National Minimum

Standard for
Comprehensive
Specialized Hospitals

Food, Medicine and Health Care

Administration and Control
Authority

October 2011

Addis Ababa, Ethiopia

 Tables of Content
Contents Page
Tables of Content ...............................................................................................................................2
Foreword..............................................................................................................................................6
Acknowledgement.............................................................................................................................7
Introduction ........................................................................................................................................8
Information and Complaint Procedures .................................................................................. 10
Section 1: General Provisions...................................................................................................... 12
1.1 General............................................................................................................... 12
1.2 General Definitions........................................................................................... 12
1.3 Scope of Application ......................................................................................... 13
1.4 Objectives .......................................................................................................... 13
Section 2: Licensure ....................................................................................................................... 14
2.1 Application for Licensure................................................................................. 14
2.2 Initial Licensure ................................................................................................ 15
2.3 License Renewal Requirements ...................................................................... 16
2.4 Removal Permits, Change of Operation and Forfeiture of License............... 17
2.5 Denial, Suspension and Revocation of a License............................................ 18
2.6 Right to Fair Hearing ........................................................................................ 20
2.7 Information to be disclosed ............................................................................. 20
Section 3: Governance ................................................................................................................... 21
3.1 Governing Board............................................................................................... 21
3.2 Chief Executive Officer ..................................................................................... 23
3.3 Chief Clinical Officer ......................................................................................... 23
3.4 Management Committee .................................................................................. 24
Section 4: Patient Rights and Responsibilities ...................................................................... 25
4.1 Informed Consent ............................................................................................. 25
4.2 Patient Rights.................................................................................................... 26
4.3 Patient Responsibilities.................................................................................... 30
Section 5: Human Resource Management ............................................................................... 32
5.1. General Requirements...................................................................................... 32
5.2. Staffing Plan ...................................................................................................... 33
5.3. Job Description and Orientations .................................................................... 34
5.4. Staff Education: ................................................................................................. 35
5.5. Medical Staff...................................................................................................... 36
5.6. Availability of Physicians ................................................................................. 36
5.7. Employee’s Health ............................................................................................ 37
5.8. Dress Code and Employee Identification Badge ............................................ 39
Section 6: Service Standards........................................................................................................ 40
6.1 Nursing Services ............................................................................................... 40
6.2 Patient flow ....................................................................................................... 51
6.3 Outpatient Services .......................................................................................... 52
6.4 Inpatient Services ............................................................................................. 55
6.5 Emergency Services.......................................................................................... 59
6.6 Internal Medicine Services............................................................................... 64
6.7 Pediatric Services ............................................................................................. 70

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 6.8 Surgical Care Services ...................................................................................... 78
6.9 Orthopedic surgical Care Services................................................................. 104
6.10 Gynecology and Obstetrics Care Services ................................................. 126
6.11 Anesthesia Services .................................................................................... 150
6.12 Intensive Care (IC) Services ....................................................................... 161
6.13 Dentistry Services ....................................................................................... 168
6.14 Otorhinolaryngology (ORL Services) ........................................................ 186
6.15 Ophthalmology Services............................................................................. 191
6.16 Mental Health Care Services ...................................................................... 197
6.17 Dermatology Services ................................................................................. 205
6.18 Cardiac Services .......................................................................................... 212
6.19 Neurology service ....................................................................................... 229
6.20 Gastroenterology ........................................................................................ 233
6.21 Renal Services ............................................................................................. 237
6.22 Rehabilitation Services ............................................................................... 242
6.23 Oncology Services ....................................................................................... 246
6.24 Nuclear Medicine Services ......................................................................... 256
6.25 Hemo-Dialysis Service ................................................................................ 266
6.26 Radiological Services .................................................................................. 269
6.27 Pathology Services ...................................................................................... 275
6.28 Medical Laboratory Services...................................................................... 282
6.29 Pharmaceutical Services............................................................................. 295
6.30 Blood Transfusion Services........................................................................ 319
6.31 Ambulance Services .................................................................................... 322
6.32 Infection Prevention ................................................................................... 325
6.33 Medical Recording ...................................................................................... 333
6.34 Food and Dietary Services.......................................................................... 337
6.35 Hospital Sanitation and Waste Management............................................ 344
6.36 Housekeeping, Laundry and Maintenance Services................................. 350
6.37 Social Works Services ................................................................................. 357
6.38 Care After Death and Morgue Services ..................................................... 360
Section 7: Physical Facility standards.....................................................................................363
7.1. General................................................................................................................................363
7.2. Site Selection Requirements .........................................................................................363
7.3. Construction Requirements ..........................................................................................364
7.4. Building Space and Elements........................................................................................366
7.5. Building Systems ..............................................................................................................371
7.6. Electrical System ..............................................................................................................374
7.7. Fire Protection System ...................................................................................................375
7.8. Call Systems .......................................................................................................................377
7.9. Medical Gas System..........................................................................................................377
7.10. Health Facility Environment.....................................................................................377
7.11. Specific Service Areas .................................................................................................378
7.12. Care and Treatment Areas.........................................................................................381
7.13. Ancillary areas..............................................................................................................381
7.14. Bubble Diagrams..........................................................................................................383

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4
...........................................................................................................................................................384
Glossary...........................................................................................................................................389
Annex: Workshop Participants List.........................................................................................402

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Foreword

6
 Acknowledgement

On behalf of the Food, Medicine and Healthcare Administration and Control Authority of
Ethiopia, FMHACA, I would like to extend my special thanks to members of the technical
working group assigned for the development of health facility standards. They were so
enthusiastic and committed in the development process of these standards. They made
unforgettable contribution to the history of the country’s initiatives on health care quality
and safety interventions. Members of TWG were Dr. Getahun Mengistu, Dr.Kidane Melles,
Ato Yohannes Jorge, Dr Adefris Debalke, Dr. Wondwossen Fantaye, Dr Faris Hussein, Dr
Petros Mitiku, Dr David A.conteh, Dr Ruth Lawson, Dr Birna Abdosh, Ato Liyusew Solomon,
Ato Edmealem Ejigu, Dr Solomon Tessema, Dr Endale Tefera, Ato Yihalem Tamiru, Dr Abyou
Kiflie, Ato K/mariam G/Michael, Ato Wondie Alemu, W/t Raey Yohannes, Ato Ayalew
Adinew, Dr Zegeye Hailemariam, Dr. Tassew Tadesse, Dr Alem Michael, Dr. Aynalem
Abraha, Dr. Mehrtu W/yes, Ato Zelalem mesele, Ato Salehunae, Dr Daniel Admassie and Dr
Tekle-ab Zaid.

My special thanks go to all the workshop participants coming from Ministry of Health,
Associations, Universities, public and private hospitals, private clinics, non-governmental
organizations and other governmental organizations for dedicating their time and giving
their valuable inputs to enrich the national draft standards for different types of health
facilities.

I would also like to extend my appreciation and thankfulness to USAID/PHSP-Ethiopia,

MSH/SPS, Clinton Foundation and Tulane University for providing financial, technical and
logistical support in the development of these health facility standards. My appreciation
also goes to our partners and stakeholders (WHO, USAID, I-CAP Ethiopia, Federal Ministry
of Health/Medical Services Directorate, AAU Medical Faculty, ALERT Hospital, Yekatit 12
General Hospital, Ophthalmology Society of Ethiopia, Ethiopian Medical Laboratory
Technologist Association, Ethiopian Dental Professionals Association and Ethiopian
Radiologists Association) who continually provide technical support in the development of
these regulatory standards.

Last but not least, it is my pleasure to extend my appreciation to the regulatory standards
setting case team at FMHACA for their commitment to facilitate the development and
finalization of the standards.

Ato Yehulu Denekew, Director General

Food, Medicine and Healthcare Administration and Control Authority of Ethiopia

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 Introduction

The FMOH has recently finalized the new design for health sector reform which reorganizes
the health sector along its three major functions: service provider, purchaser and regulatory
arm. In the new design the regulation of both public and private facilities towards ensuring
quality service and high professional standard falls under the Food Medicine and Health
Care Administration and Control Authority (FMHACA).

The FMHACA is undertaking various initiatives to ensure the quality of health services. One
of the major initiatives with this regard is the development of health facility standard; as the
provision of quality health service by each level of health care necessitates the availability of
regulatory standards for each health care service.. Moreover, the exiting regulatory
standards are not comprehensive and do not take into account the new service delivery
design. Thus, in order to protect the public from such sub-standard services and promote
quality of health service, the FMHACA as a lead agency has developed this facility standard.

In the development of this standard, the FMHACA has used the following guiding principles:
(1) Regulatory standards shall be prepared for all health facilities according to
the new health care tier system
(2) All the public and private health care delivery facilities shall be treated by
uniform standards to avoid double standards in the health sector.
(3) The service provided by the health facilities should be quantitatively and
qualitatively standardized so as to enable informed decision making with
regard to what, where, when and how services be provided.
(4) Regulatory standards are substantial evidences for ensuring quality of
healthcare services.
(5) Stakeholders shall be part of the regulatory standards development and
implementation processes
(6) Benchmarking best practices within and outside the country

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In recognition to these, the Authority has organized a technical taskforce drawn from
various institutions including FMOH, universities, hospitals, professional associations,
development partners and private sector
Accordingly, the Authority has developed these standards to:
(1) Ensure quality of healthcare delivery,
(2) Use as essential guidance and handy reference and
(3) Use as a tool for licensing of health facilities.

In general, these standards are intended for use in licensing, inspection and ensuing
enforcement actions. They are also designed to be useful for consumers and providers as a
mechanism for privately assessing the quality of care provided and for rational health
investment.

The authority recommends these tertiary level specialized hospitals to strive to be center of
excellence for teaching and research. It is expected that the fruition of these centers would
ensure the quality of public health services through the production of qualified and
competent health professionals and by generating of innovative ideas and methodologies to
solve health care problems.

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Information and Complaint Procedures

(a) Questions regarding these regulatory standards should be addressed to the

Authority at the following address:
Regulatory Standard Setting and Information Delivery Directorate, FMHACA
Regulatory Standard Setting Team
P.O. Box 5681
Telephone: 251-11-552-41-17/18
Website address: www.daca.gov.et
(b) Questions regarding information about any licensed health care facility in Ethiopian
should be addressed to:
Regulatory Standard Setting and Information Delivery Directorate, FMHACA
Regulatory Information Development and Dissemination Team
P.O. Box 5681
Telephone 251-11-552-31-42, 0115-52-41-18
(c) Complaints regarding service delivery shall be addressed to:
At federal level: Inspection and Surveillance Directorate, FMHACA
Inspection and Surveillance Team
P.O. Box 5681
Telephone 251-11-552-41-16
At regional level: Regional Level Inspection Teams

(d) Questions and complaints regarding inspection may be addressed to:

At federal level: Quality and Compliance Directorate, FMHACA
P.O. Box 5681
Telephone: 251-11-552-41-16
At regional level: To any responsible regional body to handle complaints

(e) Questions regarding review of architectural plans and approval of construction and
applications for license shall be addressed to:

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 At federal level: Healthcare Facilities and Professionals Licensing
Directorate, FMHACA
Healthcare Facilities and Professionals Licensing Team
P.O. Box 5681
Telephone: 251-11-552-32-06
At regional level: Regional Level Licensing Body
(f) Comments regarding amendments, revisions and need for new standards should be
addressed to:
Regulatory Standards Setting and Information Development and
Dissemination Directorate, Regulatory Standards Setting Team,
FMHACA
P.O. Box 5681
Telephone: +251-11-552-41-17/18
E-mail: [email protected]

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 Section 1: General Provisions

1.1 General
1.1.1. These standards shall provide minimum requirements for the establishment and
maintenance of specialized hospitals in order to protect the public interest by
promoting the health, welfare, and safety of individuals.
1.1.2. No specialized hospital shall be built or be functional by any person without prior
permission of the Authority.
1.1.3. Each specialized hospital shall have an internal quality assurance system which
can be organized in the form of committee(s) or team(s).
1.1.4. The hospital shall ensure the periodic calibration, verification, and validation of all
medical and laboratory equipments and instruments used in the hospital.
1.1.5. Any specialized hospital shall constitute a medical board that approves referral
cases to foreign countries in accordance with national referral guidelines.
1.1.6. The requirements set by these standards may not be waived by the Authority
unless otherwise for public interest and there is a substantial need for waiver and
an assurance that the waiver will not create a hazard to the health and well- being
of patients or others than the public interest.
1.1.7. These standards shall enter into force on the day of approval by the Ethiopian
Quality and Standards Authority.

1.2 General Definitions

1.2.1. Authority means the Ethiopian Food, Medicine and Healthcare Administration and
Control Authority.
1.2.2. Appropriate regulatory body means a state government organ authorized to
implement health regulatory activities regarding food, medicine and
healthcare at a state level
1.2.3. Proclamation means the Ethiopian Food, Medicine and Healthcare Administration
and Control proclamation No 661/2009.
1.2.4. Person means any physical or juridical person
1.2.5. Authorized person means any hospital staff who is responsible for a given service

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 1.2.6. A Comprehensive specialized hospital shall mean the hospital which provides
promotive, curative, preventive and rehabilitative services that require advanced
diagnostic facilities and therapeutic interventions at tertiary level of care. It scope of
service extends to at least gynecology and obstetrics, pediatrics, internal medicine,
surgery both general and orthopedic, psychiatry, ophthalmology, ENT, dentistry,
dermatology, emergency and a minimum of four sub-specialty services with a
capacity of 300 beds. It shall also include delivery of laboratory, imaging and
pharmacy services and other related services stated under these standards.
1.2.7. In case of privately owned comprehensive specialized hospitals, the definition
stated under article 1.2.6 is applicable except that the minimum bed capacity is
allowed to be 110 beds to promote private investment on health
1.2.8. Other definitions are annexed as glossary

1.3 Scope of Application

1.3.1. These standards shall be applicable for all new and already existing governmental,
non-governmental and private specialized hospitals.
1.3.2. New specialized hospitals shall comply with all relevant requirements stated under
these standards before commencement of service delivery.
1.3.3. Existing specialized hospitals shall work to comply with all relevant requirements
stated under these standards within a grace period.

1.4 Objectives
The objectives of these standards shall be:
1.4.1. To set minimum standards with respect to practices, premises, professionals and
products of the health facilities
1.4.2. To ensure the public safety and standardize the health care services
1.4.3. To license new or already existing health institutions as a specialized hospital;
1.4.4. To regulate licensed specialized hospitals to ensure provision of continuous and
quality health services as stated under these standards;
1.4.5. To promote access to quality health services

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Section 2: Licensure

2.1 Application for Licensure

2.1.1. No person shall operate a specialized hospital in Ethiopia, whether governmental,
nongovernmental or private, without being licensed as required by Proclamation
No 661/2009 and these standards.
2.1.1 Any person desiring to operate a specialized hospital shall:
(a) Apply to the Authority for a new license on forms prescribed by the Authority;
(b) Pay the prescribed license fee; and
(c) Provide any information or material that the Authority reasonably considers
relevant to the application.
2.1.2 A person desiring to operate a specialized hospital shall consult the Authority on
the plant design conformity with these standards before starting construction or
renovation work.
2.1.3 An application for the initial licensure of specialized hospital shall be submitted to
the Authority no later than ninety (90) days prior to the stated date of operation.
The license fee shall accompany the application.
2.1.4 The application for a specialized hospital license shall state each service for which
the applicant undertakes to furnish hospital care and the number of beds allocated
to each service, and shall submit other information required including:
(a) Hospital location;
(b) Previous owner, license number for existing hospital;
(c) Type and level of hospital
(d) Total bed capacity;
(e) Surrounding environment/location;
(f) Staffing (number and type for technical and administrative staff);
(g) Physical plant/hospital design and its description;
(h) Proposed use of idle space;
(i) CEO of the hospital;
(j) Person in charge in absence of CEO;
(k) CCO of the hospital;
(l) Applicant (owner);
(m)Chain organization (organization structure);

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 (n) Owner of the building;
(o) Responsible person for each service in the hospital;
(p) The name and the start date & end date of the terms of office of each
member of the governing Board or responsible person(s);
(q) The name and the terms of office of the chairperson of the hospital’s
governing Board or responsible person(s).
2.1.5 All applicants shall demonstrate that they have the capacity to operate a hospital
in accordance with these standards.
2.1.6 An application for a license or change in service shall be denied if the applicant
cannot demonstrate that the premises, products, personnel and health care
services are fit and adequate in accordance with these standards.
2.1.7 The Authority shall consider an applicant's prior history in operating a health care
facility either in Ethiopia or in other countries in making licensure decision. Any
evidence of licensure violations representing serious risk of harm to patients shall
be considered by the Authority, as well as any record of criminal convictions
representing a risk of harm to the safety or welfare of patients.

2.2 Initial Licensure

2.2.1 Every licensee shall have a separate license if he/she owns two or more
specialized hospitals.
2.2.2 The Authority shall issue each license in the name of the owner and Chief Clinical
Officer only for the premises and person named as applicant in the application and
the license shall not be valid for use by any other person or at any place other than
the designated in the license.
2.2.3 A specialized hospital license shall specify the following:
(a) The name of the person to whom the license is issued;
(b) The name and location of the hospital;
(c) Level of the hospital;
(d) Ownership of the hospital (governmental, nongovernmental or private);
(e) The licensed bed capacity;
(f) The issuance and expiration date.

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2.2.4 Prior to initial licensure of the hospital, the Authority shall conduct an on-site
inspection to determine compliance with the applicable laws and standards
governing specialized hospitals.
2.2.5 The Authority shall send a written report of the findings to the applicant no later
than five (5) working days from the conclusion of the inspection.
2.2.6 A specialized hospital with deficiencies shall correct them within one hundred and
Eighty (180) days upon receipt of the written report prior to the issuance of a
license. The hospital shall submit written proof of correction of deficiencies.
2.2.7 The Authority may require the hospital to submit a written, signed and dated plan
of correction to abate deficiencies cited no later than ten (10) working days
following the receipt of the written report of findings.
2.2.8 The Authority shall conduct a follow-up inspection to determine correction of
deficiencies cited within ten (10) days following the one hundred and Eighty
(180) day correction period or upon notification from the hospital that the
deficiencies have been corrected.
2.2.9 The Authority shall deny the application for licensure to a specialized hospital that
has not corrected deficiencies. The applicant shall reapply for licensure when
deficiencies are corrected.
2.2.10 The Authority shall conduct an on-site inspection of the specialized hospital to
assess the hospital's continued compliance with the laws and standards governing
the hospital.
2.2.11 The Authority shall issue a replacement license where the originally issued license
has been lost or destroyed upon the application supported by affidavit.
2.2.12 The original license shall be posted in a conspicuous place at all times.

2.3 License Renewal Requirements

2.3.1 A license, unless suspended or revoked or under consideration in pending case,

shall be renewable annually, upon filing by the licensee, and approval by the
Authority of an annual inspection report and upon paying the license renewal fee.
2.3.2 A specialized hospital shall submit an application for license renewal to the
appropriate regulatory body no later than ninety (90) days before the expiration
date of the current license.

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 (a) License renewal shall be done during the first quarter of each fiscal year
(Hamle 1 to meskerem 30)

(b) License renewal shall be done based on routine inspection findings over the
year.

2.3.3 Every applicant who needs to renew a license shall:

(c) Apply to the Authority in the form prescribed by the Authority;
(d) Pay the prescribed license renewal fee; and
(e) Provide any information or material that the Authority reasonably considers
relevant to the application.
2.3.4 The Authority may conduct background checks on the applicant or licensee to
determine his or her suitability or capability to operate or to continue operating a
health care facility. Background checks shall consist of the following:
(a) Verification of licensure status;
(b) Verification of educational credentials;
(c) Verification of residency status;
(d) Verification of solvency; and
(e) Contacts with Ethiopia and other country to determine outstanding warrants,
complaints, criminal convictions, and records of malpractice actions.
2.3.5 The Authority shall renew a license for a specialized hospital in substantial
compliance with the applicable laws and these standards.

2.4 Removal Permits, Change of Operation and Forfeiture of License

2.4.1 No specialized hospital or part thereof shall move from the premises for which a
license has been issued to any other premises without first having obtained from
the Authority a permit to move to the premises not covered by the license issued
to the specialized hospital.
2.4.2 The removal permit shall indicate on its face the special conditions governing the
moving of the hospital or part of the hospital as the Authority may find to be in the
interest of the public health.
2.4.3 The licensee shall inform the Authority about the issue of change in operation
within thirty (30) days before the change. Change of operation means any
alteration of services that is different from that reported on the specialized
hospital's most recent license application.

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2.4.4 Any transfer as to person or place without the approval of the Authority shall
cause the immediate forfeiture of the license. That is the license shall not be
assignable or transferable and shall be immediately void if the hospital ceases to
operate, if its ownership changes, or if it is relocated to a different site.
2.4.5 When change of ownership of a hospital is contemplated, the hospital shall notify
the Authority in writing at least thirty (30) days prior to the proposed date of
change of ownership, giving the name and address of the proposed new owner.

2.5 Denial, Suspension and Revocation of a License

2.5.1 The Authority is authorized to deny, suspend or revoke a license or order closure
of a service or unit within the hospital, cease admissions to a hospital, order
transfer of patients from a hospital, or impose a money penalty where it finds that
there has been a substantial failure to comply with these standards.
2.5.2 Without prejudice to suspension grounds provided in relevant laws, the Authority
shall suspend the license until the hospital correct the shortcomings where the
hospital:
(a) Fails to practice medical ethics;
(b) Engages in rendering services which are outside the competence of the
hospital for which the license is obtained;
(c) Conviction of a member of the Governing Board, the Chief Executive
Officer, a Chief Clinical Officer, department head, or other key staff
member of a serious offence involving the management or operation of a
specialized hospital, or which is directly related to the integrity of the
facility or the public health or safety;
(d) Has shown any act which constitutes a threat to the public health or safety;
(e) Fails to observe laws relating to health services and these standards;
(f) Fails to submit, accurately and on time, information required under the
laws and these standards.
2.5.3 Without prejudice to suspension grounds provided in relevant laws, the Authority
shall revoke the hospital license on any of the following grounds:
(a) Where the license is proved to have been obtained by submitting false
information;

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 (b) Allows a practitioner, who is not licensed pursuant to the appropriate law
or who has been suspended by a competent organ from practicing his
profession or who is addicted to alcohol or drugs, to work in the hospital;
(c) Fails to allow inspection pursuant to the law and these Standards;
(d) Where any of its permanent health personnel is found registered/
employed as a permanent staff in any other facility except where dual
appointment is permitted by law;
(e) Where the faults referred to in Sub Article 2.5.2 of this Section have been
committed for the second time or more repeatedly depending on their
gravity;
(f) Where the license is found transferred or rented to another person;
(g) Where the license is not renewed in accordance with Section 2.3 of these
Standards.
2.5.4 At least 30 days prior to voluntary surrender of its license where approved by the
Authority, or order of revocation, refusal to renew, or suspension of license, the
specialized hospital must notify each patient and the patient's physician the
intended closure.
2.5.5 Each license in the licensee's possession shall be the property of the Authority and
shall be returned to the Authority immediately upon any of the following events:
(a) Suspension or revocation of the license;
(b) Refusal to renew the license;
(c) Forfeiture of a license; or
(d) Voluntary discontinuance of the operation by the licensee.
2.5.6 The license shall be returned to the Authority within five (5) working days from
voluntary surrender, order of revocation, expiration, or suspension of license.
2.5.7 If the Authority determines that operational or safety deficiencies exist, it may
require that all admissions to the specialized hospital cease. This may be done
simultaneously with, or in lieu of, action to revoke license and/or impose a fine.
The Authority shall notify to the hospital in writing of such determination.
2.5.8 The Authority shall order and ensure in collaboration with appropriate local
health authorities the immediate transfer of patients from the specialized hospital
whose license is revoked or suspended to a similar level health facility whenever
it determines there is imminent danger to the patients’ health or safety.

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2.6 Right to Fair Hearing
2.6.1 Any applicant made subject to action by the appropriate regulatory body for
denial or suspension or revocation of license or who is assessed a fine under
terms of this section shall have the right to a fair hearing in accordance with
relevant laws.
2.6.2 Fair hearing shall be provided/arranged by the appropriate regulatory body
whenever there is an official compliant submitted to this body.

2.7 Information to be disclosed

2.7.1 Evidenced information received by the Authority through inspection and other
true sources about the specialized hospital shall be disclosed to the public in such
a way to indicate the public a decision maker or self regulator for its own health.
2.7.2 The Authority shall forward inspection reports to the specialized hospital at least
15 days prior to public disclosure.
2.7.3 Any citizen has the right to obtain information on the official profile of services of
any licensed comprehensive specialized hospital from the Authority.
2.7.4 Anyone who is interested in establishing a comprehensive specialized hospital
shall have the right to be provided with information concerning the standards
required by the Authority at any business time.

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 Section 3: Governance

3.1 Governing Board

3.1.1 A governmental comprehensive specialized hospital shall have Governing Board,
Chief Executive Officer (CEO), Chief Clinical Officer (CCO) and necessary staffs
indicated in these standards.
3.1.2 Except for Share Company where its Board of Directors shall be deemed as
Governing Board, other private comprehensive specialized hospitals licensed
otherwise under the Commercial Code shall not be required to have such
organizational structure.
3.1.3 The Board of Management of nongovernmental specialized hospitals licensed
according to Charities and Societies Proclamation No. 629/2009 shall be deemed as
Governing Board.
3.1.4 The Board shall have the authority and responsibility for the direction and policy of
the specialized hospital.
3.1.5 The Board of the hospital may issue its own rules of procedures.
3.1.6 Without prejudice to powers and duties provided by the relevant laws, the Board
responsibilities shall include:
(a) Approve all policies and guidelines to be used in the hospital;
(b) Maintaining the specialized hospital’s compliance with all applicable laws,
its policies, procedures and plans of correction;
(c) Systems are in place for ensuring the quality of all services, care and
treatment provided to patients;
(d) Designating and defining duties and responsibilities of the CEO save for the
provision of relevant laws;
(e) Notifying the Authority in writing within thirty (30) working days when a
vacancy in the CEO position occurs, including who will be responsible for the
position until another person is appointed;
(f) Notifying the Authority in writing within thirty (30) working days when the
CEO vacancy is filled indicating effective date of the appointment and name
of person appointed;

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 (g) At least once a year, reviewing the medical care provided and the utilization
of the hospital resources; and
(h) Establishing a means for effective communication and coordination among
the CEO, the medical staff and the various hospital departments.
3.1.7 Minutes of the Board Meeting shall be recorded, signed, and retained in the hospital
as a permanent record.
3.1.8 The CEO shall be the secretary and non voting members of the Board.
3.1.9 The Board shall at least develop the following policies and procedures that are
revised at least every three years:
(a) For human resource management;
(b) For ensuring the hospital is smoke- free area;
(c) For the declaration of death of patients which shall accommodate the
patient’s religious beliefs with respect to declaration of death. Such policies
shall also include indicating the cause of death, medication given,
examinations done, and practitioner who cares of the patient.
(d) For transfer of dead body to its family. If a patient dies in the facility, the
body shall be handed over to the family with in a day unless conditions
dictate otherwise.
(e) For patient visit which shall be in the best interest of patients, staffs, visitors
and the hospital environment, including, but not limited to, protection from
communicable diseases, exposure to deleterious and hazardous substances
and equipments

3.1.10 The hospital shall develop and implement a complaint procedure for patients,
families, visitors, and others. The procedure shall include, at least, a system for
receiving complaints, a specified response time, assurance that complaints are
referred appropriately for review, development of resolutions, and follow-up action.
3.1.11 There shall be an organizational chart of the specialized hospital and each service
that shows lines of authority, responsibility, and communication between and
within services.
3.1.12 There shall be a formal mechanism for communication among the Board, CEO, CCO
and the necessary medical staff.

22
3.1.13 The comprehensive specialized hospital shall establish a mechanism for involving
consumers in the formulation of the hospital policy and implementation of activities.

3.2 Chief Executive Officer

3.2.1 The Manager of Specialized Hospitals formed as Charities and business organization
shall be deemed as CEO.
3.2.2 The CEO shall be responsible for planning, organizing, and directing and controlling
the day to day operation of the hospital. The CEO shall report and be directly
responsible to the Board in all matters related to the maintenance, operation, and
management of the hospital.
3.2.3 The CEO shall be responsible to ensure the operation of the hospital twenty-four
(24) hours per day, seven (7) days per week.
3.2.4 Without prejudice to powers and duties provided in relevant laws, the CEO shall be
responsible for:
(a) Providing for the protection of patients’ health, safety, and well- being;
(b) Maintaining staff appropriate to meet patient needs;
(c) Developing and implementing procedures on collecting and reporting
information on abuse, neglect and exploitation;
(d) Ensuring that investigations of suspected abuse, neglect or exploitation are
completed and that steps are taken to protect patients; and
(e) Ensuring appropriate response to reports from the Authority;

3.3 Chief Clinical Officer

3.3.1 Each specialized hospital shall have a Chief Clinical Officer who shall be accountable
to the CEO.
3.3.2 The CCO shall oversee the clinical care provided by the hospital. In particular, the
function of the CCO shall include:
(a) Facilitating communication among the medical staff members and with the
hospital;
(b) Implementing the hospital and medical staff policies and procedures;
(c) Recommending the appointments to the medical staff and scope of clinical
privileges;
(d) Ensuring the provision of continuing medical education;

23
 (e) Taking other necessary actions necessary to govern the medical staff and
relate to the hospital board.

3.4 Management Committee

3.4.1 A department head shall be assigned to each of the medical and administrative
departments. The responsibility of department heads includes at least the following:
(a) Providing a written description of the services provided by the department
(b) Ensuring coordination and integration of these services with other
departments when relevant
(c) Recommending space, staffing, and other resources needed to fulfill the
department’s responsibility
(d) Defining the education, skills, and education needed by each category of
employee in the department
(e) Ensuring that there is an orientation and continuing education program for
the department’s employees
(f) Developing and implementing a department quality improvement program.
3.4.2 Any specialized hospital shall establish a Management Committee consisting of
heads of the medical and administrative departments. The CEO shall be the
chairperson of the Committee.
3.4.3 The Committee shall be an adviser of the CEO on the day to day management of the
hospital.
3.4.4 The Committee shall meet upon regular basis. The minutes of the meeting shall be
recorded and available to the Authority upon request.

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Section 4: Patient Rights and Responsibilities

4.1 Informed Consent

4.1.1. Each hospital shall protect and promote each patient’s rights. This includes the
establishment and implementation of written policies and procedures for the
patient right.
4.1.2. For undertaking any type of procedures and treatments an informed consent
shall be required from the patient or patient’s next of kin or guardian.
4.1.3. An informed consent may not be required during emergency cases or life
threatening situations where the patient is not capable of giving an informed
consent and his or her next of kin or guardian is not available.
4.1.4. Unless provided by the law or these standards or by the hospital policies and
procedures that an informed consent shall be given in written form, an informed
consent of the patient can be given orally or inferred from an act. A written
consent shall be needed at least for the following:
(a) Surgery and invasive procedures;
(b) General anesthesia;
(c) Blood donation and transfusion;
(d) Clinical trials/Research;
(e) High-risk procedures or treatments (including Electro Convulsive
Treatment, radiation therapy, chemotherapy).
4.1.5. The specialized hospital shall comply with relevant laws, national and
international codes of ethics in the cases of vulnerable groups like children,
women, geriatric patients etc when someone other than the patient can give
consent.
4.1.6. Patient consent forms shall be available in all applicable locations at the
hospital. The locations include at least the following:
(a) All nursing inpatient units
(b) All areas where surgery or invasive procedures are done
(c) Radiation therapy
(d) Outpatient chemotherapy area
(e) Psychiatry units where electroconvulsive treatment is done
(f) In the Blood or genetic testing laboratory

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 4.1.7. No photographic, audio, video or other similar identifiable recording is made of
without prior informed consent of a patient or next of kin.
4.1.8. A specialized hospital shall establish and implement a process to provide
patients and/or their designee appropriate education to assist in understanding
the identified condition and the necessary care and treatment.
4.1.9. A specialized hospital shall document its assessment of each patient's ability to
understand the scope and nature of the diagnosis and treatment needed.

4.2 Patient Rights

Every specialized hospital patient shall at least have the following rights:

4.2.1 To receive reasonable, respectful and safe access to health services by

competent personnel that the hospital is required to provide according to these
standards;

4.2.2 To treatment and medical services without discrimination based on race, age,
color, religion, ethnicity, national or social origin, sex, sexual preferences,
disabilities, diagnosis, source of payment or other status;
4.2.3 To retain and exercise to the fullest extent possible all the constitutional and
legal rights to which the patient is entitled by law;
4.2.4 To be informed of the names and functions of all physicians and other health
care professionals who are providing direct care to the patient. These people
shall identify themselves by introduction or by wearing a name tag;
4.2.5 To receive, to the extent possible, the services of a translator or interpreter to
facilitate communication between the patient and the hospital's health care
personnel if the patient cannot understand the working language;
4.2.6 To receive from the patient's physician(s) or clinical practitioner(s) an
explanation of his or her complete medical condition, recommended treatment,
risk(s) of the treatment, expected results and reasonable medical alternatives in
terms that the patient understands. If this information shall be detrimental to
the patient's health, or if the patient is not capable of understanding the
information, the explanation shall be provided to his or her next of kin or
guardian and be documented in the patient's personal medical record;

26
4.2.7 To give informed, written consent prior to the start of specified non-emergency
procedures or treatments only after a physician or clinical practitioner has
explained specific details about the recommended procedure or treatment, the
risks involved, the possible duration of incapacitation, and any reasonable
medical alternatives for care and treatment in terms that the patient
understands. If the patient is incapable of giving informed, written consent,
consent shall be sought from the patient's next of kin or guardian or through an
advance directive, to the extent authorized by law. If the patient does not give
written consent, a physician or clinical practitioner shall enter an explanation in
the patient's medical record;
4.2.8 To refuse medication and treatment and to be informed of the medical
consequences of refusing treatment provided that he/she is mentally clear. The
hospital shall develop a procedure on the management of the cases of patients
who refuse treatment.
4.2.9 To be informed if the specialized hospital has authorized other health care and
educational institutions to participate in the patient's treatment. The patient
also shall have a right to know the identity and function of these institutions,
and may refuse to allow their participation in the patient's treatment;
4.2.10 To be informed of the hospital's policies and procedures regarding life-saving
methods and the use or withdrawal of life-support mechanisms. Such policies
and procedures shall be made available promptly in written format to the
patient, his or her next of kin or guardian, and to the public, upon request;
4.2.11 To be informed by the attending physician and other providers of health care
about any continuing health care requirements after the patient's discharge
from the hospital. The patient shall also have the right to receive assistance from
the physician and appropriate hospital staff in arranging for required follow-up
care after discharge;
4.2.12 To receive sufficient time before discharge to have arrangements made for
health care needs after hospitalization;
4.2.13 To be informed by the hospital about any discharge appeal process to which the
patient is entitled by law;
4.2.14 To be transferred to another facility only for one of the following reasons, with
the reason recorded in the patient's medical record:

27
 (a) The transferring hospital is unable to provide the type or level of
medical care appropriate for the patient's needs. The hospital shall make
an immediate effort to notify the patient's primary care physician and
the next of kin, and document that the notifications were received; or
(b) The transfer is requested by the patient, or by the patient's next of kin or
guardian when the patient is mentally incapacitated or incompetent;
4.2.15 To receive from a physician an explanation of the reasons for transferring the
patient to another facility, information about alternatives to the transfer,
verification of acceptance from the receiving facility, and assurance that the
movement associated with the transfer will not subject the patient to
substantial, unnecessary risk of deterioration of his or her medical condition.
This explanation of the transfer shall be given in advance to the patient, and/or
to the patient's next of kin or guardian except in a life-threatening situation
where immediate transfer is necessary;
4.2.16 To be treated with courtesy, consideration, and respect for the patient's dignity
and individuality i.e. the right to care that respects the patient’s personal values
and beliefs;
4.2.17 To be free from physical and mental abuse, neglect, sexual harassment, sexual
violence and exploitation;
4.2.18 To be free from chemical and physical restraints that are not medically
necessary, unless they are authorized by a physician for a limited period of time
to protect the patient or others from injury;
4.2.19 To have personal and physical privacy during medical treatment and personal
hygiene functions, such as bathing and using the toilet, unless the patient needs
assistance for his or her own safety. The patient's privacy shall also be respected
during other health care procedures and when hospital personnel are discussing
the patient;
4.2.20 Confidential treatment information in the patient's records shall not be released
to anyone except upon the following conditions;
(a) If the patient has approved the request,
(b) If another health care facility to which the patient was transferred
requires the information,
(c) If the release of the information is required and permitted by law.

28
 (d) If the patient's identity is masked, the hospital may release data about
the patient for studies containing aggregated statistics.
4.2.21 To know the price of services and procedures;
4.2.22 To receive a copy of the hospital payment rates, regardless of source of payment.
Upon request, the patient or responsible party shall be provided with an
itemized bill and an explanation of the charges if there are further questions.
The patient or responsible party has a right to appeal the charges. The hospital
shall provide the patient or responsible party an explanation of procedures to
follow in making such an appeal;
4.2.23 To have prompt access to the information contained in the patient's medical
record, unless a physician prohibits such access as detrimental to the patient's
health, and explains the reason in the medical record. In that instance, the
patient's next of kin or guardian shall have a right to see the record. This right
continues after the patient is discharged from the hospital for as long as a copy
of the record is kept;
4.2.24 To obtain a copy of the patient's medical record, as per the standards set under
the medical record section of these standards.
4.2.25 To have access to individual storage space in the patient's room for the patient's
private use. If the patient is unable to assume responsibility for his or her
personal items, there shall be a system in place to safeguard the patient's
personal property until the patient or next of kin is able to assume responsibility
for these items;
4.2.26 To receive a medical certificate in English or Amharic or in working language of
the place where the hospital is located.
4.2.27 To present his or her suggestion or grievances, without fear of retribution, to the
hospital staff member designated by the hospital to respond to questions or
grievances about patient rights and to receive an answer to those grievances
within a reasonable period of time without discrimination. The hospital shall
post the names, addresses, and telephone numbers of ethical officers of the
hospital and relevant external government agencies to which the patient can
lodge their complaints and ask questions.

29
 4.2.28 To be given a summary of these patient rights, as approved by the Authority, and
any additional policies and procedures established by the hospital involving
patient rights and responsibilities. The hospital shall be obliged to ensure that,
(a) The patient is informed of his or her rights during the admission
process;
(b) This summary include the name and phone number of the hospital or
hospital staff member to whom patients can complain about possible
patient rights violations;
(c) This summary is provided in the patient's native language if 10 percent
or more of the population in the hospital's service area speak that
language;
(d) A summary of these patient rights is posted conspicuously in the
patient's room and in public places throughout the hospital;
(e) Complete summary copies of the patient right is available at nurse
stations and other patient care registration areas in the hospital.
4.2.29 To be informed and participate in decisions relating to their care and
participates in the development and implementation of a plan of care and any
changes.

4.3 Patient Responsibilities

4.3.1 Every patient shall have the following responsibilities:
(a) To provide, to the best of the patient’s knowledge, accurate and
complete information regarding past medical history and issues related
to the patient’s health, including unexpected changes, to the health
professional responsible for the patient’s care;
(b) To follow the course of treatment and instructions proposed by the
physician or an authorized health personnel or to accept the
consequences if treatment instructions is refused;
(c) To report any changes in his/her condition or anything that appears
unsafe to the responsible health professional;
(d) To be clerked by medical students as well as be clerked, examined and
treated by interns if the hospital is a teaching institutions;

30
 (e) To be considerate of the rights of other patients and to respect their
privacy;
(f) To respect their caregivers;
(g) To fulfill the financial obligations;
(h) To keep all appointments and notify hospital or the appropriate person
when unable to do so;
(i) To observe the hospital policies and procedures, including those on
smoking, alcohol or drug addiction, cellular phones, noise and visitors;
(j) Be considerate of the hospital facilities and equipment and to use them
in such a manner so as not to abuse them;
(k) Not to litter the hospital premises.
4.3.2 The list of a patient’s responsibilities shall be posted at various places of the
hospital premises.

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Section 5: Human Resource Management

5.1. General Requirements

5.1.1. The hospital shall have Human Resource Department (HRD) which carries out
the major functions of Human Resource Management (HRM).
5.1.2. Each service units of the hospital shall maintain a sufficient number of staff with
the qualifications, training and skills necessary to meet patient needs as per the
minimum requirement under each service standard. The hospital shall be
staffed twenty-four (24) hours a day and 365 days a year.
5.1.3. All recruitment and selection shall follow consistent approach using the
recruitment and selection manual approved by the hospital management/
governing board.
5.1.4. No health professional shall practice his/her profession in the hospital without
having professional license from the Authority or appropriate regional organ.
The hospital shall ensure that all health professionals recruited by the hospital
are licensed as per the registration and licensing requirement of the Authority
or appropriate regional organ.
5.1.5. The hospital shall ensure that all health professionals have received a copy of
professional code of ethics and scopes of practice
5.1.6. Each hospital shall ensure and maintain evidence of current active licensure,
registration, certification or other credentials for employees and contract staff
prior to staff assuming job responsibilities and shall have procedures for
verifying that the current status is maintained.
5.1.7. Whenever a licensed health-care professional is terminated as a result of a job-
related incident, the hospital shall refer a report of the incident to the
appropriate body in accordance with the appropriate health professional
regulation
5.1.8. Every health professional shall report to the hospital whenever he/she is
infected with contagious diseases. The hospital shall also establish a mechanism
for screening health professionals with contagious diseases. The health
professional shall not practice his/her profession during the period of such
infection and his/her rights provided under the relevant employment law and
the hospital’s HR manual shall be respected.

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 5.1.9. Each person, other than a physician, involved in the performance of duties
involving direct patient care shall have an occupational health screening by a
physician or other qualified health professional prior to entering active status
and at least once every Five (5) years thereafter. Each physician shall have a
health examination performed by another physician or other qualified health
care professional at the time of appointment and once every Five (5) years
thereafter. (cost, health problems, duration, time)
5.1.10. Each health screening shall include a medical history, physical examination, and
any indicated laboratory work and investigations.
5.1.11. A report, signed by an examining physician or other qualified health
professional, shall be made of each examination.
5.1.12. The report of each examination shall be kept on file in the hospital and shall be
open to inspection by the control agency.
5.1.13. Each person who is involved in direct patient care and who acquires notifiable
illness shall, prior to returning to duty, obtain certificate of fitness, as provided
in the hospital’s policies, that he or she may return to duty without apparent
danger to any patient.
5.1.14. Immunization against communicable disease shall be required of all employees
and all other persons who routinely come in contact with patients or patient
areas. Immunizations shall be in accordance with current national
immunization guidelines.
5.1.15. Each hospital shall maintain a current employment record for each staff
person. The record shall contain, at a minimum, information on credentials,
health examination (fitness for duty), work history, current job description,
evidence of orientation, in-service education/training and copies of annual
evaluation.
5.1.16. The hospital shall have human resource manual.

5.2. Staffing Plan

5.2.1. The hospital shall avail as a minimum the staff requirement stated under each
discipline

33
 5.2.2. For additional staff a staffing plan shall be developed collaboratively by the
different service units and management, which identifies the number and types
of the staff
5.2.3. The planning process shall use recognizable process for estimating the staffing
need like Workload Indicator for Staffing Need (WISN) method.
5.2.4. The staffing plan shall be reviewed on an ongoing basis and updated as
necessary
5.2.5. The staffing plan shall define the following elements:

(a) The total number and types of staff needed for the hospital as a whole and
for each service unit
(b) The total number and types of staff currently available for the hospital as a
whole and each service unit
(c) The required education, skills, knowledge, and experience required for each
position
(d) The process and time period for reviewing and updating the plan shall be
indicated. (The plan is periodically reviewed and updated as required, but it
shall be done at least every two years.)
(e) Expected/existing workload
5.2.6. The hospital shall have in effect a contingency plan for assuring adequate
staffing at all times. The plan shall detail policies and procedures to regulate
closure of available beds or services, if actual staffing levels fall below specified
levels.

5.3. Job Description and Orientations

5.3.1. All staffs shall be provided with current written job descriptions and be oriented
to their specific job responsibilities at appointment
5.3.2. The job description shall include the title and grade of the position, specific
function of the job, job requirement, reporting mechanism, evaluation criteria
and description of job site and work environment.
5.3.3. The orientation program for all employees shall include three levels of
orientation: hospital wide, service unit and job specific:
5.3.4. Orientation to hospital structure and administration shall be provided by
hospital management.

34
 5.3.5. Orientation to hospital policies, including all environmental safety programs,
infection control, and quality improvement shall be provided
5.3.6. Staff members who are not licensed to independently practice shall have their
responsibilities defined in a current job description.
5.3.7. Each hospital shall provide and maintain evidence of an orientation program for
all new staff and, as needed, for existing staff who are given new assignments.
The orientation program shall include an explanation of:

(a) Job duties and responsibilities

(b) Hospital's sanitation and infection control programs;
(c) Organizational structure within the hospital;
(d) Patient rights;
(e) Patient care policies and procedures relevant to the job;
(f) Personnel policies and procedures;
(g) Emergency procedures;
(h) The Disaster preparedness plan; and
(i) Reporting requirements for abuse, neglect or exploitation

5.4. Staff Education:

5.4.1. The hospital shall ensure that staffs receive training in order to perform
assigned job responsibilities.
5.4.2. Each staff member shall receive ongoing Continuing Professional Development
(CPD) to maintain or advance his or her skills and knowledge
5.4.3. The CPD shall be relevant to the setting in which they work as well as to the
continuing advancement of the hospital
5.4.4. The hospital shall decide the type and level of training for staff in accordance
with National CPD guideline and then carry out and document a program for
this training and education.
5.4.5. The hospital shall provide and maintain evidence of CPD for staff. A record shall
be maintained including dates, topics and participants
5.4.6. The hospital shall periodically tests staff knowledge, skill and attitude through
demonstration, mock events and other suitable methods. This testing is then
documented

35
5.5. Medical Staff
5.5.1. There shall be a policy of verifying qualifications, restrictions to practice and
professional registration of all new employees and have a system in place to
check re-registration details. There shall be documentation of staff licenses and
training certificates.
5.5.2. There shall be a policy that strengthens involvement of medical staff to take part
in the ongoing Continuing Medical Education (CME).
5.5.3. Any medical service shall be organized under the directorship of a licensed
professional who is a medical specialist in that medical service.
5.5.4. The medical staff shall be responsible to the governing authority for medical
care and treatment provided in the hospital in accordance with the standards
stipulated under the hospital administration and shall:
(a) Participate in a Quality Assurance/Performance Improvement program to
determine the status of patient care and treatment;
(b) Abide by hospital and medical staff policies;
(c) Establish a disciplinary process for infraction of the policies
5.5.5. The development and surveillance of pharmacy and therapeutic practices in
relation to drug utilization shall be performed by the medical staff the facility
pharmacists.
5.5.6. The medical staff shall see that there is adequate documentation of medical
events by a review of discharged patients that shall insure that medical records
meet the required standards of completeness, clinical pertinence and
promptness or completion of following discharge
5.5.7. The medical staff shall actively participate in the study of hospital associated
infections and infection potentials and must promote preventive and corrective
programs designed to minimize their hazards
5.5.8. There shall be regular medical staff meetings to review the clinical works of the
members and to complete medical staff administrative duties

5.6. Availability of Physicians

5.6.1. The hospital shall have physicians available on the premises at all times and
consultant physicians available on call. The physician on call shall be duty bound
to respond to calls.

36
 5.6.2. Each patient shall be under the care of a physician, regardless of whether the
patient is also under the care of an allied health professional practitioner
authorized to practice

5.7. Employee’s Health

5.7.1. The hospital shall institute systems and processes that minimize employees’
risks, protect employees and provide access to care when needed.
5.7.2. A comprehensive Occupational Health and Safety (OHS) program shall have the
following components:
(a) Staff dedicated to coordinate OHS activities
(b) Policies and Procedures that define components of the program
(c) Training for staff on program components
5.7.3. The hospital shall have a designated individual qualified (occupational health
and safety officer) to coordinate and develop the hospital’s occupational health
and safety activities full-time.
5.7.4. The standards outlined below define the core elements of an OHS program and
specify minimum requirements needed to address OHS issues.
(a) The hospital shall have an occupational health and safety policy and
procedures in place to identify, assess and address identified health and
safety risks to staff and prevent those risks that will potentially compromise
their health and safety.
 The hospital assesses and documents safety risks through formalized,
structured assessments that are done at regular intervals.
 The assessments shall be logged in some format—for example a register
or report
 The information gathered from the assessment shall be documented and
reported to the management (management committee and boards).
 Interventions shall be designed and implemented to address the risks that
are identified.
(b) The hospital shall establish a means of communicating to staff their risks
and prevention measures or interventions.
(c) The hospital shall regularly monitor its occupational health and safety
activities to assess how effective it has been in reducing risk.

37
 (d) The hospital shall have written policies and procedures to manage manual
handling risks.
(e) The hospital shall have written policies and procedures which define how
harassment, physical violence and/or aggression against staff (from
patients, caregivers, other staff etc) are addressed.
(f) The hospital shall provide services to staff to minimize work-related stress.
(g) The hospital shall ensure all employees have access to full pre-employment
health screening, covering Hep B (including other relevant vaccine), TB
status and are declared fit for their respective roles prior to employment.
This shall include having:
 Written instructions for health care workers to follow in notifying the
hospital’s administration of infectious status.
 Documentary evidence of vaccination records for all health care workers
employed, including Hep B status for all health care workers who perform
exposure-prone procedures. All staff are tested for and vaccinated against
Hep B, if there is no evidence of previous vaccination produced.
(h) The hospital ensures that all employees are provided with immunization
services to protect against infectious/communicable diseases.
(i) The hospital shall have a program in place to address injuries that could lead
to the transmission of blood-borne viruses (needle stick and other injuries).
The program shall include:
 Measures to prevent needle stick and other injuries
 Training on infection prevention techniques
 Sharps risk reduction
 Provision of post-exposure prophylaxis
 Working hours and duty hours
5.7.5. The hospital shall provide personal protective equipment (please refer to
standards for Infection Prevention and Control and Sanitation)
5.7.6. The hospital shall provide the following facilities to employees
(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)

38
 (e) Adequate toilet and shower facilities

5.8. Dress Code and Employee Identification Badge

For areas involving direct patient contact:

5.8.1. Footwear shall be safe, supportive, clean, and non-noise producing.

5.8.2. No open toe shoes shall be worn.

5.8.3. Artificial nails are prohibited. Natural nails must be kept short and jewelry must
be kept to a minimum.

5.8.4. Hair must be worn in a way that prevents contamination and does not present a
safety hazard

5.8.5. The dressing shall not interfere in any way the service provision

5.8.6. The hospital shall specify a particular style and/or color of uniform with
different style/color code; separate for each HRH category, employee and
trainees

5.8.7. The employee shall keep the uniform neat, wrinkle free and in good repair

5.8.8. The hospital shall be responsible for providing employee identification badges

5.8.9. The identification badge shall be worn at all times while at work and be easily
visible, with name, profession and department facing outward.

39
 Section 6: Service Standards

6.1 Nursing Services

6.1.1 Practice (Nursing care services)

6.1.1.1 There shall be written policies and procedures of nursing services for routine
taking and documenting vital signs, carrying out prescribed medication and
nursing care to be rendered. Such policies and procedures shall be reviewed at
least once every three years.
6.1.1.2 There shall be regulations that ensure nurses access to clinical supervision,
support and participation in regular clinical services audit and reviews.
6.1.1.3 There shall be current clinical and administrative nursing policies and
procedures available to all nursing personnel on each patient care unit at all
times.
6.1.1.4 Nursing care service shall be directed by a senior registered nurse that has at
least two years of relevant experience.
6.1.1.5 Written copies of nursing procedure manual shall be available to the nursing
staff in every nursing care unit. The manual shall be used at least to:
(a) Provide a basis for training programs to enable new nursing personnel
to acquire local knowledge and current skills
(b) Provide a ready reference on procedures for all nursing personnel.
(c) Standardize procedures and equipment.
(d) Provide a basis for evaluation and study to insure continued
improvements in techniques.
6.1.1.6 The hospital shall have established guidelines for verbal and written
communication about patient care that involves nurses.
(a) Written communication includes proper use of clinical forms, nursing
Kardex, progress notes, and/or nursing care plan for each patient and
discharge instructions.
(b) Verbal and/or written communication includes reporting to physicians;
nurse-to-nurse reporting; communication with other service units
(laboratory, pharmacy, X-Ray, social work service), with patient and
family education.

40
6.1.1.7 There shall be a procedure for standardized, safe and proper administration of
medications by nurses or designated clinical staff including regular checks of
patients’ medications and proper documentation of administered drugs.
6.1.1.8 There shall be a system/ protocols in place to handle comatose or patients on
life support system and also patients diagnosed to have communicable diseases.

Nursing care: general patient services

6.1.1.9 Assessment and documentation of the holistic needs of patients; formulating,
implementing goal-directed nursing interventions and evaluating the plan of
nursing care and involvement of patients, their relatives or next of kin in
decisions about their nursing care shall be done by licensed nurses.
6.1.1.10 All patients shall be under the supervised care of a licensed nurse at all times.
6.1.1.11 Implementation of infection prevention procedures and provision of
information on IP practices to patients, clients, family members and other
caregivers, as appropriate shall be done by the nurses; refers to infection
prevention part of these standards.
6.1.1.12 Nurses shall work with others to protect and promote the health and wellbeing
of those under their care.
6.1.1.13 Copies of Nurses’ code of professional practice shall be available; nurses shall
abide by the published code of professional practice relevant to their
professional role.
6.1.1.14 Nurses shall be open and honest, act with integrity and uphold the reputation of
their profession.
6.1.1.15 Nurses shall respect dressing code for the profession and get always neat.
6.1.1.16 All nursing staff shall wear easily readable name tags that include their name
and status, (such as licensed nurse, student, etc). The hospital shall have a policy
to identify nursing unit exceptions to this procedure where necessary.
6.1.1.17 Nurses providing care and service at specific units like OR, ICU, Recovery,
cardiac unit, etc., shall have proper orientation and minimum basic training on
related nursing activities in each unit.
6.1.1.18 The nursing care plan shall be initiated upon admission of the patient and, as a
part of the long-term goal, shall include discharge plans.

41
6.1.1.19 Each patient shall receive nursing care that is organized around ongoing,
patient-specific care planning which is consistent with medical care planning.
The planning shall include setting measurable goals with the patient and family
to the extent possible. This planning, nursing interventions and patient
responses shall be documented in the medical record.
6.1.1.20 There shall be a policy that empowers nurses to restrict number of visitors and/
or care takers based on the condition of the patient.
6.1.1.21 Documentation and completion of all patient’s recording, registers, and
reporting formats shall be the responsibility of licensed nurses in the unit.
6.1.1.22 A nurse shall write brief and pertinent nursing care plan and activity for each
patient. It shall include at minimum:
(a) Medication, treatment, and other items ordered by authorized house
staff members.
(b) Nursing care needed.
(c) Long-term goals and short-term goals.
(d) Patient and family teaching and instructional programs.
(e) The socio-psychological needs of the patient.
(f) Preventative nursing care.
6.1.1.23 Nurses shall not disclose confidential information relating to their patients.
6.1.1.24 Nurses shall explain and seek informed consent from their patients or their
relatives/next of kin (for incompetent patients) before carrying out any
procedure.
6.1.1.25 Nurses shall find solutions to conflicts caused by deep moral, ethical and other
beliefs arising from a request for nursing service through dialogue with patients.
6.1.1.26 Patient discharge instructions shall be documented in the patient's medical
record at the time of discharge.
6.1.1.27 Allergies shall be listed on the front cover of the patient's chart or, in a
computerized system, highlighted on the screen.
6.1.1.28 Patients who require assistance in feeding shall be identified, and there shall be
a mechanism in place to assure that assistance is provided.
6.1.1.29 For admitted patients, the nursing staff shall take and document the necessary
vital signs as ordered and communicate to treating /attending physician
immediately if abnormal findings observed.

42
6.1.1.30 Patients who required/prescribed to have special diet/ care shall be identified,
labeled and there shall be a mechanism in place to ensure this procedure.
6.1.1.31 There shall be clear policy that state general and oral hygiene in particular of
admitted patients as part of the nursing care.
6.1.1.32 There shall be written policies that state the procedures for communicating with
laboratory, laundry and food service. The nurse shall communicate and follow
up food orders, lab orders and lab specimens, and patient transfers.
6.1.1.33 There shall be a policy that state reporting of any signs suggestive of child abuse,
substance abuse and /or abnormal psychiatric manifestations by the nursing
staff.
6.1.1.34 There shall be a policy or guideline that assigns nurses to different specific
disciplines such as ENT, OR, ophthalmic clinic and others.

Nursing care services related to pharmaceutical services

6.1.1.35 All medications administered by nursing personnel shall be prescribed by
physician and/or authorized independent practitioner and shall be
administered in accordance with prescriber orders and Codes of Professional
Conduct and Ethics.
6.1.1.36 Medications for individual patients shall not be removed from their original
prescription containers by nursing personnel until the time of drug
administration.
6.1.1.37 Drugs packaged in unit dose containers shall not be removed from the
containers by nursing personnel until the time of drug administration. Such
drugs shall be administered immediately after the dose has been removed from
the container, and by the individual who prepared the dose for administration.
6.1.1.38 Each patient shall be identified prior to drug administration. Drugs dispensed
for one patient shall not be administered to another patient.
6.1.1.39 The nurse shall observe administration of prescribed drugs for those patients
under nursing care who are taking oral medications.
6.1.1.40 Regarding self-administration of drugs, nursing personnel shall directly observe
self-administration and implement policies and procedures developed by the
pharmacy and therapeutics committee.

43
6.1.1.41 There shall be a policy of reporting and documenting drug errors and adverse
drug reactions by attending nursing personnel immediately to the prescriber
and ADR focal person.
6.1.1.42 Drugs in patient care areas shall be maintained under proper conditions, as
indicated under pharmaceutical service standards of these standards.
6.1.1.43 All drugs, needles, and syringes in patient care areas shall be kept in locked
storage areas, except those drugs exempted by the pharmacy or equivalent
under specified conditions. Drugs for external use shall be kept separate from
drugs for internal use.
6.1.1.44 Nursing personnel shall return drugs to the central medical store of the hospital
for disposal.
6.1.1.45 Nursing personnel shall store and use needles and syringes in accordance with
the infection prevention standards of these standards
6.1.1.46 There shall be a protocol that guides nurses copying the prescription of
physician’s order.

Nursing care: use of restraints

6.1.1.47 The hospital shall have written policies and procedures regarding the use of
physical restraints that are reviewed at least once every three years and
implemented. They shall include at least the following:
(a) Protocol for the use of alternatives to physical restraints, such as staff or
environmental interventions, structured activities, or behavior
management. Alternatives shall be utilized whenever possible to avoid
the use of restraints;
(b) A delineation of indications for use, which shall be limited to:
 Prevention of imminent harm to the patient or other persons when
other means of control are not effective or appropriate; or
 Prevention of serious disruption of treatment or significant damage
to the physical environment;
(c) Contraindications for use, including at least clinical contraindications,
convenience of staff, or discipline of the patient;

44
 (d) Protocols for notifying the family or guardian of reasons for use of
restraints, and for informing the patient and requesting consent when
clinically feasible; and
(e) Protocol for removal of restraints when goals have been accomplished.
6.1.1.48 Except in an emergency, a patient shall be physically restrained only after the
attending physician or another designated physician has personally seen and
evaluated the patient and has executed a written order for restraint.
6.1.1.49 An emergency restraint procedure, beginning with the least restrictive
alternative that is clinically feasible, shall be initiated by a licensed professional
nurse only when the safety of the patient or others is endangered or there is
imminent risk that the patient will cause substantial property damage. The
attending physician, another designated physician, or independent practitioner,
or a licensed psychiatric nurse shall be notified immediately and shall respond
within one hour. An order shall be given if the use of restraints is to continue
beyond one hour. The clinical condition of the patient shall be evaluated and
documented by medical or licensed nursing personnel at least once every two
hours.
6.1.1.50 In all cases, the attending or designated physician, or independent practitioner,
or licensed psychiatric nurse shall observe the restrained patient at least once
every 24 hours to evaluate any changes in the patient's clinical status. This
evaluation shall be documented in the patient record. If a physician has ordered
the use of restraints, a subsequent order for the use of restraints shall not be
required so long as its use is in compliance with the intent of the original order
and hospital policy.
6.1.1.51 Interventions while a patient is restrained, except as indicated at (g) below,
shall be performed by nursing personnel in accordance with nursing care policy.
They shall include at least the following and shall be documented:
(a) Assessment for clinical status and reevaluation of need for restraints at
least every two hours;
(b) Toileting at least every two hours with assistance if needed;
(c) Monitoring of vital signs; and
(d) Release of restraints at least once every two hours in order to:
 Assess circulation and skin integrity;

45
  Perform skin care; and
 Provide an opportunity for exercise or perform range of motion
procedures for a minimum of five minutes per limb.
(e) Continuous or periodic visual observation based upon an evaluation of
the patient's clinical condition.
(f) Administration and monitoring of adequate fluid intake;
(g) Adequate nutrition through meals at regular intervals, snacks, and
assistance with feeding if needed;
(h) Assistance with bathing as required, occurring at least once a day; and
(i) Ambulation at least once every four hours if clinically feasible.
6.1.1.52 Licensed professional nursing staff shall evaluate and ensure appropriate
monitoring and documentation of the effects of all psychotropic medications.
These medications shall be administered only upon written physician orders as
part of the patient's treatment plan and shall not be used as a method of
restraint, discipline, or for the convenience of staff.

Nursing care: Dying patient

6.1.1.53 There shall be a policy or a protocol that state the procedure to be followed for
dead body care which contain the minimum of:
(a) Confirmation of death by at least attending physician or any
independent practitioner and the nurse giving care (2 medical
personnel),
(b) Care for the body shall be carried out according to the religion and
culture of the patient as per the facility protocol,
(c) If there is need of pathologic examination the request shall be sent to
morgue,
(d) If there is document of consent for organ donation (i.e. cornea), the
consent shall be sent to morgue
(e) The body shall be taken to morgue immediately,
(f) The time of death shall be documented on the patients chart,

6.1.2 Premises
6.1.2.1 Private room /space: for isolation or special care, with toilet room and shower,

46
6.1.2.2 Hand washing basin at each room,
6.1.2.3 Toilet rooms,
6.1.2.4 Procedure room: for nursing procedures,
6.1.2.5 Nurse changing room:
6.1.2.6 Nurses station: located in the middle of the wards with free access to all wards,

6.1.3 Professional
6.1.3.1 The nursing staff shall have a minimum of diploma from accredited college or
university.
6.1.3.2 There shall be written discrete job descriptions that detail the roles and
responsibilities of each nursing staff members at specific units; ICU, OR Scrub
nurse, midwives, CSR.
6.1.3.3 The hospital shall have in place a nursing workforce plan that addresses nurse
staffing requirements, including, at a minimum:
(a) A nurse representative in each patient care unit or case team responsible
for the operation of the professional nursing service 24 hours per day
and 365 days a year.
(b) A daily staffing schedule that ensures at least one licensed nurse in
charge and assigned exclusively to each patient care unit or case team on
each shift;
(c) A provision that at least 100 percent of direct patient care for 24 hours
in inpatient units on a hospital wide average be provided by licensed
nursing personnel,
(d) A method for assessing each unit’s additional nursing needs for each
shift.
6.1.3.4 There shall be at least one licensed nurse in charge of each patient care unit at
all times and this shall be indicated in the hospital’s organizational plan.
Additional staff shall be assigned by the hospital as required by the acuity levels.
6.1.3.5 Nurse staffing for inpatient patient care service within the hospital shall be in
accordance with not more than 6 patients under one nurse for general inpatient
care. However, for ICU and emergency there shall be one nurse for a maximum
of two patients

47
6.1.3.6 There shall be effective policy that control nursing care by junior nurses, health
assistants and nursing students shall be under direct supervision of a licensed
nurse; all being accountable.
6.1.3.7 All nursing staff shall receive orientation, training and/or update at least
annually, emergency procedures and infection prevention and control, including
at least:
(a) Hospital’s policies and procedures,
(b) Non-emergency nursing clinical procedures.
6.1.3.8 Professional Quality assurance: On-going internal institutional evaluation of
outcome-based quality indicators related to nursing care shall be in place to
assess and provide a safe and adequate level of patient care including at least:
(a) Patient injury rate;
(b) Medication process errors;
(c) Maintenance of skin integrity;
(d) Control of cross infections and nosocomial infection rates;
(e) Hospital-wide patient satisfaction with overall care, including nursing
care;
(f) Nursing turnover rate; nurse staffing
(g) Patient satisfaction with pain management; and
(h) Mix of licensed nurses and unlicensed staff (student nurses, assistants)
caring for patients.
6.1.4 Products

The following products shall be available for nursing care services. However, the
product list may vary from one department to another.
No Item Quantity Remark
1 Specimen collection set
2 Rubber Sheets
3 Restraining Equipment. E.g., cushion, belt, vest, See mental
long sleeve pullover, etc., Health
Services
4 Patient Chart Folders

48
5 Vital Sign Equipments
 Trolley for vital sign monitoring,
 Thermometer, BP apparatus,
stethoscope, measuring tape
 sphygmomanometer with
stethoscope,
 wrist watch/ wall clock,
 bedside weighing scale
 Pulseoxymetry

6 Nursing procedure equipments:

 Dressing trolley
 Dressing set,
 Minor set,
 Chest tubes and bottles,
 Enema set,
 IV stand,
 Oxygen trolley,
 Oxygen cylinder,
 Oxygen regulator/gauge,
 Oxygen face mask/ nasal catheters,
 Suction machine: electrical/pedal,
 Wheel chair,
 Waste basket,
 Safety boxes,
 Bed screens,
 Kidney basin, 475ml x 5
 Bed pan
 Urinal
 Mobile Examination light,
 Plastic apron,
 Drapes,

49
  Rubber sheets,
 Connectors,
 Cushion bags,
 NG tube, Catheter (different type , poly
, plain ,etc) , canuala of different gauge

Soiled utility room:

7  Soiled linen trolley
 Bin with lid
 Worktable with laminated top
 Wash tub (65L)
 General purpose trolley, two trays

50
6.2 Patient flow
6.2.1 Practices
6.2.1.1 The hospital shall have a written protocol of patient flow which at least
describes the following:
(a) The presence, roles and responsibility of a receptionist at the gate
(b) Triaging of patients
(c) How to get into emergency and delivery services
(d) How to get into regular outpatient case teams and chronic illness case
teams
(e) How to be admitted if admission is needed
(f) How to get pharmacy, laboratory and other diagnostic services
(g) The process of discharge
(h) The procedures of payment for services
6.2.1.2 The hospital shall follow its written patient flow procedures
6.2.2 Premises
6.2.2.1 Service areas shall be labeled in bold at a recognizable location
6.2.2.2 The office layout shall be arranged in a way that ensures patient independence
by labeling in bold and making related service provided in adjacent rooms
6.2.2.3 There shall be a clearly labeled reception and triage room.

