Medical Service Lead Executive Office

Hospital Service Performance

Monitoring for Improvement
Indicators (HSPMI)

March , 2024

Addis Ababa, Ethiopia

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) I

Hospital Service Performance
Monitoring for Improvement
Indicators (HSPMI)
Contents
FOREWORD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI

ACKNOWLEDGMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . VII

MOH Led Core Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII

ABBREVIATIONS/ACRONYMS. . . . . . . . . . . . . . . . . . . . . . . . . VIII

CHAPTER 1: INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Justification for HSPMI Manual Revision . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Purpose of this Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4 Scope of HSPMI manual . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.5 Target Audience for the Manual . . . . . . . . . . . . . . . . . . . . . . . . . 2

CHAPTER 2: A FRAMEWORK FOR HOSPITAL SERVICE PERFORMANCE MONITORING FOR IMPROVEMENT

(HSPMI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

CHAPTER 3: HOSPITAL KEY PERFORMANCE INDICATORS. . . . . . . . . . . . . . . . . . 6

3.1. INDICATORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
LIST OF HMIS INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

MODULE 1: HMIS INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.1. Out-Patient Attendance Per-Capita . . . . . . . . . . . . . . . . . . . . . . . 17
1.2. Bed Occupancy Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.3. Average Length of Stay (in days) . . . . . . . . . . . . . . . . . . . . . . . . 19
1.4. Hospital Bed Density. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5. Assistive Technology Service Utilization . . . . . . . . . . . . . . . . . . . . . . 20
1.6. Essential laboratory test availability . . . . . . . . . . . . . . . . . . . . . . . 21
1.7. Referral-out Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.8. Ambulance service utilization for referral service . . . . . . . . . . . . . . . . . . . 23
1.9. Ambulance service response rate . . . . . . . . . . . . . . . . . . . . . . . . 24
1.10. Facility emergency department mortality rate. . . . . . . . . . . . . . . . . . . . 25
1.11. Emergency room attendances with length of stay > 24 hours. . . . . . . . . . . . . . . 26
1.12. Percentage of ventilator associated pneumonia. . . . . . . . . . . . . . . . . . . 26
1.13. Mortality rate in Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . 27
1.14. Perioperative mortality rate . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.15. Average length of ICU stay. . . . . . . . . . . . . . . . . . . . . . . . . . 29
1.16. Mean duration of in-hospital pre-elective operative stay . . . . . . . . . . . . . . . . 29
1.17. Number of clients in the waiting list for elective surgical service . . . . . . . . . . . . . . 30
1.18. Delay for elective surgical admission. . . . . . . . . . . . . . . . . . . . . . . 31
1.19. Inpatient mortality rate . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 1.20. Top 10 causes of morbidity . . . . . . . . . . . . . . . . . . . . . . . . . 33
1.21. Top ten causes of institutional mortality . . . . . . . . . . . . . . . . . . . . . 33
1.22. Supplier fill rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
1.23. Essential Drugs Availability . . . . . . . . . . . . . . . . . . . . . . . . . 35
1.24. Percentage of encounters with an antibiotic prescribed. . . . . . . . . . . . . . . . . 37
1.25. Percentage of client with 100% prescribed drug filled. . . . . . . . . . . . . . . . . 38
1.26. Percentage of medicines prescribed from the facility’s medicines list . . . . . . . . . . . . 39
1.27. Pharmaceuticals wastage rate . . . . . . . . . . . . . . . . . . . . . . . . 40
1.28. PMS_EQUIP: Functionality of medical equipment . . . . . . . . . . . . . . . . . . 41
1.29. Percentage of Good governance index score . . . . . . . . . . . . . . . . . . . . 42
1.30. Proportion of reimbursed amount from the total spent. . . . . . . . . . . . . . . . . 43
1.31. Major Elective Surgeries Performed. . . . . . . . . . . . . . . . . . . . . . . 44

