EngenderHealth. (2003). COPE Handbook: Process for Improving Quality in Health

Services.
6. EngenderHealth. Facilitative Supervision Handbook.
7. Federal Civil Service Agency. (2007). Federal Civil Service Employees' Employment
Implementation Directives. Addis Ababa.
8. Federal Ministry of Health. (2008, November). Federal Ministry of Health Business

Process Re-engineering Study of Human Resources Supportive Business Process.
9. Federal Ministry of Health. System of Management for Employees Results-Oriented Plan

Performance.
10. Fried, B. (2002). Performance Management. In: Fried BJ JJ (Eds). Human Resources in
Healthcare: Managing for Success. Chicago: HumaChicago: Health Administration
Press.
11. Grand Roads Executive. (2006, 13 December) How to Write a Job Description: Gaebler
Ventures. Retrieved November 9, 2006 from
http://www.grandroads.com/howToWriteAJobDescription.htm.
12. The Hospital Employees Union. (2004). Health and Safety Manual. Retreived October
26, 2009 from
http://www.heu.org/~DOCUMENTS/Miscellaneous/Organizational/HEU_OHS.pdf.
13. Johns Hopkins University, Human Resource Manual.
14. Joint Commission International Accreditation Standards for Hospitals, 2nd edititon. Staff
Qualifications and Education (SQE).

15. Longest, B.B., Rakich, J., Darr, K. (2000). Managing Health Services Organizations and
Systems. Fourth ed. Baltimore: Health Professions Press.
16. Massad, M. (2005) The Many Uses of a Job Description. Retrieved November 11, 2006,
from http://www.entrepreneur.com/humanresources/hiring/article78506.html.
17. Management Sciences for Health. (2005). Human Resource Management Rapid
Assessment Tool for Public and Private-Sector Health Organizations. A Guide for
Strengthening HRM Systems.
18. Management Sciences for Health. (1998). Performance Management Tool. Health and
Family Planning Managers Toolkit. Retrieved October 2008 from
http://erc.msh.org/newpages/english/toolkit/pmt.pdf
19. Montana State Hospital. (2009) Montana State Hospital Policy and Procedure: Employee
Code of Conduct. Retrieved October 31, 2009 from
msh.mt.gov/volumei/humanresources/rulesofconductemployees.pdf.
20. NHS Staff Council Working in Partnership. Partnership Occupational Safety and Health
in Healthcare Group. (2009). Occupational Health and Safety Standard. Retrieved from
July 6, 2009 from
http://www.nhsemployers.org/Aboutus/Publications/Documents/Occupational%20health
%20and%20safety%20standards.pdf.
21. Payos, R and Zorilla, O. (2003). Personnel Management. Manilla: Rex Printing
Company, Inc. Administration Press.
22. Proclamation No.515/2007: The Federal Civil Servants Proclamation. (2007, 19

February) Addis Ababa: Federal Negarit Gazetta.
23. Shi, L. (2007) Managing Human Resources. Subdury: Jones and Bartlett.
24. Stolovitch, H. (1999). Handbook of Human Performance Technology. San Francisco:

Jossey-Bass/Pfeiffer.
25. Ugandan Ministry of Health. Prepared by Necochea, E. and Bossemeyer, D,. Jhpiego.
(2007) Ugandan Ministry of Health Draft Workplace Safety and Health Guidelines for
Health Workers.
26. University of Medicine and Dentistry. (2009). Maintaining a Compliant and Ethical
Environment: A Guide to the University's Compliance and Program and Code of
Conduct. Retrieved October 31, 2009.from
www.umdnj.edu/uhcomweb/pdf/Code_of_Conduct.pdf
27. US Department of Labor. Occupational Safety and Health Administration, Health Care
Wide Hazards Module.

Appendices
Chapter 11 Human Resources Management

Appendix A Tools to Aid in the Creation of the Hospitals Workforce
Development Plan
Analyis of Human Resource Demand

The office should estimate the type and size of its human resource need on the basis of the
amount of planned activities.
In order to identify and quantitatively describe the human resource required to accomplish the
planned work or activity, we can use or apply the following seven approaches, depending on
the nature of the work:-
Trend assessment
Number of service recipients
Number of posts for care and support operations
The condition of office facilities
Working hour
Number of supervisors and subordinates
Task analysis technique
Trend Assessment
This can be conducted by following these procedures;
To identify appropriate indicators and parameters of work load for the major tasks
and activities in the different work units. Example: number of documented files;
number of reviewed reports; number of studies conducted; and etc;
To prepare a table format with the list of selected work quantity indicators and to
record the quantity or amount of work accomplished during the last five years and the
number of workers who accomplished it;
To calculate the average over-head productivity of workers by dividing the amount of
work accomplished by the number of workers;
To determine the expected level of productivity; depending on the decreasing,
increasing, or content trend productivity as observed during the last five years; and
To calculate and determine the required number of man power by dividing the
planned amount of work by the set average productivity level.
It is not advisable to use this approach or technique where the Hospital cannot find data for at
least five years and when it is undergoing rapid changes.
Example: Documentation of files reported by an office

Year Documented survey Average Number of
reports Productivity workers
1994 2351 14.33 164
1995 2613 11.12 235
1996 2935 8.34 352
1997 3306 10.02 330
1998 3880 12.52 310
1999 4095 12.52 ?
2000 4283 12.52 ?
Chapter 11 Human Resources Management Appendix A: Page 1 of 5

Human resource need = planned quantity of work in the year/Workers average productivity
Human resource need for the year 1999 = 4095/12.52 = 342
Number of service recipients

In this technique human resource need is estimated in relation to the expected number of
service recipients.
Example: If one teacher is required for every 50 students, how many teachers will be required
for expected 1000 students?
For 50 students = 1 teacher
For 1000 students = X (where X is number of required teachers)

X = 1000 x 1 = 20 teachers
50
Number of core and support operations that require post holders

Here we determine the human resource need in relation to core and support operation posts to
be occupied, and therefore we can determine the number of required workers depending on
the existing officials.
Example:
Officials Required workers
Minister Executive secretary, driver office
Assistant
Core support operation Secretary
The condition of facility- analysis of the facilities available will allow the Hospital to
determine the number of workers needed in relation to the facilities available. Eg: If the
Hospital compound has two gates, this determines also the number of guards. If we require
two guards for one gate, then we require four for the two gates.
Working hours- can be used to determine the required number of workers depending on the
work to be done out of the formal working hours. Eg: Formal number of working hours for a
worker is 8 hours. A pharmacy that is open for 24 hours needs to employ two more workers
for the 16 hours outside than the formal working hours.
Number of supervisors and their subordinates- can be used to determine the required number
of supervisors in relation to the number of workers to be supervised.
Eg.: If we need one leader for a team of six experts, then we should need two leaders for one
more team of additional six experts.
Qualitative Method
This method can be employed quite easily in a situation in which there is no strong data
organization system and is applicable in situations in which circumstances are constantly
changing.

Leadership Feedback Method
The feedback method of leaders or managers can be conducted in the following manner;
The top management body of the Hospital prepares a guideline that describes and
contains predicted impacts of future work quantity on performances as well as the
strategic goals and objectives that should guide the human resource need prediction
process;
Coordinators use this guideline to prepare their human resource needs prediction in
collaboration with the human resource unit;
Coordinators are required to narrate and explain all the necessary reasons in order to
justify their need prediction and get leadership approval;
At the same time the human resource unit should prepare predictions for each of the
units within the organization;
A resource person or professional advisor would be used to appraise, review, and
comment on the human resource needs proposed by the units and to continuously
revise and consolidate requests from both sides;
The final proposal then should be approved by the head of human resource admin
unit.
Analysis of Existing Internal Human Resource Supply

Human resource supply analysis can be undertaken using two methods:
A) Using existing data on vacant and filled or occupied job positions
This involves identifying and sorting data or information on vacant and non-
vacant positions and observing the data in comparison with the entire job positions
the office has had for its work.
B) Capacity assessment and profile record

This has to do with building a detailed and systematic record or database on the
capacity, career, and performance of all employees of the office at both
managerial and non-managerial position.
Such a record can have three parts:
Information on the employees professional and personal profile upon

joining the office or the organization (e.g. Education, work experience,
etc);
Recorded performance appraisals of the employee over the last three years;
and
Detailed information on the employees future career plans and goals.
Data can be gathered or generated using questionnaires and interviews. Data records should
be are regularly and continually updated.
Quantiative Analysis Methods

Staff Turn-over
This method enables the Hospital to predict the future trend of internal human resource
availability (supply) by analyzing the current rate of turn-over. This can be done using the
following simple working formula:
Turn-over rate = Number of employees who have left the Hospital in the current one year
time /the average number of staff during the year X 100
Example: If there are 16 staff who have left the organization in the year and if there were 90
staff at the beginning and 70 staff at the end of the year, the average number of staffs would
be 90/2 + 70/2 = 160/2 = 80
And turnover rate indicator would be 16/80 X 100 = 20%
Example: Using this rate indicator, one can predict that 120 staffs out of existing 600 might
be leaving. I.e., 600 X 0.20 = 120
A) Analysis of staffs ages
Having an accurate record and a graphic data on the ages of employees is necessary in order
to be able to identify possible high rate of retirement and also limited opportunity for
promotions and to plan for the proper solutions.
Example:
Number
50-
55-
60-
<20 23-25 26-30 31-35 36-40 41-49 Age
We can see from this graph that quite a large number of employees are in the old age with
high probability of retirement. An organization that has such age graph should plan to prepare
younger ages to take the places of the older whenever there should be a turning off. Such age
analyses can be done for units, ranks, departments, sexes, etc.
B) Work-place changes and staff absenteeism

It is necessary to observe and analyze the impacts of policies, proclamations, regulations
structural changes and adjustments, working hours, health situations, absenteeism, and etc on
the internal human resource and to make preparations and plans to be able to cope.

Analysis of Human Resource Demand and Supply
S/ Work position Time of Human Resource Demand Human Resource Supply

No comparison
Remark
Title Grade Month Year Type Type
Qualifi Job Profes Skills Other Quali Job Profession Skills
Number
Number
cation experience sion ficati experience
on

Appendix B: Sample Employee Code of Conduct
EMPLOYEE CODE OF CONDUCT
I. PURPOSE
To define standards of conduct and acceptable behaviour for all employees assigned
responsibilities in this hospital and those employees of the hospital working at other
designated sites.
II. PREAMBLE
The foundation for the professional conduct of the hospital staff derives from the hospitals
Vision, Mission, Core Values, and the Statement of Patient Rights and Responsibilities. The
standards of conduct outlined below will help to ensure a positive environment for all staff,
patients and visitors, and a culture that optimizes patient care and safety. It is the
responsibility of individuals to act in a manner consistent with this code of conduct, its
supporting policies as well as regional and federal laws and regulations. It is also expected
that every employee will support this code of conduct by holding others accountable to these
standards. The hospital will not tolerate acts of retribution or consequence to any employee
who carries out the standards included in the code of conduct or reports violations of the code
of conduct. When reported, violations of this code will be addressed through appropriate
policies related to inappropriate behaviour and conduct.
III. STANDARDS OF CONDUCT

I shall treat all persons, including patients, families, visitors, employees, trainees, students,
volunteers, and healthcare professionals with respect, courtesy, caring, dignity and a sense of
fairness and with recognition of and sensitivity to the needs of individuals from diverse
backgrounds (including but not limited to gender, health condition, ethnicity, age, disability,
nationality, and religion).
I understand that all medical and financial information, records, and data to which I have
knowledge and access in the course of my employment in this facility shall not be disclosed
to anyone under any circumstance except to the extent necessary to fulfill my job
requirements and as permitted by regional and federal laws.
I shall not engage in any form of bribery or corruption. This includes, but is not limited to,
offering or receving gifts from patients in exchange for a service provided (eg. referring a
patient to a particular facility or healthcare provider) or receiving benefits in exchange for
promoting certain drug brands.
I will at all times adhere to and provide information on infection prevention practices to other
employees, patients, family members and other caregivers, as appropriate to my job
description.
I shall resolve conflicts and counsel colleagues in a non-threatening, constructive and private
manner.
I shall accept professional accountability and maintain standards of professional practice as

set by the appropriate regulatory body applicable to me profession or role.
I shall wear my name badge in a clearly visible area at all times during duty hours.
Chapter 11 Human Resources Management Appendix B: Page 1 of 3

I shall be in full uniform as designated by my department at all times during duty hours.
I shall utilize all facilities, equipment and property, including communication lines and
materials, responsibly and appropriately.
I shall participate in any education and training required by this hospital to perform my job
duties to the highest level of quality.
I shall immediately report to the appropriate person(s) in accordance with hospital policies:
suspected child or elder abuse
certain diseases
birth and deaths
staff misconduct
criminal acts, such as theft, threats, assault, attempted rape/rape and illegal drug use
I understand that the use of alcohol, khat and other drugs (either on or off the job) which
results in an employees inability to perform his job is forbidden.
I will not work in any other organization during regular working hours unless I have secured
prior approval and consent from the hospital management.
For employees who have direct contact with patients

I shall care for all patients equally and without prejudice to age, gender, and economic,
social, political, ethnicity, religious or other status and irrespective of their personal
circumstance.
I will introduce myself to all patients and their caregivers before conducting any
investigations, examinations or asking any questions.
I will obtain consent (written or verbal) from the patient or their relatives / next of kin (for
those who are not competent to give consent) before performing any investigations or
procedures upon a patient.
I shall respect patient-staff boundaries and therapeutic principles in caring for patients.
I shall communicate openly, respectfully and directly with all team members, referring
providers, patients and families in order to optimize health services and to promote mutual
trust and understanding.
I shall communicate all necessary medical information (including nature and transmission of
ill-condition, prescription intake instructions and side effects, etc) in a clear manner to all
patients and their caregivers in an effort to advance patient knowledge and prevent further
burden of illness.
I shall at all times involve the patient in his/her care by offering all options to the patient,
explaining all consequences, and providing clinical advice to inform the decision of the
patient.
I shall document in the medical record any and all activity regarding a patients care in a
timely and legible manner to avoid risk and liability to both the hospital and myself. This
includes signature and date.
I understand that I may not at any time dispose of or remove from the hospital grounds any
medical records unless authorized to by appropriate staff.
I understand that the retention and disposal of medical records must be in accordance with the
hospitals archiving and disposal policy.
I shall participate in, cooperate with and contribute to briefings, debriefings and
investigations of adverse incidents.
I hereby acknowledge, by my signature below, that I have received training on the hospitals
policies and procedures relating to all statements listed above and agree to abide by these
standards of conduct.
I understand and agree that any violation of this Code of Conduct Agreement is grounds for
disciplinary action, up to and including discharge.
___________________________________ ____________________________
Printed Name of Employee Date
___________________________________ ____________________________
Signature of Employee Date

Appendix C Statement of Employee Rights and Responsibilities
Employees are the most valuable asset of [ ] Hospital. All staff should have rewarding and
worthwhile jobs, with the freedom and confidence to act in the interest of patients. To do this, they
need to be trusted and actively listened to. They must be treated with respect at work, have the tools,
training and support to deliver care, and opportunities to develop and progress.
Employees of [ ] Hospital have extensive legal rights, embodied in National Legislation

(Federal Proclamation No 515/2007). The legal rights are there to help ensure that staff:
have a good working environment with flexible working opportunities;

have a fair pay and contract framework;
have healthy and safe working conditions and an environment free from harassment, bullying or
violence;
are treated fairly, equally and free from discrimination; and
can raise an internal grievance, and if necessary, seek redress, where it is felt that a right has not
been upheld.
In addition to these legal rights, there are a number of pledges, which [ ] Hospital is
committed to achieve. Pledges go above and beyond your legal rights. This means that they are not
legally binding but represent a commitment by [ ] Hospital to provide high-quality working
environment for staff.
[ ] Hospital commits:
to provide all staff with clear roles and responsibilities for teams and individuals that make a
difference to patients, their families and caregivers and communities;
to provide all staff with personal development opportunities, access to appropriate training for
their jobs and management support to succeed;
to provide support and required supplies for staff to maintain their health, well-being and safety;
and
to engage staff in decisions that affect them and the services they provide, individually, through
representative organisations and through local partnership working arrangements. All staff will be
empowered to put forward ways to deliver better and safer services for patients.
You should aim:

to maintain the highest standards of care and service, taking responsibility not only for the care
you personally provide, but also for your wider contribution to the aims of your team and the
Hospital as a whole;
to take up training and development opportunities provided over and above those legally required
of your post;
to play your part in sustainably improving services by working in partnership with patients, the
public and communities;
to be open with patients, their families, carers or representatives, including if anything goes
wrong; welcoming and listening to feedback and addressing concerns promptly and in a spirit of
co-operation. You should contribute to a climate where the truth can be heard and the reporting
of, and learning from, errors is encouraged; and
to view the services you provide from the standpoint of a patient, and involve patients, their
families and carers in the services you provide, working with them, their communities and other
organisations, and making it clear who is responsible for their care.
Adapted from Federal Proclamation No. 515/2007 and the NHS Constitution for England. DH,
England, 2009.
Chapter 11 Human Resources Management Appendix C: Page 1 of 2

Appendix D Sample Job Description for Laboratory Technologist
Job Title: Laboratory Technologist
Department: Laboratory
Reporting to: Laboratory Head
Employment type: Full time, regular employee (following completion of probation

period)
Education required: BSC Laboratory Technology
Job Summary: Conduct laboratory tests, prepare and report results, prepare laboratory
reagents, conduct quality assurance activities to ensure accuracy of laboratory results.
Key responsibilities:
1. Collects samples (blood, urine, excrement, sputum and other samples)

2. Conducts required tests, records results and informs requesting department of the
results
3. Manages laboratory chemicals (ensuring proper usage, non-expiry of their usage
period, timely re-stocking).
4. Makes timely requests for lab materials and chemicals, and shall keep same with care
and economization.
5. Ensures that the containers for handling and collecting samples are clean, properly
sterilized and free from contamination.
6. Shall inform his/her immediate supervisor of any defect in materials in a timely
manner.
7. Shall make exchange of experience with the relevant experts/professionals as regards
to work performance.
8. Ensures proper placement of lab materials at suitable places.
9. Participates in trainings and skill development related to laboratory work
10. Ensures proper storage and use of equipment and supplies
Supervisory responsibilities: Nil
Evaluation criteria: Performance Based Evaluation will be conducted prior to the end of
the probation period and annually thereafter. Evaluation will be conducted to assess your
performance in relation to the duties described in this job description.
Chapter 11 Human Resources Management Appendix D: Page 1 of 1

Appendix E Sample Personnel Recruiting and Posting Request
Date
1. Position Grade Salary
2. Nature of the work
Permanent Contract Temporary
3. Vacant position
Newly created position: Left vacant:
4. Knowledge, skills, competence and other essential traits requited for the vacant position
5. Expected date of starting work by the employee
6. Requisition filed by authorized person
Name
Signature
Position
7. Decisions /Recommendations issued by human resource management process owner
Name
Signature
Position
Date Month Year
Chapter 11 Human Resources Management Appendix E: Page 1 of 1

Appendix F Sample Vacancy Notice Form
Reference No: _______________ Date: ___________________
1. Name of the agency _______________________________________
2. Vacant position
a. Title
b. Grade
c. Salary
d. Number of posts available
3. Minimum requirements to quality for the position:_______________________
4. Additional requirements for the position:
a. Knowledge ______________________________________________
b. Skills ______________________________________________
c. Competence ______________________________________________
c. Other essential qualification traits ______________________________
5. Supporting documents that must be submitted with Application Form:
____________________________________________________________
6. Description of position: _______________________________________
_______________________________________________________________
7. Salary and benefits: ______ ___
8. Place of registration: ___
9. Registration closing date: __________________________________________
Applications must be submitted on a Standardized Application Form. Copies of the

Application Form and further details about the position, including a copy of the job
description can be obtained from:
Name: _______________ Tel: ________________ email: _____________________
Chapter 11 Human Resources Management Appendix F: Page 1 of 1

Appendix G Sample Employment Application Form
Name of Hospital :___________________________
Vacant position Position: _______________ Grade ___________ Salary:_________________ _______________
Personal Applicants name_______________ Father's Name ________________

information
Parental grandfathers name:___________________________________
Date of birth (date, month, year): _______________________
Address:___________________________________________
Region:____________ Zone:___________ Woreda:____________ Kebele:________ House No._____
Tel : ______________ P.O.Box : _______________ Email : _________________________________
Sex : Female Male :
Nationality: ______________________
Marital Status: Unmarried Married Separated Divorced Widowed
Number of children : __________________________
If applicable, please specify any physical or health limitations: _______________________________________
Have you ever been accused of a crime?: Yes No
If your answer is yes, specify:__________________________________________________________________
________________________________________________________________________________________
Do you know any person(s) currently working in this hospital? Yes No
If yes, specify name and relationship to you: ________________________________________________
Chapter 11 Human Resources Management Appendix G: Page 1 of 3

Educational School/College/University (specify Years attended Field of study Educational qualification received
qualification name, place)
Language Language Speaking Listening Reading Writing

(proficiency
level specify as
good, very good,
excellent )
Work Name Address From To Position Grade Salary Reason for termination of your
experience (start employment
with the most
recent )
Participation in Specify any studies and research works that you conducted outside college or school:-
Vocational _________________________________________________________________________________________________
Training _______________________________________________________________________________________
___________________________________________________________________________________________
Hobbies or _________________________________________________________________________________________________
interests: _______________________________________________________________________________________
____________________________________________________________________________________________

Personal Name Occupation Address, telephone, email (if available)
references
State additional information, if any:

_______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I, the undersigned, ascertain that the information provided by me on the application is true and genuine to the best of my knowledge and belief
Applicant's name and signature:__________________________
Date (dd/mm/yy): ____________________

Appendix H: Sample Candidate Assessment Form
Candidate Assessment Form
Position:
Candidate Name:
Interviewer Names:
Interview Date:
Based on the interview, please evaluate the candidate's qualifications for the position listed
above. In each section, space is provided to write additional job specific comments. If one of
the questions does not apply to the position, please write N/A in the comment section.
Education / Training The candidate has the necessary education and/or training required by
the position
Exceeds requirements Meets requirements Needs a more training Doesn't meet

requirements
Comments:
Work Experience The candidate has prior work experience that is related to the position.
Extensive experience Meets requirements Not related but transferable skills No

prior experience
Comments:
Skills (Technical Exam) The candidate demonstrated to your satisfaction that he/she had the
necessary technical skills to perform the job successfully. This oral exam should be conducted by
the immediate Supervisor. He/she should list technical questions below and provide a score of 1-6 to
each of the candidates responses.
SCORE KEY: 1= poor 2 = fair 3= satisfactory 4= good 5 Scor

