EHRIG - Vol1 - Final Ethiopia Wond G PDF

Federal Democratic Republic of Ethiopia
Ministry of Health
Ethiopian Hospital Reform

Implementation Guidelines
Volume 1, May 2010
Ethiopian Hospital Management Initiative

Federal Democratic Republic of Ethiopia
Ministry of Health
Ethiopian Hospital Reform Implementation

Guidelines
Volume 1
Ethiopian Hospital Management Initiative

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

Minister of Health, Federal Democratic Republic of Ethiopia

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

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

Asrade Abate (Chair) Tulane University/ Federal Ministry of Health - Plan
and Programming Department
Kedir Yimer (Dr.) Johns Hopkins University- TSEHAI
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Paulos Nigussie Ethiopian Medical Laboratory Association
Kinfe Haile Amanuel Mental Health Hospital
Mulugeta Tamene Debre Markos Hospital
Tsedale Tilahun Zewditu Hospital
Birhanu Alemayehu Dilla Hospital
Shigute Wolde Menelik II Hospital
Mohamed Dilbi Federal Ministry of Health
Ayele Zewdu Dil Chora Hospital
Yared Kifle EngenderHealth
Pharmacy Services
Hailu Tadeg Management Sciences for Health/SPS
Edmealem Ejigu Management Sciences for Health/SPS
Elias Geremew Management Sciences for Health/SPS
Ayalew Adinew Management Sciences for Health/SPS
Negussu Mekonnen (Dr.) Management Sciences for Health/SPS
Laike T/Medhin Management Sciences for Health/SPS
Yosef Wakwoya Management Sciences for Health/SPS
Yedilken Kebede Management Sciences for Health/SPS
Elizabeth W/Mariam Management Sciences for Health/SPS
Workineh Getahun Management Sciences for Health/SPS
Zenash Tessema Management Sciences for Health/SPS
Tenaw Andualem Management Sciences for Health/SPS
Edgegayehu Hailu Management Sciences for Health/SPS
Getachew Ayalew Management Sciences for Health/SPS
Tesfaye Seifu Ethiopian Pharmaceutical Association
Raey Yohannes DACA
Mesfin Goji Jhpiego
Shimelis Endailalu SCMS
Gashaw Shiferaw SCMS
Meseret Zerihun USAID/DELIVER
Jeff Sanderson USAID/DELIVER
Sami Tewfik USAID/DELIVER
Atkure Defar ALERT Hospital
Tewodros Lemessa Ras Desta Damtew Memorial Hospital
Nathan Assefa Kenema Pharmacies Enterprise
Laboratory Services
Samuel Kinde AAU School of Medical Laboratory Science
Bihil Sharezedin Johns Hopkins University- TSEHAI
Dereje Abate St. Peter’s Specialized Hospital/Ethiopian Medical
Laboratory Association
Zelalem Messele Ethiopian Medical Laboratory Association
Jin Bae Clinton Foundation
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Tina Falle Clinton Foundation
Nursing Care Standards

Berhane Gebrekidan (Chair) Ethiopian Nurses Association
Feleke Mulatu Ethiopian Nurse Midwives Association
Senait Bitew/Abebe Shume Jhpiego
Meseret G/Tsadik Amanuel Mental Health Hospital
Tadelech Fantu Tikur Anbessa Specialized Hospital
Teferi Fenta St. Paul Hospital
Zeleke W/Giorgies Menelik II Hospital
Gezashign Denekew Yekatit 12 Hospital
Mehretie Jemberie Zewditu Hospital
Kassahun Chekole Debre Markos Hospital
Imana Teferra Ambo Hospital
Mengesha Chanyalew Debre Birhan Hospital
Almaz Siraj Federal Ministry of Health
Meskerem Asnake Bishoftu Hospital
Abu Tesfaye Shashemene Hospital
Lisanework Girma ALERT Hospital
Infection Prevention
Haregewoin Kiflom Tigray Regional Health Bureau
Yayeneabeba Tadesse Ethiopian Nurses Association
Muhidin Abdo (Dr.) EngenderHealth
Hailu Yeneneh (Dr.) The Carter Center/EPHTI
Solomon Tassew JSI/MMIS
Negash Seyoum (Dr.) Jhpiego
Yodit Kidanemariam Jhpiego
Abebe Shume Jhpiego
Asefaw Abera St. Paul Hospital
Tesfaye Deressa Menelik II Hospital
Zeleke Yimechew Debre Markos Hospital
Fitsum Desalegn Debre Birhan Hospital
Tesfaye Alemu Nekemte Hospital
Ali Mohammed Shashemene Hospital
Leuleseged Yohannes (Dr.) Federal Ministry of Health,
Medical Services Directorate
Fahmi Mohammed (Dr.) World Health Organization, Africa Regional Office
Daniel Atnafu (Dr.) Johns Hopkins University- TSEHAI
Sr. Ejigayehu Sahle St. Paul Hospital
Zemichael Mekonen ALERT Hospital
Assefa Bulcha The Carter Center
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Facilities Management
Tania O’Connor Johns Hopkins University/
Tikur Anbessa Specialized Hospital
Saran Ellis Jhpiego
Abdurahman Ali Ethiopian Nurses Association
Berhanu G/Michael (Dr.) ALERT/People to People
Bethel Girma (Dr.) Federal Ministry of Health / People to People
Medical Equipment
Tania O’Connor (Chair) Johns Hopkins University/
Tikur Anbessa Specialized Hospital
Gizachew Anteneh Ethiopian Health and Nutrition Research Institute
Zelalem Eshetu (Dr.) ORBIS International
Yohannes Jorge (Dr.) Tikur Anbessa Specialized Hospital / People to People
Jennifer Barragan Clinton Foundation
Paulos Nigussie Ethiopian Medical Laboratory Association
Berhanu Gizaw (Dr.) Addis Abeba University
Negash Seyoum (Dr.) Jhpiego
Gizachew Abdeta (Dr.) Federal Ministry of Health
Tiemtu G/Selassie Abi Adi Hospital
Gebreegziabher Getahun Dil Chora Hospital
Hailu Bekele National Scientific Equipment Center (NSEC)
Demeru Yeshitla Ethiopian Biomedical and Laboratory Equipment
Engineers Association /NSEC
Tadele Gebre Federal Ministry of Health, Public Health
Infrastructure Directorate
Financial and Asset Management

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

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

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

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

3.2.1 Responsibilities of the Governing Board
3.2.2 Membership of the Governing Board
3.2.3 Officers of the Governing Board
3.2.4 Procedures of Board meetings
3.2.5 Governing Board standing committees
3.3 Chief Executive Officer 23

3.3.1 Selection and appointment of the CEO
3.3.2 Roles and responsibilities of the CEO
3.3.3 Accountability and evaluation of the CEO
3.3.4 Relationship between CEO and Governing Board Chairperson
3.4 Hospital Senior Management Team 26

3.4.1 Responsibilities of the Senior Management Team
3.4.2 Membership of the Senior Management Team
3.4.3 Appointment of Senior Management Team Members
3.4.4 Duties and responsibilities of Senior Management Team Members
3.4.5 Procedures of Senior Management Team Meetings
3.4.6 Subcommittees of the Senior Management Team
3.5 Strategic and annual planning 29
3.6 Essential service package 31
Section 4 Implementation Checklist and Indicators 31
4.1 Assessment tool for Operational Standards 31

4.2 Implementation Checklist 32
4.3 Indicators 33
Source Documents 34
Chapter 1 Hospital Leadership and Governance Page 2 of 34

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

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

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

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

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

Section 3 Implementation Guidance
3.1 Practical tools of leadership and management
Common tools for effective management include problem solving and change management. Although
there are many approaches to both problem solving and change management, some common elements
are apparent. These can be summarized in the ‘8 steps of Scientific Method of Problem Solving’
which is described below.
Step 1 Define the problem,

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

Step 1: Define the problem
As leaders we are often very familiar with the challenges and problems that face our organizations.
The first step to solving a problem is to define the problem (the ‘problem statement’) in a way that
allows us to find solutions. Defining the problem requires substantial analysis of the current situation
and how it differs from the desired situation. The defined problem reflects the priority of the
organization in a particular area and sets the path for management interventions to address the selected
problem. Therefore, the problem statement should be defined after careful consideration.
To devise a good problem statement the following should be considered:
1. Focus on a single problem: The challenges that many leaders face are complex, but it is important
to identify one single problem to work on, rather than getting lost in a tangle of multiple problems.
2. Address problems that are feasibly solved: Selecting a problem that is impossible to solve will
result in frustration and no clear progress.
3. Keep it short: Simply state, “The problem is…” Long, complex problem statements can be
confusing and may result in a lack of a shared understanding of the problem.

4. Find statements that are shared widely by key constituents: In order to gain support for your
solutions, key players must all believe that this problem exists and is important.
5. Do NOT include solutions themselves: This first step simply states the problem. Subsequent steps
focus on identifying solutions. Good leaders often may have a solution in mind, but a clear
strategy starts with the problem, and next focuses on generating multiple solutions.
Figure 1 below shows some common mistakes in defining the problem and gives suggestions for
improvement.
Figure 1 Common Mistakes and Suggestions for Problem Statements
Weak Problem Statement Suggestions for Improvement Strong Problem Statement

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

The overall objective should be phrased to address or solve the problem. The objective identifies
where the organization wants to be regarding the specific problem. In this sense, the defining of the
problem (i.e., reflecting the current state) and the setting of the objective (i.e., the desired state) is a
central part of strategic management. The objective is the goal that your team will focus all of its
efforts toward achieving, so it is important that it is clearly defined. Good overall objectives address
the problem you have defined in the problem statement and have measurable targets.
Figure 2 Relating the Problem Statement, Objective and Target
Relating the problem statement, objective and target

Problem Statement Stock-outs are common
Overall Objective Reduce the frequency of stock-outs by 50%
in the next quarter
Measurable Target Number of stock-outs per quarter

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

2) Process/policy: What procedures or policies contribute to the problem?
3) Equipment: Is there any equipment, including supplies, that contribute to the problem?
4) Environment: Does the immediate environment (i.e., the building or compound), or the broader
environment (i.e., the community, town, or nation) contribute to the problem?
As you identify factors that contribute to the problem, place them on the appropriate “fishbone.” For
each factor that you identify, ask, “What leads to that factor?” For example, in the diagram above, the
laundry machines were identified as an important factor in the lack of sanitation. This is an equipment
issue, and “Laundry Machines Broken” was placed on the equipment fishbone. The laundry machines

were broken because of 2 factors: lack of parts and a budget shortfall. Both of these were added to the
diagram.
Fishbone diagramming is useful for a number of reasons:
1) Allows for open session: Involves everyone in an open session. Using a chalkboard or other
display to brainstorm allows everyone to contribute their ideas, no matter how big or small.
2) Ideas are generated quickly: Generates an abundance of diverse ideas quickly. Because there are
many bones, there is room for many ideas.
3) Group understanding develops: Helps group members understand and appreciate others’
perspectives. Some participants will be more focused on the environmental factors while others
will focus on factors related to people. The diagram makes room for all of these perspectives.
4) Alternative approaches emerge: Helps generate alternative approaches. Identifying multiple
factors will lead to multiple possible solutions.
One drawback to the fishbone diagram is that this tool cannot display the importance or commonality
of a particular issue. To address this weakness, managers may wish to use a problem ranking matrix.
Ranking Matrix of Root Causes

A Ranking Matrix helps determine which causes are the most important to address given limited
resources. A sample Problem Ranking Matrix is presented in Figure 4.
Figure 4 Problem Ranking Matrix
In this figure, there are 2 sets of rankings used to determine the importance of a factor: risk and cost-
benefit.
Risk: Risk (indicated by the blue text) is a measure of how much the factor affects the problem. Risk
is a function of frequency (on the x-axis) and severity (on the y-axis). Consider the example of the
broken laundry machines. A breakdown occurs only occasionally (frequency), but has a critical
impact on the sanitation of the hospital (severity), resulting in a score of 4.

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

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

Figure 5 Sample flow chart
Histogram
A histogram is a useful tool for quantifying the frequency of common causes of the problem. By
quantifying the frequency, managers can focus on the biggest issues first. The histogram below shows
reasons that in-patients do not receive required drugs:
Figure 6 Sample Histogram
70
% of problems
60
50
40
30
20
10
0
Pharm is out Order not MD order not MD order Pharm lost
of drug brought to transcribed missing order
pharm
Histogram analysis provides a useful representation of data that allows managers to prioritize. This
analysis also helps generate alternative approaches and provides a tool for showing progress. One

drawback is that this analysis shows the frequency of the problem without indicating possible
solutions.
Step 4: Generate alternative interventions

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

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

When a few alternative interventions have been generated, the most promising intervention must be
identified. Comparing these alternatives can be challenging, as some members of the group may
prefer one alternative, while other members may champion a different alternative. An Options
Appraisal allows for a side-by-side comparison of the strategic alternatives using evaluative criteria to
select the best option. Consider the following options for addressing low productivity:
Problem Productivity is inadequate

Option 1 Increase staffing
Option 2 Increase pay among existing staff
Option 3 Increase supervision of existing staff
In order to compare these 3 options, the group must agree on a set of evaluative criteria. Evaluative
criteria are factors that are important to the group and the organization. For example, they may
include effect of the problem, expense, political feasibility, or time to implement. The Options
Appraisal can be qualitative or quantitative as shown in Figure 7.
Figure 7 Sample Options Appraisals
Qualitative Options Appraisal

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

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

Step 6: Select the best intervention
Based on the results of the competitive analysis, select the best intervention.
Step 7: Develop implementation plan and implement

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

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

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

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

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

Part of problem solving is monitoring your impact or success.
Box A Monitoring and Evaluation
Monitoring is the systematic and continuous collection of information over time to measure
progress or change of an activity or objective, using pre-defined indicators of progress
and/or impact of an intervention.
Evaluation is the process by which one determines if the program achieved its overall and
specific objectives; it usually is an assessment at one point in time to determine the impact
of the project.
A monitoring plan provides a set of indicators that will be monitored regularly to show the impact of
the management interventions. Indicators should be selected that reflect both processes and outcomes.
Process indicators measure interim impacts, such as the number of staff trained or the percent of drugs
properly unpacked and put away properly. Outcome indicators measure the ultimate objectives such as
patient waiting time or stock outs or patient satisfaction. A good evaluation system has both types of
indicators. In addition, the system should identify how each indicator will be measured, and ideally,
what the target is for performance (i.e., waiting time will be less than one hour for 90 percent of
patients; satisfaction scores will increase by 25%, etc.). See Chapter 13 Monitoring and Reporting for
further guidance.

The management team can use information generated from monitoring and evaluation to assess if
interventions are working as expected and identify where further work is needed to improve
performance in desired areas.
3.2 Governing Board
A well functioning Governing Board, that includes representatives from the hospital’s community, can
have a significant impact on the quality and efficiency of the hospital and its daily performance.
The establishment of a Governing Board builds in two essential characteristics of good hospitals:
• Autonomy to do what is necessary to provide good care, and
• Accountability to those served for the results of that care.
Governing Boards must be committed to creating and maintaining a strong bond between the hospital
and the community it serves and to maintaining a good working relationship with higher authorities
such as Woreda, Zonal, Regional and Federal Health Finance and other relevant Government Offices.
The following sections set out the basic principles related to the establishment, responsibilities and
operating mechanisms of Governing Boards. More detailed information on the specific powers and
duties of Governing Boards within each region are described in the Health Service Delivery and
Administration Proclamations, Regulations and Directives of each Region.
3.2.1 Responsibilities of the Governing Board
Specific responsibilities of the Governing Board include:
A) Determine the organization's mission, vision and values

It is the Governing Board's responsibility to create and regularly review a statement of mission and
vision that articulates the organization's goals and values.
A Mission statement can be defined as ‘purpose, reason for being’ or simply ‘who we are and what we
do’.
A Vision statement can be defined as ‘an image of the future we seek to create’.
Sample Hospital Vision and Mission and Value Statements are given in Appendix A.
All strategies, plans and policies of the Hospital should be in accordance with the mission, vision and
values set by the Governing Board.

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

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

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

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

F) Ensure adequate resources
The Governing Board must identify what constitutes adequate resources for the organization and
ensure the effective means to access these resources. Where necessary, the Board and staff must
devise strategies and the means to improve revenues. Such mechanisms could include fee revision,
outsourcing of activities or the establishment of private wings in accordance with the Regional
financial rules and regulations.
G) Oversee fee waiver and exemption systems

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

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

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

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

The Governing Board should periodically and comprehensively evaluate its own performance, taking
into consideration areas such as:
• Regularity of and attendance at Board meetings,
• Board vacancy rate (% of Board positions that have been filled),
• Knowledge, skills and awareness of Board members on hospital operations, finance, on key
issues affecting the hospital and any national, regional and local health priorities,
• Approval of the strategic and annual plans by set deadline,
• The relationship between the governing board, CEO and hospital Senior Management Team,
• The relationship between the hospital and communities served by the hospital, and
• Engagement with the wider health economy such as woreda, zonal and regional health
departments and any local health partnerships.
A self assessment checklist for a Governing Board is presented in Appendix C.
M) Ensure legal and ethical integrity and maintain accountability

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

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

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

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

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

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

The membership of any Board member should be revoked when:
a) The Board member has no interest to continue membership. In such circumstances the Board
member should give one to two months advance notice (as determined by Federal and Regional
Directives) in writing to the Board Chairperson and RHB Head or Minister of Health;

b) The Board member changes residence address or leaves the office he/she represented;
c) In the case of people’s or employees’ representative if the Board member loses the faith of his/her
constituency and a request is made by the constituency to replace him/her; or
d) The Board member has failed to fulfil the duties of his/her membership. This includes
considerations such as:
i. Repeated absence from Board meetings without sufficient reason
ii. Proven corruption such as earning benefits in the health facility other than the legally
permitted benefits or other corrupt practice
iii. Repeated failure to follow up on actions agreed by the Board
iv. Breach of confidentiality
In such cases, the Board should reach consensus that membership should be revoked and should make
this recommendation to the RHB Head or Minister for Health who will reach a final decision on the
matter.
If a Board member leaves office during his/her period of tenure the remaining Board members should
select one or more possible replacements and nominate the candidate(s) to the RHB or FMOH to make
the final appointment.
D) Duties and responsibilities of Board members

Board members have a duty to:
a) Attend ordinary and extraordinary meetings, respecting the time;
b) Accept and implement a decision passed by the majority;
c) Prepare for each meeting by reading agendas, minutes of the previous meeting and other
documents distributed for consideration;
d) Follow up on any actions agreed by the Board in a timely manner; and
e) Maintain confidentiality on all matters discussed by the Board.
E) Board accountability
Board members have individual and joint responsibility for the decisions they pass and are responsible
individually and jointly for any damage caused to the hospital due to their failure to accomplish the
duty entrusted to them. In the event a Board member solely opposes a decision or an agenda for
discussion, he/she may explain the reason for his/her unique opposition and make it noted on the
minutes. He/she shall not be responsible for any damage occurred due to this decision or agenda item.
Governing Boards are accountable to their respective RHB or the FMOH and should meet all
expectations that the RHB or FMOH places on the Board.
F) Allowance for Board members

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

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

The Chairperson should chair Board meetings and direct the overall functioning of the Board. The
Chairperson should take the lead in clarifying the goals of the Governing Board. This helps to build a
cohesive group and clarify expectations, while focusing the Governing Board’s attention to the
connection between its own performance and the success of the hospital.
B) Convene and facilitate board meetings and set meeting agendas

The Chairperson should ensure that regular Board meetings take place in compliance with the periods
prescribed in Federal or Regional Directives and should convene extraordinary meetings in
compliance with these Directives. The Chairperson must ensure that meetings are conducted in a
professional manner and are constructive for both the hospital and the individual Governing Board
members. The Chairperson therefore must oversee the development of a well-thought out agenda and
supporting materials. The agenda should be a collaborative effort with the CEO. The Chairperson
should expect members to arrive at meetings fully prepared to participate in Governing Board
meetings. It is important that the Chairperson knows how to clarify, summarize and move Governing
Board members to a decision, as well as set aside some time at the end of the meeting for feedback on
how the meeting went.
C) Manage Governing Board structure

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

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

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

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

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

It is essential that the Chairperson is capable of cultivating and nurturing Governing Board members
who have expertise and personal qualities that the hospital needs. He/she must be able to prepare
Governing Board members for future leadership, which requires encouraging periodic self-assessment
in order to highlight Governing Board members’ strengths and leadership possibilities.
6. Communicate with the Governing Board through an effective information system

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

are also an opportunity to provide structured education sessions for Board members on emerging
issues concerning the hospital and/or the community it serves.
(NB: General guidance/etiquette to ensure that any type of committee or meetings function effectively
are presented in Appendix D.)
A) Frequency of Board meetings

It is recommended that during the first year of establishment the Governing Board meets once every
month to become familiar with its own responsibilities, with the hospital and the health sector in
general. Thereafter the Board should develop a schedule whereby the Board meets no less than the
frequency set out in Federal or Regional Directives. Extra-ordinary meetings may be convened should
a matter of particular importance arise. Such meetings will be convened upon the decision of the
Chairperson, or if called for by a minimum of one-third of Board members.
B) Agenda items
The agenda should be set jointly by the Board Chairperson and Hospital CEO. All Board members
should be invited to nominate agenda items for consideration by the Chairperson and CEO. The
agenda and any documents for discussion at the meeting should be distributed to Board members at
least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the Board:
a) Approval of previous meeting minutes;
b) Committee reports;
c) CEO’s report – providing an overview of hospital operations, discussion of pressing issues and
immediate concerns;
d) Old business – issues unresolved from last meeting;
e) New business – any issues Governing Board members want to raise; and
f) Next steps – plans for taking action on decisions reached by the Board, with the assignment of
follow up responsibilities to individuals as appropriate.
C) Decision making
Decisions by the Board should be made by majority vote. In the case of a tie the Chairperson has the
deciding vote. Voting may only take place when a full quorum of Board members is present. A vote
passed by less than a full quorum is invalid. The criteria for a full quorum vary from Region to Region
(from 50% + 1 of Board members to 2/3rd of Board members) and are described in Federal and
Regional Directives. The CEO is an ex officio Board member and hence has no vote on the Governing
Board.
3.2.5 Governing Board standing committees
The Governing Board should assign standing committees to carry out specific functions of the Board
and report on their activities to the full Board. As a minimum the following standing committees
should be established:
a) Executive committee
b) Finance committee
c) Audit committee

Other standing committees may be established on a temporary or permanent basis as the need arises
(for example a CEO selection committee, strategic planning committee, quality assurance committee
or a committee to address an emerging clinical matter).
When selecting members for each committee the following principles should be followed:
a) Committee members should be selected from the current Board members
b) Selection should be transparent and fair, without favouritism of any kind
c) The Governing Board Chairperson should be a member of all committees
d) Each committee should have its own chairperson who will preside over the actions of the
committee
e) Hospital staff, representatives of appropriate external bodies (e.g. MOFED or Woreda Health
Office) or prominent members of the community with an active interest in the hospital and
appropriate professional expertise (e.g. an accountant for the Finance committee) may be
appointed as non-voting members to support the functions of the committee
A) Executive Committee
The Executive Committee should be chaired by the Governing Board Chairperson and should be
comprised of Officers of the Board and all key Governing Board committee chairpersons. The
Committee acts on behalf of the full Governing Board in their absence and is responsible for reporting
to the full Governing Board on such actions.
B) Finance Committee
The Finance Committee oversees the hospital’s financial planning and ongoing financial operations to
ensure the viability of the hospital. This includes monitoring that adequate funds are available for the
organization’s financial plan, safeguarding hospital assets, and ensuring that the hospital has adequate
fiscal policies. Moreover, the Finance Committee must anticipate financial problems by reviewing
hospital financial information provided at regular intervals. The Finance Committee should be
comprised of selected Governing Board members, the hospital Finance Head and possibly
representatives from the Regional or Woreda Bureaus of Finance and Economic Development and
business leaders from the local community. Other than those individuals who are members of the
hospital Governing Board, all finance committee members have no voting rights.
C) Audit Committee
The Audit Committee should make sure that all required financial audits are conducted and that
reports are presented to appropriate bodies. The committee should be chaired by the Treasurer of the
Governing Board and comprised of selected Governing Board members, the hospital internal auditor,
the Finance Head and possibly representatives from the Regional or Woreda Bureaus of Finance and
Economic Development or a respected local accountant with knowledge of bookkeeping and auditing.
Other than those individuals who are members of the hospital Governing Board, all audit committee
members have no voting rights.

Box B The Seven Deadly Sins of Poor Hospital Governance
1. Lack of mission, vision, strategies and community participation/involvement.

2. Resisting change and failure to make strategic investments
3. Making do with irrelevant, useless information
4. Lack of hospital board and management alignment
5. Hiring unqualified or ineffective leaders
6. Failure to spend meeting time on strategic priorities
7. Inability to understand or relate to staff
3.3 Chief Executive Officer
3.3.1 Selection and Appointment of the CEO
Each hospital should be managed by a CEO (General Manager) who is appointed by the Governing
Board or appointing authority following the processes set out in Federal or Regional Directives.
A qualified CEO should have a diverse set of leadership and management skills, as well as
considerable healthcare/hospital experience as either a clinician or management professional. He/she
must be capable of working with diverse groups, such as the Governing Board, various community
groups, government officials and hospital staff, patients and families. He/she should be able to think
strategically to provide vision and direction to the hospital with special attention to professional
development. An individual with an entrepreneurial spirit and who is fiscally responsible will be
valuable to the organization. He/she should be a results oriented leader with an eye for understanding
how to improve patient quality of care.
3.3.2 Roles and responsibilities of CEO
The CEO is the highest ranking management officer in the hospital and as such, directs and
administers the activities of the Hospital in accordance with instructions and plans developed by the
Governing Board. The CEO must ensure that decisions of the Governing Board are implemented
effectively and efficiently throughout the hospital and must ensure the efficient planning and
utilization of all hospital resources in order to achieve the organization’s goals. This entails the
management of human resources, supplies, revenues, and physical and capital assets based on detailed
plans developed for all aspects of the hospital’s operations (see Box C).
Box C Summary of the Role of a Hospital CEO
The Chief Executive provides executive leadership to the Hospital and has corporate
responsibility for setting the strategic direction, formulating policies, monitoring performance
and contributing to the decision making process with fellow Board Members to ensure the future
stability and success of the Hospital, whilst providing the best possible care within available
resources.

CEO responsibilities should be described in a Job Description that clarifies the expectations of
performance and boundaries of his/her responsibilities. Areas of responsibility include:
A) Governing Board development, communication and relationships

The CEO should work closely with the Governing Board to ensure that they, and any Standing
Committees, are assisted and provided with relevant information to enable them to perform their
functions effectively and efficiently. The CEO is an ex officio, non-voting member of the Governing
Board. The CEO should inform the board in a timely manner of any issues of concern or risks that
affect or may affect the hospital. The CEO should work with the Board to provide or facilitate
trainings of Governing Board members to ensure that Board members are adequately skilled for their
role.
B) Planning, monitoring and evaluation of hospital operations

The CEO should prepare hospital strategic and annual plans and submit these to the Board and all
necessary higher authorities for approval. The CEO is responsible to effectively implement these plans
and achieve strategic plan goals. Strategic and annual plans should include all hospital improvement
initiatives.
The CEO should submit to the Board regular performance and financial reports of the hospital,
showing progress towards the goals of the strategic and annual plans, and in particular highlighting
any areas of concern.
The CEO should also ensure that any reporting requirements of higher authorities (such as Woreda,
Zonal or Regional Health & Finance Departments) are submitted in a timely manner.
C) Fiscal
The CEO should prepare and submit to the Board the budget of the hospital for approval. After
approval the CEO should maintain the hospital budget within agreed upon parameters, effecting
payments in accordance with the approved budget and plans. In partnership with the Governing Board,
the CEO is also responsible for designing various mechanisms to increase hospital revenue such as:
• outsourcing non clinical services to improve the overall quality of care,
• establishing, organizing, and controlling private wing health services, and
• revising fee and revenue collection and utilization procedures.
The CEO should ensure that financial audits are performed in accordance with government
requirements and submitted to the Board for approval, and subsequently to the appropriate higher
authority in a timely manner.
The CEO should ensure that any recommendations made by internal or external financial audits are
acted upon appropriately.
D) Development of hospital management committee and other structures

Each hospital should have an organisation chart that describes the organisation of hospital functions
and personnel, including reporting structures. The organisation chart should be developed by the CEO
and approved by the Governing Board.

A skilled CEO finds other capable staff members with whom to share the workload. The CEO may
delegate part of his/her powers and duties to the employees of the hospital to the extent necessary for
the efficient performance of its activities.
The CEO is responsible to establish an effective Senior Management Team to oversee day to day
hospital operations. He/she may also establish additional committees as the need arises (examples are
given in Section 3.4.6 below). The CEO should ensure that each committee has clearly defined
membership and responsibilities, and should ensure that each committee fulfils its functions.
E) Personnel management and development

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

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

The CEO is the chief spokesperson for the hospital’s various audiences and should represent the
hospital in its dealings with third parties. The CEO should strive to enhance the reputation of the
hospital by strengthening relationships with the community, government and professional audiences.
J) Professional development
The CEO should keep current with emerging issues and technologies and ensure that staff members
are also kept current in these areas through training, access to resources, and related opportunities.
K) Leadership
The CEO should establish and increase leadership presence within the hospital and the local
community, as well as in its district, provincial and national communities.
3.3.3 Accountability and evaluation of the CEO
The CEO is accountable to the Hospital Governing Board, and is the only staff member under the
direct supervision of the Board. Evaluations of the CEOs performance should be conducted at least

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

Specific responsibilities include:
A) Assist the CEO to prepare hospital strategic and annual plans for submission to the Governing
Board.
B) Provide reports to the CEO on implementation of strategic and annual plans, according to each
committee member’s area of responsibility.
C) Identify areas of concern in the achievement of hospital plans, and assist the CEO to find
solutions.
D) Ensure that activities of the hospital are carried out with transparency and accountability and that
all required reports are submitted to higher authorities (e.g. RHB, BOFED, FMOH, MOFED) in
accordance with government requirements.
E) Ensure the hospital complies with all relevant government regulations.
F) Provide financial oversight, advising the CEO on mechanisms to generate income and minimize
expenses.
G) Ensure proper implementation of fee waiver mechanisms and reimbursement.
H) Ensure proper management of hospital buildings, estate, equipment and supplies.
I) Resolve departmental or case team problems or disputes when these are beyond the ability of the
department head or case team director.
J) Ensure high quality clinical services by establishing and implementing mechanisms to measure
and improve the quality of care.
K) Support workforce recruitment and retention, protecting the health and wellbeing of hospital staff,
and creating opportunities for staff development including leadership opportunities.
L) Communicate relevant Governing Board, CEO and Management Committee decisions with
subordinate employees.
M) Establishes mechanisms to involve patients and the public in the planning and delivery of hospital
services and to maintain close consultation with community leadership.
N) Work to enhance the organization's public standing and strengthen relationships with community,
government and professional audiences.
3.4.2 Membership of Senior Management Team
The SMT should be comprised of senior hospital leaders such as department or case team heads,
senior clinical staff and key administrative personnel. It is also recommended that a staff
representative, nominated by staff members on a rotating basis, is a member of the SMT. The exact
membership will be determined by the organization structure of the hospital but should include the
following personnel (or individuals with similar responsibilities):
1. Hospital CEO (Chairperson of SMT)

2. Finance Head
3. Head of Human Resources
4. Chief Medical Officer (or equivalent)
5. Senior Nurse Representative
6. Senior Laboratory Representative
7. Senior Pharmacy Representative
8. Chair of Hospital Quality Committee (or equivalent)
9. Staff representative

Hospital staff or representatives of appropriate external bodies may be invited to attend SMT meetings
as non-voting members, to provide reports, information or advice to the SMT as the need arises.
3.4.3 Appointment of Senior Management Team Members
The CEO should determine the membership of the SMT, taking into consideration the organization
structure of the hospital and key leadership positions. He/she should recommend the proposed
membership to the Governing Board for approval. After approval, specific individuals will
automatically be appointed by virtue of their position within the hospital. When a committee member
leaves the office which he/she represented he/she will be replaced on the SMT by the next person
assigned to that post.
The main exception to this rule is the staff representative, who should be elected by majority vote of
hospital employees. This member should serve on the SMT for a time limited period as determined by
the Governing Board (generally one year) and should then be replaced by another elected
representative.
3.4.4 Duties and responsibilities of Senior Management Team Members
Similar to Board members, SMT members have a duty to:

a) Attend ordinary and extra-ordinary meetings, respecting the time;
b) Accept and implement a decision passed by the majority;
c) Prepare for each meeting by reading agendas, minutes of the previous meeting and other
documents distributed for consideration;
d) Follow up on any actions agreed by the SMT in a timely manner; and
e) Maintain confidentiality on all matters discussed by the SMT.
3.4.5 Procedures of Senior Management Team meetings
A) Frequency and timing of SMT meetings
SMT meetings should be held at least monthly or more often as the need arises. Extra-ordinary
meetings may be called by the CEO at any time.
As far as possible SMT meetings should be held during regular working hours, and committee
members should have dedicated time within their work schedule to attend and prepare for committee
meetings.
B) Agenda items for SMT meetings
The agenda should be set by the Hospital CEO. All SMT members should be invited to nominate
agenda items for consideration by the CEO. The agenda and any documents for discussion at the
meeting should be distributed to SMT members at least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the SMT:
a) Approval of previous meeting minutes;
b) CEO’s report – providing an overview of hospital operations, discussion of pressing issues and
immediate concerns;

c) Reports from each SMT member providing an overview of their department/function and any
pressing issues and immediate concerns
d) Old business – issues unresolved from last meeting;
e) New business – any issues SMT members want to raise; and
f) Next steps – plans for taking action on decisions reached by the Committee, with the assignment
of follow up responsibilities to individuals as appropriate.
C) Decision making
Ultimately, the CEO is responsible for all hospital operations and as such has the authority to reach
decisions on hospital management matters. However, he/she may decide to determine specific issues
by a vote of the SMT. In such circumstances decisions of the SMT should be made by majority vote.
In the case of a tie the CEO has the deciding vote.
3.4.6 Subcommittees of the SMT
The SMT may establish a number of subcommittees to carry out specific duties related to hospital
management. Examples include:
A) Quality Committee
This committee is responsible to establish and monitor implementation of a quality management
strategy for the hospital. Further discussion on the roles and responsibilities of the Quality Committee
are presented in Section 3.2.1 of Chapter 12 Quality Management.
B) Drug and Therapeutic Committee

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

An Infection Prevention Committee serves to establish and monitor all infection prevention policies
and procedures in the hospital. Further guidance on the establishment and functions of an Infection
Prevention Committee are presented in Section 3.1 of Chapter 7 Infection Prevention.
D) Medical Equipment Committee

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

The Major Incident Committee is responsible to supervise and co-ordinate emergency planning. For
further information on the membership and roles of a Major Incident Committee please see Section
3.8.1 of Chapter 8 Facilities Management.
F) Disciplinary Committee
The Disciplinary Committee serves to investigate all employee disciplinary charges and to determine
the appropriate disciplinary measure. Further information on the membership and responsibilities of
the Disciplinary Committee can be found in Section 3.10.5 of Chapter 11 Human Resource
Management.
3.5 Strategic and Annual Planning
Strategic planning is the process of determining what an organization intends to be in the future and
how it will get there. The Annual Plan shows how the broader objectives, priorities and targets of the
strategic plan will be translated into practical activities. Each hospital should have strategic and annual
plans that are developed taking into consideration the mission, vision and values of the organization
and aligned with national, regional and local priorities.
Strategic plans should cover a 5 year period and should be ambitious towards reaching the desired
outcome. The annual plan should align with this, providing greater operational detail on a year by
year basis, tied to the annual budget. The Health Sector Development Programme (HSDP) and the
Regional/Zonal/Woreda Strategic Plans are the source documents for hospital strategic plans and
targets.
Detailed annual plans should have the following features:
• Scope: should reflect all activities and budgets, including those implemented by the public sector,
donor agencies, NGOs and communities
• Resource and source of finance: estimation of the total amount of resources available from all
sources (government, specific donors, internal revenue, NGOs etc).
• Implementation schedule: a list of major activities, a quarterly/monthly implementation schedule
and the responsible body for the implementation of each activity
• Monitoring framework: for assessing progress during implementation. This includes key
performance indicators, baseline data, annual targets, information sources and collection
mechanisms, as well as reporting and feedback mechanisms.
Annual plans should be developed in two stages. The core plan is about achieving national targets; the
detailed plan is the core plan plus other activities of local importance.
Figure 9 shows how the planning process works in practice. Hospitals should first review Federal,
Regional, Zonal and Woreda ‘indicative plans’, based on which the hospital should develop its owns
strategic and annual ‘indicative plan’. This is then passed back up the chain for review and approval,
with higher bodies amending their own strategic or annual plans to take account of lower level plans,
or advising amendments to lower level plans where necessary. This ‘top down, bottom up’ approach
will lead to integration of plans at all levels.
The FMOH has established an Annual Planning Template for hospitals that describes the core
indicators for each year, based on HSDP and national targets. The Planning Template for EFY 2002 is
presented in Appendix E. This template may change from year to year in accordance with national
priorities.

In addition to the planning template of the FMOH, hospitals should also follow the processes
established by MOFED/BOFED for budget allocation. This involves preparation of an annual plan and
budget using the MOFED/BOFED template and submission of this to the appropriate authority.
Further details on the budget allocation process are presented in Chapter 10 Financial and Asset
Management.
Figure 9 Strategic and Annual Planning at all Levels
3.6 Essential Service Package
Each hospital should develop an Essential Service Package that describes the core functions and
clinical services provided by the hospital. The Essential Service Package is the foundation for the
Human Resource Development Plan (see Section 3.2 of Chapter 11 Human Resource Management)
and for the Model Medical Equipment List and Equipment Development Plan (See Sections 3.5 and
3.6 of Chapter 9 Medical Equipment Management).
The Essential Services Package should be developed based on the hospital vision, mission and
strategic and annual plans.

Section 4 Implementation Checklist and Indicators
4.1 Assessment Tool for Operational Standards
In order to determine if the Operational Standards of Hospital Leadership and Governance have been
met by the hospital an assessment tool has been developed which describes criteria for the attainment

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

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

4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
Table 2 Hospital Governance and Leadership Indicators

Indicator Formula Frequency Comments
1. Number of Board meetings in Total number of board Quarterly
reporting period meetings in the reporting
period
2. a) Number of Board meetings a) Total number of board Quarterly
cancelled or deferred meetings cancelled or
b) Proportion of scheduled deferred in the reporting
Board meetings cancelled or period
deferred b) Total number of board
meetings cancelled or
deferred in the reporting
period ÷ total number of
scheduled Board meetings
x 100
3. Average attendance rate at Board ∑number of attendees ÷ [total Quarterly
meetings number of Board members x
number of meetings] x 100
4. Number of Senior Management Total number of SMT Quarterly
Team meetings held meetings held in the reporting
period
5. a) Number of SMT meetings a) Total number of SMT Quarterly
cancelled or deferred meetings cancelled or
b) Proportion of scheduled deferred in the reporting
SMT meetings cancelled or period
deferred b) Total number of SMT
meetings cancelled or
deferred in the reporting
period ÷ total number of
scheduled SMT meetings
x 100
6. Average attendance rate at SMT ∑number of attendees ÷ Quarterly
meetings [number of SMT members x
number of meetings] x 100

Source Documents
1. Addis Ababa City Administration Health Bureau. (2009, January). Directive No. 1/2001 issued to
provide for the execution of Addis Ababa City Government Health Services Provision and Health
Institutions Administration and Management Regulation No. 26/2001. Addis Ababa: Addis Ababa
City Government.
2. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 117/ 2005.
3. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 39/ 2006.
4. Department of Health. (1999, March). Clinical Governance, Quality in the New NHS. London:
Department of Health.
5. Department of Health. (2009, January). The NHS Constitution for England. London: Department
of Health.
6. Federal Democratic Republic of Ethiopia Ministry of Health. (2007). The Health Sector
Development Program Harmonization Manual.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, July). Policy, Business
Process Reengineering: Policy, Planning and Monitoring & Evaluation Core Process.
8. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Strategic Plan for Ethiopian Health Sector.
Indicator Definitions. HMIS/M&E Technical Standards Area 1.
10. Federal Democratic Republic of Ethiopia Ministry of Health. (2007, May). HMIS/M&E. Disease
Classification for National Reporting. Technical Standards Area 2.
11. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E. HMIS
Procedures Manual: Data Recording and Reporting Procedures. HMIS/M&E Technical Standards
Area 3.
Information Use Guidelines and Display Tools. HMIS/M&E Technical Standards Area 4.
13. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
14. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, June). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
15. Federal Democratic Republic of Ethiopia Ministry of Health. Data Collection Guide for
Healthcare Quality Assessment.
16. NHS Quality Improvement Scotland. (2005, October). Clinical Governance and Risk
Management: Achieving safe, effective, patient-focused care and services.
17. Oromia Regional Government Administrative Council. (2005). Oromia Regional State Health
Service Delivery and Administration Regulation No. 56/ 2005.
18. Tigray National Regional Government Council. (1999 EC). Bylaw for the Provision, Management
and Administration of Health Services in Tigray National Regional Government Number 42/1999.

