ETHIOPIAN ES3617:2012

Secretariat
STANDARD
First edition

Primary Hospital - Requirements

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 Tables of Contents
ACKNOWLEDGEMENT...............................................................................................3
FOREWORD ..................................................................................................................4
SECTION ONE: GENERAL...........................................................................................5
1. Scope....................................................................................................................5
2. Normative References...........................................................................................5
3. Terminologies and Definitions..............................................................................6
SECTION TWO: LICENSURE.......................................................................................7
2.1. General .............................................................................................................7
2.2. Application for licensure ...................................................................................7
2.3. Initial/New Licensure ........................................................................................9
2.4. License Renewal Requirements.......................................................................10
2.5. Removal Permits, Change of Operation and Forfeiture of License...................11
2.6. Suspension and Revocation of a License .........................................................12
2.7. Right to Fair Hearing.......................................................................................14
2.8. Information to be Disclosed.............................................................................14
SECTION THREE: GOVERNANCE............................................................................16
3.1. Governing Board.............................................................................................16
3.2. Chief Executive Officer...................................................................................18
3.3. Chief Clinical Officer......................................................................................18
3.4. Management Committee .................................................................................19
SECTION FOUR: PATIENT RIGHTS AND RESPONSIBILITIES ............................20
4.1. Informed Consent............................................................................................20
4.2. Patient Rights..................................................................................................21
4.3. Patient Responsibilities ...................................................................................25
SECTION FIVE: HUMAN RESOUCE MANAGEMENT ............................................27
5.1. General Requirements .....................................................................................27
5.2. Staffing Plan ...................................................................................................28
5.3. Job Description and Orientations.....................................................................30
5.4. Staff Education................................................................................................31
5.5. Medical Staff...................................................................................................31
5.6. Employee’s Health ..........................................................................................32
5.7. Dress Code and Identification Badge...............................................................34
SECTION SIX: SERVICE STANDARDS ....................................................................36
6.1 . Outpatient Services .......................................................................................36
6.2 . Inpatient services...........................................................................................40
6.3 . Maternal and Child Health (MCH) and Delivery Services .............................45
6.4 . Surgical Services...........................................................................................49
6.5 . Anesthesia Services.......................................................................................60
6.6 . Nursing Services ...........................................................................................70
6.7 Emergency Services ........................................................................................80
6.8 . Rehabilitation Services..................................................................................85
6.9 . Radiological Services ....................................................................................87
6.10 . Laboratory services....................................................................................91
6.11 Pharmaceutical Services ............................................................................ 103
6.12 Ambulance Services .................................................................................. 122
 6.13 Patient Flow............................................................................................... 125
6.14 Health Promotion Services......................................................................... 126
6.15 Medical Recording .................................................................................... 130
6.16 Morgue Services........................................................................................ 134
6.17 Social Works Services ............................................................................... 136
6.18 Infection Prevention................................................................................... 139
6.19 Hospital Sanitation and Waste Management .............................................. 146
6.20 Food and Dietary Services ......................................................................... 151
6.21 Housekeeping, Laundry and Maintenance Services.................................... 160
SECTION SEVEN: PHYSICAL PLANT STANDARDS............................................ 168
7.1. General............................................................................................................. 168
7.2. Site Selection Requirements.............................................................................. 168
7.3. Construction Requirements............................................................................... 169
7.4. Building Space and Elements............................................................................ 170
7.5. Building Systems.............................................................................................. 175
7.6. Electrical System .............................................................................................. 178
7.7. Fire Protection System...................................................................................... 179
7.8. Call Systems..................................................................................................... 181
7.9. Health Facility Environment ............................................................................. 181
7.10. Specific Service Areas................................................................................... 181
7.11. Care and Treatment Areas ............................................................................. 184
7.12. Ancillary areas .............................................................................................. 185
7.13. Bubble Diagrams........................................................................................... 188

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ACKNOWLEDGEMENT

Ethiopian Standard Agency, ESA would like to extend its special thanks to members
of the technical working group organized by the Ethiopian Food, Medicine and
Healthcare Administration and Control Authority of Ethiopia, EFMHACA in
developing the draft health facility standards.The members of the TWG were Dr.
Getahun Mengistu, Dr.Kidane Melles, Ato Yohannes Jorge, Dr Adefris Debalke, Dr.
Wondwossen Fantaye, Dr Faris Hussein, Dr Petros Mitiku, Dr David A.conteh, Dr
Ruth Lawson, Dr Birna Abdosh, Ato Liyusew Solomon, Ato Edmealem Ejigu, Dr
Solomon Tessema, Dr Endale Tefera, Ato Yihalem Tamiru, Dr Abyou Kiflie, Ato
K/mariam G/Michael, Sr Yeshialem Bekele, Ato Wondie Alemu, W/t Raey Yohannes,
Ato Ayalew Adinew, Dr Zegeye Hailemariam, Dr. Tassew Tadesse, Dr Alem Michael,
Dr. Aynalem Abraha, Dr. Mehrtu W/yes, Ato Zelalem mesele, Ato Salehunae, Dr
Daniel Admassie and Dr Tekle-ab Zaid.

In addition, the Agency would also thank all the workshop participants from the
Ministry of Health, Health Professional Associations, Universities, public and private
hospitals, private clinics, non-governmental organizations and other governmental
organizations for their commitment to enrich the draft document.

We are grateful to the USAID/PHSP-Ethiopia, MSH/SPS, Clinton Foundation and

Tulane University without whose support it would have been difficult to achieve the
desired result.

The Agency would also like to express its appreciation to FMHACA for the
commitment, effective coordination and overall leadership shown in the
development of this standard.

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FOREWORD
This Ethiopia Standard has been prepared under the direction of the Technical
Committee for Medical Care Practices (TC90) and published by the Ethiopian
Standards Agency (ESA).

The draft document (Working Draft, WD) has been submitted to the Secretariat by
the Ethiopian Food, Medicine & Healthcare Administration and Control Authority
(FMHACA).

A Primary hospital shall provide services in accordance with this standard and shall
comply with the requirements. The standard shall enter into force starting from the
day of approval as Ethiopian Standard. This standard is approved by the convention
of ……….. made on…..Application of this standard is MANDATORY with the intention
to ensure the quality and public safety of health services through standardized
licensure and inspection procedures, to promote access to quality health services
and encourage health investment.

The Ethiopian Standard Agency recommends fulfilling all the requirements

stipulated under this document. It has to be noted that the fruition of fulfilling these
requirements will ensure the quality and safety of public health services through
availing appropriate infrastructure, deployment and retention of qualified and
competent health professionals that deliver best practices and by generating
innovative ideas and methodologies to solve healthcare problems.

Finally, acknowledgement is made to the EFMHACA, Technical Working Group,

participants of national workshop and EFMHACA collaborators for their
commitment and unreserved contribution to the effort of developing Ethiopian
Standards for Health Facilities.

Ato………………W/O…………

Director General, Ethiopian Standard Agency

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SECTION ONE: GENERAL

1. Scope
1.1. This Ethiopian standard shall be applicable for all primary hospitals new and
existing, governmental and non-governmental.
1.2. The standard covers the minimum requirements with respect to practices,
premises, professionals and products or materials put into use for primary
hospitals.
1.3. Requirements of a primary hospital are stipulated under section two to
seven of this standard.

2. Normative References
The latest editions of the following laws, regulations, directives and guidelines shall
be taken as part and parcel of this Ethiopian Standard.
2.1. Ethiopian Food, medicine and Healthcare Administration and Control
Proclamation No. 661/2009
2.2. Ethiopian Food, Medicine and Healthcare Administration and Control
Regulation No. 189/2010
2.3. Federal Hospitals Administration Council of Ministers Regulation No.
167/2009
2.4. The Ethiopian Hospital Reform and Implementation Guidelines, March 2010
2.5. National Health Policy of the Transitional Government of Ethiopia, 1993
2.6. National Drug Policy of the Transitional Government of Ethiopia, November
1993
2.7. Commercial Code of Ethiopia
2.8. Criminal Code of Ethiopia
2.9. Medicines Waste Management and Disposal Directive No 2/2011
2.10. Ethiopian National Guideline for Health Waste Management, 2008

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2.11. Ethiopian Building Proclamation, No. 624/2009

3. Terminologies and Definitions

3.1
Appropriate Organ
Shall mean a state government organ authorized to implement food, medicine and
healthcare administration and control activities at a state level;
3.2
Authority
Shall mean the Ethiopian Food, Medicine and Healthcare Administration and Control
Authority.
3.3
Proclamation
Shall mean the Ethiopian Food, Medicine and Healthcare Administration and Control
proclamation No 661/2009.
3.4
Appropriate Law
Shall mean a law issued by a state to implement regulatory activities regarding food,
medicine and healthcare.
3.5
Person
Shall mean any physical or juridical person
3.6
Authorized Person
Shall mean any hospital staff who is responsible for a given service
3.7
Primary hospital
Shall mean a health facility at primary level of healthcare which provides
promotive, preventive, curative and rehabilitative services with a minimum capacity
of 35 beds and provides at least 24 hour emergency services, general medical

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services, treatment of basic acute and chronic medical problems, basic emergency
surgical intervention and Comprehensive Emergency Obstetric Care (CEOC)
including laboratory, imaging and pharmacy services and other related services
stated under this standard.

SECTION TWO: LICENSURE

2.1. General

2.1.1 This standard provides minimum requirements for the establishment and
maintenance of primary hospital in order to protect the public interest by
promoting the health, welfare, and safety of individuals.
2.1.2 No primary hospital shall be built or be functional by any person without prior
permission of the appropriate organ.
2.1.3 The requirements set by this standard may not be waived unless otherwise for
public interest and there is a substantial need for waiver. There shall be an
assurance that the waiver will not create a hazard to the health and well- being of
patients or others than the public interest.

2.2. Application for licensure

2.2.1. No person shall operate a primary hospital in Ethiopia, whether governmental,
nongovernmental or private, without being licensed as required by appropriate
law and this standard.
2.2.2. Any person desiring to operate a primary hospital shall:
a) Apply to the appropriate organ for on forms prescribed forms;
b) Pay the prescribed license fee; and
c) Provide additional information or document upon written request by the
appropriate organ.
2.2.3. A person desiring to operate a primary hospital shall consult the appropriate
organ on the plant design conformity with this standard before starting
construction or renovation work.

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2.2.4. An application for the initial licensure of primary hospital shall be submitted to
the appropriate organ no later than sixty (60) days prior to the stated date of
operation.
2.2.5. The first pre-licensing inspection shall be conducted by the appropriate organ
upon application without service fee. In case of failure to comply with this
standard during the first pre-licensing inspection, the applicant has the right to
reapply not more than two times upon paying service fee. If the applicant fails to
comply with this standard for the third time, its application for licensure shall be
suspended for three months.
2.2.6. The application for a primary hospital license shall state each service for which
the applicant undertakes to furnish hospital care and the number of beds allocated
to each service, and shall furnish other information as may be required by the
appropriate organ including,
(a) Hospital location and address;
(b) Name and address of the applicant (if the applicant is an authorized
delegate, written delegation letter shall be submitted);
(c) Previous owner, license number for existing primary hospital;
(d) Name, qualification and address of the licensee/CCO;
(e) Total bed capacity;
(f) Surrounding environment/location;
(g) Number, type, work experience and original release of all technical staffs;
(h) Number of administrative staff;
(i) Physical plant/Hospital design and its description;
(j) Proposed use of idle space;
(k) CEO of the hospital;
(l) Chain organization (organizational structure);
(m) Owner of the building;
(n) Professional license and registration certificate of the licensee and all other
health professionals responsible for each service in the hospital;
(o) Any other requirements set by the Authority
2.2.7. An application for a license or change in service shall be denied if the applicant
cannot demonstrate that the premises, products, personnel and healthcare
services are fit and adequate in accordance with this standard.
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2.2.8. The appropriate organ shall consider an applicant's prior history in operating a
health care facility either in all the regional states of the country in making
licensure decision. Any evidence of licensure violations representing serious risk
of harm to patients shall be considered by the appropriate organ, as well as any
record of criminal convictions representing a risk of harm to the safety or welfare
of patients.

2.3. Initial/New Licensure

2.3.1. Every primary hospital shall have a separate license. The appropriate organ
shall issue each license in the name of the owner and chief clinical officer
only for the premises and person named as applicant in the application and
the license shall not be valid for use by any other person or at any place
other than the designated in the license.

2.3.2. A primary hospital license shall specify the following:

a. Name and address of the primary hospital;

b. The name and professional license and registration number of the
licensee;
c. Ownership of the primary hospital;
d. Name of the owner;
e. License number, issuance and expiration dates of the license;
f. Signature and stamp of the appropriate organ and
g. Notices/reminders prepared by the appropriate organ.

2.3.3. Prior to initial licensure of the hospital, the appropriate organ shall conduct an on-
site inspection to determine compliance with the applicable laws and standards
governing primary hospital.

2.3.4. The appropriate organ shall send a written report of the findings to the primary
hospital after the conclusion of the inspection. If the primary hospital complies
with the laws and standards, initial license valid for one year shall be issued to the
applicant.

2.3.5. A primary hospital with deficiencies shall correct them and submit written proof of
correction of deficiencies.

2.3.6. The appropriate organ shall deny the application for licensure to a primary hospital
that has not corrected deficiencies. The applicant shall reapply for licensure when
deficiencies are corrected.

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2.3.7. The appropriate organ shall conduct an on-site inspection of the primary hospital to
assess the hospital's continued compliance with the laws and standards governing
the hospital.

2.3.8. The appropriate organ shall issue a replacement license where the originally issued
license has been lost or destroyed upon the application supported by affidavit.

2.3.9. The original license shall be posted in a conspicuous place at reception at all times.

2.4. License Renewal Requirements

2.4.1. A license, unless suspended or revoked or under consideration in pending
case, shall be renewable annually and the primary hospital shall submit an
application for license renewal to the appropriate organ no later than sixty
(60) days before the expiration date of the current license.

2.4.2. Without prejudice to article 2.4.1;

(a) Subsequent to submitting renewal application, the owner shall pay

the prescribed license fee
(b) License renewal shall be made during the first quarter of each fiscal
year (Hamle 1 to Nehassie 30) based on routine inspection findings
over the year
(c) In case of failure to renew license within the prescribed period,
license may be renewed upon paying penalty (50% of renewal fee)
within one month
(d) In case of failure to renew license as per article 2.4.2 (c), license
shall be considered as cancelled

2.4.3. Every applicant who needs to renew a license shall:

(a) Apply to the appropriate organ in the prescribed form;

(b) Pay the prescribed license renewal fee; and
(c) Provide additional information or document upon written request by
the appropriate organ.
2.4.4. The appropriate organ may conduct background checks on the applicant or licensee
to determine its suitability or capability to operate or to continue operating a

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 health care facility. Background checks shall consist of, but not be limited to, the
following:

(a) Verification of licensure status;

(b) Verification of educational credentials;
(c) Verification of residency status;
(d) Verification of solvency; and
(e) Contacts with federal and State government officials to determine outstanding
warrants, complaints, criminal convictions, and records of malpractice actions.
2.4.5. The appropriate organ shall renew a license for a primary hospital in substantial
compliance with the applicable laws and this standard.

2.5. Removal Permits, Change of Operation and Forfeiture of License

2.5.1. No primary hospital or part thereof shall move from the premises for which a
license has been issued to any other premises without first having obtained from
the appropriate organ a permit to move to the premises not covered by the license
issued to the hospital.

2.5.2. Without the prejudice to article 2.5.1, permit in change of address shall
indicate the special conditions governing the moving of the primary
hospital or part of it as the appropriate organ may find to be in the interest
of the public health.

2.5.3. Without prior permission of the appropriate organ, change of owner

and/or licensee shall not be made.

2.5.4. The hospital shall inform the appropriate organ any change in operation or
professional. Change of operation means any alteration of services that is different
from that reported on the primary hospital's most recent license application.

2.5.5. The license shall not be assignable or transferable to any other person or
place without the prior approval of the appropriate organ and shall be
immediately void if the primary hospital ceases to operate, if its ownership
or licensee changes, or if it is relocated to a different site.

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2.5.6. When change of ownership of a primary hospital is contemplated, the hospital
shall notify the appropriate organ in writing and give the name and address of the
proposed new owner.

2.6. Suspension and Revocation of a License

2.6.1. The appropriate organ may suspend or revoke a license or order closure of
a service/ unit within the primary hospital or order removal of patients
from the hospital where it finds that there has been a substantial failure to
comply with this standard.

2.6.2. Without prejudice to grounds of suspension provided under relevant laws,

the appropriate organ shall suspend the license for 3 to 12 months in any of
the following grounds:

(a) Where the primary hospital is legally suspended;

(b) Where the primary hospital Fails to practice medical ethics;
(c) Where the primary hospital engages in rendering services which are
outside the scope of the hospital for which the license is obtained;
(d) Where the primary hospital fails to allow inspection pursuant to relevant
law and this standard;
(e) Where the primary hospital allows a practitioner, who has been
suspended by appropriate organ from practicing his profession;
(f) Where members of the Governing Board, the Chief Executive Officer, a
Chief Clinical Officer, department head, or other key staff member are
convicted of a serious offence involving the management or operation of a
primary hospital, or which is directly related to the integrity of the facility
or the public health or safety;
(g) Where the primary hospital fails to implement or fulfill comments and
corrections given by the appropriate organ;
(h) Where the primary hospital has shown any act which constitutes a threat
to the public health or safety;
(i) Where the primary hospital fails to observe laws relating to health
services and this standard;
(j) Where the primary hospital fails to submit relevant information
required under this standard.

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2.6.3. Without prejudice to grounds of revocation provided under relevant laws,
the appropriate organ shall revoke the primary hospital license from one to
two years on any of the following grounds;

a. Where the license is proved to have been obtained by submitting

false information;
b. Allows a practitioner, who is not licensed pursuant to the
appropriate law or who has been revoked by appropriate organ
from practicing his profession;
c. Where any of its permanent health personnel is found registered/
employed as a permanent staff in any other facility;
d. Where the faults referred to in Article 2.6.2 have been committed for
the second time;
e. Where the license is found transferred or rented to another person;
f. Where the primary hospital changes types of services, name,
address and the licensee without obtaining permission from the
appropriate organ;
g. Where the license is not renewed in accordance with section 2.4 of
this standard;
h. Where the primary hospital is legally closed or ceases operation;
i. Where the primary hospital is found operating while suspended by
appropriate organ;
j. Where the primary hospital is found operating outside the scope of
services stated under this standard;

2.6.4. At least 30 days prior to voluntary surrender of its license where approved by the
appropriate organ, or order of revocation, refusal to renew, or suspension of
license, the primary hospital must notify each patient and the patient's general
medical practitioner or other clinical practitioners the intended closure.
2.6.5. Each license in the licensee's possession shall be the property of the appropriate
organ and shall be returned to the appropriate organ immediately upon any of the
following events:
(a) Suspension or revocation of the license;

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 (b) Refusal to renew the license;
(c) Forfeiture of a license; or
(d) Voluntary discontinuance of the operation by the licensee.

2.6.6. If the appropriate organ determines that operational or safety deficiencies exist, it
may require that all admissions to the primary hospital cease. This may be done
simultaneously with, or in lieu of, action to revoke license and/or impose a fine.
The appropriate organ shall notify to the hospital in writing of such
determination.
2.6.7. The appropriate organ shall order and ensure in collaboration with appropriate
local health authorities the immediate removal of patients from the primary
hospital whenever it determines there is imminent danger to the patients’ health
or safety.
2.6.8. The license shall be returned to the appropriate organ within five (5) working
days from voluntary surrender, order of revocation, expiration, or suspension of
license.

2.6.9. The appropriate organ shall issue to the primary hospital a written
notification on reasons for denial, suspension or revocation of the license.

2.7. Right to Fair Hearing

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

2.8. Information to be Disclosed

2.8.1. Evidenced information received by the appropriate organ through inspection and
other true sources about the primary hospital shall be disclosed to the public in

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 such a way to indicate the public a decision maker or self regulator for its own
health.

2.8.2. Whenever public disclosure is necessary, the appropriate organ shall

forward inspection reports to the primary hospital at least 15 days prior to
public disclosure.

2.8.3. Any citizen has the right to obtain information on the official profile of services of
any licensed primary hospital from the appropriate organ.
2.8.4. Anyone who is interested in establishing a primary hospital shall have the right to
be provided with information concerning the standards required by the
appropriate organ at any working day.

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SECTION THREE: GOVERNANCE

3.1. Governing Board

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

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 (h) Establishing a means for effective communication and coordination among
the CEO, the medical staff and the various hospital departments; and
3.1.7. Minutes of the Board Meeting shall be recorded, signed, and retained in the
hospital as a permanent record.
3.1.8. The CEO shall be the secretary and non voting members of the Board.
3.1.9. The Board shall at least develop the following policies and procedures that are
revised at least every three years:
(a) For human resource management;
(b) For ensuring the hospital is smoke- free area;
(c) For the declaration of death of patients which shall accommodate the
patient’s religious beliefs with respect to declaration of death. Such policies
shall also include indicating the cause of death, medication given,
examinations done, and practitioner who cares of the patient.
(d) For transfer of dead body to its family. If a patient dies in the facility, the
body shall be handed over to the family within a day unless conditions
dictate otherwise.
(e) For visitation which shall be in the best interest of patients, including, but
not limited to, protection from communicable diseases, protection from
exposure to deleterious substances and hazardous equipment and assurance
of health and safety of patients.
3.1.10. The hospital shall develop and implement a complaint procedure for patients,
families, visitors, and others. The procedure shall include, at least, a system for
receiving complaints, a specified response time, assurance that complaints are
referred appropriately for review, development of resolutions, and follow-up
action.
3.1.11. There shall be an organizational chart of the primary hospital and each service
that shows lines of authority, responsibility, and communication between and
within services.
3.1.12. There shall be a formal mechanism for communication among the Board, CEO,
CCO and the necessary medical staff.
3.1.13. The primary hospital shall establish a mechanism for involving consumers in the
formulation of hospital policy and implementation of activities.

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 3.1.14. The Primary hospital shall develop and implement a complaint procedure
for patients, families, visitors, and others.

3.2. Chief Executive Officer

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

3.3. Chief Clinical Officer

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

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

3.4. Management Committee

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

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SECTION FOUR: PATIENT RIGHTS AND RESPONSIBILITIES

4.1. Informed Consent

4.1.1. Each primary hospital shall protect and promote each patient’s rights. This
includes the establishment and implementation of written policies and
procedures for the patient right.
4.1.2. For undertaking any type of procedures and treatments an informed consent
shall be required from the patient or patient’s next of kin or guardian.
4.1.3. An informed consent may not be required during emergency cases or life
threatening situations where the patient is not capable of giving an informed
consent and his or her next of kin or guardian is not available.
4.1.4. Unless provided by the law or this standard or by the hospital policies and
procedures that an informed consent shall be given in written form, an informed
consent of the patient can be given orally or inferred from an act. A written
consent shall be needed at least for the following:
(a) Surgery and invasive procedures;
(b) General anesthesia; and
(c) Blood transfusion.
4.1.5. The primary hospital shall comply with relevant laws, national and international
codes of ethics in the cases of vulnerable groups like children, women, geriatric
patients etc when someone other than the patient can give consent.
4.1.6. Patient consent forms shall be available in all applicable locations like areas
where surgery or invasive procedures are done
4.1.7. No photographic, audio, video or other similar identifiable recording is made of
without prior informed consent of a patient.
4.1.8. A primary hospital shall establish and implement a process to provide patients
and/or their designee an appropriate education to assist in understanding the
identified condition and the necessary care and treatment.
4.1.9. A primary hospital shall document its assessment of each patient's ability to
understand the scope and nature of the diagnosis and treatment needed.

20
 4.2. Patient Rights
Every primary hospital patient shall at least have the following rights,
4.2.1. To receive reasonable, respectful and safe access to health services by
competent personnel that the hospital is required to provide according to this
standard;
4.2.2. To receive treatment and medical services without discrimination based on
race, age, color, religion, ethnicity, national or social origin, sex, sexual
preferences, disabilities, diagnosis, source of payment or other status;
4.2.3. To retain and exercise to the fullest extent possible all the constitutional and
legal rights to which the patient is entitled by law;
4.2.4. To be informed of the names and functions of all general medical practitioners
and/or other clinical practitioners who are providing direct care to the patient.
These people shall identify themselves by introduction or by wearing a name
tag;
4.2.5. To receive, to the extent possible, the services of a translator or interpreter to
facilitate communication between the patient and the hospital's health care
personnel if the patient can not understand the working language;
4.2.6. To receive from the patient's general medical practitioner(s) or other clinical
practitioner(s) an explanation of his or her complete medical condition,
recommended treatment, risk(s) of the treatment, expected results and
reasonable medical alternatives in terms that the patient understands. If this
information shall be detrimental to the patient's health, or if the patient is not
capable of understanding the information, the explanation shall be provided to
his or her next of kin or guardian and be documented in the patient's personal
medical record;
4.2.7. To give informed, written consent prior to the start of specified nonemergency
procedures or treatments only after a general medical practitioner or other
clinical practitioner has explained specific details about the recommended
procedure or treatment, the risks involved, the possible duration of
incapacitation, and any reasonable medical alternatives for care and treatment
in terms that the patient understands. If the patient is incapable of giving
informed, written consent, consent shall be sought from the patient's next of kin
or guardian or through an advance directive, to the extent authorized by law. If

21
 the patient does not give written consent, a general medical practitioner or
other clinical practitioner shall enter an explanation in the patient's medical
record;

4.2.8. To refuse medication and treatment and to be informed of the medical

consequences of refusing treatment provided that he/she is mentally clear
except conditions which are threatening the public health. The primary hospital
shall develop a procedure on the management of the cases of patients who
refuse treatment.

