Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From

EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool

Evolution tools
EHSTG (Ethiopian Hospital Services HSTQ(Health Sector Transformation In Quality) EHAQ4th Cycle(Ethiopian Hospital Alliance for Food, Medicine, Health Care Administration and
Transformation Guidelines ) Quality 4TH) Control Authority (EFMHACA)
Maternal Health Care MECHANISM TO AVAIL HIGH QUALITY EVIDENCE Outpatient service
Hospital Leadership, management (20%)
and Governance Section II (a). Scope Based Practices Audit tool

 SMT TOR Signed by all SMT members  written, up-to-date protocols and awareness raising materials  protocol defining facility level/specific  Policies and Procedures regarding access,
(posters) on cleaning and disinfection, hand hygiene, operating water,
 Suggestion boxes and logbooks are in sanitation and hygiene facilities, safe waste management are scope of practice.(Scope of practice availability of service and networking
place at each services area available at all areas and are visibly posted Protocol)  SOP for selection of cases for referral
 Curative and preventative risk-management plan exists for

managing and improving water, sanitation and hygiene
Interdepartmental Consultation Protocol  Procedure for referring and receiving referral
services  Triage Protocol  List of potential referral sites with contact
 suggestion box, register, complaint handling office  surgical services protocol address(referral directory)
is available for handling compliant of mothers and
 Consultation form
their families
 guide lines needed in the labor and delivery Section II (b). Standard Based Clinical  Protocols for management of at least common
room are available in the service areas Service Audit tool disease and locally significant diseases in line with
 All relevant guide lines needed in the ANC the national and international guidelines
room are available in the service areas
 Protocols are prepared for at least surgical
 All relevant guidelines needed in FP and CAC
Services, OPD Clinics, Emergency Services,
are available in the service areas
 All relevant guide lines needed in the pediatric and Neonatal ICU.
OPD and Wards are available in the service areas  protocols/policy/procedures for:
 a written, up-to-date, staffing policy is present 1. Patients rounds including bedside
indicating the numbers, types and competencies of teachings.
staff, that is reviewed on an ongoing basis according 2. Nursing Procedures
to the workload
3. Patient Transportation
 a roster is used which is accessibly displayed in all areas,
detailing the names of staff on duty, the times of their shift 4. Bad news breaking
and their specific roles and responsibilities 5. Surgical Scheduling
 Bi annual appraisal of all staff and a 6. STG
mechanism of recognizing high performing  Protocol is printed and given in booklet
workers is in place
form to clinical staff
 refresher training (bi annually)
 a written, up-to-date quality-of-care improvement  STG and Clinical protocols
plan and patient-safety program is present in the
maternity
 a written, up-to-date, leadership structure,
indicating roles and responsibilities with reporting
lines of accountability is present in the maternity
 ANC Follow up national Guide line
 Labour management and Postpartum National
Guide line
 Consent form for Surgery
 Safe Surgical Check list
 Safe Child Birth Check list
 Health-care staff in the labor and childbirth areas of
the maternity unit received training in essential
newborn care and breastfeeding support
 written breastfeeding policy that is routinely
communicated to all health care and support
staff
 written up-to-date, clinical protocols are present on
the management of pre-eclampsia and available in
the labour, childbirth and postnatal areas of the
maternity unit that are consistent with national
guidelines
 pre-eclampsia or eclampsia management National
Guide line
 fluid balance chart
 written, up-to-date, PPH management clinical
protocols are available in the childbirth and
postnatal care areas that are consistent with
national guidelines
 written, up-to-date, clinical protocols for care of
small and preterm babies in the childbirth areas of
the maternity unit that are consistent with national
guidelines
 a written, up-to-date, clinical protocol on early
diagnosis and management of neonatal
infection is present
 written up-to-date guidance on harmful practices
and unnecessary interventions during labour,
childbirth and the early postnatal period is present
 standard operating procedures and protocols in
place at all times for checking, validating and
reporting data
 written, up-to-date, protocols to ensure
privacy and confidentiality for all clients
throughout all aspects of care
 written, up-to-date, zero-tolerance, non-
discriminatory policies relating to the mistreatment
of clients
 written accountability mechanisms for redress
in an event of mistreatment
 written, up-to-date policy and protocols
outlining clients right to make a complaint
about the care received and has an easily
accessible mechanism (box) for handing in
complaints and is periodically emptied and
reviewed
 written, up-to-date, policy in place to promote for
obtaining informed consent from clients prior to
examinations and procedures
Liaison, Referral and social services Neonatal and Child Health Care
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 IMNCI chart booklet
 hospital specific admission and  Pediatric pocket book 2016
discharge protocol  National HIV Care/ART Guideline
 Referrals Service Directory  National TB Guideline
 national referral implementation  National nutrition Guideline
 ETAT manuals
guidelines.
 NICU treatment protocol
 Availability of Referral Criteria
 Essential NB care Guideline
 mechanism to truck referral feed
 National EPI Guideline
back
 National malaria Guideline
 mechanism to monitor to referred  Up to date cold chain training manual,
cases. Immunization implementation policy
 referral protocols guideline that is accessible to all staff
 SOPs for social service  Health Education Manual on EPI

