ETHIOPIAN HOSPITAL SERVICE IMPROVEMENT

GUIDELINES
ETHIOPIAN HOSPITAL MANAGEMENT INTIATIVES

FOR IMPROVEMENT OF HIGH QUALITY HEALTH CARE

ASSESSMENT HAND BOOK

MEDICAL SERVICE LEAD EXCUTIVE OFFICE

September/2023
ETHIOPIAN HOSPITALS’
SERVICE IMPROVEMENT
GUIDELINE
ASSESSMENT HANDBOOK

REVISED
September
2023 MOH
Ethiopia
 About the Revision

Considering that alignment of standards with implementation guide and assessment hand book verifications, MOH – Medical service
Lead Executive Office together with relevant partners and all the RHBs’ tried to revise the assessment hand book. The hand book helps
hospitals to provide better quality services by crosschecking their performance regularly against the set standards. To make this
effective, Hospitals should create regular awareness program for the staffs to oversee their respective service areas progress against
the standards and take actions based on findings.

The main revision is made on verification criteria that help to improve service quality as most criteria need to be verified by audits of
the whole chapters & prepared documents with adherence, observations, triangulation of data and possibly interview of staffs. And also
some chapters split and stand independently. Some standards set as ‘optional’ for primary hospitals, but expected to full fill gradually
focusing mainly on the implementation guide so as to give better quality of services.
CHAPTER-1 HOSPITAL LEADERSHIP, MANAGEMENT AND GOVERNANCE

Scoring
S/N Operational Standards Score Verification Criteria
Weight Score

Verify that the board is legally established and members are

3
officially assigned from their respective office
The hospital has a
Check the board members composition is in compliance with
functional Governing 2
the law (community representative, gender composition)
Board mandated to
1 15 Check the hospital has set a clear vision and mission of the
provide strategic 4
hospital
leadership.
Check the board provides oversight and supports the hospital's
management committee, ensuring that it has the resources and 2
guidance needed to discharge its responsibilities.
 Check the board provides clear direction in alignment with the
4
mission, vision, and strategic goals of the health sector

Score Score 15

Check the hospital has a functional management committee

that advice the CEO/CED of the hospital in running the overall 2
hospital activities
10
Check the management committee has an implementation and a
3
monitoring plan approved by the governing board

Check the management committee meets regularly and passes

The hospital has 1
decision on issues of concern.
2 functional management
Verify the management committee runs its activities in line
the runs the overall
with the set objectives and the direction given by the hospital 2
activities of the hospital board.

Check the management committee acts in the best interest of

patients. 2

Score 10

3 The board ensures that the 11 Check availability of approved structure of the hospital 2
 hospital maintains . Verify the board conducts resource gap assessment to ensure
3
appropriate levels of availability of resources to smoothly run the hospital operation

resources Check the hospital has necessary medical equipment and

. 2
technology.

Check the board has given direction to address identified

2
resource gaps through strategic and annual plan

Verify the board allocates the required resources 2

Score 11

Check the hospital respects for patient authority 1

Verify the board and management committee improve patient

2
centeredness and work in the best interest of patients
8
The board provides Ensure the hospital treats all patients fairly and without
guidance and promotes discrimination. 1
4
good ethical practice

Check the hospital keeps patients’ personal information

1
confidential

Check the hospital has an ethics violation reporting and

2
responding mechanism.
 Confirm the hospital maintains high standards of
1
professionalism and ethical behavior in its service provision.

Score 8

Check the board discharges its responsibilities in full

compliance with the government’s laws, rules and regulations, 2
and as per the mandates given it by law

Check board remains accountable to the community, providing

The hospital governing
transparency to the hospital's operations and engages in open
board establishes 2
dialogue
accountability
mechanisms 11
with patients, families, and other stakeholders
5
Check the hospital implements GGI 2

Check the hospital implements citizen charter 2

Check the board conducts self-evaluation and review its

1
performance

Confirm the board has minutes on self-evaluation and actions

1
taken based on the findings of the evaluation

Obtain a minute of a meeting held on self-assessment. 1

(Conducted every six
 month)

Score 11

Check the hospital allocates adequate budget from internal

revenue for quality 2
improvement activities

The hospital has

mechanisms and practices
to improve the quality of Verify board members interview patients about the service
6 1
delivery
healthcare 10

Verify board members hold discussion with staff concerning

the quality-of- 1
service delivery

Hospital Board and Management Committee make clinical

quality including
2
patient safety and satisfaction governance top priority of the
hospital
 Check the hospital provides direction and supports the 2
management committee to make quality of care a top priority

Check the hospital board pass decision to strengthen

department-based quality improvement taskforce of the 2
hospital

Score 10

Check the management committee has clear long-term and

operation plan to increase the hospitals revenue from diverse 2
The hospital increases sources over time.
resource generation and 8 Ensure the board and management committee engages the
improves efficiency of community and other stakeholders to increase the hospital 2
7
resource
resource use
Check internal revenue of the hospital shows increasing trend 2

Ensure the board critically reviews both the growth and

2
efficient use of the hospital’s resources
 Scores 8

Check the hospital has a capacity building plan for board and
2
8 7 management committee members
The hospital has a regular
capacity building program Check if there is a formal and ongoing orientation/training
for governing board program for the board members on their role, responsibilities, 3
members and managers and organizational structure, regulations and directives,
guideline, policies, procedures and hospitals’ operation.
Verify new board & management committee members receive
The hospital accords 2
a thorough orientation before assuming their duty.
adequate attention for
Score 7
implementation of
projects, health reforms Check projects, programs, health reforms and initiatives are
2
and initiatives.
undertaken as planned

8 Verify the board and management committee prepared separate

2
monitoring plan for projects, programs and initiatives
9

Verify the hospital monitors performance and provides timely 2

 feedback

Check timely actions are taken 2

Score 8

Verify that the hospital has prepared and signed TOR with
3
health center
The hospital has created a
link between the hospital Check the hospital provides technical and resource support to
4
10 and its catchment health 12 its catchment HCs
Centers.
Check the hospital has conducted clinical mentorship 3

Check the hospital conducts performance review meeting with

2
the catchment health centers

Scores 12

100
Total Score
CHA PTER 2 LIAISON, REFERRAL AND SOCIAL SERVICES

Scoring

S/N Operational Standard Score Verification Criteria Weight Score

1 The Hospital has established management Check if the hospital has reception service near 4
structures and job descriptions which detail 16 at the gate of the hospital with adequately
roles and responsibilities for: trained staff, stretcher and wheelchair
• Reception service The hospital has established liaison unit 4
• Liaison and referral service
The liaison and referral unit has dedicated 4
• Social service
phone line, internet connection and is equipped
with necessary office equipment and furniture.

adequate number of social workers and 4

hospital psychologists are assigned
16

Score
 The hospital should provide liaison, referral 9 Interview the head of the unit if they provide
2 3
and social liaison service 24/7.
services 24 hours a day and 7 days a week Interview the head of the unit if they provide 3
throughout the year. referral service 24/7.
Interview the head of the unit if they provide 3
social service 24/7.
Score 9

3 The hospital has a written protocol for the 12 Check for hospital specific admission and 4
admission and discharge of patients that is discharge protocol
known, and adhered to, by all relevant staff. Check if they have the protocol in selected units 4

Interview staff for their knowledge and 4

adherence to the protocol

Score 12

4 The hospital has a Referrals Service 13 Check for availability of revised/updated 4

Directory, listing facilities which the hospital service directory
may refer patients to or receive patients from The hospital has defined referral catchments 4
 (defined referral catchments) categorized by The liaison staffs know clinical services 5
the type of clinical services they provide. provided by their catchments.
Score 13

5 The hospital has developed Criteria for the Check for availability of referral criteria 4
referral of patients from the hospital to other 18 Check for mechanism to track referral feed back 5
health facilities are established.
Check for mechanism to monitor to referred 4
cases.
Ask if there are accompanying health 5
professionals for emergency cases

Score 18

6 The hospital promotes and publicizes the 8 Check if the hospital has a mechanism to 4
referral system throughout the community in promote referral system (public forum)
order to ensure that all constituents are aware Check if the hospital aware catchment facilities 4
of the applicable service pathway. to promote public awareness on the referral
pathway

Score 8
7 The hospital social services unit practices 10 Check if the hospital has social health services 5
psychosocial and spiritual services based on for the needy integrated with the liaison office
standard Check if the social service has SOPs 5
operation procedures and protocols for the
Score 10
services.

8 The hospital has established an efficient 14 Check presence of ambulance service 4

ambulance service management system management protocol

Check ambulances are equipped with the 5

minimum equipment and supplies

Check if ambulance drivers are trained on basic 5

life support skills

Score 14

TOTAL SCORE 100

CHAPTER-3 EMERGENCY AND INJURY CARE SERVICES MANAGEMENT

Scoring

S/N Operational Standard Score Verification Criteria Weight Score

1 The hospital shall have an emergency 6 Interview the ER lead and ask him/her if trained on 3
department led by an emergency director emergency care.

Ask the ER lead if he/she has training certificate 3

Score 6

2 The emergency unit shall be easily 8 Check whether the ER unit is labeled properly and 2
accessible, labeled and clearly visible upon visible from the distance
entry to the facility with an ambulance
Confirm that the emergency unit is located near to the 2
parking area and it is in close proximity to
gate
the ICU and OR.
View the ambulance parking area and confirm that it is 2
appropriate for parking

Easy access to OR and ICU 2

 Score 8

3 The emergency unit has separate areas for 18 Patient assistant area at Emergency gate 2
triage, resuscitation, examination, procedure
Triage area 2
short stay beds, isolation room and
decontamination area. Waiting area for non-critical emergency patients 2

Examination area 2

Isolation room 2

Decontamination area 2

Resuscitation area 2

Procedure area 2

The observation and treatment area (beds for 24hrs) 2

Score 18

4 The hospital has an Emergency 14 Confirm the availability of equipment and supplies to 7
department/unit equipped with necessary provide emergency medical services as per the hospital
equipment, drugs and supplies needed to tier level.
 provide emergency medical services as per confirm the availability of drugs to provide 7
the hospital tier level. emergency medical services as per the hospital tier
level.
Score 14

5 All emergency department clinical staff shall 8 Asses the availability of human resources to provide 2
have basic emergency medical services

emergency care training. Interview the head of the department about adequacy 2
of staff

Interview 3 clinicians and check whether the staffs are 2

trained to conduct emergency patient triage and
emergency care.

Ask the staffs and observe training certificates 2

Score 8

6 The Emergency Department or Unit shall use 10 Randomly select 5 patient charts and review if the triage 10
a triage for is properly completed. ( 2 points for each charts)

system of screening and classifying patients Score 10

to determine their priority needs and to ration
patient care efficiently.
7 The hospital provides emergency medical 10 View presence of emergency Pharmacy 2
service 24 hours a day and 365 days a year
View presence of emergency Laboratory 2
with a 24-hours’ access to diagnostic
laboratory, radiology, pharmacy services, Check presence of mobile x-ray access for 24hrs 1
blood products and oxygen with priority for
Check presence of ultrasound access for 24hrs 2
emergency clients.
Interview 3 ER staffs if blood is always available 1

Interview 3 ER staffs if oxygen is always available 2

Score 10

8 The hospital shall have an emergency 6 View emergency response plan 2

management team with a documented
Check the assignment of emergency response 2
emergency preparedness and response plan.
coordinator and ask his duty in case of disaster

Interview 3 members of the emergency management 1

team if they have awareness of the emergency
preparedness and response plan.

Check if emergency drill is conducted in the past one 1

year.
 Score 6

9 Emergency department or Unit has policies, 8 Check availability of triage protocol 3

protocols and treatment guidelines for
Check availability of emergency case management 3
running ED/EU.
protocol/guidelines

Check for presence of standardized triage forms. 2

Score 8

10 The emergency unit shall have a staff facility 6 Observe the presence of a separate duty room for the 3
room for rest and refreshment. ER staff.

Check the availability of quick reference materials 3

for ER staffs.
Score 6

11 The hospital has security guards dedicated 6 Observe the presence of an assigned security guard at 3
for emergency unit. ER gate

Interview 3 randomly selected ER staffs if the 3

security guard is always present
Score 6
TOTAL 100
 CHAPTER-4 MEDICAL RECORD MANAGEMENT

S/N Operational Standard Score Verification criteria Scoring

Weight Score
1 The hospital has 9 Assigned MR unit focal, registration officers and runners with JD as 3
functional medical record per the standard.
management Unit
The MR unit head is accountable to the HMIS director. (look for
reports, joint meeting minutes)
Has annual, quarterly and monthly plan 3

Has a regular weekly meeting among case team members (check the 3
minute)
Score 9
2 The hospital has a 6 Check for availability of MR room with adequate service delivery 3
standard MR room. windows as per the standard.
Adequate office furniture, computers, UPS, etc. 3

Score 6
3 The hospital has created a 12 Verify unique medical record number assigned to a patient during his/ 3
secure system to register her first visit of care. (see the register)
and retrieve medical
records.
Check the availability of digital Master Patient Index 3
 Identify MR tracking system. 3
Verify if there is a reliable backup mechanism. 3
Score 12
4 The hospital avails and 9 Card room: check the availability of patient individual folders, patient 2
utilizes a standard set of IDs, Tracer cards, MPI cards, fastened history sheets or similar digital
formats for medical record formats
registration.
OPD/EOPD rooms: check the availability of OPD registers, tally 2
sheets, Laboratory request sheets, prescription papers, triage papers,
referral sheets, feedback forms, radiology order forms, pathology order
forms etc. or similar digital formats
IPD rooms: check the availability of IPD registers, tally sheets, 2
Laboratory request sheets, prescription papers, nursing care plan
sheets, order sheets, progress note sheets, consent forms, v/s sheets,
clinical pharmacy evaluation sheets, medical oxygen monitoring
formats, consultation request sheets, medication administration record
forms, discharge planning formats, discharge summary sheets, death
summary sheets, radiology order forms, pathology order forms,
pictographs in labor and delivery wards, safe surgical checklist and
Anastasia evaluation sheets or similar digital formats
Randomly sample 10 inpatient and 5 OPD medical records of patients 3
and confirm that each, as a minimum contains as per the above lists.