MODULE 2: HSPMI INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . 46

2.1. Emergency room patients triaged within 5 minutes of arrival. . . . . . . . . . . . . . . 46
2.2. Outpatient waiting time to Consultation. . . . . . . . . . . . . . . . . . . . . . 47
2.3. Timely Outpatient service initiation . . . . . . . . . . . . . . . . . . . . . . . 48
2.4. Outpatients not seen on the same day . . . . . . . . . . . . . . . . . . . . . . 49
2.5. Percentage of hypoxemic patients treated with oxygen . . . . . . . . . . . . . . . . . 50
2.6. Medical oxygen stock out rate . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.7. Inpatient Medical Record Completeness. . . . . . . . . . . . . . . . . . . . . . 52
2.8. Percentage of acceptable EQA result . . . . . . . . . . . . . . . . . . . . . . . 53
2.9.Percentage of laboratory tests completed within TAT . . . . . . . . . . . . . . . . . . 54
2.10. Elective Surgical procedure cancellation ratio due to blood unavailability . . . . . . . . . . . 54
2.11. Clients Receiving Rehabilitation Services . . . . . . . . . . . . . . . . . . . . . 55
2.12. Antimicrobial Stewardship Functionality Score . . . . . . . . . . . . . . . . . . . 55
2.13. Anesthesia adverse outcome. . . . . . . . . . . . . . . . . . . . . . . . . 56
2.14. Elective Surgical Cases Treated within clinically recommended Time. . . . . . . . . . . . . 57
2.15. Safe Surgery Checklist Utilization . . . . . . . . . . . . . . . . . . . . . . . 58
2.16. Major OR Table Efficiency. . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.17. Surgical Site Infection Rate. . . . . . . . . . . . . . . . . . . . . . . . . 59
2.18. Percentage of Imaging Service Interruption Days . . . . . . . . . . . . . . . . . . 60
2.19. Percentages of Pathology Service Interruption Days. . . . . . . . . . . . . . . . . 61
2.20. Percentage of imaging service completed within TAT . . . . . . . . . . . . . . . . . 62
2.21. Percentage of pathology tests completed within TAT. . . . . . . . . . . . . . . . . 62
2.22. Percentage of Medical Devices Repaired. . . . . . . . . . . . . . . . . . . . . 63
2.23. IPC FLAT Score (IPC-FLAT). . . . . . . . . . . . . . . . . . . . . . . . . . 64
2.24. Pressure sore incidence. . . . . . . . . . . . . . . . . . . . . . . . . . 66

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 2.25. Percentage of women who died from Post-Partum Hemorrhage. . . . . . . . . . . . . . 67
2.26. Births by instrumental or assisted vaginal deliveries. . . . . . . . . . . . . . . . . . 67
2.27. Patient satisfaction score. . . . . . . . . . . . . . . . . . . . . . . . . . 68
2.28. Staff satisfaction score. . . . . . . . . . . . . . . . . . . . . . . . . . . 69
2.29. EHSIG Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

MODULE 3: POOL INDICATORS . . . . . . . . . . . . . . . . . . . . . . . . . 72

3.1. Blood Product Wastage Rate . . . . . . . . . . . . . . . . . . . . . . . . 72
3.2. Number of palliative Patients Seen . . . . . . . . . . . . . . . . . . . . . . . 72
3.3. Pain Assessment Performed as 5th Vital Sign. . . . . . . . . . . . . . . . . . . . 73
3.4. Pain Management per WHO Standards . . . . . . . . . . . . . . . . . . . . . 74
3.5. Palliative Home-Based Care Linkage . . . . . . . . . . . . . . . . . . . . . . . 75
3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service. . . . . . . . . . . . . 76
3.7. Functional improvement of rehabilitation clients . . . . . . . . . . . . . . . . . . . 76
3.8. Rehabilitation Service Utilization . . . . . . . . . . . . . . . . . . . . . . . . 77
3.9. Percentage of SLIPTA standards met . . . . . . . . . . . . . . . . . . . . . . 78
3.10. Drug and Therapeutics Committee (DTC) Functionality. . . . . . . . . . . . . . . . . 79
3.11. Clinical Pharmacy Service Functionality. . . . . . . . . . . . . . . . . . . . . . 79
3.12. Percentage of Medicine Actually Dispensed. . . . . . . . . . . . . . . . . . . . 80
3.13. Relative Share of Sources of Retained Revenue . . . . . . . . . . . . . . . . . . . 81
3.14. Proportion of Beneficiary Groups to total visits . . . . . . . . . . . . . . . . . . . 82
3.15. Retained Revenue spending as a share of total operating budget spending . . . . . . . . . . 83
3.16. MEMIS implementation . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.17. Mean time to respond to work order request for special healthcare setting . . . . . . . . . . 84
3.18. Proportion of vacancies filled as per the standards of the approved positions. . . . . . . . . . 85
3.19. Attrition rate of Healthcare workforce . . . . . . . . . . . . . . . . . . . . . . 85
3.20. Recipients of in-service and CPD training . . . . . . . . . . . . . . . . . . . . . 85
3.21. Grievances received and solved . . . . . . . . . . . . . . . . . . . . . . . . 86
3.22. Occupational injury incidence. . . . . . . . . . . . . . . . . . . . . . . . . 86