Emergency Medical Services Communicable Diseases Care Section III. Evidence Generation and Utilization Inpatient Services
(28%)
 job description of the emergency HIV service Section III (a). Evidence generation and  written policy for inpatient visit
department  standard operating procedures and protocols utilization Audit tool  clinical protocols for management of at least
 Emergency Response Plan in place at all times for checking, validating  standardized manual for staff training common causes of admission in the hospital
 policies, protocols, flowcharts, and reporting data  staff capacity building Plan/schedule  written protocol for admission and discharge
consultation and treatment  National HIV Care/ART Guideline  TOR for Chart audit team  morgue service standard/policy
guidelines  a written procedure or algorithm is available  protocol for triangulation of selected data  the hospital shall have medicines and
that addresses all the adherence support  annual plan linkage to facility specific consumable as per the national medicines list of
elements historical performance data Ethiopia prepared for primary hospital
 a written procedure or algorithm is available  strategic plan that addressed its past
for monitoring patients on ART and performances
responding to results of CD4 and/or viral
load tests
 A written procedure or algorithm is available for Section III (b). System redesign and
providing nutrition assessment, categorizing EHSTG Boosters Audit tool
nutrition status, and responding to assessment
results with nutrition counseling and referral per  ETAT protocol
national guidelines  pre-triage screening protocol
 routine monitoring of nutrition status through
regular anthropometric assessments (BMI or
 Protocol for patient channeling to
MUAC) per national guidelines the cough clinic
 A written procedures or algorithms for TB  airborn and droplet precaution
screening is available
 A written procedures or algorithms for IPT per protocols
national guidelines is available  OPD Services Protocol
 A written procedure or algorithm is available for
identifying and tracking defaulters
 National guidelines and job aids
 standard procedures for identifying and  Round protocol
tracking adult and pediatric ART patients who  Vital Sign Protocol
have defaulted on their appointments
 standard procedures for identifying and tracking
 Rehabilitative and palliative care
HIV positive pregnant women on ART who have protocol
defaulted on their appointments
 written procedures or algorithms for IPT per
 Biomedical equipment
national guidelines is available maintenance protocol
 standard procedures for identifying and tracking
HIV+ women after delivery who have defaulted on
 Preventive maintenance protocol
their appointments  notification protocol(notification and work order
system for facility and operating system (e.g.,
 written procedure or algorithm for provision
electrical, water, sanitation, sewerage and
of CTX to HEIs is available
ventilation) repairs.)
 standard procedures for identifying and tracking
HIV-exposed infants who have defaulted on their  Plan address skill mix for short term trainings
appointments (offsite and onsite), long term trainings and
 written procedure or algorithm is available for approved by SMT
provision of PITC in maternity  HR Management Manual
 written procedure or algorithm is available for  facility specific menu for food and beverage
provision of ARVs to mother-infant pairs in L&D service
 written procedure or algorithm for pediatric  Quality monitoring protocol/checklist for food
TB screening is available and beverage service
 written procedure or algorithm is available for providing  food and beverage service manual
nutrition assessment, categorizing nutrition status, and  Protocol - Prioritized medical equipment list with
responding to assessment results with nutrition counseling
and referral per national guidelines(for pediatrics) an inspection and preventive maintenance plan
 written procedure or algorithm is available for  strategy for rational use of drugs(The strategy
monitoring children on ART and responding to addresses prioritized drug lists for monitoring,
results of CD4 and/or viral load tests problem identification and the need for action,
 written policy for disclosure of HIV status to identification of underlying causes and
adolescents motivating factors, list out and implement
 written policy for consent for HIV testing and treatment for possible interventions)
adolescents, including provisions for testing of  Adapt/adopt recommended management
emancipated minors without consent from parent, guardian
or spouse guides with a focus on the selected prioritized
 written, up-to-date, protocols to ensure privacy and health conditions and prioritized drug lists
confidentiality for all clients throughout all aspects  TOR of clinical Audit team TOR of clinical Audit
of care team
 written, up-to-date, zero-tolerance, non-  multidisciplinary round (Grand round) protocol
discriminatory policies relating to the mistreatment  Protocol- All new admissions are audited and co-
of clients signed by day time and duty time assigned senior
 written accountability mechanisms for redress in an physicians
event of mistreatment  handover protocol
 written, up-to-date policy and protocols outlining clients
right to make a complaint about the care received and has  chart round checklist and verify that it includes
an easily accessible mechanism (box) for handing in those contents(Chart round should address
complaints and is periodically emptied and reviewed clinical evaluation and decision process, use of
 written, up-to-date, policy in place to promote for an appropriate and justified work up, rational
obtaining informed consent from clients prior to use of drugs, nursing care, staff interview, review
examinations and procedures clinical pharmacy medication care plan within
the patient chart)
Outpatient Services Diagnostic And Treatment Services Section III (c). Efficient use of healthcare Maternal and Child Health(MCH) and Delivery Service