6.2.3 Professionals
6.2.3.1 The hospital shall have runners to facilitate patient flow
6.2.3.2 Receptionists
6.2.4 Products
6.2.4.1 Wheelchairs
6.2.4.2 Stretchers with wheels

51
6.3 Outpatient Services

6.3.1 Practices
6.3.1.1 The outpatient services shall comply with the standards prescribed under
patient rights and responsibilities standard
6.3.1.2 The hospital outpatient service shall have a central triage system
6.3.1.3 The outpatient service shall have policies and procedures regarding access,
availability of service and networking
6.3.1.4 The outpatient service shall be available in working days for at least eight hours
a day
6.3.1.5 The hospital may have a system for providing after-hour (non-working hour)
follow up service.
6.3.1.6 Follow up clinic services, which shall be led by a specialist or sub-specialist, shall
be available at least once a week for eight hours per discipline.
6.3.1.7 The hospital shall have a system to make follow up of patients by the same
physician
6.3.1.8 The outpatient service shall have consultation, and functional intra and inter
facility referral system which include at least:
 Procedure for referring and receiving referral
 List of potential referral sites with contact address (referral directory)
 Referral forms
 Referral tracing mechanism (linkage)
 Feedback providing mechanism
 Documentation of referred clients
 Consultation forms
6.3.1.9 The medical assessment at outpatient services shall at least includes
comprehensive medical and social history, physical examination, diagnostics
impression as well as laboratory and other medical workups (x-ray, ultrasound,
CT scan etc) when indicated.

52
6.3.1.10 The outpatient clinic shall have clinical protocols for management of at least
common disease entities and locally significant diseases in line with the national
and international guidelines.
6.3.1.11 The range of relevant treatment options and the clinical impression shall be fully
described to client and/or their families and documented accordingly
6.3.2 Premises
6.3.2.1 The outpatient layout shall include the following:
a) Dedicated entrance
b) Waiting area: room /lobby preferably with public telephone, TV area,
drinking fountain and gender specific toilet
c) Reception and recording area/desk
d) Dedicated patient consultation and examination rooms /cubicles for each
specialty services
e) Room for minor procedures
f) Room for providing injections
g) Storage place for sterile supplies
h) Soiled utility
i) Staff room (for changing cloth)
j) Janitors closet
6.3.2.2 All rooms shall have adequate light, water and ventilation
6.3.2.3 Communication system shall be connected with major functional areas
6.3.2.4 The room arrangements of outpatient services shall consider proximity between
related services
6.3.2.5 The outpatient clinical setup shall have easy access to pharmacy, laboratory and
other diagnostic services.
6.3.2.6 The outpatient clinic shall be well marked and easily accessible for disabled
clients, elderly patients, under five children and pregnant mother.
6.3.2.7 The outpatient service shall be located where access for ambulatory patients is
the easiest and where in coming client would not have to pass through other
care service outlets ( in- patient , laboratory etc )
6.3.2.8 The outpatient clinics shall have fire extinguishers placed in visible area
6.3.3 Professionals

53
6.3.3.1 At least one general medical practitioner per discipline (Internal Medicine,
Pediatrics, Surgery, Gynecology and Obstetrics) to run the general outpatient
service shall be assigned for eight hours in each working day
6.3.3.2 One specialist or sub-specialist per discipline (specialty) to run the respective
specialized outpatient service shall be assigned
6.3.3.3 The actual number of personnel shall be determined by workload analysis using
recognizable methods
6.3.3.4 The staff shall have regular supportive supervision by senior staff or peer
review or case conferences every three months and it shall be documented
6.3.4 Products

6.3.4.1 Products that are specific to particular department are indicated under the
specific discipline
No Item
1 Weighing Scale
2 Vital Sign and Diagnostic Set
 Thermometer
 Stethoscope
 Sphygmomanometer
 Fundoscope
 Otoscope
 Pulseoxymeter
 Reflex hammer
 Snellen’s chart
3 Examination Coach
4 Minor Set
5 Dressing Set
6 Refrigerator
7 Catheterization set
8 Trolley
9 Folding Screen
10 X-Ray Film viewer

54
6.4 Inpatient Services

6.4.1 Practices
6.4.1.1 The inpatient service delivery shall comply with the patient rights standard
6.4.1.2 The inpatient service shall be available 24 hrs of a day and 365 days a year.
6.4.1.3 The inpatient service shall have consultation and functional intra and inter
facility referral system as prescribed under the outpatient service standards.
6.4.1.4 The inpatient service shall include at least the following services for admitted
patients:
a) Taking comprehensive medical and social history, comprehensive physical
examination and performing important laboratory & other medical workups
upon admission and when indicated.
b) Nursing care service over the 24 hrs of each day of admission until discharge
c) Detailed round visits at least twice a week and daily business round by the
attending physicians
6.4.1.5 The inpatient nursing care shall comply with the nursing service standard
6.4.1.6 The inpatient service shall have clinical protocols for management of at least
common causes of admission in the hospital
6.4.1.7 The hospital shall have a system to make follow up of patients by the same
physician
6.4.1.8 The range of relevant treatment options, plans and the clinical impression shall
be communicated to client and/or their families and documented accordingly
6.4.1.9 The inpatient service shall have quality improvement mechanisms that at least
include conducting regular morning sessions among relevant health
professionals
6.4.1.10 The hospital shall provide dietary service for patients who are admitted
6.4.1.11 The hospital shall provide a clean gown to admitted patients
6.4.1.12 The hospital shall secure the properties of admitted patients in a cabinet or
room with shelves
6.4.1.13 The inpatient service shall have easy access to laboratory, diagnostic and
pharmacy services as per their respective standards

55
6.4.1.14 Religious support shall be provided for admitted patients upon patient request
and this shall not disturb the privacy, dignity and right of other admitted
patients.
6.4.1.15 The inpatient service shall arrange the appropriate post discharge instructions
and follow up for the patient
6.4.1.16 The hospital shall provide a post mortem care and morgue service to deceased
6.4.1.17 The hospital shall contact the municipality or responsible body for burial service
if there is no family/guardian of the deceased.
6.4.2 Premise
6.4.2.1 Inpatient service shall have the following rooms
(a) Wards separate for male and female
(b) Nursing Station per ward
(c) Doctors office (consultation room)
(d) Bathroom for patients per ward
(e) Staff bathroom
(f) Duty room
(g) Clean utility room
(h) Soiled utility room
(i) Store
6.4.2.2 The number of beds per room shall not exceed 6 per room with the following
specification
(a) Distance of bed from fixed walls shall be 0.9 m
(b) Distance between beds shall be 1.2 m
(c) Adult beds shall have 1m width and 2m length
(d) Each bed room shall have alarm
(e) The rooms shall have safe and continuous water supply, light and ventilation
(f) There shall be washing basins for each room
6.4.3 Professionals
6.4.3.1 Specialists and sub-specialists of the related discipline with a minimum of one
shall be physically available during working hours
6.4.3.2 At least one general medical practitioner per discipline shall be physically
available in all the shifts

56
6.4.3.3 One nurse for a maximum of 10 patients per shift shall be available to provide
nursing care services
6.4.3.4 Support staff such as runner, cleaner and telephone operator shall be available
for 24 hrs a day
6.4.3.5 Actual number of professionals shall be determined based on the case load
analysis of the hospital
6.4.3.6 Engineers/Technicians for equipment maintenance and general maintenance
(power supply, water supply, drainage system) shall be available during
working hours and shall be also available either on duty or on call basis during
non working hours

6.4.4 Products
6.4.4.1 Products specific to particular departments are indicated under each discipline

No Item Quantity Remark

1 Beds and bed side cabinet Based on The bed shall

workload have a wheel for
easy movement
2 Bed pans Equivalent with
number of beds
3 Urinal (Male and Female)

4 Bed Pan carriage

Bed pans washer and Sterilizer

5 Bed pan Racks

6 IV Stand One per bed

7 Stretcher

8 Wheel chair

9 Safety Box

10 Suction machine

11 Resuscitation set

57
12 Vital sign and Diagnostic Set
 Thermometer
 Stethoscope
 Sphygmomanometer
 Fundoscope
 Otoscope
 Reflex hammer
13 Refrigerators

14 Minor Set

15 Dressing Set

16 Enema Set

17 LP set

18 Emergency Drugs

19 Catheterization set

20 Folding screens

21 X-ray Film Viewer

58
6.5 Emergency Services

6.5.1 Practices
6.5.1.1 The emergency service including emergency surgical interventions shall be
available 24hrs a day and 365 days a year.
6.5.1.2 The hospital shall have an emergency triage system
6.5.1.3 Infection prevention standards shall be implemented in the emergency room as
per the IP standards stated under these standards
6.5.1.4 Every emergency patient shall get the service without any prerequisite and
discrimination.
6.5.1.5 The emergency service shall have functional intra and inter facility referral system
which encompasses SOP for selection of referral cases, referral directory,
referral forms, referral tracing mechanism, feedback providing mechanism,
documentation of referred clients and consultation forms.
6.5.1.6 If referral is needed it shall be done after providing initial stabilization and after
confirmation of the required service availability in the facility where the patient
is to be referred to.
6.5.1.7 If the patient to be referred needs to be attended by a physician or other
professional in another hospital, the hospital shall arrange an ambulance service
and accompanying professionals to transfer the patient.
6.5.1.8 Every procedure, medication and clinical condition shall be communicated to the
patient or family member after responding for urgent resuscitation measures
6.5.1.9 There shall be a mechanism of quality improvement for the service at least by
collecting feedback from clients and having a formal administrative channel
through which clients place their complaints and grievances
6.5.1.10 The hospital shall provide a complete emergency service at least to the level of its
specialization.
6.5.1.11 The emergency service shall have a procedure for easy access to intensive care
unit, pharmacy, laboratory and radiological diagnostic services 24hrs a day and
365 days a year as per their respective standards stated under these standards.

59
6.5.1.12 The emergency service shall be directed by an emergency medicine specialist or
or a general medical practitioner trained on emergency medical services.
6.5.1.13 For labor and delivery emergencies the hospital shall follow the labor and delivery
standards stated under these standards
6.5.1.14 There shall be a written protocol for emergency services and the provision of this
service shall be done in accordance with the clinical protocols of the service
6.5.1.15 The emergency service shall have clinical protocol for the initial management of at
least the following emergency cases:
(a) Shock
(b) Bleeding
(c) Fracture and injuries
(d) Coma
(e) Seizure disorder
(f) Air way obstruction
(g) Cardiac emergencies
(h) Hypertension emergencies
(i) Acute diarrhea
(j) Psychiatric emergencies
(k) Burn
(l) Poisoning
(m)Acute abdomen
6.5.1.16 Referral system shall be strictly chained, controlled & managed by the hospital.
6.5.1.17 Other service that assist the emergency service shall be available for 24 hrs with
adequate staffing

6.5.2 Premises
6.5.2.1 The emergency room shall be located in a place where it is easily recognizable to
the public and shall be labeled in bold.
6.5.2.2 The emergency premise shall be low traffic area and there shall be reserve
parking place for ambulances.
6.5.2.3 The corridor to emergency rooms shall be stretcher friendly and spacious enough.
6.5.2.4 The emergency area shall be spacious enough (> 193 m2) to provide a space for
the following tasks:

60
 (a) Triaging
(b) Accepting and providing immediate care including emergency
procedures
(c) Admitting for a maximum of 24 hrs to provide emergency care (8
beds) equivalent to 67 square meters.
(d) Emergency pharmacy for emergency medicines, supplies and
equipments
(e) Staff/duty room
(f) Toilet facilities separate for patients and staff
6.5.2.5 Beds shall be arranged as the description of inpatient beds’ arrangement
6.5.2.6 The size of the door for the emergency room shall not be less than 1.5 meter
6.5.2.7 The emergency premise shall allow patient dignity and privacy.
6.5.2.8 The rooms shall be arranged in such a way that the first encounter to an
emergency patient coming from outside will be the examination room or space
6.5.2.9 The emergency room shall have the following facilities
(a) Adequate water, light and ventilation.
(b) Fire extinguishers placed in visible area
(c) Telephone
(d) Hand washing basin in each room
6.5.2.10 Waiting area for attendants and caregivers

6.5.3 Professionals
6.5.3.1 The team of emergency shall be changed every 8 hrs as a team and the team
composition during working and non-working hours shall have similar staffing
pattern.
6.5.3.2 The emergency service shall be opened for 24hrs a day and 365 days a year being
run by an emergency team. Each team for all the shifts shall contain a minimum
of:
(a) One emergency trained physician or emergency medicine specialist
(b) Four nurses
(c) Two cleaners
(d) One runner

61
 (e) Regarding pharmacy, laboratory and x-ray see their respective
standards stated under these standards
6.5.3.3 At least one specialist or sub-specialist for each major discipline shall be available
for consultation on call bases.
6.5.3.4 The actual number of personnel required shall be adjusted based on Workload
analysis.
6.5.3.5 All health professionals working in the emergency room shall be trained on at
least cardio-pulmonary resuscitation
6.5.3.6 Rotation of staff shall not be a routine exercise for the emergency service.
6.5.3.7 Drill-exercise of emergency case management shall be conducted on regular bases
among the teams working in the emergency service.
6.5.3.8 The staff shall have regular supportive supervision by senior staff or peer review
or case conferences every three months and it shall be documented
6.5.3.9 The hospital shall have personnel manual which also covers staff at the emergency
services
6.5.4 Products
6.5.4.1 The emergency service shall have readily arranged emergency drugs and supplies
on trolley.
6.5.4.2 There shall be at least two coaches at emergency room
6.5.4.3 There shall be at least eight beds to be used only for emergency admission
6.5.4.4 Actual number of beds, materials, and kits for emergency use shall be calculated
considering the average number of emergency cases

No Item
1 Emergency Bed
2 Mobile Stretcher
3 Wheel Chair
4 IV Stand
5 EKG
6 Suction machine

7 Defibrillator
8 Tracheotomy set

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Patient screen, partition curtains
9 NG tube
10 Minor set
11 Different types of splints
12 Mobile examination light
13 Hot air oven
Oxygen supply: oxygen, Cylinder with flow
meter, trolley and nasal prongs
14 Examination Lamp
15 Resuscitation set on trolley
16 Intubation set
17 Ambu bags of different type
18 Examination coach
19 Other relevant emergency kits

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6.6 Internal Medicine Services
6.6.1 Practices
6.6.1.1 The medical service shall be directed by a licensed internist.
6.6.1.2 There shall be written protocols and procedures which shall be enforced that
establish the management of the medical conditions in the unit as well as
consultation and transfer of patients admitted to this unit or other departments
6.6.1.3 For emergency medical condition the service shall be available 24 hours a day
throughout the year.
6.6.1.4 Triage shall be carried out (by qualified staff like independent practitioner) as
soon as a sick adult arrives in the hospital, well before any administrative
procedure such as registration
6.6.1.5 For non-emergency medical condition the medical service shall be available
during the regular working hours
6.6.1.6 For admitted patients the medical service shall be organized in such a way that
it covers all the shifts (24 hours of the day and seven days of the week)
6.6.1.7 Nursing functions shall be the responsibility of licensed nurses and shall be
supervised by a nurse assigned by the licensed internist. Nurses practicing in the
internal medicine service shall be accountable to the licensed internist.
6.6.1.8 The service shall have written policies and procedures that shall include
(a) Admission and discharge criteria specific to the service;
(b) Visitors policy that allows for 24 hour visitation by designated visitors and
specifies the number of visitors permitted for each patient at any time
(c) Infection control specified under these standards and National and or
Hospital IP guideline
(d) Transfer and referral of patients
(e) Monitoring and follow-up of patients
6.6.1.9 The administrative functions shall be a responsibility of the hospital
administration
6.6.1.10 Every medical records shall be kept for each patient as specified in the medical
records of these standards
6.6.1.11 Information contained in the medical record shall be complete and sufficiently
detailed relative to the patient's history, physical examination, diagnosis,

64
 diagnostic procedures, medication administration, and treatment. Refer to the
medical record section of these standards.
6.6.1.12 The medical unit shall have a follow-up service for patients with chronic
ailments.

6.6.1.13 Notifiable diseases shall be notified through the proper channel (to chief clinical
officer or chief executive officer and hence to the MOH)

6.6.1.14 The unit shall avail updated reference materials, treatment guidelines and
manuals (e.g. National TB and leprosy, pain management, Malaria treatment,
ART etc)

6.6.1.15 Prescriptions and different request forms for investigation like laboratory, x-ray,
etc shall be revised and updated as per service need at least every five years.

6.6.1.16 The caretakers and/or patients shall be included in the development of the
nursing patient plan of care

6.6.1.17 There shall be a system for clinical staff to refer patients directly to the social
works unit.

6.6.2 Premises
6.6.2.1 Maximum room capacity shall be six patients or beds per room

6.6.2.2 Patient rooms shall be constructed to meet a minimum of 9 meter squares for
single bed room

6.6.2.3 In case of multiple beds per room, the area per bed shall be 80 sq. ft

6.6.2.4 Dimensions and clearances- the dimensions and arrangements of rooms shall be
such that there is a minimum of 0.9m (90cm) between the sides and foot of the
bed and any wall or any other fixed wall construction. In multiple bed rooms a
clearance of 1.2 meter shall be available at the foot of each bed or between beds
to permit the passage of equipments and beds

6.6.2.5 The number of rooms and beds shall be as per the load, volume and nature of
work performed.

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6.6.2.6 The inpatient rooms for medical service shall be organized into different wards,
the number of which depends upon the size and the degree of specialization of
the medical service, available facilities, and the service needs.

6.6.2.7 The medical service unit shall have at least three isolation rooms for treatment
of conditions that require isolation.

6.6.2.8 Patients in acute care shall be under direct observation in a room near the
nurses’ station.

6.6.2.9 In addition to the ward rooms, the internal medicine service shall have the
following rooms and facilities:

a) A private area for counseling (examination room/office for physician);

b) Duty room/Station;
c) Meeting room;
d) Nurse station;
e) Utility rooms;
f) Procedure room,
g) Care after death room
h) Rooms for follow-up clinics;
i) Store;
j) Staff Toilets, showers and changing room and
k) Patient Toilet and shower at least one each per room.
6.6.3 Professionals
6.6.3.1 There shall be qualified medical and nursing personnel in the medical service
unit available at all times to meet the service needs
6.6.3.2 The number and type of technical staff shall be determined by the volume and
type of work carried out (Workload Analysis)
6.6.3.3 An internist or licensed independent practitioner shall control the nursing visits,
care, carry out and execution of the orders
6.6.3.4 An internist or licensed independent practitioner shall be available (physically
present) at all times in the adult medical service unit
6.6.3.5 An internist or licensed independent practitioner shall be on duty or on call at
all times. The physician on call shall be duty bound to respond to calls.

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6.6.3.6 A licensed nurse shall be available at all times to assess, evaluate, and supervise
the nursing care provided.
6.6.3.7 An internist or licensed independent practitioner shall be responsible for the
follow-up clinics.
6.6.3.8 The internal medicine service shall have support staff such as cleaners and
others available as per the service need

6.6.4 Products
6.6.4.1 The hospital shall prepare an emergency drug list in accordance with the
national drug list (NDL) and ensure their availability.
6.6.4.2 The medical OPD shall have the following supplies and functional equipment in
addition to office furniture’s
a) Torch, Otoscope, ophthalmoscope
b) Weighing scales for adults
c) Measuring board for measuring length and height
d) Tape meter, thermometer
e) Stethoscopes
f) Sphygmomanometer
g) X-ray viewer
h) Examination couch
i) Lumbar puncture, bone marrow aspiration (and biopsy) set, pleural (
peritoneal) biopsy set, liver biopsy set, renal biopsy set, cut down set,
pericadiocentesis set, wide bore needles for thoracentesis
j) Hand washing basin
k) Spatula, K-Y jelly, surgical and disposable gloves, antiseptics, cotton,
gauze
6.6.4.3 The inpatient service shall have the following supplies and functional
equipments
a) Torch, Otoscope, ophthalmic diagnostic set with Snellen’s chart
b) Weighing scales
c) Tape meter, thermometer, patella hammer
d) Stethoscopes and Sphygmomanometer
e) X-ray viewer

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 f) Examination couch, medicine trolley, Cup board
g) Lumbar puncture, Bone marrow aspiration set, pleural biopsy set,
tracheostomy set, chest tube
h) EKG machine, defibrillator
i) Suction machine
j) Drip counters/Infusion pump, Tourniquets and IV stands
k) Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
l) Self inflating bags for respiratory support, Masks, endotracheal tubes,
m) Laryngoscope
n) Cannulas, Nasogastric tube
o) Beds for patients and hand washing basin
p) Nebulisers for administration of salbutamol (electricity driven, or oxygen
driven or footpump driven)
q) Equipment for pleural tapping and biopsy, pericardiocentesis, and
paracentesis and drainage of ascites,
r) Equipment for skin scrapings and biopsy of dermatological lesions, bone
marrow trephine needles and slides and others
s) Gastroscope, Colonoscope and Proctoscope
t) Pulse oxymeter and Defibrillator
u) Emergency drugs
v) Glucometer and glucostick
w) Wheelchair
x) Over bed table( for feeding)
y) Bed side cabinet and bed curtain fixed with the roof and the ground
z) Waste paper basket

6.6.4.4 The service shall have at least a general follow-up clinic that shall have the
following supplies and functional equipments:-
a) Torch, Otoscope, ophthalmic diagnostic set with snellens chart
b) Weighing scales
c) Tape meter, thermometer, patella hammer
d) Stethoscopes and Sphygmomanometer
e) X-ray viewer

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 f) Examination couch
6.6.4.5 Non-emergency drugs and supplies shall be available in line with essential drug
list of the hospital

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6.7 Pediatric Services

6.7.1 Practices

6.7.1.1 Emergency care with a qualified staff shall be available 24 hours a day
6.7.1.2 Triage shall be carried out (by qualified staff) as soon as a sick child arrives in
the hospital, well before any administrative procedure such as registration
6.7.1.3 The pediatric services shall have a plan to deal with internal disasters such as
the arrival of one or more seriously injured patients
6.7.1.4 The hospital shall have pediatric intensive care services with full-fledged
neonatal unit and this service unit shall have written protocols and procedures.
6.7.1.5 Pediatric services shall have in-patient, out-patient and neonatal services
6.7.1.6 For non-emergency conditions of pediatric patients the service shall be available
during regular working hours
6.7.1.7 Admitted patients shall receive services for 24 hours a day which shall be
covered through rotation of health care providers
6.7.1.8 The service shall have written policies and procedures that shall include
(a) The age below which all patients must be admitted to a pediatric service;
(b) Admission and discharge criteria specific to the service;
(c) A visitors policy that allows for 24 hour visitation by designated visitors and
specifies the number of visitors for each patient at any one time;
(d) Infection control as per the standard prescribed under these standards
(e) Transfer and referral of patients
(f) Safety measures for the purpose of preventing electrical and bodily injury to
pediatric patients.
(g) Monitoring and follow-up of pediatric patients
6.7.1.9 There shall be an adult supervising when children under seven years of age are
present in the recreation room or playroom.
6.7.1.10 The nursing assessment and care of each pediatric patient shall consider the
patients developmental needs
6.7.1.11 The parents or guardians of pediatric patients shall be included in the
development of the nursing patient plan of care

70
6.7.1.12 Immunization services shall be available in the pediatric unit and all children
shall have their immunization status checked before discharge
6.7.1.13 The unit shall avail updated reference materials, treatment guidelines and
manuals (eg. National TB, Malaria, ART etc.)
6.7.1.14 Medical records shall be kept in line with standards
6.7.1.15 Information contained in the medical record shall be complete and sufficiently
detailed relative to the patient's history, physical examination, diagnosis,
diagnostic procedures, medication administration, and treatment.
6.7.1.16 Growth monitoring activities and nutritional advice and management shall be
there.
6.7.1.17 The pediatrics unit shall have a follow-up service for patients with chronic
ailments.
6.7.1.18 All children with notifiable diseases shall be notified through the proper channel
(to chief clinical officer or chief executive officer and hence to the MOH)
6.7.1.19 There shall be a system for clinical staff to refer patients directly to the social
works unit.

6.7.2 Premises

6.7.2.1 Maximum room capacity shall be six patients (or beds) per room
6.7.2.2 The hospital shall have intensive care unit that accommodate a minimum of
four ICU beds
6.7.2.3 Patient rooms shall be constructed to meet a minimum of 9 meter squares for
single bed room
6.7.2.4 In case of multiple beds per room, the area per bed shall be 80 sq. ft
6.7.2.5 Dimensions and clearances- the dimensions and arrangements of rooms shall be
such that there is a minimum of 0.9m (90cm) between the sides and foot of the
bed and any wall or any other fixed wall construction. In multiple bed rooms a
clearance of 1.2 meter shall be available at the foot of each bed to permit the
passage of equipments and beds
6.7.2.6 Windows-each patient room shall have at least one window
6.7.2.7 Each room shall have a hand washing station, toilet and bath room
6.7.2.8 The pediatric premises shall include at least emergency unit, outpatient,
inpatient and neonatal units.

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6.7.2.9 The pediatric outpatient shall have a functional oral rehydration therapy corner
6.7.2.10 A minimum of 10 percent of the beds used for pediatric care shall be capable of
functioning as isolation rooms.
6.7.2.11 Each pediatric unit shall have at least one playroom with recreation equipment
and child-size tables and chairs.
6.7.2.12 The number and size of the rooms shall be adequate in relation to the volume
and nature of the activity in the unit
6.7.2.13 Patients in acute care shall be under direct observation in a room near the
nurses’ station.
6.7.2.14 Premises for Neonatal unit

a) The arrangement of the rooms for the neonatal care shall be in such a way
that avoids winds.

b) It shall have the following rooms:

 Room for care of critical newborns

 Separate room for infectious cases
 Procedure room
 Kangaroo mother care room
 Room for mothers
 Milk preparation room
 Nurses station
 Staff toilet and bath
 Toilet and bath for mothers
 Store room
 Office for physicians

6.7.2.15 Premises for the pediatric OPD

a) The pediatric OPD shall have at least the following rooms:

 Room(s) for out patient examination

 Procedure room
 Room(s) for follow-up cases

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  Nurse station
 Store
 Toilets for patients and staff
 Space for waiting patients

6.7.2.16 Premises for the pediatric in-patient

a) The pediatric in-patient shall have at least the following rooms:

 Rooms for in-patient care

 Procedure room
 Room for severely malnourished patients
 Nutritional supplement preparation room
 Nurses station
 Dark room
 Staff toilet and bath
 Toilet and bath for patients and care takers
 Store room
 Office for physicians

6.7.2.17 Premises for pediatric emergency OPD

a) The pediatric emergency shall have at least the following rooms:

 Space for patient triaging

 Examination room

 Room/s for management of patients

 Procedure room

6.7.2.18 In addition to the rooms in the units mentioned above paediatrics services shall
have the following rooms:
a) Counselling room
b) Duty room
c) Meeting hall

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 d) Room for inpatient pharmacy

6.7.3 Professionals

6.7.3.1 A licensed pediatrician shall be in charge of overall pediatric services

6.7.3.2 There shall be adequate qualified medical and nursing professionals in the
pediatric unit available at all times to meet the service needs
6.7.3.3 The number and type of technical staff shall be determined by the volume and
type of work carried out (Workload Analysis)
6.7.3.4 A physician or licensed independent practitioner shall be available (physically
present) at all times in the pediatric unit
6.7.3.5 A senior pediatrician shall be on duty or on call at all times. The physician on call
shall be duty bound to respond calls.
6.7.3.6 A pediatrician or licensed independent practitioner shall be responsible for the
follow-up clinics.
6.7.3.7 The pediatric OPD, In-patient unit and neonatology units shall have at least one
paediatrician for each unit.
6.7.3.8 The nurse with administrative responsibility for nursing care in pediatrics shall
be a licensed professional nurse with at least three years of experience in
pediatrics
6.7.3.9 There shall be adequate support staff available as per the service need

6.7.4 Products

6.7.4.1 The following emergency drugs, supplies and functional equipments shall be
available 24 hours in the emergency unit in addition to office furniture’s (chairs,
tables, cabinets). These shall include the following which is not an exhaustive
list:
a) Emergency medicines
b) Oxygen cylinder, flow meter
c) Nasal prongs catheters
d) Self inflating bags for respiratory support, Masks (infant size, child size,
adult size), endotracheal tubes (pediatric and adult sizes), laryngoscope
e) Butterflies and/or cannulas of paediatric size

74
 f) NG-tubes and urinary catheters (pediatric size)
g) Equipment for intra-osseous fluid administration
h) Resuscitation stretcher, examination couches, beds for emergency services,
X-ray viewer
i) Sphygmomanometer (pediatric and adult sizes), stethoscope, thermometer,
weight scale, tape meter, Torch, Otoscope, ophthalmoscope, patella hammer
j) Glucometer with glucosticks, pulse oximetery, EKG machine and its supplies,
Cardiac monitor (optional), lumbar puncture set, minor set, chest tube set,
tracheostomy set
k) Gloves (surgical and disposable), antiseptics (alcohol, savlon, iodine), cotton,
gauze, Spatula, K-Y jelly
l) Suction machine, medicine trolley, Cup board
m) Hand washing basin
n) Nebulisers for administration of salbutamol (electricity driven, or oxygen
driven or footpump driven)
o) Spacers with masks for administration of metered doses (spray) of
salbutamol
6.7.4.2 The pediatric OPD shall have the following supplies and functional equipment in
addition to office furniture’s
a) Torch, Otoscope, ophthalmoscope, reflex hammer
b) Weighing scales for children and infants
c) Measuring board for measuring length (lying for infants) and height
(standing for older children)
d) Measuring tape, thermometer
e) Stethoscopes
f) Sphygmomanometer (pediatric and adult sizes)
g) X-ray viewer
h) Examination couch
i) Lumbar puncture, Bone marrow aspiration set, pleural biopsy set
j) Hand washing basin
k) Spatula, K-Y jelly, Surgical and disposable gloves, antiseptics, cotton, gauze
6.7.4.3 The pediatric inpatient shall have the following supplies and functional
equipments

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 a) Torch, Otoscope, ophthalmoscope, reflex hammer
b) Weighing scales for children and infants
c) Measuring board for measuring length (lying for infants) and height
(standing for older children)
d) Measuring tape, thermometer
e) Stethoscopes and Sphygmomanometer (pediatric and adult sizes)
f) X-ray viewer
g) Examination couch, medicine trolley, Cup board
h) Lumbar puncture, Bone marrow aspiration set, pleural biopsy set
i) EKG machine and its supplies
j) Suction machine
k) Drip counters/Infusion pump
l) Tourniquets and IV stands
m) Heat source
n) Oxygen cylinder, Flow-meters for oxygen
o) Nasal prongs catheters
p) Self inflating bags for respiratory support, Masks (infant size, child size,
adult size) endotracheal tubes (pediatric and adult sizes), laryngoscope
q) Butterflies and/or cannulas of pediatric size
r) NG-tubes-pediatric size
s) Spatula, K-Y jelly, Surgical and disposable gloves, antiseptics, cotton, gauze
t) Equipment for intra-osseous fluid administration
u) Beds for patients, mothers and croup tents
v) Nebulizers for administration of salbutamol (electricity driven, or oxygen
driven or foot pump driven)
w) Spacers with masks for administration of metered doses (spray) of
salbutamol
x) Emergency drugs
6.7.4.4 Neonatal intensive care unit shall have the following supplies and functional
equipments
a) Weighing scale
b) Incubators, Glucometer, Neonatal beds
c) Cardiorespiratory monitor, Pulse oximeter, Infant ventilator

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 d) Infusion pump
e) Phototherapy light
f) X-ray viewer
g) Continuous positive airway pressure apparatus
h) Torch, Otoscope, ophthalmoscope, Stethoscopes, thermometer
i) Measuring board for measuring length, Measuring tape
j) Examination couch, medicine trolley, Cup board
k) Lumbar puncture
l) Suction machine
m) Tourniquets and IV stands
n) Radiant warmers
o) Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters, Self
inflating bags for respiratory support, Masks (infant size), endotracheal
tubes (new born sizes), laryngoscope
p) Butterflies and/or cannulas of paediatric size
q) NG-tubes-paediatric size, umbilical catheters
r) Exchange transfusion sets
s) Beds for patients and hand washing basin
t) Refrigerator
u) Portable (Mobile) X-ray machine
v) Emergency medicines
6.7.4.5 The pediatric unit shall have at least a general follow-up clinic that shal have the
following supplies and functional equipments:-
a) Torch, Otoscope, ophthalmic diagnostic set with snellens chart
b) Weighing scales, height or length measuring board
c) Tape meter, thermometer, patella hammer
d) Stethoscopes and Sphygmomanometer
e) X-ray viewer
f) Examination couch
6.7.4.6 Non-emergency drugs and supplies shall be available in line with essential drug
list of the hospital

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6.8 Surgical Care Services

6.8.1 Practices

6.8.1.1 Comprehensive emergency surgical service shall be available 24 hours a day,

365 days a year,
6.8.1.2 Services for non-emergency elective surgical cases shall be available only when
all the necessary experts are available;
6.8.1.3 There shall be written protocols and procedures for admissions and discharges
with follow up.
6.8.1.4 There shall be protocols for the management of the surgical conditions in the
unit.
6.8.1.5 There shall be protocols for consultation and transfer of patients admitted to
this unit and to other departments.
6.8.1.6 There shall be a clear policy for handling emergency surgical conditions. This
service shall be available 24 hours a day throughout the year.
6.8.1.7 The hospital shall make sure the emergency surgical services is available, staffed
with the necessary technical staff, equipped with all the necessary facilities
including emergency transfusion, transportation, and electric back up.
6.8.1.8 The admission process for emergency surgery shall be done by the emergency/
duty physician with consultation to the duty surgeon.
6.8.1.9 The admission process for elective surgery shall be done by the respective
surgeon in consultation with the anesthesia department and with the other
departments as needed.
6.8.1.10 For admitted patients the surgical service shall be organized in such a way that
it covers all the shifts
6.8.1.11 The surgical service shall be directed by a licensed surgeon.
6.8.1.12 There shall be a mechanism of interdepartmental consultations with surgical
unit for which the surgeon on duty shall be responsible.
6.8.1.13 Adequate surgical records shall be kept for each patient and the patient’s
surgical record shall be integrated with the patient's over-all hospital record.

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6.8.1.14 All surgical procedures (except in life-threatening emergencies) are performed
only after appropriate history, physical examination, and indicated diagnostic
tests are completed and documented in the patient’s medical record.
6.8.1.15 The preoperative diagnosis shall be recorded in the medical record for all
patients prior to surgery.
6.8.1.16 The surgeon shall explain the disease condition, possible surgical intervention
and outcome possibilities in clear, simple and understandable terms to the
patient and/or family.
6.8.1.17 Except in life-threatening emergencies, the surgeon shall obtain an informed
consent and this must be documented in the patient’s medical record. For the
case with life threatening condition, consent shall be obtained from spouse,
family, guardian or based on the surgeon’s clinical judgment.
6.8.1.18 If there is no body to sign the consent for the patient who is in life-threatening
condition, the reason for not having the consent shall be stated.
6.8.1.19 The nursing care of patients undergoing surgery shall be planned and
documented in the medical record, directed by a trained nurse, and includes the
following:

(a) Pre-operative care,

(b) Location of post-operative care,
(c) Type of post-operative care and monitoring needed,
(d) Pain management, and
(e) Patient’s understanding of discharge instructions.

6.8.1.20 Operative reports shall be written in the patient’s record and in the OR
registration book immediately after surgery and include at least the following:

(a) Patient identification,

(b) Pre-operative diagnosis,
(c) The procedure performed,
(d) Findings during surgery,
(e) Post-operative diagnosis,
(f) Surgical specimens removed,
(g) Date and time operation started and ended,

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 (h) Name of surgeon, anesthesiologist/anesthetist, scrub nurse, and any
assistants,
(i) Signature of the surgeon
(j) Immediate post-operative orders explicitly in the order sheet.

6.8.1.21 There shall be policy that leads to positively identify the patient and ensure that
the correct procedure and the correct side are confirmed prior to starting the
surgery.
6.8.1.22 There shall be processes and policies defining the appropriate safety before,
during and immediately after surgery, including at least the following:

(a) Aseptic technique,

(b) Sterilization and disinfections,
(c) Selection of draping and gowning,
(d) Counting of sponges, instruments, and needles

6.8.1.23 The surgeon shall fill the pathology form and the specimen container shall be
properly labeled. The container shall be filled with 10% formalin.
6.8.1.24 The specimen shall be sent to the pathology department by the OR staff. It there
no pathology department in the same hospital, the specimen shall be sent to
another hospital by a family member or a relative.
6.8.1.25 There shall be a policy for preparing and availing appropriate and properly
functioning supplies, equipment, and instruments available for all surgeries
performed according to the country standard.
6.8.1.26 There shall be a protocol for patient transfer from operation theatre to recovery
room. This includes;

(a) The handover and/or transfer of immediate post-operative patients

shall be done between the anesthetist or anesthesiologist who
administered the anesthesia and the registered nurse in recovery room,
(b) The nurse in the recovery room shall immediately re-evaluate the
condition of the patient in front of the anesthesiologist or anesthetist,
(c) The follow up of immediate post-operative patients in the recovery room
shall be done by registered nurse with special training or similar
experience until the anesthesiologist, anesthetist or other qualified

80
 physician makes the decision to transfer the patient from post-
anesthesia care and this decision shall be based on the documented
results of monitoring during anesthesia recovery,
(d) The transfer from recovery room shall be done after the transfer order is
signed by the appropriate professional in the following order:
Anesthesiologist, Surgeon, Anesthetist or General Practitioner,
(e) The nurse in the recovery room shall inform the ward and the ward
nurse shall transfer the patient with the signed transfer note.

6.8.1.27 Post- operative patient in the wards shall get post operative care by qualified
nurses. The post operative care includes to the minimum:

(a) Evaluation by the surgeon or appropriate physician and ward nurses

daily or whenever needed,
(b) Follow up of vital signs and carrying out of post-operative orders shall
be done as per the order specified for individual patients. (special
orders-NPO, positioning, exercise, drainages, etc.,)

6.8.1.28 The hospital shall have clear protocol for surgical activities to be done at
outpatients level, surgical referral clinics, follow up clinics, minor operations
and orthopedic procedures
6.8.1.29 There shall be no time left without having general surgeon or physician
attending the surgical unit.
6.8.1.30 There shall be a policy or procedure that clearly shows at least one surgeon shall
be on call/ on duty to respond for surgical requests from emergency and/ or
surgical ward physician.
6.8.1.31 There shall be a mechanism that the surgeon shall be available within 30
minutes upon call.
6.8.1.32 All patients in surgical unit shall be attended by registered nurse all the time
with supervision by duty physician.
6.8.1.33 There shall be a mechanism by which the surgical unit provides board certificate
in response to hospital medical board request. The board shall be composed of,
at minimum, three specialist surgeons one of them being the treating one.

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6.8.1.34 Emergency call access to each bed in the wards and recovery room shall be in
place; at switches for emergency calls (nurse alarms) shall be placed accessible
to beds

6.8.2 Premises
6.8.2.1 Surgical Unit:
(a) A specialized hospital shall have a minimum of three operating theatres
with one septic operating theatre.
(b) The operation room shall be readily accessible to the surgical wards.
(c) The surgical unit shall be composed of operation room, recovery room,
the surgical wards, central sterilization room (CSR), toilet rooms,
showers and changing rooms with lockers, offices, store rooms, clean
and dirty utility rooms, duty rooms and cleaners room.
6.8.2.2 Operation Room /Surgical Suite:
(a) The operation room shall have three operation theatres of which one is
for septic procedures, one nurse station, four staff toilets, six shower
stands, four changing rooms with lockers, anesthesia store, nurse store,
one general store .
(b) An operating room shall have access- restricted environment where
surgical and invasive interventions are performed. It shall be organized
and equipped so that OR trafficking shall be controlled and exercised
over all persons and materials entering and leaving the area.
(c) One registration room
(d) One rest room (tea room)
6.8.2.3 Operation Theatre:
(a) At least five standard size operation theatres and two septic operation
theatres shall be available
(b) The wall of the operation theatres shall be washable; the vicinity of
plumbing fixtures shall be smooth and water resistant i.e., ceramic
plated up to the ceiling.
(c) The ceiling shall be monolithic, scrub-able and capable of withstanding
chemicals. Cracks or perforation in these ceilings are not allowed.
(d) Floors and walls penetrated by pipes, ducts and conduits’ shall be tightly
sealed.

82
 (e) The floor of the theatre shall be smooth, easily cleanable, non-slippery
and non-staining and it shall not be affected by water or germicidal
cleaning solutions; preferably made of marble or ceramic.
(f) There shall be drainage on the floor,
(g) There shall be at least six fixed electric outlets in each theatre with
cover,
(h) The entrance and exit doors to the theatre shall be fitted with self-
closing double doors,
(i) There shall be at least one operation table in each theatre,
(j) At least one ceiling operation light and one mobile operation light per
theatre shall be available
(k) Glass cabinet and shelves shall be available
(l) The OR shall be cleansed and disinfected after each operation and
thoroughly cleansed weekly. UV lights shall be installed in the OR.
(m)Appropriate temperature shall be maintained in the operation theatre
(considering the climatic conditions of the hospital location).

6.8.2.4 Scrub area:

(a) There shall be a scrubbing-up area outside but adjacent to the operating
theatre(s). The scrub area shall be in between the two self closing doors.
If there is one common scrub area for the four theatres, it shall be wide
enough to accommodate four staff scrubbing simultaneously.
(b) This area shall have direct access to the operating room,
(c) It shall be provided with multiple sinks or with wide sink and taps
for running (warm) water. The taps for running water for scrubbing
shall be hand free to be manipulated with elbow or knee joint. (e.g., long
arm of valve gate to be manipulated with elbow or knee joint.)
(d) Mirror above each sink.
6.8.2.5 Nurse station:
(a) This is a room within the restricted access areas, which is so situated,
constructed and equipped that it is possible for the nursing staff to
observe patients directly and where necessary, to render assistance.

83
 This area need not be a room, but may form an integral part of the main
patient corridor, recovery area or bed-receiving area.
(b) There shall be a corridor or allocated area for keeping charged and
empty Oxygen cylinders; the empty and charged oxygen cylinders shall
be labeled clearly,
6.8.2.6 Entrance/Patient Transfer Area:
(a) This area shall be large enough to allow for the transfer of patients from
a bed to OR stretcher.
(b) A line shall be clearly marked in red on the floor, beyond which no
person shall be permitted to set foot without putting on protective
clothing and OR shoes.
(c) Holding bay: there shall be a space or corridor to keep and observe pre-
operative patients until called to theatre.
6.8.2.7 Staff Change Rooms
(a) Suitable two separate changing room facilities shall be available and
clearly labeled for male and female,
(b) Each changing rooms shall have two doors, one entrance and the second
door accessing into the restricted access area; the entrance is from
outside the restricted access area.
(c) Each changing room shall be provided with a locker for a minimum of 10
staff to keep personal clothes and belongings.
(d) Each changing room shall be provided with shelves for Storage of clean
theatre attire and inside shoes and operation theatre gum boots.
(e) Separate storage bin shall be provided for used and soiled theatre
apparels.
(f) Wash hand basins: Toilets, showers,
6.8.2.8 Set-up Area (optional):
(a) Store area for suture materials and other supplies from where necessary
consumables could be stacked on a trolley that could be wheeled into
theatre for subsequent procedure.
(b) Doors into the operating room shall be big enough to wheel through the
set trolleys from the set up room into the operating room without
contact with doors or non sterile surfaces.

84
 (c) Packed instruments and other relevant materials shall be brought from
the CSR and stored in this area according to the daily schedules one day
prior to the scheduled operations.
(d) Mayo table and dressing trolley to set up for the next case are kept in
this area.
(e) If there is no set up area the instruments can be set up within the
operating theatre
6.8.2.9 Operating Theatre Equipment Store
(a) There shall be equipment store area in the operating room that shall be
supplied with a sufficient number of electrical plugs to keep the
electrical equipments plugged in, charged and in case of power failure to
work as back up electrical supply / or emergency electrical supply.
(b) Equipments shall always be stored at the same space/location and
properly labeled.
(c) Shelves and cabinets
6.8.2.10 Operating Theatre Sterile Supply Store: This shall be a room which is used for the
storage of all sterile instrument sets, swabs and sterile renewable, consumables
and it requires shelves.
6.8.2.11 Clean Utility, Surgical Suite: There shall be a room allocated for storage of IV
fluids, clean linen, medicines and other sundry items. Requirements:
(a) Shall be situated where OR staff have easy access to the clean utility
store.
(b) Metallic washable rack for storage shall be available,
(c) Equipments used for special procedures like splints shall be kept here
thoroughly cleaned after use,
(d) Refrigerator with thermometer shall be available for drugs requiring a
temperature range of 4 to 8 °C.
(e) Sink, cabinets and shelves
6.8.2.12 Soiled Utility/Sluice room shall be available with the followings;
(a) This room shall be located at the back of the OR.
(b) This room shall be for keeping contaminated materials until they are
disposed.

85
 (c) Sharp containers, leak proof containers with lids shall be available, used
sharps/safety boxes are to be stored here before being sent for
incineration.
(d) Container for temporary storage point for soiled linen,
(e) Hand Washing basin,
(f) Drainage on the floor,
(g) Trolley for soiled materials and waste human tissues,
6.8.2.13 Cleaner’s Room shall be available with the followings;
(a) A room provided with 2 sets of cleaning equipments and materials,
(b) Hand washing Basin,
(c) Washing sink,
(d) Detergent proof shelves and cabinets.
6.8.2.14 Central sterilization room shall be available with followings;
(a) Direct access to OR,
(b) Needs a minimum of needs rooms:
 One for reception, sorting of equipments; or clothes and
documentation process;
 One for inbuilt autoclaves;
 One separate properly ventilated room for storing and shelving sterile
clothes and instruments as per the guideline,
 One staff room and
 One cleaners’ room
(c) Shall have at least two inbuilt autoclaves, with small one as backup,
(d) Continuous water supply with extra reservoir,
(e) Shelves shall be washable ,corrosive free and metallic racks as per the
guideline,
(f) The date of sterilization & the name of the instruments shall be written
after sterilization.
(g) Staff toilets,
6.8.2.15 Recovery facilities shall be available with the followings;
(a) It shall be close to OR, and shall be within the semi- restricted area.
(b) A minimum of four beds shall be available,

86
 (c) There shall be a minimum of 1.2 meter gap between beds for patient
transferring stretcher,
(d) Recovery beds shall have flexible side protections,
(e) A minimum of two electric outlets shall be available for each bed,
(f) A trolley carrying functional emergency equipments shall be available in
the recovery room,
(g) A minimum of four bed pans
(h) A minimum of four patient screens shall be available,
(i) There shall be sufficient light for each bed, one head light per bed,
(j) There shall be a heater,
6.8.2.16 Minor operation theatre shall be available with the followings;
(a) It shall hall be located accessible to OPD, and shall be with low or no
traffic area.
(b) There shall be one operation room with two theatres,
(c) There shall be two transparent cabinets for surgical consumables in the
OR,
(d) There shall be two patient changing rooms,
(e) There shall be mark on the floor restricting movement of unauthorized
and/or person without OR suit,
(f) Rest room
(g) Utility room,
(h) Store with shelves and cabinets,
(i) Nurse station with table and chairs,
(j) Toilet rooms for male female,
(k) Cleaners room,
6.8.2.17 Surgical ward shall be available with the followings;
(a) It shall be part of the inpatient service,
(b) The beds shall be flexible and orthopedic beds,
(c) In third class, space between beds shall be at least 1.2m.
(d) There shall be a minimum of one separate room, labeled “Septic Room”
for septic patients,
(e) The beds shall be equipped with fixtures for certain surgical patients-
orthopedic cases

87
 (f) Patient screens,
(g) Patient toilets and showers with proximity to the ward, or covered
walkways to the ablution facilities.
6.8.2.18 Nurses’ station shall be available with the following;
(a) located amidst of the wards
(b) shall have table and chairs
(c) shall have lockable cabinets,
(d) shall have specimen collection station/ laminated table with racks
(e) shall have hand washing basin,
6.8.2.19 Surgical ward clean utility room (procedure room) shall be available with the
following;
(a) Dressing trolleys ,beds
(b) POP equipments sets,
(c) Deep Sink,
(d) Hand washing basin,
(e) Worktable with laminated top,
(f) Cabinets and shelves,
6.8.2.20 Surgical ward clean linen room with shelves and cabinets shall be available
6.8.2.21 Surgical ward in patient store with shelves, cabinets and fixed electrical plugs
with protection shall be available
6.8.2.22 Surgical ward soiled utility room with shelves and leak proof containers with
leads shall be available
6.8.2.23 Surgical ward cleaner’s room shall be available with the following
(a) Hand washing basin,
(b) Sinks and cleaning equipments,
(c) Shelves and Cabinet,
(d) One room for keeping patients belongings with lockers.

6.8.3 Professionals
6.8.3.1 Surgical services shall be directed by a licensed experienced surgeon.
6.8.3.2 The professionals shall be composed of a mixture of qualified professionals
involving a minimum of general surgeons, orthopedic surgeons, at least one sub

88
 specialist; general practitioners, anesthetist and/or anesthesiologist, scrub
nurses, circulating nurses, recovery nurses and ward nurses.
6.8.3.3 Minimum number of professionals for surgical service at OR for 24 hours services:
(a) Anesthesiologist 1
(b) Anesthetist 10
(c) Scrub nurses 10
(d) Circulating nurses 10
(e) Cleaners 4
(f) Technicians 2
(g) Porters 4
6.8.3.4 Minimum number of professionals for surgical service at recovery:
(a) Recovery nurses 8
(b) Porters 2
6.8.3.5 Minimum number of professionals for surgical service at CSR:
(a) CSR nurse 6
(b) Technician 1
(c) Cleaner 10
6.8.3.6 Minimum number of professionals for surgical service at surgical ward:
(a) General surgeons 3
(b) Sub specialist 1
(c) GP 6
(d) Nurses (see nursing standard)
(e) Cleaners 10
(f) Porters 5
6.8.3.7 For one operation theatre, the number of OR staff for the working hours shall be
at least,
(a) One porter per room,
(b) One janitor,
During duty time;
(a) One scrub nurse,
(b) One circulating nurse,
(c) One porter and
(d) One janitor.

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6.8.3.8 The nursing services in the OR shall be coordinated by a registered nurse
experienced in surgical nursing.
6.8.3.9 The surgical team members (e.g., the general surgeon and specialized surgeon)
shall be qualified from recognized university or similar institution and shall be
licensed by the licensing authority in the country.
6.8.3.10 The copy of the licenses shall be kept in the hospital.
6.8.3.11 At least one sub specialized surgeon (Urologist, neurosurgeon, reconstructive
surgeon, cardio-thoraxic surgeon, facio-maxillary surgeon, GI surgeon, pediatric
surgeon, etc) shall be available as full time employee.
6.8.3.12 Number of general surgeons shall be determined by the 24 hour service
availability. A minimum of 1 general surgeon in each shift is required.
6.8.3.13 Number of scrub nurse shall suffice to the number of operation theatres.
6.8.3.14 A surgeon or licensed general practitioner shall be responsible for the services
provided to each patient; while the nurse coordinator (registered nurse) shall be
responsible for all nursing care provided to the patient
6.8.3.15 The duties and responsibilities of para-medicals and porters shall be clearly
outlined by the hospital.
6.8.3.16 Orientation and continuous training shall be provided for cleaners for proper
handling and disposal of sharp materials and surgical wastes by OR
nurse coordinator or via IP committee.
6.8.4 Products
6.8.4.1 Surgical ward equipments and supplies
(a) Bed and mattress
(b) Pillows
(c) Oxygen flow meter, 0-15 L/min
(d) Chairs,
(e) Feeding table/ Over bed table
(f) Bed side cabinet
(g) Bed screen, 3 sections
(h) Waste paper basket
(i) Safety boxes
(j) Footstool
(k) IV stands

90
 (l) Wheelchairs
(m) Stretchers
(n) Oxygen on trolleys
(o) Hand washing basins
6.8.4.2 Equipment – Clean Utility Room and procedure room
(a) Dressing trolley
(b) IV stand
(c) Wheelchair
(d) Walking rail,
(e) Crutches,
(f) Pop cutters
6.8.4.3 Equipment – Nurses station
(a) Wall clock
(b) Desk
(c) Chair
(d) Trolley for vital sign monitoring
(e) Refrigerator for medication with temperature control
(f) Safety box
(g) Waste paper basket
(h) Adult sphygmomanometer
(i) Stethoscope, dual head
(j) Stethoscope, adult head
(k) Thermometer
6.8.4.4 Equipment –ward/ in patient store:
(a) General purpose trolleys, and trays
(b) Patient chart holder
(c) Bed screen, three sections
(d) Oxygen trolley, complete
(e) Suction pump, portable
(f) Bed pans
(g) Kidney basin, 475 ml
(h) Wheelchair
(i) General surgical dressing set

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 (j) Tendon hammer
(k) Mobile examination light
(l) Adult weight scales
6.8.4.5 Equipment – surgical ward soiled utility room:
(a) Soiled linen trolley
(b) Bin with lid
(c) Worktable with laminated top
(d) Washing basins
(e) General purpose trolley, trays
(f) Mobile trolley
(g) Bedpans
(h) Kidney basin, 475 ml
6.8.4.6 Equipment – surgical ward cleaner’s room:
(a) Cleaning trolley
(b) Mop rack
(c) Worktable
(d) Cabinets and shelves
(e) Pail with handle
(f) Brooms
(g) Mops
(h) Cabinet for detergents
6.8.4.7 Equipment – reception/nurse station, operating theatre suite:
(a) Wall clock
(b) Desk
(c) Desk chair
(d) Cabinet
(e) Chair, stackable, without armrests
(f) Basket, waste-paper,
6.8.4.8 Equipment – entrance, patient transfer area, operating theatre suite:
(a) Chairs
(b) Patient stretchers
6.8.4.9 Equipment –staff changing room, operating theatre suite:
(a) Soiled linen trolley

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 (b) Clean linen cabinet
(c) A big mirror
(d) Waste basket
(e) Lockers
(f) Shoe shelves
(g) Aprons
6.8.4.10 Equipment, operating theatre: Minimum equipment list for a single operating
theatre.
(a) Time clock
(b) Anesthesia trolley
(c) Oxygen cylinders ,different sizes.
(d) Worktable with laminated top
(e) Stools
(f) IV stands
(g) Kick buckets
(h) Safety boxes
(i) Swab rack with drip trays
(j) Swab count record boards
(k) Bowls and stands
(l) Instrument tables, Mayo type
(m)Framed boards with pencil trays
(n) Infusion pumps
(o) Chest tubes with bottles
(p) Blankets, warming
(q) Tourniquets
(r) Tongue depressors
(s) Coagulation unit, electro, mobile, 200 W
(t) Lights, operating, 1 large copula, ceiling mounted
(u) Mobile operating lights
(v) Operating table, 3 sections
(w)Suction machines
(x) Bone cutters
(y) IV fluid pressure bag

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 (z) X-ray viewer
(aa) Anesthesia machine with ventilator, 2 vaporizers, and gas cylinders
(bb) Laryngoscope, set (Mackintosh)
(cc) Magill forceps (adult & pediatrics)
(dd) Laryngeal mask set
(ee) Mask holder
(ff) Mouth gauge
(gg) Patient monitor
(hh) Dual head stethoscope
(ii) Tracheostomy tube,
(jj) T-tube,
(kk) Colostomy bag,
(ll) Urinary bag,
6.8.4.11 Equipment – scrub area:
(a) Soap dispenser
(b) Scrub-up brushes
(c) Sinks
(d) Mirror above each sink
6.8.4.12 Equipment: set up area
(a) Worktable with laminated top
(b) Cabinets and shelves
(c) Dressing trolley
(d) Instrument table, Mayo type
(e) Blood warmer
(f) IV fluid warmer
6.8.4.13 Equipment – operating theatre store
(a) Patient transfer, stretchers
(b) General purpose trolleys
(c) IV stands
(d) Hygrometer, humidity and temperature
(e) Pillows, abduction
(f) Support, head, operating table
(g) Positioner, bag, small

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 (h) Positioner, bag, medium
(i) Positioner, bag, large
(j) Apron, protective, small
(k) Apron, protective, medium
(l) Apron, protective, large
6.8.4.14 Equipment – operating theatre sterile supply store:
(a) General purpose trolleys, trays
(b) Gen.surg- Basic surgery set
(c) Thyroidectomy set
(d) Cholecystectomy set
(e) Thoracotomy set ,etc
(f) Gen.surg- Laparotomy set
(g) Gen.surg- Minor surgical set
(h) Gen.surg- Suprapubic puncture set
(i) Cholecystectomy set
(j) Billiary set
(k) Welicary set

6.8.4.15 Equipment – clean utility room, surgical suite:

(a) General purpose trolley, trays
(b) Worktable, laminated top
(c) Refrigerator,
(d) Shelves
(e) cabinets
6.8.4.16 Equipment – operating theatre sluice room
(a) Soiled linen trolley
(b) General purpose trolley, trays
(c) Bin with lid
(d) Worktable with laminated top
(e) Wash basins
(f) Bedpans
(g) Kidney basin, 475 ml
6.8.4.17 Equipment – cleaners’ room, operating theatre:

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 (a) Cleaning trolley
(b) Mop rack
(c) Worktable
(d) Pail with handle
(e) Brooms
(f) Mops
6.8.4.18 Renewable/Consumables for surgical unit
(a) Guedel airways: size 0, 00, 3, 4 & 5
(b) Alcohol Swabs
(c) Disposable aprons
(d) Aqua-packs Oxygen humidifier
(e) Bags - Refuse - All Colors and Sizes
(f) Bags – Urine
(g) Bandage - Crepe
(h) Batteries - Medical & General
(i) Bedpan Covers
(j) Blood Administration Sets
(k) Blood Sampling
 Needles, disposable, sterile, 20 G, 21 G, 23 G
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer Holder
 Vacutainer needle
(l) Bottles - Suction - Glass/Plastic
(m)Braun Splints (Arm)
(n) Bubble tubing box
(o) Cannula - Nasal-Oxygen
(p) Cannula, IV short, ster, disp, 18G, 20 G, 22 G, 24 G
(q) Caps - Mop/Bonnet Type
(r) Catheter - Jacques
(s) Central Venous Pressure Sets
(t) Chest, Electrode, Monitor

96
(u) Cleansing Swabs – Sterile
(v) Cleansing Swabs Non-Sterile
(w)Cold/Hot Packs
(x) Combur Tests
(y) Connector,
 Biconical Autoclavable
 Connector, T/Y
 Connectors - Plastic – Tapered
(z) Container, Sample, urine, plastic, non-sterile, 60 ml
(aa) Cotton
 Cotton Buds
 Cotton Wool Balls - Sterile/Non-Sterile
 Cotton Wool Rolls
(bb) POP
(cc) Covers - PVC - Mattress/Bed Wedge
(dd) CVP – Cannulae
(ee) Cytological Fixative Spray
(ff) Drawsheet,plastic,90x180cm
(gg) Face Mask Water Repellent
(hh) Foley Catheters – Latex/Silicone Size 10, 12 and 14
(ii) Gauze Absorbent Ribbon
(jj) Gloves:
 Household Large & Medium
 Surgical Size 6, 6 ½, 7, 7 ½, 8
 Exam, latex, disp, large, medium, small
(kk) Hand wash Antiseptic Liquid (Hibiscrub)
(ll) Hand wash Povidone (Betadine)
(mm) Hot Packs
(nn) I.V. Sets :
 I.V. Administration Sets – 15 Drop
 I.V. Administration Sets - 60 Drop
 I.V. Set, Infusion “Y”, Luer lock, air inlet

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(oo) Incontinence Sheets
(pp) Intubation stylet, adult, 15 Ch
(qq) IV Infusion set Buretrol
(rr) K.Y. Jelly
(ss) IV stands
(tt) Drums
(uu) Latex Tubing
(vv) Linen Savers
(ww) Masks - Nebulizer/Oxygen
(xx) Masks – Oxygen 40 %
(yy) Nail Brushes - Autoclavable/Disposable
(zz) Needles:
 Spinal disp, (0.9x90mm),sterile, 20G, 22G, 24G
 Disp,15G, 18G, 21G, 22G, 23G, 25G
 Butterfly 23G
(aaa) Oxygen T Pieces
(bbb) Oxygen Tubing
(ccc) Face Masks
(ddd) Razor Medical - Disposable - Single Edge
(ää) Rubber Bath Mat - Non-Slip
(öö) S.G. Meter (Urine Meters)
(ggg) Safety Pins Large & Medium
(hhh) Sharps Containers (Safety Box/used syringes and needles)
(iii) Shrouds
(jjj) Soap,toilet,bar,approx.110g,wrapped
(kkk) Spatulas - Tongue
(lll) Spigots Large, Medium and Small
(mmm) Spray Bottles - Plunger Operated
(nnn) Surgical Splints
(ooo) Suture absorbable (Chromic) for episiotomy and perinea tears
(ppp) Syringes:
 Volume: 2ml, 5ml, 10ml, 20ml
 Syringes 50 ml Conical Tip

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  Syringes 50 ml Luer Lock
 Syringes Insulin
(qqq) Tape:
 Elastic Adhesive Plaster - White 5cm and 10 cm
 Micropore tape
 Surgical Adhesive Hypo-Allergenic
 Adhesive, zinc oxide, perforated,10cmx5m
 Adhesive, zinc oxide, 2.5cmx5m
(rrr) Clinical thermometer
(sss) Fridge thermometer
(ttt) Tourniquet, latex rubber,75cm
(uuu) Tubes:
 Endo-tracheal, disp. + connector, neonate mm, w.o balloon
 Endo-tracheal, disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Suction, L125cm,ster,disp, CH10, CH12, CH16
6.8.4.19 Operating Suite Renewable/Consumables:
(a) Airway Guedel, pediatric & adult size
(b) Plastic, reusable aprons
(c) Urine bags, collecting, 2000 ml
(d) 012 Band, Esmarch, 6 cm x 5 m
(e) Survival blanketl,220x140cm
(f) Blood Sampling:
 Needle, disposable, sterile, 20G, 21G
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer holder
 Vacutainer needles, 18-24G
(g) Bouffant Nurse Cap
(h) Bubble Tubing
(i) Cannula, IV short, ster, disp, 18G, 20G, 22G, 24G
(j) Catheters:

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  Sup-Pubic, CH 10, 1.65 cm, ster, disp adult with trocar
 Ureteral, CH5, ster, disp
 Urethral, CH6, ster, disp
 Urethral, CH7, ster, disp
 Foley, ster, disp, CH10, CH12, CH14
 Three way foley catheter
(k) Compresses:
 Abdominal compress, 40 x 40 cm
 Compress, Swab, 20x 20 cm
 Compress, gauze,10x10cm,n/ster/PAC-100
 Compress, gauze,10x10cm,ster/PAC-5
 Compress, paraffin,10x10cm,ster/BOX-10
(l) Connector, biconical, OD 7-11-7mm
(m)Cotton wool,500g,roll,non-ster
(n) CVP - Set
(o) Diathermy pencil/ball/blade
(p) Disposable, dispersive, electrode(Diathermy pad)
(q) Drain, corrugated sheet, 3 cm x 25 cm
(r) 063 Drain, wound, CH 12, ster, disp, CH12, CH16, CH6
(s) Drawsheet,plastic,90x180cm
(t) Elastoplasts, 10 cm x 3 m
(u) Electrode, Chest, Monitor
(v) Extractor,mucus,20ml,ster,disp
(w)File for ampoules
(x) Gauze:
 Ball, Large (sterile)
 Ball, Large (un-sterile)
 Ball, Peanut (sterile)
 Swabs RAYTEX® 10 X 10 cm
 Swabs, Un-sterile (Green)
 Roll,90cmx100m,non-ster
 Vaseline gauze

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(y) Gloves,exam,latex,disp, large, medium & small
(z) Gloves,surg,disp, 6.0, 6.5, 7.0, 7.5, 8, 8.5
(aa) Gum elastic bougie, CH 15, 60 cm
(bb) Intubation stylet, adult, 15 Ch
(cc) Lancet,blood,ster,disp/PAC-200
(dd) Mask, Clinical, Disposable (non-woven)
(ee) Mask, Protection, High Filtration
(ff) Needle, spinal, 0.9x90mm),ster,disp, 20G, 22G, 24G
(gg) Oxygen mask, adult
(hh) Oxygen, nasal cannula
(ii) Reusable, Diathermy, Cable
(jj) Safety box for .used syrgs/ndls
(kk) Set, Infusion “Y”, Luer lock, air inlet
(ll) Scalpel blade,ster,disp,no.10, no. 11, no. 15, no. 22, no. 23
(mm) Shoe cover, disposable
(nn) Silicone Rubber Tubing
(oo) Surgeon's Cap, Easy-Tie
(pp) Suturing materials:abs,non abs,various types with and with out needles
 Abs,DEC1,need 1/2,18mm,round/BOX-36
 Abs,DEC2,need 3/8 18mm,round/
 Abs,DEC2,need 3/8,26mm,tri
 Abs,DEC3,need 1/2 30mm,round
 Abs,DEC3,need 3/8 50mm,round
 Abs,DEC3,spool
 Abs,DEC4,need 3/8 36mm,tri
 Nonabs,DEC2,need 3/8 13mm,tri
 Nonabs,DEC3,need 3/8 30mm,tri
(qq) Syringe,dispos, 2ml, 5ml, 10ml, 20ml
(rr) Tape,adhesive,Z.O,perforated,10cmx5m
(ss) Tape,adhesive,Z.O.,2.5cmx5m
(tt) Telfa, dressing (Various Sizes)
(uu) Tourniquet,latex rubber,75cm
(vv) Tubes:

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  Endo-tracheal, disp. + connector, 3 mm, w/o balloon
 Endo-tracheal, disp. + connector, 3.5 mm, w/o balloon
 Endo-tracheal, disp. + connector, 4 mm, w/o balloon
 Endo-tracheal, disp. + connector, 4.5 mm, w/o balloon
 Endo-tracheal, disp. + connector, 5 mm, balloon
 Endo-tracheal, disp. + connector, 5.5 mm, balloon
 Endo-tracheal, disp. + connector, 6 mm, balloon
 Endo-tracheal, disp. + connector, 6.5 mm, balloon
 Endo-tracheal, disp. + connector, 7 mm, balloon
 Endo-tracheal, disp. + connector, 7.5 mm, balloon
 Endo-tracheal, disp. + connector, 8 mm, balloon
 Trachea, balloon, int.can, ster, size 6
 Trachea, balloon, int.can, ster, size 8
 Suction,CH08,L50cm,ster,disp, CH08, CH10, CH14, CH16
 Double lumen endo-tracheal tubes
 N.G Tubes 12, 14, 16
6.8.4.20 Operating Room Linen:
(a) Apron Surgical, rubber
(b) Trousers, Surgical, woven, Small, Medium & Large
(c) Top(shirts), Surgical, woven, Small, Medium & Large
(d) Gown, Surgical, woven(Plain)
(e) Cap, Surgical, woven
(f) Masks, surgical, woven
(g) Drape:
 Surgical, woven(1 x 1 m)
 Surgical, woven(1 x 1.5 m)
 Surgical, woven(1.5 x 1.5 m)(fenestrated
 Surgical, woven(45 cm x 70 cm)(fenestrated)
 Surgical woven (2 x 1.5 m)
(h) Pillow case
(i) Pillows
(j) Sheet, Bed

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 (k) Sheet, draw, white
(l) Cellular Blanket
(m)Mayo cover
(n) Towel Bath
(o) Towel Hand
6.8.4.21 Equipment recovery area:
(a) Vacuum aspirator
(b) Oxygen Flow meter, 0 - 15 l/min
(c) Oxygen (one cylinder per bed)
(d) Oxygen concentrater
(e) Patient transfer, (stretchers)
(f) Dressing trolley, trays
(g) Bed with mattress
(h) Stools
(i) IV stands
(j) Bed screen, 3 sections, mobile
(k) Pedal bin
(l) Oxygen trolley, complete
(m)Pulse oximeter
(n) Resuscitator, hand operated
(o) Suction machines
(p) Mobile examination light
(q) Dual head stethoscope
6.8.4.22 Equipment-Central sterilization room
(a) Auto claves ;big
(b) Autoclaves ;small
(c) Drums
(d) Metallic shelves
(e) Cabinets
(f) Tables
(g) Chairs

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6.9 Orthopedic surgical Care Services
6.9.1 Practices
6.9.1.1 Comprehensive emergency orthopedic surgical service shall be available 24 hours
a day, 365 days a year,
6.9.1.2 Services for non-emergency elective orthopedic surgical cases shall be available
only when all the necessary experts are available;
6.9.1.3 There shall be written protocols and procedures for admissions and discharges
with follow up.
6.9.1.4 There shall be protocols for the management of the orthopedic surgical conditions
in the unit.
6.9.1.5 There shall be protocols for consultation and transfer of patients admitted to this
unit and to other departments.
6.9.1.6 There shall be a clear policy for handling emergency orthopedic surgical
conditions. This service shall be available 24 hours a day throughout the year.
6.9.1.7 The hospital shall make sure the emergency orthopedic surgical services is
available, staffed with the necessary technical staff, equipped with all the
necessary facilities including emergency transfusion, transportation, and
electric back up.
6.9.1.8 The admission process for emergency orthopedic surgery shall be done by the
emergency/ duty physician with consultation to the duty orthopedic surgeon.
6.9.1.9 The admission process for elective orthopedic surgery shall be done by the
respective orthopedic surgeon in consultation with the anesthesia department
and with the other departments as needed.
6.9.1.10 For admitted patients the orthopedic surgical service shall be organized in such a
way that it covers all the shifts.
6.9.1.11 The orthopedic surgical service shall be directed by a licensed orthopedic surgeon.
6.9.1.12 There shall be a mechanism of interdepartmental consultations with orthopedic
surgical unit for which the orthopedic surgeon on duty shall be responsible.
6.9.1.13 Adequate orthopedic surgical records shall be kept for each patient and the
patient’s orthopedic surgical record shall be integrated with the patient's over-
all hospital record.