CHAPTER 4: HOSPITAL SUPPORTIVE SUPERVISION . . . . . . . . . . . . . . . . . . . 87

CHAPTER 5: REVIEW MEETINGS . . . . . . . . . . . . . . . . . . . . . . . . . 88

Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

FOREWORD
Medical Service Lead Executive Office emphasizes the ongoing commitment to enhancing the quality of
healthcare services in Ethiopian hospitals. Despite considerable strides in expanding health services, there’s
a recognized necessity to improve the overall quality and equitable access to healthcare across the country.

With the goal of providing quality and equitable access to all segments of Ethiopian Hospitals, the Hospital
Performance and Monitoring Improvement (HPMI) manual was first published in 2011 G.C. Then revised in
2017 G.C and is presently being revised in 2023 G.C. Hospitals are at the heart of these reform efforts, with
a number of recent measures aimed explicitly at improving hospital performance and health-care quality.

The Health Sector Transformation Plan (HSTP) has significantly contributed to expanding health services,
but the current focus is on elevating the quality of healthcare provision. The recently revised Hospital Service
Performance Monitoring Improvement (HSPMI) manual in 2023 stands as a crucial tool in this endeavor. It
meticulously details 28 Medical Service HMIS Indicators, 32 Hospital Key Performance Indicators (KPI) and
additional of 22 pool indicators for Hospitals internal consumption.

Moreover, these guidelines, along with initiatives like EHSTG, NQSS, SaLTs and HMIS, are foundational tools
for performance improvement of clinical and administrative aspects hospitals. The Ministry of Health aims
to implement these guidelines aligned with revised EHSIG guideline with a focus on swift and time-bound
activities aligned with the roadmap outlined in the HSPMI guideline.

Expressing gratitude to the professionals, partners, and the ministry’s Medical Service Lead Executive Office
staff who contributed to the development and finalization of these crucial manuals, the message highlights
the collective effort and commitment toward implementing these guidelines for the enhancement of
healthcare services across Ethiopian hospitals.

Dr. Elubabor Buno

Medical Service Lead Executive Officer

Ethiopia Ministry of Health

VI Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

ACKNOWLEDGMENTS
The Ministry of Health’s Medical Service Lead Executive Office (MSLEO) spear headed the development
of the Hospital Service Performance Monitoring for Improvement (HSPMI) manuals in the Health Sector,
which is the result of the efforts of all key stakeholders in the health sector. Ministry established a national
taskforce through the HSPMI technical working group to monitor and coordinate the technical and
consultative procedures in the development of the manual. The data elements and indicators outlined in
this manual are designed to operationalize the Hospital’s Service Performance Monitoring framework and
establish a minimum bar for performing monitoring and improvement efforts at healthcare facilities across
the country.

I extend my sincere gratitude to the members of the national HSPMI technical working groups and key
stakeholders and partners for their invaluable input and oversight throughout this entire process. Their
constructive contributions, expertise, and active involvement played a critical role in shaping and finalizing
of this document.

MOH Led Core Team

We appreciate and thank the MOH-led core team members for their contributions to the preparation,
coordination, and facilitation of HSPMI guidelines development workshop briefs, consultation documents,
review of drafts and stakeholder contributions, and response to comments and recommendations, as well
as the enrichment of the manuals.