= very good 6= excellent e
1.
2.
3.
4.
5.
6.
Chapter 11 Human Resources Management Appendix H: Page 1 of 3

7.
8.
9.
10
.
Supervising Others The candidate demonstrated to your satisfaction that he/she had the
necessary experience in supervising others to perform the job successfully.

requirements
Comments:
Leadership Skills The candidate demonstrated to your satisfaction that he/she had the necessary
leadership skills to perform the job successfully.
requirements
Comments:
Interpersonal Skills Communication: articulated ideas clearly both written and orally.

requirements
Comments
Teamwork Demonstrated the ability to work well in a team and with superiors, peers, and
reporting staff.

requirements
Comments:
Time Management Demonstrated the ability to manage time independently and work
efficiently.
requirements
Comments:

Customer Service Demonstrated the ability to be customer focused.

requirements
Comments:
Motivation for the Job The candidate expressed interest and excitement about the job.

requirements
Comments:
Problem Solving Demonstrated the ability to design innovative solutions and solve problems.
requirements
Comments:
Skill Needed Demonstrated the ability to:

requirements
Comments:
Overall Recommendation
Highly recommend Recommend Need clarification of qualifications Do not

recommend
General Comments:

Appendix I Sample Reference Check Form
Before the employment offer is made, verification of a candidates credentials and

employment history should be made by the Human Resources Manager. Checking
References can help to confirm the experience, background and future success in the new job.
At least two professional work references must be completed.
Guide for Reference Checking

a) Use the telephone, which serves as the most effective means for gathering reference
information. You can listen to the tone of the reference and you can encourage the
reference to talk. You can also get clarification about a comment or observation, and
ask follow-up questions.
b) Treat all information given by the reference with confidentiality. Access to information
should be limited only to the Director of HR Department, CEO and supervisor.
c) Avoid asking questions about marital status, race, age, region, national origin, or
disabilities.
de) All references for a candidate should be checked by one person consistently and the
same questions must be asked of each reference.
f) Document all information.
I. Applicant Information
Name: Job Title and Department for which an
application was submitted:
II. Reference Contacted

Name: Position Title:
Department: Date Contacted:
Region and City:
III. Minimum Questions for Reference Contact
1. How long have you known the applicant? Number of Months_________

Years________
2. What was the applicants job title and did he/she hold other titles while at your
organization?
3. What were the applicants primary responsibilities?
4. To whom did he/she report? (No name necessary)
Chapter 11 Human Resources Management Appendix I: Page 1 of 3

Position: _________________________________
Department:___________________________
5. How would you rate the applicants ability to manage his/her time?
Poor Fair Good Very Good
6. How would you rate the applicants ability to work under pressure?
7. How would you rate the applicants work style?
8. How would you rate the quality and quantity of his/her work?
9. How would you rate the applicants interpersonal and communication skills?
10. Does the applicant accept responsibility? Yes No Please give me an
example?
11. How would you rate the applicants leadership ability? If the position is one of
management, please rate management style as well.
Why?
12. How would you rate the candidate's relationships with his/her co-workers - including
supervisors and reporting staff [if applicable]?
13. What are the applicants strengths?
14. What are the applicants weaknesses?
15. Why did the applicant leave your organization/company?
16. Would you re-hire the applicant if given the opportunity? Yes No
17. What is your overall assessment of the candidate?


18. Are there additional comments you'd like to make? Is there a question I should ask that I
may have missed?
IV. Interview Conducted by:
Name:____________________________________
Date:______________________________
Signature:__________________________________

Appendix J Sample Performance Based Evaluation for Laboratory
Technologist
WORK PLAN AND PERFORMANCE EVALUATION REPORT
NAME OF EMPLOYEE: TYPE OF REPORT (Check Appropriate Box)
DEPARTMENT/CASE TEAM: Annual Review
POSITION TITLE: LABORATORY Probationary

TECHNOLOGIST
Other (State Reason)
__________________________
THIS EVALUATION REPORT COVERS THE PERIOD FROM: _________________ TO

______________
SUMMARY OF DUTIES (WORK REQUIREMENTS)
Being accountable to their supervisor, he/she takes, examines, records and documents result
of blood, urine, excrement, sputum and other samples.
LIST SPECIFIC GOALS AND OBJECTIVES (FOR THE RATING PERIOD)
1. Collects samples (blood, urine, excrement, sputum and other samples)

2. Conducts required tests, records results and informs requesting department of the
results
3. Manages laboratory chemicals (ensuring proper usage, non-expiry of their usage
period, timely re-stocking).
4. Makes timely requests for lab materials and chemicals, and shall keep same with care
and economization.
5. Ensures that the containers for handling and collecting samples are clean, properly
sterilized and free from contamination.
6. Shall inform his/her immediate supervisor of any defect in materials in a timely
manner.
7. Shall make exchange of experience with the relevant experts/professionals as regards
with the work performance.
8. Ensures proper placement of lab materials at suitable places.
9. Participates in trainings and skill development related to laboratory work
10. Ensures proper storage and use of equipment and supplies
11. Performs other similar duties when instructed by supervisor
Chapter 11 Human Resources Management Appendix J: Page 1 of 7

Evaluation Of Performance
To Be Completed For All Employees
Performance Factor N/A Outstanding Commendable Satisfactory Needs Unsatisfactory

(5 points) (4 points) (3 points) Improvement (1 point)
(2 points)
Dependability
Punctuality
Job Knowledge & Skills
Quality of Work
Initiative & Resourcefulness
Judgment
Oral Communication
Written Communication
Organization
Time management
Interpersonal Relationships
Productivity
Resource management
Supervisory Skills

Feedback from colleagues
Discussed?
List and discuss feedback from at least two others who have supervised, been supervised by, or worked with the Yes No
employee.

Check the appropriate box for Overall Performance
Review of Overall Performance
Summary of the employees overall accomplishments and 5 4 3 2 1
standard of performance during the last period.
Outstanding Commendable Satisfactory Needs Unsatisfactory
Improvement
Comments:
Areas for Development or Improvement Staff Training and Development Needs
NB: If there are significant concerns about performance then a Performance Improvement Plan should be developed, providing more
detail about activities to be conducted to address the areas below.
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Job Description/Work plan
Does the employees job description/work plan need to be revised Yes No
If yes, attach the revised job description/work plan for review by the HR department.

Employees Statement: (Comment on your performance, career goals, or other portions of this report.)
(Optional)
Reviewing Officials Statement

Appendix
J: Page 5 of 7
Signatures
PERFORMANCE PLAN: I have read and agree to the Performance Plan against the evaluation has
conducted.
Employee Date:
Supervisor Date:
HR Unit Head: Date:
PERFORMANCE REVIEW: I have read and understand the Performance Review for this period
Employee Date:
Supervisor Date:
HR Unit Head: Date:
PERFORMANCE PLAN
We have prepared and agreed to a work plan for the coming period
Employee Date:
Supervisor Date:

Appendix
J: Page 6 of 7
Appendix K Performance Improvement Process Form
Instructions: this form serves to summarize a Performance Improvement Process discussion

to be completed by the immediate supervisor.
PERFORMANCE DISCUSSION SUMMARY
Date: _______________________________
Employee Name: Employee Position
Reason for performance improvement process: Action:
Poor attendance Positive recognition
Poor performance Coaching/counselling
Inappropriate behaviour or conduct Oral warning
Other (please specify): Written warning

_________________________________________
Final written warning
Termination of employment
Other ____________________
Summary of Positive Performance or Problem
Summary of Supervisors Discussion with Employee

(Attach relevant documents, if appropriate)
Chapter 11 Human Resources Management Appendix K: Page 1 of 2

Summary of Employees Comments (Including commitments to improve, if applicable)
Follow-up Date Deactivate Date Supervisor Signature Employee signature
Chapter 11 Human Resources Management Appendix K: Page 2 of 2

Appendix L Behaviours that Merit Rigorous Disciplinary Penalties
The following offences require rigorous (serious) penalties as defined in Proclamation

No.515/2007:
(1) Undermining ones duty by being disobedient, negligent or tardy or by none-

observance of working procedures,
(2) Deliberate procrastination of cases or mistreatment of clients,
(3) Deliberately obstructing work or collaborating with others in committing such
an offence,
(4) Unjustifiable repeated absenteeism or non-observance of office hours in spite
of being penalized by simple disciplinary penalties,
(5) Initiating physical violence at the place of work,
(6) Neglect of duty due to alcohol abuse or drug addiction,
(7) Accepting or demanding bribes,
(8) Committing an immoral act at the place of work,
(9) Committing an act of theft or breach of trust,
(10) Committing an act of misrepresentation or fraudulent act,
(11) Inflicting damages to the property of the government due to an intentional act
or negligence,
(12) Abuse of power,
(13) Committing sexual violence at the place of work,
(14) Committing any breach of discipline of equal gravity with the offence
specified under this Article.
Consistent with Proclamation No.515/2007, documentation of rigorous (severe) penalties

should remain in the employee record for 5 years.
Chapter 11 Human Resources Management Appendix M: Page 1 of 2

Appendix M Sample Grievance Form
Employee Name Position Title: Department
Date Form was received by HR department:
Date(s) of occurrence: Have you discussed this issue Supervisors Name:

with your supervisor?
Yes No
If yes, provide date(s) of
discussion: Supervisors Title:
Grievance Issue:
Description of Incident: Describe what happened, when and where, how your employment
has been affected, and indicate names of others involved. Attach any supporting
documentation, and additional sheet if space below is insufficient
Relief Requested: Indicate the action(s) that would resolve your grievance. Attach additional
sheet of space below is inadequate.
I,__________________________________________, the undersigned, hereby certify that

the information contained on this form and attachments to this form are true and factual to the
best of my knowledge. I understand the hospitals grievances resolution process and other
related issues will be held in strict confidence. If I am found to have falsified the above
information, I will be liable for corrective action, up to and including discharge.
_____________________________________ _________________________
Employees Signature Date
Chapter 11 Human Resources Management Appendix M: Page 1 of 2

Appendix N Sample Employee Exit Interview
Please take the time to complete this questionnaire. Be honest. We hope the information will
help us to analyze factors that attribute to employee turnover. Thank you.
Your Department Position
Immediate Supervisor (optional) Length of Service:

_______months ____________years
Poor Fair Satisfactory Good Excellent

1 How would you rate the spirit of cooperation and
teamwork among the employees in your department?
2 What level of respect do you have for your immediate
supervisor?
3 To what extent were you encouraged to offer
suggestions and improvements?
4 How would you rate your supervisors willingness to
answer questions and help solve problems?
5 How much of a chance do you feel you had to develop
your full potential while working here?
6 How well were you informed about changes that
affected your work?
7 How well did you understand the performance
standards you were expected to meet?
8 How would you rate the orientation you were give
when you first began working here?
9 How do you rate the training opportunities to improve
your skills, which you received through the hospital?
10 How do you feel about managements willingness to
hear complaints and make changes?
11 Compared with other organizations, how do you rate
your benefit package?
12 How do you rate the working conditions and physical
facilities?
13 What is your overall view of the hospitals policies
and procedures?
14 How would you rate this hospital as a place to work?
15 Please indicate the reason for your leaving our hospital (please mark all that apply)
Career development Relationship with manager Retirement
Change of career Family / personal reasons Don't want to work in public sector
Would like more pay Health reasons Not being valued for my work
End of contract Other (please specify)______________________________________________
16. What suggestions would you make for improving the general work environment here?
For illiterate staff, interview was conducted by:
__________________________________ __________________________________________
Name Date:
Chapter 11 Human Resources Management Appendix N: Page 1 of 2

Appendix O: Occupational Incident Register
No. Full name Age Sex Occupation/office Date of Date Time Type of Cause of Action Days Medical Expenses
of the accident accident Accident Taken Absent
employee From Salary Paid Treatment
Work During Leave and
Medication
Given
Chapter 11 Human Resources Management Appendix O: Page 1 of 1

Quality Management
Page 1 of 30
Section 2 Operational Standards for Quality Management 4

3.1 Strategies, procedures and processes for quality management 5
3.1.1 Safety and risk management
3.1.2 Clinical effectiveness
3.1.3 Professional competence
3.1.4 Patient focused care
3.1.5 Patient and public involvement in healthcare planning and delivery
3.1.6 Benchmarking
3.2 Organization structures and responsibilities for quality management 22

3.2.1 Quality committee
3.2.2 Subcommittees of the quality committee
3.3 Resources for quality management 25

4.3 Indicators 26
Source Documents 28
Appendices
Appendix A Sample quality management strategy
Appendix B WHO Surgical Safety Checklist
Appendix C Sample Incident Report Form
Appendix D Sample Risk Assessment
Appendix E Sample statement of patient rights and responsibilities
Appendix F Sample Patient Satisfaction Surveys
Figures
Figure 1 Plan, Do, Study, Act (PDSA) Cycle
Figure 2 Risk assessment matrix
Tables
Table 1 Description of PDSA model
Chapter 12 Quality Management Page 2 of 30

Table 2 Summary of qualitative study methods
Table 3 Approaches to stakeholder involvement in health service planning & delivery
Table 4 Quality Management Checklist
Table 5 Quality Management Indicators
Abbrevations
ANC Antenatal care
ART Antiretrovial therapy
ARV Antiretroviral
HIV Human immuno deficiency syndrome
PDSA Plan, Do, Study, Act
PMTCT Prevention of mother to child HIV transmission
QC Quality Committee
QM Quality Manangement
WHO World Health Organization

Quality management refers to the structures and processes by which an organization:
a) ensures the continuing quality of services provided (quality control);
b) improves the quality of services provided (quality improvement); and
c) obtains evidence to show that services meet the given requirements (quality
assurance).
Hospital quality management is focused not only on the quality of healthcare but also the
means to achieve this. Hospital Senior Management and the Governing Board should ensure
that quality management arrangements are in place and should monitor their effectiveness.
All staff should participate in quality management activities specific to their area of work.
This chapter describes a framework and tools for the quality management of hospital
services.
Section 2 Operational Standards for Quality Management

1. The hospital has a Quality Committee that is responsible to devise and implement a
Strategy for Quality Management.
2. Procedures are established to assess and minimize risk arising from the provision and
delivery of healthcare.
3. Procedures are established for reporting and analyzing incidents, errors and near misses.
4. Procedures are established to monitor clinical outcome measures and to take action to
address any problems identified. Such procedures encourage the participation of all
clinical staff.
5. The hospital adopts a statement of patient rights and responsibilities, which is posted in
public places in the hospital.
6. The hospital monitors patients experiences with care through patient satisfaction surveys
conducted on a biannual basis.
7. 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.
8. The hospital participates in benchmarking activities to learn from and share good practice
with other hospitals.

An effective quality management system establishes:
1. Strategies, procedures and processes for quality management;
2. An organizational structure and responsibilities for quality management; and
3. Resources for quality management.
Quality management is underpinned by a cycle of activity involving problem identification

and planning, implementation of an intervention and evaluation. The main steps in the cycle
are described below.
Figure 1 Plan Do Study Act (PSDA) Cycle
Table 1 Description of PDSA model

Plan Diagnose the situation
Define problem and overall objective
Conduct a root causes analysis
Generate alternative interventions; decide how to treat the problem
Conduct a comparative analysis and pick the best solution
Create an implementation plan
Do Treat the problem Implement the plan
Study Evaluate your success Did the solution have the desired effect?
Act Revise your treatment based on the evaluation; update or change your plan
for treatment as needed.
3.1 Strategies, procedures and processes for quality management
Each hospital should establish a quality management strategy that addresses the key
components of quality management including:
Safety and risk management,
Clinical effectiveness,
Professional competence,
Patient focused care,
Patient and public involvement in healthcare planning and service deliver, and

Benchmarking.
The Strategy should be approved by the hospital Senior Management Team and monitored by
the Quality Committee (see Section 3.2.1 below), with regular reports on implementation to
the Senior Management Team. A sample quality management strategy is presented in
Appendix A.
3.1.1 Safety and risk management
The first dimension of quality is to ensure that no harm is done to patients. Patient safety
addresses a range of errors and system failures associated with the delivery of patient care.
For example mistakes and delays in diagnosis, medication and treatment errors, problems
with equipment, infections acquired in hospitals and accidents such as slips and falls.
Research from America, Australia and the United Kingdom indicates that around 10% of
patient contacts result in harm to patients or staff and that half of these harmful or adverse
incidents are preventable. The physical and emotional consequences of an incident can be
significant for patients, staff and caregivers. Adverse incidents also increase costs for
additional treatment, claims and litigation.
The WHO has identified 12 domains of activities to address patient safety as illustrated in
Box A below. Further guidance on infection prevention, waste disposal and the protection of
health care workers is presented in Chapter 7 Infection Prevention, while guidance on safe
medicine practices are presented in Chapter 4 Pharmacy Services.
To ensure safe surgical care all hospitals should implement the WHO Surgical Safety
Checklist (Appendix B).
Box A WHO Domains of Patient Safety Activity
The WHO has identified 12 domains of activity to address patient safety.
1. Develop and implement a policy for patient safety

2. Improve knowledge and learning in patient safety
3. Raise awareness of patient safety
4. Address the context in which health services and systems are developed by making
patient safety an integral part of quality care improvement activities
5. Minimize healthcare associated infections
6. Protect healthcare workers
7. Ensure healthcare waste management
8. Ensure safe surgical care
9. Ensure appropriate use, quality and safety of medicines
10. Promote partnerships (between patients, family members, health professionals and
policy makers)
11. Provide adequate funding
12. Strengthen surveillance and capacity for research

A) Reporting and analysis of incidents
Hospitals should establish systems to report, analyze and learn from adverse events and
service failures that involve risk to patients and/or staff. Each event is unique. However, there
are often similarities and patterns in the sources of risk, which may go unnoticed if they are
not reported and analysed. Reporting of incidents, errors and near-misses helps us to
understand why things have gone wrong and to take action to minimize the risk.
Box B What are incidents, errors and near-misses?
1. Incident: an unintended or unexpected event that led to patient/staff harm, including

death, disability, injury, disease or suffering
2. Error: a slip, lapse, mistake or violation that leads to an incident
3. Near-miss: any situation that could have resulted in an incident, but did not due to either
chance or intervention.
A systems approach to looking at incidents recognises that human beings make mistakes and
accepts that some errors will happen in the best run health systems in the best
organisations. This approach moves away from blaming individuals and instead focuses on
incidents as a source of learning for change.
Taking a systems approach to looking at patient safety involves looking at what factors
contribute to incidents and asking:
What went wrong?
Where it happened?
Why it happened?
Once the causes are identified action can then be taken to minimise or prevent the incident
happening again. This may involve staff training, development of protocols, or the
implementation of defence mechanisms or safeguards such as double checking with
colleagues, effective labelling of medications, locked cupboards, pharmacy sign-out etc.
A successful reporting and learning system to enhance patient safety should ensure that:
Reporting is safe for the individuals who report,
Reporting leads to a constructive response,
There is expertise to analyse reports, and
Information and recommendations arising from incident reports are disseminated.
All staff should be encouraged to report incidents, errors and near misses. If necessary this
may be done confidentially to encourage reporting of all incidents without any fear of blame
or recrimination that might prevent reporting.
A sample Incident Report Form is presented in Appendix C.

An Incident Officer should be assigned to receive and investigate all Incident Reports. The
duties of the Incident Officer in relation to Incident Reporting should be clearly defined in
his/her job description. The Incident Officer should be a member of the Quality Committee.
The Incident Officer should investigate all reports received, ideally in collaboration with the
relevant Case Team/Department Head. He/she should determine whether further action is
necessary. The Quality Committee should receive regular summary reports of all incidents
reported.
NB: If an incident involves injury to a staff member the Occupational Health and Safety
Officer (OHSO) should also be informed of the incident by the Incident Officer. For further
guidance on the role of the OHSO please see Chapter 11 Human Resource Management.
B) Risk Management
Risk management is a second approach to ensure patient safety. Risk can be defined as the
likelihood, high or low, that somebody or something will be harmed by an unwanted event or
incident, multiplied by the severity of the potential harm.
Risk management involves assessing the environment for potential risks to patients then
taking action to minimize any risks identified. The process of risk management seeks to
answer four simple, related questions:
How bad?
What can go Is there a need for

action?
wrong?
How often?
Risk management proactively reduces identified risks to an acceptable level by creating a

culture founded upon assessment and prevention, rather than reaction and remedy.
Risk assessment looks at:

Hazards which are situations with the potential to cause harm; and
Risks - which are defined as the probability that a specific adverse event will occur in
a specific time period or as a result of a specific situation.
Risk assessment involved 5 steps:
Step 1 Identify the hazards (what can go wrong?): Take into account things that have gone
wrong in the past and near miss incidents. Walk around the workplace and talk to

patients and staff. Map or describe the activity to be assessed. It may be necessary to
involve a multidisciplinary team.
Step 2 Decide who might be harmed and how (what can go wrong, who is exposed to the
hazard)?
Step 3 Evaluate the risks (how bad? how often?) and decide on the precautions (is it
necessary to take further action?) A risk matrix, such as that presented in Figure 2
below can be used to evaluate the risks.
Step 4 Record the findings, proposed action and identify who will lead on each action
Step 5 Review the risk assessment and update if needed
Figure 2 Risk Assessment Matrix
Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence
Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost
certain
Likelihood
Low risk (green) quick, easy measures should be implemented immediately and further
action planned when resources permit.
Moderate risk (yellow) actions should be implemented as soon as possible, but no later than
one year.
High risk (orange) actions should be implemented as soon as possible, but no later than six
months.
Extreme risk (red) action should be taken immediately.
Hospitals should establish systems to regularly assess risk arising from the provision and
delivery of healthcare and should ensure that steps are taken to minimize risk.
Each case team/department should regularly (for example quarterly) conduct a risk
assessment and identify actions to minimize risk to patients. The whole team should be
involved in the risk assessment in an open, learning environment. Areas that could be
considered by the case team include, but are not limited to:

The physical environment is it clean, safe, free from hazards such as broken
furniture or equipment?
Are emergency exits clearly labelled and free from obstruction?
Are infection prevention policies and procedures implemented adequately?
Hazardous materials are these stored safely and securely?
Is all equipment in good working order, is maintenance required to minimize errors
and breakdowns?
Are policies for medication administration implemented to minimize drug error?
Are policies for laboratory sample collection, analysis and reporting implemented to
ensure that the correct specimen is taken from the correct patient and that accurate
results are obtained and reported in a timely manner?
Are clinical guidelines adhered to in order to ensure evidence based clinical practice?
A Safety Walk-Round is a second approach to Risk Management. A Safety Walk-Round

is where a group of hospital leaders/quality team members and other staff visit areas of the
hospital and ask front-line staff about specific events, contributing factors, near misses,
potential problems and possible solutions. The leaders then prioritize the events and the case
team/department is asked to develop solutions. The information gathered in this process often
has the solution embedded in the event description. Thus, this process can often result in
prompt changes that improve care and safety. It also can lead to culture change, as the
concerns of front-line staff are addressed and as front-line staff are engaged in continuous
observation of hazards and solutions for discussion with senior leadership. Leadership Walk-
Rounds are a low-cost way to identify hazards of concern to front-line staff and make needed
changes. They require no additional staff, equipment, or infrastructure.
A sample risk assessment is presented in Appendix D.
3.1.2 Clinical effectiveness
Clinical effectiveness is the extent to which specific clinical interventions do what they are
intended to do, i.e maintain and improve the health of patients securing the greatest possible
health gain from the available resources. Clinical effectiveness can be described as the right
person doing:
the right thing (evidence based practice)
in the right way (skills and competence)
at the right time (providing treatment/services when the patient needs them)
in the right place (location of treatment/services)
with the right result (clinical effectiveness/maximizing health gain).
Clinical effectiveness depends on adequate manpower and resources, including equipment

and drugs. It also requires that health professionals have up-to-date knowledge of the most
effective diagnostic tests, treatments and procedures.