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6.9.1.14 All orthopedic surgical procedures (except in life-threatening emergencies) are
performed only after appropriate history, physical examination, and indicated
diagnostic tests are completed and documented in the patient’s medical record.
6.9.1.15 The preoperative diagnosis shall be recorded in the medical record for all patients
prior to orthopedic surgery.
6.9.1.16 The orthopedic surgeon shall explain the disease condition, possible orthopedic
surgical intervention and outcome possibilities in clear, simple and
understandable terms to the patient and/or family.
6.9.1.17 Except in life-threatening emergencies, the orthopedic surgeon shall obtain an
informed consent and this must be documented in the patient’s medical record.
For the case with life threatening condition, consent shall be obtained from
spouse, family, guardian or based on the orthopedic surgeon’s clinical judgment.
6.9.1.18 If there is no body to sign the consent for the patient who is in life-threatening
condition, the reason for not having the consent shall be stated.
6.9.1.19 The nursing care of patients undergoing orthopedic surgery shall be planned and
documented in the medical record, directed by a trained nurse, and includes the
following:
(f) Pre-operative care,
(g) Location of post-operative care,
(h) Type of post-operative care and monitoring needed,
(i) Pain management, and
(j) Patient’s understanding of discharge instructions.
6.9.1.20 Operative reports shall be written in the patient’s record and in the OR
registration book immediately after orthopedic surgery and include at least the
following:
(k) Patient identification,
(l) Pre-operative diagnosis,
(m)The procedure performed,
(n) Findings during orthopedic surgery,
(o) Post-operative diagnosis,
(p) Orthopedic surgical specimens removed,
(q) Date and time operation started and ended,

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 (r) Name of orthopedic surgeon, anesthesiologist/anesthetist, scrub nurse,
and any assistants,
(s) Signature of the orthopedic surgeon, and the scrub nurse
(t) Immediate post-operative orders explicitly in the order sheet.
6.9.1.21 There shall be policy that leads to positively identify the patient and ensure that
the correct procedure and the correct side are confirmed prior to starting the
orthopedic surgery.
6.9.1.22 There shall be processes and policies defining the appropriate safety before,
during and immediately after orthopedic surgery, including at least the
following:
(e) The orthopedic surgeon shall fill the pathology form and the specimen
container shall be properly labeled. The container shall be filled with
10% formalin.
(f) The specimen shall be sent to the pathology department by the OR staff.
It there no pathology department in the same hospital, the specimen
shall be sent to another hospital by a family member or a relative.
 Aseptic technique,
 Sterilization and disinfections,
 Selection of draping and gowning,
 Counting of sponges, instruments, and needles,
6.9.1.23 There shall be a policy for preparing and availing appropriate and properly
functioning supplies, equipment, and instruments available for all surgeries
performed according to the country standard.(See Annex zzzzzz)
6.9.1.24 There shall be a protocol for patient transfer from operation theatre to recovery
room. This includes;
(f) The handover and/or transfer of immediate post-operative patients
shall be done between the anesthetist or anesthesiologist who
administered the anesthesia and the registered nurse in recovery room,
(g) The nurse in the recovery room shall immediately re-evaluate the
condition of the patient in front of the anesthesiologist or anesthetist,
(h) The follow up of immediate post-operative patients in the recovery room
shall be done by registered nurse with special training or similar
experience until the anesthesiologist, anesthetist or other qualified

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 physician makes the decision to transfer the patient from post-
anesthesia care and this decision shall be based on the documented
results of monitoring during anesthesia recovery,
(i) The transfer from recovery room shall be done after the transfer order is
signed by the appropriate anesthetist, anesthesiologist, or other
qualified physician,
(j) The nurse in the recovery room shall inform the ward and the ward
nurse shall transfer the patient with the signed transfer note.
6.9.1.25 Post- operative patient in the wards shall get post operative care by qualified
nurses. The post operative care includes to the minimum:
(c) Evaluation by the orthopedic surgeon or appropriate physician and
ward nurses daily or whenever needed,
(d) Follow up of vital signs and carrying out of post-operative orders shall
be done as per the order specified for individual patients. (special
orders-NPO, positioning, exercise, drainages, etc.,)
6.9.1.26 The hospital shall have clear protocol for orthopedic surgical activities to be done
at outpatients level, orthopedic surgical referral clinics, follow up clinics, minor
operations and orthopedic procedures
6.9.1.27 There shall be no time left without having general orthopedic surgeon or
physician attending the orthopedic surgical unit.
6.9.1.28 There shall be a policy or procedure that clearly shows at least one orthopedic
surgeon shall be on call/ on duty to respond for orthopedic surgical requests
from emergency and/ or orthopedic ward physician.
6.9.1.29 There shall be a mechanism that the orthopedic surgeon shall be available within
30 minutes upon call.
6.9.1.30 All patients in orthopedic unit shall be attended by registered nurse all the time
with supervision by duty physician.
6.9.1.31 There shall be a mechanism by which the orthopedic unit provides board
certificate in response to hospital medical board request. The board shall be
composed of, at minimum, three specialist orthopedic surgeons one of them
being the treating one.

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6.9.1.32 Emergency call access to each bed in the wards and recovery room shall be in
place; at switches for emergency calls (nurse alarms) shall be placed accessible
to beds
6.9.2 Premises
6.9.2.1 Orthopedic Unit:
(d) The orthopedic unit shall include orthopedic wards, operation room,
recovery room, the central sterilization room (CSR), toilet rooms,
showers and changing rooms with lockers, offices, store rooms, clean
and dirty utility rooms, duty rooms and cleaners room.
(e) If there is no separate premise for orthopedics service, it shall be shared
with surgical service).
(f) The operation room shall be readily accessible to the orthopedic wards.
6.9.2.2 Orthopedics Operation Room / Suite: (can be delivered sharing with the surgical
unit)
(e) The operation room shall have three operation theatres of which one is
for septic procedures, one nurse station, four staff toilets, six shower
stands, four changing rooms with lockers, one rest room, anesthesia
store, nurse store, one general store.
(f) An operating room shall have access- restricted environment where
orthopedic surgical and invasive interventions are performed. It shall be
organized and equipped so that OR trafficking shall be controlled and
exercised over all persons and materials entering and leaving the area.
6.9.2.3 Operation Theatre: (can be shared with surgical unit)
(n) At least three standard size operation theatres and one septic operation
theatre shall be available
(o) The wall of the operation theatres shall be washable; the vicinity of
plumbing fixtures shall be smooth and water resistant i.e., ceramic
plated up to the ceiling.
(p) The ceiling shall be monolithic, scrub-able and capable of withstanding
chemicals. Cracks or perforation in these ceilings are not allowed.
(q) Floors and walls penetrated by pipes, ducts and conduits’ shall be tightly
sealed.

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 (r) The floor of the theatre shall be smooth, easily cleanable, non-slippery
and non-staining and it shall not be affected by water or germicidal
cleaning solutions; preferably made of marble or ceramic.
(s) There shall be drainage on the floor,
(t) There shall be at least six fixed electric outlets in each theatre with
cover,
(u) The entrance and exit doors to the theatre shall be fitted with self-
closing double doors,
(v) There shall be at least one operation table in each theatre,
(w)At least one ceiling operation light and one mobile operation light per
theatre shall be available
(x) Glass cabinet and shelves shall be available
(y) The OR shall be thoroughly cleansed weekly.
(z) Heater fixed on the wall shall be available in each theatre,
6.9.2.4 Scrub area: (can be shared with surgical unit)
(e) There shall be a scrubbing-up area outside but adjacent to the operating
theatre(s). The scrub area shall be in between the two self closing doors.
If there is one common scrub area for the four theatres, it shall be wide
enough to accommodate four staff scrubbing simultaneously.
(f) This area shall have direct access to the operating room,
(g) It shall be provided with multiple sinks or with wide sink and taps
for running (warm) water. The taps for running water for scrubbing
shall be hand free to be manipulated with elbow or knee joint. (e.g., long
arm of valve gate to be manipulated with elbow or knee joint.)
6.9.2.5 Nurse station: (can be shared with surgical unit)
(c) This is a room within the restricted access areas, which is so situated,
constructed and equipped that it is possible for the nursing staff to
observe patients directly and where necessary, to render assistance.
This area need not be a room, but may form an integral part of the main
patient corridor, recovery area or bed-receiving area.
(d) There shall be a corridor or allocated area for keeping charged and
empty Oxygen cylinders; the empty and charged oxygen cylinders shall
be labeled clearly,

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6.9.2.6 Entrance/Patient Transfer Area: (can be shared with surgical unit)
(d) This area shall be large enough to allow for the transfer of patients from
a bed to OR stretcher.
(e) A line shall be clearly marked in red on the floor, beyond which no
person shall be permitted to set foot without putting on protective
clothing and OR shoes.
(f) Holding bay: there shall be a space or corridor to keep and observe pre-
operative patients until called to theatre.
6.9.2.7 Staff Change Rooms (can be shared with surgical unit)
(g) Suitable two separate changing room facilities shall be available and
clearly labeled for male and female,
(h) Each changing rooms shall have two doors, one entrance and the second
door accessing into the restricted access area; the entrance is from
outside the restricted access area.
(i) Each changing room shall be provided with a locker for a minimum of 10
staff to keep personal clothes and belongings.
(j) Each changing room shall be provided with shelves for Storage of clean
theatre attire and inside shoes and operation theatre gum boots.
(k) Separate storage bin shall be provided for used and soiled theatre
apparels.
(l) Wash hand basins: Toilets, showers,
6.9.2.8 Set-up Area (optional): (can be shared with surgical unit)
(f) Store area for suture materials and other supplies from where necessary
consumables could be stacked on a trolley that could be wheeled into
theatre for subsequent procedure.
(g) Doors into the operating room shall be big enough to wheel through the
set trolleys from the set up room into the operating room without
contact with doors or non sterile surfaces.
(h) Packed instruments and other relevant materials shall be brought from
the CSR and stored in this area according to the daily schedules one day
prior to the scheduled operations.
(i) Mayo table and dressing trolley to set up for the next case are kept in
this area.

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 (j) If there is no set up area the instruments can be set up within the
operating theatre
6.9.2.9 Operating Theatre Equipment Store (can be shared with surgical unit)
(a) There shall be equipment store area in the operating room that shall be
supplied with a sufficient number of electrical plugs to keep the
electrical equipments plugged in, charged and in case of power failure to
work as back up electrical supply / or emergency electrical supply.
(b) Equipments shall always be stored at the same space/location and
properly labeled.
(c) Shelves and cabinets
6.9.2.10 Operating Theatre Sterile Supply Store (can be shared with surgical unit): This
shall be a room which is used for the storage of all sterile instrument sets, swabs
and sterile renewable, consumables and it requires shelves.
6.9.2.11 Clean Utility, Orthopedic surgical Suite (can be shared with surgical unit): There
shall be a room allocated for storage of IV fluids, clean linen, medicines and
other sundry items. Requirements:
(a) Shall be situated where OR staff have easy access to the clean utility
store.
(b) Metallic washable rack for storage shall be available,
(c) Equipments used for special procedures like splints shall be kept here
thoroughly cleaned after use,
(d) Refrigerator with thermometer shall be available for drugs requiring a
temperature range of 4 to 8 °C.
(e) Sink, cabinets and shelves
6.9.2.12 Soiled Utility/Sluice room shall be available with the followings; (can be shared
with surgical unit)
(a) This room shall be located at the back of the OR.
(b) This room shall be for keeping contaminated materials until they are
disposed.
(c) Sharp containers, leak proof containers with lids shall be available, used
sharps/safety boxes are to be stored here before being sent for
incineration.
(d) Container for temporary storage point for soiled linen,

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 (e) Hand Washing basin,
(f) Drainage on the floor,
(g) Trolley for soiled materials and waste human tissues,
6.9.2.13 Cleaner’s Room shall be available with the followings; (can be shared with surgical
unit)
(a) A room provided with 2 sets of cleaning equipments and materials,
(b) Hand washing Basin,
(c) Washing sink,
(d) Detergent proof shelves and cabinets.
6.9.2.14 Central sterilization room shall be available with followings; (can be shared with
surgical unit)
(a) Direct access to OR,
(b) Needs a minimum of needs rooms:
 One for reception, sorting of equipments; or clothes and
documentation process;
 One for inbuilt autoclaves;
 One separate properly ventilated room for storing and shelving sterile
clothes and instruments as per the guideline,
 One staff room and
 One cleaners’ room
(c) Shall have at least two inbuilt autoclaves, with small one as backup,
(d) Continuous water supply with extra reservoir,
(e) Shelves shall be washable ,corrosive free and metallic racks as per the
guideline,
(f) The date of sterilization & the name of the instruments shall be written
after sterilization.
(g) Staff toilets,
6.9.2.15 Recovery facilities shall be available with the followings; (can be shared with
surgical unit)
(a) It shall be close to OR, and shall be within the semi- restricted area.
(b) A minimum of four beds shall be available,
(c) There shall be a minimum of 1.2 meter gap between beds for patient
transferring stretcher,

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 (d) Recovery beds shall have flexible side protections,
(e) A minimum of two electric outlets shall be available for each bed,
(f) A trolley carrying functional emergency equipments shall be available in
the recovery room,
(g) A minimum of four bed pans
(h) A minimum of four patient screens shall be available,
(i) There shall be sufficient light for each bed, one head light per bed,
(j) There shall be a heater,
6.9.2.16 Minor operation theatre shall be available with the followings; (can be shared
with surgical unit)
(a) It shall hall be located accessible to OPD, and shall be with low or no
traffic area.
(b) There shall be one operation room with two theatres,
(c) There shall be two glass cabinets for orthopedic surgical consumables in
the OR,
(d) There shall be two patient changing rooms,
(e) There shall be mark on the floor restricting movement of unauthorized
and/or person without OR suit,
(f) Rest room
(g) Utility room,
(h) Store with shelves and cabinets,
(i) Nurse station with table and chairs,
(j) Toilet rooms for male female,
(k) Cleaners room,
6.9.2.17 Orthopedic ward shall be available with the followings;
(a) It shall be part of the inpatient service,
(b) The beds shall be flexible and orthopedic beds,
(c) In third class, space between beds shall be at least 1.2m.
(d) There shall be a minimum of one separate room, labeled “Septic Room”
for septic patients,
(e) The beds shall be equipped with fixtures for certain orthopedic surgical
patients- orthopedic cases
(f) Patient screens,

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 (g) Patient toilets and showers with proximity to the ward, or covered
walkways to the ablution facilities.
6.9.2.18 Orthopedics ward Nurses’ station shall be available with the following;
(a) located amidst of the wards
(b) shall have table and chairs
(c) shall have lockable cabinets,
(d) shall have specimen collection station/ laminated table with racks
(e) shall have hand washing basin,
6.9.2.19 Orthopedic ward clean utility room (procedure room) shall be available with
the following;
(a) Dressing trolleys ,beds
(b) POP equipments sets,
(c) Deep Sink,
(d) Hand washing basin,
(e) Worktable with laminated top,
(f) Cabinets and shelves,
6.9.2.20 Orthopedic ward clean linen room with shelves and cabinets shall be available
6.9.2.21 Orthopedic ward in patient store with shelves, cabinets and fixed electrical
plugs with protection shall be available
6.9.2.22 Orthopedic ward soiled utility room with shelves and leak proof containers
with leads shall be available
6.9.2.23 Orthopedic ward cleaner’s room shall be available with the following
(a) Hand washing basin,
(b) Sinks and cleaning equipments,
(c) Shelves and Cabinet,
(d) One room for keeping patients belongings with lockers.

6.9.3 Professionals
6.9.3.1 Orthopedic services shall be directed by a licensed experienced orthopedic
surgeon.
6.9.3.2 The professionals shall be composed of a mixture of qualified professionals
involving a minimum of general orthopedic surgeons, general practitioners,
anesthetist and/or anesthesiologist, scrub nurses, circulating nurses, recovery

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 nurses and ward nurses and at least one sub specialist from each orthopedics
subspecialty.
6.9.3.3 Minimum number of professionals for orthopedic service at OR for 24 hours
services: (shared with surgical unit)
(a) Anesthesiologist 2
(b) Anesthetist 10
(c) Scrub nurses 20
(d) Circulating nurses 20
(e) Cleaners 4
(f) Technicians 1
(g) Porters 4
6.9.3.4 Minimum number of professionals for orthopedic surgical service at recovery:
(shared with surgical unit)
(a) Recovery nurses 8
(b) Porters 2
6.9.3.5 Minimum number of professionals for orthopedic surgical service at CSR: (shared
with surgical unit)
(a) CSR nurse 6
(b) Technician 1
(c) Cleaner 10
6.9.3.6 Minimum number of professionals for orthopedic surgical service at orthopedic
ward:
(a) General orthopedic surgeons 3
(b) Pediatric orthopedic surgeon 2 (optional)
(c) Hand surgeon 2 (optional)
(d) GP 6
(e) Nurses 30
(f) Cleaners 20
(g) Porters 10
6.9.3.7 For one operation theatre, the number of OR staff for the working hours shall be
at least, (shared with surgical unit)
(a) Two scrub nurses,
(b) Two circulating nurses,

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 (c) One porter,
(d) One janitor, and during duty time;
(e) One scrub nurse,
(f) One circulating nurse,
(g) One porter and
(h) One janitor.
6.9.3.8 The nursing services in the OR shall be coordinated by a registered nurse
experienced in orthopedic surgical nursing.
6.9.3.9 The orthopedic surgical team members (e.g., the general orthopedic surgeon and
specialized orthopedic surgeon) shall be qualified from recognized university or
similar institution and shall be licensed by the licensing authority in the country.
6.9.3.10 The copy of the licenses shall be kept in the hospital.
6.9.3.11 For specialized hospital where sub- specialty orthopedic surgical service
rendered, at least one sub specialized orthopedic surgeon from each specialty or
from one specialty shall be available: (hand surgeon, reconstructive orthopedic
surgeon, pediatric orthopedic surgeon, etc)
6.9.3.12 Number of general orthopedic surgeons shall be determined by the 24 hour
service availability. A minimum of 1 general orthopedic surgeon in each shift is
required.
6.9.3.13 Number of scrub nurse shall suffice to the number of operation theatres.
6.9.3.14 A orthopedic surgeon or licensed general practitioner shall be responsible for the
services provided to each patient; while the nurse coordinator (registered
nurse) shall be responsible for all nursing care provided to the patient
6.9.3.15 The duties and responsibilities of para-medicals and porters shall be clearly
outlined by the hospital.
6.9.3.16 Orientation and continuous training shall be provided for cleaners for proper
handling and disposal of sharp materials and orthopedic surgical wastes by OR
nurse coordinator or via IP committee.
6.9.4 Products
6.9.4.1 Orthopedic ward equipments and supplies (inpatient products)
6.9.4.2 Clean Utility Room and procedure room Equipments (inpatient products)
6.9.4.3 Nurses station Equipment (Inpatient service)
6.9.4.4 Orthopedic ward soiled utility room Equipment: (Inpatient service)

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6.9.4.5 Orthopedic ward cleaner’s room Equipment: (inpatient products)
6.9.4.6 operating theatre /suite reception/nurse station Equipments: (inpatient
products)
6.9.4.7 Operating theatre: Minimum equipment list for performing orthopedic
procedures:
(a) Basic Orthopedic set
(b) Amputation set
(c) Drill- electrical, pneumatic, manual
(d) Wire cutter
(e) Kritchner wire
(f) Rush pin
(g) Kuncher nail
(h) Sign nail
(i) Dynamic hip screw
(j) Cindylar screw
(k) Patellar wire
(l) Patellar clamp
(m)Bone cutters
(n) Different osteotomes: manual, electrical, compressed air
(o) Knee replacement set with implants
(p) Forearm set with plate and screw
(q) Spine fixation- plate with joint sets
(r) External fixatures, different types
(s) Hand surgery sets with microsurgery instruments
(t) Skin graft sets, manual, electrical
(u) Hip replacement set with implants
(v) Shoulder replacement set
(w)Elbow replacement set
(x) Plates (angle: 95° and 135°)
(y) Fluoroscope, C-arm
(z) Arthroscopic machine with sets
(aa) POP tray with POP
(bb) POP cutter, electrical , manual

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 (cc) POP spreader
(dd) Tourniquet, upper limb, lower limb, (pneumatic, manual)
(ee) Central compressed air system
(ff) Anesthesia machine
(gg) Anesthesia trolley
(hh) Stools
(ii) Walking rail,
(jj) Crutches,
(kk) Thomas splints,
(ll) Brown’s frame,
(mm) Oxygen cylinders, different size
(nn) Tendon hammer
(oo) IV stands
(pp) Kick buckets
(qq) Safety boxes
(rr) Swab rack with drip trays
(ss) Swab count record boards
(tt) Bowls and stands
(uu) Instrument tables, Mayo type
(vv) Framed boards with pencil trays
(ww) Blankets, warming
(xx) Coagulation unit, electro-cauthery, mobile, 200 W
(yy) Lights, operating, 1 large copula, ceiling mounted
(zz) Mobile operating lights
(aaa) Operating table, 3 sections
(bbb) Suction machines
(ccc) Hip spica tables
(ddd) Anesthesia machine with ventilator, 2 vaporizers, and gas cylinders
(eee) Apron, protective,
6.9.4.8 Surgery Equipment – OR sterile supply store:
(a) General purpose trolleys, trays
(b) Gen.surg-Suture set
(c) Minor set

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6.9.4.9 Renewable/Consumables for orthopedic surgical service: (as per the surgical
service standard)
(a) Tongue depressors
(b) Guedel airways: size 0, 00, 3, 4 & 5
(c) Disposable aprons
(d) Bags - Refuse - All Colors and Sizes
(e) Bags – Urine
(f) Bandage -
(g) Batteries - Medical & General
(h) Bedpan Covers
(i) Blood Administration Sets
(j) Blood Sampling
 Needles, disposable, sterile, 20 G, 21 G, 23 G
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer Holder
 Vacutainer needle
(k) Bottles - Suction - Glass/Plastic
(l) Braun Splints (Arm)
(m)Bubble tubing box
(n) Cannula - Nasal-Oxygen
(o) Cannula, IV short, ster, disp, 18G, 20 G, 22 G, 24 G
(p) Caps - Mop/Bonnet Type
(q) Catheter - Jacques
(r) Chest, Electrode, Monitor
(s) Cleansing Swabs – Sterile
(t) Cleansing Swabs Non-Sterile
(u) Cold/Hot Packs
(v) Connector,
 Biconical Autoclavable
 Connector, T/Y
 Connectors - Plastic – Tapered
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(w)Container, Sample, urine, plastic, non-sterile, 60 ml
(x) Cotton
 Cotton Buds
 Cotton Wool Balls - Sterile/Non-Sterile
 Cotton Wool Rolls
(y) POP
(z) Covers - PVC - Mattress/Bed Wedge
(aa) CVP – Cannulae
(bb) Drawsheet,plastic,90x180cm
(cc) Foley Catheters – Latex/Silicone Size 10, 12 and 14
(dd) Gauze Absorbent Ribbon
(ee) Gloves:
 Household Large & Medium
 Orthopedic surgical Size 6, 6 ½, 7, 7 ½, 8
 Exam, latex, disp, large, medium, small
(ff) Hand wash Antiseptic Liquid (Hibiscrub)
(gg) Hand wash Povidone (Betadine)
(hh) Hot Packs
(ii) I.V. Sets :
 I.V. Administration Sets – 15 Drop
 I.V. Administration Sets - 60 Drop
 I.V. Set, Infusion “Y”, Luer lock, air inlet
(jj) Intubation stylet, adult, 15 Ch
(kk) IV Infusion set Buretrol
(ll) K.Y. Jelly
(mm) IV stands
(nn) Drums
(oo) Latex Tubing
(pp) Linen Savers
(qq) Nail Brushes - Autoclavable/Disposable
(rr)Needles:
 Spinal disp, (0.9x90mm),sterile, 20G, 22G, 24G

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  Disp,15G, 18G, 21G, 22G, 23G, 25G
 Butterfly 23G
(ss)Oxygen T Pieces
(tt) Oxygen Tubing
(uu) Face Masks
(vv) Razor Medical - Disposable - Single Edge
(ww) Safety Pins Large & Medium
(xx) Sharps Containers (Safety Box/used syringes and needles)
(yy) Shrouds
(zz) Soap,toilet,bar,approx.110g,wrapped
(aaa) Spigots Large, Medium and Small
(bbb) Spray Bottles - Plunger Operated
(ccc) Orthopedic surgical Splints
(ddd) Syringes:
 Volume: 2ml, 5ml, 10ml, 20ml
 Syringes 50 ml Conical Tip
 Syringes 50 ml Luer Lock
 Syringes Insulin
(eee) Tape:
 Elastic Adhesive Plaster - White 5cm and 10 cm
 Micropore tape
 Orthopedic surgical Adhesive Hypo-Allergenic
 Adhesive, zinc oxide, perforated,10cmx5m
 Adhesive, zinc oxide, 2.5cmx5m
(fff) Tourniquet, latex rubber,75cm
(ggg) Tourniquet, pneumatic
(hhh) Tubes:
 Endo-tracheal, disp. + connector, neonate mm, w.o balloon
 Endo-tracheal, disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Suction, L125cm,ster,disp, CH10, CH12, CH16
6.9.4.10 Operating Suite Renewable/Consumables:
(a) Airway Guedel, pediatric & adult size

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(b) Plastic, reusable aprons
(c) Urine bags, collecting, 2000 ml
(d) 012 Band, Esmarch, 6 cm x 5 m
(e) Survival blanket, 220x140cm
(f) Blood Sampling:
 Needle, disposable, sterile, 20G, 21G
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer holder
 Vacutainer needles, 18-24G
(g) Bouffant Nurse Cap
(h) Cannula, IV short, ster, disp, 18G, 20G, 22G, 24G
(i) Catheters:
 Sup-Pubic, CH 10, 1.65 cm, ster, disp adult with trocar
 Urethral, CH6, ster, disp
 Urethral, CH7, ster, disp
 Foley, ster, disp, CH10, CH12, CH14
(j) Compresses:
 Abdominal compress, 40 x 40 cm
 Compress, Swab, 20x 20 cm
 Compress, gauze,10x10cm,n/ster/PAC-100
 Compress, gauze,10x10cm,ster/PAC-5
 Compress, paraffin,10x10cm,ster/BOX-10
(k) Connector, biconical, OD 7-11-7mm
(l) Cotton wool,500g,roll,non-ster
(m)Diathermy pencil/ball/blade
(n) Disposable, dispersive, electrode(Diathermy pad)
(o) Drain, corrugated sheet, 3 cm x 25 cm
(p) Drain, wound, CH 12, ster, disp, CH12, CH16, CH6
(q) Drawsheet,plastic,90x180cm
(r) Elastoplasts, 10 cm x 3 m

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(s) Electrode, Chest, Monitor
(t) Gauze:
 Ball, Large (sterile)
 Ball, Large (un-sterile)
 Ball, Peanut (sterile)
 Swabs RAYTEX® 10 X 10 cm
 Swabs, Un-sterile (Green)
 Roll,90cmx100m,non-ster
 Vaseline gauze
(u) Gloves,exam,latex,disp, large, medium & small
(v) Gloves,surg,disp, 6.0, 6.5, 7.0, 7.5, 8, 8.5
(w)Gum elastic bougie, CH 15, 60 cm
(x) Intubation stylet, adult, 15 Ch
(y) Mask, Clinical, Disposable (non-woven)
(z) Mask, Protection, High Filtration
(aa) Needle, spinal, 0.9x90mm),ster,disp, 20G, 22G, 24G
(bb) Oxygen mask, adult
(cc) Oxygen, nasal cannula
(dd) Reusable, Diathermy, Cable
(ee) Safety box for .used syrgs/ndls
(ff) Set, Infusion “Y”, Luer lock, air inlet
(gg) Scalpel blade,ster,disp,no.10, no. 11, no. 15, no. 22, no. 23
(hh) Shoe cover, disposable
(ii) Silicone Rubber Tubing
(jj) Orthopedic surgeon's Cap, Easy-Tie
(kk) Suturing materials:
 Abs,DEC1,need 1/2,18mm,round/BOX-36
 Abs,DEC2,need 3/8 18mm,round/
 Abs,DEC2,need 3/8,26mm,tri
 Abs,DEC3,need 1/2 30mm,round
 Abs,DEC3,need 3/8 50mm,round
 Abs,DEC3,spool

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  Abs,DEC4,need 3/8 36mm,tri
 Nonabs, DEC2,need 3/8 13mm,tri
 Nonabs, DEC3,need 3/8 30mm,tri
 Wires, different size/thickness
 Plates and screws, different size and shape
 Implants, different types and size
(ll) Tape,adhesive,Z.O,perforated,10cmx5m
(mm) Tape,adhesive,Z.O.,2.5cmx5m
(nn) Tubes:
 Endo-tracheal, disp. + connector, 3 mm, w/o balloon
 Endo-tracheal, disp. + connector, 3.5 mm, w/o balloon
 Endo-tracheal, disp. + connector, 4 mm, w/o balloon
 Endo-tracheal, disp. + connector, 4.5 mm, w/o balloon
 Endo-tracheal, disp. + connector, 5 mm, balloon
 Endo-tracheal, disp. + connector, 5.5 mm, balloon
 Endo-tracheal, disp. + connector, 6 mm, balloon
 Endo-tracheal, disp. + connector, 6.5 mm, balloon
 Endo-tracheal, disp. + connector, 7 mm, balloon
 Endo-tracheal, disp. + connector, 7.5 mm, balloon
 Endo-tracheal, disp. + connector, 8 mm, balloon
 suction,CH08,L50cm,ster,disp, CH08, CH10, CH14, CH16
 N.G Tubes 12, 14, 16
6.9.4.11 Operating Room Linen:
(a) Apron Orthopedic surgical, rubber
(b) Trousers, Orthopedic surgical, woven, Small, Medium & Large
(c) Top(shirts), Orthopedic surgical, woven, Small, Medium & Large
(d) Gown, Orthopedic surgical, woven(Plain)
(e) Cap, Orthopedic surgical, woven
(f) Masks, orthopedic surgical, woven
(g) Drape:
 Orthopedic surgical, woven(1 x 1 m)
 Orthopedic surgical, woven(1 x 1.5 m)
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  Orthopedic surgical, woven(1.5 x 1.5 m)(fenestrated
 Orthopedic surgical, woven(45 cm x 70 cm)(fenestrated)
 Orthopedic surgical woven (2 x 1.5 m)
(h) Pillow case
(i) Pillows
(j) Sheet, Bed
(k) Sheet, draw, white
(l) Cellular Blanket
(m)Mayo cover
(n) Towel Bath
(o) Towel Hand
6.9.4.12 Equipment recovery area:
(a) Vacuum aspirator
(b) Oxygen Flow meter, 0 - 15 l/min
(c) Oxygen (one cylinder per bed)
(d) Oxygen concentrater
(e) Patient transfer, (stretchers)
(f) Dressing trolley, trays
(g) Bed with mattress
(h) Stools
(i) IV stands
(j) Bed screen, 3 sections, mobile
(k) Pedal bin
(l) Oxygen trolley, complete
(m)Pulse oximeter
(n) Resuscitator, hand operated
(o) Suction machines
(p) Mobile examination light
(q) Dual head stethoscope
6.9.4.13 Equipment-Central sterilization room
(a) Auto claves ;big
(b) Autoclaves ;small
(c) Drums, metallic shelves, cabinets, tables and chairs

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6.10 Gynecology and Obstetrics Care Services

6.10.1 Practice (obstetrics, gynecology and basic newborn services)

6.10.1.1 Services for normal vaginal delivery shall be available 24 hours a day, 365 days a
year.
6.10.1.2 Comprehensive emergency obstetric care shall be available 24 hours a day and
365 days a year.
6.10.1.3 Essential newborn care and newborn resuscitation care shall be available 24
hours a day and 365 days a year. This service shall have written policies and
procedures to transfer or refer neonates to neonatal unit that require further
care.
6.10.1.4 Routine examination for detection of congenital hip dysplasia and other
congenital anomalies shall be done.
6.10.1.5 Emergency gynaecological services shall be available 24 hours a day, 365 days a
year.
6.10.2 Premises

6.10.2.1 The Maternity Unit is comprised of the maternity ward, delivery suite, nursery
and operating theatre.
6.10.2.2 The delivery suite shall be able to accommodate four first stage patients and two
deliveries simultaneously. In case of 100% occupancy of the delivery rooms, the
labour bays shall be equipped in such a way that patients can be accommodated
there to deliver.
6.10.2.3 The maternity ward and delivery suite shall be located close to each other to make
the transfer of obstetric cases to and from the delivery suite as uncomplicated as
possible.
6.10.2.4 The delivery ward shall be easily accessible to an operating theatre. An operating
theatre specifically for obstetric cases shall be located in the maternity/delivery
section.
6.10.2.5 The maternity unit shall have the following facilities:
a) Maternity Ward:

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  Facilities shall be provided for antenatal and postnatal care including
high dependency care and rooming in facilities for mother and
newborn. These can be organized into patient bays +/- separate one
or two bedded rooms for high risk patients.
 Curtain tracks shall be installed around each bed, or in their absence
bed screens shall be provided.
 Sinks shall be provided in each patient bay or room. Patient toilets and
showers shall be provided, in or adjacent to the ward. If this is not
possible then covered walkways should lead from the ward to the
ablution facilities.
 A nurses’ station shall be set up to enable nursing staff to monitor all
visitors entering or leaving the unit.
b) Maternity Ward clean utility room: This is used for:
 The storage of supplies , both clean and sterile
 Preparing and storing dressing trolleys used on the ward
 The storage, preparation and assembly of items of equipment for
diagnostic and therapeutic procedures
 IV fluid preparation
 Injection preparation
c) Maternity Ward clean linen room: This is used for the storage of linen
including bed sheets, mackintosh and draw sheets for use in the maternity
unit. It requires cabinets and shelves

d) Maternity Ward in patient store: This is used for the storage of equipment
required on the maternity ward. It requires shelving, cabinets and sufficient
electrical plugs should be available to keep the electrical equipment plugged
in and keep batteries charged.

e) Maternity Ward soiled utility room: This is used for:

 Temporary storage point for urine and stool specimens to be sent to
laboratory for analysis
 Dipstick urinalysis

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  Temporary storage point for soiled linen
 Temporary storage point for contaminated items for destruction at a
later stage
 Temporary storage point for used safety boxes prior to incineration
f) Maternity Ward cleaner’s room
g) Maternity Ward kitchen: This is used to temporarily store and prepare food
from the main kitchen and to prepare patient beverages. It requires stainless
steel sink, drainer and cabinets
h) Staff toilet, shower and changing facilities: These shall be separate from
patient ablution facilities. Staff lockers shall be included. Facilities shall be
sufficient for staff working on the maternity ward, delivery suite and
obstetric operating theatre.
i) Nursery: The nursery is used for the management of post caesarean section
babies until the mother returns to the ward and for other sick or high risk
babies. It requires:
 The nursery unit shall have a room for milk preparation
 The nursery shall have a single entrance to control access.
 Work surface for washing, drying and changing babies
 Sink, cabinets and shelves
j) Baby isolation room: This room is used for the management of babies with
high risk symptoms and infectious conditions that need isolation. It requires:

 This room shall be located close to the nurses’ station.

 A clinical basin and separate bathing facility are required.
 There shall be a work surface for basic hygiene and nappy changing.
 An extraction ventilation system with air conditioning control to
maintain and regulate room temperature shall be available, or the
room shall be designed to avoid air-borne cross infections
k) Delivery Suite shall have the following

 Labour Bay (6 beds) for the management of women in labour

including induction of labour and fetal monitoring.

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  Sink, cabinets and toilet facilities
 Delivery room store: This shall be located within the delivery suite,
with easy access from the labour and delivery rooms. It requires
shelves and cabinets
 Delivery Room (s) (two beds): Delivery rooms are used for all stages
of labour including recovery following birth. Transfer to obstetric
theatre shall be easy.
 Soiled Utility – delivery room
l) The obstetric gynecology services shall have its own operating theater for
obstetric cases.
m) The obstetric gynecology services shall have separate operating theater
(OR) for gynecologic cases. In the event that the gynecologic services does
not have separate OR there shall be clear policy and procedures on using the
OR available in the hospital.
n) Reception/Nurse station: A duty room or duty station within the restricted
access areas which is so situated, constructed and equipped that it is
possible for the nursing staff to observe patients directly and where
necessary, render assistance. This area need not be a room, but may form an
integral part of the main patient corridor, recovery area or bed-receiving
area.
o) Entrance/Patient transfer area
 This area shall be large enough to allow for the transfer of patients
from a bed to a trolley.
 A line shall be clearly marked in red on the floor, beyond which no
person from outside the operating department should be permitted to
set foot without obtaining authority and putting on protective
clothing.
 Holding bay: space shall be located to allow for the supervision of
waiting patients to go into theatre.
p) Staff Change
 Suitable separate changing room facilities shall be provided for male
and female staff.

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  The changing room shall have one door that opens into the restricted
access area, and must have a separate entrance from outside the
restricted access area.
 Storage facilities for the personnel’s personal clothing and effects.
 Storage of clean theatre attire and inside shoes and OT gum boots.
 Provision must also be made for soiled theatre apparel.
 Wash hand basins: Toilets, showers, shelves, lockers
q) Operating theatre shall have the following:
 Patient entrance into theatre and exit out of theatre shall be through
double self-closing doors situated in the centre of the operating room
entrance.
 General anaesthesia administration could be given in an anaesthetic
room and patient then transferred to the operating room.
Alternatively, the patient can be induced and anaesthesia will be
maintained in the operating room.
 Cabinets and shelves
 Scrub area
o A scrubbing-up area outside but adjacent to the operating
room shall be provided. If the scrub area serves only one
operating theatre there should be sufficient sinks for two
staff to scrub at the same time. If it serves two theatres then
the space should be sufficient for four staff to scrub up
simultaneously.
o This area shall have direct access to the operating room
o Sterile gowns and gloves shall be available on a trolley in the
scrub area or at the entrance of the operating room.
o Sink with running water shall be available
 Set-up area (optional): Store area for suture material that could be
stored on a trolley that could be wheeled into theatre. Requirements:
o Doors into the operating room should be big enough to wheel
through the set trolleys from the set up room into the

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 operating room without contact with doors or non sterile
surfaces.
o Shelves for the days sets and pack to be stored during theatre
list.
o If there is no set up area then instruments can be set up
within the operating theatre
o Mayo table, dressing trolley, and runners to set up for the
next case are kept in this area.
 Operating theatre equipment and sterile supply store
o The equipment store area in the operating room shall be
supplied with a sufficient number of electrical plugs to keep
the electrical equipment plugged in, and in case of power
failure to work on back up electrical supply / or emergency
electrical supply.
o Equipment is always stored at the same space/location so
that if needed in an emergency all staff know where the
equipment is kept.
o Shelves and cabinets
 Operating theatre sterile supply store: This room is used for the
storage of all sterile instrument sets, swabs and sterile renewable,
consumables and it requires shelves.
 Clean Utility, Surgical Suite: This room is used for storage of IV fluids,
clean linen, medicines and other sundry items, flash autoclaving of
equipment in case of emergencies.
o This room shall be so situated that operating room staff have
easy access to the clean utility store where drugs and
medication are stored.
o Storage space/room shall be provided for sterile packs. No
wood or porous shelving may be used in this area.
o Refrigerator shall be available for storing medications that
needs to be stored at a temperature of 4 º C
o Sink, cabinets and shelves shall be available

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  3-Bed Recovery: This area shall be used to stabilize the patient post-
surgery, and to prepare for transfer if transfer is needed.
o The recovery area shall be within the restricted area.
o A recovery area shall have room for two beds (one per
operating room) and one over-flow bed space to
accommodate patients from the two operating rooms.
o A clinical basin shall be provided.
o Electrical switch socket outlets for every recovery bed or
trolley shall be available.
o Facilities for screening off to ensure patient privacy: bed
screens or curtain track with curtain between the bays.
o An emergency call system shall be installed and adherence to
policy and protocol regarding emergency management
followed.
o Sufficient lighting to enable adequate observation shall be
installed.
o A work surface to do administrative tasks during recovery of
patients, and shelving to store necessary equipment are
required.
 Soiled Utility/Sluice room: This acts as a store area for contaminated
materials until they can be disposed of. Used sharps/safety boxes are
to be stored here before being sent for incineration
o The flow of the operating rooms shall run from clean to dirty.
This area shall be fitted with a deep bowl sink and/or slop
hopper, a wash hand basin with hot and cold water and
cabinets and shelves
 Cleaner’s Room: The janitor/cleaner’s room is the base from which
domestic services staff provide a cleaning service to the theatre suite.
It requires shelves, cabinets and sink with hot and cold water.
6.10.3 Professionals
6.10.3.1 A licensed obstetrician and gynecologist shall be in charge of overall gynecology
and obstetrics services

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6.10.3.2 There shall be adequate qualified medical and nursing professionals in the
gynecology and obstetrics unit available at all times to meet the service needs
6.10.3.3 The number and type of technical staff shall be determined by the volume and
type of work carried out (Workload Analysis)
6.10.3.4 A physician or licensed independent practitioner shall be available (physically
present) at all times in the gynecology and obstetrics unit
6.10.3.5 A senior obstetrician and gynecologist shall be on duty or on call at all times. The
obstetrician and gynecologist shall be able to present at the unit in a period not
to exceed thirty (30) minutes.
6.10.3.6 The nurse with administrative responsibility for nursing care in obstetric shall be
a licensed professional nurse with at least three years of experience gynecology
and obstetric
6.10.3.7 The nurse with administrative responsibility for nursing care in gynecology shall
be a licensed professional nurse with at least three years of experience
gynecology and obstetric
6.10.3.8 There shall be adequate support staff available as per the service need

6.10.4 Products
6.10.4.1 Equipment – Clean Utility Room
a) Trolley for vital sign monitoring with thermometer and sphygmomanometer
b) Dressing trolley (s)
c) Refrigerator for medication with temperature control
d) IV stand
e) Wheelchair
6.10.4.2 Equipment - Clean linen room
a) Trolley to be used for bed linen changes during patient hygiene
b) Cabinet (s)
6.10.4.3 Equipment – maternity patient ward:
a) Bed and mattress x 25
b) Vacuum aspirator, 0 – 250mm/Hg with bottle and tubing – how many?
c) Oxygen flow meter, 0-15 L/min
d) Oxygen
e) Baby cot

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 f) Bed side cabinet x 25
g) Over bed table x 25
h) Bed screen, 3 sections x
i) Footstool x 25
j) IV stands
k) Wheelchairs
6.10.4.4 Equipment – Nurses station
Crash cart, with sufficient equipment and drugs for the resuscitation of mother
and neonate, including defibrillator, intubation sets and oxygen
a) Diagnostic set with opthalmoscope and otoscope
b) Adult sphygmomanometer x 1
c) Paediatric sphygmomanometer x 1
d) Stethoscope, foetal x 1
e) Stethoscope, dual head x 1
f) Stethoscope, paediatric head x 2
g) Thermometer x 2
6.10.4.5 Equipment – maternity ward in patient store:
a) Patient transfer, roller system x 1
b) General purpose trolley, two trays, stainless steel x 1
c) Patient chart holder x 40
d) Bed screen, three sections x 3
e) IV stand x 3
f) Mobile bedpan trolley x 1
g) Oxygen trolley, complete x 1
h) Suction pump, portable x
i) Bed pan x 10
j) Kidney basin, 475 ml x 5
k) Wheelchair x 1
l) General surgical dressing set x 1
m) Tendon hammer x 1
n) Mobile examination light x 1
o) Adult weight scales x 1
6.10.4.6 Equipment – maternity ward soiled utility room:

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 a) Soiled linen trolley
b) Bin with lid
c) Worktable with laminated top
d) Wash tub (65L)
e) General purpose trolley, two trays
f) Mobile trolley and bedpans x 1
g) Bedpan x 10
h) Kidney basin, 475 ml x 5
6.10.4.7 Equipment – maternity ward cleaner’s room:
a) Cleaning trolley
b) Mop rack
c) Worktable
d) Cabinets and shelves
e) Pail with handle x 2
f) Broom x 1
g) Mop x 1
6.10.4.8 Equipment – maternity ward kitchen:
a) Pedal bin
b) Worktable with laminated top
c) Stove or kettle to prepare beverages for patients
6.10.4.9 Equipment – milk formula room:
a) Worktable with laminated top
b) Refrigerator
c) Kitchen scale
d) Sterilizing equipment or solutions
e) Stove or kettle to heat water for warming feeds
f) Baby bottles, teats and bottle brushes
g) Pedal bin
h) Stool
6.10.4.10 Equipment – nursery
a) Vacuum aspirator, 0 - 250 mm/Hg, w bottle and tubing x 4
b) Flow meter, 0 - 15 l/min x 4
c) Oxygen source x 4

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 d) Baby cot x 8
e) Chair x 2
f) Stool x 2
g) IV stand x 2
h) Infusion pump, drop controlled x 2
i) Pedal bin
j) Baby warmer or overhead heater x 1
k) Incubator, automatic x 2
l) Breast pump x 3
m) Neonatal resuscitation kit x 1
n) Infant scale x 1
6.10.4.11 Equipment – baby isolation room
a) Vacuum aspirator, 0-250mmHg, with bottle and tubing
b) Oxygen
c) Flow meter, 0 - 15 l/min
d) Oxygen hood
e) Oxygen saturation monitor
f) Baby warmer or overhead heater
g) Patient monitor
h) Baby bassinet with mattress
i) Waste container, with lid
j) Bedside cabinet
k) Baby dressing table, with padded top
l) Pedal bin
m) Chairs x 2
6.10.4.12 Equipment – labour bay:
a) Vacuum aspirator, 0-250mm/Hg with bottle and tubing x 6
b) Flow meter, 0-15l/min x 6
c) Oxygen x 6
d) 004 Wall clock
e) Worktable with laminated top
f) Bed x 6
g) Bedside cabinet x 6

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 h) Chair x 6
i) IV stand x 6
j) Bed screen, three sections x 6
k) CTG monitor on trolley x 2
l) Waste paper basket x 2
m) Foetal Doppler x 1
n) Stethoscope, dual head x 2
o) Stethoscope, dual head x 2
6.10.4.13 Equipment – delivery room store:
a) Patient transfer, roller system x 1
b) Patient stretcher x 1
c) IV stand x 2
d) Portable suction pump x 1
e) Vacuum extractor, Bird, manual, complete set x 2
f) Newborn circumcision set x 1
g) Delivery set x 1
h) Obstetric forceps x 1
Gyn/Obs- Delivery set x 1
i) Gyn/Obs- Obstetric forceps x 1
6.10.4.14 Equipment –delivery room (s)
a) Vacuum aspirator, 0 - 250 mm/Hg, w bottle and tubing x 2
b) Trolley, oxygen, complete (*) x 2
c) Flow meter, 0 - 15 l/min x 2
d) Wall clock x 2
e) Dressing trolley, two trays x 2
f) Soiled line trolley, 2 rings x 2
g) Baby cot x 2
h) Delivery bed x 2
i) IV stand x 2
j) Kick bucket, stainless steel x 2
k) Bowl and stand x 2
l) Instrument table, Mayo type, mobile x 2
m) Infusion pump, volumetric x 2

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 n) Newborn care table x 2
o) Operating light, ceiling mounted or mobile x 2
p) Neonatal resuscitation kit x 2
q) CTC monitor on trolley x 2
r) Foetal Doppler x 2
6.10.4.15 Equipment – soiled utility room, delivery suite:
a) Soiled linen trolley
b) Bin with lid
c) Worktable with laminated top
d) Wash tub (65L)
e) General purpose trolley, two trays
f) Mobile trolley and bedpans x 1
g) Bedpan x 10
h) Kidney basin, 475 ml x 5
6.10.4.16 Equipment – reception/nurse station, operating theatre suite:
a) Wall clock x 1
b) Desk x 1
c) Desk chair x 1
d) Cabinet x 1
e) Chair, stackable, without armrests x 2
f) Basket, waste-paper, metal (*) 1
6.10.4.17 Equipment – entrance, patient transfer area, operating theatre suite:
a) Patient transfer, roller system x 1
b) Patient stretcher x 2
6.10.4.18 Equipment –staff changing room, operating theatre suite:
a) Soiled linen trolley x 1
b) Waste basket
6.10.4.19 Equipment, one operating theatre:
a) Elapsed time clock x 1
b) Anaesthesia trolley x 1 and Oxygen cylinders
c) Worktable with laminated top
d) Stool x 2
e) IV stand x 2

138
 f) Kick bucket x 1
g) Swab rack with drip tray x 1
h) Swab count record board x 1
i) Bowl and stand x 3
j) Instrument table, Mayo type x 1
k) Framed board with pencil tray x 1
l) Infusion pump x 1 and Suction pump x 1
m) Blanket, warming x 1
n) Tourniquet x 1 and Tongue depressor x 2
o) Coagulation unit, electro, mobile, 200 W x 1
p) Light, operating, 1 large copula, ceiling mounted
q) Operating table, 3 sections, x 1
r) IV fluid pressure bag x 1
s) Anaesthesia machine with ventilator, 2 vaporizers, and gas cylinders x 1
t) Laryngoscope set (Mackintosh) x 1
u) Magill forceps (adult) x 1
v) Laryngeal mask set x 1 and Mask holder x 1
w) Mouth gauge x 1
x) Patient monitor x 1
y) Dual head stethoscope x 1
6.10.4.20 Equipment – scrub area
a) Soap dispenser
b) Scrub-up brushes
6.10.4.21 Equipment: set up area
a) Worktable with laminated top
b) Cabinets and shelves
c) Dressing trolley x 1
d) Instrument table, Mayo type x 2
e) Blood warmer x 1
f) IV fluid warmer x 1
6.10.4.22 Equipment – operating theatre store
a) Patient transfer, roller system x 1
b) General purpose trolley x 1

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 c) IV stand x 2
d) Hygrometer, humidity and temperature x 1
e) Newborn general care table x 1
f) Pillow, abduction x 1
g) Support, head, operating table x 1
h) Positioner, bag, patient, small x 3
i) Positioner, bag, patient, medium x 2
j) Positioner, bag, patient, large x 1
k) Apron, protective, small x 1
l) Apron, protective, medium x 2
m) Apron, protective, large x 2
6.10.4.23 Equipment – operating theatre sterile supply store:
a) General purpose trolley, 2 trays x 1
b) Gen.surg-Suture set x 1
c) Gen.surg- Abdominal set x 1
d) Gen.surg- Basic surgery set x 1
e) Gen.surg- Laparotomy set x 1
f) Gen.surg- Small dissection set x 1
g) Gen.surg- Minor surgical set x 1
h) Gen.surg- Suprapubic puncture set x 1
i) Gen.surg- Circumcision set, newborns x 1
j) Gyn/Obs-IUD set x 2
k) Gyn/Obs- Cranioplasty/craniotomy set x 1
l) Gyn/Obs- Dilation & curettage (D&C) set x 1
m) Gyn/Obs- Manual vacuum aspiration set x 1
n) Gyn/Obs- Obstetric forceps x 1
o) Gyn/Obs- Caesarean section set x 1
p) Gyn/Obs- Abdominal hysterectomy set
q) Gyn/Obs- Vaginal hysterectomy set, extras x 1
r) Gyn/Obs- Gynaecology examination set (EUA) x 1
s) Gyn/Obs- Cervical biopsy set x 1
6.10.4.24 Equipment – clean utility room, surgical suite:
a) General purpose trolley, two trays x 1

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 b) Worktable, laminated top
c) Refrigerator, 140 l + 20 l
d) Steam sterilizer
6.10.4.25 Equipment recovery area:
a) Vacuum aspirator x 3
b) Oxygen Flow meter, 0 - 15 l/min x 3
c) Oxygen (one cylinder per bed)
d) Patient transfer, roller system x 1
e) Dressing trolley, two trays x 1
f) Bed with mattress x 3
g) Stool x 1
h) Bed screen, 3 sections, mobile x 2
i) Pedal bin x 1
j) Oxygen trolle, complete x 1
k) Ventilator x 1
l) Resuscitator, hand operated x 1
m) Mobile examination light x 1
n) Dual head stethoscope x 1
6.10.4.26 Equipment – operating theatre sluice room
a) Soiled linen trolley x 3
b) General purpose trolley, two trays x 1
c) Bin with lid x 1
d) Worktable with laminated top
e) Wash tub, 65 L
f) Mobile bedpan trolley x 1
g) Bedpan x 1
h) Kidney basin, 475 ml x 5
6.10.4.27 Equipment – cleaners’ room, operating theatre:
a) Cleaning trolley
b) Mop rack
c) Worktable
d) Pail with handle x 2
e) Broom x 2

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 f) Mop x 2
6.10.4.28 Renewable/Consumables for maternity unit
 Guedel airways: size 0, 00, 3, 4 & 5
 Alcohol Swabs
 Disposable aprons
 Aqua-packs Oxygen humidifier
 Bag urine baby
 Bags - Refuse - All Colours and Sizes
 Bags – Urine
 Bandage - Crepe
 Batteries - Medical & General
 Bedpan Covers
 Blood Administration Sets
 Blood Sampling Needles, disposable, sterile, 20 G, 21 G, 23 G
 Blood Sampling Tubes:
 Vacuum 5ml (Vacutainer)
 Vacuum EDTA 5ml (Vacutainer)
 Vacuum Heparinised 5ml (Vacutainer)
 Blood Sampling Vacutainer Holder
 Bottles - Suction - Glass/Plastic
 Braun Splints (Arm)
 Bubble tubing box
 Cannula - Nasal-Oxygen
 Cannula, IV short, ster, disp, 18G, 20 G, 22 G, 24 G
 Caps - Mop/Bonnet Type
 Catheter - Jacques
 Central Venous Pressure Sets
 Chest, Electrode, Monitor
 Cleansing Swabs – Sterile
 Cleansing Swabs Non-Sterile
 Cold/Hot Packs
 Combur Tests

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 Connectors:
 Biconical Autoclavable
 Connector, T/Y
 Connectors - Plastic – Tapered
 Container, Sample, urine, plastic, non-sterile, 60 ml
 Cotton:
 Buds
 Wool Balls - Sterile/Non-Sterile
 Wool Rolls
 Covers - PVC - Mattress/Bed Wedge
 CVP – Cannulae
 Cytological Fixative Spray
 Drawsheet,plastic,90x180cm
 Face Mask Water Repellent
 Foley Catheters – Latex/Silicone Size 10, 12 and 14
 Gauze Absorbent Ribbon
 Gloves:
 Household Large & Medium
 Surgical Size 6, 6 ½, 7, 7 ½, 8
 Exam, latex, disp, large, medium, small
 Hand wash Antiseptic Liquid (Hibiscrub)
 Hand wash Povidone (Betadine)
 Hot Packs
 I.V.
 Administration Sets – 15 Drop
 Administration Sets - 60 Drop
 Set, Infusion “Y”, Luer lock, air inlet
 Infusion set Buretrol
 Incontinence Sheets
 Intubation stylet, adult, 15 Ch
 K.Y. Jelly
 Latex Tubing

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 Linen Savers
 Masks - Nebulizer/Oxygen
 Masks – Oxygen 40 %
 N.G Tubes 12, 14, 16
 Nail Brushes - Autoclavable/Disposable
 Needles:
 Spinal disp, (0.9x90mm),sterile, 20G, 22G, 24G
 Disp,15G, 18G, 21G, 22G, 23G, 25G
 Butterfly 23G
 Oxygen T Pieces and Oxygen Tubing
 Pads - Sanitary - Maternity
 Paper CTG
 Face Masks
 Razor Medical - Disposable - Single Edge
 Rubber Bath Mat - Non-Slip
 S.G. Meter (Urine Meters)
 Safety Pins Large & Medium
 Sharps Containers (Safety Box/used syringes and needles)
 Shrouds
 Soap,toilet,bar,approx.110g,wrapped
 Spatulas - Tongue
 Spigots Large, Medium and Small
 Spray Bottles - Plunger Operated
 Surgical Spirits
 Suture absorbable (Chromic) for episiotomy and perinea tears
 Syringes:
 2ml, 5ml, 10ml, 20ml
 Syringes 50 ml Conical Tip
 Syringes 50 ml Luer Lock
 Syringes Insulin
 Tapes
 Elastic Adhesive Plaster - White 5cm and 10 cm

144
  Micropore tape
 Tape Surgical Adhesive Hypo-Allergenic
 Tape,adhesive,Z.O,perforated,10cmx5m
 Tape,adhesive,Z.O.,2.5cmx5m
 Clinical thermometer
 Fridge thermometer
 Tourniquet, latex rubber,75cm
 Tube:
 Endo-tracheal, disp. + connector, neonate mm, w.o balloon
 Endo-tracheal, disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Suction, L125cm,ster,disp, CH10, CH12, CH16
 Umbilical clamp
 Umbilical cord tape

6.10.4.29 Operating Suite Renewable/Consumables:

 Airway Guedel, 00 (neonatal), 3, 4 & 5
 Plastic, reusable aprons
 Urine bags, collecting, 2000 ml
 012 Band, Esmarch, 6 cm x 5 m
 Survival blanketl,220x140cm
 First Referral Hospitals
 Blood Sampling:
 Needle, disposable, sterile, 20G, 21G
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer Holder
 Bouffant Nurse Cap
 Bubble Tubing
 Cannula,IV short,ster,disp, 18G, 20G, 22G, 24G
 Catheters:
 036 Catheter Sup-Pubic, CH 10, 1.65 cm, ster,disp., adult

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 037 Catheter, ureteral, CH5, ster, disp
 038 Catheter, urethral, CH6, ster, disp
 039 Catheter, urethral, CH7, ster, disp
 Catheter, Foley, ster, disp, CH10, CH12, CH14
 Compresses:
 Abdominal compress, 40 x 40 cm
 Compress, Swab, 20x 20 cm
 Compress,gauze,10x10cm,n/ster/PAC-100
 Compress,gauze,10x10cm,ster/PAC-5
 Compress,paraffin,10x10cm,ster/BOX-10
 Connector, biconical, OD 7-11-7mm
 Cotton wool,500g,roll,non-ster
 CVP - Set
 Diathermy pencil/ball/blade
 Disposable, dispersive, electrode(Diathermy pad)
 Drain, corrugated sheet, 3 cm x 25 cm
 063 Drain, wound, CH 12, ster, disp, 450 ml (Redon + Needle), CH12,
CH16, CH6
 Drawsheet,plastic,90x180cm
 Elastoplasts, 10 cm x 3 m
 Electrode, Chest, Monitor
 Extractor,mucus,20ml,ster,disp
 File for ampoules
 Gauze:
 Gauze Ball, Large (sterile)
 Gauze Ball, Large (un-sterile)
 Gauze Ball, Peanut (sterile)
 Gauze Swabs RAYTEX® 10 X 10 cm
 Gauze Swabs, Un-sterile (Green)
 Gauze,roll,90cmx100m,non-ster
 Gloves:
 Gloves, exam, latex, disp, large, medium & small

146
 Gloves, gynaeco, ster, disp, 6.5, 7,5 & 8.5
 Gloves, surg, disp, 6.0, 6.5, 7.0, 7.5, 8, 8.5
 Gum elastic bougie, CH 15, 60 cm
 I.U.D., copper, T
 Intubation stylet, adult, 15 Ch
 Lancet,blood,ster,disp/PAC-200
 Mask, Clinical, Disposable (non-woven)
 Mask, Protection, High Filtration
 Needle,spinal, 0.9x90mm),ster,disp, 20G, 22G, 24G
 Obstetrical Pads
 Opsite Flexi-grid (Various Sizes)
 Oxygen mask, adult
 Oxygen, nasal cannula
 Reusable, Diathermy, Cable
 Safety box for .used syrgs/ndls 5lt/BOX-25
 Set, Infusion “Y”, Luer lock, air inlet
 Scalpel blades:
 Scalpel blade,ster,disp,no.10, no. 11, no. 15, no. 22, no. 23
 Scalpel blade,ster,disp,no.11
 Shoe cover, disposable
 Silicone Rubber Tubing
 Surgeon's Cap, Easy-Tie
 Sut, abs, non-absorbable, various
 152 S0564010 Sut,abs,DEC1,need 1/2,18mm,round/BOX-36
 153 S0564011 Sut,abs,DEC2,need 3/8 18mm,round/BOX-36
 154 S0564004 Sut,abs,DEC2,need 3/8,26mm,tri/BOX-36
 155 S0564012 Sut,abs,DEC3,need 1/2 30mm,round/BOX-36
 156 S0564013 Sut,abs,DEC3,need 3/8 50mm,round/BOX-36
 157 S0564030 Sut,abs,DEC3,spool/BOX-36
 158 S0564020 Sut,abs,DEC4,need 3/8 36mm,tri/BOX-36
 159 S0565010 Sut,nonabs,DEC2,need 3/8 13mm,tri/BOX-36
 160 S0565011 Sut,nonabs,DEC3,need 3/8 30mm,tri/BOX-36

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 Syringe, dispos, 2ml, 5ml, 10ml, 20ml
 Tape,adhesive,Z.O,perforated,10cmx5m
 Tape,adhesive,Z.O.,2.5cmx5m
 Telfa, dressing (Various Sizes)
 Tourniquet,latex rubber,75cm
 Tubes:
 182 Tube, Endo-tracheal, disp. + connector, 3 mm, w/o balloon
 183 Tube, Endo-tracheal, disp. + connector, 3.5 mm, w/o balloon
 184 Tube, Endo-tracheal, disp. + connector, 4 mm, w/o balloon
 185 Tube, Endo-tracheal, disp. + connector, 4.5 mm, w/o balloon
 186 Tube, Endo-tracheal, disp. + connector, 5 mm, balloon
 187 Tube, Endo-tracheal, disp. + connector, 5.5 mm, balloon
 188 Tube, Endo-tracheal, disp. + connector, 6 mm, balloon
 189 Tube, Endo-tracheal, disp. + connector, 6.5 mm, balloon
 190 Tube, Endo-tracheal, disp. + connector, 7 mm, balloon
 191 Tube, Endo-tracheal, disp. + connector, 7.5 mm, balloon
 192 Tube, Endo-tracheal, disp. + connector, 8 mm, balloon
 204 Tube, Trachea, balloon, int.can, ster, size 6
 205 Tube, Trachea, balloon, int.can, ster, size 8
 Tube,suction,CH08,L50cm,ster,disp, CH08, CH10, CH14, CH16
 Umbilical Cord Clamp
 Operating Room Linen:
 Apron Surgical, rubber
 Trousers, Surgical, woven, Small, Medium & Large
 Top, Surgical, woven, Small, Medium & Large
 Gown, Surgical, woven(Plain)
 Cap, Surgical, woven
 Drapes:
 Drape, Surgical, woven(1 X 1 m)
 Drape, Surgical, woven(1 X 1,5 m)
 Drape, Surgical, woven(1.5 x 1,5 m)(fenestrated
 Drape, Surgical, woven(45 cm X 70 cm)(fenestrated)

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 Pillow case
 Pillows
 Sheet, Bed
 Sheet, draw, white
 Cellular Blanket (Recovery and outside blankets)
 Mayo cover
 Towel Bath
 Towel Hand

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6.11 Anesthesia Services

6.11.1 Practices
6.11.1.1 There shall be a written policy about administration of regional and general
anesthesia in the hospital,
6.11.1.2 Minor regional blocks shall be monitored in accordance with the hospital's policy,
6.11.1.3 Anesthesia services shall be administered in accordance with written policies and
procedures that are reviewed at least every three years, and revised more
frequently as needed. They shall include at least the following :
(a) Anesthesia care, which includes moderate and deep sedation, is planned
and documented in the patient’s record.
(b) pre anesthetic /sedation assessment shall be done by anesthesiologist or
anesthetist before admission and prior to induction.
(c) Each patient’s physiologic status shall be continuously monitored and
documented every 10 minutes during general anesthesia and regional
anesthesia and sedation
(d) The patient shall be reassessed immediately prior to induction of
anesthesia by an anesthesiologist or anesthetist. The plan shall be
consistent with the patient assessment and shall include the anesthesia
to be used and the method of administration.
(e) Prior to administration of any pre-anesthesia medication, a written
informed consent for the use of anesthesia must be obtained and
documented in the medical record.
(f) Each patient’s physiologic status shall be continuously monitored
during anesthesia or sedation administration and the results of the
monitoring shall be documented in the patient’s medical record on an
anesthesia form, a minimum of :
 Pulse rate and rhythm.
 Blood pressure.
 Oxygen saturation.
 Respiratory rate.