Core Team Member Organization

Dr. Elubabor Buno MoH/Medical Service Lead Executive Officer

Biniyam Kemal MoH/MSLEO – Hospital & Diagnostic Desk Coordinator
Dr. Sem Daniel MoH – Medical Service LEO – HSPMI Initiative National focal
Desalegn Bayissa MoH – Medical Service LEO – HSPMI Initiative National focal
Dr Hailemicheal Fikre MoH – Eka Kotebe Hospital
Yalemzewoud Ayalew MoH – Medical Service LEO
Kasu Tola (PhD fellow) MoH – Medical Service LEO
Biruk Kefelegn MoH – Medical Service LEO
Etaferahu Alamaw MoH – Medical Service LEO
Abebaw Derso MoH – Medical Service LEO
Dr. Gobena Godana MoH – Medical Service LEO
Emebet Tarekegne MoH – Medical Service LEO
Tiruwork Akile MoH – Medical Service LEO
Abiy Dawit (PhD fellow) MoH – Medical Service LEO
Sara Paulos AAHB
Dr. Dawit Daniel Central Ethiopia Regional Health Bureau
Dr. Yoseph Workneh Hawela Tula General Hospital
Dr. Alemayehu Gareno Sidama Regional Health Bureau
Alem Wassie Yekatit 12 Hospital – Medical College
Ibrahim Heyredin St. Peter Specialized Hospital
Habtamu Milkiyase (PhD fellow) MoH – Quality and Innovation LEO
Edessa Deriba MoH- Pharmaceutical and medical device LEO
Addisu Taso MoH- Pharmaceutical and medical device LEO

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) VII

ABBREVIATIONS/ACRONYMS
ANC Antenatal Care

ART Antiretroviral Therapy

ALOS Average Length of Stay

BOR Bed Occupancy Rate

BPR Business Process Reengineering

CEO Chief Executive Officer

CHAI Clinton Health Access Initiative

DOTS Directly Observed Therapy (Short Course)

EHSIG Ethiopian Hospital Services Improvement Guidelines

HSPMI Hospital Service Performance Monitoring Improvements

EPI Expanded Program on Immunization

FMOH Federal Ministry of Health

FTE Full time equivalent

HMIS Health Management Information System

HCFR Healthcare Finance Reform

H-CAHPS Hospital Consumer Assessment of Health Providers and Systems

HR Human Resources

I-PAHC Inpatient Assessment of Health Care

KPI Key Performance Indicator

MHA Masters in Hospital and Healthcare Administration

MCH Maternal and Child Health

NGO Non-Governmental Organization

OPD Outpatient Department

O-PAHC Outpatient Assessment of Health Care

PNC Post Natal Care

RHB Regional Health Bureau

VIII Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

CHAPTER 1: INTRODUCTION
1.1 Background
The Ministry of Health envisions all of its citizens having quality and fair access to all forms of health
services under the Health Sector Transformation Plan (HSTP-II). In order to do this, the MOH and RHBs are
leading a sector-wide reform to enhance and improve the quality of Ethiopia’s health services. Hospitals are
at the heart of these reform efforts, and a number of recent initiatives have focused on improving hospital
performance and service quality. Ethiopian Hospital Services Improvement Guidelines (EHSIG), Saving Lives
Through Safe Surgery (SaLTS-II), Diagnostic, service, Emergency and critical care, and Infection Prevention
and Control, as well as the revised Health Management Information System (HMIS) and District Health
Information System two (DHIS2), are some of the examples of national health service initiatives.

Measurement is essential to the concept of quality improvement because it allows you to specify what
hospitals actually accomplish and compare it to the original goals in order to find areas where you can
improve. This is addressed by routine data collection, aggregation, and dissemination, performance
monitoring and quality improvement, integrated supporting supervision, inspection, and operational
research/evaluation components in the monitoring and evaluation of health sectors .In the HSTP’s M&E
framework, a variety of data sources are used, including routine administrative sources (such as the Health
Management Information System), Service Provision Assessment (SPA) and the Service Availability and
Readiness Assessment (SARA), disease and behavioral surveillance, civil registration and vital statistics,
financial and management data, and disease and behavioral surveillance.

HSPMI designed to measure access, quality, and equity in healthcare provision, HSPMI plays a crucial
role in identifying performance gaps and disparities, enabling targeted resource allocation. This approach
enhances service delivery tailored to diverse populations, fostering a culture of continuous improvement. It
serves as a compass for progressing toward universal health coverage, advocating for inclusive healthcare
access. By promoting ongoing evaluation and evidence-based practices, HSPMI contributes to elevating
patient outcomes, fostering equitable healthcare systems, and enhancing public health on a national scale.