4.2.9. To be informed if the primary hospital has authorized other health care and
educational institutions to participate in the patient's treatment. The patient
also shall have a right to know the identity and function of these institutions,
and may refuse to allow their participation in the patient's treatment;
4.2.10. To be informed by the attending general medical practitioner and/or other
clinical practitioner about any continuing health care requirements after the
patient's discharge from the hospital. The patient shall also have the right to
receive assistance from the general medical practitioner and/or other
appropriate hospital staff in arranging for required follow-up care after
discharge;
4.2.11. To receive sufficient time before discharge to have arrangements made for
health care needs after hospitalization;
4.2.12. To be informed by the hospital about any discharge appeal process to which the
patient is entitled by law;
4.2.13. To be transferred to another facility only for one of the following reasons, with
the reason recorded in the patient's medical record:
(a) The transferring hospital is unable to provide the type or level of medical
care appropriate for the patient's needs. The hospital shall make an
immediate effort to notify the patient's primary care general medical
practitioner or other clinical practitioner and the next of kin, and document
that the notifications were received; or
(b) The transfer is requested by the patient, or by the patient's next of kin or
guardian when the patient is mentally incapacitated or incompetent;

22
4.2.14. To receive from a general medical practitioner or other clinical practitioner an
explanation of the reasons for transferring the patient to another facility,
information about alternatives to the transfer, verification of acceptance from
the receiving facility, and assurance that the movement associated with the
transfer will not subject the patient to substantial, unnecessary risk of
deterioration of his or her medical condition. This explanation of the transfer
shall be given in advance to the patient, and/or to the patient's next of kin or
guardian except in a life-threatening situation where immediate transfer is
necessary;
4.2.15. To be treated with courtesy, consideration, and respect for the patient's dignity
and individuality i.e. the right to care that respects the patient’s personal
values and beliefs;
4.2.16. To be free from physical and mental abuse, neglect, sexual harassment, sexual
violence and exploitation;
4.2.17. To be free from chemical and physical restraints that are not medically
necessary, unless they are authorized by a attending physician or other
clinical practitioner for a limited period of time to protect the patient or
others from injury;
4.2.18. To have personal and physical privacy during medical treatment and personal
hygiene functions, such as bathing and using the toilet, unless the patient
needs assistance for his or her own safety. The patient's privacy shall also be
respected during other health care procedures and when hospital personnel
are discussing the patient;
4.2.19. To get confidential treatment. Information in the patient's records shall not be
released to anyone outside the hospital except the followings;
(a) If the patient has approved the request,
(b) If another health care facility to which the patient was transferred
requires the information,
(c) If the release of the information is required and permitted by law.
(d) If the patient's identity is masked, the hospital may release data about
the patient for studies containing aggregated statistics
4.2.20. To know the price of services and procedures;

23
4.2.21. To receive a copy of the hospital payment rates, regardless of source of payment.
Upon request, the patient or responsible party shall be provided with an
itemized bill and an explanation of the charges if there are further questions.
The patient or responsible party has a right to appeal the charges. The hospital
shall provide the patient or responsible party an explanation of procedures to
follow in making such an appeal;
4.2.22. To have prompt access to the information contained in the patient's medical
record as per the medical record section stated under this standard, unless a
general medical practitioner or other clinical practitioner prohibits such access
as detrimental to the patient's health, and explains the reason in the medical
record. In that instance, the patient's next of kin or guardian shall have a right to
see the record. This right continues after the patient is discharged from the
hospital for as long as a copy of the record is kept;
4.2.23. To obtain a copy of the patient's medical record, as per the standards set under
the medical record section of this standard.
4.2.24. To have access to individual storage space in the patient's room for the patient's
private use. If the patient is unable to assume responsibility for his or her
personal items, there shall be a system in place to safeguard the patient's
personal property until the patient or next of kin is able to assume responsibility
for these items;
4.2.25. To receive a medical certificate in English or Amharic or in a working language
of the place where the hospital is located;
4.2.26. To present his or her suggestion or grievances, without fear of retribution, to the
hospital staff member designated by the hospital to respond to questions or
grievances about patient rights and to receive an answer to those grievances
within a reasonable period of time without discrimination. The hospital shall
post the names, addresses, and telephone numbers of the government agencies
to which the patient can complain and ask questions.
4.2.27. To be given a summary of these patient rights, as approved by the appropriate
organ, and any additional policies and procedures established by the hospital
involving patient rights and responsibilities. The hospital shall be obliged to
ensure that,

24
 (a) The patient is informed of his or her rights during the admission
process;
(b) This summary include the name and phone number of the hospital or
hospital staff member to whom patients can complain about possible
patient rights violations;
(c) This summary is provided in the patient's native language if 10 percent
or more of the population in the hospital's service area speak that
language;
(d) A summary of these patient rights is posted conspicuously in the
patient's room and in public places throughout the hospital;
(e) Complete summary copies of the patient right is available at nurse
stations and other patient care registration areas in the hospital.
4.2.28. To be informed and participate in decisions relating to their care and
participates in the development and implementation of a plan of care and any
changes.

4.3. Patient Responsibilities

4.3.1. Every patient shall have the following responsibilities:

(a) To provide, to the best of the patient’s knowledge, accurate and
complete information regarding past medical history and issues related
to the patient’s health, including unexpected changes, to the health
professional responsible for the patient’s care;
(b) To follow the course of treatment and instructions proposed by the
general medical practitioner or other clinical practitioner or to accept
the consequences if treatment instructions is refused;
(c) To report any changes in his/her condition or anything that appears
unsafe to the responsible health professional;
(d) To be considerate of the rights of other patients and to respect their
privacy;
(e) To respect their caregivers;
(f) To fulfill the financial obligations as promptly as possible;

25
 (g) To keep all appointments and notify hospital or the appropriate person
when unable to do so;
(h) To observe the hospital policies and procedures, including those on
smoking, alcohol or drug addiction, cellular phones, noise and visitors;
(i) Be considerate of the hospital facilities and equipment and to use them
in such a manner so as not to abuse them;
(j) Not to litter the hospital premises.

(k) To sign on “Against Medical Advice Notice” if he / she refuses the

recommended treatment or intervention.

4.3.2. The list of a patient’s rights and responsibilities shall be posted at various
places of the primary hospital premises.

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 SECTION FIVE: HUMAN RESOUCE MANAGEMENT

5.1. General Requirements

5.1.1 The hospital shall have Human Resource Department (HRD) or focal person
which carries out the major functions of Human Resource Management (HRM).
5.1.2 Each service units of the hospital shall maintain a sufficient number of staff with
the qualifications, training and skills necessary to meet patient needs as per this
standard.
5.1.3 All recruitment and selection shall follow consistent approach using the
recruitment and selection manual approved by the hospital management/
governing board.
5.1.4 No health professional shall practice his/her profession in the hospital without
having professional license from the appropriate organ. The hospital shall
ensure that all health professionals recruited by the hospital are licensed as per
the registration and licensing requirement of the appropriate organ.
5.1.5 Each hospital shall ensure and maintain evidence of current active licensure,
registration, certification or other credentials for employees and contract staff
prior to staff assuming job responsibilities and shall have procedures for
verifying that the current status is maintained.
5.1.6 Whenever a licensed healthcare professional is terminated as a result of a job-
related incident, the hospital shall refer a report of the incident to the
appropriate organ.
5.1.7 Every health professional shall report to the hospital whenever he/she is
infected with contagious diseases. The hospital shall also establish a mechanism
for screening health professionals with contagious diseases. The health
professional shall not practice his/her profession during the period of such
infection and his/her rights provided under the relevant employment law and
the hospital’s HR manual shall be respected.
5.1.8 Each person involved in direct patient care shall have an occupational
health screening by a physician or other qualified health professional
prior to entering active status and at least once every five (5) years
thereafter. A health professional shall not conduct health examination for
himself/ herself.

27
 5.1.9 Each health screening shall include a medical history, physical examination, and
any indicated laboratory work and investigations.
5.1.10 A report, signed by an examining physician or other qualified health
professional, shall be made of each examination.
5.1.11 The report of each examination shall be kept on file in the hospital and shall be
open to inspection by the appropriate organ.
5.1.12 Each person who is involved in direct patient care and who acquires notifiable
illness shall, prior to returning to duty, obtain certificate of fitness, as provided
in the hospital's policies, that he or she may return to duty without apparent
danger to any patient.
5.1.13 Immunization against communicable disease shall be required of all employees
and all other persons who routinely come in contact with patients or patient
areas. Immunizations shall be in accordance with the current national
immunization guidelines.
5.1.14 Each hospital shall maintain a current employment record for each staff. The
record shall contain, at a minimum, information on credentials, health
examination (fitness for duty), work history, current job description, evidence of
orientation, in-service education/training and copies of annual evaluation

5.1.15 All health professionals shall abide with health professionals Code of
conduct and respective scope of practice.

5.1.16 There shall be a policy or procedures for all health professionals to report
any suggestive signs of child abuse, substance abuse and /or abnormal
psychiatric manifestations by the patients under their care.

5.2. Staffing Plan

5.2.1. The hospital shall avail as a minimum the staff requirement stated under this
standard.
5.2.2. A staffing plan shall be developed collaboratively by the different service units
and management, which identifies the number and types of the staff
5.2.3. The planning process shall use recognizable process for estimating the staffing
need like Workload Indicator for Staffing Need (WISN) method.
5.2.4. The staffing plan shall be reviewed on an ongoing basis and updated as
necessary

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5.2.5. The staffing plan shall define the following elements:

(a) The total number and types of staff needed for the hospital as a whole and
for each service unit
(b) The total number and types of staff currently available for the hospital as a
whole and each service unit
(c) The required education, skills, knowledge, and experience required for each
position
(d) The process and time period for reviewing and updating the plan shall be
indicated. (The plan is periodically reviewed and updated as required, but it
shall be done at least every two years.)
(e) Expected workload
5.2.6. The primary hospital shall have at least the following summary of
professionals and staffing:

Professionals required Minimum number required

CEO 1
MD (licensee) 1
MD 3
Emergency surgical officer 1
HO 2
Nurses (BSc) 5
Midwives 4
Nurse (Diploma) 20
BSc anesthetist/nurse anesthetist 2
Ophthalmic nurse 1
Psychiatric nurse 1
Dental professional 2
Radiology professional 1
Radiographer 2
Physiotherapist 1
Laboratory technologist 4
Laboratory technician 2
Pharmacist 4
Pharmacy technician (Druggist) 2
Environmental Health 1
Health Information 1
Cleaners 15
Reception/Archive 8

29
 Maintenance officer (plumbing, electricity, 3
general maintenance services)
Medical equipment maintenance technician 1
Food and dietary 10
Morgue attendant 1
Social workers 1
Compliant handling officer 1

5.3. Job Description and Orientations

5.3.1. All staffs shall be provided with current written job descriptions and be oriented
to their specific job responsibilities at appointment
5.3.2. The job description shall include the title and grade of the position, specific
function of the job, job requirement, reporting mechanism, evaluation criteria
and description of job site and work environment.
5.3.3. The orientation program for all employees shall include three levels of
orientation: hospital wide, service unit and job specific:
5.3.4. Orientation to hospital structure and administration shall be provided by
hospital management.
5.3.5. Orientation to hospital policies, including all environmental safety programs,
infection control, and quality improvement shall be provided
5.3.6. Staff members who are not licensed to independently practice shall have their
responsibilities defined in a current job description.
5.3.7. Each hospital shall provide and maintain evidence of an orientation program for
all new staff and, as needed, for existing staff who are given new assignments.
The orientation program shall include:

(a) Job duties and responsibilities

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

30
5.4. Staff Education
5.4.1. The hospital shall ensure that staffs receive training in order to perform
assigned job responsibilities.
5.4.2. Each staff member shall receive ongoing Continuing Professional Development
(CPD) to maintain or advance his or her skills and knowledge
5.4.3. The CPD shall be relevant to the setting in which they work as well as to the
continuing advancement of the hospital
5.4.4. The hospital shall decide the type and level of training for staff in accordance
with National CPD guideline and then carry out and document a program for
this training and education.
5.4.5. The hospital shall provide and maintain evidence of CPD for staff. A record shall
be maintained including dates, topics and participants
5.4.6. The hospital shall periodically tests staff knowledge, skill and attitude through
demonstration, mock events and other suitable methods. This testing is then
documented

5.5. Medical Staff

5.5.1. Any medical service shall be organized under the directorship of a senior
licensed professional stated under this standard..
5.5.2. The medical staff shall be responsible to the governing authority for medical
care and treatment provided in the hospital in accordance with the standards
stipulated under the hospital administration and shall:
a) Participate in a Quality Assurance/Performance Improvement program to
determine the status of patient care and treatment;
b) Abide by hospital and medical staff policies;
c) Establish a disciplinary process for infraction of the policies
5.5.3. The medical staff shall see that there is adequate documentation of medical
events by a review of discharged patients that shall insure that medical records
meet the required standards of completeness, clinical pertinence and
promptness or completion of following discharge

31
 5.5.4. The medical staff shall actively participate in the study of hospital associated
infections and infection potentials and must promote preventive and corrective
programs designed to minimize their hazards
5.5.5. There shall be regular medical staff meetings to review the clinical works of the
members and to complete medical staff administrative duties
5.5.6. The hospital shall have general medical practitioner available on the premises
during working hours. The general medical practitioner on call shall be duty
bound to respond to calls.
5.5.7. Each patient shall be under the care of a physician or health officer, regardless of
whether the patient is also under the care of an allied health professional
practitioner authorized to practice.

5.6. Employee’s Health

5.6.1. The hospital shall institute systems and processes that minimize employees’
risks, protect employees and provide access to care when needed.
5.6.2. A comprehensive Occupational Health and Safety (OHS) program shall have the
following components:
a) Staff dedicated to coordinate OHS activities
b) Policies and Procedures that define components of the program
c) Training for staff on program components
5.6.3. The hospital shall have a full-time designated qualified individual (occupational
health and safety officer) to coordinate and develop the hospital’s occupational
health and safety activities.
5.6.4. The standards outlined below define the core elements of an OHS program and
specify minimum requirements needed to address OHS issues.
a) The hospital shall have an occupational health and safety policy and
procedures in place to identify, assess and address identified health and
safety risks to staff and prevent those risks that will potentially
compromise their health and safety.
b) The hospital assesses and documents safety risks through formalized,
structured assessments that are done at regular intervals.

32
 c) The assessments shall be logged in some format—for example a register
or report
d) The information gathered from the assessment shall be documented and
reported to the management (management committee and boards).
e) Interventions shall be designed and implemented to address the risks
that are identified.
5.6.5. The hospital shall establish a means of communicating to staff their risks and
prevention measures or interventions.
5.6.6. The hospital shall regularly monitor its occupational health and safety activities
to assess how effective it has been in reducing risk.
5.6.7. The hospital shall have written policies and procedures to manage manual
handling risks.
5.6.8. The hospital shall have written policies and procedures which define how
harassment, physical violence and/or aggression against staff (from patients,
caregivers, other staff etc) are addressed.
5.6.9. The hospital shall provide services to staff to minimize work-related stress.
5.6.10. The hospital shall ensure all employees have access to full pre-employment
health screening, covering Hep B (including other relevant vaccine), TB status
and are declared fit for their respective roles prior to employment. This shall
include having:
a)Written instructions for health care workers to follow in notifying the
hospital’s administration of infectious status.
b) Documentary evidence of vaccination records for all health care workers
employed, including Hep B status for all health care workers who
perform exposure-prone procedures. All staff are tested for and
vaccinated against Hep B, if there is no evidence of previous vaccination
produced.
5.6.11. The hospital ensures that all employees are provided with immunization
services to protect against infectious/communicable diseases.
5.6.12. The hospital shall have a program in place to address injuries that could lead to
the transmission of blood-borne viruses (needle stick and other injuries). The
program shall include:
a) Measures to prevent needle stick and other injuries

33
 b) Training on infection prevention techniques
c) Sharps risk reduction
d) Provision of post-exposure prophylaxis
e) Working hours and duty hours
5.6.13. The hospital shall provide personal protective equipment (please refer to
standards for Infection Prevention and Control and Sanitation)
5.6.14. The hospital shall provide the following facilities to employees
a) Cafeteria
b) Break room (equipped with a television and other recreational
equipment)
c) Green area
d) Library (equipped with books and computers with internet as
appropriate)
e) Adequate toilet and shower facilities

5.7. Dress Code and Identification Badge

For areas involving direct patient contact
5.7.1. Footwear shall be safe, supportive, clean, and non-noise producing.
5.7.2. No open toe shoes shall be worn.
5.7.3. Artificial nails are prohibited. Natural nails must be kept short and jewelry must
be kept to a minimum.
5.7.4. Hair must be worn in a way that prevents contamination and does not present a
safety hazard
5.7.5. The dressing shall not interfere in any way the service provision
5.7.6. The hospital shall specify a particular style and/or color of uniform with
different style/color code; separate for each human resource category.
5.7.7. The employee shall keep the uniform neat, wrinkle free and in good repair
5.7.8. The hospital shall be responsible for providing employee identification badges
5.7.9. The identification badge shall be worn at all times while at work and be easily
visible, with name, profession and department facing outward.

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35
 SECTION SIX: SERVICE STANDARDS

6.1. Outpatient Services

6.1.1 Practices
6.1.1.1 The hospital outpatient service shall provide the following core functions:
(a) Care of ambulatory patients
(b) Examination and management of preadmission patients
(c) Follow up of discharged and ambulatory patients
(d) Basic ENT, Dental, Eye, and Mental health services
(e) Pharmacy
(f) Laboratory, X-ray and other diagnostic services
6.1.1.2 The hospital shall have an outpatient central triage system
6.1.1.3 The outpatient services shall comply with the standards prescribed under
patient rights and responsibilities standard
6.1.1.4 The outpatient service shall have policies and procedures regarding access,
availability of service and networking and it shall include the followings
(a) The outpatient service shall be available in working days for at least
eight hours a day
(b) The hospital may have a system for providing after-hour (non-working
hour) follow up service.
(c) The outpatient service shall have consultation, and functional intra
and inter facility referral system which include at least:
 SOP for selection of cases for referral
 Procedure for referring and receiving referral
 List of potential referral sites with contact address (referral
directory)
 Referral forms
 Referral tracing mechanism (linkage)
 Feedback providing mechanism
 Documentation of referred clients
 Consultation forms

36
 6.1.1.5 There shall be medical assessment at outpatient services and includes;
(a) Comprehensive medical and social history
(b) Physical examination including at least:
 Vital sign (BP, PR, RR, To), weight and pain assessment
 Clinical examination pertinent to the illness
(c) Diagnostics impression
(d) Laboratory and other medical workups when indicated.
6.1.1.6 The outpatient clinic shall have clinical protocols for management of at least
common disease and locally significant diseases in line with the national and
or international guidelines.
6.1.1.7 The range of treatment options and the clinical impression shall be fully
described to client and/or their families and documented accordingly
6.1.1.8 With regard to quality assurance and transparency
(a) The hospital outpatient clinic shall collect feedback from clients
(b) The outpatient clinic shall have formal administrative channel through
which clients place their complaints and grievances
6.1.2 Premises
6.1.2.1 The outpatient layout shall include the following:
a) Dedicated entrance
b) Waiting area with toilet (flushing or VIP) separate for male and female
c) Reception and recording area/desk
d) Dedicated patient examination rooms
e) Room for minor procedures
f) Room for providing injections
g) Storage place for sterile supplies
h) Utility room for cleaning and holding used equipments and disposing
patients specimen
i) Staff room (for changing cloth)
j) Janitors closet
6.1.2.2 All rooms shall have adequate light, water and ventilation
6.1.2.3 The room arrangements of outpatient services shall consider proximity
between related services

37
 6.1.2.4 The outpatient clinical setup shall have easy access to pharmacy, laboratory
and other diagnostic services.
6.1.2.5 The medical service unit shall have at one isolation room for treatment of
conditions that require isolation
6.1.2.6 The outpatient clinic shall be well marked and easily accessible for persons
with disability, elderly patients, under five children and pregnant mother
6.1.2.7 The outpatient service shall be located where access for ambulatory patients
is the easiest and where in coming client would not have to pass through
other care service outlets ( in- patient , laboratory etc )
6.1.2.8 The outpatient clinics shall have IEC and entertaining materials in the
waiting area
6.1.2.9 The outpatient examination rooms shall promote patient dignity and
privacy.
6.1.2.10 The outpatient clinics shall have fire extinguishers placed in visible area
6.1.2.11 Glass doors shall be marked to avoid accidental collision
6.1.2.12 Potential source of accidents shall be identified and acted upon (slippery
floors , misfit in doorways and footsteps)

6.1.3 Professionals
6.1.3.1 The general outpatient services shall be directed by a licensed general
medical practitioner.
6.1.3.2 The hospital shall have the following licensed professionals
a) General practitioner
b) Health officer
c) Nurse
d) Ophthalmic nurse or cataract surgeon
e) Laboratory technologist and laboratory technicians
f) Pharmacists and pharmacy technician.
g) Bachelor of Dental Sciences (BDSc) and Dental Therapist
h) Cleaners, porters/ runners
i) The actual number of clinician shall be determined by the workload
analysis

38
6.1.4 Products
6.1.4.1 The outpatient service shall have the following materials and equipments:
a) Stethoscope
b) Sphygmomanometer
c) Thermometer
d) Weighing scale
e) Infant meter and height scale
f) Otoscope
g) Minor surgical set
h) Specula of different sizes
i) Stand lamp
j) Reflex hammer
k) Fetoscope
l) Snellen’s chart
m) Ishara color test
n) Ophthalmoscope
o) wheelchairs,
p) Sterilization drum with stand
q) Infusion stand
r) Sterilizer (steam and dry)
s) Kidney basin
t) Reflector and or Head light
u) Light Torch
v) Nasal speculum, (Adult and pediatric size)
w) Tuning forks , 500Hz
x) Packing nasal forceps,
y) Resuscitation kits,
z) Examining coach Enema set
aa) Oxygen cylinder with regulator
bb) Splint and wires
cc) Stretcher mobile type
dd) Antiseptic solutions

39
 ee) Plasters
ff) NGT different size
gg) Catheter
hh) Closets and shelves

6.2. Inpatient services

6.2.1 Practices
6.2.1.1 The inpatient service delivery shall comply with the patient rights standard
6.2.1.2 The inpatient service shall be available 24 hrs of a day and 365 days a year.
6.2.1.3 The inpatient service shall have consultation and functional intra and inter
facility referral system as prescribed under the outpatient service standards.
6.2.1.4 The inpatient service shall include at least the following services for
admitted patients:
a) Taking comprehensive medical and social history, comprehensive
physical examination and performing relevant laboratory & other
medical workups upon admission and when indicated.
b) 24 hours nursing care services
c) Detailed round visits at least twice a week and daily business round by
the attending general practitioner or health officer
6.2.1.5 The hospital shall prepare and implement written policy for inpatient visit
6.2.1.6 The inpatient nursing care shall comply with the nursing service standard
6.2.1.7 The inpatient service shall have clinical protocols for management of at least
common causes of admission in the hospital
6.2.1.8 The hospital shall have a system to make follow up of patients by the same
general medical practitioner/health officer
6.2.1.9 The range of treatment options, plans and the clinical impression shall be
communicated to client and/or their families and documented accordingly
6.2.1.10 The inpatient service shall have quality improvement mechanisms that at
least constitute:
a) Collecting Feedbacks from clients
b) Preparing a formal administrative channel through which clients place
their complaints and grievances

40
 c) Conducting regular morning sessions among health professionals across
all clinical disciplines at least three times a week
6.2.1.11 The hospital shall have written protocol for admission and discharge.
6.2.1.12 The hospital shall provide dietary service for patients who are admitted as
per dietary service standards
6.2.1.13 The hospital shall provide a clean gown to admitted patients
6.2.1.14 The hospital shall secure the properties of admitted patients in a cabinet or
room with shelves
6.2.1.15 The inpatient service shall have access to pharmacy , laboratory and other
diagnostic services as per their respective standards
6.2.1.16 Other services that support the inpatient service such as power supply,
water supply, telephone, etc shall be available all the time.
6.2.1.17 Religious support shall be provided for admitted patients upon patient
request and this shall not disturb the privacy, dignity and right of other
admitted patients.
6.2.1.18 The inpatient service shall arrange the appropriate post discharge
instructions and follow up for the patient.
6.2.1.19 The hospital shall provide morgue service as per morgue service standard
6.2.1.20 The hospital shall contact the municipality or responsible body for burial
service if there is no family/guardian of the deceased.
6.2.1.21 The hospital shall handle medical emergencies including meningitis
epidemics, epilepsy and seizure.

6.2.2 Premises
6.2.2.1 The primary hospital shall have a minimum of 35 beds capacity including
maternity beds
6.2.2.2 The room used for admission shall have an area calculated using the
following table and specifications unless otherwise stated in a specific
service of this standard:
Number of beds per room Area (m2)
1 9.3
2 17.2

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 3 25.8
4 36.4
5 43.0
6 51.6
(a) Distance of bed from fixed walls shall be 0.9 m
(b) Distance between beds shall be 1.2 m
(c) Bed width shall be 1m
(d) Bed length shall be 2m
(e) In case of multiple beds, area per bed shall be 8.6m2
6.2.2.3 The hospital shall have separate rooms for female and male patients.
6.2.2.4 The hospital shall have separate room for children under the age of 13 years.
6.2.2.5 The inpatient service of the hospital shall have an isolation room.
6.2.2.6 There shall be separate staff and patient toilet and inpatient room shall have
easy access to the toilet.
6.2.2.7 There shall be duty rooms separate for female and male with personal
lockers.
6.2.2.8 The inpatient rooms shall have safe and continuous water supply, light and
ventilation.
6.2.2.9 There shall be hand washing basins for each room.
6.2.2.10 The inpatient service shall have a nursing station/room that provides space
for chart handling and medication preparation
6.2.2.11 Store and utility room
6.2.2.12 Each bed room shall have alarm
6.2.2.13 The inpatient service shall have easy access to other services: laboratory,
pharmacy services
6.2.2.14 Patient toilets and showers with proximity to the ward, or covered
walkways to the ablution facilities.
6.2.2.15 Nurses’ station
6.2.2.16 Inpatient ward clean utility room (procedure room) shall be available with
the following;
 Dressing trolleys,
 procedure beds,

42
  Deep Sink,
 Hand washing basin,
 Worktable with laminated top,
 Cabinets and shelves,
6.2.2.17 Inpatient ward soiled utility room with shelves and leak proof containers
with leads shall be available
6.2.2.18 Inpatient ward cleaner’s room shall be available with the following

6.2.3 Professionals
6.2.3.1 The inpatient services shall be directed by a licensed general medical
practitioner
6.2.3.2 The primary hospital shall also have health officer and nurses for inpatient
services
6.2.3.3 One nurse for a maximum of six patients shall be available to provide
nursing care services.
6.2.3.4 Support staff such as runner and cleaner shall be available for 24 hrs a day
6.2.3.5 Actual number of professionals shall be determined based on the case load
analysis of the hospital
6.2.3.6 Technicians for equipment maintenance and general maintenance (power
supply, water supply, drainage system) shall be available during working
hours and shall be also available either on duty or on call basis during non
working hours as per housekeeping standards.

6.2.4 Products
6.2.4.1 Each bed shall have wheels for easy movement and be reclining,
6.2.4.2 Medicines including emergency drugs as per the drug list of the hospital
shall be available
6.2.4.3 Also the following products shall be available:
(a) Bed pans
(b) Urinal (male and female)
(c) Bed pan carriage (trolley)
(d) Bed pan washer & sterilizer
(e) Bed pan Rack

43
 (f) One chair and bed side cabinet per bed
(g) Folding screens
(h) IV (drip) stand for each bed
(i) Safety box and dust bins as per the infection prevention standard
(j) Patient stretcher mobile type
(k) Medication Cup board
(l) Examination light
(m)Diagnostic Set
(n) Refrigerator
(o) Instrument Sterilizer
(p) Vital sign set
(q) Patient chart
(r) Vital sign chart
(s) Instrument and medication trolley
(t) Suction machine
(u) Resuscitation set
(v) Side cabinet,
(f) Feeding table,
(g) Chair,
6.2.4.4 The hospital shall have medicines and consumables as per the national
medicines list of Ethiopia prepared for primary hospital.

44
6.3. Maternal and Child Health (MCH) and Delivery Services

6.3.1 Practices
6.3.1.1 The hospital shall provide delivery services 24 hours a day and 365 days a
year.

6.3.1.2 Non emergency maternal health services shall be available during regular
working hours at MCH clinics.

6.3.1.3 The primary hospital shall provided MCH services during regular working
hours which includes:

a) ANC and PMTCT services:

 Routine assessment of pregnant women, and lab investigation
services according to the national protocol,
 Close follow up of identified high risk mothers and referral,
 Provision of counseling and health education for pregnant women,
b) PNC services:
 Identification and management of complication after deliveries,
c) Immunization service:
 Routine outreach EPI,
 Cold chain management- maintenance of effectiveness of vaccines,
d) Growth monitoring services:
e) Sick baby clinic/ under five clinic services:
f) Comprehensive Family planning services:
 Counseling on and provision of oral contraceptives,
 Counseling, assessing and provision of injectables and inplants,
 Counseling on and insertion of IUCD,
 Mini-laparatomy for tubal ligation,
 Comprehensive abortion care: Manual Vacuum Aspiration,
Evacuation and curettage as per the country’s law,

6.3.1.4 Basic emergency obstetric care shall be available 24 hours a day, 365 days a
year at primary hospital

45
 6.3.1.5 The primary hospital shall have comprehensive essential obstetric care
including the following:
a) Administration of parenteral sedatives for eclampsia, parenteral
Oxytocin, antibiotics, anticonvulsants and anesthesia service.
b) Manual removal of placenta and retained products following
miscarriage or abortion.
c) Providing assisted deliveries: forceps delivery, vacuum delivery,
destructive delivery and emergency Caesarean Section.
d) Providing basic neonatal life support.
e) Blood transfusion.
f) Repair to perineal tears.
6.3.1.6 The primary hospital shall have the following basic essential gynecologic
care services:
a) Vaginal bleeding management
b) Emergency surgical intervention/ Laparatomy for ectopic
pregnancy, pelvic peritonitis and abscess, ruptured uterus, ovarian
cyst torsion and uterine perforation.
c) Pelvic infection or abscess management

6.3.1.7 The hospital shall provide Essential newborn care:

a) New born resuscitation care shall be available 24 hours a day, 365

days a year.
b) There shall be written policies and procedures for transfer &/ or
referral of neonates.
c) Routine examination for detection of congenital anomalies.