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 (g) The anesthesia record includes:
 Fluids administered.
 Medications administered.
 Blood or blood products administered.
 Estimated blood loss.
 The actual anesthesia used.
 Any unusual events or complications of anesthesia.
 The condition of the patient at the conclusion of anesthesia.
 The time of start and finish of anesthesia.
(h) The patient shall be monitored during the post-anesthesia/surgery
recovery period and the results of monitoring shall be documented in
the patient’s medical record.
(i) The time of arrival and discharge from anesthesia recovery room shall
be recorded.
(j) The observation recovery room shall be done by qualified licensed
nurses with training of basic advanced cardio-pulmonary support
(k) The decision of discharge shall be done by anesthesiologist, or
anesthetist or other qualified physician based on the documented results
of monitoring during the recovery.
(l) The discharge order from the recovery shall be documented on patients
chart and signed by anesthesiologist or anesthetist or other qualified
physician before transfer.

6.11.1.4 Provision shall be made for remote monitoring of the patient if radiation or
another direct hazard necessitates the removal of personnel from anesthetized
person.
6.11.1.5 At all times, an anesthesiologist shall be on-site or on-call and available to reach
the hospital within 30 minutes.
6.11.1.6 The anesthesiologist or anesthetist shall visit the patient before the operation and
assess the general medical fitness of the patient, receives any medication being
taken, and assess any specific anesthesia problems.

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6.11.1.7 The anesthesiologist or anesthetist shall discuss possible plans of management
with the patient and explains any options available, to enable the patient to
make an informed choice.
6.11.1.8 Information on any drugs or treatments such as blood transfusion shall be
discussed with the patient.
6.11.1.9 The anesthesiologist or anesthetist shall ensure that all the necessary equipment
and drugs are present and checked before starting anesthesia.
6.11.1.10 The anesthesiologist or anesthetist shall confirm the identity of the patient before
inducing anesthesia.
6.11.1.11 The anesthesiologist or anesthetist shall be present in the operating theatre
throughout the operation and shall be present on-site until the patient has been
discharged from the recovery room.
6.11.1.12 The conduct of the anesthesia and operation is monitored and recorded in line
with the monitoring standards and formats, to a minimum these shall contain:
a) A continuous display of the ECG,
b) Continuous pulse oximeter,
c) The inspired oxygen concentration; and
d) A written record of the anesthetic shall be kept as a permanent record in
the case notes.
6.11.1.13 Pain shall be assessed in discussion with surgeon and/ or the patient and pain
control shall be provided.
6.11.1.14 Patients shall be managed in a recovery room, except patients requiring transfer
for intensive care in ICU, until overcome effect of anesthetic.
6.11.1.15 There shall be one person on duty in the operating theatre at all times with
certified training in advanced cardiac life support.
6.11.1.16 Written discharge criteria shall be in place, including satisfactory control of pain
and nausea, spontaneous breathing, to determine when patients can be safely
discharged from the recovery room, making it clear that the final responsibility
is always with the anaesthetist or any qualified physician.
6.11.1.17 The protocols and guidelines used for anesthesia service shall be available and
well understood by the surgical team.

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6.11.1.18 Anesthetic agents administered with the purpose of creating conscious sedation,
deep sedation, major regional anesthesia, or general anesthesia shall be in
accordance with aneasthesia policies and procedures.
6.11.1.19 There shall be a written protocol to assure that surgery does not proceed when
there are disabled alarms, depleted batteries and inactive sensors in oxygen
monitors or carbon dioxide monitors, improperly positioned breathing-circuit
sensors, or other insufficiencies.
6.11.1.20 The body temperature of each patient under general or major regional anesthesia
lasting 45 minutes or more shall be continuously monitored and recorded at
least every 15 minutes.
6.11.1.21 Pulse oximetry shall be performed continuously during administration of general
anesthesia, regional anesthesia, and conscious sedation at all anesthetizing
locations, unless such monitoring is not clinically feasible for the patient. Any
alternative method of measuring oxygen saturation maybe substituted for pulse
oximetry if the method has been demonstrated to have at least equivalent
clinical effectiveness.
6.11.1.22 End-tidal carbon dioxide monitoring shall be performed continuously during
administration of all general anaesthesia, unless such monitoring is not clinically
feasible for the patient (optional).
6.11.1.23 An electrocardiogram (ECG) monitor shall be used continuously on all patients
receiving general anesthesia, regional anesthesia, or conscious sedation at any
anesthetizing location.
6.11.1.24 Blood pressure, pulse rate, and respirations, shall be determined and charted at
least every five minutes for all patients receiving anesthesia at any anesthetizing
location, except for local anesthesia and minor regional blocks.
6.11.1.25 Monitoring of regional labour analgesia shall include: documented temperature,
pulse, respiration, blood pressure, and oxygen saturation until the patient is
deemed stable. The patient shall be monitored subsequently in accordance with
hospital protocol.
6.11.2 Premises

6.11.2.1 The general anesthesia service shall be provided in the Operation theatre (OR),
together with the surgical services.

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6.11.2.2 Operation theatre; refer to the standards prescribed under the Surgical service
standard
(a) There shall be a mechanism for taking exhaust air from anesthesia
machine to outside of OR; important when performing open system for
pediatric anesthesia,
(b) There shall be central oxygen system or a system there is continuous
supply of Oxygen cylinders,
6.11.2.3 Anesthesia store: refer to the standards prescribed under the Surgical service
standard
(a) Shall be well ventilated and illuminated room with shelves and cabinets,
(b) The anesthetic shall be kept on shelves and/ or cabinets, separate from
medicines,
(c) There shall be at least 4 electric plugs in the room,
(d) Anesthetic equipments shall be stored clean and being ready for use,
(e) Ambu bags and resuscitation kits shall be kept labeled in easily reachable
place,
(f) There shall be separate place for keeping new and rechargeable Batteries
and dry cells. Used batteries and cells shall be stored and discarded
properly,
6.11.2.4 Office room: with chairs, table, cabinet; refer to the standards prescribed under
the Surgical service standard
6.11.2.5 Recovery Room: refer to the standards prescribed under the Surgical service
standard
Shall be sited within the operating suit and has a minimum of:
two beds with side protection,
monitoring equipment, including ECG;
resuscitation equipment including a defibrillator on trolley,
oxygen source,
ensures ease of communication and access for anesthesia department staff for
close follow up,
6.11.3 Professionals
6.11.3.1 Qualified licensed anesthesiologist with experience shall lead anesthesia service,
Copies of licenses of anesthesiologists and anesthetists shall be kept at the unit.

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6.11.3.2 All anesthesia providers who administer and/or supervise the administration of
general anesthesia, major regional anesthesia, or conscious sedation anesthesia
shall maintain current training in Advanced Cardiac Life Support.
6.11.3.3 General or major regional anesthesia shall be administered and monitored only by
the following:
a) An anesthesiologist; or
b) A licensed nurse anesthetist or
c) A physician resident (anesthesiology), a student nurse anesthetist, a
student anesthetist under the supervision of an anesthesiologist
and/or licensed nurse anesthetist:
6.11.3.4 The supervision of general or major regional anesthesia shall be provided by a
anesthesiologist who is immediately available. The supervising physician may
concurrently be responsible for patient care, with the exception of performing
major surgery, administering general anesthesia, or major regional anesthesia.
6.11.3.5 Minimum number of Anesthesiologist # 2 and 10 (BSC or diploma nurse)
anesthetist shall be available
6.11.3.6 Minor regional blocks shall be administered by the following licensed
professionals:
a) An Anesthesiologist, or
b) An anesthetist,
c) A physician, podiatrist (foot doctor) or dentist;
d) A medical intern, physician resident, dental resident, or a student
nurse anesthetist, or student anesthetist, licensed health officer, a
licensed nurse midwife or clinical nurse under the supervision of a
physician
6.11.4 Products
6.11.4.1 Anaesthesia supplies and equipment and safety systems shall include the
following:
a) Diameter index safety systems or equivalent shall be used on all large
cylinders of medical gases and wall and ceiling outlets of medical gases.
b) Pin index safety systems with a single washer shall be used on all small
cylinders to prevent interchangeability of medical gas cylinders.

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 c) All medical gas hoses and adapters shall be colour-coded and labelled
according to current national standards.
d) An oxygen failure-protection device ("fail-safe" system) shall be used on all
anaesthesia machines to announce a reduction in oxygen pressure, and, at
lower levels of oxygen pressure, to discontinue other gases when the
pressure of supply oxygen is reduced.
e) Vaporizer exclusion ("interlock") system shall be used to assure that only
one vaporizer, and therefore only a single agent, can be actuated on any
anaesthesia machine at one time.
f) To prevent delivery of excess anaesthesia during an oxygen flush, no
vaporizer shall be placed in the circuit downstream of the oxygen flush
valve.
g) All anaesthesia vaporizers shall be pressure-compensated in order to
administer a constant non-pulsatile output.
h) Accurate flow meters and controllers shall be used to prevent the delivery to
a patient of an inadequate concentration of oxygen relative to the amount of
nitrous oxide or other medical gas.
i) Alarm systems shall be in place for high (disconnect), low (sub
atmospheric), and minimum ventilatory pressures in the breathing circuit
for each patient under general anaesthesia.
6.11.4.2 Anaesthesia supplies and equipment and patient monitoring shall include:
a) An in-circuit oxygen analyzer shall monitor the oxygen concentration within
the breathing circuit, displaying the percent oxygen of the total mixture, for
all patients receiving general anaesthesia.
b) A respirometer (volumeter) measuring exhaled tidal volume shall be used
whenever the breathing circuit of a patient under general anesthesia allows.
c) The capacity for invasive monitoring of arterial pressure shall exist within
the operating suite/ theatre.
d) A difficult airway container or trolley shall be immediately available in each
anesthesia department for handling emergencies. The following items are
required for inclusion in the difficult airway container or trolley:
 resuscitation equipment like ambu bag, laryngoscope, defibrillator,
laryngeal mask and endotracheal tube stylet,

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  emergency drugs,
 a laryngeal mask airway,
 and/or other items of similar technical capability.
e) A precordial stethoscope or oesophageal stethoscope shall be used when
indicated on each patient receiving anesthesia. If necessary, the stethoscope
may be positioned on the posterior chest wall or tracheal area.
f) A peripheral nerve stimulator shall be available in any anesthetizing location
in which patients receive general or regional anesthesia to monitor the
patient’s extent of muscle paralysis from muscle relaxants. Another
peripheral nerve stimulator shall be available within the post anaesthesia
care unit.
g) Supplemental oxygen and a delivery system appropriate to the patient's
condition shall be immediately available for patient transport from the
operating room to the post anesthesia care /recovery unit.
6.11.4.3 Equipments:
a) Time clock
b) Anesthesia machine with ventilator, 2 vaporizers, and gas cylinders
c) Adult and pediatric anesthesia circuits with filters
d) Mechanical ventilators
e) Oxygen cylinders, oxygen trolley and oxygen regulator
f) Worktable with laminated top
g) Resuscitation equipments; Ambu bag, adult pediatric neonates, with
inflatable bag,
h) Refrigerator,
i) Stools
j) Clips
k) Bathroom Weight scale; adult & pediatric
l) Resuscitation trolley
m) Syringe pump
n) Defibrillator
o) Blood gas analyzer (optional)
p) Dust bin
q) Blankets, warming

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r) Framed boards with pencil trays
s) IV stands, infusion pumps, IV fluid pressure bags, blood warmer and IV
fluid warmer
t) Tourniquets, tongue depressors, disposable
u) Operation table and accessories:
 Operating table, with minimum of smoothly adjustable 3 sections
 Pillows, abduction
 Support, head, operating table
 Positioner, bag, small
 Positioner, bag, medium
 Positioner, bag, large
 Adjustable Head screen
 Patient transferring Stretchers
 Suction machines
 Bottles - Suction - Glass/Plastic
v) Patient monitor
 ECG monitor
 12 leads Electrode, Monitor
 Pulse oximeter
 Temperature monitor
 Nerve stimulator
 Dual head stethoscope
 BP apparatus with different size cuffs
w) Intubation gadgets:
 Airway Guedel, pediatric & adult size
 Laryngeal mask set
 Mask holder
 Cannula - Nasal-Oxygen,
 Face mask- Oxygen,
 Masks – Oxygen 40 %
 Laryngoscope sets with different size blades (Mackintosh)

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 Magill forceps (adult & pediatrics)
 Intubation stylet, adult, 15 Ch,/ Endo-tracheal tube guide
 Mouth gauge
 Guedel airways: size 0, 00, 3, 4 & 5
 Tube, Endo-tracheal:
 disp. + connector, 3 mm, w/o balloon
 disp. + connector, 3.5 mm, w/o balloon
 disp. + connector, 4 mm, w/o balloon
 disp. + connector, 4.5 mm, w/o balloon
 disp. + connector, 5 mm, balloon
 disp. + connector, 5.5 mm, balloon
 disp. + connector, 6 mm, balloon
 disp. + connector, 6.5 mm, balloon
 disp. + connector, 7 mm, balloon
 disp. + connector, 7.5 mm, balloon
 disp. + connector, 8 mm, balloon
 disp. + connector, neonate mm, w.o balloon
 disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Tube:
 Trachea, balloon, int.can, ster, size 6
 Trachea, balloon, int.can, ster, size 8
 Suction,CH08,L50cm,ster,disp, CH08, CH10, CH14, CH16
 Extractor, mucus,20ml,ster,disp
 Safety Pins Large & Medium
 Connector, Biconical, Autoclavable
 Connector, T/Y
 Connectors - Plastic – Tapered
 Masks - Nebulizer/Oxygen
 Other accessories/ suppleis:
 Braun Splints (Arm)
 Drawsheet, plastic,90x180cm
 Clinical thermometer

159
  Fridge thermometer
 Tourniquet, latex rubber,75cm
6.11.4.4 All medicines and supplies shall be available as per the national drug list for this
level of hospital
6.11.4.5 Operating Room Linen:
a) Apron Surgical, rubber
b) Trousers, Surgical, woven; Small, Medium & Large
c) Top(shirts), Surgical, woven; Small, Medium & Large
d) Gown, Surgical, woven(Plain)
e) Caps, Surgical, woven
f) Masks, surgical, woven
g) Pillow case
h) Pillows
i) Sheet, Bed
j) Sheet, draw, white
k) Cellular Blanket
l) Organ protections,
m) Shelves
n) cabinets

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6.12 Intensive Care (IC) Services

6.12.1 Practices
6.12.1.1 The hospital shall have at least one intensive care unit comprising of medical-
surgical intensive care services
6.12.1.2 This intensive care unit may have the following additional intensive care sub-
units:

(a) Neonatal intensive care unit (NICU)

(b) Pediatric intensive care unit (PICU)
(c) Psychiatric Intensive Care Unit (PICU)
(d) Coronary Care Unit (CCU)
(e) Burn Wounds Intensive Care Unit (BWICU)
(f) Trauma Intensive care Unit (TICU)
(g) Respiratory Intensive Care Unit (RICU)
(h) Neuro-Intensive Care Unit (NICU)

6.12.1.3 The ICU is open 24 hours and 7 days a week, with available medical personnel
with CPR training available round the clock with shift.
6.12.1.4 The ICU shall have written policies and procedures that are reviewed at least
once every 5 years and implemented. They shall include at least:

(a) Criteria for admission to ICU,

(b) Criteria for discharge and transfer from the service to other patient care
units in the hospital;
(c) Criteria for transfer /discharge from the service to other health care
facilities;
(d) A list of procedures that licensed physicians, who are certified/
accredited in intensive care, may or may not perform;
(e) Protocols for transfer and transport of patients within the hospital or
from the hospital to another facility including who shall accompany the
patient being transferred or transported;

161
 (f) Infection control procedures and/or protocols as indicated under
infection prevention standards;
(g) A visitors policy that specifies visiting hours and number which subject
to the discretion of the patient's physician or primary care nurse;
(h) A policy on the removal of a patient's life support system;
(i) A policy defining the physician, specialist and consulting physician to be
called for patient emergencies, including a response time for physicians
to respond to patient emergencies;
(j) Standing orders for patient emergencies;
(k) Policies and procedures which ensure that priority laboratory services
will be available to critical care patients at all times if medically
indicated;
(l) Side laboratory with specific service to ICU shall be available 24 hours a
day throughout the year,

6.12.1.5 Roles and responsibilities of specialists in management of ICU patients shall be

available in written policy or protocol. All ICU patients shall be managed or co-
managed by a dedicated intensivist, trained internist or independent
practitioner who is exclusively responsible for patients in one ICU.
6.12.1.6 Nursing functions shall be the responsibility of a licensed nurse and shall be
accountable to the attending ICU physician,
6.12.1.7 Complete medical records shall be kept for each patient: pertinent history,
physical examination, diagnosis, diagnostic procedures, medication
administration, and treatment to facilitate continuity of care. And the patient’s
medical service record shall be integrated with the patient's over-all hospital
record,
6.12.1.8 A ratio of 2 patients to 1 nurse shall be available at a general ICU.
6.12.1.9 There shall be a means of promoting harmony between critical care providers
and families. This 5-part system, known by the mnemonic VALUE, includes:

(a) Valuing and appreciating what the family members communicate,

(b) Acknowledging their emotions by using reflective summary systems,
(c) Listening to family members,

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 (d) Understanding who the patient is as a person by asking open-ended
questions and listening carefully to the responses, and
(e) Eliciting questions from the family more effectively than by simply
asking “Any question?’’.

6.12.1.10 There shall be portable life-support equipment for use in patient transport, both
within the hospital and for transfer. All ventilators in use shall be equipped with
an integral minimum ventilation pressure (disconnect) alarm. There shall be a
system for obtaining immediate emergency replacement or repair of equipment
in the critical care service.
6.12.1.11 There shall be a policy or protocol available that state availability of 24 hours
access for the services of advanced diagnostic facilities like CT scan, EEG, and
other radiologic service for ICU admitted patients.
6.12.1.12 There shall be a system in the hospital of assuring the functionality of the ICU
gadgets/ equipments at least every 3 years and labeling for the check service.
6.12.1.13 There shall be a mechanism in place for the critical care service to have access to
nutritional support services for advice on both enteral and parenteral
nutritional techniques.
6.12.1.14 There shall be a program of continuous quality improvement for the ICU service
that is integrated into the hospital continuous quality improvement program
and includes regularly collecting and analyzing data to help identify health-
service problems and their extent, and recommending, implementing, and
monitoring corrective actions on the basis of these data.

6.12.2 Professionals
6.12.2.1 The hospital ICU shall be directed by a licensed anesthesiologist or intensivist or
ICU trained internist who has clinical responsibility for the standard of care
rendered in each critical care unit or combination of critical care units.
6.12.2.2 The specialist in each discipline shall be responsible for the management of
patients in specialized ICU (Example: thoracic surgeon- surgical ICU,
neonatologist- neonatology ICU and the likes).
6.12.2.3 Each specialized ICU shall be lead by the sub-specialists.
6.12.2.4 The physicians working in the ICU shall be certified in internal medicine,
anesthesia, surgery, neonatology or general practice and/or have completed a

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 formal training program in critical care approved by the licensing body in the
country. In the case of an ICU that provides one specialty area of critical care,
such as coronary care, neonatal care, the director of the unit shall be certified in
that particular specialty or subspecialty (e.g., cardiologist/ pediatrician
neonatologist/ obstetrician).
6.12.2.5 There shall be a licensed professional nurse with administrative responsibility
for the ICU or combination of units who is accountable for all critical care
nursing rendered in the unit or units.
6.12.2.6 The nursing staff of each unit within the ICU service shall have special training in
critical care nursing and certified by the Authority.
6.12.2.7 All practicing nurses in the ICU shall be trained and certified in basic cardiac life
support.
6.12.2.8 Nurse staffing shall be determined by the number and acuity of illness of the
patients (workload analysis) on the critical care unit.
6.12.2.9 Nurse assistants assigned to ICU shall be oriented and trained on basic cardiac
life support and critical care.
6.12.2.10 There shall be at least one licensed ICU nurse in the ICU for 24 hours a day and
365 days a year.
6.12.2.11 At least the following professionals are required:
a) One anesthesiologist or intensivist
b) At least one ICU trained nurse for two beds
c) Clinical nurse
d) Cleaners
e) Porters

6.12.3 Premises
6.12.3.1 The ICU shall be located in the hospital where the traffic is very restricted.
6.12.3.2 It shall be accessible and well identified.
6.12.3.3 ICU room: The size of the room depends on the number of ICU beds. The ICU
shall be at least 8m x 10m in size that accommodate a maximum of 4 electrically
or manually operated ICU patient beds fitted with full range of monitors and a
screen.
a) The header of beds shall be 1 m away from the wall

164
 b) There shall be a 2m wide free traffic area by side of beds and between any of
two beds.
c) There shall be a nurse station within the ICU having a computer and a
computer point, telephone and telephone point, cabinets and shelves, and
lockers for controlled drugs.
d) There should be a separate physical area devoted to nursing management
for the care of the intermediate patient (32 sq m area including nurse
station).
6.12.3.4 Nurse station in the ICU:
a) Isolated with glass, full visual access to monitor admitted patients on
monitors,
b) Equipped with chairs, working laminated top tables, drawers and
computers, Linen boards, shelves, lockers
c) Telemetry monitoring for critical or post operative patients with
transmitters,
d) Telephone end,
e) Medication boards, controlled drug locker,
f) Calculators,
g) Weight scale,
h) Ready to use CPR equipments with defibrillator on trolley,
i) Patient labeling for diet, allergy, etc.,
j) Patient screen per bed and
k) IV stands, at least 2 per bed,
6.12.3.5 The ICU shall have easily accessible hand wash basin around the entrance-exit
door.
6.12.3.6 In addition to the main ICU for critical care, the unit shall have the following
spaces (rooms): toilets, nurse room, utility room, store, duty room, cleaner’s
room, staff tea room, and spacious corridor for stretchers and wheelchairs.
6.12.3.7 Toilet: ICU shall have patient toilet and shower facilities.
6.12.3.8 The ICU shall be access to laboratory service, or it shall be equipped with side
lab, dedicated and open for 24 hours a day and 365 days a year.

165
6.12.3.9 Nurse locker room: There shall be an ICU staff locker room in proximity with the
ICU. The ICU area is generally regarded as a sterile zone and there shall be shoe
and cloth change point for staff and attending families.
6.12.3.10 ICU Utility/ Sluice room: There shall be soiled utility/sluice room which acts as a
storage area for contaminated materials until they are disposed off and
temporary station for equipments until disinfected and cleaned. The soiled
utility room shall have a deep bowel sink, a hand wash basin with hot and cold
water, plus cabinet and shelves.
6.12.3.11 Store room: There shall be an ICU supply room (store) at least 4m x 4m in size
used for storage of consumables and spare equipments. It shall be equipped
with cabinets and shelves. Materials shall be labeled, arranged in order, ready
for use (charged) and there shall be ventilation and enough light.
6.12.3.12 Cleaner’s room: There shall be an ICU cleaner’s / janitor’s room for an easy
access to cleaning equipments and materials or the ICU floor. If there is a mobile
cleaning service it can be optional.
6.12.3.13 Staff tea room (optional): There shall be a staff tea room in close proximity to
the ICU in order to ensure the availability of staff at all times and as rest room
for visitors.

6.12.4 Products
6.12.4.1 Medicines selected for ICU services by the hospital shall be available at all times.
6.12.4.2 The hospital ICU shall have the following equipment, instruments and system:
a) The ICU beds shall have removable side protections; functional wheels; shall
be easily adjustable to multipurpose positions
b) mechanical ventilator to assist breathing through an endotracheal tube or a
tracheotomy opening; at least 4; All ventilators shall be equipped with an
integral minimum ventilation pressure (disconnect) alarm.
c) Different size endotracheal tubes and tracheotomy sets, at least 4 sets,
d) monitoring equipment, equipment for the constant monitoring of bodily
functions;
e) cardiac monitors including telemetry,
f) Standard 12 lead EKG machines,
g) external pacemakers,

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h) defibrillators; at least 2,
i) Reliable Oxygen delivery systems: Oxygen cylinder or oxygen concentrator,
j) Oxygen regulator, at least 2
k) pulse oximeter,
l) end-tidal carbon dioxide monitoring,
m) Titrated therapeutic interventions with infusion pumps,
n) a web of intravenous lines for drug infusions fluids or total parenteral
nutrition,
o) Suction pumps,
p) Infusion pumps,
q) Laryngoscopes with different size blades,
r) Ophthalmoscope,
s) Mouth gags, different size
t) Air ways, different size
u) Resuscitation trolleys,
v) Exam coaches,
w) Syringe pump,
x) Endotracheal tubes ,(different sets)
y) Wheel chair,
z) Patient transport stretcher,
aa) Sphygmomanometer, with adult and pediatric cuffs,
bb) Sthethoscopes: pediatric and adult,
cc) Electrical suction machine (at least 1 as a backup),
dd) Pedal suction machine,
ee) Acid base analyzer, minimum two ventilators and a mobile x-ray
ff) Nasal CPAP,
gg) Bed pan, plenty in number, different size
hh) Pacing boxes (at least 2)
ii) X-ray viewer per bed, at least 4
jj) Wall clock (at least 2)
kk) Soiled cloth hampers,

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6.13 Dentistry Services

6.13.1 Practices
6.13.1.1 There shall be written protocols and procedures for the management of dental
conditions as well as consultation, referral and transfer of inpatients
/outpatients to other services inside/outside the hospital.
6.13.1.2 The dental service shall be provided in accordance with infection prevention
standards
6.13.1.3 Emergency care with a qualified staff shall be available 24 hours a day
6.13.1.4 Emergency oral and maxillofacial surgery services shall be available 24 hours a
day and 365 days a year. This includes:
a) Facial and dent alveolar infections (cellulitis)
b) Treatment for facial injuries and associated injuries
c) Lower or upper jaw fractures
d) Evaluation and treatment of nerve injury
e) Dental trauma
6.13.1.5 Non emergency oral and maxillofacial surgery services should be available during
the regular working hours. This includes:
a) Treatment for craniofacial and jaw deformities
b) Implants and preprosthetic surgery
c) Temporomandibular joint therapy
d) Facial cosmetic surgery
e) Surgery for oral pathological lesions, including oral cancer
f) Physical therapy for orofacial pain
g) Removal of malpositioned or impacted teeth
h) Surgery for cleft lip and palate (team work)
i) Apicectomia & Cystectomia etc.
6.13.1.6 Non emergency dental services shall be available during the regular working
hours. This includes:
a) Restorative
b) Prosthetic
c) Endodontic therapy
d) Periodontal therapy

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 e) Exodontias
f) Oral Community (Oral Health Education)
6.13.1.7 For admitted patients the dental service shall be organized in such a way that it
covers all the shifts.
6.13.1.8 Adequate dental records shall be kept for each patient and the patient’s dental
service record shall be integrated with the patient's over-all hospital record
6.13.1.9 Information contained in the dental record shall be complete and sufficiently
detailed with respect to the patient's history, physical examination, oral (Intra &
Extra) examination, diagnosis, diagnostic procedures, medication
administration, and treatment to facilitate continuity of care.
6.13.1.10 Informed Consent (written/verbal) shall be complete for every dental procedure
in addition to minor & major surgery

6.13.2 Premises
6.13.2.1 The dental service shall be located in the hospital facility
6.13.2.2 Premises for emergency services shall be available and open 24 hours a day and
365 days a year.
6.13.2.3 There shall be an in-patient service room for admission of surgical cases
6.13.2.4 There shall be a minimum of one room with two dental units or set ups for non
emergency dental services
6.13.2.5 The number and size of the rooms shall be adequate in relation to the volume and
nature of the activity in the service unit
6.13.2.6 There shall be a reception area which will serve as well for oral health education
6.13.2.7 There shall be a radiology room with the dental unit- laded door and lead apron.
The design of rooms for radiology related equipment should be in accordance
with the guidelines of Ethiopian Radiation Protection Authority.
6.13.2.8 There shall be a dental laboratory for orthodontics and prosthodontics.
6.13.2.9 In addition to the rooms mentioned above dental services shall have the following
rooms:
a) Sterilization area/ Store room /shelves
b) Duty room
c) Office for Dentists
d) Meeting hall

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 e) Nurse station
f) Store
g) Room for mini pharmacy
h) Staff toilets, showers and changing room
i) Patient toilet and shower
j) Places for air compressor and equipment for evacuation
k) Places for electric generator
6.13.2.10 Operation theatre (OR) shall be available or shall be organized with surgical
services including ICU & anaesthesia services.
6.13.3 Professionals
6.13.3.1 A licensed Dental Specialist shall be in charge of overall dental services
6.13.3.2 There shall be adequate qualified dental and auxiliary personnel in the dental
service unit available at all times to meet the service needs.
6.13.3.3 The number and type of technical staff shall be determined by the volume and
type of work carried out (Work load Analysis).
6.13.3.4 A Dental surgeon/doctor or licensed independent practitioner shall be available
(Physically present) at all times in the dental unit.
6.13.3.5 A senior Dental Specialist shall be on duty or on call at all times. The specialist
shall be able to present at the service unit within thirty (30) minutes upon call.
6.13.3.6 A licensed dental auxiliary (BDSc, Dental Therapist, Dental Tecnician, Dental
Hygienist & dental nurse ) shall be available at all times to assess, evaluate ,
and supervise the dental care provided. If the unit has no inpatients, the
licensed nurse shall be available on on-call basis within thirty (30) minutes.
6.13.3.7 The Dental nurse or auxiliary with administrative responsibility for dental care in
dentistry shall be a licensed dental professional with at least three years of
experience in dentistry.
6.13.3.8 Experience of General Dental Practitioners: A minimum of five years working
experience (excluding internships) under Government centers or any
recognized institutions would be required to maintain a High level of standard
and Quality services at the specialized hospital.
6.13.3.9 All practitioners shall be licensed prior to obtaining license. Only licensed
practitioners shall be allowed to practice in providing dental services.
6.13.3.10 There shall be adequate support staff available as per the service need

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6.13.3.11 There shall be a mechanism for exchange of scientific knowledge, skills and
services in line with upgrading standard of dental services
6.13.3.12 Professionals in dental service unit shall have good clinical and laboratory
practice.
6.13.4 Products
6.13.4.1 The dental services shall have the following equipment and instruments
a) The dental units
b) Instruments for examining
c) Plastic instruments for filling treatment
d) Materials & instruments to keep the area free from moistures & to improve
visibility
e) Dental hand pieces
f) Instruments for root canal treatment
g) Materials for root canal treatment
h) Rotating instruments & hand cutting instruments
i) Instrument for Oral Surgery
j) Forceps for Dental Extractions (Deciduous teeth)
k) Mandibular forceps for anterior & posterior teeth extraction
l) Right-angled forceps for mandibular Extraction
m) Maxillar Forceps for anterior & posterior teeth extraction
n) Forceps for Maxillary and mandibular root extraction
o) Orthodontics instrument
p) Periodontal instruments
q) Prosthodontics Instruments
r) Basic Dental Laboratory Equipments
s) Equipment for Radiology Department
 Dental X-ray unit
 Panoramic radiography
 Cephalometric radiolgrapy (Optional)
t) View box for radiography (Negatoscope)
u) Automatic film processing
v) Lead aprone

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 w) Equipments for sterilization
 Super heated steam under pressure (Autoclave)
 Dry heat sterilization (Oven)
 Ultrasonic cleaner system
 Cotton roll sterilizer
 Different pans use for disinfections & sterilization of instruments
x) Equipment used for amalgam restoration
y) Different operatory cabinets
6.13.4.2 The dental service shall have the following materials
a) Dental materials: Temporary & permanent fillings
b) Dental films (Periapical, occlusal & panoramic view)
c) Light curing unit with composite materials
d) Local anesthesia (Spray, Cartridge with & without adrenalin)
e) Other consumables (analgesics, disposable syringe & gloves etc)
Annex.
Type Unit Quantity
The dental units equipped
with:
Air-water syringes
Operating light
Saliva ejector (oral
evacuator system)
Cuspidor
Adjustable work surface
Individual hand-piece holder
Halogen cure light
Dental Chair
Operator’s stool
Assistant stool
Instruments for examining
Dental mirror

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Explorers (different types,
number 521,22,17
& number 23)
Cotton pliers
Spoon excavator (different
size)
Periodontal pocket probe
Instruments for filling
treatment
Condenser (serrated & plain,
Medium, and big
size)
Beaver tail
Burnisher (ball type, football
type, interproximal
type)
Carve (Hollenback,tanner,
ward, discoid-
cleoid).
Trimmers
KKnife (interproximal,
finishing gold foil)
Amalgam carriers (doubled
ended, guntype)
Matrix retainer (different
types tofflemire,
ziqueland)
Proximal trimmer
Plastic instruments for
filling treatment
Carriers for restorative
materials

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Carvers
Condenser Beaver tail
Materials & instruments to keep the area free from moistures & to
improve visibility
Rubber dam equipment
Clamps (different type,
posterior &
anterior,
mandibular &
maxillar)
Universal rubber-Dam
clamps forceps
Rubber- dam punch
Holder young frame
Automation
The dental units equipped with
Matrix band (metallic & 2 boxes
celluloid, different
size for molar &
bicuspid)
Aticulating paper 2 boxes
Wooden wedge 2 boxes
Paper pad 2 boxes
Glass slab
Dental floss
Dappen dishes
Finishing disc (various sizes
and grits)
Abrasive stones and dics
(green, white)
Brushes (prophylaxix type)
Rubber disc with abrasives

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Rubber disc with abrasives
Polishing pastes
Sand paper disc
Mortar and pestle
Kit for friction lock retention
pin
Spatula (various sizes and
shapes metallic,
plastic)
Rubber bowl
Sets of performed
temporary
stainless steel
crown
Sets or preformed
anatomical plastic
crown of
polycarbonate
resin
Scissors:
Hemostats (curved , straight
,mosquito, Kelly
needle holder)
Crow scissors
Ligature scissors
Surgical scissors
Dental hand pieces
Low speed hand pieces
Straight hand pieces
Contra angle hand pieces
High speed hand pieces
Polishing hand pieces unit

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Ultrasonic Scaler
Instruments for root canal
treatment
Endodontic probe
Straight and curved gutta
percha pluggers
Broach (smooth and barber
type)
Files ( Hedstrom files, K
types files, Rat-Tail
files
Disposable syringe
Gates Glidden drills
Spreaders
Lebtyki sourak
Millimeter ruler
Vitalometer (electrical pulp
tester)
Glass bead sterilizer
Endodontic measureing
Gauge
Materials for root canal
treatment
Paper points
Gutta percha points (From 1
to 6 and from 7 to
12)
Endodontic kits
Materials for root canal
treatment
Rotatory cutting
instruments:

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Burs (carbide, diamonds,
plain steel,
carborundum for
slow hand piece&
high hand piece
types)
Round burs (Number ½-11)
Pear- shape burs (230-232)
Inverted cone burs (31 ½-
44)
Taper fissure burs (169-171
plain, 699-703)
Round- end
Fissure burs
Flat-end fissure burs (957-
959)
Cylinder burs
Wheel burs (11 ½ -16)
End-cutting burs
Drills for pin retention
Flames burs (242-246)
Straight fissure (55 ½-62
plain,556-563
dentate)
Composites burs
Bud Burs (44 ½-51)
Oval burs (218-221)
Cone burs (22 ½ -33)
Other rotating instruments:
Mandrel (straight and latch
type)

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Carborundum, Silica, Crocus,
discs and stones
Hand cutting instruments:
Enamel Hatches
Enamel chisel
Discoid-cleoid
Dental Hoe
Gingival margin Trimmer
Angle former
Instrument for Oral Surgery:
Periosteoteme (Periosteal
elevator)
Root elevators
Surgical Kit (MFS)
Forceps for Dental
Extractions:
Maxillary forceps for anterior
teeth:
Forceps 99 A (Canine forceps)
Forceps 99 C (incisor forceps)
Forceps 150 (Universal
forceps)
Forceps 213 (incisor forceps)
Maxillary forceps for back
teeth
Forceps 18 right and left
Forceps 24 (universal forceps
for molar)
Forceps 210 (wisdom
forceps)
Mandibular forceps for
anterior teeth

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Forceps 103-(incisors
forceps)
Forceps 203 (incisor forceps)
Forceps 1519 universal
forceps)
Mandibular forceps for
posterior teeth:
Forceps 16 (1st molar forceps)
Forceps 23 (1st molar forceps)
Forceps 297 (2nd molar
forceps)
Forceps 222 (Wisdom
forceps)
Right-angled forceps for
mandibular
Extraction:
Mead 3 forceps
Mead 4 forceps
Forceps for Maxillary Root
Extraction:
Forceps 286
(Bayonet forceps)
Forceps for
mandibular root
Extractions:
Forceps 44
Forceps for
maxillary Root
Extractions
Upper frontal milk
forceps (forceps 1)

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Upper molar milk
forceps (forceps 8)
Lower frontal milk
forceps (forceps 4)
Lower molar molk
forceps (Forceps 5)
Root forceps
(Bayonet)-(forceps
2)
Other surgical
instruments
Curettes (Angled,
Straight, different
Sizes)
Rongeurs (Bone-
cutting forceps)
Bone-file
Scalped and Handle
for scalped
Cheek and Tongue
retractors
a) Farabeut
b) 3rd molar
retractors
Mouth props
Bone chisels
Mallets
Suture needles
Irrigation syringe
Aspirating tip

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Local anesthetic
equipment (metal
anesthesia syringe
Pliers flat nose and
serrated
Contouring pliers
(Number
112,114,118,800,417
Orthodontics
instrument
Band removing
pliers
Band pusher
Band adapter
How pliers (straight
and curved)
Bird-beak pliers
Ligature cutter
Distal end cutler
Band removing
pliers
Wire bending pliers-
Lingual arch forming
pliers
Loop pliers
Clasp bending pliers
TP pliers (110,130)
Assorted
orthodontics band
Preformed edgewise
arch wires/

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Periodontal
instruments
Scalers- different
types, sickle, Jaquete,
Chisel, Hoe, file
scaler
Curettes (Universal,
Gracey)
Periodontal knives:
a) Kirkland
b) Interdentally
c) Surgical Hoe
Periodontal pocket
marker
Electro surgery
apparatus with
different netting tips
Arkansas flat stones,
Electrical sharpener,
Mounted stones
Prosthodontics
Instruments:
Crown remover
Trays-(perforated,
rim lock, acrylic,
metallic, different
sizes, for the upper &
lower jaws)
Wax carvers
Porcelain carvers
Wax spatula
Acrylic stones

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Stones for gold alloy
Bunsen burner
Basic Dental
Laboratory
Equipments:
Model trimmer
Vibrator
Bench lathe
Vacuum Spatulator
Bench motor with
Hand piece
Casting unit
Arch articulator
Sep up & units for
heating & processing
dentures materials
Laboratory spatula
Coping saw
Laboratory Knife
Equipment for
Radiology
Department:
Dental X-ray unit
Intraoral X-rays
system
Extraoral X-rays
ststem
Panoramic
radiography
Cephalometric
radiolgrapy
View box for

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radiography
(Negatoscope)
Automatic film
processing
Equipments for
sterilization
Super heated steam
under pressure
(Autoclave)
Dry heat sterilization
(Oven)
Chemical autoclave-
Ultrasonic cleaner
system
Different pans use
for disinfections &
sterilization of
instruments
Cotton roll sterilizer
Equipment used for
amalgam
restoration:
Amalgam mixing
machine
(Amalgamatory)
Equipment used for
amalgam
restoration:
Electric spot welder
Different operatory
cabinets:
Mobile cabinets

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Fixed cabinet
Central Air
compressor
Simulation
laboratory
Manikin (Phantom)
for dental training
Typodont
Contra angle hand
pieces
Right angle hand
pieces
Dental chair
Operator stool
Assistant stool

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6.14 Otorhinolaryngology (ORL Services)

6.14.1 Practices
6.14.1.1 The ORL service shall have written policies and procedures
6.14.1.2 There shall be written protocols and procedures the management of the medical
conditions in the unit as well as consultation and transfer of patients admitted to
this unit or other departments
6.14.1.3 Every medical records shall be kept for each patient as specified in the medical
records of these standards
6.14.1.4 The ORL service shall be available 24 hours a day and 365 days a year
6.14.1.5 Infection prevention standards shall be implemented in the ORL service as per the
IP standards of these document
6.14.1.6 The ORL service shall include the following.
a) Daily outpatient services.
b) Minor and major surgical services.
c) Inpatient services
d) ORL diagnostic tests and procedures.
e) Post graduate training and research, optional
f) Pre operative investigations and Postoperative follow ups.
g) Outpatient and inpatient consultations from other departments.
h) ORL emergency services.
6.14.1.7 The service shall have access to laboratory, X-ray, CT – MRI, blood bank,
pharmacy, medical record and registry and other services.

6.14.2 Premises
6.14.2.1 The ORL service shall have the following units.
a) The outpatient service unit which shall be located adjacent to the general
OPD, or in a separate area. It shall include the following rooms
 Three examination rooms 60m2
 One office for the Dept head 12m2
 One office for secretarial services 10m2

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  Staff-room and teaching hall. 30 m2
 Waiting room for patients 30m2
 Nurses room 10m2
 Toilets for staff and for patients 15 m2
b) There shall be in patient service unit for ORL services including;
 Private and common toilet rooms 15 m2
 Nurses station 10 m2
 Reception area and mini store 15 m2
 One room for duty doctors 12 m2
c) Diagnostic unit shall have the following rooms
 One room for neurotology tests and procedures 20m2
 One room for endoscopy 12m2
d) The operation theatre: shall have the following rooms:
 One major OR 30 m2
 One minor OR 20 m2
6.14.2.2 In addition to the above rooms, the ORL service shall have changing room, the
resting room and share the recovery room, OR and the ICU with other services
of the hospital.

6.14.3 Professionals
6.14.3.1 The ORL service shall be directed by an licensed ENT specialist
6.14.3.2 Students and other staff on attachment shall work under the direct supervision of
licensed ENT specialist
6.14.3.3 ORL service staff shall, at all times, perform their functions with adherence to the
highest ethical and professional standards of the medical profession
6.14.3.4 The ORL service shall have and maintain job descriptions, including qualifications
to perform specific jobs.
6.14.3.5 The ORL service management shall provide adequate training, continuing
education or access to training for technical staff, and assess staff competency at
regular intervals. All these documents shall be filed.
6.14.3.6 The otorhinolaryngology services shall have the following professionals and
staffs.

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 a) A minimum of two licensed ORL specialists
b) One neurottologist or audiometrist (Optional).
c) Two GPs
d) Five OPD nurses
e) Three in-patient nurses.
f) Two OR nurses.
g) One porter
h) One secretary
i) Three cleaners
j) One runner.

6.14.4 Products
6.14.4.1 The ORL OPD shall have
a) Three ORL diagnostic unites each integrated with :
 Suction machine
 Compressed air system
 Warm water irrigation
 Cold light source, for endoscopes
 Instrument cabin
 Container for used instruments.
 One wall mounted OPD microscope
b) Three flexible patient chairs.
c) Three mobile doctors chairs
d) One sterilizer.
e) Three tables and three chairs.
f) Three X-ray viewers.
g) Three head lights
h) Tongue depressors
i) Rhinoscopes(nasal specula)
j) Otoscopes( ear specula)
k) Laryngeal mirrors
l) Tuning forks(250,500,1000,2000,4000,8000hzs)
m) Metallic suction tips

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 n) Aural forceps
o) Packing forceps
p) Minor surgical sets
q) Ear hooks
r) Nasal packing forceps
s) Biopsy forceps(Laryngeal, Nasopharyngeal)
6.14.4.2 The in-patient unit shall have,
a) 21 adult and 4 pediatric beds.
b) One bed for duty doctor
c) One cupboard to store drugs and materials.
d) Chairs and tables for the nurses post.
6.14.4.3 The OR shall have the following:
a) Major OR
 OR table for general anesthesia
 Ceiling lights as for General Surgery.
 Operating microscope ceiling mounted or mobile
 OR Table flexible in all sides, up - Down with Head Rest.
 Drug and instrument cup Boards
 Central oxygen and suction system if possible
 Separate suction
 Cautery machine
 Cold light source and head lights
 ENT OR Chairs (mobile)
 Anesthesia machines as desired by the anesthesia department.
 One Co2 laser machine (optional).
b) Minor OR
 OR Table for local anesthesia
 ENT OR Table with head rest.
 Light Source & head lights
 Cupboards for instruments and drugs
 Suction machine
 Cautery machine
 One Mobile chair

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  Easy access to general anesthesia when needed.
c) Other ORL Surgical Instrument Sets that includes:
 Myryngoplasty sets
 Typanoplasty sets
 Mastoidectomy sets
 Surgical drill and tips
 Otoplasty sets
 FESS sets
 Rhinoplasty sets
 Septoplasty sets
 Cald –wel- luc sets
 Nasal polyp sets
 Total laryngectomy sets
 Neck dissection sets
 Laryngoscopy sets(adult)
 Laryngoscopy set(pediatric)
 Laser laryngoscopy adult set(optional)
 Laser laryngoscopy pediatric set (optional)
 Tracheostomy sets
 Tracheostomy tubes metallic (weith inner canula)
 Tracheostomy tubes plastic( with inner canmula)
 Parotidecomy set
 Adeno-tonsillectomy sets
 Suture materials
 Esophagoscopy set
 Bronchoscopy set

6.14.4.4 The diagnostic unit shall have the followings:

a) Endoscopic room with video, video camera, 21 inch TV set, Stroboscope
etc.
b) Neurotology room with audiometry, tympanometry, brain evoked
response audiometry, (BERA), Sound, proof box, computer and printer.

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6.15 Ophthalmology Services

6.15.1 Practices
6.15.1.1 The Ophthalmology service shall have written policies and procedures including:
(a) Admission and discharge criteria specific to the service;
(b) Visitors policy
(c) Transfer and referral of patients
(d) Monitoring and follow-up of patients
6.15.1.2 The Ophthalmology Service shall be directed by a licensed ophthalmologist.
6.15.1.3 Emergency services shall be rendered 24 hours a day and 365 days a year.
6.15.1.4 For non-emergency cases the medical service shall be available during the regular
working hours.
6.15.1.5 Nursing functions shall be the responsibility of licensed nurses and shall be
supervised by ophthalmic nurse assigned by the licensed ophthalmologist.
6.15.1.6 Information contained in the medical record shall be complete and sufficiently
detailed relative to the patient's history, physical examination, diagnosis,
diagnostic procedures, medication administration, and treatment. Refer to the
medical record section of these standards.
6.15.1.7 For admitted patients the medical service shall be organized in a way that it
covers all the shifts (24 hours of the day and 365 days a year)
6.15.2 Premises

6.15.2.1 The ophthalmology service shall have outpatient service areas as specified below
(a) Registration room
(b) Waiting room with TV news paper and magazines and brochures about eye
disease
(c) Examination rooms
 Visual acuity: 2 rooms each having 6 m length or 3 m with mirror and
washing basin facilities
 Visual field room: one
 Keratometery and Ultrasound room: one

191
  Two rooms having Slit lamp biomicroscopy with washing basin
(d) Physicians room
(e) Nurses room
(f) Minor OR room with washing basin
(g) Administration staff rooms
(h) Sterilization room
(i) Laundry room
(j) Toilet room for staffs separate for male and female
(k) Toilet rooms for patients separate for male and female
(l) Library
6.15.2.2 The ward shall have the following service areas:
(a) The number of rooms and beds shall be determined depending on the
nature of the work to be performed.
(b) Admission room or nurse station: one
(c) Examination room for visual acuity testing with Slit lamp and Tonometry
shall have washing basin
(d) Patients’ room: one bed room having a size of 9m2 and in case of multiple
bed rooms’ there shall be 1.20 m clearance between the beds. Each room
shall have its own shower and toilet.
(e) Laser room
(f) Duty room for physician with washing basin shower and toilet
(g) Staff toilet /shower separate for female and male
6.15.2.3 The major operating theater of ophthalmology service shall have:
a) Patient’s preparation room
b) Changing room separate for both genders with lockers
c) Scrubbing room with two washing basins
d) Operation theater with swinging doors
e) Recovery room
f) Toilet
6.15.2.4 In addition to the above mentioned rooms the following facilities shall be
considered:
a) Meeting room;
b) Utility rooms;

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 c) Store;
d) Pharmacy

6.15.3 Professionals
6.15.3.1 The service shall be directed by a licensed ophthalmologist
6.15.3.2 There shall be qualified medical and nursing personnel for ophthalmology
services at all times
6.15.3.3 An ophthalmologist shall be available at all working hours and he/she shall be
also available on call at duty hours.
6.15.3.4 A licensed nurse shall be available at all times to assess, evaluate, and supervise
the nursing care provided.
6.15.3.5 Optometrist/refractionist shall be available on working hours
6.15.3.6 Anesthesiologist/nurse anesthetist shall be hired when ever the need arises
6.15.3.7 Ophthalmic nurse/OR nurse shall be available during working hours and on call at
duty hours
6.15.3.8 The service shall have supporting staff such as cleaners, guards and others

6.15.4 Products
6.15.4.1 The ophthalmology service shall have the following medicines, supplies and
functional equipment
a) Diagnostic Equipment/Instrument
 Slit lamp
 Trial set with trial frame (children and adult), Cross cylinder
 Slit lamp biomicroscopy with applanation tonometery
 Snellen test chart (Distance chart)
 Near point Acuity test card
 Color test (Ishara)
 Fundus camera (optional)
 Lang stereo test
 PD meter
 Retinoscopy
 Autorefractometer

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  Lensometer
 Prisma set /Prisma Bar (horizontal + vertical)
 Torch (light)
 Ophthalmoscope (direct and indirect)
 Aspheric funds lenses volk: 78 /90 dpt.
 Gonioscopy lens
 Three mirror Lens
 Lacrimal dilator and probe
 Probung set
 BP apparat
 Glucometer
 Ex Ophthalmometer (Hertel)
 Aplanation tonometer /Schiotz
 A-scan ultrasound
 B-scan ultrasound
 Others: Autoclave, Povidone Iodine, Alcohol 70 %, gloves of different size,
syringes, cotton, gauze, plaster and other commonly applicable
consumables
b) Diagnostic Medicines
 Phenynephrine
 Tropicamide eye drops
 Atropin drops
 Fluorescein strips /drops
 Cyclopentlate drops
 Tetracaine drops
c) Therapeutic Equipment/Instrument
 Laser (Diode /Argon, Nd YAG Laser-Neodymium: Yttruium-Aluminium-
garnet)
 OR microscope (2)
 Cataract set (6)
 Glaucoma OP set (4)

194
  Tarsotomy set (6)
 Chalazion set (2)
 Enuclation set (2)
 Strabismus set (2)
 Keratome set,
 Crescent set
 Bucking set
 DCR set (2)
 IOL (both Posterior chamber and anterior chamber lenses of different
diopters)
 Suture different size (3.0, 4.0, 9.0, 10.0)
 Viscoelastic
 Eye pad
 Ringer, saline
 Ambu bag and oxygen cylinder
 Patient cardio-respiratory monitor
d) Therapeutic Medicines
 Lidocain injection
 Tropicamide eye drops
 Acetazolamide injection
 Acetazolamide tab.
 Pilocarpin drops /injection
 Atropin drops
 Steroide drops /injection
 Antibiotics drops /ointments /injection
 Anti pain
 Alcohol 96 %
 Hyperosmotic agents (glycerol, manitol)
 Antimetabolite (5-flurouracil and mitomycin)
 Non steroidal anti inflammatory (tabs. Injections and drops)
6.15.4.2 The inpatient service shall have the following supplies and facilities

195
 a) Beds with toilet
b) Ambu bag and oxygen cylinder
6.15.4.3 The service shall have at least a general follow-up clinic that shall have the
following supplies and functional equipments:
a) One examination bed
b) Slit lamp biomicroscopy
c) Tonometer
6.15.4.4 Both emergency and non-emergency drugs and supplies shall be available in line
with essential drug list of the hospital

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6.16 Mental Health Care Services

6.16.1 Practices
6.16.1.1 Psychiatric patients shall receive all medical, surgical, diagnostic and treatment
services as ordered by a physician.
6.16.1.2 There shall be written protocols and procedures for the management of the
psychiatric conditions in the hospital
6.16.1.3 There shall be written SOPs regarding the admission, consultation, discharge,
transfer and follow-up of psychiatric patients
6.16.1.4 There shall be psychiatry emergency service for 24 hours
6.16.1.5 There shall be psychiatry follow-up service during working hours
6.16.1.6 There shall be pharmacotherapy and ECT services in the hospital
6.16.1.7 There shall be a dedicated out patient service for mental health services
6.16.1.8 The psychiatric team shall be responsible wherever the psychiatric patient is
referred and treated for other medical illnesses within the hospital
6.16.1.9 Psychiatric service shall have written policies and procedures that shall include
(a) Admission and discharge criteria specific to the service;
(b) Visitors policy that allows for 24 hour visitation by designated visitors
specifying the number of visitors permitted for each patient at any time
(c) Infection control specified under these standards and National and or
Hospital IP guideline
(d) Transfer and referral of patients
(e) Monitoring and follow-up of patients
6.16.1.10 Inpatient service shall be there in-line with inpatient standards.
6.16.1.11 The following services shall be available as part of the program of the psychiatric
care unit;
(a) Individual, group and family therapy;
(b) Rehabilitative services;
(c) Psychological services and
(d) Recreational therapy

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6.16.1.12 A social worker shall complete a psychosocial assessment for each patient which
includes at least:
(a) Identified problems;
(b) Social and family history;
(c) Educational and employment history;
(d) Financial status; and
(e) Present living arrangements.
6.16.1.13 Psychiatric evaluation shall be documented in the medical record and shall
include at least:
(a) The chief complaint;
(b) A history of present illness;
(c) A family history;
(d) A pertinent medical history including previous reactions to psychotropic
medications;
(e) A mental status and;
(f) A diagnostic impression
6.16.1.14 An individual, comprehensive, multidisciplinary care plan shall be developed for
each patient based on an assessment of the patients’ strength and limitations.
The written care plan shall include at least:
 A psychiatric diagnosis specifying undercurrent diseases.
 Observable treatment goals
 The specific treatment methods to be used and;
 The responsibilities of each member of the interdisciplinary care team.
6.16.1.15 Nursing functions shall be the responsibility of licensed psychiatric nurses and
other mental health workers (e.g. psychiatric nurses with BSc or MSc level
training) and shall be supervised by an experienced nurse assigned by the
licensed psychiatrist. Nurses practicing in the psychiatric service department or
unit shall be accountable to licensed psychiatrist
6.16.1.16 The multidisciplinary care plan shall be discussed with the patient and/or the
patient’s next of kin and implemented.
6.16.1.17 Written discharge plan shall be developed for each patient by the members of a
multidisciplinary team, who either meet or make notes individually in the
patient’s record.

198
6.16.1.18 There shall be Infection control practices for the day/dining room, equipment and
rooms used by more than one patient based on the hospital/health facility-wide
infection control policies and procedures manual.
6.16.1.19 There shall be Safety and security precautions for the prevention of suicide,
assault, elopement and patient injury.
6.16.1.20 Emergency procedures shall be for medical and psychiatric emergencies.
6.16.1.21 There shall be mechanisms for providing immediate security assistance to staff
and patients.
6.16.1.22 Patients shall be advised of the reasons for, and expected effects of, medications
prescribed for them.
6.16.1.23 There shall be a milieu program that includes patient community meetings and
daily activities.
6.16.1.24 Every medical record relevant to psychiatric illness shall be kept for each
patient as specified in the medical records section of these standards
6.16.1.25 An accurate schedule of activities shall be posted conspicuously in the unit.
6.16.1.26 Authorized security personnel shall have immediate access to locked units.
6.16.1.27 There shall be a system for summoning help from other areas of the unit in an
emergency.
6.16.1.28 Disturbed Children and Adolescents shall have access to clinical or general
psychological, and clinical or general social works service in addition to
psychiatric service every day including emergency service that takes
consideration age specific psychiatric conditions among this age group and
psychosocial crisis.
6.16.1.29 The hospital shall have addictive substances’ detoxification, treatment,
rehabilitation services specific to the problem and shall have access to
psychiatric, clinical or general psychological, and clinical or general social works
service every day

6.16.1.30 There shall be substance abuse care and follow up service

6.16.1.31 There shall be a pediatric and adolescent psychiatric care and service
6.16.1.32 There shall be a system for clinical staff to refer patients directly to the social
works unit.

6.16.2 Premises

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6.16.2.1 A private setting shall be available for interviewing patients.
6.16.2.2 The unit shall have access to at least one acute care/seclusion room.
6.16.2.3 Acute care/seclusion rooms shall be at least 9 square meters and shall be large
enough to provide access to the patient from all sides of the bed or mattress and
have room for emergency life-sustaining equipment.
6.16.2.4 Patients in acute care/seclusion rooms shall be either under direct observation in
a room near the nurses’ station.
6.16.2.5 There shall be psychiatric ward
6.16.2.6 There shall be an Electro Convulsive Therapy procedure room with instruments
and materials needed together with documentation forms and documentation
book and a cupboard for bed sheets and mattresses with pillows the equipment
6.16.2.7 The psychiatric emergency room(s) shall have additional doors through which
escape is possible for mental health professional working there in the case of
imminent assault by acutely disturbed violent patient. Restraint of such patients
shall be carried out by trained paramedical staff so that emergency medication
shall be possible
6.16.2.8 The unit shall have a day room/dining room that allows for social interaction,
dining, and therapy.
6.16.2.9 Opportunities to participate in Space for structured physical exercise programs
shall be made available to patients.
6.16.2.10 There shall be space in each patient room for storage of patient’s personal
belongings. There shall be a system for securing patient’s valuable belongings.
6.16.2.11 The outpatient layout shall include the following:

a) Waiting area of the psychiatric wing: room /lobby

with public telephone, TV area, drinking tap water, and gender specific
toilets

b) Reception and Recording area/desk

c) Dedicated patient examination rooms

d) Room for providing injections

e) Storage place for sterile supplies

200
 f) Utility room for cleaning and holding used equipments and disposing
patients specimen

g) Staff room (for changing cloth)

h) Janitors closet

6.16.2.12 The psychiatric service unit shall have a isolation room for treatment of conditions
that require isolation for inpatients (e. g., active open TB)
6.16.2.13 Patients in acute care shall be under direct observation in a room near the nurses’
station.

6.16.3 Professionals
6.16.3.1 The Psychiatric service shall be directed by licensed psychiatrists. A psychiatrist
or licensed independent practitioner shall be on duty or on call at all times
6.16.3.2 A psychiatrist or licensed independent practitioner shall be responsible for the
follow-up clinics.
6.16.3.3 The number, type and skills of clinicians and support staff shall ensure that
patients are appropriately treated and cared for at all times.
6.16.3.4 A licensed psychiatric nurse shall be available at all times to assess, evaluate,
and supervise the nursing care provided

a) The presence of a psychiatrist and a licensed psychiatric nurse or mental

health officer in the care unit:
 Licensed psychiatrist shall supervise the overall clinical psychiatric care
services and is responsible for the direction and quality of care provided
by the medical staff.
 Clinical psychologist or General psychologist with exposure to clinical
medicine in hospital for one year shall be available
 Nursing on the psychiatrist care unit shall be directed by a licensed
professional nurse with at least 3 years of clinical psychiatric experience.
 Nurse staffing shall be based on hospital/health facility acuity levels but
at least 2 nursing staff members, one of whom is a licensed professional
nurse with clinical psychiatric experience, be on the unit.

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  A social worker assigned to the inpatient psychiatric unit shall be with
recognizable national or licensed international qualification, at least 1
year experience in social work or mental health.
 The care coordinator shall be appointed from staff on duty
 Roles and responsibilities shall be written down in job descriptions
/procedures/ protocols.
b) Patients shall receive treatment and care from appropriately trained staff.
 Multi-professional teams are jointly trained to optimize multi-
professional teams working.
 Staffs have access to and take up training in risk assessment, tailored to
individual staff needs.
 Staffs receive at least a minimum of annual training updates.
 The use of clinical policies and guidelines documents are included in
training programs.
 Staffs receive training on the prevention management of aggression and
techniques to defuse potential volatile situations.
 Clinical staffs are trained in resuscitation procedures.
 Staff induction and ongoing training makes references to professional
regulation and accountability.
6.16.4 Products
6.16.4.1 The restraint equipment needed by the unit shall be immediately available on the
unit and accessible to unit staff.
6.16.4.2 All medicines to this level of hospital shall be available at all times
6.16.4.3 Recreational and therapy equipment and supplies needed for psychiatric care
shall be available on the unit and stored in locked storage.
6.16.4.4 The psychiatric OPD shall have the following supplies and functional equipment in
addition to office furniture’s
a) Torch,
b) Weighing scales for adults and/or children
c) thermometer
d) Stethoscopes
e) Sphygmomanometer
f) Examination couch

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 g) Vaccutainer needles with stand for blood drawing for laboratory
investigation
h) Hand washing basin
i) Emergency ECT access when inpatient treatment is not possible
j) Spatula, disposable gloves, cotton, gauze
k) Prescription, certificate, and appropriate referral forms, request forms for
laboratory, X-ray and other imaging investigations
6.16.3.11. The inpatient service shall have the following supplies and functional
equipments
a) ECT machine, gags, electrode application rubbers, electrodes, gel for
electrode placement
b) Torch,
c) Weighing scales
d) Tape meter, thermometer, patella hammer
e) Stethoscopes and Sphygmomanometer
f) Examination couch, medicine trolley, Cup board
g) EKG machine,
h) Computerized EEG mach with at least 18 channels
i) Suction machine
j) Drip counters/Infusion pump, Tourniquets and IV stands
k) Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
l) Self inflating bags for respiratory support, Masks, endotracheal tubes,
m) Cannulas, Nasogastric tube
n) Beds for patients and hand washing basin
o) Glucometer
6.16.4.5 The service shall have at least a general follow-up clinic that shall have the
following supplies and functional equipments:-
a) Weighing scales
b) Tape meter (optional), thermometer, patella hammer
c) Stethoscopes and Sphygmomanometer
d) Examination couch
e) Gauzes, Vaccutainer needles with appropriate stands for blood
drawing

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 f) Disposable rubber gloves
g) partitioned spaces for Injection
h) hand Washing basin
6.16.4.6 Locked storage areas shall be available for supplies and the safekeeping of the
individual, ongoing projects of patients.
6.16.4.7 Psychotropic medications and other drugs shall be available in line with the
hospital drug list.

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6.17 Dermatology Services

6.17.1 Practices
6.17.1.1 Dermatological services shall be available for 24 hours a day and 365 days a year.
6.17.1.2 There shall be written procedures and time set for referral, appointment, care,
management and ward rounds of urgent and non-urgent patients.
6.17.1.3 There shall be an agreed definition of a day case and recognition of the time
required to perform the various surgical procedures.
6.17.1.4 When a patient is discharged from inpatient and/or outpatient care, the GPIS (GPs
with special interest in dermatology and get special training in dermatology for
minimum of 3 month) shall be informed. Advice on further management,
including follow-up shall be documented on patient card
6.17.1.5 Contracts shall incorporate protocols for referral and for shared care.
6.17.1.6 Time shall be available for the doctor to read referrals, to review and act on
results, and to dictate letters, as well as to spend sufficient time with patients
and their families as part of the consultation.
6.17.1.7 Clear referral guidelines shall be in place. These clearly indicate how and where
skin conditions should be managed. (right person, right place)
6.17.1.8 There shall be regular training/teaching of the non-dermatology ward staff to
ensure they have insight into what constitutes good nursing care of patients
with severe skin disease
6.17.1.9 The dermatologist who is responsible to direct/coordinate the service shall
ensure that there is full medical cover for inpatients at all times.
6.17.1.10 There shall be a system for the handover of clinical problems when other
dermatologists take over the care of patients (duty, weekends, leave, etc).
6.17.1.11 Dermatologists shall ensure that protocols are in place to ensure the safe and
appropriate delivery of outpatient therapy, which is usually delivered by other
members of the multi-professional team.
6.17.1.12 There shall be a system in place to ensure that the dermatologist is consulted
when there is any problem that needs his/her expertise.