Appendices
Chapter 1 Hospital Leadership and Governance

Appendix A Sample Hospital Mission, Vision and Values Statements

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

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

Improving lives. We strive to improve health and well-being and people’s experiences of our hospital.
We value excellence and professionalism wherever we find it – in the everyday things that make people’s
lives better as much as in clinical practice, service improvements and innovation.
Working together for patients. We put patients first in everything we do, by reaching out to staff,
patients, caregivers, families, communities, and professionals outside the hospital. We put the needs of
patients and communities before organizational boundaries.
Everyone counts. We use our resources for the benefit of the whole community, and make sure nobody
is excluded or left behind. We accept that some people need more help, that difficult decisions have to be
taken – and that when we waste resources we waste others’ opportunities. We recognize that we all have a
part to play in making ourselves and our communities healthier.
Adapted from The NHS Constitution for England. DOH, London, Jan 2009.
Chapter 1 Hospital Leadership and Governance Appendix A: Page 2 of 2

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

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

• Planning Cycle
• Hospital Corporate Plan
• Hospital Operational Business Plan
• Annual Budget
• Annual Report
• Revenue and Expenditure
• Raising Revenue
• Commercial activities
• Hospital enterprises
• Private Wing
• Fees and Charges
• Grants and Subsidies
• Borrowings
Chapter 1 Hospital Leadership and Governance Appendix B: Page 1 of 2

• Developer Contributions/Infrastructure Charges
Planning and Development

• Planning and Development
• Land Use Planning
• Masterplan Development
• Planning for Prosperous Hospital
• Building
Local Health Economy and Health Priorities

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

Appendix C Sample Self Assessment Checklist for Governing Board
1. Legal Structure of the Hospital and Background Information
a. Is there documentation relating to the role and Yes/No
reporting responsibilities and appointment of the
Governing Board (GB) and its members If yes, list and provide copies of documentation
available:
b. Are there any special issues or challenges facing Describe:
the hospital (i.e. member communication,
resources, stability)
c. Date of most recent governance review State date:
2. Role of Governing Board and Accountabilities
a. Role of the corporation List and provide copies of objects/purpose, mission,
vision, values, strategic directions etc
b. Date of last strategic plan and date of next review State dates:
of strategic plan
c. Is there a formal statement of corporate Yes/No
accountability? If yes, what is the date of the last
review? If yes, state date:
3. The Board’s Governance Role
a. Define the role of the Board Define:
b. Has the Board expressly adopted a statement of Yes/No

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

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

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

d. Describe participation in Board and individual Describe:
Board member evaluation (self-evaluation and/or
peer review)
5. Board Governance Policies
a. Has a formal Board Governance Policy Manual Yes/No
been prepared? What is the date of the last
review? If Yes state date of last review:
Provide copy of available

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

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

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

b. Are Committee mandates/TORs reviewed Yes/No
periodically?
Describe:
c. How are Committees established? Describe:
d. How are Committee reports dealt with by the Describe:

Board?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

12. Increase TB treatment success Percentage of cohort of new smear Total number of new smear-
Rate Positive TB cases registered in a specific positive TB cases registered in
period that successfully completed the same period
treatment
13. Increase TB Cure rate Percentage of a cohort of new Smear- Total number of new smear-
positive TB cases registered in specified positive TB cases registered in
period that was cured as demonstrated by the same period
bacteriologic evidence
14. Test newly diagnosed TB Proportion of newly diagnosed TB Total number of new TB cases
patients for HIV patients tested for HIV enrolled in the same period
15. Increase detection of new Number of new cases of Multi bacillary
leprosy cases leprosy, never treated before and
registered during the specified period of
time
16. Increase leprosy treatment Proportion of newly registered multi Total number of new multi
completion rate bacillary cases completed their treatment bacillary cases registered in the
same period
HIV/AIDS
17. Increase number of individuals Number of individuals who received VCT
counselled and tested for HIV services
[VCT]
18. Increase PIHCT Pre-test Number of individuals who received HIV All OPD and family planning
counselling Pre-test counselling that was initiated by visits
a provider
19. Increase PIHCT Testing rate Proportion of individuals counselled who Number of individuals who
received HIV testing that was initiated by received HIV Pre-test
a provider counselling that was initiated by
a provider
20. Increase number of pregnant Proportion of pregnant women counselled Total number of ANC clients in
women counselled and tested for & Tested for PMTCT the facility
HIV
21. Reduce mother to child Proportion of HIV+ pregnant women Total number of HIV+ ANC
transmission of HIV received ARVs for prophylaxis client mothers in the facility

22. Proportion of deliveries of HIV+ women The total number of HIV+
that receive a full course of ARV women who deliver during a
prophylaxis given time period
23. Proportion of infant born from HIV+ Total number of infant born
mother averted from HIV infection from HIV+ mother
24. Increase number of People Cumulative number of People Living
enrolled in HIV Care [Pre-ART] With HIV/AIDS (PLWHA) ever enrolled
in HIV care
25. Increase number of People Cumulative number of People Living
receiving ART With HIV/AIDS (PLWHA) ever started
on ART
26. Number of PLWHA currently receiving Number of People (15 to 49
ART years) with HIV in the facility
who are eligible for ART
27. Number of children (under 15
Number of eligible children receiving
years) with HIV in the facility
ART
who are eligible for ART
28. Number of eligible HIV+ pregnant Number of HIV+ pregnant
women receiving ART mothers in the facility who are
eligible for ART
29. Increase TB screening among Proportion of HIV positive clients Total number of HIV positive
HIV positive People screened for TB clients in the facility
Health Systems (Health service Utilization, management and Monitoring and Evaluation)
30. Increase out patient [OPD] Average number of out patient visit[ Population in the catchment area
attendance per capita including first and repeat visits] per
person per year
31. Increase bed occupancy rate Average percentage of occupied beds Number of beds available times
[BOR] during the period under review number of days in the period
32. Decrease average length of stay Average length of stay [in days] of Number of inpatient discharges
[ALOS] patients in an inpatient facility during a
given period of time
33. Increase number of supportive Number of supportive supervision visits Total number of planned
supervision conducted reported by respective health institutions supportive supervision visits for
respective health institutions

34. Improve performance Number of performance monitoring Total number of planned
monitoring conducted in the hospital performance monitoring
(Monthly performance
monitoring)
35. Ensure timeliness of routine Number of routine health and Total number of expected
health and administrative reports administrative reports timely sent to the reports
respective health institutions
36. Ensure routine data quality Proportion of correspondence between Total number of sample taken
data reported and data recorded in
registers and patient/client records, as
measured by a Lot Quality Assurance
Sample [LQAS]
37 Expand CEmONC Establish/strengthen CEmONC services
4. MAJOR ACTIVITIES FOR THE EFY 2002
S.N Activity Description Unit Qt 1st Q 2nd Q 3rd Q 4th Q

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

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

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

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

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

3.4.1 Outpatient Services Layout
3.4.2 Outpatient Services Management and Organization
3.4.3 Central Triage
3.4.4 Outpatient Case Management
3.5 Inpatient Services 20

3.5.1 Inpatient Services Layout
3.5.2 Inpatient Services Management and Organization
3.5.3 Inpatient Case Management
3.6 Delivery Services 26

3.6.1 Delivery Services Layout
3.6.2 Delivery Services Management and Organization
3.6.3 Delivery Services Case Management
3.7 Liaison and Referral Service 29

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

4.3 Indicators 39
Chapter 1 Patient Flow Page 2 of 41
Source Documents 41
Appendices
Appendix A WHO Paediatric Emergency Triage and Treatment (ETAT) Guidelines
Appendix B Sample Adult Triage and Treatment Guidelines
Appendix C List of Possible Day Surgery Procedures
Tables
Table 1 Human Resource Needs for Emergency Services
Table 2 Equipment and Supply Needs for Emergency Services
Table 3 Equipment and Supply Needs for Outpatient Services
Table 4 Patient Flow Checklist
Table 5 Patient Flow Indicators
Figures
Figure 1 Reception service responsibilities
Figure 2 Typical pathway for patients attending Emergency Services
Figure 3 Sample layout of outpatient department
Figure 4 Contents of a sample appointment book
Figure 5 Typical pathway for outpatients
Figure 6 Typical pathway for inpatient admission
Figure 7 Typical pathway for delivering mother
Boxes
Box A Operating Theatre
Box B Intensive Care Unit
Box C Transit Lounge
Box D Referral Network and Emergency Command Centre
Abbreviations
CEO Chief Executive Officer PA Public Announcement
ETAT Emergency Triage and Treatment WHO World Health Organization
FMOH Federal Ministry of Health
ICU Intensive Care Unit
OPD Outpatient Department
OR Operating Room

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

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

a. Manages bed occupancy,
b. Facilitates emergency and non-emergency (elective) admissions, and
c. Receives referrals from, and makes referrals to, other facilities in the referral network.
8. The hospital has a written protocol for the admission and discharge of patients that is known, and
adhered to, by all relevant staff.
9. The hospital has a Referrals Service Directory, listing facilities which the hospital may refer
patients to or receive patients from, categorized by the type of clinical services they provide.

10. Criteria for the referral of patients from the hospital to other health facilities are established,
including standardized referral and feedback forms and necessary clinical documents to
accompany referred patients, in accordance with the national referral implementation guidelines.
11. The hospital has a standardized method for managing referrals.
12. Hospital staff members are familiar with the referral systems including relevant referral protocols
and forms.
13. The hospital promotes and publicizes the referral system throughout the community in order to
ensure that all constituents are aware of the applicable service pathway.

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

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

Figure 1 Reception Service Responsibilities
3.2 Hospital Layout
Patient flow can be improved by an appropriate arrangement of services (hospital layout) supported by
well-placed signs to indicate all service areas. Services should be organized in way that:
• Minimizes patient travel time between services; and
• Reduces the likelihood of patients getting lost when going from place to place.
A site map should be displayed at the hospital entrance. Signboards should be used throughout the
facility to direct patients, caregivers and visitors to the appropriate service areas.
Hospitals should also consider establishing a colour coded system to direct patients who may not be
literate. For example, blue signs could indicate all outpatient services and red signs could indicate
emergency services, etc. The use of drawings and photographs may also be useful in directing patients.
For further guidance on the layout of patient services please see Section 3.2.1 of Chapter 8 Facilities
Management.
3.3 Emergency Services
3.3.1 Emergency Services Layout
The Emergency Services should be organized so that the Emergency Service’s entrance can be easily
accessed by ambulances and patients. This means that the entrance to the Emergency Services should
be clearly labelled in a way that is visible from the street. The Emergency Services should have the
following:

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

Patients entering the hospital through the separate Emergency Department entrance, from the
reception desk or those referred to the Emergency Department from Central Triage (see section 3.4.3
below) should undergo Emergency Triage. If further investigations and/or treatments are required
following triage, these should be provided by the Emergency Case Team. Patients that are not
classified as emergency cases should be referred to Central Triage.

B) Emergency Triage and Treatment Activity
Triage can be defined as the “sorting of patients into priority groups according to their need and the
resources available.”1 The aim of triage is to give priority treatment to those with the most critical
conditions, thus minimizing delay, saving lives, and making the most efficient use of available
resources. During emergency triage any problems identified with critical body functions (airways,
breathing or circulation) should be treated immediately. For this reason emergency triage may be
better described as ‘Emergency Triage and Treatment’ (ETAT).
Ideally, adult and paediatric ETAT areas and triage staff for emergency patients should be separate.
However, if the workload is low a single triage may serve both adult and paediatric patients in the
emergency department. In this case, paediatric patients should be given priority over adults in the
event that more than one patient requires ETAT at the same time.
The ETAT service should be provided 24 hrs a day, 365 days a year. Adult and Paediatric Triage
Protocols should be developed and implemented. Protocols should be posted on the walls of triage
areas as an ‘aide memoire’ for triage staff.
The WHO has developed detailed ETAT guidelines for paediatric cases. These are presented in
Appendix A and should be adopted by all hospitals.
The WHO is currently developing ETAT guidelines for adults. When finalized, these should also be
adopted by hospitals. In the meantime, hospitals should develop their own triage protocols following
the basic steps outlined in Appendix B.
Following the initial triage and treatment to stabilize vital functions, patients should be assigned to the
Case Management Team for further investigations, treatment and follow up. The Triage Officer should
prioritize cases, determining which patients need the immediate attention of the Case Management
Team, which patients are ‘priority’ cases, and which are less urgent (for example a patient with a
minor wound whose vital signs are intact). The Triage Officer should also identify ‘non-emergency
patients’ and refer such patients to Central (outpatient) Triage.
During triage and case management of adult and paediatric cases, runners’- should handle relevant
administrative processes (such as patient registration, retrieving the patient’s medical record, making
payments etc). For further information on the process of registration see Chapter 3 Medical Records
Management.
C) Emergency Triage and Treatment Human Resource Requirements

The Emergency Triage Officer should be trained in Emergency Triage and Emergency Case
Management. Preferably he/she should be a physician but if this is not possible another skilled health
worker may take this role. He/she should be assisted by a Clinical Nurse and runner. If the workload is
high the hospital may appoint more than one Emergency Triage Officer, Nurse and Runner.
1
World Health Organization. 2005. Emergency Treatment and Triage: Participant Manual.

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

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

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

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

• Haemoglobin,
• Haematocrit,
• Blood film,
• Blood group and cross match,
• Total cell count,
• Random blood sugar,
• Urinalysis,
• Stool examination, and
• Pregnancy test.
More complex tests may be performed in the Central Laboratory. If the sample is to be tested in the
central laboratory then a runner should take the specimen to the laboratory and collect the result.
If radiology tests are required these too should be conducted in the Emergency Department using a
portable X-Ray. If this is not possible a runner should transport the patient to the X-Ray department
where the test will be conducted. Results should be taken back to the Emergency Department by a
runner.
If medication is required, a prescription should be issued by the emergency physician and should be
dispensed by the emergency room dispensary.
A cashier service should be available within the emergency department for the payment of all
emergency room treatments, investigations, drugs and consumables. Runners should assist the patient
and/or caregiver with making payment.
Patients who require short term treatments (such as IV fluid administration, a loading dose of IV
antibiotics etc) may be transferred to a bed in the Emergency Services and kept for a maximum of 24
hours. Any patient who requires treatment for a longer period of time should be admitted to an
inpatient ward.
Following assessment, investigation and treatment the patient may be discharged home, referred for a
follow-up appointment at the outpatient services admitted to an inpatient ward or referred to another
facility.
If an outpatient follow up appointment is necessary this should be arranged by the Liaison Officer and
an appointment card should be given to the patient before he/she leaves the emergency department
(see section 3.4.3 below).

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

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

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

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

Equipment and Furniture Supplies
Stretcher Emergency Drugs
Wheel chair Cleansing agents/chemicals
Office furniture Antiseptics/Disinfectants
Screen Dressing materials
Diagnostic kits Stationary
Resuscitation tools –adult/paediatric Personal Protective Equipment
Examination beds
Short stay beds

Refrigerator
Weighing scale
IV stand
Procedure kits
Lab equipment
Mobile X ray
Ultrasound
Monitoring machines
Electrocardiogram
Oxygen cylinder with accessories
High power mobile lamps
Telephone
Computer
Wall clock
3.4 Outpatient Services
3.4.1 Outpatient Services Layout
Outpatient services consist of:

a) central triage
b) clinical assessment, sample collection and treatment rooms
c) pharmacy dispensing unit and cashier
d) laboratory team, with cashier
e) imaging diagnostic team, with cashier
Outpatient Services should be organized in a manner that reduces the amount of time that it takes a
patient to travel from one service location to another. Although each facility has a different layout and
plan, clinical services should be organized as close to one another as possible. A possible layout of
outpatient services is presented in Figure 3 below.
Figure 3 Sample Layout of Outpatient Services
C1 C2 Sample C3 C4
Collection
Outpatient Case Teams

Gate
Receptionist
Central Triage Case Team Client Waiting Area

Runners
Laboratory sample collection Imaging diagnostic team Pharmacy dispensing unit

team (with cashier) (with cashier) (with cashier)

The central triage is the first point of patient contact in outpatient services. The central triage
infrastructure should include a shaded waiting area, registration and medical record storage, cashier
and, clinical assessment areas. There should be separate assessment areas for adult and paediatric
cases. Following central triage, patients should be directed immediately to a case team, or to a shaded
waiting area where they will wait until it is their turn to be seen by their assigned case team.
3.4.2 Outpatient Services Management and Organization
Outpatient Services will be overseen by the Director of Outpatient Services. He/she is responsible for
all activities conducted in the Department including:
• Patient triage,
• Case management, and
• Laboratory, pharmacy and diagnostic services.
3.4.3 Central Triage
A) Central Triage Pathway

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

Central Triage should be open during regular working hours. All patients should undergo Central
Triage EXCEPT:
• Emergency cases (should immediately attend emergency department),
• Labouring mothers (should immediately attend delivery unit),
• Those with an appointment (should immediately go to relevant case team), and
• Private patients (should immediately go to private wing).
The first step in Central Triage activity is to assess and treat emergency signs, following the adult and
paediatric ETAT protocols described in Appendices A and B. The Triage Officer should identify
patients who would be more appropriately treated by the emergency case team, and after stabilizing
vital signs, should transfer these patients to the emergency case team. If the patient does not have an
emergency condition, the Triage Officer should then determine the nature and urgency of the client’s
medical problem and determine the appropriate service/case team required by the patient. If the
service is not available in the hospital then a referral should be made to another facility (see section
3.7.4 below). If the service is available the patient should be transferred to the appropriate case team or
given an appointment for the next available date.
When scheduling appointments for the same, or a future date, staff should take all relevant patient
information into account, including:

• The severity of the condition,
• Distance travelled by patient,
• Financial status of patient (for example financial difficulties that could prevent the patient
returning to the hospital at a future date taking into consideration transport and/or hotel costs),
and
• Social circumstances of patient (for example loss of income due to absence from work,
childcare needs of dependent children etc).
The criteria by which a patient is given priority for treatment should be written and visible to patients
and staff to ensure transparency in the process.
If the patient can receive services on the same day he/she will complete all necessary registration and
payment requirements in the Central Triage and then be directed to the relevant outpatient case team.
If the appointment is scheduled for a future date, the patient should be given an appointment card and
advised to report to the appropriate case team on the date of their appointment, without undergoing
Central Triage again. A sample Appointment Card is presented in Appendix A, item 3 of Chapter 3
Medical Records Management.
Appointment system
Outpatient appointment systems should be established for both general outpatients and for all
specialist services provided by the hospital.
To achieve this, Appointment Books should be established for each general and specialist case team.
Each Appointment Book should have a defined number of slots that are kept free for ‘urgent’ patients
who undergo triage and require treatment on the same day.
Figure 4 below presents the Contents of a Sample Appointment Book for a Case Team that can
manage 15 ‘same day treatment’ patients and 10 ‘booked appointments’ on a single day.

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

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

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

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

• Stretcher
• Screens, partitions or separate rooms
• Gloves, face masks and other personal protective equipment
• Wall clock(s)
• Microphone/PA system
E) Central Triage Training Requirements

All Central Triage clinical staff should be trained to conduct triage, following the established triage
protocols. Staff should also be trained on customer service.
3.4.4 Outpatient Case Management
A) Outpatient pathway
Outpatient services should be organized as Case Teams. There should be General Case Teams and
Specialist Case Teams for all specialist services provided by the hospital. Patients enter the outpatient
case management pathway from Central Triage or directly from the reception service if they have a
pre-booked appointment. Appropriate care is then initiated by the Case Team and based on the
outcome the patient is either admitted, discharged (with or without a further appointment) or referred.
Figure 5. Typical Pathway for Outpatients
A: Inpatient service flow D: Discharge service flow DR: Delivery service flow: DI: Diagnostic Imaging Service flow E: Epidemic
notification flow ER: Emergency Service flow F: Pharmacy service flow L: Laboratory service flow O: Outpatient service flow R:
Registration service. Source: Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report.

B) Outpatient activity
The outpatient case team will take a history and examine the patient. If laboratory tests are required
samples should be collected from the patient within the outpatient department. Ideally, samples should
be collected in the initial consultation suite by a nurse or phlebotomist, and a runner is responsible to
take the sample to the laboratory testing area and to assist the patient to make payment. If it is not
possible to take a sample in the initial consultation room then there should be a specific sample
collection and payment area within the OPD that is easily accessible to all OPD patients and has
sufficient staff to prevent delay. Runners should transport samples from the collection area to the
testing laboratory and should take all results back to the clinical case team.
The Diagnostic Imaging department should be located in close proximity to OPD and any patient who
requires imaging services should be directed there, with the assistance of a runner, if necessary.
The results of all investigations should be taken by a runner back to the patient’s case team as soon as
they are available. The patient will then be reviewed by the case team and the results of any
investigations and treatment options should be explained and discussed with the patient.
If the patient needs consultation with another Specialist this should, as far as possible, take place on
the same day. A consultation request form should be completed and this should be given to the
appropriate Specialist together with the patient’s Medical Record. A sample Consultation Request
Form is presented in Appendix B, item 6 Chapter 3 Medical Records Management.
If medication is required the patient should be directed to the pharmacy dispensing unit from where
he/she will make payment (if necessary) and obtain the necessary drugs and appropriate counselling.
Any minor procedures that are required (such as dressings change or injections) should be carried out
in the outpatient department.
If the patient needs to be admitted to hospital the case team will contact the Liaison and Referral
Service to arrange admission (emergency or elective).
C) Outpatient case team human resource needs

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

D) Outpatient case team equipment and supply needs
Each case team room should be equipped with equipment and supplies needed to provide care. The
following is a list of suggested items that should be found in the case team room. It is not an
exhaustive list of all possible equipment and supplies, but should be used by each facility as a guide
when determining equipment needs.
Table 3. Equipment and Supply Needs for Outpatient Services

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

practitioners, health officers, nurses, runners, cleaners etc. Each Case Team should be led by a Case
Team Leader. Pharmacy and laboratory personnel should also form part of inpatient services and
should provide support and advice to the Clinical Case teams on individual patient care as the need
arises (see Chapter 4 Pharmacy Services and Chapter 5 Laboratory Services for more information).
3.5.3 Inpatient Case Management
A) Admission process
All admissions should be arranged through the Liaison Service following the process described in
Sections 3.7.2 and 3.7.3 below.
The hospital should have a written protocol for the admission of patients that includes all steps to be
taken in the admission process including how to arrange admission, and the activities to be undertaken
when the patient arrives on the ward. This should be known by, and adhered to by all relevant staff.
Upon arrival on the ward the patient should be received by a nurse who will initiate the ward
admission process, including orientation to the facilities (such as toilet and showers), instructions for
care-givers etc.
The patient should be assessed by a medical doctor upon arrival on the ward and a History and
Physical Examination Assessment should be completed. This should include the immediate
management plan for the patient. A sample History and Physical Examination Assessment Form is
presented in Appendix B, item 4, Chapter 3 Medical Records Management.
Additionally, a Nursing Assessment should be completed within 24 hours of admission and a Nursing
Care Plan developed. For further information on the Nursing Process, including sample formats, see
Chapter 6 Nursing Care Standards.

Figure 6. Typical Pathway for Inpatient Admission.
Registration service. Source: Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report.
B) Inpatient activity
After the initial assessment by the physician, the patient should be reviewed regularly (at least once a
day) by the relevant Case Team and all clinical contact should be documented in the Medical Record
using a hospital Progress Sheet (see Appendix B, Chapter 3 Medical Records Management).
Any required investigations should be ordered on the relevant request forms. Laboratory specimens
should be collected from the patient while on the ward. If the patient requires an X-Ray or ultrasound
investigations he/she should be directed to the relevant department, transported to the department
using a wheelchair or stretcher and accompanied by a runner or clinical staff member if necessary.
Medications should be administered and documented using standardized formats.

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

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

The intensive care unit of a hospital should also be given attention. Recommendations on ICU
management are presented in Box B.
Box B. Intensive Care Unit (ICU)

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

• The ICU should be adjacent to the operating theatre and recovery unit.
• The number of beds should be approximately 1-2% of the total number of beds of
the hospital.
• Preferably, the ICU should have a controlled environment with medical gasses
and power sources.
Equipment and Staff: should be provided as per the national standard for general and
specialized hospitals.
C) Discharge Process
The hospital should establish a written protocol for the discharge of patients stating all the steps to be
followed when arranging discharge, including preparation of a discharge summary and handling of the
medical record after discharge. In particular, when a patient is ready for discharge he/she should be
counselled by a member of the Case Team. This should include:
• An explanation of the patient’s diagnosis, investigation results and treatments given
• An explanation of any medications that the patient should continue to take upon discharge
• Any necessary follow up arrangements
• A discussion of any ‘warning signs’ that the patient should be aware of and for which he/she
should seek medical attention
The decision for discharge should be made by a physician who should complete a discharge summary
for the patient. A copy of the discharge summary should be given to the patient and a second copy
filed in the Medical Record. If a patient was referred from another facility the discharging physician
should also complete the feedback section of the Referral Paper. A Sample Discharge Summary is
presented in Appendix B, item 21 of Chapter 3 Medical Records Management.

D) Patient death
If a patient dies in the hospital the death should be confirmed by a physician. A death summary should
be completed and should be documented in the patient’s medical record. A sample Death Report is
presented in Appendix B, item 3 of Chapter 3 Medical Records Management. If it is necessary to
confirm the cause of death a post mortem examination form should be completed and the body should
be transferred to the pathology case team for post mortem examination. A sample Post Mortem
Request Form is presented in Appendix B, item 22 of Chapter 3 Medical Records Management. When
all necessary medical examinations are complete the body should be stored in the hospital morgue
until collection by the patient’s relatives or other responsible person. If the patient does not have a
next of kin, the local authority is responsible for collecting the body.
All unexpected deaths should be reported to, and investigated by, the hospital Mortality Committee.
For further information on roles of the Mortality Committee see Section 3.2.2 of Chapter 12 Quality
Management.
E) Inpatient Service Human Resource Requirements

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

The minimum equipment and supplies for patient wards include:
• beds, mattresses, pillows, linens and blankets
• chairs, tables, and bed side tables
• bed screens
• emergency trolley with resuscitation equipment and emergency drugs
• oxygen
• suction machine
• stethoscope(s)
• sphygmomanometer(s)
• thermometer(s)
• tendon hammer
• weight scale

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

Labouring mothers should be directed immediately to the delivery suite by the reception service.
Assistance may be provided by a runner, using a wheelchair or stretcher if necessary. Within the
delivery suite the patient will be assessed by the Midwife in Charge. At the same time all relevant
administrative processes (registration, medical record retrieval, payment etc) will be conducted with the
assistance of a runner. The patient will be admitted, discharged or referred to another facility according
to her status and the availability of the necessary service in the receiving facility.

Figure 7. Typical Pathway for Delivering Mothers
Registration service. Source: Adapted from Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative,
Rehabilitative and Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report.
B) Delivery Services Activities

Upon arrival in the delivery suite the labouring mother should be assessed for signs of, and the stage,
of labour. An assessment of foetal wellbeing (using foetoscope, Doppler or cardiotocograph) should
also be conducted.
If the mother is in labour a partograph should be commenced and labour and delivery managed
accordingly.

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

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

The minimum equipment and supplies for the delivery service include:
• Beds, mattresses, pillows, blankets, linens, etc
• Chairs, bed side tables/lockers
• Bed screens
• Delivery beds
• Examination couches

• Thermometer(s)
• Sphygmomanometer(s)
• Tendon hammer(s)
• Stethoscope(s)
• Foetoscope(s) or Foetal Doppler
• Adult weight scale
• Neonatal weight scale
• Oxygen (cylinder with flow meter or oxygen concentrator) with face mask and connectors
• Suction machine and tubes
• Ambu-bag and airways
• IV stands
• Vacuum extractor (preferably with silastic cups of various sizes)
• Procedure kits:
o Delivery set
o Episiotomy set
o Perineal suture set
o Manual Vacuum Aspiration Set
o Craniotomy set
• Personal protective equipment
• Neonatal cots
• Neonatal heater/baby warmer(s)
• Neonatal incubator (s)
• Stretchers and wheelchair
• Patient trolley(s)
• Emergency drugs
• Wall clock
3.7 Liaison and Referral Service
Each hospital should establish a Liaison and Referral Service that is responsible to:
1. Manage hospital bed occupancy (bed management)
2. Facilitate emergency and non-emergency (elective) admissions
3. Provide social service support to the Emergency, Inpatient and Outpatient Case Teams
4. Manage the referral service, specifically:
• Coordinate the overall referral activities within the health facility
• Record and report the referral activities to facility management
• Compile, analyze and interpret data to improve the referral service
• Take part in the quality assurance programs of the referral system by participating in
regular review meetings within and outside the health facility
• Perform supportive supervision
• Ensure feedback is sent back to the referring health facility
The Liaison and Referral Service is staffed by Liaison Officers. Each hospital should determine the
number of Liaison Officers required based on the caseload. If the number of admissions and/or
referrals is high, then at least one Liaison Officer should be assigned to the Outpatient Case Team and
another to the Emergency Case Team. However, if the number of admissions and/or referrals is low
then a single Liaison Officer could be responsible for all Liaison and Referral Services, providing
he/she is readily accessible to each Case Team by telephone, pager or via a ‘runner’.
Additionally, the Liaison and Referral Service should include at least one social worker. Social work
assessment, advice and any necessary follow up is particularly important for emergency and paediatric
cases, and should also be provided for any patient where social work assessment is requested by the
relevant clinical case team.
The Liaison and Referral Service should establish and regularly update a Hospital Service Directory
which includes:
• information about services provided by the hospital,
• contact information for key services (such as emergency, outpatient, inpatient, and delivery
case teams, laboratory, radiology services etc), and.
• a map indicating the layout of hospital services.
Copies of the Service Directory should be distributed to Emergency, Outpatient and Inpatient Case
Teams in addition to hospital managers.
3.7.1 Bed Management

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

a) Reduce length of stay
No patient should remain in hospital any longer than is necessary. Patients are often not discharged
when ready because:
• Ward rounds are irregular or infrequent and there is no one to authorize discharge,
• Required investigations or procedures are not carried out in a timely manner,
• There is a delay in arranging necessary follow up appointments, discharge or referral papers, or
• The hospital does not provide administrative or cashier functions to handle discharges 24 hours
a day, 365 days a year.
A pro-active approach should be taken to minimized length of stay. Discharge planning should begin
at the point of admission of each and every patient when the admitting physician should outline a plan
of action, including investigations and procedures for the patient. Ward rounds should be conducted
daily and the case team should ensure that each day the treatment plan is being followed or modified
as required. On each ward round case teams should consider the possible discharge date for each

patient and should plan accordingly, ensuring that all necessary investigations and procedures are
carried out promptly, referral papers are prepared etc.
Patients should be discharged every day of the week and hence ward rounds should be conducted daily
to authorize discharge and all necessary administrative/payment functions required for discharge
should be available on each and every day.
b) Make greater use of day surgery

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

All admissions should be co-ordinated through the Liaison and Referral Service. Priority should be
given to emergency cases.
Effective management of the admission process requires knowledge of:

1. The total number of beds
2. The number of occupied beds at the midnight census (bed occupancy)
3. The number of beds that are due to be vacated or could be vacated that day
4. The number of ‘reserved beds’ for elective admissions that day, the urgency of and reason for
admission, and length of time on the waiting list for that patient.
Each night, at midnight, every ward or inpatient case team should count the number of occupied beds.
This number should be reported to the Liaison and Referral Service at the start of the working day.

Each ward/case team should also determine the number of patients due to be discharged that day, and
this number should also be reported to the Liaison and Referral Service.
At the same time, the Liaison and Referral Service should keep a record of the number of elective
admissions to each ward/case team expected for the day.
The number of available beds available in each Case Team can be calculated on a daily basis as
follows:
Number of available beds

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

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

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

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

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

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

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

At the start of each working day the number of beds available in the facility should be ascertained
by the Liaison and Referral Service (see section 3.7.1 above). When another facility phones/faxes
the service to request an emergency admission the Liaison Officer can check bed and service
availability, and if appropriate, agree to accept the referral. The Liaison Officer should then inform
the Reception Service and the relevant Case Team (Emergency or Inpatient) so that the patient can
be directed straight to the Case Team/Ward on arrival.
If the referral is non-urgent, an elective admission date can be given and the Referring Unit should
be instructed to pass this information onto the patient, advising him/her to present to the Liaison
Officer on the assigned date. As described under section 3.7.2 above, the Liaison and Referral
Service should include these patients in the ‘elective admission’ list that is presented to the
Inpatient Case Teams on a daily basis.

ii) Receiving outpatient referrals
If a telephone/fax request for an outpatient appointment is made, the Liaison Officer should obtain
all relevant patient details and confirm that the referral is appropriate. The Liaison Officer should
then book an appointment in the Appointment Book of the relevant Outpatient Case Team (see
section 3.4.3 above) and give this appointment date to the Referring Unit, instructing the Referrer
to pass this information onto the patient and to advise him/her to present at the Outpatient
Department on the assigned date.
Patients who have been given appointments in this way should be directed by the reception service
straight to the inpatient ward or to the Outpatient Case Team (without undergoing Central Triage).
iii) Receiving patients who are referred without a pre-booked appointment

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

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

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

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

If the required service and/or bed are not available in another facility then the hospital should keep the
patient and provide treatment as necessary until the patient can be discharged or until the service
and/or bed becomes available in another facility.
c) Follow up and audit of ‘received’ and ‘referred’ patients

The Liaison and Referral Service should keep a Register of all referrals received by and made from the
facility. As a ‘Receiving Unit’ the hospital should ensure that a summary of the patient attendance is
prepared and sent back to the Referring Unit. As a ‘Referring Unit’ the hospital should establish a
mechanism to track all referrals and ensure that Feedback Forms are received for all patients who were
referred by the facility. If Feedback Forms do not arrive when expected, the Liaison Officer should
follow up with the Receiving Unit to check that the patient attended and to request a copy of the
Feedback Form.
The Liaison and Referral Service should prepare regular (e.g. quarterly) reports on referral activities
including:
1. The number of referrals accepted for outpatient appointments (by speciality if appropriate)
2. The number of referrals accepted for inpatient admissions (by speciality if appropriate)
3. The number of referrals made for outpatient appointments at another facility (by speciality if
appropriate)
4. The number of referrals made for inpatient admission at another facility (by speciality if
appropriate)
5. A breakdown, by facility name, or referrals received and referrals made
The number of referrals received and made by the hospital, as a proportion of all attendances, could be
included as indicators in the Balanced Scorecard and monitored regularly by the Governing Board (see
Chapter 13 Monitoring and Reporting).
3.7.5 Availability of Liaison and Referral Service
The Liaison and Referral Service should be available 24 hours a day, 365 days a year. Possible options
to achieve this include:
1. If the caseload is high there should be a Liaison Officer ‘on shift’ within the Emergency
Department providing 24 hour cover, 365 days a year; or
2. If the caseload is low, the Emergency Case Team could handle admissions and referrals during ‘out
of hours’ periods. To achieve this, at the end of each working day the Liaison Service should
provide information to the Emergency Department indicating the number and location of beds
available in the hospital. A member of the Emergency Case Team on shift during each ‘out of
hours’ period should be assigned as ‘Deputy Liaison Officer’ for the duration of that shift. He/she
is responsible to facilitate emergency admissions to the available beds and to arrange emergency
referrals (following hospital protocols) if a bed is not available. If an outpatient appointment is
necessary this can be arranged by the ‘Deputy Liaison Officer’ by booking the appointment in the
Appointment Book of the relevant Outpatient Case Team.

If the second option is selected then the Liaison and Referral Service should collect a record of patients
admitted or referred from the Emergency Department at the start of each working day.
3.7.6 Promotion of Referral Network
The hospital should collaborate with other facilities in the network and the Regional Health Bureau to
promote, monitor and evaluate the referral system. In particular, the hospital should promote and
publicize the referral system through the community in order to ensure that all constituents are aware
of the applicable service pathway. For further guidance on mechanisms to inform and involve the
community see Section 3.1.5 of Chapter 12 Quality Management.

In order to determine if the Operational Standards of Patient Flow have been met by the hospital an
assessment tool has been developed which describes criteria for the attainment of a Standard and a
method of assessment. This tool can be used by hospital management or by an external body such as
the RHB or FMOH to measure attainment of each Operational Standard. The tool is presented in
Appendix E of Chapter 13 Monitoring and Reporting.
The following Table can be used as a tool to record whether the main recommendations outlined above
have been implemented by the hospital. This tool is not meant to measure attainment of each
Table 4. Patient Flow Checklist

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

4.3 Indicators
effectiveness/outcomes of implementation of the above recommendations.
Table 5. Patient Flow Indicators

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

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

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

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

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

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

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

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

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

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

Number of OPD visits per of OPD practitioners *22*number of indicator
practitioner per day months in period)

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

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

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

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

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

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

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

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

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

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

23. a) Number of referrals a) The total number of OPD visits, Quarterly
accepted from other ER visits and inpatient
health facilities admissions who were referred
b) Proportion of all from another facility with a
attendances that were referral paper
referred from another b) The total number of OPD visits,
facility ER visits and inpatient
admissions who were referred
from another facility with a
referral paper / total OPD visits,
ER visits and inpatient
admissions*100
24. % of inpatients indicating The number of inpatients that Biannual Survey tool
that it was it easy to find responded yes to the question on the presented in
their way around the health patient survey “Was it easy to find Appendix F
facility. your way around the health of Chapter
facility?”/total number of 12 Quality
respondents *100 Management.
25. % of outpatients indicating The number of outpatients that Biannual Survey tool
that it was easy to find their responded yes to the question on the presented in
way around the health patient survey “Was it easy to find Appendix F
facility your way around the health of Chapter
facility?”/total number of 12 Quality
respondents*100 Management.
Source Documents
1. Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business Process
Study Report. Addis Ababa, Ethiopia.
2. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, November). Guideline for
Implementation of a Patient Referral System in Ethiopia. Addis Ababa.
3. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Patient Flow: A
Manual Prepared for Heads of Hospitals and Service Providers. Addis Ababa, Ethiopia
4. WHO. (2005). Pocket Book of Hospital Care for Children. Guidelines for the Management of
Common Illnesses with Limited Resources. Geneva: World Health Organization.
5. WHO. (2005). Emergency Treatment and Triage: Participant Manual. Geneva: World Health
Organization.

Appendices
Chapter 2 Patient Flow

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

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

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

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

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

Medical Records Management
Section 2 Operational Standards for Medical Record Management 5
3.1 Retrieval of Existing MRN or Generation of New MRN 5
3.1.1 Master Patient Index
3.1.2 Patient registration
3.1.3 Starting a Medical Record for a new patient
3.1.4 Service Card
3.1.5 Storage of Medical Records
3.1.6 Retrieving existing Medical Record for a returning patient
3.1.7 Appointment Card
3.2 Documenting Patient Information 10
3.2.1 Purpose of clinical documentation
3.2.2 How and when to document
3.2.3 General rules in clinical documentation
3.2.4 Standardized documentation and forms
3.2.5 Key components of clinical documentation and Medical Record forms
3.2.6 Correcting medical record data
3.3 Handling of Medical Records 16
3.3.1 Tracking the location of Medical Records
3.3.2 Who should handle Medical Records?
3.3.3 Archiving Medical Records
3.3.4 Medical Records at discharge
3.3.5 Destruction of inactive Medical Records
3.3.6 Removal of Medical Records from hospital
3.3.7 Confidentiality
3.4 Basic requirements for establishing a Medical Record Management System 19
3.5 Human Resources for the Medical Records Department 21
3.6 Medico-legal Issues and Procedures 21
3.6.1 Patient consent for release of records
3.6.2 Procedures for releasing patient data
3.6.3 Responding to subpoena or court order request
4.3 Indicators 24
Source Documents 25
Chapter 3 Medical Records Management Page 2 of 25

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

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

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

The medical record (MR) is the central documentation of the patient’s visit to a health care facility. A
well-managed MR system is critical to providing efficient and high quality patient care. The primary
purpose of the MR is to act as an immediate record available at all times, documenting the patient’s
presenting symptoms and the subsequent care and treatment. MR management systems are designed to
improve a patient’s health status by maintaining a MR that encompasses all aspects of a comprehensive
health program. In addition, the MR function supports the surveillance and audit of hospital activities.
The system must include a readily available, complete, and accurate MR on all individuals evaluated
and treated in the hospital. A well-designed MR management system facilitates the exchange of medical
information among all health care professionals (physicians, nurses, technicians) who provide health
care to the patient.
Key aspects of MR management include: 1) retrieval of existing medical record number (MRN) or
generation of new MRN as needed, 2) documenting of patient MR information, and 3) handling of
MRs.
This chapter describes standards and guidelines for the effective management of a MR system.
Section 2 Operational Standards for Medical Records Management

1. The hospital utilizes a Master Patient Index with a single, unique Medical Record Number for each
patient.
2. The hospital utilizes a single, unified registration system for all patients, including inpatients,
outpatients, emergency patients, and specialty clinics.
3. The hospital utilizes a paper-based or computer-based system to track where the medical record is
located at all times.
4. The hospital utilizes a uniform set of forms that comprise a complete medical record for the duration
of a patient’s care.
5. The hospital has medical records management guidelines for proper handling and confidentiality of
medical records.
6. The hospital has orientation and training programs for all medical records personnel to ensure
awareness of and competency in medical record management procedures.
3.1 Retrieval of Existing MRN or Generation of New MRN
When a patient arrives at a hospital seeking care and treatment, the hospital’s first interaction with the
patient is to identify his/her status as an emergency or routine case and to identify if the patient is a new
patient (i.e., has never been given a MRN before at the facility) or a returning patient (i.e., has a MRN
at the facility from a previous visit).

Each patient should have one MRN for all visits to the health facility. The MRN is generated during the
registration process at the first visit a patient has to the health facility. Subsequently, the same MRN
will be used for all other visits, including outpatient, inpatient, and emergency visits.
The Master Patient Index (MPI) is a database of patient names, contact information, registration dates,
and the MRN for each patient ever treated at the health facility. The MPI is an essential element of
retrieving existing and generating new MRNs.
3.1.1 Master Patient Index
Each health facility should have a Master Patient Index (MPI). The MPI can be paper-based or
computer-based (with paper based back up). A paper-based MPI relies on the use of an individual
index card. Each MPI card should include the following information:
• Patient’s first name
• Patient’s father name
• Patient’s grandfather name (if available)
• Date of Birth (DOB)/Age
• Sex (Male/Female)
• Address
• MRN
• Date of registration
• Phone number
A template Patient Index Card for use in Ethiopian health facilities is presented in Appendix A, Item 1.
The index cards should be filed alphabetically by first name. When the hospital learns that a patient has
changed his/her name, a cross-index file should be made to identify the initial record with the previous
name. The MRN of the original registration should be recorded on the cross-index card.
If a patient changes any other contact details (such as address or telephone number) a new MPI card can
be prepared to replace the original. The patient name, MRN, date of registration and any other
unchanged information should be transcribed exactly as written on the original onto the new card. The
old card should be scored through with the signature of the individual preparing the new card. The new
card should be stapled to the top of the old card and both should be filed together so that the updated
information is readily available without losing any prior information. In a computer based MPI the
contact details can be amended directly in the appropriate computer fields.
Manual Paper-Based System: Vertical file cabinets for filing index cards may be purchased for
hospitals that use a paper-based MPI. The paper-based MPI should be monitored by the MR
Department, at a minimum, every quarter to ensure that the MPI is filed correctly. Each facility must
establish a procedure for this activity. Sub-headings may be added in the alphabetized system for
common names (“Me” for Meskerems, “Mo” for Mohammeds, etc).
Computer-Based System: The use of a computerized MPI permits faster retrieval of patients’ MRNs.
Health Management Information System (HMIS)’s electronic medical record system which is being
rolled out across Ethiopian hospitals includes a computerized MPI component. However, a paper-based
card file should also be maintained in case of computer technical failure/downtime. Interruptions

in the system can be caused by a variety of factors, including electrical outages or hardware/software
problems. Therefore, hospitals should maintain a back-up, paper-based system in order to ensure no
interruption in MRN retrieval.
If a computer based system is used in addition to a manual system, similar procedures should be
followed for both MR management systems to ensure optimal patient care. Both systems are effective
when implemented and used correctly.
3.1.2 Patient Registration
Patient registration is the process of documenting the patient’s visit to the facility and assigning a MRN,
which is the patient’s MRN forever at that facility. When the patient arrives at registration, the clerk
should ask the patient’s name (first, father’s first name and grandfather’s name) and then look for an
existing MRN in the paper-based MPI (i.e., set of index cards) or in the computerized MPI. This should
be done whether the patient reports that he/she has been to the hospital before or not.
If there is an existing MRN for that patient, the registration clerk should facilitate the retrieval of the
existing MR stored in the record room. A runner/transitor should retrieve the patient’s MR and then take
the MR to the area where the patient is to be treated.
If no previous MPI card or MRN can be found, the registration clerk should generate a new MRN. New
MRNs should be issued in straight numeric sequence, without skipping any numbers. Each MRN
should be assigned to one and only one patient. Reissuing a MRN to another patient should never occur.
Registration staff should both create an index card for the paper-based MPI and enter the new patient in
the computerized MPI if there is a computerized MPI.
All patients– regardless of which service they will access–should be registered at one central
registration site.
3.1.3 Starting a Medical Record for a new patient
After the MRN is generated (i.e., the next number in the sequence is assigned to the selected patient), an
individual hospital-approved folder should be assigned to the patient. Any patient information generated
by hospital staff during the period of care will be kept in this folder. A paper fastener or the equivalent
should be used to keep all pre-approved clinical documents/forms in the folder. The MRN should be
clearly displayed on the folder as a form of identification.
3.1.4 Service Card
Each new patient registered for outpatient or inpatient services should be issued a service card. This
card is a small pocket-sized card used as an identification card for each patient which should be shown
to the MR staff whenever the patient attends the hospital. Selected registration information should be
recorded on the card. Contents of the patient service card include:
1. Name of the Facility

2. Date of Registration
3. Medical Record Number
4. Name of client
5. DOB or age at registration
6. Sex

7. Client’s address
A template Service Card for use in Ethiopian health facilities is presented in Appendix A, Item 2.
3.1.5 Storage of Medical Records
All active MRs should be filed in a single, centralized file room, i.e., the Medical Records Department
or Card Room. MRs should be filed numerically according to MRN. If more than one room is needed
for file storage, files should be stored numerically (i.e. MRN 1,000-5,000 in one room 1; MRN 5,001 –
10,000 in room 2). Hospitals should audit the files periodically (quarterly or as per hospital policy) to
ensure correct filing. All patient files should be stored together, using one MPI, including those from
specialized clinics (eg ART, EPI etc). If separate record numbers and/or filing systems exist the hospital
should integrate these within a single system.
3.1.6 Retrieving existing Medical Record for a returning patient
1. Use the MRN to find the MR.
If the patient knows his/her MR number or brings his Service Card, then the MR number can be used to
find the patient’s MR. The MR is filed numerically in the MR room and hence can be easily retrieved
from the shelf.
2. Retrieving a MR by name
If the patient does not remember their MRN or does not have their service card, then MPI can be used to
search for the patient information. The patient’s index card is filed alphabetically by first name in the
MPI. When the Index Card is located the MR number can be read from the card and used to retrieve the
MR.
3.1.7 Appointment Card
An appointment card should be given to the patient stating the date and time of planned outpatient visits
or admission. A template appointment card is presented in Appendix A, Item 3.
Figure 1 below shows the flow of medical records from generation until return of the medical record to
the medical record room.