6.3.2 Premises
6.3.2.1 The hospital shall have separate MCH service unit with the following
minimum requirements:
a) Two room for ANC/ PMTCT, PNC services:
b) One room for Immunization service, with Cold chain room/corner,
c) One room for Growth monitoring services, Sick baby clinic/ under
five clinic services:
d) Two rooms for Family planning services,

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 e) Waiting area with shade,
f) The MCH rooms shall respect the privacy and dignity of clients,

6.3.2.2 The hospital shall have separate rooms for delivery service with the
following minimum requirements:
a) One room for laboring (prenatal room),
b) One room for Delivery (second stage room),
c) One room for maternity (post natal room),
d) Hand washing basin in each room,
e) Toilet room with shower facility, inside or adjacent to the ward.
f) allows easy access to operation theatre
g) The prenatal and post natal rooms shall each be with a capacity to
accommodate a minimum of two beds,
h) Single entrance to control access.
i) There shall be free area reserved for neonatal resuscitation in the
labor ward,

6.3.2.3 The delivery room shall respect the dignity and privacy of laboring mothers;
Curtain tracks shall be installed around each bed, or in their absence bed
screens shall be provided.
6.3.2.4 The hospital shall have separate admission room for obstetric patients.
6.3.2.5 There shall be a separate nurse station close to delivery room,

6.3.3 Professionals
6.3.3.1 The MCH and delivery services shall be directed by a licensed post basic BSc
midwife
6.3.3.2 The hospital shall have adequate number of midwives or experienced
clinical nurses for MCH and delivery service
6.3.3.3 The emergency obstetrics and gynecology services shall be rendered by a
licensed emergency surgical officer.
6.3.3.4 There shall be qualified nurses available 24 hours a day and 365 days a year
for MCH and delivery services.

47
6.3.4 Products
6.3.4.1 The MCH service shall have the following equipments:
a) Examination coaches i) Otoscope
b) Gynecologic coaches j) Fetoscope
c) Stethoscope k) Stand lamp
d) Sphygmomanometer l) Refrigerator
e) Thermometer m) Cold chain boxes
f) Weighing scale, Adult
g) Specula of different size
h) Infant meter and height scale

6.3.4.2 The Delivery service have the following equipments:

a) Delivery coaches o) Stand lamp
b) Stethoscope p) Refrigerator
c) Sphygmomanometer q) Autoclave
d) Fetoscope r) Infusion stand
e) Thermometer s) Instrument tray
f) Weighing scale, Adult t) Instrument trolley
g) Weighing scale, Baby u) Sterilizer (steam and dry
h) Specula of different size v) Baby crib
i) Episiotomy set w) Pickup forceps with jar
j) Delivery sets x) Vacuum extractors
k) Delivery forceps y) Suction apparatus
l) Measuring tape z) Laparatomy sets
m) Infant meter and/or height aa) Caesarian section sets
scale bb) Resuscitation set
n) Suction, manual cc) Craniotomy set

48
6.4. Surgical Services

6.4.1 Practices
6.4.1.1 The surgical service shall be directed by Emergency Surgical Officer.
6.4.1.2 Emergency obstetric and surgical service shall be available 24 hours a day,
365 days a year,
6.4.1.3 The hospital shall make sure the emergency obstetric and surgical services
is available, staffed with the necessary technical staff, equipped with all the
necessary facilities including emergency transfusion, transportation, and
electric back up.
6.4.1.4 Services for non-emergency elective surgical cases shall be restricted to
minor procedures.
6.4.1.5 There shall be written protocols and procedures for admissions and
discharges with follow up.
6.4.1.6 There shall be protocols for the management of the emergency obstetric and
surgical conditions in the hospital.
6.4.1.7 The admission process for emergency obstetric/ surgery shall be in
consultation with the trained GP/HO on emergency surgery.
6.4.1.8 Surgical records shall be kept for each patient and it shall be integrated with
the patient's over-all hospital record.
6.4.1.9 All emergency surgical procedures shall be performed only after appropriate
history, physical examination, and indicated diagnostic tests are completed
and documented in the patient’s medical record.
6.4.1.10 The preoperative diagnosis shall be recorded in the medical record for all
patients prior to surgery.
6.4.1.11 The patient shall get explanation on the disease condition, possible surgical
intervention and outcome possibilities in clear, simple and understandable
terms.
6.4.1.12 Written informed consent shall be obtained for any surgical intervention
and this must be documented in the patient’s medical record. For the case
with life threatening condition, consent shall be obtained from spouse,
family, guardian.

49
6.4.1.13 The nursing care of patients undergoing emergency surgery shall be planned
and documented in the medical record, directed by attending nurse, and
includes the following:
a) Pre-operative care,
b) Post-operative care and monitoring needed,
c) Pain management
6.4.1.14 Emergency operation reports shall be written in the patient’s record and in
the OR registration book immediately after surgery and include at least the
following:
a) Patient identification,
b) Pre-operative diagnosis,
c) The procedure performed,
d) Findings during surgery,
e) Post-operative diagnosis,
f) Date and time operation started and ended,
g) Name of emergency surgeon, anesthetist or nurse anesthetist, scrub
nurse, and any assistant,
h) Signature of the emergency surgeon, anesthetist and the scrub nurse
on operation note
i) Immediate post-operative orders explicitly in the order sheet
including pain management.
6.4.1.15 There shall be processes and policies defining the appropriate safety before,
during and immediately after surgery, including at least the following:
a) Aseptic technique,
b) Sterilization and disinfections,
c) Selection of draping and gowning,
d) Counting of sponges, instruments and needles
6.4.1.16 There shall be a policy for preparing and availing appropriate and properly
functioning supplies, equipment, and instruments available for emergency
surgery.
6.4.1.17 There shall be a protocol for patient transfer from operation theatre to in
patient ward. This includes;

50
 a) The handover and/or transfer of immediate post-operative patients
shall be done between the anesthetist who administered the
anesthesia and the nurse in charge of inpatient ward,
b) The nurse in the ward shall immediately re-evaluate the condition of
the patient when arriving in the ward,
c) The follow up of immediate post-operative patients in the ward shall
be done by the ward nurse and inpatient attending general medical
practitioner or health officer according to the order and shall be
documented accordingly.
6.4.1.18 Post- operative patient in the wards shall get post operative care by ward
nurses. The post operative care includes to the minimum:
a) Follow up of vital signs and carrying out of post-operative orders
shall be done as per the order specified for individual patients.
b) Evaluation by the Emergency surgical officer or appropriate general
medical practitioner or health officer daily or whenever needed.
6.4.1.19 The hospital shall have clear protocol for minor surgical procedures to be
done at outpatient level. Examples: Circumcisions, lipoma excisions, abscess
drainages, suturing of soft tissue injuries, etc.
6.4.1.20 There shall be a policy that shows the emergency surgery trained GP or HO
shall be on duty to respond for emergency surgical interventions.
6.4.1.21 There shall be a mechanism that the duty emergency surgery trained GP or
HO shall be available within 30 minutes upon call.
6.4.2 Premises
6.4.2.1 A primary hospital shall have one operating room.
6.4.2.2 The OR shall be composed of one standard operation theatre, central
sterilization room (CSR), and changing rooms with lockers, toilets and
showers, store room, clean and dirty utility rooms, cleaners room and duty
room.
6.4.2.3 Operation room shall have access- restricted environment where emergency
obstetric surgical interventions are performed. It shall be organized and
equipped so that OR trafficking shall be controlled and exercised over all
persons and materials entering and leaving the area.
6.4.2.4 Operation Theatre shall have:

51
 a) Standard size, with one operation table.
b) Washable walls; the vicinity of plumbing fixtures shall be smooth
and water resistant i.e., ceramic plated up to the ceiling.
c) Monolithic, scrub-able ceiling and capable of withstanding chemicals.
Cracks or perforation in these ceilings are not allowed.
d) Tightly sealed floors and walls if penetrated by pipes, ducts and
conduits,
e) Smooth Floor, easily cleanable, non-slippery and non-staining, which
shall not be affected by water or germicidal cleaning solutions;
preferably made of marble or ceramic.
f) Drainage on the floor,
g) At least four fixed electric outlets with cover,
h) self-closing doors for the entrance,
i) one mobile operation light,
j) Glass cabinet and shelf for storing suture materials and other
supplies,
k) The OR shall be cleaned immediately after every operation and
thorough cleansing weekly even if not used frequently.
l) Heater / or air-conditioner fixed on the wall shall be available in the
theatre
m) Orientation and continuous training shall be provided for cleaners
and porters for proper handling and disposal of sharp materials and
surgical wastes by OR nurse coordinator or via IP committee.

6.4.2.5 Scrub area:

a) This area shall have direct access to the operating theatre,
b) There shall be a scrubbing-up area outside but adjacent to the
operating theatre(s).
c) It shall be provided with wide sink and taps for running water. The
taps for running water for scrubbing shall be hand free to be
manipulated with elbow or knee. (e.g., long arm of valve gate to be
manipulated with elbow or knee joint.)
6.4.2.6 Nurse station/ Patient Transfer Area:

52
 a) This area need not be a room, but may form an integral part of the
main patient corridor, recovery area or bed-receiving area.
b) There shall be a corridor or allocated area for keeping charged and
empty Oxygen cylinders; the empty and charged oxygen cylinders
shall be labeled clearly,
c) Provided with a chair and table for OR staff,
d) This area shall be large enough to allow for the transfer of patients
from a bed to OR stretcher.
e) A line shall be clearly marked in red on the floor, beyond which no
person shall be permitted to set foot without putting on protective
clothing and OR shoes (OR attire).
6.4.2.7 Staff Change Rooms
a) Suitable one separate changing room,
b) Shall have two doors, one entrance and the second door accessing into
the restricted access area;
c) Shall be provided with a locker and shelf for Storage of clean theatre
attire and operation theatre gum boots.
d) Separate storage bin shall be provided for used and soiled theatre
apparels.
e) Wash hand basins: Toilets, showers,
6.4.2.8 Operating theatre mini- store
a) There shall be a store room in the operating room that shall be supplied
with a sufficient number of electrical plugs to keep the electrical
equipments plugged in, charged and in case of power failure to work as
back up electrical supply / or emergency electrical supply,
b) Equipments shall always be stored at the same space/location, properly
labeled and ready to use,
c) Enough Shelves and cabinets shall be available,
d) Anesthetic drugs shall be kept in cabinet,
6.4.2.9 Clean Utility room:
a) A room allocated for storage of IV fluids, clean linen, medicines and
other sundry items.

53
 b) Refrigerator with thermometer shall be available for drugs requiring a
temperature range of 4 to 8 °C.
c) Sink, cabinets and shelves,
6.4.2.10 Soiled Utility room /area shall be available with the followings;
a) Leak proof containers with lids shall be available for temporarily storing
placenta until properly disposed,
b) Used sharps/safety boxes are to be stored here before being sent for
incineration.
c) Container for temporary storage point for soiled linen,
d) Hand Washing basin,
e) Drainage on the floor,
f) Trolley for soiled materials,
6.4.2.11 Cleaner’s Room;
6.4.2.12 Central sterilization room/ area shall be available with followings;
a)An area or a room for reception, sorting of equipments; or clothes and
documentation process;
b) An area or room for an autoclave, dry oven and or steam sterilizer;
c) The date of sterilization & the name of the instruments shall be written
after sterilization.
6.4.2.13 There shall be continuous water supply with extra reservoir,
6.4.2.14 In addition, the hospital shall have minor operation theatre accessible to
OPD with hand wash basin.

6.4.3 Professionals
6.4.3.1 Surgical services shall be directed by a licensed emergency surgical officer.
6.4.3.2 The minimum number of professionals for emergency obstetric and other
surgical services at primary hospital to render 24 hours services are:
(a) One emergency surgical officer
(b) Two anesthetist (nurse anesthetist)
(c) Five experienced licensed (scrub) nurses

6.4.4 Products
6.4.4.1 Operating theatre: Minimum equipment list for a single operating theatre.

54
 (a) Time clock
(b) Anesthesia trolley
(c) Oxygen cylinders, different sizes.
(d) Worktable with laminated top
(e) Adjustable Stools
(f) IV stands
(g) Drums
(h) Kick buckets
(i) Caps - Mop/Bonnet Type
(j) Safety boxes
(k) Swab rack with drip trays
(l) Swab count record boards
(m)Bowls and stands
(n) Instrument tables, Mayo type
(o) Framed boards with pencil trays
(p) Chest tubes with bottles
(q) Blankets, warming
(r) Tourniquets
(s) Tongue depressors
(t) Mobile operating lights
(u) Operating table, 3 sections with removable fixtures
(v) Suction machines
(w)Bottles - Suction - Glass/Plastic
(x) Autoclave, hot air and or steam
(y) Anesthesia machine
(z) Laryngoscope, set (Mackintosh)
(aa) Intubation stylet, adult, 15 Ch
(bb) Magill forceps (adult & pediatrics)
(cc) Mouth gauge
(dd) Dual head stethoscope
6.4.4.2 Equipment – scrub area:
(a) Soap dispenser
(b) Scrub-up brushes

55
 (c) Sinks
(d) Mirror above each sink.
6.4.4.3 The hospital shall have consistent electricity (backup generator) and water
supply (backup reservoir)
6.4.4.4 Equipment – operating theatre store
(a) Drape:
 Surgical, woven(1 x 1 m)
 Surgical, woven(1 x 1.5 m)
 Surgical, woven(1.5 x 1.5 m)(fenestrated
 Surgical, woven(45 cm x 70 cm)(fenestrated)
 Surgical woven (2 x 1.5 m)
(b) Patient transfer, stretchers
(c) General purpose trolleys
(d) IV stands
(e) Worktable with laminated top
(f) Cabinets and shelves
(g) Dressing trolley
(h) Instrument table, Mayo type
(i) Pillows
(j) Surgical Splints
(k) Apron,
(l) trays
(m)Gen.surg- Basic surgery set
(n) Gen.surg- C/S set
(o) Gen.surg- Laparotomy set
(p) Gen.surg- Minor surgical set
(q) Gen.surg- Suprapubic puncture set
(r) Bedpans
(s) Kidney basin, 475 ml
(t) Renewable/Consumables for OR
 Guedel airways: size 0, 00, 3, 4 & 5
 Alcohol Swabs
 Disposable aprons

56
 Aqua-packs Oxygen humidifier
 Bags – Urine
 Bandages
 Batteries - Medical & General
 Blood Administration Sets
 Cannula - Nasal-Oxygen
 Cannula, IV short, ster, disp, 18G, 20 G, 22 G, 24 G
 Catheter, plain, foley,
 Cleansing Swabs – Sterile and Non-Sterile
 Cold/Hot Packs
 Connectors,
 Cotton
 Draw sheet, plastic, 0x180cm
 Gauze
 Gloves:
o Household Large & Medium
o Surgical Size 6, 6 ½, 7, 7 ½, 8
o Exam, latex, disp, large, medium, small
o Gauntlets
 Hand wash Antiseptic Liquid (Hibiscrub)
 I.V. Sets :
 I.V. Administration Sets – 15 Drop
 I.V. Administration Sets - 60 Drop
 I.V. Set, Infusion “Y”, Luer lock, air inlet
 K.Y. Jelly
 Nail Brushes - Autoclavable
 Needles:
 Disp,15G, 18G, 21G, 22G, 23G, 25G
 Butterfly 23G
 Oxygen T Pieces
 Oxygen Tubing
 Face Masks

57
  S.G. Meter (Urine Meters)
 Safety Pins Large & Medium
 Sharps Containers (Safety Box/used syringes and needles)
 Shrouds
 Soap, toilet, bar, approx.110g,wrapped
 Spatulas – Tongue, disposable
 Spigots Large, Medium and Small
 Syringes:
 Volume: 2ml, 5ml, 10ml, 20ml
 Syringes 50 ml Conical Tip
 Syringes 50 ml Luer Lock
 Syringes Insulin
 Tape:
 Elastic Adhesive Plaster - White 5cm and 10 cm
 Micropore tape
 Surgical Adhesive Hypo-Allergenic
 Adhesive, zinc oxide, perforated,10cmx5m
 Adhesive, zinc oxide, 2.5cmx5m
 Clinical thermometer
 Fridge thermometer
 Tourniquet, latex rubber,75cm
 Tubes:
 Endo-tracheal, disp. + connector, neonate mm, w.o balloon
 Endo-tracheal, disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Suction, L125cm,ster,disp, CH10, CH12, CH16
 Tube, Vacuum 5ml (Vacutainer)
 Tube, Vacuum EDTA 5ml (Vacutainer)
 Tube, Vacuum Heparinised 5ml (Vacutainer)
 Vacutainer holder
 Vacutainer needles, 18-24G
 Compresses:

58
 Abdominal compress, 40 x 40 cm
 Compress, Swab, 20x 20 cm
 Compress, gauze,10x10cm,n/ster/PAC-100
 Compress, gauze,10x10cm,ster/PAC-5
 Compress, paraffin,10x10cm,ster/BOX-10
 Suturing materials:abs, non abs,various with needles and with out
needles.
 Abs,DEC1,need 1/2,18mm,round/BOX-36
 Abs,DEC2,need 3/8 18mm,round/
 Abs,DEC2,need 3/8,26mm,tri
 Abs,DEC3,need 1/2 30mm,round
 Abs,DEC3,need 3/8 50mm,round
 Abs,DEC3,spool
 Abs,DEC4,need 3/8 36mm,tri
 Nonabs,DEC2,need 3/8 13mm,tri
 Nonabs,DEC3,need 3/8 30mm,tri
 Operating Room Linen:
 Apron Surgical, rubber
 Trousers, Surgical, woven, Small, Medium & Large
 Top(shirts), Surgical, woven, Small, Medium & Large
 Gown, Surgical, woven(Plain)
 Cap, Surgical, woven
 Masks, surgical, woven

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6.5. Anesthesia Services

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

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  Medications administered.
 Blood or blood products administered.
 Estimated blood loss.
 The actual anesthesia used.
 Any unusual events or complications of anesthesia.
 The condition of the patient at the conclusion of anesthesia.
 The time of start and finish of anesthesia.
 Signature of the nurse anesthetist or anesthetist.
(g) The patient shall be monitored during the post-anesthesia/surgery
recovery period and the results of monitoring shall be documented in
the patient’s medical record.
(h) The time of arrival to the general ward shall be recorded.
(i) The observation in the general ward shall be done by qualified licensed
nurses with training of basic advanced cardio-pulmonary support
together with the trained GP or HO.
(j) The decision of discharge from the general ward shall be done by a
trained GP or HO.
6.5.1.4 The anaesthetist shall visit the patient before the operation and assess the
general medical fitness of the patient, identifies any medication being taken,
and assess any specific anaesthesia problems.
6.5.1.5 The anaesthetist shall discuss possible plans of management with the
patient and explains any options available, to enable the patient to make an
informed choice.
6.5.1.6 Information on any drugs or treatments such as blood transfusion shall be
discussed with the patient.
6.5.1.7 The anesthetist shall ensure that all the necessary equipment and drugs are
present and checked before starting anesthesia.
6.5.1.8 The anesthetist shall confirm the identification of the patient before
inducing anesthesia.
6.5.1.9 The anesthetist shall be present in the operating theatre, around the patient
throughout the operation.

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 6.5.1.10 The conduct of the anesthesia and operation is monitored and recorded in
line with the monitoring standards and formats, to a minimum these shall
include:
a) Continuous pulse oximeter, and
b) A written record of the anesthetic shall be kept as a permanent record
in the case notes.
6.5.1.11 Pain shall be assessed and controlled in discussion with trained GP/HO.
6.5.1.12 Patients shall be managed in general ward, except for patients requiring
transfer to other hospitals, until overcome effect of anesthetic.
6.5.1.13 The protocols and guidelines used for anesthesia service shall be available
and well understood by the surgical team.
6.5.1.14 Anesthetic agents administered with the purpose of creating conscious
sedation, deep sedation, major regional anesthesia, or general anesthesia
shall be in accordance with aneasthesia policies and procedures.
6.5.1.15 There shall be a written protocol to assure that surgery shall not proceed
when there are person with disability alarms on the monitors,
6.5.1.16 The body temperature of each patient under general or major regional
anesthesia lasting 45 minutes or more shall be continuously monitored and
recorded at least every 15 minutes.
6.5.1.17 Pulse oximetry shall be performed continuously during administration of
general anesthesia, regional anesthesia, and conscious sedation at all
anesthetizing locations, unless such monitoring is not clinically feasible for
the patient. Any alternative method of measuring oxygen saturation maybe
substituted for pulse oximetry if the method has been demonstrated to have
at least equivalent clinical effectiveness.
6.5.1.18 Blood pressure, pulse rate, and respiratory rates shall be determined and
charted at least every five minutes for all patients receiving anesthesia at
any anesthetizing location, except for local anesthesia and minor regional
blocks.

6.5.2 Premises
6.5.2.1 The general anesthesia service shall be provided in the Operation room
(OR). Refer to the standards prescribed under the Surgical service standard

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 (a) There shall be a mechanism for taking exhaust air from anesthesia
machine to outside of OR; important when performing open system for
pediatric anesthesia,
(b) There shall be a system where there is a continuous supply of full
Oxygen cylinders,
6.5.2.2 Anesthesia store:
(a) Shall be well ventilated and illuminated room with shelves and
cabinets,
(b) The anesthetic shall be kept on shelves and/ or cabinets, separate from
medicines, properly labeled,
(c) Anesthetic equipments shall be stored clean and being ready for use,
(d) Ambu bags and resuscitation kits shall be kept labeled in easily
reachable place,
(e) There shall be separate place for keeping new and rechargeable
Batteries and dry cells. Used batteries and cells shall be stored and
discarded properly, refer to IP and waste disposal protocol,
6.5.2.3 Office room: with chairs, table, cabinet;

6.5.3 Professionals
6.5.3.1 Licensed anesthetist with experience shall lead anesthesia service
6.5.3.2 At all times, at least one anesthetist shall be on-site or on-call and shall reach
the primary hospital within 30 minutes.
6.5.3.3 All anesthesia providers who administer and/or supervise the
administration of general anesthesia, major regional anesthesia, or
conscious sedation anesthesia shall maintain current training in Advanced
Cardiac Life Support.
6.5.3.4 General or major regional anesthesia shall be administered and monitored
only by a licensed anesthetist.
6.5.3.5 Minor regional blocks shall be administered by the licensed professionals:
licensed anesthetist, trained GP or HO, dental professional, nurses, midwife.

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6.5.4 Product
6.5.4.1 Anaesthesia supplies, equipment and safety systems shall include the
following:
a) All medical gas hoses and adapters shall be color-coded and labeled
according to current national standards.
b) An oxygen failure-protection device ("fail-safe" system) shall be used on
all anaesthesia machines to announce a reduction in oxygen pressure,
and, at lower levels of oxygen pressure, to discontinue other gases when
the pressure of supply oxygen is reduced.
c) Vaporizer exclusion ("interlock") system shall be used to assure that
only one vaporizer, and therefore only a single agent, can be actuated on
any anaesthesia machine at one time.
d) To prevent delivery of excess anaesthesia during an oxygen flush, no
vaporizer shall be placed in the circuit downstream of the oxygen flush
valve.
e) All anaesthesia vaporizers shall be pressure-compensated in order to
administer a constant non-pulsatile output.
f) Accurate flow meters and controllers shall be used to prevent the
delivery to a patient of an inadequate concentration of oxygen relative to
the amount of nitrous oxide or other medical gas.
g) Alarm systems shall be in place for high (disconnect), low (sub
atmospheric), and minimum ventilator pressures in the breathing circuit
for each patient under general anaesthesia.
6.5.4.2 Anaesthesia supplies, equipment and patient monitoring shall include:
a) A difficult airway container or trolley shall be immediately available in
each anesthesia department for handling emergencies. The following
items are required to be included in the difficult airway container or
trolley:
 resuscitation equipment,
 emergency drugs,
 a laryngeal mask,
 endo-tracheal tube stylet,

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  airway, and/or
 Other items of similar technical capability.
b) A precordial stethoscope or oesophageal stethoscope shall be used when
indicated on each patient receiving anesthesia. If necessary, the
stethoscope may be positioned on the posterior chest wall or tracheal
area.
c) Supplemental oxygen and a delivery system appropriate to the patient's
condition shall be immediately available for patient transport from the
operating room to the general ward.
6.5.4.3 Equipments:
a) Time clock
b) Anesthesia machine with ventilator, 2 vaporizers, and gas cylinders
c) Adult and pediatric anesthesia circuits with filters
d) Oxygen cylinders of different sizes, oxygen trolley and oxygen regulator
e) Worktable with laminated top
f) Resuscitation equipments; Ambu bags (adult/ pediatric/ neonates), with
inflatable bag,
g) Refrigerator,
h) Stools
i) Clips
j) Weight scale; adult & pediatric
k) Resuscitation trolley
l) Syringe pump
m) Defibrillator
n) Dust bin
o) Framed boards with pencil trays
p) IV stands, infusion pumps, IV fluid pressure bags, blood warmer and IV
fluid warmer
q) Tourniquets, tongue depressors, disposable
r) Operation table and accessories:
 Operating table, with minimum of smoothly adjustable 3 sections
 Pillows,
 Support, head, operating table

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  Adjustable Head screen
 Patient transferring Stretchers
 Suction machines
s) Patient monitor
 Pulse oximeter
 Temperature monitor
 Dual head stethoscope
 BP apparatus with different size cuffs
t) Intubation gadgets:
 Airway Guedel, pediatric & adult size
 Laryngeal mask set
 Mask holder
 Cannula - Nasal-Oxygen,
 Face mask- Oxygen,
 Masks – Oxygen 40 %
 Laryngoscope sets with different size blades (Mackintosh)
 Magill forceps (adult & pediatrics)
 Intubation stylet, adult, 15 Ch,/ Endo-tracheal tube guide
 Mouth gauge
 Tube, Endo-tracheal:
o disp. + connector, 3 mm, w/o balloon
o disp. + connector, 3.5 mm, w/o balloon
o disp. + connector, 4 mm, w/o balloon
o disp. + connector, 4.5 mm, w/o balloon
o disp. + connector, 5 mm, balloon
o disp. + connector, 5.5 mm, balloon
o disp. + connector, 6 mm, balloon
o disp. + connector, 6.5 mm, balloon
o disp. + connector, 7 mm, balloon
o disp. + connector, 7.5 mm, balloon
o disp. + connector, 8 mm, balloon
o disp. + connector, neonate mm, w.o balloon

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 o disp. + connector, balloon, 6.5mm, 7mm, 7.5mm, 8mm
 Tube:
o Trachea, balloon, int.can, ster, size 6
o Trachea, balloon, int.can, ster, size 8
o Suction,CH08,L50cm,ster,disp, CH08, CH10, CH14, CH16
 Extractor, mucus,20ml,ster,disp
 Safety Pins Large & Medium
 Connectors:
o Biconical, Autoclavable
o Connector, T/Y
o Connectors - Plastic – Tapered
 Braun Splints (Arm)
 Draw sheet, plastic,90x180cm
 Clinical thermometer
 Fridge thermometer
 Tourniquet, latex rubber,75cm
6.5.4.4 The hospital shall have consumables as annexed
6.5.4.5 The hospital shall have all medicines allowed to this level of care and as per
the national drug list of Ethiopia
6.5.4.6 Operating Room Linen:
a) Apron Surgical, rubber
b) Trousers, Surgical, woven; Small, Medium & Large
c) Top(shirts), Surgical, woven; Small, Medium & Large
d) Gown, Surgical, woven(Plain)
e) Caps, Surgical, woven
f) Masks, surgical, woven
g) Bed Sheet
h) Sheet, draw, white
i) Cellular Blanket
j) Organ protections,
k) Shelves
l) cabinets