Score 9
5 The hospital complies 6 Check the availability of national guidelines and institutional SOPs to 3
with national guidelines to manage access and keep the confidentiality of patients’ medical
manage access to patients’ records.
medical records.
All MR room staffs are trained on MR guidelines and SOPs 3

Score 6
6 The Hospital has a system 9 The hospital has assigned focal person for medico-legal issues at card 3
for proper handling and room
confidentiality of medico
There is lockable shelf/box for medico-legal medical records 3
legal patients’ medical
records
Medico legal card registration, submission and return check-up system 3
is in place
Score 9
7 The hospital performs 22 There is chart audit team with defined TOR 3
medical record auditing
View the MR audit plan and audit tool 3
and takes corrective
actions on a regular basis. View quarterly audit reports for active/inactive cards, duplications, 3
incompleteness, consistency between electronic and manual system

Randomly select 10 medical records and check for proper 4

completion of the forms (at least look for date, utilization of
standard formats, discharge summary for discharged patients,
and name and signature of the physician)
 View proper shelving of medical records 3
View achieving mechanism is in place for inactive cards >2 3
years (if no adequate shelf space)

Look for action plan based on the identified gaps or linked to 3

QI projects
Score 22
8 Hospital ensures patients’ 9 Check the use of tracer card to identify the location of medical records 3
medical record tracing at all times
system.
View the mechanism of getting all medical records back at the end of 3
each service day (submission and reception form/register)
Check daily card balance reports 3

Score 9
9 The hospital implements 18 Observe implementation of EMR in triage, MR, liaison and referral, 3
fully automated medical ER, OPD, IPD
recording system.
EMR software training is provided for all clinical and other responsible 3
staff’s
All laboratory, pharmacy, radiology and finance service softwares are 3
harmonized with EMR.
EMR focal is assigned 3
Data regulation system is in place 3
 Availability of adequate electronic data collection tools and reporting 3
formats
Score 18
Total Score 100

CHAPTER-5 OUTPATIENT SERVICE MANAGMENT

Scoring

S/N Operational Standard Score Verification Criteria Weight Score

The Hospital has established management Check organogram of the hospital 2

structures and job descriptions that detail the roles
Assigned director/case team manager with JD 2
and responsibilities of each discipline within
1
services/departments/units, including reporting 10 Plan/monthly, quarterly and annual 3
relationships.
Report/monthly, quarterly and annual 3

Score 10

The hospital has well-equipped service specific Check availability of necessary equipment and supplies 4
2 OPD rooms with necessary equipment and supplies Check functionality of equipment’s 4
as per hospital tier level of care.
8

Score 8

The hospital has established functional relationship Check attendance of outpatient pharmacy, outpatient 4
between various outpatient teams laboratory and imaging department representatives on
each outpatient team meetings minutes
3
12 Check presence of joint clinical audit, quality 4
improvement activities between outpatient teams,
outpatient pharmacy, outpatient laboratory and
imaging departments
Check presence of Sample collection unit, imaging 4
unit and outpatient pharmacy near OPDs
Score 12

4 The hospital has an outpatient department waiting Check availability of adequate waiting area in 2
area with adequate lightening, ventilation and comparison with volume of patient
multimedia facilities. 11 Waiting area is ventilated and lightened 3
 Multimedia service is available (like TV, Radio etc) 3

Chairs are comfortable 3

Score 11

5 The hospital has an OPD staffed with adequate and Check clinics arranged as per specialty 2
appropriately trained personnel and OPD service
Check specialty clinics are run by specialist 2
rooms are managed by at least a GP and specialty
10
clinics by a service specific specialist/ sub- The hospital should have a well defined scope based 3
specialty clinic by sub specialist as per hospital tier practice protocol.
level of care. Check patients seen by appropriate scope of 3
professional
`
Score 10

6 Outpatient department (OPD) specific central triage Protocol for managing queue 2
procedure is established to ensure efficient patient
Registration for appointment 3
flow; and seek to reduce patient crowding.
7
Observe flow of patient at MR, Pharmacy and 2
Examination process
Score 7

7 The hospital has established OPD patient Check availability and functionality of Block 2
 appointment management systems. 8 appointment registration system
System to notify patient to come on the appointment 3
date
Verify appointment charts are retrieved and sent to 3
the appointment OPDs a day before date of
appointment
Score 8

Observe presence of outpatient procedure room 3

Observe day time surgery procedure room 3

The hospital has established OPD procedure room
9 10 availability
and day care surgery at the OPD
Observe staff assigned with necessary equipment and 2
supplies
Check registration book/report 2

Score 10

Observe the starting time of the OPD against the 3

local government working hours
10 The hospital has ensured and maintained timely Interview 5 selected patients from different OPD and 6
9
OPD service initiation ask if the service started according to the local
government working hour.
 Score 9

11 The hospital has conducted regular OPD service Assigned staff to conduct regular OPD service audit 5
audit and develop QI project
Observe QI projects align with the audit findings 5
15
QI projects are complited with the planed time 5

Score 15

Total score 100

CHAPTER-6 INPATIENT SERVICE MANAGEMENT

S/N Operational standards Verification criteria’s Scoring
weight Score
1 6 Review organization chart (organogram) and 1
The inpatient department has a management verify annual plan preparation and
structure, annual and monthly services plan, dissemination to frontline staff.
with departments/units/case teams
Confirm development of annual QI plan aligned 2
with Quality department based on gap analysis
and graduated initiative planning.

Ensure appointment of inpatient department 1

focal persons for infection prevention, pain,
oxygen and data management.
 Validate existence of data verification system 2
prior to external reporting.

Score 6
2 The Hospital provides standard inpatient 9 Ensure porters/runners are trained on safe 2
services meeting relevant regulatory standards sample and request transport, patient
transfer, and maintaining confidentiality.
Confirm appropriate skill mix assignment in 2
each service unit including phlebotomists,
clinical pharmacists, nurses etc.
Verify service provision adheres to SOPs 2
and guidelines.
Assess bed spacing and room ventilation 3
meet standards
Score 9
3 Inpatient staff regularly follow and implement 12 Check preparedness and patient awareness 2
the hospital's admission and discharge protocols of proactive discharge planning
Randomly select 10 staff from different units of 3
IPD and assess sample of staff knowledge on
hospital admission and discharge protocols.
Randomly select 10 patient charts and evaluate 3
completeness of admission and discharge
documentation in sample of charts and
registers.
Confirm patient appointment and referral 3
 linkage with liaison office at discharge.
Validate post-discharge outpatient follow-up 2
with same senior physician through sample
chart review. (check 5 patient charts)
Score 13
4 All inpatient records contain completed medical 7 Randomly audit 10 sample charts for 4
record formats complete and revised admission, progress,
discharge and death summaries.
Audit 10 sample charts for compliant 3
supplemental oxygen therapy orders
covering flow rate, delivery mode,
monitoring frequency, reporting time, device
change, weaning plan.
Score 7
5 The Hospital conducts minimum daily 10 Verify existence of daily multidisciplinary 3
multidisciplinary team rounds and specialty team rounding schedule.
rounds as necessary
Observe rounding on site visit day for 3
compliance and review rounding team
composition meets requirements.
Confirm availability and regularity of signed 2
rounding books.
Ensure joint rounds by senior physicians 2
from different specialties for complicated
cases.
 Score 10
6 The inpatient department is staffed with 4 Verify medical devices and supplies are 2
adequate personnel appropriately trained and stored and handled appropriately.
equipped for inpatient care per regulatory
Confirm professionals are acting within 2
standards
defined scope of practice.

4
7 The department has guidelines for verbal and Verify the availability of communication 2
written communication on patient care including 6 guideline.
handovers within and between disciplines
Check if shift hand over protocol is in place 2

Interview 10 staff members and assess their 2

knowledge and adherence to the handover
protocol and communication guideline.
6
8 Established procedures exist for inter- 6 Validate existence of interdepartmental 2
professional and inter-departmental consultation protocols.
consultations and patient transfers to ensure
continuity of care Audit timeliness and completeness of 2
consultation documentation.

Confirm consultations adhere to established 2

turnaround times.
 Score 6
9 A policy requires accompanying all patients by Observe patient transportation practices. 2
appropriately trained staff during diagnostic 6
services outside the department and for inter- Review transportation protocol content. 2
ward/department transfers
Interview 10 sample of admitted patients on 2
experience.
Score 6
10 Nutrition guidelines and services are in place for 8 Verify existence of hospital nutrition 2
inpatients guidelines.
Confirm availability of patient dietary 2
menus.
Check provision of standard daily meals for 2
admitted patients. (3 times a day)
Review availability of patient-tailored 2
nutritional interventions. (DM, HTN, CLD,
etc.)
Score 8
11 Informed consent is provided to all patients Confirm existence of informed consent 2
admitted 6 protocol and standardized form.
Verify informed consent provision for 2
admitted patients before provision of care.
 Audit consent form signing and 2
documentation prior to invasive procedures
through sample of charts. (audit 10 charts)
Score 6
12 Continuous oxygen supply and appropriate Assess oxygen supply availability and stock 2
utilization are ensured and monitored 12 back-up mechanisms.
Ensure a designated focal person coordinates 2
oxygen management with relevant
stakeholders.
Audit sample of all admission charts for 2
pulse oximetry records.(from Emergency,
IPD and ICU, 10 cards each)
Verify functionality and availability of 2
oxygen delivery devices and interfaces.
(Concentrators, pulse oximeters,
consumables or interfaces like nasal prong,
face mask with/out reservoir, nasal catheter,
etc.)
Review budget allocation for oxygen 2
supplies and consumables.
Confirm centralized piped oxygen system 2
with digital monitoring and cylinder
protocols.
Score 12
 13 Regular audits are conducted and quality Ensure an assigned focal person to conduct 2
improvement projects implemented 8 regular service audit
Confirm clinical audit is conducted regularly 3
Observe QI projects are ongoing 3

Score 8
Total Score 100

CHAPTER -7 NURSING CARE SERVICE MANAGEMENT

S/N Operational Standard score verification criteria Scoring
Weight Score
1 The hospital has established 6 Check the nursing management system: 1
nursing care service - Nursing director and V/director with formal written
management structure and job letter
description including - Costed annual plan
reporting relationships. - Supervising mechanisms describe the scope of practice in
each service area
Check for nursing representation in the SMT 1
 Established nursing reporting and communication systems 2

Randomly select 10 nurse staff HR file from different 2

departments and verify the availability of written JD which
describe the scope of practice in each service area

Score 6
2 The hospital has a nursing 8 The hospital has a nursing workforce plan that addresses nurse 3
workforce plan and sets staffing requirements according to the standard set for hospitals.
standardized nurse to patient
Obtain copy of nursing staffing plan and confirm this establishes 2
ratio in each service area.
nurse to patient ratios for each service area (e.g. inpatient wards,
ER, surgical suite).

Confirm the plan identifies mechanisms to reassign nursing staff 3

or call in extra staff to ensure that minimum nurse to patient
ratios are maintained at all times

Score 8
3 The hospital has written protocol 3 The hospital has written policies describing the responsibilities of 3
describing the responsibilities of nurses for the implementation of nursing process (assessment,
nurses to implementing nursing
diagnosis, planning, implementation and evaluation)
process.
All admitted and emergency
patients/clients have a nursing
process that describes holistic
nursing interventions.

Score 3
All admitted and emergency 20 Select a random sample of 10 inpatient records from different 10
patients/clients have a nursing wards and confirm that each contains a complete nursing process
process that describes holistic format.
nursing interventions.

Randomly select 5 emergency patient records and confirm 5

nursing process is done within 24 hrs

5
Check record completeness and quality against the standards

Score 20
4 All hospital nurses comply with 8 The hospital provide a written professional code of conduct and 1
ethics to all nurses
the professional code of conduct
The hospital provides orientation about code of conduct and 1
and ethics which governs their
nursing ethics
professional practice. Randomly select 20 nurses from each ward and check their 2
awareness regarding code of conduct and nursing ethics
The hospital provide complete uniforms for nurses 1
Check weather nurses comply with the national dress code all 2
the time in hospital

The hospital has a system to report illegal, incompetent or 1

impaired practice by immediate supervisors
Score 8

5 The hospital has established 4 Check the availability of written guideline for verbal and 2
guidelines for verbal and written nonverbal communication
communication about
Check nurses ‘adherence to communication guideline (interview 2
patient/client care.
5 nurses)

10 Score 4
6 The hospital has standardized Check written procedures for medication administration process 2
procedures and practice for safe Verify that procedure addresses safety, proper administration of 2
 and proper administration of nurses or designated clinical staff
medications by nurses or Review 10 Medication Administration Records from different 3
designated clinical staff. wards and confirm that each is completed correctly with the
Date and time , Full name of the medication, Dosage , Route,
Duration, Time and frequency and signature of the transcriber
and the individual who administered each medication

Check if the hospital implements central medication 3

management system to ensure medication safety
Score 10
7 The hospital has conducted 20 The hospital has nursing clinical audit committee 2
regular nursing care practice audit
and the findings are linked with The audit committee have TOR 2

QI projects. The clinical audit committee meets regularly and conducts a 2

nursing service audit

-collect data to monitor the quality of nursing/ practice 2

- The clinical audit findings are linked with QI projects 6

Nurses participate in critical review and/or evaluation of 2

policies, procedures, and guidelines to improve the quality of
 healthcare

Collaborate with the inter-professional team to implement 2

quality improvement plans and interventions

Analyze trends in healthcare quality 2

Score 20
8 The hospital has implemented 5 Check nurses are participated in the multidisciplinary team 2
nursing shift regular handover and round
rounds. Nursing staff conduct hourly rounds and make decision for 2
critically ill patients
Check documents regarding nursing care handover during shifts 1

Score 5
9 The hospital has a centralized 8 Verify the presence of necessary equipment and supplies to 4
nursing station set-up in each accomplish nursing care practice in each unit
ward with adequate space, Check if the unit has equipment for specific minor procedures 2
equipment and consumables.
The nurse assess equipment necessary to accomplish the nursing 2
practice related to safety, effectiveness and availability
Score 8
10 The hospital established skill lab 8 Check the availability of skill lab in the hospital 2
and regular need based capacity
building program for nursing
staff. Verify the presence of manuals for procedures in the skill lab 1

Check the hospital’s plan on capacity building for nurses. 1

Confirm if the capacity building is implemented (look minute, 3

interview 5 nurses)
The hospital has need assessment protocol 1
for capacity building

Score 8
Total Score 100
 CHAPTER-8 PEDIATRICS AND CHILD HEALTH SERVICES

S/N Operational standards Score Verification criteria’s Scoring

weight Scoring
1 The Hospital has established 6 Observe posted & documented organogram that addresses 1
management structure and developed Pediatric
job descriptions detailing roles and OPD and Pediatric IPD
responsibilities for all pediatric and Verify pediatric and child health services has formally 1
child health services staff. assigned
leader
Verify availability of signed job descriptions for 10 2
randomly
selected staff records
Interview 5 randomly selected staff regarding their 2
reporting lines
and communication
Score 6
2 The hospital pediatric and child health 4 Review alignment of pediatric and child health service areas 1
services have adequate space, as per with
national standards for its tier level. national standards for adequate space
Examine structural proximity through physical distance 3
between
pediatric and child health services and verify if service areas
are
located on ground floors.
Score 4
3 The hospital has separate pediatric 8 Confirm existence of separate pediatric outpatient service 4
area.
and child health inpatient and
Confirm existence of separate pediatric inpatient service 4
outpatient services. area.