Figure 1. Flow of data from registration to return of the medical record
MRD
Client seeking
Healthcare;
MR Opened
MPI
Search by MPI
Indexed
MR listed and dispatched
Clinic
Ward
Outpatient
Inpatient data
REGISTERS data REGISTERS
Pathology, Consultations,
X-ray, Operation,
Biochemistry, Anesthesia,
ECG data Physiotherapy
Data REGISTERS
REGISTERS
Client completed service
MRD
MR assembled and completed
MR Filed
------------
Source: HMIS Medical Records Training Manual, p.26, June 2008.

3.2 Documenting Patient Information
3.2.1 Purpose of clinical documentation
MR documentation is essential to ensure quality of care for every patient. All information regarding
the patient and his/her course of care at the hospital should be recorded in the MR. This includes
his/her presenting symptoms and medical history, any diagnostic test orders and results, all
documentation from care providers and consultants, interventions, medications, therapy, and
information and instructions at discharge. Any subsequent return visits to the hospital should be
recorded in the same MR.
The MR provides each clinician responsible for patient care with access to a record of the patient’s
health status, medical history, investigation procedures (lab tests, etc.), treatments and outcomes.
3.2.2 How and when to document
Each clinical event, intervention, instruction or observation should be documented by the health care
professional responsible for administering each clinical event, intervention, instruction or observation,
as soon as possible after the occurrence. MRs of discharged patients should have all documentation
completed by the discharging physician before the patient is discharged from the hospital and the
record should then be returned to the card room.
All entries should be dated and authenticated with full signatures. Professional designation (i.e. MD,
RN, etc.) should also be included.
MR information includes: the patient’s presenting symptoms and history; any diagnostic test orders
and results; all documentation from care providers and consultants; interventions, medications,
therapy, etc., provided to the patient; and information and instructions at discharge. This information is
to be filed in one folder divided in separate sections for each visit/admission in chronological order.
If the patient has a chronic disease and regularly attends a Specialized Clinic (e.g. HIV, TB etc) then a
separate section may be created in the MR folder to record all visits to the Specialized Clinic.
3.2.3 General rules in clinical documentation
• The patient's name and MRN should appear on each page.

• All handwriting should be in permanent ink that is legible when photocopied. Pencil entries in
any part of the record are not be permitted.
• All entries should be dated and authenticated, including signature and title of the author.
• Each clinician should sign those portions of the MR containing documentation of care for
which he/she is responsible.
• Transcription of verbal orders or other information should be accurate and complete. It should
be signed by the person who transcribed the verbal order or other information and co-signed by
the person giving the verbal order within 2 working days of the verbal order.

3.2.4 Standardized documentation and forms
Only approved and standard clinical forms (approved by government agencies or hospital
management) should be used in the MR. A standardized format should be used throughout the
hospital’s forms to facilitate the entry, review, and retrieval of information.
The following criteria can be applied to ensure standardization.

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

may be kept in a clip folder by the patient’s bedside or at the nurses’ station for ease of reference.
When the patient is discharged these forms should all be entered into the MR before the MR is
returned to the Medical Record Room.
For each outpatient attendance:

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

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

Function: To record patient history and physical examination assessment findings.
Location: MR

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

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

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

Function: Informs laboratory of any individual patient’s lab investigation order and allows lab result
to be recorded on these forms.
Location: MR.
Work process:
Inpatient: When any lab test is ordered, the ordering physician will sign a lab order and report form.
The lab order will be sent to lab. Lab will collect the sample and conduct corresponding test(s) upon
receiving the order. The test results will be recorded on the lab order form as well as in the log book in
the laboratory department. The completed lab order will then be sent back to the ward and kept in the
MR.

Outpatient: When any lab test is ordered, the ordering physician will sign a lab order. The lab order
will be given to the patient. For most tests, a sample will be collected by a case team member and sent
to the lab. For other tests the patient takes the lab order to the laboratory for the corresponding test(s).
The test results will be recorded on the order form as well as in the log book in the laboratory
department. The completed lab order will then be sent back to the ordering clinic/physician and kept in
the MR. If the patient goes to an external lab for test; the completed lab order will be brought to the
physician by the patient upon next follow up visit, to be filed in the MR.
9. Radiology order and report form

Function: Informs diagnostic imaging department of any individual patient’s imaging investigation
order and allows result to be recorded on this form.
Location: MR
Work process:
In-patient: When any imaging test is ordered, the ordering physician will sign a radiology request. The
radiology request will be sent to the diagnostic imaging department. The radiology technician will
schedule a test appointment upon receiving the order form. The test results will be recorded on the
order form by the radiologist, as well as in the log book in the diagnostic imaging department. The
completed radiology request and film will then be sent back to the ward and kept in the MR.
Out-patient: When any imaging test is ordered, the ordering physician will sign a radiology request.
The radiology request will be given to the patient. The patient takes the radiology request to a
diagnostic imaging department for the corresponding test(s). The test results will be recorded on the
order form, as well as in the log book in the diagnostic imaging department. The completed radiology
request will then be sent back to the ordering clinic/physician and kept in the MR. If the patient goes
to an external imaging clinic for test, the completed radiology request and film will be brought back to
the physician by the patient upon next follow up visit, to be filed in the MR.
Emergency: When any imaging test is ordered, the ordering physician will sign a radiology request. If
a mobile diagnostic imaging machine is available, the test will be done in the emergency room. The
test results will be recorded on the order form. If mobile unit is not available, steps outlined for
outpatients above should be followed.
10. Pathology order and report form

Function: Official record for the pathology request/results
Location: MR
Work process: When a pathology sample is collected (e.g. fluid aspirate, tissue biopsy) the ordering
physician will complete a Pathology Request Form. The sample and form will be taken to the
pathology department for analysis. If the required service is not available in the hospital the sample
and request form should be taken to the central laboratory where they will be stored and then
transferred to the appropriate facility, in accordance with hospital policy for sample referral.
11. Nursing Process Forms
a) Nursing admission assessment form
b) Nursing problem statement list
c) Nursing care plan

d) Nursing patient progress report
Function: To describe the nursing assessment, care plan and outcome of nursing care of an admitted
inpatient.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record.
Work process: When a patient is admitted a nurse completes a nursing assessment and care plan
within 24 hours. The outcomes of nursing care are documented on the problem list, care plan and
progress report during the course of the patient’s admission.
Further discussion on the Nursing Process is presented in Chapter 6 Nursing Care Standards.
12. Routine Observation Chart

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

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

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

Function: To record all fluid inputs and outputs for patients at risk of fluid overload or dehydration.

Work process: All fluid inputs both oral and intravenous and all outputs including urine and other
outputs such as blood loss should be documented on the chart by the nurse. At the end of every 24
hours the balance is calculated as ‘total input’ minus ‘total output’.
16. Discharge summary

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

Function: To document patient history at the hospital and to provide reason for referral
Location: One copy in the MR and one copy to patient.
Work process: If it is necessary to refer a patient to another facility the attending clinician should
complete a referral request, indicating the reason for referral, summary of the patient history and
examination and the results of any investigations conducted.
3.2.6 Correcting Medical Record Data
If any data contained within a MR requires correction, the following rules should apply:
• No erasure or other obliteration should be made.
• Incorrect data should be lined out with a single line.
• The date of correction, the signature and profession of the person making the correction, the
correct information, and the reason for the correction should be added.
3.3 Handling of Medical Records
A comprehensive MR management system encompasses the handling of the MR from the time of
patient registration, during active care delivery, through patient discharge, and ongoing filing/storage
of the MR, until removal/destruction of old MRs from storage. The flow of MRs/charts is important to

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

allow for an easy and effective method to locate MRs.
3.3.2 Who should handle Medical Records?
Only authorized personnel should have access to MRs, and only on a “need to know basis.” The
Medical Records Department should only be accessed by selected employees who have been designed
by hospital management to handle MRs and who have received MR training. When other hospital
employees need access to MRs, a request should be made to the MR staff. Patients should never
handle MRs without staff assistance.
Hospitals should develop strict procedures based on these principles and ensure that all staff members
are properly informed and trained for adherence.
3.3.3 Archiving Medical Records
Inactive files (i.e., MRs with no clinical activities for a pre-defined period of time (i.e., 2 years) may
be archived by MR staff in order to regain shelving space. Individual hospitals should establish an
archiving policy.
When archiving, these files should be numerically stored in a separate area, according to their MRNs.
The corresponding MPI index card of the patient should be labeled “archived.” NEVER create another
file numbering system for archived files.
If archived files needed to be retrieved, the same MR retrieving mechanism should be used.

3.3.4 Medical Records at Discharge
The MR of discharged or deceased patients should be returned to the Medical Record Case Team
within 24 hours of discharge. The Medical Record Case Team should review the MR to see if all
forms have been properly signed, particularly the discharge summary. If they are not signed, the MR
Department should alert the physician on record or case team leader to complete and sign the
discharge summary.
3.3.5 Destruction of Inactive Medical Records
The FMOH “Hospital Patients/Clients/Records Retention Schedule” guideline details the length of
time a MR is retained in inactive status. In general, a facility is required to retain a MR for up to 10
years after the patient’s last episode of care at that facility. After the pre-defined retention period, the
MR should be destroyed by burning, shredding or another method that is certain to maintain the
patient’s confidentiality. Destruction of the medical record should also be supervised by the head of
the MR department.
If medical records are destroyed the following key information should be maintained permanently:
• patient's full name and date of birth;
• admission and discharge dates;
• name of the attending doctor(s);
• diseases treated and operations performed; and
• a discharge summary for each admission if more than one.
A note should be included with the retained documents stating that the records have been destroyed
according to the retention policy.
The MR Department should establish a folder to collate the information above for all MRs that are
destroyed.
3.3.6 Removal of Medical Records from the Hospital
MRs should be removed from the facility only upon an order from a federal or regional jurisdiction.
The hospital should establish its own policy regarding MR removal, and should comply with federal
and regional health policies.
If a patient seeks health care from another hospital and has consented to the release of his/her clinical
information to the new hospital, only a photocopy should be given to the requesting hospital. The
original MR should never be transferred out of the hospital.
3.3.7 Confidentiality
MRs should be maintained in the strictest confidence, as they contain personal and private information
about patients, including their health status, personal family and contact information. MRs should be
stored in a secure area, and there should be clear policies regarding confidentiality and the release of
patient information.
The content of a MR should only be used for providing patient care or in the course of supporting
patient care activities (for example evaluation of services, clinical audit etc.). Access to the content of

MRs should be granted only to personnel who are undertaking the above activities. Other supporting
staff who are granted access to MRs but are not involved in delivering patient care (e.g., porters,
runners) should not read and/or disclose the content of the records.
All employees should sign a ‘Code of Conduct’ that includes a statement regarding the confidentiality
of patient information. (See Section 3.10.1 of Chapter 11 Human Resource Management).
3.4 Basic requirements for Establishing a Medical Record Management

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

Required Item Ideal Setting Possible Substitute
1) Space
Central Filing Space* Central files for MRs should be adjacent to the registration area -
with barriers necessary to impede or prevent access by
unauthorized personnel. Filing space should be provided for at
least 3 – 7 years accumulation of records.
Work space for Work stations set up according to nature of work, ideally in triage Any adequate work
registration areas or as close as possible space
Office for MR staff Office for use by MR staff for sorting MRs, keeping records
awaiting completion and filing, making out slip cards, stamping
free patient papers and other documents, etc.
Archive space Separate archive room that is easily accessible by MR staff. Designated shelves
for archiving
purposes
Supply / storage Separate room that is clean and can be used for storing forms, Any space in the
room supplies, etc. MR Department can
be used for storage
2) Equipment
Photocopier Necessary for immediately producing copies of records for Any means of
transfer files or legal reasons producing copies
Word processor for Computer Work
report and legal processor/type
documents writer
Printer - -
MPI file cabinets Vertical file cabinets for filing index cards Long index card
boxes
Shelves for filing Open unit shelves permit increased visibility and faster handling Drawer unit
of records, and they require less floor space. Aisles should be at cabinets
least 36 inches wide. Each filing unit should be labeled with the
medical record numbers of the medical records filed in that filing

Required Item Ideal Setting Possible Substitute
unit; and each filing shelf should be labeled with the range of
numbers of medical records filed on that particular shelf. Guides
should be placed at regular intervals.
3) Supplies
MPI Files Paper-based MPI Paper-based index
cards
Binders for filing Durable binders Folders
statistical reports
MR folders Durable folders with dividers to separate sections of documents Durable folders
and fasteners to hold loose papers. The file folders used with open with fasteners
shelf filing must have side tabs/visible spines for viewing MRN
for identification.
Stationeries Complete sets of stationary at various locations within the One complete set in
Department the dept
Clip boards for in- For temporarily providing easy access to observation charts, -
patients medication administration records, etc. during in-patient stay. The
clipboards should be tied to each bed.
Durable binders (2 For holding the contents of MR during inpatient care, to provide Folders
rings/3 rings) for in- easy access and frequent addition of new sheets. Preferably with
patients dividers to separate each section.
Table 2 Optional Items for a Medical Record Management System

Optional Item Details
1) Space
Offices For use by Medical Records Department staff
2) Equipment
Shredder Used for destroying copies of documents no longer necessary
Carts Used for transporting MRs from one location to another
Safety ladder / Step Used by staff to obtain MRs located on upper shelves within card / archive rooms
stool
Computer Used if an electronic registration system is used
3) Supplies
Rubber stamps / Year Rubber stamps imprinted with a year on it, in a chronological order may be purchased if
stickers folders are pre-printed.
Year stickers may be an alternative method. Both can be used for labeling files.
* Central Filing Space

It is critical that plenty of space is available for filing medical records, and that the file area is clean,
tidy and has good light. Medical records are a health record from birth to death; hence, a lot of space
will be required to store medical records.
In the majority of cases, healthcare institutions in Ethiopia possess a one room Medical Record
Department. Depending on the availability of rooms and expected annual load of patients per the
facility, preparations should be made to allocate enough space for the storage of MRs. Incomplete
medical records should be kept in a separate location in the department rather than integrated with
those completed medical records. An incomplete record area facilitates ease in retrieval for completing
records. When there is not enough room in the MRD to store all medical records for the defined
retention period, it is necessary to locate alternative storage. Optimally the storage should be in the
facility to facilitate retrieval. When an alternative storage space is needed, the space selected must be
secure and must protect the records from damage, loss or destruction.
3.5 Human Resources for the Medical Records Department
All personnel that work in the Medical Records Department should be qualified to conduct their jobs,
which require reading, keyboarding, and organizational skills. Depending on the size of the facility
and volume of patients, the number of personnel working in the Medical Records Department will
vary. However, there should be enough staff to cover the following duties, particularly during the
prime hours:
• Patient registration
• Authorization of free and credit services
• Development and maintenance of the MPI
• Retrieving and filing MRs
• Delivering files to various locations of the hospital
• Recording chart location
• Collection of MRs from individual service units
• Checking and ensuring completion of MRs after discharge or death
• Filing reports generated by the Medical Records Department
• Handling of medico-legal issues relating to the release of patient information and other legal
issues.
All MR personnel should undergo MR orientation and subsequent annual training on all MR policies.
3.6 Medico-legal Issues and Procedures
As the central documentation of the patient’s visit to a health care facility, a patient’s medical record is
considered the property of the healthcare facility. The personal data contained in the medical record is
considered confidential communication and the property of the patient. As such there are certain
measures that must be taken to ensure the security of patient records while also complying with
requests for release of patient data for medico-legal cases.

3.6.1 Patient Consent for Release of Records
Unless the patient has given written consent to release information from his or her medical record, the
information contained in it can only be released to a court by subpoena or a court order. No
information concerning a patient should be released to another person without the written consent of
the patient or the patient's legal guardian. If a patient is under the age of 14 years or otherwise subject
to a guardianship order, any consent for access to information should be given in writing by the
patient's parents or legal guardian. If the patient lacks the capacity to provide genuine consent then the
written consent must be obtained from the person's legal guardian. In the case of a patient who has
died, the written consent to access information from the patient's medical record should be provided
by the next of kin shown on the medical records.
3.6.2 Procedures for Releasing Patient Data
Information contained in a medical record may be accessed for a number of medicolegal issues. Listed
below are types cases for which medical records may be requested.
• Insurance Cases
• Worker's Compensation
• Personal Injury Claims
• Malpractice Claims
• Will Cases
• Criminal Cases
• Mental Competency
When a request for a medical record is received from a lawyer, the request should be registered and
date of receipt of request recorded by the healthcare facility administration and forwarded to the MR
Administrator for processing. The MR Department should confirm that the patient has given consent
for the release of information.
The information requested is identified and the attending doctor asked to write a report. In many
health care facilities a pre-designed form may be use or if a discharge summary is already in the
medical record, it is checked and if it includes all the requested information a copy is made.
If the actual medical record is needed, the lawyer must produce a court order of subpoena to enable the
release of the medical record.
3.6.3 Responding to Subpoena or Court Order Request
If a subpoena or court order is served it must be obeyed. On receipt of a subpoena the clerk records the
date and time the subpoena was received and records in a log book the date and time the medical
record is due in court. The Clerk should notify the attending doctor and healthcare facility
administration that a subpoena has been received for the release of the medical record to court.
The Clerk should locate the medical record and create a tracer card to indicate that the MR has been
removed. The Clerk should check that all necessary information, as specified in the subpoena, is in the
medical record and that it is complete. In some countries the original medical record is not sent to

court. If a photocopy is permissible as evidence in court all forms are photocopied and numbered and
the photocopy sent in place of the original. If a copy is made a note needs to be recorded in the
medical record indicating that a copy exists and will need to be destroyed on return from court. Some
healthcare facility’s send the original and keep a photocopy on file. When the original medical record
is returned to file the copy is removed from file and destroyed.
The medical record is placed in a large envelope addressed to the clerk of the court (or specified
person) with the receipt attached to the front. The tracer on file is changed to indicate that the medical
record was sent to the court and the date it was sent. The medical record should be forwarded under
adequate security to the clerk of the court named in the subpoena and the signed receipt obtained from
the person accepting delivery. Adequate security should involve hand delivery of the medical record
from the healthcare facility or health centre direct to the clerk of the court by an employee of the
healthcare facility or health centre or by a courier service.
On return from court the medical record is checked to ensure that all pages (forms) are present. The
file is returned to its appropriate place and the tracer removed. As mentioned previously if a
photocopy has been made it must be checked as for the original and then destroyed.
More detailed guidance on the policies concerning medico-legal issues and procedures can be found in
the Federal Ministry of Health HMIS Medical Records Training Manual, 2008, chapter 3, Pp. 34-40.
In order to determine if the Operational Standards of Medical Records Management have been met by
the hospital an assessment tool has been developed which describes criteria for the attainment of a
Standard and a method of assessment. This tool can be used by hospital management or by an external
body such as the RHB or FMOH to measure attainment of each Operational Standard. The tool is
presented in Appendix E of Chapter 13 Monitoring and Reporting.

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

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

upheld upheld/Total number of MR
complaints filed*100

Source Documents
1. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, June). Health Management
Information System (HMIS). Medical Records Training Manual.
2. Federal Democratic Republic of Ethiopia. (2007). Hospitals Patients /Clients Records Retention
Schedule.
3. World Health Organization. (2002). Medical Records Manual: A Guide for Developing Countries.
Revised and updated 2006. Manila: Regional Office for the Western Pacific. Retrieved from:
http://www.wpro.who.int/NR/rdonlyres/7FB74A3F-34F6-4C46-A9F0-
1F0D52D04254/0/MedicalRecordsManual.pdf.

Appendices
Chapter 3 Medical Records Management

Appendix A Template of Medical Records Department Forms
Item 1: Master Patient Index Card
"[Name of Facility]"
Master Patient Index Card
¾I¡U“ "`É lØ` ¾}S²Ñu<uƒ k”

Medical Record Number: Date Of Registration(DD/MM/YY)
eU ¾›vƒ eU
Patient’s Name: Father’s Name:
¾›Áƒ eU ï
Grand Father’s Name: Sex: F M
¾MÅƒ: k” ¨` ¯/U °ÉT@
Date Of Birth Day Month Year Age:
›É^h ¡MM ¨[Ç kuK?
Address: Region Woreda Kebele
ÔØ ¾u?ƒ lØ`
Gott: House Number:
Item 2: Service card (Front & Back)

¾›ÑMÓKAƒ Sታ¨mÁ "`É

SERVICE IDENTIFICATION CARD
¨[Ç/¡õK-Ÿ}T _____________________
¾Ö?“ É`Ï~ eU ____________________________ Woreda/Subcity
Facility Name
kuK? _______________________________
uÖ?“ É`Ï~ ¾}S²Ñu<uƒ k” ________________ Kebele
Date Of Registration
¾u?ƒ lØ` __________________________
¾I¡U“ "`É lØ` __________________________ House No.
Medical Record Number
eU _________________ °ÉT ____ ï ___

Name Age Sex
Item 3: Appointment card (Front & Back)

የቀጠሮ ቀን ቀጠሮ የሰጠው Aገልግሎት ክፍል

የቀጠሮ መስጫ ካርድ DATE Appointment with service
APPOINTMENT CARD
¾Ö?“ É`Ï~ eU ____________________________

Facility Name
eU ________________________________________
Name
¾I¡U“ "`É lØ` __________________________

Medical Record Number
Chapter 3 Medical Records Management Appendix A: Page 1 of 2

Item 4: Hospital Tracer Card

Tracer card
Facility Name: ________________________________________________

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

Appendix B Template of forms that are included in a Medical Record
Item 1: Hospital Patient Information Demographic Sheet

PATIENT INFORMATION
MRN: Patient’s name: Sex: Registration date:
F M / /
Phone no.:
( )
City/Town: Woreda: Kebele: House no:
Emergency contact information:
Contact’s Name:_______________________________
Telephone Number:____________________________
Chapter 3 Medical Records Management Appendix B: Page 1 of 27

Item 2: Hospital Summary Sheet of all Visit Dates

INTEGRATED FOLDER SUMMARY SHEET
(One line per visit – not for clinical notes)
MRN #: ________________________________________________
Patient’s Name: ________________________________________________

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

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

Item 3: Admission and Discharge Card (Front)
Jeú M ¾N=dw Te ¨mÁ lØ`

_________________________HOSPITAL CASH SHEET NO __________________
¾QSU}™‹ SkuÁ "`É
ADMISSION CARD
¾I¡U“ "`É lØ`
Medical Record Number (MRN) __________________
eU ¾›vƒ eU
Name _________________________________ Father’s Name _______________________
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Grand Father’s Name _____________________ Sex ___________________
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Address: Region _________________ Woreda/Subcity _______________
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Gott ___________________ Kebele_______________________
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House Number___________
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Ward No. _______________________________________ Bed No. ____________
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Admission Diagnosis __________________________________________________________
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Discharge Diagnosis ___________________________________________________________
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Condition on discharge
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Improved Dead Referred
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Left against Medical Advice Absconded
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Date of admission _________________ Signature of Admitting Dr. _________________________
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Date of Discharge _________________ Discharged by ___________________________________
¾S˜ ¡õM Lòª ’è ò`T KSÓv~ ¾S˜ ¡õM Lòª ’è ò`T KS¨<×~
Sign. Of Ward Nurse for Admission ____________ Sign. Of Ward Nurse for Discharge _________
¾Ç_¡}\ ò`T KSÓv~ (›eðLÑ> ŸJ’) KS¨<×~ (›eðLÑ> ŸJ’)
Director’s Sign. For Admission (if required) _____________For Discharge (if required) ___________
¾›=ƒ/w` X
Birr Cts.
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Number of days admitted __________________ Amount per day in birr ________________
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For X-Ray Examination _______________________________________________________
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For Medicine ______________________________________________________________
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For Operation _____________________________________________________________
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For Laboratory ____________________________________________________________
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For Various Services ________________________________________________________
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Total Payment
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Deposited
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Signature of Registrar
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_____________________ Amount to be Reimbursed
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Amount to be paid
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Signed by The Chief Accountant ____________________________

Item 3: Admission and Discharge Card (Back side)

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FINANCIAL RESPONSIBILITY
¾Ñ”²w ŸóÃ eU
Name of Individual Responsible for Bill ____________________________________________________
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Occupation _____________________________________ Tel. ________________________
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Kebele ____________ Woreda/Subcity ____________ House No. _________ Tel. __________
¾ÚÉ“¨< ¯Ã’ƒ ¨Å Jeú M ÁS×¨<

Relationship _______________________ Brought to Hospital by __________________________
eT@ ŸLÃ ¾}ÑKì¨< ŸLÃ ¾}Ö¾k¨<” Ñ”²w uS<K< ¾S¡ðM Lò’ƒ ”ÇKw˜ uò`TÂ ›[ÒÓ×KG<::
I, the above named person, accept full responsibility for payment of the charges incurred during this period of
Hospitalization.
ò`T
Signature
__________________________

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

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

/ /

Item 5: Hospital Progress Note

HOSPITAL PROGRESS NOTE
Name: OPD
MRN: IPD Ward: Bed Number:
Date &
Progress Note
Time


Item 6: Consultation Request Form

CONSULTATION REQUEST FORM
Patient Name: ___________________________ OPD

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

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

Item 7: Consent Form

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

____________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Serious or frequently occurring risks:

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

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

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

Item 8: Physician Order Sheet

PHYSICIAN ORDER SHEET
Name: Ward:
MRN: Bed Number:
Transcriber’s Date and
Physician
Date Time Order signature Time order Signature
Signature
(if relevant) completed


Item 9: Haematology Order and Report Form

HAEMATOLOGY ORDER AND REPORT FORM
Name: OPD
Age: Sex:
Clinical history:
Test ordered Result Reference
Total CBC ________ cells/mm3 ________ cells/mm3

Differential
Neutrophil ________ % ________ %
Lymphocyte ________ % ________ %
Eosinophil ________ % ________ %
Basophil ________ % ________ %
Monophil ________ % ________ %
Haemoglobin ________ G/dL ________ G/dL
Haematocrit ________ % ________ %
MCV ________ Fl ________ Fl
MCH ________ Pg ________ Pg
MCHC ________ Pg ________ Pg
3
RBC ________ cells/mm ________
Platelet Count ________ x 103 ________ x 103
ESR ________ mm/hr ________ mm/hr
Bleeding time ________ ________
Clot retraction ________ ________
Coagulation time ________ ________
Prothrombin time ________ ________
P.T.T. ________ ________
Fibrinogen ________ ________
Coomb’s test ________ ________
CD4 (absolute) ________ Cell/ul ________ Cell/ul
Other (describe):
______________________
Ordered by: __________________ Sample collected by: __________
Date of order: __________________ Date of collection: ____________
Time of order __________________ Time of collection: ____________
Lab tech comments:
Name of lab tech: __________________ Signature: __________________

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

Item 10: Clinical Chemistry Order and Report Form
CLINICAL CHEMISTRY ORDER AND REPORT FORM

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

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

Lab tech comments:


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

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

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

Lab tech comments:


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

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

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

Lab tech comments:


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

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

Lab tech comments:
Name of lab
tech: __________________ Signature: __________________


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

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


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

Name: OPD
Age: Sex:
Investigation (s) requested:
Summary of clinical history,relevant clinical findings and investigation results:
Requesting physician: Signature:

Date of request: Time of request:
Report: To be completed by trained radiologist/ultrasonographer if available.
Name of reporter: ___________________________

Signature__________________________________
Designation/Position: ________________________ Date of report:

______________________________
NB: The X ray film or Ultrasound pictures should also be sent to the requesting physician for
review and interpretation if no radiologist/ultrasonographer is available.


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

Name: OPD
Age: Sex: Date specimen collected:

Specimen type and site:
Time specimen collected:
Investigation (s) requested:
Summary of clinical history,relevant clinical findings and investigation results:
Requesting physician: Signature:
Date of request: Time of request:
Report:
Name of reporter: ___________________________

Signature__________________________________
Designation/Position: ________________________ Date of report:

_________________________

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

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

Item 19: IV fluid and Additive Administration Record

Name:____________________
MRN: ____________________
Ward: _________Bed: ______

Diagnosis: Allergy:
Mixed,
Discontinue Date of Time of checked, Time
# Date IV Fluid (Name, Volume, Rate) Additives date start start given by completed Completed by

Item 20: Fluid Balance Chart

FLUID BALANCE CHART

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

Item 21: Hospital Discharge Summary Sheet

HOSPITAL DISCHARGE SUMMARY SHEET
Name: MRN:
Ward: Date of admission:
Bed number: Date of discharge:

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

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

Item 22: Post Mortem Request Form

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

Referring Institution:
Requesting Physician:
Name: Signature: Date: / /
*Responsible professional must fill and send the following note to requesting institution
……………………………………………………………………………
Index No.____________________
To (Requesting Institution):
Dead body received by:
Name: Position: Signature: Date: / / Time:

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

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

Signature: Date : / /
Approved by: Medical Director:

Item 24: Sample Referral and Feedback Form

Section 1: Patient Details (to be completed by Referral Unit)
Name:
MRN:
Date of birth/Age: Next of kin name:
Address: Next of kin address:
Telephone number: Next of kin telephone number:
Section 2: Administrative Details (to be completed by Referral Unit)
Name of Referring Unit: Name of Receiving Unit:
Name of Liaison Officer: Name of Liaison Officer:
Contact Telephone Number: Contact Telephone Number:
Date referral made: Date referral received (to be completed by Receiving
Unit):
Section 3:Referring Clinician Information (to be completed by Referral Unit)
Name of Referring Clinician: Name of Consultant (if relevant):
Profession/Qualifications: Address:
Registration number: Telephone number:
Address:
Telephone number:
Signature:
Section 4: Clinical Information (to be completed by Referral Unit)
Reason for referral:
Basic history and statement of the problem:
Physical examination findings:
Results of investigations performed:
Treatments given:
Current medication:
Social/psychological factors:
Known allergies:
Any other relevant information:
Section 5: Feedback information (to be completed by Receiving Unit)
Summary of history:
Physical examination:
Investigation results:
Diagnosis:
Treatment given:
Management plan/advise:
Follow up appointment date (if given):
Any other relevant information:
Section 6: Receiving Clinician Information (to be completed by Receiving Unit)
Name of Receiving Clinician: Name of Consultant (if relevant)
Profession/Qualifications: Address:
Registration number: Telephone number:
Address:
Telephone number:
Signature:

Pharmacy Services
Section 2 Operational Standards for Pharmacy Services 7
3.1 Drug and Therapeutic Committee 7

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

3.2.1 Clinical Pharmaceutical Services
3.2.2 Organization and Management of Pharmaceutical Services
3.2.3 Dispensing and Medication Use Counselling
3.2.4 Compounding of Non-sterile Extemporaneous Preparations
3.2.5 Patient Medication Profile Card
3.2.6 Pharmaceutical Care Plan
3.2.7 Emergency Pharmacy Services
3.3 Drug Information Service 17
3.4 Monitoring of Drug Use Problems 18

3.4.1 Monitoring and reporting of adverse drug reactions
3.4.2 Prescription monitoring
3.4.3 Drug Utilization Monitoring
3.5 Drug Supply Management 23

3.5.1 Selection
3.5.2 Quantification
3.5.3 Procurement
3.5.4 Stores Management
3.5.5 Inventory Management
3.5.6 Distribution
3.6 Pharmaceutical Waste Management 40
3.7 Pharmacy Billing 43
3.8 Premises, Equipment and Facilities 43

4.3 Indicators 45
Chapter 4 Pharmacy Services Page 2 of 49
Source Documents 47
Appendices
Appendix A ABC method for Reviewing Hospital Formulary
Appendix B Sample Prescription Registration Book
Appendix C List of Equipment and Materials for Compounding in Hospitals
Appendix D Compounding Guidelines
Appendix E Format for Recording of the Compounding Process (Compounding Sheet)
Appendix F Compounding Prescription Registration Book
Appendix G Patient Medication Profile Card
Appendix H Sample List of Emergency Drugs
Appendix I Sample Contents of Drug Information Centre Library
Appendix J Sample Adverse Drug Reaction Reporting Form
Appendix K Sample Bin Card
Appendix L Sample Stock Record Card
Appendix M Internal Facility Report, Issue and Receipt Voucher
Appendix N Facility Combined Report and Requisition Form
Appendix O Record for Returning Unusable Commodities
Appendix P Consumption Summary Sheet
Appendix Q Losses/Adjustment Tracking Sheet
Tables
Table 1 Selected indicators to assess prescribing, patient care and facility practices
Table 2 Comparison of Quantification Methods
Table 3 Guidelines for Storage of Pharmaceuticals and Health Commodities
Table 4 Pharmacy Services Checklist
Table 5 Pharmacy Services Indicators
Boxes
Box A Selected National Reform Programmes that Impact on Pharmaceutical Services
Box B VEN Analysis
Box C Quantification Steps Using the Consumption Method
Box D Quantification Steps using the Morbidity Method
Box E Temperature & Humidity Control for Pharmaceutical Products
Box F Pharmaceuticals Requiring Cold Storage
Box G Preparation for Physical Inventory

Abbreviations
ADR Adverse drug reaction
AR Analytic reagent
DACA Drug Administration and Control Authority
DSM Drug supply management
DTC Drug and Therapeutics Committee
FCC Food chemical codex
FEFO First expiry, First out
FMHACA Food, Medicine and Healthcare Administration Control Authority
LILO Last in, Last out
PFSA Pharmaceuticals Fund and Supply Agency
PMP Patient medication profile card
STGs Standard treatment guidelines

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

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

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

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

Section 2 Operational Standards for Pharmacy Services
1. The hospital has a Drug and Therapeutics Committee (DTC) which implements measures to
promote the rational and cost-effective use of medicines.
2. The hospital has a Medicines Formulary listing all pharmaceuticals that can be used in the facility.
The Formulary is reviewed and updated annually.
3. The hospital has outpatient, inpatient, emergency pharmacies and a central medical store each
directed by a registered pharmacist.
4. The hospital ensures that all types of drug transactions and patient-medication related information
are properly recorded and documented.
5. The hospital has Standard Operating Procedures (SOPs) for all compounding procedures carried
out.
6. The hospital provides access to drug information to both health care providers and patients in order
to optimize drug use.
7. The hospital has policies and procedures for identifying and managing drug use problems,
including: monitoring adverse drug reactions, prescription monitoring and drug utilization
monitoring.
8. The hospital has a drug procurement policy approved by the DTC that describes methods of
quantification, prioritization, drug selection, supplier selection and ordering of pharmaceutical
supplies and is in line with national guidance.
9. The hospital has a paper-based or computer-based inventory management system to reduce the
frequency of stock-outs, wastage, over supply and drug expiry.
10. The hospital conducts a physical inventory of all pharmaceuticals in the store and each dispensing
unit at a minimum once a year.
11. The hospital ensures proper and safe disposal of pharmaceutical wastes and expired drugs.
12. The hospital has adequate personnel, equipment, premises and facilities required to store
pharmaceutical supplies and carry out compounding, dispensing, and counselling services.

3.1 Drug and Therapeutics Committee
Each hospital should establish a Drug and Therapeutics Committee (DTC) to promote the safe,
rational and cost-effective use of medicines

3.1.1 Membership of DTC
The DTC should be multidisciplinary including, as a minimum:

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

All hospitals should have a Hospital Formulary listing all pharmaceuticals that can be used in the
facility.
A participatory process should be followed to develop the Formulary involving clinical, laboratory,
diagnostic imaging and finance personnel.
The selection of pharmaceuticals for the Formulary should be based on:

• the national drug list (List of Drugs for Ethiopia)
• the Federal Ministry of Health’s Essential Health Services package,
• the National Standard Treatment Guidelines (STGs)
• the local pattern of disease

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

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

The DTC should establish a policy and procedures for identifying and managing drug use problems
including, as a minimum:
• Monitoring adverse drug reactions (see Section 3.4.1)
• Prescription monitoring (See Section 3.4.2)
• Drug utilization monitoring (See Section 3.4.3)
• Antimicrobial prescribing and use
Additionally, if resources are available the surveillance of antimicrobial resistance may also be
undertaken.
Strategies should be established to correct any drug related problems identified. Such interventions
may include:
• Educational programs and in-service training,
• Use of standard treatment guidelines and formularies, and
• Prescribing restrictions, etc.

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

The DTC should prepare an annual action plan, describing the main tasks to be undertaken in the year
with corresponding budget requirements to cover areas such as trainings, printing etc.
3.2 Hospital Pharmaceutical Services
3.2.1 Clinical Pharmaceutical Services
Clinical pharmacy services are patient-oriented services developed to promote the rational use of
medicines, and more specifically, to maximize therapeutic benefits (optimize treatment outcomes),
minimize risk, reduce cost, and support patient choice and decisions there by ensuring the safe,
effective and economic use of drug treatment in individual patients. To achieve this, clinical
pharmacists should get information on medication histories, perform medication reviews, attend ward
rounds, provide recommendations on drug selection and follow-up, and provide counselling to patients
and health care providers. Clinical pharmacists will therefore have the following functions:
• Provide advice to doctors, nurses and other health care workers on the clinical use of
medicines, economic drug utilization and safety,
• Offer direct patient care services through, for example, medication history-taking, medicines
education and advice, and
• Offer hospital managers, including clinical managers, appropriate advice and support to enable
them to make informed decision with respect to medicines policy, procedures and guidelines
designed to ensure safety, effectiveness and economy in medicines use.
3.2.2 Organization and Management of Pharmaceutical Services
Pharmacy services should be provided as part of the Inpatient Case Team, Outpatient Case Team and
Emergency Room Case Team. (See section 3.2.7 for further guidance on emergency pharmaceutical
services). Each of these three services should have a dispensing unit, patient counselling areas and
cashier services. Each Case Team should have one or more pharmacists who provide specific advice
and support to the Case Team when needed. The pharmacy personnel should promote the rational and
safe use of drugs and should ensure that all medication prescribed by the Case Team is included within
the hospital Drug Formulary and is in accordance with Standard Treatment Guidelines. Any
discrepancies should be discussed with the prescriber. Occasionally it is necessary to prescribe non-
formulary medication and/or to deviate from treatment guidelines. Such circumstances should be
discussed between the pharmacist and Case Team/prescriber and should be documented in the
patient’s medical record. Additionally, as part of the Case Team the pharmacist should identify which
patients would benefit from an individual Pharmaceutical Care Plan (see Section 3.2.6).
The relevant pharmacy personnel may attend Case Team meetings, ward rounds or outpatient clinics
(especially for patients with chronic diseases). It will not be necessary for the pharmacy personnel to

attend every case team meeting, ward round or clinical consultation. However, the frequency with
which the pharmacy personnel meets with the case team and/or participates in client contacts must be
sufficient to ensure that the pharmacist has a full appreciation of the clinical context in which advice
on the use of medications is given.
Pharmacy personnel should counsel patients in relation to drugs prescribed and should ensure the
detection and reporting of adverse drug reactions among patients managed by their respective Case
Team. The Service Director (Inpatient Service Director etc) is accountable for pharmaceutical
services and personnel within his/her Case Team.
Pharmaceutical staff can also provide health education to patients in the OPD, on wards or through
community outreach.
3.2.3 Dispensing and Medication Use Counselling
Dispensing involves six main steps:

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

Dispensers must make sure that prescriptions are legible, legal, complete and correct. Orders received
by word of mouth or through telephone should later be endorsed by the prescriber and be documented
in writing. Receipt of the prescription and confirmation of the integrity of the communication should
follow standard procedures for:
a) Identifying the patient, the prescriber and the entity responsible for payment (as applicable);
b) Ensuring the legality/authenticity of the prescription;
c) Interpreting the type of treatment and the prescriber's intentions;
d) Identifying the medicine, and checking the pharmaceutical/ dosage form, strength, appropriate
dosage, presentation, method of administration and duration of treatment;
e) Informing the patient of the benefits and implications of the substitution for a branded medicine of
an interchangeable multi-source medicine.
f) Helping the patient to resolve the problem when the prescription cannot be dispensed;
The pharmacist should assess the prescription to ensure the optimal use of the medicine with respect
to:

a) therapeutic aspects
i. the safety of the medicine,
ii. possible contra-indications,
iii. drug/drug interactions,
iv. drug/food interaction,
v. drug/disease interactions, and
vi. treatment duplications.
b) appropriateness for the individual and the indication for which the medication is prescribed.
c) cost of medicine and availability of cheaper alternatives.
Any problems identified should be discussed with the prescriber and a solution should be worked out
in consultation with the prescriber and patient.
Step 2 The selection, manipulation or compounding of the medicine

Patient-ready packs/pre-packed medicines may be used if available. Counting should be done on a
clean counting tray. If necessary, compounding of extemporaneous preparations may be necessary.
This should be carried out following Standard Operating Procedures in a designated compounding
room (see section 3.2.4 below).
Step 3 The labelling and supply of the medicine in an appropriate container

The containers used for dispensing must be appropriate for the product dispensed. All containers
intended for medicinal products must be protected and kept free from contamination.
All medicines to be dispensed should be labelled and the labels should be unambiguous, clear, legible
and indelible. If possible lettering should be printed. The following information must be indicated on
the label:
• the generic name of the product or each active ingredient, where applicable,
• the strength, dose, frequency of administration and total quantity,
• expiry date,
• prescriber’s name,
• the name of the person for whom the drugs are dispensed,
• the directions for use,
• the name and business address of the dispenser,
• date of dispensing, and
• special precautions as applicable.