1.2 Justification for HSPMI Manual Revision

Hospital Services performance monitoring for improvement (HSPMI) can be defined as a process by which
hospitals practice strategic use of performance standards, measures, progress reports, and ongoing quality
improvement efforts to ensure their desired results are being achieved. The existing HPMI (2017) was
revised in 2023 due to a number of driving forces that have resulted in the need for HPMI revision. Some of
the driving forces for revision include:

1) The development of 3 years Health Sector Medium-Term Development and Investment Plan
(HSDIP) from 2023/24-2025/26.
2) The need to have more quality, access and equity indicators that will provide details required to
operationalize the monitoring and evaluation framework of the HSTP II.
3) The commitment to improve the access and transform the quality of health services provided at
hospitals with magnified efficiency, accountability and ownership at all level.
4) Developments of EHSIG, Infection Prevention and Control (IPC) Strategy, Health Ageing Strategies,
National Palliative Care Strategy, National Compressive Rehabilitative Assistive Technology Service
Strategy, National strategies for Safe life through Surgery (SaLTS), Diagnostic strategy.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 1

1.3 Purpose of this Manual
The purpose of this manual is to bring together processes and activities for hospital service performance
monitoring and improvement across the sector. Its mission is to provide data to hospital senior management
teams (SMTs), governing boards (GBs), health service providers, and higher health sector offices in order
to measure and monitor hospital performance using a core set of Key Performance Indicators, as well as
conduct site visits and facilitate review meetings to ensure the effectiveness, efficiency, and quality of
services provided.
1. Data Provision for Performance Monitoring: Provide a structured approach to gather and present
data to hospital senior management teams (SMTs), governing boards (GBs), health service providers,
and higher health sector offices for monitoring and evaluating hospital performance.
2. Utilization of Key Performance Indicators (KPIs): Ensure accurate collection and evaluation of Key
Performance Indicator (KPI) data, promoting evidence-based decision-making within hospitals.
3. Instructions for Data Collection and Analysis: Offer clear instructions on collecting, analyzing,
evaluating, and utilizing performance data effectively.
4. Standardization of Performance Monitoring Definitions: Establish standardized definitions
for hospital performance monitoring and improvement, ensuring consistency and clarity in
measurements
There are additional particular instructions in the manual, such as:
1. Assuring that hospitals collect and evaluate accurate KPI data, as well as improving data utilization
for evidence-based decision-making.
2. Give instructions on how to collect, analyze, evaluate, and use performance data.
3. Establish a common standardized definition for hospital service performance monitoring and
improvement.
4. To identify areas inside hospitals where focused help from the community, government agencies,
and other partners is deemed important for further progress
5. Provide guidance on how to create and implement a comprehensive hospital performance
monitoring and improvement program
6. Create a learning culture that uses M&E data to inform management and governance decision-
making and accountability
7. It is necessary to identify and communicate best practices.

1.4 Scope of HSPMI manual

This Manual implemented in all tier of hospitals such as Primary hospitals, General hospitals, and
Compressive specialized hospitals.

1.5 Target Audience for the Manual

The goal of this manual is to help healthcare professionals obtain, synthesize, and analyze data to improve
hospital performance. The actors are:
1. National level: MOH agencies and directorates etc.
2. Regional level: RHB/Zonal departments etc.
3. Facility level: Hospital GB, SMT, Unit heads, service providers etc.
4. Community level: community forums, public wing members

2 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

CHAPTER 2: A FRAMEWORK FOR HOSPITAL SERVICE PERFORMANCE
MONITORING FOR IMPROVEMENT (HSPMI)
1. Introduction

The framework underlines the strategic approach to assess and improve hospital service performance
within Ethiopia’s healthcare system. Aligned with the overarching objectives of the Health Sector
Transformation Plan (HSTP-II) from 2023/24-2025/26, this guideline aims to serve as an essential tool in
evaluating, enhancing, and aligning hospital-level healthcare delivery with national health objectives.

2. Core Components

2.1 Access Assessment:

The assessment of hospital service performance encompasses critical dimensions such as geographical
accessibility, service availability, and equity indicators. Geographical accessibility entails scrutinizing the
proximity and ease of reaching healthcare facilities from population centers, ensuring that individuals can
readily access necessary care. Simultaneously, the evaluation of service availability involves scrutinizing the
comprehensive range and accessibility of essential healthcare services provided by hospitals. Moreover,
equity indicators play a pivotal role in guaranteeing equal access to healthcare services for all segments of
the population, regardless of socioeconomic disparities or geographic disparities, thus striving towards an
inclusive and fair healthcare system that caters to diverse demographics.