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6.5.4.7 The dental services shall have the following equipment and instruments
a) The dental units with all accessories (e.g. Low speed, high speed hand
pieces, straight & Contra angle hand pieces etc..)
 Air-water syringes
 Operating light
 Dental Chair
 Operator’s stool & Central Air compressor
b) Instruments for examining
 Dental mirror, Cotton pliers & Spoon excavator
 Periodontal pocket probe
c) Instruments for filling treatment
 Condenser (serrated & plain, Medium, and big size)
 Amalgam carriers (doubled ended, gun type), & Glass slab
 Matrix retainer (different types tofflemire, ziqueland)
 Carriers for restorative materials
 Carvers
 Condenser Beaver tail
d) Forceps for Dental Extractions (Deciduous teeth)
 Upper frontal milk tooth forceps
 Upper molar milk tooth forceps
 Lower frontal milk tooth forceps
 Lower molar milk tooth forceps
 Root forceps milk tooth (Bayonet)
e) Mandibular (lower jaw) forceps for anterior, posterior teeth & root
extraction
 Forceps (incisors, canine & universal forceps)
 Forceps ( molar & Wisdom forceps )
 Forceps for Mandibular root Extractions
f) Elevators for Extraction
g) Maxillar (upper jaw) Forceps for anterior, posterior teeth & root
extraction
 Maxillary forceps for anterior teeth
 Forceps (incisors ,canine & Universal forceps)

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  Maxillary forceps for posterior teeth (Forceps right and left)
 Forceps (universal forceps for molar & wisdom forceps)
 Forceps for Maxillary Root Extraction: Bayonet forceps
h) Periodontal instruments (scalers)
Scalers- different types, sickle, Jaquete, Chisel, Hoe, file scaler
Curettes (Universal, Gracey)
i) Equipment for dental radiology service
 Dental X-ray unit with lead aprone
 Film processing (developer & fixer)
j) Scissors
 Hemostats (curved , straight ,mosquito, Kelly needle holder)
 Crow scissors
 Ligature scissors & Surgical scissors
k) Hand cutting instruments
 Enamel Hatches, Enamel chisel
 Discoid-cleoid, Dental Hoe
 Gingival margin Trimmer, Angle former
l) Other surgical instruments
 Curettes (Angled, Straight, different Sizes)
 Rongeurs (Bone-cutting forceps)
 Bone-file
 Scalped and Handle for scalped
 Cheek and Tongue retractors
 Bone chisels, Mallets
 Suture needles, Irrigation syringe & Aspirating tip
 Local anesthetic equipment (metal anesthesia syringe)
m) Equipment used for amalgam restoration
 Amalgam mixing machine (Amalgamator)
n) Different operatory cabinets
 Mobile cabinets and/or Fixed cabinet
o) Equipments for sterilization
 Super heated steam under pressure (Autoclave)
 Dry heat sterilization (Oven)

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  Cotton roll sterilizer
 Different pans use for disinfections & sterilization of instruments
6.5.4.8 The dental service shall have the following consumable materials
a) Dental materials: Temporary & permanent fillings
b) Dental films (Periapical & occlusal)
c) Light curing unit with composite materials (optional)
d) Local anesthesia (Spray, Cartridge with & without adrenalin)
e) Other consumables (analgesics, disposable syringe & gloves etc)

6.6. Nursing Services

6.6.1 Practices
6.6.1.1 There shall be written policies describing the responsibilities of nurses for
the nursing process (assessment, diagnosis, planning, implementation and
evaluation). Such policies shall be reviewed at least once every three years.
6.6.1.2 There shall be assessable physical resources for nurses to implement the
nursing process, as detailed under the products’ section for nursing services.
6.6.1.3 There shall be appropriate arrangements for nurses to access to clinical
supervision, support and participate in regular clinical services audit and
reviews.
6.6.1.4 Nursing care service at different service delivery areas shall be directed by a
licensed nurse with a minimum of diploma from recognized college or
university and has at least two years of relevant experience.
6.6.1.5 Written copies of nursing procedure manual shall be developed and made
available to the nursing staff in every nursing care unit. The manual shall be
used at least to:
(a) Provide a basis for induction of newly employed nurses,
(b) Provide a ready reference on procedures for all nursing personnel.
(c) Standardize procedures and practice.
(d) Provide a basis for continued professional development in nursing
procedures/techniques.
6.6.1.6 The hospital shall have established guidelines for verbal and written
communication about patient care that involves nurses.

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 (a) Written communication includes proper use of clinical forms, nursing
Kardex, progress notes, and/or nursing care plan for each patient and
discharge instructions.
(b) Verbal and/or written communication includes reporting to general
medical practitioners; nurse-to-nurse reporting; communication with
other service units (laboratory, pharmacy, X-Ray, social work service),
with patient and family education.
6.6.1.7 There shall be a procedure for standardized, safe and proper administration
of medications by nurses or designated clinical staff including regular checks
of patients’ medications and proper documentation of administered
medicines.

Nursing care: general patient services

6.6.1.8 Licensed nurses shall assess and document the holistic needs of patients;
formulate, implement goal-directed nursing interventions and evaluate the
plan of nursing care and involve patients, their relatives or next of kin in
decisions about their nursing care. Nurses’ documentation shall include:
a) Medication, treatment, and other items ordered by authorized house
staff members.
b) Nursing care needed.
c) Long-term goals and short-term goals.
d) Patient and family teaching and instructional programs.
e) The socio-psychological needs of the patient.
f) Preventative nursing care.
6.6.1.9 All patients shall be under the supervised care of a licensed nurse at all
times.
6.6.1.10 Implementation of infection prevention procedures and provision of
information on IP practices to patients, clients, family members and other
caregivers, as appropriate, shall be done by the nurses; refers to infection
prevention stated under this standard.
6.6.1.11 Nurses shall work with others to protect and promote the health and
wellbeing of those under their care.

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6.6.1.12 Nurses shall be open and honest, act with integrity and uphold the
reputation of their profession.
6.6.1.13 The nursing care plan shall be initiated upon admission of the patient and
shall include discharge plans as part of the long-term care provision goals.
6.6.1.14 Documentation and completion of all patient’s recording, registers, and
reporting formats shall be the responsibility of licensed nurses in the unit as
stated under medical records standards
6.6.1.15 Nursing care shall be provided for all patients equally and without prejudice
to age, gender, and economic, social, political, ethnicity, religious or other
status and irrespective of their personal circumstance.
6.6.1.16 Nurses shall not disclose confidential information relating to their patients
unless in cases where the patient’s/ public safety is at risk.
6.6.1.17 Nurses shall explain and seek informed consent from their patients or their
relatives/next of kin (for incompetent patients) before carrying out any
procedure.
6.6.1.18 Nurses shall find solutions to conflicts caused by deep moral, ethical and
other beliefs arising from a request for nursing service through dialogue
with patients.
6.6.1.19 Patient discharge instructions shall be documented in the patient's medical
record at the time of discharge and a copy of such instructions shall be given
to the patient or next of kin.
6.6.1.20 Allergies shall be listed on the front cover of the patient's chart and/or, in a
computerized system, highlighted on the screen and this shall be posted in
the patient’s bed.
6.6.1.21 Patients who require assistance in feeding shall be identified, and there shall
be a mechanism in place to ensure that assistance is provided.
6.6.1.22 For admitted patients, the nursing staff shall take and document the
necessary vital signs as ordered and communicate findings of any deviation
from the norm to treating /attending general medical practitioner
immediately.
6.6.1.23 Nurses shall ensure patients on special diets have access to their prescribed
dietary regimes and such patients shall be identified with a visible
identifier/label that is included in their care plan and on their beds.

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 6.6.1.24 There shall be written policies that state the procedures for communicating
with laboratory, laundry and food service. The nurse shall communicate and
follow up food orders, lab orders and lab specimens, and patient transfers.
6.6.1.25 There shall be a policy or procedures for nurses to report any suggestive
signs of child abuse, substance abuse and /or abnormal psychiatric
manifestations by the patients under their care.

Nursing care services related to pharmaceutical services

6.6.1.26 All medications administered by nursing personnel shall be prescribed by

general practitioner or health officer or any other authorized health
professional and shall be administered in accordance with prescriber
orders.
6.6.1.27 Medicines packaged in unit dose containers shall not be removed from the
containers by nursing personnel until the time of medicine administration.
Such medicines shall be administered immediately after the dose has been
removed from the container, and by the individual who prepared the dose
for administration.
6.6.1.28 Each patient shall be identified prior to medicines administration. Medicines
dispensed for one patient shall not be administered to another patient.
6.6.1.29 Nurses shall ensure patients under their care swallow their prescribed oral
medicines as per general medical practitioner’s order.
6.6.1.30 Regarding self-administration of medicines, nursing personnel shall directly
observe self-administration and adhere to policies and procedures
developed by the pharmacy and therapeutics committee.
6.6.1.31 There shall be a policy for reporting and documenting medication errors,
product quality defect and adverse drug reactions by attending nursing
personnel immediately to the prescriber and ADE focal person.
6.6.1.32 Medicines, needles and syringes in patient care areas shall be maintained
under proper conditions as per the pharmaceutical service standards stated
under this standard.
6.6.1.33 Nursing personnel shall return unfit for use medicines to the central medical
store of the hospital for disposal.

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 6.6.1.34 Nursing personnel shall store and use needles and syringes in accordance
with the infection prevention standards stated under this standard.
6.6.1.35 There shall be a protocol that guides nurses coping the prescription of
physician’s order.

Nursing care: use of restraints

6.6.1.36 The hospital shall have written policies and procedures regarding the use of
physical restraints that are reviewed at least once every three years and
implemented. They shall include at least the following:
(a) Protocol for the use of alternatives to physical restraints, such as staff or
environmental interventions, structured activities, or behavior
management. Alternatives shall be utilized whenever possible to avoid
the use of restraints;
(b) A delineation of indications for use, which shall be limited to:
 Prevention of imminent harm to the patient or other persons when
other means of control are not effective or appropriate; or
 Prevention of serious disruption of treatment or significant damage
to the physical environment;
(c) Contraindications for use, including at least clinical contraindications,
convenience of staff, or discipline of the patient;
(d) Protocols for notifying the family or guardian of reasons for use of
restraints, and for informing the patient and requesting consent when
clinically feasible; and
(e) Protocol for removal of restraints when goals have been accomplished.
6.6.1.37 Except in an emergency, a patient shall be physically restrained only after
the attending general medical practitioner or another designated general
medical practitioner has personally seen and evaluated the patient and has
executed a written order for restraint.
6.6.1.38 An emergency restraint procedure, beginning with the least restrictive
alternative that is clinically feasible, shall be initiated by a licensed
professional nurse only when the safety of the patient or others is
endangered or there is imminent risk that the patient will cause substantial

74
 property damage. The attending general medical practitioner, another
designated general medical practitioner, or independent practitioner, or a
licensed psychiatric nurse shall be notified immediately and shall respond
within one hour. An order shall be given if the use of restraints is to continue
beyond one hour. The clinical condition of the patient shall be evaluated and
documented by medical or licensed nursing personnel at least once every
two hours.
6.6.1.39 In all cases, the attending or designated general medical practitioner, or
independent practitioner, or licensed psychiatric nurse shall observe the
restrained patient at least once every 24 hours to evaluate any changes in
the patient's clinical status. This evaluation shall be documented in the
patient record. If a general medical practitioner has ordered the use of
restraints, a subsequent order for the use of restraints shall not be required
so long as its use is in compliance with the intent of the original order and
hospital policy.
6.6.1.40 Interventions while a patient is restrained, except as indicated at (g) below,
shall be performed by nursing personnel in accordance with nursing care
policy. They shall include at least the following and shall be documented:

(a) Assessment for clinical status and reevaluation of need for restraints at
least every two hours;
(b) Toileting at least every two hours with assistance if needed;
(c) Monitoring of vital signs; and
(d) Release of restraints at least once every two hours in order to:
 Assess circulation and skin integrity;
 Perform skin care; and
 Provide an opportunity for exercise or perform range of motion
procedures for a minimum of five minutes per limb.
(e) Continuous or periodic visual observation based upon an evaluation of
the patient's clinical condition.
(f) Administration and monitoring of adequate fluid intake;
(g) Adequate nutrition through meals at regular intervals, snacks, and
assistance with feeding if needed;

75
 (h) Assistance with bathing as required, occurring at least once a day; and
(i) Ambulation at least once every four hours if clinically feasible.
6.6.1.41 Licensed professional nursing staff shall evaluate and ensure appropriate
monitoring and documentation of the effects of all psychotropic
medications. These medications shall be administered only upon written
general medical practitioner orders as part of the patient's treatment plan
and shall not be used as a method of restraint, discipline, or for the
convenience of staff.

Nursing care: Dying patient

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

6.6.2 Premises
6.6.2.1 The hospital shall have the followings premises for nursing services:
(a) Room /space for isolation or special care, with toilet room and shower
(b) Hand washing basin and toilet room at nurse station
(c) Procedure room for nursing procedures
(d) Nurse changing room with cabinet, chairs, cupboard
(e) Nurses station located in the middle of the wards with free access to all
rooms
6.6.3 Professional

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6.6.3.1 There shall be a policy of verifying qualifications, restrictions to practice and
professional registration of all new employees and have a system in place to
check re-registration details. There shall be documentation of staff licenses
and training certificates.
6.6.3.2 The hospital shall have a system in place for evaluating at least annually the
performance of each nursing service employee.
6.6.3.3 The nursing staff shall have a minimum of diploma from recognized college
or university.
6.6.3.4 There shall be written discrete job descriptions that detail the roles and
responsibilities of each nursing staff members.
6.6.3.5 The hospital shall have in place a nursing workforce plan that addresses
nurse staffing requirements, including, at a minimum:
(a) A nurse representative in each patient care unit or case team responsible
for the operation of the professional nursing service 24 hours per day
and 365 days a year.
(b) A daily staffing schedule that ensures at least one licensed nurse in
charge and assigned exclusively to each patient care unit or case team on
each shift;
(c) A provision that at least 100 percent of direct patient care for 24 hours
in inpatient units on a hospital wide average be provided by licensed
nursing personnel,
(d) A method for assessing each unit’s additional nursing needs for each
shift.
6.6.3.6 There shall be at least one licensed nurse in charge of each patient care unit
at all times and this shall be indicated in the hospital’s organizational plan.
Additional staff shall be assigned by the hospital as required by the acuity
levels.
6.6.3.7 There shall be effective policy that control nursing care by nursing students
that shall be under direct supervision of a licensed nurse; all being
accountable.
6.6.3.8 The hospital shall have in effect a contingency plan for assuring adequate
nurse staffing at all times. The plan shall detail policies and procedures to

77
 regulate closure of available beds, if actual staffing levels fall below specified
levels.
6.6.3.9 Nurse staffing for inpatient patient care service within the hospital shall be
in accordance with not more than 6 patients under one nurse for general
patient care.
6.6.3.10 There shall be a policy that strengthens involvement of nurses to take part in
the ongoing continuing professional development (CPD).
6.6.3.11 All nursing staff shall receive orientation, training and/or update at least
annually including at least:
(a) Hospital’s policies and procedures,
(b) Routine nursing procedures.
(c) Emergency procedures and
(d) Infection prevention and control
6.6.3.12 Professional Quality assurance: On-going internal institutional evaluation
of outcome-based quality indicators related to nursing care shall be in place
to assess and provide a safe and adequate level of patient care including at
least:
(a) Patient injury rate;
(b) Medication process errors;
(c) Maintenance of skin integrity;
(d) Control of cross infections and nosocomial infection rates;
(e) Hospital-wide patient satisfaction with overall nursing care; and
(f) Patient satisfaction with pain management;

6.6.4 Products
6.6.4.1 The hospital shall ensure that the nursing personnel have access to all the
consumables and equipment they require to provide professional nursing
care to patients under their care, including at least:
(a) Specimen collection set: tray, Tourniquets, disposable glove, cotton
swabs,
(b) Rubber sheets,

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(c) Restraining equipment in accordance with the standards under the use
of restraints and mental health services. E.g., cushion, belt, vest, long
sleeve pullover, etc.,
(d) Emergency resuscitation sets: airway, ambu bag of different size,
(e) Patient chart folders,
(f) Vital sign equipments:
 Trolley for vital sign monitoring,
 Thermometer, BP apparatus, stethoscope, measuring tape
 sphygmomanometer with stethoscope,
 wrist watch/ wall clock,
 bedside weighing scale
 Pulse oximeter
(g) Furniture and fixtures;
 Table
 Chair, stackable, without armrests
 Basket, waste-paper, metal
 Cabinet
 Patient chart holder,
 Refrigerator,
 Bedside cabinet,
 Feeding table,
 IV stands,
(h) Nursing procedure equipments:
 Dressing trolley
 Dressing set,
 Minor procedure set,
 Chest tubes and bottles,
 Enema set,
 IV stand,
 Oxygen trolley,
 Oxygen cylinder,

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  Oxygen regulator/gauge,
 Oxygen face mask/ nasal catheters,
 Suction machine: electrical/pedal,
 Wheelchair,
 Waste basket,
 Safety boxes,
 Bed screens,
 Kidney basin, 475ml x 5
 Bed pan x 10,
 Urinal x 5,
 Mobile Examination light,
 Plastic apron,
 Drapes,
 Rubber sheets,
 Connectors,
 Cushion bags,
(i) Soiled utility room:
 Soiled linen trolley
 Bin with lid
 Work table with laminated top
 Wash tub (65L)
 General purpose trolley, two trays
(j) Emergency medicines as per the hospital list

6.7 Emergency Services

6.7.1. Practices
6.7.1.1. The emergency service including emergency surgical interventions shall be
available 24hrs a day and 365 days a year.
6.7.1.2. The hospital shall have an emergency triage system.
6.7.1.3. The emergency clinic shall comply with the patient rights standards as
stated under this standard

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6.7.1.4. Infection prevention standards shall be implemented in the emergency
room as per the IP standards stated under this standard
6.7.1.5. Every emergency patient shall get the service without any prerequisite and
discrimination.
6.7.1.6. The emergency service shall have functional intra and inter facility referral
system which encompasses SOP for selection of referral cases, referral
directory, referral forms, referral tracing mechanism, feedback providing
mechanism, documentation of referred clients and consultation forms.
6.7.1.7. If referral is needed it shall be done after providing initial stabilization and
after confirmation of the required service availability in the facility where
the patient is to be referred to.
6.7.1.8. If the patient to be referred needs to be attended by a general medical
practitioner or other professional in another hospital, the hospital shall
arrange an ambulance service and accompanying health personnel to
transfer the patient.
6.7.1.9. Every procedure, medication and clinical condition shall be communicated
to the patient or family member after responding for urgent resuscitation
measures
6.7.1.10. There shall be a mechanism of quality improvement for the service at least
by collecting feedback from clients and having a formal administrative
channel through which clients place their complaints and grievances
6.7.1.11. The hospital shall provide a complete emergency service to it level of care
6.7.1.12. The emergency service shall have a procedure for easy access to pharmacy,
laboratory and other diagnostic services 24hrs a day and 365 days a year.
6.7.1.13. For labor and delivery emergencies the hospital shall follow the general
medical and surgical service standards stated under this standard
6.7.1.14. The emergency service shall promote the dignity and privacy of patients.
6.7.1.15. There shall be a written protocol for emergency services and the provision
of this service shall be done in accordance with the clinical protocols of the
service
6.7.1.16. The emergency service unit shall provide basic life support to its level of
care which may include but not limited to :
a) Cardiopulmonary resuscitation (CPR)

81
 b) airway management and/or oxygen supply
c) bleeding control
d) fluid resuscitation
6.7.1.17. The hospital emergency service shall have protocol for the initial
management of at least the following emergency cases:
(a) Shock
(b) Severe Bleeding
(c) Fracture and injuries
(d) Coma
(e) Burn
(f) Poisoning
(g) Cardiac emergencies
(h) Sever respiratory distress
(i) Seizure disorder
(j) Hypertension emergencies
(k) Cereberovascular accident
(l) Acute diarrhea ( Sever dehydration )
(m)Acute abdomen
(n) Tetanus
(o) Meningitis
6.7.1.18. Other service that assist the emergency service shall be available for 24 hrs
and 365 days of a year with adequate staffing

6.7.2. Premises
6.7.2.1. The emergency room shall be located in a place where it is easily
recognizable to the public and shall be labeled in bold.
6.7.2.2. The emergency premises shall be low traffic area and there shall be reserve
parking place for ambulances.
6.7.2.3. The corridor to emergency rooms shall be stretcher friendly and spacious
enough.
6.7.2.4. The emergency area shall be spacious enough to provide a space for the
following tasks:
(a) Triaging

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 (b) Accepting and providing immediate care including emergency
procedures
(c) Admitting for a maximum of 24 hrs to provide emergency care
(d) Access to emergency medicines, supplies and equipments
(e) Staff/duty room
(f) Toilet facilities
6.7.2.5. Beds shall be arranged as the description of inpatient beds’ arrangement
6.7.2.6. The width of the door for the emergency room shall not be less than 1.5
meter
6.7.2.7. The emergency premises shall allow patient dignity and privacy.
6.7.2.8. The rooms shall be arranged in such a way that the first encounter to an
emergency patient coming from outside will be the examination room or
space
6.7.2.9. The emergency room shall have the following facilities
(a) Adequate water, light and ventilation.
(b) Fire extinguishers placed in visible area
(c) Hand washing basin in each room
6.7.2.10. Glass doors shall be marked to avoid accidental collision
6.7.2.11. Potential source of accidents shall be identified and acted upon (slippery
floors, misfit in doorways and footsteps, etc)
6.7.2.12. Waiting area for attendants and caregivers

6.7.3. Professionals
6.7.3.1. The emergency service shall be directed by general medical practitioner or
Health officer.
6.7.3.2. The team of emergency shall be changed every 8 hrs as a team and the team
composition during working and non-working hours shall have similar
staffing pattern.
6.7.3.3. The emergency service shall be opened for 24hrs a day and 365 days a year
being run by an emergency team. Each team shall contain a minimum of:
(a) One General Practitioner or Health officer
(b) Two nurses
(c) cleaners

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 (d) runner
(e) Emergency surgical officer on call basis .
6.7.3.4. The actual number of personnel required shall be adjusted as per workload
analysis for emergency cases
6.7.3.5. All health professionals working in the emergency room shall be trained on
at least cardio-pulmonary resuscitation
6.7.3.6. Drill-exercise of emergency case management shall be conducted on regular
bases among the teams working in the emergency service.
6.7.3.7. The staff shall have regular supportive supervision by senior staff or peer
review or case conferences every three months and it shall be
documented
6.7.3.8. The hospital shall have personnel manual which also covers staff at the
emergency services

6.7.4. Products
6.7.4.1. Emergency medicines, supplies and equipments shall be always readily
available for emergency services as per the hospital list..
6.7.4.2. At least the following emergency equipment and supplies shall be available:
(a) Suction machine
(b) Tracheotomy set
(c) NG tube
(d) Minor procedure set
(e) Mobile examination lamp
(f) IV stands
(g) Resuscitation set on trolley
(h) Intubation set
(i) Ambu bags
(j) Oxygen supply: oxygen, cylinder with flow meter, trolley and nasal
prongs
(k) Dry autoclave (hot air oven)
(l) Stretcher,
(m) wheelchairs
(n) Different types of splints

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 (o) Patient screen, partition curtains
(p) IV-Canulla different size
(q) Bandage and gauze
6.7.4.3. There shall be at least two coaches at emergency room
6.7.4.4. There shall be at least two beds to be used only for emergency admission
6.7.4.5. Actual number of beds, materials, and kits for emergency use can be
adjusted based on the average number of emergency cases

6.8 . Rehabilitation Services

6.7.5. Practices
6.7.5.1. At least physical therapy/ physiotherapy services shall be available in the
hospital
6.7.5.2. There shall be specific treatment and/or procedure protocols for each
service available and rendered in the unit,
6.7.5.3. There shall be a policy that the therapist (physical therapist/
physiotherapist) shall document the entire plan in the patient’s medical
records. A note shall be entered into the medical record at least weekly or
more frequently if there is a significant change in the patient’s status or
treatment needs.
6.7.5.4. The physical therapist shall discuss the plan of care with the patient and
family.
6.7.5.5. The physical therapy service shall be available during working time.
6.7.5.6. Visual and auditory privacy shall be offered and provided to all patients
during evaluation and treatment.
6.7.5.7. There shall be training service for patients on copping disability. It includes
utilization of prostheses, orthoses, wheelchairs, walking aids.
6.7.5.8. There shall be a protocol or policy for safety and ethical practice of physical
therapy that complies with the six precepts for health care (safe, effective,
patient-centered, timely, efficient and equitable).
6.7.5.9. There shall be patient education on prevention of:
(a) pressure sores in clients with sensory loss,
(b) contractures in clients with limb and/or trunk paralysis,

85
 (c) phantom limb pain for amputees,

6.7.6. Professionals:
6.7.6.1. The service shall be directed by a licensed physiotherapist,
6.7.6.2. In addition, the hospital may have one physical therapist or physiotherapist
who work closely with treating general medical practitioner,
6.7.6.3. There shall be multidisciplinary team in the rehabilitation service to plan for
individual patients. Referring general medical practitioner shall be
involved in the process.
6.7.6.4. Continued improvement of technical skills and knowledge shall be
encouraged and such opportunities shall be facilitated for professionals by
the hospital or health facility.

6.7.7. Premises
6.7.7.1. There shall be at least one physically separated room or area for
rehabilitation and therapy
6.7.7.2. The premise shall have waiting area with shade
6.7.7.3. The premises shall be located with direct access to inpatients and
outpatients with clear labels.
6.7.7.4. The premises shall be handicap friendly and smooth pavement rail for
wheelchairs.
6.7.7.5. There shall be enough space for assistive devices and appropriate
accessories.
6.7.7.6. Private area for patients and staff when they need to change clothing before
and after treatment shall be available.
6.7.7.7. Separate toilet with hand washing facility in an accessible location,
handicapped accessible, handicapped adapted and well-ventilated shall be
available.
6.7.7.8. Call bells shall be provided to patients in the physical therapy service who
are not under visual supervision.
6.7.7.9. Workshop for production of orthosis- prostheses, walking sticks, axillary
and/or elbow crutches shall be available. If there is no workshop, there
shall be variety of walking aids.