Score 8
4 The hospital pediatric and child health 8 Identify essential medical equipment list for pediatric and 1
services are equipped with necessary child
equipment, essential drugs and health services per national standards
supplies as per its tier level.
Identify essential drugs and supplies list for pediatric and 1
child health
services
Validate availability of randomly selected vital medical 4
equipment
and drugs at service points
Score 8
5 The hospital has implement child Verify implementation of child friendly settings at OPD 3
friendly health services at pediatric 6 (e.g.
and child health services points/areas playgrounds, paintings, posters, TVs)

Verify implementation of child friendly settings at IPD (e.g. 3

playgrounds, paintings, posters, TVs)

Score 6
6 The hospital has provided outreach 7 Verify assigned coordinator for outreach services 2
 pediatric and child health services. Review outreach service plans and schedules 2

Examine sample outreach activity records and reports 3

Score 7
7 The hospital has established separate 11 Examine availability of separate pediatric emergency 4
pediatric emergency, triage, services per national
assessment and treatment (ETAT) standards
services.
Validate pediatric emergency triage and treatment services 3
are delivered by
trained staff

Review presence and utilization of pediatric emergency 4

protocols
Score 11
8 The hospital has separate pediatric 7 Examine existence of separate pediatric intensive care unit 3
intensive care services with written aligned to national
protocols and procedures as per the standards
tier level.
Confirm pediatric ICU services are delivered by trained 2
staff

Validate availability of basic medical equipment in pediatric 2

ICU per national
standards
Score 7
9 The hospital provides immunization, 15 Inspect existence of separate room for EPI, growth 3
growth monitoring, developmental monitoring, developmental
assessment and promotion services. services
Review staff training records to verify appropriately 2
trained personnel for
services
Examine schedule and service records to validate 2
provision on all working days
Validate availability of functional refrigerator, 2
thermometer, cold box, vaccine
carrier, and ice packs for EPI
Review temperature monitoring logs to ensure twice daily 2
recordings
Examine records regarding vaccine and supply stock 2
management
Review developmental assessment and promotion records 2
as per protocol
Score 15
10 The hospital has established Neonatal 12 Inspect availability of separate neonatal care units, KMC 5
Care services with trained staff. and mother resting areas
Validate neonatal care unit meets basic equipment, drug 3
and supply standards
Review sample of staff training records for neonatal care 4
capabilities
Score 12
11 The hospital has provided nutritional 10 Confirm existence of separate nutritional rehabilitation 3
screening, assessment & treatment unit/area
 services. Review availability of nutritional care protocols and 2
supplies.
Validate nutritional unit staff are trained on protocols 2
Review 5 sample charts to verify nutritional care provision 3
adheres to protocols
Score 10
12 The hospital regularly conducts 6 Review records of quarterly clinical audits with 3
clinical audit at pediatric and child interventions.
health services and links findings to
Check for linkage of audits to quality improvement projects 3
QI projects.

Track timely graduation status of previous quality 2

improvement projects.

Score 6
Total Score 100
 CHAPTER-9 MATERNAL, NEWBORN, REPRODUCTIVE HEALTH AND MIDWIFERY MANAGEMENT SERVICES

No Operational Standard Score Verification Criteria Weigh Score Remark

t
1 The hospital has established preconception 6 Observe and ensure preconception 3
service as per the national protocol for improving service availability
obstetric outcome. Ensure the services provided using 3
pre-
conception protocols

Score 6

2. The hospital ANC unit provides individualized, Observe designated ANC unit with 3
client centered and evidence-based care to clients 11 necessary equipment, supplies and
trained
on all working days and high-risk mothers should
HR.
be seen in the referral clinic. Interview 5 clients to ensure the 4
service
 provision is client
centered(confidentiality,
privacy, preference etc)
Observe high risk mother treated by 4
senior
physicians.
Score 11
3. The hospital shall establish a separate obstetric 6 Ensure separate Obstetric triage unit
triage unit and provide care services obstetric 2
management protocols.
Ensure availability of Obstetric 2
triage
management Protocol
Avail Skilled man power, necessary 2
supplies
Score 6

4. The hospital should ensure the provision of intra- 6 Ensure and observe intra-partal unit 3
partal care as per national obstetric management with
protocols. privacy precaution of laboring mother
Observe Obstetric management 3
Protocols
Score 6
5 The hospital should ensure provision of 9 Ensure availability of skilled man 3
Comprehensive Emergency Maternal and power
Observe the availability of 3
Newborn Care (CEmONC) services
Comprehensive
 Emergency Maternal and Newborn
Care
(CEmONC protocol
Ensure the availability of necessary 3
supplies and equipment’s
6 Score 9
The hospital has established postnatal care unit 8 Ensure the availability of Post natal 2
and provide comprehensive post-natal care for Care unit
improving obstetric outcome as per national Check the availability of the national 4
obstetric management protocol. obstetric protocol and its adherence
Ensure the availability of supplies, 2
trained
man power to provide the service.
Score 8
7 The hospital should ensure women friendly 10 Ensure the availability of women 5
services at all Maternal and neonatal units friendly
including pain management. services like (coffee ceremony,
making
porage, laboring mother accompanied
by
one family member if the need arise)
Is there a mechanism of pain
assessment 5
• and management for laboring
mother.
 Score 10

8 Hospitals have comprehensive Neonatal Care Ensure the availability of KMC and 3
service that includes KMC, mother’s waiting 6 Mothers’ waiting room.
Observe availability of Mothers’ 3
room and isolation rooms.
isolation
room
Score 6
. 9

The hospital should ensure provision of family Observe and Ensure the availability 3
9 planning (with focus on long term methods) and of all
comprehensive abortion care services following types of family planning
the national guideline and policies. commodities

Ensure the availability of national 3

guidelines and policy for comp.
Abortion Care
Ensure the availability of Skilled man 3
power
for provision of service and
Counseling
10 The hospital maternity and neonatal unit 10 Score 9
 undertakes CQI activities by conducting audit 2
Verify the availability of QI team
programs and regularly implement maternal
A mechanism of conducting clinical 2
and perinatal death surveillance and response Audit regularly,
activities. Check the availability of QI projects 2
based on clinical audit
Check QI projects are graduated with 4
the time frame
Score 10
11 Midwives should implement the midwifery 4 Select randomly 5 MR and check the 4
process at all hospitals for all admitted patients. availability of completeness of
Midwifery process
Score 4
12 The hospital has established system for providing 11 Ensure the availability of cooperative 4
maternal and new born related services and support package with catchment
facilities
cooperation and support package with catchment
Check the MOU agreement with the 4
facilities facilities
Ensure the provision of service 3
between the facilities based on MOU
Score 11
13 The hospital shall provide adolescent and youth 4 Ensure the availability of adolescent 4
friendly services. and youth friendly service
(Psychosocial
support, HIV/STI testing, pregnancy
 test, FP ,Abortion care etc)

Score 4
Total Score 100

CHAPTER-10 SURGICAL AND ANESTHESIA SERVICE MANAGEMENT

Scoring
S/N Operational Standard Score Verification Criteria Weight Score
1 The hospital has established 16 Check the presence of Hospital specific Surgical and Anesthesia 2
functional Surgical and service management organogram
Anesthesia Service Check for assignment letter for OR coordinator/ director 2
management Structure

Check the presence of functional multidisciplinary SaLTS team 2

(look for assignment letter, TOR , meetings minute in the last 3
months)
 Verify for the presence of standard work flow pattern among 2
different department practicing OR services (look OR schedule,
register, staff interview…)

Check for the presence of necessary guidelines, SOPs and 2

policies
Check if all members of surgical work force are trained for 2
surgical care competency
Has a regular weekly meeting among case team members (check 2
the minute)
Look for OR service annual, quarterly and monthly plan 2

Score 16
2 The hospital has established 16 Check the presence of minimum number of functional OR table 2
standard surgical service as per hospital tire level (designated ORs for specialty services)
working environment. Look the presence of demarcated 4 OR zones (restricted, semi 2
restricted, transitional, non-restricted)

Check the presence and functionality of Minor OR and 2

Emergency OR (dedicated emergency OR table for Primary
Hospitals)
 Separate rooms are present for the following services: Recovery 2
room, clean and dirty utility rooms , Changing Rooms with
lockers (separate for male and female), Toilets and showers,
scrub area, mini-store, nurse station (near the recovery area),

Check the presence of adequate OR equipment for elective and 2

emergency surgical supplies and medications as per the hospital
tire level (refer the regulatory guideline)

Check the presence of OR pharmacy or at least a pharmacy near 2

the OR
Confirm continuous 24/7 water supply with 2
back up source is available.

Confirm continuous 24/7 electric supply 2

with automatic backup generator is
available
Score 16
3 The OR service is 14 Observe OR equipment, floor, walls and over all physical 2
safe and patient friendly structure of the OR room
for cleanness
Floors of the operation theatre are non-slippery surface and 2
even. (check if there is any crack or opening on the floor, walls
or ceilings)
Observe availability functional OR friendly sinks, disinfectants, 2
soup, anti-septic solutions, waste bins and other IPC
equipment’s and supplies
Check for separate space for scrubbing and hand washing 2
facility.
Observe the presence of adequate amount of cubicle curtains 2
(privacy screens) and/or designated space for clients for
securing IV lines and catheterization
Check for SSC Audit protocol and regular monthly audit reports 2
with feedbacks (check 5 randomly selected charts)
Surgical patients are given the opportunity to discuss their 1
concerns and preferences a day before their surgeries (interview
clients)
Written informed consent is taken before any surgical procedure 1
and induction of anesthesia (review 5 randomly selected charts)
Score 14
4 The Hospitals has established 12 Check the presence of referral clinics, aligning with all surgical 2
pre-operative patient services, with necessary furniture and medical equipment
preparation system
Check for utilization and adherence of Pre-admission evaluation 2
protocol including work up standards
Confirm if there is an established pre-operation surgical and 2
anesthesia evaluation system (review at least 5 inpatient pre-
operative charts)
Verify the presence and functionality of Pre-operative multi- 2
disciplinary conference before OR schedule.

Check pre-op prophylactic antibiotics are given as per standard 2

(review 5 charts)

Check if cross-match was done for all elected and emergency 2

surgical patients before operation. (review 5 randomly selected
charts)
Score 12
5 The hospital implements 13 Check the presence of OR dashboard that address at least 2
strategies to enhance efficiency, safety and access
efficiency and productivity of Check the presence of computer based surgical backlog 2
 surgical team management system (check interventions taken)
Check the mechanism to monitor major surgeries per table per 2
day in the facility

Check if audits are done for rate of cancellation and delays for 3
elective surgery,

Check the presence of day care surgery practice 2

Verify if daily preventive maintenance is done for OR 2
equipment early in the morning. (check for checklists and
reports)
13
6 The hospital has established 6 Check the availability of and utilization of SSI protocol. 2
a system to track and reduce
Check for availability of separate SSI Registers at Inpatient 2
surgical site infections.
wards, OPDs etc

Check the presence of a mechanism established for SSI tracking 2

after discharge based on WHO SSI surveillance check list
(Document Review, Staff Interview , Chart Review)

6
7 The Hospital provides 9 Check if there is a written policy about administration of 2
standard Anesthesia Service regional and general anesthesia in the hospital

Check if the anesthesia team document the anesthesia 2

management form (check 5 randomly selected charts)

Verify the presence of post-anesthesia care service (check for 3

documentation in 5 randomly selected charts)
Verify anesthesia adverse outcome audit system is in place. 2
(check for audit findings, if action was taken accordingly)
9
8 The hospital has a mechanism 6 Check oxygen was continuously available in the OR for the last three 2
to ensure availability and months. (staff interview, see the stock)

rational use of medical oxygen Check the functionality and availability of different medical 2
in the OR. devices and consumables (Concentrators, pulse-oximeters,
consumables or interfaces like nasal prong, face mask with/out
reservoir, nasal catheter, etc.)
Verify proper and complete order for medical oxygen is in place and 2
its implementation (Check 10 patients’ charts for medical oxygen
delivery for hypoxemia in the OR. Look at the order sheets and
 anaesthesia management sheets; Flow rate, Delivery system/mode,
Monitoring)

6
9 The Hospital regularly 8 Check the presence of regular quarterly clinical audits in surgical 2
conducts surgical service and anesthesia services (see last quarter audit reports)
performance audits and takes
appropriate actions on Check the presence of Peri-operative Mortality audit system (look the 2
audit guideline and audit reports)
identified gaps
Check for performance review minutes and its regularity 2

Check if appropriate actions taken for clinical audit gaps or data 2

driven QI projects are conducted
Score 8
Total Score 100%
CHAPTER-11 SPECIALTY AND SUB SPECIALTY SERVICE MANAGEMENT
S/N Operational Standard Score Verification Criteria Scoring

Weight Score

1 The hospital has functional specialty 8 The hospital’s medical director or vice medical director is 2
and sub-specialty service program assigned with written letter to coordinate specialty sub-
lead by hospital medical director or specialty service program in the hospital.
vice medical director. The hospital established Multi- disciplinary Specialty and 2
sub specialty service committee ( look assignment letter
of committee members)
The committee has Term of Reference and perform 2
regular monthly meeting ( look for ToR and meeting
minutes)
Look for Specialty and sub specialty service annual plan ( 2
that shows the service expansion plan ,HR development
plan, renovation and premises expansion or new building
 plan, procurement plan and Financing aligned with
national specialty sub specialty service roadmap.)
Score 8

2 The hospital has protocols, 8 The hospital has clinical protocols and guidelines for each 2
guidelines, scope of practice for specialty and sub specialty service.(check guidelines for
different specialty and sub specialty
services. randomly selected specialties)
The hospital has defined scope of practice for different 2
levels of physicians (intern, GP, residents, specialists and
sub specialists)
The hospital has interdepartmental consultation guidelines 2
(the client should be seen by the highest available
physician)
Look for Senior Chart audit tool, scope based teaching 2
manuals, one stop shop protocols and other additional
self-developed SOPs.
Score 8

3 The hospital has OPD/IPD/ED 8 Look regulatory, specialty and sub specialty road map 2
specialty and sub- specialty service as based service list of the hospital /Visit and verify available
per hospital tier level of care.
specialty and sub-specialty services.
Look for appropriate infrastructure, layout, equipment and 2
 HR as per the national standard.

The hospital provides nurses, paramedics and specially 2

trained supportive staffs aligned with the specialty -sub
specialty service.
The hospital facilitates demand based contractual/ part 2
time specialty and sub specialty service.