2.2 Quality Improvement Indicators:

The comprehensive evaluation of hospital service performance includes critical aspects such as clinical
effectiveness, patient safety, and patient-centeredness. Clinical effectiveness involves diligent monitoring
of healthcare outcomes, adherence to established clinical protocols, and the utilization of evidence-
based practices to ensure optimal patient care. Additionally, patient safety remains paramount, entailing
the meticulous tracking of infection rates, safety incidents, and strict adherence to safety protocols to
safeguard patient well-being within healthcare settings. Moreover, focusing on patient-centeredness
involves assessing patient satisfaction levels and their active involvement in care processes, ensuring that
healthcare services are tailored to meet individual needs and preferences, fostering a more personalized
and patient-centric approach to healthcare delivery.

2.3 Equity Evaluation:

Assessing equitable healthcare provision encompasses two fundamental components: fair distribution
and accessibility for vulnerable populations. Fair distribution necessitates a comprehensive evaluation of
how healthcare services are equitably distributed among diverse social and economic groups, ensuring that
access to care is justly allocated across various demographics. Simultaneously, ensuring accessibility for
vulnerable populations is crucial, aiming to provide equal opportunities and unhindered access to healthcare
services for marginalized or vulnerable groups. This facet emphasizes the importance of removing barriers
and disparities, guaranteeing that those in need, irrespective of their socioeconomic status or vulnerabilities,
have equitable access to essential healthcare services

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 3

2.4 Performance Improvement Strategies:

The section focusing on performance improvement strategies encompasses key elements vital for
enhancing hospital service delivery. Target setting plays a pivotal role, involving the establishment of
measurable targets aligned with objectives related to access, quality, and equity, providing a clear direction
for improvement efforts. Concurrently, the development of action plans forms a cornerstone, delineating
comprehensive strategies aimed at continually improving the quality of healthcare services offered by
hospitals. Moreover, the aspect of capacity building is crucial, providing guidance for the training and skill
development of healthcare professionals, ensuring they meet set standards and are equipped with the
necessary competencies to deliver high-quality care in line with established objectives.

2.5 Data Collection and Reporting Mechanisms:

Within the realm of data collection and reporting mechanisms, several critical components shape the
evaluation of hospital service performance. Firstly, defining standardized tools, sources, and methodologies
for data collection and analysis stands as a pivotal step, ensuring consistency and reliability in acquiring
pertinent information. Secondly, the establishment of measurement tools plays a crucial role in evaluating
performance indicators and establishing benchmarks for assessing hospital service quality. Lastly, outlining
robust reporting methods is essential, delineating procedures for data reporting, comprehensive analysis,
and efficient dissemination of findings, thereby enabling stakeholders to make informed decisions and
implement targeted improvements based on the collected data.

2.6 Benchmarking and Comparisons:

The benchmarking and comparisons segment of hospital service evaluation involves pivotal steps toward
enhancing overall performance. Firstly, comparing hospital performance against established national
benchmarks and best practices serves as a crucial measure for assessing the effectiveness of healthcare
delivery. Secondly, fostering a culture of learning and sharing becomes imperative, encouraging hospitals to
share successful initiatives and best practices among one another. This exchange of knowledge facilitates
continuous improvement, allowing hospitals to learn from each other’s successes and adopt innovative
approaches to further elevate the quality of healthcare services provided

2.7 Governance and Leadership:

In the domain of governance and leadership, establishing clear guidelines and accountability mechanisms
is fundamental to the effective implementation of the HSPMI framework. Firstly, defining explicit roles
and responsibilities for stakeholders involved in implementing the HSPMI framework is crucial, ensuring
that each party comprehends their specific duties and accountabilities within the framework. Secondly,
embedding robust accountability mechanisms becomes essential to monitor and achieve performance
improvement objectives. By establishing clear lines of responsibility and accountability, this framework
cultivates an environment of transparency and ensures that all stakeholders are committed and responsible
for driving the improvements outlined within the HSPMI guideline.

4 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.8 Supportive Supervision and Review Meetings:

Supportive supervision and review meetings play a pivotal role in ensuring the successful implementation
of improvement initiatives within hospital settings. To facilitate this, providing structured guidelines for
conducting effective supportive supervision and review meetings becomes imperative. These guidelines
offer a framework for conducting sessions that are productive, focused, and conducive to addressing
performance-related issues and implementing necessary improvements. Additionally, offering action plan
templates is essential, providing hospitals with a standardized format for developing action plans. These
templates delineate clear objectives and timelines for implementation, aiding in the systematic execution
of improvement strategies and ensuring that initiatives are well-defined, actionable, and trackable to
achieve desired outcomes within set timeframes.