resources Audit tool
TB Patient mgmt  Section III (c). Efficient use of healthcare  Written policies and procedures for transfer&/or
 director/case team manager with JD  customized National guideline or protocol for managing resources Audit tool referral of neonates
 JD for All Professionals TB and their complications AND is/are available in the  Harmonization of planning, budgeting and
TB clinic to be used as a reference.
 Protocol for managing queue budget execution processes, including
 Guidelines for clinical and programmatic
management of TB, TB/HIV and leprosy in producing and disseminating the required
Ethiopia financial and audit reports
 TB/HIV treatment manual
 Guideline on programmatic management of
drug resistance TB in Ethiopia
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 IPPS national manual
 Cough triage protocol
 written, up-to-date, staffing policy, indicating the
numbers, types and competencies of staff working in the
clinic
 standard operating procedures and protocols in
place at all times for checking, validating and
reporting data
 written, up-to-date, zero-tolerance, non-
discriminatory policies relating to the
mistreatment of clients
 written accountability mechanisms for
redress in an event of mistreatment
 written, up-to-date policy and protocols outlining
clients right to make a complaint about the care
received and has an easily accessible mechanism
(box) for handing in complaints and is periodically
emptied and reviewed
 written, up-to-date, policy in place to promote for
obtaining informed consent from clients prior to
examinations and procedures
 protocol for routine TB screening in the facility
Inpatient Service Management Malaria Diagnosis And Treatment Section IV Focus Service Areas (34%) Surgical Services
 Job Description for Case team  written protocols and procedures for admissions
manager Section IV (a). Quality Nursing Care Audit tool and discharges with follow up
 IPD Admission and Discharge Protocol  Section IV (a). Quality Nursing Care  protocols for the management of the emergency
 Appointment Systems for IPD Audit tool obstetric and surgical conditions in the hospital
 MDT Round Schedule  Nursing Round protocol includes Daily  Process and policies defining the appropriate
 Medical record completeness Format nursing round is conducted (1 hour vs safety before, during and immediately after
and their completeness 3 hrs. nursing round for 4P‟s,) surgery, including at least the following:-
 national guideline is available in the OPD and  Aseptic technique
 Verbal and Written Communication  nursing audit team TOR
inpatients with job aids posted in the wall  Sterilization and disinfections
Guideline  Nursing Audit Protocol(Audit should
 Shift Handover Protocol address the implementation and  Section of draping and gowning
 Consultation protocol quality of nursing process, patient  Counting of sponges, instruments and needles
 Patient transportation protocol monitoring, pain management,  Policy for preparing and availing appropriate
medication administration and client and properly functioning supplies,
education (Audit against the standards equipment, and instruments available for
set under S3.1)) emergency surgery
 shift handover protocol  Protocols for patient transfer from operating
 Nursing code of conduct including theatre to inpatient ward
dress code, Cleanness and IPC  Clear Protocol for minor surgical procedures
Practices to be done at outpatient level. Example:
 round package and emergency table Circumcisions, lipoma excisions, abscess
preparedness protocol. drainages, suturing of soft tissue injuries etc
 ICU Nursing care package  Policy that shows the emergency surgery
/Protocol(Protocolize - ICU nursing trained GP or HO shall be on duty to
care package with their indications respond for emergency surgical
and implementation requirements) intervantions
The package should at least address  Written policy about administration of
V/S and fluid balance monitoring regional and general anesthesia in the
requirements, enteral nutrition, GI hospital
prophylaxis, DVT prophylaxis and  The protocols and guidelines used for
medication administration anesthesia service shall be available and well
 Capacity building protocol/ guide understood by surgical team
 Written protocol to assure that the surgery
 capacity building plan
shall not proceed when there are person
 Patient Orientation Protocol
with disability alarms on the monitors
Section IV (b). Surgical service efficiency and
safety Audit tool
 Elective surgery Protocol
 Schedule communication format (The
hsospital has a customized Format and
schedule notification system for head
nurse and scrub nurses (prior
preparedness for adequate drape and
required instruments and suturing
materials))
 Pre admission Evaluation Protocol for
OR Patient to reduce Cancellation
 pre-operative workup protocol
(Standardize preoperative evaluations
and work-ups )
 Protocolize - Preoperative and
postoperative hospital stay
 briefing and debriefing protocol(The
hospital has a daily team briefing and
debriefing at the bigning and end of
the OR day.)
 day care surgery protocol(Protocolize -
define day care surgery clinical
conditions for each department and
ensure necessary infrastructure)
 SSC Audit protocol
Section IV (C). Improve neonatal intensive care
Audit tool
 Neonatal care guidelines, protocols
updated versions
Section IV (d). Improve Emergency, trauma and
critical care Audit tool
 national emergency leveling
document checklist.
 plan for capacity building
 national ICU leveling document
checklist.
 plans of upgrading ICUs to meet
national standards
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 ICU admission, treatment and
discharge protocols
 standard Protocols and guidelines for
referral, triage, burn, poisoning,
trauma ED ICU services
 WHO trauma registry
 revised ICU, Emergency, Liaison
referral and ambulance service
registers.