Step 4 The provision of information and instructions to a patient
All drugs should be dispensed with adequate and appropriate information and counselling. Information
must be structured to meet the needs of individual patients and questions and answers should be used
to check the patient’s understanding. Written information should be provided to supplement verbal
communication as appropriate. Counselling should ensure that the patient has an unequivocal
understanding of the instructions for use, and any distinct characteristics or requirements of the
medicine. Counselling should cover matters that will enhance or optimize medicine therapy and
should include:
• Name and description of the medicine used,
• Intended use of the medicine and expected action,
• Dosage form, dose, route of administration,
• duration of therapy with emphasis given to completing the entire course, e.g. antibiotics,
• expected time to see a response of the medication and instructions on what to do if the
medicine appears not to have the desired effect,
• the time the drug should be taken in relation to other drugs, food, life style interactions etc,
• clear instructions on measurement and administration of medicine (for example liquid, aerosol,
topical preparations or suppositories). If necessary a demonstration such as opening and
closing containers or using an aerosol may be necessary,
• Techniques for self-monitoring of medication therapy,
• Action to be taken in the event of a dose not being taken,
• explanation of harmless effects of the medication such as urine discoloration,
• Common severe side or adverse effects or interactions and therapeutic interactions that may be
encountered, including their avoidance and the action that required if they occur,
• storage instructions,
• advice regarding keeping medicines out of reach and sight of children, and clarification on the
consequences of sharing medication or keeping extra doses at home, and
• Prescription repeat information.
Step 5 Recording the transaction

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

retained by the patient, the word “dispensed” should be stamped adjacent to those items which have
been dispensed.
For prescriptions which are to be refilled on a later date, the dispensing information should be entered
into the registration book before returning the prescription to the patient. The official seal of the
pharmacy, name and signature of the dispenser, the date of dispensing and the next refill date should
be written on the back of the prescription.
Step 6 Prescription filing

Each prescription should be signed and accountability accepted by the pharmacist or other authorized
person for the correctness of the dispensing of the medicine and confirming that the medicine was
supplied.
1. At the close of each day all dispensed prescriptions should be organized into normal or special
(e.g. Narcotic drugs) prescriptions and filed.
2. Prescriptions should be filed sequentially by day in a single container/carton for each month. The
container should be labelled with the month and year .
3. Containers should be arranged on a monthly basis.
4. Normal prescriptions should be filed securely for two years and special prescriptions for 5 years.
Prescriptions, patient and medication related records and information should be documented and kept
in a secure place that is easily accessible only to the authorized personnel.
3.2.4 Compounding of Non-sterile Extemporaneous Preparations
Compounding involves the preparation, mixing, assembling, packaging, and labelling of a drug or
device in accordance with a licensed practitioner's prescription. This may include the reconstitution or
manipulation of commercial products. Compounding should only be undertaken by capable, qualified
and authorized personnel who have been trained for the type of compounding conducted.
Standard Operating Procedures (SOPs) should be established for all compounding procedures carried
out by the pharmacy department. An SOP should include:
• the name, strength and dosage form of the preparation compounded,
• all ingredients and the quantities needed,
• equipment needed for preparation,
• mixing instructions including:
o order of mixing
o mixing temperature
o duration of mixing
• beyond-use date,
• the packaging or container to be used for dispensing,
• storage requirements,
• labelling instructions,

• quality control procedures (e.g. measurement of the degree of weight variation between
capsules; checking the adequacy of mixing, odour, colour, consistency, clarity or pH of
preparation as appropriate).
A list of equipment and materials for compounding is presented in Appendix C. Further details on the
compounding process are described in Appendix D.
A Compounding Record should be kept of all compounding activities. The record should list:
• the name and strength of the compounded preparation,
• the formulation record reference for the preparation,
• the sources and lot numbers of ingredients,
• the total number of dosage units compounded,
• the name of the person(s) who prepared and approved the preparation,
• the date of preparation,
• the assigned beyond-use date,
• the prescription number, and
• the results of quality control procedures (e.g. the weight range of filled capsules).
Sample Format for Recording of the Compounding Process (Compounding Sheet) and Compounding
Prescription Registration Book are presented in Appendix E and F, respectively.
To ensure the safety and quality of compounded preparations SOPs should be strictly followed, and
the compounder should check and recheck each step of the preparation process to guarantee that each
weight or measurement is correct as stated in the SOP. Specific quality control measures for each
procedure should be described in the SOP.
3.2.5 Patient Medication Profile Card
All patients with a chronic illness should have a patient medication profile card (PMP). The PMP
should be updated by the dispensing pharmacist whenever drugs are dispensed to the patient.
The PMP can be in hard copy or computerized with hard copy back up and should contain the
following information:
a) Name of the health institution,
b) Patient medical record number,
c) The full name, sex, age and weight of the patient,
d) The address of the patient and next of kin (if appropriate),
e) Principle diagnosis/diagnoses and any concomitant diseases,
f) History of adverse drug reactions,
g) A list of all medicines (prescription as well as non-prescription) used by the patient,
h) Reason for any changes made in the regimen of the patient,
i) Name or initial of prescriber and prescription number,
j) Dispensing and / or prescription date,
k) Appointment / Refill date, and
l) Signature of the dispenser.

PMPs should be filed sequentially by medical record number or alphabetically by patient name in the
dispensing unit.
When a patient presents to the pharmacy for a refill the pharmacist must assess the patient for signs of
compliance, effectiveness and safety of the therapy. The pharmacist should identify areas for
therapeutic modification and should refer to the prescriber when appropriate.
A sample PMP is presented in Appendix G.
3.2.6 Pharmaceutical Care Plan
A pharmaceutical care plan should be considered for selected inpatients and outpatients including:
• Those with multiple conditions/diseases,
• Those whose age, weight or clinical state may affect drug absorption or disposition, alter
dosage requirements or predispose the patient to adverse reactions or drug toxicity,
• Patients taking medicines known to have a high risk of toxicity and a narrow therapeutic index,
• Patients taking medicines which may interact,
• Patients taking an investigational medicine,
• Patients whose therapy is changed frequently, and
• Patients receiving IV therapy.
The pharmaceutical care plan defines treatment goals, determines appropriate interventions and helps
to assess whether the patient’s needs have been met. It also defines responsibilities for the pharmacist
and patient.
The first step in developing a pharmaceutical care plan is to assess the patient, with particular attention
to:
• General health and activity status,
• Past medical history,
• Medication history,
• Social history,
• Diet and exercise history,
• History of present illness, and
• Economic situation (self-pay, insured or ‘fee waived’ status).
Information on the above can be obtained directly from the patient or carers, from the patient’s
medical record or from other clinical staff (nurses or physicians).
The plan should address each of the patient’s diseases or conditions, taking into consideration the cost
and/or complexity of therapy and patient adherence. The plan should be developed in consultation
with the patient and the Case Team or clinician responsible for the care of the patient. In developing
the plan the pharmacy staff member should ensure that the patient is well informed on:
• the various pros and cons (cost, side effects etc) of the treatment options,

• instances where one option may be more beneficial based on the pharmacy staff member’s
professional judgment,
• The disease and the therapy/medications described in the plan, and
• The essential elements of the plan, including the patient’s responsibilities.
The pharmacist is responsible for monitoring the patient’s progress in achieving the outcomes
specified in the pharmaceutical care plan. Progress should be documented in the care plan and any
necessary changes to the plan should be coordinated with the patient and his/her other healthcare
providers as appropriate.
A final evaluation should be undertaken by the pharmacist to determine whether the actions and
interventions of the care plan have achieved the desired outcomes. This can be done in person or by
follow-up telephone contact depending on the circumstances.
3.2.7 Emergency Pharmacy Services
According to the current health sector reforms, emergency pharmacy service is one of the basic health
care services to be provided under the emergency service unit of a hospital.
Emergency pharmacy service should be directed by a registered pharmacist who is accountable to the
emergency unit of the hospital. Services should be available 24 hours a day.
The responsible pharmacist shall take the duty to coordinate and prepare emergency pharmaceuticals
list (A sample list is provided in Appendix H) and ambulance kits for the hospital and he/she has to
exert all the necessary efforts to ensure continuous availability of pharmaceuticals for the emergency
unit and hospital ambulances.
Orders received by word of mouth or through telephone during an emergency should later be endorsed
by the prescriber and be documented in writing within 48 hours of the order. The quantity prescribed
should be limited to emergency period only.
The emergency pharmacy, in addition to supply of pharmaceuticals, shall ensure safe and correct use
of medications as medication error is significantly high in this service area.
3.3 Drug Information Service
All hospitals should provide a drug information service for health professionals, patients and members
of the public. The service generally responds to patient-oriented drug problems received from clinical
staff or patients. However, the drug information service can also provide education and training to
health professionals and/or the public regarding appropriate and safe drug use.
A drug information centre (DIC) should be established in each hospital. The Centre should have
sufficient space with appropriate furniture and equipment including a dedicated telephone with
answering machine, filing cabinets, printer and computer, preferably with internet access. The DIC
should contain a current collection of reference materials such as books, journals, drug profiles,

formularies and manufacturer’s information. A list of possible resource materials is presented in
Appendix I.
The DIC should be open during normal pharmacy hours and should be staffed by appropriately skilled
personnel who are trained in the provision of drug information.
To guide operations of the unit, SOPs should be established for:

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

Vigilance is required to detect ADRs. Individuals susceptible to an ADR include:
• those with multiple diseases,
• those on multiple drug therapy,
• geriatric or paediatric patients,
• those receiving medicines that are known to be associated with serious adverse effects,
• those receiving drugs with a low therapeutic index or potential for multiple interactions,
• those with organ impairment that may alter drug pharmacokinetics, and
• those who have had a previous ADR.
A standardized form should be used to record and report ADRs. This should include:
• Patient name, sex, age, medical record number
• Clinical diagnosis
• Current medication
• History of previous ADR if any
• Details of adverse reaction
• Causality assessment
• Recommendations given
A sample is presented in Appendix J.
An ADR focal person should be appointed by the DTC. He/she is responsible to:
• ensure that all health professionals are involved in detecting, assessing, managing and
reporting potential ADRs
• ensure that ADR report forms are readily available in all clinical areas and that health
professionals are familiar with the form and how to complete it
• receive ADR report forms from clinical staff
• investigate potential ADRs
• analyze ADR data and compile reports
• provide regular reports to the DTC/and Hospital Management on ADRs in the facility
• report all ADRs to the Regulatory Body
The DTC should receive regular reports from the ADR focal person and make any necessary decisions
regarding the use of the drug in the facility. Where necessary the hospital formulary should be
amended to take account of detected ADRs.
Suspected ADRS should be investigated and managed as follows:

1. Assess suspected ADR with respect to:
a) Patient details: age, gender, organ function, height, weight; diagnosis and other relevant co-
morbidities prior to reaction; previous exposure to suspected drug(s) or related drug(s).

b) Medicine details: non-prescription drugs, alternative treatments, recently ceased medicines;
name, dose, route of administration, manufacturer, batch; date and time commenced; date and
time discontinued (if applicable); indication.
c) Comprehensive adverse reaction details: description of the reaction; time of onset and
duration of reaction; complications and sequelae; treatment and outcome of treatment; relevant
investigation results or autopsy report.
2. Perform causality assessment to assess likelihood of the drug causing the observed reaction.
A literature review may be undertaken to assess the likelihood that a suspected ADR was caused by a
particular drug and/or the advice of other health professionals may be sought.
The ADR should be classified as:

• Certain: a clear temporal association is established between medicine administration and the
reaction; and/or the results of investigations confirm that there is a relationship between the
administration of the medicine and the reaction; and/or the reaction recurs upon re-exposure to
the drug; and/or the reaction is commonly known to occur with suspected drug;
• Probable: the reaction is known to occur with the suspected drug, and there is a possible
temporal association between the reaction and medicine administration; and/or the reaction
resolves or improves upon withdrawal of the suspected medicine and other medicine therapy
remains unchanged; and/or an uncommon clinical event occurs in the absence of other
potentially causative factors;
• Possible: an alternative explanation for the reaction exists; and/or more than one medicine is
suspected; and/or recovery follows withdrawal of more than one drug; and/or the temporal
association between the reaction and administration of the medicine is unclear; or
• Doubtful: another cause is more likely to have accounted for the clinical event, e.g. underlying
disease.
3. Make recommendations on treatment options, including possible alternative treatments taking into
consideration:
• the likelihood of the suspected drug(s) having caused the reaction,
• the clinical significance of the reaction,
• the condition of the patient,
• the requirement for therapy,
• the risks and benefits associated with continuing therapy,
• the relative efficacy and safety of other therapeutic options, and
• the prophylactic use of other medicines to prevent future adverse reactions.
4. Document the ADR and provide follow up advice:

All ADRs should be clearly highlighted in the patient’s case notes. Any patient who has experienced
an ADR should receive advice about the drug and reaction, should be advised to avoid the drug in the
future and should be given an ‘alert card’ that states the drug involved and nature of the reaction.
He/she should be advised to show this card at any future clinical consultation to prevent the same drug
being prescribed again.

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

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

a) Indicator study methods:
In Indicator studies a selected indicator is set and performance against this indicator is measured.
Indicators can be developed to assess prescribing, patient care or facility practices. Table 1 presents
possible indicators that could be used for an Indicator Study.
Table 1. Selected indicators to assess prescribing, patient care and facility practices
Prescribing Indicators Patient Care Indicators Facility Indicators
• Average number of medicines • Average consultation time • Availability of
per encounter • Average dispensing times essential medicine list
• % of medicines prescribed by or formulary
• % of medicines actually
generic name dispensed • Availability of key set
• % of encounters with an of indicator medicines
• % of medicines that are
antibiotic prescribed adequately labelled • Availability of
• % of encounters with an standard treatment
• % of patients who know how
injection prescribed guideline (STG)
to take their medicines
• % of medicines prescribed
which are from the essential
medicines list or formulary list
Steps to be taken when conducted an indicator use study include:

• Determine objectives of study,
• Define indicators and data collection procedures,
• Determine study design and sampling methods,
• Pilot test,
• Train data collectors,
• Collect data as per the time line,
• Compile and analyze data,
• Prepare report and recommendations based on findings of study,
• Present report and recommendations to DTC and relevant hospital staff, and
• Implement recommendations arising from study, repeat study to assess impact.
b) Drug Use Evaluation (DUE) methods

‘Drug Use Evaluation’ studies can be undertaken to measure the use of a specific drug and/or
adherence to standard treatment guidelines (STGs). DUE studies are particularly important to
investigate:
• Perceived overuse or underuse of medications,
• Problems identified by indicator studies,
• High numbers of ADRs,
• Excessive amounts of non-formulary medicines used,
• Use of high-costs medicines when less expensive alternatives exist, and
• Use of excessive numbers of medicines within a therapeutic category.

Steps to be undertaken in conducting a DUE study include:
Step 1: Define appropriate medicine use (for example medicine use described in national or local
STGs)
Step 2: Audit actual prescribing practice against the set criteria
Step 3: Analyze data, prepare report and recommendations based on findings
Step 4: Present report and recommendations to DTC and relevant staff
Step 5: Implement recommendations arising from study, repeat study to assess impact
Problems identified by Indicator Study or DUE studies may be further investigated using qualitative
methods further described in Chapter 12: Quality Management; section 3.2.1.
3.5 Drug Supply Management
Effective drug supply management ensures the uninterrupted availability of quality, approved, safe
and effective pharmaceuticals. Drug supply management involves six basic functions: selection,
quantification, procurement, storage, distribution and use. The Hospital should have a pharmacist for
overall drug supply management, a pharmacy technician for store manager and a data clerk to enter
data.
3.5.1 Selection
All hospitals should have a Hospital Formulary that lists all pharmaceuticals that can be used in the
hospital. The Formulary should be approved by the DTC and be based on the List of Drugs for
Ethiopia/ National Formulary. The Formulary is the basis for drug selection and procurement.
3.5.2 Quantification
After the Formulary is prepared, the quantity of each product required by the hospital for a given
period of time should be determined. To guide this process, a Quantification Policy should be
developed and approved by the DTC. The Quantification Policy should indicate:
• The methodology to be used for quantification
• Techniques for cost analysis and prioritization for periods when funds are insufficient (see Box
B)
• The annual schedule for quantification

Box B VEN Analysis
If funds are limited, VEN analysis is a method to prioritize for medicine purchase. This
analysis is used to identify high-priority medicines for procurement and low-priority
medicines that the DTC should analyze carefully for deletion from the formulary.
VEN stands for:
V = Vital: Potentially lifesaving and crucial to providing basic health services
E = Essential: Effective against less severe but significant illness, not vital
N = Non essential: Effective for minor illnesses but have high cost and low therapeutic
advantage
Steps for conducting a VEN analysis are as follows:
• Step 1. Classify all medicine on the list as V, E, or N
• Step 2. Analyze the “N” items. Where possible, reduce quantities to purchase or
eliminate them.
• Step 3. Identify and limit therapeutic duplications.
• Step 4. Reconsider proposed purchase quantities.
• Step 5. Find additional funds if needed or possible.
Any quantification method should aide in :

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

• consumption methods;
• morbidity methods;

Table 2. Comparison of Quantification Methods
Method Uses Essential Data Limitations
• First choice for • Reliable inventory • Must have accurate
procurement forecasts, records consumption data
Consumption given reliable data • Records of supplier lead • Can perpetuate irrational
• Most reliable predictor of time use
future consumption • Projected drug costs
• Estimating need in new • Data on population and • Morbidity data not
programs or disaster patient attendances available for all diseases
assistance • Actual or projected • Standard treatments
Morbidity • Comparing use with incidence of health may not really be used
theoretical needs problems
• Developing and justifying • Standard treatments
budgets (ideal, actual)
• Projected drug costs
Every quantification method should address at least the following:

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

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

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

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

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

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

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

• adherence to delivery schedules, contract or purchasing agreements
• the maintenance of up-to-date price records to ensure that the most favourable prices are
obtained
• establishing and maintaining adequate records of purchases for inventory control and
satisfaction of legal requirements.
• establishment and maintenance of a system for reporting errors and withdrawing defective
products
Order placement and receiving of pharmaceuticals should be made using official and serially
numbered vouchers. There must be only a small number of authorized signatories. Telephone orders
must be confirmed in writing immediately.
3.5.3.1 Procurement through PFSA
Hospitals should procure preferentially through PFSA. A contract agreement should be entered
between PFSA and the hospital that describes, as a minimum:
• routine ordering and reporting processes
• emergency ordering
• payment terms
• processes for handling discrepancies, damages and losses

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

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

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

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

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

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

in our settings, eight alphanumeric characters can be adequate. For instance, GI-100-001 can be used
as a stock number for a drug in gastrointestinal tract category.
Inventory coding should be done in accordance with the following procedures.

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

Product Category Sub-Category Product Item Stock Number
Aluminium hydroxide + GI-100-001
Magnesium trisilicate susspension
310mg+620mg in 5ml (001)
Antacid Agents Aluminium hydroxide mixture GI-100-002
Gastrointestinal (GI) (100) 320mg/5ml (002)
Aluminium hydroxide suspension GI-100-003
360mg/5ml (003)
Antulcer Agents Cemitidine 400mg tablet (001) GI-200-001
(200) Ranitidine 300mg tablet (002) GI-200-002
Note:
1. In cases when a product has been registered in more than one sub-category, give code using
the category where it appears first in the latest national drug list of Ethiopia
2. In situations where a new drug is added to the formulary list assign its stock number as
described above by disregarding the alphabetic order.
Establishing Shelf Numbers: the pharmacy personnel should follow procedures listed below in order
to assign shelf numbers in the central medical store.
• Apply six digit numeric characters for shelf numbering i.e 100-001. The first three digits
represent the rows and the next three digits represent the columns.
• The first box of the first row from the top takes a shelf number 100 and the first box of the first
column from the top takes a shelf number 001 and its number at the end becomes 100-001.
• Accordingly, all boxes inside the store shelve will have unique shelf number. A practical shelve
template with shelf number is presented below.
• These numbers should be indicated on bin cards for each drug.

Template for numbering stock shelves
100-001 100-002 100-003 100-004 100-005
200-001 200-002 200-003 200-004 200-005
300-001 300-002 300-003 300-004 300-005
3.5.5.2 Inventory Control System
The purpose of an inventory control system is to maintain appropriate stock levels to meet the needs of
patients. A well designed inventory control system informs personnel when and how much of a
commodity to order and helps to reduce shortages, oversupply, and expiry of commodities.
Effective inventory management is underpinned by a Logistics Management Information System

(LMIS). An LMIS is a computerized database for inventory management that records all drug
transactions and connects all levels of the supply chain.
The purpose of LMIS is to support the management of all pharmaceuticals by collecting, organizing
and reporting information to other levels in the system.
Three essential data items that must be captured by the LMIS are:
1. Stock on Hand: Quantities of usable stock available at a given point in time
2. Consumption Data: The quantity of health commodities used during a time period or reporting
period (or a proxy of consumption calculated from issues data)
3. Losses/Adjustments: Losses are the quantities removed from stock for any reason other than the
provision of services to patients or the transfer of commodities to another facility (e.g. expiry, loss,
theft, or damage). Losses are recorded as negative (-) numbers. Adjustments are quantities of a
product received from any source other a regular supplier, or issued to another facility outside the
regular procedures. An adjustment may also be a correction due to an error in mathematics. An
adjustment may be a negative (-) or positive (+) number.
An effective inventory control system has 3 key elements:
1. The maximum months of stock is the largest amount of each pharmaceutical a facility should hold
in the store at any one time. If a facility has more than the maximum for a commodity, it is
‘overstocked’ and risks having commodities expire before they are used.
2. The minimum months of stock is the approximate level of the ‘stock on hand’ at the time of the
expected arrival of the next delivery from the supplier.

3. The emergency order point is the level where the risk of stocking out is likely, but there is still
time to receive an emergency delivery to avoid the stock-out.
To help maintain adequate stock levels, the maximum months of stock, minimum months of stock and
an emergency order point will be regularly established within the new national system. These levels
are largely determined by the order interval (length of time from order to order) and the safety stock
requirements.
For commodities procured from private suppliers, it may be necessary to set different minimums and
maximums to reflect different delivery schedules.
Standardized forms for inventory management are described below:
1. Bin Card (See Appendix K)
A Bin Card should be prepared for each product in the Pharmaceutical Store. The Bin Card should be
kept with the product inside the store. All transactions of the product to or from the store should be
recorded on the Bin Card. The Bin Card should also include a column for the loss/adjustment of stock
and a column for the stock balance. The stock balance should be updated after each and every
transaction or adjustment.
2. Stock Record Card (See Appendix L)
The Stock Card is similar to the Bin Card but is used to track stock based on issuing and receiving
orders. The Stock Card should be kept in the Store Manager’s Office. Whenever Stock Cards are
updated the totals should be checked against those on the Bin Card and any discrepancies should be
investigated.
A combined Bin/Stock Card System provides a measure of internal control that helps to minimize
leakages of stock due to theft or loss.
Paper based or electronic Stock Cards can be used. If an electronic system is installed there should be
regular back up of data.
3. Internal Facility Report, Issue and Receipt Voucher (IFRIR) (See Appendix M):
The IFRIR Voucher is used to report the internal transfer of items between the hospital pharmaceutical
store and Dispensing Units. The IFRIR also calculates the quantity of each item that should be
provided to the Dispensing Unit to reach maximum stock levels. A copy of the IFRIR is given in
Appendix H.
4. Facility Combined Report and Requisition Form (FCRRF) (See Appendix N)
The FCRRF is used to order health commodities from PFSA. Orders should be placed every second
month. The quantity to be ordered is calculated as follows:

Quantity requested = quantity issued from the store room in the previous reporting period x 2 minus
stock on hand.
An example FCRRF is presented in Appendix I. All requisitions/orders shall carry a unique order
number so that they can be official documents (replacing MOFED Models 19 to 22). If an order is
placed to PFSA by telephone this should immediately be confirmed in writing.
5. Record for Returning Unusable Commodities (RRUC) (See Appendix O):
The RRUC form is used to track the transfer of supplies back to PFSA. The form should be submitted
to PFSA every second month.
The recommended inventory control system for the new national system is a Forced Ordering
Maximum/ Minimum inventory control system. This means that all facilities are required to report on
a fixed schedule, and PFSA is expected to supply on a fixed schedule. Facilties will place orders to
return their stock levels to the maximum determined for each pharmaceutical. All products are
resupplied each time a report and order is completed/sent to PFSA. In emergencies, an emergency
order can be placed.
3.5.5.3 Physical Inventory (Physical Count)
A Physical Inventory (also called Physical Count) is an actual count of each commodity in stock at
any given time. A Physical Inventory should be done regularly in the store and each dispensing unit, at
a minimum of once per year. If the facilty decides the Physical Inventory could be done every two
months to coincide with PFSA’s planned delivery schedule. Bin Cards and Stock Record Cards should
be updated at the end of each physical count.
Each facility should establish an SOP providing details on how the Physical Inventory should be
conducted. Box G below provides is a checklist that can be used prior to initiating a physical
inventory:

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

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

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

For Non - PFSA Products:
All purchase orders with suppliers other than PFSA should include an agreed delivery schedule. At the
time of delivery, the truck should wait while products are counted and assessed in order to obtain
proof of delivery and to take note of any discrepancies with the shipment.
3.5.5.5 Facility Financial Issues
PFSA or other suppliers should be paid for the delivery of health commodities using one of three
different options:
• Advance: Pharmaceutical budget allocations are made to PFSA on an annual basis by the
health facility. As pharmaceuticals are ordered from and delivered by PFSA, the cost is
deducted from the facility’s ‘account’.
• Cash and Carry: PFSA will be paid for the commodities at the time of delivery to the facility.
Most hospitals are expected to use this method of payment.
• Credit: As far as possible hospitals should avoid obtaining pharmaceutical supplies on credit.
Sufficient budget should be allocated (using raised revenue if necessary) to purchase
pharmaceutical supplies. Hospitals may, with the approval of MOFED/BOFED, decide to
operate a separate bank account for pharmaceutical supplies to ensure that funds are available
and are not used for other purposes. If any supplies are obtained on credit then payment should
be made as soon as funds become available.
3.5.6 Distribution
Pharmaceuticals should be managed centrally by the hospital Central Medical Store. All products
should be received into the hospital Central Medical Store, and most of commodities should be stored
there until they are issued to the various dispensing units within the facility. The distribution of
pharmaceuticals within a hospital (from the store to any of the various dispensing units) should be
directed by a pharmacist.
Pharmacy Dispensing Units should be established within Outpatient Services, Inpatient Services and
Emergency Services. Pharmaceutical supplies will also be distributed to the hospital laboratories
(outpatient, inpatient and emergency) and radiology unit.
Each dispensing unit should have an agreed list of stock items including the maximum quantity to be
stored in the dispensing unit. Stock levels in the ‘cabinet/storage area’ of each dispensing unit should
be kept to a minimum, preferably less than one month. The stock list of each Dispensing Unit should
be determined by the relevant Service Director (Inpatient, Outpatient, Emergency Services etc) and
should be approved by the DTC. Each Dispensing Unit should maintain Bin Cards for all
pharmaceuticals in the unit.
SOPs, approved by the DTC, should be established for:

• Obtaining supplies from the Central Medical Store
• Action to be taken in the case of incomplete documentation or other queries
• Return of expired, damaged, leftover and empty packs from the dispensing units to the Central
Store

The Central Medical Store manager should establish a resupply schedule for each of the dispensing
units, generally between one week to one month. Each dispensing unit should have a designated day to
receive its resupply (for example every Monday for weekly supply or the first Monday of every month
for monthly supply). On that day, the dispensing unit staff should complete their part of the Internal
Facility Report, Issue and Receipt Voucher (see Appendix M). The Central Medical Store Manager
will use this information to determine the resupply quantities needed to serve clients until the next
scheduled resupply day. For example, every Monday (on a weekly basis), the service provider reports
data to the Central Medical Store, and the store resupplies enough product to serve clients until the
next week (the dispensing unit will also keep a small safety stock). This system ensures that the
dispensing units are not overworked with pharmaceutical management responsibilities, and the
quantities issued to the dispensing units from the Central Medical Store reflect actual consumption by
clients. It also spreads out the workload of the store across the week.
3.5.6.1 Resupply Options
Low volume dispensing units (for example MCH, TB/Leprosy etc): Dispensing units that dispense a
low volume of drugs may use Bin Cards to record drug transactions. Such units should have a
‘cabinet’ of drugs that is stocked with sufficient supplies for the reporting and resupply period
(weekly, every two weeks or monthly). At the start of each day drugs can be taken from the ‘cabinet’
and placed in the consultation rooms where patients are seen. Drugs are dispensed to patients directly
from the consultation room. At the end of the day any unused drugs are returned to the ‘cabinet’. All
transactions from and to the ‘cabinet’ should be recorded on the Bin Card. Losses and Adjustments
should also be recorded on the Bin Card when they are made/discovered. At the end of the reporting
period, the dispensing unit should complete its part of the Internal Facility Report and Resupply Form
using information contained on the Bin Cards.
High volume dispensing units (for example OPD/IPD/Emergency pharmacy dispensaries): Dispensing
units that dispense a high volume of drugs should establish a Prescription Registration Book (PRB)
that records every pharmaceutical issued to a patient. An example PRB is presented in Appendix B.
At the end of the reporting period the consumption data should be aggregated from the PRB using a
Consumption Summary Sheet (see Appendix P). The Dispensing Unit should also complete a
Losses/Adjustment Tracking Sheet (Appendix Q) for the reporting period. This data, together with
stock-on-hand balances from the previous reporting period should be used to complete the Dispensing
Unit part of the Internal Facility Report and Resupply Form.
The Store Manager/Pharmacy Head should ensure that adequate control and monitoring procedures
are in place for all commodities kept by the dispensing units within the hospital. He/she should
occasionally visit and verify the stock-on-hand in the dispensing unit before issuing. The Store
Manager/Pharmacy Head has the right to delay issuing to a particular dispensing unit if proper
procedures have not been followed; however, problems should be resolved immediately so as not to
risk stock-outs in that dispensing unit.

3.6 Pharmaceutical Waste Management
Pharmaceuticals which are eligible for disposal include the following:

• All expired/damaged pharmaceuticals,
• All unsealed syrups or eye drops (expired or unexpired),
• All cold chain products not stored as per manufacturers’ recommendations (e.g.: insulin,
hormones, gamma globulins and vaccines),
• All bulk or loose tablets and capsules with containers which are not sealed, properly labelled or
within broken blister pack, and
• All unsealed or damaged tubes of creams, ointments, lotions and related products.
Each hospital should establish a pharmaceutical disposal committee comprised of representatives from
pharmacy, finance/audit, and sanitation services to ensure the proper disposal of pharmaceutical
wastes in accordance with the country laws.
Each hospital should establish an SOP for the management of pharmaceutical waste. The SOP should
include the schedule, methods, materials and equipment required for disposal and the responsible
person. The SOP should be approved by the hospital DTC. Disposal of pharmaceutical wastes should
be supported by proper documentation, including the price of the products, for audit and other legal
requirements.
Basic steps to be adhered for the disposal of pharmaceutical wastes are:

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

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

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

1. Solids, semisolids and powders:
• Medium temperature incineration should be applied for solid forms.
• If there is no incinerator, encapsulation of the drugs before discharge to a land fill is necessary.
o Solids, semisolids and powders should be removed from their outer packages but should
remain in their packaging.
o The disposed drugs then should be covered by municipal waste immediately to prevent
scavenging.
• Pharmaceuticals classed as biodegradable organic material in the solid or semisolid form such
as vitamins, can also be disposed of in a landfill.

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

• Pressurized gas containers.
• Large amounts of reactive chemical waste.
• Silver salts and photographic or radiographic wastes.

• Halogenated plastic such as polyvinyl chloride (PVC), which is mostly used for I.V. fluids
container.
• Waste with high mercury or cadmium content; such as broken thermometers, used batteries,
and lead-lined wooden panels.
• Sealed ampoules or ampoules containing heavy metals.
For further guidance on waste management, including management of hazardous material spills refer
to Chapter 7 Infection Prevention.
3.7 Pharmacy Billing
The provisions of Health Care Finance Reform Legislation enable hospitals to raise and retain
revenue. The sale of pharmaceutical products is an important source of hospital income. With the
exception of exempted health programs (immunization, TB, ART and the like) pharmaceuticals can be
sold at a price that covers the actual cost of the medicine plus a service charge. Clear and uniform
procedures should be established for setting the sale price of each commodity and for recording sales
transactions.
The sale price of each pharmaceutical should be entered on the IFRIR form by the Central medical
store. Each dispensing unit should sell pharmaceuticals at the stated price. All pharmaceuticals should
be dispensed/sold using a standard sales ticket designed for the purpose.
3.8 Premises, Equipment and Facilities
The hospital should have sufficient space for the storage, compounding, counselling and dispensing of
drugs and for the conduct of related administrative activities. A dispensing unit, counselling area,
cashier services (with or without compounding facilities) should be established in each main service
area (Inpatient Services, Outpatient Services and Emergency Services). The pharmaceutical products
and quantities of each that are maintained in each dispensing unit should be approved by the hospital
Drug and Therapeutics Committee (see section 3.3 of Chapter 2 Patient Flow for the minimum
contents of the Emergency Services Dispensing Unit).
Counselling areas should be arranged to ensure reasonable privacy and minimize background noise.
All areas where pharmaceutical services are provided (for example dispensing units, central medical
store etc) should be clearly labelled. Access should be controlled to ensure that only authorized
personnel enter the premises and that only designated personnel have access to keys. A procedure
should be established to ensure access to pharmacy premises in an emergency situation.
All equipment used for compounding, distribution and administration of medication should be
regularly calibrated and maintained according to manufacturer’s requirements. The need for
continuous electrical supply should be determined and all critical items of equipment (for example
refrigerators) should be protected by individual UPS devices and should be connected to the hospital
back-up power supply (generator or alternative). All compounding and dispensing rooms should have

a sink with hot and cold running water. There should be sufficient computers within each service area
for the functions carried out. Ideally, telephones should also be available within each services area.
The main medical store should be accessible to vehicles to allow the easy delivery of supplies. Where
possible, the central medical store should be located by itself on a separate area to enhance security
and minimize human and vehicle congestion.

In order to determine if the Operational Standards for Pharmacy Services have been met by the
hospital an assessment tool has been developed which describes criteria for the attainment of a
Table 4. Pharmacy Services Checklist

Yes No
1. A Drug and Therapeutics Committee has been established.
2. Terms of reference for the Drug and Therapeutics Committee are defined.
3. A Medicines Formulary is created and is shared with staff.
4. Pharmacy services are integrated in the emergency, outpatient and inpatient
case teams.
5. There are SOPs to describe different compounding procedures.
6. A Drug Information Centre is established to provide drug information to
staff and patients alike.
7. Procedures are established to receive, investigate adverse drug reactions.
8. Procedures are established to monitor prescriptions and drug utilization
9. There is a drug procurement policy.
10. An inventory management system to manage drug supply and distribution
is established.
11. There is process to dispose of expired drugs.
12. Adequate personnel to provide pharmacy services are in place.
13. Facilities and equipment needed to provide pharmacy services are in place.

4.3 Indicators
Table 5. Pharmacy Services Indicators

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

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

non-formulary item written during reporting
period/ Total number of prescriptions
written during reporting period*100

12. Number of drug information Total number of drug information request filled Quarterly
requests filled
13. a) Expired drug stock value a) ∑ (number of expired drugs x price of that drug) Quarterly
b) % of total inventory value

b) Σ (number of expired drugs*price of that
drug)/ (Σ drugs in inventory at time of
evaluation*price of drug at time of
evaluation)
14. a) Value of items lost; items a) ∑ of number of pharmaceuticals lost * price Quarterly
lost is defined as of pharmaceutical
pharmaceuticals expired,
damaged, and lost in the
reporting period
b) % of total inventory value
b) ∑ of number of pharmaceuticals lost *
price/ ∑ pharmaceuticals in inventory at
time of evaluation * price
15. Proportion of drug budget out of Proportion of budget allocated to drugs/total Quarterly HMIS
the total recurrent budget recurrent budget * 100
16. Attrition rate of pharmacy staff Number of pharmacy staff leaving/total number Quarterly HMIS
of pharmacy staff at beginning of reporting
period * 100
17. a) Cumulative number of a) Total number of pharmacy staff trained Quarterly HMIS
pharmacy staff who have from beginning of year until end of
undergone in-service reporting period
training
b) Cumulative proportion of b) Cumulative number of staff who received
pharmacy staff who have training/total number of staff at beginning
received in service training of period *100
18. a) Cumulative number of a) Total number of pharmacy staff who have Quarterly
pharmacy staff who have undergone performance evaluation from
undergone performance beginning of year until end of reporting
evaluation period
b) Cumulative proportion of
pharmacy staff who have b) Cumulative number of staff who have
undergone performance undergone performance evaluation /total
evaluation number of staff at beginning of period *100
19. In patient satisfaction survey : Total number of inpatients who respond ‘always Biannual Survey tool
% of respondents who answer or usually’ to the questions listed/ Total number presented in
‘always or usually’ to the of inpatients respondents. Appendix F
following questions “Before of Chapter
giving you any new medication, 12 Quality
how often did staff describe Management
possible side effects in a way you
could understand?”
20. Out patient satisfaction survey : Total number of outpatients who respond ‘yes’ Biannual Survey tool
% of respondents who answer to the questions listed / Total number of presented in
‘yes’ to the following questions outpatients respondents.. Appendix F
“The staff described the of Chapter
medications possible side effects 12 Quality
in a way I could understand?” Management

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UPPSALA monitoring center. Geneva: World Health Organization.

Appendices
Chapter 4 Pharmacy Services

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

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

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

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

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

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

Appendix D Compounding Guidelines
A. General Procedures for Compounding

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

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

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

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

a. Compounding pharmacists should avoid ingredients and conditions that could
result in excessive physical deterioration or chemical decomposition of drug
preparations, especially when compounding.

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

Where the Manufactured Drug Product is the Source of Active Ingredient— The beyond-
use date is not later than 25% of the time remaining until the product’s expiration date or
6 months, whichever is earlier.
Where a USP or BP Substance is the Source of Active Ingredient— The beyond-use date
is not later than 6 months.
For Water-Containing Formulations (prepared from ingredients in solid form):

The beyond-use date is not later than 14days for liquid preparations when stored at cold
temperatures between 2 and 8 (36 and 46 F).
For All Other Formulations:

The beyond-use date is not later than the intended duration of therapy or 30 days,
whichever is earlier. These beyond-use date limits may be exceeded when there is
supporting valid scientific stability information that is directly applicable to the specific
preparation (i.e., the same drug concentration range, pH, recipients, vehicle, water
content, etc.).
2.Labelling
Compounded products must be labelled according to regulatory requirements. In addition,
labels of these products should also include names of any preservatives used. This

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

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

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

Yield: …………………………………………….
Loss: ……………………………………………
Reason for loss: ………………………………………………………………………………………….

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

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

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

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

Appendix G Patient Medication Profile Card
PATIENT MEDICATION PROFILE CARD
Name of Health Institution: _________________________________
Patient Information Clinical Information
Card No: ____________ Type of Chronic Illness: _____________________________________
Name: _________________________ Current Status: □ On active treatment □ Transferred-out □ Lost to Follow-up □ Deceased
Sex: □ Male □ Age: _____ years History of ADR or Side Effects Concomitant Diseases Reason for Change in Regimen or other
Female remarks
Wt. on Start: ___ Date Description Date Description Date Description
Date Started: Kg
________
Patient Source:
□ Inpatient □ Outpatient
Patient’s: Support Person’s:
__________ __________
Address
Drug Dispensing Information
Date Reason Prescriber Drugs Dispensed Other Date of Signature
for Visit Drugs Next
Drug One Drug Two Drug Three Visit
Start
Drug Drug Drug
Refill
Initial
Weight in Kg
Name Name Name
Brand
Brand
Brand
Presc. No.
Strength
Strength
Strength
Quantity
Quantity
Quantity
In/Outpatient (I/O)
Chapter 4 Pharmacy Services Appendix G: Page 1 of 1
Appendix H Sample List of Emergency Drugs
Sample List of Emergency Drugs

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

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

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

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

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

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

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

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

Level: Point:
Doc. No. Received Price

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

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

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

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

Facility:
Reporting Period: From: To:

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

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

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

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

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

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

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

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

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

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

Laboratory Services
Section 2 Operational Standards for Laboratory Services 5

3.1 Customer Services 6
3.1.1 Tests available
3.1.2 User manual
3.1.3 Clinical advice service
3.1.4 Information sharing
3.1.5 Service and satisfaction
3.2 Tests to be provided by a Hospital Laboratory 8
3.3 Blood Transfusion Service 9
3.4 Laboratory Equipment Management 9
3.4.1 Equipment required in a hospital laboratory
3.4.2 Procurement of equipment
3.4.3 Inventory control
3.4.4 Equipment maintenance
3.5 Control of Laboratory Reagents and Supplies 12
3.5.1 Reagent and supply inventory control
3.6 Standard Operating Procedures 13
3.7 Referrals and Transportation of Laboratory Samples 15
3.8 Organisation of the Laboratory Working Environment 16
3.9 Laboratory Safety 17
3.10 Information Management 19
3.10.1 Document management
3.10.2 Record management
3.11 Quality Assurance 21

3.11.1 External quality assurance
3.11.2 Internal quality assurance
3.12 Laboratory Staff Management 23

4.3 Indicators 25
Chapter 5 Laboratory Services Page 2 of 27

Source Documents 27
Appendices
Appendix A The Laboratory Network: Responsibilities of Laboratories at Different Tier Levels in
Ethiopia
Appendix B Sample Preventive Maintenance Log
Appendix C Sample Corrective Maintenance Log
Appendix D Sample SOP for Haemoglobin Estimation
Appendix E National SOP Template
Appendix F Sample Laboratory Risk Assessment Form
Appendix G List of Notifiable Diseases
Tables
Table 1 Laboratory Services Checklist
Table 2 Laboratory Services Inidcators
Abbreviations
AFB Acid Fast Bacilli
ALT Alkaline Transferase
BPR Business Process Re-engineering
DNA Deoxyribonucleic acid
EHNRI Ethiopian Health and Nutrition Research Institute
EQA External Quality Assessment
FMHACA Food, Medicine and Healthcare Administration and Control Authority
OHSO Occupational Health and Safety Officer
PCR Polymerase Chain Reaction
PIHCT Provider Initiated HIV Counselling and Testing
PMTCT Prevention of Mother to Child HIV Transmission
PPE Personal Protective Equipment
PT/ EQA Proficiency Testing/ External Quality Assessment/
QA Quality Assurance
QC Quality Control
QI Quality Improvement
RPR Rapid Plasma Reagin

SOPs Standard Operating Procedures
STS Sample Transfer Service
TPHA Treponema Pallidum Haemagglutination
TPPA Treponema Pallidum Particle Agglutination
UPS Uninterruptible Power Supply

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

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

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

3.1 Customer Services
3.1.1 Tests available
The Laboratory Manager, in collaboration with the Finance Department, should produce a list of all
tests that are provided by the laboratory, including the fee per test. The list should be updated on an
annual basis (or more often as required) and should be posted in all sample collection areas and readily
available to all clinical staff and patients.
3.1.2 User manual
A user manual should be prepared by each laboratory for the benefit of clinical staff ordering diagnostic
tests. The user manual should be distributed to all sample collection areas including wards, emergency
room, operating room, labour and delivery, outpatient department etc.
The user manual should include:

• A list of all tests available at the laboratory and average turn-around time for each
• A list of tests that may be taken by the laboratory and referred to a higher tier for analysis, and turn-
around time for each

• For each test:
o Basis for reference range
o Critical range notification
o Test interference or procedure limitations
o Sensitivity
o Specificity
o Accuracy
o Precision
o Any other pertinent test characteristics
o Interpretation
• Test ordering procedures
• Copy of test order form. Sample test order forms are presented in Appendix B of Chapter 3
Medical Records Management.
• Sample collection and sample disposal procedures
3.1.3 Clinical advice service
The laboratory should provide a service to clinical staff to assist with the interpretation of results and
to advise on the need for additional tests. To achieve this laboratory staff may make comments on the
result report form, either commenting on the interpretation of the results and/or suggesting additional
investigations that might aid the diagnosis. Laboratory personnel should be available to answer queries
from clinical staff about individual test results or the need for further investigation. Additionally, the
laboratory should establish ‘panic results’ (i.e. a result which should be communicated immediately to
the physician for urgent action) for each investigation and processes by which such results are
communicated immediately to the ordering clinician.
3.1.4 Information sharing
The hospital should have a process to update clinical staff on areas such as new tests, interpreting
laboratory results etc. There should also be a forum through which laboratory staff can discuss
individual patient care with clinicians when necessary. Possible mechanisms include:
a) ‘In house’ education sessions at which all laboratory staff members who attend workshops/trainings
share this knowledge with their laboratory and other clinical colleagues.
b) Clinical review meetings of all clinical staff (nurses, physicians, X-ray, lab, pharmacy) or of each
clinical case team. These meetings should be a forum for presentations and discussion on general
clinical issues. Laboratory staff should participate in these meetings and could use these meetings to
provide clinical advice/update information about laboratory services to clinical staff.
3.1.5 Service and satisfaction
Each lab should develop a system to collect and measure data on how much the laboratory services
and products satisfy the patients and clinical staff and should take steps to address any problems
identified. This could be done through suggestion boxes or satisfaction surveys.
The laboratory should have a mechanism to record complaints from staff and clients. All complaints
and problems reported to the laboratory as well as corrective action taken should be documented.