Score 8

4 The hospital as inter facility specialty Check for inter facility level specialty and sub specialty 2
8
and sub specialty service partnerships service related communication, consultation, patient
and collaboration plat form. transfer, HR and resource sharing protocol/plan.
Look for agreed public private partnership plan and 2
practical activity report which includes specialty and sub
specialty service.
Look for specialty and sub specialty service related 2
bilateral agreement and twinning activity report
The hospital provides or receives tele-health service. 2
(Observe tele-health service MOU, service documents and
equipment.)
Score 8
5 The hospital ensures suitability of 10 The hospital drug procurement list is updated to include 2
specialty and sub specialty services.
all drugs and consumables needed for specialty and
subspecialty services as per the hospital tier level (see
annual procurement plan & observe the presence )
The medical director ensures that equipment and essential 2

laboratory tests needed for specialty and sub specialty

service are integrated in to the facilities annual
procurement plan as per the hospital tier level(see annual
procurement plan and observe the presence)
Verify as if all specialty and sub-specialty services are 3
integrated in to the regular clinical audit and continuous
quality improvement program of the hospital. (see clinical
audit report and any QI projects )
Clinical leadership program implementation and senior 3
engagement in SMT

Score 10

6 The hospital applies technological 7 Check for any published researches specialty or sub- 3
innovations, researches and other specialty service in hospital
 systems to improve specialty and sub Check for any new innovations devices, software’s, local 2
specialty service activities. production of consumables or any innovative system that
accelerate specialty or sub-specialty service provision
Check for any new procedures/ technique/ updated 2
clinical evidence based practice

Score 7

7 The hospital has a system to monitor 7 Check for established M&E frame work for efficient 3
work load and productivity level of utilization of specialists and sub specialists. (clinical
specialty and sub specialty service. ,teaching , research & community )
Check if there is regular work load analysis for each 2
specialty and sub specialty service. (look reports)
Check if specialists and subspecialist productivity level is 2
regularly assessed.
Score 7

8 The hospital provides a radiology 14 Check if the hospital receives yearly ERPA certification 2
service 3
Check if the radiology unit has adequate number and mix
of professionals (radiographer technicians, radiographer
technologists, radiologists etc are maintained as per ESA
and / or ERPA standards.
 Check if the hospital insures that appropriate and 3
functioning diagnostic equipment is available as per the
standard
Check if the hospital insures that the radiology unit has 2
the appropriate infrastructure and adequate utilities.
Check if the radiology unit, has a clear plan and design 2
mechanism through which all medical equipment availed
for radiology services is periodically maintained,
calibrated, their functionality checked and quality control
testing done by qualified and licensed personnel.
The hospital has and implements written policies, 2
protocols and guidelines for the delivery of all
radiological and imaging services,
Score 14

9 The hospital provides a Pathology 13 Check if there is adequate number and mix of 3
service professionals (Histo-technicians, trained GPs,
Pathologists, Lab technicians etc are maintained as per
ESA standards )
Check if the unit ensure that appropriate quantities of 2
supplies and reagents are always available
 Check if the pathology laboratory has appropriate and 2
functioning equipment. as per ESA standards
Check if the pathology laboratory has the appropriate 2
infrastructure and utilities as per ESA standards
Check if the hospital has and implements written policies, 2
protocols and guidelines for the delivery of all Pathology
services,
Check if the hospital has internal quality audit with action 2
plan
Score 13

10 The hospital provides ICU service. 17 Check if the Hospital has ICU unit with necessary 3
infrastructure and equipment as per National Intensive
care unit implementation guideline or ESA standards
Check if the Hospital has ICU unit staffed with all 2
necessary, trained and qualified personnel as per as per
ESA standards (check if HR is trained as per requirement )
Check if the hospital has one ICU head to lead all ICU services 2
and the hospital should assign focal person for each ICU.
(Adult ICU , Pediatrics ICU and NICU) as per the hospital tier
level.
Check if all ICU equipment users are appropriately trained 1
on the operation and preventive maintenance of such
equipment
Check if the hospital has ICU rooms that accommodate 5- 2
10% of total beds of a hospital.

Check if the hospital has all the necessary guidelines and 1

protocols for ICU department. (Communication, patient
safety, formal consent, admission and discharge
procedure…..)
Check if the hospital implements a minimum of 2 times 2
per day multidisciplinary team patient round. (ICU nurse,
clinical pharmacists, anesthesiologist or intensivist or
pulmonary & critical care Sub-specialist or emergency
medicine and critical care specialist or appropriately ICU
trained GP, respiratory therapist ,nutritionist,
physiotherapist, ...)
Check if the ICU MDT has regular dash board based 2
follow up of ICU performance
 Check for regular ICU specific clinical audit with action 2
plan/ QI on identified gaps

Score 17

Total Score 100

CHAPTER 12 REHABLITATION SERVICE MANAGMENT

S/N Operational Standard Score Verification Criteria Scoring

weight Score

1. The hospital has a rehabilitation 11

There is rehabilitation unit (observe)
unit/department, led by a 4
physiotherapist or equivalent
Obtain letter of assignment with job description 1
rehabilitation professional, who is a
member of the senior management team Obtain a copy of the organogram and check the 2
and accountable to the medical director. department
head is accountable to medical director
 Obtain copy of ToR is prepared and signed by all 1
members
of SMT
There is an annual plan cascaded to each unit using the 3
balanced score card(BSC) framework
Score 11

2. The hospital's rehabilitation 10 A physiotherapist is available in the hospital 4

unit/department has a multidisciplinary
A psychosocial worker (psychologist, social worker, 4
rehabilitation team with established job
psychiatrist, psychiatry nurse) is available in the hospital
descriptions.
There is job description for each rehabilitation personnel 2
(check the job description)
Score 10

3. The hospital's rehabilitation 20 There is physical therapy/physiotherapy service 8

unit/department provides physical
therapy/physiotherapy, psychosocial and
mental rehabilitation, occupational There are mental rehabilitation/psychosocial services 8
 therapy and facilitates community-based There are disability prevention services as clubfoot 4
rehabilitation and prevention of disability
services, such as clubfoot management.

20
Score

4 The width of the door is 90 cm, and the door handle is not 3
15
above 90 cm tall.
Doors are easy to open, long and easy to hold for opening 1
The premises of the rehabilitation and accessible to a wheel chair users.
unit/department should be accessible for Windows are well lit. 1

persons with disabilities. Pathways have a free space that can rotate wheelchair 2
freely.
The free space size is 1.50 cm or above diameter
The floor of the stair is not sleeper; it built by rough 3
substances/materials.
There is ramp for wheelchair users (not applicable if not 2
necessary)
The toilet room has 1.50 cm x 1.50 cm square/diameter. 2

The toilet has seat type 1

 16 Score 15

5 The rehabilitation unit/department should check presence of rehabilitation equipment and supplies per 16
be equipped with appropriate equipment the regulatory standard (see
and supplies as per regulatory standards. the annex 1 for each item)
Score 16

6 The head of the rehabilitation 3 Obtain the copy of TOR that can show the lead is the 3
unit/department is a member of the member of hospital medical equipment management
hospital's medical equipment management committee
committee and has to contribute to the
inventory management system.

Score 3

7 The rehabilitation unit/department 5 Obtain the copy of agreement (MOU)/with partners, other 2
provides and facilitates rehabilitation hospitals or rehabilitation centers
services in collaboration with public- Observe if there is copy of filled client referral sheet to the 3
private partnerships, in accordance with party in agreement
the agreement/MOU.

Score 5
8 The rehabilitation unit/department has a 10 Obtain evidence of a quality assurance system, including 2
quality assurance system and conducts policies,
regular clinical audits linked with quality procedures, and guidelines for conducting clinical audits
improvement activities. and quality
improvement activities.
Staff members received training on the quality assurance 1

There are appropriate audit tools in place to collect data on 3

the
quality of care provided, and these tools should be regularly
reviewed and updated as necessary.
The unit/department conduct ongoing quality improvement 2
activities
in place that are linked to the results of the clinical audits,
and
progress on these activities
The clinical audit findings are linked to QI projects 2

Score 10

9 The rehabilitation unit/department has a 5 The rehabilitation personals have taken continuous 2
 plan for continued professional professional development (see any document on taken
development and performance appraisal CPD)
and/or evaluation procedures.

Obtain copy of certificate or attendance 1

Observe evidence of a plan for continued professional 2

development
and performance appraisal and/or evaluation procedures.

Score 5

10 The hospital's rehabilitation 5 There are education materials for clients or guardians 2
unit/department has developed and (teaching tools as picture, video, leaf late, brochures etc.)
implemented client education materials (observe)
and outcome measures. Outcome measures are applied (ADL, IADL, barthel 2
index,6-minute walk test, berg balance scale, pain
score…observe implementation)
Check the outcome measures are attached to the client 1
folder (see 5 random patient folders)
 Score 5

Total score 100

CHAPTER-13 PAIN & PALLIATIVE CARE MANAGEMENT SERVICE

S/N Operational Standard Score Verification Criteria Scoring

Weight Score

1. The hospital has functional Designated area/office for Pain and palliative care 1
pain and palliative care service 13
organization. There is assigned full time pain and palliative care 2
service coordinator (look assignment letter)
Full time Pain and palliative care unit staffs are assigned 2
as per the hospital tier level
Service area pain focals are assigned in OPD, IPD, 2
ER…(look assignment letter)
Look palliative care service as part in the hospital 2
organogram as responsible for Medical director.
Look for Pain and palliative care plan with specific 2
budget list
All clinical staffs are trained on pain management (look 2
for training record or certificate)
 Score 13
2. The hospital has 10 There is a multidisciplinary pain and palliative care 2
multidisciplinary team for pain service committee (look assignment letter of committee
and palliative care service members)
Look TOR for the multi- disciplinary committee 1
Regular monthly meeting (look meeting minutes) 2
Submit pain and palliative care service agenda for SMT
decision and follow up schedule
1
Training and capacity building for multi-disciplinary 2
team (look for training record or certificate)
Support other hospital or health centers in the hub 2
specific in pain and palliative care

Score 10
3. The hospital has written 6 Check Pain and palliative care guidelines in all service 1
standard Documents/tools for delivery areas ( OPDs, IPDs, ER…)
pain and palliative care services
Look the hospital Palliative care SOP & protocols 1
approved by the hospital management
Look for availability of standard pain and palliative care 1
patient reporting tool ( See annex 1)
Adult and pediatric Pain Management protocol is 1
available in the hospital in wards and clinical areas
Palliative patient assessment tools available for use 1

Patient satisfaction format available (See annex 3 ) 1

 Score 6
4. The hospital has all the 10 Pain medications are included in the vital list of hospital 2
necessary medication
equipment and supplies for
pain and palliative care. Check availability of all the vital Pain and Palliative 2
care Medications in store and dispensaries (see annex 4)

The hospital DTC has representative from pain and

palliative care department (check DTC letter of
assignment) 1
The hospital shall have a clear strategy for opioid
consumption and reporting (see annex 5) for pain
medication reporting form 1

The hospital pharmacy department promote Good

Dispensing practice for pain medication
2

The hospital avail all the necessary palliative care 2

equipment and supplies as per the tier system ( See
annex 6 )
Score 10
5 Hospital has implemented pain 10 Have a written policy on pain is 5 th vital sign and must be 2
as a 5th vital sign assessed and managed.

Pain score integrated with patient chart as fifth vital sign 2

 Patients pain assessed and scored as per standard scale 3
(See annex 7)
Holistic pain assessment and management approach is 3
implemented
Score 10
6 Pain is managed according to Patients pain managed according to WHO analgesic 3
WHO analgesic ladder 6 Ladder (look 5 IPD Medical records in different wards)
All departments provide appropriate pain symptom
control (Look for 5 IPD Medical records V/S progress
3
in different wards)

Score 6
7 The hospital has regular health 8 Pain and palliative care service is integrated in health 2
education program on pain and education program of the Hospital.
palliative care.
There is a system to check the patients awareness on 2
proper utilization of pain medication.

The hospital Post information, lectures and pamphlet

about how to report pain in a visible area and use of
medication for patients and care givers. 2
 Availability of short audio video for health education in 2
pain and palliative care

Score 8
8 The hospital has conducted There is quarterly Pain and Palliative care assessment 2
regular pain assessment and 6 and management audit. (see annex 8)
management audit
Pain and palliative care KPIs are regularly done 2
Clinical audits results analyzed and action plan/ QI 2
projects developed
Score 6
9 The Hospital Provides pain There is a practice of pain management in outpatient, 2
management service in 13 inpatients and emergency service areas
outpatient, inpatient, Look for self-developed adherence follow up 2
emergency, MCH and other system/checklist
necessary area. There is regular support for pain and palliative care 3
focals of each service area
Observe palliative care patients referral in and referral
out - registry in palliative care service area is available
3
Registry for admitted patients, outpatients and other area 3
patients linked for homecare are available

Score 13
10 Pain and Palliative care unit/ 18 Look for Home-based palliative care Guidelines, 3
department Protocol, Registration book ,education materials etc.
facilitates the delivery of home HBC Service plan (nursing care, Companionship etc.) 3
based care palliative care and staff visiting schedule

Look for the presence of MDT for HBC or trained team 3

in facilities of the cluster/hub
Look for reporting format, Activity Report or referral 4
service linkage reports
Check the presence of necessary HBC set Medical 5
equipment’s (vital sign monitoring set, suction catheters
,pulse oximetry etc)

18
Score
Total Score 100
CHAPTER 14. PHARMACY SERVICES AND PHARMACEUTICAL SUPPLY MANAGEMENT
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

1. The hospital pharmacy service 10 Presence of separate outpatient, inpatient, and 3

and supply management are emergency units, with dedicated premises and
organized in a way that personnel
facilitates pharmaceutical care
and enables coordination with Presence of separate drug information service unit 0.5
program/clinical services with dedicated premises and personnel

Presence of clinical pharmacy service with dedicated 0.5

personnel

Presence of separate supply management unit with 0.5

dedicated premises and personnel

Presence of separate stores for 3

a. Medicines,

b. Medical equipment

c. Medical supplies, laboratory reagents and

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

chemicals with standard premises and

personnel

The incorporation of pharmacy service and supply 0.5

management activities within the hospital annual
plan

The hospital fulfilled the pharmacy workforce need 1

as per the pharmaceutical service positions and
workload analysis

Availability of workforce competency assessment 0.5

result , development plan and its implementation

Availability of staff induction and skill transfer 0.5

mechanism (reports, procedures, interview of new
staff, etc.)

Score 10

2. The hospital has a functional 4 Assigned DTC members by official letter, has 0.5
Drug and Therapeutics approved TOR and annual action plan
Committee (DTC)
Meets regularly at least every two months with 0.5
documented minutes
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

Has updated health facility specific pharmaceutical 0.5

list prioritized by VEN

Has medicine use policy and procedures (at least one 0.5
new policy developed during the reporting period)

The hospital DTC generates ADE/AEFI reports and 0.5

taking action on the finding

Conduct supply and medicine use studies (at least 0.5

one semiannually) and ABC/VEN analysis annually

Take actions based on the supply and medicine use 0.5

study findings with report, minutes, letter of action
any related document

Report its performance activities to the management 0.5

Score 4

3. The hospital has effective 23 Presence of annual pharmaceutical quantification 1

system for pharmaceutical (Forecasting and supply plan) approved by the
selection, quantification, hospital DTC
procurement, warehouse and
inventory management, The hospital procures all pharmaceuticals from the 1
distribution and information facility specific medicine list (see report)
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

management including The hospital performs supplier fill rate analysis 2

emergency supply chain regularly
management
All pharmaceuticals are stored as per good storage 2
practices (see Annex..)