A) Clinical Guidelines and Standards
Important tools to support clinical effectiveness include evidence based guidelines and
clinical standards. Such tools are particularly important where there is variation between
hospitals or geographical areas in clinical outcomes or access to treatments.
Clinical guidelines and standards may be developed internationally, nationally or locally. At

hospital level, local guidelines may be developed to address an area of uncertainty or
disagreement in clinical practice, or where clinical outcomes are poor. The development of
clinical guidelines involves a critical appraisal of the literature, combined with the views of
experts in the particular field. Examples of both International and Ethiopian evidence based
guidelines are presented in Box C.
Box C Selected examples of International and Ethiopian National Evidence

Based Clinical Guidelines
International:
Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors.
World Health Organization, Geneva, 2003
Pocket Book of Hospital Care for Children: Guidelines for the management of common
illnesses with limited resources. World Health Organization, Geneva, 2005.
National:
Standard Treatment Guidelines for health centers, district and zonal hospitals
Drug Administration and Control Authority, January 2004
National Guidelines for HIV/AIDS and Nutrition. Federal HIV/AIDS Prevention and Control
Office, 2008
Guidelines for Management of Opportunistic Infection and ART. Federal HIV/AIDS

Prevention and Control Office, 2007

Health professionals have a duty of care to follow national and local clinical guidelines and
standards. Each hospital should establish a process to monitor adherence to clinical
guidelines. This may be done through clinical audit (see below).
B) Clinical Indicators
Clinical indicators can be used to measure the effectiveness of clinical interventions. Clinical
indicators include outcome measures such as mortality or survival rates, complication rates
and measures of clinical improvement. Any measure selected must be:
Valid (does it measure what it is supposed to?)
Reliable (is it reproducible when taken at different times or in different
circumstances?)

Sensitive to change (does it discriminate between good and poor quality of care, and
can it detect small but worthwhile improvements?)
There are numerous clinical outcome measures. Some are disease or treatment specific while
others are generic for a range of diseases or patient groups. Box D gives examples of
different types of clinical outcome measures.
Box D Selected examples of clinical indicators
In patient mortality rate

Disease specific inpatient mortality rate (eg malaria, TB, HIV)
Post operative mortality rate
Post operative infection rate
Emergency re-admission rate within 28 days of discharge
The Health Management Information System (HMIS), has defined a number of clinical
outcome measures that should be monitored by health facilities and reported to higher
authorities (such as Woreda, Zonal and Regional health offices) and subsequently to the
Federal Ministry of Health. The aim of HMIS is to establish a core set of indicators that can
be used to monitor implementation of the Health Sector Development Program, progress
towards the Millennium Development Goals and other donor programs. However, the most
important function of HMIS indicators is to support and strengthen local action-oriented
performance monitoring. Hospitals and health offices are expected to analyze and interpret
the information, and take appropriate action to address any areas of concern. HMIS clinical
outcome indicators for hospitals are presented in Box E. For further discussion on HMIS and
hospital monitoring and reporting requirements please see Chapter 13 Monitoring and
Reporting.

Box E HMIS Clinical Outcome Indicators for Hospitals
% Caesarean section
Proportion of maternal deaths
Stillbirth rate
% Institutional early neonatal deaths
Inpatient mortality rate
Inpatient malaria case fatality rate - < 5 years
Inpatient malaria case fatality rate - >/= 5 years
% ANC attendees receiving PMTCT
% HIV positive women delivered in facility and received full course of HIV prophylaxis
TB treatment success rate (all ages)
Leprosy treatment success rate (MB & PB) all ages
% of pregnant women receiving ANC who receive testing for HIV
% of deliveries of HIV positive women who receive a full course of ARV prophylaxis
ART cohort alive and on ART at 6 months
Case fatality rate for meningitis (in patient)
Source: Health Management Information System/Monitoring and Evaluation. Strategic Plan for
the Ethiopian Health Sector. FMOH, January 2008.
The Senior Management Team must ensure that clinical outcomes are monitored within the
hospital, and that timely action is taken to address any problems identified. In addition to the
HMIS indicators, hospitals may select additional clinical indicators for monitoring on a
quarterly or annual basis. These indicators should be selected in consultation with clinical
staff and may be modified over time in accordance with local priorities. Selected clinical
indicators should be included within the Balanced Scorecard and monitored by the Governing
Board on a regular basis (see Chapter 13 Monitoring and Reporting).
C) Clinical audit
A further tool to ensure clinical effectiveness is clinical audit. Clinical audit can be defined as
a quality improvement process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the implementation of change. Clinical
audit aims to ensure that all patients receive the most effective, up to date and appropriate
treatments, delivered by clinicians with the right skills and experience. Clinical audit against
good practice criteria or standards answers the question are patients given the best care?
Clinical audit involves 4 main steps:
1. Identify standards or criteria for clinical care in selected area
Standards/criteria that could be considered include:

National or international drug treatment guidelines,
National or international diagnostic and treatment guidelines, and
Best practice evidence identified through literature review.
2. Assess current practice against standards

This can be done by retrospective or prospective case note review, direct observation,
questionnaire survey or interview.
3. Take action to address identified deficits in clinical care

If the audit identifies that best care is not being achieved the reasons why should be
investigated and steps put in place to correct this. Qualitative methods, such as those
described in Table 2 below can be used to investigate further. Investigation should involve
discussion amongst all relevant stakeholders (for example physicians, nurses, pharmacy,
laboratory, case teams, hospital management) to ensure that the problem is addressed
comprehensively. The findings of qualitative studies should be used to make
recommendations for change in practice.

Table 2 Summary of qualitative study methods
METHOD ADVANTAGES DISADVANTAGES
Focus Group Discussion Inexpensive Groups may not represent the larger
< 2-hour recorded discussion Quick population
610 non-random respondents Easy to organize Successful outcome is very
dependent on the skills of the
24 discussions for each Identifies a
significant target population moderator who must balance
range of beliefs
outspoken participants against shy
Moderator leads discussion
ones.
Respondents have similar
characteristics e.g. age, gender, Tape recorders may inhibit
social status participants but a note-taker may
miss some data
Discussion topics pre-defined
Informal, relaxed, ambient
Reveals beliefs, opinions and
motives
In-depth Interviews Can reveal May generate lots of data which are
One-to-one extended interview unsought but difficult to manage
Questions are pre-determined but significant data Time-consuming and expensive
open-ended Bias due to respondent saying things
Often covers up to 30 topics to please the interviewer
Reveals beliefs, attitudes, and Different interviewers may
knowledge interview differently
Structured Observation Observes actual May be time consuming and
Data collection instrument is behavior as expensive
structured opposed to Observation may cause change in
Observers are trained to blend stated behavior, the behavior of health workers
which may not
into their surroundings Different observers may observe
be the same
Observers are trained to record differently
what they actually see
Useful for recording provider
patient interactions
Assesses actual behavior
Structured Questionnaires Can generalize Interviewers may ask questions and
Questions are standardized with the results to the interpret answers incorrectly
a fixed set of responses or wider population Different interviewers may ask
options questions differently
Respondents are selected so as to Questions may be ambiguous
represent the larger population Respondents may give answers to
Useful for a large sample of please the interviewer
respondents
Measures the frequency of
attitudes, beliefs, and knowledge
Corrective measures will vary from situation to situation but might involve staff training,
providing aid memoires for staff, developing and implementing clinical guidelines or
ensuring the availability of appropriate drugs or diagnostic procedures.
4. Re-assess practice against standards
After the corrective measures have been put in place the audit should be repeated to measure
the impact of the interventions and identify whether further action is needed.
Clinical audit provides a forum for the participation of all clinical staff in quality
improvement activities and is an ideal mechanism for multidisciplinary team members or
specific clinical department staff to work together to improve performance. Ideally all clinical
staff should take part in at least one clinical audit project each year and the audit findings
should be shared across the hospital. All hospital staff should be encouraged to identify
possible audit projects, based on their observations of clinical activity and patient outcomes
within the hospital. Similarly, hospital management may recommend a specific audit project
in response to reported clinical outcome measures. For example, if a high or increasing post
operative infection rate is detected through regular reporting, hospital management may
request an audit of the use of prophylactic antibiotics for surgical cases, seeking to identify
whether appropriate use was being made of antibiotics in accordance with national or
international guidelines.
The Quality Committee should receive copies of all completed Clinical Audit Reports and
should keep a record of all clinical audit projects undertaken. Participation in clinical audit
could be used as a performance measure when staff members undergo performance based
evaluation, or when assessing the contribution of specific departments or case teams to the
hospitals strategic plan.
If possible, a clinical audit officer should be appointed by the hospital to support audit
activities. The audit officer would support clinical staff to design audit protocols and data
collection tools and would undertake data entry and analysis in consultation with clinical
staff. If it is not possible to appoint an audit officer then hospital management should ensure
that all necessary equipment and supplies (stationary, access to photocopier, access to
computer) are available to staff undertaking audit activities.
The Senior Management Team should ensure that clinical audit activities are undertaken
within the hospital. The Governing Board may choose to include the number of audit projects
completed as an indicator on the Balanced Scorecard described in Chapter 13 Monitoring
and Reporting.

Box F Case Study Clinical Audit at Gondar Hospital
Gondar University Hospital, with support from Leicester University Hospitals (UK) has
established a program of clinical audit. All departments are involved Nursing, Surgery,
Medicine, Paediatrics, Obstetrics and Gynaecology and Laboratory Services.
An Audit Committee has been established with membership comprised of the head of every
clinical department. The committee meets regularly to discuss the progress of audits and writing
of guidelines. A qualified nurse has been appointed as an audit clerk, to analyze the data
collected by health staff. Training in clinical audit and developing evidence based guidelines
was provided to hospital staff.
To date over 30 audits have been undertaken, primarily by means of a short, user friendly
questionnaire devised by medical, nursing or laboratory staff as appropriate. The questionnaires
were self administered by the department staff. The questionnaires used standards and
guidelines from accepted texts such as WHO manuals or locally written guidelines based on
standard medical texts. Audits were conducted both prospectively and retrospectively by case
note review.
Through the audits, areas of good practice and areas where practice needs to be improved have
been identified. Examples of improvements as a result of audit include:
Further training of laboratory staff on preparation of blood films for malaria slides
Changing from Wrights to Giemsa staining for malaria films
Provision of glucose testing on the childrens ward
Extra training to nursing staff on IV line insertion and administration of IV drugs
Source: Setting up clinical audit in Gondar Hospital, Ethiopia. Elaine Carter, Sisay Yifru et al.
Ethio Med J, Vol 46, No 3

3.1.3 Professional competence
Practice as a health professional involves life-long learning, to keep up to date with new
knowledge of diseases and effective treatments. To ensure that clinicians are able to access
the most up to date information deriving from research hospitals must have a systematic
approach to the collection and dissemination of evidence. Hospital management should
ensure that standard undergraduate and post graduate text books and all national clinical
guidelines are available for the reference of clinical staff. Additionally, hospitals should
provide access to the common Ethiopian medical journals such as the Ethiopian Medical
Journal, Journal of the Ethiopian Public Health Association and Federal Ministry of Health
Policy and Practice Quarterly Health Bulletin.
Internationally, the maintenance of a license to practice as a health professional commonly

requires the submission of evidence that the individual continues to participate in professional
learning through attending workshops and seminars, undertaking audit or research activities,
developing clinical guidelines or self directed learning such as reading journals and
undertaking literature reviews. Although such a requirement for licensing is not currently
established in Ethiopia, it is good practice for clinical staff to maintain a record of the
learning activities that they under-take, and to identify and address areas of educational need.
Each clinical staff member should be evaluated annually to assess performance against the
individuals job description. This performance review should also be used to identify staff
training needs. Based on individual and collective training needs the hospital should put in
place measures to facilitate learning. These training needs should be considered in the
Workforce Development Plan (see Section 3.2 of Chapter 11 Human Resource
Management).
Examples include:
grand rounds whereby unusual or interesting clinical cases are presented and discussed
by multi-disciplinary clinical teams
Clinical audit activities
Mortality reviews whereby all deaths within the hospital, or within a particular specialty
of case team, are reviewed to identify underlying factors and discuss the treatment given
Journal clubs whereby selected journal articles are presented by a health professional to
other colleagues and then discussed to assess the strengths and weaknesses of the article
and its relevance for clinical practice in the hospital
Mentoring of junior staff by a senior staff member, and
Supportive supervision
Hospital management should support such activities and facilitate in-house training for staff,
or support attendance at external training events where appropriate. The hospital management
and Governing Board should ensure that professional staff are gaining access to the
knowledge and evidence that they need to improve the quality of their work. One way to
monitor this would be to include the number of staff trainings held as an indicator within
the Balanced Scorecard described in Chapter 13 Monitoring and Reporting. Additionally the

number of staff appraised could also be included as an indicator to demonstrate to
Governing Boards that staff are undergoing appraisal and that learning needs are being
identified.
Each hospital should ensure that systems are in place to identify and address any poor clinical
performance of staff. Poor performance can be identified through performance evaluation,
clinical audit, supervision, monitoring of clinical outcome measures or the confidential
reporting of other staff members or patients. Where there is concern about the clinical
competence of a staff member this should be discussed in the first instance between the
individual and their immediate supervisor, and learning needs identified. Depending on the
nature of the poor performance steps that might be taken to address this include: supervision,
mentoring, personal study or attendance at workshops or seminars. Whichever approach is
taken this should be followed by a reassessment of the individuals skills and knowledge to
ensure that he/she is fit to practice before returning to independent work. For further
discussion on actions that might be taken in cases of poor performance see Section 3.8 of
Chapter 11 Human Resource Management.
Finally, whenever duties are delegated to a junior staff member or student, the person
delegating should ensure that the junior staff member or student is competent to carry out the
task and should always check that the task has been carried out appropriately.
3.1.4 Patient focused care
Quality of care includes the quality of caring the compassion, dignity and respect with
which patients are treated. Every patient wants to be treated as an individual, and has the right
to courtesy, respect, privacy and confidentiality and to receive full information about their
condition, investigations provided and treatments offered. Patient focused care involves
planning and delivering quality care as a partnership between staff, patients and caregivers.
The effective management of every patient is made up of a mix of professional skill and
compassion. It requires a careful balance of:
Consideration,
Talking, and
Listening.
Hospitals should adopt a statement of patient rights and responsibilities. This should be
readily available to patients, for example by posting in the outpatient department or inpatient
wards. All staff should be aware of the Statement of Patient Rights and Responsibilities to
ensure that they treat patients in a manner consistent with the Statement. An example of a
Statement of Patient Rights and Responsibilities is presented in Appendix E.
Quality of care also includes the quality of hotel services provided to patients such as
housekeeping, laundry, food services etc. The hospital should ensure that these services are
provided to a high standard within the available budget, using opportunities to outsource
these services to ensure cost efficiency and to improve quality. For further guidance on the

outsourcing of non-clinical services see section 3.9 of Chapter 10 Financial and Asset
Management.
Quality of care can only be improved by analyzing and understanding patients satisfaction
with their own experiences. Hospital management and the Governing Board should monitor
patients perspectives on their care through Patient Satisfaction Surveys. Appendix F contains
both Inpatient and Outpatient Satisfaction Surveys that have been developed, piloted and
validated in Ethiopian hospitals. Patient surveys should be conducted on a regular basis and
summary results reported to the Governing Board. The summary results can be included in
the Balanced Scorecard described in Chapter 13 Monitoring and Reporting. Additionally,
staff attitudes and relationships with patients and caregivers should be a component of
performance based evaluation (see Section 3.8 of Chapter 11 Human Resource
Management).
Hospitals should also establish a policy for receiving complaints from patients and or the
public. The policy should describe: the responsible person to receive complaints, the process
by which complaints will be investigated, and the process by which the complainant will
receive feedback. The number of complaints received and the percentage of those that were
upheld (ie. where the investigation of the complaint found that the complainant had a valid
concern) could be included as an indicator in the Balanced Scorecard and reviewed by the
Governing Board on a regular basis (see Chapter 13 Monitoring and Reporting).
3.1.5 Patient and public involvement in healthcare planning and delivery
Health services should be tailored to the needs and expectations of the population served. The
perspective of patients and the public can help identify what does and doesnt work in the
delivery of treatments and services.
Before involving patients and the public it is important to identify:

What you want to know,
Why you want their views,
How you will use their views, and
What the patient and service will gain from this involvement.
Involvement of patients and the public can take place in three ways:
Informing: where people passively receive information,
Consulting: where the users of a service are asked to give information or advice, or
Partnership: involving the public as partners in decision-making.
Decisions about the level of involvement will influence both who is involved and the
approach to be taken. For example, if the objective is to give the public information about
the appropriate management of diarrhoeal disease this may be done through posters placed in
the community or at the hospital, or through hospital or community based health education
lectures. On the other hand, if the objective is to involve the community in the establishment
of a new child health clinic this may be done through focus groups, questionnaire survey or

participatory public meetings. Each situation will require involvement to be tailored for the
purpose.
Using more than one approach will give more people a chance to participate. Every approach
has strengths and weaknesses and some may overlap. Table 3 describes different approaches
to stakeholder involvement. Further guidance on each method is presented in Appendix A.
Table 3 Approaches to stakeholder involvement in healthcare planning and delivery

Approach Activity
Informing Patient information leaflets
Poster displays in hospital or community
Publications in local press
Presentations at public meetings
Consulting Patient satisfaction surveys
Suggestion boxes
Complaints procedures
Participatory public meetings
Patient interviews
Focus groups
Partnership Community representation on hospital Governing Board
Stakeholder membership of service or hospital planning
committees
The process of patient and public involvement may be on a one-off basis, or an ongoing
process depending on the circumstances. Whatever approach is taken it should be planned
carefully and the outcomes monitored so that it is known whether the goals have been
achieved.
3.1.6 Benchmarking
Benchmarking involves comparing one or more hospitals with each other on a range of
measures. Differences between them can then be investigated so that good practice can be
shared. Benchmarking should be a supportive and learning process led by hospitals
themselves. It is distinct from hospital ranking, whereby hospitals are assessed by an external
body and good performing and poor performing hospitals are identified. Instead,
benchmarking is a tool to facilitate shared learning among hospitals in a non critical
environment.
Hospitals should participate in benchmarking activities and develop networks to learn from
and share good practice with each other. There are a variety of ways in which this can be
done such as hospital twinning, mentoring of management or professional staff,
benchmarking clubs, exchange visits, master classes etc. The impetus to search for good
practice must come from within the organization and be part of its culture.

Box G Benchmarking in Ethiopian Hospitals - Tigray Regional Hospital
Conference
Tigray Region has established monthly Hospital Conferences between all 12 public hospitals
and the Regional Health Bureau (RHB). The Conference is chaired by the RHB and each
hospital is represented by the CEO and Chief Clinical Officer plus Governing Board members.
The monthly Conference offers hospitals the opportunity to learn and share good practice with
each other. Evidence from Conference presentations and discussions on achievements and
challenges in implementing hospital reforms from the 8 conferences held to date shows that:
1. All hospitals have fully engaged in hospital strengthening reforms including BPR, EHMI
Blueprint and Barometer (Balanced Score Card). The Barometer is providing evidence on
the effectiveness of hospital services and acts as a benchmark to compare facilities.
2. There is an increased awareness on improving quality and safety in hospitals as an essential
requirement for quality improvement; and
3. There is a shared understanding of the RHBs efforts to support hospitals and enable
hospitals to implement the reforms as learning organisations, sharing practice and
embedding the reforms in a non critical environment.
The 8th Conference held at Dansha Hospital in September 2009 further motivated hospitals to
continue to share good practice and challenges. The Conferences main focus was on hospital
building blocks with particular emphasis on financing including private wings, financial
management and control, outsourcing and auditing. Governing Board participants emphasized
their commitment to drive forward quality improvements, human resource development and
community involvement with hospitals. The Conference also discussed the possibility of
twinning each hospital with an international partner and this will be followed up by the RHB.
3.2 Organizational structures and responsibilities for quality

management
The implementation of quality management activities in hospitals can be supported by

appropriate structures and committees that serve to:
a. assign responsibility for quality management processes at a senior level, and
b. encourage the participation of all staff in quality management processes.
Each Case Team should establish its own quality management processes incorporating the
various activities described above. The Case Team Leaders are responsible to ensure that
quality management activities take place within the Case Team and are responsible to report
these activities to the Quality Committee (see below). Each case team should have regular
review meetings of its own performance (at a minimum quarterly).
3.2.1 Quality Committee
Each hospital should establish a Quality Committee to oversee all quality management
functions of the hospital. (NB: The Quality Committee may be called by a different name
for example quality improvement team, quality management team or similar). The important

issue is not the name of the team per se, but rather to ensure that the functions/responsibilities
described below are carried out by designated individuals).
The Quality Committee (QC) should be comprised of a Chair and between 4-6 Quality
Officers (QOs). The QC should be multidisciplinary, with members appointed from different
clinical, administrative and support case teams within the hospital. The Chair of the QC
should be a member of the hospital senior management team. Where circumstances permit,
and depending on the size of the hospital, the Chair and Quality Officers should be full time
in their role. Where this is not possible, the members of the QC should have specified time
allocated within their regular working week for quality assurance activities.
Roles of the QC include:
a) To develop the quality management strategy and present to the Senior Management
Team for approval,
b) To develop an implementation plan for the quality management strategy and monitor its
execution,
c) To ensure that quality management activities relate to the vision and mission of the
hospital, and are aligned with the hospital strategic and annual plans,
d) To co-ordinate all quality management activities,
e) To promote and support the participation of all staff in quality management activities,
f) To receive and analyze feedback information from patients, staff and visitors,
g) To receive clinical audit reports and maintain a record of all clinical audit activities,
h) To review selected hospital deaths (see Box H),
i) To monitor HMIS performance (see Box I),
j) To conduct peer review in response to specific quality and safety concerns and to take
appropriate action and follow-up when deficiencies are identified, and
k) To update hospital staff on quality management activities and findings including:
a) Comparisons across time
b) Comparisons between Case Teams/Departments
c) Comparisons with other health facilities.
3.2.2 Subcomittees of the Quality Committee
If the workload is high, and the hospital has sufficient numbers of staff, the Quality
Committee may establish a number of sub-committees to undertake some of the above
functions (for example a Mortality Committee or a Clinical Audit and Research Committee).
The Chair of all sub-committees should be a member of the Quality Committee and should
provide regular update reports to the Quality Committee.
For further discussion on HMIS and hospital monitoring and reporting see Chapter 13
Monitoring and Reporting.