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 6.7.8. Products
6.7.8.1. All equipment shall be clean and functional.
6.7.8.2. Equipment shall be stored in a safe and accessible place and shall not be
stored in a public walkways and hallways.
6.7.8.3. Standard equipments and consumables which shall be available for
rehabilitation services include:
(a) Physiotherapy mats
(b) Massaging coach
(c) Splinting materials
(d) Balance boards
(e) Mirror
(f) Walking rail/ parallel bars, adult and pediatric
(g) Sticks
(h) Crutches
(i) Walking aids/ walking frames (adjustable)
(j) POP cutter
(k) Pulley
(l) Chair and table
(m) Shelf for storing reference books and personal items
(n) Disposable glove
(o) Cotton roll
(p) Plastic apron
(q) POP

6.9. Radiological Services

6.9.1. Practices

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6.9.1.1. The radiology service shall have written policies and procedures that are
reviewed at least once every three years and implemented. These policies
and procedures shall include at least:
a) Safety practices;
b) Management of the critically ill patient;
c) Infection control, including patients in isolation;
d) Timeliness of the availability of diagnostic imaging procedures and the
results
e) Quality control program covering the inspection, maintenance, and
calibration of all equipment
6.9.1.2. Policies and procedures for radiology services shall be available to all staff in
the radiology unit.
6.9.1.3. There shall be a written protocol for managing medical emergencies in the
radiological suite. All radiological staff shall be instructed in this protocol
and know their roles in the case of such an emergency.
6.9.1.4. All radiological examinations shall be seen by the requesting general
medical practitioner or health officer as early as possible.
6.9.1.5. The radiology service of the hospital shall have x-ray service.
6.9.1.6. The radiology staffs shall make every effort to ensure that patients waiting
for radiology services or transport from radiology are safe while waiting.
6.9.1.7. The radiology service unit shall be free of hazards to patients, care giver and
staff.
6.9.1.8. Proper safety precautions shall be maintained against fire and explosion
hazards, electrical hazards, and radiation hazards.
6.9.1.9. The hospital shall get approval from the Ethiopian Radiation Protection
Authority through periodic inspection and hazards shall be promptly
corrected if identified
6.9.1.10. The primary hospital shall have a policy that radiology professionals shall
use the TLD while in duty.
6.9.1.11. Radiation workers shall be checked periodically for amount of radiation
exposure by the use of exposure meters or badge tests and this shall be
documented

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6.9.1.12. Signed reports shall be filed with the patient's medical record and duplicate
copies kept in the service unit.
6.9.1.13. Requests by the attending general medical practitioner or health officer for
x-ray examination shall contain a concise statement of reason for the
examination.
6.9.1.14. Reporting form shall have minimum information such as date, patient name,
age, gender, findings and name and signature of radiographer
6.9.1.15. X-ray films shall be labeled with minimum information such as date, name,
age, gender, right/left mark and name of radiographer.
6.9.1.16. A radiation safety program including timely reporting of radiation safety
findings shall be in place, followed, and documented.
6.9.1.17. The professional/practitioner who delivered the radiology service shall be
responsible for claims arising from wrong findings
6.9.1.18. Radiology services shall be accessible to all requiring medical service units.

6.9.2. Premises
6.9.2.1. Minimum number and size of rooms within radiology services are indicated
below
Type of premises Number Size(m2) Each
required
Conventional x-ray room 1 As per ERPA
Dark room, if necessary 1 standards
Toilet for staff and patient separately 2
Patient dressing rooms 1
Waiting room 1
Duty room 1
Store room 1

6.9.3. Professionals
6.9.3.1. The radiology service shall be directed by licensed BSC professional in
radiology.

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6.9.3.2. A licensed radiographer shall be available at all time.
6.9.3.3. Trained dark room technician and cleaners shall be available in radiology
service as full time.

6.9.4. Products
6.9.4.1. The following medical equipments shall be available for radiology services.
a) Standard conventional x-ray machine
b) Mobile x-ray machine (optional).
c) Viewing boxes
d) Telephone service
e) Computer (optional)
6.9.4.2. All diagnostic equipment shall be regularly inspected, calibrated and
maintained, and appropriate records shall be documented.
6.9.4.3. All radiation generating equipment shall be installed with a building wall
thickness that fulfills the minimum criteria set by the Ethiopian Radiation
Protection Authority.
6.9.4.4. Radiology service equipments shall be installed at central areas to all clinical
services
6.9.4.5. At least the following radiation protection equipments shall be available in
radiology services:
a) lead gloves
b) lead aprons
c) lead goggle
d) gonadal shield
e) Other shields e.g for pregnant women (if x-ray is highly indicated)
6.9.4.6. Safety procedures during practices and disposal of unfit for use equipments
shall be installed as per the requirements set by the Ethiopian Radiation
Protection Authority during all procedures.

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

a) Periodic reporting(monthly, quarterly)

b) Preliminary analysis and utilization of results

c) Collection of useful and appropriate information

d) Archiving and retrieval

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

a) Laboratory request forms

b) Laboratory report forms

c) Laboratory specimen and results registers

d) Quarterly/monthly reporting forms including

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  Summary of tests conducted
 Summary of tests referred
 Summary of quality assurance report

e) Equipment and supplies inventory registers

f) Quality assurance record forms

g) Referral forms

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

a) adherence to SOPs

b) adherence to safety guidelines

c) QA activities

d) Laboratory performance and workload

e) Laboratory services

6.10.1.5. The hospital shall have policies and procedures for the availability of
laboratory services including the emergency services for 24 hours a day and
365 days a year.
6.10.1.6. The laboratory shall have procedures or (SOP) for proper specimen
collection that address specific collection requirements such as:
a) Preferred sample type (venous, arterial, capillary, urine, spinal fluid)
b) Type of anticoagulant
c) Sample volume considered acceptable
d) Patient identification
e) Requirements for patient preparation and storage of specimens.
6.10.1.7. Policies and procedures shall be documented and communicated to all
personnel.
6.10.1.8. The laboratory shall follow standard operating procedures (SOP) and
conduct routine quality assessments to ensure reliable and cost-effective
testing of patient specimens.
6.10.1.9. Laboratory management shall review all operational procedures at regular
intervals. The frequency should be every four month (at least annually).
6.10.1.10. The process of analysis shall be specified by validated written or electronic
procedures maintained in and by the laboratory. Procedures may be

92
 written by the laboratory staff or may be adapted from previously
published materials including, but not limited to, product inserts,
procedure or instrument manuals, textbooks, journals, or international
guidelines.
6.10.1.11. Laboratory staff shall test quality control materials every eight hour and
document in combinations suitable to detect analytical error.
6.10.1.12. The right patient with the right request form shall be identified during
collection and delivery of result.
6.10.1.13. Requests for testing shall provide:
a) The name of the ordering general medical practitioner or other person
authorized to order testing
b) The clinician’s working address
c) Type of primary sample collected
d) The anatomic site where appropriate
e) The test requested
f) Patient gender
g) Age
h) Pertinent clinical information as appropriate for purposes of test
interpretation (Clinical Diagnosis)
i) Date and time of sample collection and receipt in the laboratory
6.10.1.14. There shall be SOP or criteria developed for acceptance or rejection of
clinical samples.
6.10.1.15. Laboratory shall monitor the transportation of samples to the laboratory
such that they are transported, within time frame, within temperature
interval specified in the primary sample collection manual or SOP and in a
manner that ensures safety for carrier.
6.10.1.16. The laboratory shall maintain a record of all samples received.
6.10.1.17. Laboratory shall have a procedure for storage of clinical samples if it is not
immediately examined.
6.10.1.18. Patient samples shall be stored only for as long as necessary to conduct
the designated tests (or other permitted procedure) according to fixed
storage times, and shall be destroyed safely and confidentially after
storage.

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6.10.1.19. Once a sample is used, it shall be maintained in the laboratory for a
specified period of time (or as required by regulation) and at a
temperature that ensures stability of the sample in the event the sample is
needed for retesting.
6.10.1.20. Provision shall be made to carry out adequate clinical laboratory
examinations including chemistry, hematology, and clinical microscopy
either in the hospital or licensed outside laboratory based on contractual
agreement for the minimum tests required at primary hospital
6.10.1.21. Laboratory report
a) All laboratory test result/reports shall have reference (normal) ranges
specific for age and gender.
b) Copies or files of reported results shall be retained by the laboratory
such that prompt retrieval of the information is possible. The length of
time that reported data are retained shall be 5 years for legal reason
minimal errors or loss of patient test results.
c) Reports shall be filed with the patient's medical record and duplicate
copies shall be filed in the laboratory in a manner which permits ready
identification and accessibility and with appropriate backup.
d) In the case of laboratory tests performed by an outside laboratory, the
original report from such laboratory shall be contained in the medical
record.
e) Quality assured test results shall be reported on standard forms to the
general medical practitioner with the following minimum information:
 Patient identification (patient name, age, gender,)
 Date and time of specimen collection
 The test performed and date of report.
 The reference or normal range
 The laboratory interpretation where appropriate,
 The name and initial of the person who performed the test, and
the authorized signature of the person reviewing the report and
releasing the results.
 Hospital address

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 f) Laboratory results shall be legible, without transcription mistakes and
reported only to persons authorized to receive them such as the
ordering general medical practitioner or nursing staff in a hospital
environment
g) The laboratory shall have policies and procedures in place to protect the
privacy of patients and integrity of patient records whether printed or
electronic. Policies shall be established which define who may access
patient data and who is authorized to enter and change patient results,
correct billing or modify computer programs.
6.10.1.22. When reports altered, the record shall show the time, date and name of the
person responsible for the change.
6.10.1.23. Safe disposal of samples shall be in line with standards prescribed under
infection prevention
6.10.1.24. No eating, drinking, smoking or other application of cosmetics in
laboratory work areas or in any area where workplace materials are
handled.
6.10.1.25. No food and drink to be stored in the laboratory (may be stored in the staff
room)
6.10.1.26. The medical laboratory shall have safety guideline. In addition, the
laboratory shall protect the environment and public by assuring the health
laboratory waste is disposed of legally and an environmentally friendly
manner
6.10.1.27. Wearing of protective clothing of an approved design(splash proof),
always fastened, within the laboratory work area and removed before
leaving the laboratory work area
6.10.1.28. At regular intervals, the laboratory shall review any contracts for services
to its clients (including but not limited to clinicians, health care bodies,
pharmaceutical companies, other departments such as pharmacy or
nursing within the hospital structure) to ensure that the laboratory can
meet the contractual requirements such as methodologies, turn-around
times, availability of expert opinion, etc. Records of these reviews shall be
kept and maintained by the laboratory, including deviations from
contracts.

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6.10.1.29. Where services are provided by an outside laboratory, the conditions,
procedures, and availability of services offered shall be in writing and
available in the hospital.
6.10.1.30. The laboratory shall meet regularly with clinical staff regarding services
and clinical interpretations.
6.10.1.31. The laboratory must keep a record of the complaint. The record shall
include the nature of the complaint, the date of occurrence, individuals
involved, any investigations undertaken by the laboratory and resolution.

6.10.2. Premises
6.10.2.1. The hospital shall have a well organized, adequately supervised and staffed
clinical laboratory with the necessary space, facilities and equipment to
perform those services commensurate with the hospital's needs for its
patients.
6.10.2.2. The laboratory working environment shall be kept organized and clean, with
safe procedures for handling of specimens and waste material to ensure
patient and staff protection from unnecessary risks at all time.
6.10.2.3. The laboratory shall have space allocated so that its workload can be
performed without compromising the quality of work, quality control
procedures, and safety of personnel or patient care services.
6.10.2.4. The laboratory shall have adequate lighting, ventilation, water, waste and
refuse disposal. Work areas shall be clean and well maintained.
Precautions must be taken to prevent cross contamination.
6.10.2.5. The laboratory shall have controlled temperature of refrigerator for
reagents, blood sample, calibrator, control materials which affect the
analytical results.
6.10.2.6. Facilities shall provide a suitable environment to prevent damage,
deterioration, loss or unauthorized access.
6.10.2.7. The laboratory shall be located and designed to
a. provide suitable, direct access for patients
b. Allow reception of deliveries of chemicals
c. Allow safe disposal of laboratory materials and specimens.

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6.10.2.8. Doors shall be located in places where entry and exit is easy and does not
interfere with the laboratory benches or equipment. Laboratory doors
shall not be less than 1 m wide to allow easy access of equipment. In some
areas, double doors, 1.2 m wide, shall be provided for passage of large
equipment, such as deep-freezes. All doors shall be opened towards the
corridor.

6.10.2.9. The primary hospital laboratory shall have the following premises
setup.

a) Waiting area
b) Recording and reporting room
c) Specimen collection room
d) Serology, parasitology and urinalysis room
e) Hematology and Clinical Chemistry room
f) Bacteriology room
g) Store-room
h) Staff room
i) Separate Toilets for patients (1 for Male and 1 for female)
j) Separate Toilet for staff (Male and female)
k) There shall be access to emergency shower
6.10.2.10. The primary hospital may arrange the laboratory service in one main
working room except bacteriology with access to emergency shower, staff
room, waiting area, store and toilets
6.10.2.11. The laboratory facilities shall meet at least the following:
a) The laboratory shall have a reliable supply of running water. At least
two sinks shall be provided in each room, one for general laboratory
use and the other reserved for hand washing and shall have access to
hospitals reserve tank whenever there is water interruption.
b) Continuous power supply
c) Working surface covered with appropriate materials
d) Suitable stools for the benches. Bench tops shall be impervious to
water and resistant to moderate heat and the organic solvents, acids,
alkalis, and chemicals used to decontaminate the work surface and
equipment.

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 e) Internal surfaces, i.e. of floors, walls, and ceilings shall be :
 Smooth, impervious, free from cracks, cavities, recesses, projecting
ledges and other features that could harbor dust or spillage
 Easy to clean and decontaminate effectively
 Constructed of materials that are non-combustible or have high
fire-resistance and low flame-spread characteristics
f) Laboratory furniture is capable of supporting anticipated loading and
uses. Spaces between benches, cabinets, and equipment are accessible
for cleaning.
g) Lockable doors and cupboards
h) Closed drainage from laboratory sinks (to a septic tank or deep pit)
i) Deep pit to discard contaminated material or access to a simple
incinerator
j) Separate toilets/latrines for staff and patients
k) Emergency of safety services such as deluge showers and eye-wash
stations, fire alarm systems and emergency power supplies shall be
included in the laboratory services design specifications

6.10.3. Professionals
6.10.3.1. All laboratory services shall be directed by a licensed medical laboratory
technologist.
6.10.3.2. Medical Laboratory staff shall be present at the hospital to provide
laboratory service at all times.
6.10.3.3. Students and other staff on attachment shall work under the direct
supervision of a licensed medical laboratory technologist.
6.10.3.4. The Laboratory service shall have and maintain job descriptions, including
qualifications to perform specific functions.
6.10.3.5. The Laboratory management shall provide adequate training, continuing
education or access to training for technical staff, and assess staff
competency at regular intervals.
6.10.3.6. Laboratory staff shall, at all times, perform their functions with adherence to
the highest ethical and professional standards of the laboratory
profession.

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6.10.3.7. The primary hospital shall have the following minimum laboratory staffing
requirements.
a) Medical Laboratory Technologists (BSc): #2
b) Medical Laboratory Technologist (BSc) for QC/QA: #1
c) Additional Laboratory technologist and technicians (depending on
the work load)
d) Supportive staff (clerk, cleaner)

6.10.4. Products

6.10.4.1. All equipment shall be in good working order, routinely quality controlled,
and precise in terms of calibration.
6.10.4.2. Laboratory shall establish a programme that regularly monitors and
demonstrates proper calibration and function of instruments, reagents
and analytical system and this shall be documented.
6.10.4.3. When equipment is removed from the direct control of the laboratory or is
repaired or serviced, the laboratory shall ensure that it is checked and
shown to be functioning satisfactorily before being returned to laboratory
use or operation.
6.10.4.4. Laboratory shall have a documented and recorded programme of preventive
maintenance which at a minimum follows the manufacturer’s
recommendation.
6.10.4.5. Equipment shall be maintained in a safe working condition. This shall
include examination of electrical safety, emergency stop devices.
Whenever equipment is found to be defective, it shall be taken out of
service and clearly labeled.
6.10.4.6. There shall be a written chemical hygiene plan that defines the safety
procedures to be followed for all hazardous chemicals used in the
laboratory. The plan defines at least the following:
a) The storage requirements
b) Handling procedures
c) Requirements for personal protective equipment
d) Procedures following accidental contact or overexposure

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e) The plan is reviewed annually, and updated if needed, and is part of
new employee orientation and the continuing education program.

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 6.10.4.7. The following minimum equipments and consumables shall be available in
the hospital.
Tests Major Equipment
Clinical chemistry:
 Blood glucose  Autoclave
 Liver function tests  Timer
o ALKP  Clinical chemistry
o AST analyzer(Automated or semi
o ALT automated)
o GGT  Glucometer
o Total bilirubine  Power surge protectors
o Direct bilirubine  Weighing balance
o Total protein  Micropipettes of different volumes
o Albumin  Timer with alarm
 Renal function tests
o Urea
o Creatinine
o Uric acid
Parasitology:  Microscope
 Stool microscopy  Slide
 Blood film for malaria and  Staining reagents
other hemoparasite/ Malaria  Rapid test kits
Rapid Test
Urine and body fluid analysis:  Microscope
 Urinalysis  Slide
 CSF analysis  Staining reagents
 Ascitic fluid  CSF analysis reagents
 Pleural fluid
Mycology:  Microscope
 KOH test  Slide
 KOH

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

 ESR  Binocular microscope x10, x40, x100

 Hematocrit  Haemocytometer

 Platelet count  Microhematocrit centrifuge

 Microhematocrit reader
 Differential counter
 Tally counter
 Deep freezer
 Centrifuge
 Timer
 Distillation unit
Serology:  All serological test kits
1. H.Pylori  Shaker
2. HBs Ag
3. HCV
4. ASO
5. RF
6. RPR
7. Salmonella Typhi-O
8. Salmonella Typhi-H
9. Proteus-OX19
10. HIV-test
11. HCG
12. Blood Group: Anti-A, Anti-B, Anti-
D, Compatibility testing and Cross
match
Bacteriology:  All necessary bacteriology equipments
 Gram stain, Ziehl Neelson stain
and Indian Ink

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6.11 Pharmaceutical Services
6.11.1. Practices
6.11.1.1. Dispensing and Medication Use Counseling
a) Standard operating procedure for dispensing and medication use counseling
shall be established to ensure patients’ safety and correct use of
medications.
b) The dispensers shall make sure that prescriptions are legible, written by
authorized prescriber and complete. Prescription papers shall be
standardized and must contain at least the following information and the
prescriber shall complete all these information:
 Name of patient, sex, age, weight and card number
 Diagnosis and allergy
 Name of the medicine, strength, dosage form, dose, frequency, and
route of administration
 Duration of treatment
 Prescriber’s name, qualification, license number and signature
 Dispenser’s name, qualification, license number and signature
 Hospital name and address
c) The pharmacist shall check the correctness of prescriptions in terms of
appropriateness for the patient, dosage, and drug interactions based on
approved national standard treatment guidelines before dispensing”
d) All medicines shall be dispensed with adequate and appropriate information
and counseling to patients for correct use of their medications.
e) Pharmacists shall be required to make an in-depth professional judgment to
make sure that each medicine and its dosage form has all of its attributes of
quality and an acceptable ratio of safety.
f) The containers used for dispensing shall be appropriate for the medicines
dispensed and all containers intended for medicines shall be protected and
kept free from contamination, moisture and light.
g) All medicines to be dispensed shall be labeled and the labels shall be
unambiguous, clear, legible and indelible. The following minimum
information shall be indicated on the label/sticker:

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  The generic name of the medicine or each active ingredient,
where applicable;
 The strength, dose, frequency of administration and total
quantity;
 The name of the person for whom the medicines are dispensed;
 The directions for use and route of administration tailored to
patient or caregiver literacy and language;
 The name of the dispenser;
 Date of dispensing;
 Expiry date/beyond use date and
 Special precautions as applicable
h) Filled prescriptions shall be signed and accountability must be accepted by
the dispensing pharmacist.
i) Each primary hospital shall establish and implement policies, guidelines
and/or procedures for reporting any errors or any suspicion in
administration or provision of prescribed medications. Errors shall be
reported to the prescriber in a timely manner upon discovery and a written
report of the error prepared and documented. Any suspicion or error shall
be communicated to the prescriber and clarified/corrected before
dispensing without affecting patient’s confidence on medical practices.
j) The pharmacy shall keep individualized information for patients with
chronic illnesses medication program using standardized information
tracking formats and update patient medication profile during each refill
visit.
k) The counseling of patients or their caregivers shall be undertaken to
promote the correct and safe use of medicines. The responsible pharmacist
must ensure that patients are counseled before they receive medicines that
they are to self-administer.
l) The pharmacist shall assess each patient's ability to understand the
information imparted by question and answer and must be able to modify
his/her approach accordingly. Care shall be taken with counseling where
understanding is likely to be a problem.

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 m) Cautionary instructions and ancillary information about medications shall
be communicated in writing to the personnel responsible for administering
medications.
n) If the hospital prepares extemporaneous preparations, it shall comply with
the standards prescribed for hospital based medicine preparations.
6.11.1.2. Control of Drug Abuse, Toxic or Dangerous Drugs
a) The primary hospital shall establish Policies and procedures to control
the administration of narcotic drugs and psychotropic substances with
specific reference to the duration of the order and the dosage in
accordance with relevant laws.
b) A record of the stock on hand and of the dispensing of all these drugs
shall be maintained in such a manner that the disposition of any
particular item may be readily traced.
c) All controlled substances (narcotic and psychotropic drugs) shall be
dispensed to the authorized health professional designated to handle
controlled substances by a licensed pharmacist in the hospital. When the
controlled substance is dispensed, the following information shall be
recorded into the controlled substances (proof-of-use) record.
 Name and signature of pharmacist dispensing the controlled
substance
 Name and signature of authorized health professional receiving
the controlled substance.
 The date and time controlled substance is dispensed.
 The name, the strength, and quantity of controlled substance
dispensed.
 The serial number assigned to that particular record, which
corresponds to same number recorded in the pharmacy's
dispensing record.
d) When the controlled substances are not in use, they shall be maintained
in a securely locked, substantially constructed cabinet or area. All
controlled substance storage cabinets shall be permanently affixed.
Controlled substances removed from the controlled substance cabinet
shall not be left unattended.

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e) The administration of all controlled substances to patients shall be
carefully recorded into the standard record for controlled substances
and returned back to the pharmacist upon refill of controlled substances.
The following information shall be recorded during administration to
patients.
 The patient's name, card number
 The name of the controlled substance and the dosage
administered.
 The date and time the controlled substance is administered.
 The signature of the practitioner administering the controlled
substance
 The wastage of any controlled substance, if any.
 The balance of controlled substances remaining after the
administration of any quantity of the controlled substance
 Day-ending or shift-evening verification of count of balances of
controlled substances remaining and controlling substances
administered shall be accomplished by two (2) designated
licensed persons whose signatures shall be affixed to a permanent
record.
f) All partially used quantities of controlled substances shall be recorded in
to the control substance record and returned back to the responsible
pharmacist for disposal.
g) All unused and unopened quantities of controlled substances which have
been removed from the controlled substance cabinet shall be returned to
the cabinet by the practitioner at the end of each shift.
h) Any return of controlled substances to the pharmacy in the hospital shall
be documented by a licensed pharmacist responsible for controlled
substance handing in the hospital.
i) The hospital shall implement procedures whereby, on a periodic basis, a
licensed pharmacist shall reconcile quantities of controlled substances
dispensed in the hospital against the controlled substance record. Any
discrepancies shall be reported to the Director of the respective medical
services and to the Chief Clinical Officer/Chief Executive Officer of the

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 hospital. Upon completion, all controlled substance records shall be
returned to the hospital's pharmacy by the designated responsible
person.
j) The hospital shall submit regular report to the appropriate organ
regarding the consumption and stock of controlled drugs.

6.11.1.3. Inpatient Pharmacy Services

a) The hospital through drug and therapeutic committee shall establish

policies and procedures for the provision of inpatient pharmacy services
b) The inpatient pharmacy shall comply with the standards stated under
dispensing and medication use counseling when appropriate
c) The hospital shall have one inpatient pharmacy managed by a licensed
pharmacist.
d) The hospital shall have a mechanism to ensure the appropriate use of
medications and supplies in different wards
e) The responsible pharmacist shall have access to patient specific
medication therapy information
f) There shall be a mechanism for consultation on medication use among
the prescriber, pharmacist, nurse and patient
g) The pharmacist shall review, monitor and propose for modification of
the therapeutic plan in case of adverse effects, patient noncompliance,
evidence based efficacy problem and as appropriate, in consultation
with the patient, prescriber and nurse.
h) Medication education shall be delivered to patients or their caregivers
upon discharge by the pharmacist as appropriate.
i) As a member of the health care team, the pharmacist shall attend and
participate at multidisciplinary ward rounds/morning meetings and
contribute to patient care through the provision of medicine
information, dose calculations and adjustment, assisting in the rational
prescribing decision, alternative regimens and reducing the frequency
and duration of medication errors.

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

6.11.1.4. Emergency Pharmacy Services

a) Emergency pharmacy service shall be available for 24 hours a day
during non-working hours the pharmacist shall prepare and complete
the emergency trolley.
b) Orders received by words of mouth or through telephone during
emergency (in case of immediate administration is necessary, no
appropriate alternative treatment is available and when it is not
reasonably possible for the general medical practitioner to provide a
written prescription prior to dispensing) shall latter be endorsed by the
prescriber and be documented in writing within 24 hours. The quantity
shall be limited to emergency period only.
c) The responsible pharmacist shall take the duty to coordinate and
prepare emergency medicines lists and ambulance kits for the hospital
based on national primary hospital’s medicine list and he/she has to
exert all the necessary efforts to ensure continuous availability of
medicines for emergency unit and hospital ambulances.
d) The emergency pharmacy, in addition to supply of medicines, shall
record patient medication information and ensure correct use of
medications.

6.11.1.5. Adverse Drug Event/ Pharmacovigilance

a) The primary hospital pharmacy shall appoint an ADE (adverse drug
event) focal person responsible for the collection, compilation, analysis
and communication of adverse drug reaction, medication error and
product quality defect related information to the DTC and appropriate
organ.
b) Health professionals of the hospital shall be responsible to report
suspected ADE cases to the ADE focal person.

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 c) DTC shall discuss and make necessary recommendations to the hospital
management for decision on adverse drug event reported within the
facility.
d) The primary hospital pharmacy shall consistently update the safety
profile of medicines included in the formulary list for immediate
medicines use decisions and consideration during the revision of the list.
e) Adverse medication effects shall be noted in the patient’s medication
record
f) All the ADE reports, patient identity, reporters and medicine trade
names shall be kept confidential until verified by concerned authority.
g) The reporting of ADE shall be done by the national ADE prepaid yellow
form prepared by FMHACA.

6.11.1.6. Medicines Supply and Management

a) A drug and therapeutics committee (DTC) representing different service
units of the hospital shall be in place for selection of medicines and other
medical items and developing the formulary list as well as policies and
guidelines on managing medicines based on the medicine lists for
primary hospitals.
b) The purchase of medicines shall be the responsibility of a pharmacist
who is assigned to manage and control the hospital central medical
store.
c) The primary hospital shall have written policies for the procurement of
medicines from government and private suppliers. These policies shall
be prepared by the DTC and approved by the management/board of the
hospital. The procurement policy must ensure at least:
 The right source of medicines
 Medicines availability
 Safety, quality and efficacy of medicines
 Transparency of the procedure and documentation
 Minimal decision points
 Flexibility to respond for emergency situations
 Compatibility with the state and national laws of the country
 Effective batch recall of medicines when necessary

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d) A pharmacist shall not purchase any medicinal product where he/she
has any reason to doubt its safety, quality or efficacy.
e) The pharmacist shall ensure that both the supplier and the source of any
medicine purchased are reputable and licensed by the appropriate
organ.
f) The hospital central medical store shall be responsible to display or
disseminate new arrivals or alternative medicines to each service
delivery points.
g) The hospital shall be responsible to make sure that medicines promotion
made by suppliers or manufacturers in the hospital premises is made by
a licensed pharmacist in accordance with the country’s laws.
h) The hospital shall be responsible to make sure that donation of
medicines has been made in accordance with the country’s laws.
i) There shall be a pharmacist assigned as medicine Supply Management
Officer that is responsible for the procurement, stock management,
warehouse management, distribution of medicines and disposal of
medicine waste. There shall be also a responsible pharmacy personnel
assigned for receiving, storage, issuing, recording, monitoring and
reporting.
j) The storage condition shall provide adequate protection to the
medicines from all environmental factors until the medicines is
delivered to the patient.
k) The responsible pharmacist must ensure that all areas where medicines
are stored are of acceptable standards (palletized or shelved, easy for
free movement, ventilated, rodent free, temperature and moisture
controlled and others) for a medicine store.
l) The responsible pharmacist shall ensure that all medicine storage areas
are inspected regularly to ensure that:
 Medicines are stored and handled in accordance with the
medicines manufacturer’s requirements and this standard
 Expired or obsolete medicines are stocked separately until
disposition

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  Medicines requiring special environmental conditions shall be
stored accordingly
 Temperature and humidity are maintained according to
manufacturer’s requirement
 Stock levels are adequate to ensure the continuous supply and
acceptability of medicines at all times, including the availability of
essential medicines.
 Inflammable substance are stored separately and in an
appropriate manner
 Disinfectants and preparations for external use are stored
separately from medicines for internal use
m) Special storage conditions shall be maintained for medicines requiring
cold chain system, controlled substances, inflammable substances and
medical gases, if any.
n) Firefighting equipment or system shall be installed to medicines storage
places
o) Distribution of medicines within a hospital shall be under the direction
and control of a pharmacist and must be in accordance with the policy
developed by DTC. All issuing activities shall be made using official and
serially numbered vouchers.
p) There shall be written SOPs on how supplies of stock are to be
obtained from the medical store. Procedures must define normal action
to be taken by pharmacy personnel for routine stock replacement and
action to be taken in the case of incomplete documentation or other
queries.
q) Written procedures shall be available for the return of expired, damaged,
leftover and empty packs from outlets to medical store to prevent
potential misuse.
r) The responsible pharmacist shall ensure that adequate control
procedures are in place for all stock circulating at all outlets within the
hospital.