Non Communicable Diseases Section V. Patient Preferences and Value Audit Nursing Services
Medical Records management tool
 national guidelines on handling and  customized standard treatment guideline or  letter of assignment and check the job  Nursing Process Policy
confidentiality of medical records. protocol for managing NCDs and their description for Health literacy Committee  Written copies of nursing Procedure manual shall
complications AND is/are available in the Chronic
care/specialty clinic to be used as a reference.
members be developed and made available to the nursing
 protocol for discharge planning staff in every nursing care unit. The manual shall
 appointment protocol
 written, up-to-date, staffing policy, indicating the  pain management protocols be used at least to:-
numbers, types and competencies of staff, that is  Letter and JD for pain facal a. Provide a basis for induction of newly
reviewed on an ongoing basis according to the  chronic pain and Palliative care clinic employed nurses
workload. guideline/protocol b. Provide a ready reference on procedure for
 standard operating procedures and protocols in
 availability and utilization of social service all nursing personnel
place at all times for checking, validating and
reporting data. protocol c. Standardize procedures and Practice.
 written procedure or algorithm is available for d. Provide a basis for continued professional
identifying and tracking defaulters. development in nursing
 standard procedures for identifying and tracking procedures/techniques
patients who have defaulted on their appointments  Verbal and written communication
 standard form for clinical progress notes during
each visit to facilitate information exchange guideline that addresses :-
 written, up-to-date, protocols to ensure privacy and a. Written communication includes proper
confidentiality for all clients throughout all aspects use of clinical forms, nursing kardex,
of care
 written, up-to-date, zero-tolerance, non- Progress notes, and/or nursing care plan
discriminatory policies relating to the mistreatment for each patient and discharge
of clients instructions.
 written accountability mechanisms for redress in an
event of mistreatment b. Verbal and/or written communication
 written, up-to-date policy and protocols outlining includes reporting to general medical
clients right to make a complaint about the care practitioners; Nurse to nurse reporting;
received and has an easily accessible mechanism
(box) for handing in complaints and is periodically communication with other service units(
emptied and reviewed Laboratory, Pharmacy, X-ray, social work
 written, up-to-date, policy in place to promote for service), with patient and family
obtaining informed consent from clients prior to
examinations and procedures education.
 written, up-to-date, clinical protocols for  Procedure for standardized, safe and proper
management of hypertension (can be administration of medications by Nurses or
endorsed/customized National STG) designated clinical staff including regular checks
 protocol for routine screening of hypertension for a
of patients’ medications and proper
high risk groups
 written, up-to-date, clinical protocols for documentation of administered medicines
management of CHF (can be endorsed/customized  Written policies that state the procedure for
National STG) communicating with laboratory, laundry and
 protocol for routine screening of DM for a high risk food service. The nurse shall communicate and
groups follow up food orders, lab orders and lab
 Asthma management guideline
 cervical and breast cancer screening specimens, and patient transfer.
 Policy or procedures for nurses to report any
guidelines/protocols and is available in the
exam room suggestive sign of child abuse, substance abuse,
and/or abnormal psychiatric manifestation by
the patients under their care
 Policy for reporting and documenting
medication errors, product quality defect and
adverse drug reactions by attending nursing
personnel immediately to the prescriber and
ADE focal person.(medicines needles and
syringes in patient care areas shall be maintained
under proper conditions as per the
pharmaceutical service standards stated under
this standard. Nursing personnel shall store and
use needles and syringes in accordance with the
infection prevention standards stated under this
standard)
 Protocols that guides nurses coping the
prescription of physician’s order
 Written policies and procedures regarding the
use of physical restraints that are reviewed at
least once every three years and implemented
 Interventions while a patient is restrained shall
be performed by nursing personnel in accordance
with Nursing care policy
 Policy or protocol that state the procedure to be
followed for dead body care.
 Policy for verifying qualifications, restrictions to
practice and professional registration of all new
employees and have a system in place to check
re-registration details. Here shall be
documentation of staff licenses and training
certificates.
 Written discrete job description that details the
roles and responsibilities of each nursing staff
members.
 The hospital shall have a system in place for
evaluating at least annually the performance of
each nursing service employee
 Nursing workforce plane that addresses nurse
staffing requirements.
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 Policy that control nursing care by nursing
students that shall be under direct supervision of