Box H Mortality Review
In order to learn from experience and take measures to improve patient care the Quality
Committee should review selected patient deaths. As a minimum all unexpected deaths should
be reviewed, including:
Intra-operative deaths,
Deaths within 24 hours of surgery,
Maternal deaths and
Deaths due to hospital acquired infection.
The Quality Committee may also choose to review deaths from the main causes of mortality
in the hospital (for example deaths due to malaria, TB, HIV/AIDS, diarrhoea or malnutrition)
or may even decide to review all deaths in the hospital, regardless of cause.
Each Clinical Case Team leader should be familiar with the mortality reporting criteria and
should report to the Chair of the Quality Committee any death that meets these criteria. The
Quality Committee should review each death by reviewing the Medical Record of the patient
and/or interviewing key staff to identify the treatment and care offered to the patient. The
review should seek to identify any avoidable factors that contributed to the patients death or
any areas where clinical care was substandard. The purpose of the Mortality Review is to
learn from experience and take measures to improve patient care rather than punitive action.
The Quality Committee should provide feedback to the Case Team on areas where the quality
of care should be improved and if necessary should make recommendations to senior
management if there is a need for new or revised hospital policies or guidelines.
If the hospital is large and resources are available a multidisciplinary Mortality Committee
could be established to carry out Mortality Reviews. The Mortality Committee should be
chaired by a member of the Quality Committee, and should report directly to the Quality
Committee.
Box I Health Management Information System
Hospitals should monitor and report all hospital indicators defined by the National Health
Management Information System (HMIS). An HMIS Officer should be appointed. He/she
should be a member of the Quality Committee.
The Quality Committee should ensure that:

a) The hospital uses standard HMIS procedures and recording and reporting forms
b) Staff get proper orientation/training on HMIS procedures and formats
c) HMIS stationary and supplies are readily available
d) HMIS data is complete and valid before being used or reported
e) Data is collected and reported according to the HMIS timeframe
f) Data is reviewed by hospital management and used to identify problems with service
delivery
g) Action is taken to address any problems identified using HMIS data

3.3 Resources for quality management
Effective quality management requires both human and financial resources. Staff who
regularly perform quality management functions (for example quality officers) should have
these duties clearly described in their job descriptions and should have sufficient time
allocated in their working schedule to undertake these activities.
Resources such as computers, printers, internet access etc should be available to support QM
activities. The costs of implementing the QM strategy (for example costs of community
meetings, printing costs for surveys etc) should be calculated and should be included within
the hospital budget. If the quality officers are assigned full-time, they should be provided
with an office space.

In order to determine if the Operational Standards of Quality Management have been met by
Table 4. Quality Management Checklist

Yes No
1. A quality committee has been established with members from different
case teams.
2. Terms of reference for the Quality Committee are defined and have been
approved by the Governing Board.
3. The role of Quality Committee members in relation to Quality activities is
clearly described in their job description.
4. Each case team conducts quality review meetings as a minimum every
quarter.
5. A quality management strategy has been devised and approved by the
Senior Management Team.
6. An Incident Officer has been assigned and procedures are in place to report

and analyze incidents.
7. A risk analysis is conducted by each clinical case team at a minimum every
6 months.
8. Each clinical case team conducts clinical audit activities and submits audit
reports to the Quality Committee.
9. Processes are established for the participation of all clinical staff in peer
learning events, for example grand rounds; mortality reviews; journal
clubs etc.
10. Each clinical case team has established procedures to monitor selected
clinical outcome measures (for example mortality rates, infection rates etc).
11. A statement of patient rights and responsibilities has been developed and
approved by the senior management team. The statement is posted in OPD,
ER and patient wards.
12. Inpatient and outpatient satisfaction surveys are conducted at least twice
per year.
13. A strategy for patient and public involvement has been developed and
approved by the Senior Management Team.
14. Suggestion boxes are placed in the main patient service areas, for example
OPD, ER, wards.
15. Processes are established to receive and investigate patient/public
complaints.
16. The hospital takes part in benchmarking activities with other hospitals.
17. Sufficient resources are available to support quality management activities
including computer, printer and internet access for all staff.
4.3 Indicators
Table 5. Quality Management Indicators

Inpatient Case Team
Number of patients with an infection
Healthcare acquired
arising >48 hours after admission/total Quarterly
infection rate
1 number of admissions *100
Number of IPD deaths / Total number
Inpatient mortality rate Quarterly
2 of admissions * 100 HMIS
Number of Caesarean
% of Caesarean section sections/Number of deliveries Quarterly
3 attended *100 HMIS
Proportion of maternal Number of maternal deaths/total
Quarterly
4 deaths number of deliveries*100 HMIS
Number of stillbirths/number of births
Stillbirth rate Quarterly
5 (live and still) attended*100 HMIS
Number of deaths in first 24 hours of
Neonatal death rate (day 0) life/Total number of livebirths Quarterly
6 attended*100 HMIS

Number of deaths in days 1-6 of
Neonatal death rate (day 1-
life/Total number of livebirths Quarterly
6)
7 attended*100 HMIS
Number of deaths in children aged <5
Case fatality rate of malaria due to malaria/Number of admissions
Quarterly
in children < 5 years in children aged < 5 due to
8 malaria*100 HMIS
Number of deaths in persons aged 5
Case fatality rate of malaria and above due to malaria/Number of
Quarterly
in patients 5 years and above admissions in persons aged 5 and
9 above due to malaria*100 HMIS
Number of deaths due to
Case fatality rate for
meningitis/number of admissions with Quarterly
meningitis
10 diagnosis of meningitis*100 HMIS
Number of pressure sores/number of
Pressure sore incidence rate Quarterly
11 admissions*100
Unplanned readmission rate Number of unplanned
within 28 days following readmissions/Number of admitted Quarterly
12 discharge patients in same time period *100
Number of clinical audits Number of completed audit reports
completed by Inpatient Case submitted to Quality Committee by Quarterly
13 Team Inpatient Case Team
Number of Incidents
Number of Incidents reported to
reported by Inpatient Case
Incident Officer by Inpatient Case Quarterly
Team
Team
14
Number of incidents reported by
Inpatient incident rate Inpatient Case Team/ Total number of Quarterly
15 admissions*100
Average rating of hospital on score of
Inpatient overall rating of
0-10 from Inpatient Satisfaction Biannual
hospital
16 Survey
Number or respondents answering
Patients' willingness to 'definitely' or 'probably' yes/total
Biannual
recommend hospital number of respondents *100 from
17 Inpatient Satisfaction Survey
a) Number of complaints a) Total number of complaints
received against received in relation to inpatient
Inpatient Case Team services
Quarterly
b) % of complaints b) Number of complaints in relation to
supported (upheld) inpatient services supported (upheld)
/total number of inpatient complaints
18 received*100
Emergency Case Team
Emergency re-attendance Number of emergency re-
rate within 28 days attendances/Number of attendances in Quarterly
1 following ER attendance same time period *100
completed by Emergency submitted to Quality Committee by Quarterly
2 Case Team Emergency Case Team
Number of Incidents Number of Incidents reported to Quarterly

reported by Emergency Case Incident Officer by Emergency Case
3 Team Team
Emergency incident rate Emergency Case Team/ Total number Quarterly
4 of attendances*100

Emergency patients average rating of
Emergency patient overall
hospital on score of 0-10, using Quarterly
rating of hospital
5 Outpatient Satisfaction Survey Tool
Number or Emergency patients
answering 'definitely' or 'probably'
Patients' willingness to
yes/total number of respondents *100 Quarterly
recommend hospital
using Outpatient Satisfaction Survey
6 Tool
Number of complaints
Total number of complaints received
received against Emergency Quarterly
in relation to emergency services
7 Case Team
Number of complaints in relation to
% of complaints supported emergency services supported
Quarterly
(upheld) (upheld) /total number of emergency
8 complaints received
Outpatient Case Team
completed by Outpatient submitted to Quality Committee by Quarterly
1 Case Team Outpatient Case Team
Number of Incidents Number of Incidents reported to
reported by Outpatient Case Incident Officer by Outpatient Case Quarterly
2 Team Team
Outpatient incident rate Outpatient Case Team/ Total number Quarterly
3 of outpatient attendances*100
Out patients average rating of hospital
Outpatient overall rating of
on score of 0-10, using Outpatient Quarterly
hospital
4 Satisfaction Survey Tool
Number out patients answering
Outpatients' willingness to 'definitely' or 'probably' yes/total
Quarterly
recommend hospital number of respondents *100 using
5 Outpatient Satisfaction Survey Tool
Number of complaints
Total number of complaints received
received against Outpatient Quarterly
in relation to outpatient services
6 Case Team
Number of complaints in relation to
% of complaints supported outpatient services supported (upheld)
Quarterly
(upheld) /total number of outpatient complaints
8 received
Source documents
1. Department of Health. (2000). An Organisation with a Memory. London, England: Her

Majestys Stationary Office.
2. Donabedian, A. (1980). Explorations in Quality Assessment and Monitoring. The

Definition of Quality and Approaches to its Assessment. Vol. I. Ann Arbor, MI: Health
Administration Press.
3. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). Health

Management Information System/Monitoring and Evaluation. Strategic Plan for the
Ethiopian Health Sector. Addis Ababa, Ethiopia.

Sector. Addis Ababa, Ethiopia.
5. Institute of Medicine. (1999). To Err is Human. Building a Safer Health System.

Washington, DC: National Academy Press.
6. NHS Quality Improvement Scotland. (2005). National Standards. Clinical Governance

and Risk Management: Achieving Safe, Effective, Patient-Focused Care and Services.
7. Standards Australia and Standards New Zealand. (2004). AS/NZS 4360:2004. Risk
Management. Sydney, NSW. ISBN 0 7337 5904 1.
8. World Health Organization. World Alliance for Patient Safety. (2005). WHO Draft
Guidelines for Adverse Event Reporting and Learning Systems. From information to
action. . Retrieved from:
http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf
9. World Health Organization. Patient Safety, World Alliance for Safer Healthcare. (2009).
Implementation Manual Safe Surgery Checklist 2009. Retrieved from:
http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf.

Appendices
Chapter 12 Quality Management

Appendix A Sample Quality Management (QM) Strategy
Table of Contents
1.0 Development of the Quality Management (QM) Strategy

2.0 Purpose of the QM Strategy
3.0 Safety and Risk Management
4.0 Clinical Effectiveness
5.0 Patient focused care
6.0 Patient and public involvement in health service planning and delivery
7.0 Benchmarking
8.0 Review and update of the QM Strategy
1.0 Development of the Quality Management Strategy
This strategy was developed by XXX. The following individuals/groups were consulted
during the development:
Xxx
Yyy
Etc
The strategy was approved by the Hospital Senior Management Team on dd/mm/yyyy.
.
Quality management refers to the structures and processes by which an organization:
a) ensures the continuing quality of services provided (quality control);
b) improves the quality of services provided (quality improvement); and
c) obtains evidence to show that services meet the given requirements (quality
assurance).
2. 0 Purpose of the QM Strategy
[ ] Hospital is committed to provide high quality services that are safe, effective and
meet the needs and expectations of the communities we serve. Our quality management
strategy establishes the structures and activities by which [ ] Hospital will:
a) ensure the continuing quality of services provided (quality control);
b) improve the quality of services provided (quality improvement); and
c) obtain evidence to show that services meet the given requirements (quality assurance).
Our Quality Management activities will address:
Safety and risk management

Clinical effectiveness
Professional competence
Patient focused care
Patient and public involvement in healthcare planning and service delivery
Benchmarking
Chapter 12 Quality Management Appendix A: Page 1 of 5

A Quality Management Committee will be established to oversee all QM activities. The
Chair of the QM Committee will be a member of the hospital Senior Management Team and
will provide regular reports to Senior Management on QM activities.
3.0 Safety and Risk Management
To ensure patient and staff safety and minimize the risk of harmful events [ ] Hospital
will implement measures for the reporting and investigation of critical incidents that involve
patient care or the safety of patients, visitor and staff. An Incident Officer will be appointed
as a focal person to receive all Incident Reports. All staff will be encouraged to report critical
incidents and each incident will be investigated to identify any action that needs to be taken
to prevent similar problems arising in the future. The Incident Officer will prepare summary
reports to the QM Committee on all Incidents that occur.
Each department/case team will undertake regular risk assessment to identify potential risks
to patients and to implement action to minimize these risks. The risk assessment will consider
areas such as:
the environment (is it clean, safe, free from broken equipment or furniture etc)
Implementation of infection prevention procedures
Protection from hazardous materials
Effective equipment maintenance to minimize errors and breakdowns
Implementation of clinical guidelines to ensure evidence based practice
Implementation of policies for medication administration to minimize drug errors
Implementation of policies for laboratory procedures to ensure the correct specimen is
taken from the correct patient and that accurate results are obtained and reported in a
timely manner
4.0 Clinical effectiveness
[ ] Hospital will ensure that National Standards and Guidelines are available as a
resource and implemented by Clinical Staff. Local guidelines will be developed for areas
where there is uncertainty or disagreement in clinical practice. Adherence will be monitored
through clinical audit projects.
Selected clinical outcome indicators will be identified and monitored by each Case
Team/Department. These will include, but are not limited to the clinical outcome indicators
specified by the National Health Management Information System. Case Teams/Departments
will hold regular clinical review meetings to review outcome indicators and identify action
necessary to address any problems identified.
All clinical staff will be expected to participate in clinical audit activities. Clinical audit can
be defined as a quality improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit criteria and the implementation
of change. A Clinical Audit and Research Committee will be established to oversee and
provide support for all audit activities.
[ ] Hospital will ensure that all staff have the required knowledge, skills and
competence to carry out their duties. Annual performance appraisal will be implemented to
identify staff training and development needs. Staff will be given opportunities to participate
in both in house and external trainings events to address their training needs.
Performance appraisal will also be used to identify staff members whose clinical knowledge
skills are below expectations, and corrective measures will be taken (such as training, transfer
of duties or disciplinary measures if necessary).
5.0 Patient focused care
Patient focused care involves planning and delivering quality care as a partnership between
staff, patients and caregivers. A statement of patient rights and responsibilities has been
adopted by [ ] Hospital (Appendix A). This will be displayed in all clinical service areas
and staff will be oriented to ensure that they treat patients with courtesy, respect, privacy and
confidentiality and ensure that patients receive full information about their condition,
investigations provided and treatments offered.
Patient satisfaction with hospital services will be monitored through quarterly patient
satisfaction surveys conducted in the outpatient, emergency and inpatient departments/case
teams.
6.0 Patient and public involvement in health service planning and

delivery
We believe that involving our stakeholders (see Box A) in the planning and monitoring of
hospital services will help us to improve service quality and to improve the experience of
patients who receive care in our hospital.
Box A Stakeholders of [ ] Hospital

Our stakeholders are those who have an interest in the services provided by our hospital. This
includes:
Patients of the hospital
Family and carers of patients
Local residents
Voluntary and community organizations
Hospital staff
Hospital Governing Board members
Woreda, Zonal and Regional Health and other Government Departments
Others
Involving patients and the public in health service design and delivery will assist us to:
have a stronger understanding of the needs and priorities of our communities, so we can
shape services around the patient, their caregivers and families;
provide services that meet the specific needs of the diverse population that we serve;
improve hospital services and develop policies and strategies from the perspective of
patients and the public; and
ensure that decision-making is informed by the patient voice at all levels of the
hospital, from individual treatment to the development of hospital-wide strategy.
[ ] Hospital will involve stakeholders in the following areas:
Individual treatment processes;

The design and improvement of services; and
The development and implementation of hospital strategies and plans.
There are three main ways in which involvement of patients and the public will take place:
Informing: where people passively receive information;

Consulting: where the users of a service are asked to give information or advice; and
Partnership: involving the public as partners in decision-making.
SpecificactivitiesundereachoftheseapproachesaredescribedinTable1below.
Table 1 Approaches to stakeholder involvement

Approach Activity
Informing Patient information leaflets
Poster displays in hospital or community
Publications in local press
Presentations at public meetings
Consulting Patient satisfaction surveys
Suggestion boxes
Complaints procedures
Participatory public meetings
Patient interviews
Focus groups
Partnership Community representation on hospital Governing
Board
Stakeholder membership of service or hospital planning
committees
[ ] Hospital will adopt a range of approaches to stakeholder involvement, with specific

activities tailored for the purpose. Examples to be implemented include:
1. Biannual patient satisfaction surveys. A validated survey tool will be used to assess
patient satisfaction with both outpatient and inpatient services. The results will be
analyzed and presented to the Governing Board. The Governing Board will approve any
necessary action to address problems identified.
2. Suggestions boxes: These will be established in all main service areas (outpatient
department, patient wards, emergency department etc). The boxes will be opened and
contents reviewed by a designated individual on a monthly basis. Findings will be
summarized and presented to the hospital CEO who will take any necessary action.
3. Complaints procedures: The hospital will implement a policy for handling patient
complaints that describes: the responsible person to receive complaints; the process by
which complaints will be investigated; the process by which the complainant will receive
feedback. The number of complaints received and the % of those that were upheld (ie
where the investigation of the complaint found that the complainant had a valid concern)
will be reported to the Governing Board on a quarterly basis.
4. Public meetings: the hospital will hold participatory public meetings at a minimum every
6 months. Meetings will be widely advertised by a variety of mechanisms (for example
informing kebele leaders, displaying posters, announcements in local press). Meeting will
be open to the general public and will be held at times that are convenient for
stakeholders. Each meeting will be attended, as a minimum, by the hospital CEO and
Chair of the Governing Board. The CEO will present an overview of hospital activities
and plans, and invite feedback from meeting participants. To avoid raising false
expectations, at the outset of each meeting the CEO should be clear about what is
expected from the meeting and should be honest about what can change and what is non-
negotiable.
5. Patient groups: The hospital will identify clinical areas where the creation of a patient
group may be advantageous, for example diabetes patient group or HIV patient group.
The hospital will support the establishment of a patient group and will support regular
meetings of the group. The group will be asked to provide feedback to hospital
management on the specific service and ways in which it might be improved.
6. Engagement with marginalized groups: The hospital will develop means of engaging with
stakeholders who have not in the past been well represented in involvement and feedback
activities, to ensure that their views and involvement can be secured. This may include
going out in to the community and drawing on the experience of others, for example
religious leaders or kebele leaders.
7. A stakeholder representative(s) (patient or member the public) will be included in all

hospital planning or service re-organization committees.
7.0 Benchmarking
[ ] Hospital will seek to share experiences and learn from the experience of other
hospitals in [ ] Region and Nationally. We will achieve this through a variety of
means including participation in meetings of all hospitals in the Region and experience
sharing site visits to other hospitals in the Region to learn from good practice.
8.0 Review and update of the QM Strategy
This QM Strategy will be reviewed and updated as necessary. As a minimum a full review
will be undertaken very three years.