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6.17.1.13 Thorough, contemporaneous records shall be kept and systems be in place to
ensure continuity of care when patients are transferred between assessment
and admission units or from other wards and hospitals.
6.17.1.14 Dermatologists shall give patients information in a way they can understand and
ensure that patients give informed consent to their clinical care
6.17.1.15 There shall be a protocol/policy in the hospital that states critical conditions
which need urgent response/intervention like suspected melanoma or
squamous cell carcinoma.
6.17.1.16 There shall be a teamwork involving other disciplines when necessary.
6.17.1.17 The outpatient services shall have:
(a) Occupational skin disease clinic
(b) Photo dermatology clinic
(c) Specialized skin cancer/pigmented lesion (dermato- oncology clinic)
(d) Allergy clinic with side laboratory
(e) Venerology/STI clinic
(f) Paediatric dermatology clinic(eg. atopic eczema)
(g) Electrocautery
(h) Cryotherapy
6.17.1.18 The outpatient services may have:
(a) Photodynamic therapy
(b) Specialist clinics in psoriasis, eczema, Vitiligo, Fungal infections, leprosy,
cutaneous leishmaniasis, leg ulcers, connective tissue disease,
lymphoedema, psychosomatic disorders and others - depending upon
available expertise and population.
(c) Teledermatology support for a managed clinical network
(d) Iontophoresis
(e) Botulinum toxin (example: palmar, plantar and axillary hyperhydrosis )
(f) Dermatoscopy
(g) Dermojet (for intralesional administration of drugs)

6.17.1.19 The inpatient services shall have:

a) A 24 hours admission services

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 b) Admission, treatment and discharge criteria for patients requiring such
facilities which includes
 generalized skin failure (eg erythroderma of different causes),
 severe drug eruptions( eg Stevens-Johnson syndrome and TEN)
 severe blistering disorders (eg immunobullous diseases),
 Leprosy reactions and diffuse cutaneous leishmaniasis
 Acute neutrophilic dermatoses (eg pyoderma gangrenosum, sweet
syndrome amongst others.
6.17.1.20 Dermatologic interventions shall be rendered by licensed dermatologists or
trainee physician or medical student under the direct supervision of the
dermatologist.
6.17.1.21 Students and other staff on attachment shall work under the direct supervision of
the dermatologist. Dermatologists shall ensure that these staff are adequately
trained to carry out surgical or other therapeutic procedures
6.17.1.22 There shall be a mechanism that ensures 24 hours access to specialized services
provided by dermatologists on call basis
6.17.1.23 There shall be cooperation with the pharmacy services to have access for the
preparation of topical medicaments and allergens for contact allergy testing.
6.17.1.24 The phototherapy units may
(a) deliver narrowband UVB (TL 01),BBUVB,UVA1 and PUVA (psoralen plus
UVA) light treatment
(b) be supervised by a named consultant thus ensuring accuracy of dosimetry,
record keeping and the training and monitoring of the staff who administer
treatment
(c) have a yearly evaluations and calibrations of the output of each unit by
medical physicist .
6.17.1.25 The LASER unit may
(a) be supervised by a named consultant thus ensuring accuracy of Lasers
irradance dose and time for specific disorders .
(b) be calibrated and evaluated by medical physicist annually

6.17.2 Premises

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6.17.2.1 The hospital shall have patient friendly (maintains privacy, handicapped,
illuminated) premises
6.17.2.2 The hospital shall have adequate rooms and facilities needed for routine and
emergency outpatients, skin cancers, day treatment, wound care including leg
ulcer management, dermatological surgery, contact allergy testing,
phototherapy, cryosurgery, electrocautery treatment and patient education.
6.17.2.3 There shall be well shaded patient waiting area
6.17.2.4 Specialized service facilities shall be installed with physical proximity to
inpatient and outpatient facilities.
6.17.2.5 The hospital may have accommodation within a paediatric service unit for
paediatric dermatology clinics and the outpatient treatment of children.
6.17.2.6 The dermatological services shall have the following units:
(a) Outpatient units (for detail refer outpatient standards)
(b) Surgical units
(c) Phototherapy units, optional
(d) LASER unit, optional
(e) Inpatient units (for detail refer inpatient standards)
(f) Dermato-histopathology and immuno-pathology unit, optional
(g) Laboratory unit (eg. to perform dermatologic and STI diagnostic tests,
culture and serologic test)
6.17.2.7 Outpatient units shall have a dedicated outpatient area with consultation and
examination rooms large enough for patients and their accompanying persons
with the following requirements
a) Examination room :
 Two adjacent communicating rooms per doctor
 Patient undressing room
 Hand wash basin
 External wall fitted with laminated glass above 1.8 meters high
 Space for cautery machine,
 Space for cryotherapy machine,
 Phototherapy unit including UVB and UVA panel(phototest,
photopatch test, etc), optional
 Natural lighting and additional lighting

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  wound dressing area
 Treatment rooms with facilities for adults and children
b) Waiting area (room or shaded area)
c) Side Laboratory with facilities for contact allergy testing (Patch testing, prick
tests) including appropriate storage for allergens, optional
d) Separate room for Medical photography services, optional
e) Special room for Wood lamp

6.17.2.8 The surgical units shall have the following requirements:

a) Well-lit operating and ventilated rooms with couches.
b) Access to latex free facilities.
c) Facilities for freezing biopsies and storing frozen samples, optional
d) Laser-safe areas where required
e) Facilities for Mohs surgery, eg specialist micrographic surgery, cryostat and
histopathology equipment in some specialist units, optional
6.17.2.9 LASER units may be equipped and confer different wavelength laser for different
skin disease that are amenable to laser treatment.
6.17.2.10 The inpatient service unit shall have:
a) Two dedicated dermatological beds per 100,000 populations, but a
minimum of eight beds may be necessary to support appropriate staffing for
a self-contained unit.
b) Proximity to the outpatient unit and staff may be able to operate flexibly
between the two.
c) Dedicated dermatology beds for adults in internal medicine ward and
children in pediatric ward.
d) At least one bed in a side room, with provision for isolation and
photoprotection.
e) Adjacent bathing and showering facilities.
f) A treatment area.
6.17.2.11 Dermatology offices shall include:
a) One dermatologist’s office
b) One GPIS room /GPIS
c) One nurses room

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 d) One support staff room

6.17.3 Professionals
6.17.3.1 The dermatologic services shall be directed by experienced dermatologist who
shall be licensed by the Authority
6.17.3.2 The phototherapy units may be staffed by dermatological nurses who can provide
skin care, rather than physiotherapists
6.17.3.3 LASER units may be staffed by cosmetology trained technicians
6.17.3.4 The following professionals shall be available:
a) Dermato-venereologist
b) Experienced/ specialist dermatology nurses
c) GPIS
d) Supportive staffs
6.17.3.5 In addition to professional stated under article 6.18.3.4, the following
professionals may be required
a) Sub-Specialists in dermatopathology, photodermatology,
dermatosurgery, tropical dermatology, etc
b) Medical physicist,
c) Cosmetology technician,
d) Pharmacist,
e) Medical immunologist,

6.17.4 Products
6.17.4.1 The following products shall be available to provide dermatological services
a) Dermatology examination kit
b) Examination lamp
c) Cautery machine,
d) Cryotherapy machine,
e) Wood lamp
f) Dermojet,
g) Dermatoscope,
h) Magnifying glass
i) Laser machine

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j) Specula
k) Punch biopsy set and minor set
l) Phlebotomy set and others
m) Examination couches.
n) Surgical packs of appropriate instruments
o) Equipment for electrocautery, ( diathermy and hyfrecation)
p) Equipment for cryosurgery and storage for liquid nitrogen
q) PUVA (1,3,5 Trimethoxy Psoralen, UV-A)
r) Radiation monitoring equipment

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6.18 Cardiac Services

6.18.1 Practices
6.18.1.1 Outpatient services

(a) Emergency services listed below shall be available 24 hours a day and 365 days a
year.
 Resuscitation of patients with sudden cardiac events like cardiac arrest
and malignant ventricular arrhythmia.
 Treatment, including defibrillation or cardioversion for patients with
sudden life threatening rhythm disturbances
 Resuscitation of patients with cardiogenic shock and severe hemodynamic
instability
 Resuscitation of newborns with life threatening congenital heart disease.
 Resuscitation and management of sudden cardiac arrest in children with
congenital or acquired cardiac lesions.
(b) Regular outpatient service listed below shall be available during working hours.
 Acceptance and evaluation of patients with heart diseases
 Follow-up care for patients on whom cardiac surgery or interventional
catheterization has been performed
 Follow-up of patients on whom medical or conservative management has
been decided
(c) Stress testing
(d) Echocardiography

6.18.1.2 Clinical Ward: The following clinical ward services shall be available for 24
hours a day and 365 days a year

(a) Admission of patients on emergency basis for care and management of cardiac
related conditions
(b) Admission of patients for cardiac surgery or interventional catheterization
purposes
(c) Transfer of patients from ICU after cardiac surgery or interventional procedure

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6.18.1.3 ICU: The following Intensive Care Unit (ICU) services shall be available for 24
hours a day and 365 days a year

(a) Care of patients with acute life threatening cardiac conditions like
myocardial infarction, malignant arrhythmias, acute heart failure,
pulmonary thromboebolism and others.
(b) Care of patients after cardiac surgery or interventional procedures
(c) Care of critical cardiac patients before or long after cardiac surgery or
interventional procedure

6.18.1.4 Operating Theatre: Operation Room (OR) – Standard cardiac surgery facility is
mandatory for any center established to provide cardiac surgery, while a cardiac
catheterization facility is optional. This shall include:

(a) Open heart surgery for patients with acquired or congenital cardiac diseases
(b) Closed heart operations for different types of heart diseases in a child or an
adult
(c) Insertion of chest tubes, drainage of pericardial effusions, insertion of
permanent pacemakers etc.

6.18.1.5 Catheterization Laboratory – is mandatory for cardiac centers established to

provide invasive coronary treatment, while a cardiac surgery facility is optional.
This shall include one or more of but not limited to:

(a) Diagnostic cardiac catheterization for purpose of cardiac anatomy and

function
(b) Interventional cardiac catheterization for coronary angiography and
Percutaneous Coronary Intervention (PCI)
(c) Interventional cardiac catheterization for different types of congenital and
acquired heart diseases
(d) Cardiac catheterization for the purpose of electrophysiological studies and
transcatheter radiofrequency ablation.

6.18.2 Premises
6.18.2.1 Out Patient: The outpatient service shall have the following space with specified
requirements

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 (a) The regular outpatient area
 The room shall have adequate space (at least 20 square meters wide with
good lighting and ventilation windows).
 It shall be provided with a working laminated top table, at least three
chairs and a hand washing sink plus a hand maneuvered patient
examination coach.
 Outside the outpatient room there shall be a patient waiting area
equipped with chairs accommodating at least 10 patients at a time.
(b) The emergency resuscitation room
 The emergency resuscitation room shall at least be 50 sq.m square meters
wide with a good lighting and ventilation windows.
 There shall at least be two resuscitation coaches, cupboards and shelves, a
wheelchair and patient transporter.
(c) Stress testing room:
 The size of the room shall be at least 4 x 5m wide with good lighting and
ventilation.
 There shall be a Treadmill or a bicycle ergo meter, the stress test
recording panel and at least a chair.
 There shall be a resuscitation trolley and a defibrillator available for
immediate use.

6.18.2.2 Wards: The clinical wards shall fulfill the followings:

(a) At least ten beds with no more than two beds in one room.
(b) Each room shall be at least 20 m2 wide with a distance of not less than two
meters between the two beds.
(c) There shall be staff toilet, shower and changing facilities
(d) Nursing stations with telephone and telephone terminals, computer and
computer points, chairs and working laminated top tables.
(e) Patient toilet and shower facilities.
(f) Clean utility room used for storage of supplies both clean and sterile
consumables and linen, preparing and storing dressing trolleys, the storage,
preparation and assembly of items or equipment for diagnostic and
therapeutic procedures

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6.18.2.3 Intensive Care Unit:

(a) The cardiac ICU shall be at least 15m x 10m in size and shall accommodate
at least 6 electrically operated patient beds fitted with full range of monitors
and a screen, better with a central monitor.
(b) There shall be a distance of at least one and half meters between any of two
beds.
(c) There shall be a nurse station within the ICU having a computer and a
computer point, telephone and telephone point, cabinets and shelves, and
lockers for controlled drugs.
(d) There shall be patient toilet and shower facilities, and hand wash sink. There
shall be an ICU staff locker room in proximity with the ICU.
(e) The ICU area is generally regarded as a sterile zone and there shall be shoe
and cloth change point for families and staff.
(f) There shall be soiled utility/sluice room which acts as a storage area for
contaminated materials until they are disposed off as well as disinfecting
and cleaning of contaminated equipments.
(g) There shall be an ICU supply room at least 4m x 4m in size used for storage
of consumables and spare equipments and shall be equipped with cabinets
and shelves.
(h) There shall be an ICU cleaner’s / janitor’s room for an easy access to
cleaning equipments and materials or the ICU floor.

6.18.2.4 Operating Theatre: The operating zone shall be sterile and demarcations shall
be clear beyond which one cannot cross without scrub shoes on. The operating
area shall consist of the operating theatre, scrub room, the heart lung machine
supply room, the OR supply room, the staff locker rooms, and a soiled
utility/sluice room with the following requirements:

(a) The theatre room:

 The theatre room size shall at least be 9m x 7m wide and shall
accommodate all the equipments mentioned under the section ‘OR
equipments’.

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  There shall be enough space for the surgical team (surgeon, surgeon
assistant, anesthetist, Transesophageal echocardiographer, perfusionist,
theatre nurse and circulating nurse).
(b) The scrub room:
 The scrub room shall be in close proximity with the theatre room and no
more than one door crossed after scrubbing.
 The room size shall at least be 4 x 2 m.
 The scrub room shall be able to accommodate at least two professionals
scrubbing simultaneously.
(c) The OR supply room:
 The OR supply room shall be in proximity / continuity with the theatre
room and is used for storage of consumable and small sized equipments
for all theatre, anesthesia and perfusion purposes.
 There shall be separate staff locker rooms for ladies and gentlemen used
for staff changing facilities, placement of scrub suits and scrub shoes.
 There shall be separate staff toilets and shower facilities for ladies and
gentlemen in proximity with the locker rooms.
(d) Staff locker rooms:
 There shall be separate locker rooms for ladies and gentlemen located in
proximity with the procedure room.
 There shall be toilet, shower facilities and hand wash sinks either in or in
proximity with the locker rooms.
(e) Soiled utility / sluice rooms:
 The room shall be at least 4m x 3m in size shall have the facility for
storage of contaminated materials until they are disposed off as well as
cleaning of contaminated equipments.
 There shall be adequate supply of clean gloves and heavy duty gloves for
those working in the soiled utility area.

6.18.2.5 CAT Lab: The diagnostic and interventional cardiac catheterization laboratory
shall consist of the cath room itself, the control room, the scrub room and the
cath lab supply room.

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(a) Cath room / procedure room:
 The procedure room shall be at least 36 sq. m and accommodate all the
equipments mentioned under ‘cath lab equipments’.
 There shall be enough space for the operator, assistant operator, scrub
nurse, circulating nurse, anesthetist, sonographer and the X – ray
technologist.
 There shall be catheter hangers on the wall with in the procedure room
itself.
 The doors and wall of the procedure room shall be leaded or the wall
thickness shall be appropriately thick to reduce radiation hazards to the
surrounding area and the radiation safety shall be approved by the
Ethiopian Radiation Protection Authority.
(b) The control room:
 The size shall at least be 12 m2 in size and accommodate the CATHCOR
system, the HICOR system and the CD writer system and all other data
management systems.
 The control room shall be separated from the procedure room with a
leaded door and there must be a leaded glass window of at least 2m x 1m
size to enable visual communication between the staff in the procedure
room and the control room.
(c) The Cathlab scrub room:
 The scrub room shall be in proximity with the procedure room and there
shall be no more than one door separation between the two.
 The scrub room shall have adequate scrub facilities and allow at least two
professionals scrubbing simultaneously.
(d) Cathlab supply room:
 The supply room shall in close proximity to the Cathlab and is used for
storage of a range of consumables used for the procedure.
 The size of the room shall at least be 16sq.m in size and furnished with
shelves, cupboards and lockers.
(e) Staff locker rooms:

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  There shall be separate locker rooms for ladies and gentlemen located in
proximity with the procedure room.
 There shall be toilet, shower facilities and hand wash sinks either in or in
proximity with the locker rooms.

6.18.3 Professionals
(a) All health professionals practicing in the cardiac center shall be registered by the
Authority.
(b) There shall at least be one qualified cardiac/cardiothoracic surgeon with enough
experience in open and closed cardiac surgery for adult service and/or qualified
pediatric cardiac surgeon if the center is to provide pediatric cardiac surgical
service.
(c) There shall at least be one qualified cardiologist with at least nine months of his/her
training spent in diagnostic and interventional cardiac catheterization laboratory.
(d) There shall be cardiology fellow or pediatrician/internist with good experience in
cardiology to cover off duty work hours and the cardiologist and/or cardiac surgeon
shall be available on call.
(e) There shall at least be one qualified anesthesiologist with at least six months of
training in cardiovascular anesthesia.
(f) There shall at least be one perfusionist with at least two years of training.
(g) There shall be one nurse to one patient ratio as long as the patient stays in the
cardiac intensive care unit available 24 hrs a day and 365 days a year, if there is no
central monitor. If the ICU is assisted with a central monitor the nurse to patient
ratio can be reduced to at least one to two.
(h) There shall be at least three qualified nurses with enough experience in the
operating room.
(i) There shall be at least three qualified nurses with enough experience in the
diagnostic and interventional catheterization laboratory.
(j) There shall be one nurse to three patient ratios while the operated patients stay in
the step-down care and shall be available 24 hrs a day and 365 days a year.
(k) There shall be at least two qualified nurses in the out patient and emergency
department available 24 hrs a day and 365 days a year.
(l) There shall be an x-ray technologist with at least three months of training in the
diagnostic and interventional catheterization laboratory.

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 (m)There shall at least be one qualified laboratory technologist available 24 hrs a day
and 365 days a year.
(n) There shall be at least one pharmacist available during the working hours.
(o) There shall be one biomedical engineer responsible for fixing the equipments and
ensuring continuous power supply within the center.

6.18.4 Products
6.18.4.1 Outpatient Service Unit

(a) Equipment
 A functioning sphygmomanometer
 stethoscopes
 Thermometers
 A pulse oximeter
 Weight and height scales
 Standard 12 lead EKG machines
 Holter monitors (24 hour ambulatory EKG) or event recorder
 Resuscitation trolleys
 A well functioning ultrasound machine with 2D, color Doppler, spectral
Doppler and tissue Doppler
 Reliable oxygen source (preferably central oxygen supply)
 Exam coaches
 Syringe pumps
 Endotracheal tubes
 Laryngoscopes
 Defibrillators
 Wheel chair
 Patient transport stretcher
(b) Medicines as per the national list of such hospitals

6.18.4.2 Clinical wards

(a) Equipments

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  Patient beds fitted with  Dressing sets
non-invasive monitors and  Bed pans
mounting rails behind all  Kidney dishes
beds  Scissors
 Chairs (one per bed)  Surgical blade holders
 Drip stands  Lockers and cupboards
 Medical gas ports  shelves
 Telephone terminals  Telemetry monitoring for
 Working laminated top post operative patients with
table transmitters for step down
 Nurse trolleys care and selected patients
 Resuscitation trolleys in the ward.
 Reliable oxygen source  Nurse stations with chairs
 Syringe pump and computers plus

 Endotracheal tubes of computer points.

different sizes
 Laryngoscopes
 Defibrillators
(b) Consumables
 Disposable gloves  Venous cannulae of
 Sterile surgical gloves different sizes

 Foley catheters of different  Transfusion sets

sizes  Surgical blades
 Sterile gauze  Patient cards/charts
 Needles and syringes of
different sizes

(c) Medicines as per the national list for such hospitals

6.18.4.3 Operating room

(a) Equipments
 Scrub room with a scrub  Vacuum/electrical suctions
facility (at least 4x2m) (at least 3 terminals)
 Surgical instrument cabinet  Medical gas supply (ports for
 Endoscope cabinets oxygen, atmospheric air and

 Sterile instruments cabinet nitrous oxide)

 Electrically maneuvered  Diathermy (at least 2)

operating tables  Theatre trolleys (at least 2)
 Anesthesia machine  Anesthetic trolley (at least 2)
designed and dedicated for  Perfusionist’s trolley
cardiovascular anesthesia  Bowl trolley
 Laryngoscope  Sterilized device and cloth
 Backup cylinder ports for trolley
oxygen/air  Medication trolley
 Heart lung machine with all  Medical waste trolley
its accessories  Laundry collection trolley
 Standard OR lights (at least  Mayo stand
3)  Sharp container’s (at least 4)
 Surgeons head light  Wall white board (at least 2
 Headlight source each at least 80x50cm)
 Cardiac monitors with  Digitally operated air
screens (fitted with all conditioner
invasive monitors)  Autoclaves (Tabletop steam
 Surgeon’s goggles sterilizer at least 1)
 Surgeon’s sitting and  Wall sockets (minimum 12)
standing stools  Open heart surgical set (at
 Scrub shoes least 2)
 Tubing clump and Tubing  Closed heart surgical set (at
scissors least 2)
 Drip stands (minimum 3)  Electric / pneumatic saw
 Drums (at least 5)  Defibrillator with internal
 kidney dishes (at least 12) paddles
  Echo machine with pediatric  Transport monitor
and adult Transesophageal  Transport oxygen cylinder
facilities (at least 1)
 Heater/cooler  Activated Clotting time
 Patient warmer with electric Testing machine (ACT
blanket machine)
 Heating cabinet to warm  Temporary pacing boxes
patient fluid  Refrigerators (at least 2 each
 Balloon pump 180 liters each)
 Pressure transducers (at  Sharp/blunt sterile scissors
least 3)  Oxygen saturation probes
 Syringe pumps (at least 2) (newborn, infant pediatric)
 Pressure bags (at least 5)  Patient transport stretcher
 Stainless steel bowls (at least (at least 1)
2)
 Racks (at least 2)
 Blood gas analyzer
(b) Consumables
 Scrub brushes with soap  Arterial for perfusion
and iodine (range of sizes)
 Antiseptics  Left heart vent catheters
 Angled perfusion cannullae  Blood transfusion filters
of different sizes for perfusion
 IV cannullae of different  Arterial Cannullae of
sizes different sizes
 Pressure domes  Coated, braided polyester
 Oxygenator and venous sutures (1/0, 2/0, 3/0, 4/0,
reservoir 5/0, 6/0)

 Cardioplegia set  ECG electrodes

 Cardiovascular set  Diathermy pencils
 Hear exchanger  Gore-Tex stretch graft
 Disposable connectors suture

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 Gore-Tex large diameter  Blood transfusion set
stretch graft  Hypodermic needles
 Gore-Tex stretch graft (orange, blue, white,
 Quadrilumen CVC sets green)

 Triplelumen CVC sets  Connecting 3-way

 ACT cartridges stopcocks

 Pediatric multi-lumen  Bladder syringes

Central Venous  Luer-lock syringes
Catheterization sets of  Luer-Slip syringes
different sizes  Sterile suction tubing
 Swan-Ganz pulmonary  Non-sterile examination
artery wedge catheters of gloves
different sizes  Sterile surgical gloves of
 Uncuffed Endotracheal different sizes
tubes of different sizes  Tender tip suction catheter
 Cuffed Endotracheal tubes of different sizes
of different sizes  Wound care packs
 I-STAT cartridges  Sterile oral hygiene packs
 Temporary pacing wires  Non-woven swabs
 Blood burettes  X-ray detectable gauze
 Clear fluid burettes swabs
 Chest tube set  Pre-injection swabs
 Urine bags with urinary  Nasogastric tubes of
catheters and urine meter different sizes
 Intraosseous infusion  Silk stitches
needle  Sterile drapes
 Nasal cannula  Scrub suits
 Oxygen face mask (infant,  Ambubag
pediatric, adult)  Snapper plate
 Nebulisers  Haemofilters
 Micropore tape
 IV site dressing
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  Balloon tipped silicon  Powder free latex sterile
coronary artery ostial gloves of different sizes
cannula of different sizes  Surgical blades of different
 Foley catheter of different sizes
sizes  Thoracic catheter of
 Steel wires different sizes
 Surgical gowns of different
sizes
 Chest drainage bottles
(c) Medicines as per the national list for such hospitals

6.18.4.4 Intensive Care Unit

(a) Equipment
 Electrically maneuvered  Refrigerator (at least 1)
pediatric and adult beds  Nasal CPAP
fitted with monitors and  Bed pan (1 per bed)
screens  Pacing boxes (at least 2)
 Invasive pressure  Device trolleys (1 per bed)
transducers (1 per bed)
 Pharmacy trolley (at least
 Ventilators with 1)
accompanying accessories
 Resuscitation trolley (at
 Feeding tables (per bed) least 1) Refrigerator
 Ports for oxygen,  Defibrillator (at least 1)
atmospheric air and
 Electrical sockets on the
vacuum (1 of each per bed)
nurse station desk (at least
 Electrical suction machine 12-16)
(at least 1 as a backup)
 2 meter long mounting
 Drip stands (2 per bed) rails behind all beds
 Infusion pumps (1per bed)  10 main sockets behind
 Syringe pump (3 per bed) each bed
 Incubators and radiant
warmers

224
  Portable x-ray machine  Arterial pressure bags
with protective lead apron  Blood gas analyzer
and lead curtain  A 12 – lead standard ECG
 X-ray viewer machine
 Echocardiography machine  Medication boards
with 2D, color, spectral  Controlled drug locker
Doppler and tissue  Calculators
Doppler.
 Weight scale
 Nurse stations equipped
 Wall clock (at least 2)
with chairs, tables,
 Soiled cloth hampers
drawers and computers,
 Manual
shelves, lockers
sphygmomanometers with
 Linen boards
infant, pediatric and adult
 Screen and curtain (for
cuffs.
privacy)
 Thermometers
 Water supply and sink
 Stethoscope
facility with soap
 Intubation set
 Paper towel dispenser
 Telephone and telephone
point
(b) Consumables
 Non-sterile examination gloves
 Sterile surgical gloves
 Chest drainage bottles
 Foley catheters with urine bags
 Adhesive plasters
 Cannullae of different sizes
 Needles
 A range of crystalloid and colloid IV fluids
 Patient charts/cards (case summary, order sheet, nurses monitoring sheet
etc.) and other stationeries.
(c) Medicines as per the national drug list for such hospitals

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6.18.4.5 Diagnostic and interventional cardiac catheterization laboratory

(a) Equipments
 At least a single C-arm  Scrub room with scrub
angiography machine with facilities
a movable angiography  Drip stands (at least 2)
table  Light source
 Angiography and RGB  Lead aprons and thyroid
monitoring screens shield for every member of
 A well functioning staff working in the cath
CATHCOR system lab
 CD recorder  A telephone and telephone
 Digitally operated air point
conditioner  Catheter and wire rinsing
 At least a stand alone basins
pressure injector system  Drums at least 4
 A pressure amplifier box  Galipot at least 8
 Pressure transducer cables  At least 4 kidney dishes
 ECG monitor system  Scissors
 Syringe pump (at least 2)  Artery forceps
 Infusion pump (at least 1)  Surgical blade holders
 An anesthesia machine  Sponge forceps
 Laryngoscope  Blood gas analyzer
 Gas ports for oxygen,  Nurse trolleys (at least 1)
medical air and nitrous  Device trolley (at least 1)
oxide  Resuscitation trolley
 Echocardiogram with  Defibrillators
pediatric and adult
 Computer and computer
Transesophageal facilities
network terminal
 An Ambubag
 Patient transport coaches
 A control room with chairs
 Pulse oximeter
 Vital sign tray

226
  Waste baskets for soiled  Apron hangers
and dry linen
 Sharp disposal containers
 Catheter hangers

(b) Consumables
 Local anesthetics  Exchange range guide
(Lidocaine, Bupivacaine, wires (a range of sizes)
Xylocaine, etc)  Super stiff guide wires (a
 Contrast injector syringes range of sizes)
 3, 5 and 10ml syringes  Contrast agents (Omnipac,
 Puncture needles Iopamiron)

 Surgical blades  Balloon angiocatheters of

 Disinfectants different types ( with a

 Sterile gauze range of sizes)

 Small guide wires (J-guide  Coronary stents with

wires) associated delivery

systems (a range of sizes)
 Valved introducers with
dilators (with a range of  Vascular stents with

sizes) associated delivery

systems (a range of sizes)
 Multipurpose catheters (a
range of sizes)  Duct occluders with
associated delivery
 NIH catheters (with a
systems (a range of sizes)
range of sizes)
 Septal occluders with
 Pigtail catheters (a range
associated delivery
of sizes)
systems (a range of sizes)
 Balloon tipped flow guided
 Face mask
catheters (a range of sizes)
 IV cannullae (a range of
 Left and right coronary
sizes)
catheters (a range of sizes)
 Butterfly needles
 Soft tipped guide wires (a
range of sizes)  Patient drapes

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  Scrub suits (single use or  Adult and pediatric ECG
fabric) electrodes
 Pressure domes and  Non sterile examination
connectors gloves
 Injector connecting tubes  Sterile surgical gloves of
 Endotracheal tubes of different sizes
different sizes  Suction tubes
 Cidex solution for probe  Medicines as per the
cleaning national list of such
 Probe covers hospitals

 Lubricant and
transmission gel
6.18.4.6 In addition the service unit should have the following devices

(c) Stent graft thrombectomy device

(d) Distal protection device
(e) Intra aortic balloon counterpulation

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6.19 Neurology service

6.19.1 Practice
6.19.1.1 The Neurology service unit shall have at least two of the following services:
(a) outpatient service
(b) follow-up clinic
(c) neurologic consultations
(d) referral services to respective facilities
(e) Emergency and or stroke care
(f) Inpatient neurologic care for different diseases (optional)
(g) headache and pain (optional)
6.19.1.2 There shall be written protocols and procedures which shall be enforced that establish
the management of the neurological conditions in the unit as well as consultation and
transfer of patients admitted to this unit or other services
6.19.1.3 For emergency neurological condition the service shall be available 24 hours a day
throughout the year.
6.19.1.4 For non-emergency condition the neurological service shall be available during the
regular working hours
6.19.1.5 For admitted patients the neurological service shall be organized in such a way that it
covers all the shifts (24 hours of the day and seven days of the week)
6.19.1.6 Nursing functions shall be the responsibility of a licensed nurse and shall be supervised
by the head nurse which in turn is accountable to the leading physician
6.19.1.7 The service shall have written policies and procedures that shall include
(a) Admission and discharge criteria specific to the service;
(b) A visitors policy that allows for 24 hour visitation by designated visitors and specifies
the number of visitors permitted for each patient at any one time
(c) Infection control as per National and or Hospital IP guideline
(d) Transfer and Referral of patients
(e) Monitoring and follow-up of patients
6.19.1.8 The administrative functions shall be a responsibility of the hospital administration
6.19.1.9 Every neurological records shall be kept for each patient

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6.19.1.10 Information contained in the neurological record shall be complete and sufficiently
detailed relative to the patient's history, physical examination, diagnosis, diagnostic
procedures, medication administration, and treatment. Refer to the medical record
section for details of the information that needs to be recorded.
6.19.1.11 The neurological unit shall have a follow-up service for patients with chronic ailments.
6.19.1.12 Notifiable diseases shall be notified through the proper channel (to medical director,
chief executive officer and hence to the MOH)
6.19.1.13 The unit shall avail updated reference materials, treatment guidelines and manuals (eg.
National TB and leprosy, pain management, Malaria treatment, ART, meningitis etc)
6.19.1.14 The different request forms for investigation like laboratory; x-ray, etc shall be revised
and updated as per service need at least every five years.
6.19.1.15 The caretakers and/or patients shall be included in the development of the nursing
patient plan of care
6.19.1.16 There shall be a system for clinical staff to refer patients directly to the social works unit.

6.19.2 Premises
6.19.2.1 Capacity- maximum room capacity shall be six patients or beds per room
6.19.2.2 Area- patient rooms shall be constructed to meet a minimum of 9 meter squares per bed
6.19.2.3 Dimensions and clearances- the dimensions and arrangements of rooms shall be such that
there is a minimum of 0.9m (90cm) between the sides and foot of the bed and any wall or
any other fixed wall construction. In multiple bed rooms a clearance of 1.2 meter shall be
available at the foot of each bed (or between beds) to permit the passage of equipments
and beds
6.19.2.4 The number of rooms and beds shall be as per the load, volume and nature of work
performed.
6.19.2.5 The inpatient rooms for neurological l service shall be organized into different wards, the
number of which depends upon the size and the degree departmentalization of the
neurological service, available facilities, and the service needs
6.19.2.6 The neurological service unit shall have an isolation room for treatment of conditions that
require such services
6.19.2.7 Patients in acute care shall be under direct observation in a room near the nurses’ station.
6.19.2.8 In addition to the wards, in patients the unit shall have the following space (rooms)
(a) A private area for counseling (examination room/office for physician)

230
 (b) Duty room/Station
(c) Meeting room
(d) Nurse station
(e) Utility rooms
(f) Rooms for follow-up clinics
(g) Store
(h) Staff Toilets, showers and changing room
(i) Patient Toilet and shower at least one each per room

6.19.3 Professionals
6.19.3.1 The neurological service shall be directed by a licensed neurologist
6.19.3.2 There shall be qualified neurological and nursing personnel in the neurological service
unit available at all times to meet the service needs
6.19.3.3 The number and type of technical staff shall be determined by the volume and type of
work carried out (Workload Analysis)
6.19.3.4 The neurologist or licensed physician shall
(a) be responsible for the services provided to each patient; while the licensed nurse shall
be responsible for all nursing care provided to the patient
(b) control the nursing visits, care, carry out and execution of the orders
(c) be available (physically present) at all times in the adult medical service unit
(d) be on duty or on call at all times. This physician or practitioner shall be able to present
at the unit in a period of time not to exceed thirty (30) minutes.
(e) be responsible for the follow-up clinics.
6.19.3.5 A licensed nurse shall be available at all times to assess, evaluate, and supervise the
nursing care provided.
6.19.3.6 There shall be adequate support staff available as per the service need
6.19.3.7 The neurology unit shall have at least the following professionals:
(a) A licensed neurologist
(b) Two licensed nurses
(c) EEG trained nurse or EEG technician
(d) Janitor

6.19.4 Products

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6.19.4.1 The neurology service unit shall have at least the following instruments:
(a) reflex hammers
(b) ophthalmoscope
(c) thermometer
(d) sphygmomanometer
(e) Snellen’s chart
(f) Tuning fork
(g) EEG machine
(h) Nerve conduction/electromyography
(i) Examination coach
(j) Doppler ultrasound (optional)
(k) Lumbar puncture set with manometer
6.19.4.2 The neurology service unit shall have all medicines in accordance with the national drug
list

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6.20 Gastroenterology
6.20.1 Practices
6.20.1.1 The Gastroenterology unit shall have the following services:
(a) outpatient service,
(b) follow-up clinic,
(c) referral services to respective facilities,
(d) Emergency gastroenterology and/ or care for GI bleedings,
(e) Inpatient care for different gastroenterology diseases,
(f) Investigation & interventions with endoscopies.
6.20.1.2 There shall be written protocols/ procedures for the consultation and management of
cases that shall include:
(a) Identifying critical cases,
(b) Handling of Emergency & critically ill patients,
(c) Infection control specified under these standards and National IP guideline,
(d) Procedures, interventions and special investigations like Endoscopy,
sigmoidoscopy, proctoscopy, etc. ,
(e) Referral of patients,
(f) Monitoring and follow-up of patients.
(g) Inpatient Gastroenterology Service.
6.20.1.3 The unit shall avail medical service for emergency conditions for 24 hours throughout the
year.
6.20.1.4 Information contained in the medical record shall be complete and sufficiently detailed
relative to the patient's history, physical examination, diagnosis, diagnostic procedures,
medication administration, and treatment. Refer to the medical record section of these
standards.
6.20.1.5 The Gastroenterology unit shall have a follow-up service for patients with chronic
ailments.
6.20.1.6 Diseases under national surveillance shall be reported to FMOH through the proper
channel.
6.20.1.7 The Gastroenterology unit shall avail updated reference materials, treatment guidelines
and manuals within its scope of practice (e.g. TB, pain management, etc)
6.20.1.8 The unit shall use standard prescriptions and different request forms for investigation
like laboratory, x-ray, etc.

233
6.20.1.9 The unit shall have a system for involving patients, family members &/ or caretakers in
the process of care & treatment.
6.20.1.10 There shall be chronic care follow up service for certain prevalent neurological conditions
in the unit.
6.20.1.11 There shall be a protocol for instrument processing & sterilization.

6.20.2 Premises
6.20.2.1 The unit shall have at least ten dedicated inpatient admission beds.
6.20.2.2 Admission rooms shall be with a maximum capacity of six beds per room.
6.20.2.3 The Gastroenterology unit shall have an isolation room for treatment of conditions that
require such services.
6.20.2.4 The nurse station shall be situated in a central place where direct observation for patients
in acute care.
6.20.2.5 In addition to the ward rooms the Gastroenterology unit shall have the following rooms &
facilities:
(a) A private area for counseling (examination room/Doctors office)
(b) Duty room/Station
(c) Nurse station
(d) Utility rooms
6.20.2.6 The summary of minimum premises for Gastroenterology unit shall be as follows:

6.20.3 Professionals
6.20.3.1 The Gastroenterology unit shall be directed by a gastroenterologist with a minimum of
two years related experience.
6.20.3.2 At least one gastroenterologist shall be available to run the outpatient and inpatient
service during working time.
6.20.3.3 The unit shall have an internist and general practitioner.
6.20.3.4 The nursing service in the unit shall be directed by licensed nurse trained on
gastroenterology patient care.
6.20.3.5 There shall be adequate support staff available as per the service need
6.20.3.6 Additional number and type of technical staff shall be determined by the volume and type
of work carried out (Workload Analysis)
6.20.3.7 There shall be adequate support staff available as per the service need.

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6.20.4 Products
6.20.4.1 The gastroenterology unit shall have the following supplies and functional equipments at
OPD:
a) Diagnostic Equipments:
 Stethoscope,
 Sphygmomanometer,
 Weighing scales for adults,
 Height Measurement,
 Tape meter,
 Thermometer,
 Reflex/patellar hammer,

b) X-ray viewer, j) Resuscitation kits: Ambu bag,

c) Examination couch, air ways,
d) Examination light, k) Oxygen cylinder, Flow-
e) Biopsy set, meters for oxygen, Nasal
f) Cut down set, prongs/ catheters,
g) Endoscope, l) Plastic bowels for chemical
h) Proctoscope, disinfection,
i) Laryngoscope (optional),

6.20.4.2 The inpatient service of Gastroenterology unit shall have the following supplies
and functional equipments:
a) Examination couch, j) Oxygen face mask,
b) Patient beds, k) Nasal prongs catheters,
c) Diagnostic sets: (Torch, l) Self inflating bags for
Otoscope, funduscope, patella respiratory support, Masks,
hammer etc… endotracheal tubes,
d) Weighing scales, m) Laryngoscope,
e) Vital sign set: thermometer, BP n) Cannulas,
apparatus, stethoscope etc… o) Nasogastric tubes,
f) Medicine trolley, p) Glucometer and glucostick,
g) Suction machine, q) Pulseoximeter,
h) IV stands, r) Wheelchair,
i) Oxygen source/ Oxygen s) Over bed table( for feeding),
cylinder, Flow-meters for t) Bed side cabinet,
oxygen, u) Curtain fixed with the ceiling,

235
 v) Kick buckets, w) Cup board

6.20.4.3 The unit shall have the following emergency medicines and supplies at all times.
a) Emergency drugs:
a. Esomprazole inj., f. Lidocaine,
b. Adrenaline, g. Sclerosing agents, inj.,
c. Diazepam, h. KCl,
d. Pethidine, i. Calcium Gluconate,
e. Hydrocortisone, j. IV fluids, of all types,
b) Spatula, K-Y jelly, surgical and disposable gloves, antiseptics, cotton, gauze
c) Glucometer and glucosticks,

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6.21 Renal Services
6.21.1 Practice
6.21.1.1 The Renal unit shall provide both medical & surgical services (i.e., Nephrology &
Urology) with the following modalities:
(a) Outpatient service,
(b) Follow-up clinic,
(c) Referral services to respective facilities,
(d) Emergency service for kidney & related problems,
(e) Inpatient care for related diseases,
6.21.1.2 There shall be written protocols and procedures for medical & surgical management of
common genito- urinary & kidney conditions.
6.21.1.3 The unit shall avail both nephrology & urology services for emergency renal conditions
for 24 hours a day throughout the year,
6.21.1.4 The unit shall have access to Intensive Care Unit (ICU) with all requirements stipulated
under ICU standards
6.21.1.5 The unit shall provide anesthesia services as per the standards stipulated for anesthesia
services.
6.21.1.6 For non-emergency condition the nephrology & urology services shall be available
during the regular working hours.
6.21.1.7 The nephrology & urology services shall be organized to cover all the shifts for admitted
patients (24 hours of the day and seven days of the week),
6.21.1.8 Nursing functions for each shift shall be carried out by the nurse responsible for the
shift,
6.21.1.9 The service shall have written policies and procedures that shall include:
(a) Admission and discharge criteria specific to the service;
(b) A visitors policy,
(c) Infection control as per National and or IP guideline of the center,
(d) Transfer and Referral of patients,
(e) Monitoring and follow-up of patients,
6.21.1.10 The renal unit shall have the following urology services:
(a) Urethroscopy,
(b) Extracorporal Shock Wave Lithotripsy,
(c) Percutaneous lithotripsy,
(d) Insertion of stents,
(e) Transurethral diagnostic procedures &/ or lithotripsy

237
 (f) And other related services
6.21.1.11 The renal unit shall have the following nephrology services:
(a) Medical treatment,
(b) Dialysis,
6.21.1.12 The unit shall develop & implement operational policies addressing at least the
following concerns:
(a) Lithotripsy:
o Maximum number of shocks &/ or voltage allowable,
o Post ESWL follow-up,
o Contraindicated medication,
o Pre-admission testing requirements,
o Pediatric cases,
o Criteria for: - treatment; cancelation; retreatment;
o General safety protocols,
o Inspection of lithotripter by qualified person; with documentation of all
preventive maintenances,
(b) Hemodialysis:
 Admission criteria that includes acceptance of patients who have
communicable or transmittable diseases,
 Orientation of new patients to the unit,
 Contraindications,
 Pre-admission testing requirements,
 Criteria for: - treatment; cancelation; retreatment;
 General safety protocols,
 Infection control protocol & dialysis waste management,
 Specific facility response to medical & non-medical emergencies including,
for e.g., equipment failure & water supply problems,
 Regular inspection of hemodialysis machine by qualified person; with
documentation of all preventive maintenances,
 There shall be proper written and verbal instruction for patients about
dialysis process and the machine used.
6.21.1.13 There shall be a red alarm light and an audible beep on the machine.
6.21.1.14 The set up for hemodialysis is to the level of intensive care, there shall be isolation and
restriction of traffic.
6.21.1.15 The patient or guardian or care giver shall be oriented, explained about the machine and
its part before and during the dialysis process.
6.21.1.16 All medical records & lab investigations with plan shall be documented on each patient’s
record.

238
6.21.1.17 Information contained in the medical record shall be complete and sufficiently detailed
relative to the patient's history, physical examination, diagnosis, diagnostic procedures,
medication administration, and treatment.
6.21.1.18 The unit shall use standard prescription & different request forms for investigation like
laboratory, x-ray, etc.
6.21.1.19 The unit shall have a system for involving patients, family members &/ or caretakers in
the process of care & treatment.
6.21.1.20 There shall be chronic care follow up service for certain prevalent renal conditions in the
unit.

6.21.2 Premises
6.21.2.1 The renal unit shall have at least ten inpatient admission beds.
6.21.2.2 Admission rooms shall be with a maximum capacity of six beds per room.
6.21.2.3 The renal unit shall have an isolation room for treatment of conditions that require such
services.
6.21.2.4 The number of rooms and beds shall be as per the load, volume and nature of work
performed.
6.21.2.5 The renal unit shall have urethroscopy room, lithotripsy (ESWL) room, dialysis unit and
operation table dedicated to renal unit.
6.21.2.6 The nurse station shall be situated in a central place where direct observation for
patients in acute care.
6.21.2.7 The Nurse station in the dialysis unit:
l) Isolated with glass, Full visual access to monitor admitted patient on machine,
m) Equipped with chairs, working laminated top tables, drawers and computers, Linen
boards, shelves, lockers,
n) Telephone end,
o) Medication boards,
p) Weight scale,
q) Patient screen per bed and
r) Dust bins, separate leak proof containers on trolley for used dialysis sets and waste
products.
6.21.2.8 In addition to the ward rooms, the renal unit shall have the following rooms & facilities:
(a) A private area for counseling (examination room/Doctors office),
(b) Duty room/Station,
(c) Nurse station,
(d) Utility rooms

239
6.21.3 Professionals
6.21.3.1 The renal unit shall be directed by a licensed nephrologist or urologist/ urosurgeon
6.21.3.2 At least one nephrologist and urologist shall be available to run the outpatient and
inpatient service during working time.
6.21.3.3 The nephrologist shall be responsible for:
(a) Medical services provided to each patient; while the licensed nurse shall be
responsible for all nursing care provided to the patient, nursing visits, care, carry out
and execution of the orders
(b) Control of the hemodialysis service,
(c) Being available (physically present) during working time, and on call basis during after
hours,
(d) While on duty or on call, the specialist shall be able to present at the unit in a period
of time not to exceed thirty (30) minutes.
6.21.3.4 The urologist shall be responsible for:
(a) Surgical services provided to patients; -tripsy, -scopy,
(b) Being available (physically present) during working time, and on call basis during after
working hours,
(c) While on duty or on call, the specialist shall be able to present at the unit in a period
of time not to exceed thirty (30) minutes.
6.21.3.5 The unit shall have an internist and general practitioner.
6.21.3.6 The nursing service in the unit shall be directed by licensed nurse trained on renal
patient care.
6.21.3.7 There shall be one to one ratio among nurses and dialysis machines at all times.
6.21.3.8 The dialysis machine shall be attended & checked all the time by appropriate technician
or engineer.
6.21.3.9 There shall be adequate support staff available as per the service need
6.21.3.10 Additional number and type of technical staff shall be determined by the volume and
type of work carried out (Workload Analysis),
6.21.4 Products
6.21.4.1 The outpatient service of the renal unit shall have the following equipment & supplies:
(a) Examination couches,  thermometer
(b) Examination light,  sphygmomanometer
(c) X-Ray viewer,  Tuning fork
(d) Diagnostic sets: (e) Weighing scale,
 reflex hammers (f) Height measurement,
 ophthalmoscope

240
 (g) Doppler ultrasound (h) Cystoscope,
(optional),

6.21.4.2 The inpatient service for renal unit shall have the following equipments & supplies:
(a) Patient beds, (n) Laryngoscope,
(b) Diagnostic sets: (Torch, (o) Cannulas,
Otoscope, funduscope, (p) Nasogastric tubes,
patella hammer etc… (q) Glucometer and glucostick,
(c) Weighing scales, (r) Pulseoximeter,
(d) Vital sign set: (thermometer, (s) Wheelchair,
BP apparatus, stethoscope (t) Over bed table(for feeding),
etc… (u) Bed side cabinet,
(e) Examination couch, (v) Curtain fixed with the ceiling,
(f) Medicine trolley, (w) Kick buckets,
(g) Cystoscope, (x) Cup board,
(h) Suction machine, (y) Wall clock,
(i) Drip counters/Infusion (z) Trolley for vital sign
pump, monitoring,
(j) IV stands, (aa)Refrigerator with
(k) Oxygen source with flow- temperature control for
meters, medication,
(l) Oxygen face mask/ nasal (bb) Medication Cupboard with
prongs catheters, lock,
(m) Self inflating bags for (cc) Patient chart holder,
respiratory support, Masks,
endotracheal tubes,

6.21.4.3 The unit shall have emergency medicines at all times

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6.22 Rehabilitation Services

6.22.1 Practices:
6.22.1.1 At least two of the following services shall be available in the hospital:
(a) Physical therapy/ physiotherapy: treatment aimed at the attainment
or recovery of optimal neuro-musculoskeletal function to help ones
strength, mobility and fitness,
(b) Occupational therapy: therapy aimed at giving people "skills for the job
of living" or "the skills for employment." to help with ones daily
activities,
(c) Vocational Rehabilitation: The continuous and coordinated process of
rehabilitation which involves the provision of vocational guidance,
vocational training and selective placement, designed to enable a
person with a disability to secure and retain suitable employment
(d) Drug rehabilitation: for dependency on psychoactive substances such
as alcohol, prescription drugs, and illicit drugs such as cocaine, heroin
or amphetamines
(e) Speech therapy
(f) Pain Treatment
6.22.1.2 There shall be written policies and protocols that ensure rehabilitation services
are properly provided,
6.22.1.3 There shall be specific treatment and/or procedure protocols for each service
available and rendered in the unit,
6.22.1.4 There shall be a policy for patient referral and inter discipline consultation,
6.22.1.5 There shall be a policy that the therapist (occupational therapist/
physiotherapist) shall document all the plan in the patient’s medical records. A
note shall be entered into the medical record at least weekly or more frequently
if there is a significant change in the patient’s status or treatment needs.
6.22.1.6 The physical therapist shall discuss the plan of care with the patient and family,
if possible.
6.22.1.7 The physical therapy service shall offer services at least 5 days a week,
excluding holidays

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6.22.1.8 Visual and Auditory privacy shall be offered and provided to all patients during
evaluation and treatment, when clinically indicated.
6.22.1.9 There shall be a policy that states written orders shall be given to patients when
patients are discharged with exercise or treatment to continue at home.
6.22.1.10 There shall be a protocol or policy for safety and ethical practice of physical
therapy, identifying six precepts for health care in the future, namely, that the
health care system must be: safe, effective, patient-centered, timely, efficient,
and equitable.
6.22.1.11 There shall be patient education on prevention of:
(a) pressure sores in clients with sensory loss,
(b) contractures in clients with limb and/or trunk paralysis,

6.22.2 Professionals:
6.22.2.1 The service shall be directed by a qualified practitioner graduated or certified
from recognized university or institute
6.22.2.2 There shall be at least four physiotherapist
6.22.2.3 The hospital shall have at least a chiropractor, physiotherapist, occupational
therapist, clinical psychologist/health psychologist, speech therapist for each
respective service areas mentioned above.
6.22.2.4 All practitioners shall be licensed and only licensed practitioners shall provide
service.
6.22.2.5 There shall be multidisciplinary team in the rehabilitation service to plan for
individual patients.
6.22.2.6 Continued improvement of technical skills and knowledge should be encouraged
and such opportunities shall be facilitated by the hospital.
6.22.2.7 A copy of each physical therapist’s and physical therapist assistant’s license shall
be conspicuously posted in the physical therapy service.
6.22.2.8 Trained and certified therapist shall be available or shall supervise daily
sessions of physiotherapy
6.22.2.9 The service shall have dedicated cleaners.

6.22.3 Premises
6.22.3.1 The shall be physically separated room or area for rehabilitation and therapy

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6.22.3.2 There shall be direct access to inpatients and outpatients with clearly written
labels
6.22.3.3 The premises shall be disabled people friendly and smooth pavement rail for
wheelchairs
6.22.3.4 There shall be enough space for assistive devices and appropriate accessories
6.22.3.5 There shall be waiting area with shade
6.22.3.6 Staff room for developing documentation and storing reference books and
personal items shall be available
6.22.3.7 Private room for patients and staff when they need to change closing before and
after treatment shall be available.
6.22.3.8 Separate toilet with hand washing facility in an accessible location, handicapped
accessible, handicapped adapted, and well-ventilated shall be available
6.22.3.9 Call bells/bipper bells shall be provided to patients in the physical therapy
service who are not under visual supervision.
6.22.3.10 Workshop for production of prostheses, walking sticks: auxiliary and/or elbow
crutches shall be available or there shall be a documented mechanism of
accessing such services
6.22.3.11 There shall be a separate room for exercise therapy

6.22.4 Products:
6.22.4.1 All equipment shall be clean and function.
6.22.4.2 Equipment shall be stored in a safe and accessible place and shall not be stored
in a public walkways and hallways.
6.22.4.3 Standard equipments and consumables which shall be available for
rehabilitation services include:
(a) Physiotherapy mats,
(b) Splinting materials,
(c) Bobath balls,
(d) Balance boards,
(e) Mirror,
(f) Waking rail/ parallel bars,
(g) Pressure garment materials,
(h) Goniometers,

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(i) Spring,
(j) Rollers,
(k) Infrared,
(l) Ultraviolet/ blue lamp,
(m) Paraffin bath,
(n) Muscle stimulator,
(o) Ultrasound therapy equipment,
(p) Diathermy,
(q) Electro-massage apparatus for hands, legs, spine,
(r) Massaging coach,
(s) Organ protection pad,
(t) Educational toys,
(u) Material for making assistive devices for daily living functions,
(v) Specific assessment tools for occupational-, speech-, and
physiotherapy,
(w) Screening audiometer,
(x) Developmental screening charts for detecting speech abnormality,
(y) Disposable glove,
(z) Cotton roll,

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6.23 Oncology Services

6.23.1 Practices
6.23.1.1 The oncology outpatient services shall include:
(a) New patient services,
(b) Follow-up services,
(c) Radiotherapy planning services,
(d) Radiotherapy treatment cessions,
(e) Weekly Radiotherapy treatment checks,
(f) Chemotherapy cessions,
(g) Oncologic emergency services including emergency procedures,
(h) Health education on cancer related topics
(i) Pain clinics if possible,
6.23.1.2 The oncology inpatient services shall include:
(a) Delivering chemotherapy cessions,
(b) Nursing care according to individual patients’ needs
(c) Brach therapy (Low dose rate or high dose rate, preferably high dose rate
sources)
6.23.1.3 There shall be a multidisciplinary cancer committee, chaired by a physician for a
defined period that is responsible for at least the development of oncology
policies and procedures, tumor review, and tumor registry.
6.23.1.4 The multidisciplinary team shall consist of clinical oncologist designated leader,
surgeon who deals with the respective tumor type, pathologist, radiologist,
nuclear medicine physician depending on the type of malignancy, oncology
nurse and there shall be meetings on a regular basis.
6.23.1.5 The service shall have written policies and procedures that are reviewed at least
once every five years, revised more frequently as needed, and implemented.
They shall include at least:
a) Criteria for admission
b) Guidelines for mixing chemotherapy, when performed on the unit,
c) Guidelines for administering chemotherapy

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 d) Training of nursing and housekeeping staff in the disposal of
chemotherapeutic agents;
e) Use, handling, storage, and disposal of specific chemicals, agents, and body
wastes;
f) Assuring informed consents to chemotherapy; and
g) Psychological/social and spiritual aspects of patient care.

6.23.1.6 There shall be a formal mechanism for communication between the oncology
service and each of the following clinical areas: nursing, dietary, social work,
nuclear medicine, laboratory, pathology and pharmacy.
6.23.1.7 All patients with cancer shall be managed by a multidisciplinary process. It
includes diagnosis and all aspects of treatment and care, including symptom
management and end-of-life care. It considers each individual patient’s need and
preference for care and treatment. The multidisciplinary process shall include
the followings:
a) There shall be a multidisciplinary management protocols covering
systems for referral (including to medical, surgical, oncology and palliative
care services), investigation, diagnostics, staging for treatment, treatment,
follow-up and end-of-life care for patients with cancer.
b) All patients shall have access to palliative and supportive care appropriate
to their needs
c) There shall be written local protocols for discharge planning, which
includes details for pre-discharge, actual discharge and post-discharge
arrangements.
d) All patients with cancer shall have individualized care plans, developed
jointly and agreed between the patient and members of the
multidisciplinary care team, documenting clinical and non-clinical issues
and the proposed action to address such issues.
e) A comprehensive, single care plan shall be available to the patient and
members of the multidisciplinary care team including health professionals
6.23.1.8 Care, support and services for cancer shall be provided in partnership with
patients and care givers. There shall be a clear record of what the patient or care

247
 givers has been told about the condition, treatment and care options, outcomes,
risks and side-effects.
6.23.1.9 Patients with cancer shall be enabled and supported to make decisions
throughout their care experience. All patients with cancer shall have access to a
healthcare worker with experience and knowledge of their current care needs
and the skills to facilitate informed decision-making.
6.23.1.10 Patient and family teaching shall be provided in any case where the patient and
family are in need of and able to receive instruction.
6.23.1.11 Criteria shall be developed in consultation with the social work department for
identifying patients in need of social work services and/or discharge planning
and making referrals as needed.
6.23.1.12 There shall be a system to refer patients and family and direct staff to in-house
and community support groups and services.
6.23.1.13 There shall be a program of continuous quality improvement for oncology that is
integrated into the hospital continuous quality improvement program and
includes regularly collecting and analyzing data to help identify health-service
problems and their extent, and recommending, implementing, and monitoring
corrective actions on the basis of these data.
6.23.1.14 There shall be a pain clinic if possible, but there should be the national pain
management guidelines and be utilized properly and accordingly.
6.23.1.15 Pain shall be considered as a 5th vital sign. The Oncology nurse shall utilize
appropriate pain assessment tools and will encourage the patient “self-report”
of pain.
6.23.1.16 Principles of pain management including non-pharmacological methods of pain
management may be taught.
6.23.1.17 The oncology nurse shall document pain assessment and interventions.
6.23.1.18 The patient will be protected from infection and cross contamination according to
infection prevention standards mentioned in this doucument.Nursing personnel
shall institute specific precautions to prevent infection in patients with an
absolute neutrophil count (ANC) of less than 1,000
6.23.1.19 Medications shall be administered per written policies and procedures.
a) Chemotherapy shall be administered as per written procedures.

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 b) The pharmacist and nursing staff shall wear protective gloves and approved
chemotherapy gowns when compounding/preparing and administering
chemotherapy to patients
c) Licensed nurses shall take necessary steps to prevent and treat
extravasations of chemotherapeutic agents so that the patient will have
minimum complications
d) Treatments, medications, and IV’s ordered by the physician shall be
instituted
6.23.1.20 Patients shall be admitted to patient care areas according to their physical and
psychosocial needs, unit admission criteria, and bed availability.
6.23.1.21 The patient shall be oriented to the room, service unit and to their assigned nurse
upon arrival.
6.23.1.22 Identified patient needs and subsequent nursing interventions shall be evaluated
and documented in the Integrated Notes.
a) The nursing staff shall provide assessment and care during every shift to the
patient with mucositis, an inflammatory response to chemotherapeutic
agents. Patient education will be provided.
b) The nursing staff shall initiate and teach appropriate precautions for the
patient with myelosuppression
c) The nursing staff shall provide assessment, care, and evaluation of
interventions to the patient receiving chemotherapy with high emetogenic
potential.
6.23.1.23 Patient teaching shall begin during the admission process and shall be ongoing.
Documentation shall include the teaching plan and patient response.
6.23.1.24 Nursing personnel shall provide information to patients regarding administered
chemotherapeutic agents
6.23.1.25 Nursing staff shall seek input from the patient and other health care professionals
to plan and implement care. Oncology nursing staff shall utilize the nursing
process to provide for the physical, emotional, and spiritual needs of oncology
patients and make referrals as appropriate.
6.23.1.26 The nurse shall utilize available resources to facilitate an optimal transition
between health care settings. The patient or family who is complex, unable to

249
 cope, or being discharged which requires coordination by the multidisciplinary
team will be followed by Integrated Case Management.
6.23.1.27 Patient’s comfort level shall be assessed and comfort measures/pain management
will be provided to meet patient needs.
6.23.1.28 Consent for procedure and patient understanding shall be verified prior to
implementation.
6.23.1.29 Additional information regarding advance directives shall be provided as
requested by patient.
6.23.1.30 Patient’s spiritual and cultural beliefs shall be considered when planning and
implementing care. The nursing staff shall utilize the nursing process to assess
the patient and family’s ability to cope with his/her diagnosis and treatment of
disease. Interventions shall be congruent with the patient/family belief system.
6.23.1.31 Available resources shall be utilized to maximize patient’s support and care giver
as needs are identified. Patients who are assessed by oncology staff as unable to
cope shall be referred to the social worker or appropriate support group.
6.23.1.32 Chemotherapy
a) All chemotherapy regimens shall be given according to the treatment
guidelines
 Staff dealing with cytotoxic drugs shall follow the safety guidelines;
 Vertical Laminar Air Flow Hood shall be used during the preparation
of all chemotherapy on the unit.
 Goggles, masks, gloves shall be worn when dealing with
chemotherapy.
 Office of Occupational Medicine shall be used to develop procedures
for preparing chemotherapy. Example using Fume hood for
chemotherapy mixing
b) Inpatient chemotherapy shall only be given in wards where it is agreed as
the whole of, the wards allowed activities.
c) Out-patient chemotherapy shall only be given in outpatient areas where it is
agreed as part of, or the whole of, that areas allowed activity.
d) While out-patient chemotherapy is being given the area shall only be used
for this purpose and other aseptic treatments and procedures on cancer
patients.

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 e) Oncology nurse administers parentheral chemotherapy as prescribed by the
oncologist in the presence of oncologist or other trained physician
6.23.1.33 Radiotherapy
a) The safety standards of radiotherapy shall be according to the Ethiopian
National Radiation Protection Authority (ENRPA) /IAEA standards
b) The radiotherapy technician can deliver Radiation in the presence of a
radiation oncologist
c) Both acceptance and commissioning test should be done by experienced
medical physicist for Barchytherapy and teletherapy machine before being
used for patients’ treatment.
6.23.1.34 There shall be one oncologist available during working hours and on call basis at
all times for consultation.
6.23.1.35 As the patient’s condition or nursing interventions warrant, the bed will be kept in
the low position with the wheels locked and upper side rails in the up position
and call light within reach of patient. Oncology nursing staff will implement
thrombocytopenic precautions for patients with platelets less than or equal to
20,000
6.23.1.36 An allergy label shall be placed on the front of each patient’s chart with “Allergies”
or “No Known Allergies” listed as appropriate. Allergies” or “No Known
Allergies” will be entered into the patient’s medical record (Care vision) during
the admission process and updated as appropriate
6.23.1.37 Vital signs shall be completed, unit routine, physician order, or as patient
condition warrants.
a) Patients receiving blood or blood products shall have vital signs monitored
b) Patients with neutropenia shall have vital signs taken
6.23.1.38 Psychological and psychiatric services shall be available in the premises
6.23.1.39 Chaplin or related religious counseling may be facilitated upon patient request

6.23.2 Premises
6.23.2.1 Buildings and rooming styles shall generally be in accordance with the
ENRPA/IAEA standards
6.23.2.2 Minimal requirements for outpatient section
a) Nurses office 1

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 b) Staff offices at least 4
c) One examination room for Gynecology examination and procedure
d) Two examination rooms for general oncology patients
e) Radiotherapy planning room with planning coach & measuring utensils at
least one
f) One store for immobilizers and consumables and
g) Conference room.

6.23.2.3 Minimal requirements for radiotherapy treatment rooms

a) Therathrone at least 2
b) Linear accelerator room at least 1
c) Simulation room 1
d) Brach therapy room 1
e) Office of Occupational Medicine (to prepare chemotherapy.)
f) Chemotherapy rooms with at least 3 coaches/ reclining chairs each, at least
2
g) Library with shelves for quick reference 1
h) Public toilets separate for male and female
i) staff toilets separate for male and female
6.23.2.4 Minimum requirements for inpatient section
(a) Nurses post 1
(b) Single bed rooms with ensuite bath room/toilets at least 2
(c) Rooms with 3 beds 4, (the distance between the beds shall be at least 1.2
meter)
(d) Rooms with 4 beds at least 2 (the distance between the beds shall be at
least 1.2 meter)
(e) Duty rooms for Doctors, 1
(f) Duty rooms for nurses 1
(g) Shared toilets at least 2
(h) Inpatient store
(i) Separate toilets for staff at least 1
(j) Moulding room at least 1
(k) Physics Lab with planning computers

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 (l) The single bedrooms shall be available as needed to accommodate
patients with neutropenia, or critically ill patient and the other single bed
room will be a septic room for those with offensive smelling wounds, that
needs wound care
(m)All patients will be provided with an environment conducive to
rest/recovery.
(n) The Oncology staff will promote patient hygiene by providing a bath or
shower for each patient daily. Daily morning care will include offering
mouth care, a wet washcloth, and repositioning the patient for breakfast.

6.23.3 Professionals
6.23.3.1 The oncology service shall have at least the following licensed professionals
a) Two clinical oncologists
b) Three general practitioners with adequate on job training in the care of
malignancies
c) Two medical physicist
d) Four radiotherapy technicians
e) Four radiographers with adequate on job training and assist the RTT
f) One full time technician
g) A mechanism to access biomedical engineer service. Document has to be
available to ensure this service to the regulatory body
h) Eight specialist oncology trained nurses
i) Ten staff nurses with adequate on job training
6.23.3.2 Other core allied licensed health professionals required are:
a) A dietitian
b) A physiotherapist
c) A speech therapist
d) An occupational therapist
e) An oncology pharmacist
6.23.3.3 Designated social worker/s who is a member of social work services of the
hospital shall be assigned to the unit to provide psychosocial services, assist
with discharge planning, and provide information regarding financial aspects of
care

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6.23.3.4 One data manager for the service is required

6.23.4 Products
6.23.4.1 All antineoplastic medicines and pain medications included in the national drug
list of Ethiopia shall be available at the hospital pharmacy
6.23.4.2 Supplies
a) Lead Bars ( supply)
b) Goggles for chemotherapy
c) Orfit Packs 5 per year
d) Moulding foams
e) Leaded Aprons at least 3, for RT planning, and simulation and C-Arm
imaging
6.23.4.3 Equipments
a) Teletherapy machines
 CO-60 machine at least 1
 Linear Accelerator at least 1
 Orthovoltage X-Ray 100KvP at least 1
 CT simulator at least 1
 C-Arm machines at least one
b) Brach therapy machines
 High dose rate source of CO-60 or low dose rate Cesium source 1
 Immobilization devices
 Breast Board Minimum 2, Plastic head rests A, B, C, D, E, F Total Two
Sets, thermoplastic head casts, head and neck uniframe immobilizer set
2
 Digitizer at least 1
 Moulding Machine( cutter) at least 2
 Planning computers with color printers at least 1 and with backup
system
 Boiler for orfit preparation 1
 Lead Melting machine for moulding lead at least 1
 Fume hood for chemotherapy mixing at least 1

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  Perfuser atleast 2
c) One brachytherapy machine
d) Simulation equipment : one CT simulator and C-Arm x-ray unit
e) Mould room equipment
 Alloy melting pot 1
 Steriofoam cutter 1
 Boiler for orfit preparation 1
 Coach 1
f) Dosimeter equipment
 Farmer dosimeter 1
 Electrometer 1
 Personal dosimeter 2
 Survey meter 1
 Appropriate Ion chambers to radiotherapy machines used
 Water phantom
 Barometer
 Digital thermometer
g) Treatment planning system
 Two computers with printers ( one of the printers should be colour
printer)
 Treatment planning software
 Digitizer
h) Immobilizers
 Breast board
 Plastic head rests ( with size A, B, C, D, E, F) two sets
 Head and Neck uniframe immobilizers two sets
 Pelvi-meter 1
 Flexi curve ruler 1
 Orfit packs as required
i) Chemotherapy equipment: One fume hood and two perfuser for
chemotherapy

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6.24 Nuclear Medicine Services

6.24.1 Practices:
6.24.1.1 The hospital shall have written procedure for in vitro techniques such as radio-
immunoassay (RIA) and immuno-radiometric assay (IRMA).
6.24.1.2 The hospital shall have written procedure for the diagnosis of different health
problems using radiopharmaceuticals or radionuclides for both in vivo imaging
and non-imaging diagnostic techniques.
6.24.1.3 Any loaner unit that is in use for more than one month will be required to submit
evidence of testing by a qualified medical physicist within 90 days of
installation. If the loaner is in place for longer than six months, the facility must
submit the unit for accreditation evaluation, including clinical and phantom
image assessment and the corresponding fee.
6.24.1.4 Acceptance testing and commissioning shall be performed based on written
policies and procedures. The procedures shall address the followings;
a) Major nuclear medicine instruments like Rectilinear Scanner, Whole
Body Scanner, Planar Gamma Camera, SPECT, PET, SPECT/CT, PET/CT
etc shall be tested during installation.
b) A qualified practicing medical physicist, nuclear medicine technologist
or medical physicist shall perform these tests using internationally
accepted protocols.
c) The test results shall be reviewed by the qualified medical physicist and
documented in the annual survey report. Based on this report the
supervising physician is responsible for assuring compliance with the
recommendations of the medical physicist.
d) External auditing shall be done at least annually. The performance tests
listed below shall be performed on all units as per the ENRPA or NEMA
and/or the IAEA QC protocols:
 Intrinsic Uniformity
 System Uniformity
 Intrinsic or System Spatial Resolution

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 Image Resolution Test
 Linearity Test
 Sensitivity
 Center of Rotation Test and Caliberation
 Energy Resolution
 Count Rate Parameters
 Formatter/Video Display
 Overall System Performance for SPECT Systems
 System Interlocks
 Dose Calibrators (Radionuclide Calibrator) - Performed as per the
protocol of NEMA or/and the IAEA to verify that readings from this
instrument are accurate (accuracy test). All basic measurements of
performance must be done at the time of installation and repeated
after major repair. This test must be done according to protocols
accepted by the appropriate National Regulatory Authority (Ethiopian
Radiation Protection Authority (ERPA)).
 “Test” measurement of battery voltage (if applicable)
 Zero adjustment (if applicable)
 Background adjustment
 Accuracy and precision tests with NIST traceable standard
 Linearity
 Geometry
 Constancy test
 Operational Checks (Check of Reproducibility and
Background Response)
 Thyroid Uptake Probe and Other Counting Systems for gamma
radiation measurements for in vitro (e.g. Gamma spectrometers/well-
type scintillation counters) - performed to verify, integral background
count rate, function of scalar timer/rate meter, energy calibration,
energy linearity, energy resolution, sensitivity, and reliability (Chi-
squared test) for the measurement of organ function, the assay of

257
 patient samples and for counting of other related radioactivity
sources using short and long lived radionuclides like:
 I-123 or I-131 capsule
 Tc-99m and
 long-lived standard calibration sources(e.g. Cs-137, Co-57)
6.24.1.5 The nuclear medicine technologist shall be responsible for verifying day-to-day
operation of instruments and performing a few additional tests on a quarterly
basis.
6.24.1.6 The following quality control tests shall be made by the nuclear medicine
technologist:
a) Intrinsic or System Uniformity (each day of use)
b) Intrinsic or System Spatial Resolution (weekly)
c) Center-of-Rotation or Multiple Detector Registration Calibration/Test
for SPECT Systems (monthly).
d) High-Count Floods for Uniformity Correction for SPECT Systems
(frequency as recommended by a qualified medical physicist).
e) Overall System Performance for SPECT Systems (quarterly).
f) Dose Calibrators (daily, quarterly, and semiannual)
 Daily - Tests are performed to verify that the calibrator is
accurate and reliable for the assay of doses administered to
patients.
 Quarterly - A linearity test must be performed to document that
accurate readings are provided through the entire range of
activities used clinically. Other qualified personnel may do these
tests.
 Semiannual - All non-exempt radionuclide sources must be
tested to verify that radioactivity is not leaking from the sources.
Other qualified personnel may also do these tests.
g) Thyroid Uptake and Counting Systems (each day of use) - Standards are
measured to verify energy calibration and sensitivity for the
measurement of organ function and the assay of patient samples.
6.24.1.7 Documentation of compliance with all quality control tests and corrective action
shall be required as part of the application process.