The hospital has approved warehouse and inventory 1

management SOP

The hospital conducts physical inventory and SSA 2

every quarter in the medical store (check for official
report)

Availability, completeness and the update of all 3

PMIS formats (Bin cards, SRC, RRF, IFRR, M-19 H,
M-22 H)

Regular reporting of IFRR (hint: take recent IFRR 2

reports of one pharmacy DU and two SDU for
checking adherence to schedule) and RRF reporting
(2 recent reports, timeliness, completeness, accuracy)

Presence of functional electronic health products and 2

service management system (hint: take 3 products
randomly to check inventory accuracy)
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

All dispensing units register dispensed products 2

regularly

Presence of updated patient information sheet (PIS), 2

patient tracking chart (PTC) (hint: take recent 5 PIS
and PTC randomly) and ART pharmacy monthly
report (See recent 3month reports)

Availability of SOP for emergency pharmaceutical 0.25

supply management

Availability of updated list of medicines and supplies 0.5

for emergency response

Presence of emergency supply management response 1

plan (quantified list of medicines and supplies with
budget)

Assigned responsible workforce for emergency 0.5

supply management(see the evidence)

Availability of trained staff on emergency supply 0.25

management system

Score 23
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

4. The hospital has standardized 5 The vaccines/products are stored in appropriate ice 1
pharmaceutical cold chain and lined refrigerator (ILR) or deep freezer in the
vaccine management system. medicine store

All ILR are fitted with the correct vaccine storage 0.5
baskets and vaccines are arranged in appropriate
compartment

All refrigerators are attached to standardized 0.5

functional UPS

The temperature of the refrigerator is recorded at 0.5

least twice per day

The vaccine vial monitors are daily checked and 0.5

recorded

Presence of cold chain management policy/procedure 0.5

Regular cleaning and maintaining functionality of 0.5

refrigerator

Regularly requesting and resupply of vaccine (VRF) 0.5

The vaccine distribution to service delivery units is 0.5

done by using cold boxes/Vaccine Carrier
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

5. The hospital has effective 4 Medical oxygen and consumable oxygen devices are 0.5
medical oxygen supply included in the FSML and hospital pharmaceutical
management system quantification

Presence of focal person and policy for medical 0.5

oxygen supply management

Oxygen cylinders are checked during receiving to 1

ensure proper filling (see signed receiving
documents)

Medical oxygen is stored in secured and separate 0.25

area for empty and filled cylinders

Presence of updated Bin card for medical oxygen 0.5

stock management (for filled and empty cylinders)
(check at Oxygen storeroom) - Cylinders will be
coded

The facility practice reporting and requesting forms 0.75

for oxygen supply (check 3 recent reports from
maternal, inpatient, ICU and emergency)

Presence of monthly consumption report (check 3 0.25

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

recent reports)

Oxygen prescriptions contain flow rate and 0.25

monitoring frequency

Score 4

6. The hospital conducts 3 Presence of guideline/SOP for disposal of 0.25

continuous segregation, pharmaceuticals
documentation, and safe
disposal of pharmaceutical Expired/unfit for use pharmaceuticals are separately 0.5
wastes. segregated and registered

The facility disposed unfit-for-use medicines in the 1

past 1 year (check disposal certificate and list of
disposed products with description)

The hospital has pharmaceutical wastage 1

minimization mechanism ( see the evidence)

Wastage rate should be less than 2% 0.25

Score 3

7. The hospital has functional 10 Presence of dedicated pharmacy accountant with 0.75
auditable pharmaceutical office, computer, shelf, and file folders
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

transactions and services Presence of standardized premises to keep patient 0.25

(APTS) and executes good safety, privacy, and satisfaction (entry and exit doors,
dispensing practices at all counter design, and workflow arranged as
dispensing outlets. evaluator/biller → cashier → counselor at OPD
pharmacy and appropriate arrangement in other
dispensing outlets

Presence of properly recorded sales tickets and 0.25

credit/free registers at dispensaries

Bin ownership is implemented in dispensary 0.25

(assigned names, FEFO arrangement, documented
IFRR, damage and expiry report)

Implementation of pharmaceutical coding system in 0.5

all dispensaries and stores (check M-19 health, M-22
health, sales ticket, credit/free registers, inventory,
and price control sheet)

Presence of monthly reports for finance and services 0.5

and quarter report for products (hint: see at least last
3 reports)

Presence of financial, product, and service audit 0.5

report (internal) (hint: last 6 months)
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

Presence of dispensing aiding materials (tablet 1

counter, cutter, packaging material like envelope,
labeling material)

Presence of prescribing and dispensing reference 0.5

materials (at least soft or hard copy STG or
Formulary in dispensaries and OPD clinics, FSML in
dispensaries)

Evaluation of prescription using the standard 0.5

checklist (check for DTP assessment, prescription
completeness, legality, legibility)

Presence of proper labeling practice (hint: observe 5 2

patients randomly)

Achievement of 100% patient knowledge on correct 1

dosage (dose, frequency, route, & duration) (hint:
interview randomly selected 5 patients)

Achievement of 80% patient satisfaction level on 1

dispensing service (hint: use the hospital recent
report)

Presence of good documentation practice (hint: take 1

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

5 prescriptions randomly and check their record)

Provision of reconstitution of oral powdered dosage 1

form to patients

score 10

8. The hospital has effective 7 The hospital assigned pharmacists dedicated for the 0.75
clinical pharmacy services at service areas
inpatient, outpatient and
departments. The service is provided in wards continuously (24/7) 0.50

Assess medication history at admission 0.25

Participate in multidisciplinary round and pharmacy 0.50

only rounds

Participate in multidisciplinary morning session 0.25

Identify drug therapy need / problem 1

Perform medication therapy management for chronic 1

care patients

Perform medication reconciliation 0.75

Monitor oxygen therapy 1

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

Provide discharge planning and counseling 0.5

All clinical pharmacy service activities documented 0.5

and reported monthly

Score 7

9. The hospital provides drug 11 The hospital has allocated a required facilities (i.e. 0.75
information services room, equipment, furniture, telephone, internet,
reference materials) and dedicated pharmacist for
DIS

The hospital DIS has approved annual action plan for 0.25
the fiscal year

The DIS has standard operating procedure 0.25

The DIS provides therapeutic and pharmaceutical 0.75

information using standardized query and responses
formats

The DIS organizes medicine use education to patients 0.5

and general public, and training program to the
hospital staff at least monthly (health education
programs, community forums)
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

The DIS prepares and disseminate drug 0.75

alerts/newsletters, new arrivals, bulletins, therapy
updates, monographs, error prone abbreviations,
look-alike and sound alike medication at least
monthly

The DIS provides poison information 0.25

The DIS prepare and disseminate performance 0.5

reports monthly

Score 11

10. The hospital has a functional 5 Presence of dedicated and trained pharmacy 0.25
compounding service. professional for compounding service

Presence of dedicated room with basic equipment 0.5

required for compounding services

Availability of pharmaceutical grade chemicals 0.5

required for compounding and personal protective
equipment (at least salicylic acid powder, white
petrolatum, liquid paraffin, absolute alcohol, hair
covers, gown, gloves, facemasks, aprons, eye google)

Availability of SOP and job aids (see documents) 0.25

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

Activities segregated in a way to prevent 1

contamination and ensure good compounding
practice (weighing, compounding, and cleaning
station )

Presence of proper labeling for compounded product 0.25

Presence of dermatological preparations and alcohol 1

based hand rub (ABHR) (Hint: at least
dermatological preparations and production of
ABHR and other disinfectants)

The presence of documentation system for 0.75

compounded product

Calibration of weighing balance annually (hint: 0.5

certificate)

Score 5

11. The hospital has Antimicrobial 4 The hospital assigned ASP members by official letter 0.25
Stewardship Program (ASP)
The hospital included ASP’s role and responsibilities 0.25
of the chair and secretary in their Job description

Presence of Terms of Reference and action plan for 0.5

S/N Operational Standard Weight Verification Criteria Scoring

weight Score

the ASP Committee

Presence of antimicrobial drug use policy 1

Hospital AMS categorizes antibiotics into Access, 1

watch and reserve (AWaRe)

Conducts prospective audit and feedback 1

Hospital ASP team conducts review of the facility 1

antimicrobial consumption/use and resistance at least
annually

Score 5

12. The hospital has narcotic, Availability of standard prescriptions for narcotic 0.25
psychotropic and other drugs and psychotropic substances
5
controlled substances
distribution and handling Availability of prescription movement records for 0.25
system. control of prescriptions pads (issuing for prescribing
departments and return of copies of used prescription
pad)

Availability of registration for dispensed narcotic 0.5

drugs and psychotropic substances
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

Presence of report for consumption and stock on 1.25

hand of narcotic drugs and psychotropic substances
every 6 months

Availability of lockable cabinets for storing narcotic 0.25

drugs and psychotropic substances and their
prescriptions

Presence of standard operating procedures to control 1

the prescription, handling, and administration of
narcotic drugs and psychotropic and other controlled
substances

Prescriptions are separately stored for five years 0.5

Score 5

13. The performance of pharmacy 9 Presence of assigned M&E focal person at pharmacy 2
service and supply unit (hint: check assigned letter)
management is regularly
monitored and evaluated Presence of quarterly reports as per the monitoring 1
and evaluation framework (4 reports in the past year)

Presence of regular and timely reporting and 2

completeness of 6 key performance indicators
reported via DHIS2 (Check: previous quarter
S/N Operational Standard Weight Verification Criteria Scoring

weight Score

aggregated data sources, documents reported and

reconciled with DHIS2 report)

Presence of official letters/any reporting platform 1

indicating M&E reports are sent quarterly to the next
higher level (last quarter)

Presence of quarterly internal pharmacy service and 1

supply management performance review (check:
minutes/proceedings)

The hospital management utilizes M&E findings for 2

decision making (hint: check minutes for feedback
given or action plans developed)

Score 5

Total score 100

CHAPTER 15 LABORATORY SERVICES MANAGEMENT
Scoring

S/N OPERATIONAL STANDARDS Score VERIFICATION CRITERIA Weight Score

1 The hospital has established laboratory 6 View organization chart, 1

management structure and

Check the laboratory has personnel record for each2
accountability arrangement. its staff (Educational qualification, Experience,
license, JD, training certificates, COC…)

Check assignment of full time quality and safety 1

officers

1
Check central laboratory controls the emergency and
inpatient laboratory services (minutes, reports.)

View central, emergency and inpatient laboratories1

functionality

Score 6
2 The hospital laboratory management 14 Inspect certification of accreditations and how much6
scopes are accredited. If 6 and more scopes
has develop and implement quality
accredited give full point. Below 6 will have
management system to ensure
equivalent score.
continually quality improvement
View the laboratory-produced updated quality 1

manual, and sample management guidelines.

Availability of SOPs for all technical and 1

administrative procedures in all service areas at work

place

Confirm the availability of updated, Formats , Job 1

aids and instructions in work place

Check each lab, Staff are aware of and follows the 1

SOP for the laboratory tests they are performing.

Check the laboratory has identified the quality gaps 2

and prepared annual quality improvement plans.

Confirm at least 50% of lab staff have competence2

assessment result with the moment assigned task
 Score 14

3 The hospital laboratory has established 8 Check SOPs for document preparation 2

system for management of documents.

Check SOPs for document control (Master List 1

documents)

Check absence of obsolete document at work place 1

Check SOPs for record control 2

View record disposal procedure with practice 2

Score 8

4 The hospital laboratory has established 8 Confirm the laboratory handbook is prepared and 2
system and practice to monitor the distributed to clinical departments.
effectiveness of its customer service
View customer satisfaction survey report and 2
program.
implementation of identified gaps

View presence of suggestion box /book, summary of1

reviews and actions taken in the past quarter.
 The laboratory has established communication 1

mechanism for panic results. Check list of panic test

results is posted

The laboratory has all types of tests listed in menu 2

based on national standards for the hospital level.

Score 8

5 The hospital laboratory has 13 1

Confirm if the laboratory is implementing MEMS for ·

its laboratory equipment management

established and implements a proper
equipment and supply management Check record of equipment/method verification 1

done.
system.
Check the laboratory has updated equipment 1

inventory

Check a record of preventive and corrective 1

maintenance for all clinical laboratory equipment as

per manufacturer recommendation (Maintenance log)
·
Check the implementation of electronic supply chain1
management system.
Check record of regular calibration of equipment as 2
per the manufacturer’s recommendation.

Check updated SOPs ( Operational, Preventive 1

maintenance) job aids, forms,… for each M/Es at

each department

View laboratory has mini store for lab supplies and 2

reagents that should be clean, safe and well
ventilated with regular room temperature monitoring

View updated Bin cards are used to manage 1

laboratory supplies and reagents (check 5 randomly

selected bin to update)

Confirm the use of IFRR for requesting and 1

receiving reagents and supplies from the store

·

View SOP for reception, storage, acceptance testing1

and inventory management of reagents and
consumables.

Score 13
6 The hospital laboratory shall implement 14 Pre- examination: 1

a process control system and documented

procedure to identify and manage View well established and isolated sample collection
nonconformities in any aspect of the area.
quality management system.
1
View sample collection manual ready for use in work
place.

check record of risk identification, evaluation and 2

management plan and notification to SMT for a better
risk apatite.

Examination phase: 2

Obtain records of valid IQC for all tests in regular ·

manner

Confirm whether the laboratory participates in any 2

recognized EQA (PT scheme) or intra laboratory
evaluation and scored ≥80% for tests included in that
scheme.
 Check IQC and EQA out comes evaluated regularly 2
with Lab. staffs and SMT with actions for gaps

1
Lab. staffs forum with clinical staffs at least quarterly
to improve services and Pt, care

Post- Examination: 1

Confirm a system to review results before release

independent of testing personnel

View a TAT established for every test and evaluated1

regularly

Verifay And Check record of point of care testing 1

quality assurance

Score 14

7 The hospital laboratory has established 4 View records of occurrences or incidences 2 ·

incident handling and reporting system.

View deviations identified and actions taken for 2

improvement and prevent recurrence

Score 4
8 The hospital has established Laboratory 6 View written procedure for the laboratory 2

Information Management System information management system

The hospital established computer based laboratory 2

information management system linked with the rest
of EMR

All laboratory personnel are training in of EMR 1

recording and reporting system.