3. Implementation Guidelines

The implementation phase of the HSPMI guideline necessitates practical application and proper training for
stakeholders involved in hospital service provision. Guidelines for practical application and recommended
training programs ensure the effective utilization of this framework to drive meaningful and sustainable
improvements in hospital service delivery.

In conclusion, the comprehensive framework detailed within the National Hospital Service Performance
Monitoring Improvement Indicator guideline presents a structured approach towards assessing, monitoring,
and enhancing hospital service performance. The guideline stands as a beacon, guiding the healthcare
system toward a data-driven approach to achieve equitable, accessible, and quality healthcare delivery at
a national level.

Fig 1: Framework

Performance monitoring team

Performance standards Performance measurement Performance reporting

• Identify relevant standards • Collection, aggregation & analy- • Regular KPI reporting
• Select indicators sis of data • Review & analyze KPI report
• Set goals and targets • Data quality assurance • Provide feedback results
• Communicate expectations • Performance assessment • Regular supportive supervision
Quality improvement Unit (guidance team)

• Enhance data systems • Summit

Performance improvement champions(s)

• Performance review meeting

Performance
management

Continuous quality improvement process

Apply Kaizen and model for improvement

Implement the improvement

Public health stakeholders

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 5

CHAPTER 3: HOSPITAL KEY PERFORMANCE INDICATORS
It’s clear that Key Performance Indicators (KPIs) are crucial in assessing and improving hospital performance.
These indicators serve as benchmarks for tracking progress toward goals and identifying areas needing
improvement. Here are some common types of KPIs used in hospitals:

1. Clinical Quality Indicators: These KPIs measure the quality of care delivered by clinical teams. They
may include metrics related to patient outcomes (e.g., mortality rates, infection rates, readmission
rates), adherence to clinical guidelines, patient satisfaction scores, etc.
2. Financial Performance Indicators: These indicators focus on the financial health of the hospital.
Metrics may include revenue, operating costs, profitability, cash flow, billing and collection efficiency,
etc.
3. Operational Efficiency Indicators: These KPIs assess the effectiveness of hospital operations.
They can cover metrics like bed occupancy rates, length of stay, emergency department waiting
times, surgery turnaround times, etc.
4. Patient Access and Throughput Indicators: These KPIs measure how easily patients can access
care and how efficiently they move through the system. Metrics might include appointment wait
times, admission rates, discharge rates, etc.
5. Staffing and Workforce Indicators: These indicators assess the hospital’s workforce management,
including metrics on staff satisfaction, turnover rates, staffing levels compared to patient demand,
training and development metrics, etc.
6. Compliance and Regulatory Indicators: These KPIs ensure adherence to legal and regulatory
standards. They may include metrics related to compliance with healthcare regulations, accreditation
status, adherence to safety protocols, etc.
7. Patient Safety and Risk Management Indicators: These KPIs focus on reducing medical errors,
ensuring patient safety, and managing risks. Metrics may include incident reporting rates, adverse
event rates, near misses, etc.

The selection of KPIs should be strategic and aligned with the hospital’s objectives and priorities. It’s crucial
to not overwhelm stakeholders with excessive data but to focus on a concise set of indicators that provide
a comprehensive view of hospital performance.

Regular monitoring and analysis of these indicators allow for early detection of issues, benchmarking
against industry standards or other hospitals, and enable proactive decision-making to improve hospital
performance and quality of care.

Furthermore, it’s important for relevant authorities (such as the ZHD/RHB and FMOH) to regularly review
these KPIs, identify areas needing support or improvement, and provide timely feedback and resources to
ensure continuous enhancement of hospital services.

3.1. INDICATORS
1. HMIS Indicators: The HMIS is designed primarily to monitor and refine the implementation of
Health Sector Transformation Plans. It gathers data from routine services and administrative
records, aligning its indicators with broader national and international goals like the Sustainable
Development Goals (SDGs)

6 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 2. HSPMIs Indicators: The HSPMIs encompass a smaller collection of 32 indicators, with each
hospital conducting self-assessments and reporting to the Ministry of Health through DHIS2.
These indicators are specifically crafted to aid Hospital staff, Senior Management Teams (SMTs),
Governing Boards, Regional Health Boards (RHBs), and Ministry of Health (MOH) in overseeing
hospital operations. The primary goal of these specific KPIs is to offer a concise yet comprehensive
overview of hospital performance.