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6.24.1.8 Policies and procedures related to quality, patient education, infection control,
and safety shall be developed and implemented in accordance with the IAEA
Policy on Quality Control and Improvement, Safety, Infection Control and Patient
Education Concerns.
6.24.1.9 The site shall have a quality assurance program that incorporates the following
two elements:
a) Physician Peer Review: Examinations should be systematically reviewed
and evaluated as part of the overall quality improvement program at the
facility using written procedures.
b) Appropriateness/ outcomes analysis: The results of an
appropriateness/outcomes analysis and the actions taken to correct any
deficiencies should be maintained as quality assurance records at the
facility. Policy and procedures should be in place to look at the
diagnostic accuracy and outcome of nuclear medicine examinations.
Documentation may be requested as part of an on-site survey.
6.24.1.10 Data shall be collected and processed according to the instructions provided in the
testing package. The procedures may differ from those normally used by the
applicant but were designed to minimize the variability in the images submitted
by different facilities.
6.24.1.11 All films (or hard copies) or/and burned CDs are an important part of the medical
record. The following shall be permanently recorded on each image of the study:
patient name, patient age (or date of birth), patient identification number, date
of exam, and institution name. The technologist's name, initials, or other means
of identifying the technologist who performed the study shall also be indicated.
6.24.1.12 A corresponding, dated physician report that clearly states the type of
examination performed and the clinical history shall accompany all
examinations. The parameters that will be scored on the clinical images include:
radiopharmaceutical biodistribution, image acquisition, processing, and display,
as well as film and report identification. Patient films or/and the corresponding
hard copy or burned CDs shall be returned as required with the final report.
6.24.1.13 The hospital shall notify the regulatory body if they have permanently withdrawn
(i.e., removed) a unit from service, if they have replaced that unit with a new one
or have added another unit.

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 Radiopharmacy
6.24.1.14 The hospital shall have written procedure(s) for the preparation of various
radiopharmaceuticals.
6.24.1.15 The compounding and dispensing area for radioactive drugs shall be separate
from that of non-radioactive drugs, and shall be secured from unauthorized
personnel.
6.24.1.16 In addition to any labeling requirements for non-radioactive drugs, the immediate
outer container of a radioactive drug to be transported, stored and/or
dispensed shall also be labeled with:
a) the standard radiation symbol;
b) the words "Caution - Radioactive Material";
c) the radionuclide;
d) the chemical form;
e) the amount of radioactive material contained, in millicuries or
microcuries;
f) if a liquid, the volume;
g) the calibration time for the amount of radioactivity contained;
h) the expiration time; and
i) the name, address, and telephone number of the nuclear pharmacy
practice site.
6.24.1.17 The immediate container shall be labeled with:
a) the standard radiation symbol;
b) the words "Caution - Radioactive Material";
c) the name of the drug; and
d) the medical or prescription order number.
6.24.1.18 The amount of radioactivity shall be determined by radiometric methods for each
product immediately prior to dispensing.
6.24.1.19 A nuclear pharmacy practice site shall conduct and keep proper records of
appropriate internal test assessments on all radiopharmaceuticals, with
interpretation of the resulting data to determine suitability for use in humans.
6.24.1.20 A nuclear pharmacy practice site shall conduct authentication of product history
by identifying and keeping proper records of the purchasing source, the ultimate

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 fate, and any intermediate handling of any component of a
radiopharmaceuticals.
6.24.1.21 Products shall be protected from unintended discharges arising during its
preparation and the environment shall be protected from unintended discharge
of radioactive materials from the radiopharmacy
6.24.1.22 The hospital shall have written procedure for the management and disposal
of radiopharmaceutical and other nuclear medicine wastes.

6.24.2 Premises
6.24.2.1 Adequate facilities shall be provided for the overall service delivery so that patient
comfort, safety, dignity, and privacy are ensured as well as staff comfort and
safety. Areas must have sufficient space, be well maintained and be clean. This
includes:
(a) Interpretation areas
(b) Patient records, reports, and digital data storage areas
(c) Administration records and support areas
(d) Equipment/supply storage areas
(e) Therapeutic procedures areas, if applicable
(f) Waiting, reception, and patient/staff bathrooms
(g) Radioactive materials use and storage areas
(h) Diagnostic imaging and processing areas which shall include adequate space
and proper orientation to eliminate “cross talk” (counts being acquired from
other than the patient being imaged) into images from other patients,
radioactive materials, or radioactive waste.
(i) Patient education, consultation and examination areas including accessible
hand washing for staff
(j) Performance of stress procedures within appropriate proximity of the
imaging area including adequate space for performing resuscitation in case
of emergency
6.24.2.2 Adequate space, facility configuration, and doorways for the emergency transport
of patients from patient care areas and for emergency exit of staff.

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6.24.2.3 Adequate utilities shall be available, based upon the types of procedures and
workload. These include water taps, lighting, electrical outlets, emergency
power, telephones, heating/cooling and ventilation.
6.24.2.4 All surfaces of Radiopharmacy: walls, floors, benches, tables and seats shall be
smooth, impervious and non-absorbent, to allow for easy cleaning and
decontamination.
6.24.2.5 Adequate space shall be provided for the storage of digital data. The storage must
ensure confidentiality of data and should be safe from fire/flood.
6.24.2.6 In-vitro section of the nuclear medicine shall have a minimum of 24 meter square
space to conduct all RIA/IMRA procedures.
6.24.2.7 A nuclear pharmacy practice site shall contain adequate space,
commensurate with the scope of services required and provided.
6.24.2.8 All pharmacy practice sites handling radiopharmaceuticals shall provide adequate
radioactive storage and product decay area, preferably at the hot laboratory.
Besides, there shall be the compounding, dispensing, quality control/assurance
and office areas.
6.24.2.9 Radiopharmacy shall have a minimum of 40 m2 space with two or more rooms.
6.24.2.10 Imaging section of the nuclear medicine service shall have a minimum of 30 meter
square space to install and use one SPECT machine
6.24.2.11 Additionally, minimum space requirement for examination room 30 m2, patient
waiting area 20 m2 (two rooms for active and passive patients), injection room
10 m2 and office rooms 50 m2
6.24.2.12 Others like staff and patient toilets separate for male and female, office and
reception area shall be available

6.24.3 Professionals
6.24.3.1 The clinical nuclear medicine service of the hospital shall be directed by a licensed
specialized medical doctor who has been trained in nuclear medicine.
6.24.3.2 The Radiopharmacy service of the hospital shall be directed by a licensed
pharmacist who has been trained in nuclear pharmacy.
6.24.3.3 In addition, the nuclear medicine service of the hospital shall have at least the
following licensed professionals

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 a) Nuclear medicine technologist: A radiographer with B.Sc degree in
Radiography and who has been trained in nuclear medicine technology
b) Nuclear medicine technician: A radiographer with Diploma in
Radiography and who has been trained in nuclear medicine technology
c) RIA/IRMA Technologist: A biologist/ chemist /laboratory technologist/
pharmacist who has been trained in RIA/IMRA techniques.
d) Nuclear medicine physicist: A physicist who has been trained in nuclear
medicine physics
e) Radiopharmacy technician: A pharmacy technician who has been trained
in nuclear pharmacy services
f) Nuclear medicine nurse: A nurse who has been trained in nuclear
medicine services.
g) Nuclear medicine engineer/Biomedical engineer (may not be necessary
as full time job).
h) Radiation protection committee presided by Radiation Protection Officer
or Radiation Safety Officer.

6.24.4 Products
6.24.4.1 The following shall be minimum equipment requirements for RIA/IMRA work:
a) Refrigerator
b) Deep freezer
c) Centrifuge to hold 60-100 tubes
d) Thermostatically controlled water bath
e) Ice bath
f) RIA Counter
g) Distilling or de-ionizing water
h) Voltage stabilizer,
i) Precision balance
j) Semi-analytical balance
k) Magnetic stirrer with Teflon coated stirring bars,
l) Vortex mixer,
m) Automatic pipette washer,
n) Scientific calculator

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 o) Ultrasonic cleaner
p) Foot-operated dustbin
q) Air conditioner
r) Centrifuge
s) Survey meter data ‘monitor’
6.24.4.2 The following equipment shall be needed for the QC of Scintillation Gamma
Camera:
a) Sufficient Supply of Tc-99m Generators
b) Co-57 Flood Source
c) Four Quadrant Bar Phantom
d) SPECT Phantom
e) Disposable; Petri dish, Capillary tubes
f) The following Equipments are also recommended in order to follow
good work practices:
 Refillable flood source
 Copper plates for evaluation of count rate response
 Computer generated test image
6.24.4.3 The following shall be the list of Equipment and Instrumentation used in the
imaging and clinical nuclear medicine section:
a) Dose calibrator or decay correction calculation system
b) Imaging/counting equipment
c) Radiation monitoring devices including
 portable survey meter (required)
 removable contamination counting equipment (as applicable)
 fixed area survey meter for dose preparation/storage areas (as
applicable)
d) Resuscitation equipment and supplies (appropriate to the types of
procedures being performed)
 oxygen
 defibrillator/AED (checks scored in B3.3.1)
 emergency drugs (including a master list; all unexpired)
e) Exercise equipment (as applicable)
f) ECG equipment (as applicable)

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 g) Ancillary monitoring equipment (as applicable)
h) Infusion pumps/automated injectors (as applicable)
i) Glucometers (as applicable)
j) Hood for volatile radionuclides or cell handling (as applicable)
k) Xenon (or other gas) trap (as applicable)
l) Lead apron, decontamination solution, goggle and thyroid shield

6.24.4.4 Each nuclear pharmacy practice site shall contain at least the following list of
products (equipment):
a) Radiopharmaceuticals and non-radioactive supplies as per the national
drug list
b) Vertical laminar flow hood;
c) Dose calibrator;
d) Gamma spectrometer;
e) Analytical balances and PH Meters
f) Lead pot, lead syringe carrier and lead bencher with glasses
g) Refrigerator, dry and wet autoclaves
h) Radiation exposure monitor;
i) Portable survey meter;
j) Single or multiple channel scintillation counter;
k) Microscope, test tubes, different supplies;
l) Radio chemical exhaust hood and filter system
m) Lead apron, decontamination solution, goggle and thyroid shield

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6.25 Hemo-Dialysis Service

6.25.1 Practices:
6.25.1.1 There shall be a written policy or protocol stating the admission criteria, the
procedures and steps to be followed.
6.25.1.2 Hemodialysis can be an outpatient or inpatient therapy.
6.25.1.3 Routine Hemodialysis is conducted in a dialysis outpatient facility, either a
purpose built room in a hospital or a dedicated, stand alone clinic.
6.25.1.4 Dialysis clinic shall be directed by a physician trained and certified on dialysis
treatment from recognized institute,
6.25.1.5 Dialysis treatment shall be approved by nephrologist or trained physician. The
duration and frequency of dialysis treatment shall be stated by ordering
physician.
6.25.1.6 Dialysis treatments shall be initiated and managed by specialized staffs made up
of nurses and technicians who have got proper training and certificate on
managing the dialysis machine.
6.25.1.7 All the indications and lab investigations with plan shall be documented on
patient’s record.
6.25.1.8 There shall be proper written and verbal instruction for patients about dialysis
process and the machine used.
6.25.1.9 There shall be a red alarm light and an audible beep on the machine.
6.25.1.10 The set up is intensive care, there shall be isolation and restriction of traffic.
6.25.1.11 There shall be protocol for Infection control and management of waste from
dialysis machine.
6.25.1.12 There shall be a protocol and practice that before the patient is connected, the
machine should be setup and rinsed.
6.25.1.13 The patient or guardian or care giver shall be oriented, explained about the
machine and its part before and during the dialysis process.

6.25.2 Premises
6.25.2.1 The dialysis clinic or unit shall be located in the hospital facility where the traffic
is very restricted.

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6.25.2.2 Shall be accessible and well identified.
6.25.2.3 The size of the room depends on the number of dialysis machines available. The
dialysis room shall be at least 3m x 4m in size that accommodate one dialysis
machine and one dialysis patient bed.
6.25.2.4 The header of beds or dialysis chairs shall be 0.5m away from the wall. There
shall be a 1m wide free traffic area by side of beds and between any of two beds.
6.25.2.5 There shall be a nurse station area within the room having a clear view to see the
patient and dialysis machine. Wash basin shall be available close by
6.25.2.6 Nurse station in the dialysis unit:
s) Isolated with glass, Full visual access to monitor admitted patient on
machine,
t) Equipped with chairs, working laminated top tables, drawers and
computers, Linen boards, shelves, lockers
u) Telephone end,
v) Medication boards, Controlled drug locker,
w) Calculators,
x) Weight scale,
y) Patient screen per bed and
z) Dust bins
6.25.2.7 There shall be separate leak proof containers on trolley for used dialysis sets and
waste products.
6.25.2.8 In addition to the dialysis room, the unit shall have the following spaces (rooms):
toilets, utility room, and store
6.25.2.9 Toilet: It shall also have patient toilet and shower facilities.
6.25.2.10 Nurse locker room: There shall be a staff locker room in proximity. The dialysis
room is generally regarded as a sterile zone and there shall be shoe and cloth
change point for staff and attending families.
6.25.2.11 Sluice room: There shall be soiled utility/sluice room which acts as a storage area
for contaminated materials until they are disposed off. It can also serve as
temporary station for equipments until disinfected and cleaned. The soiled
utility room shall have a deep bowel sink, a hand wash basin with hot and cold
water, plus cabinet and shelves.

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6.25.2.12 Store room: There shall be a store room at least 4m x 4m in size used for storage
of consumables and spare equipments. It shall be equipped with cabinets and
shelves. Materials shall be labeled, arranged in order, ready for use (charged)
and there shall be ventilation and enough light.
6.25.3 3. Professionals
6.25.3.1 The dialysis unit or clinic shall be directed by nephrologists or internist who has
training on Dialysis.
6.25.3.2 At least one certified physician on dialysis shall have clinical responsibility for the
standard of care rendered in dialysis unit.
6.25.3.3 The physician or the nurse working in the unit and or running the dialysis
machine shall have completed a formal training program in dialysis.
6.25.3.4 Professional numbers:
Nephrologists / trained physician at least 1
Trained nurse one for two machines
Registered nurses 3
Cleaners 2 (shared)
Porters 3 (shared)

6.25.4 Product

6.25.4.1 Hemodialysis machine at least 2 per dialysis unit

6.25.4.2 Water treatment facility: This includes sand filter, carbon filter and reverse
osmosis machine.

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6.26 Radiological Services
6.26.1 Practices
6.26.1.1 The radiology service shall have written policies and procedures that are
reviewed at least once every five years and implemented. These policies and
procedures shall include at least:
a) Radiation protection and safety practices;
b) Emergencies;
c) Adverse reactions;
d) Management of the critically ill patient;
e) Infection control, including patients in isolation;
f) Diagnostic imaging and result delivery
g) Quality control program covering the inspection, maintenance, and
calibration of all equipment
6.26.1.2 Policies and procedures for radiology services shall be available to all staff in the
radiology unit.
6.26.1.3 All conventional x-rays should be taken by trained radiographer or radiological
technologists
6.26.1.4 All x-rays imaging requests shall be done by licensed physician
6.26.1.5 There shall be a written protocol for managing medical emergencies in the
radiological suite. All radiological staff shall be instructed in this protocol and
know their roles in the case of such an emergency.
6.26.1.6 Radiologists shall supervise and interpret all radiologic procedures, unless
performed by clinical practitioners in specialty areas who are trained and
experienced in these procedures.
6.26.1.7 All radiologic tests shall be interpreted on a preliminary basis within 24 hours at
all times.
6.26.1.8 Ultrasound service shall be given by a radiologist or any health professional
trained and certified on ultrasound
6.26.1.9 The radiology service of the hospital shall have the following services at all
times
(a) Conventional x-ray,

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 (b) Computer tomography service.
(c) MRI ( magnetic resonance imaging) services
(d) Ultrasound service.
(e) Mammography
(f) Special procedures such as angiography and interventional procedures
6.26.1.10 The radiology staff shall make every effort to ensure that patients waiting for
radiology services or transport from radiology are comfortable while waiting
and that the service responsible for transporting the patient back to the unit is
notified when the patient is ready to be returned.
6.26.1.11 The radiology service unit shall be free of hazards to patients and personnel.
6.26.1.12 Proper safety precautions shall be maintained against fire and explosion
hazards, electrical hazards, and radiation hazards.
6.26.1.13 The hospital shall get approval from the Ethiopian Radiation Protection
Authority through periodic inspection and hazards shall be promptly corrected
if identified
6.26.1.14 Radiation workers shall be checked periodically for amount of radiation
exposure by the use of exposure meters or badge tests and this shall be
documented
6.26.1.15 With fluoroscopes, attention shall be paid to modern safety design and
operating procedures and records all fluoroscopes’ output shall be maintained.
6.26.1.16 Signed reports shall be filed with the patient's medical record and duplicate
copies kept in the service unit.
6.26.1.17 Requests by the attending physician for x-ray examination shall contain a
concise statement of reason for the examination.
6.26.1.18 Reports of interpretations shall be written or dictated and signed by the
radiologist.
6.26.1.19 Reporting form shall have minimum information such as name of institution,
date, patient name, age, gender, findings and name and signature of radiologist
6.26.1.20 X-ray reports and roentgenographies shall be preserved or microfilmed
according to the country’s laws.
6.26.1.21 X-ray films shall be labeled with minimum information such as date, name, age,
gender, right/left mark and name of radiographer.
6.26.1.22 Radiology services shall operate according to applicable country’s laws.

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6.26.1.23 A radiation protection and safety program including timely reporting of
radiation safety findings shall be in place, followed, and documented.
6.26.1.24 The professional/practitioner who delivered the radiology service shall be
responsible for claims arising from wrong findings
6.26.1.25 Radiology services shall physically accessible to all requiring medical service
units.
6.26.1.26 Safety provision shall be available based on minimum criteria set by the
Ethiopian Radiation Protection Authority
6.26.1.27 Radiological equipment quality assurance/control test shall be available
6.26.1.28 Dark room design and accessories shall meet the requirements set by Ethiopian
Radiation Protection Authority (ERPA)
6.26.1.29 The radiology service staff shall be supplemented with dietary protections as
required by the Ethiopian Radiation Protection Authority.

6.26.2 Premises
6.26.2.1 All radiation generating equipment shall be installed with a building wall
thickness that fulfills the minimum criteria set by the Ethiopian Radiation
Protection Authority /IAEA
6.26.2.2 Radiology service equipments shall be installed at central areas to all clinical
services
6.26.2.3 Minimum number and size of rooms within radiology services are indicated
below
Type of premises Number required Size(m2) Each
Conventional x-ray room 2 As per ERPA
Fluoroscopy room 1
CT room* 1
MRI room* 1
Mammography room 1
Ultrasound room 3
Angiography room 1
Dark room 1
Staff and Patients toilets 4
Patient dressing rooms 4

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 Waiting rooms 1
Reporting room 1
Doctors rooms 1
Duty room 2
Store room 1
Conference and data room 1
Computerized x-ray unit 1
Technician room 1
Film library/Archive 1

** The number of rooms of MRI and CT should depend on the requirement of specific
equipment
* Digital image archiving and printing is preferable

6.26.3 Professionals

6.26.3.1 All radiologists performing diagnostic radiology services in the hospital shall be
registered by the Authority.
6.26.3.2 A radiologist shall be available in the hospital during working hours all the time
or if on call shall arrive within 30 minutes of being summoned
6.26.3.3 A registered radiology technologist or radiographer or experienced technician
shall be present in the hospital at all times.
6.26.3.4 A registered interventional radiologist shall be available preferably all the times
and is responsible to conduct interventional procedures like angiography,
vascular catheterization, stent placement, image guided biopsy and fluid
drainage.
6.26.3.5 A registered radiology technologist shall participate in conventional x-ray
taking, assisting the radiologist during special procedures and compiling and
reporting departmental activities.
6.26.3.6 A registered professional nurse shall be available in the radiology service to
administer medications and perform other nursing duties.
6.26.3.7 Equipment maintenance engineer as part time shall be available to ensure the
proper functioning of all diagnostic radiology equipment.

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6.26.3.8 X-ray technician for dark room, a receptionist, cleaners shall be available in
radiology service as full time.

6.26.4 Products

6.26.4.1 All medical equipments which shall be available for radiology services at this
hospital level are indicated below
a) Two color duplex ultrasound machines for general purpose.
b) One dedicated echocardiography ultrasound machine with cardiac probe.
c) Two standard conventional x-ray machines
d) Combined x-ray machine(x-ray with fluoroscopy)
e) One high quality CT machine
f) One high quality MRI machine ( High Tesela)
g) One mammography machine
h) Manual & automatic processor
i) Quality controls tools
j) Video recorder
k) Viewing boxes
l) Resuscitation equipments
m) A refrigerator
n) Telephone service
o) Emergency drugs/supplies
p) Procedure sets
q) Computers and typewriter
r) Dark room accessories
s) Actinic marker

6.26.4.2 At least the following radiation protection equipments shall be available in

radiology services:
a) lead gloves
b) lead apron
c) Gonad shield
d) lead eye-glass/goggle

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 e) Dosimeter
6.26.4.3 Safety procedures during practices and disposal of unfit for use equipments
shall be installed as per the requirements set by the Ethiopian Radiation
Protection Authority during all procedures.

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6.27 Pathology Services

6.27.1 Practices
6.27.1.1 There shall be written procedures and protocols for pathology service.
6.27.1.2 The pathology service shall be available for at least 8-hours of a day
6.27.1.3 In the absence of a pathologist there shall be an established procedure for
sending to a pathologist outside the hospital all tissues requiring examination.
6.27.1.4 All tissues removed during surgery shall be subjected to examination by the
pathology service unit.
6.27.1.5 All examined results shall be signed by the pathologist
6.27.1.6 Signed reports of tissue examinations shall be filed within the patient's medical
record and duplicate copies kept in the pathology service unit.
6.27.1.7 A tissue file paraffin blocks and slides shall be maintained in the hospital.
6.27.1.8 There shall be a QA and QC mechanism for Pathology services.

6.27.2 Premises
6.27.2.1 The hospital shall have an organized separate pathology service area
6.27.2.2 The pathology service shall have the following facilities:
(a) Surgical Pathology:
 Reception & Recording room
 Gross room
 Tissue processing room
 Special stain room
(b) Histochemistry Unit:
 Immunostaining room
 Microscope reading room
 Store with two shelves (Chemical & Reagent)
(c) Cytology Examination Unit:
 Reception room
 Waiting room
 Procedure room

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  Superficial organ aspiration room
 Aspiration of internal organs room
(d) Autopsy Unit:
(which shall be close to the morgue with dead body freezer and good
ventilation):
 Procedure room
 Dressing room with locker, toilet and shower
 Reception & Record room
 post mortem technician/assistant room
(e) Frozen section unit:
(f) Forensic Autopsy: (Optional)

6.27.2.3 In addition, the pathology service shall have the following rooms for:
(a) Service head office
(b) Pathologists office
(c) Photography room
(d) Chief Lab. Technician room
(e) Lab. Technician room with lockers
(f) Store room for Paraffin block
(g) Toilet rooms for staff and patients (Male and Female)
6.27.3 Professionals
6.27.3.1 All pathology services shall be organized and directed under the direct
supervision of a pathologist on a full-time.
6.27.3.2 The pathologist shall participate in staff, departmental and clinical-pathologic
conferences.
6.27.3.3 All tissues removed from patients during surgery shall be macroscopically, and
if necessary, microscopically examined by the pathologist.
6.27.3.4 A list of tissues which routinely require microscopic examination shall be
developed in writing by the pathologist or designated physician with the
approval of the medical staff
6.27.3.5 The number and type of technical staff shall be determined by the volume and
type of work carried out (Workload Analysis). The following staffs shall be
available:

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 (a) Autopsy unit
 A Pathologist (shared with surgical)
 A Lab. Technician
 An Autopsy assistant
 A Post mortem technician/assistant
(b) Surgical Pathology
 A Pathologist (shared with autopsy)
 Two Lab. Technicians
(c) Histochemistry
 A Pathologist (shared with Cytology)
 A Lab technician
(d) Cytology examination unit
 A Pathologist (shared with histochemistry)
 Two Lab. Technicians
6.27.4 Products
6.27.4.1 Autopsy Unit
(a) Procedure Room:
 One body table with cold and warm water sinks
 Display table with glass curtail
 Cupboard for instruments
 Refrigerator
 Scale
 Pedaled tape recorder
 Video camera with screen/Camera with stand
(b) Dressing Room with documentation facility:
 Locker
 Reading table with two chairs
 Book shelves
 Computer
 Toilet and shower

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 (c) Reception and Record Room:
 Shelf with locker
 File cabinet
 A table with two chairs
 Computer
(d) Postmortem Technician/Assistant Room:
 Personal locker
 A table with two chairs
6.27.4.2 Surgical Pathology Unit
(a) Reception and Record Room (can be shared with gross room):
 Lab. table or counter
 Computer
 Shelf
(b) Gross Room:
 One dissection table with cold and warm water
 one dissect table cutting board placed in metal box and ready access to
a sink with cold and warm water
 One wheeled chair
 Pedaled recording tape
 Camera with stand
 Lidded garbage container
 Tissue shelf store
 X-ray
 Electric skull saw
 Box for instruments
i. Heavy & small scissors
ii. Different size smooth & toothed forceps
iii. Malleable probe
iv. Scalpel handle
v. Disposable bladders
vi. King knife
vii. Pins for attaching specimen to a cork surface.

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(c) Tissue Processing Room:
 Two embedding system lab tables
 Tissue processor –vacuum processor and Rotary processor
 Dry air oven
 Refrigerator large & small
 Freezer
 Balancer weighing scale
 Microtome
 Box with cassettes and labels
 A large formalin container
 Water bath
 HE staining table
 Fume extractor
 Knife sharpener
 Large sink for dissection of wage specimens
 Central table for multiple use
 Ruler
(d) Special stain rooms with fume extractor
(e) Histochemistry Room:
 Lab table
 Rotary chair
 Refrigerator
 Microtones
 Water bath
 PH meter
 Staining bench
(f) Immunostaining Room:
 Refrigerator
 Microtones
 Water bath
 PH meter

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  Staining bench
(g) Microscopy Reading Room:
 Two multiple headed microscopes >6 heads at a time
 12 metal stools
(h) Chemical Reagent Store:
 Two shelves
 Lab. Table two rotary chairs
 Fume extractor
6.27.4.3 Cytology Examination unit
(a) Reception and Record Room:
 Office table
 Two chairs
(b) Waiting Room: 10 chairs
(c) Procedure Room:
 One coach table
 One office table
 One reading table
 One mobile illumination
 One rotary chair
 One locker
6.27.4.4 Office Facilities
(a) Service head office
 Office tables arranged in T-pattern
 Book shelf
 File cabinet
 Bi-headed microscope
 Swivel chair
 Normal chair
 Computer
(b) Secretary office
(c) Consulting pathologist office

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  Office table
 Book shelf
 File cabinet
 Bi-headed microscope
 Swivel chair
 Normal chair
 Computer
(d) Photography room
 Bi-headed microscope fitted to video camera
 Camera (normal and video)
 Chair
 Computer
 Video
 TV
(e) Chief Lab. Technician room
 Microscope
 Office table
 Chair
 Computer
 File cabinet
 Meeting room

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6.28 Medical Laboratory Services

6.28.1 Practices

6.28.1.1 The laboratory shall have written policies and procedures and include at least
the followings:
a) Procedure manuals (Standard Operating Procedure, SOP) or guidelines
for all tests and equipment
b) Report times for results (Established turn around time)
c) Quality assurance and control processes
d) Inspection, maintenance, calibration, and testing of all equipment
e) Management of reagents, including availability, storage, and testing for
accuracy
f) Procedures for collecting, identifying, processing, and disposing of
specimens
g) All normal ranges for all tests shall be stated
h) Laboratory safety program, including infection control
i) There shall be documentation of quality control data (internal and
external quality control), calibration report, refrigerator readings and so
on.
6.28.1.2 The hospital shall have policies and procedures for the availability of paper
based or electronic laboratory information management system (LIMS). The
data management system shall include the followings:

a) Periodic reporting(monthly, quarterly)

b) Preliminary analysis and utilization of results

c) Collection of useful and appropriate information

d) Archiving and retrieval

6.28.1.3 The hospital shall have standardized data collection instruments and including
at least the followings:

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 a) Laboratory request forms

b) Laboratory report forms

c) Laboratory specimen and results registers

d) Quarterly/monthly reporting forms including

 Summary of tests conducted

 Summary of tests referred
 Summary of quality assurance report

e) Equipment and supplies inventory registers

f) Quality assurance record forms

g) Referral forms

6.28.1.4 The hospital shall develop monitoring and evaluation tools to assess activities
including:

a) adherence to SOPs

b) adherence to safety guidelines

c) QA activities

d) Laboratory performance and workload

e) Laboratory services

6.28.1.5 The hospital shall have policies and procedures for the availability of laboratory
services including the emergency services for 24 hours a day and seven days a
week, including holidays.
6.28.1.6 The laboratory shall have procedures or (SOP) for proper specimen collection
that address specific collection requirements such as:
a) Preferred sample type (venous, arterial, capillary, urine, spinal fluid)
b) Type of anticoagulant
c) Sample volume considered acceptable
d) Patient identification

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 e) Requirements for patient preparation and storage of specimens.
6.28.1.7 Policies and procedures shall be documented and communicated to concerned
personnel.
6.28.1.8 The laboratory shall have a policy for making amendments and corrections to
laboratory procedures and all amended laboratory procedures shall be
reviewed and approved for use.
6.28.1.9 Test procedures developed by the laboratory (in-house procedures) must be
validated and fully documented before being put into use. All procedures shall
be in a language commonly understood by laboratory staff.
6.28.1.10 The laboratory shall follow standard operating procedures (SOP) and conduct
routine quality assessments to ensure reliable and cost-effective testing of
patient specimens.
6.28.1.11 Laboratory management shall review all operational procedures at regular
intervals. The frequency should be every four month (at least annually).
6.28.1.12 The process of analysis shall be specified by validated written or electronic
procedures maintained in and by the laboratory. Procedures may be written by
the laboratory staff or may be adapted from previously published materials
including, but not limited to, product inserts, procedure or instrument manuals,
textbooks, journals, or international guidelines.
6.28.1.13 Laboratory staff shall test quality control materials every eight hour and
document in combinations suitable to detect analytical error.
6.28.1.14 The right patient with the right request form shall be identified during collection
and delivery of result.
6.28.1.15 Requests for testing shall provide:
a) The name of the ordering physician or other person authorized to
order testing
b) The clinician’s working address
c) Type of primary sample collected
d) The anatomic site where appropriate
e) The test requested
f) Patient gender
g) Age

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 h) Pertinent clinical information as appropriate for purposes of test
interpretation (Clinical Diagnosis)
i) Date and time of sample collection and receipt in the laboratory
6.28.1.16 There shall be SOP or criteria developed for acceptance or rejection of clinical
samples.
6.28.1.17 Laboratory shall monitor the transportation of samples to the laboratory such
that they are transported, within time frame, within temperature interval
specified in the primary sample collection manual or SOP and in a manner that
ensures safety for carrier.
6.28.1.18 The laboratory shall maintain a record of all samples received.
6.28.1.19 Laboratory shall have a procedure for storage of clinical samples if it is not
immediately examined.
6.28.1.20 Patient samples shall be stored only for as long as necessary to conduct the
designated tests (or other permitted procedure) according to fixed storage
times, and shall be destroyed safely and confidentially after storage.
6.28.1.21 Once a sample is used, it shall be maintained in the laboratory for a specified
period of time (or as required by regulation) and at a temperature that ensures
stability of the sample in the event the sample is needed for retesting.
6.28.1.22 The hospital shall carry out clinical laboratory examinations including clinical
chemistry, microbiology, hematology, coagulation, general immunology,
serology, parasitology, urine and body fluid analysis, mycology and clinical
microscopy
6.28.1.23 There shall be documentation of inspection and quality control of the tests done
under the hospital.
6.28.1.24 Laboratory report
a) All laboratory test result/reports shall have reference (normal) ranges
specific for age and gender.
b) Copies or files of reported results shall be retained by the laboratory
such that prompt retrieval of the information is possible. The length of
time that reported data are retained shall be 5 years for legal reason
minimal errors or loss of patient test results.

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 c) Reports shall be filed with the patient's medical record and duplicate
copies shall be filed in the laboratory in a manner which permits ready
identification and accessibility and with appropriate backup.
d) In the case of laboratory tests performed by an outside laboratory, the
original report from such laboratory shall be contained in the medical
record.
e) Quality assured test results shall be reported on standard forms to the
physician with the following minimum information:
 Patient identification (patient name, age, gender,)
 Date and time of specimen collection
 The test performed and date of report.
 The reference or normal range
 The laboratory interpretation where appropriate,
 The name and initial of the person who performed the test, and the
authorized signature of the person reviewing the report and
releasing the results.
 Hospital address
f) Laboratory results shall be legible, without transcription mistakes and
reported only to persons authorized to receive them such as the
ordering physician or nursing staff in a hospital environment
g) The laboratory shall have policies and procedures in place to protect the
privacy of patients and integrity of patient records whether printed or
electronic. Policies shall be established which define who may access
patient data and who is authorized to enter and change patient results,
correct billing or modify computer programs.
6.28.1.25 When reports altered, the record shall show the time, date and name of the
person responsible for the change.
6.28.1.26 Safe disposal of samples shall be in line with standards prescribed under
infection prevention
6.28.1.27 No eating, drinking, smoking or other application of cosmetics in laboratory
work areas or in any area where workplace materials are handled.
6.28.1.28 No food and drink to be stored in the laboratory (may be stored in the rest area)

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6.28.1.29 The medical laboratory shall have safety guideline. In addition, the laboratory
shall protect the environment and public by assuring the health laboratory
waste is disposed of legally and an environmentally friendly manner
6.28.1.30 Wearing of protective clothing of an approved design(splash proof), always
fastened, within the laboratory work area and removed before leaving the
laboratory work area
6.28.1.31 At regular intervals, the laboratory shall review any contracts for services to its
clients (including but not limited to clinicians, health care bodies,
pharmaceutical companies, other departments such as pharmacy or nursing
within the hospital structure) to ensure that the laboratory can meet the
contractual requirements such as methodologies, turn-around times, availability
of expert opinion, etc. Records of these reviews shall be kept and maintained by
the laboratory, including deviations from contracts.
6.28.1.32 Where services are provided by an outside laboratory, the conditions,
procedures, and availability of services offered shall be in writing and available
in the hospital.
6.28.1.33 The laboratory shall meet regularly with clinical staff regarding services and
clinical interpretations.
6.28.1.34 The laboratory must keep a record of the complaint. The record shall include the
nature of the complaint, the date of occurrence, individuals involved, any
investigations undertaken by the laboratory and resolution.

6.28.2 Laboratory Premises

6.28.2.1 The hospital shall have a well organized, adequately supervised and staffed
clinical laboratory with the necessary space, facilities and equipment to perform
those services commensurate with the hospital's needs for its patients.
6.28.2.2 The laboratory working environment shall be kept organized and clean, with
safe procedures for handling of specimens and waste material to ensure patient
and staff protection from unnecessary risks at all time.
6.28.2.3 The laboratory shall have space allocated so that its workload can be performed
without compromising the quality of work, quality control procedures, and
safety of personnel or patient care services.

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6.28.2.4 The laboratory shall have adequate space and a safe environment to perform
testing. It must provide adequate lighting, ventilation, water, waste and refuse
disposal. Work areas shall be clean and well maintained. Precautions must be
taken to prevent cross contamination.
6.28.2.5 The laboratory shall have controlled temperature of refrigerator for reagents,
blood sample, calibrator, control materials which affect the analytical results.
6.28.2.6 Facilities shall provide a suitable environment to prevent damage, deterioration,
loss or unauthorized access.
6.28.2.7 The laboratory shall be located and designed to
 provide suitable, direct access for patients
 allow reception of deliveries of chemicals
 allow safe disposal of laboratory materials and specimens.
6.28.2.8 Doors shall be located in places where entry and exit is easy and does not
interfere with the laboratory benches or equipment. Laboratory doors shall not
be less than 1 m wide to allow easy access of equipment. In some areas, double
doors, 1.2 m wide, shall be provided for passage of large equipment, such as
deep-freezes. All doors shall be opened towards the corridor.
6.28.2.9 There shall be effective separation between adjacent laboratory sections in
which there are incompatible activities.
6.28.2.10 The following shall be minimum space for comprehensive specialized hospital
laboratory
a) One main working room for recording and reporting (9 m2)
b) Specimen collection room (15 m2)
c) Medical Microbiology room (40 m2)
d) Serology room (12 m2)
e) Parasitology and urine analysis room (16 m2)
f) Two viral load rooms (4m2 and 4 m2)
g) Hematology room (12 m2)
h) Clinical chemistry room (16 m2)
i) Sterilization, disinfection and media preparation
room (16 m2)
j) Store-room (9 m2)
k) Staff room and office (12 m2)

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 l) Separate Toilets for patients (2 for Male and 2 for female)
m) Separate Toilet for staff (Male and female)
n) There shall be access to shower upon emergency
6.28.2.11 The laboratory facilities shall meet at least the following:
a) The laboratory shall have a reliable supply of running water. At least two
sinks shall be provided in each room, one for general laboratory use and
the other reserved for hand washing and at least 5000L reserve tank in
case of interruption.
b) Continuous power supply
c) Working surface covered with appropriate materials
d) Suitable stools for the benches. Bench tops shall be impervious to water
and resistant to moderate heat and the organic solvents, acids, alkalis,
and chemicals used to decontaminate the work surface and equipment.
e) Internal surfaces, i.e. of floors, walls, and ceilings shall be :
 Smooth, impervious, free from cracks, cavities, recesses, projecting
ledges and other features that could harbor dust or spillage
 Easy to clean and decontaminate effectively
 Constructed of materials that are non-combustible or have high
fire-resistance and low flame-spread characteristics
f) Laboratory furniture is capable of supporting anticipated loading and
uses. Spaces between benches, cabinets, and equipment are accessible
for cleaning.
g) Lockable doors and cupboards
h) Closed drainage from laboratory sinks to a septic tank
i) Facilities for disposal of contaminated materials and solid waste
j) Separate toilets/latrines for staff and patients
k) Emergency of safety services such as deluge showers and eye-wash
stations, fire alarm systems and emergency power supplies shall be
included in the laboratory services design specifications
l) Telephone or radio communication.

6.28.3 Laboratory Professionals

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6.28.3.1 All laboratory services shall be directed by a licensed medical laboratory
technologist.
6.28.3.2 Medical Laboratory staff shall be present at the hospital to provide laboratory
service at all times.
6.28.3.3 Students and other staff on attachment shall work under the direct supervision
of a licensed medical laboratory technologist.
6.28.3.4 The Laboratory service shall have and maintain job descriptions, including
qualifications to perform specific functions.
6.28.3.5 The Laboratory management shall provide adequate training, continuing
education or access to training for technical staff, and assess staff competency at
regular intervals.
6.28.3.6 Laboratory staff shall, at all times, perform their functions with adherence to the
highest ethical and professional standards of the laboratory profession.
6.28.3.7 In general the following shall be the minimum laboratory staffing requirements.
a) One professional with masters of degree in any of the clinical laboratory
science specialties (Hematology , clinical chemistry, laboratory
management and Medical microbiology)
b) Two Medical Laboratory Technologists (BSc) for hematology
c) One Medical Laboratory Technologists (BSc) for clinical chemistry
d) Four Medical Laboratory Technologists (BSc) for parasitology, serology
and urinalysis
e) One Medical Laboratory Technologists (BSc) for virology
f) Two Medical Laboratory Technologists (BSc) for microbiology and
mycology
g) One Medical Laboratory Technologist (BSc) for QC/QA
h) Supportive staff (clerks, cleaners, trained sample collectors)
6.28.3.8 In addition to the above mentioned professionals, the hospital may have
additional laboratory technicians.

6.28.4 Products (Techniques and Equipments Specific Tests)

6.28.4.1 Laboratory shall be furnished with all items of equipment required for the
provision of services.

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6.28.4.2 All equipment shall be in good working order, routinely quality controlled, and
precise in terms of calibration.
6.28.4.3 Laboratory shall establish a programme that regularly monitors and
demonstrates proper calibration and function of instruments, reagents and
analytical system. It shall also have a document.
6.28.4.4 When equipment is removed from the direct control of the laboratory or is
repaired or serviced, the laboratory shall ensure that it is checked and shown to
be functioning satisfactorily before being returned to laboratory use.
6.28.4.5 Laboratory shall have a documented and recorded programme of preventive
maintenance which at a minimum follows the manufacturer’s recommendation.
6.28.4.6 Equipment shall be maintained in a safe working condition. This shall include
examination of electrical safety, emergency stop devices. Whenever equipment
is found to be defective, it shall be taken out of service and clearly labeled.
6.28.4.7 There shall be a written chemical hygiene plan that defines the safety
procedures to be followed for all hazardous chemicals used in the laboratory.
The plan defines at least the following:
a) The storage requirements
b) Handling procedures
c) Requirements for personal protective equipment
d) Procedures following accidental contact or overexposure
e) The plan is reviewed annually, and updated if needed, and is part of
new employee orientation and the continuing education program.
6.28.4.8 The following minimum equipments and consumables shall be required (See
also annex IX)

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Tests Major Equipment
Clinical chemistry:  Autoclave
 Blood glucose  Timer
 Lipid profile  Clinical chemistry analyzer (Automated)
o Cholesterol  Chemistry analyzer (semi automated)
o Triglyceride  Glucometer
o LDL  PC and a printer
o HDL  Bunsen burner
 Serum electrolytes  Power surge protectors
o Na+,K+,Cl-  Weighing balance
 Liver function tests  Spectrophotometer/ Colorimeter

o ALKP, AST, ALT,  GT  Micropipettes of different :

o Total bilirubine  Hemacytometers

o Direct bilirubine  Hemacytometer cover slips

o Total protein (standardized thickness)

o Albumin  Microcapillary tubes (if dilutions are not

 Renal function tests needed)

o Urea  WBC pipette

o Creatinine  RBC pipette

o Uric acid  Pipette bulb Petri dish and cover

 Cardiac function tests  Timer with alarm

o LDH  Hormonal assay analyzer

o CK-MB
o Troponine
o CPK
 Hormonal tests
o T3, T4, TSH, FSH, LH
o Testosterone
o Prolactine

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 Parasitology:
 Stool microscopy
 Blood film for malaria and other
hemoparasite/ Malaria Rapid Test
 Occult blood
Urine and body fluid analysis:
 Urinalysis
 CSF analysis
Mycology:
 KOH test
 Fungal culture
Microbiology Smear and Culture

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Hematology:
 Haemoglobin  Haemoglobinometer
 Total WBC count  Automated Hematology analyzer
 Differential white cell count  Blood roller/mixer
 Peripheral blood film  Water bath

 ESR  Coagulometer

 Hematocrit  Refrigerator

 Platelet count  Electrophoresis machine

 Bleeding time  Binocular microscope x10, x40, x100

 Reticulocyte count  Haemocytometer

 Microhematocrit centrifuge
 prothrombin time
 Microhematocrit reader
 Hb electrophoresis
 Differential counter
 Lupus Erythematosus
 Tally counter
Serology:
 Deep freezer
 H.Pylori
 Centrifuge
 Troponin
 Timer
 HBs Ag
 Vortex mixer
 HCV
 Distillation unit
 Toxoplasma latex
 CD4 machine
 ASO
 Viral load machine
 RF
 Autoclave
 CD4 count
 Dry oven
 RPR
 Safety cabinet
 TPHA
 Refrigerator
 CRP
 Deepfrezer
 Salmonella Typhi-O
 Waterbath
 Salmonella Typhi-H
 Incubator
 Proteus-OX19
 PH meter
 HIV-test
 Digital balance
 Viral load
 Microscope
 Blood Group (Anti-A, Anti-B, Anti-D,
 And other major culture and sensitivity
Compatibility testing and Cross match)
equipments
Bacteriology:
 Gram stain
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 Ziehl Neelson stain
 India Ink,
 Culture and sensitivity test
6.29 Pharmaceutical Services

6.29.1 Practices

6.29.1.1 Dispensing and Medication Use Counseling:

a) Standard operating procedure for dispensing and medication use
counseling shall be established to ensure patients’ safety and correct use
of medications.
b) Dispensers shall make sure that prescriptions are legible, written by
authorized prescriber and complete. Prescription papers shall be
standardized and must contain at least the following information and the
prescriber shall complete all these information:
 Name of patient, sex, age and card number
 Diagnosis and allergy
 Name of the drug, strength, dosage form, dose, frequency, and route
of administration
 Duration of treatment
 Prescriber’s name, qualification and signature
 Prescriber’s address (hospital name and address)
c) The pharmacist shall check the correctness of prescriptions in terms of
appropriateness for the patient, dosage, and drug interactions based on
approved standard treatment guidelines
d) All drugs shall be dispensed with adequate and appropriate information
and counseling to patients for correct use of their medications.
e) Pharmacists shall be required to make an in-depth professional
judgment to make sure that each drug and its dosage form has all of its
attributes of quality and an acceptable ratio of safety.
f) The containers used for dispensing shall be appropriate for the product
dispensed and all containers intended for pharmaceuticals shall be
protected and kept free from contamination, moisture and light.

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g) All pharmaceuticals to be dispensed shall be labeled and the labels shall
be unambiguous, clear, legible and indelible. The following minimum
information shall be indicated on the label/sticker:
 the generic name of the product;
 the name of each active ingredient for compounded preparations;
 the strength, dose, frequency of administration and total quantity;
 the name of the person for whom the drugs are dispensed;
 the directions for use and route of administration tailored to patient
or caregiver literacy and language;
 the name and business address of the dispenser;
 date of dispensing;
 Expiry date or beyond use date and
 Special precautions as applicable
h) Filled prescriptions shall be signed and accountability must be accepted
by the dispensing pharmacist.
i) Each hospital shall establish and implement policies, guidelines and
procedures for reporting any errors or any suspicion in administration
or provision of prescribed medications. Errors shall be reported to the
prescriber in a timely manner upon discovery and a written report of the
error prepared and documented. Any suspicion or error shall be
communicated to the prescriber and clarified/corrected before
dispensing without affecting patient’s confidence on medical practices.
j) The pharmacy shall keep individualized information for patients with
chronic illnesses medication program using standardized information
tracking formats and update patient medication profile during each refill
visit.
k) The counseling of patients or their caregivers shall be undertaken to
promote the correct and safe use of pharmaceuticals. The responsible
pharmacist must ensure that patients are counseled before they receive
pharmaceuticals that they are to self-administer.
l) The pharmacist shall assess each patient's ability to understand the
information imparted by question and answer and must be able to

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 modify his/her approach accordingly. Care shall be taken with
counseling where understanding is likely to be a problem.
m) Cautionary instructions and ancillary information about medications
shall be communicated in writing to the personnel responsible for
administering medications.
6.29.1.2 Control of Drug Abuse, Toxic or Dangerous Drugs:
a) The classification ordinarily thought of as toxic, dangerous or drugs of
abuse shall be narcotics, psychotropics, anticoagulants, antibiotics,
oxytocic and cortisone products, antineoplastic agents and shall include
other categories so established by federal or state laws.
b) Policies shall be established to control the administration of these drugs
with specific reference to the duration of the order and the dosage.
c) A record of the stock on hand and of the dispensing of all these drugs
shall be maintained in such a manner that the disposition of any
particular item may be readily traced.
d) All controlled substances (narcotic and psychotropic drugs) shall be
dispensed to the responsible person (licensed anesthetic nurse and
anesthesiologist), designated to handle controlled substances in the
operating room, by a licensed pharmacist in the hospital. When the
controlled substance is dispensed, the following information shall be
recorded into the controlled substance (proof-of-use) record.
 Name and signature of pharmacist dispensing the controlled
substance
 Name and signature of designated licensed person receiving the
controlled substance.
 The date and time controlled substance is dispensed.
 The name, the strength, and quantity of controlled substance
dispensed.
 The serial number assigned to that particular record, which
corresponds to same number recorded in the pharmacy's dispensing
record.
e) When not in use, all controlled substances shall be maintained in a
securely locked, substantially constructed cabinet or area. All controlled

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 substance storage cabinets shall be permanently affixed. Controlled
substances removed from the controlled substance cabinet shall not be
left unattended.
f) The administration of all controlled substances to patients shall be
carefully recorded into the standard record for controlled substances
and returned back to the pharmacist upon refill of controlled substances.
The following information shall be recorded during administration to
patients.
 The patient's name, card number
 The name of the controlled substance and the dosage administered.
 The date and time the controlled substance is administered.
 The signature of the practitioner administering the controlled
substance
 The wastage of any controlled substance.
 The balance of controlled substances remaining after the
administration of any quantity of the controlled substance
 Day-ending or shift-evening verification of count of balances of
controlled substances remaining and controlling substances
administered shall be accomplished by two (2) designated licensed
persons whose signatures shall be affixed to a permanent record.

g) All partially used quantities of controlled substances shall be registered

in to the control substance record and returned back to the responsible
pharmacist for control substances for disposal.
h) All unused and unopened quantities of controlled substances which have
been removed from the controlled substance cabinet shall be returned to
the cabinet by the practitioner at the end of each shift.
i) Any return of controlled substances to the pharmacy in the hospital shall
be documented by a licensed pharmacist responsible for controlled
substance handing in the hospital.
j) The hospital shall implement procedures whereby, on a periodic basis, a
licensed pharmacist shall reconcile quantities of controlled substances
dispensed in the hospital against the controlled substance record. Any

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 discrepancies shall be reported to the Director of the respective medical
services and to the Chief Clinical Officer/Chief Executive Officer of the
hospital. Upon completion, all controlled substance records shall be
returned to the hospital's pharmacy by the designated responsible
person.
k) The hospital shall submit regular report to the appropriate organ
regarding the consumption and stock of controlled drugs.

6.29.1.3 Hospital Based Pharmaceuticals Preparations:

a) Written procedures/SOPs for hospital based pharmaceutical
preparations shall be established for preventing errors, drug-drug
interactions and drug contamination. This SOP shall contain an approved
Master Formula for each type of preparation that shows the list of
ingredients and their quantities required for the formulation of a
specified amount of the preparation.
b) Licensed pharmacists shall be responsible for the preparations of
various pharmaceutical formulations such as eye drop preparations,
dosage form changes, extemporaneous preparations, IV infusions and IV
admixture when deemed necessary by the hospital.
c) The hospital shall have a pharmacy-based intravenous infusion
admixture program, which may include services related to preparation
of total parenteral nutrition, antineoplastic agents, and large and small,
continuous or intermittent volume products for infusion. A pharmacist
licensed to practice pharmacy shall prepare, sterilize if necessary, and
label parenteral medications and solutions.
d) The pharmacist responsible for pharmaceutical preparations shall
ensure that quality is built into the preparations of products.
e) Ingredients used in preparations shall have their expected identity,
quality, purity and shall be from legally licensed sources.
f) Pharmaceutical preparations shall be of acceptable strength, quality, and
purity, with appropriate packaging and labeling, and prepared in
accordance with good compounding practices, official standards, and
relevant scientific data and information. Labels on compounded

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 products for individual patient shall have a minimum of the following
information:
 Patient's name
 Name of the compounding pharmacist
 Name and address of the compounding institution
 A complete list of ingredients and preparation name
 Strength
 Quantity of each ingredients and total quantity
 Directions for use
 Date of preparation
 Beyond-use date
 Storage condition
 Batch number
g) Critical processes shall be validated to ensure that procedures, when
used, will consistently result in the expected qualities in the finished
preparation.
h) Appropriate stability evaluation shall be performed or determined using
international standards for establishing reliable beyond-use date to
ensure that the finished preparations have their expected potency,
purity, quality, and characteristics, at least until the labeled beyond-use
date.
i) Written procedures and records shall exist for investigating and
correcting failures or problems in compounding, testing, or in the
preparation itself.
j) Pharmaceutical preparations compounded in the hospital shall be
packaged in containers meeting standard requirements mentioned
under the official national or international standards for such
preparations.

6.29.1.4 Clinical Pharmacy Services:

a) The hospital through drug and therapeutic committee shall establish
policies and procedures for the provision of clinical pharmacy services

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b) Depending on the number of beds available and convenience for service
delivery, the hospital shall have inpatient pharmacy or ward pharmacies
each managed by a licensed clinical pharmacist or a licensed pharmacist
trained on clinical pharmacy practice.
c) The responsible pharmacist for clinical pharmacy services shall have
access to patient specific medication therapy information
d) Patient-specific medication therapy information must be evaluated and a
drug therapy plan shall be developed by the pharmacist mutually with
the patient, the prescriber and nurse.
e) The pharmacist shall review, monitor and propose for modification of
the therapeutic plan in case of adverse effects, patient noncompliance,
evidence based efficacy problem and as appropriate, in consultation
with the patient, prescriber and nurse.
f) Through prescription and medication history monitoring, the
pharmacist shall identify problems or opportunities for optimizing
treatment and hence safeguard the patient and ensure the optimal use of
medicine
g) The processes of prescribing, dispensing and administering
pharmaceuticals are inherently risk-laden and hence the clinical
pharmacy services shall take responsibility for ensuring safe,
appropriate and effective use of pharmaceuticals (minimizing risk) at all
stages of the patient medication journey.
h) Medication education shall be delivered to patients or their caregivers
upon discharge by the clinical pharmacist.
i) The pharmacist shall make sure that the patient has all supplies,
information and knowledge necessary to carry out the drug therapy
plan.
j) As a member of the health care team, the pharmacist shall attend and
participate at multidisciplinary ward rounds/morning meetings and
contribute to patient care through the provision of medicine
information, dose calculations and adjustment, assisting in the rational
prescribing decision, alternative regimens and reducing the frequency
and duration of medication errors.

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 k) The drug and therapeutic committee of the hospital shall develop/adopt
and implement antimicrobial prescribing, dispensing and usage policy

6.29.1.5 Emergency Pharmacy Services:

a) Emergency pharmacy service shall be opened for 24 hours and directed
by a licensed pharmacist who is accountable to the emergency unit of
the hospital.
b) Orders received by words of mouth or through telephone during
emergency (in case of immediate administration is necessary, no
appropriate alternative treatment is available and when it is not
reasonably possible for the physician to provide a written prescription
prior to dispensing) shall latter be endorsed by the prescriber and be
documented in writing within 24 hours. The quantity shall be limited to
emergency period only.
c) The responsible pharmacist shall take the duty to coordinate and
prepare emergency pharmaceutical lists and ambulance kits for the
hospital and he/she has to exert all the necessary efforts to ensure
continuous availability of pharmaceuticals for emergency unit and
hospital ambulances.
d) The emergency pharmacy, in addition to supply of pharmaceuticals, shall
record patient medication information and ensure correct use of
medications.

6.29.1.6 Adverse Drug Reactions/ Pharmacovigilance:

a) The hospital pharmacy shall appoint an Adverse Drug Reactions (ADR)
focal person responsible for the collection, compilation, analysis and
communication of ADR related information to the DTC and regulatory
authority as appropriate.
b) Health professionals of the hospital shall be responsible to report
suspected ADR cases to the ADR focal person.

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 c) DTC shall discuss and make necessary recommendations to the hospital
management for decision on adverse drug reactions reported within the
health facility.
d) The hospital pharmacy shall consistently update the safety profile of
drugs included in the formulary list for immediate drug use decisions
and consideration during the revision of the list.
e) Adverse medication effects shall be noted in the patient’s medication
record
f) All the ADR reports, patient identity, reporters and medicine trade
names shall be kept confidential until verified concerned authority.

6.29.1.7 Pharmaceuticals Supply and Management:

a) A drug and therapeutics committee (DTC) representing different service
units of the hospital shall be in place for selection of pharmaceuticals
and other medical items and developing the formulary list as well as
policies and guidelines on managing pharmaceuticals.
b) A national drug list and hospital formulary list shall be used as the basis
for the selection of pharmaceuticals and other medical items.
c) The purchase of pharmaceuticals shall be the responsibility of a
pharmacist who is assigned to manage and control the hospital central
medical store.
d) Written policies for the procurement of pharmaceuticals from
government and private suppliers shall be available in the pharmacy.
These policies shall be prepared by the DTC and approved by the
management/board of the hospital. The procurement policy must
ensure at least:
 The right source of pharmaceuticals
 product availability
 safety, quality and efficacy of pharmaceuticals
 transparency of the procedure and documentation
 minimal decision points
 flexibility to respond for emergency situations
 compatibility with the regional and national laws of the country

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  effective batch recall of pharmaceuticals when necessary
e) A pharmacist shall not purchase any medicinal product where he/she
has any reason to doubt its safety, quality or efficacy.
f) The pharmacist shall ensure that both the supplier and the manufacturer
of any medicine purchased are reputable and registered by the
regulatory body.
g) The hospital central medical store shall be responsible to display or
disseminate new arrivals or alternative drugs to each service delivery
points.
h) The hospital shall be responsible to make sure that pharmaceuticals
promotion made by suppliers or manufacturers in the hospital premises
is made by a licensed pharmacist in accordance with the country’s laws.
i) The hospital shall be responsible to make sure that donation of
pharmaceuticals has been made in accordance with the country’s laws.
j) Pharmaceutical storage areas of the hospital shall be under the direct
control of the responsible pharmacist (drug supply management officer
who is a trained pharmacist)
k) There shall be a pharmacist assigned as drug supply management officer
who is responsible for the procurement, stock management, warehouse
management, distribution of pharmaceuticals and waste disposal.
l) There shall be a responsible pharmacy personnel (druggist or pharmacy
technician) assigned for receiving, storage, issuing, recording,
monitoring and reporting.
m) The storage condition shall provide adequate protection to the drugs
from all environmental factors until the drug is delivered to the patient.
n) The responsible pharmacist must ensure that all areas where
pharmaceuticals are stored are of acceptable standards (palletized or
shelved, ventilated, rodent free, temperature and moisture controlled
and others) for a drug store.
o) The responsible pharmacist shall ensure that all medicine storage areas
are inspected regularly to ensure that:

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  pharmaceuticals are stored and handled in accordance with the
pharmaceutical manufacturer’s requirements and regulatory
standards
 expired or obsolete pharmaceuticals are stocked separately until
disposition
 pharmaceuticals requiring special storage conditions shall be stored
accordingly
 Temperature and humidity are maintained according to
manufacturer’s requirement
 stock levels are adequate to ensure the continuous supply and
acceptability of pharmaceuticals at all times, including the
availability of essential drugs as per the latest edition of the drug
formulary list
 inflammable substance are stored separately and in an appropriate
manner
 disinfectants and preparations for external use are stored separately
from pharmaceuticals for internal use
p) Special storage conditions shall be maintained for pharmaceuticals
requiring cold chain system, controlled substances,
radiopharmaceuticals and medical gases.
q) Fire fighting equipment or system shall be installed to pharmaceutical
storage places
r) Distribution of pharmaceuticals within a hospital shall be under the
direction and control of a pharmacist and must be in accordance with
the policy developed by DTC. All issuing activities shall be made using
official and serially numbered vouchers.
s) Written SOPs shall be provided on how supplies of stock are to be
obtained from the pharmaceuticals store. Procedures must define
normal action to be taken by pharmaceutical staff for routine stock
replacement and action to be taken in the case of incomplete
documentation or other queries.

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 t) Written procedures shall be available for the return of expired, damaged,
leftover and empty packs from outlets to pharmaceuticals store to
prevent potential misuse.
u) The hospital shall maintain stock control system (manual and/or
computerized system) in the central medical store and dispensaries.
v) The responsible pharmacist shall ensure that adequate control
procedures are in place for all stock circulating at all outlets within the
hospital.
w) Daily drug consumption at different outlets of the hospital shall be
recorded, compiled and analyzed for the appropriate supply and use of
pharmaceuticals.
x) The hospital pharmacist who is responsible for the management of
pharmaceuticals should conduct regular drug use studies to ensure
maximum patient benefit from the formulary list
y) The DTC should be responsible for developing policies and guidelines on
how to organize and conduct drug use studies.

6.29.1.8 Drug Information Services:

a) The hospital shall establish a drug information center which provides
drug information services and shall be directed by a licensed pharmacist
trained in the provision of drug information services.
b) The drug information pharmacist shall be member of the hospital DTC
c) The drug information service shall be part and parcel of the day-to-day
activities of a health facility and shall provide objective and unbiased
information to health care professionals and the public. It shall receive
and respond to drug information queries as per written SOPs and
provide continuing education on drug-related topics to health
professionals.
d) Provision of drug information services to patients and community shall
be in accordance with the standard operating procedures that will be
developed by the Authority and adopted by the hospital. Procedures
shall include:
 details of standards of practice;

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  range of services provided;
 availability of service;
 procedures for enquiry receipt and retrieval of data;
 details of available resources;
 quality assurance practices;
 job descriptions for all staff and local practices including site-specific
regulations or procedures.
e) The drug information center shall provide reference materials such as
medical and pharmaceutical related books, journals, drug profiles,
electronic information, CD-ROM, relevant formularies and
manufacturers' information and updated list of drugs available in the
hospital central medical store to health care professionals
f) The service shall be available at least during normal pharmacy working
hours.

6.29.1.9 Pharmacy Waste Management and Disposal:

a) The disposal of pharmaceutical wastes shall be in compliance with the
national/state disposal guideline or procedure
b) Hospital pharmacy shall take responsibility, through supportive policies
and procedures for the environmental and societal safety by efficiently
managing the pharmaceutical wastes.
c) Every attempt shall be made to minimize the amount of pharmaceutical
waste generated in the hospital.
d) Hospital pharmacy and cleaning staff shall be trained and well informed
about the potential risks of hazardous pharmaceutical wastes and their
management.
e) Cleaners or anybody to handle hazardous pharmaceutical wastes shall
wear protective devices like apron, plastic shoes, gloves, head gears and
eye glasses when the need arises.
f) General wastes shall be collected daily from the pharmacy and placed in
a convenient place outside the pharmacy to facilitate coordinated
disposal by the hospital.

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 g) Solid wastes from the pharmacy shall be categorized as “hazardous” and
‘non-hazardous” and shall be collected separately for proper treatment.
h) All hazardous chemicals spills shall be immediately reported to head of
the pharmacy or responsible person for safety (if available) to minimize
the risk and take immediate action.
i) Spillages of low toxicity shall be swept into a dust pan and placed into a
suitable container for that particular chemical and dispose accordingly.
j) Drugs in single dose or single use containers which are open or which
have broken seals, drugs in containers missing drug source and exact
identification (such as lot number), and outdated medications shall be
returned to the pharmacy for disposal.
k) The hospital shall form a pharmaceutical disposal committee to ensure
safety, accountability and transparency.
l) Disposal of pharmaceutical wastes shall be supported by proper
documentation including the price of the products for audit, regulatory
or other legal requirements.
m) Those items which can’t be disposed by the capacity of the hospital shall
be managed by one central body (e.g. radiopharmaceuticals)

6.29.1.10 Recording:
a) Each hospital shall maintain records to assure that patients receive the
medications prescribed by a medical practitioner and maintain records
to protect medications against theft and loss.
b) There shall be a standardized Prescription Registration Book for
recording prescriptions and dispensed medicine. A computerized
dispensing and registration system with backup can be used instead if
available.
c) Each patient with a chronic disease shall have a separate Patients
Medication Profile Card (PMP) that should be filled appropriately with
all the relevant information for each patient. A computerized system
with backup can be used instead if available.

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 d) Controlled and non-controlled prescriptions shall be documented and
kept in a secure place that is accessible only to the authorized personnel
for at least five and three years respectively.
e) Patient and medication related records and information shall be
documented and kept in a secure place that is easily accessible only to
the authorized personnel
f) Every transaction related with pharmaceuticals should be recorded on
stock control cards and/or computerized stock control system in the
medical store and dispensaries.

6.29.1.11 Billing:
a) Drugs shall be received and issued using standard receiving and issuing
vouchers with serial number licensed by the appropriate finance bureau
of the government. Issuing and receiving of drugs has to be signed by
both the receiver and issuer and approved by an authorized pharmacist.
Receiving and issuing vouchers shall have the following minimum
information.
 Name of drugs received and issued
 Unit of measurement, quantity and source (supplier’s or
manufacturer’s name) of drugs
 Expiry date and batch number
 Unit and total price
 Date received and issued
 Name and signature of receiver and issuer
 Address of the hospital
b) All drugs issued from the dispensary shall be dispensed/sold using
standard sales ticket with serial number licensed by the appropriate
finance bureau. Sales tickets have to be signed and stamped.
c) Dispensing pharmacies shall use a standard stamp and seal for
approving legal transactions
d) Writing one bill for two clients shall be forbidden
e) The consumer has the right to know the exact price of a prescription
before it is filled

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 f) The hospital shall ensure that each customer has the right to get receipt
which has the following minimum information about drugs dispensed.
 Name of patient
 Name and dosage form of drugs dispensed
 Unit of measurement and quantity
 Unit and total price
 Date
 Signature of dispenser and cashier
 Address of the hospital

6.29.1.12 Organization Management and Quality Improvement:

a) A multidisciplinary drug and therapeutic committee chaired by the
CEO/CCO and supported by a licensed pharmacist representing the
hospital pharmacy services as a secretary must be functional for the
overall improvement of pharmaceutical services in the hospital
b) The pharmaceutical services shall be represented by a licensed senior
pharmacist in every management meetings of the hospital.
c) Customer satisfaction survey on pharmaceutical services shall be
conducted at least once in a year and measures shall be taken in
accordance with survey findings.
d) There shall be a program of continuous quality improvement for the
pharmacy service that is integrated into the hospital continuous quality
improvement program and includes regularly collecting and analyzing
data to help identify pharmacy service problems and their extent, and
recommending, implementing, and monitoring corrective actions on the
basis of these data.
e) The pharmacy service shall have in effect a patient profile system for
monitoring drug therapy. This system shall be used by the hospital to
identify inappropriate prescribing practices and develop interventions.
f) The pharmacy service shall inspect at least once every two months all
patient care areas in the hospital, and at least once every three months
all other areas of the hospital where drugs intended for administration
to patients are dispensed, administered, or stored. The pharmacy service

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 shall maintain a record of the inspections. Identified problems shall be
addressed.
g) A quality improvement program of the pharmacy service shall monitor,
at a minimum, the use of drugs, including medication errors and use of
antibiotics. Serious or consistent patterns of medication error shall be
reported to the drug and therapeutics committee or its equivalent for
correction and this must be documented.