Appendix B WHO Surgical Safety Checklist
Source: WHO, Patient Safety, World Alliance for Safer Healthcare, 2009. http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf
Chapter 12 Quality Management Appendix B: Page 1 of 1

Appendix C Sample Incident Report Form
This form should be completed and submitted to the Incident Officer [insert name and contact
details of Incident Officer] who will follow up on the incident and investigate further if
necessary.
Section A - to be completed by person reporting the event
Date and time of event:

Location of event:
Description of event ( please describe what happened and who was involved):
Action taken in response to event (please describe any action that was taken immediately or
in response to the event):
Other comments (please add any other information that you think is relevant):
Name of person reporting the event:
(NB: This is necessary for the Incident Officer to follow up and investigate the event further
if necessary. However the name of the person reporting the incident will be kept confidential
by the Incident Officer)
Contact details of person reporting event:
Section B to be completed by Incident Officer

Date of review of incident report form:
Is further investigation required? Yes No (please circle).
If yes, please describe below action taken to investigate further and the results of
investigation (for example, name(s) of staff/patients interviewed for further information,
summary of the information gathered etc):
Recommendations (please describe below any recommendations or action that must be taken
to prevent a similar event occurring in the future):
Responsible person to act on recommendations (please state the name and position of an
Chapter 12 Quality Management Appendix C: Page 1 of 2

individual who is responsible to act on the recommendations above):
Any other comments (please describe any other relevant information or comments that are
not captured above):
Name of Incident Officer who completed Section B:

Date of completion of report:
Chapter 12 Quality Management Appendix C: Page 2 of 2

Appendix D Sample Risk Assessment Template
Date of risk assessment: dd/mm/yy

Department/Case Team/Service Area: Operating theatres
Participants who took part in Risk Assessment: (list names and position)
Risk Assessment Matrix:
Catastrophic Yellow Orange Red Red Red

Major Yellow Orange Orange Red Red
Consequence
Moderate Green Yellow Orange Orange Red

Minor Green Yellow Yellow Orange Orange
Negligible Green Green Green Yellow Yellow
Rare Unlikely Possible Likely Almost certain
Likelihood
Chapter 12 Quality Management Appendix D: Page 1 of 3

Hazard Consequence Likelihood Category Action to be Responsible Date for
identified (negligible, (rare, unlikely, (green, yellow, taken person completion of
minor, possible, likely, orange, red) action
moderate, almost certain)
major,
catastrophic)
1. Old, broken Moderate Likely ORANGE Remove Head of Case Within one
equipment in equipment to Team (name) week, by
corridor and maintenance dd/mm/yy
potential that
department
patients or
staff may trip
and fall, or
injure
themselves on
the items
2. No sharp Major Likely RED Install sharp Senior Nurse Within two days,
boxes boxes (name) By edd/mm/yy
available and
potential to
cause needle-
stick injury to
staff or
patients
3. Interrupted Catastrophic Possible RED Back-up CEO As soon as
electrical generator to be possible, no later
supply installed than 3 months
Potential for
dd/xx/yy
failure of
lights,
anaesthesia
machine
during
surgical
procedure and

hence patient
harm
4. Shortage of Catastrophic Possible RED Add more Head of Case Within three
nursing staff nursing staff to Team and Head months,
to monitor department or of Human Ie by dd/mm/yy
patients in
change skill mix Resource
recovery
area and of existing staff Department
potential for
patient harm
due to poor
monitoring
and clinical
care
5. Lack of pre- Major Possible ORANGE Prepare pre- Senior Surgeon Within two
surgical surgical check (name) months, ie by
check list and list and train dd/mm/yy
potential for
ward staff in its
cancelled
surgery use
because
patient not
prepared
adequately

Appendix E Patient Rights and Responsibilities
Patient rights
Access to health services:

You have the right to access services at No Name Hospital. You will not be refused access
on unreasonable grounds.
You have the right to expect No Name Hospital to assess the health requirements of the
local community and to put in place the services to meet those needs as considered necessary.
You have the right not to be unlawfully discriminated against in the provision of services at
No Name Hospital including on grounds of gender, race, religion or belief, sexual
orientation, disability (including learning disability or mental illness) or age.
Quality of care and environment:

You have the right to be treated with a professional standard of care, by appropriately
qualified and experienced staff
You have the right to expect No Name Hospital to monitor, and make efforts to improve,
the quality of healthcare it provides.
Respect, consent and confidentiality:

You have the right to be treated with dignity and respect, in accordance with your human
rights.
You have the right to accept or refuse treatment that is offered to you, and not to be given
any physical examination or treatment unless you have given valid consent. If you do not
have the capacity to do so, consent must be obtained from a person legally able to act on your
behalf, or the treatment must be in your best interests
You have the right to be given information about your proposed treatment in advance,
including any significant risks and any alternative treatments which may be available, and the
risks involved in doing nothing.
You have the right to privacy and confidentiality and to expect No Name Hospital to keep
your confidential information safe and secure.
You have the right of access to your own health records. These will always be used to
manage your treatment in your best interests.
Involvement in your healthcare and in the planning and delivery of services at No Name
Hospital:
You have the right to be involved in discussions and decisions about your healthcare, and to
be given information to enable you to do this.
You have the right to be involved, directly or through representatives, in the planning of
services at No Name Hospital, the development and consideration of proposals for changes in
the way those services are provided, and in decisions to be made affecting the operation of
those services.
Chapter 12 Quality Management Appendix E: Page 1 of 2

Complaint and redress:
You have the right to have any complaint you make about No Name Hospital dealt with
efficiently and to have it properly investigated.
You have the right to know the outcome of any investigation into your complaint.
You have the right to take your complaint to ???, if you are not satisfied with the way your
complaint has been dealt with by the NHS.
You have the right to compensation where you have been harmed by negligent treatment.
Patient and public responsibilities
You should recognise that you can make a significant contribution to your own, and your
familys, good health and well-being, and take some personal responsibility for it.
You should treat staff and other patients at No Name Hospital with respect and
recognise that causing a nuisance or disturbance on NHS premises could result in
prosecution.
You should provide accurate information about your health, condition and status.
You should keep appointments, or cancel within reasonable time.
You should follow the course of treatment which you have agreed, and talk to your
clinician if you find this difficult.
You should participate in important public health programmes such as vaccination.
You should give feedback both positive and negative about the treatment and care you
have received, including any adverse reactions you may have had.
Adapted from The NHS Constitution for England. DoH, UK, Jan 2009.
Chapter 12 Quality Management Appendix E: Page 2 of 2

Appendix F Sample Patient Satisfaction Surveys
Background:
The following Inpatient and Outpatient Surveys were modelled after the Hospital Consumer
Assessment of Health Providers and Systems (H-CAHPS), a standardized survey of patients
experiences in health care. Additionally, 14 focus groups were conducted in diverse geographical
settings in Ethiopia to identify additional key influences on patient experiences with health care
delivery in Ethiopia. This process resulted in the addition, deletion, and modification of several
items from the H-CAHPS to ensure its relevance in Ethiopia.
Subsequently the Inpatient (I-PAHC) and Outpatient (O-PAHC) surveys were piloted in 4
hospitals and 3 health centres in Ethiopia. A total of 350 completed surveys were received. A
validation study was undertaken to ensure the items were internally consistent, showed evidence
of construct validity, and were effective instruments for detecting differences in patient
experiences between hospitals, if such differences existed. Minor modifications to the survey
instruments were made in light of the pilot and validation study findings. Statistical power
analyses was also conducted to support the recommendation that a sample of 50 patients for each
patient survey area (inpatient, outpatient) would be sufficient to detect, with 80% statistical
power, a 1.0 point change in the overall patient satisfaction rating over time within one hospital
or between hospitals.
The following survey tools are the results of the above process. The surveys can be used by
hospitals to monitor patient satisfaction with hospital services and changes in satisfaction over
time.
Administration of surveys:
Number of survey forms to be completed

A total of 50 Inpatient and 50 Outpatient Survey Forms should be completed. Although similar,
the survey for outpatients and the survey for inpatients are slightly different. Therefore the
analysis and reporting of each should be separate. A total of 50 surveys are required for each
type of survey at each survey period (ie 50 completed O-PAHC and 50 completed I-PAHC
surveys). Since some patients may decline to complete the survey it is likely that the surveyor(s)
will need to approach more than 50 patients in order to collect 50 completed survey forms.
Assign Surveyor(s)
Each hospital should assign one or more individuals to administer the surveys to patients. The
individual conducting the survey (also referred to as surveyor) should understand the survey
well, including all survey items and responses. To minimize bias the surveyor should not be
involved in direct patient care. The person should be viewed as impartial and able to keep a
professional distance from the respondent and willing to follow the survey protocol reliably. A
surveyor must have good interpersonal skills to interact sensitively with patients and must not
Chapter 12 Quality Management Appendix F: Page 1 of 5

lead the patients to particular responses but administer the survey objectively. Each surveyor
must be trained to ensure he/she understands the purpose and process of the PAHC surveys.
Surveyors are responsible for collecting all completed surveys and returning them to a
centralized collection area determined by the hospital.
Patient recruitment
Participation is voluntary and patient anonymity must be maintained. No identifying information
(such as patients name) is collected. Verbal consent should be obtained from the patient before
the survey is administered.
For the outpatient survey, patients should be selected to reflect a diversity of outpatient areas,
including emergency room and other outpatient areas.
For the inpatient survey patients should be selected from a range of different wards to reflect the
diversity of services.
[NB: If a hospital wishes to specifically assess the patient experience in one particular service
area (for example Emergency Room only, or Surgical Ward only) this may be done. In this
instance, 50 surveys are required from that particular service area.]
In order to ensure that the surveys are representative of the patient experience the surveys should
be collected over a time period of one to two weeks. The surveys should be collected on different
days and at different times of day (morning and afternoon). No more than 10 surveys should be
collected on a single day. As far as possible, surveys should be collected from a mixture of male
and female patients and from patients of different ages.
Criteria for participation

All patients must be 18 years old or older. In addition, for I-PAHC, participants must have a
hospital stay of greater than 1 day. Participants are excluded from both surveys if cognitively
impaired and unable to understand the survey questions.
How is the survey completed?

An ID number should be assigned to each survey sequentially as conducted. The ID number
should be entered on the survey form.
The survey may be written or oral. The patient may complete the form themselves (written) or
the surveyor may read each survey question to the patient and transcribe the patient response
(oral).
Respondents may leave items blank if they are uncertain about their response, or do not feel
comfortable answering the question.
When should the survey be given to patients?

The I-PAHC survey should be administered at time of discharge.
The O-PAHC survey should be given at the end of the outpatient visit, right before the
patient leaves the outpatient area.

Response rate
The surveyor should record the total number of patients who were asked to complete the survey
and calculate the response rate as follows:
Response rate =
number of completed surveys total number of patients asked to complete survey x 100
A low response rate (e.g < 60%) might indicate that the sample is not truly representative of all
patients. Reasons for the low response rate should be investigated and if possible the survey
should be repeated to attain a higher response rate.
Data entry and analysis

A computerized database should be used to record and analyse all survey results.
To assist hospitals, the Ethiopian Hospital Management Initiative has developed a tool for data
entry and analysis using Microsoft Access and Excel. Copies of this tool, together with the full
protocol for data entry and analysis can be found on the CD that accompanies this document or
on request from the Medical Services Directorate of the FMOH.

I-PAHC Survey
Survey # Department Ward:
Male 1 Female 2 Date (DD/MM/YYYY): Age:
Never Sometimes Usually Always

1. During this health facility stay, how often did nurses treat you with
1 2 3 4
courtesy and respect?
2. During this health facility stay, how often did nurses listen carefully to
1 2 3 4
you?
3. During this health facility stay, how often did nurses explain things in a
1 2 3 4
way you could understand?
4. During this health facility stay, how often did doctors/health officers treat
1 2 3 4
you with courtesy and respect?
5. During this health facility stay, how often did doctors/health officers listen
1 2 3 4
carefully to you?
6. During this health facility stay, how often did doctors/health officers
1 2 3 4
explain things in a way you could understand?
7. I could distinguish between doctors/health officers and nurses. 1 2 3 4
8. During this health facility stay, how often was the room you were
1 2 3 4
sleeping in kept clean?
9. During this health facility stay, how often was the area around you quiet
1 2 3 4
at night?
10. During this health facility stay, how often did you have enough personal
1 2 3 4
privacy?
11. During this health facility stay, did you experience any pain? 1 Yes 2 No, Skip 12 & 13
12. During this health facility stay, how often was your pain well controlled? 1 2 3 4
13. During this health facility stay, how often did staff do everything they
1 2 3 4
could to help you with your pain?
14. During this health facility stay, were you given any medication that you
1 Yes 2 No, Skip 15 & 16
had not taken before?
15. Before giving you any new medication, how often did staff tell you what
1 2 3 4
the medicine was for?
16. Before giving you any new medication, how often did staff describe
1 2 3 4
possible side effects in a way you could understand?
17. Did anyone discuss with you what symptoms to look out for after you
1 Yes 2No
left the health facility?
18. Was it easy to find your way around the health facility? 1 Yes 2 No

19. On a scale of 0-10 (0 being the worst facility, 10 being the best facility),
0 1 2 3 4 5 6 7 8 9 10
how would you rate this health facility?
Worst facility...Best facility
1 2 3 4
20. Would you recommend this health facility to your friends and family? Definitely Probably Probably Definitely
no no yes yes
21. Did you have to pay for this health facility stay? 1Yes 2 No, Skip Q22
22. Do you consider this health facility stay too expensive? 1 Yes 2 No

O-PAHC Survey
Survey No. Health Facility Name:
Age: Date (DD/MM/YYYY):

Male 1 Female 2
Morning/Afternoon Department:
Strongly Strongly
Disagree Agree
Disagree Agree
1. During this visit, nurses treated me with courtesy and respect. 1 2 3 4
2. During this visit, nurses listened carefully to me. 1 2 3 4
3. During this visit, nurses explained things in a way I could understand. 1 2 3 4
4. During this visit, doctors/health officers treated me with courtesy and

1 2 3 4
respect.
5. During this visit, doctors/health officers listened carefully to me. 1 2 3 4
6. During visit, doctors/health officers explained things in a way I could

1 2 3 4
understand.
7. I could distinguish between doctors/health officers and nurses. 1 Yes 2 No
8. The outpatient department was clean. 1 2 3 4
9. The bathrooms/latrines were clean (leave blank if not applicable). 1 2 3 4
10. I was prescribed new medication at this visit. 1 Yes 2 No, Skip Q11, 12, & 13
11 The staff told me what the medication was for. 1 Yes 2 No

12 The staff described the medications possible side effects in a way I could
1 Yes 2 No
understand.
13 All the medications I needed were available at the drug dispensary here. 1 Yes 2 No
14 Someone discussed with me what symptoms to look out for after I left the
1 Yes 2 No
health facility.
15. It was easy for me to find my way around the facility. 1 Yes 2 No
16. On a scale of 0-10 (0 being the worst facility, 10 being the best facility), I
would you rate this health facility a: 0 1 2 3 4 5 6 7 8 9 10
Worst.....Best
1 2 3 4
17. I would recommend this outpatient department/clinic to my friends and
Definitely Probably Probably Definitely
family.
no no yes yes
18. I had to pay for this outpatient visit. 1 Yes 2 No, Skip Q19
19. I consider this outpatient visit too expensive. 1 Yes 2 No

Monitoring and Reporting
Page 1 of 11
Section 2 Operational Standards for Monitoring and Reporting 4
3.1 Health Management Information System 5
3.2 Role of the Governing Board to monitor hospital performance 6
3.3 The Balance Scorecard 6
Source Documents 10
Appendices
Appendix A HMIS Indicators by Level and Frequency of Collection
Appendix B HMIS / M&E Implementation Roles and Responsibilities at Hospitals
Appendix C Methodology of LQAS
Appendix D Definition of BSC indicators
Appendix E Assessment Tool for Operational Standards of National Hospital Reform
Implementation Guidelines
Tables
Table 1 Monitoring and Reporting Checklist
Figures
Figure 1 Sample Balanced Scorecard for Governing Board
Figure 2 Sample Balanced Scorecard for Emergency Case Team
Chapter 13 Monitoring and Reporting Page 2 of 11

Abbreviations
BSC Balanced Scorecard
LQAS Lot Quality Assurance Sampling
WOFED Woreda Office of Finance and Economic Development

Hospital management and Governing Boards are responsible to monitor hospital
performance.
Monitoring has a number of objectives including:

To ensure that activities are proceeding as planned and on schedule (i.e. to ensure that
the annual plan is being implemented),
To maximize the quality, effectiveness and efficiency of services,
To ensure financial viability of the hospital, and
To ensure that the hospital contributes to attainment of national health sector targets
and objectives.
In addition to internal monitoring, hospitals are required to report a core set of indicators
defined in the Health Management Information System (HMIS) to the relevant Health Office
(Woreda, Zonal, Regional or Federal). As described in Chapter 10 Financial and Asset
Management hospitals should also submit regular budget reports to the appropriate finance
office (WOFED, BOFED or MOFED).
This chapter considers the role of the Health Management Information System (HMIS) for
the internal monitoring of hospital performance, and as a tool through which RHBs and the
Federal Ministry of Health (FMOH) can oversee hospital performance and measure the
contribution of the hospital towards national targets and goals.
Additionally, the chapter considers the role of the hospital Governing Board to monitor
hospital performance and introduces a tool and a set of indicators (the Balanced Scorecard)
that could assist Governing Boards in this function.
Section 2 Operational Standards for Monitoring and Reporting

1. The hospital has an HMIS Monitoring Team (or equivalent) that reviews HMIS indicators
and takes action to address any areas of concern.
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.
3. The hospital submits monthly, quarterly and annual HMIS reports to the relevant higher
office within the agreed time limit.
4. The correspondence between data reported on HMIS forms and data recorded in registers
and patient / client records, as measured by a Lot Quality Assurance Sample (LQAS) is
80%.

5. In collaboration with the CEO, the Governing Board has established performance
indicators for the hospital that are described in a Balanced Scorecard (BSC). BSC reports
are presented by the CEO to the Governing Board as a minimum every quarter.
6. Indicators included in the BSC are a combination of national/regional indicators and other
local indicators as determined by the Governing Board.
7. Hospital staff are oriented to the BSC and case teams/departments determine indicators
and monitor their own performance using the BSC.

3.1 Health Management Information System
The Health Management Information System (HMIS) is a national database of indicators that
were developed by the FMOH and partners with the primary aim to support and strengthen
local action-oriented performance monitoring. Additionally, the indicators can be used at
National level to monitor implementation of the Health Sector Development Program,
progress towards the Millennium Development Goals and other donor programs.
HMIS defines 108 indicators in 4 main categories:

Family Health
Disease Prevention and Control
Resources
Health Systems
The full list of HMIS Indicators is presented in Appendix A. Definitions of each indicator,
reporting forms and the methods of data collection can be found in the FMOH HMIS
Implementation Manuals. Hospitals should establish mechanisms to collect and report all
indicators defined within HMIS. The list of requirements for a hospital to implement HMIS
is presented in Appendix B.
Each hospital should establish an HMIS Performance Monitoring Team (or equivalent) to
review the hospital data and take action to address any areas of concern. The team is
responsible to ensure that:
The hospital uses standard HMIS procedures and recording and reporting forms
Staff get proper orientation/training on HMIS procedures and formats
HMIS stationary and supplies are readily available
HMIS data is complete and valid before being used or reported
Data is collected and reported according to the HMIS timeframe
Data is reviewed by hospital management and used to identify problems with service
delivery
Action is taken to address any problems identified using HMIS data

HMIS/M&E guidelines call for each health institution to internally assess its own
performance at least quarterly (self-assessment). For further discussion on the role of the
HMIS Monitoring Team as part of the hospitals overall Quality Management activities
please see Section 3.2.1 of Chapter 12 Quality Management.
Additionally, hospitals should collect and report monthly, quarterly and annual HMIS
indicators to the relevant higher office, using standardized formats, as described in the
FMOH HMIS Implementation Manuals.
In order for the data to be useful, it is important that HMIS data is accurate, complete and
reported within agreed time frames. A Lot Quality Assurance Sample (LQAS) can be used
to check the accuracy of HMIS data reporting. A description of the methodology for LQAS is
given in Appendix C. HMIS has set a minimum target of 80% as the correspondence between
data reported on HMIS forms and data recorded in registers and patient /client records, as
measured by LQAS.
3.2 Role of the Governing Board to monitor hospital performance
The hospital Governing Board is responsible to direct and supervise the overall activities of
the hospital, to provide proper financial oversight, to ensure adequate resources for hospital
operations, and to ensure that the hospital provides services to the highest possible standard
in an environment that is safe for patients, staff and visitors.
As described in Chapter 1 Hospital Leadership and Governance the Governing Board fulfils
these functions by establishing corporate strategies, plans and policies and by overseeing the
performance of the CEO who is responsible for implementation of these.
The Governing Board cannot and should not monitor day- to- day activities of the hospital.
Similarly, it is not feasible for the Governing Board to review and monitor the full set of
HMIS Indicators for the hospital. None-the-less, the Board must have sufficient information
to assure itself that the hospital is performing to a high standard and that proper mechanisms
are in place to deliver safe, efficient and high quality services. One means to achieve this is
to monitor a core set of indicators of hospital performance. Ideally, the number of indicators
should be small and should be presented in a user friendly format that aids understanding.
The Balanced Scorecard is a tool that can be used by Governing Boards to achieve this.
3.3 The Balanced Scorecard
The Balanced Scorecard (BSC) is a planning, monitoring and evaluation tool that considers
performance in four key areas:
Customer perspective
Finance perspective
Internal processes

Learning and growth of the organization
The BSC is recommended by the FMOH as a management and measurement tool for all
levels of the health sector. The use of the BSC as a monitoring tool assists Governing Boards
to oversee the performance of the hospital. The indicators within the BSC provide only a
summary of hospital performance. The Governing Board should review each BSC report,
identifying areas of good performance and areas of concern and should discuss these with the
CEO, seeking clarification or further information where necessary.
Governing Boards should determine selected indicators within each of the four key areas and
should receive quarterly reports from hospital management on these indicators. (NB Patient
surveys may be conducted on a bi-annual basis, but all other indicators within the BSC
should be reported to the Governing Board as a minimum every quarter). A sample BSC for a
hospital Governing Board is presented in Figure 1 below. In the figure, the additional domain
of safety and quality has been added to highlight the importance of patient safety and
quality of services provided. A definition of each indicator presented in Figure 1 is given in
Appendix D. An assessment tool measuring the attainment of the Operational Standards of
the National Hospital Reform Implementation Guidelines is presented in Appendix E.
The BSC can also act as a tool to orient staff to the objectives of the hospital and strengthen
staff engagement with hospital improvement efforts. To achieve this, hospital staff should be
oriented to the BSC and in particular should be familiar with the BSC indicators that will be
reviewed by the Governing Board. The Governing Board may choose to consult with hospital
staff when defining the core set of indicators that will be monitored on the BSC. Staff should
understand the purpose of each indicator and method of data collection in order to strengthen
the completeness and accuracy of the data.
Additionally, each Case Team/Department should set its own objectives (in consultation with
Senior Management) and should monitor its own performance using defined indicators. In
this way, the activities of each Case Team can be aligned with the objectives of the hospital
and each Case Team can be encouraged to improve its own performance. A sample BSC for
the Emergency Case Team is given in Figure 2 below.
NB: The sample BSC for Governing Boards presented in Figure 1 contains some, but not all
HMIS indicators. Hospital management should ensure that there is a monitoring process for
all HMIS indicators but it is not necessary for the Governing Board to review each and every
HMIS indicator. For this reason, the BSC in Figure 1 contains only a selected number of
HMIS indicators that should be reviewed by the Governing Board. Additionally, the BSC
contains indicators that are not part of the HMIS data set but that would be useful to the
Governing Board to effectively govern the hospital. x

Figure 1 Sample Balanced Scorecard for Governing Board
Hospital Name:
No. of approved beds: Catchment population
No. of operational beds: Catchment area (km2)
Current period Last period Current period Last period