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 s) Daily medicine consumption at different outlets of the hospital shall be
recorded, compiled and analyzed for the appropriate supply and use of
medicines.
t) The hospital pharmacist who is responsible for the management of
medicines should conduct regular medicine use studies to ensure
maximum patient benefit from the formulary list

u) The primary hospital shall make every attempt to minimize the

amount of medicines waste generated in the hospital.

v) The DTC should be responsible for developing policies and guidelines on

how to organize and conduct medicines use studies.

6.11.1.7. Medicine/Drug Information Services

a) The hospital pharmacy shall be responsible to provide medicines
information services to hospital staff and patients
b) The medicine information service shall be part and parcel of the day-to-
day activities of the hospital and shall provide relevant and unbiased
information to health care professionals and the public.
c) The medicine information service shall include provision of reference
materials such as medical and medicines related books, journals,
medicine profiles, electronic information, CD-ROM, relevant formularies
and manufacturers' information and updated list of medicines available
in the hospital central medical store to health care professionals
d) The service shall be available at least during normal pharmacy working
hours.

6.11.1.8. Medicine Waste Management and Disposal

a) The disposal of medicine wastes shall be in compliance with the

medicines waste management and disposal directives issued by
FMHACA.

b) The primary hospital shall take responsibility, through supportive

policies and procedures for the environmental and societal safety by
efficiently managing the medicines wastes.

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 c) All personnels involved in medicines waste handling shall be trained
and/or well informed about the potential risks of hazardous medicines
waste and their management.
d) All personnels involved in handling medicines waste shall wear
protective devices like apron, plastic shoes, gloves, head gears and eye
glasses when appropriate.
e) General wastes shall be collected daily from the pharmacy and placed in
a convenient place outside the pharmacy to facilitate coordinated
disposal by the hospital.
f) Solid wastes from the pharmacy shall be categorized as “hazardous” and
‘non-hazardous” and shall be collected separately for proper treatment.
g) All hazardous chemicals spills shall be immediately reported to head of
the pharmacy or responsible person for safety (if available) to minimize
the risk and take immediate action.
h) Spillages of low toxicity shall be swept into a dust pan and placed into a
suitable container for that particular chemical and dispose accordingly.
i) medicines in single dose or single use containers which are open or
which have broken seals, medicines in containers missing medicine
source and exact identification (such as lot number), and outdated
medications shall be returned to the pharmacy for disposal.
j) The hospital shall form a medicines disposal committee to ensure safety,
accountability and transparency.
k) Disposal of medicines waste shall be supported by proper
documentation including the price of the products for audit, regulatory
or other legal requirements.

6.11.1.9. Recording

a) Each hospital shall maintain records to assure that patients receive the
medications prescribed by a medical practitioner and maintain records
to protect medications against theft and loss.
b) There shall be a standardized Prescription Registration Book for
recording prescriptions and dispensed medicine. A computerized

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 dispensing and registration system with backup can be used instead if
available.
c) Each patient with a chronic disease shall have a separate Patients
Medication Profile Card (PMP) that should be filled appropriately with
all the relevant information for each patient. A computerized system
with backup can be used instead if available.
d) Controlled and non-controlled prescriptions shall be documented and
kept in a secure place that is accessible only to the authorized personnel
for at least five and three years respectively.
e) Patient and medication related records and information shall be
documented and kept in a secure place that is easily accessible only to
the authorized personnel
f) Every transaction related with medicines should be recorded on stock
control cards and/or computerized stock control system in the medical
store and dispensaries.

6.11.1.10. Billing
a) Medicines shall be received and issued using standard receiving and
issuing vouchers with serial number licensed by the appropriate finance
bureau of the government. Issuing and receiving of medicines has to be
signed by both the receiver and issuer and approved by an authorized
pharmacist. Receiving and issuing vouchers shall have the following
minimum information.
 Name of medicines received and issued
 Unit of measurement, quantity and source (supplier’s or
manufacturer’s name) of medicines
 Expiry date and batch number
 Unit and total prices
 Date received and issued
 Name and signature of receiver and issuer
 Address of the hospital

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 b) All medicines issued from the dispensary shall be dispensed/sold using
standard sales ticket with serial number licensed by the appropriate
finance bureau. Sales tickets have to be signed and stamped.
c) Dispensing pharmacies shall use a standard stamp and seal for
approving legal transactions
d) Writing one bill for two clients shall be forbidden
e) The consumer has the right to know the exact price of a prescription
before it is filled
f) The hospital shall ensure that each customer has the right to get receipt
which has the following minimum information about medicines
dispensed.
 Name of patient
 Name and dosage form of medicines dispensed
 Unit of measurement and quantity
 Unit and total prices
 Date
 Signature of dispenser and cashier
 Address of the hospital
6.11.1.11. Organization Management and Quality Improvement
a) A multidisciplinary drug and therapeutic committee chaired by the
medical director and supported by a licensed pharmacist representing
the hospital pharmaceutical services as a secretary must be functional
for the overall improvement of pharmaceutical services in the hospital
b) The pharmaceutical services shall be represented by a licensed
pharmacist in every management meetings of the hospital.
c) Customer satisfaction survey on pharmaceutical services shall be
conducted at least once in a year and measures shall be taken in
accordance with survey findings.
d) There shall be a program of continuous quality improvement for the
pharmaceutical service that is integrated into the hospital continuous
quality improvement program and includes regularly collecting and
analyzing data to help identify pharmaceutical service problems and

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 their extent, and recommending, implementing, and monitoring
corrective actions on the basis of these data.
e) The pharmaceutical service shall have in effect a patient profile system
for monitoring medicine therapy. This system shall be used by the
hospital to identify inappropriate prescribing practices and develop
interventions.
f) The medicines supply and management officer shall inspect all patient
care areas in the hospital, where medicines intended for administration
to patients are stored, dispensed, or administered at least once every
two months. The pharmaceutical service shall maintain a record of the
inspections and action taken for identified problems.
g) A quality improvement program of the pharmaceutical service shall
monitor, at a minimum, the use of medicines, including medication
errors and use of antibiotics. Serious or consistent patterns of
medication error shall be reported to the drug and therapeutics
committee or its equivalent for correction and this must be documented.
6.11.2. Premises
6.11.2.1. The design and layout of the pharmacy shall permit a logical flow of work,
effective communication and supervision and ensure effective cleaning
and maintenance and must minimize the risk of errors, cross-
contamination and anything else which would have an adverse effect on
the quality of medicines and service delivery.
6.11.2.2. The area(s) of counseling shall be arranged or constructed in such a manner
that it provides adequate space, have professional look and ensure
reasonable privacy to the patient at all times and eliminate background
noise as much as possible.
6.11.2.3. Dispensing counter shall be designed to secure patient privacy and
confidentiality
6.11.2.4. All parts of the premises shall be maintained in an orderly and tidy
condition.
6.11.2.5. The external appearance of pharmacies shall be painted white and inspire
confidence in the nature of the health care service that is provided and
portray a professional image.

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6.11.2.6. Entrances, dispensing counters and doorways shall be accessible to persons
with disability.
6.11.2.7. The dispensing environment (dispensing counter and counseling area) shall
ensure confidentiality and allow simultaneous service delivery for
multiple customers by multiple providers.
6.11.2.8. A waiting area(s), which is under cover, shall be situated near the dispensing
area, areas for counseling/consultation and the provision of information.
6.11.2.9. The pharmacy premises shall be clearly demarcated and identified from the
premises of any other business or practice. The location of the pharmacy
premises shall take into account patient convenience and ease of loading
and unloading of medicines.
6.11.2.10. Careful consideration shall be given to the overall security of the
pharmacy. It must be lockable and shall prevent any unauthorized entry.
6.11.2.11. A security policy shall be implemented which is designed to ensure the
safety of both staff and medicines, and shall take account of local crime
prevention advice.
6.11.2.12. The responsible pharmacist of a pharmacy shall ensure that every key
which allows access to a pharmacy is kept only with him/her or the
designated personnel.
6.11.2.13. A procedure shall be in place to ensure access to pharmacy premises in an
emergency situation.
6.11.2.14. Ceilings, floor and walls of dispensaries and store shall be constructed to
protect safety of medicines from burglary, rodents, direct sunlight,
moisture and damages.
6.11.2.15. Medicines shall be shelved a minimum of 20cm above the floor, 1m wide
between shelves and 50cm away from the wall and ceiling. If pallets are
used, there shall be 20cm above the floor, one meter between pallets and
50cm away from the wall
6.11.2.16. The pharmacy premises shall have the following minimum space

a) Waiting area

b) Inpatient dispensing room

c) Outpatient dispensing with counseling room

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 d) Compounding room, optional

e) Cashier room

f) Medical store intended for medicines, vaccines, lab reagents

and medical equipments storage

g) Office and duty room

h) Staff toilet (female and male)

6.11.3. Professionals
6.11.3.1. The overall hospital pharmaceutical services shall be directed by a licensed
pharmacist
6.11.3.2. In addition, the hospital shall have licensed pharmacists at least one for each
of the following pharmacies:
a) Outpatient pharmacy
b) Inpatient pharmacy
c) Emergency pharmacy and Central medical store and
d) Pharmacy technicians as appropriate
6.11.3.3. The number of dispensing pharmacists shall be increased based on
workload analysis.
6.11.3.4. The dispensing of all prescriptions and medication use counseling shall be
carried out by licensed pharmacists and pharmacy technicians to their
levels.
6.11.3.5. The pharmacist who is working at the inpatient pharmacy shall serve as ADE
focal person for the hospital.
6.11.3.6. The hospital shall have written policies and procedures for pharmacy
workforce determination, recruitment, performance evaluation, staff
development and other related issues.
6.11.3.7. The hospital pharmacy shall have pharmacy clerks, cashiers, cleaners and
porters.
6.11.3.8. The responsible pharmacist shall ensure that written job descriptions are
prepared for all staff and that all staff are acquainted with their job
descriptions and responsibilities.

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

6.11.4. Products

6.11.4.1. The hospital may have its own medicine list in accordance with the
prevailing diseases epidemiology and within the framework of the
national primary hospitals medicine list prepared by FMHACA.
6.11.4.2. There shall be adequate, suitable dispensing equipment in the dispensary.
Each item must be clean, in good repair and of suitable material.
Equipment shall be specific for each service which may be provided in the
pharmacy.
6.11.4.3. The hospital’s outpatient, inpatient and its central medical store shall have
fire extinguisher, refrigerators, deep freezers, security alarms and
racks/shelves.
6.11.4.4. The medicine information service in the pharmacy shall maintain a current
collection of reference materials such as books, journals, drug profiles,
electronic information, relevant formularies and manufacturers'
information and other furniture.
6.11.4.5. Hand-washing facilities shall be provided in the toilet area together.
Facilities must include readily available water, soap and clean towels or
other satisfactory means of drying the hands.

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6.11.4.6. The hospital pharmacy shall be provided with consistent electricity,
telephone, office furniture and optional facilities such as internet services,
computers and other necessary supplies.

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6.11.4.7. In summary, minimum standard for pharmacy equipment and
facilities at different service delivery points shall be as follows.

Pharmaceutical Service Delivery Points

Equipment and facilities
outpatient Inpatient Medical Store
Pharmacy pharmacy
1. Refrigerators and deep x x x
freezers with
thermometer
2. Wall thermometers x x x
3. Ventilator or AC as x x x
required
4. Hygrometer x x
5. Tablet counter x x
6. Scientific calculator x x x
7. Table and chair x x x
8. Scissors x x x
9. Adult and pediatric x x
weighing balance
10. Electric light x x x
11. Tape water access x x x
12. Toilet and shower x x x
13. Telephone line x x x
14. Internet facility access x x x
(optional)

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6.12 Ambulance Services
6.12.1. Practice
6.12.1.1. The ambulance service shall be provided to every emergency patient who
needs the service without any prerequisite and discrimination
6.12.1.2. The ambulance service shall be available 24 hrs a day and 365 days a year
6.12.1.3. The ambulance service shall provide the following services to patients with
urgent need of medical attention or in a medical emergency
a. Transportation service from the hospital to other health facilities
b. Clinical examinations including brief history, vital signs, very pertinent
physical examination and glucose test when needed
c. Clinical life saving support that includes:
 Fluid resuscitation
 Bleeding control
 Air way cleaning , oxygen administration, severe asthma management
 Attending labor
 Immobilizing a fracture
 Providing anti-pain
 Managing seizure
 Providing emergency medicines like adrenaline, hydralazine, glucose
etc
6.12.1.4. The ambulance service shall comply with the patient rights standards stated
under this standard.
6.12.1.5. Every procedure, medication and clinical condition shall be communicated
to the patient or family member or caregivers or next of kin
6.12.1.6. Up on arrival to the hospital the ambulance staff shall transfer the patient to
the emergency service. The handover of patients shall be accompanied by
a written document which at least includes identification, date, time and
services provided until arrival to the hospital.
6.12.1.7. If death happens on the way to a hospital the dead body shall be taken back
to the referring hospital and death shall be confirmed. Dead body care

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 shall be provided as per the standards stated under the morgue service
standard
6.12.1.8. Ambulances of the hospital shall serve only for designated emergency
medical services
6.12.1.9. After providing a service the vehicle shall be cleaned and disinfected
6.12.1.10. The ambulance kit shall be checked every time after providing the service
6.12.2. Premises
6.12.2.1. The parking of the ambulance car shall be within the hospital around
emergency service.
6.12.2.2. The hospital ambulance shall have telephone/radio communication means
with the command center (emergency service unit) for ambulances
6.12.2.3. The hospital shall have a command center, which is the emergency service
unit, for ambulance distribution which is equipped with a telephone/radio
to communicate with the public and the ambulance team
6.12.2.4. The ambulance car shall have adequate space for accommodating the
following:
(a) A couch
(b) One family attendant
(c) At least two nurses
(d) Medical items needed for providing immediate life saving support
6.12.2.5. The vehicle shall be labeled and have an alarm/siren
6.12.2.6. The vehicle shall have adequate internal light and ventilation
6.12.2.7. The vehicle shall fulfill requirements of road transport authority
6.12.3. Professionals
6.12.3.1. Minimum standards for personnel of the ambulance service shall include:
(a) Two nurses pulled from emergency service unit
(b) Licensed driver
6.12.3.2. The nurses shall be trained on emergency medical services
6.12.3.3. The driver shall be oriented on emergency situation management
6.12.4. Products
6.12.4.1. The ambulance service shall include the following medicines, supplies and
medical equipments:
(a) Medicines:

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

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6.13 Patient Flow

6.13.1. Practices
6.13.1.1. The hospital shall have a written protocol of patient flow which at least
describes the following:
(a) The presence, roles and responsibility of a receptionist at the gate
(b) Triaging of patients
(c) How to get into emergency and delivery services
(d) How to get into regular outpatient case teams and chronic illness case
teams
(e) How to be admitted if admission is needed
(f) How to get pharmacy, laboratory and other diagnostic services
(g) The process of discharge
(h) The procedures of payment for services
6.13.1.2. The hospital shall follow its written patient flow procedures

6.13.2. Premises
6.13.2.1. Waiting room for triaging with triaging station
6.13.2.2. Service areas shall be labeled in bold at a recognizable location
6.13.2.3. The office layout shall be arranged in a way that ensures patient
independence by labeling in bold and making related service provided in
adjacent rooms

6.13.3. Professionals
6.13.3.1. The hospital shall have runners to facilitate patient flow
6.13.3.2. Receptionists

6.13.4. Products
6.13.4.1. Wheelchairs
6.13.4.2. Stretchers with wheels

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6.14 Health Promotion Services
6.14.1. Practice
6.14.1.1. The hospital shall plan, schedule, coordinate, lead and monitor health
promotion activities
6.14.1.2. The hospital shall have a written policy and procedures for health
promotion. This shall include:
a. Content of health promotion package, the target groups and
implementation of this package as a part of the overall hospital quality
improvement system, aiming at improving health outcomes for patients,
relatives, staff and community.
b.Identifying responsibilities for the process of implementation, evaluation
and regular review of the promotion package.
c. Allocating resources to the processes of implementation, evaluation and
regular review of the promotion package.
d.Enlightening staffs on health promotion package.
e. Ensuring the availability of procedures for collection and evaluation of
data in order to monitor the quality of health promotion activities.
f. Ensuring that staff has relevant competences to perform health promotion
activities and supports the acquisition of further competences as
required.
g. Ensuring the availability of the necessary infrastructure, including
resources, space, equipment, etc. in order to implement health
promotion activities.
h.Providing information, education and communication (IEC) and
behavioral change communication (BCC) service to the general
population on major public health intervention areas such as but not
limited to:
 Environmental health
 Nutrition
 Family planning, MCH and immunization
 STI and HIV diseases

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  TB, leprosy, malaria, etc.
 Chronic diseases (Hypertension, diabetics, mental, etc)
 Substance abuse (alcohol, tobacco, etc)
 Prevention and control of out-breaks and epidemics
 Medication use
6.14.1.3. The hospital in partnership with patients shall systematically assess needs
for health promotion activities. This shall includes:
a. The availability of procedures for all patients to assess their need for
health promotion.
b. Procedures to assess specific needs for health promotion for diagnosis
related patient-groups.
c. The assessment of patients’ needs for medical services for health
promotion is done immediately after their hospitalization
d. The patients’ health information, provided to the hospital by primary
health services, should also be used in the identification of patients’
needs for health promotion
e. This is kept under review and adjusted as necessary according to
changes in the patient's clinical condition or on request.
f. The patients' need assessment ensures awareness of and sensitivity to
social and cultural background.
g. Information provided by other health service partners is used in the
identification of patient needs.
h. Patients’ satisfaction with the information, provided about their case,
and medical services for health promotion offered
6.14.1.4. The hospital shall provide patients with information on significant factors
concerning their disease or health condition and health promotion
interventions are established in all patient pathways. This shall include:
a. Based on the health promotion needs assessment, the patient is
informed of factors impacting on their health and, in partnership with
the patient, a plan for relevant activities for health promotion is agreed.
b. Patients are given clear, understandable and appropriate information
about their actual condition, treatment, care and factors influencing their
health.

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 c. Health promotion is systematically offered to all patients based on
assessed needs.
d. Information given to the patient and health promoting activities are
documented and evaluated, including whether expected and planned
results have been achieved.
e. All patients, staff and visitors have access to general information on
factors influencing health.
f. When necessary, an individual plan for medical services for health
promotion should be drawn up, being documented into the patient’s
medical file;
6.14.1.5. The hospital management shall establish conditions for the development of
the hospital as a healthy workplace. This shall include:
a. Development and training of staff in health promotion skills.
b. Implementation of a policy for a healthy and safe workplace providing
occupational health for staff.
c. Involvement of staff in decisions impacting on the staff's working
environment.
d. Availability of procedures to develop and maintain staff awareness on
health issues.
6.14.1.6. The hospital shall have a planned approach to collaborate with other health
service levels and other institutions and sectors on an ongoing basis. This
shall include:
a. Health promotion services are coherent with current health promotion
policies and health plans of the country
b. Cooperate with existing health and social care providers and related
organizations and groups in the community.
c. Availability and implementation of activities and procedures after
patient discharge during the post-hospitalization period.
d. Documentation and patient information is communicated to the relevant
recipient/follow-up partners in patient care and rehabilitation.
6.14.1.7. The health promotion committee shall highlight specific issues such as:
a. Health Promoting Hospitals as partners in the health care chain /
network and in healthy alliances; and

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 b. Investing in health for the future by promoting the health of children and
youth.
6.14.1.8. The hospital shall make sure that health promotion practice provides
unbiased and evidence based information.
6.14.1.9. Patient education shall be customer focused

6.14.2. Premises
6.14.2.1. The hospital shall have the following facilities:
a. waiting areas at different wards, follow up clinics
b. meeting hall

6.14.3. Professionals
6.14.3.1. A health professional shall be designated to coordinate health promotion
activities.
6.14.3.2. The roles and responsibilities of the designee in relation to health promotion
shall be specified in his/her job descriptions

6.14.4. Products
6.14.4.1. The hospital may have the following health promotional materials:
a. Printed material (Posters, Brochures, Leaflets, News paper, Health
bulletin)
b. IEC materials
c. Audio visual materials
d. Mini media
e. TV
f. VCD
g. DVD
h. Radio
i. Tape-recorded
j. Public health journals
k. Information desk
l. Internet

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6.15 Medical Recording
6.15.1. Practices
6.15.1.1. Medical record shall be maintained in written form for every patient seen at
all points of care including emergency, outpatient, labor & delivery,
inpatient and operation theatre.
6.15.1.2. The hospital shall maintain individual medical records in a manner to
ensure accuracy and easy retrieval. A patient shall have only one medical
record in the hospital. However, if the patient has lost his/her index card
number, the hospital shall provide a new one.
6.15.1.3. The medical information of a patient during ambulance service including
medication administered shall be documented and attached into the
medical record
6.15.1.4. The hospital shall establish a master patient index with a unique number for
each patient
6.15.1.5. Each piece of paper that contains a medical record shall have the
appropriate identification on the paper
6.15.1.6. The hospital shall have a written policy and procedure that are reviewed at
least once every three years which include at least:
(a) Procedures for record completion
(b) Conditions, procedures, and fees for releasing medical information
(c) Procedures for the protection of medical record information against
the loss, tampering, alteration, destruction, or unauthorized use.
6.15.1.7. When a medical record is taken out and returned to the record room it shall
be documented to create a good tracking mechanism
6.15.1.8. Any medical record shall be kept confidential, available only for use by
authorized persons or as otherwise permitted by law.
6.15.1.9. All entries in the patient's medical record shall be written legibly in
permanent ink (blue or black color), dated, and signed by the
custodian/recording person.
6.15.1.10. The medical record forms shall be prepared in line with the national/state
guideline and approved by the hospital management.
6.15.1.11. Each medical record shall at least contain the following information:
Identification (name, age, sex, address)

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

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 transfer his/her medical record shall be respected. Patient will get
information from the regulatory body regarding the location of their
medical records.
6.15.1.21. The hospital shall establish a procedure for removal of inactive medical
records from the central medical record room.
6.15.1.22. Medical records shall be destroyed as per the law by using techniques that
are effective enough to assure confidentiality of medical records. However,
records which are active for more than ten years shall not be destroyed.
6.15.1.23. There shall be computerized medical recording system
6.15.1.24. There shall be collection, compilation, processing and reporting system

6.15.2. Premises
6.15.2.1. There shall be a separate medical record room
6.15.2.2. The premises shall have one meter wide space in between and around
shelves. The medical records shall be shelved 20-30cm above from the
floor.
6.15.2.3. The medical record room shall have adequate space to accommodate the
following:
(a) Central filing space
(b) Work space
(c) Archive space
(d) Supply/Storage room
6.15.2.4. The medical record room shall have adequate light and ventilation
6.15.2.5. The medical record room shall be built far from fire sources
6.15.2.6. There shall be a room for archiving dead files until they are permanently
destroyed

6.15.3. Professionals
6.15.3.1. There shall be a full-time custodian/medical record personnel (Health
Information Technician or statistician or any person trained on data
collection and processing) with basic computer skill and ability to organize
medical records responsible for medical records management

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6.15.3.2. Other additional staffs (like card sorter and runner) to perform patient
registration, retrieving, filing and recording chart location.
6.15.3.3. The actual number of staff shall be determined based upon the total number
of active charts in a day (Workload analysis)
6.15.3.4. The hospital shall provide basic training on medical record keeping to the
staffs

6.15.4. Products
6.15.4.1. The Medical record room shall have:
(a) Shelves
(b) Master patient index boxes
(c) Computer
(d) Cart
(e) Ladder
(f) Patient folder
(g) MPI Cards
(h) Log book
(i) Fire extinguisher

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6.16 Morgue Services

6.16.1. Practices
6.16.1.1. The hospital shall have written policies and procedures for morgue
(dead body care) services. These policies shall delineate the
responsibilities of the medical staff, nursing and morgue services staff
and shall include procedures for at least the following:
a. Identification of the body, recording and labeling
b. Safe and proper handling of the body to prevent damage and this shall
be according to the patient religion and culture
c. Treatment of the dead body with formalin
d. Safeguarding personal effects of the deceased and release of personal
effects to the appropriate individual
e. Proper handling of toxic chemicals by morgue and housekeeping staff
f. Infection control, including disinfection of equipment as per IP standard
g. Identifying and handling high-risk and/or infectious bodies
h. Release of the body to the family shall be as immediately as possible
6.16.1.2. There shall be a death certificate issued by authorized general medical
practitioner or health officer for each death and this shall be
documented.
6.16.1.3. The service shall be available for 24 hours a day and 365 days of a year
6.16.1.4. Any dead body shall pass through morgue after the confirmation by the
general medical practitioner or health officer
6.16.1.5. Dead body discharge shall be through the morgue exit
6.16.2. Premises
6.16.2.1. The morgue premises shall fulfill at least the followings:
(a) Dead body care taking room
(b) Adequate Water supply
(c) Well ventilated
(d) Adequate supply of light
(e) Office

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6.16.3. Professionals
6.16.3.1. Morgue attendant and cleaner
6.16.4. Products
6.16.4.1. If there is a refrigerated space in the morgue, this shall be maintained at
temperatures between 32 and 45 degrees Fahrenheit (0 and 6.6
degrees Celsius) and shall have an automatic alarm system that
monitors the temperature.
6.16.4.2. In addition, the following products shall be available for morgue
services:
(a) Plastic sheets (m) Head cover
(b) Aprons (n) Goggles
(c) Stretcher (o) Disinfectants
(d) Knives (p) Plastic bags
(e) Scalpels (q) White clothes
(f) Scissor (r) Body table with hot
(g) Formalin and cold water sink
(h) Detergents (s) Cupboard for
(i) Cotton instrument
(j) Gloves (t) Scale
(k) Boots (u) Syringe 30cc, 50cc
(l) Gowns

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6.17 Social Works Services

6.17.1. Practices
6.17.1.1. The primary hospital shall have social work service at least during
working hours
6.17.1.2. There shall be an organizational chart or alternative documentation
clearly delineating the lines of responsibility, authority and
communication for the social services.
6.17.1.3. The social work service shall have written policies and procedures that
are reviewed at least once every five years.
6.17.1.4. The policies and procedures concerning the social work services shall
address the following areas:
a) Counseling
b) Discharge management and planning
c) Social work assessment
d) Consultation and referral to support groups, centers and/or
organizations
e) Patient advocacy
f) Community liaison and education.
6.17.1.5. The social work service shall have a protocol to ensure that social work
services are offered to all needy patients.
6.17.1.6. Patient directory for those who received social service shall be available
in the hospital and shall be updated
6.17.1.7. The social work services shall have criteria for identifying at the time of
admission and promptly assessing high-risk patients in need of
psychosocial intervention and/or discharge planning.
6.17.1.8. The social work service shall participate in the development and review
of the hospital's agreements with extended and long-term care
facilities.
6.17.1.9. There shall be a system for clinical staff to refer patients directly to the
social work service

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 6.17.1.10. The social worker shall consult members of other disciplines providing
patient care and services.
6.17.1.11. Each patient who has received social work intervention shall be
informed that he or she may call the social work service for questions
after discharge.
6.17.1.12. Patient’s families or guardians should be included in services provided
by the social work service, where indicated.
6.17.1.13. The social work service shall assist patients directly or indirectly in
identifying the need for implementing and verifying guardianship as
part of discharge planning.
6.17.1.14. The social work service shall report victims of abuse to the appropriate
body according to the Ethiopian laws.
6.17.1.15. When a patient is transferred or linked to another health care facility
after discharge, the social work service shall assure that relevant social
work service documentation or information is provided to the facility in
order to assure continuity of care.
6.17.1.16. When social work intervention is provided, a record shall be kept in
accordance with standards in the medical record. The record shall have
at least the following information
a) The reason for intervention
b) The name (s) of social workers involved and dates of intervention
c) A social work assessment
d) A treatment plan and referrals
e) Notes reflecting interventions before discharge.
6.17.1.17. Patients’ files, at social work service, shall be kept physically secure and
confidential.
6.17.1.18. All reasonable efforts shall be made for privacy in patient and family
interviews and in the handling of confidential phone calls by social
workers. .
6.17.1.19. Adoptions by individuals or groups shall abide the laws and regulations
of the country

6.17.2. Premises

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 6.17.2.1. The hospital shall have separate social work service area
6.17.2.2. At least a room shall be available for patient and family interview and
handling of confidential phone calls & archive

6.17.3. Professionals
6.17.3.1. All social work services given by the hospital shall be under the direct
supervision of a social worker/sociologist/nurse psychiatrist/ a nurse
with experience in social work
6.17.3.2. All the social work staff shall be given multidisciplinary patient care
training and the information about their training shall be documented.

6.17.4. Products
6.17.4.1. The social work service unit shall have the following products and
facilities:
a) Telephone
b) The necessary forms for referral, adoption and transfer
c) Filing cabinet

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6.18 Infection Prevention
6.18.1. Practices
6.18.1.1. The infection control program shall review areas of potential risk
and populations at risk and shall be effectively and efficiently
governed and managed.
6.18.1.2. The hospital shall identify the procedures and processes associated
with the risk of infection and shall implement strategies to reduce
infection risk.
6.18.1.3. The hospital shall perform the following infection risk-reduction
activities:
a) equipment cleaning and sterilization
b) laundry and linen management
c) disposal of infectious waste and body fluids
d) handling and disposal of blood and blood components
e) kitchen sanitation and food preparation and handling
f) operation of the mortuary area
g) disposal of sharps and needles
h) separation of patients with communicable diseases from patients
and staff who are at greater risk due to immunosuppression or
other reasons
i) management of hemorrhagic (bleeding) patients
j) Engineering controls.
6.18.1.4. The following written policies and procedures shall be maintained
a) Hand hygiene
 Standard precautions for hand hygiene
 Personal protective measures
 Monitoring and surveillance of hand hygiene practices
b) Transmission-based precautions
 Contact precautions
 Droplet precautions
 Airborne precautions

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

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  When cleaning patient areas.
 Gowns shall be worn when but not limited to:
 Performing surgical procedures,
 Splattering of blood or body fluids is possible,
 Handling bulk soiled linen (housekeeping),
 Performing waste collection for infectious waste,
 Handling any type of medical waste,
 Conducting hospital laundry washing.
 Masks, goggles, or other types of face shields shall be worn when but
not limited to:
 Splattering of blood or body fluids to the face is possible,
 Handling biohazardous and soiled linens
 Performing waste collection for hazardous or non-hazardous
waste.
c) Soiled patient-care equipment, textiles and laundry shall be handled
appropriately
d) Any type of face shield that is apparently soiled or splattered with body
fluids shall be washed and sterilized with a disinfectant.
e) Procedures shall be developed and implemented for routine care,
cleaning, and disinfecting environmental surfaces, especially frequently
touched surfaces in patient care areas.
f) Used needles shall not be recapped, bent, broken, or manipulated by
hand. Single handed scoop technique shall only be used when recapping
is required.
g) Safety features shall be used when available and used "sharps" shall be
placed in a puncture-resistant container specially designated bin for
hazardous waste.
6.18.1.6. There shall be transmission-based precautions and the hospital shall
have its own guideline for the followings:
a) Contact precautions as described in article 6.18.1.6
b) Droplet precautions
c) Airborne precautions( for diseases like SARS ,TB, Swine flu, etc)
 Isolation room

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  Negative pressure in relation to surrounding areas
 A minimum of 6-9 air exchanges per hour
 Air discharged outside the building and away from intake ducts, or
through a high-efficiency filter if re-circulated
 Door kept closed whether or not patient is in the room
 After discharge door kept closed until sufficient time has elapsed to
allow removal of airborne organisms
 Patient confined to room
 Room shall have toilet, hand washing and bathing facilities
6.18.1.7. The hospital shall have procedures in place to minimize crowding and
manage the flow of patients and visitors. This shall include
a) Patient crowd control
b) Assess urgent and non-urgent cases
c) Patient sign-in
d) Caregiver and visitor control.
6.18.1.8. The hospital shall train all staff on how to minimize exposure to blood
borne infections. These include:
a) Immediate first aid
b) Reporting exposures
c) Assign area for starter packs 24-hours access per day
d) Counseling and testing for exposed staff
e) Reporting and monitoring protocols
f) Evaluate PEP program
7.1.1.1 The hospital shall provide regular education on infection prevention and control
practice to staff, patients, and as appropriate, to family, visitors and caregivers
including the followings.
a) Prevention of the spread of infections,
b) Improving the quality of patient care,
c) Promoting safe environment for both patients and staff

6.18.2. Premises
6.18.2.1. There shall be the following facilities:
a) Working Office for IP officer

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 b) Meeting rooms for IP committee
6.18.2.2. The hospital shall have a designated sterilization room as per the
surgical service standards

6.18.3. Professionals
6.18.3.1. The hospital shall have an IP committee coordinated by assigned IP
trained physician or health officer or BSc nurse knowledgeable of
infection prevention principles and hospital epidemiology.
6.18.3.2. IP committee shall be trained on infection prevention as well as
hospital epidemiology
6.18.3.3. The IP committee shall be composed of professionals at least from the
following service units
a) Nursing care h) Laundry
b) Medical services i) Kitchen
c) Environmental health j) Instrument sterilization &
d) Housekeeping supply
e) Administration k) Occupational health & safety
f) Pharmacy l) Quality management
g) Laboratory
6.18.3.4. The infection prevention committee or designate shall have written
protocols, and procedures, and shall oversee the following activities
and this shall be documented:
a) Developing the health facility annual infection prevention and
control plan with costing, budgeting and financing
b) Monitoring and evaluating the performance of the infection
prevention program by assessing implementation progress as well
as adherence to infection prevention and control practice
c) Conducting surveillance to monitor nosocomial infections,
antimicrobial use and outbreaks of infectious diseases.
d) Formulating a system for surveillance, prevention and control of
nosocomial infections.
e) Reviewing surveillance data, reporting findings to management and
other staff and identifying areas for intervention

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 f) Assessing and promoting improved IPC practice within the hospital
g) Developing an IEC strategy on IP for health-care workers
h) Ensuring the continuous availability of supplies and equipment for
patient care management
i) Monitoring, providing data and measuring the overall impact of
interventions on reducing infection risk

6.18.4. Products
6.18.4.1. The hospital shall ensure that equipments and supplies necessary for
infection prevention are available
6.18.4.2. The hospital shall have the following adequate supplies and equipment
needed for infection prevention and control practice.
a) Waste management equipment and supplies:
Incinerator  Large garbage
Placenta pit bin
Wheelbarrows  Plastic garbage
Ash pit bags (optional)
Burial pit  Safety boxes
Garbage bins
b) Cleaning

Mop  Cleaning cloth

Bucket  Detergent

Broom  Bleach

Dust mop
c) Laundry
 Washing  Dryers
machine  Irons
 Sink  Wheelbarrows
 Washing basin (to transport
 (for linens to/from
decontaminatio wards)
n of linens)  Detergent
 Drying rack/line  Bleach
d) Instrument processing

 Autoclaves and steam sterilizers,

 Test strips
 Chemicals
 Commercial steamer

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  Boiler
 Oven
 0.5% chlorine solution (diluted bleach)
 Storage shelves for the medical equipment
 Disinfectant chemicals
 Brushes (tooth brush for small items)

e) Hand hygiene
 Sinks (ward and  Alcohol based
other areas) hand rub
 Water container  Personal Towels
with faucet  Paper Towel
 Soap

f) Personal Protective Equipment

 Heavy duty glove  Surgical/Disposable
 Surgical glove  Respiratory mask
 Examination glove  Other type of face
 (latex or nitrile) mask
 Other types (ex.  Plastic apron
those worn by  Other types
cleaning and laundry  Boots
staff)  Nurse shoes
 Eye shield  Other protective
 Goggle shoes
 Visors  Caps
 Dust mask  Face shield

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6.19 Hospital Sanitation and Waste Management
6.19.1. Practices
6.19.1.1. Hospital environment shall ensure the following conditions
a) sanitary, clean and safe environment
b) access to continuous, safe and ample water supply
6.19.1.2. There shall be written procedures to govern the use of sanitation
techniques in all areas of the hospital.
6.19.1.3. Sanitation techniques shall be regularly reviewed by the infection
prevention committee and documented as per Infection prevention
section of these standard
6.19.1.4. There shall be a written policy and procedures for ground water
treatment.
6.19.1.5. Infectious and medical wastes shall be handled and managed according
to the recent Health Care Waste Management National Guideline.
6.19.1.6. Infectious and non infectious medical waste contained in disposable
containers shall be placed for storage, handling, or transport in
disposable or reusable pails, cartons, drums, or portable bins. The
containment system shall be leak proof, have tight-fitting covers and be
kept clean and in good repair.
6.19.1.7. Reusable containers for infectious medical waste and general medical
waste shall be thoroughly washed and decontaminated each time and
emptied according to the recent Health Care Waste Management
National Guideline
6.19.1.8. Reusable pails, drums, or bins used for containment of infectious waste
shall not be used for containment of waste to be disposed of as
noninfectious waste or for other purposes except after being
decontaminated by procedures described in the latest Health Care
Waste Management National Guideline.
6.19.1.9. Placenta disposal pit shall be available in the hospital and shall be
secured

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6.19.1.10. Wastes shall be segregated and Segregation of health care waste shall
include the following procedures.
a) Separate different types of waste as per the national guideline
b) The hospital shall provide colored waste receptacles specifically
suited for each category of waste
c) Segregation shall take place at the source, like ward bedside, OR,
laboratory etc
d) There shall be 3 bin systems used to segregate different types of
waste in the hospital

Segregation category Color Container

Non risk waste Black bag or bin
Infectious waste yellow bag or bin
Sharp waste yellow safety box
Heavy Metal red secure container
Medicines vials, ampoules white bag or bin
Hazardous medicines and cytotoxic yellow bag or bin
wastes

6.19.1.11. Medical waste which is not infectious shall be disposed according to

Health Care Waste Management National Guideline by one of the
following methods:
a) By incineration
b) By sanitary landfill,
6.19.1.12. Treatment or disposal of infectious medical waste shall be performed
according to Health Care Waste Management National Guideline by one
of the following methods:
c) By incineration
d) By steam sterilization
e) By discharge via approved sewerage system
f) Recognizable human anatomical remains shall be disposed of by
incineration or internment, unless burial at an approved landfill is

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 specifically authorized by municipality and/or environmental
health professional.
g) Chemical sterilization
h) Gas sterilization (shall be handled safely)
6.19.1.13. The hospital shall routinely clean and sanitize patient areas and waiting
rooms at least twice daily and more when ever needed. Areas where
there is blood splash shall be cleaned immediately.
6.19.1.14. In order to maintain a clean and safe environment, the hospital shall
have an organized method for the transport and washing of linens.
6.19.1.15. The hospital shall have an organized waste disposal and removal
system and shall ensure the safe handling of all waste
6.19.1.16. Chemicals and radioactive waste shall be disposed according to
national guidelines
6.19.1.17. All generators of infectious medical waste and general medical waste
shall have a medical waste management plan that shall include the
following:
a) Storage of medical waste
b) Segregation of medical waste
c) Transport of medical waste
d) Disposal of medical waste
6.19.1.18. Sewage disposal shall be according to Health Care Waste Management
National Guideline and fulfill the following conditions:
a) Hospitals shall have a functional sewerage system
b) Hospitals shall dispose of all sanitary waste through connection to a
suitable municipal sewerage system
c) The hospital shall have only flushing toilet system
d) The hospital shall have a designated waste storage room for solid
waste or septic tank for liquid waste
e) There shall be written procedures defining instrument processing
procedures (disinfection and sterilization).
f) All fixtures located in the kitchen, including the dishwasher, shall be
installed so as to empty into a drain which is not directly connected
to the sanitary house drain.

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 g) Kitchen drain shall empty into a manhole or catch basin having a
perforated cover with an elevation of at least 24 inches below the
kitchen floor elevation, and then to the sewer.
6.19.1.19. The hospital shall have the following supportive sanitation measures
a) Clean water where there is no plumbing
b) Hand hygiene practice
c) Sterilization of medical instruments
d) Isolating infectious patient in special isolation room
e) Alternatives to protective equipment.

6.19.2. Premises
6.19.2.1. Placenta disposal pit shall have dimension of height 2.5m, width 2.5m.
Lateral to the disposal pit, the two sides shall be filled with concrete.
6.19.2.2. In addition, the hospital sanitary system shall have
a) Functional sewerage system
b) Adequate flushing toilets or ventilated improved pit latrine with
hand wash basin
c) Kitchen
d) Laundry
e) Sanitary office
f) Incinerator
g) Dumpster (Genda for solid waste accumulation)

6.19.3. Professionals
6.19.3.1. Hospital sanitation shall be administered by a licensed environmental
health or any related licensed professional trained on sanitary sciences
6.19.3.2. The hospital shall have the following personnel to conduct sanitation
activities.
a) Environmental health professional
b) waste handlers
c) Gardeners
d) Incinerator operator
e) Instrument processors (disinfector and sterilizer)

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 6.19.3.3. The hospital shall officially designate staff in charge of handling waste
on a regular basis.
6.19.3.4. The assigned staff shall be responsible for the collection and disposal of
waste products in the hospital in accordance with national guidelines
and this standard..
6.19.3.5. Continuing education shall be provided to all personnel engaged in
sanitation activities on the relevant procedures
6.19.3.6. Staff shall be oriented on personal protection methods

6.19.4. Products
6.19.4.1. The hospital shall have equipment and supplies required for sanitation
activities which includes:
a) Incinerator j) Autoclave
b) Ash pit k) Pressure cooker/dry
c) Burial pit oven
d) Placenta pit l) Cleaning supplies
e) Garbage bins (detergents,
f) Safety boxes disinfectants and
g) Trolley other cleaning
h) Dumpster (Genda) solutions etc)
shall be placed in a m) Laundry washers,
clean isolated and n) Laundry dryers,
fenced area. o) Mops and dust bins
i) PPE(personal
protective
equipments)

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6.20 Food and Dietary Services

6.20.1. Practices
6.20.1.1. The hospital shall provide nutritionally adequate meals, food
supplement supplies for inpatients and staffs on duty
6.20.1.2. The dietary service shall be available for 24 hours a day and 365 days a
year
6.20.1.3. The dietary service shall have written policies and procedures for all
dietary services including
a) Purchasing, preparation and handling
b) Meal distribution and/or request and receive special event service
for inpatients.
c) Special diet order
d) A diet manual detailing nutritional and therapeutic standards for
meals and snacks, and a nutrient analysis of menus.
e) Nutritional assessment guide for patients' nutritional needs for
food and food supplements.
6.20.1.4. A current diet manual shall be available at each nurse’s station and in
the dietary service unit.
6.20.1.5. There shall be a policy to promote the participation of the dietary
service in meetings of multidisciplinary health care teams to assess
patients.
6.20.1.6. All new admissions shall be listed with the dietary service immediately
6.20.1.7. Each patient's diet shall be recorded in the medical record. records of
diet instructions shall include:
a) The diet instruction provided to the patient and/or responsible
person.
b) Patient response, participation and understanding.
c) Written instructional material provided to the patient and/or
responsible person.

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6.20.1.8. A general medical practitioner/health officer shall write a specific
dietary order and /or nutritional supplements for each patient.
6.20.1.9. All diets shall be prepared in conformity with the hospital's dietary
manual.
6.20.1.10. At least three meals (breakfast, lunch and dinner) shall be served daily,
and no more than 15 hours shall elapse between dinner and breakfast.
6.20.1.11. Nourishment may be provided between meals and at night.
6.20.1.12. Changes in diet orders made by a general medical practitioner or health
officer shall be effected by the next mealtime.
6.20.1.13. The dietary service shall follow the policies and procedures developed
by the drug and therapeutics committee regarding possible food/drug
interactions.
6.20.1.14. There shall be a mechanism for evaluating patients on each nursing unit
to ensure they are being adequately nourished.
6.20.1.15. There shall be a mechanism for the dietary service to be informed if the
patient does not receive the diet that has been ordered, or is unable to
consume the diet.
6.20.1.16. There shall be a mechanism for patients and their families to interact
with the dietary service.
6.20.1.17. Patients with special dietary needs, based on criteria established by the
hospital, shall receive dietary instruction from a general medical
practitioner or health officer during hospitalization.
6.20.1.18. The dietitian or hospital catering chef shall provide diet information to
the Canteen staff for appropriate selections of food items during
purchase.
6.20.1.19. The dietitian or hospital catering chef shall provide nutrition
information as requested by the patient, family, or treatment team
including
a) diet instructions,
b) written instructional material,
c) community dietary referrals regarding special diets,
d) current diet order,
e) nutritional problems,

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 f) appetite,
g) nutritional counseling,
h) comprehension of diet instruction,
6.20.1.20. The dietitian or hospital catering chef shall provide dietary information
to the discharging patient as per the general medical practitioner or
health officer instructions or as planned by the treatment team.
6.20.1.21. Inpatient’s or discharged patient’s diet instructions shall include
education involving:
a) Therapeutic or modified diets
b) Food-drug interactions
c) Nutritional care for certain diagnoses/conditions
d) Recommendations for changes in diet order,
e) Treatment plan,
f) Significant food allergy (lactose, wheat gluten, Soya ,egg,
dairy)
6.20.1.22. Nutrition consultations
a) Nutrition consultations shall be completed immediately after general
medical practitioner’s order.
b) Nutrition consultations shall be individual or group, and may include
family and/or responsible person.
c) The dietitian or hospital catering chef shall determine the type and
frequency of follow-up care after the initial consultation. Follow-up
consultation may include evaluation of nutritional care, diet
education, or other nutritional concerns.
6.20.1.23. Treatment Planning
a) Therapeutic goals related to nutritional needs shall be based on the
following standards
 Standard Height/Weight
 Dietary Reference Intakes
 Nutrition-related laboratory values
 Body Mass Index for Adults
6.20.1.24. Diet Orders and Nutritional Supplements

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 a) General medical practitioner/health officer diet orders shall be
legible, concise and written in an understandable manner. The
following information shall be included in diet orders:
 Patient Name
 Unit
 Date
 Specific diet order; including food allergies/intolerances
 General medical practitioner’s or health officer signature
b) Dietary services shall receive written notification of:
 New diet orders
 Change in diet order
 Discontinued or canceled diet orders
 Unit transfers
 Isolation or special trays
c) All written diet orders shall be sent to dietary services immediately.
d) Special requests for meals or supplemental foods shall be provided
as ordered to accommodate alterations in diets or meal service
schedules due to new admissions, personal dietary needs, or other
circumstances.
e) Diabetic and Calorie-Controlled diet orders shall include the calorie
level desired.
f) The dietitian or hospital catering chef shall recommend appropriate
nutritional supplemental foods according to general medical
practitioner or health officer orders..
g) Dietary and nursing services shall be responsible to ensure dietary
compliance and quality nutritional care of patients
6.20.1.25. There shall be appropriate food safety and sanitations to ensure safe
food service for the patients.
6.20.1.26. Dry or staple food items shall be stored at least 12 inches off the floor in
a ventilated room which is not subject to sewage or waste water back-
flow, or contamination by condensation, leakage, rodents or vermin.

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6.20.1.27. All perishable foods shall be refrigerated at the appropriate
temperature and in an orderly food safety manner (cold and hot
holding principle).
6.20.1.28. Each refrigerator shall contain a thermometer in good working order.
6.20.1.29. Foods being displayed or transported shall be protected from
contamination.
6.20.1.30. Three compartments washing procedures and techniques shall be
developed and carried out in compliance with the national hotel and
catering sanitary control guideline.
6.20.1.31. All garbage and kitchen refuse which is not disposed of shall be kept in
leak proof non-absorbent containers with close fitting covers and be
disposed of routinely in a manner that will not permit transmission of
disease, a nuisance, or a breeding place for flies.
6.20.1.32. All garbage containers shall be thoroughly cleaned inside and outside
each time emptied.
6.20.1.33. Requests for alternative food supplies shall be considered on an
individual basis.
6.20.1.34. Foods shall be transported and served as close to preparation/re-
thermalization time as possible. Maximum cold food temperatures shall
be 5°C and minimum hot food temperatures shall be 60° C at time of
service.
6.20.1.35. Dietary services shall ensure prescribed diet compliance as well as
minimize food-borne illness.
6.20.1.36. Cancellations of ordered diets shall be made as soon as possible to
avoid possible spoilage and/or waste of food items.
6.20.1.37. Hospitals may provide dietary services by one of the followings:
a) In traditional configuration where the kitchen is located in the
hospital premise;
b) Provide the service directly, but may prepare the bulk of the
meals in a kitchen owned by the hospital, located off-site; and
c) Contract out for dietary services through an off-site vendor and
the contract shall be documented. However, regardless of how

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 the hospital provides the service, the hospital shall ultimately be
responsible for meeting the dietary service standards.
6.19.4.2. If the food dietary service is provided from an off-site location, the
hospital shall be responsible for the safety and quality of the foods,
Compliance with the dietetic policies and procedures in regards to meal
service for off hours’ admissions, late trays, food substitutions,
reasonable meal schedules, posting of current menus in the hospital as
well as in the off-site kitchen, tray accuracy, emergency food supplies
and deliveries
6.19.4.3. Catering hygiene shall fulfill the following conditions
a) There shall be guidelines for pest control and restricting the
presence of animals (eg. cats, dogs etc) visibly posted in the kitchen.
b) There shall be a system to screen and control the health of kitchen
personnel.
c) The responsible kitchen personnel health shall be controlled for:
 Personal hygiene including uniform (protective clothes)
 Periodical medical check-up for acute and chronic diarrhea and
other infectious diseases
 Those with infected open skin lesions are not allowed to work as
kitchen personnel.

6.20.2. Premises
6.20.2.1. The following minimum facilities shall be available for dietary services
a) Food preparation room
 All cooking appliances shall have ventilating hood
 Washing sink with three compartment
o Dish washing sink
o Pot washing sink
o Cart cleaning sink
o Can washing sink
b) Storage room
c) Cart storage.
d) Dietitian's or chef office.

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 e) Janitor’s closet
f) Personnel toilets with hand washing facilities
g) Approved fire extinguisher system in range hood.
h) Continuous electricity (power) supply
i) safe and adequate water supply

6.20.3. Professionals
6.20.3.1. The hospital shall have an organized dietary service unit directed by a
dietitian or hospital catering chef.
6.20.3.2. In addition, the hospital shall have the following food handlers:
(a) Meal distributors
(b) Catering Chef
(c) Kitchen workers
(d) Store keeper
(e) Bakers
(f) Dishwashers
6.20.3.3. The number of personnel, such as cooks, bakers, dishwashers and
clerks shall be adequate to perform effectively all defined functions
(based on workload analysis).
6.20.3.4. There shall be procedures to control dietary employees with infectious
and open lesions (controlling personal hygiene).
6.20.3.5. Food handlers shall meet routine health examinations according to the
Ethiopian Food Handlers’ Hygiene Guideline for food service personnel.
6.20.3.6. There shall be an in-service training program on proper handling of
food and personal grooming to dietary employees.
6.20.3.7. All kitchen workers shall wear protective kitchen clothes according to
the Ethiopian Food Handlers’ Hygiene Guideline.
6.20.3.8. A dietitian or hospital catering chief shall be a full-time employee.
6.20.3.9. Written job descriptions for all dietary employees shall be given,
oriented and documented.

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158
6.20.4. Products
6.20.4.1. The following products shall be available for dietary services:
a) Refrigerator
b) Kitchen utensils
c) Pots
d) Jars
e) Carts
f) Dishes
g) Oven
h) Knives
i) Detergent materials
j) Pressure cooker/dry oven
k) Stoves
l) Working closes (apron, boots, hair cover, gown, hand gloves, etc)
m) Lockers convenient to, but not in the kitchen proper
n) Barrel (garbage containers) for kitchen rest handling

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6.21 Housekeeping, Laundry and Maintenance Services
6.21.1. Practices

6.21.1.1. All areas of the primary hospital including the building and
grounds shall be kept clean and orderly.

6.21.1.2. The housekeeping service shall have the following sanitary activities.
a) Basic cleaning such as dusting, sweeping, polishing and washing
b) Special cleaning of
 Different types of floors
 Wall & ceiling
 Doors & windows
 Furniture & fixtures
 Venetian blinds
c) Cleaning and maintenance of toilet.
d) Water treatment, filtering & purification.
6.21.1.3. In the housekeeping service, the types and sources of offensive odors in
hospital premises shall be identified, controlled and removed
immediately
6.21.1.4. Collection, transportation and disposal of hospital wastes shall be
supervised and controlled
6.21.1.5. The safety of fire, electrical and natural hazards in the risk areas in the
hospital shall be supervised and controlled and shall work closely with
hospital fire brigade and safety committee.
6.21.1.6. The designee/ environmental health professional shall identify,
supervise and organize the control and eradication of pests, rodents
and animal nuisance in the hospital.
6.21.1.7. The housekeeping staffs shall create pleasant environment to patients,
staffs and visitors
6.21.1.8. The housekeeping staffs shall ensure proper lighting and ventilation in
different hospital areas.
6.21.1.9. The following LINEN services shall be provided in the hospital

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 a) Maintain an adequate supply of clean linens at all times
b) Obtain linen from stores and laundry.
c) Ensure proper storage of linen.
d) Supervise washing, sterilization in the laundry.
e) Maintain linen properly
f) Issues linen in service units like wards.
g) Keep proper accounting of linen.
h) Ensure proper sorting of linen.
i) Understand different color scheme.
6.21.1.10. If the hospital uses a laundry which is not owned by the hospital, it shall
maintain the sanitary standards of the hospital regarding the
processing of its linens and shall maintain a satisfactory schedule of
pickup and delivery.
6.21.1.11. Regular surveillance of overhead and underground tank, proper cover,
regular chlorination and cleaning shall be undertaken
6.21.1.12. The infection control measures shall be carried out in accordance with
the hospital infection prevention section of this standard.
6.21.1.13. There shall be reserve electrical generator for power supply for
continuous 24 hours.
6.21.1.14. Potable water and electrical services shall be available 24 hours a day
and 365 days a year.
6.21.1.15. The hospital shall conduct regular preventative maintenance for all
facilities and operating systems (e.g., electrical, water, ventilation) to
ensure patient and staff safety and comfort.
6.21.1.16. There shall be 24 hours maintenance service for all facilities
6.21.1.17. There shall be a hospital facility safety maintenance organization as
described below:
a) A multidisciplinary safety committee that develops a comprehensive
hospital-wide safety program and reviewed at least once every three
years and implemented accordingly.
b) A mechanism to report all incidents, injuries and safety hazards to the
safety committee.