licensed nurse; all being accountable.
 The hospital shall have in effect a contingency
plan for assuring adequate nurse staffing at all
times. The plan shall detail policies and
procedure to regulate closure of available beds,
if actual staffing levels fall below specific levels.
 Policy that strengthens involvement of nurses to
take part in the ongoing continuing professional
development (CPD)
Nursing and Midwifery Care services STG Adherence Section VI: CLUSTER ACTIVITY (EHAQ Pharmaceutical Services
Management Networking and engagement) Audit tool
 Representation in SMT (Letter)  National Treatment Guideline  TOR and shared with all members of the
 Yearly Operation Plan and budgeting cluster
 JD for all Nursing and Midwifery  plan and performance report for cluster.  Standard operating procedure for dispensing
 JD for Metron and vice metron  Cluster regular meeting is conducted, medication use counselling shall be established
 NCP/MCP Policy recorded and follow-up action plan is  Primary hospital shall establish and implement
 Nurse to patient ratio policy developed policies, guidelines and/or procedure for
 Professional code of conduct and  written received feedback from Lead reporting any errors or any suspicious in
ethics policy Hospital administration or provision of prescribed
 Dressing code of conduct policy  Community forum action plan developed, medications.
 The pharmacy shall keep individualized
 Verbal and written communication communicated and implemented
and documentation guideline information for patient with chronic illnesses
medication program using standardized
 Nursing Round policy
information tracking format and update patient
 Safe and proper medication
medication profile during each refile visit.
administration policy
 Policies and procedures to control the
 Nursing and midwifery audit TOR
administration of narcotic drugs and psychotropic
 Nursing and midwifery Standard
substances.
procedure policy/guideline
 Control substance record substance format
 The hospital through drug and therapeutic
committee shall establish policies and procedures
for the provision of inpatient pharmacy services.
 Consultation on medication use and among the
prescriber, pharmacist, nurse and patient
 The drug and therapeutic committee of the
hospital shall develop/adopt and implement
antimicrobial prescribing, dispensing
and usage policy
 The responsible pharmacist shall take the duty to
coordinate and prepare emergency medicine lists
and ambulance kits for the hospital based on
national primary hospital’s medicine list.
 DTC develop the formulary list as well as policies
and guidelines
 Written policies for the procurement of
medicines from government and private
suppliers.(prepared by DTC and approved by the
management/board of the hospital)
 Written SOPs on how supplies of stock are to be
obtained from the medical store
 Written procedures shall be available for the
return of expired, damaged, leftover and empty
packs from outlets to medical store to prevent
potential misuse.
 DTC should be responsible for developing polices
and guidelines on how to organize and conduct
medicines use studies.
 A security policy shall be implemented which is
designed to ensure the safety of both staff and
medicines
 Written polices and procedures for pharmacy
workforce determination, recruitment,
performance evaluation, staff development and
other related issues.
 JD for all pharmacy staffs
 Medicine information service in the pharmacy
shall maintain a current collection of reference
materials such as books, journals, drug profiles,
electronic information, relevant formularies, and
manufacturer’s information and other furniture.
Maternal, Neonatal and child health Services Infection Prevention
Management Surgical Services
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 written, up-to-date protocols and awareness  Infection Prevention Procedure and
 Invitation Letter for partners raising materials (posters) on cleaning and processes associated with risk of infection
 vacuum aspiration (manual or disinfection, hand hygiene, operating and and shall implement strategies to reduce
electric) for pregnancies of maintaining water, sanitation and hygiene infection risk
gestational age up to 12–14 weeks facilities, safe waste management are  The following written polices and
according to the national guideline. available at all areas and are visibly posted
procedures shall be maintained:
 National Abortion Guide line  Curative and preventative risk-management
a. Hand hygiene
plan exists for managing and improving
 NICU National Guideline b. Transmission – based precautions
water, sanitation and hygiene services
 c. Post-exposure prophylaxis program(PEP) for
 A written, up-to-date quality-of-care
improvement plan and patient-safety program some communicable disease like rabies. HIV,
is present in OR and surgical ward meningitis
 a written, up-to-date, leadership structure, d. Environmental infection prevention
indicating roles and responsibilities with reporting e. Waste management
lines of accountability is present in OR and surgical  Specific standard precautions guideline
ward
 Transmission-based precautions guideline
 Protocol for hand Ove and consultation  The hospital shall have procedures in place to
Mechanism are Present minimize crowding and manage the flow of
 Established procedure of handing over is patients and visitors.
present while receiving patient from OR to
Wards and ICU
(transfer form documented)