6.29.2 Premises
6.29.2.1 The design and layout of the pharmacy shall permit a logical flow of work,
effective communication and supervision and ensure effective cleaning and
maintenance and must minimize the risk of errors, cross-contamination and
anything else which would have an adverse effect on the quality of products and
service delivery.
6.29.2.2 The area(s) of counseling shall be arranged or constructed in such a manner that
it provides adequate space, have professional look and ensure reasonable
privacy to the patient at all times and eliminate background noise as much as
possible.
6.29.2.3 Dispensing counter shall be designed to secure patient privacy and
confidentiality
6.29.2.4 All parts of the premises shall be maintained in an orderly and tidy condition.
6.29.2.5 The external appearance of pharmacies shall be painted white and inspire
confidence in the nature of the health care service that is provided and portray a
professional image.
6.29.2.6 Entrances, dispensing counters and doorways shall be accessible to disabled
persons.
6.29.2.7 The dispensing environment (dispensing counter and counseling area) shall
ensure confidentiality and allow simultaneous service delivery for multiple
customers by multiple providers.
6.29.2.8 A waiting area(s), which is under cover, shall be situated near the dispensing
area, areas for counseling/consultation and the provision of information.
6.29.2.9 The pharmacy premises shall be clearly demarcated and identified from the
premises of any other business or practice. The location of the pharmacy

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 premises shall take into account patient convenience and ease of loading and
unloading of pharmaceuticals.
6.29.2.10 Careful consideration shall be given to the overall security of the pharmacy. It
must be lockable and shall prevent any unauthorized entry.
6.29.2.11 A security policy shall be implemented which is designed to ensure the safety of
both staff and pharmaceuticals, and shall take account of local crime prevention
advice.
6.29.2.12 The responsible pharmacist of a pharmacy shall ensure that every key which
allows access to a pharmacy is kept only with him/her or the designated
personnel.
6.29.2.13 A procedure shall be in place to ensure access to pharmacy premises in an
emergency situation.
6.29.2.14 Compounding premise shall be maintained adequate, clean and ventilated.
6.29.2.15 Ceilings and walls of dispensaries and store shall be constructed to protect
safety of pharmaceuticals from burglary, rodents, direct sunlight, moisture and
damages.
6.29.2.16 Medicines shall be shelved a minimum of 20cm above the floor, 1m wide
between shelves and 50cm away from the wall and ceiling.
6.29.2.17 In general, minimum standard for pharmacy premises at different service
delivery points shall be as follows.
Components of Pharmacy Pharmaceutical Service Delivery Points
Premises Inpatient Outpatient Emergency Medical Compounding
Pharmacy Pharmacy Pharmacy Store Pharmacy
1. Main room 16 m2 40 m2 16 m2 250 m2 12 m2
2. Cashier office 4 m2
3. Counseling 9 m2
4. Duty room included included included
5. DIC 20 m2
6. Ceiling height >2.6m >2.6m >2.6m >2.6m >2.6m

7. Office Included Include

8. Patient waiting room 10 m2
9. Window(s) X X X X X

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10. Floor (concrete) X X X X X
11. Cold room (optional) X
12. Ventilation X X X X X
13. Internet service X X X X X
(optional)

6.29.3 Professionals /Human Resource

6.29.3.1 The hospital pharmacy shall have licensed pharmacists at least:

a) Two for outpatient pharmacy,
b) Two for inpatient pharmacy (including ward or satellite pharmacies),
c) One for emergency pharmacy and
d) One for central medical store and overall pharmaceutical supply
management.
6.29.3.2 In addition, the number of dispensing pharmacists shall be increased by one per
1000 pharmacy clients per month.
6.29.3.3 The hospital shall have one pharmacy technician/druggist for central medical
store and may also have additional pharmacy technicians/ druggists for other
services.
6.29.3.4 The dispensing of all prescriptions and medication use counseling shall be
carried out by licensed pharmacists.
6.29.3.5 The pharmacist who is responsible to lead the drug information service shall
serve as ADR focal person for the hospital.
6.29.3.6 The hospital shall have written policies and procedures for pharmacy workforce
determination for additional pharmacy staff based on the workload to ensure
quality service standard.
6.29.3.7 The hospital pharmacy shall have an accountant, pharmacy clerks, cashiers,
cleaners and porters.
6.29.3.8 The responsible pharmacist shall ensure that written job descriptions are
prepared for all staff and that all staff are acquainted with their job descriptions
and responsibilities.
6.29.3.9 All staff shall receive appropriate training, information and orientation at the
time of appointment to any position in the pharmacy

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6.29.3.10 The requirements of the national/state pharmacy laws with respect to persons
handling pharmaceuticals and related products shall be adhered.
6.29.3.11 Pharmacists responsible for the practical training of pharmacy students shall
comply with the necessary duties and responsibilities stated in the country’s
pharmacy legislatives.
6.29.3.12 The pharmacist shall wear white gown or any color accepted by the hospital
with easily readable name tag (badge) that include their name and status, such
as junior pharmacist, senior pharmacist, or any other.
6.29.3.13 A pharmacist licensed to practice pharmacy shall be on duty or on call at all
times outside working hours.

6.29.4 Products (Equipment and Facilities)

6.29.4.1 The hospital shall have its own medicine list within the framework of the
national medicine list of the country prepared by the regulatory authority.
6.29.4.2 There shall be adequate, suitable dispensing equipment in the dispensary. Each
item must be clean, in good repair and of suitable material. Equipment shall be
specific for each service which may be provided in the pharmacy.
6.29.4.3 The hospital’s outpatient, inpatient and emergency pharmacies and its central
medical store shall have fire extinguisher, refrigerators, deep freezers, security
alarms and racks/shelves.
6.29.4.4 Equipment used for measuring and weighing shall be designed and maintained
in such a way as to be suitable for its intended use; facilitate thorough cleaning
when necessary; minimize any contamination of drugs and their containers; and
minimize the risk of confusion or the omission of a processing step such as
filtration or sterilization.
6.29.4.5 There shall be a suitable, clean wash hand basin made of a smooth, washable
and impermeable material which is easy to maintain in a hygienic condition and
has a source of hot and cold tap water and a closed drainage system.
6.29.4.6 The drug information center shall be equipped with furniture and equipment
including a dedicated telephone, computer, internet and lockable filing cabinets.

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6.29.4.7 The drug information center shall maintain a current collection of reference
materials such as books, journals, drug profiles, electronic information, relevant
formularies and manufacturers' information.
6.29.4.8 Toilet facilities shall be kept clean and in good order. Hand-washing facilities
shall be provided in the toilet area together. Facilities must include readily
available water, soap and clean towels or other satisfactory means of drying the
hands.
6.29.4.9 The hospital pharmacy shall be provided with consistent electricity, telephone,
internet services(optional) and office facilities such as computers, furniture and
other necessary supplies.
6.29.4.10 In general, minimum standard for pharmacy equipment and facilities at
different service delivery points shall be as follows.
Equipment and facilities Pharmaceutical Service Delivery Points
At least Outpatient Emergency Medical Compounding
one Pharmacy Pharmacy Store Pharmacy
Inpatient
Pharmacy
1. Refrigerators and deep x x x x x
freezers
2. Thermometer x x x x x
3. Tablet counter x x x
4. Working bench: Level, x
smooth, impervious,
free of cracks and
crevices and non-
shedding; covered
with protector sheets
of plastic, rubber or
absorbable paper
when appropriate
5. Mortar and pestle: 250 x
ml capacity or more;
glass type and

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 porcelain type

6. Water distiller: x
Stainless steel of 20
liter capacity or more
7. Water bath: Stainless x
steel of 4 openings or
more
8. Electrical hotplate: x
Various Sizes and
Features
9. Evaporating dish: x
Stainless steel (glazed
inside) and porcelain
type; with/without
handling
10. Spatula: Stainless x
steel and plastic type,
flexible and non-
flexible, different
blade lengths.
11. Gloves: disposable, X
non-sterile
12. Glass rod: Different X
length and
thicknesses
13. Wash bottle: 250ml X
capacity, polyethylene
14. Funnel: Glass type and X
plastic type
(polyethylene)
15. Beakers: Glass type; X

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 different capacity

16. Volumetric flask: X

Glass type; different
capacity
17. Balances: X
Prescription, torsion,
manual triple beam,
electronic; capacities
of not less than 300
gm; sensitivity of not
less than 0.1 mg.
18. Ointment tile: Glass X
type
19. Micropipettes: Glass X
type; different
capacities (less than
1ml); with pipette
bulb
20. Glass type; different X
capacities (1ml-
100ml); with pipette
bulb
21. Cylindrical graduate: X
Glass and plastic type;
different capacity
22. Conical graduate: x
Glass and plastic type;
different capacity
23. Weighing dishes: x
Plastic, aluminum,
stainless steel type

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24. Weighing paper: x
Normal paper; grease-
proof for semisolids
25. Thermometer: Fridge x
and wall thermometer
26. Scientific calculator x x x x x
27. Table and chair x x x x x
28. Scissors x x x x x
29. Adult and pediatric x
weighing balance
30. Electric light x x x x x
31. Tape water-Access x x x x x
32. Toilet and shower x x x x x
33. Balance x x x x x
34. Telephone line x x x x x
35. Internet facility- x x x x x
access (optional)

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6.30 Blood Transfusion Services

6.30.1 Practices
6.30.1.1 The hospital shall have blood transfusion services 24 hours a day and 365 days a
year
6.30.1.2 Transfusion of blood and blood products shall be provided or readily available
consistent with the size and scope of operation of the hospital.
6.30.1.3 Blood shall be prescribed by a licensed physician.
6.30.1.4 There shall be written procedure for blood typing, cross-matching, risk
assessment and testing, storage and transportation activities
6.30.1.5 There shall be written procedure for laboratory investigation of transfusion
reactions under the direct supervision of a physician.
6.30.1.6 For emergency situations the hospital shall maintain at least a minimum blood
supply in the hospital at all times, be able to obtain blood quickly from Regional
blood banks, or have an up-to-date list of donors.
6.30.1.7 Blood shall be transported in appropriate containers that can maintain the cold
chain system from the centre to the hospital blood store
6.30.1.8 Blood shall be counter checked by two health professionals for proper labeling
consisting of the name, expiry date, blood type and Rh and the serial number at
each delivery points.
6.30.1.9 Blood storage facilities in the hospital shall have a functional alarm system in
case of power failure and out of range temperature, which is regularly inspected
and is otherwise safe and adequate.
6.30.1.10 Records shall be kept on file indicating the receipt and disposition of all blood
provided to patients in the hospital.
6.30.1.11 Samples of each unit of blood used at the hospital shall be retained for further
retesting in the event of reactions. Blood which has exceeded its expiration date
shall be disposed promptly.
6.30.1.12 There shall be a hospital transfusion committee that shall review all
transfusions of blood or blood products and make recommendations concerning
policies governing such practices.

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6.30.1.13 The hospital transfusion committee shall receive patient complaints and
investigate all transfusion reactions occurring in the hospital and make
recommendations to the medical staff regarding improvements in transfusion
procedures
6.30.1.14 A hospital transfusion committee shall report all transfusion reactions occurring
in the hospital at least on quarterly basis to the Chief Clinical Officer/Medical
Director
6.30.1.15 Consent shall be signed between the blood recipient or his/her caregiver and
the hospital
6.30.1.16 Facilities and testing procedures to ensure safety of blood shall be installed in
the hospital
6.30.1.17 The hospital shall make sure that donated blood is labeled with all the
appropriate identifications, date of collection and expiry date.
6.30.1.18 There shall be written procedure for the disposal of unfit for use donated blood
including partially used and expired blood bags as per waste management
standard
6.30.1.19 There shall be a standardized blood request paper prepared and approved by
the hospital

6.30.2 Premises

6.30.2.1 The hospital shall have a minimum of one room for blood storage unit that can
accommodate the cold chain facilities
6.30.2.2 The blood storage unit shall be clearly demarcated and identified from the
premises of any other business or practice.
6.30.2.3 The hospital blood storage unit shall have record keeping and documentation
facility
6.30.2.4 The hospital blood storage unit shall have consistent electricity, telephone and
water supply
6.30.2.5 Toilet facilities shall be kept clean and in good order. Hand-washing facilities
shall be provided in the toilet area together.

6.30.3 Professionals

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6.30.3.1 A licensed laboratory technologist shall be responsible for blood typing and
cross-matching
6.30.3.2 A licensed nurse or laboratory technician shall be assigned to manage the blood
storage unit and its stock management.
6.30.3.3 There shall be a mechanism to utilize laboratory staff to clean blood storage
unit.

6.30.4 Products
6.30.4.1 The hospital blood storage unit shall have at least the following equipment and
facilities:
a) Two refrigerators which is specially designed for blood storage
b) A deep freezer
c) Incubator
d) Thermometer
e) Timer
f) Pipette
g) Reagent dispenser
h) Cold boxes
i) Anti A antisera
j) Anti B antisera
k) Anti D (RH Typing)
l) Antihuman globulin
m) One heating block
n) One water bath for cross-matching

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6.31 Ambulance Services

6.31.1 Practice
6.31.1.1 The ambulance service shall be provided to every emergency patient with out any
prerequisite and discrimination
6.31.1.2 The ambulance service shall be available 24 hrs a day and 365 days a year
6.31.1.3 The ambulance service shall provide the following services to patients with urgent
need of medical attention or in a medical emergency
(a) Transportation service to the hospital and from the hospital to other health
facilities
(b) Clinical examinations including brief history, vital signs, very pertinent
physical examination and glucose test when needed
(c) Clinical life saving support that includes:
 Fluid resuscitation
 Bleeding control
 Air way cleaning , oxygen administration, sever asthma management
 Attending labor
 Immobilizing a fracture
 Providing anti-pain
 Managing seizure
 Providing emergency medicines like adrenaline, hydralazine, glucose etc
6.31.1.4 The ambulance service shall comply with the patient rights standards stated
under these standards.
6.31.1.5 Every procedure, medication and clinical condition shall be communicated to the
patient or family member or caregivers or next of kin
6.31.1.6 Up on arrival to the hospital the ambulance staff shall transfer the patient to the
emergency service. The handover of patients shall be accompanied by written a
document which at least includes identification, date, time and services provided
until arrival to the hospital.

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6.31.1.7 If death happens on the way to a hospital the dead body shall be taken to the
hospital and death shall be confirmed. Dead body care shall be provided as per the
standards stated under these standards.
6.31.1.8 Ambulances of the hospital shall serve only for designated emergency medical
services
6.31.1.9 After providing a service the vehicle shall be cleaned
6.31.1.10 The ambulance kit shall be checked every time after providing a service

6.31.2 Premises
6.31.2.1 The parking of the ambulance car shall be within the hospital around emergency
service.
6.31.2.2 The hospital ambulance shall have telephone/radio communication means with
the command center (emergency service unit) for ambulances
6.31.2.3 The hospital shall have a command center, which is the emergency service unit,
for ambulance distribution which is equipped with a telephone to communicate
with the public and the ambulance team
6.31.2.4 The ambulance car shall have adequate space for accommodating the following:
(a) A couch
(b) One family attendant and
(c) At least two nurses
(d) Medical items needed for providing immediate life saving support
6.31.2.5 The vehicle shall be labeled and have an alarm/siren
6.31.2.6 The vehicle shall have adequate internal light and ventilation
6.31.2.7 The vehicle shall fulfill requirements of road transport authority

6.31.3 Professionals
6.31.3.1 Minimum standards for personnel of the ambulance service shall include:
(a) Two nurses pulled from emergency service unit
(b) Three licensed driver
6.31.3.2 The nurses shall be trained on emergency medical services
6.31.3.3 The driver shall be oriented on emergency situation management

6.31.4 Products

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6.31.4.1 The ambulance service shall include the following medicines, supplies and medical
equipments:
(a) Medicines:
 Anti pains, adrenaline, hydralazine, IV fluids (all types), dextrose 40%,
diazepam iv, phenytoin iv, atropine iv, etc.
(b) Supplies
 IV cannula, IV stand, syringe with needle, tourniquet, plaster, gauze,
bandage, spatula, antiseptic solution, catheters
 Personal protective devices (gown, mask, gloves, goggles)
 Waste disposing containers
 Support material for immobilization purpose
(c) Equipment:
 Minor surgical set (forceps, scissors, kidney dish, stitch, sterile gauze, needle
holder) in a drum
 Oxygen supply, ambubag, suction machine
 Stethoscope, sphygmomanometer, thermometer
 Portable radio or telephone
 Emergency trachiostomy (wide bore needle insertion), air way, laryngeal
mask, intubation set
 Glucometer
(d) Log book (stating time of call, time of arrival, time of return)
(e) Bed (couches) with fixed chair that is designed for ambulances, wheel chair,
emergency light
(f) Two standby ambulances:

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6.32 Infection Prevention

6.32.1 Practices
6.32.1.1 All activities performed for infection prevention shall comply with the national
/state infection prevention guidelines.
6.32.1.2 Infection prevention and control shall be effectively and efficiently governed and
managed.
6.32.1.3 The hospital shall identify the procedures and processes associated with the risk
of infection and shall implement strategies to reduce infection risk.
6.32.1.4 In general, infection risk-reduction activities shall include:
a) equipment cleaning and sterilization, in particular, invasive equipment;
b) laundry and linen management;
c) disposal of infectious waste and body fluids;
d) the handling and disposal of blood and blood components;
e) kitchen sanitation and food preparation and handling;
f) operation of the mortuary and postmortem area;
g) disposal of sharps and needles;
h) separation of patients with communicable diseases from patients and staff
who are at greater risk due to immunosuppression or other reasons;
i) management of hemorrhagic (bleeding) patients; and
j) Engineering controls, such as positive ventilation systems, biological hoods
in laboratories, and thermostats on water heaters.
6.32.1.5 The following policies and procedures shall be maintained
a) Hand hygiene
 Standard precautions for hand hygiene
 Personal protective measures
 Monitoring and surveillance of hand hygiene practices
b) Transmission-based precautions
 Contact precautions
 Droplet precautions

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  Airborne precautions
c) Post-Exposure Prophylaxis programming (PEP) for some communicable
diseases like rabies, HIV, meningitis, hepatitis
 Standard precautions to follow
 PEP policy
 Procedures for PEP
d) Environmental infection prevention
 General hospital hygiene
 Structural infection prevention
 Physical hospital organization
e) Waste management
 Cleaning medical instruments
 Implementation of a disposal system
 Handling medical waste
 Waste removal
6.32.1.6 The following specific standard precautions shall be practiced and the hospital
shall have it own guidelines:
a) Hand hygiene shall be performed after touching blood, body fluids,
secretions, excretions, and contaminated items, both immediately after
removing gloves and between patient contacts.
 Consider every patient infectious:
 Thorough hand washing:
 Use high-level disinfectants:
 Standard procedure for using a high-level anti-septic cleaner:
b) Personal PE (protective equipment) shall include gloves, mask, eye
protection (goggles) and face shield
c) Gloves shall be worn in the following situations but not limited to:
 When there is direct contact with exposed wounds, blood, body fluids,
body organs or any type of lesion.
 When drawing blood or handling medical instruments involved with
invasive procedures (catheters, IV insertion, probes, etc.).
 When there is contact with a patient who might be infectious.

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  When handling contaminated items.
 When cleaning patient areas.
d) Gowns shall be worn when but not limited to:
 Performing surgical procedures,
 Splattering of blood or body fluids is possible,
 Handling bulk soiled linen (housekeeping),
 Performing waste collection for infectious waste,
 Handling any type of medical waste, and
 Conducting hospital laundry washing.
e) Masks, goggles, or other types of face shields shall be worn when but not
limited to:
 Splattering of blood or body fluids to the face is possible,
 Handling biohazardous, soiled linens, and
 Performing waste collection for hazardous or non-hazardous waste.
f) Soiled patient-care equipment, textiles, and laundry shall be handled
appropriately
g) Any type of face shield that is apparently soiled or splattered with body
fluids shall be washed and sterilized with a disinfectant.
h) Procedures shall be developed and implemented for routine care, cleaning,
and disinfecting environmental surfaces, especially frequently touched
surfaces in patient care areas.
i) Used needles shall not be recapped, bent, broken, or manipulated by hand.
Handed scoop technique only shall be used when recapping is required.
j) Safety features shall be used when available, and used "sharps" shall be
placed in a puncture-resistant container specially designated bin for
hazardous waste.
6.32.1.7 There shall be transmission-based precautions and the hospital shall have it’s
own guideline for the followings:
a) Contact precautions
 Shall be intended to reduce the risk of transmission through direct and
indirect contact with an infectious patient.

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  Shall be used when a patient is known to have a specific disease that is
easily transmitted by direct contact.
 Shall be used for known multi-drug resistant disease, such as some forms
of TB.
 Shall exercise strict barrier precautions for any type of contact with the
patient and their surrounding environment.
 Do not share medical equipment between patients:
 Clean surfaces near patients daily:
 Wash linens and surfaces after patient discharge:
 Clean medical equipment:
b) Droplet precautions
c) Airborne precautions( for diseases like SARS ,TB, Swine flu, etc)
 Isolation room
 Negative pressure in relation to surrounding areas
 A minimum of 6-9 air exchanges per hour
 Air discharged outside the building and away from intake ducts, or
through a high-efficiency filter if re-circulated
 Door kept closed whether or not patient is in the room
 After discharge door kept closed until sufficient time has elapsed to allow
removal of airborne organisms
 Patient confined to room
 Room shall have toilet, hand washing and bathing facilities
6.32.1.8 Each hospital site shall train all staff on how to minimize exposure to blood-
borne diseases. These include:
a) Immediate first aid
b) Reporting exposures
c) Assign area for starter packs 24-hours access per day
d) Counseling and testing for exposed staff
e) Reporting and monitoring protocols
f) Evaluate PEP program.

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6.32.1.9 The infection prevention committee or designate shall have written protocols,
procedures and shall oversee the following activities and this shall be
documented:
a) Developing the health facility annual infection prevention and control plan
with costing, budgeting and financing
b) Monitoring and evaluating the performance of the infection prevention
program by assessing implementation progress as well as adherence to IPC
practice
c) Conducting surveillance to monitor nosocomial infections, antimicrobial
resistance, antimicrobial use, and outbreaks of infectious diseases.
d) Formulating a system for surveillance, prevention, and control of
nosocomial infections.
e) Reviewing surveillance data, reporting findings to management and other
staff and identifying areas for intervention
f) Assessing and promoting improved practice at all levels of the hospital
g) Developing an IEC strategy for health-care workers
h) Ensuring the continuous availability of supplies and equipment for patient
care management
i) Monitoring, providing data and measuring the overall impact of
interventions on reducing infection risk
j) The hospital’s overall quality improvement program and shall receive
formal advice from all other services upon its request.
6.32.1.10 The hospital shall provides regular training on infection prevention and control
practice to staff, patients, and as appropriate, to family and caregivers
6.32.1.11 The following training guidelines shall be available
a) Prevention of the spread of infections,
b) Improving the quality of patient care,
c) Promoting safe environment for both patients and staff
6.32.1.12 The hospital shall have procedures in place to minimize crowding and manage
the flow of visitors. This shall include
a) Patient crowd control
b) Assess urgent and non-urgent cases
c) Patient sign-in

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 d) Caregiver and visitor control.

6.32.2 Premises
6.32.2.1 There shall be the following facilities:
a) Working Office for IP officer
b) Meeting rooms for IP-committee
6.32.2.2 The hospital shall have a designated sterilization room

6.32.3 Professionals
6.32.3.1 The hospital shall have an IP committee coordinated by a full-time infection
prevention and control officer (environmental health professional)
6.32.3.2 The officer shall be a licensed environmental health professional or infectious
diseases specialist or a public health specialist knowledgeable of infection
prevention principles and hospital epidemiology.
6.32.3.3 IP committee shall be trained on infection prevention as well as hospital
epidemiology
6.32.3.4 The IP committee shall be composed of professionals at least from the following
service units
a) Sanitation
b) Nursing care
c) Medical services
d) Housekeeping
e) Administration
f) Pharmacy
g) Laboratory
h) Laundry
i) Kitchen
j) Instrument sterilization and supply

6.32.4 Products
6.32.4.1 The hospital shall have the following adequate supplies and equipment needed
for infection prevention and control practice.
a) Waste management equipment and supplies:

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  Incinerator  Garbage bins
 Placenta pit  Large garbage bin
 Wheelbarrows  Plastic garbage bags
 Ash pit (optional)

 Burial pit  Safety boxes

b) Cleaning
 Mop  Cleaning cloth
 Bucket  Detergent
 Broom  Bleach
 Dust mop
c) Laundry
 Washing machine  Wheelbarrows (to
 Sink transport linens

 Washing basin to/from wards)

 (for decontamination of  Detergent

linens)  Bleach
 Drying rack/line
 Dryers
 Irons
d) Instrument processing
 Autoclaves and steam  0.5% chlorine solution
sterilizers, (diluted bleach)
 Test strips  Storage shelves for the
 Chemicals medical equipment

 Commercial steamer  Disinfectant chemicals

 Boiler  Brushes (tooth brush
 Oven for small items)

e) Hand hygiene
 Sinks (ward and other  Water container with
areas) faucet
 Soap
  Alcohol based hand rub  Paper Towels
 Personal Towels
f) Personal Protective Equipment
 Heavy duty glove  Respiratory mask
 Surgical glove  Other type of face mask
 Examination glove  Plastic apron
(latex or nitrile)  Other types
 Other types (ex. those  Boots
worn by cleaning and  Nurse shoes
laundry staff)  Other protective shoes
 Eye shield  Caps
 Goggle  Face shield
 Visors
 Dust mask
 Surgical/Disposable

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6.33 Medical Recording

6.33.1 Practices

6.33.1.1 Medical record shall be maintained in written form for every patient seen at all
points of care including emergency, outpatient, labor & delivery, inpatient and
operation theatre.
6.33.1.2 The hospital shall maintain individual medical records in a manner to ensure
accuracy and easy retrieval. A patient shall have only one medical record in the
hospital.
6.33.1.3 The medical information of a patient during ambulance service including
medication administered shall be documented and attached into the medical
record
6.33.1.4 The hospital shall establish a master patient index with a unique number for each
patient
6.33.1.5 Each piece of paper that contains a medical record shall have the appropriate
identification on the paper
6.33.1.6 The hospital shall have a written policy and procedure that are reviewed at least
once every three years which include at least:
(a) Procedures for record completion
(b) Conditions, procedures, and fees for releasing medical information
(c) Procedures for the protection of medical record information against
the loss, tampering, alteration, destruction, or unauthorized use.
6.33.1.7 When a medical record is taken out and returned to the record room it shall be
documented to create a good tracking mechanism
6.33.1.8 Any medical record shall be kept confidential, available only for use by authorized
persons or as otherwise permitted by law.
6.33.1.9 All entries in the patient's medical record shall be written legibly in permanent
ink, dated, and signed by the custodian/recording person.
6.33.1.10 The medical record forms shall be prepared in line with the national/state
guideline and approved by the hospital management.
6.33.1.11 Each medical record shall at least contain the following information:

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 (a) Identification (name, age, sex, address)
(b) History, physical examination, investigation results and diagnosis
(c) Medication, procedure and consultation notes
(d) Name and signature of treating physician
(e) Consent form where applicable which shall be signed by the patient. In
case where someone other than the patient signs the forms, the reason
for the patient's not signing it shall be indicated on the face of the form,
along with the relationship of the signer to the patient.
6.33.1.12 Any consent form for medical treatment that the patient signs shall be printed in
an understandable format and the text written in clear, legible, non technical
language.
6.33.1.13 There shall be a mechanism for medical record controlling and tracing, whenever
patients medical records are taken from and returned to the central medical
record room.
6.33.1.14 There shall be a mechanism to make medical records with appointment ready for
use and return seen cards back to the central medical record room within 24hrs.
6.33.1.15 The patient's death shall be documented in the patient's medical record upon
death.
6.33.1.16 Original medical records shall not leave hospital premises unless they are under
court order or in order to safeguard the record in case of a physical plant
emergency or natural disaster.
6.33.1.17 If a patient or the patient's legally authorized representative requests, in writing, a
copy of the medical record shall be given.
6.33.1.18 If the patient is provided with medical certificates, copies of certificates and other
records shall be documented and/or recorded on the original medical record
6.33.1.19 If the patient is transferred to another hospital on a non emergency basis, the
hospital shall maintain a transfer record reflecting the patient's immediate
needs and send a copy of this record to the receiving hospital at the time of
transfer.
6.33.1.20 If the hospital ceases to operate, the regulatory body shall be notified in writing
about how and where medical record will be stored at least 15 days prior to
cessation of operation. The patient choice on where to transfer his/her medical

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 record shall be respected. Patient will get information from the regulatory body
regarding the location of their medical records.
6.33.1.21 .The hospital shall establish a procedure for removal of inactive medical records
from the central medical record room.
6.33.1.22 Medical records shall be destroyed as per the law by using techniques that are
effective enough to assure confidentiality of medical records. However, records
which are active for more than ten years shall not be destroyed.

6.33.2 Premises
6.33.2.1 There shall be a separate medical record room
6.33.2.2 The premises shall have one meter wide space in between and around shelves.
The medical records shall be shelved 20-30cm above from the floor.
6.33.2.3 The medical record room shall have adequate space to accommodate the
following:
(a) Central filing space
(b) Work space
(c) Archive space
(d) Supply/Storage room
6.33.2.4 The medical record room shall have adequate light and ventilation
6.33.2.5 The medical record room shall be built far from fire sources
6.33.2.6 There shall be a room for archiving dead files until they are permanently
destroyed
6.33.3 Professionals
6.33.3.1 There shall be a full-time medical record personnel (Health Information
Technician) with basic computer skill and ability to organize medical records
responsible for medical records management
6.33.3.2 Other additional staffs (like card sorter and runner) to perform patient
registration, retrieving, filing and recording chart location.
6.33.3.3 The actual number of staff shall be determined based upon the total number of
active charts in a day (Workload analysis)
6.33.3.4 The hospital shall provide basic training on medical record keeping to the staffs

6.33.4 Products

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6.33.4.1 The Medical record room shall have:
(a) Shelves made from metal and must be fire proof
(b) Master patient index boxes
(c) Computer
(d) Cart
(e) Ladder
(f) Water proof patient folder
(g) MPI Cards
(h) Log book
(i) Fire extinguisher

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6.34 Food and Dietary Services

6.34.1 Practices
6.34.1.1 The hospital shall provide nutritionally adequate meals, supplemental food
supplies for inpatients and staffs on duty
6.34.1.2 The dietary service shall be available for 24 hours a day and 365 days a year
6.34.1.3 The dietary service activities shall be managed by a dietician
6.34.1.4 The dietary service shall have written policies and procedures for all dietary
services including
a) Preparation and handling
b) Meal distribution and/or request and receive special event service for
inpatients in the hospital.
c) Special diet order
d) Holidays
e) A diet manual detailing nutritional and therapeutic standards for meals
and snacks, and a nutrient analysis of menus.
f) Nutritional assessment guide for patients' nutritional needs for food and
food supplements.
6.34.1.5 A current diet manual shall be available at each nurse’s station and in the dietary
service unit and medical library.
6.34.1.6 There shall be a policy to promote the participation of the dietary service in
meetings of multidisciplinary health care teams to assess patients.
6.34.1.7 All new admissions shall be listed with the dietary service
6.34.1.8 Each patient's diet shall be documented in the medical record. Documentation of
diet instructions shall include a description of:
a) The diet instruction provided to the patient and/or responsible person.
b) Patient response, participation and understanding.
c) Written instructional material provided to the patient and/or responsible
person.
6.34.1.9 A physician shall write a specific dietary order and /or nutritional supplements
for each patient.
6.34.1.10 All diets shall be prepared in conformity with the hospital's dietary manual.

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6.34.1.11 At least three meals (breakfast, lunch and dinner) shall be served daily, and no
more than 15 hours shall elapse between dinner and breakfast.
6.34.1.12 Nourishment may be provided between meals and at night.
6.34.1.13 Food production shall be sufficient in quantity and quality to meet nutritional
needs.
6.34.1.14 Changes in physician orders for diets shall be effected by the next mealtime,
6.34.1.15 The dietary service shall follow the policies and procedures developed by the
drug and therapeutics committee or any responsible government body
regarding possible food/drug interactions.
6.34.1.16 There shall be a mechanism for evaluating patients on each nursing unit to
ensure they are being adequately nourished.
6.34.1.17 There shall be a mechanism for the dietary service to be informed if the patient
does not receive the diet that has been ordered, or is unable to consume the diet.
6.34.1.18 There shall be a mechanism for patients and their families to interact with the
dietary service.
6.34.1.19 Patients with special dietary needs, based on criteria established by the hospital,
shall receive dietary instruction from a dietician or authorized designee during
hospitalization.
6.34.1.20 The dietitian shall provide diet information to the Canteen staff to help the
nursing / rehabilitation staff guide appropriate purchase selections of food
items.
6.34.1.21 The dietitian shall provide nutrition information as requested by the patient,
family, or treatment team including
a) diet instructions,
b) written instructional material,
c) community dietary referrals regarding special diets
d) current diet order,
e) nutritional problems,
f) appetite,
g) nutritional counseling,
h) comprehension of diet instruction,
6.34.1.22 The dietitian shall provide timely discharge diet instructions upon notification
with a physician-ordered diet consultation or as planned by the treatment team.

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6.34.1.23 Inpatient’s or discharged patient’s diet instructions shall include education
involving:
a) therapeutic or modified diets
b) food-drug interactions
c) nutritional care for certain diagnoses/conditions
d) recommendations for changes in diet order,
e) treatment plan,
f) significant food allergy (lactose, wheat gluten, soya ,egg, dairy)
6.34.1.24 Nutrition consultations
a) The dietitian shall provide nutrition consultations upon notification
with a physician-ordered consultation. The order shall include a
brief reason for the consultation.
b) Nutrition consultations shall be completed immediately after
physician’s order.
c) Nutrition consultations shall be individual or group, and may include
family and/or responsible person.
d) The dietitian shall determine the type and frequency of follow-up
care after the initial consultation. Follow-up consultation may
include evaluation of nutritional care, diet education, or other
nutritional concerns.
6.34.1.25 Treatment Planning
a) Therapeutic goals related to nutritional needs shall be based on the
following standards
 Standard Height/Weight Tables
 Dietary Reference Intakes
 Nutrition-related laboratory values
 Body Mass Index for Adults
6.34.1.26 Diet Orders and Nutritional Supplements
a) Physician diet orders shall be legible, concise, and written in an
understandable manner. The following information shall be included
in diet orders:
 Patient Name
 Unit

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  Date
 Specific diet order; including food allergies/intolerances
 Physician’s signature
b) Dietary services shall receive written notification of:
 New diet orders
 Change in diet order
 Discontinued or canceled diet orders
 Unit transfers
 Isolation or special trays
c) All written diet orders shall be sent to dietary services immediately.
d) Special requests for meals or supplemental foods shall be provided
as ordered to accommodate alterations in diets or meal service
schedules due to new admissions, personal dietary needs, or other
circumstances.
e) Diabetic (ADA) and Calorie-Controlled diet orders shall include the
calorie level desired.
f) The dietitian shall recommend appropriate nutritional supplemental
foods according to physician orders.
g) An electronic or manual spreadsheet of all diet orders shall be
maintained by the dietitian to provide a current resource of all
regular and therapeutic diets.
h) Dietary and nursing services shall be responsible to ensure dietary
compliance and quality nutritional care of patients receiving
physician-ordered diets.
6.34.1.27 There shall be appropriate food safety and sanitations to ensure safe food
service for the patients
6.34.1.28 Dry or staple food items shall be stored at least 12 inches off the floor in a
ventilated room which is not subject to sewage or waste water back-flow, or
contamination by condensation, leakage, rodents or vermin.
6.34.1.29 All perishable foods shall be refrigerated at the appropriate temperature and in
an orderly food safety manner (cold and hot holding principle).
6.34.1.30 Each refrigerator shall contain a thermometer in good working order.
6.34.1.31 Foods being displayed or transported shall be protected from contamination.

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6.34.1.32 Three compartments dish washing procedures and techniques shall be
developed and carried out in compliance with the national hotel and restaurants
sanitary control guideline.
6.34.1.33 All garbage and kitchen refuse which is not disposed of mechanically shall be
kept in leak proof non-absorbent containers with close fitting covers and be
disposed of routinely in a manner that will not permit transmission of disease, a
nuisance, or a breeding place for flies.
6.34.1.34 All garbage containers shall be thoroughly cleaned inside and outside each time
emptied.
6.34.1.35 Requests for alternative food supplies shall be considered on an individual basis.
6.34.1.36 Foods shall be transported and served as close to preparation/ Re-
thermalization time as possible. Maximum cold food temperatures shall be 41° F
(5oC) and minimum hot food temperatures shall be 135° F (60oC) at time of
service.
6.34.1.37 Dietary Services shall ensure prescribed diet compliance as well as minimize
food-borne illness.
6.34.1.38 Cancellations of ordered diets shall be made as soon as possible to avoid
possible spoilage and/or waste of food items.
6.34.1.39 There are three ways by which hospitals may provide dietary services:
a) Hospitals may provide the service in the traditional configuration
where the kitchen is located in the hospital premise;
b) Hospitals may provide the service directly, but may prepare the bulk
of the meals in a kitchen owned by the hospital, located off-site; and
c) Hospitals may contract out for dietary services through an off-site
vendor and the contract shall be documented. However, regardless
of how the hospital provides the service, the hospital shall ultimately
be responsible for meeting the dietary service standards.
6.34.1.40 When dietary services are provided from an off-site location, the hospital shall
be responsible to ensure:
a) Compliance with the quality assurance guideline,
b) Compliance with the infection prevention standard
c) Compliance with the dietetic policies and procedures in regards to
meal service for off hours’ admissions, late trays, food substitutions,

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 reasonable meal schedules, posting of current menus in the hospital
as well as in the off-site kitchen, tray accuracy, food handling safety
practices, emergency food supplies and deliveries, staffing and
patient satisfaction,
d) The presence of a current therapeutic diet manual approved by the
dietitian and medical staff,
e) The presence of nutritional assessment indicating nutritional needs
are in accordance with recognized dietary practices as well as with
orders of the practitioners responsible for the care of the patients.
6.34.2 Premises
6.34.2.1 The following minimum facilities shall be available for dietary services
a) Food preparation room with
 All cooking appliances shall have ventilating hood
 Dish washing facility with three compartment
 Pot washing facilities
 Cart cleaning facilities
 Can wash facilities
b) Storage room
c) Cart storage.
d) Dietitian's office.
e) Janitor’s closet
f) Personnel toilets with hand washing facilities and lockers convenient
to, but not in, the kitchen proper.
g) Approved automatic fire extinguisher system in range hood.
h) Continuous electricity (power) supply
i) Ample and safe water supply
j) Sink
6.34.3 Professionals
6.34.3.1 The hospital shall have an organized dietary service unit directed by a licensed
dietitian (who has a basic education on dietetic sciences) & food sciences & /or
food technologist.
6.34.3.2 Food handlers:
(a) Meal distributor

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 (b) Chief cooker
(c) Kitchen workers
(d) Store keeper
(e) Bakers
(f) Dishwashers
6.34.3.3 The number of personnel, such as cooks, bakers, dishwashers and clerks shall be
adequate to perform effectively all defined functions (based on workload
analysis).
6.34.3.4 There shall be procedures to control dietary employees with infectious and open
lesions.
6.34.3.5 Food handlers shall meet routine health examinations according to the
Ethiopian Food Handlers’ Hygiene Guideline for food service personnel.
6.34.3.6 There shall be an in-service training program on proper handling of food and
personal grooming to dietary employees.
6.34.3.7 All kitchen workers shall wear protective kitchen clothes according to the
Ethiopian Food Handlers’ Hygiene Guideline.
6.34.3.8 A licensed dietitian shall be a full-time employee.
6.34.3.9 Written job descriptions for all dietary employees shall be given and
documented.
6.34.4 Products
6.34.4.1 The following products shall be available for dietary services:
a) Refrigerator (size and number shall be based on demand)
b) Kitchen utensils
c) Pots and Jars
d) Carts
e) Dishes
f) Oven
g) Knives
h) Detergent materials
i) Pressure cooker
j) Stoves
k) Working closes (apron, boots, hair cover, gown, hand gloves …)
l) Barrel (garbage containers) for kitchen rest handling

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6.35 Hospital Sanitation and Waste Management

6.35.1 Practices
6.35.1.1 Hospital environment shall ensure the following conditions
a) Sanitary, clean and safe environment
b) access to continuous, safe and ample water supply
6.35.1.2 There shall be written procedures to govern the use of aseptic techniques and
procedures in all areas of the hospital.
6.35.1.3 To keep infections at a minimum, such procedures and techniques shall be
regularly reviewed by the infection prevention committee and documented see
al so Infection prevention standard…
6.35.1.4 There shall be a written policy and procedures for ground water treatment.
6.35.1.5 Infectious and medical wastes shall be handled and managed according to the
recent Health Care Facility Waste Management National Guideline.
6.35.1.6 Infectious and non infectious medical waste contained in disposable containers
shall be placed for storage, handling, or transport in disposable or reusable pails,
cartons, drums, or portable bins. The containment system shall be leak proof,
have tight-fitting covers and be kept clean and in good repair.
6.35.1.7 Reusable containers for infectious medical waste and general medical waste
shall be thoroughly washed and decontaminated each time and emptied
according to the Health Care Facility Waste Management National Guideline
6.35.1.8 Reusable pails, drums, or bins used for containment of infectious waste shall not
be used for containment of waste to be disposed of as noninfectious waste or for
other purposes except after being decontaminated by procedures described in
Health Care Facility Waste Management National Guideline.
6.35.1.9 Placenta disposal pit shall be available in the hospital and shall be secured
6.35.1.10 Segregation of health care waste shall includes the following procedures
a) Separate different types of waste
b) The hospital shall provide colored waste receptacles specifically suited for
each category of waste

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 c) Segregation shall take place at the source, like ward bedside, OR, laboratory
etc
d) There shall be 3 bin systems used to segregate different types of waste in the
hospital
Segregation category color container
Non risk waste Black bag or bin
Infectious waste yellow bag or bin
Sharp waste yellow safety box
Heavy Metal red secure container
Drug vials, ampoules white bag or bin
Hazardous pharmaceutical yellow bag or bin
and cytotoxic wastes
6.35.1.11 Treatment or disposal of infectious medical waste shall be performed according
to Health Care Facilities Waste Management National Guideline by one of the
following methods:
a) By incineration
b) By steam sterilization
c) By discharge via approved sewerage system
d) Recognizable human anatomical remains shall be disposed of by
incineration or internment, unless burial at an approved landfill is
specifically authorized by municipality and/or environmental health
professional.
e) Chemical sterilization
f) Gas sterilization (shall be handled safely)
6.35.1.12 The hospital shall routinely clean and sanitize patient areas and waiting rooms
at least twice daily and more when ever needed.
6.35.1.13 The hospital shall ensure appropriate ventilation system
6.35.1.14 Medical waste which is not infectious shall be disposed according to Health Care
Facilities Waste Management National Guideline by one of the following
methods:
a) By incineration
b) By sanitary landfill,

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6.35.1.15 In order to maintain a clean and safe environment, the hospital shall have an
organized method for the transport and washing of linens.
6.35.1.16 Housekeeping items shall be clean and sanitize regularly
6.35.1.17 The hospital shall have an organized waste disposal and removal system and
shall ensure the safe handling of all waste
6.35.1.18 Chemicals and radioactive waste shall be disposed according to national
guidelines.
6.35.1.19 All generators of infectious medical waste and general medical waste shall have
a medical waste management plan that shall include the following:
a) Storage of medical waste
b) Segregation of medical waste
c) Transport of medical waste
d) Disposal of medical waste
6.35.1.20 Sewage disposal shall be according to Health Care Facilities Waste Management
National Guideline and fulfill the following conditions:
a) Hospitals shall have a functional sewerage system
b) Hospitals shall dispose of all sanitary waste through connection to a suitable
municipal sewerage system
c) The hospital shall have only flushing toilet system
d) The hospital shall have a designated waste storage room for solid waste or
septic tank for liquid waste
e) There shall be written procedures defining instrument processing
procedures (disinfection and sterilization).
f) There shall be written procedures to govern the use of aseptic techniques
and procedures in all areas of the hospital.
g) All fixtures located in the kitchen, including the dishwasher, shall be
installed so as to empty into a drain which is not directly connected to the
sanitary house drain.
h) Kitchen drain shall empty into a manhole or catch basin having a perforated
cover with an elevation of at least 24 inches below the kitchen floor
evaluation, and then to the sewer.
6.35.1.21 Plumbing shall fulfill the following conditions:
a) An approved municipal water system

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 b) An approved method of supplying hot water
c) Supply piping within the building shall be in accordance with plumbing
procedures
6.35.1.22 Catering hygiene shall fulfill the following conditions
a) There shall be guidelines for pest control and restricting the presence of
animals (eg. cats, dogs etc) visibly posted in the kitchen.
b) There shall be a system to screen and control the health of kitchen
personnel.
c) The responsible kitchen personnel health shall be controlled for:
 Personal hygiene including uniform (protective clothes)
 Periodical medical check-up for acute and chronic diarrhea and
other infectious diseases
 Those with infected open skin lesions are not allowed to work as
kitchen personnel.
6.35.1.23 The hospital shall have supportive sanitation majors
a) Clean water where there is no plumbing
b) Hand hygiene practice
c) Sterilization of medical instruments
d) Isolating infectious patient in special isolation room
e) Alternatives to protective equipment.
6.35.2 Premises
6.35.2.1 Placenta disposal pit shall have dimension of height 2.5m, width 2.5m and
lateral to the disposal pit the two sides shall be filled with concrete see annex
for placenta disposal pit
6.35.2.2 In addition, the hospital sanitary system shall have
a) Functional sewerage system
b) Flushing toilet
c) Plumbing setup stores
d) Kitchen
e) Laundry
f) Sanitary office
g) Incinerator

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 h) Dumpster (Genda for solid waste accumulation)

6.35.3 Professionals
6.35.3.1 Hospital sanitation shall be administered by a licensed environmental health or
any related licensed professional trained on sanitary sciences
6.35.3.2 The hospital shall have the following personnel to conduct sanitation activities.
(see also Housekeeping, Maintenance and Laundry Standards)
a) Sanitarians
b) Housekeeping staff such as cleaners and waste handlers
c) Laundry staff
d) Gardeners
e) Incinerator operator
f) Instrument processors (disinfector and sterilizer)
g) Plumber
6.35.3.3 The hospital shall officially designate staff in charge of handling waste on a
regular basis.
6.35.3.4 The assigned staff shall be responsible for the collection and disposal of waste
products in the hospital.
6.35.3.5 Continuing education shall be provided to all personnel engaged in sanitation
activities on the relevant procedures
6.35.3.6 Staff shall be oriented on personal protection methods

6.35.4 Products
6.35.4.1 The hospital shall have equipment and supplies required for sanitation
activities. Required equipment and supplies includes:
a) Incinerator
b) Ash pit
c) Burial pit
d) Placenta pit
e) Garbage bins
f) Safety boxes
g) Trolley to transport waste
h) Dumpster (Genda) shall be placed in a clean isolated and fenced area.

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i) PPE (personal protective equipment)
j) Autoclave
k) Pressure cooker
l) Cleaning supplies (detergents, disinfectants and other cleaning solutions
etc)
m) Laundry washers,
n) Laundry dryers,
o) Mops and dustpans

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6.36 Housekeeping, Laundry and Maintenance Services

6.36.1 Practices
6.36.1.1 The housekeeping service shall have the following sanitary activities.
a) Basic cleaning such as dusting, sweeping, polishing and washing
b) Special cleaning of
 Different types of floors
 Wall & Ceiling
 Doors & Windows
 Furniture & Fixtures
 Venetian Blinds
c) Cleaning and maintenance of toilet.
d) Water treatment, filtering & purification.
6.36.1.2 In the housekeeping service, the types and sources of unwanted odors in
hospital premises shall be identified, controlled and removed
6.36.1.3 Collection, transportation and disposal of hospital wastes shall be supervised
and controlled
6.36.1.4 The safety of fire, electrical and natural hazards in the risk areas in the hospital
shall be supervised and controlled and shall work closely with hospital fire
brigade and safety committee.
6.36.1.5 The designee/ sanitarian shall identify, supervise and organize the control and
eradication of pests, rodents and animal nuisance in the hospital.
6.36.1.6 The housekeeping staffs shall create pleasant environment to patients, staffs and
visitors
6.36.1.7 The housekeeping staffs shall ensure proper lighting and ventilation in different
hospital areas.
6.36.1.8 The following LINEN services shall be provided in the hospital
 Maintain an adequate supply of clean linens at all times
 Obtain linen from stores and laundry.
 Ensure proper storage of linen.
 Supervise washing, sterilization in the laundry.

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  Maintain linen properly
 Issues linen in service units like wards.
 Keep proper accounting of linen.
 Ensure proper sorting of linen.
 Understand different color scheme.
6.36.1.9 If the hospital uses a laundry which is not owned by the hospital, it shall
maintain the sanitary standards of the hospital regarding the processing of its
linens and shall maintain a satisfactory schedule of pick up and delivery.
6.36.1.10 Regular surveillance of overhead and underground tank, proper cover, regular
chlorination and cleaning shall be undertaken
6.36.1.11 The infection control measures shall be carried out in accordance with the
hospital infection prevention standard stated in this document.
6.36.1.12 Potable water and electrical services shall be available 24 hours a day and 365
days a year.
6.36.1.13 The Hospital shall conduct regular preventative maintenance for all facilities
and operating systems (e.g., electrical, water, ventilation) to ensure patient and
staff safety and comfort.
6.36.1.14 There shall be 24 hours maintenance service for all facilities
6.36.1.15 There shall be a hospital plant safety maintenance organization as described
below:
a) A multidisciplinary safety committee that develops a comprehensive hospital-
wide safety program and reviewed at least once every three years and
implemented accordingly.
b) A mechanism to report all incidents, injuries and safety hazards to the safety
committee.
c) The committee shall review all reports and be responsible for ensuring that all
reports are referred appropriately and follow-up action is documented.
6.36.1.16 Plant maintenance services
a) The building maintenance service shall have written policies and procedures
that are reviewed at least once every three years and implemented
accordingly.
b) The standby emergency generator shall be checked weekly, tested under load
monthly, and serviced in accordance with accepted engineering practices.

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 c) Floors, ceilings, and walls shall be free of cracks and holes, discoloration,
residue build-up, water stains, and other signs of disrepair.
d) Routine inspections of elevators shall be conducted in accordance with local
ordinances.
6.36.1.17 Construction and renovation
a) Whenever construction and renovation projects are planned in and around a
health care facility, a risk assessment shall be conducted to determine the
impact of the project on patient areas, personnel, and mechanical systems.
b) The infection control program shall review areas of potential risk and
populations at risk.
6.36.1.18 There shall be written protocols and procedures for diagnostic equipment
maintenance service including:
 Plan for equipment maintenance (both preventive and curative),
replacements, upgrades, and new equipments
 Safe disposal procedures
 An effective tracking system to monitor equipment maintenance activity.
 A monitoring method that ensures diagnostic equipment operates with
predicted specificity and sensitivity.
6.36.1.19 Fire and emergency preparedness
a) The hospital shall comply with the National Fire Protection standard
b) All employees, including part-time employees, temporary agency personnel,
and private duty nurses shall be trained in procedures to be followed in the
event of a fire and instructed in the use of fire-fighting equipment and patient
evacuation of hospital buildings as part of their initial orientation and shall
receive printed instructions on procedures and at least annually thereafter.
c) A written evacuation diagram specific to the unit that includes evacuation
procedure, location of fire exits, alarm boxes, and fire extinguishers shall be
posted conspicuously on a wall in each patient care unit.
d) Fire extinguishers shall be visually inspected at least monthly; fully inspected
at least annually, recharged, repaired and hydro-tested as required by
manufacturer's instructions; and labeled with the date of the last inspection.

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 e) Fire detectors, alarm systems, and fire suppression systems shall be inspected
and tested at least twice a year by a certified testing agency. Written reports of
the last two inspections shall be kept on file.
f) There shall be a comprehensive, current, written preventive maintenance
program for fire detectors, alarm systems, and fire suppression systems that
includes regular visual inspection. This program shall be documented.
6.36.1.20 If the hospitals contract out for housekeeping, laundry and maintenance services
there shall be documentation for a contractual agreement.
6.36.1.21 Housekeeping equipment or supplies used for cleaning in isolation or
contaminated areas shall not be used in any other area of the hospital before it
has been properly cleaned and sterilized.
6.36.1.22 All areas of the hospital, including the building and grounds, shall be kept clean
and orderly.
6.36.1.23 There shall be frequent cleaning of floors, walls, woodwork and windows.
6.36.1.24 The premises shall be kept free of rodent and insect infestations.
6.36.1.25 Accumulated waste material and rubbish shall be removed at frequent intervals.
6.36.1.26 No flammable cleaning agents or other flammable liquids or gases shall be stored
in any janitor's closet or other area of the hospital except in a properly fire rated
and properly ventilated storage area specifically designed for such storage.

6.36.2 Premises
6.36.2.1 If the hospital maintains its own laundry, it shall have separate areas for:
a) Collection of soiled linens.
b) Washing, drying and ironing.
c) Clean linen storage and mending area.
6.36.2.2 Boiler Room shall be available for the installation and maintenance of
the required machinery.
6.36.2.3 The laundry design and operation shall comply with the manufacturer’s
requirements and/or institutional sanitation guideline
6.36.2.4 Clean linen storage shall be readily accessible to nurses' stations
6.36.2.5 Dirty linen storage shall be well ventilated and shall be located convenient to the
laundry or service entrance of the hospital. The storage of appreciable quantities
of soiled linens is discouraged.

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6.36.2.6 There shall be separate space provided for the storage of housekeeping
equipment and supplies
6.36.2.7 A separate office shall be available for the maintenance and the housekeeper.
6.36.2.8 Adequate space shall be available for service specific janitor’s closets and
cleaning equipment & supplies which shall be maintained separately for the
following areas (shall not be used for cleaning in any other location):
a) Surgical Suites.
b) Delivery Suites.
c) Newborn Nursery.
d) Dietary Department.
e) Emergency Service Area.
f) Patient Areas.
g) laboratories, radiology, offices, locker rooms and other areas
6.36.2.9 Exits, stairways, doors, and corridors shall be kept free of obstructions.
6.36.2.10 The hospital shall have an alternate emergency power supply. If such emergency
power supply is a diesel emergency power generator, there shall be enough
stored fuel to maintain power for at least 24 hours.

6.36.3 Professionals
6.36.3.1 The housekeeping, maintenance and laundry functions of the hospital shall be
under the direction of a licensed sanitarian.
6.36.3.2 The designated officer shall plan, organize, co-ordinate, control and monitor all
housekeeping activities.
6.36.3.3 The housekeeping, maintenance and laundry personnels shall take basic
trainings on the following issues and this shall be documented in their personal
profile.
a) Basic principles of sanitation and peculiarity to hospital environment.
b) Basic principles of personal hygiene
c) Basic knowledge about different detergent and disinfectants
d) Different cleaning procedures applicable to different hospital areas
e) Basic knowledge about cleaning equipments operation techniques and their
maintenance.
f) Different processes of water treatment & purification, removing bacteria.

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 g) Basic principals of ventilation, composition of Air, Air flow, Humidity and
temperature.
h) Common types of odors and their sources of origin, identification and
control.
i) Removal and control technique of different types of odors.
j) Various equipments and materials used for odor control operation.
k) Hospital Waste, Source and generation of waste
l) Hazards of hospital waste to hospital population and community.
m) Principles of collection of different types of hospital wastes
n) Operational procedures of equipments
o) Safety measures in operation
p) Hospital lay out, configuration work, flow of men, material and equipment in
different hospital areas. Air, water, noise, pollution, causes of pollution and
their control and prevention in hospital.
6.36.3.4 Electrician, Plumber, Painter.
6.36.3.5 Maintenance technician (Bioengineer if possible)
6.36.4 Products
6.36.4.1 The hospital shall have the following tools, equipment & raw materials for
housekeeping services.
a) Equipment:
 Floor cleaning brush air
 Floor wiping brush
 Hockey type brush
 Counter brush.
 Ceiling brush
 Glass cleaning / wiping brush.
 Scrappers
 Dustbins paddles.
 Waste paper basket.
 Plastic Mug
 Plastic Bucket
 Plastic drum

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  Wheel barrow
 Water trolley
 Ladder
 Scraping pump
 Spraying pump
 Flit pump.
 Rate trapping cage
 Gum boots
 Gown, masks & heavy duty gloves
 Torch
 Manual sweeping machine.
 Floor scrubbing/polishing machine
 Wet vacuum cleaner.
 Dry vacuum cleaner portable
 Fumigation machine (Oticare)
 Bed pan washer.
b) Cleaning material
c) Disinfectant and air freshener
d) Laundry cleaning material
e) Insecticides & rodenticides
f) Stain removal

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6.37 Social Works Services

6.37.1 Practices
6.37.1.1The hospital shall have an organized, supervised and well staffed social work
services.
6.37.1.2There shall be an organizational chart or alternative documentation clearly
delineating the lines of responsibility, authority and communication for the
social services.
6.37.1.3The social work service shall have written policies and procedures that are
reviewed at least once every three years, or revised more frequently as needed,
and implemented.
6.37.1.4The policies and procedures concerning the social work services shall address the
following areas:
a) Counseling,
b) Discharge management and planning,
c) Social work assessment
d) Consultation and referral to support groups, centers and/or organizations
e) Patient advocacy
f) Community liaison and education.
6.37.1.5 The social work service shall have a protocol to ensure that social work services are
offered to all needy patients.
6.37.1.6Patient directory shall be available in the hospital and shall be updated
6.37.1.7The social work services shall have criteria for identifying at the time of admission
and promptly assessing high-risk patients in need of psychosocial intervention
and/or discharge planning.
6.37.1.8 The social work service shall participate in the development and review of the
hospital's agreements with extended and long-term care facilities.
6.37.1.9There shall be a system for clinical staff to refer patients directly to the social work
service
6.37.1.10 The social worker shall consult members of other disciplines providing patient
care and services.

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6.37.1.11 Each patient who has received social work intervention shall be informed that
he or she may call the social work service unit for questions after discharge.
6.37.1.12 Patient’s families or guardians should be included in services provided by the
social work service unit, where indicated.
6.37.1.13 The social work service unit shall assist patients directly or indirectly in
identifying the need for implementing and verifying guardianship as part of
discharge planning.
6.37.1.14 The social work service unit shall report victims of abuse to the appropriate
body according to the Ethiopian laws.
6.37.1.15 When a patient is transferred or linked to another health care facility after
discharge, the social work service unit shall assure that relevant social work
service documentation or information is provided to the facility in order to
assure continuity of care.
6.37.1.16 When social work intervention is provided, a record shall be kept in accordance
with standards in the medical record. The record shall have at least the
following information
a) The reason for intervention;
b) The name (s) of social workers involved and dates of intervention;
c) A social work assessment;
d) A treatment plan and referrals; and
e) Notes reflecting interventions before discharge.
6.37.1.17 Patients’ files, at social work service unit, shall be kept physically secure and
confidential.
6.37.1.18 All reasonable efforts shall be made for privacy in patient and family interviews
and in the handling of confidential phone calls by social workers.
6.37.1.19 The hospital shall have a program of continuous quality improvement for social
work that is integrated into the hospital continuous quality improvement
program and pertains to the scope of social work services provided.
6.37.1.20 Adoptions by individuals or groups shall abide the laws and regulations of the
nation

6.37.2 Premises

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6.37.2.1The hospital shall have a well organized, adequately staffed separate social work
service unit or area
6.37.2.2The following separate rooms shall be available:
a) Social worker office
b) Patient and family interview room
c) Handling of confidential phone calls room
d) Archive

6.37.3 Professionals
6.37.3.1 All social work services given by the hospital shall be under the direct supervision
of a social worker graduated from a recognized College/University or
psychologist or nurse psychiatrist or a nurse with experience in social work.
6.37.3.2 Each social worker shall be under the direct supervision of the head social work
services of the hospital.
6.37.3.3All the social work staff shall take multidisciplinary patient care training at least
annually and the information about their training shall be documented.

6.37.4 Products
6.37.4.1The social work service unit shall have the following products and facilities:
a) Telephone
b) The necessary forms and documenting means for referral, adoption and
transfer
c) Computer
d) Filing cabinet

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6.38 Care After Death and Morgue Services

6.38.1 Practices
6.38.1.1 The hospital shall have written policies and procedures for morgue (dead body
care) services. These policies shall delineate the responsibilities of the medical
staff, nursing, and morgue services staff, and shall include procedures for at least
the following:
a. Confirmation of death by physician, identification of the body, recording and
labeling;
b. Safe and proper handling of the body to prevent damage and this shall be
according to the patient religion and culture;
c. Safeguarding personal effects of the deceased and release of personal effects
to the appropriate individual;
d. Proper handling of toxic chemicals by morgue and housekeeping staff;
e. Infection control, including disinfection of equipment as per IP standard;
f. Identifying and handling high-risk and/or infectious bodies;
g. Release of the body to the family shall be as immediately as possible;
h. Autopsy service if available
6.38.1.2 There shall be a death certificate issued by authorized physician for each death
and this shall be documented.
6.38.1.3 The service shall be available for 24 hours a day and 365 days of a year
6.38.1.4 Any dead body shall be treated in a human way that respects human dignity
(postmortem autopsy shall not destroy the anatomical structure as much as
possible and closure of open body shall respect again the dignity of human
being)
6.38.1.5 Any dead body shall pass through morgue after the confirmation by the
physician
6.38.1.6 Dead body discharge shall be through the morgue exit

6.38.2 Premises

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6.38.2.1 The morgue shall be equipped with refrigerated space to store at least two
bodies. Hospitals with more than 100 beds shall provide additional space using
a ratio of one space to every additional 100 beds.
6.38.2.2 In addition, the morgue premises shall fulfill at least the followings:
(a) Dead body care taking room
(b) Postmortem room
(c) Adequate Water supply
(d) Well ventilated
(e) Adequate supply of light
(f) Office

6.38.3 Professionals
6.38.3.1 In hospitals where autopsy service is available, there shall be a licensed
pathologist
6.38.3.2 Trained nurse, trained morgue attendant and cleaner

6.38.4 Products
6.38.4.1 Refrigerated spaces in the morgue shall be maintained at temperatures between
32 and 45 degrees Fahrenheit (0 and 6.6 degrees Celsius) and shall have an
automatic alarm system that monitors the temperature.
6.38.4.2 In addition, the following products shall be available for morgue services:
(a) Plastic sheets
(b) Aprons
(c) Stretcher
(d) Knives, Scalpels, Scissor
(e) Formalin, Detergents, Disinfectants
(f) Cotton, bandage, gloves, boots, gowns, head cover
(g) Goggles
(h) Plastic bags
(i) White clothes
(j) Body table with hot and cold water sink
(k) Cupboard for instrument
(l) Scale

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(m)Cold chain room
(n) Syringe & long needle and
(o) Minor sets including retractor

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Section 7: Physical Facility standards

7.1. General

7.1.1. Every specialized hospital subject to these Minimum Standards shall be housed
in a safe building which contains all the facilities required to render the services
contemplated in the application for license. The term "safe" used in this Section
shall be interpreted in the light of compliance with the requirements of the
latest country building codes presently in effect.

7.2. Site Selection Requirements

7.2.1. The entry points to the hospital shall be clearly defined from all major exterior
circulation modes ( roadways, bus stops, vehicle parking)
7.2.2. Boundaries of the hospital between public and private areas shall be well
marked and clearly distinguished. And clearly visible and understandable
signage and visual land marks for orientation shall be provided
7.2.3. All specialized hospitals shall be located 1,000 - 1500 meters far away from
unordinary conditions of undue noises, smoke, dust or foul odors, and shall not
be located adjacent to railroads, freight yards, airports, grinding mills, traffic
pools, industrial plants and disposal plants.
7.2.4. As ditto but located 200 – 500 meters far away from bars & night clubs, schools,
commercial market centers, religious facilities and children's playgrounds.
7.2.5. No hospital shall be located nearer than 1,500 meters to a gas depot or cross-
country petroleum or gas pipelines.
7.2.6. The locations of a hospital shall comply with all national and state level
regulations applicable to health facilities.
7.2.7. In addition to these requirements stated above the site selection criteria shall
consider or include the followings, but not limited to:
a) The minimum size of a specialized hospital premises shall be 30, 000 m2
with two side adjacent road access.
b) The hospital shall be built preferably in a terrain with a gentle slop

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 c) The foundation schemes, soil test and investigation shall be done and it
shall comply with the national building code and seismic requirements.
d) The hospital shall be provided with road access, water supply, electric city
and communication facilities.
e) The building shall be parallel to the wind direction, sun glare and heat. In
case difficulties to fulfill these, there shall be technical solutions for such
natural effects.
f) The surroundings of the hospital shall be free from dangers of flooding,
landslide, theft, intrusion of stray/wild animals, pollution of any kind
(example air, water and sound) and health hazards.
g) The hospital shall be landscaped, therapeutic, appealing scenery, attractive
with green areas/beautiful trees and possible outdoor recreation facilities.

7.3. Construction Requirements

7.3.1. The Authority shall be consulted before commencement of any health facility
physical development for new, remodeling and additions to an existing licensed
hospitals to ensure conformity to the standards.
7.3.2. The hospital or the investor shall sign memorandum of understanding of plan
agreement prepared by the Authority in line with these regulatory standards.
7.3.3. Plans and specifications for any hospital construction or remodeling shall
comply with Ethiopian Building Code. Based on the plan agreement, the
following plans shall be submitted to the Authority for review:
a) Preliminary Design Report: Includes schematics of building designs, plot
plans showing size and shape of entire site, existing structures, streets and
location and characteristics of all needed utilities, floor plans of every floor
dimensioned and with proposed use of each room or area shown and
preliminary engineering estimates. If it is for additions or remodeling,
provide plan of existing building showing all proposed alterations, outline
specifications to include a general description of the construction, type of
finishes, and type of heating, ventilating, plumbing and electrical systems
proposed. In summary the design report shall include all requirements
healthy facility premises stipulated under this document.