For further discussion on ways to ensure a patient centred service please see Sections 3.1.4 and 3.1.5
of Chapter 12 Quality Management.
3.2 Tests to be provided by a Hospital Laboratory
The following diagnostic tests should be provided by primary and district hospital laboratories (Level
II Laboratories):
Haematology
• CBC with Automated Differential
• CBC – Manual
• Blood film
• CSF Cell Counts
• CD4 (absolute)
• Type and Cross-match
Clinical Chemistry
• Chemistry Panel
o Liver function tests (ALT, bilirubin)
o Serum electrolytes
o Renal function tests (creatinine, urea, nitrogen)
o Lipid profile
o Serum amylase
o Glucose
• Whole Blood Lactate
Microbiology
• AFB Smear
• India Ink Stain
• Gram Stain
• Microbiology culture and sensitivity
• Wet Mounts – Direct Microscopy
Serology
• HIV Serology Rapid Test
• Cryptococcal Antigen Test
• Hepatitis B
• Hepatitis C
• TPPA/ TPHA/ RPR
Parasitology
• Malaria Rapid Test
• Malaria smear microscopy (Blood Film)

• Stool examination: Direct microscopy and concentration techniques
Urine tests
• Urine Dipstick with Microscopy
• Urine Pregnancy Rapid Test
Tertiary referral hospitals (Level III laboratories) should provide the following tests and services:
• All tests performed at Levels I and II
• Viral load (by PCR, DNA or other methods)
• Microbiology culture, identification and susceptibilities
• Blood cultures
• Complete chemistry panel
• AFB smear
• AFB culture, identification and susceptibility (first-line drugs)
• Nucleic acid PCR test (Example: HIV DNA PCR)
3.3 Blood Transfusion Service
Hospital laboratories should establish a blood bank and provide a blood transfusion service. Blood
donations should be screened for pathogens–as a minimum HIV, syphilis, Hepatitis B and C. Blood
should be stored securely and quality assurance measures should be in place to ensure the correct
temperature for storage at all times. Refrigerators or freezers for blood storage should have an
alternative power supply as a back-up in case of mains failure.
3.4 Laboratory Equipment Management
The following sections provide an overview of the management of laboratory equipment. For more
detailed guidance please see Chapter 9 Medical Equipment Management.
3.4.1 Equipment required in a hospital laboratory
To perform the tests described in section 3.2 above hospital laboratories must, as a minimum, have the
following equipment:
• Centrifuge
• 40C lab refrigerator, 240V
• Biological Safety Cabinet Type 1 or Type 2
• Tachometer (to verify speed of centrifuge)
• 3D bi-directional rotator 240V, 50/60Hz
• Blood tube rocker/rotator
• Refrigerator with freezer compartment, -200 to -400C
• Water distiller, complete with wall bracket and tubing
• 560C Water bath, 15L, 240V, 50/60Hz
• Test tube agglutination viewer
• Binocular microscope
• Dry heat sterilizer
• Autoclave

• Vortex mixer
• Automated haematology analyzer
• Automated chemistry analyzer
• Coagulation analyser
• CD4 analyzer
• Cold box and ice pack
• Water distiller
• Thermometers for fridge, freezer and water bath
• Micropipettes with different volumes
• UPS
The laboratory should be connected to a back-up power supply (generator) in cases of interruption to
the mains electrical supply.
Additionally, the laboratory should have a telephone(s), fax machine, sufficient computers and printers
for administrative purposes and internet connection if possible.
3.4.2 Procurement of equipment
A senior laboratory technician should be a member of the Medical Equipment Committee that is
responsible to approve the procurement of all medical equipment including laboratory equipment.
Prior to ordering or accepting equipment there must be a check to ensure that the laboratory has
adequate room size and access for the equipment, together with an adequate electrical system,
plumbing and ventilation, as required.
For all new equipment there must be an agreement with the vendor for installation, calibration,
maintenance, trouble shooting, reagent supply, service and repair and training of staff for a specified
time period. All new equipment should be supplied with a user manual. All procurement decisions
must factor in reagent supply. There should be a sustainable supply of reagents, and as far as possible
required reagents should be integrated across systems.
All donated equipment must be assessed by laboratory management before acceptance. This
assessment should include the need for the item and any maintenance and reagent requirements to
ensure that any necessary spare parts or reagents are readily available in the country.
3.4.3 Inventory control
Every lab should have an inventory of all equipment and instruments that includes:
• Name of manufacturer,
• Model and serial number,
• Date of purchase or acquisition,
• Purchase cost,
• Current location,
• Record of contracted maintenance, and
• Record of equipment breakdowns.

Manufacturers’ manuals should be attached to, or stored beside, each instrument. Laboratory
equipment should only be used by appropriately trained staff. An equipment usage log book or form
can be completed by laboratory staff to indicate the duration of use and name of the person who used
the equipment.
3.4.4 Equipment Maintenance
There should be a program for preventive maintenance, calibration and monitoring of equipment
function that is documented and at a minimum follows manufacturer’s recommendations. The Quality
Assurance (QA) Officer (see section 3.11) is responsible to ensure that instruments in the laboratory
are maintained properly, daily controls and calibrators are run, and maintenance logs are kept up to
date.
There should be a timetable for the calibration and maintenance of each piece of equipment.
Calibration should be performed every six months if specific instructions are absent.
Otherwise calibration should be performed:

• Based on the specifications of the manufacturer
• After a complete change of reagents
• Where controls show unusual trends
• After major preventive maintenance
• After replacement of critical parts
• When the procedure requires more calibration
There should be close follow up of instruments’ functional abilities such as temperature of

refrigerators, incubators, rotation of centrifuges etc. Log books or standard forms should be stored
near or attached to the instrument and should be completed on a regular basis by the laboratory staff.
Each instrument should have a named individual responsible for these checks who is assigned by the
Laboratory Manager. The QA officer is responsible to review the log books or forms to ensure that
the required checks have been done.
All preventive maintenance should be documented in a computer/log book and kept in each
laboratory. All records of corrective actions taken, repair and services should be documented and kept
in the laboratory and in the maintenance dept of the hospital. For instruments that are not functioning
properly an ' OUT OF ORDER' label should be attached on an easily visible part of the instrument
body until corrective maintenance is done. Instrument down time should be recorded.
Good maintenance practices minimize instrument repair costs and limit instrument downtime and
workflow interruptions. There are two types of maintenance: planned preventive maintenance and
corrective maintenance. For each item of equipment a log should be kept of all maintenance activities.
Only individuals who have taken appropriate training on the specific piece of equipment should
undertake maintenance activities. For some equipment this will require a certified service engineer.

a) Preventive Maintenance
Periodic maintenance prior to equipment failure will prevent accidental breakdown and increase
performance. Systematic Preventive Maintenance includes adjusting, calibrating, changing parts,
following shut down procedures, and performing general cleaning procedures (such as blowing,
rinsing, wiping, flushing). Cleaning procedures should adhere to Standard Operating Procedures that
apply to each instrument.
The Operator (user) should perform daily, weekly, monthly and/or quarterly preventive maintenance
for each type of equipment in the laboratory. All preventive maintenance activities should be recorded
in a maintenance log for each piece of equipment. A sample Preventive Maintenance Log is presented
in Appendix B.
Service engineers from the appropriate company or EHNRI should perform semi-annual or annual
preventive maintenance on the larger more complex instruments. A log must be completed with
copies held on site and by the service engineer.
b) Corrective Maintenance
Corrective maintenance involves equipment repair and replacement of parts. Instrument operators can
perform simple corrective maintenance such as replacing blown out fuses and removing blockage
from the fluidics system by using troubleshooting charts from instrument user manuals. However,
most corrective maintenance must be performed by a qualified service engineer. All corrective
maintenance activities should be recorded in a maintenance log for each piece of equipment. A
sample Corrective Maintenance Log is presented in Appendix C.
Only engineers sent by the supplier can perform corrective maintenance on instruments still under
warranty.
3.5 Control of Laboratory Reagents and Supplies
Laboratories require reagents, controls and supplies for:

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

• catalogued and stored accordingly to aid retrieval,
• properly stored according to manufacturer’s instructions,

• discarded when the shelf life is expired,
• labelled to indicate identification and, when applicable, significant titre strength or
concentration,
• marked with date of preparation or receipt
• marked with the date opened:
o The date that the reagent was first opened must be written on the container with a
standard plastic laminated form. If reagents are dispensed from intact stock containers
by dilution or any other treatment, the date of preparation as well as the duration of
should be written,
• the components of reagent kits of different lot numbers should not be interchanged unless
otherwise specified by the preparer.
Reagent validation and monitoring should be done prior to use.
3.5.1 Reagent and supply inventory control
Laboratory management should have control over the purchase, storage and distribution of laboratory
reagents and supplies. If another department (for example finance or pharmacy) is responsible for the
purchase of laboratory reagents and supplies this should be done in consultation with the Laboratory
Manager and there should be a system through which the Laboratory Manager can order stock when
necessary.
The laboratory should establish a control system to catalogue the purchasing and supply of reagents
and supplies. This can be done through a log book or an electronic cataloguing system. Reagent
name, supply on hand and expiration date of reagents and supplies should be recorded in the log book
or electronic system. This will allow laboratory staff to compare the current stock in the laboratory
and in the warehouse to avoid unpredicted stock out.
Laboratory reagents and supplies should be stored in a mini-store that is managed by the Laboratory
Manager.
3.6 Standard Operating Procedures
Standard Operating Procedures (SOPs) are created for regularly recurring work processes that are
conducted in the laboratory. This is done to ensure that activities are performed consistently and in a
manner that achieves results of the highest quality, and that the laboratory is run as efficiently as
possible. All laboratory staff should participate in the creation of SOPs. Each SOP should be
approved by the Laboratory Manager and Quality Assurance Officer prior to implementation.
SOPs should be available for:

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

a) Action upon receipt of a sample:
Upon receipt each laboratory should check the availability of the requested test in that laboratory,
including the turnaround time for results. If the service is not available, the laboratory should notify

the customer and refer the sample to a different laboratory capable of performing the request test (see
section 3.7). If the service is available, the sample must be checked according to the acceptance and
rejection criteria. A specimen can be rejected if:
• it is received without a request form,
• it is unlabeled, incompletely labelled or if the name on the label does not match the name on
the request form,
• it is leaking,
• it is in a broken container,
• it is the wrong type of specimen for the requested test,
• it was not transported according to requirements,
• the time since collection is too long (depending on the type of test),
• it is haemolytic (depending on the type of test),
• there is insufficient volume of a specimen, or
• there is bacterial overgrowth present.
b) Documentation of sample receipt:
A log book should be used to record the receipt of samples. This should include:
• the name of the patient and identification number,
• the source of the specimen,
• the name of the submitter, and
• the date of collection.
2. All testing procedures:
All SOPs for individual tests should include:

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

n) References to relevant and pertinent materials,
o) Criteria for the referral of specimens to and from other health facilities, and
p) Transport requirements (e.g. cold chain) if the specimen is to be transferred to another laboratory.
A sample SOP for haemoglobin estimation is presented in Appendix D.
a) SOPs should also be available for:

b) Testing algorithms (The procedure for analyzing a sample that has more than one test request)
c) The maintenance and monitoring of each piece of equipment (see section 3.4)
d) Sample referrals and transportation (see section 3.7)
e) Safety procedures and waste management, including proper specimen disposal (see section 3.9)
f) Quality assurance procedures (see section 3.11)
Each SOP should be reviewed on a regular basis (for example annually). The revision level and due
date for the next review should be stated on each SOP. The national SOP template, developed by
EHNRI is presented in Appendix E.
3.7 Referrals and Transportation of Laboratory Samples
Within hospitals, support staff (‘runners’) should be used to transport samples and results between the
laboratory and clinical areas. The transport between the hospital and external facilities is handled by
the Sample Transfer Service (STS). The STS is a system that outlines the process of referring and
transporting laboratory samples in a coordinated, timely, and effective manner. The quality of
laboratory results is dependent upon the quality of the specimen received. Therefore, the STS is
designed to minimize the time from when the specimen is collected to when it is delivered.
There should be an assigned contact person to oversee the referral and transport process and a trained
courier (preferably a non-technical staff member) for the transportation of samples. Transport should
be arranged in accordance with the SOP of each test taking into account any special requirements (e.g.
maintenance of the cold chain). All relevant personnel (runners, couriers, laboratory staff and
clinicians) should be trained in the collection, preservation and transport of specimens as appropriate.
The hospital should establish linkages with other facilities for the receipt and referral of samples.
There should be a policy, agreed between relevant facilities, that specifies:
• The lower level facilities from which samples may be received,
• The type of samples and tests that will be conducted for lower level facilities,
• The turnaround time for each test and process by which results will be reported back to the
referring facility,
• The higher level facility(s) to which samples may be referred,
• The type of samples and tests that will be conducted at the higher level facility(s), and
• The turnaround time for each test and process by which results will be reported back to the
hospital.
Laboratory samples may also be received from external private health facilities. The hospital may
decide to charge a higher fee for the testing of these samples.

A system should be established to track referred and received samples to ensure that no samples or
results are lost and to keep a record of test results.
3.8 Organisation of Laboratory Working Environment
The physical structure of the laboratory should be of an appropriate size, location, and layout to ensure
safety to staff, patients, and others. A diagram of the layout of the laboratory department should be
clearly displayed on the wall of the central laboratory.
The laboratory space should be sufficient to accommodate:

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

contaminants from seeping through. Internal and external walls should be maintained in good
condition.
A mini-store for reagents and supplies should be located within the laboratory department. There
should be sufficient power outlets for all electrical equipment within the laboratory and the use of
extension cords should be minimized. Laboratory equipment, including refrigerators, should be
protected by Uninterrupted Power Supply (UPS) devices. Essential equipment should be connected to
the backup power supply in the event of power failure.
Access to the laboratory should be restricted to authorized personnel. Laboratory buildings should be
secured with window locks or burglar bars, door and cupboard locks as necessary. Keys should be
held by authorized personnel only.
3.9 Laboratory Safety
Within the laboratory there should be someone responsible to oversee health and safety activities. The
Laboratory Manager could fill this position if necessary. Responsibilities include:
1. To conduct regular risk assessments of laboratory premises
2. To maintain a safe working environment
3. To ensure adequate safety equipment is available at all times
4. To ensure the safe disposal of laboratory waste
5. To prepare the laboratory health and safety manual
6. To prepare the department-specific Major Incident Plan
7. To train laboratory staff on health and safety procedures
8. To establish mechanisms to report laboratory accidents or injuries
9. To ensure that remedial action is taken in response to any accidents or injuries
1. Risk assessment
A regular risk assessment of laboratory premises should be conducted at a minimum every quarter. A
standard assessment tool should be used. A sample Laboratory Risk Assessment Form is presented in
Appendix F. Based on the findings of the risk assessment appropriate steps should be taken to
minimize risk.
Copies of all risk assessments and a description of remedial action taken should be maintained in the
laboratory.
2. Laboratory environment
Laboratories should be adequately signed to indicate:
• Entrances to areas where bio-hazardous materials are kept,
• Fire exits and fire extinguishers,
• First aid kit,
• Eye wash station, and
• Safety shower.
Bio-hazardous materials should be stored in secure and clearly demarcated.

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

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

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

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

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

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

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

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

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

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

Laboratory EQA programs are implemented in the form of:
• Proficiency panel testing
A number of proficiency panels are sent to a laboratory by the regional
laboratories or EHNRI
Analysis tests are performed
Results are compared between labs
• Blind re-checking
A random selection of samples are collected from the routine work load and
sent to a laboratory
Any errors detected reflect the reality of everyday performance in that lab
• On-site assessments
In due course external QA processes will be developed for other laboratory tests. Hospitals must
comply with all national external QA requirements.
Additionally hospitals may establish external QA mechanisms with other accredited agencies or may
develop inter-institutional QA processes.
3.11.2 Internal QA
Internal laboratory QA involves the following steps:
Pre-analytical
• Ensuring the correct sample is taken from the correct patient
• Ensuring sample request forms contain all relevant information
• Ensuring samples are transported appropriately
• Ensuring samples are stored appropriately prior to analysis
Analytical
• Ensuring that requested laboratory tests are performed in a timely manner and recorded
• Ensuring samples are prepared appropriately and tests conducted in accordance with SOPs
• Ensuring test results are accurate (i.e. fall within an appropriate range)
• Includes the regular monitoring of test results from the use of controls.
o Control samples, either prepared or purchased, are analyzed with test samples to
evaluate any bias in the test methods precision or results. The control samples should
be treated in the same manner as the test samples.
o All laboratories should establish an official QA procedure which includes:
Identification of the control being used
Instructions for the preparation and handling of controls
Frequency with which controls are run
How the accepted limits for controls are established
New limits must be determined for each new lot/shipment of control
substance
The corrective actions taken when results do not fall within the pre-determined
range
How QA data is to be documented and stored

All control results and remedial actions should be recorded.
QA data has to include a QA number, standard QA answer sheet, test result,
date of testing and name of the laboratory analyst who took the test.
What should occur if no controls are available
• The laboratory is responsible to check each new shipment of reagents, discs, stains, antisera
and identification systems for positive, negative, or graded reactivity when either being
prepared or opened.
• The laboratory must test staining materials for intended reactivity each day in order to ensure
accuracy of results.
• The laboratory must test fluorescent stains for positive and negative reactivity each time of use.
o Any abnormal results should be documented, reviewed, and corrected in a timely
manner.
Post-analytical
• Ensuring the correct result is received by the referring clinician in a timely manner
• Ensuring the correct result is recorded in the patient medical record
Finally, QA processes must ensure that only qualified and trained personnel complete the above steps
and that any problems identified by the QA system result in appropriate action. All QA processes,
results found, and any corrective action should be appropriately documented.
3.12 Laboratory Staff Management
Key elements of a successful laboratory staff management plan include:

• Identification of duties performed and staff needed to perform those duties
• Assignment of duties and responsibilities to each staff person (job description)
• Creation of a rotation schedule
• Implementation of effective retention strategies for laboratory staff
o Routine guidance
o A good working environment
A clean, well-organized laboratory
Provision of all necessary materials and equipment for testing
Ensuring that all of these are in working order
o Diversity of tasks to ensure against a monotonous schedule
This also ensures that laboratory personnel are trained in multiple different
areas
o The availability of formal training and peer-to-peer knowledge sharing
There should be established mechanisms by which all staff who receive external
training can share the information learned with their colleagues
o Standardized wages/per diems
o A fair and non-biased system for recognition and rewards
o Clear and open communication channels, opportunities to address complaints, and
responsive action
• Career paths that allow the opportunities for progression and career advancement, including
further training and research. Priority for career advancement should be given to those with
longer lengths of service and good performance evaluations

• Regular staff meetings
• Staff performance reviews
In addition to technical staff the laboratory should have sufficient clerical staff for registration of
samples, documentation of lab results and archiving of materials.
Further guidance on the above is presented in Chapter 11 Human Resource Management.

In order to determine if the Operational Standards of Laboratory Services have been met by the
Standard and a method of assessment. This tool can be used by hospital management or by an
external body such as the RHB or FMOH to measure attainment of each Operational Standard. The
tool is presented in Appendix E of Chapter 13 Monitoring and Reporting.
Table 1. Laboratory Services Checklist

Yes No
1. There is a list of laboratory tests offered including the price of each test that is
current.
2. Information is provided on the interpretation of test results or tests to staff and
patients alike.
3. There are adequate personnel to provide laboratory services.
4. Facilities and equipment needed to provide laboratory services are in place.
5. Reagents and other supplies needed to provide laboratory services are available.
6. Laboratory services are integrated in the emergency, outpatient and inpatient case
teams.
7. There is a central laboratory with functional overview of all hospital laboratories.
8. There is a monitoring system to manage reagent and other consumables supply.
9. There is an SOP for specimen management.
10. There are SOPs for all testing procedures.
11. There is an SOP for testing algorithms.
12. There is an SOP for waste management.
13. There are SOPs for maintenance and monitoring (of each item of equipment).

14. There is an SOP for quality assurance.
15. There are policies and procedures or sample collection, transport and disposal.
16. There is a health and safety manual that defines safety procedures.
17. There is a data management system.
18. Quality assurance procedures are developed and implemented.
4.3 Indicators
Table 2. Laboratory Services Indicators

Indicator Formula Frequency Comment
1. Total number of samples received Total number of samples received by Quarterly
by laboratory services laboratory services (inpatient, outpatient and
emergency) during the reporting period
2. a) Number of samples rejected a) Total number of samples rejected by Quarterly
b) Proportion of laboratory laboratory services (inpatient, outpatient
samples rejected and emergency) during the reporting
period)
b) Total number of samples rejected by
laboratory services (inpatient, outpatient
and emergency) ÷ Total number of
samples received (inpatient, outpatient and
emergency) x 100
3. a) Number of samples referred a) Total number of samples referred into Quarterly
into laboratory services from laboratory services from another facility
another facility during the reporting period
b) Number of samples referred into
b) Proportion of laboratory laboratory services ÷ total number of
samples that were referred by laboratory samples x 100
another facility
4. a) Number of samples referred a) Total number of samples referred to Quarterly
by laboratory services to another facility laboratory services during
another facility the reporting period
b) Number of samples that were referred to
b) Proportion of laboratory another facility ÷ total number of
samples that were referred to laboratory samples x 100
another facility
5. Average turnaround time per ∑ turnaround time for each discipline ÷ number Quarterly
laboratory discipline (chemistry, of tests conducted in that discipline
haematology, urine, stool etc)
6. Test availability [∑tests x ∑days available] ÷ [∑tests x ∑total Quarterly
number of days in time period] x 100
7. Average number of tests per Total number of tests conducted ÷ [number of Quarterly
laboratory employee per day laboratory staff x number of working days in
reporting period]

8. Attrition rate laboratory staff Number of laboratory staff who left during Quarterly HMIS
reporting period ÷ total number of laboratory
staff at beginning of reporting period x 100
9. Cumulative proportion of Total number of laboratory staff who received Quarterly HMIS
laboratory staff who received in in service training from beginning of year to
service training end of reporting period ÷ number of staff at
beginning of year x 100
10. Cumulative proportion of Total number of laboratory staff who Quarterly
laboratory staff who underwent underwent performance evaluation from
performance evaluation beginning of year to end of reporting period ÷
number of laboratory staff at beginning of year
* 100
11. Number of complaints received Total number of complaints against laboratory Quarterly
against laboratory services services
12. a) Number of complaints against a) Total number of complaints against the Quarterly
laboratory services upheld laboratory upheld
b) Proportion of complaints b) Number of complaints upheld ÷ number of
against laboratory services complaints received x 100
upheld

Source Documents
1. CDC, WHO, ASCP, USAID, SCMS, Bill & Melinda Gates Foundation, Clinton Foundation &
The Global Fund. (2008, January). Maputo Consensus Report. Consultation on Technical and
Operational Recommendations for Clinical Laboratory Testing Harmonization and
Standardization. Maputo, Mozambique.
2. Ethiopian Health and Nutrition Research Institute. (2008, December). Ethiopian Health and
Nutrition Research Institute Master Plan for the Public Health Laboratory System in Ethiopia,
Second Edition (2009 – 2013). Addis Ababa, Ethiopia.
3. Ethiopian Health and Nutrition Research Institute. (2008, August). Ethiopia: National Guidelines
for In-Service Laboratory Training. Addis Ababa, Ethiopia.
4. Ethiopian Health and Nutrition Research Institute. (2008). National Health and Safety Guidelines
for Public Health Laboratories in Ethiopia. Addis Ababa, Ethiopia.
5. Ethiopian Health and Nutrition Institute. (2006, September). Public Health Laboratory System of
Ethiopia: National Policy Guidelines (Draft 2) Manual on Communication Between EHNRI,
Regions, and Other Stakeholders Regarding HIV/AIDS Laboratory System Operations. EHNRI,
Dept of Regional Laboratory Support.
6. Ethiopian Health and Nutrition Research Institute. (2008, August). Quality Manual for EHNRI
Laboratories. Addis Ababa, Ethiopia.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Manual for Public
Health Laboratory Services. Addis Ababa, Ethiopia.
8. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, April). National Notifiable
Diseases and Conditions Reporting Rule and General Control Measures for the Control of Public
Health Threats. Ethiopian Public Health Institute. Addis Ababa, Ethiopia.
9. SNNP, RHB, RHL and JHU-Tsehai. (2007, April). Standard Operating Procedure for Laboratory
Sample Transfer Service at Health Centers. Addis Ababa, Ethiopia.
10. USAID. (2006). Assessment Tool for Laboratory Services (ATLAS).

Appendices
Chapter 5 Laboratory Services

Appendix A The Laboratory Network: Responsibilities of Laboratories at Different
Tier Levels in Ethiopia
A tiered laboratory network is an integrated system of laboratories organized in alignment with the public
health delivery network in a country. There should be four levels of laboratories in the national network:
1. Level I-Primary: Health post and health center laboratories that primarily serve outpatients.
2. Level II- Secondary: Laboratories in intermediate referral facilities (e.g., district hospitals).
3. Level III-Tertiary: Laboratories in a regional referral hospital that may be part of a regional or
provincial health bureau.
4. Level IV-National Reference Laboratory: The national public health reference laboratory for the
country.
The tiered levels of a laboratory system and the testing performed at each level may vary depending on
the population served (e.g., infants, adults), physical infrastructure, electricity, water, road conditions, and
the availability of trained technical personnel in-country.
Level I Laboratories
Level I laboratories would consist of health post or health center laboratories that would primarily serve
outpatients. Essential infrastructure, such as clean water, refrigeration and electricity, may or may not be
available. These laboratories would serve as peripheral branches of Level II laboratories, which would be
the center or hub. Health posts may refer specimens to health center laboratories. Diploma level staff at
Level I laboratories would be very limited, with usually no more than one trained laboratory assistant or
nurse providing services. The laboratory would offer diagnostic and monitoring services for HIV/AIDS,
TB and malaria. If essential infrastructure were lacking, then the on-site test menu would be restricted to
manual tests. Sites with reliable power and water would perform certain automated chemistry tests
required for antiretroviral therapy (ART) monitoring. Same day performance and delivery of results must
be available while the patient is present for immediate counseling, treatment and regimen modification.
When required testing exceeds the scope of services available from Level I facilities, the “parent” Level II
laboratories would provide a range of consultant services, including receipt of referral specimens and
patients.
Level II Laboratories
Level II laboratories would consist of district hospitals or primary hospital laboratories that perform tests
beyond the capabilities of Level I facilities. Health posts may refer specimens to Health Center
Laboratories under Level I. Serving inpatients; these laboratories would have dedicated laboratory space,
formally trained personnel, UPS systems, and a consistent source of reagent grade water. The laboratory
would be staffed by a minimum of three formally trained technologists or technicians. One staff member
who has managerial skills would serve as the senior or supervisory technologist.
The Level II laboratories would have more extensive test menus for diagnoses and treatment.
Consolidating testing at the district level for certain tests provides necessary volumes for automated
equipment platforms. The Level II laboratories would coordinate the services of Level I laboratories in
the district as well as serve as reagent and supply reservoir/back-up repositories for these laboratories. In
Chapter 5 Laboratory Services Appendix A: Page 1 of 4

addition, Level II laboratories would provide the following consultant services and support for Level I
laboratories:
• Managerial oversight of an outreach program of peripheral primary laboratories (World Health

Organization [WHO], 2003a)
• Referral laboratory services with a more extensive test menu
• On-site quality assessment visits
• Assistance with resolving technical problems
• Data management support with a strong paper-based laboratory information system (should be
part of a national system of data collection by the Ministry of Health [MOH])
• Development and implementation of quality assurance (QA) activities (including, but not limited
to, QC, QI and EQA/PT)
• Periodic review of QC
• Information and training for adequate specimen collection
• Coordination of EQA
• Collection of data for assessment of quality indicators
• Approval and annual review of SOPs and policies to ensure alignment with current practices
• Assistance with development of SOPs and safety procedures
• Staff development/training, performance management, competency assessment, and retraining
• Coordination of courier/transport services
• Assistance with results reporting and record retention
• Equipment maintenance and service support including review of maintenance logs
• Follow-up on laboratory incident and accident reports
• Assessment of safety management practices
Level III Laboratories
Level III laboratories would consist of laboratories in tertiary referral facilities such as regional or
provincial hospitals. These laboratories would perform a complete menu of testing for HIV/AIDS, TB
and malaria as well as testing for many other diseases. Level III laboratories would complete the more
sophisticated tests that Level II laboratories were not able to perform. These facilities must have
dedicated laboratory space that would include a separate microbiology space, a Biosafety Level 3
designated area, and UPS systems. Reagent grade water would also be required. Formally trained,
diploma level technologists who are able to meet workload demands would staff Level III laboratories.
One technologist who has managerial skills would serve as the laboratory supervisor. Level III
laboratories would act as laboratory resource groups for the facilities in their regions.

In addition, Level III laboratories would provide the following services:
• A more comprehensive test menu than that provided at Level II laboratories
• Coordinate laboratory services and information management with other Level III laboratories
• Perform assessments of laboratories in the region; evaluate the QA data from laboratories in the
region
• Coordinate surveillance data collection from lower levels in an effort to obtain country-wide
statistics
• May collect and report inter-laboratory comparisons and EQA data for the region
• Develop training programs and coordination of continuing education
• Assure adequate requisition and reporting mechanisms as well as record retention procedures
• Standardize units, methodologies and reference ranges based on national reference laboratory
recommendations
• Determine the amount of patient history/clinical presentation required for tests referred to other
levels
• Provide logistical and management support to their service areas
Level IV Laboratories (National Reference Laboratories)
Level IV national reference laboratories are recommended to strengthen laboratory capacity for diseases
of public health concern. Ideally, they would provide linkages with clinical trials and other public health
laboratories, forming integrated laboratory networks. Senior program employees, laboratory management
and senior laboratory technologists/scientists would staff these laboratories. Level IV laboratories would
possess the infrastructure, equipment, information systems, and logistical capabilities of sophisticated
reference laboratories. In some countries lacking a unique national reference laboratory, Level III
laboratories may serve as national reference laboratories.
Level IV National Reference Laboratories would:
• Perform all testing performed at the other levels
• Perform molecular and esoteric testing beyond the technical capabilities of Level III laboratories
(e.g., nucleic acid assays, HIV drug resistance studies, TB drug susceptibility studies)
• Develop laboratory standards and processes for laboratory accreditation
• Develop monitoring and evaluation activities for laboratories
• Serve as the national coordinator for HIV, TB, and malaria laboratory programs
• Maintain national database of equipment and maintenance in country

• Participate in international EQA programs and develop/oversee national EQA programs
• Provide input on national laboratory policy development
• Determine what information needs to be supplied with the test result to better interpret the test
• Provide courier and logistics management support for the regions
• Develop and implement testing algorithms and reflex protocols for laboratory utilization
• Establish standards for quality management and assist with policy and procedure development
• Provide assistance with reference range validations and development of national reference
ranges specific to equipment/methods used
• Coordinate the collection of surveillance data to obtain and monitor country-wide statistics
• Introduce and implement new technologies, appropriate for each level, to reflect current best
practices
• Select and evaluate diagnostic tests
• Define sensitivity and specificity requirements in order to select methods that would be
evaluated with a method validation plan

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

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

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

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

Appendix D Sample SOP for Haemoglobin Estimation
Purpose:
The measurement of haemoglobin is useful for the detection of anaemia, its severity, and the
patient’s response to treatment as well as the quality of a donor’s blood before donation.
Method
Cyanmethemoglobin method. This involves the use of Drabkins solution, which contains
Potassium ferricyanide and potassium cyanide.
Principle
When whole blood is diluted 1 in 201 in Drabkins solution, it is haemolysed and the
haemoglobin is oxidized to methemoglobin by the ferricyanide. The methemoglobin formed
is converted to stable hemiglobicyanide by the cyanide. The absorbance of the HiCN
solution is read at 540 nm and compared with that of a reference HiCN standard solution.
Sample
Whole blood mixed with EDTA or capillary blood.
Reagents
1) Drabkins solution
2) Potassium ferricyanide (hexacyanoferrate III)
3) Potassium cyanide
4) Potassium dihydrogen phosphate
5) Non-ionic detergent (e.g. Nonidet)
6) Distilled or deionised water.
This solution must be stored in an opaque brown glass container or plain glass with silver foil
wrapped around it. It is pale, yellow and clear and should be discarded if turbid.
Equipment
Spectrophotometer with 540nm wavelength
Procedure
1) Measure out 0.02ml of capillary or venous blood well mixed with EDTA and dispense into
4ml of Drabkins solution.
2) Stopper the tube, mix well and let stand for 4 –5mins away from sunlight.
3) Using the 540 nm wavelength in the spectrophotometer, zero with Drabkins fluid and read
the absorbance of test solution.
4) Read off the haemoglobin value from the calibration graph already prepared.
Chapter 5 Laboratory Services Appendix D: Page 1 of 2
Note. Daily control tests are necessary to ensure that the Drabkins solution and
spectrophometer are functioning adequately. This can be done using a control haemolysate,
preserved whole blood control or use of HiCN reference standard. Also the Drabkins
solution can be visibly examined for turbidity or measured against a water blank at 540 nm at
which the Drabkins should give a 300 reading.
Calculation
This is done by directly reading off the value from the already prepared graph.
Avoiding errors
a) Ensure that the blood collected is well mixed
b) The Drabkins solution used must be clear and without any signs of turbidity and at room
temperature before use.
c) The volume of blood collected in the pipette must be exactly 0.02ml.
d) Ensure that the cuvette surfaces are clean and dry without finger prints.
e) Avoid using unmatched or scratched cuvettes or chipped pipettes.
f) Do not allow air bubble in the solution.
Normal values
Men 14 – 16 g/dl
Women 12 – 14 g/dl
Children 11 – 13 g/dl
Chapter 5 Laboratory Services Appendix D: Page 2 of 2

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

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

Storage
Limitations:
Special Safety
Precautions
Use table if necessary

Maintenance Step Action
1
2
3
Prepared by: Authority:
NOTE: This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic version prior to use.
Chapter 5 Laboratory Services Appendix E: Page 1 of 2
Department of Infectious and Non Infectious Diseases
Ethiopian Health and Nutrition Research Institute
Addis Ababa
TITLE: Revision Date:

Document Number: Status:
Quality Control Level Stability Frequency Preparation

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

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

Appendix F Sample Laboratory Risk Assessment Form
Laboratory/ Department: ________________________________________________________
Name of Institution: ____________________________________________________________
Inspected by: _______________________________ Month/Year: _____________________
ITEM YES NO
1. LABORATORY SIGNS
a. Entrance to biohazardous areas clearly marked
b. Emergency contacts listed (First-Aid, Fire etc.)
c. Emergency signs posted (Fire exit. Eye wash station etc.)
d. Emergency telephone numbers (Fire, ambulance etc.)
2. SAFETY EQUIPMENT
a. Safety manual present/ read by all
b. Material Safety Data Sheets (MSDS) available
c. Safety Shower
1. Unobstructed and labelled
2. Tested within past one month
d. Eye wash station present
1. Unobstructed and labelled
2. Water changed weekly
e. First-Aid Kit available and labelled
1. Fully stocked
3. PROTECTIVE CLOTHING
a. PPE present (goggles, gloves, coats, face shield etc)
b. Visitor coats and safety glasses available
c. Proper heat resistant/cryogenic gloves available
d. Appropriate personal clothing and footwear
4. HAZARDS
a. Walkways, doors and fire escape routes unobstructed
b. Adequate lighting in all areas
c. Work benches and floors cleaned daily
d. Storage areas accessible, clean and dry
5. SPILL PROCEDURE
a. Spill kits available (biological/chemical/radioactive)
b. Clearly posted with instruction for use
c. Chemical spills documentation present
6. ELECTRICAL
a. Power distribution board clearly labelled
b. Extension cords only for temporary use
c. Multiplugs used only on computers
d. Surge protection (UPS) present
Chapter 5 Laboratory Services Appendix F: Page 1 of 5

e. Electrical cords not frayed
f. Electrical plugs in good condition
g. Earth leakage system in good working condition
7. GAS CYLINDERS
a. Properly and individually chained to the wall
b. Labelled empty or full
c. Labelled as to cylinder contents
d. Safety caps on cylinders not presently in use
e. “No smoking” & “Danger of explosion” signs present
8. REFRIGERATORS/FREEZERS
a. “No Food or Drink” signs posted on doors
9. CHEMICAL STORAGE
a. Chemicals stored by reactive class (flammables, acids etc)
b. Incompatible chemicals physically separated
c. Chemicals properly labelled
d. Chemicals dated on receipt and when opened
e. Inspected monthly for leakage, cracked stoppers, etc.
f. Storage areas labelled with hazard stickers
g. Acids/corrosives/solvents stored in compatible trays
h. No chemicals stored on bench tops/in fume hoods/under sinks
i. Flammable liquid storage cabinet present and labelled
j. List of chemicals available present with MSDS
10. FIRE EQUIPMENT

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

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

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

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

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

a. Temperature control systems adequate
b. Dust and fumes minimized
c. Noise level acceptable
General observations: __________________________________________________________

_______________________________________________________________
______________________________________________________________
Action to be taken: ___________________________________________________________

________________________________________________________________
_______________________________________________________________
Signed by: _________________________________________________
Laboratory Manager: ________________________________________
Date: _____________________________________________________

Appendix G List of Notifiable Diseases
The FMOH declares the following conditions to be of concern to the public health and
reportable as required by law:
a. Acute Flaccid Paralysis (AFP)/Polio
b. Avian Human Influenza
c. Cholera
d. Dysentery
e. Measles
f. Malaria
g. Meningococcal meningitis
h. Neonatal Tetanus
i. Plague
j. Relapsing fever
k. Rift Valley Fever (RVF)
l. SARS
m. Smallpox
n. Typhoid Fever
o. Typhus
p. Viral Hemorrhagic Fever
q. Yellow Fever
r. Any unusual occurrence of infectious or communicable disease or any unusual or
increased occurrence of any illness that may indicate public health hazard, including any
single case or multiple cases of a newly recognized, emergent or re-emergent disease or
disease-producing agent, including newly identified multi-drug resistant bacteria or a
novel influenza strain such as a pandemic influenza strain.
s. Any outbreak, epidemic, or unusual or increased occurrence of any illness that may
indicate an outbreak or epidemic. This includes suspected or confirmed outbreaks of
foodborne disease, waterborne disease, disease caused by antimicrobial resistant
organisms, any infection that may indicate a bioterrorism event, or of any infection that
may indicated a public health hazard.
In addition to the reportable conditions, the FMOH requires the following emergency illnesses
or health conditions to be of concern to the public health and reportable:
i. Clusters of Respiratory illness (including upper or lower respiratory tract infections,
difficulty breathing and Adult Respiratory Distress Syndrome);
ii. Clusters of Gastrointestinal illness (including vomiting, diarrhoea, abdominal pain, or
any other gastrointestinal distress);
iii. Influenza-like constitutional symptoms and signs;
iv. Clusters neurologic symptoms or signs indicating the possibility of meningitis,
encephalitis, or unexplained acute encephalopathy or delirium;
v. Cluster of Rash illness;
vi. Haemorrhagic illness;
vii. Botulism-like syndrome;
viii. Sepsis or unexplained shock;
ix. Febrile illness (illness with fever, chills or rigors);
Chapter 5 Laboratory Services Appendix G: Page 1 of 2

x. Non traumatic coma or sudden death; and
Reports should be submitted to the Woreda Health Office, Regional Health Bureau or Federal
Ministry of Health using a Standard Report Form.
Source: National Notifiable Diseases and Conditions Reporting Rule and General Control
Measures for the Control of Public Health Threats. FMOH, Ethiopian Public Health Institute.
April 2009.
Chapter 5 Laboratory Services Appendix G: Page 2 of 2

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

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

3.2.1 Nursing Admission Assessment
3.2.2 Nursing Diagnosis/Problem Identification
3.2.3 Nursing Care Plan
3.2.4 Implementation of Nursing Care Plan
3.2.5 Evaluation of the Nursing Care Plan
3.3 Communication 13
3.3.1 Written Communication: Medical Record Documentation
3.3.2 Verbal Communication
3.3.3 Physician Orders
3.4 Medicines’ Management 16

4.3 Indicators 20
Source Documents 21
Appendices
Appendix A Sample Nursing Admission Assessment Form
Appendix B Sample Nursing Problem Statement List
Appendix C North American Association of Nurses Approved Nursing Diagnoses
Appendix D Sample Nursing Care Plan
Appendix E Sample Nursing Patient Progress Report
Appendix F Sample Patient Caregiver Contract
Chapter 6 Nursing Care Standards Page 2 of 22

Tables
Table 1 Nursing Care Standards Checklist
Table 2 Nursing Care Standards Indicators
Box A Physician vs. Nursing Diagnoses

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

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

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

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

multidisciplinary team, the patients, patients’ relatives and hospital managers. In working with
colleagues and hospital management, the nurse must:
• collaborate with the patient and their caregivers,
• work with colleagues in the formulation of overall goals, plans and decisions related to
patients,
• work with other members of the multidisciplinary team in caring for patients,
• consult with other health care providers on patient care, as appropriate,
• make referrals, including provisions for continuity of care, as appropriate, and
• collaborate with other disciplines in teaching, consultation, management, and research
activities as opportunities arise.
It is essential that within a case team, ward/unit or department there exists a clear management
structure that delineates the ultimate roles and responsibilities within the given team and clinical
setting, determining who has clear authority over certain decision-making processes.
3.1.3 Clinical Supervision and Delegation
Clinical supervision is “a formal process of professional support and learning which enables individual
practitioners to develop knowledge and competence, assume responsibility for their own practice and
enhance consumer protection and safety of care in complex clinical situations”. In all work settings
nurses should receive adequate support and supervision to ensure that they have the opportunity to
gain professional knowledge and expand their skills.

Nurses may delegate nursing procedures to junior nurses/health assistants and/or to student nurses.
Before delegating the nurse must ensure that anyone they delegate to is able to carry out the
instructions, and the nurse must provide adequate supervision to ensure that the outcome of any
delegated task meets required standards.
3.1.4 Nursing Workforce Plan
Shortages of appropriate nursing staff or inappropriate distribution of available staff adversely affects
the quality of patient care. Inappropriate workforce planning has been shown to increase staff
dissatisfaction and nurse turnover, increase patient mortality, increase hospital-acquired infections,
and increase the risk of needle-stick injuries.1
The hospital should establish a nursing workforce plan that:

• sets minimum nurse to patient ratios for each inpatient ward/service, taking the skill mix of
staff into consideration,
• identifies priority areas where the nurse count must at all times meet the minimum ratio
requirements (for example intensive care/high dependency units, post operative recovery,
emergency department, labour and delivery etc), and
• establishes procedures for transferring nurses across clinical settings, or calling in extra nurses
from home in order to maintain minimum nurse to patient ratios, especially in the priority
areas.
Determining the minimum nurse staffing level is a complex process. Factors to be considered include:
• the severity of the clinical condition of patients,
• the intensity of nursing care needed, for example the frequency of nursing interventions such
as observations, medication administration, wound care, stoma care, bathing etc,
• the number of admissions and discharges,
• the availability of technology (patient monitors, beepers etc),
• the skill mix of staff, and
• the availability of and responsibilities of patient caregivers.
There should be a minimum of a registered professional nurse in-charge of each ward/unit who has a
diploma or bachelor degree education and relevant knowledge, skills and experience to manage a
ward/unit and the nursing staff therein. The nurse-in charge, together with hospital management
should determine the minimum nurse to patient ratio for the unit. The ratio should be kept under
review and amended as necessary.
The nursing workforce plan should also consider the role of nurses in outpatient and specialist clinics
and the nursing contribution to hospital management and governance structures (such as quality
committees, infection prevention committees etc).
3.1.5 Provision of Resources
Hospitals should ensure that nurses have access to and are trained on how to use resources (including
equipment and consumables) correctly and cost-effectively. Nurses are responsible for forecasting
1
Needlemann, Jack; Buerhaus, Peter; Mattke, Soeren; Steward, Maureen; Zelevinsky, Katya; Nurse-Staffing Levels and the Quality of
Care in Hospitals, N Engl J Med. 2002; 346 (22): 1715 – 1722

stock-outs of nursing formats and other consumables on the ward, and should inform the appropriate
party of the need for additional resources to prevent stock out.
3.2 Nursing Process

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

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

• Problem-oriented,
• Goal-oriented,
• Orderly, planned, systematic,
• Open to accepting new information during its application,
• Interpersonal, and
• Permits creativity among nurses and clients.
3.2.1 Nursing Admission Assessment
A nursing assessment is a tool used to collect and document critical data regarding a patient’s health,
psychological and social status. This assessment remains accessible to the entire health care team
during the course of a patient’s stay in order to assist the team in determining proper patient care and
treatment.
In the nursing assessment, the nurse gathers and examines both Subjective and Objective data.
1. Subjective data are what the patient/client actually states (e.g. "I'm tired"). These are his/her
feelings and perceptions.
2. Objective data are concrete, observable information such as:

• vital signs
• laboratory studies
• changes in physical appearance.