 standard operating procedures and protocols

in place at all times for checking, validating
and reporting data
 written, up-to-date, protocols to ensure
privacy and confidentiality for all clients
throughout all aspects of care
 written, up-to-date, zero-tolerance, non-
discriminatory policies relating to the mistreatment
of clients
 written accountability mechanisms for redress
in an event of mistreatment
 written, up-to-date policy and protocols outlining
clients right to make a complaint about the care
received and has an easily accessible mechanism
(box) for handing in complaints and is periodically
emptied and reviewed
 written, up-to-date, policy in place to promote for
obtaining informed consent from clients prior to
examinations and procedures

Laboratory Services management Hospital Sanitation and Waste management

Nursing and Midwifery Service Quality
Standards
 Written procedures to govern the use of
 Quality manual Guide line sanitation techniques in all areas of the
 Safety manual Guide line  Nursing process Guideline
hospitals
 Laboratory Hand book  Nursing communication Guideline
 Written policy and procedure for ground
 Standard Operational Procedures for
all Technical and Managerial  Safe drug administration policy/Guideline water treatment
 Health care Waste management
Procedures in work place
 nursing management has annual operational plan
 Customer satisfaction survey Report national guideline.
 Sample collection Manual  Chemical and radioactive waste management
 Written procedure for laboratory national guideline
information management system 
 Official letters for Blood bank focal
and committee
 Documents and records for blood
received, blood issued and
compatibility test and SOPs.
 Cold chain SOP
 Blood request Form
 Blood Transfusion Committee TOR
Pharmacy Services Management CRC and Patient Centered Care Food and Dietary Services

 CRC-PC strategy is developed as per the  Written policies and procedures for all dietary
 DTC annual Plan national CRC framework services
 DTC TOR  CRC-PC operational plan is developed  A current diet manual shall be available at nurse
 Letters for DTC Committee Members  TOR is developed station and in the dietary service unit( dietary
 SOPs for all compounding procedure  Patient education materials on CRC-PC manual sample)
 Procurement Policy appropriate for readers of varying literacy  Policy to promote the participation of the dietary
levels and for speakers of different native
 Annual Pharmaceutical quantification service in meetings of multidisciplinary health
languages are available to the staff care teams to assess patients
and supply plan
 TOR for the SMT ( leadership) to interact 
 Presence of ADE focal and Report Policies and procedures developed by the drug
directly with Patients and families (at least
 SOP for Continues segregation, weekly)
and therapeutic committee regarding possible
documentation and safe Disposable food/drug interactions
of Pharmaceutical waste  National hotel and catering sanitary control
 Certificate for disposable Medicine guideline
 Guideline for pest control and restricting the
presence of animals
 Ethiopian Food handlers’ Hygiene Guideline for
food service personnel
 Written JD for all Dietary Employee shall be
given, oriented and documented