HOSPITAL EFFFICIENCY QUALITY INDICATORS
UTILISATION Healthcare acquired infection rate
Inpatient admissions Inpatient mortality rate
New outpatient visits Pressure sore incidence rate
Repeat outpatient visits Unplanned readmission rate within 28 days
Number (%) of persons with exempt service Drug stock out days of tracer drugs
Number (%) of persons with fee waiver service Number of clinical audits completed
REFERRALS Number of occupational injuries reported
Number (rate) of referrals received FINANCE
Number (rate) of referrals made REVENUE MIX
WAIT TIME Govt. Allocation (% of total revenue)
ER wait time to triage Private wing (% of total revenue)
OPD wait time to triage Insurance payment (% of total revenue)
OPD consultation transit time Non insurance patient fees (% of total revenue)
DELAY FOR ELECTIVE ADMISSION AND PROCEDURE Other sources (% of total revenue)
Medical admission Operating margin
Surgical admission Ratio of budget utilization to allocation
Delay for elective surgical procedure % reimbursed amount to total fees waived
BED OCCUPANCY RATE PATIENT AND COMMUNITY PERSPECTIVE
AVERAGE LENGTH OF STAY Inpatient overall rating of hospital
BED TURNOVER RATE Inpatient willingness to recommend hospital
PRODUCTIVITY RATIOS Outpatient overall rating of hospital
Number of major surgeries per surgeon Outpatient willingness to recommend hospital
Inpatient days per doctor Staff overall rating of hospital
Inpatient days per nurse Staff willingness to recommend hospital
Inpatient days per other clinical staff Number of complaints received
OPD visits per practitioner per day Number (%) of complaints upheld
Doctors per bed GROWTH AND INNOVATION
Nurses per bed % of posts filled as per the Regional standard
Other clinical staff per bed Total number (attrition rate) medical staff
COSTS Total number (attrition rate) health officers
Salary expenses (% of total expenses) Total number (attrition rate) nursing staff
% of hospital recurrent budget spend on administration Total number (attrition rate) other clinical staff
Cost per patient day equivalent Total number (attrition rate) non clinical staff
% OF HOSPITAL REFORM OPERATIONAL STANDARDS MET Cumulative number (%) of staff evaluated
Cumulative number (%) of staff who received in service training
Number of functional computers

Figure 2 Sample Balanced Scorecard for Emergency Room (ER)
Hospital Name:
No. of approved beds: Catchment population
No. of operational beds: Catchment area (km2)
Current Last
Current period Last period
HOSPITAL EFFFICIENCY period period QUALITY INDICATORS
UTILISATION ER mortality rate
Number of ER attendances Unplanned re-attendance within 28 days
New of patients admitted to hospital from ER (% of ER attendances) Number of clinical audits complete by ER staff
Number of patients kept in ER for up-to 24 hours (% of ER attendances) Number of occupational injuries reported by ER staff
REFERRALS PATIENT AND COMMUNITY PERSPECTIVE
Number of ER referrals received from other facilities (% of all ER attendances) ER patient overall rating of hospital
Number of ER referrals made to other facilities (% of all ER attendances) ER patients willingness to recommend hospital
WAIT TIME Number of complaints received about ER service
Average ER wait time to triage % of complaints about ER service upheld
Average ER transit time from arrival to discharge GROWTH AND INNOVATION
Average ER wait time from completion of ER treatment to admission to inpatient bed Cumulative number (%) of ER staff appraised
PRODUCTIVITY RATIOS Cumulative number (%) of ER staff who received in-service training
Average daily number of attendances per doctor STAFFING
Average daily number of attendances per health officer Total number (attrition rate ER medical staff
Average daily number of attendances per nurse Total number (attrition rate) ER health officers
Average daily number of attendances per other clinical staff Total number (attrition rate) ER nursing staff
FINANCE Total number (attrition rate) ER other clinical staff
ER salary expenses (% of ER operational expenditure)
Cost per ER attendance
Number (%) of ER patients provided with free service

In order to determine if the Operational Standards of Monitoring and Reporting have been
met by the hospital an assessment tool has been developed which describes criteria for the
each Operational Standard. The tool is presented in Appendix E.
Table 1. Monitoring and Reporting Checklist

Yes No
1. An HMIS Monitoring Team (or equivalent) has been established.
2. Self assessments of hospital performance are conducted.
3. Monthly, quarterly and annual HMIS reports are submitted to relevant
bodies.
4. Lot Quality Assurance Samples have been done.
5. Lot Quality Assurance Samples show a result 80%.
6. The CEO and Governing Board have defined performance indicators (that
are a combination of national, regional and other local indicators) in a
Balanced Scorecard
7. Performance indicators in a Balanced Scorecard (BSC) have been reported
to the Governing Board.
8. BSC orientations have been provided to staff.
Source Documents
1. Federal Democratic Republic of Ethiopia Ministry of Health (2008, July). Business

Process Reengineering: Policy, Planning and Monitoring & Evaluation Core Process.
2. Federal Democratic Republic of Ethiopia Ministry of Health (2008, January). HMIS/M&E.

Strategic Plan for Ethiopian Health Sector.
3. Federal Democratic Republic of Ethiopia Ministry of Health (2008, January). HMIS/M&E.

Indicator Definitions. HMIS/M&E Technical Standards Area 1.

4. Federal Democratic Republic of Ethiopia Ministry of Health (2007, May). HMIS/M&E.
Disease Classification for National Reporting. Technical Standards Area 2.
5. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS

Procedures Manual: Data Recording and Reporting Procedures. HMIS/M&E Technical
Standards Area 3. HMIS/M&E.

HMIS/M&E. Information Use Guidelines and Display Tools. HMIS/M&E Technical
Standards Area 4.

Sector.
8. Federal Democratic Republic of Ethiopia Ministry of Health (2009, June). Performance

Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector. FMOH.

Appendices
Chapter 13 Monitoring and Reporting

Appendix A HMIS Indicators by Level and Frequency of Collection

Monthly / Quarterly Annual
Facilities Administration Facilities Administration
HP HC Hosp WorHO RHB FMOH HP HC Hosp WorHO RHB FMOH
total indicators: 108 28 63 63 66 65 65 16 28 30 39 39 42
A. Family Health - total indicators : 21
A1. Reproductive health - total indicators: 12
1. Contraceptive prevalence rate X X X

2. Contraceptive acceptance rate X X X X X X
3. Antenatal care coverage X X X X X X
4. Abortion care X X X X X
5. Delivery attendant
a. Skilled attendant (WHO definition) X X X X X
b. HEW X X X X
c. tTBA X X X X
6. Caesarean section rate X X X X X
7. Proportion of maternal deaths
X X X X X
(institutional)
8. Stillbirth rate (institutional) X X X X X
9. Neonatal death rate (institutional) X X X X X
10. Postnatal care coverage X X X X X X
A2. Child health - total indicators: 3
1. Low birth weight proportion X X X X X X

2. Proportion of moderate/severe
malnutrition amongst weights recorded X X X X X X
for children under 3 years
3. IMNCI implementation. X X X
A3. EPI - total indicators: 6
1. DPT1+HepB1+Hib1 coverage X X X X X X
2. DPT3+HepB3+Hib3 coverage X X X X X X
3. Measles immunization coverage X X X X X X
4. Full immunization coverage X X X X X X
5. Protection at birth (PAB) against
X X X X X X
neonatal tetanus
6. Vaccine wastage rate X X X X X X
B. Disease Prevention and Control - total indicators: 47
Facility-based morbidity and mortality rates for specific diseases available as needed from disease reports
B1. All diseases - total indicators: 5
1. Top 10 causes of morbidity amongst

X X X X X X
children under five years
Chapter 13 Monitoring and Reporting Appendix A: Page 1 of 6

2. Top 10 causes of mortality amongst
X X X X X
children under five years
3. Top 10 causes of morbidity, five
X X X X X X
years and above
4. Top 10 causes of mortality, five
X X X X X
years and above
5. In patient mortality rate X X X X X
B2. Communicable diseases - total indicators: 39
B2a. Malaria - total indicators: 4
1. Malaria cases reported per 1000

population (reported by clnical /
confirmed (p. falciparum / other)
a. in under 5 children X X X X X X
b. in age groups 5 years and above X X X X X X
2. Case fatality rate of malaria
a. in under 5 children [in patients] X X X X X
b. in age groups 5 years and above
X X X X X
[in patients]
B2b. TB and Leprosy - total indicators: 10
1. Case detection rate of new smear

X X X X X
positive pulmonary TB patients
2. Treatment results of smear-positive
pulmonary TB cases (DOTS cohort)
a. treatment success rate X X X X X
b. cure rate X X X X X
c. defaulter rate X X X X X
d. death rate X X X X X
3. New cases of leprosy X X X X X
4. Grade II disability rate amongst new
X X X X X
cases of leprosy
5. Proportion of leprosy cases amongst
X X X X X
children under 15 years of age
6. Leprosy treatment completion rate
a. Multi-bacillary (MB) leprosy X X X X X
b. Paucibacillary (PB) leprosy X X X X X
B2c. TB/HIV coinfection - total indicators: 2
1. Proportion of registered TB patients

X X X
who are tested for HIV
2. Proportion of registered TB patients
X X X
who are HIV positive
B2d. HIV/AIDS - total indicators: 17
1. Number of health facilities, by type,

X X X X X
providing VCT services.

2. VCT counseling and testing
a. Clients receiving pretest
X X X X X
counseling
b. Clients receiving HIV test X X X X X
c. Clients with positive HIV test X X X X X
3. PIHCT counseling and testing
a. Clients receiving pretest
X X X X X
counseling
X X X X X
providing PMTCT services
5. Pregnant women receiving PMTCT
services
a. Clients with at least one ANC visit
X X X X X
(at PMTCT site)
d. HIV-infected pregnant women
receiving full course of ARV X X X X X
prophylaxis
X X X X X
providing ART services
7. AIDS patients receiving ARV
combination therapy
a. Persons ever enrolled in HIV care X X X X X
b. Persons ever started on ART X X X X X
c. Persons currently receiving ART
X X X X X
(by regimen)
d. Survival rates at 6, 12, 24, 36, etc
X X X X X
months
B2e. Other communicable diseases, including diseases targeted for eradication or elimination - total indicators: 6
1. Case fatality rate for meningitis

X X X X X
[inpatients]
2. Polio cases X X X X X X
3. Acute flaccid paralysis (non-polio)
X X X X X X
(AFP) rate
4. Measles cases X X X X X X
5. Neonatal tetanus cases X X X X X X
6. Guinea worm cases X X X X X X
B3. Noncommunicable diseases - total indicators: 1
1. Cataract surgical rate X X X X
B4. Hygiene and Environmental Health - total indicators: 2
1. Latrine Coverage X X X X X X
2. Safe water coverage X X X X X X

C. Resources - total indicators: 28
C1. Assets - total indicators: 7
1. Facility to population ratio (by type of

X X X
facility)
2. Number of hospitals, HCs and HPs
X X X
newly constructed and upgraded
3. Proportion of HIs with
communication equipment: a.
telephone or b. radio
a. telephone X X X X X X
b. radio X X X X X X
4. Proportion of HIs with electricity X X X X X X
5. Proportion of HIs with water supply X X X X X X
6. Proportion of HIs with latrine with
X X X X X X
functioning water supply
C2. Finance - total indicators: 9
1. Share of health budget as a

X X X
proportion of total budget
2. Government budget allocation to the
X X X
health sector (absolute amount)
3. Ratio of Health budget utilization to
X X X
allocation
4. Per capita public expenditure on
X X X
health
5. Percentage of non-salary recurrent
budget from total recurrent budget at X X X
woreda level
6. Proportion of drug budget out of the
X X X
total recurrent budget
7. Share of internal revenue generated
X X X X X
to total health budget
8. Proportion of reimbursed amount out
X X X X X
of total patient fees waived
9. Proportion of hospital recurrent
X X X X
expenditures spent on administration
C3. Human Resources - total indicators: 4
1. Health Staff to population ratio by

category (doctor, health officer, nurse, X X X X X X
midwife, health extension worker)
2. Proportion of institutions staffed as
per standards by level ( FMOH, RHB, X X X X X X
woreda, hospital, HC, HP)
3. Attrition rate by category ( doctor,
health officer, nurse, midwife, health X X X X X X
extension worker)

4.Proportion of health professionals
who have undergone in service training X X X X X X
during the last one year
C4. Logistics - total indicators: 2
1. Essential drugs availability (tracer

drugs including contraceptive) by X X X X X X
health facility level
2. Average stock out duration for
essential drugs (tracer drugs including X X X X X
contraceptive) by health facility level
C5. Laboratory and blood bank - total indicators: 6
1. Total number of units of blood

collected by the National Blood X
Transfusion Service (NBTS)
2. Number / percentage of facilities
accessing service through the National X
Blood Transfusion Service (NBTS).
3. Percentage voluntary non-
X
remunerated blood donations
4. Capacity for malaria parasite
X X X X X X
diagnosis
5. Laboratory capacity for pulmonary
X X X X X
tuberculosis (PTB) diagnosis
6. Quality control in laboratories X X X X X
D. Health Systems - total indicators: 12
D1. Health service coverage and utilization - total indicators: 8
1. Primary health care coverage X X X X X X

2. Outpatient attendance per capita X X X X X X
3. OPD visits per practitioner per day,
X X X X X X
disaggregated by level
4. Admission rate X X X X X
5. Bed occupancy rate X X X X X
6. Average length of stay X X X X X
7. Availability of BEOC X X X
8. Availability of CEOC X X X
D2. Management - total indicators: 2
1. Number of supervisory visits

X X X X X X
received
2. Number of self-assessment and
X X X X X X
participatory review meetings held
D3. HMIS and M&E - total indicators: 2

1. Completeness and timely
submission of routine health and X X X
administrative reports
2. Data quality X X X X
E. Population Denominators: supplied by Central Statistics Authority.
1. Total population
2. Estimated number of households
3. Population growth rate
4. Expected pregnancies
5. Expected deliveries
6. Live births
7. Children under 1 year
8. Surviving infants
9. Children under 5 years
10. Females 15-49 years
note: Health Stations use the same indicators as Health Posts

Appendix B HMIS / M&E Implementation Roles and Responsibilities
at Hospitals
1. Obtain sanction for HMIS, Hospital Information System (HIS), and card room posts
and hire staff.
Optimal
a. HMIS / HIS
One person/ 150 patients/clients/ day
Professional background: Diploma in HMIS or Medical Records or
Statistics
b. Card room: 5 minimum + 1/100 patients/clients/ day
Required to begin implementation
a. Minimum 1 full time HMIS professional person.
b. Card room: 5 minimum
2. Establish an HMIS implementation team.
a. Composed of Medical Director (team leader), Medical Administrator, Matron,
HMIS staff, and at least one Disease Prevention and Control and Family Health
specialist (MD, HO, or senior nurse).
b. Prepare Hospital HMIS implementation plan. In the plan, care should be taken to
ensure that all reengineering and personnel requirements are fulfilled before
training begins at the Hospital.
c. Monitor execution of implementation plan and provide guidance and support as
necessary.
d. Assist woreda / subcity , regional and FMOH training teams in training and
followup supervision.
e. Provide orientation / sensitization to other public sector and civil society
organizations as required.
3. Training.
a. Assist woreda / subcity, regional, and FMOH training team to train all hospital
staff.
b. Provide post-training followup supervision, in collaboration with regional and
federal training teams, to ensure that training is put into practice.
4. Resource mobilization for all.
a. HMIS and medical statistics staff and their office furnishings, including ICT, if
any, and an HMIS storage area including space for archives and storage of
stationery.
b. Budget for hospital HMIS work stationery, office supplies, and, if appropriate,
ICT consumables (paper, ink cartridges, CDs, etc) and ICT maintenance.
c. Estimate costs, if any, for reengineering card room for integrated medical records
folder and fast track. Estimate costs for additional card room staff needed, if any.
Higher level hospitals request funds from RHB; district hospitals from woreda.
Chapter 13 Monitoring and Reporting Appendix B: Page 1 of 2

5. Establish a performance monitoring team, as specified in HMIS Information Use
Guidelines. Include HMIS implementation progress on regular management agenda
during preparation phase, and monthly / quarterly performance monitoring when the
HMIS has been installed. Conduct meetings with other groups as specified in
Harmonization manual.
6. Specific responsibilities of HMIS officer.
a. In collaboration with clinical staff, supervise recording of client/patient
information on cards and registers according to standard.
b. Perform monthly data quality checks
c. Ensure that HMIS reports are completed in a timely fashion
d. Provide tables and charts as needed for performance monitoring team
e. Ensure that display charts, worksheets, and performance monitoring team meeting
minutes are maintained.
f. Establish mechanism for ensuring a supply of HMIS reporting and recording
formats.
Chapter 13 Monitoring and Reporting Appendix B: Page 2 of 2

Appendix C Methodology of LQAS
If data in the monthly report are not accurate, then decisions based on those data may not
produce the effects that are intended. Lot quality assurance sampling (LQAS) is a
methodology that originated in manufacturing as a low-cost way to assess and assure quality.
Based on a small sample size, one can estimate the level of quality. In recent years this
methodology has been applied to assess the quality of various aspects of health services,
including data quality.
The following steps show how the quality of HMIS data can be estimated using a sample of
12 data elements and comparing the results with a standard LQAS table. Selected data
elements from the monthly report submitted to the woreda are compared with the tallies and
register sums that are the sources of these data elements. If a high proportion of the numbers
are the same, then the quality of the data can be assumed to be high; if a low proportion is the
same, then the quality of the data is low.
1. Selection of data elements is random, which means data elements are selected without
any preference. A broad representation of the data elements from different sections of the
monthly report form is required to assure all data elements are given equal opportunity for
selection. A sample of 12 data elements is required based on LQAS table.
2. Select randomly one data element from each section of the previous monthly report.
Write the selected data element in the first column of the data accuracy check sheet given
below. Repeat the procedure until all data elements from different sections are entered in
first column.
3. Copy the figures of the selected data elements as reported on the monthly report form in
second column of data quality check sheet, under the heading of figures from monthly
report form.
4. Pick the register or tally sheet which has the selected data element. Sometimes there may
be several registers or tally sheets. Count the actual entries in the register or tally related
to a specific selected data element. Put the figure you counted in third column of check
sheet, under the heading figure from register. Repeat this procedure for all data
elements.
5. If the figures in column 2 and 3 are same, tick under YES in column four. If they are not
the same (do not match), put a tick under NO in column four. Repeat this procedure for
all data elements.
6. Count the total ticks under YES and write in row of total for YES. Repeat the
procedure for NO column. The sum of YES and NO totals should be equal to the
sample size of 12.
Chapter 13 Monitoring and Reporting Appendix C: Page 1 of 2

Data Accuracy Check Sheet
Month for which data accuracy is checked______________
Figures from Figures Do figures
Randomly Selected Data Elements from the monthly the Monthly counted from from
reporting form report form registers & columns 2
(2) tallies (3) & 3 Match?
YES NO
1. Disease cases for a single disease / age / gender
group
2. OPD attendance for a single age / gender group
3. Family planning monthly report section
4. Maternal health monthly report section
5. Child health
6. EPI monthly report section
7. Logistics
8. TB (if service provided)
9. HIV/AIDS (if service provided)
10.
11.
12.
Total
1. The total in number in the Yes column corresponds to the percentage of data
accuracy in the following LQAS table. For example, if total yes number is 2, the
accuracy level is between 30-35%; if total number in the yes column is 7, the
accuracy level is between 65-70%.
LQAS Table: Decisions Rules for Sample Sizes of 12 and Coverage Targets/Average of 20-95%
Average Coverage (Baselines)/ Annual Coverage Targets (Monitoring and Evaluation)
Les
Sample s
Size 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
than
% % % % % % % % % % % % % % % %
20
%
N/A
12 1 1 2 2 3 4 5 5 6 7 7 8 8 9 10 11
2. Circle the data accuracy percentage and write it in section D3.2 of the monthly report
and submit to the woreda office.
You could set a target for achievement in a specified period and use it for monitoring
progress. The target can be broken down on monthly basis. For example, if data accuracy
is improving by 5% on monthly basis, the correct match number should increase
accordingly as shown in the LQAS table. As the correct match number increases
compared to previous months, it reflects improvement in level of data accuracy.
Achievement of data accuracy level at 95% means a high level of accuracy and needs to
be maintained at that level.
Note: Please note that with sample size of 12 data elements, the data accuracy ranges +15%.
That means that if the data accuracy is 30%, the range is between 15% and 45%.
Chapter 13 Monitoring and Reporting Appendix C: Page 2 of 2

Appendix D Definition of Indicators in Sample BSC for Governing Board
Indicator Definition Methodology/Formula

HOSPITAL EFFICIENCY AND EFFECTIVENESS
UTILIZATION
The number of patients admitted
(including transfer ins) to an Total number of admitted (including transfer in)
Inpatient admissions
inpatient bed during the reporting patients
period
The number of new outpatient

visits (including emergencies and
New outpatient visits Total number of new outpatient visits
specialized clinics such as ART,
VCT) during reporting period
The number of repeat outpatient

visits (including emergencies and
Repeat outpatient visits Total number of repeat outpatient visits
specialized clinics such as ART,
VCT) during reporting period
Number of patients provided with a) Total number; and

Number (%) if persons provided an exempt services (as % of all b) Number of patients provided with exempt
with exempt services attendances) during the reporting services Total number of OPD, ER and
period inpatient attendances x 100
a) Total number; and
Number (%) of persons Number of 'fee waiver' patients,
b) Number of 'fee waiver' patients Total
provided with 'fee waiver' (as % of all attendances) during
number of OPD, ER and in patient
service the reporting period
attendances x 100
REFERRALS
The total number of OPD a) Total number of OPD attendances, ER
attendances, ER attendances attendances and admitted in patients with
and inpatient admissions who referral paper from another facility; and
were referred from another facility b) Number of OPD attendances, ER
Number (Rate) of referrals
with a referral paper (as a % of attendances and admitted in patients with
received
total OPD attendances, ER referral paper from another facility
attendances and inpatient total number of OPD attendances, ER
admissions) during the reporting attendances and admitted inpatients x
period 100
The total number of OPD a) Total number of OPD attendances, ER
attendances, ER attendances attendances and admitted in patients
and inpatient admissions who referred to another facility; and
were referred to another facility b) Number of OPD attendances, ER
Number (Rate) of referrals
with a referral paper (as a % of attendances and admitted in patients
made
total OPD attendances, ER referred to another facility total
attendances and inpatient number of OPD attendances, ER
admissions) during the reporting attendances and admitted inpatients x
period 100
WAIT TIME
Average time from arrival at the time from arrival at the emergency
ER wait time to triage emergency department to department to initiative of triage number of
initiation of triage (minutes) attendances
Average time from arrival at the
time from arrival at OPD to initiative of triage
OPD wait time to triage outpatient department to initiation
number of attendances
of triage (minutes)
The time from beginning of OPD
Time from beginning of OPD consultation to
consultation to discharge from the
discharge from facility (following completion of
OPD consultation transit time facility (following completion of
investigations and purchase of any necessary
investigations and purchase of
drugs) number of attendances
any necessary drugs)
Chapter 13 Monitoring and Reporting Appendix D: Page 1 of 5