NB: SS=Subjective data are Stated.
OO = Objective data are Observed.
Examples:
Subjective data Objective data:
• "I feel sick.” • Blood pressure of 110/70 mmHg.
• "I have a stabbing pain in my side." • Rash on right arm
• "I wish I were home." • Walks with a limp
• "I feel like nobody likes me." • Ate all of his breakfast
• Urinated 150 ml clear urine
A) Procedure of Nursing Admission Assessment
1. Patient arrival: Upon the patient’s arrival to the unit, place him/ her in a bed and orient him/
her to the given surroundings. Be certain to provide directions to the toilet and wash facilities,
how to call for assistance and any other pertinent information about the hospital unit’s routine
operations.
2. When patient is settled into bed: After settling the patient into bed, take the patient’s blood
pressure, pulse, temperature and respirations. Record this information on both the:
(1) Admission Assessment (See Appendix A of this Chapter) and (2) Routine Observation
Sheet (See Appendix B, item 17; Chapter 3 Medical Records Management).
3. Complete nursing assessment: Within 24 hours of the patient’s arrival, the nursing admission
assessment should be completed and filed in the patient’s medical record. Data should be
collected from the patient as a first priority. If the patient is not able to participate, then the
information should be collected from a family member or a guardian. The Physician History
and Physical Examination Assessment may also be used as a source of information (see
Chapter 3 Medical Records Management, Appendix B: Item 4).
B) Admission assessment
A nursing admission assessment complements the physician assessment by focusing on the patient’s
environmental, psychological and social conditions. The nursing assessment gives particular attention
to the patient’s ‘activities of daily living’ such as sight, hearing, speech and language, mobility,
independence and self care.
A sample Nursing Admission Assessment Form is presented in Appendix A.
3.2.2 Nursing Diagnosis/ Problem Identification
The purpose of nursing diagnosis is to identify problems or needs that require nursing input. The
nursing diagnosis differs from the physician’s diagnosis as illustrated in Box A.

Box A Physician vs Nursing Diagnosis
Physician diagnosis is disease focused, for example:
“Ato Yidnek has pain and swelling in all his joints. Diagnostic studies indicate that he has
rheumatoid arthritis. Anti-inflammatory drugs will be prescribed to treat the rheumatoid
arthritis”
Nursing diagnosis is holistic, considering both the problem and its effect on the patient and
family, for example:
‘Ato Yidnek has pain and swelling in all his joints making it difficult to feed and dress himself.
He states that he feels worthless when he cannot even feed himself’.
The nursing diagnosis forms the basis for providing nursing care. Factors to consider when making a
nursing diagnosis include:
• self care limitations or impaired functioning related to mental and emotional distress or mental
retardation;
• deficits in the functioning of significant biological, emotional and cognitive systems;
• emotional stress or crisis components of health problems, pain and disability;
• self-concept changes, developmental issues, and life process changes;
• problems related to emotions such as anxiety, aggression, sadness, loneliness, and grief;
• alterations in thinking, perceiving, symbolising, communicating and decision making;
• difficulties in relating to others;
• behaviours and mental states that indicate the patient is a danger to self or others or has a
severe disability;
• interpersonal, socio/ethnic/cultural, spiritual or environmental circumstances or events which
have an affect on the mental and emotional well being of the patient family or community; and
• symptom management, side effects associated with medications and other aspects of the
treatment regimen.
The nursing diagnosis/diagnoses should be written as a three-part statement(s) which includes:

1. The problem (P)
2. Its cause or etiology (E)
3. Signs and symptoms (S)
The PES format describes the problem and its etiology, together with data (signs and symptoms) that
validate the chosen diagnosis. To write a diagnostic statement for an actual nursing diagnosis, link the
problem and its cause by using “related to” then add “as manifested by” or “as evidenced by” and state
the major signs and symptoms that validate the diagnosis.

Example 1:
Problem Etiology (cause) Symptom/Sign
“ineffective airway clearance related to incisional pain as manifested by poor cough effort”
Example 2
Problem Etiology (cause) Symptom/Sign
“impaired communication related to inability to speak Amharic as manifested by inability to follow

instructions in Amharic and verbalisation of requests in English”.
Nurses may also note that a patient has certain risk factors that put him/her at risk of a particular
nursing diagnosis. These risk factors and the related ‘potential nursing diagnosis’ should be
documented so that the nursing care plan can include actions to prevent the problem. For example: ‘at
risk of impaired skin integrity due to patients’ age, weight, immobility and confinement to bed”. The
nursing care plan would then include action to prevent irritated or broken skin such as regular turning,
massage etc).
A sample Nursing Problem Statement List is presented in Appendix B.
Appendix C presents the North American Association of Nurses Approved Nursing Diagnoses
(NANDA).
3.2.3 Nursing Care Plan
The Nursing Care Plan is designed to provide consistency in care and treatment to a patient by
documenting all aspects of the patient’s nursing care regime. The goal of any plan of care is to aid the
patient’s return to his/her best state of health, to help him/her maintain independence and to ensure a
smooth transition to home. The Nursing Care Plan should be based on the nursing assessment and
nursing diagnoses, and should be individualized, tailored to the patient’s health problems or
psychotherapeutic and physiological needs. The nursing care plan guides each nurse to intervene in a
manner congruent with patient needs and goals and provides outcome criteria for measurement of
progress.
In implementing nursing care plans, nurses should use a wide range of interventions designed to
promote, maintain, and restore mental and physical health. Nursing interventions should be:
• based on current knowledge and principles of relevant treatment modalities,
• selected based on the needs and/or desires of the patient,
• selected according the nurse’s level of practice, education, and certification,
• implemented within the established plan of care,
• performed in a safe, ethical and appropriate manner,
• adapted to changing patient needs and situations, and

• reviewed in order to understand the progress or lack of progress toward identified goals.
The following aspects of nursing care should be considered when developing and implementing a
nursing care plan:
1. Therapeutic relationship
The development of a therapeutic relationship between the nurse and the patient promotes patient
engagement and motivation for self-care. It contributes to patient cooperation with nursing and
treatment regimes.
2. Counselling
The counselling role is part of nursing practice and reinforces healthy behaviour and interaction
patterns, helps the patient to modify or discontinue unhealthy ones and promotes the patient’s personal
and social integration.
3. Promoting self-care activities
The nurse needs to ensure that:

• the self-care interventions assist the patient in meeting his/her unique needs and assuming
personal responsibility for activities of daily living,
• the self-care activities of daily living are appropriate for the patient’s age, developmental level,
gender, sexual orientation, ethnic/social/cultural background, and education,
• self-care interventions are aimed at maintaining and improving the patient’s functional status,
and
• patients are referred to community/extended family/social support network resources, as
necessary.
4. Psychobiological interventions
Psychobiological interventions provide the foundation for the treatment regimen and nurses are in an
excellent position to support the use of such interventions. Nurses should explore patients’ feelings
and concerns related to:
• illness and diagnosis,
• prescribed medication, and
• hospitalization.
5. Health education
Patients need to understand their medical as well as their nursing diagnosis, assessments, interventions
and their side effects, and they must develop, as much as possible, self-sufficiency in caring for
themselves.

6. Assigning a ‘ named nurse’
A ‘named nurse’ is responsible to arrange and coordinate all the needed health care services at all of
the necessary points of service, and acts as the main point of contact between the patient/caregivers
and the healthcare team. Assigning a ‘named nurse’ is particularly helpful for patients with multiple
problems or with a long length of hospital stay.
In writing the nursing care plan, the nurse should think about:
• Who is it for? (the patient and other members of nursing team)
• What are the short term and long term goals?
• How can you determine that you have reached the goals? (measurable)
• How will the patient know he/she has achieved the goals? (realistic)
• Who is involved in the delivery of the care? (The patient (and family), yourself, the nursing
team, medical staff, multidisciplinary team, labs, investigations, procedures etc)
• How quickly is the problem likely to change?
• How soon will you need to re-evaluate the plan?
• How many problems are there?
• Which order of priority?
The nursing care plan should also:

• act as an educational programme related to the patient’s health problems, treatment, and self-
care activities,
• indicate responsibilities of the nurse and the patient, and other case team members if relevant,
• give direction for patient-care activities that can be delegated by the nurse to other care
providers,
• provide for appropriate referral and case management to ensure continuity of care,
• establish a process for discharge planning, and
• employ a systematic strategy to monitor the patient’s health status and to evaluate and revise
the care plan.
A sample nursing care plan is presented in Appendix D.
3.2.4 Implementation of Nursing Care Plan
The nursing care plan should be presented to the multidisciplinary case team for discussion and
affirmation on the appropriateness of the planned interventions. The nursing care plan should be
implemented by all nurses who care for a particular patient. Hence all nursing staff should be familiar
with the care plan for each patient and should ensure that the activities described in the nursing care
plan are carried out during each nursing shift.
Implementation of the nursing care plan should be documented in a Nursing Patient Progress Report
(Appendix E).
On the Progress Report nurses document the administration of prescribed care and treatment, the
patient’s response to that care and treatment, the patient’s emotional adjustment, health education
given to the patient, and any other related patient care information. Nurses chart a progress report at
the end of each shift worked.

3.2.5 Evaluation of the Nursing Care Plan
Nursing care is a dynamic process involving change in the consumer’s health status over time, giving
rise to the need for new data, different diagnoses, and modifications in the plan of care.
As new problems arise they should be entered onto the Problem Index List and related goals and
activities to address the problem should be entered onto the Nursing Care Plan. Similarly, if a
problem resolves this should be recorded on the Problem Index List to indicate that goals and activities
related to that particular problem are no longer necessary.
The nursing care plan should be regularly reviewed and modified as necessary. The following
questions should be considered:
1. Have the goals of the nursing care plan been achieved?
2. If not, why not? Were the goals realistic? Was the patient committed to the goals? Was there
enough time to achieve the goals? Did other problems arise that impeded progress? Were
interventions consistently performed as prescribed?
3. Have any new problems developed that have not been addressed?
4. Could more have been achieved than originally hoped for? Should new goals be set?
3.3 Communication
Every hospital should establish clear guidelines for both verbal and written forms of communication
that involve nurses.
a) Written communication: This includes the written documentation of all findings, progress, care and
treatment provided to the patient by the medical team, including the nurses. A written record
permits immediate access to all information related to the patient’s care and facilitates the
exchange of information between all members of the case team.
b) Verbal communication: For nurses, this entails the act of reporting and conversing with other
members of the health care team regarding the patient’s progress and status.
3.3.1 Written Communication: Medical Record Documentation
The following items are used by nurses to document a patient’s course of treatment. It is the nurse’s
responsibility to ensure that a patient’s medical record is complete, containing all the necessary forms
in the proper sequence. The forms are intended to guide the entire medical team and to become a
permanent record maintained in the patient’s medical record.
1) Clinical forms: Nurses must record patient data and findings on clinical forms that include:
• Routine Observation Sheet
• Intravenous Fluid Administration Record,
• Fluid Balance Chart
• Medication Administration Record
Samples of the above forms are presented in Chapter 3 Medical Records Management, Appendix B.

It is the nurse’s responsibility to chart on the appropriate form and to make sure that the information is
timely and accurate.
2) Nursing Process Forms: As described in Section3.2 above, nurses should record all steps in
the nursing process on the appropriate forms:
• Nursing Admission Assessment Form (Appendix A)
• Nursing Problem Statement List (Appendix B)
• Nursing Care Plan (Appendix D)
• Nursing Patient Progress Report (Appendix E)
3.3.2 Verbal Communication
1) Reporting to Physicians: Whenever a patient’s status changes, the physician should be

informed. The status should be reported in an objective manner, allowing for the physician’s
recommendation(s). Any physician’s order should then be documented in the medical record
by the nurse as a verbal order. Verbal orders from a physician to a nurse must be told to 2
nurses simultaneously in order to ensure that instructions are clearly understood and verifiable.
The transcribed order should be signed by the physician within 24 hours.
2) Nurse-to-Nurse Report: During a shift change, the off-going nurse should verbally report to
the on-coming nurse concerning the status of each patient using a standard format. The report
consists of a general synopsis of the patient, any significant events during the shift, as well as a
progress report of the work completed. Updates should be provided on IV administration, tests
done or pending, abnormal laboratory findings, and general patient progress.
Follow the format below for performing nurse-to-nurse shift report.

• Patient name
• Patient age
• Reason for seeking care/Chief complaint
• Patient diagnosis: present all current diagnoses
• Current IVs
• Tests completed or pending
• Abnormal lab findings: do not report normal findings
• Events during the shift: synopsis of what occurred during the shift
• Patient progress: description of patient’s response to any treatment or events that
occurred during the nurse’s shift, including the patient’s progression towards
discharge
3) Nurse to Junior Nurse/Health Assistant/Student Report: At the start of each shift, the nurse is
responsible for reporting to the junior nurse/health assistant/student regarding patient(s) under
his/her care. Specific care information related to bathing, ambulating, eating, toileting, and
other similar concerns should be discussed. A written checklist of tasks to be completed
should be given to the junior nurse/health assistant/student.

Use the following format for performing a nurse to junior nurse/health assistant/student report. It is
important that the assigned tasks are specific to ensure that the junior nurse/health assistant/student is
able to accomplish them during their shift.
a) Vital Signs: Describe the frequency required for assessing a patient’s vital signs. Is it
necessary to assess them:
• Once a shift,
• Twice a shift,
• Every hour, or
• Other unique needs.
b) Bathing: Describe the level of assistance the patient requires for bathing and changing
linens. Is the level:
• Complete assistance during both bath and bed linen changing,
• Required assistance when bringing bathing materials to the patient who must remain in
the bed while linens are changed,
• Required assistance when bringing bathing materials to the patient who is capable of
getting out of the bed while the linens are changed, or
• No assistance necessary because the patient is independent during bathing and the
patient is capable of getting out of bed while the linens are changed.
c) Activity: Describe the activity level of the patient as follows:

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

f) Safety: Describe how often the aide needs to make rounds on the patient.
4) Patient Education: It is important to educate the patient, his/her spouse/partner, and his/her
family about the illness and course of treatment being provided as a preventative and/or curative
measure. It informs and empowers the patient, thus improving his/her ability to achieve a higher
level of wellness and ability to manage specific needs. Efforts to educate the patient should be
realistic, relevant and provide time for patient practice and opportunity to seek clarification.
Patient education should also incorporate family members and other caregivers who often play strong
role in facilitating patient care in coordination with medical staff. One suggestion to improve the
family and staff relationship is through the use of a Patient Caregiver Contract, whereby the
relationship is formalized between families/caregivers and medical staff (A sample Patient Caregiver
Contract is presented in Appendix F). This allows patient families to act as “aides” and provide
certain services (feeding, bathing, ambulating, bringing fresh sheets and food, etc.) within guidelines
that are acceptable to medical staff. Such a formalized process can greatly improve the patient’s
quality of care. It is also important to ensure that such a contract is fully understood by both the patient
and caregiver prior to signing.
3.3.3 Physician Orders
Physicians provide both written and verbal forms of communication in order to direct a patient’s care.
It is the nurse’s responsibility to ensure that a physician’s orders and plan for a patient’s care are put
into action.
Physician’s orders should be recorded by the physician on a Physician Order Sheet (See Chapter 3
Medical Records Management, Appendix B, item 8). When the order is carried out this should be
documented on the order sheet, including the date and time that the order was carried out, and the
signature of the person confirming that the order has been completed.
All physician orders, even verbal orders, must be documented.
Any/all verbal orders from a physician must be given to two (2) nurses simultaneously in order to
ensure verbal instructions are clearly understood and verifiable. The physician should be clear about
which nurse (of the two) is to implement his/her verbal orders. Once received, the order is
immediately transcribed into the Physician Order Sheet by the implementing nurse. The nurse who is
writing the order completes the transcription by writing “verbal order given by (the name of the
physician)/the nurse’s signature.” All verbal orders are to be reviewed and co-signed by the physician
within twenty-four (24) hours.
3.4 Medicines’ Management

It is the nurse’s responsibility to safely administer the medications to a patient as ordered by the
physician. Nurses should be aware of the desired outcome, dosage, preparation and side effects of
each prescribed medication.

Procedure
1) Physician Order: A physician’s order is required for the administration of all medications.
There are several types of orders:
• Standing order: To be carried out as specified until it is canceled by another order
(including PRN orders).
• Single order: To be carried out only once, as directed.
• Stat order: To be carried out immediately.
• Verbal order: An order that has been communicated through the phone or verbally.
These orders are reserved for times when the physician is unable to reach the
patient’s medical record. Verbal orders can only be taken by a nurse, who must
immediately transcribe the verbal order into the Physician Order Sheet. Verbal
orders from a physician to a nurse must be told to 2 nurses simultaneously in order
to ensure that instructions are clearly understood and verifiable. All verbal orders
must be co-signed by the physician within 24 hours.
Physician orders need to include the following information when they are transcribed into the
Physician Order Sheet in order to be considered complete. Orders are not to be carried out unless all
of these elements are present. If an element is missing, the physician who issued the order should be
called to complete the order.
• Date and time: When the order was written.
• Full name of the medication: Either the chemical or generic name can be used
without abbreviations.
• Dosage: Specify the amount of medicine to be given. Abbreviations are
discouraged.
• Concentration: If the medication is to be diluted in IV fluid, the amount and type
of diluent/s ordered.
• Duration: If the medication is to be given over a period of time, such as IV
administrations, the duration of the infusion ordered should be recorded by the
physician. Nurses should then translate and document the duration of infusion into
number of (micro) drops per minute.
• Time and frequency: The time of day and how often a medication is to be given, as
ordered by the physician. The nurse who transcribes the order will identify the
specific time that the medication is to be given by following a standardized
schedule.
• Route: For medications that can be given in several ways, the route of
administration needs to be clearly written.
• Physician Signature: Is to be clearly written immediately following the order.
2) Transcribing the Order: Medication orders are transcribed by the nurse from the physician
order sheet to the Medication Administration Record. The nurse will document that the
order has been transcribed by putting a signature next to the order.

The nurse is responsible for questioning the physician regarding any medication order or element of an
order that is in his/her judgment an error. The perceived error may be in the drug ordered, dosage,
route, time and/or frequency to be given.
3) Administration of Medications: The following steps should be followed by the nurse when
administering medications. Two processes are outlined which differ based on whether the
medication is stored at the patient’s bedside or in a central cabinet. There are three distinct
steps to administering medications: preparation, administration and documentation. Each
step requires safety checks to ensure that the right drug is given to the right patient.
Medications at the Bedside

• The nurse brings the Medication Administration Record to the patient’s bedside.
• The nurse checks the prescribed medication from the patient’s bedside to the
Medication Administration Record three times to ensure that it is the proper
medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
Medications in a Cabinet
• The nurse brings the Medication Administration Record to the cabinet.
• The nurse checks the prescribed medication from the cabinet to Medication
Administration Record three times to ensure that it is the proper medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
• Medications should be prepared one patient at a time. Each medication for a single
patient should be organized into a group for that individual patient, prior to
dispensing medications for another patient.
• When medications are to be given to more than one patient, the medication
cup/container should be clearly marked with each bed number.
• Before administering medication, the nurse should cross-reference the bed number
(on cup/container) with the bed number and name listed on the Medication
Administration Record.
4) Administration:
• The nurse who prepares the medication should always be the nurse who administers
the medication.
• During administration, medications should never be out of the sight of the
administering nurse.
• It is the nurse’s responsibility to confirm that they are giving the correct drug to the
correct patient. When the nurse arrives at the patient’s bedside, the nurse must
confirm using two methods that the patient is properly identified.
• Check the name on the Medication Administration Record with the patient’s
posted name.
• Ask the patient to repeat their name.

• Once the correct patient is verified, administer the medication. If it is an oral
medication do not leave it for the patient to take later. The nurse needs to observe
all medications being taken to assure that the medication has been adequately
administered.
• If a patient refuses a medication, the physician should be notified and it should be
clearly documented in the medical record.
5) Documentation: Immediately following the administration of a patient’s medication, the

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

In order to determine if the Operational Standards of Nursing care standards have been met by the

Table 1. Nursing Care Standards Checklist

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

4.3 Indicators
Table 2. Nursing Care Standards Indicators

S/N Indicators Formula Frequenc Comment
y
1. Number of pressure Quarterly HMIS
sores/number of
Pressure sore incident rate admissions*100
2. Total number of nurses Quarterly HMIS
leaving/total number of
nurses at beginning of
Attrition rate of nursing staff reporting period * 100
3. a) Cumulative number of nursing a) Total number of nursing Quarterly HMIS
staff who received in service staff with in-service training
training from the beginning of year
to the end of reporting
b) % of nursing staff who received in period
service training
b) Cumulative number of
nursing staff who received
training/ Total number of
nurses at beginning of year
* 100
4. In patient satisfaction survey : Total number of inpatients Biannual Survey tool
% of respondents who answer ‘always who respond ‘always or presented in
or usually’ to the following questions: usually’ to the questions Appendix F of
a) During this health facility stay, listed/ Total number of Chapter 12 Quality
how often did nurses treat you inpatients respondents*100 Management.
with courtesy and respect?
b) During this health facility stay,
how often did nurses listen
carefully to you?
c) During this health facility stay,
how often did nurses explain
things in a way you could
understand?

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24. Royal College of Nursing. (2003). Guidance for nurse staffing in critical care. London: Royal College of
Nurses.
25. Royal College of Nursing. (2006). Policy Guidance 15/2006: Setting Appropriate Ward Nurse Staffing
Levels in NHS Acute Trusts. London: Royal College of Nurses.
26. Rush, S., Fergy, S. and Wells, D. (1996). Professional Development. Care Planning: Knowledge for
practice. Nursing Times. 92(38)1-4.
27. Scally, G. and Donaldson, LJ, (1998). Clinical governance and the drive for quality improvement in the
new NHS in England. British Medical Journal. 317(7150) 4 July pp.61-65.
28. World Health Organization. (2003), Nursing and Midwifery Workforce Management. Analysis of Country
Assessments. SEARO Technical Publication No.26. New Delhi: WHO Regional Office for Southeast Asia
http://www.searo.who.int/LinkFiles/Publications_Analysis_Cntry_Asses_11Sep.pdf.
29. World Health Organization Release. (15 August 2003).
http://www.who.int/mediacentre/releases/pr80/en/print.htm.
30. Parish, C. (2002). Minimum effort: The introduction of minimum nurse-to-patient ratios can have
maximum effect on recruitment and morale, in nursing standard, Vol. 16, No 42.
FURTHER READING
1. Bowman, G.S., Thompson, D., and Suttin, T. (1983). Nurses attitudes towards the nursing process. Journal
of Advanced Nursing. 8(2) p.125129.
2. Braden, S. (1998). Evaluating nursing interventions: A theory driven approach. London: Sage Publications.
3. Cohen, E., Gesta, T. (2001). Nursing case management from essential to advanced practice application. 3rd
edition. USA: Mosby.
4. Faulkner, A. (2000). Nursing: The reflective approach to adult practice. 2nd Edition. Cheltenham: Bailliere
Tindall.
5. Joint Commission International. (2002). Joint Commission International Accreditation Standards for
Hospitals. Second Edition. Illinois: Joint Commission on Accreditation of Healthcare Organizations.
6. New Jersey Department of Health and Senior Services. (2005). Hospital Licensing Standards. N.J.A.C.
Title 8: Chapter 43 G. Trenton, New Jersey: NJDOHSS.

Appendices
Chapter 6 Nursing Care Standards

Appendix A Sample Nursing Admission Assessment Form
Nursing Admission Assessment Form

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

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

Perception
Patient’s understanding of the reason of admission:
Family or next of kin’s understanding of the reason for admission:
Medication Patient is Currently Taking (incl. “over the count”)

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

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

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

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

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

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

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

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

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

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

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

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

Comments:
12. Psychological Care

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

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

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

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

Appendix B Sample Nursing Problem Index List
Nursing Problem Index List

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

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

Appendix C 2009–2011 North American Association of Nurses Approved Nursing
Diagnoses
Activity/Rest Constipation, perceived Allergy Response, risk for latex

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

Appendix D Sample Nursing Care Plan
Nursing Care Plan

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

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

Appendix E Sample Nursing Patient Progress Report
Nursing Patient Progress Report

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

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

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

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

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

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

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

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

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

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

Signed: ________________________________________________________________________
2) Print Caregiver Name: ____________________________________________________________

Signed: ________________________________________________________________________
3) Ward Staff Witness: ______________________________________________________________

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

Infection Prevention
Section 2 Operational Standards for Infection Prevention 6

3.1 Management of Infection Prevention Activities 6
3.1.1 Infection Prevention Committee’s Scope of Work
3.1.2 Infection Prevention Plan
3.2 Standard Precautions 8

3.2.1 Hand Hygiene
3.2.2 Personal Protective Equipment
3.2.3 Infection Prevention in the Surgical Unit
3.2.4 Infection Prevention in the Laboratory
3.3 Transmission based precautions 16

3.3.1 Contact precautions
3.3.2 Droplet precautions
3.3.3 Airborne precautions
3.3.4 Cohorting
3.3.5 Special precautions for TB infected patients
3.4 Environmental Hygiene 20

3.4.1 Waste management
3.4.2 Linen processing
3.4.3 Housekeeping
3.4.4 Instrument processing
3.4.5 Traffic Flow
3.4.6 Food Safety
3.5 Worker Safety 33

3.5.1 Injection safety
3.5.2 HIV post exposure prophylaxis
3.6 Equipment, Supplies and Infrastructure 39
3.7 Monitoring and surveillance 41

3.7.1 Monitoring
3.7.2 Surveillance of nosocomial infections
3.7.3 Using the data
3.8 Infection Prevention Training 43

3.8.1 Educating patients, caregivers, and other visitors regarding IP policies
Chapter 7 Infection Prevention Page 2 of 50

4.3 Indicators 46
Source Documents 48
Appendices
Appendix A Handwashing Techniques
Appendix B Summary of Procedures for Handling and Disposal of Healthcare Waste
Appendix C Suggested Cleaning Guidelines for Hospital Environments
Appendix D Post-exposure prophylaxis forms: Post Exposure Prophylaxis Decision Making Tool
(from draft National PEP Guideline)
Appendix E Post-exposure prophylaxis forms: Sample Post Exposure Prophylaxis Patient Tracking
Form
Appendix F Post-exposure prophylaxis forms: Sample Occupational Blood and Needle Stick
Exposures Recording Form
Appendix H Monitoring and surveillance forms: Sample Hand Hygiene Monitoring Form
Appendix G Monitoring and surveillance forms: Sample of a Minimum Data Collection Form for
HCAI Prevalence Study
Appendix H Monitoring and surveillance forms: Sample Infection Prevention Checklist to assess
each Case Team/Unit
Tables
Table 1 Personal Protective Equipment: Types
Table 2 Personal Protective Equipment: Uses
Table 3 Personal Protective Equipment: Cleaning and Disposal
Table 4 Needs Assessment for Infection Prevention Supplies and Equipment
Table 5 Infection Prevention Checklist
Table 6 Infection Prevention Indicators
Figures
Figure 1 Segregation of health care waste by waste type
Figure 2 Instrument processing steps
Boxes
Box A Personal protective equipment for cleaning staff
Box B Inputs required for PEP service

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

The potential for the transmission of infections in the health care setting is high. Both those receiving
and providing care in a hospital are at risk of acquiring and transmitting infections through exposure to
blood, body fluids or contaminated materials.
The term most commonly used to describe the type of infection acquired in a healthcare setting is
healthcare acquired infections (HCAIs). Healthcare acquired infections are defined as infections that
are acquired in any healthcare setting by a patient who was admitted for a reason other than that
infection. The patient population is often sick, immunocompromised and more susceptible to
infections and is also more likely to transmit infections to others.
Healthcare workers may be exposed to infection through the provision of care. Invasive clinical
procedures and the use of instruments and sharps expose healthcare workers to needlestick injuries and
in turn to potentially infectious agents.
Although minimal data is available on the prevalance of HCAIs in Ethiopian hospitals, in developing
countries with health systems and resources similar to Ethiopia, studies have shown HCAI rates as
high as 40%1.
Establishing an infection prevention program with the aim of stopping the transmission of infectious
agents is the only way to reduce the occurrence of HCAIs, and demonstrates a hospital’s commitment
to the well-being of patients and staff by minimizing the likelihood of HCAIs and assuring a clean and
safe environment. Moreover, hospitals must ensure that the safety of employees, patients and visitors
is upheld by preventing the acquisition and transmission of infections. The prevalence of infectious
diseases such as tuberculosis, Human immunodeficiency virus (HIV), Hepatitis B (HBV) and
Hepatitis C (HCV) and other infectious diseases in Ethiopia heightens the urgency for hospitals to
implement a comprehensive infection prevention program which includes:
• Effective management,
• Staff engagement and involvement,
• Provision of necessary equipment and supplies,
• Monitoring and surveillance, and
• Training.
Implementing an infection prevention and control program will a) help improve the quality of patient
care and b) save valuable resources in the long-term.
This chapter outlines the key components of a comprehensive hospital infection prevention program.
1
Admasu, K. Assessment of Infection Prevention Practices in Hospitals in Addis Ababa, 2008.
Section 2 Operational Standards for Infection Prevention
1. Hospital Management supports improvement efforts in infection prevention by ensuring that

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

3.1 Management of Infection Prevention Activities
Effective management is essential to creating an effective infection prevention (IP) program. There are
two tiers of management of an IP program: direct management of IP activities by a designated
individual(s); as well as senior level management from the Chief Executive Officer (CEO), Senior
Management Team and the Governing Board.
Hospitals should have a designated person or persons to oversee day to day infection prevention
activities. Their roles and responsibilities in relation to IP activities should be described in their job
description and each should be allocated sufficient time in their work schedule to fulfil their IP duties.
Resources permitting, it is recommended that one person is designated to coordinate overall infection
prevention activities as his/her primary responsibility. This person could be a nursing staff member,
environmental health worker or any other staff member who has been trained in infection prevention
and control principles.
In addition to a full-time IP designate, the hospital should also have an Infection Prevention
Committee charged with overall coordination and monitoring of the hospital’s infection prevention
work. The committee should be multi-disciplinary and representative of the hospital staff and should

have no more than 5-8 members. Committee members should be individuals who are interested and
engaged in infection prevention work and are able to direct hospital staff to implement the IP program
and incorporate IP strategies into their daily work responsibilities.
Hospital staff from key areas should be represented on the IP committee. Representatives from the
following areas should be considered for membership on the hospital’s infection prevention
committee:
• Inpatient, outpatient and emergency case teams
• Environmental Health
• Nursing
• Medical
• Housekeeping
• Administration (CEO, or another senior manager)
• Pharmacy
• Laboratory
• Laundry
• Kitchen
• Instrument processing unit
• Occupational health and safety
• Quality Management (e.g. Incident officer)
In addition to the above members, it is advisable to include a representative from the hospital finance
unit (head of hospital finance, accounting). It is critical that those who can commit funds and who can
assure that funds are allocated to support IP functions (purchase of critical supplies, such as soap,
antiseptics, disinfectants, personal protective equipment, etc.) are involved with or aware of the
infection prevention committee’s work. Having the appropriate people participate in the committee
can empower individuals to take ownership of the program and can assist in assuring the long-term
sustainability of the program.
Senior level management should support the IP committee’s efforts by:

• Monitoring the IP committee’s overall activities,
• Ensuring that equipment and supplies needed for IP activities are available,
• Reviewing committee reports (e.g. on healthcare acquired infections prevalence) and acting on
actionable items, and
• Encouraging staff adherence to and involvement in IPC activities.
This core group of hospital leaders can guide the infection prevention program by identifying areas of
critical need, prioritizing areas to focus the program, and committing funds to make the program
successful.
3.1.1 Infection Prevention Committee’s Scope of Work
The infection prevention (IP) committee and infection prevention designate(s) are responsible for
coordination of the hospital’s overall infection prevention activities as well as development of an
operational plan for infection prevention activities.

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

2. Monitor and evaluate the performance of the infection prevention program by assessing
implementation of the plan and adherence to practice.
3. Establish a program for the surveillance of HCAIs.
4. Review HCAI surveillance data.
5. Report findings on HCAI surveillance and performance of the infection prevention (IP)
program to management and other staff and identify areas for intervention.
6. Ensure, in collaboration with relevant staff, appropriate staff training in infection prevention
guidelines.
7. Ensure, in collaboration with relevant staff, the consistent and adequate supply of personal
protective equipment and other infection prevention supplies and equipment.
8. Create a sense of individual responsibility for IP amongst all staff.
3.1.2 Infection Prevention Plan
A number of national guidelines exist which outline infection prevention policies and practice
including the Federal Ministry of Health’s Infection Prevention Guidelines for Healthcare Facilities in
Ethiopia. These documents should serve as a resource to hospital staff, particularly staff engaged in
infection prevention activities. However, the successful implementation of an IP program requires an
operational plan that defines how the national guidelines will be implemented at hospital level.
The IP plan should define the infection prevention policies of the hospital, how those policies will be
implemented and by whom.
The plan should outline all of the activities to be included in the hospital’s infection prevention
program. At a minimum the plan should address the hospital’s policies and procedures for:
• Standard precautions,
• Transmission based precautions,
• Equipment and supplies for IP activities, including personal protective equipment,
• Monitoring and evaluation of IP activities, and
• IP training.
3.2 Standard Precautions
Standard precautions are a set of recommendations to minimize the spread of infections in a health
care setting. Healthcare workers should apply the principles of standard precautions with each
encounter with a patient and consider every person, patient or staff, as potentially infectious or
susceptible to infection.

Most HCAIs can be prevented through readily available and relatively inexpensive strategies. The
elements of standard precautions include implementation of recommended practices regarding:
• Hand hygiene,
• Personal protective equipment,
• Safe work practices (such as safe injection practice, safe practice in the operating room),
• Safe house keeping,
• Disposal of health care waste management, and
• Processing of instruments and linens.
3.2.1 Hand Hygiene
Hand hygiene is one of the most important measures for infection prevention. Studies have shown that
effective and consistent hand hygiene practice among hospital staff can significantly reduce the
occurrence of HCAIs. Hand hygiene generally refers to hand washing, hand antisepsis (with alcohol
based hand rub) and surgical hand scrub. Hand hygiene should be practiced by all healthcare
providers before and after contact with a patient/client regardless of their health status. Steps of hand
hygiene (hand washing and hand antisepsis) should be posted close to every sink and steps of surgical
hand scrub near scrubbers’ sink (See appendix A for a sample hand washing poster). To achieve the
greatest compliance in hand hygiene all staff should be trained in proper hand hygiene techniques as
part of infection prevention training program and hand hygiene facilities (such as functioning sinks,
soap and water) should be in place in all patient care areas. The hospital should provide a consistent
supply of clean water for all patient care areas. This can be achieved by short term provision of water
using containers with improvised sinks (buckets with faucets fixed to it) and /or temporary storage
tankers or long term provision of water from a reliable supply designed for the hospital.
The hospital should also provide plain soap, in the form of bar or liquid, antiseptic soap, and/or
alcohol and glycerine (for preparation waterless antiseptic hand rub) for all patient care areas on a
regular basis. If bar soap is used, provision of small bars and draining soap racks is recommended to
prevent accumulation of contaminated liquid which harbours microorganisms. When the soap
dispensers are reused they should be thoroughly cleaned before refilling; adding soap to a partially
empty soap dispenser is not recommended as it leads to bacterial contamination of the soap. The major
and minor operation rooms should be provided with plain soap, antiseptic soap, 2-4% chlorohexidine
and 7.5-10% povidone iodine, alcohol, non-contaminated glycerine, and nail cleaners/soft brushes for
surgical hand scrubs.
In procedure areas, it is advisable to install faucets with foot controls or faucets that can be closed by
elbow to minimize contamination after hand washing. Disposable paper towels should be placed close
to the faucets for easy access after washing hands. If it is not possible to supply disposable towels,
every health care provider should have a pair of personal towels for everyday use to dry hands after
washing. These personal towels should be washed and dried every day. Using common towels should
be avoided as this is associated with cross contamination.
In addition to staff training, the hospital should ensure that hand hygiene is included in the health
education program given to patients and caregivers.

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

Personal Protective Equipment Type
Gloves Heavy duty gloves
Surgical gloves
Examination gloves (latex or nitrile)
Other types (ex. those worn by cleaning and laundry staff)
Protective Eyewear Eye shield
Goggle
Visors
Masks Dust mask
Surgical
Respirators
Other type of face mask
Aprons Plastic apron
Other types
Protective shoes Boots
Nurse shoes
Other protective shoes
Caps
Face shield
Each personal protective has a different use and application. Table 2 presents a summary of the types of PPE, when each
should be worn and by whom.
2
CDC, Guidance for the selection and use of personal protective equipment in healthcare settings.
Table 2. Personal Protective Equipment: Uses
Type of PPE Who should wear PPE? What is When PPE should be worn
Protected?
Gloves Medical, nursing staff Hands When there is direct contact with exposed
Surgical (normal and (including students) wounds, blood, body fluids, or any type of lesion.
elbow length)
Examination When drawing blood or handling medical
Nitrile instruments involved with invasive procedures
Latex (catheters, IV insertion, probes, etc.).
Heavy duty During surgical procedures
Porters When handling waste items or others

Runners/transitors contaminated surface
Cleaning, laundry staff
When cleaning patient areas.
Protective eyewear Medical, nursing staff Eyes When splattering of blood or body fluids to the
(including students) face is possible,
Porters
Runners/transitors When handling biohazardous, soiled linens,
Cleaning, laundry staff as When performing waste collection for hazardous

needed or non-hazardous waste.
Masks Medical, nursing staff Mouth, nose To protect mucous membranes of mouth and nose
Surgical mask (including students) when splattering of blood, body fluids, secretions
Porters or excretions is possible
Runners/transitors
Cleaning, laundry staff as

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

Porters excretions
Runners/transitors To reduce spread of microorganisms from
healthcare personnel to patient or food
Synthetic long sleeve aprons, goggles and masks should be provided to all staff involved with
conducting invasive procedures. Synthetic long sleeve aprons, goggles and masks should be
consistently used when splashes are anticipated.
3.2.2.1 Selecting the Appropriate PPE
When selecting what PPE should be worn, the health care worker should assess:
I. Type of exposure anticipated
a. Spray or contact - The health care worker should assess the type and volume of body fluid or
blood that he/she may potentially encounter in caring for the patient and select appropriate PPE
accordingly.
b. Type of isolation precaution (airborne, contact or droplet) - The health care worker should also
consider the level or type of isolation precaution that the patient is on.
II. Durability and appropriateness for the task.
III. Correct fit of the PPE.
3.2.2.2 Cleaning and disposal of PPE
Reusable PPE should be cleaned following standard cleaning procedures (see Section 3.4.4).
Table 3. Personal Protective Equipment: Cleaning and Disposal Methods

Equipment Standard procedure
Apron If reusable: clean with detergent and water, dry, disinfect with 70% alcohol
If disposable: discard in appropriate waste container according to the health care
facility waste management guidelines
N 95 or standard surgical Discard in appropriate waste container according to the health care facility
mask(Use disposable mask guidelines
only)
Eye protector/goggles/face If reusable: clean with detergent and water, dry, and disinfect with 70 % alcohol or
shield soak in 1% hypochlorite solution for 20 minutes and rinse and dry.
If disposable: discard in appropriate waste bag according to the health care facility
guidelines.

Gown If reusable: launder as per the health care facility guidelines for soiled linen For
example: launder in hot water (70° - 80° C) if possible OR Soak in clean water with
bleaching powder 0.5% for 30 minutes Wash again with detergent and water to
remove the bleach. Dry in a clothes drier or in the sun.
Cap If reusable: launder as per the health care facility guidelines for soiled linen For
(Use of disposable cap is example: launder in hot water (70° - 80° C) if possible OR Soak in clean water with
recommended) bleaching powder 0.5% for 30 minutes Wash again with detergent and water to
remove the bleach. Caps should be dried in a clothes drier or in the sun.
If disposable: discard in appropriate waste bag. Seal the bag.
Gloves If gloves are disposable it is advisable to decontaminate (by washing) before

(Use disposable gloves disposal.
only)
Gloves should be changed and disposed of properly after contact with every patient
or contaminated item.
Surgical gloves can be reused after reprocessing using sterilization or high level
disinfection (HLD) techniques. Surgical gloves should not be reprocessed more
than three times.
Gloves are not reusable if the glove has been torn, punctured, or broken.
Housekeeping staff should wash the exterior of their utility gloves after cleaning
each patient area/room to prevent the spread of infectious agents.
Gloves should be discarded in the appropriate waste container according to the
waste management guidelines
Source: Adapted from Practical Guidelines for Infection Control in Health Care Facilities, WHO, 2003.
3.2.3 Infection Prevention in the Surgical Unit
The surgical unit is inherently a high risk area. Providers are exposed to blood and injuries from the
use of sharp instruments used to perform surgeries. Patients are also at risk of acquiring infections as
a result of the procedures performed. Standard precautions described above must be adhered to by all
surgical unit staff. Described below are additional safe practices to minimize the risk to patients and
staff in the surgical unit.
A. Organization of the Surgical Unit
The surgical unit should have well delineated areas: unrestricted, transition, semi-restricted and
restricted areas. All three areas should be clearly marked.
The unrestricted area is the area at the entrance and is isolated from other areas of the surgical unit.
Staff, patients and materials are supplied to the surgical unit through this entry point.
The transition zone is where staff dressing rooms and lockers are located. Staff change into their
surgical attire in this area. Only authorized staff should enter this area.