Radiological and imaging Services Housekeeping, laundry and maintenance Services
Management
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 Comprehensive hospital-wide safety
strategic and Annual Plan with budgets program
Approved by SMT Yearly ERPA  Written policies and procedures for routine
Certification
maintenance, preventive maintenance and
SOPs are developed and in use
renovation maintenance
for the regular operation and maintenance
of all Equipment in the Unit  Written protocols and procedures for
OPs for( diagnostic equipment maintenance service.
 Request reviewing  A written evacuation diagram specific to the
 Client communication and consenting unit that includes evacuations procedure,
 Turnaround time location of fire exits, alarm boxes, and fire
 Patient preparation and positioning extinguishers shall be posted conspicuously
 Radiation Safety protocols on a wall in each patient care unit.
 Contrast administration  Comprehensive, current, written preventive
 Management of specific situations maintenance program for fire detectors, alarm
(pediatric patients, pregnancy, clients systems and fire suppression system that
needing sedation, emergency includes regular visual inspection.
patients and prioritization protocols)
 Quality improvement activities
(identification of quality gaps, action
plan development and
implementation))
 Reporting formats and standards
 Policies and procedures for recording
and reporting (including remote
reporting)
 Communication policy with the unit
and other clinical departments
Rehabilitative And Palliative Care Services Emergency Services
Management Patient Safety Quality Standards

 Patient Safety Strategy  Infection Prevention standards

 Rehabilitation and palliative care  Patient safety Operational plan is prepared  The emergency service shall have functional intra
treatment protocol  code of ethics policy, for example in and inter facility referral system which
 written guidelines and SOPs for the relation to research, resuscitation, encompasses SOP for selection of referral cases,
assessment, implementation and consent, confidentiality. referral directory, referral forms, referral tracing
evaluation of rehabilitation and  occupational health program policy mechanism, feedback providing Mechanism,
palliative care services  Annual plan is prepared for an documentation of referral clients and
 Protocols related to information occupational health consultation forms.
sharing communication and  Hand over Protocol safe and thorough  Procedure for easy access to pharmacy,
confidentiality developed handover of patients between clinical laboratory and other diagnostic services
teams (including shift staff).  Written protocols for emergency services and
 The hospital implements the use of a the provision of this service shall be done in
surgical safety checklist and conforms to accordance with the clinical protocol of the
guidelines service
 The hospital screens patients to identify  Emergency care service Protocol for the
those vulnerable to harm (e.g. falls, following cases:
pressure ulcers, suicide, malnutrition, a. Shock
infection) and acts to reduce risk. b. Sever bleeding
 guidelines prepared to reduce risk c. Fracture and injury
 Checklist use to screen patients to d. Coma
identify those vulnerable to harm (e.g. e. Burn
falls, pressure ulcers, suicide, f. Poisoning
malnutrition, infection) g. Cardiac emergencies
 IPPS national protocol h. Sever respiratory distress
 policy of giving HBV vaccination for all high i. Seizure Disorder
risk groups working in the hospital (health care j. Hypertension emergencies
providers, cleaners, laundry workers etc.)
k. Cereberovascular accident
 safe blood and blood products guide line.
l. Acute diarrhea(severe dehydration)
 safe pre-transfusion procedures for m. Acute abdomen
extreme emergency cases n. Tetanus
 recruitment, selection and o. Meningitis
retention of voluntary blood 
donors association members
 Blood screening (minimum for
HIV, HBV, HCV, syphilis).
 safe blood transfusion checklist to be
used before transfusion (safety of the
blood) and after transfusion (diagnosis
of blood transfusion reaction)
 guidelines on safe and appropriate
prescribing of blood and blood products,
including the use of alternative fluids.
 policy and procedures to manage
medication error.
 smoke-free policy and signage
Infection Prevention and patient safety Rehabilitation Services
Health Care Data Quality Standards
 Specific treatment and/or procedure
 TOR for IPPS/CASH Committee  guideline about what is reported to whom, protocols for each service available and
 Strategies/policies for IPPS/CASH and how and when reporting is required
rendered in the unit
 Developed operation plan on CASH  confidentiality should be maintained in
accordance with international or national  There shall be a policy that the
and IPPS by committee
guidelines therapist(physician therapist/ physiotherapist)
 Hand Washing Poster on Visible Area
 Source documents (e.g. medical records, shall document the entire planning the
 National IPPS Guidelines
registers) should be kept and made available patient’s medical records
 Educational materials and supplies
related to IPPS
in accordance with a written policy.  There shall be aa protocol or policy for safety
 clearly defined and followed procedures to and ethical practice of physical therapy that
identify and reconcile discrepancies in
complies with the six precepts for health
reports.
 clearly defined and followed procedures to care(safe, effective, patient centered, timely,
periodically verify source data efficient and equitable.)