DELAY FOR ELECTIVE ADMISSION AND PROCEDURE
The average number of days
from when a patient was added to number of days on waiting list number of
Medical admission
the medical waiting list to patients
admission
from when a patient was added to number of days on waiting list number of
Surgical admission
the surgical waiting list to patients
admission
Delay for elective surgical from when a patient was admitted number of days in hospital awaiting surgery
procedure for elective surgery, to the actual number of elective surgical admissions
procedure being performed
Total length of stay in days (sum total of each

The average percentage of
daily inpatient census) during reporting period
BED OCCUPANCY RATE occupied beds during the period
[Number of beds available x number of
under review
days in period]
The average number of days Total length of stay in days (sum total of each
AVERAGE LENGTH OF STAY from admission to discharge for daily patient census) [Total discharges +
each inpatient. transfer outs + deaths]
The ratio of patient discharges to Total number of discharges (including transfer

BED TURNOVER RATE outs and deaths) Average number of beds
beds
during reporting period
PRODUCTIVITY RATIOS
The average number of major
Number of major surgeries per Total number of major surgeries total
surgical procedures per specialist
surgeon number of surgeons
surgeon
The average number of in-patient Total length of stay in days (sum total of each
In patient days per doctor
bed days per doctor daily patient census) number of physicians
The average number of inpatient Total length of stay in days (sum total of each
In patient days per nurse
bed days per nurse daily patient census) number of nurses
Total length of stay in days (sum total of each
In patient days per other clinical The average number of inpatient
daily patient census) number of other
staff bed days per other clinical staff
clinical staff
The average number of OPD
Total number of outpatient visits [number of
OPD visits per practitioner per visits per OPD practitioner
OPD practitioners x 22 x number of months in
day (physician, nurse, health officer)
reporting period]
per day
Doctors per bed The ratio of doctors per bed Number of doctors average number of beds
Nurses per bed The ratio of nurses per bed Number of nurses average number of beds
The ratio of other clinical staff per Number of other clinical staff average
Other clinical staff per bed
bed number of beds
COSTS
The total amount expensed for
Salary expenses as % of total salaries divided by the hospitals Total expenditure on salaries total hospital
expenses total operational expenditure operational expenditure x 100
during the reporting period
Proportion of hospital recurrent
% of hospital recurrent Amount of recurrent expenditure on
expenditures spent on
expenditure spent on administration total amount of recurrent
administration during reporting
administration expenditure x 100
period

The average cost for a patient
day equivalent. The Cost per
PDE is obtained by dividing the
total hospital operational costs by
Total operational costs [number of inpatient
Cost per patient-day equivalent the number of inpatient days plus
days + (OPD and ER visits/4)]
the number of OPD and ER visits
divided by four. It assumes that
the cost of one inpatient day is
equivalent to four OPD visits
% of Operational Standards of
% OF HOSPITAL REFORM the National Hospital Reform Number of standards met Total number of
STANDARDS MET Implementation Guidelines that standards x 100
are met
QUALITY INDICATORS
An infection occurring in a patient
in a hospital or other health care
facility in whom the infection was Number of patients with an infection arising
Healthcare acquired infection
not present or incubating at the >48 hours after admission total number of
rate
time of admission. Infections admissions x 100
occurring >48 hours after
admission.
% of deaths among admitted Number of IPD deaths Total number of
Inpatient mortality rate
inpatients admissions x 100
A chronic ulcer of the skin caused
Number of pressure sores number of
Pressure sore incidence rate by prolonged pressure on it (as
admissions x 100
in bedridden patients)
Proportion of discharged patients
who are re-admitted to hospital
for the same condition or a
Unplanned readmission rate
complication of that condition Number of unplanned readmissions Number
within 28 days following
within 28 days of discharge. of admitted patients x 100
discharge
Planned admissions (eg. for
further treatment or
investigations) are excluded
Average stock out duration is the
Drug stock out days of tracer number of days in which a tracer of stock out days of tracer drugs throughout
drugs drug was not available averaged reporting period total number of tracer drugs
over all tracer drugs.
Number of completed audit
Number of clinical audits Number of completed audit reports submitted
reports submitted to clinical audit
completed to clinical audit officer
officer
Number of occupational injuries Number of occupational injuries Number of occupational injuries reported to
reported reported to Incident Officer Incident Officer
FINANCE
REVENUE MIX
a.Revenue from Govt. allocation; and
Government allocation (% of Amount of govt. allocation (as a
b.Revenue from govt. allocation total
total revenue) % of total revenue)
revenue x 100
a.Revenue from private wing; and
Amount of private wing revenue
Private wing (%) b.Revenue from private wing total revenue
(as a % of total revenue)
x 100
a. Revenue from insurance payments; and
Amount of insurance payments
Insurance payment (%) b. Revenue from insurance payments total
revenue (as a % of total revenue)
revenue x 100
a.Revenue from patient fees; and
Non insurance patient fees Amount of patient fee revenue
b.Revenue from patient fees total revenue x
(%) (as a % of total revenue)
100
a.Revenue from other sources; and
Amount of revenue from other
Other sources (%) b.Revenue from other sources total revenue
sources (as a % of total revenue)
x 100

The % of operating revenue
[Total operating revenue - total operating
Operating margin remaining after all operating
expenses] total revenue x100
expenses are paid
Proportion of allocated heath
Ratio of health budget
budget that was utilized during Budget utilized budget allocated x 100
utilization to allocation
% of reimbursed amount out of Proportion of patient fees waived Amount of waived fees reimbursed amount
the patient total fees waived that were reimbursed. of fees waived x 100
PATIENT AND COMMUNITY PERSPECTIVE

Average rating of hospital on a
Inpatient overall rating of scores given number of inpatients
score of 0-10 from inpatient
hospital surveyed
satisfaction survey
% of respondents answering
'definitely yes' or 'probably yes' to
Number or respondents answering 'definitely'
Inpatients' willingness to the question "Would you
or 'probably' yes total number of inpatients
recommend hospital recommend this hospital to your
surveyed x 100
family/friends? from inpatient
satisfaction survey

Outpatient overall rating of scores given number of outpatients
score of 0-10 from outpatient
hospital surveyed
satisfaction survey
'definitely yes' or 'probably yes' to
Number or respondents answering 'definitely'
Outpatients' willingness to the question "Would you
or 'probably' yes total number of outpatients
recommend hospital recommend this hospital to your
surveyed x 100
family/friends?' from outpatient
satisfaction survey

Staff overall rating of hospital scores given number of staff surveyed
score of 0-10 from staff survey
'definitely yes' or 'probably yes' to Number or respondents answering 'definitely'
Staff willingness to recommend
the question "Would you or 'probably' yes total number of staff
hospital
recommend this hospital to your surveyed x 100
family/friends? from staff survey
Number of written complaints Total number of written complaints received by
Number of complaints received
received by hospital hospital
Number of complaints supported
% of complaints supported (upheld) by complaints review Number of complaints supported total
(upheld) committee as a % of all number of complaints received x 100
complaints
GROWTH AND INNOVATION
% of posts filled as per regional Proportion of posts filled as per Total number of posts filled total number of
standard regional standards. posts as per regional standard x 100
a.Number of physicians at end of reporting
a. Total number of physicians at period; and
Total number (Attrition rate) - end of period; and b.Number of physicians who left during
medical staff b. Proportion of physicians who reporting period total number of
left during reporting period physicians at beginning of reporting
period x 100
a.Number of HOs at end of reporting period;
a. Total number of HOs at end of
and
Total number (Attrition rate) - reporting period; and
b.Number of HOs who left during reporting
health officers b. Proportion of HOs who left
period total number of HOs at
beginning of reporting period x 100

a.Number of nurses at end of reporting period;
a. Total number of nurses at end
and
Total number (Attrition rate) - of reporting period; and
b.Number of nurses who left during reporting
nursing staff b. Proportion of HOs who left
period total number of nurses at
beginning of reporting period x 100
a. Total number of other clinical a.Number of other clinical staff at end of
staff at end of reporting reporting period; and
Total number (Attrition rate) period; and b.Number of other clinical staff who left during
other clinical staff b. Proportion of other clinical staff reporting period total number of other
who left during reporting clinical staff at beginning of reporting
period period x 100
a. Total number of non clinical a.Number of non clinical staff at end of
staff at end of reporting reporting period; and
Total number (Attrition rate) - period; and b.Number of non clinical staff who left during
non clinical staff b. Proportion of non clinical staff reporting period total number of non
who left during reporting clinical staff at beginning of reporting
period period x 100
Total number of staff who a.Total number of staff evaluated from
Cumulative number (%) of staff underwent performance beginning of year to end of reporting
who underwent performance evaluation from beginning of year period; and
evaluation to end of reporting period (as a % b. Total number of staff evaluated number of
of all staff) staff at beginning of year x 100
Total number of staff who a.Total number of staff trained from beginning
Cumulative number (%) of staff received training from beginning of year to end of reporting period; and
who received in service training of year to end of reporting period b.Total number of staff trained number of
(as a % of all staff) staff at beginning of year x 100
Number of functional computers

Number functional computers at the facility Number of functional computers

Appendix E Assessment Tool for Operational Standards of the National Hospital Reform Implementation Guidelines
CHAPTER 1. HOSPITAL LEADERSHIP AND GOVERNANCE

Std # Standard Method of evaluation Unmet Met Comments
1. The Hospital Governing Board is developed using clear and Interview CEO to identify process of Board selection and
transparent systems and processes and includes a representative appointment
sample of community members. Obtain list of Board members and confirm that there is
community representation
2. An assigned Board Chairperson leads and manages Board activities. Identify Board Chairperson
Confirm that he/she leads the Board by setting agendas,
calling Board meetings, creating goals for the Board
3. The Board selects the Chief Executive Officer (CEO), who leads on Interview CEO. Confirm that he/she was selected by
all Hospital operations and functions. Board
Review Job Description or duties of CEO
4. The Board approves annual and strategic plans for the Hospital to View strategic and annual plans
achieve its goal of improving its communitys health and welfare. Confirm that both were approved by Board (by reviewing
Board minutes, or confirming signature of CEO or
Board Chair on plans)
5. The Board has open communication via effective and regular View minutes of previous 3 Board meetings
meetings and written minutes of meetings, which are reviewed and Confirm that approval of previous meeting minutes is
approved by vote of the Board members. documented in minutes of subsequent meeting
Interview CEO check frequency and regularity of
Board meetings
6. The CEO is evaluated annually, consistent with FMOH or Regional View most recent evaluation of CEO
Legislation to ensure he/she is meeting operational and strategic Confirm that evaluation conducted within past year
plans as established by the Board and the CEO collectively.
TOTAL ______ ______
Chapter 13 Monitoring and Reporting Appendix E: Page 1 of 19

CHAPTER 2. PATIENT FLOW
Std# Standard Method of Evaluation Unmet Met Comments
1. Procedures are established to ensure efficient patient flow; such Obtain a copy of the following protocols:
procedures are specific to emergency, outpatient, and inpatient o Triage
settings and seek to reduce patient crowding. o Admission
o Discharge
o Referral
o Hospital access/security
o Appointment systems
2. The Hospital has Emergency triage, staffed with appropriately Confirm that the hospital has an emergency triage by
trained personnel and equipped with necessary equipment and visiting the site.
supplies View emergency triage protocol
Interview Emergency triage officer to assess staff
training and equipment/supply availability in triage area
3. The Hospital has a Central triage, staffed with appropriately trained Confirm that hospital has a Central triage by visiting the
equipped with necessary equipment and supplies site.
View Central Triage protocol
Interview Central triage officer to determine if staff have
received training in triage and confirm that necessary
equipment/supplies are available in the triage area
4. All patients (except labouring mothers, patients with an appointment Review triage protocol
for an outpatient clinic or admission) undergo triage. Interview Triage Officer (s) to determine the types of
patients who undergo triage
5. Outpatient appointment systems are in place for all disciplines Confirm that an outpatient appointment system exists by
provided by the hospital. reviewing patient appointment book.
6. Appointment systems are in place for elective inpatient admissions Confirm that an elective inpatient appointment system
in all disciplines that are provided by the hospital. exists by reviewing patient appointment book.
7. The hospital has a Liaison and Referral service that: Identify Liaison and Referral officer in the hospital
a) Manages bed occupancy Interview the Liaison and Referral officer and confirm
b) Facilitates emergency and non-emergency (elective) that he/she:
admissions o tracks the bed occupancy rate in the hospital
c) Receives referrals from, and makes referrals to, other o facilitates admissions
facilities in the referral network o manages referrals
8. The Hospital has written protocols for the admission and discharge Identify written protocols for patient admission and
of patients that are known, and adhered to, by all relevant staff. discharge

Interview 3 random members of inpatient case team and
confirm that they know the criteria for admission and
discharge
9. The Hospital has a Referrals Service Directory, listing facilities Obtain a copy of the referrals directory and verify that it
which the Hospital may refer patients to or receive patients from, includes a list of facilities which the hospital may refer
categorized by the type of clinical services which they provide. to or receive patients from as well as the clinical services
provided.
10. Criteria for the referral of patients from the Hospital to other health Identify written protocol for the referral process and
facilities are established, including standardized referral and documentation including:
feedback forms and necessary clinical documents to accompany o Criteria for referrals
referred patients, in accordance with the national referral o Standardized forms
implementation guidelines.
11. The hospital has a standardized method for managing referrals. Obtain a copy of the hospitals referral protocol.
Obtain documentary evidence of tracking system (for
example referral log book or database).
12. Hospital staff members are familiar with the referral systems Interview 3 random staff members from inpatient,
including relevant referral protocol and forms. outpatient and emergency case team and ask them to
describe the hospitals referral protocol.
All interviewed staff should be familiar with and able to
fully explain the referral system as per hospital protocol.
13. The Hospital promotes and publicizes the referral system throughout Interview CEO or Liaison and Referral Officer to
the community in order to ensure all constituents are aware of the identify the methods by which the hospital promotes and
applicable service pathway. publicizes the referral system throughout the community
TOTAL ______ ______
CHAPTER 3. MEDICAL RECORDS MANAGEMENT

Std # Standard Method of Evaluation Unmet Met Comments
1. The Hospital utilizes a Master Patient Index with a single, unique Identify the Master Patient Index
Medical Record Number for each patient. Verify that unique medical record numbers are given
to all patients.
2. The Hospital utilizes a single, unified registration system for all Interview Head of Medical Records Department (or
patients, including in-patients, out-patients, emergency patients, and equivalent) and confirm that only one registration
specialty clinics. system exists for ALL patients, including inpatients,
outpatients, emergency patients, and specialty clinic
patients.

3. The Hospital utilizes a paper-based or computer-based system to View MR tracking system.
track where the medical record is located at all times.
4. The Hospital utilizes a uniform set of forms that comprise a Verify that medical record guideline outlines the set of
complete medical record for the duration of a patients care. forms that must be included in each medical record.
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 has medical records management guidelines for proper Obtain copy of written guidelines for handling and
handling and confidentiality of medical records. confidentiality of medical records.
6. The Hospital has orientation and training program for all medical Review outline of or documents used in new hire
records personnel to ensure awareness of and competency in medical orientation program.
record management procedures. Obtain documentary evidence that all MR personnel have
completed the orientation and training program
TOTAL ______ ______
CHAPTER 4. PHARMACY SERVICES

1. The Hospital has a Drug and Therapeutics Committee which Review DTC TOR and confirm that responsibilities
implements measures to promote the rational and cost-effective use include as a minimum: development of the Hospital
of medicines. Formulary; development of standard treatment
guidelines; development of policies and guidelines for
managing formulary and non-formulary items,
establishing mechanisms to identify and address drug
use problems, and establishing and overseeing the
Drug Information Service.
2. The Hospital has a Medicines Formulary listing all pharmaceuticals Obtain copy of Hospital Formulary. Check date of
that can be used in the facility. The Formulary is reviewed and creation or date of most recent update/review and
updated annually. confirm this was undertaken within past year.
3. The hospital has outpatient, inpatient, emergency pharmacies and a Interview CEO. Confirm that the hospital has outpatient,
central medical store each directed by a registered pharmacist. inpatient and emergency room pharmacies and a
pharmacy store. Obtain the names and qualifications of
the individual(s) in charge of each. Confirm that the
individuals in charge are registered BSC Pharmacists.
4. The Hospital ensures that all types of drug transactions and patient- Select random sample of 10 inpatient records and check
medication related information are properly recorded and that there is a Medication Administration Record and

documented. that all drugs administered have been signed by the
administering health professional.
Interview CEO or senior pharmacist in each case team
and confirm that medications are dispensed only with a
signed prescription. Visit each dispensing unit and
confirm that a Prescription Registration Book is
maintained in each.
5. The Hospital has SOPs for all compounding procedures carried out. Obtain list of all compounding procedures carried out and
view a copy of the SOP for each.
6. The Hospital provides access to drug information to both health care Visit Drug Information Centre.
providers and patients in order to optimize drug use. Interview pharmacist in charge to confirm that the
service is available to staff and patients.
7. The Hospital has policies and procedures for identifying and Obtain copy of policies for monitoring adverse drug
managing drug-use problems, including: monitoring adverse drug reactions, prescription monitoring and drug utilization
reactions, prescription monitoring and drug utilization monitoring. monitoring.
8. The Hospital has a drug procurement policy approved by the DTC Obtain a copy of the drug procurement policy.
that describes methods of quantification, prioritization, drug Ensure that policy describes methods of quantification,
selection, supplier selection and ordering of pharmaceutical supplies. prioritization, drug selection, supplier selection and
ordering of pharmaceutical supplies.
9. The Hospital has a paper-based or computer-based inventory View inventory management system and confirm that this
management system to reduce the frequency of stock-outs, wastage, contains mechanisms to monitor stock levels and
over supply and drug expiry. prompt for ordering when supplies reach a
predetermined level.
Interview Storeroom Manager (or equivalent) to confirm
that all pharmaceutical products are included in the
inventory.
10. The Hospital conducts a physical inventory of all pharmaceuticals in View copy of physical inventory report. Confirm this was
the store and each dispensing unit at a minimum once a year. conducted within the past one year.
11. The Hospital ensures proper and safe disposal of pharmaceutical View protocol for disposal of pharmaceutical waste.
wastes and expired drugs.
12. The Hospital has adequate personnel, equipment, premises and Observe the inpatient, outpatient, emergency pharmacies
facilities required to store pharmaceutical supplies and carryout and central store and interview pharmacists in charge
compounding, dispensing, and counseling services. to ensure that each has appropriate space to perform
duties, store drugs and supplies.
TOTAL ______ _____

CHAPTER 5. LABORATORY
1. A current list of laboratory tests provided by the facility and the View list of tests and prices.
price of each test is accessible to all clinical staff and patients. Visit various clinical service areas (eg OPD, ER) and
confirm that copies of the tests and price of each are
available.
2. Laboratory management ensures that advice on examinations and the Interview Case Team Heads (inpatient, outpatient,
interpretation of test results is available to meet the needs and emergency). Confirm that laboratory advice on
requirements of customers. examinations and interpretation of tests is provide to
case teams as required.
3. Hospital management ensures that the Hospital laboratory has the Interview Case Team Heads (inpatient, outpatient,
necessary space, working environment, reagents, consumables, emergency). Confirm that the space provided within
analyzers and associated equipment needed to conduct the required each laboratory area is sufficient for needs.
repertoire of tests.
4. Interview laboratory technician in each case team
Laboratory staff members monitor stocks of testing reagents and (inpatient, outpatient, emergency). Verify that a
other consumables so that supplies are ordered early and in sufficient process to prevent stock out or oversupply is
quantity to prevent stock-outs or oversupply. implemented in each case team laboratory.
5. Obtain list of laboratory tests.
The Hospital Laboratory has available and follows standard View all SOPs. Confirm that an SOP exists for all tests
operating procedures for: conducted, for specimen management, testing
algorithms, safety procedures and waste management
a.Specimen management
and quality assurance processes.
b. All testing procedures
Visit each laboratory (inpatient, outpatient, ER). Select
c.Testing algorithms
two items of equipment. Confirm that an SOP is
d. Safety procedures and waste management
located beside each piece of equipment.
e.The maintenance and monitoring of each piece of equipment
f. Quality assurance procedures
6. The Hospital has policies and procedures in place for sample View policy.
collection, transport and disposal.
7. The central laboratory has functional overview of all hospital View organization chart.
laboratories (e.g. emergency room laboratory, in-patient laboratory Interview senior staff member of Central Laboratory and
etc). confirm that Central Lab has functional overview of all
laboratory services.
8. The laboratory work environment is organized and clean at all times, Inspect inpatient, outpatient and emergency laboratory
with safety procedures for handling of specimens and waste material areas for cleanliness and tidiness.

to ensure patient and staff protection from unnecessary risks at all
times.
9. View health and safety manual and check that this
The laboratory has a health and safety manual with procedures that
includes: action in the event of a fire, action in the
include: action in the event of a fire, action in the event of a major event of a major spillage of dangerous chemicals or
spillage of dangerous chemicals or clinical material; action in the clinical material; action in the event of an inoculation
event of an inoculation accident; reporting and monitoring of accident; reporting and monitoring of accidents and
accidents and incidents; disinfection processes; decontamination of incidents; disinfection processes; decontamination of
equipment; chemical handling; storage and disposal of waste. equipment; chemical handling; storage and disposal of
waste.
10. Laboratory management establishes a policy for the management of View data management policy. Confirm that this
data and information that includes: addresses: security, access, confidentiality and data
protection, backup system, storage, archive and
security retrieval and data destruction.
access (including level of access)
confidentiality and data protection
backup system
storage, archive and retrieval
data destruction
11. The laboratory has and implements a quality assurance policy that View quality assurance policy. Confirm this addresses pre
covers all aspects of laboratory functions. analytical, analytical and post analytical quality
assurance.
Request external QA reports. Confirm laboratory takes
part in external QA activities.
Request internal QA reports to confirm that laboratory
conducts internal QA activities.
TOTAL _____ ______
CHAPTER 6. NURSING CARE STANDARDS