The hospital has external data backup system 1

Score 6

9 The laboratory shall develops and 8 View the laboratory has updated safety manual 1

implements a program to ensure the safety

Ensure the laboratory has safety program (check if 2
of laboratory services and facilities
there is annual safety objectives and plans) and
monitored accordingly

Confirm the following safety equipment and supplies2 ·

are available, inspected and are working; first aid kit,
fire extinguisher, and emergency shower, eye wash,
PPE etc)
 Observe every laboratory staff are using proper PPE1
while working in the laboratory

Work stations, floor and walls are clean and well 1

maintained.

Observe for restricted access when work is in 1

progress

Score 8

10 The hospital laboratory shall have backup 5 Confirm if a system designed for back-up laboratory2
laboratory service within and between service
hospital laboratory
View MOU signed with back up laboratory facility. 1

View back-up (water, equipment, electric power, 2

supply) made ready by the hospital

5 ·

Score
11 The hospital laboratories create public- 3 Observe MOU of Public private partnership between1
private partnership in the delivery
private and governments laboratory
laboratory service.
1

Check MOU contain at least following: list of

laboratory

service, price, payment mechanism and schedule,

turnaround time, responsibility on quality of service
etc

Check MOU is reviewed based on the schedule. 1

Score 3

12 The hospital has blood bank service that 11 The hospital has separate mini blood bank 2

adhered to appropriate standards of practice ·

The laboratory has formally assigned qualified 1

laboratory personnel for blood bank and/or

transfusion services.

2
The blood bank laboratory has developed and updated
SOPs and guidelines for its services
Check the laboratory maintains and monitors 1

temperature of storage areas for blood and

components.

The hospital has transfusion committee and focal 1

person. (Check letter of assignment letter, TOR and

annual plan of the committee members and focal
person.)

Check the HTC coordinated a blood collection 1

campaign as per the plan and schedule

1
Check updated equipment and supplies inventory and
check their functionality of each equipment. For mini
blood bank

Check the presence of documents and records for 1

blood received ,blood issued and compatibility test

Check if the laboratory is calculating average daily 1

consumption for each unit of blood and blood product

Score 11
 Total Score 100

CHAPTER 16 -INFECTION PREVENTION AND PATIENT SAFETY (IPC ) MANAGEMENT

SN Operational Standard Wt. Verification Criteria Scoring

Weight Score
1 The hospital has functional IPC 8 The hospital IPC program is led by full time, trained IPC 2
Program focal person
The hospital has clearly defined objectives and annual 2
Plan for its IPC activities

The Hospitals has allocated a dedicated budget for its IPC 2

program

The IPC program is supported by IPC team with dedicated 2

time for IPC activities
Score 8
2 14 The hospital has national IPC guidelines (check the 3
The hospital has adapted evidence presence of national IPC policy, strategy, M&E guide, IPC
based IPC guidelines, SOPs and reference manual
monitoring tools ➢ the has prepared/adapted SOPs for at least the following 4
IPC practices
▪ hand hygiene 0.5
▪ decontamination of medical devices and patient care 0.5
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
equipment
▪ environmental cleaning 0.5

▪ health care waste management 0.5

▪ injection safety 0.5

▪ HCW protection (for example, postexposure 0.5

prophylaxis, vaccinations)
▪ triage of infectious patients 0.5

▪ specific SOPs to prevent the most prevalent HAIs based 0.5

on the local context/ epidemiology;
Check that the hospital has monitoring and audit tools for 1
its IPC practices
Check that the hospital has provided specific training on 1
the guidelines
All the facility level IPC SOPs/ guidelines are easily 1
accessed by healthcare workers
Score 14
3 6 Check all front-line clinical staff and cleaners has received 2
The hospital has training and education and training on the facility IPC guidelines/SOPs
education program for its HCWs upon employment
Check the hospital has annual education and training for 2
its existing staff

Check that all IPC staff has received specific IPC training 2
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
Score 6
4 6 Facility has adopted the national HAI surveillance 2
The hospital has active guideline
surveillance for its prioritized
HAIs (optional for primary Check the hospital has active surveillance based on 2
hospitals) prioritized HAIs

Check that timely and regular feedback has been provided 2

to HCWs and key stakeholders for appropriate action

Score 6
5 The hospital implements 4 Check multimodal strategies are used to improve 2
multimodal strategy to improve its prioritized IPC practices
prioritized IPC interventions Check the evidences of implementation of multimodal 2
strategy is well documented
Score 4
6 6 The hospital has well-defined monitoring and audit plan 2
The hospital conducts regular with clear goals, targets and activities
monitoring and audit and provide
Check that the IPC focal/ team has conducted periodic or 2
feedback to ensure compliance of
continuous monitoring of selected IPC practice process
standardized IPC practice and structure based on the priorities of the facility(using
IPC FLAT)
Check evidence of timely and regular feedback has been 2
given to key stakeholders for appropriate action,

Score 6
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
7 8 The facility has adequate single isolation rooms or at least 2
The facility has appropriate built one room for cohorting patients with similar pathogens
environment, materials and Rooms and wards allow adequate natural ventilation 2
equipment for IPC
The facility has reliable power source and backup 2
(generators)
Check no more than one patient per bed 1

Check spacing of at least one meter between the edges of 1

beds
Score 8
8 Hand hygiene practice is 7 ABHR is available facility-wide with continuous supply at 2
implemented and supplies are each point of care
provided at all service points at all The hospital has continuous supply of clean running water 1
time Soap is available at each sink 1

The hospital has performed direct observation of hand 2

hygiene compliance of its HCW at least annually (using
the WHO Hand Hygiene Observation tool or similar
technique)
Hand hygiene posters (my 5 moments, correct technique 1
of HH) are displayed at the hand hygiene stations.
Score 7
9 Safe injection practices are 7 Hand hygiene is practiced before and after each injection 1
implemented to minimize risk to
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
clients, staff and surrounding Injection are prepared in clean environment and using 2
community aseptic technique

Single use injection items (Syringe and needles, single-use 1

medication vials, ampoules, and bags or bottles of
intravenous solution) are used for only one patient
Spot check /interview whether recapping of used syringes 1
is not practiced

Check availability of safety boxes for safe disposal of 2

syringe, needles and sharps at the right spot
Score 7
10 The hospital practices safe 8 Check/Observe for the: 1
healthcare waste management HCWs received training on proper waste segregation.
Color coded/ labeled waste bins and safety boxes are 1
available at each clinical area.
There is designated primary waste storage area 1

Check wastes are properly segregated by observing from 1

each category of waste bins.
Check that waste handlers have appropriate PPE(Utility 1
gloves, heavy duty apron, boots/ closed toe shoe, masks)
The hospital has well-designed functional incinerator with 1
ash pit and proper use
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
The hospital has properly fenced and ventilated placenta 1
pit with tight fitting cover( if applicable)

Proper disposal of liquid wastes check presence of septic 1

tank/ absence of leakage of the sewerage system (waste
should not be discharged without treatment)

Score 8
11 8 Cleaning staff are provided with appropriate PPE( gloves, 1
The hospital ensures cleanliness of gowns, masks) and cleaning supplies (cleaning products,
health care environment disinfectants, surface cleaning cloths, mops, buckets, floor
safety signs…..
Cleaners has received training on the facility IPC 2
guidelines/SOPs upon employment and regular refresher
trainings
Hospital has regular cleaning schedule for each service 1
area based on their level of risk

High-touch surfaces are free from soil, stains, dust, 1

fingerprints, grease, and spillages

Floors, walls, windows, ceilings and doors are visibly 1

clean

The hospital conducts regular monitoring of 1

environmental cleaning and provide feedback
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
Score 8
12 12 The facility has adequate laundry space for 2
The hospital avails adequate and segregation of soiled linens, washing, drying, ironing
functional laundry service and storage room
The laundry has uninterrupted water availability 2

Appropriate PPE is available and used by the laundry 2

personnel at all times (Heavy duty gloves, water proof
apron, masks, boots)
Separate doors for entrance of dirty and dispatch of clean 2
linen
Separated cart for clean and soiled linen 2

Adequate detergents and disinfectants 2

Score 12
13 The hospital has proper medical 16 Staff working in the CSR are trained on different aspects 2
devices decontamination and of decontamination and instrument processing and
reprocessing mechanism evidences are well documented
Check that gross soil and sharps are removed at point of 2
use, soaking in hypochlorite/ saline solution is not
practiced
Check staff working at manual cleaning station wear 2
appropriate PPE (heavy duty glove, face cover, gown,
waterproof apron and closed shoe/boots) when cleaning
medical devices
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
Check inspection, assembly and packaging takes place in a 2
separate clean area.

The packages are labeled with the content, date, expiry 2

date and load number

An external chemical indicator is used to differentiate 2

between clean and sterile instruments

The process of sterilization is monitored and documented 2

(physical parameters, indicators…)

Sterile packages are stored off the floor, walls and ceiling 2
in dry, clean, dust-free environment
Score 16
14 The hospital has a monitoring 8 1
system to ensure safety of food Food handlers are trained on food safety principles and
and water served in the premises practices
Kitchen staff applies PPE ( Apron, mask and head cover) 1

The kitchen is well maintained and food preparation area, 2

floor, wall and ceiling are visibly clean
Temperature of the refrigerator is checked regularly 2

Food handlers undergo medical examinations for 2

foodborne transmittable infections at least every three
months
SN Operational Standard Wt. Verification Criteria Scoring
Weight Score
All water sources are lab tested periodically every 3 2
months.
Score 8
15 The hospital ensures all 14 Check 2
preventive and post exposure presence of procedures to follow in case of injuries
interventions and procedures are in
documentation of injuries, or incidents 3
place in case of occurrence of
occupational risks
Preventive intervention measures such as hepatitis 3
vaccination for staff and PEP

Check presence of preventive interventions to minimize or 3

avoid injuries.
Presence of assigned occupational safety officer 3

Score 14
Total 100 Total Score 100
 CHAPTER 17- TEACHING AND TEACHING AND AFFILIATED
HOSPITALS SERVICES

MANAGEMENTAFFILIATED HOSPITALS
SERVICES MANAGEMENT Scoring
S/N Operational Standard Score Verification Criteria Given
Score
Weight
1 View the organogram of the hospital 1
The hospital has established a 9 Review clear customized job descriptions 2
functional management and prepared for CED, CRD, CCD, CAD
governance structure integrating Verify that the hospital SMT oversees the 2
medical education, health hospital's academic and service activities by
services, research, and making it a standing agenda item. (revise minutes)
community health priorities. Confirm that the strategic and annual plans 2
(Optional for affiliated hospitals) coordinate the three areas of services (CRD, CCD,
CAD)
Validate the engagement of physicians in the three 2
areas of services
Score 9
10 Check for the presence of a letter of delegation 3
2 with customized job descriptions for the
coordinator
2 Review customized job descriptions with 3
assignment letters for all members involved in
teaching
Examine the terms of reference (TOR) prepared 2
and agreed upon by all members
 Review the plans, performance appraisal meeting 2
The teaching and affiliated minutes, and reports
hospital has established
functional management
procedures directing all
teaching processes, student
attachments, and community
field activities.

Score 10
3 The hospital develops and Verify the presence of orientation guidelines 3
implements an orientation 11
protocol for
Ensure orientation guidelines address all areas of 3
students/interns/residents on
hospitals reforms, clinical audit and quality
hospital and national reforms
improvement
before clinical attachments.
Interview at least 5 students/interns/residents 5
randomly to confirm they received orientation
before clinical attachments.

Score 11
4 The teaching and affiliated 14 Verify TOR, plans, and available resources 2
hospital conducts regular Confirm the presence of clinical audits for services 4
clinical audits of patient care provided by students, interns, and residents
provided by
students/interns/residents and Check the participation of students, interns and 4
develops quality improvement residents on hospital clinical audit and quality
projects based on audit improvement projects.
 findings. Check the availability of QI projects implemented 4
by the students interns and residents based on the
clinical audit findings.
Score 14
5 11 Review protocols including confidentiality and 3
The teaching and affiliated privacy policies and communication, partnership
hospital has established a and teamwork guidelines
system to ensure care provided
Interview 10 patients and attendants from different 4
and student practices maintain
wards regarding their privacy, confidentiality and
patient confidentiality and
involvement in the care process
privacy at all times.
Observe patient care areas for privacy 4
considerations
Score 11
6 10 Check the presence of Library 3
The hospital has functional
Check the presence of skill labs and simulation 7
Library, skill labs and
centers
simulation centers
Score 10
7 15 Verify the presence of protocols defining types of 1
The teaching and affiliated rounds (ward/bedside rounds and teaching rounds)
hospital has established Interview staff regarding their knowledge on the 2
protocols/policies and protocol and adherence in each service area
procedures for ward rounds Confirm defined student-to-patient ratios for 2
and bedside student teachings rounds
to maximize patient benefit. 2
Confirm daily departmental multidisciplinary team
morning sessions for critically ill patients
 Review the availability and adherence to schedules 2
and time spent on bedside/teaching rounds
Check on-duty physician shift records to confirm 2
all inpatients were seen at least once per shift and
as needed for critically ill patients
Compare consultation/round logs to patient charts to 2
verify implementation of consultants'
recommendations from bedside/teaching rounds
Confirm the presence and adherence of scope-based 2
practice guidelines through staff interviews
Score 15
8 10 Review posted schedules listing 4
The teaching and affiliated
supervisors/teachers for each unit and date
hospital ensures
student/intern/resident patient Beside students/interns/residents, confirm the 4
care is supervised by their
hospital assigns staff accountable and responsible
respective teachers/hospital- for all their respective patient care activities at all
based instructors at all times.
times by reviewing schedule adherence.
Verify scheduling systems alignment with hospital 2
human resource management systems

Score 10
9 Review guidelines/MoUs for community affiliation 5
The teaching and affiliated 10 and field activities
hospital has established
Examine mechanisms for monitoring 5
guidelines, memoranda of
implementation of guidelines/MoUs
 understanding and procedures
for affiliating with other
teaching institutions,
communities and field
activities.