The semi restricted area includes preoperative and recovery rooms, storage space for sterile and
high-level disinfected items, and corridors leading to the restricted area. Support activities (e.g.,
instrument processing and storage) for the operating room can occur here. Traffic in this area should
be limited to authorized staff and patients at all times. Clean, closed shoes should be worn by staff to
protect against fluids and dropped items (ex. sharps). Staff working in this area should wear surgical
attire and a cap. The area should be separated by doors limiting access to the restricted area of the
surgical unit.
The restricted area consists of the operating room(s) and scrub sink areas.
• Never store instruments and other items in the operating room.
• Limit traffic to authorized staff and patients at all times.
• Keep the door closed at all times, except during movement of staff, patients, supplies and
equipment.
• Scrubbed staff must wear full surgical attire and cover head and facial hair with a cap and
mask.
• Staff should wear clean, closed shoes that will protect their feet from fluids and dropped items.
• Masks are required when sterile supplies are open and scrubbed staff are operating.
• Patients entering the surgical unit should wear clean gowns or be covered with clean linen, and
have their hair covered.
The Unit should have a consistent and adequate supply of all surgical antiseptics of proper
concentrations and personal protective equipment. The staff should be regularly inspected for the
proper use of personal protective equipment and surgical antiseptics.
There should be appropriate facilities for surgical hand scrub: antiseptic soap, clean water, soft brush
or sponges (not hard brushes), and 60-90% alcohol and glycerin. It is advisable to post steps of
surgical hand scrub near the scrubber’s sink and instruct the staff to adhere to the recommended hand
scrub techniques.
Waste containers for sharps, contaminated and non-contaminated wastes should be in place and
regularly checked for proper use. All the decontamination containers and bleach should be in place for
the processing of contaminated items.
B. Surgical Antisepsis
The majority of post operative wound infections can be prevented through the use of surgical
antisepsis procedures which include:
• Hand hygiene (as described in section 3.2.1),
• Surgical hand scrub and gloving of the surgical team, and
• Applying an antiseptic agent to the surgical site.
Surgical Hand scrub

The hospital should have a regular supply of antiseptics for hand hygiene and skin preparation for
surgery. All types of antiseptics should be regularly supplied to all procedure rooms. This includes,
but is not limited to, alcohol (ethyl or isopropyl) 70%, chlorohexidine2-4%, iodine preparation 3%,
iodophors 7.5-10%. Hospital staff should be monitored for the proper use of each antiseptic solution.

Antiseptics should be poured into a small, reusable container for daily use. Gauze or cotton wool
should not be stored in antiseptics. Antiseptic solutions should not be filled on top of the existing
solution in the dispensers. Containers/dispensers with antiseptic solutions should be emptied and
washed with soap and water every time before refilling. There should be an established routine
schedule for preparing new solutions and cleaning containers. Reusable containers should be labeled
with the date each time they are washed, dried, and refilled. Concentrated antiseptic solutions should
be stored in a cool, dark area.
Surgical site preparation

Microorganisms (usually bacteria or sometimes fungi) normally found on the patient’s skin can lead to
postoperative wound infections. Conducting pre-operative antisepsis can help reduce risk of infection.
Before the operation, the patient’s skin (at the incision site) should be washed with soap and water and
cleansed with an antiseptic agent in order to minimize the number of microorganisms on the skin or
mucous membrane. Do not shave hair at the operative site (if necessary, trim hair close to skin surface
immediately before surgery).
C. Safer Operations
Before each operation, the surgical team performing the surgery should review how sharps will be
handled during the operation. This will help minimize the number of sharps injuries. The team should
try to use the “least dangerous instrument or device that will effectively accomplish the task, while at
the same time minimizing the risks to the patient and surgical team.”
“Hand-free” technique of passing surgical instruments should be used. Instruments should be placed in
a sterile or highly disinfected kidney basin, or other small container to pass from one staff to another
during the operation. Scalpel blades can be dulled when placed in a metal container. Placing a sterile
cloth in the bottom of a metal container or using a plastic container can protect against the dulling of a
blades. The surgeon should be verbally alerted before transferring a sharp instrument by saying
“sharps”.
Regular inspection should be done to ensure consistent implementation of the safe (recommended)
practices.
Further guidance is presented in Appendix B (WHO Surgical Safety Checklist) of Chapter 12 Quality
Management.
3.2.4 Infection Prevention in the Laboratory
Laboratory workers are exposed to blood, body fluids and other potentially infectious materials
through the course of their work. In order to reduce the risk of occupationally-acquired infections
laboratory workers must adhere to standard precautions described above.
In addition, laboratory staff should:

• always wear new examination gloves when handling blood, body fluids and/or specimens
containing pathogenic microorganisms,
• not eat, drink or smoke in the laboratory,
• not store food in refrigerators used for clinical and research specimens,
• not mouth pipette, but use the appropriate mechanical device,
• never open the centrifuge while it is in motion,
• always cover the end of blood collection tubes with cloth or paper towel, or point them away
from anyone’s face when opening,
• decontaminate work surface with 0.5% chlorine solution daily or when contaminated with a
spill,
• wear protective face shield, masks or goggles if splashes and/or sprays of blood, body fluids or
fluids containing infectious agents are possible,
• wear heavy duty or utility gloves when cleaning laboratory glassware,
• use puncture-resistant, leak proof containers for sharps, and
• place infectious waste materials in appropriate waste container (see section 3.4.1.1 on waste
management).
Further guidance on safety practices for the laboratory staff can be found in Chapter 5 Laboratory
Services; section 3.9.
3.3 Transmission based precautions
Transmission-based precautions are sets of extra precautions that need to be employed when routes of
the transmission are not interrupted though use of Standard Precautions alone. Each of these
precautions should be used in conjunction with Standard Precautions.
The hospital should provide private rooms for patients with airborne, droplet or contact transmissions
of microorganisms. All providers entering private rooms should be trained or at least well oriented
about all types of precautions to apply.
Specific precautions for each type of exposure are outlined below.
3.3.1 Contact precautions
Contact precautions are intended to reduce the risk of transmission through direct and indirect contact
with an infectious patient. Direct contact transmission includes skin to skin contact and the physical
transfer of pathogens from an infectious patient. This includes contact during bathing, turning, and
other patient care activities. Indirect contact means that the infectious patient has contaminated an
object in their environment and then the object comes into contact with a potential host. Contact
precautions should be used when a patient is known to have a specific disease that is easily transmitted
by direct or indirect contact.
Illnesses that require contact precautions include but are not limited to the following:
• Acute diarrhoea in an incontinent or diapered patient,
• Diarrhea in adult with recent antibiotic use,
• Bronchitis or croup in infants and young children,
• History of infection with multi drug resistant organisms (except TB), and
• Abscess or draining wound that cannot be covered.

Patient Placement
• Private room
• Door may be left open
• If private room is not available, place patient in room with patient having active infection with
the same microorganism, but with no other infection (cohorting)
Precautions
• Exercise strict barrier precautions for any type of contact with the patient and their surrounding
environment.
• Disposable gloves must be worn by all hospital staff that enter the room/patient area. All PPE
must be disposed of properly when contact with the patient is finished. If disposable gloves are
not available then gloves and gowns must be placed for washing and appropriate disinfection.
• Hand washing using antiseptic soap must occur after removing gloves and other PPE.
• Medical equipment must not be shared between patients. If it is to be shared, then any
equipment that comes into contact with a new patient must be disinfected. When cleaning, all
surfaces within the vicinity of the patient must be cleaned on a daily basis. This should include
cleaning bed rails, patient over-the-bed tables, night stands, floors, patient sinks, doorknobs,
and other item that may have come into direct contact with the patient.
• After an infectious patient leaves or is discharged, all surfaces and linens must be properly
cleaned and disinfected.
• All stationary and portable medical equipment must be cleaned. Examples include
thermometers, cardiac monitors, respiratory equipment, wheelchairs, and stretchers.
Patient Transport
• Limit transport of patient for essential purposes only
• During transport, ensure precautions are maintained to minimize risk of transmission of
organisms
3.3.2 Droplet precautions
Droplet precautions are intended to reduce the transmission of infectious pathogens from contact with
an infectious person to the mucous membranes of the nose or mouth of a healthy individual. Infectious
droplets can come from an infected person who coughs, sneezes, talks, or breathes heavily. Droplets
travel up to 1 metre in distance. Thus, droplet precautions require the use of masks within 1 metre of
the infected patient.
Patient Placement
• Private room
• Door may be left open
the same disease, but with no other infection (cohorting)
• If neither option is available, maintain separation of at least 1 metre (3 feet) or more between
patients
Respiratory Protection
• A mask must be worn by all hospital staff who come within 1 meter (3 feet) of patient
Patient Transport
• Limit transport of patient for essential purposes only
• During transport, patient must wear surgical mask
• Notify area/unit receiving patient in advance
3.3.3 Airborne precautions
Airborne precautions are additional precautions needed for infectious patients whose pathogens are
spread by an airborne route. Typically, this applies to most patients who are known to have respiratory
infections and measles.
The following are procedure specifications for airborne precautions:
Patient Placement
• Private room
• Door closed at all times
Respiratory Protection
• Masks must be worn by all hospital staff entering the room/ patient area.
o If TB is known or suspected, a particulate respirator mask should be worn, if available.
o If chicken pox or measles:
Immune persons—no mask is required
Susceptible persons—should not enter the room
o Mask should be removed after leaving the room and placed in a plastic bag or
• Room air should be exhausted to the outside (negative air pressure) using fan or other filtration
system.
the same disease, but with no other infection (cohorting).
• Nursing staff should be held responsible for screening visitors who are allowed to enter the
patient area/room. Persons who are susceptible (not immune or vaccinated) should not enter
the room or be assigned to the care of a patient known to be infected with the respective
disease. However, if visitation is allowed, then the visitor is required to abide by all infection
prevention guidelines and airborne precautions.
Patient Transport
• If the patient must leave the unit for diagnostic procedures, then all medical personnel involved
in the medical care of the patient should be notified before the patient leaves the medical ward.
This enables the medical technician and all staff to prepare and wear appropriate equipment.

• Before patient transport, the transporter should place a clean sheet over the wheelchair or
stretcher.
• For patient transport, the patient should wear a facial mask to prevent the spread of airborne
pathogens.
3.3.4 Cohorting
The hospital should provide private rooms for patients with airborne, droplet or contact transmissions
of microorganisms. If single rooms are not available, or if there is a shortage of single rooms, patients
infected or colonized by the same organism can be cohorted (sharing of room/s).
When cohorting is used during outbreaks, these room/s should be in a well-defined area (a designated
room or designated ward), which can be clearly segregated from other patient care areas in the health
care facility used for non-infected/colonized patients.
3.3.5 Special precautions for Tuberculosis infected patients
The prevention of tuberculosis (TB) begins with stopping hospital-acquired TB infections from
patient-to-patient and patient-to-staff contact. Active TB is easily transmitted from person to person
through the airborne route. TB remains a formidable threat in global health, as one third of the world is
infected. Ethiopia is one of the 22 high TB burden countries which together produce 20% of the
world’s TB cases.3 Prevention of TB transmission within the hospital setting is important to upholding
high standards for patient safety and minimizing the spread of TB in the population. Strict airborne
precautions are critical when caring for TB patients, as airborne droplets of TB patients can remain
suspended in the air for longer periods of time than other airborne pathogens.
Precautions should be made for:

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

• If a patient is suspected, but not yet confirmed to have TB, precautions should be employed
3
The Global Fund Sixth Call for Proposals Tuberculosis Prevention and Control.
http://www.theglobalfund.org/grantdocuments/6ETHT_1317_0_full.pdf

until confirmed to be negative.
• N-95 and HEPA masks should be worn whenever coming into patient area if available
(Note: Such masks are expensive and not readily available in Ethiopia, but if they become
so they should be worn.)
• Before entering patient area/room, hospital staff should make sure that the masks are fit-
tested to ensure they are secure
• For patient areas that have several patients, the N-95/HEPA masks do not need to changed
UNLESS the patient is known to have MDR-TB
• Hand hygiene needs to be performed before and after contact with the mask and patient
• Patients should be advised to use a tissue when coughing or sneezing, even when no one
else is in the room. This is because the droplets of TB patients remain in the air for an
extended period of time.
• If a patient must exit the room for a medical procedure, the patient should be fitted with a
tight fitting surgical mask or a N-95 mask, if possible. A HEPA mask cannot be used.
• Visitors must exercise similar precautions as medical staff. Visitors should use a N-95 mask
if possible or a tight fitting surgical mask if one is not available.
• Any visitors that have been known to have close contact with the patient prior to admission
should be tested for TB if possible and advised about symptoms that could occur.
3.4 Environmental Hygiene
3.4.1 Waste Management
By some estimates, nearly 80% - 85% of waste generated in healthcare establishments is municipal
waste and 20%-15% is infectious waste. However, in most health care facilities in Ethiopia waste is
not segregated according to proper segregation methods and it is difficult to quantify the type and
amount of waste produced. A varying proportion of healthcare waste (HCW) requires special
attention, including sharps (e.g. needles, razors, scalpels etc.), pathological waste, other potentially
infectious waste, pharmaceutical waste, biological waste, and hazardous chemical waste. In addition,
all waste generated under certain circumstances, such as in isolation wards and microbiological
laboratories, requires special attention.
Healthcare facilities produce waste that is potentially harmful to public health and the environment.
Healthcare workers, patients, waste handlers, waste pickers, and the general public are exposed to
health risks from infectious waste (particularly sharps), chemicals, and other special HCW. Improper
disposal of special HCW, including open dumping and uncontrolled burning, increases the risk of
spreading infections and of exposure to toxic emissions from incomplete combustion. Proper
management of HCW through an integrated, effective waste management system can minimize the
risks both within and outside healthcare facilities.
3.4.1.1 Waste Management Procedures
Waste management is a multi-step process involving:

• Waste Minimization
• Segregation
• Handling

• Collection
• Storage
• Transportation
• Treatment and Disposal
Waste Minimization
In a proper HCW management system, the first step is waste reduction or minimization. It helps to
ensure good sanitation of the health facility and the safety of workers and communities by reducing
the quantity of wastes generated. Waste minimization also reduces the environmental impact by
decreasing air pollution and the landfill capacity needed for disposal. Significant reduction of waste
generated in health care facilities may be encouraged by implementing:
• source reduction such as by avoiding or reducing unnecessary injections,
• improved waste reuse/recycling practice,
• good management and work control practices (rational use of different reagents, medical
equipments and materials, etc ), and
• proper waste segregation system.
Segregation
Segregation denotes the separation of waste into a range of classes according to its character. Waste
separation reduces the quantity of waste that requires specialized treatment and care. Generally,
facility waste is classified into 3 categories of waste: non-infectious, sharps waste and infectious
waste.
Non-infectious waste is waste that is non-hazardous and under normal circumstances poses no health
risk. It includes paper, packaging, left-over foods, boxes, glass, plastic, etc.
Sharps waste includes sharp materials and equipment that are disposed after being used. For
example, used syringes, needles, lancets, blades, scalpels, broken glass, etc.
Infectious waste is a waste material that has, in part or in whole, been in contact with blood and/or
body fluids. Due to the presence of blood and body fluids, such wastes are regarded to be infectious
waste and can potentially transmit microorganisms to susceptible people. It includes contaminated
gauze, dressings, cultures, IV lines, used gloves, anatomical wastes, placenta, tissues and the like.
Segregation must:
• take place immediately and at the source where the waste is generated; waste must never be re-
sorted.
• ensure that proper segregation techniques are used and that infectious HCW is not mixed with
non-infectious waste.

The 3 categories of HCW shall be segregated into colour coded containers as follows:
Segregation Category Color-coded container Non-color coded bins
Non-infectious waste/ Black bin Bins should be labelled
General waste non-risk waste
Infectious waste Yellow bin Bins should be labelled
infectious waste
Sharp waste Yellow safety box The box should be labelled
biohazard waste.
Note that in the absence of colour coded bins, it is possible to in place waste segregation system using
labelled waste bins with an infectious and non-infectious symbol or text on the side of the bins.
However, such bins should not be used for liquid waste.
To maximize efficiency and safety, these three waste categories must be handled and disposed of
separately throughout the main steps of: segregation, collection, handling, storage, transport,
treatment, and disposal.
Location of segregation containers

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

Figure 1. Segregation of health care waste by waste type
Source: Training Health Workers in the Management of Sharps Waste, PATH, 2005.
Handling
When handling waste, waste management staff should wear protective clothing at all times. Wearing
PPE reduces risk from sharps and protects against exposure to blood and other bodily fluids, and
splashes from chemicals. PPE that is recommended to be worn when handling waste includes:
• Dust mask,
• Face shield,
• Heavy duty, gloves,
• Plastic apron,
• Clothes that cover the body,
• Heavy duty, boots,
• Head cover, and
• Goggle.
See also section 3.4.3 below, Box A.
Handling sharps
• Place the syringe in a safety box immediately after use
• Do not recap, bend, or remove needles from syringe.
Handling safety boxes

• Safety boxes must be fully and properly assembled before use.
• Safety boxes must be sealed and collected when they are ¾ full.
• Safety boxes must never be emptied or opened.

• Put sharps containers as close to the point of use as possible and practical, ideally within arm’s
reach.
• Mark or label safety boxes so that people will not unknowingly use them as a garbage
container or for discarding other items.
• Don’t shake a safety box to settle its contents and make room for more sharps.
Handling infectious waste bins

• Infectious waste bins should be covered before collection.
• Bins should be cleaned and disinfected by using 0.5% chlorine solution for 10 minutes after
emptying.
Collection
Schedule
• At a minimum, the infectious waste bins should be collected each day.
• Safety boxes should be collected when ¾ full or daily.
• Garbage bins should be collected each day.
• No infectious bag or bin should be collected unless it is labeled with its point of production and
content.
Rotating bins
• A rotating bin system must be used if bins are collected during patient hours. When a bin or
safety box is collected, an empty bin or safety box must immediately be put in its place. This
practice is not necessary if bins are collected when the facility is closed, however emptied bins
and new safety boxes must be in place when the facility opens.
Storage
• Each hospital should have a specially designated room for waste storage.
• The room should be used only for storage of safety boxes and infectious waste until final
disposal.
• Infectious waste should not be stored for more than two days before being treated or disposed
of.
• Safety boxes may be stored for up to one week before incineration or transport. The frequency
of incineration should be based on the amount of sharps waste produced and on incinerator
capacity.
• The storage room should be totally enclosed and locked.
• The storage room should be inaccessible to the public, animals, rodents, birds and insects.
• There should be good lighting and ventilation of storage room.

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

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

• Sharps waste:
o Incineration using either properly built brick incinerator or another incinerator,
o Transport to off-site incinerators, if there is centralized treatment service or
o On-site burial.
• Infectious waste:
o On-site burial or
o On site incineration provided that the incinerator is standard incinerator and capable of
destroying such wastes.
• Non-risk waste:
o Collection by municipal truck for landfill disposal or
o On-site secured burning.
Incineration
All incinerators should be inspected and maintained by an environmental health professional on a

regular basis, and report of the inspection should be provided to hospital management. Incineration
must follow standard operating procedures, including proper loading, preheating, and control,
according to the design of the incinerator. Dangerous materials must not be incinerated, including:
PVC plastics, mercury thermometers, batteries, x-ray materials, aerosol cans, glass vials. Incinerator

operators must remove ash from the ash chamber and grate before using the incinerator. Ash should be
put in an ash pit or waste pit.
Operator
Incinerator operators must wear protective equipment when loading and operating the incinerator.
Proper equipment includes heavy duty gloves, boots, apron, and goggles. Protective equipment should
be made of materials that do not easily burn or melt.
Burial of infectious waste
Burial pits must be properly constructed and protected. Pits must be above the water table (the bottom
of the pit should at least be 1.5 meter away from the ground water table) and fenced to prevent access
by animals and the community. Non-risk waste must not be dumped into infectious waste burial pits.
Waste Spills
Despite the implementation of preventive measures, waste spills can occur. Outlined below are
procedures to manage waste spills according to type. Further guidance on managing pharmaceutical
waste spills is given in Chapter 4 Pharmacy Services.
All those managing waste spills should wear personal protective equipment such as protective gloves,
goggles and masks.
A) Infectious Waste Spills

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

A bleach (Sodium Hypochlorite) solution should be poured over waste and allowed to stand for 15
minutes. After the allotted time has passed, using a dustpan and broom, the waste should be carefully
brushed off the ground and into a puncture proof container. Do not allow hands to contact sharps.
Ensure no sharps fragments remain in the broom. After waste has been removed, cover the area with
bleach solution.
C) Managing spills of broken thermometer and blood pressure equipment

Those handling spills of broken thermometer and blood pressure equipment should wear examination
gloves on both hands. All droplets of mercury should be collected with a spoon (or similar utensil),
and placed in a small, closed container for disposal or reuse. Wash or clean the area with a bleach
(chlorine) solution. When process is complete, examination gloves that were used should be removed
carefully and hands washed properly.
Please see Appendix B for a summary of procedures for handling and disposal of healthcare waste.

3.4.2 Linen Processing
The laundry plays a key role in the function of the hospital and in preventing the spread of infection.
The unit is responsible for transporting linens from wards and other patient areas to the laundry,
laundering the linens and returning items to respective areas. These procedures ensure the provision of
clean linens and clothing for patients and staff alike.
Hospitals may provide the laundry service through its own staff or, or may contract out services to an
outside vendor. However, regardless of how the service is provided and by whom, the hospital must
ensure that standards are met and the guidance adhered to.
The hospital laundry should be equipped with a washing machine, dryer (where possible) and ironing
machine. However, each hospital should first quantify the volume of work done by the laundry
(average number of linens processed by the laundry per day) in order to accurately assess the number
and type of machines that should be purchased. Larger hospitals with a high volume of work should
have large capacity machines that can handle a high volume of linens and/or an increased number of
machines Heavy-duty washers/dryers are recommended for a large hospital with high patient load.
The hospital should provide leak proof plastic containers with a lid or leak proof plastic bags at each
procedure room to store soiled linens and to prevent spills from soiled linen until they are transported
to the laundry. The laundry should also–at a minimum–have two separate carts to transport clean and
soiled linens to and from the laundry as well as storage shelves to store clean linens before they are
returned to the appropriate work area. The hospital should ensure that there is a separate folding and
storage room from areas where soiled linen is presorted.
It is recommended that each unit/work area should be allotted with a designated shelf to allow
separation of linens by case teams and ensure accurate management of linens. Linens should be
checked regularly for holes and/or threadbare areas. Repairs, replacement or disposal should be done
based on the assessment.
Work plan
Each hospital laundry should develop an operating procedure or work plan for laundry services. The
plan should give guidance on the following:
• segregation of linen at the ward level,
• transport of linens to and from the laundry,
• washing procedures,
• operation of machines,
• segregation of linen by the laundry staff after washing,
• storing of linen and transport to different case teams/wards,
• registration/recording of incoming and outgoing linen, and
• staffing plan (define number and name of personnel assigned to work each shift).
Supplies
The laundry should ensure that there is always an available supply of detergent and bleach.

Procedures
Linens with visible contamination by blood, body fluids, secretions and excretions are categorized as
“soiled" or "contaminated”. Other used linen is termed “used”. These two categories should be
segregated and treated separately. Linen should be handled with minimum agitation to avoid
aerosolisation of pathogenic microorganisms. Soiled/contaminated linens should be placed in leak
proof bags or containers to avoid any spills or drips of blood, body fluids, secretions or excretions
during transportation. Linen from an isolation room should not be sorted, shaken, or handled
excessively. As a general rule all linens used in a procedure should be considered infectious, even if
there is no visible contamination.
Linens should be disinfected by using hot water and/or bleach. Heavily soiled linen should be washed
separately from non-soiled linens. Staff handling linens should ensure that they wear personal
protective equipment such as boots, heavy-duty gloves, eye protection, aprons and masks to protect
against splashes.
Wash linen (sheets, cotton blankets) in hot water and detergent, rinse and dry preferably in a dryer or
in the sun. Wash wool blankets in warm water and dry in the sun, or in dryers at cool temperatures.
Check all items for cleanliness and rewash if needed.
Linens being supplied to the operating rooms/theatres and high-risk areas, e.g. burns units should first
be autoclaved.
Mattresses and pillows with plastic covers should be wiped over with a detergent. Mattresses without
plastic covers should be steam cleaned (if available) if they have been contaminated with body fluids.
Pillows should be laundered using standard procedures described above.4
Laundry staff should be trained and/or oriented on the laundering process.
Safety
Below are some hazards that laundry staff may face:
• Exposure to blood, body fluids, and other excretions,
• Exposure to sharps and other materials,
• Contact with chemicals,
• Noise exposure, and
• Slips/Trips/Falls.
The hospital should ensure that appropriate measures are put in place to protect staff from these and
other hazards. For example, the floor should be kept clear of water, and personal protective equipment
should be provided to protect laundry staff against exposure to contaminated materials. Laundry staff
at minimum should have plastic aprons, heavy duty gloves, masks, protective eyewear (such as
goggles) and protective shoes. Other protective equipment should be provided as necessary. Staff
should also be monitored to ensure the proper use of personal protective equipment.
4
WHO, Practical Guidelines for Infection Control in Healthcare Facilities, 2003.

3.4.3 Housekeeping
Maintaining a clean environment is essential to providing quality care for patients. Proper cleaning
will reduce the number of microorganisms in patient care areas and will help to minimize the risk of
exposure to infectious agents to patients, families, caregivers, visitors and hospital staff. Hospitals
may provide the housekeeping service through its own staff or, or may contract out services to an
outside vendor. However, regardless of how the service is provided and by whom, the hospital must
ensure that standards are met and the guidance adhered to.
Work plan
The housekeeping department should develop operating procedures or work plan on the cleaning
process and schedule for each unit (clinical vs. administrative areas). Appendix C presents guidelines
for cleaning procedures and schedule for the outpatient and inpatient units. The provided procedures
are meant to serve as a guide for hospitals in devising their own cleaning schedule and procedures.
Further detailed guidance can be found in Infection Prevention Guidelines for Healthcare Facilities in
Ethiopia.
Supplies
The hospital should have a regular supply of all necessary cleaning materials. At a minimum each
hospital should provide the following:
• Disinfectants and detergents, bleach, powder detergents e.g. Omo
• Mops, cloths for dusting, brooms, soaps , buckets
• Personal protective equipments for cleaning staff and alcohol for hand rub preparation.
The head of the department should plan for and request supplies to meet monthly consumption needs.
Procedures
Administrative and office areas with no patient contact require normal domestic cleaning including
sweeping, dusting and washing floors and windows with detergent.
All patient care areas should be cleaned by wet mopping, scrubbing or dusting and or scrubbing using
disinfectant cleaning solutions. Dry sweeping is not recommended.
The cleaning solution should be prepared according to the guidance outlined in the Infection
Prevention Guidelines for Healthcare Facilities in Ethiopia. Staff should be trained/oriented on how
to prepare cleaning solutions and procedures for preparing the solution should be posted in an area
visible to the cleaning staff.
The pattern of cleaning should be from least soiled area to most soiled and from high to lows areas.
Any areas visibly contaminated with blood or body fluids should be cleaned immediately.
Isolation rooms and other areas that have patients with known transmissible infections should be
cleaned with a detergent/disinfectant solution at least daily.
All patient care areas, including horizontal surfaces and all toilet areas should be cleaned twice a day.

Safety
The hospital should provide cleaning staff with personal protective equipment appropriate for the
work. For example, all cleaning staff should have plastic aprons, heavy duty gloves, masks and
protective shoes. Staff likely to be exposed to substances that may splash or splatter should also be
supplied with goggles. Other protective equipment should be provided as necessary.
Box 1 below provides a graphic of representation of what should be worn by cleaning staff.
Box A. Personal protective equipment for cleaning staff.
Wearing PPE reduces risk from sharp, germs,

exposure to blood and other bodily fluids, and
splashes from chemicals.
Staff handling waste should wear the following:

• Dust mask
• Face shield
• Heavy duty, gloves
• Plastic apron
• Clothes that cover the body
• Heavy duty, boots
• Head cover
• Goggle
Other cleaning staff should wear PPE as appropriate

to their exposure.
SOURCE: Adapted from Waste Handlers, PATH, July 2006.
Staff should also be monitored to ensure the proper use of personal protective equipment and cleaning
supplies.

3.4.4 Instrument processing
There are four main steps in instrument processing as outlined in Figure 2 below: decontamination,
cleaning, sterilization or high-level disinfection and storage.
Figure 2: Instrument processing steps
Decontaminate
Clean
Sterilization High-level disinfection

Chemical (HLD)
High-pressure Chemical
steam Steaming
Dry heat Boiling
Dry/cool and store
Based on guidance given in Infection Prevention Guidelines for Healthcare Facilities in Ethiopia, the
hospital should outline clear procedures on how instrument processing should be done. Instrument
processing protocols should be posted in procedure rooms and all staff responsible for instrument
processing should be trained/oriented on the process. In addition, all staff responsible for
decontamination should be trained on how to prepare 0.5% and 0.1% chlorine solutions from different
concentrations of bleach. Instructions for preparing chlorine solutions should be posted in the
procedure rooms and staff instructed to follow the outlined procedures.
Each hospital should have a consistent supply of bleach (with a visible labelling of the concentration
of chlorine), brushes (preferably tooth brushes), three plastic containers (one for each step in the
process washing with soap (detergent) and water, cleaning with 0.5% chlorine solution, and rinsing)
and personal protective equipment for each procedure room. The person in charge of the procedure
room should plan for and request bleach, detergent and related supplies to meet monthly consumption
needs to ensure that supply is not interrupted. Stop watches should be provided for each procedure
room to ensure compliance to timing for each step in the decontamination and/or cleaning process.

The hospital should have functioning autoclaves and dry heat ovens for sterilization of medical
equipment. There should also be a supply of 2-4% glutaraldehyde or 8% formaldehyde for chemical
sterilization of plastic items. Steamer pans and boilers should be in place for high level disinfection
purposes. The persons operating the autoclaves and dry heat ovens should adhere to machine
operation instructions. In addition, all staff should be trained on the use of the machines. The hospital
should regularly monitor the effectiveness of sterilizers using specified indicators. Mechanical,
chemical and biological indicators can be used. Mechanical indicators are most commonly used. This
would include checking adherence to recommended time, temperature and pressure. Chemical
indicators are often used as supplement to mechanical indicators. Although biological indicators
(using bacteria) are considered to be the best method for monitoring the effectiveness of sterilizers,
Ethiopian hospitals may not currently have the capacity to implement this.
All sterile items should be stored in an area and manner to protect the packs or containers from
contaminants such as dust, dirt, moisture, animals, and insects. The storage area of sterile items for the
hospital is best located next to or connected to the place where sterilization occurs. The space should
be in an area separate, enclosed, with limited access and should be used only to store sterile and
patient care supplies.
Persons responsible for instrument processing should be regularly supervised to ensure their adherence
to protocols, proper performance and consistent use of personal protective equipments during the
procedure.
3.4.5 Traffic Flow
Proper management of patient care areas – flow of patients and visitors– in the hospital is integral to
maintaining high standards of infection prevention. Overcrowding can help the spread of infections
among patients, staff, and visitors. The organization of the patient and visitor population will not only
prevent the unnecessary transmission of disease, but also will allow the hospital to operate in an
efficient manner. Clinical and supportive staff must be able to perform their tasks in a hospital
environment where distractions are minimized. Furthermore, standards need to be established so that
the duties and roles of both staff and patient’s visitors are clearly delineated and understood by all
parties involved with patient care. With appropriate patient and visitor control, the hospital can
provide quality care in a clean and safe environment.
Each hospital should strive to control the organization of all patient areas and public spaces. The
hospital layout should be organized in a way that promotes the efficient movement of traffic
throughout the hospital. As much as possible services should be organized close to one another to
minimize patient transit time. Hospitals should ensure that waiting areas have ample space and provide
a secure, shaded area in which patients can wait for care. Further guidance on hospital layout can be
found in Chapter 2 Patient Flow and Chapter 8 Facilities Management.
Patients and visitors should not be allowed to enter into areas of the hospital where they are not
receiving a service (for example outpatients should not enter inpatient wards, visitors to inpatients
should not go to OPD etc).

Caregiver and visitor control: Putting visitor controls in place serves to prevent confusion and
disputes that may arise between visitors and hospital staff, thus enabling more efficient hospital
operations. The use of visitation hours and placing limits on the total number of non-hospital staff
entering a patient ward area at a given time are both effective methods for controlling caregiver and
visitor access. Visiting hours should be established with consideration for when health providers
conduct the morning and evening rounds, cleaning staff conducts daily duties, and hospital has meal
times. The hospital should establish a system to regulate the number of visitors and caregivers allotted
for each patient. Limits should be set on the number of visitors and caregivers allowed to be with a
patient at any given time. ID badges or identification cards should be issued to visitors and/or
caregivers to assist hospital staff in monitoring patient rooms. To ensure that there is clear
communication between a caregiver and the nursing staff, it is suggested that each caregiver sign a
contract (see Chapter 6 Nursing Care Standards, Appendix F for a sample patient caregiver contract,
which delineates the caregiver’s role in the care of the patient). The contract holds caregivers
accountable for their duties and their conduct within the hospital ward. Furthermore, it prevents
disputes between staff and visitor when a potential conflict arises. Contracts should outline
caregiver’s responsibilities such as proper visiting hours and leaving the ward to permit cleaning and
nursing staff to perform their duties.
3.4.6 Food Safety
The provision of nutritious, good-tasting and sanitary food is an essential part of patient care. Meals
provided to patients can lessen the need for drugs and other interventions and hasten a patient’s
recovery shortening their hospital stay. Food borne outbreaks are not uncommon at hospitals thus
measures should be taken to minimize the likelihood of food borne illnesses.
Food safety should be ensured through the provision of adequate, clean facilities for food preparation
and storage.
It is imperative that:
• The kitchen is kept clean and free from bacteria
• Quality of produce and meats is reviewed and maintained
• Quality and taste of food is monitored by Head of Kitchen or other senior manager
• Kitchen staff maintain personal hygiene and health
Food purchase and storage

A committee consisting of representatives from the kitchen, environmental hygiene and procurement
unit should be created to oversee the delivery of food items for the kitchen. Possible committee
members could be the kitchen manager, dietician, sanitarian, and purchaser.
When food items are delivered to the kitchen the kitchen manager or delegate should check the items
to ensure that that the food that is delivered is of the desired quality. If possible all members of the
committee should be present. If the quality of the food is not acceptable, then the supplier should be
informed, “rejected” items returned, and if possible, the supplier should provide replacements that
meet the committee’s specifications.

The food items that are delivered to the kitchen have to be properly stored in a separate clean area in
the kitchen. Food that is perishable and warm should be cooled before storage.
Food handling and preparation

• There should be separate cutting boards for meat products and non-meat products.
• Cooking staff should be oriented on safe handling of food.
• Cooking should be done at proper temperature and for the appropriate length of time.
• All kitchen staff should follow hand hygiene procedures outlined in section 3.2.1. Hand
hygiene should be practiced both before and after handling food. In addition to hand hygiene,
kitchen staff should also maintain their personal hygiene. Facilities for bathing should be
made available to all kitchen staff.
Cleaning
The kitchen should be cleaned at the end of each day. Waste should be disposed of regularly (see
section 3.4.1 on waste management). Special attention should be given to food preparation areas and
cooking equipment and utensils.
Safety
Kitchen staff should have access to face masks, hair covers, and plastic aprons at a minimum. Other
personal protective equipment should be supplied as necessary.
To ensure patient safety and minimize the risk of infection transmission, kitchen staff should regularly
be tested for communicable diseases. Staff should be tested at least every three months for diseases
that can be transmitted through unsafe handling of food; for example typhoid fever. Any kitchen staff
identified as having an active infection should be removed from food handling and preparation until
24-48 hours after symptoms have resolved.
Below are some hazards that kitchen staff can face:

• Ergonomics (repetitive motions, reaching/lifting etc),
• Kitchen equipment (hot surfaces, electrical shocks, use of sharp objects etc),
• Fire (improper storage of flammable items, poor cleaning etc),
• Hazardous chemicals (pesticides, disinfectants etc),
• Machine guarding,
• Food borne disease,
• Slips/falls,
• Electrical safety, and
• Infectious materials.
Protective measures should be in place to minimize accidents incurred due to the above listed hazards.
Quality Assurance
Food temperature should be checked. Hygienic and aseptic conditions should always be checked by
the dietician.
The guidelines outlined above apply to any food services provided by the hospital. Hospitals may
provide the service directly, or may contract out services to an outside vendor. Regardless of how the

hospital provides the service, the hospital must ensure that standards are met and the guidance adhered
to.
3.5 Worker safety
In addition to the procedures outlined above, the hospital should ensure that mechanisms are in place
to identify and address occupational health and safety risks to staff. The hospital should also ensure
that staff can access services in the event that they are exposed to infectious agents.
For more detailed guidance on Occupational Health and Safety refer to Chapter 11 Human Resources
Management; section 3.13 on Occupational Health and Safety. For more guidance on Hospital Safety
please refer to Chapter 8 Facilities Management; section 3.8.
3.5.1 Injection safety
The use of injection materials in the hospital setting exposes healthcare personnel to needle stick
injuries and potentially to infectious materials. The WHO estimates that “contaminated injections
caused annually 21 million HBV infections, two million of HCV infections and 260,000 HIV
infections. These infections led to 49,000, 24,000 and 210,000 deaths respectively. 40% of global
burden of HBV and HCV among health workers is attributable to occupational exposure.”5 It is
imperative that hospitals establish an injection safety plan as part of an infection prevention program.
The injection safety plan should include the hospital’s procedures to address the following areas:
• Needle and syringe usage and disposal:
o Every injection is given using a single sterile syringe and needle combination
o Syringes are not reused
o No recapping, manual detaching or manipulation of used needles
o After each use, the needle and syringe are safely disposed of in a puncture proof
container (See section 3.4.1.1 on waste management)
• Provision of injection materials such as auto-disable syringes and disposable syringes that are
of the recommended quality and sterility of the syringes (within expiry date, WHO/UNICEF
certified brand)
• Needle stick injuries:
o There is a reporting and tracking mechanism for needlestick injuries
o HIV Post exposure prophylaxis plan (see below)
3.5.2 HIV Post exposure Prophylaxis
The risk of HIV infection after a needle stick injury or other exposure to HIV-infected blood is
estimated to be 0.3% (3 in 1000 or 1 in 300). However, several cases of seroconversion among
healthcare workers exposed to HIV via mucous membrane or non-intact skin have been documented.
Implementation of standard precautions (as described in section 3.2) will significantly reduce
occupational exposure of hospital staff (both healthcare workers and support staff) to HIV and other
blood borne pathogens. In the event that healthcare personnel (HCP) are exposed, hospitals should
have a PEP program in place to identify, assess staff needing PEP and provide care and treatment.
5
WHO, Technical Guidance for Global Fund HIV Proposals, 2008. http://www.who.int/hiv/pub/toolkits/Injection%20safety.pdf
NB: The following guidelines only address the management of occupational exposure among
healthcare workers. In addition to PEP for occupational exposures, hospitals should provide PEP
services for non-occupational exposure to HIV, such as sexual assault. The recommendations provided
in this section are based on the draft national PEP protocol. The protocol has not yet been approved
but the recommendations provided here can serve as a guide for hospitals until the national PEP
protocol is finalized.
3.5.2.1 Components of a PEP Program
All hospital staff should be aware of standard IP practices to minimize exposure, as well as where and
to whom an occupational exposure should be reported (refer to section 3.13, Chapter 11 Human
Resources Management; for more guidance on occupational health and safety services).
PEP services can be offered within case teams or through the hospital’s ART clinic. Regardless of
where PEP services are provided, the hospital should ensure that there are an adequate number of staff
members that have had PEP training or participated in trainings that include PEP (e.g. Basic ART,
IMAI/IMNCI, and STI/PEP). In addition, the hospital should ensure the provision of the equipment
and supplies necessary for PEP outlined in Box B.
Box B Inputs Required for PEP Service
All Service Outlets

The required IP supplies and hospital infrastructure—as described in other sections of this chapter--
must be made available in every service outlet
PEP Outlets
• PEP drugs:
o Zidovudine (AZT) or Stavudine (d4T) or Tenofovir (TDF)
o Lamuvudine (3TC)
o Kaletra (Lpr/r) or Efavirenz : one pack in each service outlet area
• Rapid HIV test kits
• PEP protocols
• PEP decision-making tool (wall charts)
• PIHCT guideline
• PIHCT protocols
• Standard patient education materials on HIV, PIHCT, and ART
• National IP guideline
• Condoms
• Penile models
• Intra-facility referral forms
ART Clinic
• In addition to the items mentioned above for PEP service outlets, the PEP register should be
available in the ART clinic and preferably this should be the primary place of operation for
the PEP focal person.

The availability of PEP services in the health facility should be made known to all staff. Details of the
services that are offered (location, who to contact etc) should be posted in areas visible to all staff. In
addition, availability of PEP services should be included as part of the hospital’s new hire orientation,
in service orientation, or in trainings offered through the hospital’s occupational health and safety
services or infection prevention training.
3.5.2.2 PEP Procedures
If an occupational exposure occurs, the following procedures for PEP should be followed:
Step 1 Treat exposure:

• Use soap and water to wash areas exposed to potentially infectious fluids as soon as possible
• Flush exposed mucous membranes with water
• Flush exposed eyes with water or saline solution
Step 2 Report exposures: Report and document the exposure. The incident should be reported to the
healthcare personnel’s immediate supervisor or case team leader. The supervisor or other appropriate
person should complete an Occupational Blood and Needle Stick Exposures Recording form presented
in Appendix F. The occurrence of the incident should also be reported to the hospital Incident Officer
and Occupational Health and Safety Officer.
Step 3 Determine the level of risk: It is important to determine risk of HIV transmission to the HCP
associated with the HCP’s exposure. A number of criteria that should be used to determine the level
of risk are described in detail in thePEP decision-making tool presented in Appendix D. This tool
should also be used to determine the need for PEP, to decide if PEP is indicated and whether or not a
2-drug or 3-drug regimen is required.
If the exposure occurs during working hours, the case team leader (where the exposure happened) can
treat the exposure site, assess the source patient status, and determine the exposure code.
After working hours (nights, weekends, & holidays): The exposed HCP should report to the Emergency
Case Team for exposure risk assessment. The physician or nurse should complete the Occupational
Blood and Needle Stick Exposures Recording form (Appendix F) and should utilize the PEP decision-
making tool to determine if PEP is indicated.
• If PEP is not indicated, the Emergency case team personnel will advise the HCP accordingly
and the exposure case is considered closed at this point.
• If PEP is indicated outside regular working hours then the HCP should be given a ‘PEP starter
pack’. PEP starter packs should contain sufficient drugs for three days medication and should be
available in the Emergency pharmacy. The HCP should be instructed to report to the ART clinic
on the next working day for further management and investigations.
Step 4 Counseling and Testing: All healthcare personnel who have been exposed and have PEP
indication should be provided with HIV counselling and testing. Counselling and testing can either be
provided by a trained member of the case team where the exposure occurred or at the ART clinic.

Step 5 Provide PEP treatment: Begin appropriate drug and PEP treatment.
• Exposed individuals who test negative for HIV, should receive comprehensive counselling on
PEP and receive follow-up care according to the standard PEP protocol, including the
completion of the one month treatment and subsequent HIV tests at 3 and 6 months post-
exposure.
• Individuals who test positive for HIV should be enrolled in chronic HIV care and receive
standard HIV/ART services.
A sample Post Exposure Prophylaxis Patient Tracking Form (from draft National PEP Guideline) is
presented in Appendix E. This form should be used to track HCP over the course of their treatment.
Step 6 Follow-up testing: Follow-up laboratory testing should be done at 3-months and 6-months
post-exposure.
Step 7 Maintain records: Keep records of all exposed staff. These records should be maintained
securely to ensure confidentiality.
3.5.2.3 Management of PEP Services
To ensure that PEP services are implemented according to the standard protocol, hospitals should
assign a PEP focal person. This role could be held by the Occupational Health and Safety officer (see
section 3.13 of Chapter 11 Human Resource Management). He/she should regularly (at least weekly)
monitor the availability of inputs (as listed in Box B above) and supplies necessary to provide PEP
services, the quality of PEP services, the efficiency of referral linkages for patients who started PEP
during non-regular hours and the completeness of PEP registries. The PEP focal person should be an
active member of the hospital ART multi-disciplinary team (MDT) and IP committees and participate
in meetings with the MDT and IP committees at least monthly. The PEP focal person should also
prepare reports for the IP committee and Senior Management Team (SMT) on PEP services. The
report should include:
• The number of occupational and non-occupational exposures (categorized by type) reported in
the hospital
• The age, sex, and occupation (including case team) of workers reporting an exposure
• The number of patients that started PEP treatment
• The number of patients that completed the PEP treatment
• The number of patients that received 3 or 6 month post-exposure HIV testing
The data generated from the PEP outlets should be used by case teams and senior management to
identify ways of improving PEP and ART services in the hospital as well as ways to prevent the
occurrence of occupational exposures among HCP.
3.5.2.4 Monitoring and Evaluation of PEP Services
Hospital management should monitor the implementation of PEP services by checking the availability
of the inputs, following the process and the output of the PEP service (as defined below) first at
baseline and every 4-6 months thereafter.