Federal and Teaching Hospital Services Laboratory Services
management
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 policies and procedures for availability of paper
 orientation guidelines based or electronic laboratory information
 compliance on policies and management system (LIMS)
procedures  Safety Guidelines
 protocols for conducting teaching on  Policies and procedures for the availability of
patients confidentiality and privacy laboratory service including the emergency
 protocols/policies and procedures for services for 24hrs a day 365 days in a year
ward rounds and bedside students’  Procedure or SOP for proper specimen collection
teaching to maximize patients’ that address specific collection requirement Such
benefit. as:
 guidelines/MoU for affiliation, a. Preferred sample type (venous, arterial, capillary,
community and field activities urine, spinal fluid)
b. Type of anticoagulant
c. Sample volume considered acceptable
d. Patient identifications
e. Requirement for patient preparation and storage
of specimens
 SOP or criteria developed for acceptance or
rejection of clinical sample
 Policies and procedures in place to protect the
privacy of patients and integrity of patient
records whether printed or electronic
 Written chemical hygiene plan that define the
safety procedure to be followed for all hazardous
chemical used in the laboratory. The plan defines
at least the following:
a. The storage requirements
b. Handling procedures
c. Requirements for personnel protective
equipment
d. Procedures following accidental contact or
overexposure
e. The plan is reviewed annually, and updated
if needed, and is part o new employee
orientation and the continuing educational
program
 Safe procedure for handling of specimens
and waste material
 Laboratory service shall have and
maintained JDs, including qualifications to
perform specific functions
Medical Equipment Management

 Operational Plan
 MEC(Medical Equipment committee)
TOR That includes(develop and
monitor implementation of medical
equipment strategy; oversee
establishment of medical equipment
inventory; develop a model medical
equipment list; develop and
implement medical equipment
policies; determine annual budget for
medical equipment strategy; review
incident reports related to medical
equipment.)
 SOP for equipment use, inventory
data collection form and risk
assessment form.
 policies and procedures for medical
equipment management and verify
that they address acquisition,
commissioning, decommissioning,
disposal, donations, and outsourcing
technical services.
 Equipment Log File.
 Acceptance Test Log Form.
 SOP for each item(Medical
Equipment)
 medical equipment work orders
Protocol.

Facility management
 organization chart
 maintenance log (for, as a minimum:
electrical systems, water and
sewerage.)
 transport policy for the use of and
access to hospital vehicles.
 policy for addressing access to the
hospital premises.
 fire safety plan.
 emergencies, epidemics and natural
or other disasters response plan.
Human Resource Managemnet

 Designated staff members of the HR

Case Team
 human resource development
plan(addresses staff numbers, skill
mix and staff training and
development.)
 policies for recruiting and hiring staff.
 Extracted List of Protocols, Guidelines, Policies, Standard Procedures … From
EHSTG, HSTQ, EHAQ4th and EFMHACA Primary Hospital Evaluation tool
 policies that support employee
motivation and retention including as
a minimum: policy for compensation
and benefits, training and
development and employee
recognition.\
 hospital’s Employee Manual
 Employee Hand Book(Manual)
 Hospital personnel policies and
procedures such as working hours,
leave, benefits
 Code of Conduct and Professional
Ethics policy
 performance management process
and reward policies in which all
employees are formally evaluated at
least semiannual, higher performers
are recognized and
 staff survey
 occupational health and safety
policies and procedures.

Health Financing and Asset Management

 hospital has an operational plan
 cost Unit, staffed as the guideline
Described
 bilingual service fee schedule posters
are clearly displayed.
 contractual document(Health
insurance benefit package and for
other services )
 insourcing contracts
 request formats are appropriate and
are available both in hard and soft
copy for timely request
payment/claims/reimbursement for
services to the Health Insurance
Agency
 Contractual agreement procedures
have been developed that define the
outsourcing process and what
services are outsourced
 Annual budget documentation
 stock management ranging from
identifying the need for a property to
materials and supplies in order to
receive, use and dispose complies
with the relevant guidelines and
disaggregated by each departments
Clinical Governance and Quality
Improvment

 TOR and list of members of Quality

Committee.
 clinical governance and quality
improvement strategy and an
operation plan includes()
o Safety and risk management
o Clinical effectiveness
o professional competence
o Patient focused care
o Patient and public involvement
o Benchmarking
 Incident Officer who has a job
description
 Posted patient rights and
responsibilities in public places in the
hospital.
 patient Involvement strategy.
 patient satisfaction survey.
 document of the Hospital’s Public
Forum
 Compassionate, Respectful and
Caring Healthcare Professional
Strategy(covers issues about respect
and dignity, effective communication,
better hotel services (housekeeping,
nursing care, balanced diet (food)
services, laundry services))
 TOR of HMIS/KPI Monitoring Team to
confirm that role includes review of
indicators.

Prepared by Yaye Primary Hospital(YPH)