Score 10
Total score 100

CHAPTER 18 HEALTH CARE TECHNOLOGY SERVICE MANAGEMENT

SN Operational Standards score Verification Criteria Score
Weight Score
1 The hospital has organized 12 The unit is reflected in the hospital organogram 2
Healthcare Technology the unit is staffed with appropriate staff in terms of number and 2
Management (HTM) professional mix
Unit/department/team/director
Presence of the HTMU staff JD 1
ate
The unit has updated annual plan 2
Confirm the HTMU led by a Biomedical professional 1
Availability of budget for the unit 2
Ensure the HTMU head/Director is the member of hospital 2
management team
Score 12
2 The hospital has HTM 6 The members are assigned with official letter 0.5
 committee (HTMC) from Availability of TOR 1
multi-disciplinary team Conducting regular meeting every 2 months with documented 1
minutes
Presence of HTMC action plan 1
Presence of updated model medical device list approved by the 1
committee
Verify the availability of MDDP 0.5
Ensures the execution of medical device and related policies, 1
procedures, and guidelines and SOP (minute review)
Score 6
3 The hospital has a functional 8 Each medical device has updated bin card (check for 10 1
HTM information system medical devices)
Presence of updated medical device Inventory in 2
hardcopy/softcopy and on MEMIS
Availability of appropriate ICT infrastructures 2
Is the staff trained on the HTM information system 1
Presence of updated history file for each medical device in 2
HTM information system with hardcopy
Score 8

4 The hospital has standard 10 Presence of well-equipped staff office with mini library (e - 2
medical device maintenance library ) at the workshop
workshop Presence of mini- store(for spare part and accessories) in the 1
medical device workshop
Presence of maintenance, calibration & testing tools, 3
appropriate gases (e.g. Acetylene, oxygen) & other tools
Availability of equipped maintenance training workshop 2
 capable of mechanical & electrical activities
Presence of appropriate and adequate space for loading and 2
unloading of medical devices
Score 10
5 The hospital has medical 7 Availability of medical oxygen production quality and capacity 2
oxygen devices management monitoring system (oxygen production registration document
system using analyzer)
Ensure Oxygen cylinders are color coded as per the standard, 2
safely stored and transported
Ensure the hospital has medical oxygen manifold and central 1
pipeline system (observation)
Presence of Oxygen Cylinder refilling, Inspection & acceptance 2
testing practice
Score 7
6 The hospital has cold chain 7 Availability of separate CCE and spare part inventory 2
equipment (CCE)
management system Availability of adequate CCE with temperature monitoring 2
devices
Confirm CCEs maintain its appropriate temperature range 3
(observe CCE temperature monitoring )
Score 7
7 The hospital has separate 6 Presence of assigned BME/T for managing medical device and 2
medical device and spare part spare part store
store
Availability of bin card and stock card 2
There is proper management and labeling practice of medical 2
devices (MD Name & status)
Score 6
8
The hospital has appropriate Confirm medical device need assessment is conducted 2
acquisition system for 10 Presence of approved Short-term & long-term MDDP with 1
medical devices estimated budget
Confirm preparation of medical devices specification based on 2
HTA
Confirm involvement of BME/T on medical device 2
procurement process
Ensure managing/follow-up of after sale service as per the 2
contract agreement.
Ensure execution of medical devices procurement as per MDDP 1

Score 10
9 The hospital has proper 8 Confirm site preparation is done as per the manufacturer 2
medical devices installation recommendation
and commissioning practice
Confirm all new equipment undergoes acceptance testing 2
(document review)

Confirm commissioning of medical devices according to the 2

pack list
Ensure user and BME/T trained on commissioned device as per 2
the contract agreement
Score 8
10 The hospital has a proper 12 Presence of schedule for performance testing, calibration, 3
medical device maintenance Preventive and corrective Maintenance
practice Presence of prioritized medical device list for corrective 2
maintenance
Presence of work order based maintenance practice 2
 Availability of SOPs, manual & risk assessment for each 2
medical device
Confirm the PM & CM has been done on time (check PM 3
schedule & work order)
Score 12
11 The hospital conducts 8 Plan for short and long term training for users and BME/T 2
capacity building for users
and BME/T on proper Provision of end user and technical training 2
utilization, safety, and
maintenance of medical Availability of recorded training conducted by other 2
devices organizations
Presence of incident management system (tracking, recording, 2
reporting and intervention )
Score 8
12 The hospital has a proper 6 Presence of functional Medical Equipment Disposal Committee 1
decommissioning and as per EFDA guideline
disposal system List of medical devices to be disposed is approved by HTM 1
committee
Presence of secured warehouse for decommissioned devices 2
until it is disposed
Ensure decommissioning and disposal of medical devices is 2
based on EFDA guideline
Score 6

100 Total score

100
CHAPTER- 19 HOSPITAL INFRUSTRUCTURE AND ASSET MANAGEMENT

Scoring
SN Operational Standards Score Verification Criteria

Weight Score
 The hospital has a functional Check whether Basic Service and Asset Management
2
executive officer is assigned
Basic View the organization chart and confirm that the hospital
has assigned individuals to undertake the hospital’s 1
Service and Asset 5 infrastructure and asset management activities.
1
Check assigned individuals have clear Job descriptions. 1
Management
Check head the executive office working as IPC/CASH,
Executive office structure. 1
incidence, committee member

Score 5
Check availability of:
The hospital complies with Relevant laws, Guidelines, SOPs, hospital site map. 1
2 relevant 3 Approved construction plan/ with updates if modification is
laws, regulations, directives 1
done
License (by FMHACA) 1
Scores 3
Check the infrastructure and asset management activities
The hospital grounds are 1
are integrated with the Annual plan
regularly inspected, Check all walkways are covered and safe for the
1
movement of patients.
maintained, and their View patient and staff areas (garden, waiting for areas, etc.
1
11 are tidy, clean, and free from hazards.
3
cleanliness is ensured for the
Check adequate reserve water/a backup is available 2
safety of patients, visitors, and Obtain evidence that water sources are tested for safety at
2
least every 3 months.
staff. Check that quarterly sample checks reports and actions
1
taken based on the results and recommendations
 Electrical services are available 24 hours daily through
1
regular or alternate sources (Generators, solar panels).
Confirm Generator operator is assigned and functionality
1
and continuity of the service
. Check about 5 randomly selected areas for functional
1
sockets & lighting
Scores 11
2
Check asset management database is established and
The hospital has included its regularly updated.
9
infrastructure, asset Check the hospital has listed out major assets and
documented complete information, including
2
procurement, and maintenance manufacturing/building time, actual or estimated cost, and
4 lifetime
plan in its long-term and The major Assets' data are kept both in hard and soft copies, 1
Confirm that the infrastructure and Asset Management Plan
annual plans. 2
are budgeted and made part of the hospital’s general plan
Check the hospital procurement bidding processes align 2
with the government's procurement law.
Score 9
The hospital has a maintenance Confirm that the maintenance workshop has adequate space
3
(Check for ventilation and lighting of the room)
workshop with technical Confirm that there are hand-washing facilities for cleaning
15 and disinfection equipment, a storage area, SOPs, and 1
5
personnel, sufficient space, and necessary reference materials
The maintenance workshop has appropriate tools and
adequate ventilation testing equipment to ensure the routine calibration of the 2
testing equipment is performed as required (test for circuits,
 switch leak, power)

Confirm that regular preventive maintenance is conducted.

3
Confirm documentation for preventive maintenance
Confirm that a notification and work order system exists. 1
Check data for;
Number of work orders received 1
Number of completed work orders/actions taken 1
Number of incidents reported and actions taken 1
View at least 5 recent work order requests, then check for
1
corresponding reports on corrective maintenance
Check randomly selected service areas maintained per the
1
schedule in the previous months
Scores 15
Check vehicle maintenance, including Ambulance, is
2
conducted according to the manufacturer's recommendation
The hospital has a transport 7 Check whether the has provided Life-Support training for
2
Ambulance drivers.
policy for using and accessing View logs of two randomly selected hospital vehicles and
6
confirm that vehicle utilization complies with transport 2
the hospital's vehicles. policy
Check whether measures are taken by regulatory bodies on
drivers due to violation of the transport policy prepared by 1
the hospital
Scores 7
7 The hospital has a safety and 20 Check policy, including (Visiting hours and traffic control, )
3
and post at the gate and inwards
 security policy. Visit wards and confirm that all attendants wear appropriate
2
ID badges (showing Wards and Bed No.)
Observe all staff, clients, and vehicles searched/checked on
2
entry and exit at a hospital checkpoint
Check security training conducted at least annually and to
1
new staff
Check prohibition policy and handover of weapons/sharps
1
by the security department
View fire safety plan is available, and evacuation drilling 2
Check hydrant hoses exist within the facility, at least at
1
potential fire points (optional for primary hospitals)
A Fire and Evacuation Drill’ is conducted at least annually. 2
Check fire extinguishers are filled and updated properly 1
Check for the presence of SOPs for Extinguishers
2
utilization
Check Fire safety inspection is done by an authorized body
1
(optional for PH)
Check training is conducted annually, and staff are trained
about their roles in fire safety, security, hazardous materials, 2
and emergencies
Scores 20
The hospital has a plan for Check major incidence plan, MIP prepared and approved
8 by SMT and distributed at least to each service area as 1
responding reference
View safety and response plan for the safety of all
8
to likely incidences in the possible incidences are addressed (fire, buildings, 2
sewerages, water sources, Epidemics, etc.)
hospital and other disasters. Check Roles and Responsibilities of staff and external
1
stakeholders addressed in the MIP in response to disaster
 management

Check the plan's implementation with the incident officer

2
and head of the executive office.
Check availability of alarm/command post and Check staff
1
responses on alarming
Check the disposal manual available for the management of
hazardous materials in the hospital (Laboratory, Pharmacy, 1
main Stores)
Scores 8
View the annual procurement plan that is approved by the
2
hospital governing board
View the use of transparent, competitive procurement
The hospital stock 11 2
methods (Bid documents)
management system Take some sample and check whether the quality of
2
procured items are as per the specification of the requests
9 is in place, and disposal is
Confirm that there is an adequate internal controls system to
done in compliance with the reduce the risk of committing mistakes and fraud. 2
relevant laws and guidelines. (stock/Bin cards, computer-based registrations)
Verify compliance with rules for processing, recording, use,
and disposal of stokes with relevant guidelines (disposal 3
manual, property management manual)
scores 11
Check that fixed assets of the hospital are tagged and
history files are documents. 2
5
The hospital conducts an
10 Check that the hospital conducted an annual inventory and 1
annual Asset Inventory
has an inventory report.
Confirm all assets are included in the annual inventory
2
(properties, medication, supplies, disposal documents,
 APTS reports, and minutes.)
Score 5
The hospital has allocated a
Check the budget allocated for the procurement and 3
budget for procuring and maintenance of buildings, equipment, and utilities.
6
maintaining medical and non-
11
medical devices, buildings,
Verify medical equipment and other assets purchased and
vehicles &utilities from 3
maintained from the retained revenue budget.
retained revenue.

Score 6
Total Score 100 100

CHAPTER-20 HUMAN RESOURCE MANAGEMENT AND DEVELOPMENT

SN Operational Standard Score Verification Criteria Scoring

Weight Score
1 The hospital should have a Human Resources
Management Directorate/Department/ which lead 8 HR needs Identified and priorities set 2
and manage the HR management and development HRMD directorate developed TOR,
of the hospital detailed implementation plan….
.
HRMD directorate actively engages in
SMT and takes part in the decision 2
making process of the hospital
HRMD directorate Set an agenda of the 2
HR and presents to the SMT of the
hospital
Score 8
2 8 The plan details acquisition of the staff in 1
The hospital has a human resource development the required numbers, professional mix
plan and backed by budget
The plan details capacitating the existing 1
staff as well as the newly recruited staff in
a continuous manner (CPD)
Select topics based on the training needs 1
of the hospital
 Select trainers, trainees, and training 2
centres to provide basic HRD training to
its staff to acquire Knowledge and Skills
Provides certificate for trainees 0.5

Put a mechanism to conduct follow up 1

after training and ensure staff competency
assessment score with the improvement
plan
Best experiences sharing for staff from 1.5
local or international experiences

Score 8

3 The hospital establish/updates the 1

9 hospital’s recruitment and hiring
committee with involvement of pertinent
The hospital has established a transparent and department/experts.
accountable system of staff acquisition The recruitment committee engages the 1
concerned service area for which staff are
hired and set selection criteria based on
the laws and regulations of the civil
service commission.

The hospital uses objective assessment 2

methods both for written examine and
interviews to assess the knowledge and
skills of the candidates.
The content of the exam should be based 1
on the need of the hospital/service area
The hospital puts in place a mechanism to 1
respond to the complaints of the
candidates, if any.
The hospital provides staff induction for 1
new selected hire before deployment

The hospital provides JD/Scope and 1

employee’s handbook which is signed by
individual staff.
 Puts a mechanism to avoid a conflict of 1
interest in the hiring process and make
accountable those who violates the rules and
the regulations.

Score 9
4 8 Ensure that the plan by HR department 3
addresses staff numbers, necessary budget,
The hospital has the number and professional mix and training schedule based on need
in accordance with the regional/national standards. assessment with departments and /or service
area.
The plan must be approved by hospital board. 2
he required number and professional mix of 3
staff are hired and/or capacitated

Score 8
5 8 All the staff profile (including professional 2
license of health profession) captured in
HRIS database of the hospital
The HRMD Directorate/Department maintains 1
each personnel file and fully implement HRIS
Ensure that each personnel’s file is up to date 2
so that the promoted, terminated, newly
recruited staff’s profile are well kept.
Complete personal information is captured in 1
HRIS
Employee JD is aligned with the HR plan of 2
the hospital, job standard and meet the
hospital needs and current position/staff’s
rotations.

Score 8
9 Staff motivation package plan approved 1
by GB
The HR directorate/department head 1
The HRMD Directorate/Department creates monitors plan implementation
6 conducive work environment to motivate health The hospital creates conducive working 2
work force. environment by availing
o Staff stations with internet
access,
o Mini library,
o Staff cafeteria,
o Sporting field/outdoor playing
areas
Standardize duty room service provision 1
Make the compound of the hospital, the 2
restroom, and every individual room neat
and clean.
Conduct recognition program for best 2
performing staff periodically.

Score 9

The hospital strengthens a system to have 6 The hospital should orient its staff so that 1
Motivated, Competent, and Compassionate each employee must be compassionate
(MCC) human resource for the hospital. All the staff should provide client-centered 1
service and uphold this value.
7 The hospital needs to provide continues 1
orientations on Heath Professional ethics,

The HRMD department needs to put in place 1

a system to regularly monitor implementation
of compassionate care by involving pertinent
work areas/service points.
The hospital must ensure the staff use 0.5
appropriate
ID badges and uniform all the time. 0.5
The hospital establishes a compliant handling 1
and management system with this regard.

Score 6

8 9 The hospital has staff’s performance 2

evaluation plan where every staff is
The hospital has a performance management objectively evaluated without discrimination.
process and reward policies in which all The hospital has clear and transparent 2
employees are formally evaluated. evaluation criteria including performance,
knowledge, skills and attitude
 Employees are formally evaluated at least 1
semi annually
higher performing staff are recognized and 1
rewarded annually
Action plans prepared to capacitate low 2
performing staff
Hospital evaluates departments and select best 1
performers, rated and posted (possibly by
photo and name) on quarterly basis after
result approval by SMT & GB.

Score 9
10 The hospital has safety-officer 1
The hospital has an occupational health 2
The hospital has occupational health and safety and safety plan.
9
policies, plan, and procedures.
The safety officer conducts regular 2
assessment to identify risk areas and
undertakes mitigation measures.
The hospital ensures that the required 1
safety devices and kits are available
 The hospital ensures that all appropriate 2
staffs get immunized for HBV and others.