The hospital management should monitor the process of the PEP program implementation by
assessing:
• The availability of all input materials
• The continuous availability of PEP services both at regular and non-regular working hours
• The adherence of healthcare workers to the national PEP protocol
• The presence of regular (monthly) IPC committee meetings
• The minutes of hospital IPC committees
• Reporting system for the IPC committees to the hospital management
• The implementation of operational (action) plans developed for PEP following IPC committee
meetings
3.6 Equipment, Supplies and Infrastructure
The IP Committee should conduct a needs assessment to identify:

• current stock of supplies (personal protective equipment and cleaning supplies such as gloves,
soap, towels, linens, alcohol, etc)
• availability and functionality of sinks, toilets
• availability and functionality of incinerator and other waste disposal equipment
• availability and functionality of laundry equipment
• availability and functionality of ventilation systems
• availability and quality of water supply
The assessment should be done periodically (at a minimum annually) to ensure that any new needs are
identified. Conducting an evaluation not only permits the IP committee and hospital management to
estimate needed supplies and equipment for implementing IP policies, but allows staff to identify their
own needs. Hospital management can also use information from the evaluation to properly plan and
budget for purchase/maintenance of IPC-related supplies and equipment.
The need for IP supplies and equipment can be assessed on a department/service area basis as outlined
in Table 4 below:
Table 4. IP Supplies and Equipment Needs Assessment

Case Team Hazard PPE need
Laundry Blood contaminated linens Gloves
Apron
Boots
Masks etc.
Operating room Blood splash Apron
Goggles
Face shield etc.
IP supplies should be purchased regularly to ensure that there is an adequate supply available. If IP
supplies are purchased through a bidding process, clear specifications should be given to the bidding
committee or unit responsible for purchasing the IP supplies that outline the desired quality and type
of materials to be purchased.

In addition to assessing supply needs, the IP committee should also assess infrastructural needs
required to support infection prevention activities. The IP committee should assess the availability,
functionality of infrastructure as well as quantify the cost of repair/replacement. The assessment could
include plumbing and sewage, sinks, incinerator for waste disposal and laundry equipment.

The key infrastructural needs are outlined in brief below. For more detailed guidance please refer to
the Chapter 8 Facilities Management.
Buildings
The design and layout of the hospital building can impact the effectiveness of infection prevention
practice. Increasingly architects of hospitals design facilities to improve traffic flow and minimize
risk of infections. When additions or new constructions are planned, the IP committee should be
consulted to provide input (with respect to infection prevention) on the design of the facility.
Water, sewage and plumbing

The hospital should ensure that safe water is available 24 hours a day. Provisions should be in place to
ensure that when water outages/shortages occur that water supply is not interrupted. Tankers or other
water storage containers should be in place. They should be cleaned regularly and the quality of water
should be sampled periodically to check for contamination.
Sinks, toilets
It is important that all wards within a hospital have properly functioning sink and toilet facilities. At a
minimum, there should be a sink in each patient care area. Facilities should be accessible to patients,
staff and visitors. Larger wards or those with more than one entrance are recommended to have a
minimum of two sinks with plumbing. There should also be a functional sink at each patient area,
clinical room, and nursing station. Investments must also be made to ensure existing sinks work
properly and preventive maintenance is done. Repairs should be scheduled as necessary. Sinks and
toilets should be cleaned and disinfected regularly.
Electricity
The hospital should ensure that electricity is available 24 hours a day. In particular, procedure rooms
and operating rooms should have adequate lighting. A generator or other energy supply should be
available for use when power supply is interrupted.
Ventilation
Proper ventilation of patient care areas can reduce trapping of air, promote air circulation and help to
minimize the transmission of infections.
General patient care areas should be well ventilated. In the absence of HEPA filters and mechanical
filtration systems, windows should be opened to allow for ventilation of rooms. A study conducted in
Peru showed that hospitals which had high ceilings and large windows and used natural ventilation
minimized the risk of airborne transmission of infections such as tuberculosis.6 Natural ventilation
can be a low cost intervention that can minimize the spread of infection.
6
Escombe et al, 2007
Lay out of patient beds
Patient rooms should be organized in a way that will reduce transmission risk. In wards with an open
layout, spacing between beds should be 1-2 meters.
3.7 Monitoring and Surveillance
An IPC program must include routine monitoring and surveillance. The hospital must assess the
success of its infection prevention program by measuring adherence to IP guidelines as well as
identifying and tracking HCAIs quarterly, at a minimum.
3.7.1 Monitoring
Hospitals should measure the effectiveness of all components of the IP program including inputs,
processes and outcomes:
For example:
Inputs: IP inputs would include equipment and supplies for hospital staff. Input data can be used to
assess the availability, quantity and quality of supplies and equipment needed for IP practice. In
addition, data can be used to conduct cost analysis.
Process and Outcomes: This data can be used to assess the safety and effectiveness of a hospital’s
operations and can be collected through the following methods:
• Performance indicators: The IP Committee must develop and monitor performance indicators
to assess the progress of the IP program. Targets should be set for each indicator based on
improvements using a percentage scale. For example, a key target may be a 50% improvement
in the number of staff observed using proper infection prevention techniques within a given
day; or rate of healthcare facility acquired infection. This will allow the IP committee to work
towards continual improvements, rather than reaching a particular benchmark.
• Qualitative methods for assessing quality include clinical vignettes and consultation
observation. Clinical vignettes involve providing staff with hypothetical cases and recording
their response on how they would handle the given cases. Consultation observations involve
observing staff as they interact with patients and adhere to national IP guidelines.
• Surveys: Often used to collect data on facility procedures, for example, hand hygiene
procedures being used by facility staff (please see Appendix G). A checklist can also be used
to assess adherence to IP guidelines (please see Appendix I). Surveys are more common as
they can be used to collect a large amount of data at once and is easier to implement than
continuous reporting.
• Observation: The IP Committee also can conduct unannounced site visits to various case teams
on a monthly basis. These site visits would ostensibly be carried out to determine what is
working and what is not. This approach could provide a strong incentive for the case teams to
maintain a high level of IP practices. It would also act as an indicator which the IP Committee
could use to determine the efficacy of the IP program and implement changes where
necessary.

3.7.2 Surveillance of Nosocomial Infections
Monitoring and measuring healthcare acquired infections can provide valuable information on the
effectiveness of the hospital’s infection prevention program. Tracking the number of HCAIs or rate of
HCAI allows hospitals to assess quality of care and patient safety. In addition, data can reveal areas
for improvement or gaps in practice that need to be revised or strengthened. HCAIs should be
included as one of the indicators in the Balanced Scorecard that is monitored regularly by the
Governing Board (See Chapter 13 Monitoring and Reporting).
In devising a surveillance program the IP committee should consider the following:

• Patients and units to be monitored
• Type of infections and relevant information to be collected
• Frequency and duration of monitoring
• Methods of data collection
• Methods for data analysis, feedback and dissemination
• Methods to ensure confidentiality of information
The methods to be used and staff responsible for coordinating and conducting surveillance should be
clearly outlined in the hospital’s HCAI surveillance protocol. In addition, staff involved in
coordinating or collecting HCAI data should include someone trained/oriented in IP practice and
knowledgeable in data collection and analysis techniques.
Either prevalence or incidence of HCAIs can be tracked. Prevalence studies would be conducted at
one point in time and would measure infections that exist on the day the survey is done. Incidence
surveys measure number of infections that occur in patients over a defined period of time. For an
incidence survey, patients would be tracked throughout the course of their stay in the hospital and the
incidence of an infection would be recorded. This method is most effective when conducted for
specific infections (surgical site infections) or in specific units (surgical unit or ICU).
Conducting surveillance of HCAIs can be a time consuming and costly undertaking. Therefore when
resources are limited, facilities can choose to focus on specific units or specific types of infections.
For example, the hospital HCAI surveillance can begin with tracking surgical site infections and/or
surveillance of particular invasive procedures such as endoscopy. Various strategies and the
methodologies that should be used are outlined in detail in the WHO document: Prevention of
Hospital Acquired Infections: A Practical Guide — WHO/CDS/CSR/EPH/2002.12. For further
guidance on setting up a HCAI surveillance protocol please reference this document. In addition, a
sample data collection tool for monitoring HCAIs is presented in the Appendix H).
3.7.3 Using the data
The results of the surveillance studies should be compiled by a member of the IP committee in a
written report on a regular basis. The report should include details of the study including: time frame,
the department(s) included, the number of patients seen by the department(s) within the time frame,
number of HCAI detected, and rate of HCAI. The report should also include analysis of the potential
causes of the HCAIs, problems identified and recommended solutions. The report should be submitted
to the IP Committee and Senior Management Team for action or resolution.

Data can be used to show the savings in cost that preventing HCAIs can bring. In order to show the
benefits of reducing HCAIs, simple calculations can be done based on the following assumptions:
1) Assume a hospital acquired infection rate of 20% of the patients admitted: (Note that the
literature states that HCAIs can be as high as 40%).
2) Average daily admission of seventeen patients. (Approximate number for a 250 bed hospital.)
3) Assume three additional nights stay in-hospital resulting from HCAIs.[20]
Calculation based on previous assumptions:

In one month of 30 days, we would expect approximately 510 admissions. 102 those patients would
contract an HCAI per month. These 102 patients would result in an additional 306 days of admission
and care.
Over the course of a full year, the total number of avoidable in-hospital days could be as high as 3,672.
The staff time and resources needed to treat these avoidable in-hospital days becomes a very
significant drain on already overcrowded hospitals with limited resources. In fact, if the hospital can
implement a very aggressive and effective IP program a greater number of in-hospital days can be
avoided as follows:
Percentage Reduction Avoided In-Hospital

In HCAI Rates Days per Year
10% 1,836
20% 3,672
30% 5,508
40% 7,344
Implementing an effective IP program that can reduce the rate of HCAIs will increase both staff time
and resources used by the hospital to implement better infection prevention practices and thus further
reduce the rate of HCAIs.
In addition, information that is gathered through surveillance can be used to reward individuals or case
teams that are performing well. As an added incentive, a “Case Team of the Month” certificate or
award could be presented to those units who have significantly lowered the HCAIs in their case teams
or have implemented innovative changes that could be used as models for other case teams to follow
within the hospital. Recognition and reward can go a long way in motivating staff and creating a
sense of ownership for their work.
3.8 Infection Prevention Training
Successful adoption of infection prevention standards requires periodic Infection Prevention training
for all staff. In order to effectively implement IP practices, staff must first be informed and educated
on current IP principles.
The Infection Prevention team should assess training needs of the staff and provide required training
in collaboration with the human resource department. Trainings should include general information
on IP practice and principles as well as practical skills training. Trainings for all staff should include

general IP principles but should also be tailored and appropriate to staff job functions. Hospitals can
contact partner organizations to provide standardized IP trainings for staff—through either on site or
off site trainings. In addition, orientation on IP can be provided on site by hospital staff. Materials
should be adapted from standard training materials and trainers should be trained in IP. Hospitals
should provide periodic re-training or orientation for staff and review the impact of trainings. Further
IP information can be given to staff through awareness programs and campaigns.
A motivated and invested hospital workforce is essential to ensuring the sustainability of IP policies.
As such, successful adoption of infection prevention standards requires that Infection Prevention
trainings not only educate hospital staff on IP policies, but also motivate the staff to adhere to the IP
guidelines. Staff ownership can be cultivated by:
• Involving staff by asking their input on IP policies
• Assigning a staff member of each case team a role in coordinating and monitoring staff on
infection prevention policies
• Providing orientation and sensitization on the importance of IP
The following are additional recommendations on what elements should be included in a

comprehensive IP training to support implementation of an IP program.
Establish the importance of IP with staff: To facilitate staff investment in implementing IP policies,
the IP committee should ensure that all staff understand that the IP policies they are being trained in:
• Prevent the spread of unnecessary infections
• Improve the quality of patient care
• Promote a safe environment for both patients and staff, and
• Ensure that patients have a clean environment so that recovery and length of stay is at an
ideal standard.
Use appropriate training techniques: It is necessary that infection prevention policies are clearly
understood by all hospital staff. This can be accomplished by using group-based training and
demonstrative techniques to ensure that all staff, including low-literate staff, are sufficiently informed
on IP practices.
Foster Staff Motivation: To maximize the benefits of infection prevention training, the following items
are suggested to maintain a motivated staff:
• Senior management, physicians, and case team leaders should be role-models in following
infection prevention guidelines. They show due diligence in adhering to infection prevention
policies
• Make and award certificates of achievement following the IP training
• Suggest that letters of recommendation be written and placed on file for staff after good
performance evaluations are achieved
• Publicly recognize staff as individuals or in case teams that exemplify “excellence in infection
prevention practice”. For example, a “wall of recognition” or “employee of the month” award
can be used to create positive reinforcement for staff

Distribute IP guidelines throughout hospital: Once training has been completed, materials relating to
IP guidelines should be posted in both public and private spaces throughout the hospital. The IP
guidelines should be strategically located in places where IP must be practiced, for example, hand
hygiene posters should be posted in all hospital bathrooms as a reminder to staff to wash their hands.
3.8.1 Educating patients, caregivers, and other visitors regarding IP policies
Family members/caregivers are integral in the health delivery process, as they may assist in the care of
the patient while he/she is hospitalized. Therefore it is critical to ensure that family members and
other caregivers are informed and educated on IP policies. Since caregivers and visitors are not trained
hospital staff, special attention is needed in educating all visitors on appropriate IP policies.
Involve the nursing staff in training patients and visitors. The nursing staff are responsible for
educating patients and visitors about IP practices within the hospital. Nurses should be held
accountable for effectively communicating proper IP policies to both patients and visitors. Since some
patients may be illiterate, it is necessary that representatives from the nursing staff recite the roles and
responsibilities to all patients and visitors who enter the site.
Educate patients and visitors on IP policies using illustrative pamphlets. The nursing staff can
educate patients and visitors in either a group or an individual basis. The hospital should have
pamphlets and/ or brochures that highlight the IP practices that the patients, caregivers and visitors are
expected to abide by. For example, educational pamphlets should address hand hygiene procedures
and visiting hours. Brochures, pamphlets, or other educational materials should be illustrative in
nature. This enables all visitors and patients — regardless of education or literacy level—to quickly
grasp the concepts of IP policies. Wherever possible, posters detailing IP practices also should be
posted in patient care areas.

In order to determine if the Operational Standards for Infection Prevention have been met by the


Table 5. Infection Prevention Checklist
Yes No
1. An Infection Prevention Committee has been established.
2. Terms of reference for the Infection Prevention Committee are defined.
3. An operational plan that defines the hospital’s infection prevention
activities has been developed.
4. Monitoring of infection prevention activities is conducted and reported to
the senior management team.
5. Healthcare acquired infections are tracked.
6. Standard precaution practices are defined and in place.
7. Transmission based precaution practices are defined and in place.
8. Equipment needed to provide infection prevention activities are available.
9. Supplies needed to provide infection prevention activities are available.
10. Trainings and orientations on infection prevention are provided to staff.
11. Health education on infection prevention is given to patients and
caregivers.
4.3 Indicators
Table 6 Infection Prevention Indicators

S/N Indicators Formula Frequency Comment
1. Total number of patients with an infection Quarterly
arising >48 hours after admission during
reporting period /total number of admissions
Healthcare acquired infection rate during reporting period *100
2. a) Number of occupational a) Total number of occupational exposures Quarterly
exposures reported in the during reporting period, categorized by
hospital, categorized by type type of exposure
of exposure b) Total number of non-occupational
exposures during reporting period,
b) Number of on-occupational categorized by type
exposures reported in the
hospital, categorized by type
of exposure
3. Quarterly
The number of people that started Total number of people started on PEP
PEP treatment treatment during the reporting period

4. Total number of people that completed PEP Quarterly
treatment during the reporting period/
Total number of people who should have
% of people that completed the completed PEP treatment during the reporting
PEP treatment period*100
5. a) Number of days when a) Total number of days that the incinerator Quarterly
incinerator was not working was not working during the reporting
period
b) % of total days b) Total number of days that the incinerator
was not working during the reporting
period/total number of days in reporting
period *100
6. Inpatient satisfaction survey: % of Biannual Survey tool
respondents who answered presented in
‘always’ or ‘usually’ to the Total number of inpatients who respond Appendix F
question “During this health ‘always or usually’ to the listed question/ Total of Chapter 12
facility stay, how often was the number of inpatients respondents*100 Quality
room you were sleeping in kept Management
clean?”
7. Biannual Survey tool
Outpatient satisfaction survey: % presented in
of respondents who answered Total number of outpatients who respond Appendix F
‘agree’ or ‘strongly agree’ to the ‘agree’ or ‘strongly agree’ to the listed of Chapter 12
question “The outpatient questions/ Total number of outpatients Quality
department was clean respondents*100 Management


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51. Recommendations of the Advisory Group of Infection’s Subgroup on Surveillance of
Antimicrobial Resistance and Hospital Acquired Infections (HAI). A Framework for National
Surveillance of Hospital Acquired Infections in Scotland.
52. Draft Infection Prevention Operational Guidelines (WHO/FMOH). (2008) unpublished.
Appendices
Chapter 7 Infection Prevention

Appendix A Hand washing Techniques
SOURCE: WHO. 2005. Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. WHO: Geneva
Chapter 7 Infection Prevention Appendix A: Page 1 of 1

Appendix B Summary of Procedures for Handling and Disposal of Health Care Waste
Type of Waste Procedures

• General waste is immediately placed in the general waste bin (black) by the person
General waste generating it.
• Waste handler collects general waste daily, using a wheelbarrow/cart designated for
general waste.
• If offsite disposal is available, the waste is stored until the scheduled collection day.
• On days when the incinerator is being operated, the general waste is taken directly to the
incinerator or to burial pit.
• If the incinerator is not operating on that day, the waste handler stores general waste in a
covered, secure location until final disposal. (Waste should not be stored for more than
2 days).
• Incinerator operator destroys general waste according to schedule.
• Incinerator operator removes ash and disposes of it in an ash pit. (Remove ash only after
the incinerator has cooled down completely)
• Food waste is immediately placed in the designated bin.
Food Waste • Waste handler collects and disposes of food waste immediately after meal times.
• If offsite disposal is practiced, food waste should only be stored for up to 1 day.
• If no on-site disposal, waste handler buries food waste daily. It is highly recommended
that food waste should be composted. (When burying, strictly follow the guidelines on
burying waste)
• Health care provider immediately places infectious waste in the infectious waste bin
Infectious waste with liner bag. (yellow)
• Waste handlers collects waste every day or when the liner bag is full using a
wheelbarrow/cart designated for infectious waste
• On days when the incinerator is being operated, the infectious waste is taken directly to
the incinerator or it shall be disposed using burial technique.
• If the incinerator is not operating on that day, the waste handler stores infectious waste
in a covered secure location until final disposal. (Infectious waste should be disposed of
within 2 days, but placenta and anatomical waste should be disposed on daily basis).
• Incinerator operator destroys infectious waste according to schedule.
• Incinerator operator removes ash and disposes of it in an ash pit
• Injection provider immediately places used syringe in a safety box
Sharps • Injection provider closes safety box when its ¾th full and obtains new safety box,
• Waste handler collects filled safety boxes for storage in a secure covered, dry location
awaiting final disposal.
• Waste handler transports safety boxes to incineration site using a wheelbarrow/cart
designated for infectious waste.
• Incinerator operator destroys safety boxes according to schedule. (Safety boxes should
be destroyed within one week).
• Incinerator operator removes ash and disposes of it in an ash pit
Chapter 7 Infection Prevention Appendix B: Page 1 of 1

Appendix C Suggested Cleaning Guidelines for Hospital Environments
Item/Area Method Minimum Frequency

Outpatient Waiting Use clean cloths and change frequently during Twice daily; pay attention to chairs
area cleaning; disinfectant solution preferred and tables and other surfaces in
(follow contact time). Wet mop floor frequent contact with hands.
(detergent is adequate).
Exam Use clean cloths for each room; change cloths Between patients unless surfaces
room/area frequently when doing a large area; are covered (then daily) or
disinfectant solution preferred (follow contact immediately when contaminated
time). Wet mop floor (detergent is adequate with blood/body fluids. Pay
unless contaminated with blood/body fluids attention to exam table, chairs, and
then use a disinfectant). tables.
Hand Use disinfectant to clean sink, water tap, and Twice daily; more often as needed
washing faucet handles. Re-supply soap, clean towels.
sinks
Bathrooms Use dilute bleach or other disinfectant to clean Twice daily; more often as needed
toilet, sink, water tap, faucet handles, and door
knobs. Wet mop floor with a disinfectant
solution. Re-supply soap, clean towels.
Corridors Wet mop floors; detergent/water solution is Twice daily; more often as needed
adequate. Change bucket solution and mop
head frequently.
Linen Soiled linen should be minimally handled in Daily, more often as needed.
such a way to avoid aerosolization; bagged,
stored separately until delivered to laundry.
Trash Empty daily, more often as needed.
Chapter 7 Infection Prevention Appendix C: Page 1 of 2

Item/Area Method Minimum Frequency
Inpatient Open wards Use clean cloth; disinfectant (appropriate Daily; area around a patient when
contact time); clean all horizontal surfaces discharged before next patient put
including bed rails, tables, chairs; clean door in the bed.
knobs, light switches/plates. Wet mop floors;
detergent/water solution is adequate. Change
bucket solution and mop head frequently.
Individual Use clean cloth; disinfectant (appropriate Daily and at discharge

patient contact time); clean all horizontal surfaces
rooms including bed rails, table, chairs; clean door
knobs, light switches/plates. Wet mop floors;
detergent/water solution is adequate. Change
bucket solution and mop head frequently.
Bathrooms Use dilute bleach or other disinfectant to clean Every shift if shared; daily if not
toilet, sink, water tap, faucet handles, door shared. Tubs should be cleaned in
knobs, showers/tubs. Re-supply soap, clean between each patient.
towels.
Hand Use a disinfectant to clean sink, water tap, Every shift

washing faucet handles. Re-supply soap, clean towels.
sinks
Corridors Wet mop floors; detergent/water solution is Twice daily; more often as needed
adequate. Change bucket solution and mop
head frequently.
Linen Soiled linen should be minimally handled in Daily, more often as needed.
such a way to avoid aerosolization; bagged,
stored separately until delivered to laundry.
Trash Empty daily, more often as needed.
Chapter 7 Infection Prevention Appendix C: Page 2 of 2

Appendix D Post-exposure Prophylaxis Forms: Decision Making Tool
1. Determine the Status Code (SC)

¾ Risk assessment of the source patient – choose SC1, SC2, or SC unknown
2. Determine the Exposure Code (EC)

¾ Risk assessment of the exposure – choose EC 1, EC 2, or EC 3
Decision tree to evaluate need for PEP.
Source patient
HIV - HIV + Unknown/ unwilling to be tested*
High risk background Low risk background
No PEP PEP No PEP
*CDC recommendation: usually PEP unnecessary; consider use if source patient is high risk.
** If HCW is HIV +, he/she would not take PEP, but should be referred to ART clinic for continued care.
If HIV status of HCW unknown or previously negative (-), PEP may/may not be indicated depending on
the risk assessment.
Chapter 7 Infection Prevention Appendix D: Page 1 of 2

Determining HIV status code of the source (SC)
HIV Negative No PEP
Asymptomatic / Viral load < 1500 copies/ml = HIV SC1
HIV Positive
Symptomatic HIV infection, AIDS, Acute seroconversion, patient on

antiretroviral therapy, Viral load > 1500 copies/ml= HIV SC2
HIV status unknown or source unknown = HIV SC unknown
Determining the exposure code (EC)

Exposure on mucous membrane or broken skin
↓
Estimate volume
↓
Few drops, short duration = EC1
Several drops/ long duration/ major blood splash = EC2
Exposure on intact skin → No PEP
Percutaneous exposure → Determine severity →Solid, superficial injury = EC2
Hollow needle deep puncture = EC3
Recommended HIV post exposure prophylaxis for percutaneous injuries

Exposure code
Status code EC 2 EC 3
SC 1 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
SC 2 Recommend expanded 3-drug PEP Recommend expanded 3-drug PEP

SC unknown Generally, no PEP warranted; however, Generally, no PEP warranted;
consider basic 2-drug PEP for source however consider basic 2-drug PEP
with HIV risk factors. for source with HIV risk factors
HIV-Negative No PEP warranted No PEP warranted.
Recommended HIV post exposure prophylaxis for mucous membrane exposures and nonintact skin
exposures
Exposure code
Status code EC 1 EC 2
SC 1 Consider basic 2-drug PEP Recommend basic 2-drug PEP
SC 2 Recommend basic 2-drug PEP Recommend expanded 3-drug PEP
Generally, no PEP warranted. If PEP is Generally, no PEP warranted;

SC unknown offered & administered and the source however consider basic 2-drug PEP
is later determined to be HIV-negative, for source with HIV risk factors.
PEP should be discontinued.
HIV-Negative No PEP warranted No PEP warranted.
Adapted from Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Post exposure Prophylaxis. MMWR Recomm Rep 2005; 54 (No RR-9): 1-17 & MMWR 1998;
47(No. RR-7): 1-33.
Chapter 7 Infection Prevention Appendix D: Page 2 of 2

Appendix E Post-exposure Prophylaxis Forms: Sample Patient Tracking Form
Patient tracking form for patients who started PEP drugs (from draft National PEP guidelines)
Type of exposure Appointment date: dd/mm/ yr Address

Occupational(Case Non 2 weeks 3 months 6 months Region, Woreda, Telephone
Name of patient Team/Department) Occupational Kebele, House No.
Chapter 7 Infection Prevention Appendix E: Page 1 of 1

Appendix F Post-exposure Prophylaxis Forms: Sample Occupational Blood and Needle Stick
Exposures Recording Form
Note: This form is for recording exposures only

Date:____________________
1) Name: ____________________________
2) Telephone #:________________________
3) Age: ________
4) Sex: ________
5) Date, time & location of exposure: ___________________________________
6) Type of injury? *Please circle appropriate letter

a) Hollow needle deep prick
b) Hollow needle superficial prick
c) Solid needle deep prick
d) Solid needle scratch
e) Splash to the conjunctivae
f) Splash to the oral cavity
g) Splash to intact skin
h) Splash to broken skin (specify:________________________________)
i) Bite
7) Substance involved? *Please circle appropriate letter

a) Blood
b) Amniotic fluid
c) CSF
d) Body cavity fluids (specify:___________________________________)
e) Vaginal secretions
8) Did the body cavity fluid contain visible blood? *Please circle appropriate letter
a) Yes
b) No
c) Not aware
9) Circumstance of injury? *Please circle appropriate letter

a) Trying to secure intravenous line
b) Needle stick injury during surgery (specify:________________________)
c) Needle stick while disposing of waste
d) Amniotic fluid splash during delivery
e) Splash with body cavity fluids during procedure (specify:_____________)
f) Other (specify:_________________________________________________)
10) Is HIV status of HCP already known? *Please circle appropriate letter
a) Yes (the HCP is HIV +)
b) Yes (the HCP is HIV -)
c) No (HIV status is unknown)
11) HIV status of the source case? *Please circle appropriate letter
a) Positive
b) Negative
c) Unknown
Chapter 7 Infection Prevention Appendix F: Page 1 of 2

12) Clinical stage of confirmed HIV infection in the source case? *Please circle appropriate letter
a) Asymptomatic
b) Mild symptoms not requiring hospitalization (specify)
c) Admitted with OI to the hospital but not seriously sick
d) Seriously sick (terminally ill)
e) Altered state of consciousness
13) If the exposure has occurred to the mucous membrane, how do you estimate the volume of
blood or body cavity fluid? *Please circle appropriate letter
a) Few drops and once only
b) Few drops but repeatedly
c) Major blood splash
d) Several drops and repeatedly
e) Unable to estimate
14) Assessor (ER physician or ART clinic personnel): after completing the questions above, please
reference decision tree & report if exposed should initiate PEP? *Please circle appropriate
letter
a) Should initiate PEP
b) PEP NOT indicated
15) If PEP is indicated, is the HCP agreeable to starting PEP treatment? *Please circle
appropriate letter
a) Not ready
b) Ready to initiate
16) Previously known medical problems or medications being taken by the HCP?
17) If female HCP, record last menstrual period (LMP) and if there is a risk of pregnancy?
________________ _____________________ ________________

Name of Assessor Signature of Assessor Date
Chapter 7 Infection Prevention Appendix F: Page 2 of 2

Appendix G Monitoring and Surveillance Forms: Sample: Hand Hygiene monitoring form
Hand Hygiene Feedback Form

Staff Member __________________________ Date: ________________
To improve hand washing practices and to ensure that our patients are free from acquiring infections
during their hospital stay, I want share with you my recent observations
Date &
Present
Absent
Providing General Medical Services

Shift
NA
Performed hand hygiene before contact with each patient, disinfected with
either water and soap, an alcohol-based gel, or rubbing hands with alcohol
soaked cotton balls.
Patient was on transmission-based precautions; appropriate PPE donned.
Patient was on transmission-based precautions; PPE was removed and
discarded in the room, or closest waste receptacle, when exiting.
After contact with a patient, equipment that may have been in contact with a
patient (bedpan, commode, Foley bag), or the handling of contaminated items
such as linens, diapers, wash cloths, and wastes, hand hygiene is performed
immediately after service is completed.
If experienced contact with a patient’s blood or other bodily fluids, then hands
washed with soap and water. Disinfection with alcohol-based gels or alcohol-
soaked cotton swabs will not suffice.
For patients on transmission-based precautions, all visitors were attired w/
appropriate PPE.
Performed hand hygiene, if gloves were donned. Performed before seeing next
patient and/or leaving patient area.
Invasive Procedures
Before seeing a patient, gathered needed equipment first and then performed
hand hygiene.
Performed hand hygiene before contact with each patient, preferably before
entering the room or patient area
Donned gloves before performing any procedures
Donned gowns in situations that posed potential for the splattering of blood or
body fluid onto clothing
Donned masks, glasses/goggles, or face shields in situations where there was
potential of mucous membrane exposure of the face to blood or body fluids.
discarded in the room, or nearest waste receptacle, when procedure is finished.
Adhered to safe disposal or sterilization of medical equipment guidelines
Ensured the gloves were removed and discarded within the room, or nearest
waste receptacle, when interaction with patient is finished.
Medication Administration
Once meds dispensed nurse proceeded directly to patient room/area. Hand
hygiene performed before contact with each patient.
Needed to perform additional tasks before entering patient room/area. Hand
hygiene performed just before contact with each patient.
Chapter 7 Infection Prevention Appendix G: Page 1 of 2

discarded in the room, or nearest waste receptacle, before seeing next patient
or exiting patient area.
Hand hygiene performed before seeing next patient or exiting patient area.
For patients on transmission-based precautions, visitor attired w/ appropriate
PPE.
Passing Meal Trays
Performed hand hygiene before entering first room to pass food tray (not on
transmission-based precautions).
Delivered tray, then consistently performed hand hygiene when exiting each
room.
Was interrupted during tray passing after exiting the room to do another task.
Performed hand hygiene before passing the next tray.
discarded in the room when exiting.
Patient was on transmission-based precautions: Trays passed last.
Phlebotomy
Specimen obtained according to policy (Gloves donned, arm band checked,
venous access assessed, tourniquet applied, skin prepped w/ alcohol, blood
drawn, sharps disposed in sharps container)
Specimen labelled & placed in plastic bag, placed on cart outside room.
Gloves removed & placed in waste basket in room.
Repeat hand hygiene
Patient was on transmission-based precautions; specimens obtained last.
Hand hygiene=wash with soap and water or alcohol hand rub
Hand hygiene Sinks (ward and other areas) Soap

Alcohol based hand rub
Personal Towels
Paper Towels
Chapter 7 Infection Prevention Appendix G: Page 2 of 2

Appendix H Monitoring and Surveillance Forms: Sample Example of a Minimum Data Collection
Form for HCAI Prevalence Study
Example of a minimum data collection form for prevalence study

Date (dd/mm/yy) ______________________
Hospital ______________________
Unit ______________________
Unit specialty ______________________
Patient
Patient identification ______________________
Age (years) ______________________
Gender □ male □ female
Date of admission in the hospital (dd/mm/yy) _____________________
Patient exposure
Surgical procedure (during the last month) □ Yes □ No
Urinary catheter □ Yes □ No
Mechanical ventilation □ Yes □ No
Intravascular catheter □ Yes □ No
Antibiotic □ Yes □ No
If yes, prescription for □ Prophylaxis □ Therapy □ Other/unknown
Nosocomial infection □ Yes □ No

If yes, fill the following items
Surgical site infection □ Yes □ No
Urinary tract infection □ Yes □ No
Bloodstream infection □ Yes □ No
Pneumonia □ Yes □ No
Other respiratory infection □ Yes □ No
Line-related infection □ Yes □ No
Other nosocomial infection □ Yes □ No
Chapter 7 Infection Prevention Appendix H: Page 1 of 3

Example of a data collection form for surgical site infection surveillance
Date (dd/mm/yy) ______________________
Hospital ______________________
Unit ______________________
Unit specialty ______________________
Patient
Patient identification _______________________
Age (years) _______________________
Gender □ Male □ Female
Date of admission in the hospital (dd/mm/yy) ______________________
Date of discharge (from the unit) (dd/mm/yy) ________________________
Operation
Date of operation (dd/mm/yy) ________________________
Main procedure (code) ________________________
Wound class □ Clean □ Contaminated

□ Clean/contaminated
□ Dirty/infected
ASA score □1 □2 □3 □4 □5
Duration of operation (minutes) __________________________
Urgent □ Yes □ No
Prosthesis/implant □ Yes □ No
Multiple procedures □ Yes □ No
Coeliosurgery □ Yes □ No
Antibiotics
Antimicrobial prophylaxis □ Yes □ No
Starting date (dd/mm/yy) __________________________

Duration (days) __________________________
Surgical site infection
Surgical site infection □ Yes □ No
Date of infection (dd/mm/yy) ___________________________
Infection site □ Superficial □ Deep □ Organ/space
Microorganism 1 __________________________
Microorganism 2 __________________________
Date of last contact (dd/mm/yy) __________________________
Source: Excerpted from: PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL

GUIDE — WHO/CDS/CSR/EPH/2002.12

Appendix I Monitoring and Surveillance Forms: Sample Infection Prevention Checklist to Assess each Case Team/ Unit
Case Team or Unit _____________________________

Date of Assessment ______________________________
OBSERVATION RESPONSE (circle one) (N/A= Not applicable)

Hand Hygiene (Provider)
Hands are thoroughly washed immediately:

1. Before and after each patient contact? ………………………………………..………………………………. Yes No N/A
2. Before handling and putting on gloves? ………………………………………..……………………………… Yes No N/A
3. After handing objects which might be contaminated? ……………………….………………………………… Yes No N/A
4. After contact with blood or mucous membranes? ……………………………...…………………………….. Yes No N/A
5. After removing gloves? …………………………………………………….…………………………………….. Yes No N/A
6. Is soap or antiseptic hand rub available at sinks and toilets? ………………….…………………………… Yes No N/A
7. Is there antiseptic hand rub available for use before and after contact with each patient contact? ….… Yes No N/A
Environmental Hygiene
8. Sheets and blankets are clean and changed regularly? ……………………….……………………………. Yes No N/A
9. Patients are wearing clean pyjamas or gowns? ……………………………………………………………… Yes No N/A
10. Mosquito nets (if necessary) are being used and are clean? ……………………………………………….. Yes No N/A
11. Staff are separating and disposing of ward waste properly? …………………………………………………
Yes No N/A
Linens Processing
12. Soiled linens are handled, stored and transported properly? ………………………………………………… Yes No N/A
13. Is there a separate room for sorting soiled linens? ……………………………….………………………….. Yes No N/A
14. Is there a separate room for sorting clean linens? …………………………………..………………………… Yes No N/A
15. Is there a separate room for storing clean linens? ……………………………………………………………..
Yes No N/A
16. Are separate carts designated and used for transporting contaminated/soiled linens and clean linens ?
Yes No N/A
Housekeeping
17. Are sinks in patient care areas clean, disinfected, tidy and functioning? …………………………………… Yes No N/A
18. Are ceilings, walls and floors in patient care areas clean? ……………………………….…………………… Yes No N/A
19. Is lighting adequate in patient care areas? ………………………..…………………………………………… Yes No N/A
20. Are patient rooms well ventilated? ……………………………………………………………………………… Yes No N/A
Chapter 7 Infection Prevention Appendix I: Page 1 of 3

Transmission based precautions
21. Are isolation rooms available for highly contagious patients? ………………………………………………... Yes No N/A
Waste Disposal
22. The hospital has an operating incinerator? …………………………………………………………………… Yes No N/A
23. Are separate (preferably colour coded) bins/containers used for segregating waste into infectious, non-
infectious and sharps waste? ...................................................... ………………………………………… Yes No N/A
24. Are infectious and sharps waste disposed by burning or burying? …………………………………………
Yes No N/A
25. The hospital has a properly constructed placenta pit ?……………………………...…………………………
Yes No N/A
Observation of Single-use Needles, Scalpel Blades and other Sharp Objects
26. Needles, scalpel blades and other sharp objects are disposed of immediately after use? ……………… Yes No N/A
27. Needles, scalpel blades and other sharp objects are disposed of in a puncture resistant container? …… Yes No N/A
28. All sharps containers are removed when they are ¾ full and taken to the incinerator or the approved
waste burial site? ……………………………………….………..………..………………………………………
Yes No N/A
Decontamination and Cleaning
29. Blood spills are cleaned by flooding with a disinfectant and then wiped up? …………………………… Yes No N/A
30. Instruments are decontaminated in a 0.5% chlorine solution immediately after use for 10 minutes? …… Yes No N/A
31. Instruments are thoroughly cleaned, rinsed and dry before sterilization or HLD use of labelled plastic
buckets for decontamination?………..………..………..………..………..……………………………………
Yes No N/A
Sterilization
32. What method of sterilization is used?
- High-pressure steam (if YES, go to # 2) ………………………………………………………………….... Yes No N/A
- Dry heat (if YES, go to #3) ……………………………………………….....……………………………….. Yes No N/A
33. When steam sterilizing, is the high – pressure steamer operating.

- At 1210C ( 250 oF ) …………………………………………………………………………………………. Yes No N/A
- At a pressure of 106 KPa, 15 Ib /in2 ………………………………………………………………………. Yes No N/A
- For at least 20 minutes for unwrapped items; 30 minutes for wrapped ……….………………………. Yes No N/A
34. When using dry heat, are the instruments kept:

- At 170oC ( 340oF) for sharps, ………………………………………………….…………………………… Yes No N/A
- At the required temperature ( 170o ) for at least 1 hour, or ……………………………………………… Yes No N/A
- At 160oC for 2 hours ………………………………………………………......……………………………… Yes No N/A

High Level Disinfection
35. What method of high-level disinfection is used?
-Boiling (if YES, go to # 40) ……………………………………………………...……………………………….. Yes No N/A
-Steaming (if YES, go to # 41) …………………………………………………...……………………………….. Yes No N/A
-Chemical disinfectants ( if YES, go to # 42 )……………………………………. …………………………….. Yes No N/A
36. When boiling, are the instruments:

- Boiled for at least 20 minutes once boiling begins, and ……………………….…………………………. Yes No N/A
- Nothing is added after timing begins ………………………………………………………………………. Yes No N/A
37. When steaming, are the instruments:

- Steamed for at least 20 minutes once boiling begins, and……………………..………………………… Yes No N/A
- Nothing is added after timing begins ......…………………………………….. ………………………….. Yes No N/A
38. when chemical high-level disinfectants are used:

-is an appropriate chemical used?………………………………………………….…………………………… Yes No N/A
-are items completely submerged?………………………………………………..……………………………. Yes No N/A
-are instruments soaked for at least 20 minutes? ……………………………………..………………………. Yes No N/A
-are instruments rinsed with sterile/boiled water? ……………………………………………………………... Yes No N/A
Worker’s Health and Safety

1. Has training on occupational hazards and safety measures been given in the last year? …… ………… Yes No N/A
2. Personal protective clothing and equipment is available (i.e. goggles, boots, aprons etc) ……………… Yes No N/A
3. Is PIHCT/VCT service available 24 hours a day? ……………………………..……….…………………….. Yes No N/A
4. Is there a “Post Exposure Prophylaxis” (PEP) protocol in place and posted for all staff to see? ………… Yes No N/A
5. Does the hospital provide immunizations for common communicable diseases? ………………………… Yes No N/A
Case Team Leader Evaluator
Name ___________________________ Name _________________________
Signature ________________________ Signature ______________________

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Federal Democratic Republic of Ethiopia

Ethiopian Hospital Reform

Ethiopian Hospital Management Initiative

Ethiopian Hospital Reform Implementation

Ethiopian Hospital Management Initiative

Hon. Minister Tedros Adhanom Ghebreyesus (PhD)

Hospital Leadership and Governance and Quality Management

Medical Records Management

Nursing Care Standards

Financial and Asset Management

Human Resource Management

Federal Democratic Republic of Ethiopia Ministry of Health,

Clinton Health Access Initiative

Photographs courtesy of Ismael Ali and Salem Fisseha.

Chapter 1. Hospital Leadership and Governance

Chapter 2. Patient Flow

Chapter 3. Medical Records Management

Chapter 4. Pharmacy Services

Chapter 5. Laboratory Services

Chapter 6. Nursing Care Standards

Chapter 7. Infection Prevention

Section 2 Operational Standards for Hospital Leadership and Governance 4

Section 3 Implementation Guidance 5

3.1 Practical tools of leadership and management 5

3.2 Governing Board 14

3.3 Chief Executive Officer 23

3.4 Hospital Senior Management Team 26

3.5 Strategic and annual planning 29

3.6 Essential service package 31

Section 4 Implementation Checklist and Indicators 31

4.1 Assessment tool for Operational Standards 31

Chapter 1 Hospital Leadership and Governance Page 2 of 34

Box A Monitoring and Evaluation

Chapter 1 Hospital Leadership and Governance Page 3 of 34

Effective hospital governance requires:

Section 2 Operational Standards for Hospital Leadership and

Chapter 1 Hospital Leadership and Governance Page 4 of 34

Step 1 Define the problem,

To devise a good problem statement the following should be considered:

Chapter 1 Hospital Leadership and Governance Page 5 of 34

Figure 1 Common Mistakes and Suggestions for Problem Statements

Weak Problem Statement Suggestions for Improvement Strong Problem Statement

Step 2: Set the overall objective

Figure 2 Relating the Problem Statement, Objective and Target

Relating the problem statement, objective and target

Chapter 1 Hospital Leadership and Governance Page 6 of 34

Figure 3 Sample Fishbone Diagram

1) People: Are staff behaviours or characteristics contributing to the problem?

Chapter 1 Hospital Leadership and Governance Page 7 of 34

Fishbone diagramming is useful for a number of reasons:

Ranking Matrix of Root Causes

Figure 4 Problem Ranking Matrix

Chapter 1 Hospital Leadership and Governance Page 8 of 34

Flow charts are useful because they:

Chapter 1 Hospital Leadership and Governance Page 9 of 34

Figure 6 Sample Histogram

Chapter 1 Hospital Leadership and Governance Page 10 of 34

Step 4: Generate alternative interventions

Good alternatives are: