Final EHTG Volume I
Final EHTG Volume I
MINISTRY OF HEALTH
ETHIOPIAN HOSPITAL
TRANSFORMATION GUIDELINES
Volume 1, July 2016
ETHIOPIAN HOSPITAL
TRANSFORMATION GUIDELINES
Version 1.0
Forward
The earliest modern efforts to improve the quality of government hospitals throughout Ethiopia
began in 2006 with the Ethiopia Hospital Management Initiative (EHMI), envisioned by the then
Minister of Health, Dr. Tedros Adhannon, and supported by the Clinton Health Access Initiative
in collaboration with the Yale Global Health Leadership Institute. The EHMI resulted in the
creation of the Ethiopian Hospital Reform Implementation Guidelines (EHRIG), which built on
both the Business Process Reengineering (BPR) and Hospital Blueprint efforts, as well as the
Masters in Hospital and Healthcare Administration (MHA) degree programme. Subsequently,
the country developed a hospital performance monitoring system based on achievement of key
performance indicators (KPI) and the Ethiopia Hospital Alliance for Quality (EHAQ) to spread
best practices and promote collaborative learning in government hospitals nationally. EHAQ has
focused on patient satisfaction, labour and delivery management, and provides a national
framework for continuous quality improvement in hospitals across Ethiopia.
The Ethiopian Hospital Transformation Guidelines (EHTG) build on and expand the Ethiopian
Hospital Reform Implementation Guidelines (EHRIG) and are consistent with the Health Sector
Transformation Plan (HSTP). The EHTG, which is consistent with the national focus on quality
improvement in health care, contains a common set of guidelines to help hospital Chief
Executive Officers(CEOs), managers, and clinicians (care providers) in steering the consistent
implementation of these transformational systems and processes in hospitals throughout the
country. The EHTG focused on selected management and clinical functions, including new
individual service specific chapters for Emergency Medical, Outpatient and Inpatient Services,
Nursing and Midwifery, Maternal, Neonatal and Child Health and Teaching Hospitals’
Management. These guidelines also incorporate recent lessons from the operationalization of the
EHRIG, as well as, new national initiatives such as the Guidelines for the Management of
Federal Hospitals in Ethiopia, Hospital Development Army (HDA), Clean and Safe Hospital
(CASH), and Auditable Pharmaceutical Transaction and Service (APTS).
It is expected that the guidelines will continuously evolve as new evidence emerges regarding
improved hospital care and practices that are better tailored to particular needs and circumstances
of different tiers of public hospitals.
We are grateful to all partners that have participated in the production of these guidelines.
Special thanks go to our colleagues at the Clinton Health Access Initiative for their substantial
contributions and support throughout the development of these guidelines as well as their
dedicated efforts in support of our health reform efforts in so many other capacities.
Laboratory Services
Helen T/Birhan FMOH
Atsbaha Gebregziabher EPHI
Habtamu Asrat EPHI
Ratalegn Geleta EMLA
Yakob G/geberiabher National Blood Bank
Zelelem Messele CHAI
Zelalem Getachew FMOH
Markos Paulos FMOH
Pharmacy Services
Regassa Bayissa FMOH
Ayalew Adinew USAID/SIAPS
Belete Ayalneh School of Pharmacy,AAU
Dawit Teshome School of Pharmacy,AAU
Edmealem Ejigu USAID/SIAPS
Elias Geremew USAID/SIAPS
Hailu Tadeg USAID/SIAPS
Sufyan Abdulber FMOH
Yaregal Benti FMOH
Radiological and Imaging Service Management
Esayas Mesele FMOH
Dr. Ashenafi Abera St. Paul’s Hospital
Dr. Asmeraw Gisila TASH
Facility Management
Gobena Godana FMOH
Asnake Wakjira TASH
Bemnet Gebriel TASH
Azeb Lemma FMOH
Editorial Team
We would especially like to acknowledge the contribution of the editorial team for their
meticulous review of all chapters for font type and size, sentence clarity, consistency and
correctness in English language and logic. Their review included a critical review of the chapters
to ensure that the standards, implementation guidance, implementation checklist and indicators
are aligned and consistent in terms of content covered. Among these editors, we extend special
thanks to David Ansu Conteh, Salem Fisseha and Dr. Nicola Ayers for editing the first set of
chapters and David Ansu Conteh for the subsequent and final editorial of all chapters with the
Yale GHLI Team for the pre-print formatting of the document.
Lastly, the review of the EHRIG and HPMI which led to the development of the EHSTG
contained in this document would not have been possible without the inspiration and ongoing
FMOH and RHBs’ leadership support in ensuring these guidelines are availed for the
transformation of public hospital services across Ethiopia. It was only through their leadership
and matched financial support that this effort was possible.
Contents
Chapter 5 InpatientServices
Tables
The Federal Government of Ethiopia through the Health Care Financing Strategy has established
the legislative framework for enhanced hospital autonomy with authority decentralized to
hospitals in areas such as strategy, planning and budget development. To achieve this, hospitals
majority of hospitals have established Governing Boards (GBs) that are responsible to appoint
the CEO who in turn leads on all hospital operations and functions. However, established GBs in
some hospitals do not meet regularly and the Hospital Development Army (HDA)
approach/programme is non-functional in some hospitals.
The hospital governing board and senior management team seeks the best ways to achieve the
strategic goals and objectives and enhances the long-term vitality of the hospital so that it can
pursue its mission. For this to happen, the leadership team and hospital governing body require a
unique set of skills to manage and lead their hospital in this dynamic and rapidly changing
environment. To foster good governance for health, the hospital governing boards, senior
management teams, and those who lead and manage at all levels must become more
knowledgeable and skilful about practices of leadership, management and governance.
This chapter describes the operational standards, implementation modalities, and tools to help
you achieve the stated Leadership, Management and Governance standards.
1. The hospital has a functional governing board with a representative sample of community
members that meets regularly to oversee the service delivery of the hospital.
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2. The hospital has a functional senior management team (SMT) that meets regularly to manage
and execute the overall hospital activities.
4. The hospital has an established and implements a resource mobilization plan and ensures
resources are utilized effectively and efficiently.
5. There is a system and practice for measuring performance and results in the hospital.
6. The hospital promotes good ethical practice and has an ethics violation reporting and
responding mechanism.
7. The hospital has a regular capacity building programme for governing board members and
senior managers.
8. The CEO is evaluated every six months, consistent with FMOH or Regional Legislation to
ensure he/she is meeting operational and strategic plans as established by the Board and the
CEO collectively.
Leadership, management, and governance are interdependent, reinforce each other, interact in a
balanced way and overlap among the roles to serve a purpose and to achieve a desired result.
Effective leadership is a prerequisite for effective management and governance. Leaders need to
know how to scan, focus, align/mobilise, and inspire workforces. Managers need to know how to
plan, organise, implement, and monitor and evaluate. People who govern must know how to
cultivate accountability, engage stakeholders, set shared direction, and steward resources.
Working together and supporting all aspects of a hospital, these practices lead to improved
hospital performance, which, in turn, leads to better health outcomes.
Leadership Practices
To lead well, you need to focus your staff’s attention on achieving results that fulfil clients’
needs and preferences, as well as respond to key stakeholders’ interests. With your full support,
the frontline staff that provide health services can learn to identify their own obstacles to service
quality, initiate improvements, and serve their clients well. For good leadership,
followingleading practices need to be considered:
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a. Scanning: Scan for up-to-date knowledge about management (to be aware how your
behaviour and values affect others), staff, hospital, and the environment.
b. Focusing: Focus staff’s work on achieving the organisational mission, strategy, and
priorities.
c. Align and mobilising: Align and mobilise stakeholders’ and staff’s time and energies as well
as the material and financial resources to support organisational goals and priorities.
d. Inspiring: Inspire your staff to be committed and to continuously learn how to adapt and do
things better.
Management Practices
When managers use good management practices, they make sure that operational plans and
reporting structures are clear and reflect organisational priorities. Staff receive feedback on their
work through appraisal, supportive supervision and monitoring and evaluation systems that
provide timely and reliable information.To manage a hospital well, managers need to
continuously pay attention to the health services that the hospital provides to be consistently high
quality to meet clients’ needs.
a. Planning: Plan how to achieve results by assigning resources, accountabilities, and timelines.
Hospitals need to have a strategic plan and annual plan approved by the governing board.
The Ethiopian Government, through the Civil Service Reform Programme, requires all public
bodies in Ethiopia to plan using the Balanced Scorecard (BSC) approach, a strategic planning
and management system designed to help everyone in an organisation understand and work
towards a shared vision and strategy.
b. Organising: Organise people, structures, systems, and processes to carry out the plan.
c. Implementation: Implement activities efficiently, effectively, and responsively to achieve
defined results/objectives.
d. Monitoring: Monitor and evaluate achievements and results against plans, and continuously
update information and use feedback to adjust plans, structures, systems, and processes for
future results.
Cultivate Accountability
a. Enhance personal accountability. As governing body members are entrusted with resources
to serve the common good. Board members need to be accountable personally; by attending
meetings and taking assignments that are executed on time and of good quality.
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b. Enhance internal corporate accountability (accountability within the hospital). Internal
transparency increases employee loyalty and collaboration. The hospital board should be able
to:
Ensure a free flow of information internally within the hospital.
Encourage calculated risk-taking, by recognizing effort and courage,even when intended
results are not achieved.
Provide clear guidance to staff on goals and tasks for which they will be held
accountable, without micromanaging the process to accomplish them.
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Responding to the health needs of socially disadvantaged communities is central to the
performance goals of the hospital leadership and governing board. To do so, the hospital’s SMT
and governing board:
Need to work closely with these communities through district and Kebele level (and
their associations/organisations) to have an understanding of their health needs and use a
deliberate approach for addressing those needs.
Make sure that their needs are periodically assessed and addressed in the hospital plans
and strategies
Engage with staff. Staff feel engaged when they have involvement in decision-making.
Engaged staff feel valued, respected, and supported. They are engrossed in their work
and take pride in what they do.
Engage with senior clinicians.The Board and the SMT should be able work together to
create a platform that encourages senior clinicians to contribute to improve services. You
can improve engagement with doctors and clinicians in many ways: by mutually
discovering a common purpose such as improving outcomes and efficiency, making
them partners in improving quality, involving them from the beginning, valuing their
time, making it easy for them to do the right thing for patients, identifying and
encouraging champions among them.
Shared direction comes from agreeing on which ‘ideal state’ everyone is trying to get to. If there is
no agreement on what or where you are moving to, agreeing on approaches for how to get there
will be that much more difficult. If you know that you are all moving in the same direction, you
will find it easier to gather support for the planning process, assess readiness, and define strategy to
achieve this vision. You can then design a shared action plan with measurable goals for reaching it
and setup accountabilities to accomplish the plan.
Stewarding Resources
Stewarding resources is raising, mobilising, and allocating resources, and making sure that there
sources are ethically and efficiently used for delivering services that are of high quality, affordable,
cost-effective, and appropriate to the needs of the population, and that achieve better health for the
people. Good stewards protect and wisely use their sources entrusted to them to serve people, as if
these resources were their own. They ensure proper resource utilisation and advocate for using
resources to maximize the health and well-being of the public. They collect, analyse, and use
information and evidence for making decisions on the use of resources.
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Hospital board members must: (1) define the scope and nature of the resources required to
implement their organisations’ strategic plans; (2) raise these needed resources from diverse
sources; and (3) cause to have these resources carefully used and expended by managers, clinicians,
and health workers. Smart governance requires the careful stewardship of scarcer sources-human,
technological, physical, and financial.
Good governance is not static, it is dynamic and always seeking ways to improve the performance
of essential practices described above. Those who govern must make a personal and a collective
commitment to continuously enhance the strategies, structures and style of governance practices.
Working as Governing board members and members of hospital SMT, to ensure Continuous
Governance Enhancement, the following essential strategies should include:
Governance orientation and training
Governance assessments and development of improvement plan that should be monitored
as required
The Government of Ethiopia has put the establishment of a functional HDA as a top priority. The
HDA is regarded as the key vehicle that would help Ethiopia achieve its ambitious health sector
targets.HDA is an initiative to expand best practices on a large scale within a short period of time by
fostering networkingamong individuals, units and facilities to reach at the intended standards.
The main goal for the Hospital Development Army, at the hospital level, is to enable the hospital
staff to learn from each other, to identify potential gaps in health service delivery and devise the
optimum solution, and identify best practices and scale up in the hospital.
1. Identify locally salient obstacles that hinder case teams from delivering quality health services
and implementation of hospital reform;
2. Come up with feasible strategies to address these problems;
3. Implement the strategies; and
4. Evaluate their activities.
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The HDA does also involve hospital-community and hospital-staff meetings. These large public
conferences and hospital – staff forums provide the platform to share prioritised obstacles and strategies.
Building Health Development Army in the hospital needs high level commitment from the hospital
board and senior management team.
For successful implementation of Health Development Army, regular monitoring and evaluation at
all level is crucial. The three M&E elements; Follow up on report, Inspection/Supervision and
Feedback are need to be done in order to build effective army.
B. Healthcare Kaizen
Kaizen can be defined as a set of principles and specific practices for continuous improvement.
At a high level, kaizen is a process that, ideally engage everybody in identifying problems or
opportunities for improvement and then involves them in identifying, testing and evaluating
improvements in a scientific and iterative way. Kaizen is rigorous without being bureaucratic.
Kaizen is built upon the improvement cycle of PDSA or Plan, Do, Study and Adjust (sometimes
called PDCA or Plan, Do, Check and Act). In Kaizen PDSA cycle, employees, co-workers and
managers:
Plan: Identify a problem or opportunity, understand the current situation and cause of the
problem and brainstorm various actions that can be taken.
Do: Perform a small test of change aimed at making a quantitative or qualitative
improvement in a system.
Study: Honestly evaluate the effectiveness of the action and use if created any
unanticipated results or any side effects.
Adjust: based on the evaluation, one can choose to adopt the change or adjust it in some
way, or the change might be abandoned altogether. With kaizen, participants can go back
to the plan stage, to try again, without shame.
Continually improve.
No idea is too small.
Identify report and solve individual problems.
Focus change on common sense, low-cost and low-risk improvements, and not major
innovations.
Collect, verify and analyse data to enact change.
Problems in the process are a major source of quality defects.
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Decreasing variability in the process is vital to improving quality.
Identify and decrease non-value added steps.
Every interaction is between a customer and a supplier
Empower the worker to enact change
All ideas are addressed and responded to in some way.
Decrease waste.
Address the workplace with good housekeeping discipline.
The Scientific Method of Problem Solving is an approach that integrates the strategic function of
leadership, involving goal and objective setting with the subsequent organizational action
required to achieve the set objectives. The Scientific Method of Problem Solving uses an eight-
step approach, outlined below. The steps, while sequenced in the description, are in reality
completed in a more iterative fashion with feedback loops and adjustments throughout the
process.
To successfully move from one step to the next, leaders can rely on a number of useful
management tools including:
Root cause analysis, including ‘fishbone’ diagramming, flow charting, and histograms,
Options appraisal using evaluative criteria, and
Gantt chart.
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3.3 Governing Board
The establishment of a Governing Board builds in two essential characteristics for good
hospitals:
Autonomy to do what is necessary to provide good care and
Accountability to those served for the results of that care.
Governing Boards must be committed to creating and maintaining a strong bond between the
hospital and the community it serves and maintaining a good working relationship with higher
government authorities.
The following sections set out the basic principles related to the establishment, responsibilities
and operating mechanisms of Governing Boards. More detailed information on the specific
powers and duties of Governing Boards within each region and Federal hospitals are described in
the Health Service Delivery and Administration Proclamations, Regulations and Directives of
each Region and Guidelines for Management of Federal hospitals.
It is the Governing Board's responsibility to create and regularly review a statement of vision that
articulates the organisation's goals and values, but should be in line with the stated mission.
A Mission statement can be defined as ‘purpose, reason for being’ or simply ‘who we are and
what we do’.
A Vision statement can be defined as ‘an image of the future we seek to create’.
All strategies, plans and policies of the Hospital should be in accordance with the mission, vision
and values set by the Governing Board.
The Governing Board should ensure that corporate policies (such as policies for staff recruitment
and retention, for income generation and expenditure, for quality assurance etc.) are available to
govern the operations of the facility.
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C) Ensure effective organisational planning
Governing Boards must actively participate in an overall organisational planning process. This
includes examining and approving the strategic and annual plans of the hospital, and ensuring
that such plans are in accordance with the mission, vision and values of the hospital.
Furthermore, that they are aligned with local, regional and national health sector priorities and
targets.
Governing Boards must monitor progress towards the goals and targets of the strategic and
annual plans. If the hospital is not on track to meet its stated plans, the Governing Board must
identify the reasons why, and, should assist the CEO and hospital management team to identify
and implement solutions.
The Governing Board must review and approve the hospital’s annual budget, and implement
proper financial controls to follow up on its utilisation and ensure that the hospital operates
within its budget. This includes implementation of revenue retention and utilisation as per the
Federal or Regional financial rules and regulations. Additional responsibilities include ensuring
that internal and external financial audits are carried out as required by legislation. The
Governing Board should regularly review audit reports and ensure that action is taken on any
recommendations made.
The Governing Board must identify what constitutes adequate resources for the organisation and
ensure the effective means to access these resources. Where necessary, the Board and staff must
devise strategies and the means to improve revenues and diversify the source. Such mechanisms
could include fee revision, outsourcing of activities or the establishment of private wings in
accordance with the Regional financial rules and regulations.
Governing Boards must ensure the provision of health services to fee waived patients without
discrimination, and must ensure the provision of exempted services as described in the Regional
or Federal financial rules and regulations. Boards must ensure the reimbursement of fee waiver
expenses from the appropriate Fee Waiver Certificate issuing authorities.
The Governing Board must ensure that hospital services are provided to the highest possible
standard. The Board should ensure that systems are in place for monitoring and evaluating the
quality and outcome of patient care, customer services and use of resources. The Board should
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ensure there are appropriate mechanisms and activities to minimise risk, to identify and correct
problems, and to identify opportunities to improve patient care and services.
It is the responsibility of the Governing Board to ensure that the public hospital should leverage
technical capabilities available only in the private hospitals, and that the private hospitals should
not engage themselves in practices that compromise the quality of services in public hospitals. In
addition, the Governing Board should oversee the outsourcing of clinical and non-clinical
services to the private vendors. This includes ensuring that the bidding process is in line with the
government procurement procedure, the parties sign legal contracts as per the guideline, and the
contractual services are delivered as per the contract.
Governing Boards must ensure that the most qualified individual is appointed to the position of
Chief Executive Officer (CEO), following the processes set out in Federal or Regional
Directives. The CEO should be qualified by education and experience appropriate to the
position. The authority and duties of the CEO must be defined and documented by the Governing
Board or appointing authority.
The Governing Board should ensure that the performance of the CEO is assessed at least
annually by the Board or appointing authority. Should the CEO fail to meet the expectations of
the Governing Board, his/her employment should be terminated, following the processes
described by Federal or Regional Directives.
M) Provide orientation for new Board members and ensure ongoing education for
existing members
All Governing Boards should participate in ongoing education to assist members to carry out
their role in the hospital. For newly appointed board members, there should be a planned
orientation programme that ensures members understand their responsibilities.
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The Governing Board should periodically and comprehensively evaluate its own performance,
taking into consideration areas such as:
Regularity of and attendance at Board meetings
Board vacancy rate (% of Board positions that have been filled)
Knowledge, skills and awareness of Board members on hospital operations, finance, on
key issues affecting the hospital and any national, regional and local health priorities
Approval of the strategic and annual plans by set deadline
The relationship between the Governing Board, CEO and hospital Senior Management
Team
The relationship between the hospital and communities served by the hospital
Engagement with the wider stakeholders such as woreda, zonal and regional health
departments and any local health partnerships
The Governing Board is responsible for ensuring adherence to legal standards and ethical norms.
It ensures that activities of the hospital are carried out with transparency and accountability and
that all required reports are submitted to higher authorities (e.g. RHB, BOFED, FMOH, and
MOFED) in accordance with government requirements.
The Governing Board should ensure that mechanisms are established to enhance the involvement
of patients and the public in the planning, delivery of hospital services, and monitoring phases
and to maintain close consultation with community leadership. The governing board should
establish hospital-community forums and conduct them at least every quarter.
The Governing Board should clearly articulate the hospital's mission, vision, values
accomplishments and goals to the public and garner support from the community.
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give management the full authority to run the hospital and do not “micro-manage” the
hospital leaders;
commit the time required for meetings, dialogue, etc;
subscribe to the principles of accountability for themselves and others;
prioritize the benefits of the hospital rather than personal benefits;
are participatory in planning, decision-making, and activities; and
declare any conflicts of interest and excusethemselves from any decisions that have
immediate benefit for themselves, their families or their business interests.
Governing Board members should be residents of the area where the hospital is established.
Additional factors to be taken into consideration when appointing board members include:
Due consideration to gender and professional mix,
Community representation, and
Professional efficiency, time and experience that will enable the Board member to
contribute to the improvement of the health sector.
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ii. Proven corruption such as earning benefits in the health facility other than the legally
permitted benefits or other corrupt practice
iii. Repeated failure to follow up on actions agreed by the Board
iv. Breach of confidentiality
In such cases, the Board should reach consensus that membership should be revoked and should
make this recommendation to the RHB Head or Minister for Health who will reach a final
decision on the matter.
If a Board member leaves office during his/her period of tenure the remaining Board members
should select one or more possible replacements and nominate the candidate(s) to the RHB or
FMOH to make the final appointment.
E) Board accountability
Board members have individual and joint responsibility for the decisions they pass and are
responsible individually and jointly for any damage caused to the hospital due to their failure to
accomplish the duty entrusted to them. In the event a Board member solely opposes a decision or
an agenda for discussion, he/she may explain the reason for his/her unique opposition and make
it noted on the minutes. He/she shall not be responsible for any damage occurred due to this
decision or agenda item.
Governing Boards are accountable to their respective RHB or the FMOH and should meet all
expectations that the RHB or FMOH places on the Board.
The Governing Board should appoint three to five Officers, who form the Executive Committee
of the Board.
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Officers of the Board include:
a) The Chairperson
b) The Vice-Chairperson
c) The Secretary
The Governing Board should be led by a Chairperson, who is appointed by the RHB or FMOH
or University presidents from among the Board members. The main responsibilities of the
Chairperson are to:
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external forces that affect the hospital’s inner workings, making certain to execute any health
policies as required by the appropriate government body.
7. Maintain a productive relationship with the CEO and the appropriate government
body
Maintaining productive relationships with both the CEO of the hospital, plus the appropriate
government body, are extremely important. It requires clarity of roles, trust, honesty and frequent
communication.
The Vice Chairperson is appointed from among Board members and acts on behalf of the
Chairperson in the Chairperson’s absence.
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The Secretary of the Governing Board is appointed from among Board members. This position
could be filled by the hospital CEO. The Secretary is responsible for taking minutes of Board
meetings. Minutes should be reviewed and approved by the Chairperson before distribution to
Board members.
The main purpose of Board meetings is to ensure effective governance of the hospital. This
includes developing, debating and approving strategic and annual plans, monitoring
implementation, discussing and approving corporate policies and addressing any legal and
ethical issues that arise. Board meetings are also an opportunity to provide structured education
sessions for Board members on emerging issues concerning the hospital and/or the community it
serves.
(NB: General guidance/etiquette to ensure that any type of committee or meetings function
effectively are presented in Appendix D.)
B) Agenda items
The agenda should be set jointly by the Board Chairperson and Hospital CEO. All Board
members should be invited to nominate agenda items for consideration by the Chairperson and
CEO. The agenda and any documents for discussion at the meeting should be distributed to
Board members at least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the Board:
a) Approval of previous meeting minutes;
b) Committee reports;
c) CEO’s report – providing an overview of hospital operations, discussion of pressing issues
and immediate concerns;
d) Old business – issues unresolved from last meeting;
e) New business – any issues Governing Board members want to raise; and
f) Next steps – plans for taking action on decisions reached by the Board, with the assignment
of follow up responsibilities to individuals as appropriate.
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C) Decision making
Decisions by the Board should be made by majority vote. In the case of a tie the Chairperson has
the deciding vote. Voting may only take place when a full quorum of Board members is present.
A vote passed by less than a full quorum is invalid. The criteria for a full quorum vary from
Region to Region (from 50% + 1 of Board members to 2/3 rd of Board members) and are
described in Federal and Regional Directives. The CEO is an ex officio Board member and
hence has no vote on the Governing Board.
The Governing Board should assign standing committees to carry out specific functions of the
Board and report on their activities to the full Board. As a minimum the following standing
committees should be established:
a) Executive committee
b) Finance committee
c) Audit committee
Other standing committees may be established on a temporary or permanent basis as the need
arises (for example a CEO selection committee, strategic planning committee, quality assurance
committee or a committee to address an emerging clinical matter).
When selecting members for each committee the following principles should be followed:
a) Committee members should be selected from the current Board members
b) Selection should be transparent and fair, without favouritism of any kind
c) The Governing Board Chairperson should be a member of all committees
d) Each committee should have its own chairperson who will preside over the actions of the
committee
e) Hospital staff, representatives of appropriate external bodies (e.g. MOFED or Woreda Health
Office) or prominent members of the community with an active interest in the hospital and
appropriate professional expertise (e.g. an accountant for the Finance committee) may be
appointed as non-voting members to support the functions of the committee
A) Executive Committee
The Executive Committee should be chaired by the Governing Board Chairperson and should be
comprised of Officers of the Board and all key Governing Board committee chairpersons. The
Committee acts on behalf of the full Governing Board in their absence and is responsible for
reporting to the full Governing Board on such actions.
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B) Finance Committee
The Finance Committee oversees the hospital’s financial planning and ongoing financial
operations to ensure the viability of the hospital. This includes monitoring that adequate funds
are available for the organization’s financial plan, safeguarding hospital assets, and ensuring that
the hospital has adequate fiscal policies. Moreover, the Finance Committee must anticipate
financial problems by reviewing hospital financial information provided at regular intervals. The
Finance Committee should be comprised of selected Governing Board members, the hospital
Finance Head and possibly representatives from the Regional or Woreda Bureaus of Finance and
Economic Development and business leaders from the local community. Other than those
individuals who are members of the hospital Governing Board, all finance committee members
have no voting rights.
C) Audit Committee
The Audit Committee should make sure that all required financial audits are conducted and that
reports are presented to appropriate bodies. The committee should be chaired by the Treasurer of
the Governing Board and comprised of selected Governing Board members, the hospital internal
auditor, the Finance Head and possibly representatives from the Regional or Woreda Bureaus of
Finance and Economic Development or a respected local accountant with knowledge of
bookkeeping and auditing. Other than those individuals who are members of the hospital
Governing Board, all audit committee members have no voting rights.
Each hospital should be managed by a CEO who is appointed by the Governing Board or
appointing authority following the processes set out in Federal or Regional Directives.
A qualified CEO should have a diverse set of leadership and management skills, as well as
considerable healthcare/hospital experience as either a clinician or management professional.
He/she must be capable of working with diverse groups, such as the Governing Board, various
community groups, government officials and hospital staff, patients and families. He/she should
be able to think strategically to provide vision and direction to the hospital with special attention
to professional development. An individual with an entrepreneurial spirit and who is fiscally
responsible will be valuable to the organisation. He/she should be a results oriented leader with
an eye for understanding how to improve the quality of patient care.
The CEO is the highest ranking management officer in the hospital and as such, directs and
administers the activities of the Hospital in accordance with instructions and plans developed by
the Governing Board. The CEO must ensure that decisions of the Governing Board are
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implemented effectively and efficiently throughout the hospital and must ensure the efficient
planning and utilisation of all hospital resources in order to achieve the organisation’s goals. This
entails the management of human resources, supplies, revenues, and physical and capital assets
based on detailed plans developed for all aspects of the hospital’s operations
CEO responsibilities should be described in a job description developed by the board that
clarifies the expectations of performance and boundaries of his/her responsibilities. Areas of
responsibility include:
The CEO should submit to the Board regular performance and financial reports of the hospital,
showing progress towards the goals of the strategic and annual plans, and in particular
highlighting any areas of concern.
The CEO should also ensure that any reporting requirements of higher authorities (such as
Woreda, Zonal or Regional Health & Finance Departments) are submitted in a timely manner.
C) Fiscal/ Budgeting
The CEO should prepare and submit the budget of the hospital to the Board for approval. After
approval the CEO should maintain the hospital budget within the agreed upon parameters,
effecting payments in accordance with the approved budget and plans. In partnership with the
Governing Board, the CEO is also responsible for designing various mechanisms to increase
hospital revenue such as:
outsourcing non clinical services to improve the overall quality of care,
establishing, organizing, and controlling private wing health services, and
revenue collection and utilisation procedures.
The CEO should ensure that financial audits are performed in accordance with government
requirements and submitted to the Board for approval, and subsequently to the appropriate higher
authority in a timely manner.
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The CEO should ensure that any recommendations made by internal or external financial audits
are acted upon appropriately.
A skilled CEO finds other capable staff members with whom to share the workload. The CEO
may delegate part of his/her powers and duties to the employees of the hospital to the extent
necessary for the efficient performance of its activities.
The CEO is responsible to establish an effective Senior Management Team to oversee day to day
hospital operations. He/she may also establish additional committees as the need arises. The
CEO should ensure that each committee has clearly defined membership and responsibilities,
and should ensure that each committee fulfils its functions.
F) Quality of care
The CEO should establish mechanisms to measure the quality of care and establish programmes
to continuously strive for improved levels of quality. The CEO should ensure that patients’ rights
are respected by all staff.
G) Regulations compliance
The CEO should oversee compliance with all relevant regulations from government bodies. Such
regulations may include safety regulations, employment regulations, finance and audit
regulations among others.
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J) Professional development
The CEO should keep current with emerging issues and technologies and ensure that staff
members are also kept current in these areas through training, access to resources, and related
opportunities.
M) Leadership
The CEO should establish and increase leadership presence within the hospital and cultivate
leadership practices from lower to top level management of the hospital through inspiring the
hospitals vision and becoming a role model in all aspects.
The CEO is accountable to the Hospital Governing Board, and is the only staff member under
the direct supervision of the Board. Evaluations of the CEOs performance should be conducted
at least every six month by the Board and/or appointing authority. Evaluation criteria should be
based on the job description of the CEO. Annual performance expectations should be spelled out
at the beginning of each year in discussion between the Governing Board Chairperson, or
appropriate member of the appointing authority, and the CEO.
If the Governing Board is concerned about the CEO’s performance at any time it should use the
evaluation criteria to address these concerns. The discussion can lead to goals for performance
improvement in the future. If these concerns have been addressed in the past and no
improvements have been made, the discussion may ultimately lead to the termination of
employment of the CEO following the process described by Federal or Regional Directives.
The relationship between the CEO and the Governing Board Chairperson must be ‘managed’
well by both individuals in order for the overall operations of the hospital to be conducted at
their best. It is mostly the responsibility of the CEO to ensure that this relationship remains
professional, courteous, and informative and defines the leadership of the organisation. While
Governing Board Chairpersons may come and go, as an appointed volunteer with defined terms
of service, the CEO is the hired professional who will hopefully work alongside and maintain the
organisation through Governing Board Chairperson successions. The final authority overseeing
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the hospital is the Governing Board, and as such, the CEO serves at the pleasure of the
Governing Board and its Chairperson.
Attending to the needs and dictates of the Governing Board Chairperson is the duty of the CEO,
and this hierarchical relationship can be made constructive and successful if the two individuals
understand each other’s strengths, weaknesses, management/governance styles, responsibilities
of their office and each other’s personalities. The CEO must elicit support from the Chairperson
on matters of importance to the hospital and the community it serves, so that together the Chair
and the CEO can be successful in designing strategies that the Governing Board members can
endorse and that the CEO can implement within the hospital.
Each hospital should have a Senior Management Team (SMT) that supports the CEO to oversee
the day to day operations of the hospital. The SMT provides information and advice to the CEO,
and serves as a forum to shared decision making, thus strengthening the transparency and
accountability of hospital leadership.
Terms of Reference for the SMT should be defined including: a description of the membership
of the SMT, the roles and responsibilities of the SMT, frequency of meetings, voting rules and a
statement of confidentiality. Each SMT member should sign a copy of the TOR indicating
his/her acceptance.
The SMT should at least meet every week to provide appropriate directions/ decisions, evaluate
performance of each unit and identify issues that require the board direction/decision.
The main purpose of the SMT is to assist the CEO and serve as a forum to shared decision
making, and, as such, many of the functions of the Management Committee, are similar to that of
the CEO.
A) Work with the CEO to prepare hospital strategic and annual plans for submission to the
Governing Board.
B) Provide reports to the CEO on implementation of strategic and annual plans, according to
each committee member’s area of responsibility.
C) Identify areas of concern in the achievement of hospital plans, and assist the CEO to find
solutions.
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D) Ensure that activities of the hospital are carried out with transparency and accountability and
that all required reports are submitted to higher authorities (e.g. RHB, BOFED, FMOH, and
MOFED) in accordance with government requirements.
E) Ensure the hospital complies with all relevant government regulations.
F) Provide financial oversight, advising the CEO on mechanisms to generate income and
minimise expenses.
G) Ensure proper implementation of fee waiver mechanisms and reimbursement.
H) Ensure proper management of hospital buildings, estate, equipment and supplies.
I) Resolve departmental or case team problems or disputes when these are beyond the ability of
the department head or case team director.
J) Ensure high quality clinical services by establishing and implementing mechanisms to
measure and improve the quality of care.
K) Support workforce recruitment and retention, protecting the health and wellbeing of hospital
staff, and creating opportunities for staff development including leadership opportunities.
L) Communicate relevant Governing Board, CEO and Management Committee decisions with
subordinate employees.
M) Establishes mechanisms to involve patients and the public in the planning and delivery of
hospital services and to maintain close consultation with community leadership.
N) Work to enhance the organisation's public standing and strengthen relationships with
community, government and professional audiences.
The SMT should be comprised of senior hospital leaders such as department or case team heads,
senior clinical staff and key administrative personnel. It is also recommended that a staff
representative, nominated by staff members on a rotating basis, is a member of the SMT. The
exact membership will be determined by the organisational structure of the hospital but should
include the following personnel (or individuals with similar responsibilities):
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13. General Services Head
14. Medical Equipment Management Head
Hospital staff or representatives of appropriate external bodies may be invited to attend SMT
meetings as non-voting members, to provide reports, information or advice to the SMT as the
need arises.
The CEO should determine the membership of the SMT, taking into consideration the
organisation structure of the hospital and key leadership positions. He/she should recommend
the proposed membership to the Governing Board for approval. After approval, specific
individuals will automatically be appointed by virtue of their position within the hospital. When
a committee member leaves the office which he/she represented he/she will be replaced on the
SMT by the next person assigned to that post.
The main exception to this rule is the staff representative, who should be elected by majority
vote of hospital employees. This member should serve on the SMT for a time limited period as
determined by the Governing Board (generally one year) and should then be replaced by another
elected representative.
SMT meetings should be held at least monthly or more often as the need arises. Extra-ordinary
meetings may be called by the CEO at any time.
As far as possible SMT meetings should be held during regular working hours, and committee
members should have dedicated time within their work schedule to attend and prepare for
committee meetings.
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B) Agenda items for SMT meetings
The agenda should be set by the Hospital CEO. All SMT members should be invited to nominate
agenda items for consideration by the CEO. The agenda and any documents for discussion at the
meeting should be distributed to SMT members at least one week in advance of the meeting.
The following should be regular standing items on each and every agenda of the SMT:
a) Approval of previous meeting minutes;
b) CEO’s report – providing an overview of hospital operations, discussion of pressing issues
and immediate concerns;
c) Reports from each SMT member providing an overview of their department/function and any
pressing issues and immediate concerns
d) Old business – issues unresolved from last meeting;
e) New business – any issues SMT members want to raise; and
f) Next steps – plans for taking action on decisions reached by the Committee, with the
assignment of follow up responsibilities to individuals as appropriate.
C) Decision making
Ultimately, the CEO is responsible for all hospital operations and as such has the authority to
reach decisions on hospital management matters. However, he/she may decide to determine
specific issues by a vote of the SMT. In such circumstances decisions of the SMT should be
made by majority vote. In the case of a tie the CEO has the deciding vote.
The SMT may establish a number of subcommittees to carry out specific duties related to
hospital management. Examples include:
A) Quality Committee
This committee is responsible to establish and monitor implementation of a quality management
strategy for the hospital.
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The Medical Equipment Committee serves to oversee all medical equipment maintenance in the
facility, including development of a medical equipment strategy, equipment inventory control,
procurement plan and preventive and corrective maintenance
F) Disciplinary Committee
The Disciplinary Committee serves to investigate all employee disciplinary charges and to
determine the appropriate disciplinary measure.
Strategic planning is the process of determining what an organization intends to be in the future
and how it will get there. The Annual Plan shows how the broader objectives, priorities and
targets of the strategic plan will be translated into practical activities. Each hospital should have
strategic and annual plans that are developed taking into consideration the mission, vision and
values of the organization and aligned with national, regional and local priorities.
Strategic plans should cover a 5 year period and should be ambitious towards reaching the
desired outcome. The annual plan should align with this, providing greater operational detail on
a year by year basis, tied to the annual budget. The Health Sector Transformation Plan (HSTP)
and the Regional/Zonal/Woreda Strategic Plans are the source documents for hospital strategic
plans and targets.
Scope: should reflect all activities and budgets, including those implemented by the public
sector, donor agencies, NGOs and communities
Resource and source of finance: estimation of the total amount of resources available from
all sources (government, specific donors, internal revenue, NGOs etc).
Implementation schedule: a list of major activities, a quarterly/monthly implementation
schedule and the responsible body for the implementation of each activity
Monitoring framework: for assessing progress during implementation. This includes key
performance indicators, baseline data, annual targets, information sources and collection
mechanisms, as well as reporting and feedback mechanisms.
Annual plans should be developed in two stages. The core plan is about achieving national
targets; the detailed plan is the core plan plus other activities of local importance.
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In addition to the planning template of the FMOH, hospitals should also follow the processes
established by MOFED/BOFED for budget allocation. This involves preparation of an annual
plan and budget using the MOFED/BOFED template and submission of this to the appropriate
authority. Further details on the budget allocation process are presented in Chapter 18 Financial
and Asset Management.
Each hospital should develop an Essential Service Package that describes the core functions and
clinical services provided by the hospital. The Essential Service Package is the foundation for the
Human Resource Development Plan (see Chapter 17 Human Resource Management) and for the
Model Medical Equipment List and Equipment Development Plan (See Chapter 15 Medical
Equipment Management).
The Essential Services Package should be developed based on the hospital vision, mission and
strategic and annual plans.
In order to determine if the Operational Standards of Hospital Leadership and Governance have
been met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of Chapter 20 Monitoring and
Reporting.
The following table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. The table does not measure attainment of each
Operational Standard but rather provides a checklist to record implementation activities.
Yes No
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2. Terms of Reference for the Board are defined
11. The CEO has signed a job description that outlines his/her
duties to lead the hospital
17. The hospital has a strategic plan that has been approved by the
Governing Board
18. The hospital has an annual plan that has been approved by the
Governing Board
19. All staff have been oriented to the hospital strategic and annual
plans
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21. The hospital assigns a unit to timely collect, properly document,
and submit reports of violation, as well as, takes proper actions
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
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Source Documents
1. Addis Ababa City Administration Health Bureau. (2009, January). Directive No. 1/2001
issued to provide for the execution of Addis Ababa City Government Health Services
Provision and Health Institutions Administration and Management Regulation No. 26/2001.
Addis Ababa: Addis Ababa City Government.
2. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 117/ 2005.
3. Amhara National Regional State. (2005). Health Service Delivery and Administrative
Proclamation. Healthcare Financing Regulation. Regulation No. 39/ 2006.
4. Department of Health. (1999, March). Clinical Governance, Quality in the New NHS.
London: Department of Health.
5. Department of Health. (2009, January). The NHS Constitution for England. London:
Department of Health.
6. Federal Democratic Republic of Ethiopia Ministry of Health. (2007). The Health Sector
Development Program Harmonization Manual.
7. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, July). Policy, Business
Process Reengineering: Policy, Planning and Monitoring & Evaluation Core Process.
8. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Strategic Plan for Ethiopian Health Sector.
9. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Indicator Definitions. HMIS/M&E Technical Standards Area 1.
10. Federal Democratic Republic of Ethiopia Ministry of Health. (2007, May). HMIS/M&E.
Disease Classification for National Reporting. Technical Standards Area 2.
11. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
HMIS Procedures Manual: Data Recording and Reporting Procedures. HMIS/M&E
Technical Standards Area 3.
12. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, January). HMIS/M&E.
Information Use Guidelines and Display Tools. HMIS/M&E Technical Standards Area 4.
13. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, August). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
14. Federal Democratic Republic of Ethiopia Ministry of Health. (2009, June). Performance
Monitoring and Quality Improvement Guideline for the Ethiopian Health Sector.
15. Federal Democratic Republic of Ethiopia Ministry of Health. Data Collection Guide for
Healthcare Quality Assessment.
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16. NHS Quality Improvement Scotland. (2005, October). Clinical Governance and Risk
Management: Achieving safe, effective, patient-focused care and services.
17. Oromia Regional Government Administrative Council. (2005). Oromia Regional State
Health Service Delivery and Administration Regulation No. 56/ 2005
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Appendices
Appendix A Sample Hospital Mission, Vision and Values Statements
A Mission can be defined as ‘purpose, reason for being’ or simply ‘who we are and what we do’.
A Vision can be defined as ‘an image of the future we seek to create’.
Mission statement
The mission of [ ] Hospital is to provide all patients quality, accessible and cost effective health care.
Vision Statement
[ ] Hospital strives to be the premier hospital in Ethiopia, recognized nationwide for the quality of
care provided.
We aspire to:
provide an excellent standard of service
deliver patient care in a way that inspires public confidence
expand our skills and knowledge to serve our clients
continually build up our services to meet our clients’ needs
be cost effective and financially secure
be recognized as an ‘employer of choice’ in the Ethiopian health system
Values of [ ] Hospital
Respect and dignity.We value each person as an individual, respect their aspirations and commitments in
life, and seek to understand their priorities, needs, abilities and limits. We take what others have to say
seriously. We are honest about our point of view and what we can and cannot do.
Commitment to quality of care. We insist on quality and striving to get the basics right every time:
safety, confidentiality, professional and managerial integrity, accountability, dependable service and good
communication. We welcome feedback, learn from our mistakes and build on our successes.
Compassion. We respond with humanity and kindness to each person’s pain, distress, anxiety or need.
We search for the things we can do, however small, to give comfort and relieve suffering. We find time
for those we serve and work alongside. We do not wait to be asked, because we care.
Improving lives. We strive to improve health and well-being and people’s experiences of our hospital.
We value excellence and professionalism wherever we find it – in the everyday things that make people’s
lives better as much as in clinical practice, service improvements and innovation.
Working together for patients. We put patients first in everything we do, by reaching out to staff,
patients, caregivers, families, communities, and professionals outside the hospital. We put the needs of
patients and communities before organisational boundaries.
Everyone counts. We use our resources for the benefit of the whole community, and make sure nobody
is excluded or left behind. We accept that some people need more help, that difficult decisions have to be
taken – and that when we waste resources we waste others’ opportunities. We recognize that we all have a
part to play in making ourselves and our communities healthier.
Adapted from The NHS Constitution for England. DOH, London, Jan 2009.
Appendix B Sample content of Governing Board training programme
Governance:
What is hospital governance?
What are RHB expectations of Governing Boards?
Roles and responsibilities of Governing Board
Jurisdiction and Power of Hospital Governing Board
Leadership and Code of Conduct for Governing Board Members
Role of Chairman, Members and CEO
Disclosure of Gifts and Loans
Conflict of Interest
Meeting Agendas and Rules
8 Deadly Sins of Hospital Governance
Policies, Guidelines and Protocols
Hospital Committees
Complaints Management
Adopting the Code of Conduct
Public Interest vs. Private Interest
Dealing with Official Misconduct
Performance monitoring:
So you think your hospital is doing in a good job. How do you know?
Hospital Reporting System to Board
Benchmarking
Other
WHO Six Building Blocks of a Health System
Worldwide trends in hospital development
Twinning
Universal principles for hospital reform
Appendix C Sample Self-Assessment Checklist for Governing Board
4) Set schedule for meetings, ideally at a fixed frequency, day and time. (For example, the first Monday
of every month at 4pm; or every Wednesday at 3pm). A fixed schedule makes it easier for committee
members to plan their schedule and remember to attend the meetings.
5) The Secretary and Chair should circulate an agenda, the minutes of the previous meeting, and papers
for discussion in advance of the meeting. These should be circulated to all committee members in
advance (ideally one week before the meeting).
6) All committee members should review the agenda, minutes and items for discussion BEFORE the
meeting so that they have full information for discussion at the meeting. If the meeting is spent
reviewing items for the first time then much time will be wasted and the meeting will be
unproductive.
7) Begin and end the meeting ON TIME. Do not wait more than a few minutes for members who are
late.
8) Be concise and stay on topic. If the agenda is long, a time limit should be set for each agenda item.
9) Begin the meeting by reviewing the minutes of the previous meeting and obtaining an update report
on any action points that were assigned from the previous meeting.
10) For each item on the agenda agree any action points that need to be followed up after the meeting. For
each action assign a specific individual to complete the task and a deadline for completion (for
example prior to next meeting, or within one month etc)
11) Prepare minutes of each meeting. These should include a summary of discussions and all action
points should be clearly stated with the name of the responsible individual.
2
Liaison, Referral and Social Services
Table of Contents Page
Section 1 Introduction 2-1
Tables
Table 1 Liaison, Referral and Social Services Checklist
Table 2 Liaison, Referral and Social Services Indicators
Figure
Reception Service Responsibilities
Box
Referral Network and Emergency Command Centre
Abbreviations
A&D: Admission and Discharge
CGQI: Clinical Governanceand Quality Improvement
ICU: Intensive Care Unit
OR: Operating Theatre
OPD: Out Patient Department
Section 1 Introduction
Critical to improving the quality of hospital care is having an effective networked health care
system that strives to deliver quality and efficient health services to the consumer. Public
hospitals have been implementing the referral and liaison services as part of the Patient Flow
Operational Standards and Guidance contained in the Ethiopian Hospital Reform
Implementation Guidelines for the past 6 years and under the Ethiopian Hospital Management
Initiative for the past 10 years. Liaison, admission and discharge, referral processes and hospital
based social services are critical inputs to efficient flow of patients between services. Properly
designed and implemented Liaison, admission and discharge, referral processes and hospital
based social services will reduce patient waiting times, increase provider efficiency and staff and
client satisfaction as well as improve overall quality of care.
Separating these patient flow related inputsinto a chapter calls for the collective efforts of all
hospitals’ staff toenhance the efficiency and effectiveness of patient flow within and between
hospitals, or between hospitals and patients’ homes. This chapter details the inputs required to
ensure well-organized patient flow and describes themanagement structures and roles and
responsibilities for reception, liaison and referral and social services, the systems and processes
for the admission and discharge of patients, and the criteria for the referral of patients between
services/ professionals in a given hospital and from one hospital to other health facilities.
1. The Hospital has established management structures and job descriptions which detail roles
and responsibilities for:
Reception service
Liaison and referral service
Social service
2. The hospital has a written protocol for the admission and discharge of patients that is known,
and adhered to, by all relevant staff.
3. The hospital has a Referrals Service Directory, listing facilities which the hospital may refer
patients to or receive patients from, categorized by the type of clinical services they provide.
4. Criteria for the referral of patients from the hospital to other health facilities are established,
including standardized referral and feedback forms and necessary clinical documents to
accompany referred patients, in accordance with the national referral implementation
guidelines.
5. The hospital has a standardized method for managing referrals and staff members are
familiar with the referral systems including relevant referral protocols and forms.
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6. The hospital promotes and publicizes the referral system throughout the community in order
to ensure that all constituents are aware of the applicable service pathway.
7. The hospital has established hospital based social service which addresses the social care
needs of patients affecting the efficient and effective flow of patients.
Reception staff should be easily identifiable (by uniform or identification badges). Reception
staff‘s ability to communicate additional local language would be a plus so as to deliver
appropriate information or to direct a patients/visitors to the right track. The reception staff
should be knowledgeable of the services provided by the hospital, the staff who provide services
(case team leaders etc.), and the layout of the hospital. He/she is directly responsible
(accountable) to the outpatient director. Reception staff should ascertain the following from each
patient and direct the patient accordingly.
2-2
Figure 1 Reception Service Responsibilities
Liaison service is vital for effective communication and sustainable smooth flow of patients that
need to be operated by liaison officers with special training for the position.Liaison Officer is
thus a person that runs the liaison services and liaises between two or more organizations and the
public to communicate and coordinate their activities.Generally, a liaison service aims at:
Each health facility should establish a liaison and referral service that is responsible to:
1. Manage hospital bed occupancy (bed management).
2. Facilitate emergency and non-emergency (elective) admission.
3. Facilitate social support to the emergency, inpatient and outpatient case teams.
4. Manage the referral service, specifically:
Coordinate the overall referral activities.
Record and report the referral activities to facility management.
Compile, analyze and interpret data to improve the referral service.
Take part in the quality assurance programs of the referral system by participating in regular
review meeting within and outside the health facility.
Performance monitoring and evaluation.
Ensure feedback is sent back to the referring health facility.
Update the elective admissions waiting list.
Assign an admission date to patients based on the urgency of the clinical need as date
indicated by the physician in the patient notes.
Ensure regular bed census is carried out, reported and used to update and manage the bed
utilization.
Each hospital should establish a Referral Protocol that outlines the criteria for making a referral
to another facility and the process to be followed when making a referral, including use of the
Referral and Feedback Form and any necessary clinical documents that should accompany the
referred patient. The protocol should be known and adhered to by all relevant staff.
Each hospital should establish a Referrals Service Directory that lists facilities to/from which
patients can be referred or received and the services available at each facility (the Referral
Network). The contact details of each facility in the Referral Network should be documented.
The criteria for receiving/referring patients to each facility should also be documented and
agreed between all facilities participating in the Network. Standardized Referral and Feedback
formats should be used by all facilities participating in the Network.
For further guidance please also refer to the Guideline for Implementation of a Patient Referral
System in Ethiopia.
A hospital can be both a ‘Receiving Unit’ for patients referred from other facilities and a
‘Referring Unit’ to refer patients to another facility.Referrals can be made for both outpatient
services and for inpatient admissions.
A. Emergency Referral in
Each day, (every 8 hours) the liaison officer should asses the number of unoccupied beds,
number of patients in the emergency unit/department waiting to be transferred to inpatient
wards, and number of patients in the ICU to be transferred to the ward.
If dispatch/command center is available, the liaison officer has to give report on vacant beds
three times a day to the center and update information of the particular day.
If the service is not available direct communication will be made between health institutions.
Ensure the ambulance service is in place for 24 hour and is equipped with the necessary
medical supplies for critical emergency patients. When a facility calls to refer emergency cases a
liaison officer should check the following things before accepting the referral:
1. The availability of beds in the case team where the patient requires service
2. The availability of the service and professional (some service can be given by a highly trained
individual professional; in such case the liaison should check the presence of the professional and the
service).
3. Appropriateness of the referral, that is, the referral should be based on the referral network and any
referrals should not be out of the referral network agreement, or the importance has to be justified with a
discussion with the accepting physician.
4. Information on the patient’s clinical condition, to insure safe transportation and to consider patient is
accompanied by a professional who has life-saving skills.
5. Inform the accepting unit about the incoming patient’s status, and the estimated time of arrival to the
unit so that the accepting unit will make the necessary arrangements accordingly.
When a facility calls to refer a non-emergency case that needs admission, the liaison should check the
appropriateness of the referral (the same procedure listed above) and the nature of the disease in case the
waiting time is becoming prolonged. This information helps to identify the disease progress such as if
cancer is diagnosed at its early stage and prolonged appointment may lead for worsening of the diseases,
therefore this information will help to prioritize admissions. There could be arrangement of elective
admission date and inform the patient through the referring liaison officer. A liaison should present the
elective admission list to inpatient case team on regular base preferably on daily bases.
Box- Referral Network and Emergency Command Centre
Once the Clinician has decided to refer out a patient the case should be immediately linked to liaison
office.
Before referring out a patient a liaison officer should:
After checking all necessary steps listed above and identifying appropriate facility the liaison officer
should communicate with receiving facility liaison officer to pass the appointment information to the
patient.
The hospital should collaborate with other facilities in the network and the Regional Health
Bureau to promote, monitor and evaluate the referral system. In particular, the hospital should
promote and publicize the referral system through the community in order to ensure that all
constituents are aware of the applicable service pathway. For further guidance on mechanisms to
inform and involve the community see Chapter 19 Clinical Governance and Quality
Improvement.
A system to track a referral from point of initiation to point of delivery and, as a feedback
loop, from point of service delivery back to point of initiation is needed to ensure that the
client is using the service(s) needed.
It is clear that the capacity of the lower level health facilities has a great impact on overall
health delivery system of a country; in particular the referral linkages of the health delivery
system. Feedback and communication in the referral system is a critical step in addressing
capacity issues. In addition effective communication facilitates learning and, can inform
professionals about the outcomes of the patients that they refer.
Written feedback provides evidence that the referral process was completed and the service
was delivered, and should indicate whether there were problems. Using the original referral
request, documenting the status of service delivery and other pertinent information and
returning the form to the site of referral initiation is one method of feedback communication.
The effectiveness of a referral system is determined by the individuals being referred, so it is
essential to find out if a client is satisfied with the service received and whether her or his
need was met. One method of getting this information is that the facility that made the referral
will contact the client directly for feedback, if the client agrees. Another way is to carry out
periodic surveys at different points (hospital, health centre etc) in the system.
The aim of bed management is to make maximum use of hospital beds, ensuring high bed
occupancy, high patient turnover and minimum waiting times for elective admission.
At any time the liaison should and have the following information:
If all the above mentioned solutions are not applicable, refer to the nearest health
facility after the patient is made stable and bed/service is secured in the accepting health
facility.
Effective and coherent admissions and discharge policy for emergency and elective patients are
very important for proper utilization of hospital beds. Based on admitting physician’s
recommendation liaison officer should coordinate beds for admission (Please refer Annex VI:
Admission urgency notification card).
When request for admission is made the liaison officer should follow the steps below:
The liaison officer should inform the case team leader of the receiving ward that the
patient should be transferred to that ward and any necessary administrative tasks carried
out with the assistance of runner.
Is there any patient in the relevant case team /ward due to be discharge that day?
If yes --- confirm that patient will be discharged. Identify and address any factors that are
delaying discharge. Consider moving patient to transit lounge (if available) or another
waiting area. In this way the bed can be freed and the new patient can be admitted
- Agreement on the parameters for scheduling operation theatre lists with the OR team.
The hospital should provide an admission and discharge service 24 hours a day, 7 days a week,
365 days a year, including holidays and weekends. Admissions and discharges should be
arranged and facilitated through the Liaison office. A written protocol for the admission of
patients should include: mechanism for arrangement of admission, and activities to be
undertaken at the arrival of the patient at the ward.
Upon arrival on the ward, there should be a quick assessment of the condition of the patient by
the receiving nurse.
Patients in critical condition or with emergency signs needing immediate attention,
should be received by a nurse who will evaluate the nature and severity of the illness and
inform the responsible physician in 15 minutes. If there are emergency clinical signs to
be addressed by physicians, the informed physician must come and see the patient
immediately.
For patients in a stable condition, the nurse will initiate the ward admission process,
including orienting patients and families to the facilities such as toilets, showers,
introducing relevant staff, giving instructions for care-givers etc. The responsible duty
physician should then complete the evaluation of the patient in no less than 2 hours.
Being the most critical patients directed to the inpatient department, these patients should
have comprehensive evaluation, addressing all components of health and diagnosis
should not rely on OPD evaluation notes as there may be a misdiagnosis or developments
in the condition of the patient.
Nursing process need to be completed in no later than 8 hours (before the next shift) and
all efforts have to be made to make patient centered and improve the overall quality of
the care beyond documentation.
C. Discharge process
The hospital should establish a written protocol for patient discharge. The hospital should also
design and own a discharge summary and mechanism of handling medical records afterwards.
Decision for discharge should be made by the treating physician, who should complete a
discharge summary. First copy of the discharge summary should be given to the patient, while
the second copy has to be documented in the Medical Record. If the patient was referred from
another facility, the discharging physician should also complete the feedback section of the
referral paper, and, that should, be given to the patient, to give to the referring health institution.
Patients ready for discharge should be counseled by the attending physician, nurse in charge and
clinical pharmacist before discharge. Pre-discharge counselling encompasses the following:
Share the discharge plan while patient is on the ward, before starting the process
An explanation of any medications that the patient should continue to take upon
discharge
Arrangements for follow up, if any
There shall be a policy or a protocol that states the procedure to be followed for dead body care,
including how the staff breaks or informs the families and also considers the cultural ceremony
to be followed. A death occurring in the hospital should be confirmed by at least an attending
physician or any independent practitioner and the nurse giving care. The Inpatient service
should have a separate room for ‘after death care’. A death summary should be completed and
documented in the patient’s medical record, to ensure accuracy and easy retrieval.
In case of a need for pathologic examination and confirmation for cause of death, a post mortem
examination form should be completed and the body should be transferred to the pathology case
team or morgue. Following completion of necessary medical examinations, the body shall be
stored in the hospital’s morgue until it is collected by the patient’s relatives or other responsible
person. If the patient does not have a next of kin, the local authority is responsible for collecting
the body. Any unexpected deaths should be reported to and investigated by the hospital’s CGQI unit.
At least two liaison officer per shift but differ based on the number of patient served
(BSc or MSc in nursing)
At least two social workers (BSc or MSC in Sociology/Social work)
At least two receptionists but, the number differs based on the complexity of the hospital.
Runners (at least two)
Computer
Office furniture (chair and table)
Wheelchair
Stretcher
Telephone (direct line and Mobile)
Shelve
Social work is an academic and professional discipline that seeks to facilitate the welfare of
communities, individuals and societies. It may promote social change, development, cohesion,
and empowerment. Underpinned by theories of social sciences and guided by principles of social
justice, human rights, collective responsibility, and respect for diversities, social work engages
people and structures to address life challenges and enhance wellbeing.A social work service in a
hospital is organized to provide services such as case management (linking clients with
agencies and programs that will meet their psychosocial needs including finance), counseling
and psychotherapy services.
In order to determine if the Operational Standards of Liaison, Referral and Social Care have been
met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of chapter 20 Monitoring and
Reporting.
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implementation activities.
Yes No
1. A Liaison and Referral Officer has been assigned.
2. A hospital social worker is in post.
3. There is hospital liaison and referral service.
4. There is a hospital based social service.
5. There are personnel trained in liaison, referral and hospital based social care work
services.
6. Emergency and central triages are equipped with necessary supplies and equipment.
7. Outpatient appointment system is in place.
8. There is an appointment system for elective inpatient admission.
9. There is a written protocol for admission and discharge of patients.
10. There is a written protocol for the referral of patients (receiving into the hospital and
referring outside of the hospital).
11. There is a referral directory listing which facilities that hospitals can receive patients
from or refer patients to.
12. Bed occupancy information is gathered and reported.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
Source Documents
Tables
Table 1 Human Resource Needs for Emergency Services
Table 2 Equipment and Supply Needs for Emergency Services
Table 3 Emergency Medical Services Checklist
Table 4 Emergency Medical Services Indicators
Figures
Figure 1 Domains of Acute Care
Section 1 Introduction
Hospital based emergency medical services are part of the patient flow in a hospital setting and
includes the processes and procedures needed to ensure the efficient flow of patients between
services. Patient flow requires various inputs including human resources, infrastructure,
equipment, protocols and pathways. Properly designed and implemented hospital based
emergency medical care services will reduce patient emergency triage and treatment times,
increase provider efficiency and staff and client satisfaction as well as improve overall quality of
care.
Emergency Medical Services (EMS) overall are a network of services and resources coordinated
to provide aid and medical assistance from primary response to definitive care, involving trained
personnel and use of appropriate technologies in the rescue, stabilization, transportation, and
advanced treatment of traumatic, obstetric and medical emergencies.
EMS can be given in a pre-hospital or hospital setting. Pre-hospital refers to all environments
outside an emergency department resuscitation room or a place specifically designed for
resuscitation and/or critical care in a healthcare setting. It usually relates to an incident scene but
includes the ambulance environment or a remote medical facility.
This chapter details the inputs required to ensure well-organized hospital based emergency
medical services from the patient’s arrival at the entrance of the hospital until the patient is either
admitted as inpatient/transferred to outpatient services, referred to other health facilities,
discharged home and exits the hospital. Emergency Medical Service processes described in the
chapter include EMS organisation, triage and treatment and case management processes are also
outlined.
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Section 3 Implementation guidance
The Emergency Case Team should be overseen by a Director of Emergency Services. He/she is
responsible for all activities conducted in Emergency Services including:
Patient triage,
Case management, and
Laboratory, pharmacy and diagnostic services.
The Director of Emergency Services is responsible for managing all department staff and should
ensure that sufficient equipment and supplies are available for the patient load.The Emergency
Department or Unit shall serve as the definitive specialized care area/facility, equipped and
staffed to provide rapid and varied emergency care to all people with life-threatening conditions.
The Emergency Department or Unit shall provide initial appropriate care and arrange subsequent
disposition as per domain of care (see figure1 below).
Ideally, adult and paediatric ETAT areas and triage staff for emergency patients should be
separate. However, if the workload is low a single triage may serve both adult and paediatric
patients in the emergency department. In this case, paediatric patients should be given priority
over adults in the event that more than one patient requires ETAT at the same time.
The ETAT service should be provided 24 hrs a day, 365 days a year. Adult and Paediatric
Triage Protocols should be developed and implemented. Protocols should be posted on the walls
of triage areas as an ‘aide memoire’ for triage staff.
Following the initial triage and treatment to stabilize vital functions, patients should be assigned
to the Case Management Team for further investigations, treatment and follow up. The Triage
Officer should prioritize cases, determining which patients need the immediate attention of the
Case Management Team, which patients are ‘priority’ cases, and which are less urgent (for
example a patient with a minor wound whose vital signs are intact). The Triage Officer should
also identify ‘non-emergency patients’ and refer such patients to Central (outpatient) Triage.
During triage and case management of adult and paediatric cases, runners’- should handle
relevant administrative processes (such as patient registration, retrieving the patient’s medical
record, making payments etc). For further information on the process of registration see Chapter
6 Medical Records Management.
1
World Health Organization. 2016. Updated guideline: paediatric emergency triage, assessment and treatment. Geneva: World
Health Organization.
3-3
health worker may take this role. He/she should be assisted by a Clinical Nurse and runner. If the
workload is high the hospital may appoint more than one Emergency Triage Officer, Nurse and
Runner.
3-4
E) Emergency Triage and Treatment Training Requirements
All emergency triage clinical staff should be trained to conduct triage and emergency treatment,
following the established triage protocols
Patients enter the emergency case management pathway upon referral from the Emergency
Triage Officer. Appropriate care is then initiated by the emergency physician and based on the
outcome the patient is either admitted, discharged (with or without a follow up appointment) or
referred.
Laboratory samples should be obtained within the emergency department and analyzed either
within the department or at the central laboratory, depending on the test requested.
More complex tests may be performed in the Central Laboratory. If the sample is to be tested in
the central laboratory then a runner should take the specimen to the laboratory and collect the
result.
If radiology tests are required these too should be conducted in the Emergency Department using
a portable X-Ray. If this is not possible a runner should transport the patient to the X-Ray
department where the test will be conducted. Results should be taken back to the Emergency
Department by a runner.
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If medication is required, a prescription should be issued by the emergency physician and should
be dispensed by the emergency room dispensary.
A cashier service should be available within the emergency department for the payment of all
emergency room treatments, investigations, drugs and consumables. Runners should assist the
patient and/or caregiver with making payment.
Patients who require short term treatments (such as IV fluid administration, a loading dose of IV
antibiotics etc) may be transferred to a bed in the Emergency Services and kept for a maximum
of 24 hours. Any patient who requires treatment for a longer period of time should be admitted to
an inpatient ward.
Following assessment, investigation and treatment the patient may be discharged home, referred
for a follow-up appointment at the outpatient services admitted to an inpatient ward or referred to
another facility.
If the patient is to be admitted to the hospital the Liaison Officer will check the availability of a
bed and arrange for the patient to be transferred to the appropriate ward, escorted by a runner
with his/her medical record.
If a bed or the service required is not available at the hospital, the Liaison Officer will contact
other facilities or the Regional Emergency Command Centre (if available) to identify a hospital
with the capacity to provide care to the patient and will facilitate referral following agreed
protocols. If the service is not available in another facility the patient must be kept in the hospital
to receive treatment.
NB: some of the personnel described in Table 1 below (such as Specialists, Social Worker) may
also be part of the Inpatient Case Team, however they should be readily available to provide
support/consultation to the Emergency Case Team whenever required. The Emergency Case
Team should have ready access to the Liaison and Referrals Service.
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Clinical Non-Clinical
General Practitioner/Health Officer Data clerk
Professional/Clinical Nurse Runner
Pharmacist/Druggist Porter
Lab Technologist/Technician Cashier
Imaging Personnel Cleaner
Specialists (e.g. Internal Medicine, Paediatrics, Surgery, Security
Gynaecology etc) Social Worker
3-7
3.3.1 Emergency Services Layout
The Emergency Services should be organized so that the Emergency Service’s entrance can be
easily accessed by ambulances and patients. This means that the emergency unit should be
located on the ground floor for ease of access and should be clearly labelled in a way that is
visible from the hospital’s gate. Its entrance signage should be clearly illuminated and has multi-
lingual labels in red colourthat is visible from the street (even at night), and addressing the
cultural and linguistic diverse needs of its communities. There should also be an area dedicated
for patient drop-off and ambulance parking.
The hospitals should have adequately designated space for emergency unit and eemergency
services should have the following facilities in required standards:
B) Ambulance service
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Hospitals should have in-house ambulance service for inter-hospital or inter facility transfer of
patients and should utilize such a service for advanced life support to assist the pre hospital
providers. The ambulance should be used only for transportation and management of emergency
patients. All ambulances in hospitals should be equipped with equipment and supplies to
render minimum Basic Life Support/BLS/, Advance Life Support/ALS/ and have trained
ambulance drivers. Hospitals’ caseloads and availability of ambulance access areas should
determine the appropriate number of ambulances in hospitals, including those used for
non-emergency patients.
E) Decontamination Room
A decontamination room should be available for patients who are contaminated with toxic
substances. In addition to the requirements of an isolation room, this room must:
- Be directly accessible from the ambulance bay without entering any other part of the
department.
- Have a flexible water hose, floor drain and contaminated water tap.
- Have storage space for personal protective and decontamination equipment
3-9
An operational relationship between medical records, cashier and social worker should exist to
ensure patient details are recorded, or a previous medical record is retrieved. The patient assistant
should assist patients or their relatives with registration payments to the cahier, the latter which
should be situated next to the medical record personnel. Patients without the ability to pay for
their treatment should be referred to the hospital social services without delay.
There must be a separate emergency medical record corner (under the main MR in the hospital).
Access is required to ensure patients’ previous medical histories are obtainable without delay. So
emergency patients must not have to line up to get registered. A system of mechanical or
electronic medical record transfer is desirable to minimize delays and labour costs. Access to
medical records must be available 24 hours/day and 365 days a year.
Regardless of the availability/non-availability of accompany family member of an emergency
patient, medical registration should be carried out with the help of or fully by the nurse
assistants/ runners.
Serving patients in a single window (one stop shopping) is strongly recommended to ensure
cashiers are located next to the medical registration room.
G) Waiting area
The emergency-waiting area should be located near to the triage area with easy access and
suitable for observation and follow up of patients by the triage nurse. Patients with stable
conditions should remain in the waiting area until the physician is ready to evaluate their
conditions. The triage nurse should continue to observe, communicate, reassurance and re-triage
waiting area patients, as per need, until they are discharged home or transferred to another
service within the hospital or to another facility. The waiting area should be kept clean, brightly
lit and well ventilated.
H) Isolation room
Isolation rooms should be provided for the treatment of potentially infectious patients. They
should have a room with scrub up facilities, negative ventilation, and be self-contained linen-
suite facilities. The rooms should be fitted with acute treatment area facilities and located
adjacent to patients’ reception area, i.e. triage to allow for the immediate isolation of potentially
highly infectious based on the hospital’s standards.
Isolation rooms may also be used to treat patients with conditions which require separation from
other patients e.g. patients who require privacy for clinical conditions, or who are a source of
visual or auditory distress to others. Deceased patients may be placed for grieving relatives to
spend time with their deceased ones. These rooms must be enclosed completely from floor to
ceiling.
I) Resuscitation area
The resuscitation area is a key area of an emergency department. It usually contains several
individual resuscitation inlets, usually with a dedicated fully equipped pediatric resuscitation area
3-10
adjacent to triage area. Each bay is equipped with resuscitation equipment and supplies (see
annex) with systematic refill mechanism and displayed in one cart (crash cart)
J) Emergency OR
The operating room should be readily accessible to the Emergency Services Case Team. If the
workload is high, there should be a specific operating theatre for Emergency Services only.
However, the general operating theatre may be used if the workload is less, in which case
emergency cases should always be given priority over elective/cold surgical cases
K) Examination area
A separate examination room for each patient and physician is not mandatory at the ED/EU since
emergency patients’ physical examination can be done in the resuscitation room. However,
multi-purpose examination cubicles should be organized for less critical patients. ED/EU
physicians should use the multi-disciplinary station/counter in-between patient interventions for
writing. Implementing such an arrangement will ensure one cubicle can serve many physicians
and patients.
L) Procedure area
This is an area where clean and sterile procedure equipments are stored and non-critical
procedures like minor wound care and others are carried out. Procedures for critical
patients should be carried out in the resuscitation area with continued/ongoing
resuscitation.
M) The observation and treatment area
This is an area for stabilization and observation of patients who still need to be confined to
bed or an area to keep patients overnight (24hrs) or less until they are transferred to
inpatient wards or other health institutions. The observation area is a continuum of the
resuscitation area, and patients in this area require strict follow up and continuation of
initiated treatment. Nurses need to monitor patients ’vital signs regularly and physicians’
need to conduct frequent medical rounds (expected 2-3times/day), write up progress
notes 2-3times/day according to patients’ conditions and as per national treatment
guidelines.
N) Pharmacy
All medications and equipment for the resuscitation and management of emergency patients
should be readily available at each treatment and or procedure areas. Proximity is desirable to
enable prescriptions to be filled by patients with limited mobility. The aim of having readily
accessible pharmacy services is to ensure speedy refilling of fast moving essential
emergency drugs and supplies without delay and auditable drug and supply management.
The pharmacist/druggist should work closely with the nurse responsible for refilling and
establish an efficient refilling process. Laboratory/ sample collection and testing facilities
3-11
Laboratory samples should be obtained within the emergency department and analyzed either
within the department or at the central laboratory, depending on the test requested.
At a minimum the following tests should be provided in the Emergency Department:
Haemoglobin,
Haematocrit,
Blood film,
Blood group and cross match,
Total cell count,
Random blood sugar,
Urinalysis,
Stool examination, and
Pregnancy test.
More complex tests may be performed in the Central Laboratory. If the sample is to be tested in
the central laboratory then a runner should take the specimen to the laboratory and collect the
result.
O) Portable imaging facilities and bay in tertiary hospital level
This is used to house and charge mobile x-ray equipment which should readily be accessible to
the major treatment areas including the plaster room. Having the portable X-ray and ultrasound
minimizes delay of management of patients; therefore it has to be considered as mandatory. And
there should be a 24/7 radiology service with a radiologist or a delegate available.
P) Nurses and physicians station
This is an area where a counter table with multiple chairs and computer is placed. All
documentation tools and patient charts are kept electronically and manually here. Additionally,
the station should internet network and reading materials for easy reference.
Q) Administration room
Offices provide space for the administrative, managerial safety and quality, teaching, and
research roles of the emergency department. Office spaces should be provided based on the role
delineation of the emergency department.
R) Staff room /Meeting room
This is an area where staff in the ED/EU will have refreshment during duty hours. Ideally
emergency staff should not go out for tea/ lunch/dinner, or to duty rooms for rest. Such rooms
should be equipped with comfortable chairs, equipment’s and supplies for refreshment.
Adjacent to or in the ED/EU, hospitals should also provide nurses and physician’s morning
meeting room according to discuss cases and resolve identified major problems through quality
improvement trainings and discussions within the ED/EU.
S) Utility areas
3-12
Clean Utility
This should be of sufficient size for the storage of clean and sterile supplies with
adequate bench top area for the preparation of procedure trays and equipment.
Dirty Utility/Disposal Room
Access should be available from all clinical areas. There should be sufficient space to house the
following:
Stainless steel bench top with sink and drainer
Pan and bottle rack
Bowl and basin rack
Utensil washer
Pan/bowl washer sanitizer
Flushing sink
Storage space for testing equipment, eg. urinalysis
An optional disposal room adjacent to the dirty utility should be considered.
3-13
services. For fast and efficient communication between the ED staff, all staffs in the ED have to
have pager.
Equipment/store room: This is used for the storage of equipment (eg. IV poles) and disposable
medical supplies for the department. There should be sufficient space to store and charge battery
powered equipment, e.g. Infusion pumps. This does not include storage space within treatment
areas. As a general principle, emergency departments should have sufficient storage space to
carry 72 hrs supplies of disposable medical supplies and intravenous fluids. Local logistic issues
and risk management considerations may dictate larger storage capacity. This area should be
accessed by the nursing and physician staff available.
U) Disaster or mass causality equipment store
This should be located near the ambulance entrance and should be of a size consistent with the
role of the ED in a major incident or disaster. There needs to be hanging space for specialized
clothing/ protective suits, work benches for equipment checking and power outlets for battery
banks.
3-14
Act as liaison for members of the public and other health care Professionals.
B) Resuscitation
All unstable patients and with CVS arrest admitted to this area for resuscitation. In one ED/EU
there must be 2-3 resuscitation couches for adult and same number for children. The staff ratio
has to be 1:1(one nurse for one patient). At the beginning of the resuscitation multiple specialty
physicians and nurses might participate according the patient’s condition. The nurse on charge
for this coach is responsible for availing and maintaining emergency supplies and drugs. After
resuscitation the patient must be transfer to the appropriate designated area (observation room,
ward, OR, or can be referred to the appropriate level of health facility for continuation of
management)
C) Observation
After resuscitation or patients who require temporary short term observation and management is
admitted to this area. The number of beds for observation varies from hospital to hospital
according their load, but it is advisable to have 5-10beds as a minimum. Patients kept in this area
needs frequent evaluation by the ED/EU physician, available senior and nurses. The nurse
patient ratio is 1:3.
3-15
Disaster preparedness and response plan uses all hazards, all agencies, and comprehensive
approaches and focuses the importance of careful planning. For detail information, please see
the National Disaster Health Preparedness and Response Guideline, 2015
In order to determine if the Operational Standards of Emergency Medical Services have been
met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of chapter 20 Monitoring and
Reporting.
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implementation activities.
Yes No
13. There is an emergency triage.
14. A Director for Emergency Medical Services is assigned to oversee all activities
conducted in Emergency Department/Unit.
15. There are personnel trained in triage processes working in the emergency triage.
16. Bed occupancy information is gathered and reported.
17. Number of available materials and drugs checked prior to each shift.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
3-16
1. Number of ER Total number of ER attendances Quarterly
attendances
3-17
Source Documents
1. Federal Ministry of Health. National Liaison and Referral Manual. Unpublished. Federal
Democratic Republic of Ethiopia Ministry of Health. (2008). Curative, Rehabilitative and
Treatment Sub-Business Process. The New General and Specialized Hospital Business
Process Study Report. Addis Ababa, Ethiopia.
3. Federal Democratic Republic of Ethiopia Ministry of Health. (2008, October). Patient Flow:
A Manual Prepared for Heads of Hospitals and Service Providers. Addis Ababa, Ethiopia
4. WHO. (2016). Pocket Book of Hospital Care for Children. Guidelines for the Management
of Common Illnesses with Limited Resources. Geneva: World Health Organization.
7. Federal Ministry of Health. The National Admission and Discharge Protocols for Ethiopian
Hospitals. July 2012. Addis Ababa, Ethiopia.
Appendices
Appendix 1 Triage minimum basic equipment’s and supplies list
Desk
Chairs
Examination coach/stretcher
Thermometer
Adult Stethoscope
Pediatric Stethoscope
Adult sphygmomanometer
Pediatric sphygmomanometer
Light source
Tourniquet
Pulse oximeter
Glucometer
ECG monitor
Oxygen
Neck colar, back board and lumbar brace
Ambu bags- adult/pediatric size
Suction machine and tubes
Dry dressings/ bandages
Casting materials and splint
Torniqet
Finger prick glucotest & finger prick hemoglobin
Urine dipsticks & urine pregnancy tests
Weight scale- adult/paediatric- hanging, tape measures
Screens, partitions or separate rooms
Walkers, wheelchairs, stretchers
Gloves, face masks & other personal protective equipment
Emergency drug supply (See Chapter 4 Pharmacy Services; Appendix H for a list of
recommended drugs).
Resuscitation minimum equipment’s and supplies list
BASIC
Airway equipment,
Oxygen system-cylinder, concentrator, face mask, nasal prong, flow meter
Suction machines
Intravenous set/cannula and fluids,
Emergency and analgesia drugs
ECG machines,
Non-invasive ventilation (NIV)
Foley catheters
Chest drain sets
Tracheotomy sets
Tubes; NG, Rectal,
Wide bore needle/cricothyrotomy / GENERAL/TERITIARY LEVEL/
Defibrillator,
Monitors
Ventilator
Intubation sets
Anesthesia drugs
Portable X-ray facilities
Portable ultrasound devices
Intraosseous needles and drill
Central lines
Appendix 2 General minimum Equipment and Supply Needs for Emergency unit/departments
Appendices
Tables
Table 1 Equipment and Supply Needed for Outpatient Services
Table 2 Outpatient Services Checklist
Table 3 Outpatient Services Indicators
Figures
Figure: 1 Sample Layout of Outpatient Services
Figure 2: Typical Pathway for Outpatients Service
Abbreviations
CO Chief Clinical Office
ECG Electro cardiograph
HMIS Health Management Information System
JD Job Description
MD Medical Director
MRN Medical Record Number
OPD Outpatient Department
IPPS Infection Prevention and Patient Safety
ROPD Regular Outpatient Department
TB Tuberculosis
TV Television
Section 1 Introduction
Hospital outpatient services management refers to the processes and procedures needed to ensure
the efficient flow of patients between outpatient services and providing quality health care to
clients. Efficient flow of patients requires various inputs including human resources,
infrastructure, equipment, protocols and pathways. Properly designed and implemented patient
flow will reduce patient waiting times, increase provider efficiency and staff/client satisfaction,
proper resource utilization as well as improve overall quality of care. This chapter details the
inputs and process required to ensure well-organized patient flow at the outpatient department
and describes the flow of services from the patient’s first encounter with the reception service at
the entrance of the hospital until the patient exits the outpatient department.
4-1
Section 3 Implementation Guidance
The hospital’s outpatient services should be organized in clinical teams according to the clinical
services provided by the hospital. The outpatient department will be led by full time outpatient
director / outpatient case team manager with nurse coordinator and will be accountable to the
hospital’s CCO/MD. The outpatient directorate/case team manager will have an office with
office furniture’s, secretary, plan, report and evaluation system.
Outpatient Services should be organized in a manner that reduces the length of time that it might
takes a patient to travel from one service area to another. Although each facility has a different
layout and plan, clinical services should be organized as close to one another as possible.
Outpatient services consist of
a) Central triage and patient waiting area
b) Medical Record Room
c) Examination(clinical assessment) room, sample collection and treatment rooms
d) Pharmacy dispensing unit and cashier
e) Laboratory team, with cashier
f) imaging diagnostic team, with cashier
4-2
Figure: 1 Sample Layout of Outpatient Services
The central triage is the first point of patient contact in outpatient services. The central triage
infrastructure should include a waiting area with adequate seats, registration and clinical
assessment areas.
Patients will be directed to Central Triage from the reception service or Emergency Department.
Within Central Triage the patient will undergo a triage assessment and all relevant administrative
processes (registration, medical record retrieval, payment etc) will be conducted. The triage
assessment will assign each patient to appropriate case team (emergency, ROPD, specialty and
sub- specialty clinic or back referral with appropriate counseling. The patient will then be
directed to the relevant case team and his/her medical record will be delivered to the case team
by a runner. Possible flow of outpatient services is shown in Figure 2 below:
The first step in Central Triage activity is aiming in identifying and treating emergency signs.
The Triage Officer should identify patients who would be more appropriately treated by the
emergency case team and after resuscitation, should transfer these patients to the emergency case
team. If a patient does not have an emergency condition, the Triage Officer should then
determine the nature and urgency of the client’s medical problem and determine the appropriate
service/case team required by the patient. If the service is available the patient should be
transferred to the appropriate case team or given an appointment for the next available date while
a referral should be arranged to another facility for services not available in the hospital. When
scheduling appointments for the same, or a future date, staff should take all relevant patient
information into account, including:
The severity of the condition
Financial status of patient (for example financial difficulties that could prevent the patient
returning to the hospital at a future date taking into consideration transport and/or hotel
costs
Social circumstances of patient (for example loss of income due to absence from work,
childcare needs of dependent children and etc).
The criteria by which a patient is given priority for treatment should be written and visible to
patients and staff to ensure transparency in the process.
If the patient can receive services on the same day he/she will complete all necessary registration
and payment requirements in medical record management unit and then be directed to the
relevant outpatient case team.
If the appointment is scheduled for a future date, the patient will complete all necessary
registration and payment requirements in medical record management unit, given an appointment
4-4
card and advised to report to the appropriate case team on the date of their appointment, without
undergoing Central Triage again. The hospital should have a clear management system to for
isolating patients with communicable diseases like patients having chronic cough and suspected
of TB. The hospital should also have a separate waiting area for children and adults.
Appointmennt
for follow-up ? All patients assisted by
receptionists at the gate
No
Central Triage
registration and R
payment
Patient
Referral paper?
Refer
Yes
Examination
Yes and check
Diagnostic Lab sample Pharmacy
Imaging collection services
L F
Need
Admission? No Treat and send
Yes
No Refer
Check availability
of bed and Liaison person
services?
Yes
A: Inpatient service flow D: Discharge service flow DR: Delivery service flow: DI: Diagnostic Imaging Service flow E:
Epidemic notification flow ER: Emergency Service flow F: Pharmacy service flow L: Laboratory service flow O: Outpatient
service flow R: Registration service.Source: Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative,
Rehabilitative and Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report.
4-5
The Central Triage Case Team consists of both clinical and non-clinical staff. Ideally, triage
should be carried out by a General Practitioner. However, depending on the availability
of human resources, it can be conducted by a Health Officer or BSc Nurse. Non-clinical
members of the Central Triage case team include runners, cashiers, registrars/ clerks and
cleaners. The runners are responsible to facilitate the registration of patients and to transport
patients as needed. The Central Triage Case Team should have ready access to the Liaison and
Referrals Service.
The outpatient case team will take a history, examine the patient and record the findings. If
Diagnostic laboratory or imaging tests are needed, a request filled with all the necessary
4-6
information (as per the laboratory standard) and the patient has to be sent to the respective
departments guided by a runner. A note entered to the patient card should include at least
pertinent history, physical examination and laboratory/imaging findings pointing to the patient
diagnosis. If diagnostic or therapeutic procedures as lumbar puncture, abscess drainage etc are
required, it has to be performed within the outpatient department. The results of any
investigations and treatment options should be explained and discussed with the patient.
If the patient needs consultation with Specialist (intra or interdepartmental) this should, as far as
possible, take place on the same day. A consultation request form should be completed and this
should be given to the appropriate Specialist together with the patient’s Medical Record. A
sample Consultation Request Form is presented in Annex.
If medication is required the patient should be directed to the pharmacy dispensing unit from
where he/she will make payment (if necessary) and obtain the necessary drugs and appropriate
counselling.
Any minor procedures that are required (such as dressings change or injections) should be
carried out in the outpatient department.
If the patient needs to be admitted to hospital or be referred to other hospital, he/she will be
guided to the Liaison office with the help of runner for admission or referral arrangement.
Sample collection, procedure and payment area within the OPD should be easily accessible to all
OPD patients and should have sufficient staff to prevent delay. Runners are responsible to
facilitate patient registration, transport patients (if needed), transport samples from the collection
area to the laboratory unit and back results to the clinical case team (if needed).
The Diagnostic Imaging department should be located in close proximity to OPD and every
patient who requires imaging services should be directed there with the assistance of a runner, if
necessary.
The hospital should ensure documentation of all HMIS diagnosis in to the HMIS register daily
and complete, correct and timely reports have to be compiled and sent to the plan and monitoring
or other units.
A. Human resource needs for Outpatient
4-7
Outpatient Director / outpatient case team manager
o Organize and lead the outpatient service as per the national standards and
treatment guidelines
o Ensure the availability of adequate human power and equipment’s for outpatient
services.
o Plan, budget and report the outpatient activities
Nurse coordinator
o Coordinate the outpatient nursing service
o Plan the necessary supplies, drugs and equipment’s for patient care
o Coordinate and Monitor daily recording of all patient diagnosis in to the HMIS
register
o Monitor and evaluate the implementation of outpatient specific nursing standards
General medical practitioner per discipline (Internal medicine, pediatrics, surgery,
gynecology and obstetrics) to run the regular outpatient service for eight hour in each
working hour
o Examine and treat a patient
o Plan, document and report daily activities
Specialists or sub specialist per discipline (specialty) to run the respective specialty and
sub specialty clinic services assigned
o Examine and treat a patient at a specialty follow up clinic
o Plan, document and report daily activities
Nurse should be assigned at outpatient unit as per patient load
o To deliver the complete nursing care
o Record all patient diagnosis in to HMIS register
Adequate number of laboratory, pharmacy and imaging workers
Runners
o To assist patients on every outpatient activities
o To collect lab and imaging results from the respective unites
Cashier
o Collect daily cash from outpatient service users
4-8
o Number of cashiers and windows should depend on the case load
Cleaner,
o Clean and protect the outpatient facilities as per standards
Phlebotomist,
o Collect samples from patients and deliver to lab units
Security guards will be assigned based on the hospital context.
o Will safe guard the patients and staff and visitors
B. Outpatient case team equipment and supply needs
Each case team room should be equipped with equipment and supplies needed to provide care.
The following (Table: 1) is a list of suggested items that should be found in the case team room.
It is not an exhaustive list of all possible equipment and supplies, but should be used by each
facility as a guide when determining equipment needs.
The outpatient clinic should encompass a procedure room where diagnostic and therapeutic
minor procedures and tests can be performed and where simple bedside tests can be carried out.
The procedure room should be staffed and equipped with: nurse, cleaner, dressing set, minor OR
set, hand washing facilities, coach, IV stand, IPPS materials. The infrastructure at the outpatient
4-9
clinic should facilitate easy access way to treatment services for differently abled people and
other people in need of special help.
Waiting area of the hospitals should be located closest to the reception and should incorporate
the followings:
Staff assigned at waiting area of the outpatient clinic should be trained on special need training in
order to ease their communication between people with special needs, thereby give necessary
information (guide) for differently abled people. Supporting devices such as wheelchair,
stretcher should also be accessible at waiting area.
The hospital should have a clear management system to for isolating patients with communicable
diseases like patients having chronic cough and suspected of TB. The hospital should also have a
separate waiting area for children and adults.
In order to determine if the Operational Standards of Outpatient Services Management have been
met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of chapter 20 Monitoring and
Reporting.
4-10
4.2 Implementation Checklist
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implementation activities.
Yes No
1. There is a central triage.
2. There are personnel trained in triage processes working in both the central triage.
3. Central triage is equipped with necessary supplies and equipment.
4. Outpatient appointment system is in place.
5. Outpatient department is managed by at least a GP and specialty clinics by a service
specific specialist/ sub- specialty clinic by sub specialist as per hospital tier level of
care.
6. There is a written protocol for admission and discharge of patients.
7. There is a written protocol for the referral of patients (receiving into the hospital and
referring outside of the hospital).
8. There is a referral directory listing which facilities that hospitals can receive patients
from or refer patients to.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
4-11
practitioner per day visits/(number of OPD indicator
practitioners *22*number of
months in period)
3. OP wait time to triage Σ triage wait time/number of Quarterly HMIS
[Average time from arrival at attendances indicator
the outpatient department to
initiation of triage (minutes)]
Σ time from beginning of OPD Quarterly HMIS
consultation to discharge from indicator
4. OP consultation transit time the facility (following completion
of investigations and purchase of
any necessary drugs)/ number of
attendances
5. % of outpatients indicating The number of outpatients that Biannual Survey tool
that it was easy to find their responded yes to the question on
way around the health the patient survey “Was it easy to
facility find your way around the health
facility?”/total number of
respondents*100
6. Outpatient satisfaction score [sum total of O-PAHC rating Quarterly Survey tool
scores ÷ [Number of O-PAHC
surveys completed]
7. Outpatient attendances seen Number of new and repeat Monthly HHPMI
by private wing service outpatient attendances at private
wing (Q4) ÷ [Number of new and
repeat outpatient attendances at
public facility (Q3) + Number of
new and repeat outpatient
attendances at private wing (Q4)]
x 100
8. Outpatients not seen on same Number of outpatients not seen Quarterly Survey tool
day on same day as registration
during the reporting period (Q7)
÷ [Number of new and repeat
4-12
outpatient attendances at public
facility (Q3) + Number of new
and repeat outpatient attendances
at private wing (Q4)] x 100
Source Documents
4-13
5 Inpatient Services Management
Table of Contents Page
Section 1 Introduction 5-1
Figures
Figure Typical Pathway for Inpatient Admission.
Boxes
Box A Operating Theatre
Box B Intensive Care Unit (ICU)
Abbreviations
BSc Bachelor of Science
CGQI Clinical Governance Quality Improvement
CSR Centralized Sterilization Room
The hospital should maintain an organizational culture that respects value and diversity, cultural
competencies, promotes collaboration and team work, encourages professional and personal
development of the staff, and commits to providing the highest quality of services.
5-1
Section 3 Implementation Guidance
3.1 Inpatient Services Management and Organization
The Director of Inpatient Services should oversee all inpatient activities. Clinical and support
staff should be organized into Case Teams by type of Speciality (e.g. Surgery, Internal Medicine,
Paediatrics, Obstetrics and Gynaecology). Case Teams should be comprised of specialists,
general practitioners, health officers, nurses, runners, cleaners etc. Each Case Team should be led
by a Case Team Leader. Pharmacy and laboratory personnel should also form part of inpatient
services and should provide support and advice to the Clinical Case teams on individual patient
care as the need arises (see Chapter 9 Laboratory Services and Chapter 10 Pharmacy Services for
more information).
Patient wards should be located at close proximity to the emergency and outpatient departments,
and should be easily accessible from elevators, ramps or stairways. Each ward should have an
adequate number of well-ventilated rooms with a separate dining corner, functioning set of
adequate number of toilets, sinks and showers. If mixed-sex wards are used there should be
separate rooms for male and female patients. Similarly, if adult and Paediatric wards are mixed
there should be separate rooms for each. Each ward should have a case team station. Wards
should be laid out to facilitate collection of samples from patients (i.e. sufficient space around
beds, bed screens or curtains to maintain privacy during undertaking of: wound examination,
swab collection, etc. Each ward should have a procedure room where minor diagnostic or
therapeutic procedures can be performed and simple bedside tests such as urinalysis can be
carried out.
Laboratory and pharmacy dispensary services should also be readily accessible to the inpatient
wards.
5-2
The hospital should have a written protocol for the admission of patients that includes all steps to
be taken in the admission process including how to arrange admission, and the activities to be
undertaken when the patient arrives on the ward. This should be known by, and adhered to by all
relevant staff.
Upon arrival on the ward the patient should be received by a nurse who will initiate the ward
admission process, including orientation to the facilities (such as toilet and showers), instructions
for care-givers etc.
Receiving nurse should assess all patients/clients’ conditions on arrival in the ward and informs
the on-duty physician for immediate medical assessment for critically ill patients and within 2
hours for patients with stable conditions.
The nursing process needs to be completed within 8 hours (before the next shift)and all efforts
made to ensure patient safety is not compromised with delayed nursing/physician intervention ,
resulting in improved overall quality of the care patients/clients receive following admission.
Additional to the receiving nurse’s assessment, the patient should be assessed by a medical
doctor upon arrival on the ward and a History and Physical Examination Assessment should be
completed. This should include the immediate management plan for the patient. A sample
History and Physical Examination Assessment Form is presented in Chapter 6 Medical Records
Management.
After the initial assessment by the physician, the patient should be reviewed regularly
(physicians at least once a dayfor stable patients and two or more times for critically ill patients,
and nurses four hourly for stable patients and more often for critically ill-patients) by the relevant
Case Team and all clinical contact should be documented in the Medical Record using a hospital
Progress Sheet and for nurses/midwives, nursing/midwifery progress sheets.
Further guidance on inpatient nursing care service provision is presented in Chapter 7 Nursing
and Midwifery Care Services and the Ethiopian Hospital Alliance for Quality Change Packages
1 and 2 . The latter contains guidance on 8 hour shift working arrangements, nurse rounding and
central medicines’ storage and medicines’ administration.Medications should be administered
and documented using standardized formats.
Any required investigations should be ordered on the relevant request forms. Laboratory
specimens should be collected from the patient while on the ward by the phlebotomist/laboratory
team/competent nurse or physician. If the patient requires an X-Ray or ultrasound investigations
he/she should be directed to the relevant department, transported to the department using a
wheelchair or stretcher and accompanied by a runner or clinical staff member if necessary.
5-3
Samples of all Medical Record Forms, including Investigation Order and Report Forms,
Medication Administration Record etc, are presented in Appendix B of Chapter 6Medical
Records Management.
Patient needs
admission
Physician
completes record/
admission form
Ward clerk/nurse
receives patient ,
register and put
MR on IP folder
Orient patient to
the ward and
Assessment by
ward case team
Inpatient Care
- Progressive care and feedback to
Discharge patient and family
-- Diagnostic services
- Pharmacy services
A: Inpatient service flow D: Discharge service flow DR: Delivery service flow: DI: Diagnostic Imaging Service flow E:
Epidemic notification flow ER: Emergency Service flow F: Pharmacy service flow L: Laboratory service flow O: Outpatient
service flow R: Registration service.Source: Federal Democratic Republic of Ethiopia Ministry of Health. (2008). Curative,
Rehabilitative and Treatment Sub-Business Process. The New General and Specialized Hospital Business Process Study Report.
5-4
conditions that require separation from other patients e.g. patients who require isolation to avoid
visual or auditory sources of distress, as in the case of tetanus management.
Management: The Operating Theatre should be under the team leader (or equivalent) of
surgical services who is accountable to the Inpatient Services Director.
Layout: For a successful outcome of the operation in terms of healing the wound,
decreasing blood loss and controlling pain, the OR should be a place that is comfortable
and unobstructed by the movement of other staff. It should have a table that is strong
enough to hold the patient and is easy to clean.
The Operating Theatre should have basic services of water, light and medical gasses and an
adequate place to store instrument. The number of OR tables depends on the number of
beds of the hospital. There should be one OR table for every 25 surgical beds. Ideally, the
Operating Theatre should be located on the floor as the surgical ward and should be
connected to the ward by the simplest possible route. Preferably the Operating Theatre
should adjoin the sterilization units, delivery suites and intensive care unit.
The following service areas are needed in an operating theatre suite:
1. Reception and office area, 2. Transfer area: large enough to transfer a patient from bed to
trolley, 3. Holding bay: to allow supervision of patients waiting for the OR, 4. Staff
changing room, 5. Operating theatre 6. Scrub room 7. Trolley parking 8. Recovery room 9.
Specialists 10. Anaesthetists 11. Scrub up and circulating nurse 12. Cleaners and 13.
Porters.
Equipment and Staff: should be provided as per the national standard for general and
specialized hospitals. Pleasesee Section 6 under Surgical and Orthopaedic Care Services of
the National Minimum Standards for General Hospital and of the Peri-operative
Guidelines..
5-5
The intensive care unit of a hospital should also be given attention. Recommendations on ICU
management are presented in Box B.
The ICU should be adjacent to the operating theatre and recovery unit.
The number of beds should be approximately 1-2% of the total number of beds of the hospital.
Preferably, the ICU should have a controlled environment with medical gasses and power
sources.
Equipment and Staff: should be provided as per the national standard for general and specialized
hospitals.. For HR, layout, equipment and supplies, please see Section 3.2.1 under Facilities
Management of the Minimum Standards for Specialized Hospitals 2011,
The hospital should develop and implement written protocols and procedures for the
management of inpatient psychiatric care, including the admission, consultation; transfer,
discharge and follow up (please see the Chapter Mental Health Services in the Minimum
Standards for Specialized Hospitals, 2011 for further guidance on inpatient hospital psychiatric
care).
Patients ready for discharge should be counseled by the attending physician, nurse in charge and
clinical pharmacist before discharge. Pre-discharge counselling should include:
An explanation of the patient’s diagnosis, investigation results and treatments given
An explanation of any medications that the patient should continue to take upon
discharge
Any necessary follow up arrangements
Any discussion of any ‘warning signs’ that the patient has to be aware of and for which
he/she should seek medical attention
The discharging nurse has to make sure all the necessary registers are filled and administrative
duties, including financial issues are settled before the patient is sent to the liaison office
The discharge process should be complete in no more than 2 hours (including administrative
issues). The patient with their medical record must to be sent to the liaison office, with the help
of a runner. The liaison officer has to check the completeness of all the necessary documents and
send the patient home after filling the necessary registers (With appointment card and
appointment register filled, if appointment was asked for on the discharge summary sheet).
General practitioner(s)
Nurses
Laboratory technologists
Dietitian
Porters/runners
Cleaners
Cashiers
Security guards
suction machine
IV stands,bed screens
Minor Set procedure sets according to the type of ward/case team, dressing sets
Refrigerators
Shelves
The hospital should establish and implement communication guidelines that detail
communication among health professionals of the same discipline (nurse to nurse, physician to
physician, etc), between disciplines and departments/services regarding inpatient care toensure
timely and appropriate inpatient care provision.All discussions, including referrals for inpatient
care between nurses and physicians or General Practitioners and Specialists, etc, should be
clearly documentedin the patient’s records. Clear communication such as task allocation
(removal of cannula, catheter etc.), prioritization of patients, and, task ownership, facilitates
patient’s safety. The ward team should use unified electronic or structured written forms to
record all communications with the patient/caregivers, and other healthcare professionals based
on relevant national guidance.Good communication among health care providers about patient
issues ensures continuity of care, avoids duplication and breaking up of care and is essential for
medico-legal reasons.
Handover of clinical care ismore than just the transfer of information-it is also a transfer of
professional responsibilities. Furthermore, handover of clinical care can provide a valuable
platform for communication about operational issues that might improve the quality of care to be
delivered in the subsequent shift and offers opportunities to spot and mitigate errors.
Accordingly, hospitals (wards) should ensure that all staff have access to relevant, accurate and
up to date sources of information (written or verbal handover) during the 24 hour cycle. Equally
important, jargon related to medication details should be minimized to reduce the risk of
misunderstandings.Good handover requires:
Well- coordinated shift work
Adequate and fixed time, allowing an opportunity for discussion between the giver and
receiver of patient information
Should be supervised by the most senior clinician present and must have clear leadership.
In the hospital setting the range of professionals involved in the ward round /care of individual
patient varies across clinical specialties. It largely depends on the way in which the service is
organized in a given inpatient environment. Ward rounds should be conducted by a multi_
professional team (e.g. doctors, nurses, pharmacists, dietician, related health professionals,
patient and caregivers). It creates an opportunity to review the patient’s condition and develop a
coordinated plan of care and action, strengthens communication channels and builds a team
culture, sharing information and joint learning through active participation of all members of the
multidisciplinary team. In contrast, failure to communicate actions and information could result
in discontinuity of care or unnecessary repetition of efforts.
In order to determine if the Operational Standards of Inpatient Services Management have been
met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of chapter 20 Monitoring and
Reporting.
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implementation activities.
Yes No
9. There is an established inpatient management structure in place.
10.Inpatient department is managed by a medical director.
11.There are job descriptions that detail the roles and responsibilities for each inpatient
discipline, including reporting relationships.
12.All admitted patients have medical, nursing/midwifery care plans.
13.There established guidelines for verbal and written communication about inpatient
care, including verbal orders and patient handover by discipline and between
disciplines.
14.There is a written protocol for admission and discharge of patients.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the above recommendations.
Source Documents
A well-organized medical recording system ensures the availability of reliable healthcare data in the
health system; in which it can serve as an input for the implementation of national health sector
transformation strategic plan (HSTP) in particular to the information revolution agenda. Poor data quality
management system including incomplete medical recording and reporting practices, lack of information
technology and its use, shortage of human resource and professional mix, failure to audit medical records
and failure to adhere with existing guidelines and SOPs are major observed challenges in hospital’s
medical record management system.
1. Unique medical record number is assigned to a patient during his/her first visit of care.
2. The hospital shall have a single unified medical registration unit for all patients’ registration.
3. The hospital utilizes paper and computer-based systems to register and retrieve medical records.
4. The hospital avails and utilizes a standard set of formats that comprise a complete medical record for
continuum of patient’s care.
5. The hospital shall implement and comply with national guidelines to manage access to patient’s
medical records.
6. The hospital performs medical record auditing, data quality checks, archiving/culling procedures and
takes corrective actions on a regular basis.
7. The hospital ensures patient’s medical records return from different service units to medical records
unit at the end of each service day in accordance with medical record tracing system.
8. The hospital shall automate health information system through implementation of integrated
electronic medical record system.
6-1
Section 3Implementation Guidance
3.1 Retrieval of Existing Medical Record Number or Generation of New Medical
Record Number
When a patient arrives at a hospital, the hospital’s primary role is to identify the patient’s status as an
emergency or routine case and to identify if the patient is a new patient (i.e., has never been given a
medical record number (MRN) before at the facility) or a returning patient (i.e. has a MRN at the facility
from a previous visit).
Each patient should have one MRN for all visits to the health facility—the MRN generated during the
registration process at the patient’s first visit to the health facility. Subsequently, the same MRN should
be used for all other visits, including outpatient, inpatient, and emergency visits.
The Master Patient Index (MPI) is a database of patient names, contact information, registration dates,
and the MRN for each patient ever treated at the health facility. The MPI is an essential element of
retrieving existing and generating new MRNs.
Each health facility should have a MPI. The MPI can be paper-based or computer-based (with paper
based back up). A paper-based MPI relies on the use of an individual index card. Each MPI card should
include the following information:
Sex (Male/Female)
Address
MRN
Date of registration
Phone number
The index cards should be filed alphabetically by first name. When the hospital learns that a patient has
changed his/her name legally, a cross-index file should be made to identify the initial record with the
previous name. The MRN of the original registration should be recorded on the cross-index card.
6-2
If a patient changes any other contact details (such as address or telephone number) a new MPI card can
be prepared to replace the original. The patient name, MRN, date of registration and any other unchanged
information should be transcribed exactly as written on the original onto the new card. The old card
should be scored through with the signature of the individual preparing the new card. The new card
should be stapled to the top of the old card and both should be filed together so that the updated
information is readily available without losing any prior information. In a computer based MPI the
contact details can be amended directly in the appropriate computer fields.
Manual Paper-Based System: Hospitals that use a paper-based MPI may purchase vertical file cabinets
for filing index cards. The paper-based MPI should be monitored by the MR Unit, at a minimum, every
quarter to ensure that the MPI is filed correctly. Each facility must establish a procedure for this activity.
Sub-headings may be added in the alphabetized system for common names (“Me” for Meskerems, “Mo”
for Mohammeds, etc).
Computer-Based System: The use of a computerized MPI permits faster retrieval of patients’ MRNs. E-
Health Management Information System (HMIS) is being rolled out across Ethiopian hospitals includes a
computerized MPI component. However, a paper-based card file should also be maintained in case of
computer technical failure/downtime. Interruptions in the system can be caused by a variety of factors,
including electrical outages or hardware/software problems. Therefore, hospitals should maintain a back-
up, paper-based system in order to ensure no interruption in MRN retrieval.
If a computer based system is used in addition to a manual system, similar procedures should be followed
for both MR management systems to ensure optimal patient care. Both systems are effective when
implemented and used correctly.
Patient registration is the process of documenting the patient’s visit to the facility and assigning a MRN,
When the patient arrives at registration, the clerk should ask the patient’s name (first, father’s first name
and grandfather’s name) and then look for an existing MRN in the paper-based MPI (i.e., set of index
cards) or in the computerized MPI. This should be done whether the patient reports that he/she has been
to the hospital before or not.
If there is an existing MRN for that patient, the registration clerk should facilitate the retrieval of the
existing MR stored in the record room. A runner/transistor should retrieve the patient’s MR and then take
the MR to the area where the patient is to be treated as per the request of health care provider.
6-3
If no previous MPI card or MRN can be found, the registration clerk should generate a new MRN. New
MRNs should be issued in straight numeric sequence, without skipping any numbers. Each MRN should
be assigned to one and only one patient. Reissuing a MRN to another patient should never occur.
Registration staff should both create an index card for the paper-based MPI and enter the new patient in
the computerized MPI if there is a computerized MPI.
All patients regardless of which service they will access should be registered at one central registration
site.
6-4
Figure 1 Patient registration process and patient card path in a hospital
Ce nteral
Triage
R e tu r n M e d ic a l R e c o r d
* Emergency
A v a il M e d ic a l R e c o r d
Is Emergency? Yes
Service Unit
No
Emergency?
No *R Runner/Patient-Attendant
Yes
New Repeat
Retrieve patient record Registration staff will handle
Register patient New patient
Retrieve registration
Patient
Registeration Record
Avail Patient
Record to New or repeat? Open new
Get Units
patient Repeat
Service New patient
Provide patient record to medical record card
OPD case team
i.e.* - Registration
All patients/clients regardless of which service they will access should be registered at one central registration site (i.e., the MR Unit).
6-5
3.1.3 Starting a Medical Record for a new patient
After the MRN is generated (i.e., the next number in the sequence is assigned to the selected patient), an
individual hospital-approved folder should be assigned to the patient. Any patient information generated
by hospital staff during the period of care should be kept in this folder. A paper fastener or the equivalent
should be used to keep all pre-approved clinical documents/forms in the folder. The MRN should be
clearly displayed on the folder as a form of identification.
Each new patient registered for outpatient or inpatient services should be issued a service card. This card
is a small pocket-sized card used as an identification card for each patient which should be shown to the
MR staff whenever the patient attends the hospital. Selected registration information should be recorded
on the card. Contents of the patient service card include:
የአገልግሎትመታወቂያካርድ
Service Identification Card
የአገልግሎትመታወቂያካርድ የግልድርጅት የማህበረሰብአቀ የህብረተሰብአቀ የነጻ
Service Identification Card ታካሚ ፍኢንሹራንስታ ፍኢንሹራንስታ /የዱቤአገልግሎትማህ
ካሚ ካሚ ተም
Private CBHI SHI Free/Credit Service
የተ Ì ሙስም stamp
__________________
Name of facility
በጤናድርጅቱየተመዘገበበትቀን
Date of Registration__________________
ስም
የህክምናካርድቁጥር
ክፍለከተማ/ዞንወረዳ
የቤትቁጥር__________________________
House No
ስልክቁጥር__________________________________
Phone number
6-6
6. Sex
7. Client’s address
8. Phone number
9. Free service stamp space
If the patient knows his/her MR number or brings his Service Card then the MR number can be used to
find the patient’s MR. The MR is filed numerically in the MR room and hence can be easily retrieved
from the shelf.
2. Retrieving a MR by name
If the patient does not remember their MRN or does not have their service card, then MPI can be used to
search for the patient information. The patient’s index card is filed alphabetically by first name in the
MPI. When the Index Card is located the MR number can be read from the card and used to retrieve the
MR.
Figure 1 below shows the flow of medical record from generation until return of the medical record to the
medical record room.
6-7
Figure 3 Patient Appointment Card
የቀጠሮመስጫካርድ
Appointment Card
የቀጠሮ ቀጠሮየሰጠዉባ ቀጠሮየሰጠውአገልግሎት
ለሙያ ክፍል
ቀን ሰዓት Appointing Appointment with
Date Professional service
time
6-8
Figure 4. How information being created in patient’s chart during service delivery
MRU
Client Seekig Healthcare
MR Opened
MPI
Indexed
Procedure,
Searched by MPI
Outpateint Prescription &
Register Seervice Units Concent Data Register
Outpatient Data
Referral, Financial
Register Investegation Register
Data
Service
MRU
MR Assembled & Completed
MR Filed
_________
6-9
3.2 Documenting Patient Information
3.2.1 Purpose of clinical documentation and what should be documented
MR documentation is essential to ensure quality of care for every patient. All information
regarding the patient and his/her course of care at the hospital should be recorded in the MR.
This includes his/her presenting symptoms and medical history, any diagnostic test orders and
results, all documentation from care providers and consultants, interventions, diagnostics,
medications, therapy, and information and instructions at discharge. Any subsequent return visits
to the hospital should be recorded in the same MR.
The MR provides each clinician responsible for patient care with access to a record of the
patient’s health status, medical history, investigation procedures (lab tests, etc.), treatments and
outcomes.
All entries should be dated and authenticated with full signatures. Professional designation (i.e.
MD, RN, etc.) should also be included.
This information is to be filed in one folder divided in separate sections for each visit/admission
in chronological order.
If the patient has a chronic disease and regularly attends a Specialized Clinic (e.g. HIV, TB etc)
then a separate section may be created in the MR folder to record all visits to the Specialized
Clinic.
6-10
All handwriting should be in permanent ink that is legible when photocopied. Pencil
entry in any part of the record is not permitted.
All entries should be dated and authenticated, including signature and title of the author.
Each clinician should sign those portions of the MR containing documentation of care for
which he/she is responsible.
Transcription of verbal orders or other information should be accurate and complete. It
should be signed by the person who transcribed the verbal order or other information and
co-signed by the person giving the verbal order within oneworking day of the verbal
order.
Key identifiers such as the name of the form, patient’s name and medical record number
should be located in the same place on all medical record and clinical documentation
forms.
Demographic sheet
Summary sheet of all visit dates (including inpatient, outpatient, and emergency care)
For each inpatient admission:
Admission Card
Progress notes
6-11
Consent form (if relevant)
Discharge summary
Referral form(s)
NB: While the patient is in hospital some of the above forms (e.g. Nursing Care Plan, Routine
Observation Chart, Medication Administration Record, IV fluid and Additive Administration
Record) may be kept in a clip folder by the patient’s bedside or at the nurses’ station for ease of
reference. When the patient is discharged these forms should all be entered into the MR before
the MR is returned to the Medical Record Room.
Progress notes
Referral form(s)
Samples of the Nursing Process Forms are presented in Chapter 7 Nursing and Midwifery Care
Standards and the pharmaceutical care plan is described in Chapter 10 Pharmacy Services.
Templates of all other forms listed above are presented in Appendix B.
Other forms that could be included in the MR if relevant include, but are not limited to:
Obstetrical care
1. Demographic sheet
Function: A page recording all patient demographic and contact information for all clinicians to
reference (patient name, date of registration, date of birth/age, sex, address, emergency contact
information).
Work process: When the patient is first registered, a demographic sheet will be put in the
patient’s MR.
Work process: All visit dates, for both inpatient and outpatients, will be recorded on the
summary sheet.
6-13
3. History and physical examination assessment
Location: MR
Work process: When a patient is admitted as an in-patient a full history and physical examination
should be conducted by the attending physician.
4. Progress notes
Location: MR
Work process: When the patient is seen by a clinician, the information obtained will be recorded
with date, clinical details, and signature of the attending clinician.
Function: When a different specialty opinion is sought, the form serves as a communication tool
for the different consulting parties.
Work process: When any consultation is needed, the original physician will put the request in
the physician’s order sheet and sign a consultation request. Nurses or appropriate case team
member will contact the consulting specialist to see the patient. The consulting specialist should
record the result/opinion on the consultation request.
6. Consent forms
Function: The consent form outlines the risks associated with a particular procedure. A signed
consent form indicates that the patient (or designated proxy) has been informed of the risks and
has authorized the procedure.
Location: MR
Work process: Before any procedure that has associated risks, the patient should be counseled
regarding all risks and alternative options for treatment and asked to sign a consent form to
6-14
indicate his/her agreement to the procedure. Consent should be obtained by the person who will
perform the procedure.
Function: All physicians will write orders on this form, including diet, nursing care, medication,
and investigation procedures (lab, imaging, consultation, etc.).
Location: MR.
Work process: When patient is admitted to a ward, a physician order form will be put in the MR.
A physician will write his/her orders on this form and other individual request forms (i.e.,
medication prescription, lab order form, consultation request form, etc.).
Function: Informs laboratory of any individual patient’s lab investigation order and allows lab
result to be recorded on these forms.
Location: MR.
Work process:
Inpatient: When any lab test is ordered, the ordering physician will sign a lab order and report
form. The lab order will be sent to lab. Lab will collect the sample and conduct corresponding
test(s) upon receiving the order. The test results will be recorded on the lab order form as well as
in the log book in the laboratory department. The completed lab order will then be sent back to
the ward and kept in the MR.
Outpatient: When any lab test is ordered, the ordering physician will sign a lab order. The lab
order will be given to the patient. For most tests, a sample will be collected by case team member
and sent to the lab. For other tests the patient takes the lab order to the laboratory for the
corresponding test(s). The test results will be recorded on the order form as well as in the log
book in the laboratory department. The completed lab order will then be sent back to the
ordering clinic/physician and kept in the MR. If the patient goes to an external lab for test; the
completed lab order will be brought to the physician by the patient upon next follow up visit, to
be filed in the MR.
6-15
9. Radiology order and report form
Work process:
In-patient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be sent to diagnostic imaging department. The radiology
technician will schedule a test appointment upon receiving the order form. The test results will
be recorded on the order form by the radiologist, as well as in the log book in the diagnostic
imaging department. The completed radiology request and film will then be sent back to the
ward and kept in the MR.
Outpatient: When any imaging test is ordered, the ordering physician will sign a radiology
request. The radiology request will be given to the patient. The patient takes the radiology
request to a diagnostic imaging department for the corresponding test(s). The test results will be
recorded on the order form, as well as in the log book in the diagnostic imaging department. The
completed radiology request will then be sent back to the ordering clinic/physician and kept in
the MR. If the patient goes to an external imaging clinic for test, the completed radiology request
and film will be brought back to the physician by the patient upon next follow up visit, to be filed
in the MR.
Emergency: When any imaging test is ordered, the ordering physician will sign a radiology
request. If a mobile diagnostic imaging machine is available, the test will be done in the
emergency room. The test results will be recorded on the order form. If mobile unit is not
available, steps outlined for outpatients above should be followed.
Location: MR
Work process: When a pathology sample is collected (e.g. fluid aspirate, tissue biopsy) the
ordering physician will complete a Pathology Request Form. The sample and form will be taken
6-16
to the pathology department for analysis. If the required service is not available in the hospital
the sample and request form should be taken to the central laboratory where they will be stored
and then transferred to the appropriate facility, in accordance with hospital policy for sample
referral.
Function: To describe the nursing assessment, care plan and outcome of nursing care of an
admitted inpatient.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as a permanent record.
Work process: When a patient is admitted, a nurse completes a nursing assessment and care
plan within 8 hours. The outcomes of nursing care are documented on the problem list, care plan
and progress report during the course of the patient’s admission.
Further discussion on the Nursing Process is presented in Chapter 7 Nursing and Midwifery
Care Standards.
Function: To record the vital signs of each specific patient during the hospital stay.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as a permanent record at patient discharge
Work process: When vital sign measurements are needed, the observation sheet will be put in
the bed-side clip board. The nurse will record all vital sign measurements on this form. When
one sheet is finished, a new blank sheet will be put on top of the finished sheet. When the patient
is discharged, all the forms will be put in the MR.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.
Work process: When medication is ordered for an in-patient the name of the medication, route
of administration, dosage and frequency of administration should be documented on the
medication administration record and signed by the transcriber. When the medication is
administered, the nurse should sign the appropriate box on the form.
Function: The record should detail all specific infusions, including rate of drops and duration of
infusions while the patient is confined.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.
Work process: When medication or IV fluid is ordered for an in-patient the name of the IV fluid
and rate of infusion should be documented on the IV fluid administration record. The name and
dosage of any additives should also be documented. When the IV infusion is given, the start time
and end time of the each bag of fluid should be documented and signed by the responsible nurse.
Function: To record all fluid inputs and outputs for patients at risk of fluid overload or
dehydration.
Location: Bed-side clip board during the patient’s stayed, but must ultimately be included in the
patient’s MR as part of the permanent record at patient discharge.
Work process: All fluid inputs both oral and intravenous and all outputs including urine and
other outputs such as blood loss should be documented on the chart by the nurse. At the end of
every 24 hours the balance is calculated as ‘total input’ minus ‘total output’.
Function: An instruction sheet to summarize all needed information for the patient upon
discharge.
6-18
Location: One copy in the MR and one copy to patient.
Work process: Discharging physician will fill out the discharge summary that includes a
summary of the patient’s diagnosis, treatment and investigations and any instructions following
discharge (for example medications, wound care, diet, activity and follow-up appointments). The
form will be kept in the MR for hospital record and a copy will be given to the patient to take
home.
Function: In the event that a patient dies, to document patient’s health records, care received
and cause of death.
Location: MR
Work process: After death the attending physician should complete a death summary. If a post
mortem examination is required, the death summary should be completed AFTER the results of
the post-mortem examination are known.
Function: To document patient history at the hospital and to provide reason for referral
Work process: If it is necessary to refer a patient to another facility the attending clinician should
complete a referral request, indicating the reason for referral, summary of the patient history and
examination and the results of any investigations conducted.
If any data contained within a MR require correction, the following rules should apply:
The date of correction, the signature and profession of the person making the correction,
the correct information, and the reason for the correction should be added.
6-19
3.3 Handling of Medical Records
A comprehensive MR management system encompasses the handling the MR from time of
patient registration, during active care delivery, through patient discharge, and ongoing
filing/storage of the MR, until removal/destruction of old MRs from storage. The flow of
MRs/charts is important to ensure a balance between availability of clinical information and
patient confidentiality. A well-designed system minimizes the loss of MRs.
Tracer Card
On a daily basis, assigned MR staff should refer to the logbook and ensure that all MRs are
returned to the card room. The only exception is for admitted inpatients whose treatment is
ongoing. This step is important, as it prevents loss and misuse of MRs. In addition, when a MR is
removed, one can put in its place a tracer card, which is a card the size of the MR, on which is
written the patient name, the MRN, where the MR is going, and the date it was removed from the
file. This can help track where records are outside the Medical Records Room. When not in use
the tracer card should be stored in the back of the MR. A sample tracer card is included in
Appendix A.
6-20
3.3.2 Who should handle Medical Records?
Only authorized personnel should have access to MRs, and only on a “need to know basis.”
Selected employees who have been designed by hospital management to handle MRs and who
have received MR training should only access the Medical Records Unit (MRU). When other
hospital employees need access to MRs, a request should be made to the MR staff. Patients
should never handle MRs without staff assistance.
Hospitals should develop strict procedures based on these principles and ensure that all staff
members are properly informed and trained for proper implementation practice.
When archiving, these files should be numerically stored in a separate area, according to their
MRNs. The corresponding MPI index card of the patient should be labeled “archived”. NEVER
create another file numbering system for archived files.
If archived files needed to be retrieved, the same MR retrieving mechanism should be used.
6-21
maintain the patient’s confidentiality. Destruction of the medical record should also be
supervised by the head of the MR department.
If medical records are destroyed, the following key information should be maintained
permanently:
Medical record name
Diagnosis/Patient status;
Table XX - Registration logbook for retaining vital patient information while destroying
Medical Full name Sex/Date of Last Patient first Diagnosis/Patient Name of the Investigations and Discharge
record birth visit/Admission/Dis date of visit status attending operations/Procedur summary
number charge date doctor(s) es performed
(MRN
A note should be included with the retained documents stating that the records have been
destroyed according to the retention policy.
6-22
The MR Department should establish a folder to collate the information above for all MRs that
are destroyed.
If a patient seeks health care from another hospital and has consented to the release of his/her
clinical information to the new hospital, only a photocopy should be given to the requesting
hospital. The original MR should never be transferred out of the hospital.
3.3.7 Confidentiality
MRs should be maintained in the strictest confidence, as they contain personal and private
information about patients, including their health status, personal, family and contact
information. MRs should be stored in a secure area, and there should be clear policies regarding
confidentiality and the release of patient information.
The content of a MR should only be used for providing patient care or in the course of
supporting patient care activities (for example evaluation of services, clinical audit etc.). Access
to the content of MRs should be granted only to personnel who are undertaking the above
activities. Other supporting staff that are granted access to MRs but are not involved in
delivering patient care (e.g., porters, runners) should not read and/or disclose the content of the
records.
All employees should sign a ‘Code of Conduct’ that includes a statement regarding the
confidentiality of patient information.
6-23
Department will vary. However, there should be enough staff to cover the following duties,
particularly during the prime hours:
Patient registration
Handling of medico-legal issues relating to releasing patient information and other legal
issues.
All MR personnel should undergo MR orientation and subsequent annual training on all
departmental policies. Professional mix of the staffs of medical record unit should incorporate
MRU head, Information Technology professional, Health Information Technology (HIT)
workers, runners and cashers.
6-24
the electronic medical record systemwill be reflected as well as primary input for eHMIS.
Maintaining the implemention and ensuring the sustainability of the implementation will be the
responsibility of the facility ; however, hospitals can request technical support from the FMOH
when necessary. The FMOH is responsible to provide integrated support as well as work closely
on every step of the process. Hospitals are required to avoid parallel and repetitive automated
system implementation and should instead plan and ensure an integrated automated systems as
well as substandard automations.
In order to determine if the Operational Standards of Medical Records Management have been
met by the hospital an assessment tool has been developed which describes criteria for the
attainment of a Standard and a method of assessment. This tool can be used by hospital
management or by an external body such as the RHB or FMOH to measure attainment of each
Operational Standard. The tool is presented in Appendix E of chapter 20 Monitoring and
Reporting.
6-25
4.2 Implementation Checklist
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implement,ation activities.
4.3 Indicators
In addition, the following indicators should be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
Source Documents
3. World Health Organization. (2002). Medical Records Manual: A Guide for Developing
Countries. Revised and updated 2006. Manila: Regional Office for the Western Pacific.
Retrieved from: http://www.wpro.who.int/NR/rdonlyres/7FB74A3F-34F6-4C46-A9F0-
1F0D52D04254/0/MedicalRecordsManual.pdf.
6-27
Appendices
Appendix A Inpatient Medication Profile Form
3. Current Medications
Indication Drug & Dosage Regimen Start Date Stop Date
(Name, Dosage Form, Dose, Frequency)
5. Recommendations/Interventions:
Function: To record the patient’s current status and key interventions implemented from time to
time to achieve the goals of therapy stated for each patient.
Location: One copy in the MR
Work process: The pharmaceutical care progress note-recording sheet is completed by the
pharmacist during each patient visit. The pharmacist records the current status, the effectiveness
and safety of the medications and key interventions implemented.
በኢትዮጵያፌደራላዊዲሞክራሲያዊሪፐብሊክ
የገንዘብናየኢኮኖሚልማትሚኒስቴር
Federal Democratic Republic of Ethiopia,
Ministry of Finance and Economic Development
የዱቤ/የነጻፍጆታመመዝገቢያቅጽ
Credit/Free Sales Dispensing Register/CSDR
የመድሀኒት/የላቦራቶሪቅመሞችናየህክምናመገልገያዎችየዱቤሽያጭ/ፍጆታመመዝገቢያቅጽ
Drugs & Medical Supplies Credit Sales/Consumption Registration Book
Function: This sheet is used to record medicines, supplies and reagents with their financial
values consumed by admitted patients.
Work process: The nurse records medicines, supplies and reagents with their financial values
consumed by the patient during admission. During discharge of the patient, the recorded values
of medicines consumed will be reconciled and approved by the pharmacy personnel in charge
with his /her records and payment will be effected if the patient has to pay or will be documented
for sponsors if the patient will not pay.
7
Nursing and Midwifery Care Services
Table of Contents Page
Section 1 Introduction 7-1
Box
Box A Physician vs. Nursing Diagnoses
Abbreviations/Acronyms
Control Authority
HC Health Center
HO Health Officer
Nursing and Midwifery services are an essential part of the hospital system in
improving the health outcomes of individuals, families and communities. As
individuals, members and coordinators of inter-professional teams; nurses and
midwives bring people–centred care close to the communities where they are
needed most. Thereby contributing greatly in improving the health outcomes of
those under their care as well as improving the overall cost effectiveness of
health care services.
Nursing /Midwifery staff work closely with their own team and with other
professionals, making sure patients’ care and treatment is coordinated, is of a
high standard and has the best possible outcome. Furthermore, that they lead by
example, develop themselves and other staff, and influence the way care is given
in a manner that is open, and, responds to individual needs.
Nurses and midwives play a pivotal role in any hospital. Encompassing the
largest workforce in a hospital, nurses/midwives act as direct caregivers who
serve a hospital twenty-four hours a day, seven days a week. This gives
7-2
nurses/midwives a unique perspective on both patient care and hospital
operations. Given the complexities of hospital management and the direct
relationship between hospital operations and patient care, nursing/midwifery
responsibilities have expanded to include a greater managerial role. This
includes assuming an increased role in hospital leadership and contributing to
effective decision-making within the overall hospital structure, as well as within
case teams, wards/units or departments.
It is essential that within a case team, ward/unit or department there exists a clear
management structure that delineates the ultimate roles and responsibilities
within the given team and clinical setting, determining who has clear authority
over certain decision-making processes.
7-3
assume responsibility for their own practice and enhance client/patient protection
and safety of care”.
2
Needlemann, Jack; Buerhaus, Peter; Mattke, Soeren; Steward, Maureen; Zelevinsky, Katya; Nurse-Staffing
Levels and the Quality of Care in Hospitals, N Engl J Med. 2002; 346 (22): 1715 – 1722
7-4
the availability of technology (patient monitors, beepers etc.),
the skill mix of staff, availability and responsibilities of caregivers.
7-5
Subjective data are what the patient/client actually states (e.g. "I'm tired").
These are his/her feelings and perceptions.
Objective data are concrete, observable information and investigation.
.Examples:
a) Nursing/midwifery diagnoses
7-6
Box A Physician vs Nursing Diagnosis
“Ato Yidnek has pain and swelling in all his joints. Diagnostic studies indicate that he has
rheumatoid arthritis. Anti-inflammatory drugs will be prescribed to treat the rheumatoid
arthritis”
Nursing diagnosis is holistic, considering both the problem and its effect on the patient and
family, for example:
‘Ato Yidnek has pain and swelling in all his joints making it difficult to feed and dress himself. He
states that he feels worthless when he cannot even feed himself’.
Nursing diagnoses are those problems for which nurses can legally prescribe
definitive interventions independently.
The nursing/midwifery diagnosis forms the basis for providing nursing care.
Some factors to consider when writing a nursing diagnosis include:
7-7
Behaviours and mental states that indicate the patient is in a danger to self
or others or has a severe disability;
Interpersonal, socio/ethnic/cultural, spiritual or environmental
circumstances or events which have an effect on the mental and emotional
well-being of the patient family or community;
Actual nursing diagnoses should be written as a three-part statement(s)
which includes:
The PES format describes the problem and its etiology, together with data (signs
and symptoms) that validate the chosen diagnosis. To write a diagnostic
statement for an actual nursing diagnosis, link the problem and its cause by using
“related to” then add “as manifested by” or “as evidenced by” and state the major
signs and symptoms that validate the diagnosis.
Example:
Nurses/midwives may also note that a patient/client has certain risk factors that
put him/her at risk of a particular nursing/midwifery diagnosis. These risk factors
and the related ‘potential diagnosis’ should be documented so that the nursing
care plan can include actions to prevent the problem. For example: ‘at risk of
impaired skin integrity due to patients’ age, weight, immobility and confinement
to bed’. The care plan would then include action to prevent irritated or broken
skin such as regular turning, massage etc.).
7-8
b) Collaborative Problems
In addition to nursing/midwifery diagnoses and their related nursing/midwifery
interventions, nursing/midwifery practice involves certain situations and
interventions that do not fall within the definition of nursing diagnoses. These
activities pertain to potential problems or complications that are medical in
origin and require collaborative interventions with the physician and other
members of the health care team. The term collaborative problem is used to
identify these situations. Collaborative problems are certain physiologic
complications that nurses/midwives monitor to detect changes in status or the
onset of complications. Nurses/midwives manage collaborative problems using
physician prescribed and nursing/midwifery prescribed interventions to minimise
complications. A primary focus of the nurse/midwife when treating collaborative
problems is monitoring the patient for the onset of complications or changes in
the status of existing complications. The complications are usually related to the
patient’s disease process, treatments, medications, or diagnostic studies. The
nurse/midwife prescribes nursing interventions that are appropriate for managing
the complications and implements the treatments prescribed by the physician.
After the nursing diagnoses and collaborative problems have been identified,
they are recorded on the plan of nursing care.
The care plan is a record of interventions that will address the identified
problems. It should be based on the problem identification and the diagnoses,
and should be individualised or tailored to the patient’s/community’s health
problems. The care plan guides each nurse/midwife to intervene in a manner
congruent with individual or community needs and goals and provides outcome
criteria for measurement of progress.
7-9
2. Specifying expected outcomes.
3. Specifying the immediate, intermediate, and long-term goals of nursing action.
4. Identifying specific nursing/midwifery interventions appropriate for attaining
the outcomes.
5. Identifying interdependent interventions.
6. Documenting the nursing/midwifery diagnoses, collaborative problems,
expected outcomes, nursing goals, and nursing/midwifery interventions on the
plan of nursing care.
7. Communicating to appropriate personnel any assessment data that point to
health needs that can best be met by other members of the health care team.
1. Therapeutic relationship
2. Counselling
7-10
The self-care interventions assist the client in meeting their unique needs and
assuming personal responsibility for activities.
The group interventions are aimed at maintaining and improving the
community functional status, and for referral purposes to the community and
social support network resources.
4. Psychobiological interventions
The care plan should be implemented by all nurses/midwives who care for
patients/clients. Hence, all staff should be familiar with the care plan and should
ensure that the activities described in the care plan are carried out during each
shift.
7-11
supporting respiratory and elimination functions; facilitating the ingestion of
food, fluids, and nutrients; managing the patient’s immediate surroundings;
providing health teaching; promoting a therapeutic relationship; and carrying out
a variety of therapeutic nursing/midwifery activities. Judgment, critical thinking,
and good decision-making skills are essential in the selection of appropriate
scientifically and ethically based nursing/midwifery interventions. All
nursing/midwifery interventions are patient-focused and outcome-directed and
implemented with compassion, confidence and a willingness to accept and
understand the patient’s responses. Although many nursing/midwifery actions
are independent, others are interdependent, such as carrying out prescribed
treatments, administering medications and therapies, and collaborating with other
health care team members to accomplish specific expected outcomes and to
monitor and manage potential complications. Such interdependent functioning is
just that—interdependent. Requests or orders from other health care team
members should not be followed blindly but should be assessed critically and
questioned when necessary. The implementation phase of the nursing process
ends when the nursing interventions have been completed.
7-12
Selected according to the nurse’s level of practice, education and
certification.
Implemented within the established plan of care.
Performed in a safe, ethical and appropriate manner.
Adapted to changing patient needs and situations.
Reviewed in order to recognise the progress or lack of progress, and,
reassignment of priorities is required towards identified goals.
Nurses/midwives should document progress reports at the end of each shift
which should consist of nursing/midwifery interventions, patient/client
responses, patients/clients emotional adjustment and rendered patient/client
education.
Evaluation is the process of determining the extent to which the set goals have
been achieved. The nurse/midwife must evaluate the results to determine whether
the interventions were effective.
As new problems arise they should be entered on the Problem Index List and
related goals and activities should be established to address the problem.
Similarly, if a problemis resolved, this should be recorded on the Problem Index
List to indicate that goals and activities related to that particular problem are no
longer necessary.
The care plan should be regularly reviewed and modified as necessary and
should consider the following questions:
7-13
5. Did other problems arise that impeded progress?
6. Which interventions were consistently performed as prescribed?
7. Have any new problems developed that have not addressed?
8. Could more have been achieved than originally hoped?
9. Should new goals be set?
10. The action plan should be checked at intervals, randomly by the nurse
supervisors/head nurses and should be documented.
7-14
format for nurses to track all of those day-to-day learning activities in the
Learning Log. These activities might include:
In-service training
Grand rounds
Reading journal articles
Online searches on nursing related practice areas
Conferences /workshops
Discussion with colleagues and/or physicians
The hospital should establish clear guidelines for both verbal and written forms
of communication for in-patient, Emergency; Outpatient and Delivery Case
Teams.
a) Written communication: This includes the written documentation
of all findings, progress, care and treatment provided to the client by the
multidisciplinary team. A written record permits immediate access to all
information related to the patient’s care and facilitates the exchange of
information between all members of the case team.
7-15
b) Verbal communication: this entails the act of reporting and
conversing with other members of the health care team regarding the client’s
progress and status.
c) Verbal orders will only accepted in emergencies. The
nurse/midwife receiving the verbal order is responsible to document the order
immediately.
Nurses should give health education for all patients, also incorporate family
members and other caregivers who often play a strong role in facilitating patient
care in coordination with the medical staff. One suggestion to improve the family
7-16
and staff relationship is with the use of a Patient Caregiver Contract, whereby the
relationship is formalized between families/caregivers and medical staff..
Procedure
1) Physician Order: A physician’s order is required for the administration of
all medications. There are several types of orders:
Standing order: To be carried out as specified until it is
canceled by another order (including PRN
orders).
Physician orders need to include the following information when they are
transcribed into the Physician Order Sheet in order to be considered complete.
Orders are not to be carried out unless all of these elements are present. If an
element is missing, the physician who issued the order should be called to
complete the order.
Date and time: When the order was written.
Full name of the medication: Either the chemical or generic
name can be used without abbreviations.
7-17
Dosage: Specify the amount of medicine to be given.
Abbreviations are discouraged.
Concentration: If the medication is to be diluted in IV fluid,
the amount and type of diluent/s ordered.
Duration: If the medication is to be given over a period of
time, such as IV administrations, the duration of the infusion
ordered should be recorded by the physician. Nurses should
then translate and document the duration of infusion into
number of (micro) drops per minute.
Time and frequency: The time of day and how often a
medication is to be given, as ordered by the physician. The
nurse who transcribes the order will identify the specific time
that the medication is to be given by following a standardized
schedule.
Route: For medications that can be given in several ways, the
route of administration needs to be clearly written.
Physician Signature: Is to be clearly written immediately
following the order.
The nurse is responsible for questioning the physician regarding any medication
order or element of an order that is in his/her judgment an error. The perceived
error may be in the drug ordered, dosage, route, time and/or frequency to be
given.
7-18
The nurse brings the Medication Administration Record to the
patient’s bedside.
The nurse checks the prescribed medication from the patient’s
bedside to the Medication Administration Record three times
to ensure that it is the proper medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
Medications in a Cabinet
The nurse brings the Medication Administration Record to the
cabinet.
The nurse checks the prescribed medication from the cabinet
to Medication Administration Record three times to ensure
that it is the proper medication:
1. When reaching for the container of medication,
2. Immediately prior to the pouring the medication, and
3. When returning the container to its proper location.
Medications should be prepared one patient at a time. Each
medication for a single patient should be organized into a
group for that individual patient, prior to dispensing
medications for another patient.
When medications are to be given to more than one patient,
the medication cup/container should be clearly marked with
each bed number.
Before administering medication, the nurse should cross-
reference the bed number (on cup/container) with the bed
number and name listed on the Medication Administration
Record.
4) Administration:
The nurse who prepares the medication should
always be the nurse who administers the medication.
During administration, medications should
never be out of the sight of the administering nurse.
It is the nurse’s responsibility to confirm that
they are giving the correct drug to the correct patient. When
the nurse arrives at the patient’s bedside, the nurse must
confirm using two methods that the patient is properly
identified.
7-19
Check the name on the Medication Administration Record
with the patient’s posted name.
Ask the patient to repeat their name.
Oncethe correct patient is verified, administer
the medication. If it is an oral medication do not leave it for
the patient to take later. The nurse needs to observe all
medications being taken to assure that the medication has
been adequately administered.
If a patient refuses a medication, the physician
should be notified and it should be clearly documented in the
medical record.
Hospitals should ensure that nurses have access to and are trained on how to use
resources (including equipment and consumables) correctly and cost-effectively.
Nurses are responsible for forecasting stock-outs of nursing formats and other
consumables on the ward, and should inform the appropriate party of the need
for additional resources to prevent items being out of stock.
7-20
Improves quality of record keeping.
Focuses on care provided and not on care provider.
Contributes to research.
7-21
State patient outcome criteria
State acceptable degree of goal achievement
Specify the source of information
Determine the design and type of data collection tool
7-22
Section 4 Implementation Checklist and Indicators
4.1 Assessment Tool for Operational Standards
The following Table can be used as a tool to record whether the main recommendations
outlined above have been implemented by the hospital. This tool is not meant to measure
attainment of each Operational Standard, but rather to provide a checklist to record
implementation activities.
Yes No
1. There is a system for coordinating and managing nursing staff.
2. Job descriptions for nursing positions have been developed.
3. A nursing workforce plan has been developed.
4. The hospital’s nurse staff requirements are defined in the nursing
workforce plan.
5. Nurse to patient ratios for each service area are defined in the nursing
workforce plan.
6. There is a written policy for the nursing process.
7. Nurses complete nursing admission assessments for inpatients.
8. Nurses complete a nursing care plan for inpatients.
9. There are written guidelines for nursing verbal and written
communication.
10. There are written guidelines for medication administration.
11. There is an established nursing/midwifery care practice audit programme.
12. Nurses implement regular nursing/midwifery hours (eight)’ shift.
13. Nurses conduct nursing care hourly rounds.
14. There is a central medication room or cabinet.
15. There is a centralized nursing/midwifery station set-up in each ward.
7-23
7-24
4.3 Nursing/Midwifery Care Standards’ Indicators
In addition, the following indicators should be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
Table 2 Nursing/Midwifery Care Standards Indicators
7-25
understand?
Source Documents
1. Aiken, LH et al (2002). Hospital Nurse Staffing and patient Mortality, Nurse Burnout and Job
Dissatisfaction. Journal of American Medical Administration. 288(16):1987-93.
2. Arnold, E. and Boggs, K. (1999). Interpersonal relationships: Professional communication
skills for nurses. 3rd Edition. Philadelphia: W.W. Saunders.
3. Audit Commission. (2001). Acute Hospital Portfolio- Ward staffing. London: Audit
Commission.
4. Buchan, J. (2004). A Certain Ratio? Minimum Staffing Ratios in Nursing. London: Royal
College of Nurses.
5. Clarke, Sean P.; Sloane, Douglas M.; Aiken, Linda H.; Effects of Hospital Staffing and
Organizational Climate on Needlestick Injuries to Nurses. American Journal of Public
Health, 2002; 92 (7): 1115 – 1119.
6. College of Registered Nurses of Nova Scotia. (2004). Standards of Nursing Practice. Halifax:
College of Registered Nurses of Nova Scotia.
7. Cook, D, and Sportsman, S. (2005). DSHS Nursing Standards of Care and Nursing
Standards of Professional Performance.Texas Department of State Health Services.
8. Department of Health. (1993). A Vision for the Future. London: HMSO.
9. Department of Health. (1997). The New NHS: Modern, Dependable. London: The Stationery
Office.
10. Department of Health. (2000). National Minimum Standards. London: The Stationery
Office.
11. Department of Health. (2001). Good practice in consent implementation guide: consent to
examination or treatment. Retrieved from:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida
nce/DH_4005762 on 02/03/09.
12. Dougherty, L, and Lister, S. (Eds) (2008) The Royal Marsden Hospital Manual of Clinical
Nursing Procedures. 7th Edition. Oxford (UK): Wiley-Blackwell.
13. Department of Health. (2003). Building on the best: choice, responsiveness and equality in
the NHS. London: The Stationery Office.
14. FEPI (2009) Code of Ethics and Conduct for European Nursing: Protecting the public and
ensuring patient safety. European Council of Nursing Regulators. Retrieved from:
http://www.fepi.org/userfiles/file/FEPI_Code_of_Ethics_and_Conducts_170908.pdf on
02/03/09.
15. International Council of Nurses. (2009). Nursing Matters. Nursing: Patient Ratios.
7-26
16. Heaven, C.M and Maguire, P. (1996). Training hospice nurses to elicit patient concerns.
Journal of Advanced Nursing. 23, 280-286.
17. Kennedy, I. (2001). Learning from Bristol: the Report of the Public Inquiry into children’s
heart surgery at the Bristol Royal Infirmary. London: The Stationery Office.
18. Needlemann, J., Buerhaus, P., Mattke, S., Steward, M., Zelevinsky, K. (2002). Nurse-
Staffing Levels and the Quality of Care in Hospitals,N Engl J Med. 2002; 346 (22): 1715 –
1722.
19. Nursing and Midwifery Council. (2004). Standards of proficiency for pre-registration
nursing education: Protecting the public through professional standards. London: Nursing
and Midwifery Council.
20. Nursing and Midwifery Council. (2008). The Code: Standards of conduct, performance and
ethics for nurses and midwives. http://www.nmc-uk.org/aArticle.aspx?ArticleID=3056.
21. Roper, W., Logan, W., and Tierney, A. (1990). The elements of nursing based on a model of
living. 3rd edition. London: Churchill Livingston.
22. Royal College of Nursing. (2003.) Clinical Supervision in the workplace: Guidance for
occupational health nurses. London: Royal College of Nurses.
23. Royal College of Nursing. (2008).’Dignity: at the heart of everything we do’ campaign.
London: Royal College of Nurses.
24. Royal College of Nursing. (2003). Guidance for nurse staffing in critical care. London:
Royal College of Nurses.
25. Royal College of Nursing. (2006). Policy Guidance 15/2006: Setting Appropriate Ward
Nurse Staffing Levels in NHS Acute Trusts. London: Royal College of Nurses.
26. Rush, S., Fergy, S. and Wells, D. (1996). Professional Development. Care Planning:
Knowledge for practice. Nursing Times. 92(38)1-4.
27. Scally, G. and Donaldson, LJ, (1998). Clinical governance and the drive for quality
improvement in the new NHS in England. British Medical Journal. 317(7150) 4 July pp.61-
65.
28. World Health Organization. (2003), Nursing and Midwifery Workforce Management.
Analysis of Country Assessments. SEARO Technical Publication No.26. New Delhi: WHO
Regional Office for Southeast Asia
http://www.searo.who.int/LinkFiles/Publications_Analysis_Cntry_Asses_11Sep.pdf.
29. World Health Organization Release. (15 August 2003).
http://www.who.int/mediacentre/releases/pr80/en/print.htm.
30. Parish, C. (2002). Minimum effort: The introduction of minimum nurse-to-patient ratios can
have maximum effect on recruitment and morale, in nursing standard, Vol. 16, No 42.
31. walravenkcrysta8.typepad.com/blog/2012/06/nanda-nursing-diagnosis-list-2012-2014-
complete-list-of.html
7-27
Appendices
Patients’ Nursing Care Plan Documentation
Please Complete or Affix Label HOSPITAL
Name: Father Name:
Address:- City: Sub city:
Ward: _____________________________________
Kebele: House no.
Bed No.: ___________________________________
MRN: Age:
Tel. No.:
Personal Details
Language:
Patient’s support
1. Name: 2. Name:
Relationship: Relationship:
Health Perception/Management
Patient’s understanding of reason of admission:
Understanding of Medication (what, how and why) Patient is taking before admission (incl. “over the counter” and
known allergies)
_______________________________________________________________
Self-employed?
Yes No If no, please state who helps with & how many
Is patient independent?
Cooking: __________ Washing / Dressing: ___________
Level of consciousness
Reflexes (Eye , hand grasp and movement of extremities)
Sensorial (eye, ear, nose, tongue and skin)
Pain
Cognition (primary language, speech deficit and any LD)
Special diet
Pattern of daily food
Fluids intake
Appetite
Weight
Nausea and vomiting
GI Pain
Condition of mucous membrane
Dental condition
Skin (warm, dry, cold, moist, thurgor)
Mobility
Colour (pink, pale, dark, jaundice, cyanosed,)
Odema
Wound/drainage/dressings
IV Line
5. Psychological Care
Coping with stress
Response to stress
Relaxation methods
Support groups/ counselling resources
6. Spiritual/Dying
Value and belief:
7. Sleeping
Sleep/rest pattern:
Male
Monthly testicular examination
Prostate problems
Penile discharge
ummary subjective data Summary objective data
MRN: Age:
Tel. No.:
Date No Nursing Diagnosis (Problem) Signature Date Signature
and and
Identified Resolved
and Designation and Designation
Time Time
Nursing Care Plan
Date
Signature
Problem
and Nursing Outcome/Goal Intervention/Action and
No
Designation
Time
Nursing Patient Progress Report
Below is the list of the 16 New? NANDA Nursing Diagnosis List for 2012-2014
Insomnia
Sleep deprivation
Readiness for enhanced sleep
Disturbed sleep pattern
Risk for disuse syndrome
Impaired bed mobility
Impaired physical mobility
Impaired wheelchair mobility
Impaired transfer ability
Impaired walking
Disturbed energy field
Fatigue
Wandering
Activity intolerance
Risk for activity intolerance
Ineffective breathing pattern
Decreased cardiac output
Risk for ineffective gastrointestinal perfusion
Risk for ineffective renal perfusion
Impaired spontaneous ventilation
Ineffective peripheral tissue perfusion
Risk for decreased cardiac tissue perfusion
Risk for ineffective cerebral tissue perfusion
Risk for ineffective peripheral tissue perfusion
Dysfunctional ventilator weaning response
Impaired home maintenance
Readiness for enhanced self-care
Bathing self-care deficit
Dressing self-care deficit
Feeding self-care deficit
Toileting self-care deficit
Self-neglect
Domain 5 Perception/ Cognition
Unilateral neglect
Impaired environmental interpretation syndrome
Acute confusion
Chronic confusion
Risk for acute confusion
Ineffective impulse control
Deficient knowledge
Readiness for enhanced knowledge
Impaired memory
Readiness for enhanced communication
Impaired verbal communication
Domain 6 Self-Perception
Hopelessness
Risk for compromised human dignity
Risk for loneliness
Disturbed personal identity
Risk for disturbed personal identity
Readiness for enhanced self-control
Chronic low self-esteem
Risk for chronic low self-esteem
Risk for situational low self-esteem
Situational low self-esteem
Disturbed body image
Stress overload
Risk for disorganized infant behavior
Autonomic dysreflexia
Risk for autonomic dysreflexia
Disorganized infant behavior
Readiness for enhanced organized infant behavior
Decreased intracranial adaptive capacity
Domain 7 Role Relationships
Ineffective breastfeeding
Interrupted breastfeeding
Readiness for enhanced breastfeeding
Caregiver role strain
Risk for caregiver role strain
Impaired parenting
Readiness for enhanced parenting
Risk for impaired parenting
Risk for impaired attachment
Dysfunctional family processes
Interrupted family processes
Readiness for enhanced family processes
Ineffective relationship
Readiness for enhanced relationship
Risk for ineffective relationship
Parental role conflict
Ineffective role performance
Impaired social interaction
Domain 8 Sexuality
Sexual dysfunction
Ineffective sexuality pattern
Ineffective childbearing process
Readiness for enhanced childbearing process
Risk for ineffective childbearing process
Risk for disturbed maternal-fetal dyad
Domain 9 Coping/ Stress Tolerance
Post-trauma syndrome
Risk for post-trauma syndrome
Rape-trauma syndrome
Relocation stress syndrome
Risk for relocation stress syndrome
Ineffective activity planning
Risk for ineffective activity planning
Anxiety
Compromised family coping
Defensive coping
Disabled family coping
Ineffective coping
Ineffective community coping
Readiness for enhanced coping
Readiness for enhanced family coping
Death anxiety
Ineffective denial
Adult failure to thrive
Fear
Grieving
Complicated grieving
Risk for complicated grieving
Readiness for enhanced power
Powerlessness
Risk for powerlessness
Impaired individual resilience
Readiness for enhanced resilience
Risk for compromised resilience
Chronic sorrow
Stress overload
Risk for disorganized infant behavior
Autonomic dysreflexia
Risk for autonomic dysreflexia
Disorganized infant behavior
Readiness for enhanced organized infant behavior
Decreased intracranial adaptive capacity
Domain 10 Life Principles
Impaired comfort, Readiness for enhanced comfort, Nausea, Acute pain, Chronic pain, Impaired
comfort, Readiness for enhanced comfort and Social isolation
8
Maternal, Neonatal and Child Health Services
Table of Contents Page
Section 1 Introduction 8-1
BP Blood Pressure
ER Emergency Room
FP Family Planning
Hgb Hemoglobin
IO Intra Osseous
IV Intra venous
LP Lumbar Puncture
NB New Born
OI Opportunistic Infection
QI Quality Improvement
OR Operation Room
PR Pulse Rate
RH Rhesus Factor
TB Tuberculosis Bacilli
TT Tetanus Toxoid
U/A Urinalysis
Appendices
Appendix 2: List of NICU equipment and essential drugs for child health
Appendix 5: Facility, Supplies and Equipment for Pediatric OPD and ART Clinic
Appendix 7 Essential drugs that must be available in emergency drug cabinet of L& D ward
Appendix 8 Medical equipment in labor and delivery ward and operation theatre
Figures
Figure 1: Rapid assessment of labouring mothers to advance care
Figure 2: Flow chart for triage and registration of labouring mothers
Section 1 Introduction
The time of childbirth and the period immediately after birth are particularly critical for maternal, fetal
and neonatal survival and well-being. Effective care to prevent and manage complications during this
critical period is likely to have a significant impact on reducing maternal deaths, stillbirths and early
neonatal deaths. Within this critical period and during antenatal care, quality of care improvement
efforts would target essential maternal and newborn care and additional care for management of
complications that could achieve the highest impact on maternal, fetal and newborn survival and well-
being.
To address the high perinatal and U5 mortality, neonatal and child health services need to be
standardized. Use of revised standard guidelines, establishing and maintaining newborn corners in
maternities, setting separate triage and emergency pediatric care, running separate pediatric wards and
OPDs, establishing a well-equipped neonatal unit, assigning adequate number of qualified health
workers in each pediatric unit with training on revised national guidelines and setting functional
vaccination/EPI clinic are essential components of quality pediatric care that address the challenges of
high perinatal and U5 mortality rates.
The purpose of the Standards for Maternal, Neonatal and child Care is to assist program managers and
health care providers of a hospital to:
Introduce standards setting and a quality improvement process at facility level as a means to
improve access and quality of maternal, neonatal and child health services;
Provide effective maternal, neonatal and child health services;
Use existing resources to achieve the optimal health care outcomes; and improve
individuals', families' and community's satisfaction and utilization of maternal, neonatal and
child health services.
1. The hospital ANC unit provides individualized, client centered and evidence based care to
clients on all working days and high risk mothers should be seen in the referral clinic.
2. The hospital should ensure provision of Comprehensive Emergency Maternal and Newborn
Care (CEmONC) services
8-1
3. The hospital should ensure women and child friendly services at all MNCH units including pain
management.
4. The hospital ensures all equipment, essential drugs, supplies and reference materials are
available in maternity and pediatric units
5. The hospital should ensure the provision of intra-partal care as per national protocols
6. The hospital should provide comprehensive postnatal care in the facility as per national
standards
7. The hospital should ensure provision of family planning (with focus on long term methods) and
comprehensive abortion care services following the national guideline and policies.
8. Hospitals have established separate pediatric OPD, emergency and triage services.
9. Hospitals have comprehensive Neonatal Care service that includes NICU, KMC, mother’s room
and isolation rooms.
10. Hospitals have separate Pediatric Wards composed of separate critical, general, SAM, isolation
and procedure rooms.
11. Midwives should implement the midwifery process at all hospitals for all admitted patients.
The maternity head monitors all the activities of the maternity unit
Leads the maternity QI subcommittee to conduct regular audit meeting and draw action plan
depending on the finding.
She/he communicates with the hospital SMT, arrange trainings for all staffs, make sure that
there is proper hand over mechanisms, and proper follow up of day to day clinical activity.
He/she should make sure that at least 5% of vaginal deliveries should be attended either by
obstetrician or IESO.
The heads of the maternity units (ANC, delivery ward and postnatal ward) will have roles and
responsibilities in each respective unit. They prepare and compile monthly, quarterly and yearly report
and action plan. They should be members of maternal death audit committee/QI committee and prepare
schedule for the unit and make sure that all the necessary materials and supplies are always available.
8-2
They communicate with the obstetrician/IESO whenever they have any challenges in their respective
units.
The maternity unit should do audits regularly. Maternity unit audits should be performed every month
and client/mom’s satisfaction survey should be performed every 3 months. Data should be displayed on
white board at ANC, labor and delivery and postnatal ward and updated.
Regular review meetings should be held at least every week to discuss audit findings, ongoing
challenges, weekly ward activity and other findings.
Community involvement in the form of pregnant forum or community forum should be held at least
every 3 months.
Midwives should implement the midwifery process at all hospitals for all admitted patients. All
midwives should assess, diagnose, plan, implement and evaluate their admitted patient according
midwifery care practice. (Refer a book, Standard of Midwifery Care Practice in Ethiopia)
3.1.3 ANC
Hospital should provide ANC service open throughout working days by skilled professionals. A
midwife will be the head of the ANC unit and all the service providers should be trained on FANC. The
ANC room keeps privacy by using curtains / screen and all ANC services including U/S will be
provided free of charge. The ANC clinic provides evidence based care to clients.
HIV positive pregnant mothers and their exposed infants should be provided option B+, and both
should be followed in the clinic until 18 months and beyond and DBS should be done in the clinic.
Invitation paper will be given for partners of pregnant women to increase partner involvement. The
ANC unit should have a referral clinic for high risk mothers run by obstetrician or IESO. The referral
clinic should be open at least two days per week and at least 25% of ANC mothers should be seen in the
referral clinic.
Investigation results should be ready on the same day. Iron folate supplementation will be done at least
for three months (90tabs) and deworming after first trimester; drugs should be available and provided
on site free of charge. All mothers who come for ANC should be counseled on birth preparedness and
8-3
complication readiness, immunization, breast feeding, infant feeding, family planning, HIV, and
nutrition. Mothers are better allowed to hold their ANC follow up card after 36 weeks.
8-4
The labor ward rooms are clean, well ventilated and with good temperature (neither hot nor cold).
Labor ward needs to have emergency drug cabinet that has labeled essential drugs. The labor ward
should have functional refrigerator with temperature monitoring chart. It should have all essential
functional medical equipment. The ward should have functional clock, weighing scale, head lamp and
tape meter.
Privacy must be maintained for first and second stage of labor by screens or curtains and sufficient
space should be available for laboring mothers and one companion. Mothers are allowed oral fluids and
light food during labor. Family member/support person should be allowed to remain with woman
constantly during labor and delivery. There should be functional bathroom and toilets with hand
washing basin and soap accessible to laboring mothers. The labor ward has running water and soap for
hand washing for the staff.
The labor and delivery ward should have at least four beds for first stage of labor and two delivery
coaches for second stage of labor. The maternity unit needs to have an ICU or HDU available near the
nursing station for seriously ill patients.
Partograph should be consistently used and third stage should be managed actively. Date and time of
admission, identification and previous obstetric history, admission findings of BP, PR, Temperature, lie
and presentation, FHB, uterine contraction, cervical status (dilatation and effacement), membrane status
(intact or ruptured), molding and station should be documented.
8-5
The partograph has to be used correctly and consistently. If an intervention has to be made, it should be
from the partograph findings and the action has to be appropriate and timely.
All intervention including instrumental delivery and C/S should be based on justified indications and
performed timely. Pertinent findings and decision notes should be entered in to the medication record.
HGB, blood GP and RH, VDRL for syphilis and HIV testing should be done for all and FHB and
uterine contraction monitored every 30 minutes; Cervical dilatation assessed every four hours. and/or
on indications (signs of 2nd stage or membrane ruptured). Maternal BP measured every four hours for
mothers with no pre-eclampsia or eclampsia and pulse rate every half an hour.
Safe child birth check list should be used for all laboring mothers. Delivery coach is comfortable with
all accessories and mothers are allowed to deliver in their preferred position. Third stage should be
managed actively. Well-equipped newborn corner for routine essential newborn care and neonatal
resuscitation should be available in the labor ward; Clamp cord after 1-3 minutes (unless the neonate is
asphyxiated and needs to be moved immediately for resuscitation), cut the cord with sterile instrument,
put sterile tie, and put identity label on the baby( the identity label should contain mother’s name, card
number, gender of the baby and time of delivery).The newborn corner facility should include radiant
warmer, new born sized ambu bag of sizes 0 and 1, and suction bulb and/or suction machine. All
midwives should be trained on Helping Babies Breath and NICU should be available for advanced care.
Ideally NICU should be adjacent to labor ward. Delivery summary should be filled completely on form
at the back of Partograph.
8-6
be used for all surgeries and documentation should be complete for all cesarean sections. Audit to
assess completeness of documentation should be done every three month and rate and indications for
C/S should be displayed in white board every month. Spinal anesthesia used in the absence of
contraindication.
The clinical causes of most maternal deaths in Ethiopia are hemorrhage, anemia, eclampsia, obstructed
labor and unsafe abortion. All of these complications are preventable. Therefore each hospital should
be able to deal with these pressing challenges to significantly reduce maternal mortality and morbidity
by treating a mother according to Management Protocol on Selected Obstetrics Topics (FMOH,
January, 2010)
3.1.9 FP services
It is basic right of individual and family to be provided with service, supplies and information how to
plan their families. Family planning clients shall receive information, education and counseling on
sexual and reproductive health, family planning and STI/HIV/AIDS.
The hospital should have open access to and availability of full range of family planning services as
integral part of basic health services with particular emphasis on long term methods. Services provided
should be patient focused, ensuring good communication and client counseling.
8-7
All working staffs should have received appropriate training, demonstrate competent skills and the
services should be evidence based including use of national guideline and policies.
The hospital should ensure availability of all contraceptive methods with particular emphasis on long
term methods and the service shall be available at all working hours.
Rapid triage for all children presenting to hospital needs to be put in place to identify and manage
children with emergency or priority signs. Once emergency signs are identified, prompt emergency
treatment needs to be given (in the emergency room that is located next to the triage area) to stabilize
the condition of the child.
8-8
Emergency triage area for pediatric cases should be set within pediatric OPD premises for triaging all
children upon their arrival in a hospital. Children should be triaged immediately (before any registration
or other process) and categorized as emergency, priority and non-urgent cases so that to provide
immediate emergency treatment to those with emergency signs, to bring to the front of the OPD queue
those with priority signs and to identify non-urgent cases that can wait for their turn at the regular
pediatric OPD. Appropriate identification codes such as color coding should be used to categorize
triaged children.
Emergency treatment room with necessary equipment and emergency drugs should be prepared
adjacent to the triage area where children with emergency signs are given emergency treatment such as
oxygen administration for children with severe respiratory distress, anticonvulsant treatment for those
children who are convulsing etc. Professionals with training in ETAT should be assigned in the
emergency and triage unit (see annex for the list of equipment and supplies)
3.2.3 Hospitals have a pediatric OPD separate from adult OPD, with emphasis on IMNCI
target diseases in managing U5 children
Every day, a large number of parents seek health care for their sick children, taking them to
hospitals, health centers, pharmacists, doctors and traditional healers. The majority of sick children
8-9
are treated in OPDs, and in most of them, history and signs and symptoms will determine a course
of management that makes the best use of the available resources.
In addition to the establishment of newborn corners at the maternity ward, hospitals should establish a
comprehensive neonatal unit for the in-patient management of neonates. All newborns at the maternity
and neonatal unit should have standard identification tags attached to the arm and/or leg of the newborn.
Rooming in of all newborns with their mothers and early initiation (within one hour of delivery) of
exclusive breast feeding should always be encouraged. Attention should be given to correct nutrition in
sick neonates. No newborns should be discharged from a hospital in the critical first 24 hours of life,
and without receiving essential NB care including birth doses of vaccines.
8-10
Neonatal care unit layout and physical structure
Neonatal Care Unit should be located as close as possible to the Labor Ward, including the rooms
specified for operative deliveries. Ideally the unit should be immediately adjacent to the Labor Ward
and on the same floor. The postnatal wards should also be in close proximity. Components of the
Neonatal Care Unit
Mothers and care givers of newborns and children admitted to hospitals have the right to know
about the health status of their children and should be regularly communicated
Informative, systematic and regular communication is essential to engage families in the care of
their children. Mothers and care givers should be encouraged to be involved in the care of their
children and health education in the future care of their children should be given.
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EPI clinic is ideal unit for growth monitoring of well infants and for educating mothers on
the care of their children
Hospitals should establish pediatric in-patient service separate from that of adults
The following should be part of pediatric ward
Therapeutic feeding room for children with complicated SAM
Pediatric ICU or at least dedicated room for critically ill children next to nursing station
Isolation room for children with communicable diseases
Clean, ventilated procedure room with good light source
Separate room for pediatric surgical cases
Resuscitation room/table
Each room should have clean beds and sheets should be changed daily
Essential supplies, drugs and equipment should be available (Annex 6)
Laboratory services that provide essential lab tests for diagnosing and managing sick
children should be available all times
Case management guidelines including pocket books and wall charts and job aids should be
available and used, with reference to standard text books when required
The ward room painting should be child friendly
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Admission and progress notes, vital sign sheets as well as discharge or death summaries should
be attached to the patient charts
8-15
Source Documents
1. Federal Democratic Republic of Ethiopia: Ministry of Health, HSDP IV. Addis Ababa, Ethiopia:
Annual Performance Report EFY 2004 (2011/2012); 2013.
2. Federal Ministry of Health, Health Sector Development Program IV 2010/11-2014/15. Addis
Ababa: Federal Ministry of Health; 2011.
3. Federal Ministry of Health of Ethiopia, Health Sector Transformation Plan (HSTP) 2014/15-
2019/20, Addis Ababa, 2015.
4. Windau-Melmer, Tamara. 2013. A Guide for Advocating for Respectful Maternity Care.
Washington, DC: Futures Group, Health Policy Project.
5. Federal Democratic Republic of Ethiopia: Ministry of Health, Standard of Midwifery Care
Practice in Ethiopia, August, 2013.
6. Federal Democratic Republic of Ethiopia: Ministry of Health, Management Protocol on Selected
Obstetrics Topics, January, 2010
7. Technical andProcedural GuidelinesforSafe AbortionServicesin Ethiopia, Secondedition, June
2014
8. Federal Democratic Republic of Ethiopia: Ministry of Health, National Guideline for Family
Planning Services in Ethiopia, February – 2011
9. WHO recommendations on postnatal care of the mother and newborn. Geneva (Switzerland):
World Health Organization (WHO); 2013 Oct. 62 (p. 120)
10. Federal Ministry of Health, National Mother and Baby Friendly Service Guideline, 2016
11. Integrated Management of Pregnancy and Childbirth, Standards for Maternal and Neonatal Care,
WHO, 2007.
12. Pocket book of hospital care for children, second edition: WHO, 2013
13. Global Initiatives for Improving Hospital Care for children: State of the Art and Future Prospects
PEDIATRICS Volume 121, Number 4, April 2008
14. Assessment Tool for Hospital Care for Children, Second Edition: WHO 2015
Appendices
Appendix 1: List of Emergency Drugs and Equipment for Child health
Equipment Yes No
Nebulizer
Spacer
Orophargngeal (Guedel) Airways: at least 3 different sizes
Self-inflating bags: adult and children
Masks: 3 sizes for children
Electric (or foot) suction pump and suction catheters: size 15 FG.
Oxygen concentrator or oxygen cylinder with regulator, pressure gauge and flow mete
Oxygen tubing, nasal prongs or catheters
High pressure oxygen source with oxygen adopter and oxygen bag
Sandbags
Blankets
Scissors
Iris forceps without teeth
Consumables
Adhesive tape, at least 2 different sizes
Cotton wool
Cardboard to make splints
IV Infusion sets
Scalp vein needles (size 21 or 23 G)
IV Cannulae (size 22 or 24 G)
Needles for intraosseous insertion (size 21G)
Tuberculin syringes (if not available 2 cc syringe)
Test strips and scale for blood sugar
Adhesive tape
Umbilical catheter, 3.5F or 5F
Small clamps
Scalpel
Three way stop cock
14 gauge stop angiocath / over needle intravenous catheter attached 5 or 10 ml syringe
8 or 3 endotracheal tube ventilator adaptor
Fluids and drugs
Ringer’s lactate or normal saline
Normal saline with 5% glucose solution or half-strength Darrow’s with 5% glucose
solution
Glucose 10% or 50% glucose
ORS
ReSoMal (commercially bought or prepared)
Diazepam IV or Lorazepam
Adrenaline
Salbutamol puff
Corticosteroids:
Hydrocortisone IV
Dexamethasone IV
Prednisolone PO
Appendix 2: List of NICU equipment and essential drugs for child health
Equipment Yes No
Incubators
Radiant warmers
Phototherapy machines
Cardiac monitors
CPAPs
Pulse oxymeter
Perfuser
Oxygen concentrators
Oxygen cylinders with gauge
Nasal prongs
Room heaters
Suction machines
Ambu bags and different sizes of face masks
Neonatal cribs
Neonatal BP apparatus
Bulb syringes
Resuscitation table
Refrigerator
Endotracheal tubes
Oropharyngeal airways
Infant weight scales
Umbilical catheterization set
Exchange transfusion set
IV stands
Thermometers
Supplies
Sterile and clean gloves
Syringes and needles
IV sets and blood transfusion sets
IV cannulas and butterfly needles
Soap and antiseptic solutions
NG tubes
Drugs
Antibiotics:
Ampicillin injection (250mg, 500mg, 1g)
Cefotaxime sod (500mg, 1g vials)
Ceftazidime (500mg, 1g, 2g vials)
Ceftriaxone (250mg, 500mg, 1g vials)
Clindamycin (150mg/ml)
Gentamicin (10mg/ml, 40mg/ml)
Nafcillin (1g, 2g vials)
Penicillin G (crystalline, 5MIU…)
Vancomycin (500mg, 1g, 5g vials)
Ringer’s lactate or normal saline
Normal saline with 5% glucose solution
Glucose 10%, 40% or 50% solution
Anticonvulsants
Diazepam 5mg/ml ampule
Phenobarbitoneinj, 60mg/ml, 65mg/ml
Phenytoin inj, 50mg/ml
Appendix 3: List of guidelines and job aids for child health
Unit (department) List of GL and job aids Yes No
Emergency Unit ETAT guideline (manuals)
Pocket book on hospital care for children (national)
ETAT flow sheets (for triage, airway and breathing,
circulation, convulsion, etc)
Pediatric OPD Hospital care for children (national)
ART guideline
TB guideline
Nutrition guideline
Malaria guideline
Standard pediatrics text books
Neonatal unit Hospital care for children (national)
NICU guideline
Neonatal Resuscitation flow sheet
Standard pediatrics text books
EPI clinic EPI guideline
Pediatric ART clinic Consolidated HIV care/ART GL (national)
National TB guideline
National nutrition guideline
National PMTCT guideline
Pediatric wards Pocket Book on Hospital care for children (national)
Consolidated HIV care/ART guideline (national)
National TB guideline
National nutrition guidelines
Standard pediatrics text books
Appendix 4: List of pediatric ARVs and OI drugs
ARV Drugs Yes No
FDC: AZT/3TC/NVP
FDC: AZT/3TC
FDC: ABC/3TC/NVP
FDC: TDF/3TC/EFV
FDC: TDF/3TC
FDC: AZT/3TC/LPV/r
FDC: ABC/3TC/LPV/r
FDC: LPV/r sprinkles
OI drugs
Co-trimoxazole suspension (240mg/5ml)
Co-trimoxazole tablet (480mg)
INH tab (100mg)
Nystatin suspension (100,000 U/ml)
Clotrimazole mouth paint, 1%
Miconazole tab (250mg), oral gel 25mg/ml
Amoxicillin suspension (125mg/5ml, 250mg/5ml)
Amoxicillin/clavulanic acid suspension
156mg/5ml
312mg/5ml
228mg/5ml
457mg/5ml
Appendix 5: Facility, Supplies and Equipment for Pediatric OPD and ART
Clinic
Functional hand washing basins Yes No
Examination beds with clean sheets
Table and chair for the physician (clinician)
Weight and height measuring scales for infants and children
MUAC tapes
Thermometers
Otoscopesand torches
Pediatric BP apparatus (different sizes)
Disposable and sterile gloves and alcohol swab
Syringes and needles as required
Printed papers such as admission cards, prescription papers, lab request forms, X. ray
and U/S request forms, referral papers
HMIS/IMNCI registers
Appendix 6: Facility, Supplies and Equipment for Pediatric Wards
Yes No
General
Functional hand washing basins in each room
Functional showers and toilets for staff
Functional showers and toilets for patients
Printed papers:
History sheets
Order sheets
Prescription and lab request papers
Consultation papers
Discharge and death summary forms
Referral papers
Equipment and supplies
Pediatric BP apparatus (different sizes)
Thermometers
LP sets
Bone marrow sets
Endotracheal tubes and oral airways
Ambu bags with different sizes of masks
Stretchers
Sterile and clean gloves
Syringes and needles (different gauges)
Urinary catheters
Kidney dishes
Rectal tubes
Enema sets
Chest tubes
Appendix7 Essential drugs that must be available in emergency drug
cabinet of L& D ward
Tables
Table 1 Laboratory Services Checklist
Table 2 Laboratory Services Indicators
Abbreviations
ART Antiretroviral therapy
AFB Acid Fast Bacilli
ALT Alkaline Transferase
BPR Business Process Re-engineering
CPD Continuing professional development
DNA Deoxyribonucleic acid
EPHI Ethiopian Public Health Institute
EQA External Quality Assessment
FMHACA Food Medicine and Healthcare Administration and Control Authority
FMOH Federal Ministry of Health
The current laboratory service in Ethiopia is organized in a structure that follows the
general health care delivery system of the country, incorporating specialized, general
and primary hospitals in addition to health centres and health posts. At the apex of
this system, there are currently twelve Regional Reference Laboratories and a
National Reference Laboratory at the Ethiopian Public Health Institute (EPHI). A
detailed description of the responsibilities of laboratories at different tier levels in
Ethiopia is presented in Appendix A.
As part of the Ethiopian laboratory network, hospitals receive specimens for analysis
from the lower level of laboratories and also from the same level of facilities and may
refer specimens to a higher level facility, in accordance with agreed protocols and
guidelines. This chapter sets standards and guidelines to ensure that hospital
laboratories provide accurate, reliable and timely test results for patient care. Effective
laboratory management ensures the implementation of standard laboratory quality
management system to perform agreed tests with minimal ‘down time’ in service
provision.
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5. The hospital laboratory has a system in place for documenting/recording and
reporting diagnostic results.
6. The hospital laboratory has and implements a proper management system for its
equipment that includes the calibration, maintenance and inventory to ensure the
provision of accurate, reliable and timely test results.
7. The hospital has a laboratory supplies management system.
8. The hospital has established internal quality control (IQC) for all tests and
participates in external quality assurance (EQA).
9. The hospital laboratory has established incident handling and reporting system
which includes errors or near errors (also called near misses).
10. The hospital has established laboratory management information system.
11. The hospital laboratory should be designed and organized at least for bio safety
level 2 or above and work environment is clean and well maintained at all times.
12. The hospital laboratory has appropriate storage and stock management systems for
blood and blood products received from blood banks
The laboratory shall have its own organizational structure that enables the laboratory
to communicate internally and externally with vendors, other health institutions to
create collaboration and partnership and EQA program providers by working under
the organizational umbrella of the hospital. Each laboratory must have an
organizational chart (organogram) that describes the management and supervisory
arrangements in the laboratory.
The hospital laboratory should have functional central, emergency and inpatient
laboratories. Both emergency and inpatient laboratories should provide services 24hrs
a day and 365 days a year. The central laboratory should have a functional overview
of all other labs to ensure the provision of quality services.
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a) Provide effective leadership of the medical laboratory service, including
planning, budgeting and overall financial management, in accordance with
organizational assignment.
b) By representing the hospital, liaise and work effectively with applicable
regulatory authority and accrediting agencies, appropriate administrative
officials, the healthcare community, and the patient population served.
c) Ensure that there are appropriate number of staff with the required education,
training and competence to provide medical laboratory services that meet the
needs and requirements of the users
d) Ensure the implementation of laboratory quality policy
e) Implement a safe laboratory environment in compliance with good practice and
applicable requirements
f) Develop hospital laboratory specific annual plan and ensure that adequate budget
is allocated
g) Ensure the provision of clinical advice with respect to the choice of
examinations, use of the service and interpretation of examination results
h) Provide professional development programs for laboratory staff and opportunities
to participate in scientific and other activities of professional laboratory
organizations
i) Define, implement and monitor standards of performance and quality
improvement of the medical laboratory service or services
j) Maintain strong communication/relationship among clinical and non-clinical
staff.
Standard Operating Procedures (SOPs) are created for regularly recurring work
processes that are conducted in the laboratory. This is done to ensure that activities
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are performed consistently and in a manner that achieves results of the highest quality,
and that the laboratory is run as efficiently as possible. All laboratory staff should
participate in the creation of SOPs. Each SOP should be approved by the Laboratory
Manager and Quality officer prior to implementation.
Upon receipt each laboratory should check the availability of the requested test in that
laboratory, including the turnaround time for results. If the service is not available,
the laboratory should notify
the customer and refer the sample to a different laboratory capable of performing the
request test. If the service is available, the sample must be checked according to the
acceptance and rejection criteria. A specimen can be rejected if:
it is received without a request form,
it is unlabelled, incompletely labelled or if the name on the label does not match
the name on the request form,
it is leaking,
it is in a broken container,
it is the wrong type of specimen for the requested test,
it was not transported according to requirements,
the time since collection is too long (depending on the type of test),
it is haemolytic (depending on the type of test),
there is insufficient volume of a specimen, or
there is bacterial overgrowth present.
A log book should be used to record the receipt of samples. This should include:
the name of the patient and identification number,
the source of the specimen,
the name of the submitter, and
the date of collection.
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a) The full test name, including the full name of the methodology used (commonly
used abbreviations should be listed at the beginning of the SOP),
b) The types of reactions, specimens, or organisms involved in the test,
c) Guidelines for the storage of specimens to ensure their integrity until testing is
complete,
d) The clinical reasoning for performing the test,
e) Any calculations and formulas needed to obtain a result,
f) The methodology used, including the limitations of procedures and reagents,
g) Standards by which a sample is accepted or rejected,
h) Safety issues related to that particular test,
i) The test procedure, including:
A complete set of instructions
Detailed descriptions such as measuring units, etc.
How to prepare slides, solution, calibrators, control, reagents, stains, etc. for use
j) The criteria for what to do if a test system becomes inoperable,
k) A corrective action guideline (when necessary),
l) Interpretation of results, including:
Reportable ranges
Critical or panic values
m) Methods of disposal for specimens and other products used,
n) References to relevant and pertinent materials,
o) Criteria for the referral of specimens to and from other health facilities, and
p) Transport requirements (e.g. cold chain) if the specimen is to be transferred to
another laboratory.
Each SOP should be reviewed on a regular basis (for example annually). The revision
level and due date for the next review should be stated on each SOP.
3. Job Aids
Job aids, or work instructions, are shortened versions of SOPs that can be posted at
the bench for easy reference on performing a procedure. They are meant to
supplement, not replace, the SOPs.
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3.3 Customer Service
Each laboratory should develop a system to collect and measure data on how much
the laboratory services and products satisfy the costumer (the patients and clinical
staff) and should take steps to address any problems identified. This could be done
through suggestion boxes, suggestion books and/or satisfaction surveys as part of or
additional to the overall hospital’s clinical governance and quality improvement
programme.
The laboratory should have a mechanism to record complaints from patients, staff and
clients. All complaints and problems reported to the laboratory as well as corrective
action taken should be documented and the handling procedure should be part of the
overall hospital’s complaint handling and management system.
The hospital should ensure the laboratory management produces a list of all tests that
are provided by the laboratory based on the national regulatory guidelines, including
the fee per test and turnaround time. The list should be updated on regularly and
should be posted in all sample collection areas and readily available to all clinical
staff and patients. The hospital laboratory have at least minimum test menu based on
FMHACA standards.
9-6
o List of tests that can be ordered
o Detailed information on sample collection requirements
o Sample transport requirements, if any
o Expected turnaround times
o Description of how urgent requests are handled—this should include a list of what
kinds of tests are done on an urgent basis, what are the expected turnaround times,
and how to order these tests
Test ordering procedures
Sample collection and sample disposal procedures
9-7
3.4 Documentation and reporting
Written policies, processes, and testing procedures should be stored in the laboratory
quality manual for each laboratory. These documents are a reflection of the
laboratory’s organization and its quality management. A well-managed laboratory
will always have a strong set of documents to guide its work.
Information management is a system that incorporates all the processes needed for
effectively managing data—both incoming and outgoing patient information. The
information management system may be entirely paper-based, computer-based, or a
combination of both. When planning and developing an information management
system, whether it is a manual, paper-based system, or an electronic system, there are
some important elements to consider:
Unique identifiers for patients and samples
Standardized test request forms (requisitions)
Logs and worksheets
Checking processes to assure accuracy of data recording and transmission
Protection against loss of data
Protection of patient confidentiality and privacy
Effective reporting systems
Effective and timely communication.
It is important to establish a means to protect against loss of data. For paper based
systems, this will involve using safe materials for recording and storing the
records properly. For computerized systems, scheduled or regular backup
processes are very important.
It is of utmost importance to safeguard a patient’s privacy and, in this regard,
security measures must be taken to protect the confidentiality of laboratory data.
Laboratory directors/manager is responsible for putting policies and procedures in
place to ensure confidentiality of patient information are protected.
Attention should be given to the reporting mechanism to ensure that it is timely,
accurate, legible and easily understood.
There shall be pre-defined schedule and guideline for proper data back-up.
9-8
Laboratory registration books
Daily test record form
Specimen referral form
Report form (monthly, quarterly)
Stock inventory form
Fridge/Freezer charts
Equipment Maintenance Logs
QA Charts and External QA Records
Error logs
Accident Logs
9-9
All patient information should follow confidentiality policies and procedures of the
hospital.
a. Clinical service area
1. The Patient comes to the clinical service area (emergency, outpatient and
inpatient case teams etc) and a request form is written.
2. A sample is drawn.
b. Laboratory
1. Sample Reception Area
- The request form and sample are both received
- The quality of the sample is checked
- The data on the request form is checked
- The sample is entered into the logbook and assigned a lab code
2. Testing Lab
- The sample is prepared and tested
- The results are checked and validated
- The results form is completed
- The results form is checked
- The results are archived
c. Clinical service area
d. Result Data Management
- The results are received and placed in the patient’s file
- The patient file is given to the responsible healthcare provider (e.g.
nurse, physician)
- The responsible healthcare worker tells the results to the patient
Hospitals should aim to install electronic data management systems through which
laboratory tests can be ordered and results reported to the relevant clinical team. Such
systems should be protected by passwords or other security mechanisms to control
levels of access. When electronic systems are installed there should always be a
paper back-up in place.
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informed of the occurrence of any notifiable diseases or potential disease outbreaks to
determine if further action is required by the hospital.
III. Archiving
The quality officer is responsible for the proper archiving of documents and records.
The laboratory respects the national regulations or legislations concerning the
retention time of all records. A copy of an obsolete document should be kept to
provide a means for review if the need arises.
Hospital laboratories should establish a mini blood bank and provide a blood
transfusion service. Blood received from the regional blood bank should be stored in
regularly monitored refrigerator/s. Quality assurance measures should be in place to
ensure the correct storage temperature is maintained at all times. Refrigerators or
freezers for blood storage should have a back- up electricity supply in case of mains
failure.
The hospital shall have transfusion committee and signed MOU with respective blood
bank service and should have enough space, equipment, to perform compatibility test
and to store blood and blood products received from the blood bank service.
The minimum area of the hospitals’ blood and blood product store should be 12
M2.The size will increase depending on the amount of products the health facility
receives from the blood bank service and should have the following:-
4. Blood warmer
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Whenever possible, temperatures of refrigerators and freezers in which blood and/or
blood components are stored should be fitted with a device that continually measures
and records the temperature inside the equipment. A maximum and minimum
temperature recording thermometer should be placed in the refrigerator or freezer and
the following temperatures should be recorded a minimum of four times a day (every
6 hours).
The hospital shall have awareness creation and community mobilization strategy in
collaboration with respective blood bank service
4. The hospital may support local level blood donor’s group/clubs whenever they
conduct motivational and awareness creation programmers.
The standard transfusion request form prepared by National Blood Bank Services
should be filled appropriately.Blood units are packed in a sealed, temperature-
validated transport container according to SOP for the type of component being
issued.Only one patient’s components are packed per transport container for facilities
9-12
that do not have appropriate blood storage equipment.For other facilities, components
requiring different storage temperatures should be packed in different transport
containers.
The hospital laboratory has a system for proper laboratory equipment management to
create and ensure the provision of accurate, reliable and timely test results of its
minimum standard. The laboratory should be connected to a back-up power supply
(generator) in cases of interruption to the mains electrical supply. Additionally, the
laboratory should have a telephone(s), fax machine, sufficient computers and printers
for administrative purposes and internet connection if possible.
Every laboratory should have a life book and inventory mechanism of all equipment
and instruments that includes:
Name of manufacturer
Model and serial number
Date of purchase or acquisition
Date of installation
Purchase cost
Current location
Electric power requirement
Record of contracted maintenance, and
Record of equipment down time
Manufacturers’ manuals should be attached to, or stored beside, each instrument.
Laboratory equipment should only be used by appropriately trained staff (s). An
equipment usage logbook or form can be completed by laboratory staff to indicate the
duration of use and name of the person who used the equipment.
9-13
Curative maintenance of laboratory equipment must be performed by trained senior
professionals or engineers (bio-medical engineers) as soon as possible to minimize
equipment down time and decrease client waiting time in the facility. The equipment
supplier office or bio-medical engineer contact information must be posted on specific
equipment. The record of curative maintenance should be signed and documented in
equipment life book.
3.6.2.1 Preventive Maintenance
The Operator laboratory professional (user) should perform daily, weekly, monthly
and/or quarterly preventive maintenance for each type of equipment in the laboratory.
All preventive maintenance activities should be recorded in a maintenance log for
each piece of equipment.
Service engineers from the appropriate company or EPHI should perform semi-
annual or annual preventive maintenance on the larger more complex instruments. A
log must be completed with copies held on site and by the service engineer.
9-14
catalogued and stored accordingly to aid retrieval,
reagents and supplies should be dispensed first expires first out.
properly stored according to manufacturer’s instructions,
discarded when the shelf life is expired,
labelled to indicate identification and, when applicable, significant titre strength or
concentration,
marked with date of preparation or receipt,
marked with the date opened, the date that the reagent was first opened must be
written on the container with a standard plastic laminated form. If reagents are
dispensed from intact stock containers by dilution or any other treatment, the date
of preparation as well as the duration should be written,
the components of reagent kits of different lot numbers should not be interchanged
unless otherwise specified by the preparer,.
reagent validation and monitoring should be done prior to use by authorized
bodies.
The laboratory should establish a control system to catalogue the supply of reagents
and supplies. This can be done through using stock/bin card or an electronic
cataloguing system. Reagent name, supply on hand and expiration date of reagents
and supplies should be recorded in the stock/bin card or electronic system. This will
allow laboratory staff to compare the current stock in the laboratory and in the
warehouse to avoid unexpected stock out.
Transaction of commodities should take place by using formats like internal facility
report and requisition form (IFRR) (refer to Pharmacy Services chapter for more
details) in order to make the transaction traceable and auditable.
The reagents and supplies should be stored in appropriate storage areas with better
security, adequate ventilation and monitored appropriate temperature. The storage
temperature should be monitored with standardized and calibrated thermometers. The
reagents and chemicals should not be exposed to direct sunlight. Laboratory reagents
and supplies should be stored in a mini-store that is managed by the Laboratory
Manager.
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3.8 Process control
Process control is comprised of several factors that are important in ensuring the
quality of the laboratory testing processes. These factors include quality control for
testing, participating in external quality assessment program, appropriate management
of the sample, including collection and handling, and method verification and
validation.
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3.8.2 Analytical phase
3.8.2.1 Internal Quality Control (IQC) programme
The goal of IQC is to detect, evaluate, and correct errors due to test system failure,
environmental conditions or operator performance, before patient results are reported.
All laboratory tests should have quality control mechanism. Quality control processes
vary, depending on whether the laboratory examinations use methods that produce
quantitative, qualitative or semi quantitative results. These examinations differ in the
following ways:
Quantitative examinations measure the quantity of an analyte present in the sample,
and measurements need to be accurate and precise. The measurement produces a
numeric value as an end-point, expressed in a particular unit of measurement. The
laboratory should follow the following steps during implementing a quantitative QC:
Establish policies and procedures
Assign responsibility for monitoring and reviewing
Train all staff in how to properly follow policies and procedures
Select good QC material
Establish control ranges for the selected material
Develop graphs to plot control values—these are called Levey–Jennings charts
Establish a system for monitoring control values
Take immediate corrective action if needed
Maintain records of QC results and any corrective actions taken.
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The laboratory should participate in EQA challenges, and this should include EQA for
all testing procedures performed in the laboratory. Currently EPHI coordinates EQA
activities at national levels and provide panels different laboratory tests in Ethiopia.
Laboratory EQA programs are implemented in the form of:
Proficiency testing—external provider sends unknown samples for testing to a set
of laboratories, and the results of all laboratories are analyzed, compared and
reported to the laboratories.
Rechecking or retesting—slides that have been read are rechecked by a reference
laboratory; samples that have been analyzed are retested, allowing for inter-
laboratory comparison.
On-site evaluation—usually done when it is difficult to conduct traditional
proficiency testing or to use the rechecking/retesting method.
The laboratory should ensure that all EQA samples are treated in the same manner as
patient samples tested and this will be supported with an SOP. Procedures should be
developed to address:
Handling of samples—these will need to be logged, processed properly and stored
as needed for future use.
Analyses of samples—consider whether EQA samples can be tested so that staff
does not recognize them as different from patient samples (blinded testing).
Appropriate record keeping—Records of all EQA testing reporting should be
maintained over a period of time, so that performance improvement can be
measured.
Investigation of any deficiencies—for any challenges where performance is not
acceptable.
Taking corrective action when performance is not acceptable—the purpose of
EQA is to allow for detection of problems in the laboratory, and to therefore
provide an opportunity for improvement.
Communication of outcomes to all laboratory staff and to management.
Hospital laboratory must comply with all national EQA requirements. Another
method of inter-laboratory comparison is the exchange of samples among a set of
laboratories.
The laboratory result should be reported on a standard report format that contains
laboratory, patient, sample and other information (name of requester, person
authorising result release, reference range, etc...) related to the test/s performed. The
laboratory request should be cross-checked with results to ensure all tests have been
completed. The result should be reviewed and signed out by name of authorised
personnel before released to requester or patient. The laboratory should also have a
9-18
policy and procedure for how it handles samples unsuitable for testing and how all
samples are managed after reporting the result.
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3.10 Occurrence/Incidence management
An occurrence is any event that has a negative impact on an organization, including
its personnel, the product of the organization, equipment, or the environment in which
it operates. All such events must be addressed in an occurrence management program.
The laboratory should take actions that may be undertaken to rectify occurrences,
including the following.
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chemical and radiation safety, how to use personal protective equipment (PPE),
how to dispose of hazardous waste, and what to do in case of emergencies; setting
up a process to conduct risk assessments—this process should include initial risk
assessments, as well as ongoing laboratory safety audits to look for potential
safety problems.
The safety officer should be assigned responsibility for ensuring that there is an
adequate supply of appropriate equipment for safety and biosafety, such as:
Personal Protective Equipment (PPE)
Fire extinguishers and fire blankets
Appropriate storage and cabinets for flammable and toxic chemicals
Eye washers and emergency shower
Waste disposal supplies and equipment
First aid equipment.
The laboratory shall put in place measures to safeguard against malicious use of
chemicals, infectious agents and other harmful materials. Policies should be put in
place that outline the safety practices to be followed in the laboratory. Standard
laboratory safety practices include:
Limiting or restricting access to the laboratory;
Washing hands after handling infectious or hazardous materials and animals, after
removing gloves, and before leaving the laboratory;
Prohibiting eating, drinking, smoking, handling contact lenses, and applying
cosmetics in work areas;
Prohibiting mouth pipetting;
Using techniques that minimize aerosol or splash production when performing
procedures—biosafety cabinets should be used whenever there is a potential for
aerosol or splash creation, or when high concentrations or large volumes of
infectious agents are used;
Preventing inhalation exposure by using chemical fume hoods or other
containment devices for vapours, gases, aerosols, fumes, dusts or powders;
Properly storing chemicals according to recognized compatibilities—chemicals
posing special hazards or risks should be limited to the minimum quantities
required to meet short-term needs and stored under appropriately safe conditions
(i.e. flammables in flammable storage cabinets)—chemicals should not be stored
on the floor or in chemical fume hoods;
Securing compressed gas cylinders at all times;
Decontaminating work surfaces daily;
Decontaminating all cultures, stocks and other regulated wastes before disposal
via autoclave, chemical disinfection, incinerator or other approved method;
Implementing and maintaining an insect and rodent control programme;
Using PPE such as gloves, masks, goggles, face shields and laboratory coats when
working in the laboratory;
9-21
Prohibiting sandals and open-toed shoes to be worn while working in the
laboratory;
Disposing of chemical, biological and other wastes according to laboratory
policies.
Hospital Laboratory staff who have direct contact with harmful infectious agents
should be vaccinated. For example, they should be vaccinated for Hepatitis B.
Construction and renovation of laboratories shall be in conformity with national
standards and guidelines (Refer FMHACA National Minimum Standard for
different Health Facilities).
The following Table can be used as a tool to record whether the main
recommendations outlined above have been implemented by the hospital. The Table
does not measure attainment of each Operational Standard but rather provides a
checklist to record implementation activities.
2. Does the laboratory management have adequate and competent personnel for each position
because the most important laboratory resource is competent and motivated staff.Personnel
management includes:-
Job description
Orientation
Training
Competency assessment
Continuing education
Performance appraisal
3. Does the hospital laboratory have controlled, reviewed and approved documents and records to
ensure the provision of quality laboratory services. Documents and records includes:-
9-22
Preparation of Quality, Safety & Sample management manuals
Preparation Laboratory Hand book
Preparation of standard operating procedures for all Technical and Managerial
procedures
Guidelines ,Formats , Job aids and instructions
4. Does the hospital laboratory have a system to check the satisfaction of customers? Customer
service includes:-
Establishing information desk
Establish complaint monitoring system
Perform customer satisfaction survey
Put suggestion box and/or suggestion book in the laboratory
Avail advisory service to customers
List of minimum available tests in each tier system
5. Does the hospital laboratory have a system for proper laboratory equipment management to
create and ensure the provision of accurate, reliable and timely test results? Equipment
management includes:-
Calibration
Maintenance (Scheduled, preventive and curative maintenances)
Retiring and disposal
Equipment life book
6. Do the hospital laboratories have appropriate functional purchasing and inventory system to
ensure adequate supplies and reagents are available to support uninterrupted delivery of the
laboratory service.
7. Does the hospital laboratory implement a process control system that monitors the processes
from pre analytical to post analytical phases of testing and allows for detecting errors due to test
system failure, adverse environmental conditions or operator performance to develop laboratory
confidence that test results are accurate and reliable before patient results are reported. Process
control includes:
Must Establish a QC program for all tests.
Must Participate in External quality assessment program and the performance has to be
≥ 80 Percent.
The laboratory must establish a written policy for sample management and reflected in
the laboratory handbook.
The laboratory must establish a written policy for sample collection, storage, retention
and disposal.
8. Does the hospital laboratory have a system for internal audit planning, organizing and carry out
by the quality officer or qualified designated personnel without auditing their own activities.
The procedures for internal audits shall be defined, documented and include the types
of audit, frequencies, methodologies and required documentation.
When deficiencies or opportunities for improvement are noted, the laboratory shall
undertake appropriate corrective or preventive actions, which shall be documented and
carried out within an agreed time.
The hospital laboratory should subject to perform internal audit at least once a year.
9-23
9. Does the hospital laboratory have a procedure to handle occurrence/ incidence by which errors
or near errors (also called near misses) are identified and to correct the errors in either testing or
communication that result from an event, and to change the process so that the error is unlikely
to happen again.
10. Does the hospital Laboratory have an established information management systems in electronic
or paper based and strengthened to promote laboratory performance, quality patient care,
surveillance, evidence-based planning, policy formulation and research?
The laboratory information system shall be strengthened and mainstreamed into other
HMIS and disease control information systems
Use and dissemination of laboratory information shall be in accordance with national
standard and guidelines to ensure confidentiality and archiving.
There shall be pre-defined schedule and guideline for proper data backup
11. Has the hospital laboratory established a process improvement program to ensure continual
improvement in laboratory quality over time? Process improvement includes:
Identify potential sources of any system weakness or error
Develop plans to implement improvement and Implement the plan
Review the effectiveness of the action through the process of focused review and audit
Adjust the action plan and modify the system in accordance with the review and audit
result.
12. Does the hospital laboratory have enough working space and safety tools such that the workload
can be performed without compromising the quality of work and the safety of the laboratory
staff, other health care personnel, patients and the community?
The laboratory shall have procedures and required resources (first aid kit, spill kit, fire
extinguisher, and emergency shower, eye wash, PPE) for laboratory safety.
Prepare/customize, review, update and avail the laboratory safety manual for the
laboratory services.
Construction and renovation of laboratories shall be in conformity with national
standards and guidelines.
The laboratory shall put in place measures to safeguard against malicious use of
chemicals, infectious agents and other harmful materials.
Hospital Laboratory staff who have direct with harmful infectious agents should be
vaccinated.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this
chapter.
9-24
number of samples received
(inpatient, outpatient and emergency)
x 100
2. Test interruption: Quarterly
a) Proportion of a) Test interruption days due to <1%
test interruptions supply shortage/12 months
due to supply *100
shortage b) Test interruption days due to
b) Proportion of equipment failure/12 months
test interruption *100
due to
equipment
failure
3. Number of tests with Total number of laboratory tests with Monthly 100%
internal quality control routine quality control
performed/Total tests available
4. a) Proportion of a) Total number of tests Quarterly a) 100%
External quality enrolled with external b) 100%
assessment quality assessment
(EQA) program/total tests available
participation *100
b) Percentage of b) EQA feedbacks greater or
EQA equal to 80%.
performance
5. Proportion of equipment The number of days in a month that Quarterly 0%
downtime in the year the equipment is not functional due to
breakdown/ 365 days*100
6. a) Proportion of a) Presence of uninterrupted Quarterly 100%
uninterrupted power power supply /365 days*100
supply b) Presence of uninterrupted
b)Proportion of water supply /365 days*100
uninterrupted water
supply
9-25
Source Documents/References
1. World Health Association regional office for Africa. Stepwise Laboratory Quality
Improvement Process Towards Accreditation (SLIPTA) Checklist Version
2:2015: For Clinical and Public Health Laboratories.
2. CDC, WHO, ASCP, USAID, SCMS, Bill & Melinda Gates Foundation, Clinton
Foundation & The Global Fund. (2008, January). Maputo Consensus Report.
Consultation on Technical and Operational Recommendations for Clinical
Laboratory Testing Harmonization and Standardization. Maputo, Mozambique.
5. Ethiopian Health and Nutrition Research Institute. (2008). National Health and
Safety Guidelines for Public Health Laboratories in Ethiopia. Addis Ababa,
Ethiopia.
9-26
10. SNNP, RHB, RHL and JHU-Tsehai. (2007, April). Standard Operating
Procedure for Laboratory Sample Transfer Service at Health Centers. Addis
Ababa, Ethiopia.
9-27
Appendices
Appendix A The Laboratory Network: Responsibilities of
Laboratories at Different Tier Levels in Ethiopia
1. Level I-Primary: Health post and health centre laboratories that primarily serve
outpatients.
The tiered levels of a laboratory system and the testing performed at each level may vary
depending on the population served (e.g., infants, adults), physical infrastructure, electricity,
water, road conditions, and the availability of trained technical personnel in-country.
Level I Laboratories
Level I laboratories would consist of health post or health enter laboratories that would
primarily serve outpatients. Essential infrastructure, such as clean water, refrigeration and
electricity, may or may not be available. These laboratories would serve as peripheral
branches of Level II laboratories, which would be the centre or hub. Health posts may refer
specimens to health centre laboratories. Diploma level staff at Level I laboratories would be
very limited, with usually no more than one trained laboratory assistant or nurse providing
services. The laboratory would offer diagnostic and monitoring services for HIV/AIDS, TB
and malaria. If essential infrastructure were lacking, then the on-site test menu would be
restricted to manual tests. Sites with reliable power and water would perform certain
automated chemistry tests required for antiretroviral therapy (ART) monitoring. Same day
performance and delivery of results must be available while the patient is present for
immediate counselling, treatment and regimen modification.
When required testing exceeds the scope of services available from Level I facilities, the
“parent” Level II laboratories would provide arrange of consultant services, including receipt
of referral specimens and patients.
Level II Laboratories
Level II laboratories would consist of district hospitals or primary hospital laboratories that
perform tests beyond the capabilities of Level I facilities. Health posts may refer specimens
to Health Centre Laboratories under Level I. Serving inpatients; these laboratories would
have dedicated laboratory space, formally trained personnel, UPS systems, and a consistent
source of reagent grade water. The laboratory would be staffed by a minimum of three
formally trained technologists or technicians. One staff member who has managerial skills
would serve as the senior or supervisory technologist.
The Level II laboratories would have more extensive test menus for diagnoses and
treatment. Consolidating testing at the district level for certain tests provides necessary
volumes for automated equipment plat forms. The Level II laboratories would coordinate the
services of Level I laboratories in the district as well as serve as reagent and supply
reservoir/back-up repositories for these laboratories.
In addition, Level II laboratories would provide the following consultant services and
support for Level I laboratories:
Level III laboratories would consist of laboratories in tertiary referral facilities such as
regional or provincial hospitals. These laboratories would perform a complete menu of
testing for HIV/AIDS,TB and malaria as well as testing form any other diseases. Level III
laboratories would complete the more sophisticated tests that Level II laboratories were not
able to perform. These facilities must have dedicated laboratory space that would include a
separate microbiology space, a Bio safety Level3 designated area, and UPS systems. Reagent
grade water would also be required. Formally trained, diploma level technologists who are
able to meet workload demands would staff Level III laboratories. One technologist who has
managerial skills would serve as the laboratory supervisor. Level III laboratories would act as
laboratory resource groups for the facilities in their regions.
These shall be available in each hospital tier system according to FMHACA minimum
standards.
1.
2.
3.
4.
User comments
Signature Date
Appendix D Sample Corrective Maintenance Log
Corrective action
Time required
4. 5. 6.
User comments
Purpose:
The measurement of haemoglobin is useful for the detection of anaemia, its severity, and the
patient’s response set treatment as well as the quality of a donor’s blood before donation.
Method
Cyanmet haemoglobin method. This involves the use of Drabkins solution, which contains
Potassium ferricyanide and potassium cyanide.
Principle
Sample
Reagents
1) Drabkins solution
3) Potassium cyanide
Thissolutionmustbestoredinanopaquebrownglasscontainerorplainglasswithsilverfoil wrapped
around it. It is pale, yellow and clear and should be discarded if turbid.
Equipment
Spectrophotometer with540nmwavelength
Procedure
1) Measureout0.02mlofcapillaryorvenousbloodwellmixedwithEDTAanddispenseinto 4ml of
Drabkins solution.
2) Stopper the tube, mix well and let standfor4–5minsaway from sunlight.
4) Read off the haemoglobin value from the calibration graph already prepared.
Note. Daily control tests are necessary to ensure that the Drabkins solution and
spectrophometerarefunctioningadequately.Thiscanbedoneusingacontrolhaemolysate,
preserved whole blood control use of HiCN reference standard. Also the Drabkins solution
can be visibly examined for turbidity or measuredagainstawaterblankat540nm at which the
Drabkins should give a 300 reading.
Calculation
This is done by directly reading of the value from the already prepared graph.
Avoiding errors
b) The Drabkins solution used must be clear and without any signs of turbidity and at room
temperature before use.
d) Ensure that the cuvette surfaces are clean and dry without fingerprints.
Normal values
Men 14 – 16 g/dl
Women 12 – 14 g/dl
Children 11–13g/dl
Appendix F National SOP Template
Purpose
Abbreviations
Reagents
Materials
Reagents preparation:
Supplies
Limitations:
Special
Safety
Precautions
Control
preparation: Note:
Step Action
Calculation
Result
Interpretation
Expected
Values
Principle
Clinical Utility
Reference
Laboratory/Department:
Name of Institution:
2. SAFETYEQUIPMENT
a. Safety manual present/read by all
b. Material Safety Data Sheets(MSDS)available
c. Safety Shower
1. Unobstructed and labelled
2. Tested with in past one month
d. Eyewash station present
1. Unobstructed and labelled
2. Water changed weekly
e. First-Aid Kit available and labelled
1. Fully stocked
3. PROTECTIVECLOTHING
a. PPE present (goggles, gloves, coats, face shield etc.)
b. Visitor coats and safety glasses available
c. Proper heat resistant/cryogenic gloves available
d. Appropriate personal clothing and footwear
4. HAZARDS
a. Walk ways, door sand fires routes unobstructed
b. Adequate lighting in all areas
c. Work benches and floors cleaned daily
d. Storage areas accessible, clean and dry
5. SPILLPROCEDURE
a. Spill kits available (biological/chemical/radioactive)
b. Clearly posted with instruction for use
c. Chemical spills documentation present
6. ELECTRICAL
a. Power distribution board clearly labelled
b. Extension cords only for temporary use
c. Multi plugs used only on computers
d. Surge protection(UPS)present
7. GASCYLINDERS
a. Properly and individually chained to the wall
b. Labelled empty or full
c. Labelled cylinder contents
d. Safety capson cylinders not presently in use
e. “No smoking” & “Danger of explosion” signs present
8. REFRIGERATORS/FREEZERS
a. “No Food or Drink” signs posted on doors
9. CHEMICALSTORAGE
a. Chemicals stored by reactive class(flammables, acids etc.)
b. Incompatible chemicals physically separated
c. Chemicals properly labelled
d. Chemicals dated on receipt and when opened
e. Inspected monthly for leakage, cracked stoppers, etc.
f. Storage are as labeled with hazard stickers
g. Acids/corrosives/ solvents stored incompatible trays
h. No chemicals stored on bench tops/ in fume hoods/ under
i. Flammable
sinks liquid storage cabinet present and labeled
j. List of chemicals available present with MSDS
10. FIREEQUIPMENT
a. Fire extinguishers present, clearly labeled in working order
b. Fire blankets present and clearly labeled
c. Fire hose present, clearly labeled, and in working order
d. Fire alarm system present
e. All equipment serviced within the last year
11. BIOHAZARDWASTE
a. Appropriate containers available and clearly marked
b. Containers sealed and stored correctly before disposal
c. Regular disposal system in place & records kept
12. BIOHAZARDCABINETS/EXTRACTIONHOODS
a. In good working condition
b. Inspected and serviced within last year
c. Smoke testd one regularly (minimum once a week)
d. Cleaned daily
13. SAFETYPROCEDURES&DOCUMENTATION
a. In-house training up-to-date
b. Risk assessment procedures up-to-date
c. Medical surveillance records up-to-date
d. Fire drill practiced
e. Safetymeetingsheldregularly&recordskept
f. Injuryon-dutyreportsuptodate
g. Standardoperatingproceduresuptodate
14. AUTOCLAVE
a. Ingoodworkingcondition
b. Inspectedandservicedwithinthelastyear
c. Pressuretestedwithinthelasttwoyears
d. Logbookfordailytemperatureandpressurerecording
andqualitycontrolindicatorspresent
15. ACCOMODATION
a. Buildingadequate
b. Receivingofficeadequate
c. Stafffacilitiesadequate
d. Laboratoryspaceadequate
e. Benchspaceadequate
f. Otherrooms(Phlebotomy,Office,nightduty,etc.)
16. LABORATORYEQUIPMENT
a. Cleanandingoodworkingorder
b. Properlyguarded
c. Properelectricalconnections
d. Staffadequatelytrainedinuse
17. VENTILATION&NOISE
a. Temperaturecontrolsystemsadequate
b. Dustandfumesminimized
c. Noiselevelacceptable
General observations:
Action to be taken:
Signed by:
Laboratory Manager:
Date:
Appendix G List of NotifiableDiseases
The FMOH declares the following conditions to be of concern to the public health and reportable
as required by law:
a. Acute Flaccid Paralysis (AFP)/Polio
b. Avian Human Influenza
c. Cholera
d. Dysentery
e. Measles
f. Malaria
g. Meningococcal meningitis
h. Neonatal Tetanus
i. Plague
j. Relapsing fever
k. Rift Valley Fever(RVF)
l. SARS
m. Smallpox
n. Typhoid Fever
o. Typhus
p. Viral Haemorrhagic Fever
q. Yellow Fever
r. Any unusual occurrence of infectious or communicable disease or any unusual or
increased occurrence of any illness that may indicate public health hazard ,includingany
singlecaseormultiplecasesofanewlyrecognized,emergentorre-emergentdiseaseor disease-
producing agent, including newly identified multi-drug resistant bacteria or a no
velinfluenzastrain such as apandemicinfluenzastrain.
s. Any outbreak, epidemic, or unusual or increased occurrence of any illness that
mayindicateanoutbreakorepidemic.Thisincludessuspectedorconfirmedoutbreaksof
foodborne disease, water borne disease, disease caused by antimicrobial resistant
organisms,anyinfectionthatmayindicateabioterrorismevent,orofanyinfectionthat may
indicated a public health hazard.
In addition to the reportable conditions, the FMOH requires the following emergency illnesses
or health conditions to be of concern to the public health and reportable:
i. ClustersofRespiratoryillness(includingupperorlowerrespiratorytractinfections, difficulty
breathing and Adult Respiratory Distress Syndrome);
ii. ClustersofGastrointestinalillness(includingvomiting,diarrhoea,abdominalpain,or any
other gastrointestinal distress);
iii. Influenza-like constitutional symptoms and signs;
iv. Clusters neurologic symptoms or signs indicating the possibility of meningitis,
encephalitis, or unexplained acute encephalopathy or delirium;
v. Cluster of Rash illness;
vi. Haemorrhagic illness;
vii. Botulism-like syndrome;
viii. Sepsis or unexplained shock;
ix. Febrile illness(illness with fever, chills or rigors);
x. Non traumatic coma or sudden death ;and
Reports should be submitted to the Woreda Health Office, Regional Health Bureau or Federal
Ministry of Health using a Standard Report Form.
Source: National Notifiable Diseases and Conditions Reporting Rule and General Control
Measures for the Control of Public Health Threats. FMOH, Ethiopian Public Health Institute.
April 2009.
10 Pharmacy Services
Table of ContentsPages
Tables
Table 1 Selected indicators to assess prescribing, patient care and facility practices
Figures
Abbreviations
Abbreviations
ADR Adverse drug reaction
AR Analytic reagent
DACA Drug Administration and Control Authority
DSM Drug supply management
DTC Drug and Therapeutics Committee
FCC Food chemical codex
FEFO First expiry, First out
FMHACA Food, Medicine and Healthcare Administration Control Authority
LILO Last in, Last out
PFSA Pharmaceuticals Fund and Supply Agency
PMP Patient medication profile card
STGs Standard treatment guidelines
Section 1 Introduction
Pharmacy service is the last and critical step for client’s services in hospitals. Since the ultimate
health outcome is determined by appropriate selection, dosage and adherence to medications,
pharmacy services should be designed to provide assurance that quality and safety is maintained
at all stages of service provision.
To implement good dispensing practices, hospitals should ensure convenient environment and
workflow at dispensing units both to patients and staffs.
Government is responsible to protect and treat its citizens from manmade and natural factors
causing morbidity and deaths. To do so, medicines are indispensably required. In Ethiopia,
diseases such as pneumonia, diarrhea, malaria, and hemorrhage of mothers during delivery had
been the major causes of morbidity and mortality. Essential medicines are those that satisfy the
priority health-care needs of the population whereas specialty medicines are those drugs used to
treat disease of specialty cases. Medicines used to treat cancer; ophthalmology diseases, heart
diseases, dermatology, and orthopedics are specialty drugs. Both types of medicines have to be
selected with due attention to disease prevalence, consumption pattern, laboratory and
diagnostic facilities and personnel expertise available to prescribe, dispense and manage
medicine, financial resources available to buy the medicine and comparative cost-effectiveness.
Health system relies on availability and proper use of such key vital and essential medicines.
Therefore, vital and essential medicines have to be available at all times in adequate amounts, in
the appropriate dosage forms, with assured quality, and at a price the individual and the
community can afford.
A functioning pharmacy service involves a complex and interdependent process of selection,
procurement, storage and distribution, and rational use of medicines, patient care and treatment.
10-1
Section 2 Operational Standards for Pharmacy Services
9. The hospital has efficient and effective pharmaceutical logistics management system that
reduces the frequency of stock-outs, wastage, over supply and drug expiry.
10-2
The head/director of pharmacy department performs the following activities (in collaboration
with other colleagues): develops, implements and monitors annual action plans which are
approved by the hospital management to fulfill the mission, vision, goals, and scope of services
of the hospital.
Follows developments and trends in health care and hospital pharmacy practice, and
communicates to everyone involved in the provision of pharmacy services
Makes sure national service standards and guidelines pertaining to pharmacy practices
are availed and implemented
Continuously perform workload analysis and alert the hospital management for possible
action
Participate in hospital committees and meetings representing the pharmacy department
including drug and therapeutics committee (DTC)
Makes sure that new staffs are properly oriented and supervised.
Designs and implements professional development programs for all staff as appropriate
to enhance their knowledge and skills.
Regularly evaluates the performance of pharmacy staffs and takes measures accordingly.
Communicates and collaborates with other departments and services throughout the
hospital
Produces and communicates performance reports to the hospital management and
relevant government bureaus and agencies
Organization of the pharmacy services should ensure patient’s safety, privacy and satisfaction.
To achieve this, the following issues should be addressed:
10-3
B) OPD Pharmacy: can be organized in multiple locations (e.g. ART pharmacy, Adult
OPD pharmacy, pediatric OPD pharmacy, chronic care pharmacies, MCH pharmacy etc.)
depending on the arrangement of the OPD clinics, geographical proximity and complexity of the
hospital so as to improve accessibility and convenience to patients. Patient waiting areas at the
OPD pharmacy units should be fitted with appropriate seat and should provide enough safety and
protection.
In situations where the above systems do not work, orders for medicines may be made via
telephone or orally. The ordering physician or nurse should submit the prescriptions not later
10-4
than end of shift and payments should be effected accordingly. Patients served can be paying,
free or credit. Emergency pharmacy services should function for 24 hours and 7 days a week.
G) Drug Information Services (DIS): The hospital pharmacy should have a drug
information service unit to effectively provide evidence based and up-to-date drug information
for health care providers and patients.
3.2.1 Personnel
In order to deliver efficient and quality pharmaceutical services, the hospital pharmacy should
be staffed by appropriate professional mix and number based on the volume of services and work
load. Hospital pharmacies should have at least the following positions and professional mix:
10-5
OPD pharmacist: include evaluators, billers, processors and counselors. They
dispense medicines to patients and manage assigned bins in dispensaries. In addition,
chronic care pharmacist provides pharmaceutical care for patients with chronic
diseases.
Inpatient pharmacist: provides, documents and reports clinical pharmacy service for
inpatients. In addition dispenses in ward pharmacies.
Drug Information Pharmacist: provides up-to-date and unbiased drug information for
the healthcare provider and patients
Compounding pharmacist: undertakes hospital based pharmaceutical preparations
Pharmaceutical supply management pharmacist: manages the selection,
quantification, procurement, storage, inventory and distribution of pharmaceuticals.
Emergency pharmacist: provides pharmaceutical services in the emergency
department.
Pharmacy Accountants: in charge of aggregating and documenting pharmacy transactions
and services.
Cashiers: receives cash from clients and deposits received money in banks and delivers
financial documents to accountants
Porters: responsible for loading, unloading, delivering and arranging pharmaceuticals under
the supervision of the respective unit coordinators of the pharmacy.
Cleaners: responsible to keep service delivery premises clean and tidy all the time.
Patient assistant: responsible to keep order at dispensing outlets so that patients could be
served in an orderly and secure manner
The hospital should have sufficient space for the storage, compounding, counseling and
dispensing of medicines and for the conduct of related administrative activities. Cashiers should
be located within the dispensing room in a cubicle to ensure patient convenience. The pharmacy
accountant offices should be stationed adjacent or near dispensaries. The store should be located
in an area that is accessible for trucks to facilitate loading and unloading activities. Separate
office with office assistant should also be arranged for the head of pharmacy department.
10-6
The hospital should ensure availability of equipment to deliver proper pharmacy services
including: shelves, computers, software, printers, UPS, tablet counters, lockable cabinets,
refrigerators, thermometers, dispensing counters, calculators, etc. All service areas should be
clearly labeled. Access should be controlled to ensure that only authorized personnel enter the
premises and that only designated personnel have access to keys.
All pharmacy service units should have a sink with running water and continuous electricity with
power backup (connected to hospital generator). Appropriately located toilet should be
available. Telephones and internet services should also be available within each service area.
Each hospital is expected to establish a functional Drug and Therapeutics Committee (DTC)
having multidisciplinary representative members to bring together all the relevant professionals
to work jointly to improve health-care delivery. The hospital DTC has the responsibility of
promoting the safe, rational and cost effective use of pharmaceuticals.
10-7
Other non-voting, non-executive participant can be invited to attend DTC meetings to discuss
specific issues that require their particular expertise. All DTC members, especially the chair and
secretary, should be given sufficient time for their DTC functions and this should be included in
their job descriptions.
Sub-committees of the DTC may be formed to address specific issues as the need arises (for
example a policy on the use of antimicrobials etc.).
10-8
3. The DTC promotes the adoption and utilization of standard treatment guidelines (STG).
Standard treatment guidelines (STGs) promote the rational use of medicines and provide a
benchmark for optimum treatment for the monitoring and audit of drug use. The DTC should
promote implementation of national STGs. Specialized hospitals may also develop their own
STGs based on availability of required expertise, facility, etc.
4. The DTC establishes mechanisms to identify and address drug use problems
The DTC should establish policy/procedures for identifying and managing drug use problems
including, as a minimum:
o Monitoring adverse drug reactions
o Prescription monitoring
o Drug utilization monitoring
o Rational use of antimicrobials
The DTC follows the implementation of these activities by setting up a taskforce composed of
relevant departments. Additionally, if resources are available the surveillance of antimicrobial
resistance may also be undertaken. When problems are identified, the DTC should devise
specific interventions to improve practices. Interventions may be any one or a combination of the
following strategies:
o Educational programs such as in-service training,
o Managerial interventions such as use of standard treatment guidelines and
formularies, establishing antimicrobial stewardship programs
o Regulatory actions such as controlling medicine promotions, etc.
5. The DTC establishes and oversee the Drug Information Service (DIS)
Each hospital should establish a drug information service that provides information and advice to
health professionals, patients and the public.
6. Establishing antimicrobial stewardship program
10-9
3.4 Hospital Specific Drug List / Medicines Formulary Manual
All hospitals shall develop hospital specific pharmaceuticals list comprised of medicines,
medical supplies, consumable medical equipment and laboratory reagents which are prioritized
as vital (V), essential (E) and non-essential (N). This list is developed based on the national
formulary. The hospital should use the list for procurement purposes and monitoring use. In
addition, specialized hospitals shall have formulary manual for specific medicines used for their
specialty services. These hospitals may include pharmaceuticals not included in the national list.
The selection of pharmaceuticals for the Hospital specific medicines list/ formulary manual
should be based on:
10-10
3.5 Drug Information Services
Due to the vast number of medicines and the information related to them, it would be very
difficult for the health professional to search for all credible sources of information and use it in
routine practice. Hence access to authoritative, unbiased and well-referenced drug information is
fundamental for the rational and effective use of drugs.
All hospitals should establish drug information center (DIC) and provide the service for health
professionals, patients and members of the public. The service generally responds to drug
information queries received from the health care team or patients. It also provides education and
training to health professionals and/or the public regarding appropriate and safe use of
medicines. Regular drug information publications such as drug alerts, newsletters, monographs,
therapy updates shall be prepared and distributed to keep the health care team up-to-date. It also
notifies availability of pharmaceuticals to the hospital staff weekly. The hospital shall also
provide poison information services. The premise of this service can be either within the DIC or
independently if resources allow.
The DIC should have a dedicated room that has sufficient space and appropriate furniture and
equipment including telephone, computer, printer, filing cabinets and internet access. The DIC
should have a current collection of national and international authoritative reference materials
such as books, journals, guidelines, formularies, and databases. The DIC should be staffed by
appropriately skilled drug information pharmacists that are trained in the provision of drug
information.
The operations of the drug information service should be guided by appropriately formulated
standard operating procedures (SOPs)/guidelines prepared in line with national documents. The
guidelines/SOPs should be established for receiving and answering drug information queries,
developing and distributing educational materials and information publications, documentation
activities, education and training activities. It needs also to guide monitoring and evaluation
activities, participation in other clinical pharmacy services, supporting DTC activities and
conducting research. The center is a resource for the DTC in formulary preparation and revision.
The DIC should be open during normal working hours. The services provided by the center
should be documented on standard formats prepared for the purpose.
Educating patients on the rational use of medicines through different mechanisms is a crucial
activity of the DIC. Patients need be given appropriate information about the medicines they use
to achieve optimum adherence that results in better treatment outcomes. Medicine use education
is needed so that people have the skills and knowledge to make informed decisions about how to
use and store medicines and to understand the role of medicines in health care, with their
potential benefits and risks. All relevant staffs of the pharmacy department should be involved in
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the provision of education for the patient as appropriate. Under the hospital health education
program, the unit will have weekly breakdown of topics assigned to responsible pharmacists.
The DIC should develop annual action plan on each activities and should be communicated to
the head/director of pharmacy department. All services provided should be documented and
performance report should be sent to the head of the pharmacy department regularly.
Clinical pharmacy services are patient-oriented services developed to promote the rational use of
medicines, and more specifically, to maximize therapeutic benefits, minimize risk, and reduce
cost. Clinical pharmacists assume responsibility for managing medication therapy in direct
patient care settings (inpatient, outpatient and emergency). They assess patients, identify drug
therapy needs and problems, propose care plan, recommend choices and hence contribute to
therapeutic decisions thereby improving treatment outcomes. The service should be well
integrated with all clinical departments.
Clinical pharmacy services are provided based on pharmaceutical care principles. The delivery
of pharmaceutical care involves the following logical processes:
Assess the patient’s medicine therapy needs and identify actual and potential drug therapy
problems (DTP)
Develop a care plan to resolve and/or prevent the DTPs
Implement the care plan
Evaluate and review the care plan
A) Assess the patient’s medicine therapy needs and identify actual and potential drug
therapy problems (DTP)
A drug therapy problem is any undesirable event experienced by a patient, which involves or is
suspected to involve, medicine therapy, and which interferes with the achievement of the desired
goals of therapy. Through assessment the pharmacist establishes the existence of any therapy
needs or problems with the drug therapy by interpreting information collected from patient,
caregivers, medical records and other healthcare professionals.
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interventions are determined to resolve DTPs, achieve goals, and prevent new problems by
considering therapeutic alternatives and selecting patient-specific pharmacotherapy, patient
education, and other nondrug interventions. Finally a schedule is established for follow-up
evaluation that is clinically appropriate and convenient for the patient. The responsible clinician
should be informed and agree on the plan before implementation. In developing the care plan
the pharmacist should ensure that the patient is well informed on the process being undertaken.
During the provision of clinical pharmacy services in the inpatient setup, the following activities
need to be performed:
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Past or current medications (Prescription drugs, over the counter drugs, herbal medicines
or supplements)
Any known drug allergy (KDA)
Adverse drug reactions
Overall patient adherence to therapy
Social habits
Immunization status, for a child and pregnancy status for women
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involves documenting discrepancies identified between the medication history and current
medication orders and how these discrepancies were resolved.
All patients should have their medication reconciled as soon as possible after admission or
presentation. If medication reconciliation cannot be completed for all patients, prioritize patients
most likely to obtain maximum benefit. The service should be documented using Medication
reconciliation form.
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pharmacy and updated by the dispensing pharmacist whenever drugs are dispensed to the patient.
The PMP can be in hard copy or computerized with hard copy back up and should contain the
following information:
a) Name of the health institution,
b) Patient medical record number
c) The full name, sex, age and weight of the patient,
d) The address of the patient and next of kin (if appropriate)
e) Diagnoses and any concomitant diseases
f) History of adverse drug reactions
g) Description of all medicines (prescription and non-prescription) used by the patient
h) Reason for any changes made in the regimen of the patient
i) Name or initial of prescriber and prescription number
j) Dispensing and / or prescription date
k) Appointment / Refill date, and
l) Signature of the dispenser
PMPs should be filed sequentially by medical record number or alphabetically by patient name
in chronic care pharmacies. When a patient presents to the pharmacy for a refill, the pharmacist
must assess the patient for signs of compliance, effectiveness and safety of therapy. The
pharmacist should identify areas for therapeutic modification and should refer to the prescriber
when appropriate.
Unit dose system is characterized by providing 24 hrs supplies, in a single dose package, in a
ready to administer form and pharmacy specific documentation will be retained. In this system,
the pharmacist reviews all medication orders written by the physician (patient chart) brought to
the ward pharmacy by the nurse. Then the pharmacy professional prepares the medication
needed for 24-hrs period and make ready to be taken to patient care areas by the nurses. Before
administering each dose, the nurse compares the medication label on the drug product with the
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appropriate medication administration record (MAR). The nurse then administers the dose to the
patient and records the fulfillment of the order on the MAR.
Depending on availability of expertise and resources, advanced clinical pharmacy services can
be provided particularly in specialized hospitals in collaboration with other departments. These
include therapeutic drug monitoring, total parenteral nutrition, oncology, anticoagulation,
dialysis, transplantation pharmacy services.
To ensure uninterrupted supply of safe, effective and quality pharmaceuticals, the hospital
pharmacy shall have effective and efficient supply chain management system. This needs well
organized and functioning Logistics Management Information Systems. In addition, assessing
stock status of the hospital regularly and selecting the right pharmaceuticals in the right
quantities and delivering to the right place at the right time for the right cost in the right
condition is very critical.
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consultation with the various departments in the hospital selects the required medicines for
procurement as per the approved list. Whenever there is a need for procuring pharmaceuticals
which are not included in the list of the hospital, it is necessary to demonstrate their significance
for safe and effective care of individual patients.
Quantification
The pharmaceutical supply management unit should collect relevant data from HMIS, HCMIS,
and other relevant sources of information which are essential for forecasting and supply
planning. Data to be collected from these sources include:
o Consumption data: quantity of each product dispensed or consumed over the past 12 month
period
o Services data: number of visits, number of services provided, lab tests conducted, treatment
episodes, or number of patients on treatment over the past 12-month period
o Morbidity data: incidence and prevalence of specific diseases/health conditions (may be
available by population group or through surveillance or research study group, and
extrapolated to estimate national-level incidence and prevalence of specific diseases/health
conditions)
o Demographic and population data : population numbers and growth, demographic trends
o Information on current program performance, plans, strategies, and priorities, including
specific program targets for each year of the quantification.
o The monthly forecasted consumption of each product for each year
o Stock on hand (preferably from physical inventory) data of each product to be quantified
(should include losses and adjustments)
o Expiration dates of products in stock, to assess whether they will be used before expiration
o Quantity on order from PFSA and/or other supplier which is not yet received
o Procurement lead time(s) and supplier lead time(s)
o maximum and minimum stock levels of the hospital for each program and each product
o Product information such as whether the selected products are within the Essential
pharmaceutical List of the hospital and specific product characteristics (formulations,
dosages, number of units per pack size, unit cost, and others)
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o Supplier and procurement information regarding their prices, funding source and
procurement
o Any information which has direct influence on demand for the hospital services and
pharmaceuticals should be collected and considered while building assumptions
Forecasting:
The above collected data may be multiple in types and obtained from different sources, thus, the
pharmaceutical supply management unit should organize by type (as consumption, services,
morbidity, or demographic data) and assess their quality to determine if they can be used for the
quantification. While assessing the data quality, the pharmacist should consider at least the
reporting rate of the store and dispensaries, period and frequency of stock outs, timeliness of the
data and other factors which affect quality. Then, the necessary adjustment should be made on
these unreliable, outdated, or incomplete data.
The quantification team also should build and obtain consensus on the forecasting assumptions
such as expected uptake in services, compliance with recommended treatment guidelines (i.e. on
product characteristics and how products should be prescribed and dispensed), impact of
changing program policies and strategies on supply and demand, service capacity, provider
behavior, client access to services, seasonality, geographic variations in disease incidence,
prevalence and other factors that might affect demand. Once the team has built consensus on the
forecasting assumption, the demand for each product is forecasted using the appropriate method.
Ideally, multiple types of data should be used to calculate one or more forecasts. Then these
results should be compared and reconciled to arrive at the best forecast consumption figures. To
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make rational reduction of the forecasted products, different prioritizing mechanisms such as
ABC and VEN analysis can be used.
Supply planning:
Based on the above forecast, the pharmaceutical supply management unit of the hospital prepares
monthly supply planning regarding the product, supplier (if the product is unavailable from
PFSA), budget, amount, procurement method and its lead time, distribution related costs, current
stock status, minimum and maximum stock level.
The pharmaceutical supply management unit estimates the total pharmaceuticals required for the
specified period based on previous forecast. It also estimates the overall cost by considering
updated information on the price of pharmaceuticals, transportation, loading/unloading, and
telephone cost and other expenses as needed. It prepares a supply plan that outlines quantities
and delivery schedules.
Procurement
The pharmaceutical supply management unit prepares specifications for the selected
pharmaceuticals to be procured. Whenever necessary, the respective departments such as
laboratory prepare specification in consultation with the unit. Then, it assess the appropriate
procurement options and calculate the budget requirements based on the results of
quantifications and considering all the necessary expenses.
As per the public procurement policy of the country and the proclamation of pharmaceutical fund
and supply agency, the pharmaceutical supply management unit procures the required
pharmaceuticals and also asses its performance. All hospitals should procure preferentially
through PFSA and the payment can be made on credit/cash based on the signed agreement
between PFSA/PFSA hubs and the hospital. During procurement, principles of good
pharmaceutical procurement practice and procedures should be followed in all transactions.
Whenever pharmaceuticals are not available at PFSA and an out of stock is secured from the
agency, procurement from private suppliers on request for quotation, restricted tendering, open
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bidding and direct procurement can be considered as per the conditions set by the public
procurement agency of Ethiopia. Additionally, for products that cannot be supplied by PFSA but
their timely purchase and delivery are critical for the hospital services, the hospital may consider
establishing preferred supplier arrangements as an option each year by signing flexible
framework agreement. This process of selecting preferred supplier(s) should be done in open bid
and competitive process.
Inventory control systems
To maintain appropriate stock levels to meet the needs of patients, the unit should assesses its
stock status every two months based on established maximum and minimum months of stock and
an emergency order point for the hospital. The hospital should report to PFSA and order every
two months to bring its stocks up to the maximum level. Whenever the stock on hand for any
product in the hospital falls below the emergency order point (i.e. 2 weeks of stock) before the
end of the reporting period, it place an emergency order. This informs the responsible pharmacist
what and how much of pharmaceuticals to order.
The received pharmaceuticals should be stored at central pharmaceutical store until they are
issued to dispensing/service delivery units in the facility.The store manager should properly store
pharmaceuticals following the guideline for good storage practice for pharmaceuticals, undertake
visual inspection, identifies and resolves common product quality problems found during a
visual inspection.
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Up on issuing, the dispensing/service delivery unit should fill Internal Facility Report and
Resupply Form (IFRR) and the store manager should issue using model 22/health. The
distribution of pharmaceuticals should always be based on first expire first out the principle.
After issuing, the store manager updates Bin Card and the Stock Card Clerk updates stock card
and files all the above documents. The store manager also determines the available warehouse
space before ordering pharmaceuticals for the next procurement period. There should be a
system approved by DTC for returning of expired, damaged, leftover and empty packs from the
dispensing unit and other areas to the Central store.
The pharmaceutical store manager should establish a resupply schedule for each of the
dispensing units, preferably not less than two week to not more than four weeks unless in
emergency situations. Each dispensing unit should have a designated date to receive its resupply.
On that day, the dispensing unit bin owners should complete their part of the Internal Facility
Report Requisition form (IFRR) and compile to send to store. The request should be approved
by the head of pharmacy department. The store resupplies to each dispensaries as per the
approved request.
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The pharmacy workflow begins when the pharmacist receives and evaluates (validation,
interpretation and checking appropriateness) the prescription. Then the pharmacist should
calculate the price of the medicines and inform the same to the patient. He/she then writes the
medicines with uniquely identifying codes and retail prices on a sales ticket. Then the sales ticket
is given to the cashier. Once payment is effected, the cashier transfers the prescription to the
processor/counselor pharmacy professional. He/she selects, counts, assembles and delivers
medicines with the prescription to the counselor pharmacist. Then the counselor pharmacist,
packs, labels, checks whether the payment is effected, and gives the medicine with verbal and
written counseling to the patient.
Good dispensing practice refers to the delivery of correct medicines to the right patient, in the
required dosage and quantities in a package that maintains acceptable potency and quality for the
specific duration with clear labelling instruction and drug use counseling. The dispensing process
includes evaluation of prescriptions, billing and payment, processing, packaging, labeling, and
counseling of patients on appropriate use of medicines. For details, see the six dispensing steps
below.
The pharmacist receives prescriptions in a professional manner and validates for completeness,
legality and legibility. All hospitals should use FMHACA’s standard prescription paper. He/she
should also correctly interpret type of treatment and the prescriber's intentions, abbreviations and
brands. Then, the pharmacist confirms the appropriateness of the drug choice, dosage form,
strength, dose, frequency, and duration of treatment with the diagnosis. The pharmacist is also
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required to identify any medicine interactions, contraindications, ADR and treatment
duplications giving special attention to pregnant mothers and children.
Orders received by word of mouth or through telephone for emergency cases should later be
endorsed by the prescriber and be documented in writing. During receipt of a prescription the
pharmacist should identifying the patient, the prescriber and the entity responsible for payment
(as applicable). The pharmacist informs the patient about the benefits and implications of any
substitution (if any) including branded medicine and therapeutic alternatives. The pharmacist
should also help patients to solve problems with prescriptions that cannot be dispensed due to
cost, religion, culture and lifestyle. Any problems identified should be discussed and solution
should be solicited in consultation with the prescriber, pharmacists and patient.
The pharmacist should perform the necessary calculations related to quantity and cost of
medicines to be dispensed. Medicines dispensed should be recorded and documented as proof of
transaction between the patient and the pharmacy professional. Prescriptions can therefore be
traced back if any need arises. Billing and recording of transactions (products and services)
should be conducted using serially numbered sales tickets and registers approved by ministry of
finance and economic development. For drugs that are not available in the pharmacy, those
items should be copied on a blank prescription and signed by the dispenser with a word ‘copied’
on the prescriber’s signature space. On the original prescription, which is retained by the
pharmacy, ‘√’ mark should be placed adjacent to those items which have been dispensed and ‘X’
for items that are not dispensed.
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The packaging materials for dispensing must maintain quality and potency of medicines. It
should protect from moisture, light, and contamination. All medicines to be dispensed should be
labeled and the labels should be clear, legible and indelible. Printed labels are advisable for
patient safety. The following information must be indicated on the label:
Patient name
The generic name of the product or (active ingredients, for compounding) with strength
and dosage form
Dose, route, frequency of administration, duration of treatment and total quantity
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Action to be taken if a dose is missed
How to prevent, identify, and manage common and severe adverse effects or harmless
effects of the medication such as urine discoloration
Counsel on clinically significant interactions (drug-drug, drug-food, drug-disease)
Storage instructions including advice regarding keeping medicines out of reach of
children,
Any other information as appropriate
Each prescription (signed by evaluators and counselors), sales tickets and registers should be
filled. All registers and prescriptions, patient and medication related records and information
should be documented and kept in a secure place that is easily accessible only to the authorized
personnel. Filing will include:
1. At the close of each day all dispensed prescriptions should be organized into normal or
special (e.g. Narcotic drugs) prescriptions and filed.
2. Prescriptions should be filed sequentially by day in a single container/carton for each month.
The container should be labeled with the month and year.
3. Containers should be arranged on a monthly basis.
4. Normal prescriptions should be filed securely for two years and special prescriptions for 5
years.
5. Free and credit registers should be filed for two years:
The flow of pharmaceuticals from distributers to end users in the hospital shall include:
i. Receiving:
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All pharmaceuticals (medicines, lab reagents, medical supplies, and equipment) should be
received and managed by the hospital Pharmaceuticals Store. Receiving is an important step for
proper inventory management. At this step pharmaceuticals must be assessed for quality and
quantity and added into the inventory of the store. Hence pharmaceuticals need to be physically
inspected before receiving. In physical inspection, the store manager and supply management
officer make sure that the products received are as per the list, quantity ordered and expected
quality. Once pharmaceuticals are received, inventory records are immediately updated.
Pharmaceuticals should be requested using standard format (RRF) from PFSA every two month.
ii. Issuing:
Each dispensing unit should have an agreed list of pharmaceuticals including the maximum (one
month) and minimum (two weeks) quantity to be stocked in the dispensing unit. The stock list of
each dispensing unit should be approved by pharmacy head. Each dispensing unit should
maintain Bin Cards for all pharmaceuticals in the unit with shared responsibility by bin owners.
The retail price of each pharmaceutical should come from the store in issue vouchers (model
22/health). Each dispensing unit should sell pharmaceuticals at the stated price. All
pharmaceuticals should be dispensed/sold using a standard sales ticket designed for the purpose
and approved by Federal Ministry of Finance and economic development.
The pharmacy professional is responsible to record each medicine with full descriptions,
uniquely identifying codes, retail prices in the intended sales tickets or free registers. The
pharmacist also has to record all service provided, DTP identified by prescription evaluators, and
counseling made for clients. The pharmacy accountant summarizes all transactions (financial
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value, dispensed medicines and services) on daily basis and prepares report on monthly basis as
per the APTS guideline. Auditors in collaboration with pharmacy professionals and DTC
members should use the document for auditing of the above transactions and improving the
service.
A committee established by the DTC should develop compounding SOP and secure approval by
the DTC. The SOP includes:
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equipment needed for preparation, mixing instructions including order of mixing, mixing
temperature, duration of mixing
beyond-use date
storage requirements
labeling instructions
Quality control procedures (e.g. checking the adequacy of mixing, odour, colour,
consistency, clarity or pH of preparation as appropriate).
A Compounding Record should be kept of all compounding activities. The record should list:
Pharmaceutical wastes are all wastes that are generated from the hospital during diagnosis,
treatment, immunization, compounding and manufacturing of pharmaceuticals. To protect
patients, health workers, supportive staff, community, and environment handling, transportation
and disposal of pharmaceutical wastes should be guided by EFMHACA pharmaceutical wastes
disposal guideline. Each hospital should establish a pharmaceutical disposal committee
comprised of representatives from pharmacy, finance/audit, and sanitation services to ensure the
proper disposal of pharmaceutical wastes in accordance with the country laws. The DTC should
prepare an SOP which contains the schedule, methods, materials and equipment required for
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disposal that will be used by the committee. The SOP should also clearly identify the responsible
person for the proper management of pharmaceutical waste.
Hospital pharmacy and cleaning staff should be trained/ well informed about the potential risks
of hazardous pharmaceutical wastes and their management.
The following key activities are performed in pharmaceutical waste management:
Segregate, count, record and place separately all expired, damaged/unfit for use
pharmaceuticals from the usable pharmaceuticals.
Submit the segregated pharmaceuticals data to the management of the hospital to secure
approval for the disposal. It should be accompanied with lists of products to be disposed
clearly stating trade name and/or generic name, strength (where applicable), dosage form,
pack type and size, quantity, batch number, expiry date, manufacturer, supplier, country
of origin, and product price.
Sort the expired or unfit for use pharmaceuticals based on the pharmaceutical dosage
form and chose the appropriate disposal method. The hospital shall submit applications
for disposal of unfit for use medicines to central disposal sites, respective suppliers, or
licensed disposal firms and shall report/copy to the appropriate organ. In addition, it also
request for approval of disposal of medicines waste, except recyclable materials, cartons,
leaflets and labels, by submitting applications to the appropriate organ.
Select the appropriate disposal method and conduct the disposal process in the presence
of an inspector of the appropriate organ. Unfit for use medicines of the hospital, except
recyclable materials, cartons, & leaflets, shall be returned back to respective suppliers for
disposal. The appropriate organ shall be sent a copy of the referral/receipt form by the
health institutions (Annex X).
The hospital should retain signed and stamped certificate of disposal from the authorized
body entitled to dispose the drugs. Depending on the risk of medicines waste and
complexity of the disposal method, the hospital may use disposal referral system. If that
is the case, disposal service applications to licensed disposal firms shall be
reported/copied to the appropriate organ by the health institutions (Annex V).
Adjust the inventory management system for each disposed pharmaceuticals.
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Disposal of pharmaceuticals should be supported by proper documentation including the price of
products for audit and other legal requirements.
Medication use play vital role in the health care delivery since it is the core intervention in
treating patients. Medication use involves a multistep process including prescribing, transcribing
and documenting, dispensing, administering, and monitoring. Through all these process, patients
should receive medications appropriate to their clinical needs, in doses that meet their own
individual requirements, for an adequate period of time, and at the lowest cost to them and their
community".
However, safety about medication is a growing concern in today’s medical practice because
patients are getting harm as a result of medication error, ADR, poor quality products, and system
problems. Therefore, it is crucial to ensure patient safety through the implementation of safe
medication use practice. Each hospital should implement medication safety programs including
ADE monitoring and reporting, performing medication reconciliation activities, identifying high
alert medications, and implementing new and existing national standards and systems.
Medication use monitoring
To monitor the use of medications in the hospital, the pharmacy department in collaboration with
the DTC should undertake activities periodically using the following methods.
Monitoring of prescriptions
Aggregate data methods (ABC, VEN)
Indicator study methods
Drug use evaluation methods
A dedicated pharmacist(s), who works in close collaboration with the DTC should be assigned
by the pharmacy department, is responsible for continuously performing medication use
monitoring; presenting the findings and recommendations to the DTC, following interventions
proposed by the DTC and measuring outcomes.
Prescription Monitoring
Prescriptions should be regularly monitored to identify trends and ensure proper prescribing and
dispensing practice in the hospital. This activity should be conducted quarterly. The results
should be communicated to the DTC for proper implementation and follow-up.
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Appropriateness of prescription papers used (NPS)
Appropriateness of prescribers
ABC-VEN Analysis
ABC and VEN analysis are aggregate data methods that are used to identify medication use
problems. Each hospital should employ these methods annually to monitor drug use and take
interventions accordingly.
ABC analysis is a method for determining and comparing pharmaceutical costs within the
formulary system. It follows the Pareto principle “separating the vital few from the trivial many”.
ABC Analysis can be explained in terms of budget consumed and number of drugs in the budget
list as follows:
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VEN analysis
If funds are limited, VEN analysis is a method to prioritize for medicine purchase. This analysis
is used to identify high priority medicines for procurement and low priority medicines that the
DTC should analyze carefully for deletion from the formulary. VEN stands for:
E= Essential: effective against less severe but significant illness. Not vital.
N= No-essential: effective for minor illness but have high cost and low therapeutic advantage.
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Table 1 Selected indicators to assess prescribing, patient care and facility practices
Prescribing Indicators Patient Care Indicators Facility Indicators
Complementary Indicators
% of patients treated without medicines
Average medicine costs per encounter
% of medicine cost spent on antibiotics
% of medicine cost spent on injections
% of prescriptions in accordance with STG
% of patients satisfied with care provided
% of facilities with access to impartial information
Steps to be taken when conducted an indicator use study include:
Determine objectives of study,
Define indicators and data collection procedures,
Determine study design and sampling methods,
Pilot test,
Train data collectors,
Collect data as per the time line,
Compile and analyze data,
Prepare report and recommendations based on findings of study,
Present report and recommendations to DTC and relevant hospital staff, and Implement
recommendations arising from study, repeat study to assess impact.
Drug Use Evaluation (DUE) methods
‘Drug Use Evaluation’ studies can be undertaken to measure the use of a specific drug and/or
adherence to standard treatment guidelines (STGs). DUE studies are particularly important to
investigate:
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Perceived overuse or underuse of medications,
Problems identified by indicator studies,
High numbers of ADRs,
Excessive amounts of non-formulary medicines used,
Use of high-costs medicines when less expensive alternatives exist, and
Use of excessive numbers of medicines within a therapeutic category.
Steps to be undertaken in conducting a DUE study include:
Step 1: Define appropriate medicine use (for example medicine use described in national or local
STGs)
Step 2: Audit actual prescribing practice against the set criteria
Step 3: Analyze data, prepare report and recommendations based on findings
Step 4: Present report and recommendations to DTC and relevant staff
Step 5: Implement recommendations arising from study, repeat study to assess impact
Problems identified by aggregate methods, Indicator Study and DUE studies may be further
investigated using the following qualitative methods: In-depth interviews, Focus Group
Discussions, Structured Observations, and Structured Questionnaires.
The pharmacy department shall coordinate, in cooperation with medical and nursing staff and
possibly other facilities in the region, an adverse drug reaction program. This shall include:
the identification and immediate reporting of adverse drug reactions to the prescribing
physician and pharmacy,
the investigation and validation of adverse drug reactions including collection of follow-
up information, treatment and outcome,
documentation in the patient’s health care record,
the regular reporting of adverse drug reactions to the Pharmacy and Therapeutics
Committee,
the regular reporting of adverse drug reactions to FMHACA
The pharmacy department shall also maintain current information about adverse drug reactions
occurring within the hospital and in literature
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All health care professionals should vigilate susceptible individuals for ADR including:
those with multiple diseases,
those on multiple drug therapy,
geriatric or paediatric patients,
those receiving medicines that are known to be associated with serious adverse effects,
those receiving drugs with a low therapeutic index or potential for multiple interactions,
those with organ impairment that may alter drug pharmacokinetics, and
those who have had a previous ADR.
A standardized form should be used to record and report ADRs. This should include:
Patient name, sex, age, medical record number
Clinical diagnosis
Current medication
History of previous ADR if any
Details of adverse reaction
Causality assessment
Recommendations given
An ADR focal person should be appointed by the DTC. He/she is responsible to:
ensure that all health professionals are involved in detecting, assessing, managing and
reporting potential ADRs
ensure that ADR report forms are readily available in all clinical areas and that health
professionals are familiar with the form and how to complete it
receive ADR report forms from clinical staff
investigate potential ADRs
analyze ADR data and compile reports
provide regular reports to the DTC/and Hospital Management on ADRs in the facility
report all ADRs to the Regulatory Body
The DTC should receive regular reports from the ADR focal person and make any necessary
decisions regarding the use of the drug in the facility. Where necessary the hospital formulary
should be amended to take account of detected ADRs.
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1. Assess suspected ADR with respect to:
a) Patient details: age, gender, organ function, height, weight; diagnosis and other relevant
co-morbidities prior to reaction; previous exposure to suspected drug(s) or related
drug(s).
b) Medicine details: non-prescription drugs, alternative treatments, recently ceased
medicines; name, dose, route of administration, manufacturer, batch; date and time
commenced; date and time discontinued (if applicable); indication.
c) Comprehensive adverse reaction details: description of the reaction; time of onset and
duration of reaction; complications and sequelae; treatment and outcome of treatment;
relevant investigation results or autopsy report.
2. Perform causality assessment to assess likelihood of the drug causing the observed reaction.
A literature review may be undertaken to assess the likelihood that a suspected ADR was caused
by a particular drug and/or the advice of other health professionals may be sought.
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the prophylactic use of other medicines to prevent future adverse reactions.
4. Document the ADR and provide follow up advice:
All ADRs should be clearly highlighted in the patient’s case notes. Any patient who has
experienced an ADR should receive advice about the drug and reaction, should be advised to
avoid the drug in the future and should be given an ‘alert card’ that states the drug involved and
nature of the reaction. He/she should be advised to show this card at any future clinical
consultation to prevent the same drug being prescribed again.
The Hospital Pharmacy section should avail reporting form, retain the necessary documentation
and also mail the ADR report to regulatory authority FMHACA as per the guidance provided.
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Consider protocols for vulnerable populations such as the elderly, pediatric, and
obese patients.
2. Methods to identify errors and harm include:
Include reminders and information about appropriate monitoring parameters in the
order sets, protocols, and flow sheets.
Ensure that critical lab information is available to those who need the information and
can take action.
Implement independent double-checks where appropriate.
Instruct patients on symptoms to monitor and when to contact a health care provider
for assistance.
3. Methods to mitigate harm include:
Develop protocols allowing for the administration of reversal agents without having
to contact the physician.
Ensure that antidotes and reversal agents are readily available.
Have rescue protocols available.
Medication reconciliation
“Medication reconciliation is the process of creating the most accurate list possible
of all medications a patient is taking- including drug name, dosage, frequency, and
route — and comparing that list against the physician’s admission, transfer, and/or
discharge orders, with the goal of providing correct medications to the patient at all
transition points within the hospital.”
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The three steps of the medication reconciliation process can prevent prescribing errors
(omissions, wrong dosage or frequency of medications, and duplicate orders). A good strategy to
make medication reconciliation process effective is use of a standardized form. The form is often
an admission intake, medication, or physician order form. The standardized form's components
are medication history or current medication list, the medication orders, the continuation or
discontinuation of the medication, and the reason for a medication discontinuation.
The medication reconciliation process should be done in sequence, starting from the admission
process, then the transfer process, and then finally the discharge process. Each process relies on
the process before it. To ensure that all the patient’s home medications are taken into
consideration, it is important to check the home list at each step of the process, including
admission, transfer and discharge. In addition to transfer and discharge, the list of current
medications must be taken into account.
Medication reconciliation is important at transition points. Care transition points include:
1. Admission to the hospital
2. Transfers within the hospital (Intra-hospital transfer)
3. Discharge from the hospital
Medication reconciliation on admission to the hospital involves comparing the home medication
list recorded on admission (medication history) to the physician admission medication orders.
Any medication that appear on one list and not on the other without documentation as to why
they were added or removed are considered unreconciled and need to be clarified with the
physician.
Medication reconciliation on Intra-Hospital Transfer involves comparing the medication history
and the current medication list (Medication Administration Record-MAR) to the physician
transfer medication orders. Any medications that appear on one list and not the other, without
documentation as to why they were added or removed, are considered unreconciled and need to
be clarified with the physician.
Medication reconciliation on Discharge from the hospital involves comparing the admission
medication reconciliation list and the current medication list (Medication Administration Record-
MAR) to the physician discharge medication orders. Any medications that appear on one list and
not the other without documentation as to why they were added or removed are considered
unreconciled and need to be clarified with the physician.
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Section 4 Implementation checklist and indicators
In order to determine if the Operational Standards for Pharmacy Services have been met by the
hospital, the following assessment checklist should be used. It describes operational standards,
method of evaluation and rating (met or unmet). This tool can be used by hospital management
or by an external body such as RHB or FMOH to measure attainment of each Operational
Standard. The tool is presented in Appendix E of chapter 20 Monitoring and Reporting.
The following Table can be used as a tool to record whether the main recommendations outlined
above have been implemented by the hospital. This tool is not meant to measure attainment of
each Operational Standard, but rather to provide a checklist to record implementation activities.
Yes No
1. A Drug and Therapeutics Committee has been established.
2. Terms of reference for the Drug and Therapeutics Committee are
defined.
3. A Medicines Formulary is created and is shared with staff.
4. The hospital develops, utilizes and annually updates a
comprehensive list of pharmaceuticals prioritized by VEN.
5. Pharmacy services are integrated in the emergency, outpatient and
inpatient case teams.
6. The hospital implements transparent and accountable
pharmaceuticals transactions
7. The hospital has a functional compounding service with SOPs to
describe different compounding procedures.
8. A Drug Information Centre is established to provide drug
information to staff and patients alike.
9. Procedures are established to receive, investigate adverse drug
reactions.
10. Procedures are established to monitor prescriptions and drug
utilization
11. There is a drug procurement policy.
12. An inventory management system to manage drug supply and
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distribution is established.
13. There is process to dispose of expired drugs.
14. Adequate personnel to provide pharmacy services are in place.
15. Facilities and equipment needed to provide pharmacy services are in
place.
4.3 Indicators
In addition, the following indicators may be monitored on a regular basis to assess the
effectiveness/outcomes of implementation of the recommendations provided in this chapter.
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S Indicators Formula Frequenc Comment
N y
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S Indicators Formula Frequenc Comment
N y
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S Indicators Formula Frequenc Comment
N y
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S Indicators Formula Frequenc Comment
N y
possible side
effects in a way
you could
understand?”
20. Out patient Total number of outpatients who respond Biannual Survey tool
satisfaction ‘yes’ to the questions listed/ Total presented in
survey : number of outpatients respondents.. Appendix F
% of respondents of Chapter
who answer ‘yes’ 12 Quality
to the following Managemen
questions “The t
staff described
the medications
possible side
effects in a way I
could
understand?”
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