1. The Hospital has established management structures and job Identify organizational structures within nursing.
descriptions that detail the roles and responsibilities of each nursing Identify job descriptions for nurses and verify that they
professional, including reporting relationships. include responsibilities and reporting relationships.
2. The hospital has a nursing workforce plan that addresses nurse Obtain copy of nursing staffing plan and confirm this
staffing requirements and sets minimum nurse to patient ratios in establishes nurse to patient ratios for each service area
each service area. (e.g. inpatient wards, ER, surgical suite, labour and
delivery). 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 Identify written policies that describe the nursing
nurses for the nursing process including the admission assessment, process.
planning, implementation and evaluation of nursing care. Verify that the following are addressed:
o Nursing admission assessment
o Nursing care planning, implementation and
evaluation
4. All admitted patients have a nursing care plan that describes holistic Select a random sample of 10 inpatient records from
nursing interventions to address their needs. The plan is regularly different wards. Confirm that each contains a nursing
reviewed and updated as required. care plan.
5. The Hospital has established guidelines for verbal and written Identify written guidelines for nurses verbal and
communication about patient care that involves nurses, including written communication about patient care.
verbal orders.
6. The Hospital has standardized procedures for the safe and proper Identify written procedures for process of medication
administration of medications by nurses or designated clinical staff. 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.
TOTAL _____ ______
CHAPTER 7. INFECTION PREVENTION AND CONTROL

1. Hospital Management to supports improvement efforts in infection Interview IP lead or chair of IP committee. Confirm that
prevention by ensuring that operational and technical capacity, hospital management supports IP activities by
financial and human resources required to adhere to infection assigning adequate budget and personnel for the IP
prevention guidelines are available. program.
2. A designated group and/or individual(s) are in place to effectively Identify individual(s) responsible for IP activities and
implement and monitor infection prevention and control activities. review the job description or terms of
reference/responsibilities of the individual or group.
3. The Hospital has an operational plan for the implementation of Obtain operational plan for infection prevention
infection prevention activities. The plan follows national guidelines guidelines.

and includes guidance on infection prevention practice and Verify that the plan was developed based on national
procedures and materials. guidelines.
4. Standard practices that prevent, control and reduce risk of hospital Review policy/protocol for IP and confirm that this
acquired infection are in place. describes Standard Precautions.
Interview Case Team Heads and confirm that Standard
Precautions are implemented by staff.
5. The Hospital has an adequate plan to address transmission based Review policy/protocol for IP and confirm that this
precautions for staff, patients, caregivers and visitors. describes transmission based precautions
Interview Case Team Heads and confirm that Standard
Precautions are implemented by staff.
6. The Hospital ensures that equipment, supplies and Interview Head of each Case Team and confirm that:
facilities/infrastructure necessary for infection prevention and sufficient PEP materials are available within case team;
control are available. that water is available in all patient contact areas.
Interview the Heads of Housekeeping and Laundry (or
equivalent) and confirm that sufficient equipment,
cleaning materials and linens are available. Confirm
that the hospital has a functioning incinerator.
7. All hospital staff are trained using standard infection prevention View IP training materials.
training materials. Obtain Documentary evidence that all staff members have
been trained in IP.
8. The Hospital provides health education to patients, caregivers and Interview Case Team Leaders and confirm that each Case
visitors, as appropriate on infection prevention and control practices Team provides health education to patients, caregivers
and visitors, as appropriate on infection prevention and
control practices.
TOTAL ______ ______
CHAPTER 8. FACILITIES MANAGEMENT

1. The Hospital complies with relevant laws, regulations, and facility Interview CEO to identify any relevant laws, regulations
inspection requirements. or inspection requirements and confirm that the
hospital complies with these.
2. Designated Hospital staff members are assigned for facility View organization chart.
maintenance and safety functions. 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 Interview Facilities Manager (or equivalent). Check
appropriate, improved to ensure cleanliness of grounds and safety of process/schedule for grounds inspection and
patients, visitors and staff. maintenance.
View patient and staff areas (garden, waiting areas etc).
Confirm that these are tidy, clean and free from
hazards (eg discarded equipment or other materials).
4. Potable water is available 24 hours a day, seven days a week through Interview CEO or Head of Facilities. Confirm that an
regular or alternate sources to meet essential patient care. alternative source of water exists (eg 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 Interview CEO or Head of Facilities. Confirm that an
through regular or alternate sources to meet essential patient care. 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 centre with technical personnel, View maintenance center. Confirm that this has adequate
sufficient space and adequate ventilation to conduct maintenance and space and is not crowded. Confirm that the medical
repair work on the facility operating systems (e.g., electrical, water, equipment service are is separated from the general
sanitation, sewerage and ventilation) and equipment. This includes maintenance area. Confirm that there are hand-washing
proper hand washing facilities, proper disinfection and cleaning of facilities, facilities for cleaning and disinfection, a
equipment facilities, a storage area, and a library. storage area and a library.
7. The centre has appropriate tools and testing equipment to perform Interview Head of Maintenance Dept (or equivalent).
repairs, as well as procedures to ensure the routine calibration of the Confirm that sufficient tools are available for all
testing equipment is performed as required. maintenance functions and that routine calibration of
testing equipment is performed as required.
8. The Hospital conducts regular preventive and corrective Interview Head of Maintenance Dept (or equivalent).
maintenance for all facilities and operating systems (e.g., electrical, Confirm that regular preventive and corrective
water, sanitation, sewerage and ventilation) to ensure patient and maintenance is conducted.
staff safety and comfort. 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 Interview Head of Maintenance Dept (or equivalent).

operating system (e.g., electrical, water, sanitation, sewerage and Confirm that a notification and work order system
ventilation) repairs. 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 View transport policy.
hospital vehicles. 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 View fire safety plan.
and response to fires. A Fire and Evacuation Drill is conducted at Obtain documented evidence of most recent Fire Drill and
least annually. confirm that this was conducted within the past one
year.
13. The Hospital has a plan for responding to likely community or View response plan.
hospital emergencies, epidemics and natural or other disasters.
14. Staff members are trained and knowledgeable about their roles in the Interview 10 randomly selected staff members from
plans for fire safety, security, hazardous materials, and emergencies. different Case Teams. Confirm that each one knows
what action to take and their individual responsibility
in the event of a fire, security threat or other
emergency.
TOTAL ______ ______

CHAPTER 9. MEDICAL EQUIPMENT MANAGEMENT
1. The Hospital has a Medical Equipment Committee composed of Review MEC TOR and ensure the following
doctors, nurses, technicians, pharmacists, and administrative responsibilities are included: develop and monitor
personnel that oversees the medical equipment management implementation of medical equipment strategy; oversee
program. 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.
2. The Hospital has a paper-based or computer-based inventory View inventory management system and confirm updated
management system that tracks all equipment included in the within past year.
equipment management program. Confirm (by interview with Head of Equipment
Maintenance (or equivalent)) that all medical
equipment in the equipment management program is
listed in the inventory.
3. The Hospital has a paper-based or computer-based spare parts View inventory management system.
inventory management system. The system is used for ensuring that Confirm (by interview with Head of Equipment
there is an adequate supply of spare parts on hand. Maintenance (or equivalent)) that the inventory system
is used to manage the stock of spare parts.
4. An Equipment History File is maintained for all medical equipment Take a random sample of 10 Equipment History Files and
containing all key documents for the equipment. check that each includes: SOP for equipment use,
inventory data collection form and risk assessment
form.
5. The Hospital has policies and procedures in place for acquisition of Obtain copy of policies and procedures for medical
new medical equipment, commissioning, decommissioning and equipment management and verify that they address
disposal of equipment, the receipt of donations, and outsourcing acquisition, commissioning, decommissioning,
technical services. disposal, donations, and outsourcing technical services.
6. All new equipment undergoes acceptance testing prior to its initial Request list of all equipment purchased in the past year.
use to ensure the equipment is in good operating condition. Randomly select 10 items (or all items if less than 10
Equipment is installed and commissioned in accordance with the were purchased) and review Equipment Log File.
manufacturers specifications. Confirm that this contains a copy of the Acceptance
Test Log Form.

7. All equipment users are appropriately trained on the operation and Visit a minimum of 3 different departments/case teams
maintenance of medical equipment with standard operating (for example ER, laboratory, pharmacy, delivery,
procedures readily available to the user. 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.
8. There is a schedule for inspection, testing and preventive See 6.4 above. For the 10 randomly selected Equipment
maintenance for each piece of equipment as guided by the History Files confirm that the schedule for Inspection,
manufacturers recommendations and that schedule is appropriately testing, and maintenance is present in the equipment
implemented. history file and confirm that inspection, testing and
maintenance has been conducted as described in the
schedule.
9. The Hospital has a notification and work order system for the repair Identify written protocol for medical equipment work
of medical equipment. orders.
Review at least 5 copies of notification and work order
and reports.
TOTAL ______ ______
CHAPTER 10. FINANCIAL AND ASSET MANAGEMENT

1. Bilingual fee posters are displayed beside each departmental Visit different departments (OPD, ER, inpatient wards
reception desk, in all waiting areas and at all cash points. Each and cash collection points) and confirm that bilingual
poster shows the fees and exemptions and advises patients to obtain fee posters are clearly displayed.
and keep receipts for all payments. Confirm that the poster shows fees, exemptions and
advises patients to keep receipts for all payments.
2. The hospital Accountant prepares a monthly report for the Hospital View last 3 Financial Statements.
Management with details of credit granted, credit repaid and balance Confirm that these are monthly reports.
outstanding. Confirm that each provides details of credit granted,
credit repaid and balance outstanding.
3. The hospital has a procurement policy, approved by the Senior View policy. Confirm that it details the process of
Management Team that details: submitting procurement requests, the responsible
The process of submitting procurement requests body/person for approval of procurement requests, the
The responsible body/person for approval of procurement means of procuring and the responsible person(s) for
requests purchasing activities.
Responsible person(s) for purchasing activities
4. Monthly reconciliation is undertaken for every hospital bank account Obtain list of all bank accounts and donor grants.

and any donor grants. View reconciliation documents for last 3 months. Confirm
that reconciliation has been done for all accounts and
grants. Confirm that each, reconciliation is signed by
Accountant.
5. Monthly and quarterly reports on revenue, expenditures, receivables, View most recent 3 reports from Finance Dept to Senior
payables, trial balance, the status of budget utilization and others Management and Governing Board.
including the hospitals operating margin are prepared by the Confirm that these are monthly reports.
Finance Department and submitted to the hospital management and Confirm that reports contains details of revenue,
Governing Board. expenditures, receivables, payables, trial balance, status
of budget utilization and operating margin.
6. Internal and external audit of hospital accounts is conducted as a View most recent internal and external audit reports.
minimum annually and audit reports are reviewed by the Governing Confirm this each has been conducted within past year.
Board. Confirm that each was reviewed by the Governing Board
(by reviewing Board minutes)
7. The hospital has a Memorandum of Understanding with Waiver Obtain list of all authorities with which hospital has Fee
Certificate Granting Authorities providing details on the type of Waiving agreement.
service and mode of payment. Confirm there is an MOU with each authority.
Confirm the MOU details the type of services to be
provided through Fee Waivers and the mode of
payment.
8. The hospital provides exempted services in accordance with the Obtain relevant Regional Health Care Finance Reform
relevant Regional Legislation and displays a list of exempted Directive.
services at appropriate locations through the hospital for the Obtain list from CEO of all exempted services that are
information of patients, staff and the public. provided by the hospital.
Confirm that the list presented by the CEO matches the
exempted service list in the Regional Directive.
Visit various patient services areas (OPD, ER, MCH,
wards) and confirm that a list of exempted services is
posted at each site.
9. In hospitals where a private wing is established, the operations of the Verify if the hospital has a private wing.
private wing are governed by policies and procedures that are If yes, view policies and procedures.
approved by the Governing Board. Confirm (by reviewing Board minutes or by signature of
Board Chairman on relevant documents) that the
policies and procedures are approved by the Governing
Board.
10. In cases where non-clinical services are outsourced, procedures are Verify if any services are outsourced.
in place to monitor the contract and services provided. If yes, obtain list of outsourced services.
View contract for each outsourced service.
Confirm that there is a manager assigned by the
contacting firm for each outsourced service.
Confirm that a hospital manager is assigned to monitor

each outsourced contract and that clear methods of
monitoring are documented and adhered to (eg
evidence of quality of service provided, adherence to
agreed deliverables etc).
11. There is a current hospital accounting manual which establishes all View accounting manual and confirm it describes policies
policies and procedures relating to financial management in the and procedures for financial management.
hospital.
TOTAL _____ ______
CHAPTER 11. HUMAN RESOURCE MANAGEMENT

1. The Hospital has a Human Resource Case Team staffed by Identify designated staff members of the HR case team
individuals with management skills and experience dealing with Check experience of case team members and confirm
individual personnel matters. that personnel staff have requisite skills (training and
personnel management experience).
2. The Human Resources Case Team maintains a personnel file for Interview Head of HR Case Team. Confirm that the
each and every hospital employee. 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 Human Resource Head (or equivalent) is on the Hospitals Obtain list of SMT members from CEO and confirm
Senior Management Team. that Head of HR Case Team is a member.
4. The Hospital has a human resource development plan that addresses Review a copy of the human resource development
staff numbers, skill mix, and staff training and development plan.
Ensure that it addresses staff numbers, skill mix and
staff training and development.
5. Each employees responsibilities are defined a current job See standard 11.2 above. Confirm that the 10 randomly
description which has been signed by the employee and filed in the selected files contain a signed employee job
personnel file. description.
6. The Hospital has policies and procedures for recruiting and hiring Identify written policies for recruiting and hiring staff.
staff
7. The Human Resource Case Team provides services to employees to Identify documented policies that support employee
ensure satisfactory productivity, motivation, morale as evidenced by motivation and retention including as a minimum:
effective policies and procedures for personnel retention, policy for compensation and benefits, training and
compensation and benefits, training and development and employee development and employee recognition.

recognition
8. HR policies are documented in an Employee Manual that is Obtain a copy of the hospitals Employee Manual
distributed to all staff and updated, at a minimum, every 3 years. The Ensure that it contains Hospital personnel policies and
Employee Manual contains policies and procedures that define procedures such as working hours, leave, benefits.
employee/employer relations. 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.
9. The Hospital has an Employee Code of Conduct that is known and Obtain a copy of employee code of conduct.
adhered to by staff. 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.
10. The Hospital has a performance management process in which all See Standard 11.2 above. Confirm that the 10 randomly
employees are formally evaluated at least annually and action plans sampled files contain a performance evaluation
for improved performance are documented. 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 performance.
11. The hospital regularly conducts a staff survey to assess staff View results of last staff survey.
perspectives on the workplace. Summary results are presented to the Confirm that survey conducted within last 6 months.
Senior Management Team and Governing Board.
12. ID badges and appropriate uniforms are worn by employees at all Observation. Confirm that each staff member
times. interviewed or observed in the course of the
assessment is wearing an ID badge and uniform
13. The Hospital has occupational health and safety policies and Obtain a copy of occupational health and safety policies
procedures to identify and address health and safety risks to staff. and procedures.
TOTAL ______ ______

CHAPTER 12. QUALITY MANAGEMENT
1. The hospital has a Quality Committee that is responsible to devise View TOR and list of members of Quality Committee.
and implement a Strategy for Quality Management. View Quality Management strategy. Ensure that 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 CEO or documentary
evidence) that reports on implementation of QM
strategy are received by Senior Management Team.
2. Procedures are established to assess and minimize risk arising from View risk assessments of inpatient, outpatient and ER
the provision and delivery of healthcare. case teams.
Check date of risk assessment and confirm conducted
within the previous 1 year.
3. Procedures are established for reporting and analyzing incidents, Confirm that the hospital has an Incident Officer who has
errors and near misses. a job description that outlines his/her duties in relation
to Incident Investigation and management.
View two recent Incident Reports and confirm that the
reported incidents were investigated and any necessary
follow up action documented by the Incident Officer.
4. Procedures are established to monitor clinical outcome measures and Interview chair of QC and ask for list of clinical outcome
to take action to address any problems identified. Such procedures measures that are monitored regularly.
encourage the participation of all clinical staff. Ask chair of QC to show the most recent results of at least
3 clinical outcome measures.
Determine (by interview with Chair of QC) that
appropriate action was taken in response to the
outcome measures.
5. The hospital adopts a statement of patient rights and responsibilities, View statement of patient rights and responsibilities.
which is posted in public places in the hospital. Visit patient service areas (as a minimum OPD, ER and
inpatient wards) and confirm that statement is clearly
displayed.
6. The hospital monitors patients experiences with care through patient View results of last patient satisfaction survey.

satisfaction surveys conducted on a biannual basis. Confirm that survey conducted within last 6 months.
7. The hospital implements a strategy for the involvement of patients View strategy.
and the public in service design and delivery including procedures to Confirm (by interview with CEO or Chair of QC) that at
be followed when engaging with patients and the public. 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 participates in benchmarking activities to learn from Confirm (by interview with CEO or other documented
and share good practice with other hospitals. evidence) that hospital participates in benchmarking
activities. For example regular attendance at regional
hospital/RHB meetings; participation in hospital cluster
activities etc.
TOTAL _____ ______
CHAPTER 13. MONITORING AND REPORTING

1. The hospital has an HMIS Monitoring Team (or equivalent) that 1. Interview CEO. Confirm that HMIS Performance
reviews HMIS indicators and takes action to address any areas of Monitoring Team (or equivalent) is in place.
concern. 2. View TOR of HMIS Monitoring Team to confirm that
role includes review of indicators.
3. View minutes of last 3 HMIS performance monitoring
team meetings to confirm that HMIS indicators are
reviewed and action taken as a result.
2. The hospital conducts a self assessment of its own performance at a View copy of last 3 self assessment meetings. Confirm that
minimum every quarter, using HMIS indicators and any additional frequency was at least quarterly.
local indicators determined by hospital management.
3. The hospital submits monthly, quarterly and annual HMIS reports to View HMIS reports for last year. Confirm that monthly,
the relevant higher office within the agreed time limit. quarterly and annual reports were submitted as per
schedule.
4. The correspondence between data reported on HMIS forms and data View LQAS result on last 3 HMIS reports. Confirm LQAS
recorded in registers and patient / client records, as measured by a is > 80%.

Lot Quality Assurance Sample (LQAS) is 80%.
5. In collaboration with the CEO, the Governing Board has established 1. View list of BSC indicators.
performance indicators for the hospital that are described in a 2. View last 3 BSC reports submitted to Governing Board.
Balanced Scorecard (BSC). BSC reports are presented by the CEO Confirm that frequency of BSC reports to Governing
to the Governing Board as a minimum every quarter. Board was quarterly as a minimum.
6. Indicators included in the BSC are a combination of View list of BSC indicators and confirm that some are
national/regional indicators and other local indicators as determined national indicators (HMIS) while others are local indicators
by the Governing Board. set by the Governing Board.
7. Hospital staff are oriented to the BSC and case teams/departments Identify BSC reports for 3 different case teams (for
determine indicators and monitor their own performance using the example Emergency Case Team, Inpatient Case Team,
BSC. Outpatient Case Team, Finance and Procurement Case
Team, Human Resource Case Team etc).
TOTAL _____ ______

Hospital Reform Implementation Guidelines - All

Uploaded by

Copyright:

Available Formats

Hospital Reform Implementation Guidelines - All

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hospital Reform Implementation Guidelines - All

Uploaded by

Copyright:

Available Formats

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

NATIONAL HOSPITAL REFORM IMPLEMENTATION

Ethiopian Hospital Management Initiative

National Hospital Reform Implementation

Ethiopian Hospital Management Initiative

Hon. Minister Tedros Adhanom Ghebreyesus (PhD)

Hospital Leadership and Governance and Quality Management

Medical Record Management

Infection Prevention and Control

Financial and Asset Management

Human Resource Management

Federal Democratic Republic of Ethiopia Ministry of Health,

Clinton Health Access Initiative

Chapter 1. Hospital Leadership and Governance

Chapter 2. Patient Flow

Chapter 3. Medical Record Management

Chapter 4. Pharmacy Services

Chapter 5. Laboratory Services

Chapter 6. Nursing Care Standards

Chapter 7. Infection Prevention and Control

Chapter 8. Facilities Management

Chapter 9. Medical Equipment Management

Chapter 10. Financial and Asset Management

Chapter 11. Human Resource Management

Chapter 12. Quality Management

Chapter 13. Monitoring and Reporting

Section 2 Operational Standards for Hospital Leadership and Governance 4

Section 3 Implementation Guidance 5

3.1 Practical tools of leadership and management 5

3.2 Governing Board 14

3.3 Chief Executive Officer 24

3.4 Hospital Senior Management Team 27

3.5 Strategic and annual planning 31

3.6 Essential service package 33

Section 4 Implementation Checklist and Indicators 33

4.1 Assessment tool for Operational Standards 33

Chapter 1 Hospital Leadership and Governance Page 2 of 36

Box A Monitoring and Evaluation

Chapter 1 Hospital Leadership and Governance Page 3 of 36

Effective hospital governance requires:

Section 2 Operational Standards for Hospital Leadership and

Chapter 1 Hospital Leadership and Governance Page 4 of 36

Section 3 Implementation Guidance

Step 1 Define the problem,

Step 1: Define the problem

To devise a good problem statement the following should be considered:

Chapter 1 Hospital Leadership and Governance Page 5 of 36

Figure 1 Common Mistakes and Suggestions for Problem Statements

Weak Problem Statement Suggestions for Improvement Strong Problem Statement

Step 2: Set the overall objective

Chapter 1 Hospital Leadership and Governance Page 6 of 36

Relating the problem statement, objective and target

Step 3: Conduct a Root Cause Analysis

Figure 3 Sample Fishbone Diagram

Chapter 1 Hospital Leadership and Governance Page 7 of 36

Fishbone diagramming is useful for a number of reasons:

Ranking Matrix of Root Causes

Chapter 1 Hospital Leadership and Governance Page 8 of 36

Cost-benefit: Cost-Benefit (indicated by black text) is a measure of how difficult or costly it