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 b) The hospital or the investor shall get consensus on preliminary design
report in writing from the Authority.
7.3.4. The authority may be consulted on construction processes and milestones for
conformity to the standards.
7.3.5. Upon completion of construction the authority shall inspect and issue a license
for operation of the hospital if all the findings are in conformity to these
standards.
7.3.6. In case of partial completion of construction, the Authority may be consulted to
start lower level of health services in line with other standards. This is
applicable if only if the completed portion of the construction will not be
affected during the completion of the remaining part of construction.
7.3.7. Buildings designed for other purposes shall not be used for the operation of a
hospital unless it is remodeled in accordance with these standards.
7.3.8. All hospitals shall be designed, constructed, and maintained in a manner that is
safe, clean, and functional for the type of care and treatment to be provided.
7.3.9. All hospitals shall have at least three entry/exit sites and they shall be accessible
to roads.
a) Main public entrance
b) Emergency entrance
c) Staff and service entrance
d) Morgue entrance and/or exit (optional)
7.3.10. The construction shall comply with the following codes and guidelines to
provide a safe and accessible environment that is conducive to the care and
treatment to be provided:
a) The Ethiopian Building Proclamation 624/2009;
b) The Ethiopian Standard Building Code;
c) Life Safety Code (National Fire Protection Code);
d) National Electrical Design Code;
e) The Ethiopian Disability Code;
f) Other codes – ex. Sanitation codes, environmental protection laws, water
codes

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 7.3.11. Building entrances used to reach the outpatient & inpatient services and exit
sites shall be easily accessible, clearly marked/labeled and located, in order to
patients and visitors will have clear way finding.
7.3.12. Utilization of proper construction materials should be used in conformity to the
Ethiopian Building Code, that suit the health services delivery.

7.4. Building Space and Elements

7.4.1. All horizontal and vertical circulation areas that include stairs, doors, windows,
corridors, exits and entrances of the hospital shall be kept clear and free of
obstructions and shall not be used for other functional purposes that include
storages.
7.4.2. Rooms: All room size and space allocation shall consider room loadings based
on the current staff, clients involved, usable medical equipments, furniture and
applicable functions.
7.4.3. The hospital circulation (main and sub corridors): shall be wide enough to
allow passage for its function
7.4.4. Patient serving corridors: should not be less than 240cm wide, and
proportionally the openings to the corridor needs to be designed to allow easy
movement of coaches and be equipped as needed by the patient with safety and
all assistive devices (it includes: door stopper, protecting girders, alarms, self
opening electronic devices, etc).
7.4.5. Doors: all Doors shall be able to easily open and close, doors swing into
corridors shall be avoided.
7.4.6. Patient rooms: Each patient room shall meet the following requirements:
a) All patient functioning rooms, toilet, and bathing room doors shall provide
privacy yet not create seclusion or prohibit staff access for routine or
emergency care.
b) Area: Shall contain 9.20m2 (100ft2) of floor area for a single bedroom and
7.50m2 (80ft2) per bed in multi-bedrooms.
c) Ceiling Height: Ceiling height needs to be determined based on the
functional requirements considering air space, technical requirements,
room size proportions, number of occupants and other parameters. The
height of the ceiling of the rooms shall not less than 240cm high for

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 support services, 220cm for technical corridors (operation theater 320
cms, X-ray 320 cm, room requiring interstitial floor needs to be more than
580cms) and 280cm for other clinical rooms.
d) Windows. All rooms housing patients shall have access to natural light and
ventilation, or prove the availability of artificial ventilation and light at all
times. (please refer the annex regarding detail lux requirements for
functional rooms). Rooms shall have window area proportional to that of
floor areas which is equal to 1’8" of the floor area. The sill shall not be
higher than 36 inches above the floor and shall be above grade. For toilets
and washing rooms, over desk laboratory tables, laundry and kitchen
utensils, the height can be modified accordingly) Windows shall not have
any obstruction to vision (wall, cooling tower, etc.) within 50 feet as
measured perpendicular to the plane of the window.
e) Storage: Each patient shall be provided with a hanging storage space of not
less than 40.cm x 60.cm x 130cm (16" x 24" x 52") for his personal
belongings.
f) Furnishings: A hospital shall provide comfortable patient trigonometric
designs, applicable functions, and technical requirements. They have to be
hygienic (washable, dust and bacteria protective and resistant for
cleansing reagents) durable that can control vandalism and avoid
accidents.
g) Curtains: rooms shall be equipped with curtains or blinds at windows. All
curtains shall have a flame spread of 25 or less or as per the national fire
protection code. And all as per the national infection prevention guidelines
requirements.
h) Cubicle curtains or equivalent built-in devices for privacy in all multi-bed
rooms shall be provided. They shall have a flame spread of 25 or less or as
per the national fire protection code.
i) Finishing
 Walls, floors and ceilings of procedure rooms, isolation rooms, sterile
processing rooms, work room, laundry and food-preparation areas
shall be suitable for easily washing. All floors of the hospital clinical
service areas shall be washable, smooth, non- adsorptive, surfaces

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 which are not physically affected by routine housekeeping cleaning
solutions and methods. Acoustic lay-in ceilings, if used, shall be non-
perforated.
 Public spaces such as reception areas, waiting areas, cafeterias, areas
requiring silence and sub specialty areas like psychiatry shall be
designed with acoustic control and the lamination/lay shall be non-
perforated.
 Scrub-able room finishes provided in operating rooms and isolation
rooms shall have smooth, non-adsorptive, non-perforated surfaces
that are not physically affected by harsh germicidal cleaning solutions
and methods.
 All walls and ceiling finishing materials used shall have a 1-hour fire
rating (One hour rated products offer more than "one hour's" worth
of fire protection).
j) Sanitary Finishing
 A lavatory equipped with wrist action handles, shall be located in the
room or in a private toilet room.
 For hospitals with multiple bed wards without private toilet room
shall provide bedpan washer.
 All sanitary room facilities floors, walls and ceilings shall be
completed with washable finishing materials
 Floors and walls penetrated by pipes, ducts and conduits shall be
tightly sealed to minimize entry of rodents and insects
k) Electrical Finishing
 Patient bed light shall be controlled by the patients.
 Room light luminescence shall be bright enough for staff activities but
needs to be controlled not to disturb the patients.
 All electrical fixtures inlets, outlets shall fulfill Ethiopia Electrical
Safety requirements and if applicable fitted with guards
 For psychiatry service area light fixtures, sprinkler heads and other
apparatus shall be of a temper resistant type.
7.4.7. Outdoor Areas: the hospital outdoor area shall be equipped and situated to
allow for the safety and abilities of patients, care givers, staff and visitors.

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 7.4.7.1. The landscape shall be designed with patient room visual acquit or access
7.4.7.2. Walkways, connection roads and elevation differences shall be
designed to allow movements of coaches/stretchers and persons with
disabilities.
7.4.7.3. The outdoor traffic arrangement shall not cross each other to avoid
accidents
7.4.8. Windows: In all rooms, windows shall comply with lux requirements of room
space without compromising room temperature and ventilation.
7.4.8.1. Windows shall be a minimum of 50 cm wide x 100cm high. However,
in case of hot climate areas, this may not be applicable
7.4.8.2. No window shall swing inside the room except those which require
security and safety measures such as grid for theft and insect mesh for
malaria porn areas.
7.4.8.3. Windows that frequently left open for cross ventilation purpose (like
TB clinic room windows) shall be equipped with insect screen. At least a
top portion of a window shall be left open fitted with insect mesh for
uninterrupted circulation of air.
7.4.8.4. Safety glass, tempered glass or plastic glass materials shall be used
for pediatrics and psychiatric service units to avoid possible injuries.
7.4.9. Vertical Circulation: All functioning hospital rooms shall be accessible
horizontally.
7.4.9.1. Stairs: All stairways and ramps shall have handrails and their
minimum width shall be 120cm.
 All stairways shall have a 2-hour fire enclosure with a "B" (1.5 hour)
label door at all landings or as per the national fire protection code.
 All stairways shall be fitted with non slippery finishing materials
 All stair threads, riser and flight shall comply with patient type as
per the Ethiopia Building proclamation
7.4.9.2. Ramp: Ramps shall be designed with a slope of 6 to 9 percent,
minimum width of 120 cm and the landing floor of 240cm wide on both
sides.

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 7.4.9.3. Shoots: Hospital buildings having services in the upper floor shall
have shoots facility. Shoots shall be free of possible accidents and the inlets
and outlets shall be confined in a lockable room.
7.4.9.4. Elevators: In the absence of engineered traffic study, at least two
hospital type elevators shall be installed where 1-200 patient beds are
located in the upper floors. In case of more than 200 beds, the number of
elevators shall be determined from a study plan and expected vertical
transportation requirements. Minimum cab dimensions required for
elevators transporting patients is 195cm x 130cm inside clear
measurements and minimum width for hatchway and cab doors shall be
100cm.
7.4.10. Fire Safety Considerations:
7.4.10.1. One-Story Building: Wall, ceiling and roof construction shall be of
1-hour fire resistive construction as defined by National Fire Code. Floor
systems shall be of non-combustible construction.
7.4.10.2. Multi-Story Buildings: Must be of two-hour fire resistive
construction as defined in National Fire Code as specified to hospitals.
7.4.10.3. Travel Distances and alternative vertical circulation: Hospital
facilities travel distance from service giving room to the stairs should be as
specified in the National Fire Code. Alternative fire escape stair should be
provided otherwise.
7.4.11. Parking areas:
7.4.11.1. The hospital shall have separate parking spaces for hospital
ambulance.
7.4.11.2. Parking space shall have a clear mark for Staff, Patients and Visitors
with separate 10% of it for person with disability parking all as per
Ethiopia Building Proclamation and building code.
7.4.11.3. General services of the hospital that require loading unloading
docks, heavier truck movement and temporary truck parking place shall be
available.
7.4.11.4. The parking space shall not cross pedestrian walkways, if it is
mandatory to cross proper precaution measures such as Zebra Road, Speed

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 Breaker, guiding notice and traffic stopping culverts or signals should be
provided.

7.5. Building Systems

Hospitals shall have building systems that are designed, installed and operated in such a
manner as to provide for the safety, comfort and well being of the patient.

7.5.1. Water supply and plumbing:

a) Continuously circulated as per the type of fixture used, filtered and treated
water systems shall be provided as required for the care and treatment in
the hospital
b) All hospitals subject to be connected to an approved municipal water
system whose purity has been certified by the concerned body. The water
supplies must be sampled, tested, and its purity certified at least twice
annually and immediately following any repair or modification to the
underground lines, the elevated tank, or to the well or pump.
c) All hospitals subject to be connected to its own separate water supply
system shall qualify and certified by the concerned body regularly. In
house quality control shall be established, the water supplies must be
sampled, tested, and its purity certified at least twice semi-annually and
immediately following any repair or modification to the underground
lines, the elevated tank, or to the well or pump.
d) The hospital shall have and maintain an accessible, adequate both as to
volume and pressure, safe and potable supply of water. Where an
authorized public water supply of satisfactory quantity, quality, and
pressure is available, the hospital shall be connected to it and its supply
used exclusively. Deficiencies in either safety and adequacy in volume or
pressure must be remedied by the provision of auxiliary pumps, pressure
tanks or elevated tanks as may be required.

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 e) The collection, treatment, storage, and distribution potable water system
of a hospital shall be constructed, maintained, and operated in accordance
with all provisions of the Safe Drinking Water of the country.
f) Supply piping within the building shall be in accordance with plumbing
standards. Special care must be taken to avoid use of any device or
installation which might cause contamination of the supply through back-
siphonage or cross connections or the water distribution system shall be
protected with anti-siphon devices, and air-gaps to prevent potable water
system and equipment contamination.
g) A treated backup water supply shall be readily available in the hospital
like a reservoir or dedicated well. In case, if for any reason the main water
supply is inaccessible. A contingency plan should be envisage in severe
cases where supply disconnected and backup finished.
h) The hospital shall have an approved method of supplying hot water for all
hospital consumption. Water to lavatories and scrub sinks must be 37.8 -
540C. Water to mechanical dishwashers must be delivered at 82 0C for
rinsing.

7.5.2. Sewerage and Waste Processing Systems

7.5.2.1. The hospital shall maintain a sanitary and functioning sewage system in
accordance with the national healthcare waste management guidelines
and Ethiopian building code.
7.5.2.2. In addition, the health facility shall fulfill the following requirements;
a) The hospital shall dispose all sanitary wastes produced in the
hospital through connection to a suitable municipal sewerage
system or through a private sewerage system if applicable.
Where there is no municipal or private sewerage system the
hospital shall provide a designed and well marked septic tank, or
other similar facility according to the local environment and
protected method that require the approval of the regulatory
authority

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 b) The hospital sewage system shall be segregated from hazardous
hospital waste before it enters the municipal or private sewage
system.
c) The hospital shall provide areas to collect, contain , process, and
dispose of medical and general waste produced within the
hospital in such a manner as to prevent the attraction of rodents,
flies and other insects and vermin, and to minimize the
transmission of infectious diseases in accordance with waste
management standards of this health facility.
d) The hospital shall have all the required waste management
facilities (such proper segregation and disposal system by the
nature of waste, over 600 degree Celsius combustor incinerator
or sterilizer steam grinder, etc) as recommended by the national
healthcare waste management guidelines.

7.5.3. Heating and Cooling, Ventilating and Air-Conditioning Systems:

a) The hospital shall provide a heating and air conditioning system for the
comfort of the patient and capable of maintaining the temperature in
patient care and treatment areas.
b) In the hospital, the system shall be capable of producing a temperature of
at least seventy five degrees Fahrenheit (75°F) during heating conditions
and a temperature that does not exceed eighty-five degrees Fahrenheit
(85°F) during cooling conditions.
c) The hospital to have a central air distribution and return systems which
have the following percent dust spot rated filters:
 General areas: thirty (30) +%; and
 Care, treatment, and treatment processing areas: ninety (90) +%.
d) Surgical areas shall have heating and cooling systems that are capable of
producing a room temperatures at a range between sixty-eight Fahrenheit
(68°F) and seventy-three degrees Fahrenheit (73°F) and humidity at a
range between thirty (30%) and sixty percent (60%) relative humidity.
e) Airflow shall move from clean to soiled locations. Air movement shall be
designed to reduce the potential of contamination of clean areas.

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 f) Floors in operating rooms, procedure rooms and other locations subject
to wet cleaning methods or body fluids shall not have openings to the
heating and cooling system.
g) All hospitals shall provide adequate ventilation and/or clean air to
prevent the concentrations of contaminants which impair health or cause
discomfort to patients and employees.
h) Hospitals shall provide a mechanical exhaust ventilation system for
windowless toilets, baths, laundry rooms, housekeeping rooms, kitchens
and similar rooms at ten air changes per hour.
i) hospitals shall provide mechanical ventilation system(s) capable of
providing air changes per hour (hereafter "ACH") as follows:
 Care and treatment areas: five (5) ACH;
 Procedure and airborne isolation areas: fifteen (15) ACH; and
 Operating rooms: twenty (20) ACH.
j) Hospitals shall provide an emergency backup ventilation system for all
patient rooms without operable windows.
k) Toilets, janitors’ closets, soiled linen, dishwashing and similar areas shall
have six (6) air changes per hour. Areas occupied by patients shall have
two (2) air changes per hour.

7.6. Electrical System

7.6.1. The hospital shall have an electrical system that has sufficient capacity to
maintain the care and treatment services and other services that are provided
and that properly grounds care and treatment areas.
7.6.2. All facilities shall provide the minimum average illumination levels as follows or
as per the Ethiopian Electrical Design Code:
a) General purpose areas: five (5) foot candles;
b) General corridors: ten (10) foot candles;
c) Personal care and dining areas: twenty (20) foot candles;
d) Reading and activity areas: thirty (30) foot candles;
e) Food preparation areas: forty (40) foot candles;
f) Hazardous work surfaces: fifty (50) foot candles;
g) Care and treatment locations: seventy (70) foot candles;
h) Examination task lighting: one hundred (100) foot candles;

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 i) Procedure task lighting: two hundred (200) foot candles;
j) Surgery task lighting: one thousand (1000) foot candles; and
k) Reduced night lighting in patient rooms and corridors.
l) Three hours Emergency light shall be provided in exit, entry and in
all landing of staircase.
7.6.3. Essential Power System: Hospitals shall have an automatic power generator
for all care and treatment locations which involve general anesthetics or
electrical life support equipments, and in emergency procedure and treatment
rooms.
a) Different generators shall be available, at least diesel generator and
white fuel generator.
b) There shall be enough stored fuel to maintain power for at least 24
hours.
c) If a generator is used, there must be a staff member assigned to the
regular maintenance of the generator to guarantee it will function
properly when needed.
d) Staff member will also ensure a sufficient supply of diesel gas and
charged batteries for start-up purposes
e) Solar panels are also an acceptable if used as backup power option.
f) Central UPS system for ups outlets of selected area (like ICU, delivery,
Operation Theater, laboratory) shall be provided as backup power
option
.

7.7. Fire Protection System

7.7.1. The hospital shall comply with the National Fire Protection "Life Safety Code”.
7.7.2. The Hospitals shall have an automatic fire alarm and smoke detector system for
all care and treatment rooms.
 Heat detectors used for car park, kitchen, transformer room lift pit area.
 Sounder base photo electric smoke detector will be proposes for the bed –
room and all other rooms.
 Typical floor station located to convenient location in the lobby.

7.7.3. Essential Public Address System: Hospitals shall have an automatic voice
communication /evacuation signal, from different sources; automatic control

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 signal from fire alarm system, tape/CD player for pre recorded message to all
care and treatment locations rooms.
7.7.4. Lightening Arrestor and Grounding System: Hospitals shall have technically
advised lightning protection system, comprises air termination, down conductor
and earth termination. Protection zone shall cover a minimum of the diameter of
the building
7.7.5. All employees, including part-time and contract or temporary employees shall
be trained in procedures to be followed in the event of a fire and instructed in
the use of fire-fighting equipment and patient evacuation of hospital buildings as
part of their initial orientation and at least annually thereafter.
7.7.6. All employees, including part-time and contract or temporary employees shall
receive printed instructions on procedures to be followed in case of emergency,
including patient evacuation of the buildings.
7.7.7. A written evacuation diagram specific to the unit that includes evacuation
procedure, location of fire exits, alarm boxes, and fire extinguishers shall be
posted conspicuously on a wall in each patient care unit.
7.7.8. Fire extinguishers shall be visually inspected at least monthly; fully inspected at
least annually, recharged, repaired and hydrotested as required by
manufacturer's instructions; and labeled with the date of the last inspection.
7.7.9. Fire detectors and alarm systems shall be inspected and tested at least twice a
year by a certified testing agency. Written reports of the last two inspections
shall be kept on file.
7.7.10. There shall be a comprehensive, current, written preventive maintenance
program for fire detectors, alarm systems, and fire suppression systems that
includes regular visual inspection. This program shall be documented.
7.7.11. There shall be a procedure for investigating and reporting fires. All fires that
result in a patient or patients being moved shall be reported to the regulatory
Authority. Immediately in writing within72 hours. In addition, a written report
of the investigation shall be forwarded to the regulatory Authority as soon as it
becomes available.

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7.8. Call Systems
7.8.1. Call systems shall be operable from all patient private spaces. Such us from
patient beds (except at psychiatric or mental hospital beds), procedure and
operating rooms, and recovery bed, bathing and toilet locations.
7.8.2. The system shall transmit a receivable (visual, audible, tactile, or other) signal to
on-duty staff which readily notifies and directs the staff to the location where
the call was activated.
7.8.3. In locations where patients are unable to activate the call, a dedicated staff
assists or code call device shall promptly summon other staff for assistance or
continuous visual connection to supper attending staff should be provided.

7.9. Medical Gas System

7.9.1. The hospital shall safely provide centrally managed medical gas and vacuum by
means of portable equipment or building installation systems as required.
Electromechanical system for central supply shall be installed for areas such as
operation theater, Delivery, special procedure rooms, Intensive care unit,
laboratory and sterilization,
7.9.2. The installation, testing, and certification of nonflammable medical gas, clinical
vacuum, and air systems shall comply with the requirements of the Life Safety
Code (National Fire Protection agency proclamation).
7.9.3. The hospital shall identify portable and system components, and periodically
test and approve all medical gas piping, alarms, valves, and equipment for
patient care and treatment. The hospital shall document such approvals for
review and reference.

7.10. Health Facility Environment

7.10.1. The hospital shall provide and maintain a safe environment for patients,
personnel and the public.
7.10.2. All facilities shall comply with the following applicable codes and standards to
provide a safe environment:
a) Ethiopian Environmental requirements for hospital facilities
b) Life Safety Code (National Fire Protection agency); and
c) The Food standard, Ethiopia, FMHACA Regulations

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 7.10.3. Existing and new facilities shall comply with the physical facility standards
contained in this chapter. The hospital shall maintain all building materials and
structural components so that total loads imposed do not stress materials and
components more than one and one-half times the working stresses allowed in
the building code for new buildings of similar structure, purpose, or location.

7.11. Specific Service Areas

7.11.1. The hospital may have dining areas as per the following requirements:
a) Dining areas for patients shall have an outside wall with windows for
natural light and ventilation.
b) Dining areas shall be furnished with tables and chairs that accommodate
or conform to patient needs.
c) Dining areas shall have a floor area of at least 15-20 square feet (1.4m2
to1.9m2) per patient.
d) Dining areas shall allow for group dining at the same time in either
separate dining areas or a common dining area, or dining in two (2)
shifts, or dining during open dining hours.
e) Dining areas shall not be used for other services.
7.11.2. Bathing and Toilet Rooms:
a) In case of common bathing and toilet room, one shall be dedicated for
seven patients at all times.
b) A hospital shall provide a bathing room consisting of a tub and/or
shower adjacent to each bedroom or provide a central bathing room on
each floor with patient rooms. Tubs and showers regardless of location
shall be equipped with hand grips or other assistive devices as needed or
desired by the bathing patient.
c) The hospital shall provide toilet rooms with hand-washing sinks for
patient and staffs shall use separately for each service units. In addition
the following requirements shall be ensured
 Flushable toilets shall be available throughout the workplace.
 Posted signs (written and/or visual messages) shall be indicated
describing which is for ladies and gentle
 Indicating arrows shall be located on the corridors

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  At least one toilet room shall be designated for patients with
disability with all assisted services.
7.11.3. Patient Rooms: the hospital shall provide patient rooms which allow the
provision of medical intervention shall have space for sleeping, afford privacy,
provide access to furniture and belongings, and accommodate inpatient care and
treatment. In addition Patient Rooms:
a) Shall be arranged to maximize staff supervision and nursing assistances.
b) No patient room shall be located away from nursing stations without
proper covered gang ways and travel premise requirements.
c) Shall not be accessed directly through a bathroom, food preparation
area, laundry or another bedroom;
d) Shall be located on an outside wall with a window with a minimum glass
size of 8 square feet or equivalent meter square per patient.
e) If they have multiple beds, shall allow for an accessible arrangement of
furniture, which provides a minimum of three (3) feet or equivalent
meter between beds.
7.11.4. Isolation Rooms: The number and type of isolation rooms in a hospital shall be
determined by the hospital and direct caregiver. The determination shall be
based upon an infection control risk assessment, patients requirements and
patients influence on other room occupants. In addition:
a) Hospitals shall make provisions for isolating patients with infectious
diseases prevention.
b) An isolation room shall have an adjoining bath and toilet room.
c) Hospitals shall equip isolation rooms with hand-washing and gown
changing facilities at the entrance of the room.
7.11.5. Observation Areas: If the hospital provides medical observation, extended
recovery or behavior intervention methods, the hospital shall provide one or
more appropriately equipped rooms for patients needing close supervision.
Each room shall:
a) Have appropriate temperature control, ventilation and lighting;
b) Be void of unsafe wall or ceiling fixtures and sharp edges;

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 c) Have a way to observe the patient, such as an observation window or if
necessary, flat wall mirrors so that all areas of the room are observable
by staff from outside of the room;
d) Have a way to assure that the door cannot be held closed by the patient
in the room which could deny staff immediate access to the room; and
e) Be equipped to minimize the potential of the patient's escape, injury,
suicide or hiding of restricted substances.
f) Shall be provided with proper safety communication systems and
emergency signaling.
7.11.6. Critical Care Rooms/ICU: If monitored complex nursing care is provided, the
hospital shall provide one or more rooms for patients needing the care.
a) Each room shall be appropriately located and equipped to promote staff
observation of patients.
b) Rooms with a single occupant shall have a minimum floor area of not less
than one hundred and thirty (130) square feet or equivalent meter square.
c) Multiple bed locations shall contain at least one hundred and ten (110)
square feet or equivalent meter square per bed with a minimum of four
(4) feet or equivalent meter between beds.
d) The room shall include provision for life support, medical gas, sleeping,
and convenient bathing and toileting facilities.
7.11.7. Cubicles: Patient care and treatment cubicles shall have a minimum floor area
of sixty (60) square feet with at least three (3) feet between bedsides and
adjacent side walls.
7.11.8. Examination Rooms: Each examination room shall have a minimum floor area
of eighty (80) square feet and a minimum of three (3) feet clear dimension
around three (3) sides of the examination table or chair.
7.11.9. Treatment Rooms: Treatment room for procedures performed under topical,
local, or regional anesthesia without pre-operative sedation shall have a
minimum floor area of one hundred and twenty (120) square feet and a
minimum of ten (10) feet clear dimension.
7.11.10. Procedure Rooms: Procedure rooms for invasive and minor surgical
procedures performed in conjunction with oral, parenteral, or intravenous
sedation or under analgesic or dissociative drugs shall have a minimum floor

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 area of two hundred (200) square feet and a minimum of fourteen (14) feet
clear dimension.
7.11.11. Operating Rooms: Operating rooms for major surgical procedures that
require general or regional block anesthesia and support of vital bodily
functions shall have a minimum floor area of three hundred (300) square feet
and a minimum of sixteen (16) feet clear dimension.
7.11.12. Privacy: In multiple bed patient rooms, visual privacy, and window curtains
shall be provided for each patient. The curtain layout shall totally surround each
care and treatment location which will not restrict access to the entrance to the
room, lavatory, toilet, or enclosed storage facilities.

7.12. Care and Treatment Areas

7.12.1. The hospital shall not share care and treatment areas for those services
which require dedicated space
7.12.2. The hospital shall not provide services in detached structures unless the
way of service delivery allows or proper building configuration established.
7.12.3. The care and treatment areas of the hospital shall comply with the
requirements stipulated under the premises of each service standards.

7.13. Ancillary areas

7.13.1. Dietary: If food preparation is provided in the hospital (in case of inpatient
services), the hospital shall dedicate space and equipment for the
preparation of meals and separate washing room (dishes and other food
preparation equipments), refrigerated and non-refrigerated storage areas
in accordance with the standards mentioned under the Food and dietary
services of this health facility.
7.13.1.1. If contractual services are used for dietary services, the hospital shall
have areas for immediate storage spaces, cleaning and disposal spaces.
7.13.1.2. If contractual services are used, the hospital shall have a clear
contractual agreement and the contractor shall comply with all the
requirements prescribed under this standards.
7.13.2. Laundry: The hospital shall provide laundry services by contract or on-site.

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 a) Contract:
 If contractual services are used, the hospital shall have areas for
soiled linen awaiting pickup and separate areas for storage and
distribution of clean linen.
 Separate clean linen supply storage area shall be conveniently
located in each care and treatment locations
 If contractual services are used, the hospital shall have a clear
contractual agreement and the contractor shall comply with all
the requirements prescribed under this standards.
b) On-site: If on-site services are provided, the hospital shall have
areas dedicated to laundry in accordance with the following
requirements:
 The laundry areas shall be equipped with a washer and dryer
for use by patients. The hospital shall provide a conveniently
located sink for soaking and hand-washing of laundry.
 Hospital laundry area for hospital processed bulk laundry shall
be divided into separate soiled (sort and wash areas) and clean
(drying, folding, and mending areas) rooms. In new facilities a
separate soaking and hand-washing sink and housekeeping
room shall be provided in the laundry area.
 Separate clean linen supply storage facilities shall be
conveniently located in each care and treatment location.
 In general the standards stipulated under housekeeping section
of this document shall be respected.

7.13.3. Administrative Areas: Administrative Offices shall be located separately

from care and treatment areas and it shall be clearly labeled and easily
accessible to both patients and visitors. It includes;
a) Finance and business office.
b) Administration office.
c) Staff rooms with toilet separate for male and female
d) Staff cafeteria
e) Visitors cafeteria

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 f) Spaces for conferences and in-service training
g) General Library (at least 40m2)

7.13.4. General Storage areas. There shall be a two hour fire rated lockable room
large enough to store.
7.13.5. Boiler Room. Space shall be adequate for the installation and maintenance
of the required machinery.
7.13.6. Maintenance Area: Sufficient area for performing routine maintenance
activities shall be provided and shall include office for maintenance
engineer.
7.13.7. Incinerator: The hospital shall comply with the directives developed by the
authority for health care waste management.
7.13.8. Janitor rooms: the hospital shall have separate janitor rooms in each care
and treatment areas.
7.13.9. Green area: The hospital shall dedicate at least 20% of the total hospital
compound for green area.

Note: All dimension, sizes and quantities noted herein will be determined by
rounding fractions to the nearest whole number and measuring units like feet
can be converted to country specific measuring units.

7.14. Bubble Diagrams

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Glossary

1. Advanced Cardiac Life Support (ACLS) means that an individual has successfully
completed a course of training offered by an individual who is currently certified as an
instructor or by a recognized accrediting organization appropriate to the licensee's
field of practice. For example, for those treating adult patients, training in ACLS is
appropriate and for those treating children, training in pediatric advanced life support
(PALS) is appropriate.
2. Adverse drug reaction: A response to a drug that is noxious and unintended and that
occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of
disease or for the modification of physiological functions.
3. Ambulance service: is a service that is provided to a patient until reaching a
hospital. It includes the transportation and providing an immediate intervention for
life threatening conditions.
4. Intensive care unit (ICU) is a specialized department used in many hospitals that
provides intensive/critical life support or organ support systems in patients who are
critically ill and who usually requires intensive monitoring. Patients requiring
intensive care usually require support for hemodynamic instability
(hypertension/hypotension), airway or respiratory compromise (such as ventilator
support), acute renal failure, potentially lethal cardiac dysrhythmias, and frequently
the cumulative effects of multiple organ system failure. Patients admitted to the
intensive care unit not requiring support for the above are usually admitted for
intensive/invasive monitoring, such as the crucial hours after major surgery when
deemed too unstable to transfer to a less intensively monitored unit.
5. Operating theatre is a restricted access environment where surgical and invasive
interventions are performed.
6. Analgesia means the absence of the sensibility to pain without loss of consciousness
or decrease in the intensity of pain.
7. Anesthesia consists of general anesthesia, and spinal or major regional anesthesia. It
does not include local anesthesia.
8. Anesthesiologist means a physician who has successfully completed an approved
residency program in anesthesiology.

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9. Anesthetic agent means any drug or combination of drugs administered with the
purpose of creating conscious sedation, deep sedation, regional anesthesia, or general
anesthesia.
10. Anesthetizing location means any location in a health care facility where aesthetic
agents are administered.
11. Authority: means the Ethiopian Food, Medicines and Healthcare Administration and
Control Authority
12. Aviation dentistry: a subcategory of (military) aviation medicine deals with dental
topics related to aircrews, e.g., dental barotrauma and barodontalgia. In addition, the
aircrew population is a unique high-risk group to several diseases and harmful
conditions due to irregular work shifts with irregular self-oral care habits and
irregular meals (usually carbonated drinks and high energy snacks) and work-related
stress.
13. Biohazardous waste: Microbiologic waste and sharps.
14. Cardiac catheterization facility: is a facility where diagnostic and interventional
procedures are performed through insertion of a thin, flexible tube (catheter) into a
vein or artery and guiding it into the heart.
15. Cardiac center: is a center where patients with heart disease are treated or cared for.
16. Cardiac surgery center: is a facility capable of providing invasive diagnostic
catheterization and all treatment modalities including open and closed heart surgical
procedures.
17. Caregiver:……………….
18. Certified licensed nurse anesthetist (CRNA) means a licensed professional nurse
who is licensed by the FMOH and who holds current certification under a programme
governed or approved and meets the conditions for practice as set forth by the FMOH.
19. Chiropractic: an approach and profession that emphasizes diagnosis, treatment and
prevention of mechanical disorders of the musculoskeletal system, especially the
spine. The main treatment involves manual therapy including manipulation of the
spine, other joints, and soft tissue; treatment also includes exercises and health and
lifestyle counseling.
20. Clinical Laboratory: A facility for the microbiological, serological, chemical,
immunohematological, hematological, pathological, clinical microscopy, or other
examination of materials derived from the human body for the purpose of providing

390
 information for the prevention, diagnosis, or treatment of any disease or impairment
of, or the assessment of the health of, human beings. These examinations also include
procedures to determine, measure, or otherwise describe the presence or absence of
various substances or organisms in the body.
21. Clinical pharmacy: A series of patient-related services, including prescription
monitoring, therapeutic drug response monitoring and patient counseling.
22. Compounding: The preparation, mixing, assembling, packaging or labeling of a
medicine. Such a medicine is then dispensed to a patient on prescription or on
imitative in the course of professional practice by a pharmacist or prescriber.
23. Conscious sedation means a drug induced depression of consciousness during which
patients respond purposefully to verbal commands, either alone or accompanied by
light tactile stimulation. No interventions are required to maintain an open airway,
and spontaneous ventilation is adequate. Adequate cardiovascular function is usually
maintained.
24. Coronary care unit (CCU) is a hospital ward specialized in the care of patients with
heart attacks, unstable angina and (in practice) various other cardiac conditions that
require continuous monitoring and treatment.
25. Count Rate Parameters - Performed to ensure that the time to process an event is
sufficient to maintain spatial resolution and uniformity in clinical images acquired at
high count rates.
26. Deep sedation means a drug induced depression of consciousness during which
patients cannot be easily aroused but respond purposefully following repeated or
painful stimulation. The ability to independently maintain ventilatory function may be
impaired. Patients may require assistance in maintaining a patent airway and
spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained.
27. Delivery suite is the area where laboring mothers are managed and delivery
conducted.
28. Dental anesthesiology: the study of how to relieve pain through advanced use of
local and general anesthesia techniques is not yet considered to be one of the
recognized dental specialties. However, CODA is in the process of accrediting all
dental anesthesiology programs.[citation needed]
29. Dental public health: study of dental epidemiology and social health policies

391
30. Dentistry service encompasses trauma surgery, place implants, graft tissue to repair,
restore and maintain teeth, gums and oral structures lost or damaged by accidents or
disease in order to maintain and improve oral health, quality of life and appearance by
diagnosing and treating conditions that affect the teeth, tongue, gums, lips and jaws.
31. Dentistry: is that branch of medicine which deals with the study and practice of
diagnosis, prevention, and treatment of diseases of the mouth, the maxilla, and the
face.
32. Dispensing: Interpretation and evaluation of a prescription, selection and
manipulation or compounding of a pharmaceutical product, labeling and supply of the
product in an appropriate container according to legal and regulatory requirements
and the provision of information and instructions by a pharmacist or under the
supervision of a pharmacist to ensure the safe and effective use by the patient
33. Documentation: A document is a record of any information or instructions including
policy statements, quality manuals, procedures, specifications, calibration tables,
reports, job description, documents of external origin such as regulations, standards
and examination procedures, etc. Documents may be stored either as hard copy or
electronically.
34. Drug and therapeutic committee (DTC): is an essential component of a health care
organization’s drug selection and use program. This committee evaluates the clinical
use of drugs, develops policies for managing drug use and administration and
manages the formulary system.
35. Drug information service: is the provision of unbiased, well-referenced, and
critically evaluated information on any aspect of pharmacy practice
36. Drug therapy monitoring: Also known as therapeutic drug response monitoring, is a
means of monitoring drug levels in the blood. I t is employed to measure blood drug
levels so that the most effective dosage can be determined, with toxicity prevented. It
is also utilized to identify noncompliant patients (those patients who, for whatever
reason, either can’t or will not comply with drug dosages as prescribed by the
physician.
37. Drug therapy plan: A detailed schedule outlining the pharmacist’s and patient’s
activities and responsibilities, completed by the pharmacist with the input and
participation of the patient, designed to solve any drug therapy problems, successfully

392
 achieve the therapeutic goals of the patient and prescriber and finally prevent any
potential drug therapy problems.
38. Elective surgery: any type of planned surgical intervention given for conditions not
life threatening by the time of decision.
39. Emergency service: is a service provided for patients with life threatening conditions
that need an immediate intervention.
40. Emergency surgery: any type of surgical intervention for life threatening conditions;
such as large bowel and small bowel obstructions, injuries to the head; abdomen;
chest and extremities, acute appendicitis, perforated viscus, multiple fractures, chest
tube insertion, suturing of bleeding soft tissue injuries, and others.
41. Endodontics: root canal therapy and study of diseases of the dental pulp.
42. Energy Resolution - Performed to verify that scatter rejection is sufficient to provide
optimal contrast in clinical studies. Note: On some systems, energy resolution is very
difficult to measure precisely.
43. Epidural means an anaesthetic injected into the epidural space surrounding the fluid
filled sac (the dura) around the spine which partially numbs the abdomen and legs.
44. Forensic odontology consists of the gathering and use of dental evidence in law. This
may be performed by any dentist with experience or training in this field.
45. Formatter/Video Display - Performed to ensure that systems used to produce hard
copy and monitors that are used for interpretation of clinical studies provide
satisfactory image quality in terms of uniformity and spatial resolution.
46. General anaesthesia means a drug induced loss of consciousness during which
patients are not arousable, even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients often require assistance in
maintaining a patent airway, and positive pressure ventilation may be required
because of depressed spontaneous ventilation or drug induced depression of
neuromuscular function. Cardiovascular function may be impaired.
47. General waste: Waste not associated with patient care.
48. Geriatric dentistry or geriodontics: the delivery of dental care to older adults
involving the diagnosis, prevention, and treatment of problems associated with
normal ageing and age-related diseases as part of an interdisciplinary team with other
health care professionals.

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49. Hospital: means an institution, whether operated for profit or not, whether
maintained, supervised or controlled by government of the country or any other
county or privately, which maintains and operates facilities for the diagnosis,
treatment or care of individuals suffering from physical or mental infirmity, illness,
disease, injury or deformity, and/or a place devoted primarily to provide emergency,
out-patient, surgical, obstetrical, nursing care, and other medical care is rendered for
periods exceeding 24 hours. The term “hospital” does not include convalescent or
boarding homes, children’s homes or homes for aged or other like establishments
where rooms and boards only are provided, neither offices nor facilities where
patients are not regularly kept as bed-patients.
50. Immediately available on-site means that the supervising physician is present and
available to respond and proceed immediately to the anesthetising location.
51. Infection prevention - is an action of preventing disease transmission from patient
to patient, patient to staff, staff to staff, staff to patient and prevention of acquiring
new infection in the hospital
52. Infectious medical wastes: includes solid or liquid wastes which may contain
pathogens with sufficient virulence and quantity such that exposure to the waste by a
susceptible host has been proven to result in an infectious disease.
53. Inpatient service: is a service provided for admitted patients at a health facility.
Patient admissions at emergency are not considered as inpatient in this document.
54. Intrinsic or System Spatial Resolution - Performed to ensure that the detector
resolution is sufficient to provide satisfactory detection of lesions and delineate detail
in clinical images.
55. Intrinsic Uniformity - Performed to ensure that the intrinsic detector integral and
differential uniformity are sufficient to minimize the production of artifacts and
ensure that patient abnormalities can be visualized without interference from the
imaging system. These tests also monitor a scintillation unit for electronic problems
and crystal deterioration (hydration).
56. Laboratory instruments and equipment: These include equipment, instruments,
reference materials, reagents, analytical systems and test kits
57. Labour analgesia means the reduction or management of pain during labour, which
involves the use of anaesthetic agents and/or an epidural.

394
58. Licensee: means the corporation, association, partnership or person authorized by
the Authority to operate a specialized hospital and on whom rests the responsibility
for maintaining acceptable standards in all areas of operation.
59. Local anaesthesia consists of drugs or agents which produce a transient and
reversible loss of sensation in a circumscribed portion of the body.
60. Major regional anaesthesia means nerve blocks such as epidural, caudal, axillary,
brachial, and spinal anesthesia.
61. Maternity unit is an area where babies are delivered and post natal care is given to
both mother and baby.
62. Medical recording: is recoding of all relevant information obtained from a patient on
a specific file/chart that is opened to him/her.
63. Medical Waste: means all waste generated in direct patient care or in diagnostic or
research areas that is non-infectious but aesthetically repugnant if found in the
environment.
64. Medication error: Any incorrect or wrongful administration of a medication, such as
a mistake in dosage or route of administration, failure to prescribe or administer the
correct drug or formulation for a particular disease or condition, use of outdated
drugs, failure to observe the correct time for administration of the drug, or lack of
awareness of adverse effects of certain drug combinations.
65. Medication use counseling: The process of providing information, advice and
assistance to help patients use their medications appropriately. It also includes
information about the patient’s illness and lifestyle modification.
66. Minor regional block means the injection of a local anaesthetic agent to stop a
painful sensation in a severely circumscribed area of the body (local infiltration or
local nerve block), or the block of a nerve by direct pressure and refrigeration.
67. Minor surgery- any types of surgical services given under local or topical anesthesia
which may or may not need admission; such as circumcision, soft tissue mass
excision, biopsy, abscess drainage, fractures and others.
68. Monitoring means the observation of a patient including the use of instruments to
measure, display, and/or record (continuously or intermittently) the values of certain
physiologic variables such as temperature, pulse, respiration, blood pressure and
oxygen saturation.

395
69. Morgue is a place for dead bodies: a room or building usually run by a Hospital in
which dead bodies are kept until they are autopsied or identified or delivered to
Families or relatives.
70. Narcotics and psychotropic drugs: Any drug or substance, natural or synthetic, or
any natural material or any salt or preparation of such substance or material included
in the list of narcotic and psychotropic drugs or substances specified in the country’s
legislations
71. Neonatal ICU (NICU) is a unit of a hospital specializing in the care of ill or premature
newborn infants. The NICU is distinct from a special care nursery (SCN) in providing a
high level of intensive care to premature infants while the SCN provides specialized
care for infants with less severe medical problems.
72. Nuclear Medicine is a clinical specialty or specialty of the practice of medicine
devoted to or dealing with the diagnostic, therapeutic and investigative use of
Radiopharmaceuticals or Radionuclides for various diseases. Nuclear medicine
services include diagnostic services (in-vitro services and in-vivo services) and
therapeutic services
73. Occupational therapy: Occupational therapy is intended to enhance a person's
ability to do basic self-care activities, useful work, and leisure activities.
74. Oncologist: A doctor who specializes in treating cancer.
75. Oncology: The study of the biology and physical and chemical features of cancers.
Also the study of the causes and treatment of cancers.
76. Operating room means a unit for the performance of surgery.
77. Oral and Maxillofacial Pathology: study, diagnosis, and sometimes the treatment of
oral and maxillofacial related diseases
78. Oral and maxillofacial prosthodontics: a discipline concerned with the replacement
of missing facial structures such as ears, eyes, nose, etc.
79. Oral and Maxillofacial Radiology: study and radiologic interpretation of oral and
maxillofacial diseases
80. Oral and Maxillofacial Surgery: extractions, implants, and facial surgery
81. Oral Biology: Research in Dental and Craniofacial Biology
82. Orthodontics and Dentofacial Orthopaedics: straightening of teeth and
modification of midface and mandibular growth

396
83. Otorhinolaryngology: is a medical specialty that deals with diseases of Ear, Nose and
Throat organs. It also deals with a wide spectrum of problems with direct influence on
multiple functions such as taste, smell, hearing, speech and breathing. Another name
of this specialty is OTTORHINO LARYNGOLOGY, which means ear, nose throat in the
Greek Language and is abbreviated as ORL Head and Neck Surgery The service may
have these sub-specialties: ear surgery, head and neck surgery, pediatric ENT surgery,
neurotology and phoniatry.
84. Outpatient service: is a service provided for non-admitted patients at a health
facility. Emergency services are not considered as part of outpatient services in these
standards.
85. Overall System Performance for SPECT Systems - Performed to quantitatively
verify that SPECT systems provide satisfactory tomographic uniformity, contrast, and
spatial resolution.
86. Pain management means the administration of drugs to a patient, which are not
intended to result in a loss of consciousness, awareness or defensive reflexes, but
which are intended to alleviate pain occurring in the absence of an invasive, operative,
or manipulative procedure.
87. Patient means any person who is held or accepted for diagnosis, treatment, and/or
care of physical or mental condition.
88. Patient medication profile: It is a record of patient medication which contain at least
patient information, allergy information, diagnosis and pre-existing conditions,
schedule medications and non schedule or non-recurring medications.
89. Pediatric dentistry: dentistry for children, formerly known as "pedodontics".
Pediatric dentistry is an age-defined specialty that provides both preventive and
therapeutic dental care for infants, children and adolescents.
90. Periodontics: study and treatment of diseases of the periodontium (non-surgical and
surgical, and placement and maintenance of dental implants),
91. Pharmaceutical care: The responsible provision of drug therapy for the purpose of
achieving definite outcomes that improve or maintain a patient’s quality of life. It is a
collective
92. Pharmaceutical services: All services rendered by pharmacists and pharmacy
technicians to support the provision of pharmaceutical care. Beyond the supply of
pharmaceuticals, pharmaceutical services include information, education and

397
 communication to promote public health, the provision of drug information and
counseling, regulatory services, education and training of staff
93. Pharmaceutical waste: Waste containing pharmaceutical substances. Examples
include: Expired, unused, spillages, and contaminated pharmaceuticals, such as
expired drugs, vaccines and sera. Naturally, there is concern that human health and
aquatic life may be impacted as a result of exposure to pharmaceutical compounds.
94. Pharmaceuticals: Pharmaceuticals can be loosely defined as any substance intended
for use in the diagnosis, cure, mitigation, treatment, or prevention of disease
95. Pharmacist: A person professionally qualified in pharmacy, the branch of health
sciences dealing with the preparation, dispensing and use of medicines. The role of the
pharmacist has evolved from that of a provider of medicines to that of a provider of
patient-centered pharmaceutical care.
96. Pharmacovigilance: The science and activities relating to detection, assessment,
understanding and prevention of drugs adverse effects or any other medicine related
problem in post marketing usage
97. Pharmacy practice: The provision of medications and other health care products and
services and to help people and society to make the best use of them
98. Pharmacy technician/druggist: A pharmacy staff member who is licensed by the
regulatory body and works under the direct supervision of a licensed pharmacist, and
performs many pharmacy-related functions.
99. Physical restraints are defined as devices, materials, or equipment that are attached
or adjacent to a person and that prevent free bodily movement to a position of choice,
with the exception of devices used for positioning supports necessary for medical
treatment.
100. Physical therapy: Physical therapy involves exercising and manipulating the body. It
can improve joint and muscle function, helping people stand, balance, walk, and climb
stairs better. Techniques include range-of-motion exercises, muscle-strengthening
exercises, coordination and balance exercises, ambulation (walking) exercises, general
conditioning exercises, transfer training, and use of a tilt table.
101. Physiotherapy: the therapeutic use of physical agents or means, such as massage,
exercises, etc.
102. Practitioner means a licensed physician, dentist or podiatrist.

398
103. Prescriber: An authorized person such as a physician who prescribes medications or
any other prescription devices using an approved prescription paper by the
regulatory body
104. Privileges means having been granted permission by a hospital to provide specified
anaesthesia services, such as administration or supervision of one or more types of
anaesthetic agents or procedures.
105. Prosthodontics: dentures, bridges and the restoration of implants.
106. Quality control (QC): A system for verifying and maintaining a desired level of
quality in an individual test or process.
107. Radiation oncology, Radiation therapy: it is the medical use of ionizing radiation as
part of cancer treatment to control malignant cells
108. Radiation therapist: A health care worker who treats cancer using beams of high-
energy radiation, administering therapy prescribed by radiation oncologists.
109. Radiologist: A physician specialized in radiology, the branch of medicine that uses
ionizing and non-ionizing radiation for the diagnosis and treatment of disease.
110. Radiology Service: it is the use of radiation in medical imaging and diagnosis
111. Radiology technologist: A healthcare professional who applies doses of ionizing
radiation or radioactive materials to patients in order to reduce or eradicate tumors
and cancer cells and create medical images of the human anatomy to aid radiologist
and doctors diagnose and treat illness and injury.
112. Radiopharmaceuticals are substances which can be attached to specific organs,
bones or tissues. They are drugs or pharmaceuticals labeled with radionuclides or
radioisotopes used to diagnose or treat various diseases. They emit gamma rays that
can be detected externally by special types of imaging instrument called Planar
Gamma Camera, Single Photon Emission Computed Tomography (SPECT) or Positron
Emission Tomography (PET) or the hybrid instruments such as SPECT/CT, PET/CT
and PET/MRI. These imaging instruments work in conjunction with computers used
to form images that provide data and information about area of body being imaged.
113. Radiopharmacy: the place where radioactive drugs are prepared and dispensed. The
Radiopharmacy also serves as a storage place for radioactive materials and non-
radioactive supplies. Nuclear medicine uses radioactive or radiopharmaceuticals to
diagnose and treat diseases.

399
114. Regional anaesthesia means the administration of anaesthetic agents to interrupt
nerve impulses.
115. Licensed nurse anaesthetist means an individual who is a qualified candidate for
certification under a programme governed or approved by the FMOH.
116. Rehabilitation: After a serious injury, illness or surgery, there may be slow recovery.
One has to regain ones strength, relearn skills or find new ways of doing things one
did before. This process is rehabilitation. Rehabilitation services are needed by people
who have lost the ability to function normally, often because of trauma, a stroke, an
infection, a tumor, surgery, or a progressive disorder (such as arthritis).
117. Sensitivity - Performed to verify that count rate per unit activity is satisfactory to
maintain image quality and preserve the integrity of quantitative studies.
118. Special needs dentistry: is dentistry for those with developmental and acquired
disabilities.
119. Special procedure means various diagnostic or therapeutic interventions which may
require the administration of sedation, analgesia, or anaesthesia. Examples include,
but are not limited to endoscopy, oral surgery, radiologic procedures or emergency
procedures.
120. Special procedure room means the appropriately equipped hospital location in
which special procedures are performed.
121. Specialized hospital represents tertiary level of healthcare system which provides
curative and rehabilitative service that requires advanced diagnostic facilities and
therapeutic interventions which shall include any hospital which assures provision of
specific or comprehensive specialized diagnosis, care, treatment and rehabilitation.
Specialized hospitals include hospitals which are specialized in one or more service
areas like cardiac hospitals, cancer hospitals, psychiatric hospitals, pediatric hospitals
etc.
122. Supervision means responsibility by a physician who has obtained privileges in
accordance with medical staff bylaws, and is immediately available on- site overseeing
the administration and monitoring of anaesthesia by anaesthesia personnel.
123. System Interlocks - Performed to verify that all system interlocks are operating as
designed and that the system is safe and reliable for the nuclear medicine technologist
to operate and for imaging patients.

400
124. System Uniformity - Performed to check all commonly used collimators for defects
that might produce artifacts in planar and tomographic studies.
125. Universal precautions mean a set of precautions; in accordance with published
infection prevention and control standards/guidelines for Hand washing and Hospital
Environmental Control (see the IPC section).

401
 Annex: Workshop Participants List
Job Title/
Organization Profession/ Responsibilit
S.N Full Name /Facility Qualification y Mobile No. City/Town

1 Ayele Shanko W. Sodo Hospital H.O. manager 0912 28 72 73 Sodo

Ethiopia RSPNED
2 Surur Kedir Radiotherapy Physicist D/P/Dire 0911 67 38 88 A.A.
Solomon Med. Lab.
3 Abitew Assosa Hospital Tech 0913 34 37 13 Assosa

4 Aster G/Hiwot MCM Head Nurse Head Nurse 0911 18 37 30 A.A.

Dr. Worku
5 Mekonnen Yordanos Hospital Orthopedist Director 0911 20 40 03 A.A.
Chem.
6 Aweke Kebede EHNRI Nutrition Researcher 0911 43 60 02 A.A.
Dr. Shibiru Clinical
7 Berhanu Cu. ICAP Internist Service D. 0911 38 50 09 A.A.
Regulatory
Wondimeneh Process
8 Belay Amhara RHB Pharmacist Owner 0912 12 13 56 B/dar
Wassie Pub. H. Disease
9 Shiferaw SNNPR H.B. Specialist Prevention 0916 82 53 54 Hawassa
Mezemir
10 Ketema ALERT Management CEO 0911 25 39 83 A.A.
Dr Kidane
11 Melles DACA Internist Internist 0913 25 62 66 A.A.

Cardiologist
12 Dr. Fikru maru ACH Internist Cardiologist 0911 40 84 73 A.A.
Pub.
13 Abinet Leykun Abt. PHSP HealthSpecil. DCOP 0911 63 88 80 A.A.

Ariaya AAU/ Scl.of

14 Haymete Pharmacy Pharmacist Teacher 0911 33 50 99 A.A.

Berhanu
15 Tadesse (Dr.) Nobil H. Clinic Gen. Surgeon Med. Director 0911 21 81 60 A.A.

Lemlem Pub. H. Health Dep. 0915

16 Bezabih DD Health Bureau Officer Head 734343(5) Dire dawa

Dr. Solomon Med. Orthopedic

17 Aweke ESOT Specialist Surgeon 0911 407943 A.A.
Addisalem Hosp.
18 Ergete Bilal Hospital Manager manager 0915 730062 Dire dawa

402
 G/Kidan
19 Yohannes NE. DACA Drugist Inspector 0914 706909 Mekelle
Inspctn &
Survelance
20 Sisay Mamo DACA Pharmacist Dirtr. 0911 18 55 55 A.A.
Medical
21 Tesfaye Taye Harar H.B. Servic. 0915 019479 Harar
Delenessaw 0911
22 Anteneh F.R.P.H. Nurse Matron 638047(2) A.A.
Dietary
23 Fesseha Melaku Yekatir 12 Hospital Service Head -- A.A.
Dr. Aschalew
24 Assefa Dessie R. Hospital Pediatritian Head 0911 481004 Dessie
Dr. Tsehaysina
25 G/yesus Amanuel Hospital Internist CEO 0911 408053 A.A.
Eshetu
26 Cherinet M.Meda Hospital Lab. Tech. Lab. Tech. 0913 312227 M.Meda
Dr. Solomon Chief Clinical
27 Ayele Dilechora Hospital MD Officer 0915 732481 Dire dawa
Yemane
28 Mekonnen FENAPD Makt E.C. 0911 118838 A.A.
Berenesh
29 G/selase H.E. worker H.E. worker 0913 990572 Alamata
30 Tigist Bekele Balcha Nurse Translet 0911 140663 A.A.
Dr. Aschalew
31 Endale FMOH Physician HIV/AIDS 0911 392067 A.A.
Dr. Kasaye
32 Ketsela St. Gebriel Hospital Physician Hosp. Director - A.A.
Dr. Mulualem Dental Dental
33 Tegegnwork Fed. Police Hsopital Surgeon Surgeon 0911 112378 A.A.
Getachew Ministry of Works & Hisl ???
34 Mandefro Urban devt Architect Expert 0911 023381 A.A.
Dr. Petros Program
35 Mitiku PHSP MD Officer 0911 408420 A.A.
Dr. Tekle-ab Sen. Policy
36 Zaid PHSP MD Advisor 0911 224763 A.A.
Nuclear
37 Yohanes Jorge AAU- FM Pharmacist Medicine 0911 406065 A.A.
Oman Ogula M/S/T Dept
38 Ogala Gambella RHB Nurse Head 0911 913751 Gambella
Gambela
39 Riang Miyol Gambela Hospital Nurse Hospital staff 0913 311635 Gambella
40 Serawit Tesfaye Dil Chora Hosp. Data Clerk Card Room 0915 010950 Dire dawa
Tagainesh Awi Zone Zewala D. Health Ext. Health Ext.
41 Zerihun H.Post worker worker 0918 802511 B.dar

403
42 Legesse Gebre MOTI Chemist Director Tech 0911 472837 A.A.
Dr Yohannes
43 Kebede WHO Physician NPO/BLS 0911 405602 A.A.
Alemu
44 H.mariam A.A. HB Anesthtist Quality Team 0911 641346 A.A.
curative
&reahbilitativ
45 Baye Atnaf ANRS RHB H.O. e prog. 918 768608 B.dar
46 Fuja Shukri Harar H.B. E.H. Mobilization 0913 482311 Harar
Mesay Armed Forces Physiotherapi
47 Mohamed Hospital P.T. st 0911 71 18 70 A.A.
Anesthesiolo
Assefu gist
48 W/tsadik AAU /M.F. physician Asst. Profess. 0911 405796 A.A.
Ethio. Med. Lab. Med.
49 Tedla Mindaye Associatn. Technologist Gen. Manager 0911 634324 A.A.
Assefa Beyene
50 (Dr) Assosa Hospital Physician Med. Director 0911 70 89 95 Assosa
Getachew Chief
51 Gurmu Bethzatha Hosp. Pharmacist Pharmacist 0910 931823 A.A.
Dr. Alemayehu Senior
52 Negash Amanuel Hospital Phsychiatrist Psychiatrist 0911 41 43 07 A.A.
Training
53 Behailu Aferu QSAE Chemist Expert 0911 64 16 30 A.A.
Zhurouleva
54 Tatyana (Dr) Balcha Doctor Medical A.A.
55 Kassa Daka DACA Pharmacist Branch Head 0916 82 50 38 Hawassa
Samson
56 Abraham DACA Chemist P.R. 0911 06 28 82 A.A.

57 Abnet Demeke ERTA Journalist Editor 0910 161296 A.A.

58 Asrar Demessie AAU Nursing Director 0911 201135 A.A.
Opthomologi
59 Alem Michael OSE st Med. Director 0911 403201 A.A.
60 Adefris Debalke AAUMF/Ykatit 12 ORL (ENT) ENT Spe. 0911 209690 A.A.

61 Ahmed Kassaw St. Peter EHO Head EHO 0912 60 9050 A.A.
Mintewab
62 Habtamu MCM Nurse Metron 0911 729839 A.A.

63 Tufa Gemechu AAU /M.F. Pathologist Asso. Prof 0911 406076 A.A.
Edmealem
64 Ejigu MSH Pharmacist TA 0911 633558 A.A.

404
 L. Ass.Researche
65 Frehiwot Abera EHNRI Technologist r 0911 484550 A.A.

66 Fikru Worku EPA Pharmacist V/President 0917 802302 A.A.

67 Ayalew Adinew ALERT/MSH/SPS Pharmacist 0911 687759 A.A.

Dessalegne MPH , B.
68 Tesfaye FMOH/HPDPCD Pharm CS Advisor 0911 113501 A.A.
Asmamaw
69 Zeleke DACA North West Pharmacist Acting Head 0912 042585 B.dar
Capacity B.
70 Abinet Tekabe PHSP MPH Advisor 911 031297 A.A.
Faris Hussein
71 (Dr.) USAID MD USAID 0911 474932 A.A.
Sintayehu
72 G.medhin (Dr.) Axum Hospital MD medical 0911 96 11 70 Axum
Mehretu
73 Weldeyes (Dr.) AAU MD+ DV Asst. Pro. 0913 031136 A.A.

74 Addisu Melaku DACA MADL ML Director 0911 684468 A.A.

Liyusew Junior Pro.
75 Solomon Tulane University Lawyer Offcer 0911 56 1727 A.A.
Junior
Liyuwork Radiological Radiological
76 Biresaw Gambela HB Technologist Technologist 0912 176125 Gambela

77 Abiyou Kiflie MOH MD Quality ass. 0912 001645 A.A.

Shifa Hamid
78 (Dr.) Bishoftu Hospital MD Internist 0911 018103 Bishoftu
Mohamod Nur TB
79 Abdu Afar RHB Bsc. (H.O.) coordinator 0911 980045 Semera
Board
Member
Macha Ethio. Consumer Health
80 Chamargachew Protection Biochemist Professional 0911 730039 A.A.
Shewatatek
81 H/mariam DACA RSS team 0911 646755 A.A.
Ejigayehu
82 Yeshitela DACA Pharmacist Expert 912011590 A.A.
Messele
83 Deresse DACA Pharmacist Expert 0911 466442 A.A.

84 Aida Arefayne DACA Pharmacist DI Case W 0911 14 33 12 A.A.

405
 Aynalem
85 Abraha (Dr.) TASH (Onchologist) Onchologist Onchologist 0913 184883 A.A.
Zelalem Teaching
86 Messele EMLA Labal ?? Head 0911 63 2473 A.A.
Dr. Berhanu
87 Tekle MAPPP-E Physician President 0911 226135 A.A.

88 Dawit Dikasso DACA Dep. Director Dep. Director 0913 475033 A.A.
Alemayehu
89 Shewarega FMOH PHID Architect Dep. Director 0911 240366 A.A.
Tesfaye
90 Tadesse (Dr) ESGMP Physician Chair Person 0911 669193 A.A.
Endeshaw
91 Legesse HERQA Mgt Expert 0911 128804 A.A.
Negussu
92 Mekonnen (Dr) MSH Pharmacist Country Rep. 0911 226909 A.A.

93 Berhan G.Kidan Nursing Association Nurse Lecturer 0911 125186 A.A.

Anteneh
94 Adinew ERTD Cameraman Cameraman 0911 871500 A.A.
Head
Foziya diredawa
95 Mohammed DACA Pharmacist branch 0911 935802 Dire dawa
Tassew
96 Tadesse (Dr) Yekatir 12 Hospital Physician Surgeon 0911 735126 A.A.
Ethio. Investment Proj.
97 Abraham Lema Agency Proj Coordinator 0913 103069 A.A.
Getahun
98 Mengistu ICAP Physician AAU MF 0911 647580 A.A.
Zegeye Prog
99 H/mariam (DR) ENHRI/ PHEM Consultant Coordinator 0911 66 56 48 A.A.
Ashebir Central Univer. CUC Dert.
100 Tsegaye College Pharmacist Head 0911 810182 A.A.

101 Berhanu Amare Health Center Health Officer Drug Control 0911 935129 Alamata

102 Abrahim Salih Harar H.B. Pharmacist Regulatory 0911 300270 Harar
Wondim
103 Getenet (Dr.) Jimma University Radiologist Head Of Deprt 0917 800607 Jimma
Tesfa Etana B.G. Health Bureau H.O 912074769 Assosa
104
Solomon FMOH Pediatrician Ped. clinical 911403936 A.A
105 Tessema Dr. admin.

406
 Kassahun Yirgalem Hospital Pharmacist Pharmacy 911052818 Yirgalem
106 Tizazu head
Andinet Harar R.H.B Envi’t Prof. Regional H.B. Harara
107 Tesfaye
Dawit Mengistu South Regulatory Public Director 916022854 Hawassa
108
Bekele AAU Med. Faculty Cardiologist Head. C. Unit 911228950 A.A
109 Alemayehu
Wolderufael AAHB BSCN Core Process 911663611 A.A
110 Dirar Head
Abebe Berhanu Dire Dawa H.B Enviro. Prof Disease pre 915757068 Dire Dawa
111
Frehiwot Belete Kirkos sub city H.B H.O 11531347 A.A
112
Dr. Ayelign St. Paul’s Hospital Surgeon Head, 911403442 A.A
113 Tsehay Department
Dr. AAU. Denatl School Dentist Dental 911652674 A.A
Wondwossen
114 Fantye
Dr. Biruktowit Jugal Hosipta Medical Medical 911314105 Harar
115 Kebede Doctor Director
Yihalem FMOH, HDDP Nurse HCT Advisor 911378982 A.A
116 Tamiru
Ruth Lawson Cilnton Fundation Dr. Region 913094583 A.A
117 Director
Dr. Abraham FMOH, MSD MD Ass/Director 911226375 A.A
118 Endeshaw
Biruk T.Selassie ESOG MPH Project 911405963 A.A
119 coordinator
Saulehunae Chemonics inc Architect Director Dp. 911210462 A.A
120 Kefyalew
Roda Warsame Somali RHB Pharmacist Pharmacy 911855741 Jijiga
121 Head
Dr. Digafe Ethio. Dermatologis 911407695 A.A
122 Tsegaye Dermatological …. t
Raey Yohannes DACA Pharmacist RSS team 913098635 A.A
123
Ejigu Kebede Nuclear Med. Unit Med. Med. Physicist 911998569 A.A
124 Physicist
Ataklty Kahsay A.F.G.H BSC Nurse BSC Nurse 910117092 A.A
125
Dr. Mernbere MU(CHS) Physician Pediatrics 911978814 Mekelle
126 G/ananie (MD)

407
 Afework Bekele Eth. Druggist Asso Druggist Member 911694384 A.A
127
Abebe DACA MPH Director 911370415 A.A
128 Asmelash
Dr. Birna TUTAST Health HRH 913344871 A.A
129 Abdush Economics
Yakub Soman FMOH/MSD Public Officer 912498492 A.A
130
Anteneh DACA, S.W. Branch Pharmacist Head (Remp) 913302534 Jimma
131 Alemeyehu
Dr. Desta Ataro Hawassa University Physician Internist 916824298 Hawassa
132
Yitagsu Alemu Dlach T.H T.H T.H 910131962 Dalach
133
Dr. Girma ERCS Director NBCS Director 911250688 A.A
134 Tesfaye
Dr. Abenezer Army Hospital Dental Dental 911615605 A.A
135 Hailu Surgeon Surgeon
Dr. Zeihun Qwhiha Hospital Ophthalmolo Ophthalmolog 911405357 Mekelle
136 Mekonnen gist y
Regulatory
Lijalem Process
137 H/selassie Tigray.H.B. Health Owner 0914 720473 Mekelle
Curative &
138 Atakilti Abreha Tigray.H.B. Rehab PO 0914 724762 Mekelle
Senior Ph.
139 Hailu Tadeg MSH/SPS Pharmacist Advisor 0911 671137 A.A.

140 Agazi Tiruneh Afar RHB Physician Surgeon 0911 408018 Dubti
Bogale Tikur Anbessa
141 Solomon (Dr.) Hospital Onchologist Consultant 0911 228553 A.A
Information
142 Gadissa Merga Bishoftu Hospital Science HMIS Officer 0911 913555 Bishoftu
Asegid
143 W/tsadik O.R.H.B GMPH Regulation 0910 963802 A.A
Amanuel
144 Kidane Gambella Hospital GP 0911 304942 Gambella
Abreham
145 Shiferaw Betsegah Hospital OBGYN Obstetrician 0911 228663 A.A
Jelaludin Rana
146 (Dr.) SRHB Physician MD Gode H. 0911 542537 Gode

147 Sada Ali Afar Region BSc Nurse Head Nurse - Alidar

408
148 Jemal Endris Afar RHB Bsc PHP Head 0913 985956 Semera
K/mariam
149 G/michael DACA Pharmacist RSS 0912 042567 A.A
CHAI (Clinton Technical Nursing&
150 David A.Conteh Found.) Advsr. Quality Mgt. 0912 727555 A.A
Mohammed
151 Ibrahim Afar RHB H.O Desk Head 0913 033216 Semera

409