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 c) The committee shall review all reports and be responsible for ensuring
that all reports are referred appropriately and follow-up action is
documented.
6.21.1.18. The primary hospital shall conduct regular routine and
preventative maintenance for all facilities and operating systems.
Maintenance shall consider the infection prevention and control
principles and measures
6.21.1.19. Facility maintenance services
a) The building maintenance service shall have written policies and
procedures for routine maintenance, preventive maintenance
and renovation maintenance.
b) The standby emergency generator shall be checked weekly, tested
under load monthly and serviced in accordance with accepted
engineering practices.
c) Floors, ceilings and walls shall be free of cracks and holes,
discoloration, residue build-up, water stains and other signs of
disrepair.
d) Routine inspections of elevators (if any) shall be conducted.
6.21.1.20. Construction and renovation
a) Whenever construction and renovation projects are planned in and
around a health care facility, a risk assessment shall be conducted to
determine the impact of the project on patient areas, hospital staff,
residents, natural resources like lakes and mechanical systems of the
existing premises.
b) The infection control program shall review areas of potential risk and
populations at risk.
6.21.1.21. There shall be written protocols and procedures for diagnostic
equipment maintenance service including:
a) Plan for equipment maintenance (both preventive and curative),
replacements, upgrades and new equipments
b) Safe disposal procedures
c) An effective tracking system to monitor equipment maintenance activity.

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 d) A monitoring method that ensures diagnostic equipment operates with
predicted specificity and sensitivity.
6.21.1.22. The maintenance personnel including the management of the
hospital shall take basic trainings on the following issues and this
shall be documented.

a) Building fabrics and utilities

b) Building services and economics

c) Planning maintenance demand

d) Preventive and routine maintenance practice

e) Maintenance with regard to IP and hygiene

6.21.1.23. Fire and emergency preparedness

a) The hospital shall comply with the National Fire Protection standard
b) All employees shall be trained in procedures to be followed in the event
of a fire and instructed in the use of fire-fighting equipment and patient
evacuation of hospital buildings as part of their initial orientation and
shall receive printed instructions on procedures and at least annually
thereafter.
c) A written evacuation diagram specific to the unit that includes
evacuation procedure, location of fire exits, alarm boxes, and fire
extinguishers shall be posted conspicuously on a wall in each patient
care unit.
d) Fire extinguishers shall be visually inspected at least monthly; fully
inspected at least annually, recharged, repaired and hydro-tested as
required by manufacturer's instructions and labeled with the date of the
last inspection.
e) Fire detectors, alarm systems and fire suppression systems shall be
inspected and tested at least twice a year by a certified testing agency.
Written reports of the last two inspections shall be kept on file.
f) There shall be a comprehensive, current, written preventive
maintenance program for fire detectors, alarm systems and fire

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 suppression systems that includes regular visual inspection. This
program shall be documented.
6.21.1.24. The hospital does not have its own housekeeping, laundry and
maintenance services; it may have a contract agreement with external
organizations. The hospital shall check and maintain the sanitary
standards of the hospital regarding the processing of its linens and shall
maintain a satisfactory schedule of pickup and delivery.
6.21.1.25. If the hospitals contract out for housekeeping, laundry and maintenance
services there shall be documented contractual agreement.
6.21.1.26. Housekeeping equipment or supplies used for cleaning in isolation or
contaminated areas shall not be used in any other area of the hospital
before it has been properly cleaned and sterilized.
6.21.1.27. There shall be frequent cleaning of floors, walls, woodwork and
windows.
6.21.1.28. The premises shall be kept free of rodent and insect infestations.
6.21.1.29. Accumulated waste material and rubbish shall be removed at frequent
intervals.
6.21.1.30. No flammable cleaning agents or other flammable liquids or gases shall
be stored in any janitor's closet or other area of the hospital except in a
properly fire rated and properly ventilated storage area specifically
designed for such storage.

6.21.2. Premises
6.21.2.1. If the hospital maintains its own laundry, it shall have separate areas
for:
a) Collection of soiled linens.
b) Washing, drying and ironing.
c) Clean linen storage and mending area.
6.21.2.2. The laundry design and operation shall comply with the manufacturer’s
requirements and/or institutional sanitation guideline
6.21.2.3. Clean linen storage shall be readily accessible to nurses' stations

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 6.21.2.4. Dirty linen storage shall be well ventilated and shall be located
convenient to the laundry or service entrance of the hospital. The
storage of appreciable quantities of soiled linens is discouraged.
6.21.2.5. There shall be separate space provided for the storage of housekeeping
equipment and supplies
6.21.2.6. A separate office shall be available for the maintenance and the
housekeeper.
6.21.2.7. Adequate space shall be available for service specific janitor’s closets
and cleaning equipment & supplies which shall be maintained
separately for the following areas (shall not be used for cleaning in any
other location):
f) Surgical suites
g) Delivery suites
h) Dietary service unit
i) Emergency service unit
j) Patient areas
k) Laboratories, pharmacy, radiology, offices, locker rooms and
other areas
6.21.2.8. Exits, stairways, doors and corridors shall be kept free of obstructions.
6.21.2.9. The hospital shall have an alternate emergency power supply. If such
emergency power supply is a diesel emergency power generator, there
shall be enough fuel to maintain power for at least 24 hours.

6.21.3. Professionals
6.21.3.1. The housekeeping, maintenance and laundry functions of the hospital
shall be under the direction of a licensed environmental health
professional.
6.21.3.2. The designated officer shall plan, organize, co-ordinate, control and
monitor all housekeeping activities.
6.21.3.3. The housekeeping, maintenance and laundry personnel shall take basic
trainings on the following issues and this shall be documented in their
personal profile.
a) Basic principles of sanitation and peculiarity to hospital environment.

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 b) Basic principles of personal hygiene
c) Basic knowledge about different detergent and disinfectants
d) Different cleaning procedures applicable to different hospital areas
e) Basic knowledge about cleaning equipments operation techniques and
their maintenance.
f) Different processes of water treatment & purification, removing
bacteria.
g) Basic principles of ventilation, composition of air, air flow, humidity and
temperature.
h) Common types of odors and their sources of origin, identification and
control.
i) Removal and control technique of different types of odors.
j) Various equipments and materials used for odor control operation.
k) Hospital waste, source and generation of waste
l) Hazards of hospital waste to hospital population and community.
m) Principles of collection of different types of hospital wastes
n) Operational procedures of equipments
o) Safety measures in operation
p) Hospital lay out, configuration work, flow of men, material and
equipment in different hospital areas. Air, water, noise, pollution, causes
of pollution and their control and prevention in hospital.
6.21.3.4. In addition the hospital shall have electrician, plumber, painter,
building maintenance technician, diagnostic equipment maintenance
technician

6.21.4. Products
6.21.4.1. The hospital shall have the following tools, equipment & materials for
housekeeping services.
a) Equipment:
 Reserve electrical generator
 Floor cleaning brush air
 Floor wiping brush
 Hockey type brush

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  Counter brush.
 Ceiling brush
 Glass cleaning / wiping brush.
 Scrappers
 Dustbins paddles.
 Waste paper basket.
 Plastic Mug
 Plastic Bucket
 Plastic drum
 Wheel barrow
 Water trolley
 Ladder
 Scraping pump
 Spraying pump
 Flit pump.
 Rate trapping cage
 Gum boots
 Gown, Masks & Gloves
 Torch
 Manual sweeping machine.
 Floor scrubbing/polishing machine
 Wet vacuum cleaner.
 Dry vacuum cleaner portable
 Fumigation machine (Oticare)
 Bed pan washer.
b) Cleaning material
c) Deodorants & disinfectant
d) Laundry cleaning material
e) Insecticides & rodenticides
f) Stain removal

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SECTION SEVEN: PHYSICAL PLANT STANDARDS

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

7.2. Site Selection Requirements

a) The entry points to the hospital shall be clearly defined from all major exterior
circulation modes ( roadways, bus stops, vehicle parking)
b) Boundaries of the hospital between public and private areas shall be well marked
and clearly distinguished. And clearly visible and understandable signage and
visual land marks for orientation shall be provided
7.1.1. The primary hospitals shall be located away from unordinary conditions of
undue noises, smoke, dust or foul odors, and shall not be located adjacent
to railroads, freight yards, grinding mills, chemical industries, gas depot
and waste disposal sites.
c) The locations of a hospital shall comply with all national and state level regulations
applicable to facilities.
d) In addition to these requirements stated above the site selection criteria shall
consider or include the followings, but not limited to:
a) The minimum size of a primary hospital premises shall be 5,000 -10,000
m2 with at least one side adjacent road access.
b) The hospital shall be built preferably in a terrain with a gentle slop
c) The foundation schemes, soil test and investigation shall be done and it
shall comply with the national building code.
d) The hospital shall be provided with road access, water supply, electric city
and communication facilities.
e) The building shall be parallel to the wind direction, sun glare and heat. In
case difficulties to fulfill these, there shall be technical solutions for such
natural effects.

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 f) The surroundings of the hospital shall be free from dangers of flooding,
landslide, theft, intrusion of stray/wild animals, pollution of any kind
(example air, water and sound) and health hazards.
g) The hospital shall be landscaped, therapeutic, appealing scenery, attractive
with green areas/beautiful trees and possible outdoor recreation facilities.

7.3. Construction Requirements

a) The appropriate organ shall be consulted before commencement of any facility

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

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 e) Upon completion of construction the appropriate organ shall inspect and issue a
license for operation of the hospital if all the findings are in conformity to this
standard.
f) In case of partial completion of construction, the appropriate organ may be
consulted to start lower level of health services in line with other standards.
This is applicable if only if the completed portion of the construction will not be
affected during the completion of the remaining part of construction.
g) Buildings designed for other purposes shall not be used for the operation of a
hospital unless it is remodeled in accordance with this standard.
h) All hospitals shall be designed, constructed, and maintained in a manner that is safe,
clean, and functional for the type of care and treatment to be provided.
i) All hospitals shall have at least two entry/exit sites and they shall be accessible to
roads.
a) Main public entrance
b) Emergency entrance
j) The construction shall comply with the following codes and guidelines to provide a
safe and accessible environment that is conducive to the care and treatment to
be provided:
a) The Ethiopian Building Proclamation 624/2009;
b) The Ethiopian Standard Building Code;
c) Life Safety Code (National Fire Protection Code);
d) National Electrical Design Code;
e) The Ethiopian Disability Code;
f) Other codes – ex. Sanitation codes, environmental protection laws, water
codes
k) Building entrances used to reach the outpatient & inpatient services and exit sites
shall be easily accessible, clearly marked/labeled and located, in order to
patients and visitors will have clear way finding.
l) Utilization of proper construction materials should be used in conformity to the
Ethiopian Building Code, that suit the health services delivery.

7.4. Building Space and Elements

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a) All horizontal and vertical circulation areas that include stairs, doors, windows,
corridors, exits and entrances of the hospital shall be kept clear and free of
obstructions and shall not be used for other functional purposes that include
storages.
b) All room size and space allocation shall consider room loadings based on the current
staff, clients involved, usable medical equipments, furniture and applicable
functions.
c) The hospital circulation (main and sub corridors) shall be wide enough to allow
passage for its function.
d) Patient serving corridors should not be less than 240cm wide, and proportionally
the openings to the corridor needs to be designed to allow easy movement of
coaches and be equipped as needed by the patient with safety and all assistive
devices (it includes door stopper, protecting girders, alarms, self opening
electronic devices, etc).
e) All doors shall be able to easily open and close and doors swing into corridors shall
be avoided.
f) Each patient room shall meet the following requirements:
a) All patient functioning rooms, toilet, and bathing room doors shall provide
privacy yet not create seclusion or prohibit staff access for routine or
emergency care.
b) Room area shall be 9.20m2 (100ft2) for a single bedroom and 7.50m2
(80ft2) per bed in multi-bedrooms.
c) Ceiling height needs to be determined based on the functional
requirements considering air space, technical requirements, room size
proportions, number of occupants and other parameters. The height of the
ceiling of the rooms shall not less than 240cm high for support services,
220cm for technical corridors, 320 cm for Operation Theater and X-ray
and 280cm for other clinical rooms.
d) Windows: All rooms housing patients shall have access to natural light and
ventilation, or prove the availability of artificial ventilation and light at all
times. (Please refer the annex regarding detail lux requirements for
functional rooms). Rooms shall have window area proportional to that of
floor areas which is equal to 1/8th of the floor area. The sill shall not be

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 higher than 36 inches above the floor and shall be above grade. For toilets
and washing rooms, over desk laboratory tables, laundry and kitchen
utensils, the height can be modified accordingly. Windows shall not have
any obstruction to vision (wall, cooling tower, etc.) within 50 feet as
measured perpendicular to the plane of the window.
e) Storage: Each patient shall be provided with a hanging storage space of not
less than 40.cm x 60.cm x 130cm (16" x 24" x 52") for his personal
belongings.
f) Furnishings: A hospital shall provide comfortable patient trigonometric
designs, applicable functions, and technical requirements. They have to be
hygienic (washable, dust and bacteria protective and resistant for
cleansing reagents) durable that can control vandalism and avoid
accidents.
g) Curtains: rooms shall be equipped with curtains or blinds at windows. All
curtains shall have a flame spread of 25 or less or as per the national fire
protection code. And all as per the national infection prevention guidelines
requirements.
h) Cubicle curtains or equivalent built-in devices for privacy in all multi-bed
rooms shall be provided. They shall have a flame spread of 25 or less or as
per the national fire protection code.
i) Finishing
 Walls, floors and ceilings of procedure rooms, isolation rooms, sterile
processing rooms, work room, laundry and food-preparation areas
shall be suitable for easily washing. All floors of the hospital clinical
service areas shall be washable, smooth, non- adsorptive, surfaces
which are not physically affected by routine housekeeping cleaning
solutions and methods. Acoustic lay-in ceilings, if used, shall be non-
perforated.
 Public spaces such as reception areas, waiting areas, cafeterias, areas
requiring silence and areas like psychiatry shall be designed with
acoustic control and the lamination/lay shall be non-perforated.
 Scrub-able room finishes provided in operating rooms and isolation
rooms shall have smooth, non-adsorptive, non-perforated surfaces

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 that are not physically affected by harsh germicidal cleaning solutions
and methods.
 All walls and ceiling finishing materials used shall have a 1-hour fire
rating (One hour rated products offer more than "one hour's" worth
of fire protection).
j) Sanitary Finishing
 A lavatory equipped with wrist action handles, shall be located in the
room or in a private toilet room.
 For hospitals with multiple bed wards without private toilet room
shall provide bedpan washer.
 All sanitary room facilities floors, walls and ceilings shall be
completed with washable finishing materials
 Floors and walls penetrated by pipes, ducts and conduits shall be
tightly sealed to minimize entry of rodents and insects
k) Electrical Finishing
 Patient bed light shall be controlled by the patients.
 Room light luminescence shall be bright enough for staff activities but
needs to be controlled not to disturb the patients.
 All electrical fixtures inlets, outlets shall fulfill Ethiopia Electrical
Safety requirements and if applicable fitted with guards
 If there is psychiatry service, its area light fixtures, sprinkler heads
and other apparatus shall be of a temper resistant type.
g) Outdoor Areas: the hospital outdoor area shall be equipped and situated to allow
for the safety and abilities of patients, care givers, staff and visitors.
a) The landscape shall be designed with patient room visual acquit or access
b) Walkways, connection roads and elevation differences shall be designed to
allow movements of coaches/stretchers and persons with disabilities.
c) The outdoor traffic arrangement shall not cross each other to avoid
accidents
h) Windows: In all rooms, windows shall comply with lux requirements of room space
without compromising room temperature and ventilation.
a) Windows shall be a minimum of 50 cm wide x 100cm high. However, in case
of hot climate areas, this may not be applicable

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 b) No window shall swing inside the room except those which require security
and safety measures such as grid for theft and insect mesh for malaria porn
areas.
c) Windows that frequently left open for cross ventilation purpose (like TB
clinic room windows) shall be equipped with insect screen. At least a top
portion of a window shall be left open fitted with insect mesh for
uninterrupted circulation of air.
d) Safety glass, tempered glass or plastic glass materials shall be used for
pediatrics and psychiatric service units (if any separate unit) to avoid
possible injuries.
i) Vertical Circulation: All functioning hospital rooms shall be accessible horizontally.
a) Stairs: All stairways and ramps (if any) shall have handrails and their
minimum width shall be 120cm.
 All stairways shall have a 2-hour fire enclosure with a "B" (1.5 hour)
label door at all landings or as per the national fire protection code.
 All stairways shall be fitted with non slippery finishing materials
 All stair threads, riser and flight shall comply with patient type as
per the Ethiopia Building proclamation
b) Elevators: at least one hospital type elevator shall be installed where
patient beds are located in the upper floors. Minimum cab dimensions
required for elevators transporting patients is 195cm x 130cm inside clear
measurements and minimum width for hatchway and cab doors shall be
100cm.
c) Ramp: Ramps shall be designed with a slope of 6 to 9 percent, minimum
width of 120 cm and the landing floor of 240cm wide on both sides.
j) Fire Safety Considerations:
a) One-Story Building: Wall, ceiling and roof construction shall be of 1-hour
fire resistive construction as defined by National Fire Code. Floor systems
shall be of non-combustible construction.
b) Multi-Story Buildings: Must be of two-hour fire resistive construction as
defined in National Fire Code as specified to hospitals.
c) Travel Distances and alternative vertical circulation: Hospital facilities
travel distance from service giving room to the stairs should be as specified

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 in the National Fire Code. Alternative fire escape stair should be provided
otherwise.
k) Parking areas:
a) The hospital shall have separate parking spaces for hospital ambulance.
b) Parking space shall available within the hospital premises.
c) General services of the hospital that require loading unloading docks,
heavier truck movement and temporary truck parking place shall be
available.
d) The parking space shall not cross pedestrian walkways, if it is mandatory to
cross proper precaution measures such as Zebra Road, Speed Breaker,
guiding notice and traffic stopping culverts or signals should be provided.

7.5. Building Systems

Hospitals shall have building systems that are designed, installed and operated in such a
manner as to provide for the safety, comfort and well being of the patient.
a) Water supply and plumbing:
a) Continuously circulated as per the type of fixture used, filtered and treated
water systems shall be provided as required for the care and treatment in
the hospital
b) All hospitals subject to be connected to an approved municipal water
system whose purity has been certified by the concerned body. The water
supplies must be sampled, tested, and its purity certified at least twice
annually and immediately following any repair or modification to the
underground lines, the elevated tank, or to the well or pump.
c) All hospitals subject to be connected to its own separate water supply
system shall qualify and certified by the concerned body regulatory. The
water supplies must be sampled, tested, and its purity certified at least
twice semi-annually and immediately following any repair or modification
to the underground lines, the elevated tank, or to the well or pump.
d) The hospital shall have and maintain an accessible, adequate both as to
volume and pressure, safe and potable supply of water. Where an
authorized public water supply of satisfactory quantity, quality, and

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

b) Sewerage and Waste Processing Systems

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

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

c) Heating and Cooling, Ventilating and Air-Conditioning Systems:

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

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

7.6. Electrical System

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

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

7.7. Fire Protection System

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

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c) Essential Public Address System: Hospitals shall have an automatic voice
communication /evacuation signal, from different sources; automatic
control signal from fire alarm system, tape/CD player for pre recorded
message to all care and treatment locations rooms.
d) Lightening Arrestor and Grounding System: Hospitals shall have technically
advised lightning protection system, comprises air termination, down
conductor and earth termination. Protection zone shall cover a minimum of
the diameter of the building
e) All employees, including part-time and contract or temporary employees
shall be trained in procedures to be followed in the event of a fire and
instructed in the use of fire-fighting equipment and patient evacuation of
hospital buildings as part of their initial orientation and at least annually
thereafter.
f) All employees, including part-time and contract or temporary employees
shall receive printed instructions on procedures to be followed in case of
emergency, including patient evacuation of the buildings.
g) A written evacuation diagram specific to the unit that includes evacuation
procedure, location of fire exits, alarm boxes, and fire extinguishers shall be
posted conspicuously on a wall in each patient care unit.
h) Fire extinguishers shall be visually inspected at least monthly; fully
inspected at least annually, recharged, repaired and hydrotested as required
by manufacturer's instructions; and labeled with the date of the last
inspection.
i) Fire detectors and alarm systems shall be inspected and tested at least twice
a year by a certified testing agency. Written reports of the last two
inspections shall be kept on file.
j) There shall be a comprehensive, current, written preventive maintenance
program for fire detectors, alarm systems, and fire suppression systems that
includes regular visual inspection. This program shall be documented.
k) There shall be a procedure for investigating and reporting fires. All fires that
result in a patient or patients being moved shall be reported to the
appropriate organ. Immediately in writing within 72 hours. In addition, a

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 written report of the investigation shall be forwarded to the appropriate
organ as soon as it becomes available.

7.8. Call Systems

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

7.9. Health Facility Environment

a) The hospital shall provide and maintain a safe environment for patients,
personnel and the public.
b) All facilities shall comply with the following applicable codes and standards
to provide a safe environment:
 Ethiopian Environmental requirements for hospital facilities
 Life Safety Code (National Fire Protection agency); and
 The Food standard, Ethiopia, FMHACA Regulations
c) Existing and new facilities shall comply with the physical facility standards
contained in this chapter. The hospital shall maintain all building materials
and structural components so that total loads imposed do not stress
materials and components more than one and one-half times the working
stresses allowed in the building code for new buildings of similar structure,
purpose, or location.

7.10. Specific Service Areas

a) The hospital may have dining areas as per the following requirements:
 Dining areas for patients shall have an outside wall with windows for
natural light and ventilation.

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  Dining areas shall be furnished with tables and chairs that accommodate
or conform to patient needs.
 Dining areas shall have a floor area of at least 15-20 square feet (1.4m2
to1.9m2) per patient.
 Dining areas shall allow for group dining at the same time in either
separate dining areas or a common dining area, or dining in two (2)
shifts, or dining during open dining hours.
 Dining areas shall not be used for other services.
b) Bathing and Toilet Rooms:
 In case of common bathing and toilet room, one shall be dedicated for
seven patients at all times.
 A hospital shall provide a bathing room consisting of a tub and/or
shower adjacent to each bedroom or provide a central bathing room on
each floor with patient rooms. Tubs and showers regardless of location
shall be equipped with hand grips or other assistive devices as needed or
desired by the bathing patient.
 The hospital shall provide toilet rooms with hand-washing sinks for
patient and staffs shall use separately for each service units. In addition
the following requirements shall be ensured
o Flushable toilets shall be available throughout the workplace.
o Posted signs (written and/or visual messages) shall be indicated
describing which is for ladies and gentle
o Indicating arrows shall be located on the corridors
o At least one toilet room shall be designated for patients with
disability with all assisted services.
c) Patient Rooms: the hospital shall provide patient rooms which allow the provision
of medical intervention shall have space for sleeping, afford privacy, provide
access to furniture and belongings, and accommodate inpatient care and
treatment. In addition Patient Rooms:
 Shall be arranged to maximize staff supervision and nursing assistances.
 No patient room shall be located away from nursing stations without
proper covered gang ways and travel premise requirements.

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  Shall not be accessed directly through a bathroom, food preparation
area, laundry or another bedroom;
 Shall be located on an outside wall with a window with a minimum glass
size of 8 square feet or equivalent meter square per patient.
 If they have multiple beds, shall allow for an accessible arrangement of
furniture, which provides a minimum of three (3) feet or equivalent
meter between beds.
d) Isolation Rooms: The number and type of isolation rooms in a hospital shall be
determined by the hospital and direct caregiver. The determination shall be
based upon an infection control risk assessment, patients requirements and
patients influence on other room occupants. In addition:
 Hospitals shall make provisions for isolating patients with infectious
diseases prevention.
 An isolation room shall have an adjoining bath and toilet room.
 Hospitals shall equip isolation rooms with hand-washing and gown
changing facilities at the entrance of the room.
e) Observation Areas: If the hospital provides medical observation, extended recovery
or behavior intervention methods, the hospital shall provide one or more
appropriately equipped rooms for patients needing close supervision. Each
room shall:
 Have appropriate temperature control, ventilation and lighting;
 Be void of unsafe wall or ceiling fixtures and sharp edges;
 Have a way to observe the patient, such as an observation window or if
necessary, flat wall mirrors so that all areas of the room are observable
by staff from outside of the room;
 Have a way to assure that the door cannot be held closed by the patient
in the room which could deny staff immediate access to the room; and
 Be equipped to minimize the potential of the patient's escape, injury,
suicide or hiding of restricted substances.
 Shall be provided with proper safety communication systems and
emergency signaling.

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 f) Cubicles: Patient care and treatment cubicles shall have a minimum floor area of
sixty (60) square feet with at least three (3) feet between bedsides and adjacent side
walls.
g) Examination Rooms: Each examination room shall have a minimum floor area of
eighty (80) square feet and a minimum of three (3) feet clear dimension around
three (3) sides of the examination table or chair.
h) Treatment Rooms: Treatment room for procedures performed under topical, local,
or regional anesthesia without pre-operative sedation shall have a minimum floor
area of one hundred and twenty (120) square feet and a minimum of ten (10) feet
clear dimension.
i) Procedure Rooms: Procedure rooms for and minor surgical procedures performed
in conjunction with oral, parenteral, or intravenous sedation or under analgesic or
dissociative drugs shall have a minimum floor area of two hundred (200) square
feet and a minimum of fourteen (14) feet clear dimension.
j) Operating Rooms: Operating rooms for major surgical procedures that require or
regional block anesthesia and support of vital bodily functions shall have a
minimum floor area of three hundred (300) square feet and a minimum of sixteen
(16) feet clear dimension.
k) Privacy: In multiple bed patient rooms, visual privacy, and window curtains shall be
provided for each patient. The curtain layout shall totally surround each care and
treatment location which will not restrict access to the entrance to the room,
lavatory, toilet, or enclosed storage facilities.

7.11. Care and Treatment Areas

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

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7.12. Ancillary areas
a) Dietary: If food preparation is provided in the hospital (in case of inpatient
services), the hospital shall dedicate space and equipment for the preparation of
meals and separate washing room (dishes and other food preparation equipments),
refrigerated and non-refrigerated storage areas in accordance with the standards
mentioned under the Food and dietary services of this health facility.
 If contractual services are used for dietary services, the hospital
shall have areas for immediate storage spaces, cleaning and
disposal spaces.
 If contractual services are used, the hospital shall have a clear
contractual agreement and the contractor shall comply with all
the requirements prescribed under this standards.
b) Laundry: The hospital shall provide laundry services by contract or on-site.
a) Contract:
 If contractual services are used, the hospital shall have areas for
soiled linen awaiting pickup and separate areas for storage and
distribution of clean linen.
 Separate clean linen supply storage area shall be conveniently
located in each care and treatment locations
 If contractual services are used, the hospital shall have a clear
contractual agreement and the contractor shall comply with all
the requirements prescribed under this standards.
b) On-site: If on-site services are provided, the hospital shall have
areas dedicated to laundry in accordance with the following
requirements:
 The laundry areas shall be equipped with a washer and dryer
for use by patients. The hospital shall provide a conveniently
located sink for soaking and hand-washing of laundry.
 Hospital laundry area for hospital processed bulk laundry shall
be divided into separate soiled (sort and wash areas) and clean
(drying, folding, and mending areas) rooms. In new facilities a
separate soaking and hand-washing sink and housekeeping
room shall be provided in the laundry area.

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  Separate clean linen supply storage facilities shall be
conveniently located in each care and treatment location.
 In general the standards stipulated under housekeeping section
of this document shall be respected.
c) Administrative Areas: Administrative Offices shall be located separately from care
and treatment areas and it shall be clearly labeled and easily accessible to both
patients and visitors. It includes;
 Finance and business office.
 Administration office.
 Staff rooms with toilet separate for male and female
 Staff cafeteria
 Visitors cafeteria
 Spaces for conferences and in-service training
 General Library (at least 40m2)

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

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

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7.13. Bubble Diagrams

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