The safety officer collaborates with other 1

departments and different committees
regarding occupational safety.
The hospital periodically revises the safety 1
policy in line with the national/regional
safety policy and procedures.

Score 10
7 Provides orientation on time management to 2
The hospital HRMD directorate/department department heads
enhances Productivity and proper time
10 Establishes electronic attendance management 1
management
system
Facilitate and monitor shift-working 1
schedules
Monitor/review staff time data base and 1
provide timely feedback
 Approves timesheet of service areas before 2
payments are made
Score
7
10 Check whether employee handbooks 3
which contains key policies, laws,
regulations, collective and individual
11
HRMD directorate/department prepares an responsibilities and benefits is developed
Employee Handbook that contains policies and Verify whether the employee handbook 2
procedures to ensure consistency in service specifies the key responsibilities and
delivery benefits of the employees such as working
hours, vacation, promotion process, duty
allowance, performance evaluation
process, unpaid leaves, retirement plan
etc.
Check if the employee handbook includes 1
restrictions such as discrimination of any
kind, workplace harassment, etc.
 Make sure the employee handbook is 1
approved by the hospital governing
board/SMT.

Ask hospital staff if the employee hand 1

book is distributed/disseminated

The employee handbook needs to be 2

updated periodically, preferably within 3-
5 years.

Score 10

8 Verify whether the survey assesses the staff 3

opinions about their workplace, at least
The hospital regularly conducts a staff job biannually
12
satisfaction survey and exit interview. Check any documentation if the hospital 2
conducts a staff exit interview as a staff
terminates her/his employment.
 Verify whether the HRMD uses satisfaction 3
survey and exit interview data to develop an
improvement plan based on the identified
gaps
Score 8

Total Score 100

CHAPTER-21 HEALTH CARE FINANCE MANAGEMENT

Scoring
S.N. Operational Standards Verification Criteria

weight Score

Check there is an approved financial structure

The hospital has a finance 15 4
in the organogram
structure with relevant
1
finance personnel assisted Confirm the hospital issues. Job Description for
3
with technology. every finance staff
 Verify that the finance department has the
necessary equipment and computers and internet 4
access.

Verify the hospital has capacitated its finance

4
staff by providing periodic training

Score 15

Check the hospital has prepared its strategic and

annual revenue and expenditure plan in line with 4
the overall plan of the hospital

Verify that the financial plan is in line with set

priorities and reflects the need of each 3
13
2 department
The hospital has a strategic
and annual financial plan
Check the financial operation of the hospital is
in alignment with the 3
in line with the strategic plan.
hospital's overall plan.

Check the financial plan is approved by the MC

3
and the board.
 Verify the financial plan is approved by the
3
board.

Score 13

Check there is a financial plan reviewed by the

Management Committee and approved by the 3
hospital’s governing board.

Verify the hospital has diversified its revenue

3
sources other than health services
3 13
Ensure the hospital has allocated retained
3
revenue budget for quality improvement
The hospital continuously
increases internal revenue Check the internal revenue and corresponding

collection and its expenditure for quality-improving activities of 2

allocation for quality the hospital has grown over time

improvement. Check whether financial implementation is in

2
line with the approved plan

Score 13
 The hospital establishes Check a comprehensive financial plan detailing
systems and practices for both the treasury, internal revenue budget, and 3
improving its resource resources from different sources
utilization. Verify all the allocated budget was utilized at
3
the end of the fiscal year.
4
Check there is no difference in the utilization of
the internal revenue budget and operational 3
12
treasury budget.

Verify that no budget is allocated on the

3
negative list

Score 12

The hospital has put in Confirm that the hospital has concluded a legal
14
place a mechanism for agreement with insurance schemes, companies, 2

timely reimbursement of agencies, and pertinent partners.

5 costs. Check the hospital has established a data-based
system to record services given on a post- 3
payment/credit basis.

Confirm that the hospital has a register to record

both services given and corresponding costs
2
incurred for exempted health services & on a
credit basis

Ensure the hospital submits timely requests for

2
reimbursement

Verify the hospital has a reimbursement

2
followup mechanism

Ascertain costs are reimbursed per the

1
agreement reached with pertinent clients

Score 14

Verify the hospital has conducted a feasibility

10 2
analysis before it outsources services
 The hospital has
Check the proposal for outsourcing is approved
established a system to 1
by the hospital governing board
implement outsourcing of
services.
6

Check detailed biding document has been

2
prepared

Verify the hospital has established a technical

team providing technical support in outsourcing 1
and implementation.

Verify that the quality of services is improved

2
after outsourcing

Check the hospital has a monitoring mechanism 2

Score 10

Check the hospital has conducted an assessment

The hospital has opened a 1
7 private wing to the 10 to open up a private wing

requirements of the Verify the board has approved the establishment 1

 federal/regional proposal
regulation/directive
Check services in the private room do not
2
compromise the general services

Verify the supplies are reimbursed for the

2
hospital

Verify the hospital gets its share from the

1
private revenue collected in the private wing.

Staff performance at the private wing is

1
equivalent to the regular hours

The board approves the private wing services 1

fees
Check the private wing has a directive by
1
which implementation is guided.
Score 10

The hospital fully Verify there are pertinent financial regulations,

8 13
complies with government manuals, vouchers, and safe boxes in the finance 3

finance rules and department

 regulations. Confirm the hospital's internal revenue is
collected, deposited in a bank, and appropriated 3
before use.

Check that hospital procurement is done in line

2
with the government financial rules.

Ensure the hospital conducts regular internal

3
audit

Verify annual external audit is conducted

annually, the audit report is reviewed, and
2
corrections are made, if any, based on the
findings.

Score 13

Total score 100

CHAPTER- 22 HEALTH SERVICE QUALITIES

S/N Operational Standard Score verification criteria Scoring
Weight Score
1 The hospital has an 8 Ensure that the HSQ Directorate/Office is led by full time Senior 2
established Health Service Physician or General Practitioner or MPH or other equivalent
Quality Directorate/Office. qualifications with clear JD and assignment letter.

Verify Health Service Quality director/head is a member of the SMT 1

and accountable to the CEO/CED.
The health service quality team constitutes multi-disciplinary 1
members.
There is dedicated room, Directorate/Office furniture, computers, 2
printers, internet access, etc.
Ensure that health service quality strategic, annual, and quarterly 2
plans are developed.
Score: 8
2 The hospital has functional 5 Check for Health Service Quality council/committee member 1
Health Service Quality appointment letters.
council/committee Review the Terms of Reference (TOR) and agreed activity plan of the 2
Health Service Quality council/committee.
Verify that the Health Service Quality council/committee conducts 2
regular monthly meetings by checking meeting minutes.

Score: 5
3. The hospital coordinates 5 Confirm that the Health Service Quality Directorate/Office regularly 1
health service reform coordinates implementation of health system reform initiatives.
activities and integrates into Check that appropriate feedback is provided to respective responsible 2
the existing system. bodies based on assessment findings.
 Verify the presence of a daily follow-up dashboard or checklist along 2
with an improvement plan for routine reform activities.

Score: 5
4. The hospital has established a 7 Verify the presence of a Standard Operating Procedure (SOP) for risk 1
system to manage health care management.
delivery related risks. Check for documentation of identified risks in the facility. 2
Confirm the presence of risk mitigation, control, reduction and 2
response plans.
Verify that the risk management process is notified to the Senior 2
Management Team through letters or minutes.
Score: 7
5. The hospital has functional 9 Check for the establishment of a multidisciplinary clinical audit team. 2
clinical audit program
Verify defined Terms of Reference (TOR) and activity plan for the 1
clinical audit team.
Confirm the presence of a clinical audit guideline and audit tools. 1

Triangulate clinical audit findings with HSTQ reports. 2

Verify that re-audits are conducted to close gaps identified in previous 1
audits
Confirm that improvement actions are taken or data-driven quality 2
improvement projects conducted based on identified gaps.
Score: 9
6. The hospital actively 7 Confirm hospital participation as a lead or member of an EHAQ 1
participates in collaborative cluster by reviewing the EHAQ Terms of Reference (TOR) and
 learning and experience sharing agreed activity plan.
platforms.
Verify that the EHAQ cluster conducts quarterly recorded meetings 2
with follow-up action plans developed.
Confirm that best practices are documented and shared among 2
member hospitals of the EHAQ cluster.
Validate that the hospital participates in benchmarking activities to 2
share and learn good practices with other hospitals.

Score: 7
7. There is regular Hospital to 6 Confirm that hospital quarterly conducts mentorship, supportive 2
health center support system supervision for catchment health centers. (assess performance
reports)
Verify that the hospital regularly monitors performance of lead 2
catchment area health centers by reviewing performance reports.
Validate that the hospital regularly supports catchment area health 2
centers with human resources, medical equipment, and supplies by
reviewing evidence from the previous quarter.

Score: 6
8. The hospital develops a system 11 Observe the posted Statement of Patient Rights and Responsibilities 2
to insure patient preference and in service areas including Outpatient, Emergency Room, and Inpatient
value. Departments.
Verify the presence of a patient complaint handling mechanism. 2
 Confirm that suggestion books or boxes are utilized in each 2
department/case team with suggestions compiled, analyzed, and acted
upon.
Check for the presence and functionality of a patient advisory 2
committee by reviewing letters, minutes, Terms of Reference (TOR),
etc.
Validate the presence and functionality of community forums. 1
Review the mechanism established to address patient preferences and 2
family concerns in clinical service decisions by examining patient
charts.
Score: 11
9. The hospital regularly conducts 4 View results of last patient satisfaction survey conducted. 1
patient satisfaction surveys. Confirm a patient satisfaction survey was conducted within the last 1
quarter.
Verify that actions were taken based on the patient satisfaction survey 2
results.
Score: 4
10. The hospital has established a 10 Observe the health literacy desk. 2
health literacy desk. Look for assigned health literacy desk staff with appointment letters 2
and job descriptions.
Check the presence of registers, health education materials, sample 2
leaflets, posters, audiovisual aids, etc.

Review the health education timetable and compare to actual practice. 2

 Verify the availability of a mechanism to assess client health 1
awareness and knowledge.
Confirm that data-driven quality improvement projects are conducted 1
based on identified gaps.

Score: 10
11. The hospital identifies priority 9 Look for ongoing and graduated QI project documents. 6
problems in service delivery
areas and implements QI Check for implemented change ideas, health system innovations, 1
projects. technologies, or other creative actions taken to improve care quality.

Observe changes after project implementation. 2

Score: 9
12. The hospital ensures equitable 9 Verify actions taken to address language barriers through a multi- 2
service delivery. lingual approach.
Check for the presence and functionality of sign language trained 2
staff.
Look for accessibility provisions like ramps, walkways, latrines, etc. 3
for patients with disabilities.
Confirm the presence of a patient prioritization mechanism for special 2
situations in service delivery areas.

Score: 9
13. The hospital establishes a 8 Verify the presence of effective appointment system. 2
 system to ensure timeliness of Check for a system monitoring service delivery delays like 2
care. Emergency Room triage times, Outpatient Department waiting times,
etc.
Confirm the presence of manual or electronic queuing management 2
systems in Outpatient, Inpatient, Emergency Room, Laboratory,
Pharmacy departments, etc.

Verify early initiation of services. 2

Score: 8
14. The hospital establishes a 6 Confirm the presence of systems checking professional productivity. 2
system to control efficiency of
healthcare delivery.
Verify the presence of system to check laboratory and radiology order 2
justification.

Confirm the presence of systems ensuring rational utilization of 2

personal protective equipment, medications, consumable supplies, etc.

Score: 6
Total Score : 100

CHAPTER- 23 HOSPITAL PERFORMANCE MONITORING AND REPORTING MANAGEMENT

S/N Operational Standard score verification criteria Scoring

Weight Score
1 The hospital has established 15 Assigned HMIS unit focal with JD 3
Performances Monitoring and HMIS unit focal is a Member of SMT and Accountable for 3
Reporting unit CEO/CED
Check for the presence of separate or integrated room, office 3
furniture, computer, printer, UPS, internet access.etc
Has a regular weekly meeting among case team members 3
(check the minute)
Look for as annual, quarterly and monthly plan 3

Score 15
2 The hospital has a functional 10 Check for assignment letter, TOR 3
Performances Monitoring View minutes of consecutive monthly PRT meetings in the 3
Committee last 3 months.
Look for activity plan and implemented corrective measures 4

Score 10
3 The Hospitals has daily EMR data 12 Look for data monitoring protocol 3
monitoring system or equivalent Check access to daily EMR data and Privilege to access self- 3
dashboard to track key clinical and report
administrative data. Verify the presence of dash board to monitor daily service area 3
and administrative data
 Joint triplet meeting among Medical Record Unit, Hospital 3
Service Quality and Performance Monitoring and reporting
unit
Score 12
4 The hospital conducts integrated - 9 View 3 copy of integrated -interdepartmental assessment 3
interdepartmental performance reports.
assessment Verify assessment reports contains with HMIS indicators and 3
any additional local indicators determined by hospital
management.
Check for action measurements taken on identified gaps of 3
assessment reports
Score 9
5 The hospital has regular 15 Verify Data Quality Assurance (DQA) and Lot Quality Assurance 3
mechanism to ensure data quality Sample (LQAS) done monthly
Verified by PMT meetings 3

Confirm LQAS is > 85% 3

Look for availability of protocol for triangulation of selected data 3
and triangulation reports
Check availability of regular supportive supervision of HMIS 3
unit/department.
 Score 15
6 The hospital submits complete 13 Observe the availability of adequate manual or electronic 3
monthly, quarterly and annual registers, tally sheets and reporting formats in all service
reports to the relevant higher delivery area
office within the agreed timelines. Verify all reports are evaluated by PRT prior to HMIS 3
reporting period.
Confirm that all expected monthly, quarterly biannual annual 3
and annual reports are submitted
Verify hospital specific report completeness and timeliness in 4
DHIS2
Score 13
7 The hospital has regular data 14 Check for availability regular trend analysis at each service 3
driven decision making practiced delivery area
There is a mechanism to encourage evidence generation (gap 4
oriented research)
Verify institutional QI project devised based on data findings 3

Check for annual plan linkage to facility specific historical 4

performance data
Score 14
8 Hospital staff receive orientation 8 Check and verify with selected staff about their awareness of 2
 on all HMIS and KPIs KPI’s.

Check availability of data owners from each case team/service 2

area.

Check case teams/departments determine indicators and 2

monitor their own performance using the process improvement
model
View reports/minutes of case team on performance data 2
utilization
Score 8

9 In collaboration with the 4 Confirm that HMIS and KPI reports are presented to hospital 2
Governing Board through the SMT monthly
CEO, the PMR unit presents core
and selected HMIS and KPI for Core indicators identified and presented/ summarized in a 2
GB ‘user friendly’ manner as BSC to GB quarter (See appendix of
sample BSC for GB)
,
Score 4
Total Score 100