3. Pool Indicators: Individual hospitals have the option to use Pool indicators as needed without the
obligation and no need of report them through DHIS2 to the Ministry of Health. This integration
permits a comprehensive evaluation, enabling the assessment of indicators customized to each
hospital’s specific needs while also considering those that align with broader objectives in the
healthcare sector.

This joint assessment could help in:

• Identifying overlaps or gaps between the hospital-specific indicators and the broader health sector
goals tracked by the HMIS.
• Streamlining data collection processes to avoid duplication and ensure efficient use of resources.
• Providing a comprehensive understanding of how hospital performance contributes to the larger
healthcare landscape and national health objectives.

Regular joint assessments can facilitate informed decision-making, strategic planning, and targeted
interventions aimed at improving both hospital operations and the overall health system performance in
alignment with national health priorities.

Data Collection

Establishing efficient data collection strategies is crucial for accurately monitoring Hospital Key Performance
Indicators (HKPIs). steps and considerations for effective data collection:

1. Clear Data Collection Procedures: Develop standardized and documented procedures for data
collection, ensuring clarity on what data needs to be collected, how it should be gathered, and
when it needs to be reported.
2. Data Validation and Quality Assurance: Implement measures to ensure data accuracy and quality.
This might involve data validation checks, verification processes, and regular audits to identify and
rectify errors or inconsistencies.
3. Designated Responsibilities: Assign a dedicated focal person for HKPIs and designate specific
data owners for each indicator. These individuals will be responsible for overseeing data collection,
analysis, and reporting, ensuring accountability and accuracy.
4. Training and Capacity Building: Provide necessary training and support to staff responsible for
data collection. This includes training on data collection methods, tools, and the importance of
accurate and timely reporting.
5. Use of Technology: Leverage technology where possible to streamline data collection processes.
Implementing electronic data collection systems or utilizing software solutions can improve
efficiency and reduce errors.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 7

 6. Regular Review and Analysis: Establish a schedule for regular review and analysis of collected
data. This enables identification of trends, performance evaluation against targets, and timely
corrective actions if discrepancies or issues are identified.
7. Documentation and Reporting: Ensure proper documentation of data collection processes,
analysis, and reporting. Develop clear and concise reports that highlight performance against HKPIs
and EHSIGs facilitating informed decision-making.
8. Feedback Loops: Create mechanisms for feedback and communication between data collectors,
focal persons, and stakeholders. This facilitates continuous improvement and adjustments in data
collection processes based on feedback and evolving needs.

By implementing these strategies and ensuring a systematic approach to data collection, hospitals can
enhance the reliability, accuracy, and relevance of the collected data. This, in turn, supports effective
decision-making, goal attainment, and overall improvement in hospital performance aligned with EHSIGs.

3.4.1 Data Owners of KPIs

Specific data owners responsible for managing the primary data sources linked to Hospital Key Performance
Indicators (HKPIs) is crucial for maintaining data accuracy and integrity. Here’s a breakdown of the
responsibilities for HKPI data owners:

Responsibilities of HKPI Data Owner:

1. Management of Primary Data Sources: The HKPI data owner is accountable for ensuring that
the primary data sources, such as registers, records, databases, or relevant systems, are regularly
updated, accurate, and complete. This involves overseeing data collection, entry, and maintenance
procedures.
2. Calculation of HKPIs: At the end of each reporting period, the data owner is responsible for
performing calculations based on the collected data to generate the HKPI values. This involves
applying the predefined formulas or methodologies to compute the specific indicators accurately.
3. Timely Submission of Data: The data owner must submit the HKPI and EHSIG data to the
designated HKPI focal person within the stipulated time frame. Timely submission ensures that
the information is available for analysis and reporting purposes.
4. Analysis and Action Planning: The data owner, in collaboration with relevant stakeholders,
should examine the HKPIs and associated standards to evaluate performance against targets
or benchmarks. If performance falls below expectations, they should initiate action plans or
performance improvement initiatives to address identified gaps.

Example, the Chief of Human Resources (HR) department is designated as the HKPI data owner for
Employee satisfaction KPI. This individual would oversee employee satisfaction data sources, ensure data
accuracy, compute the HKPI value based on collected information, and submit it to the HKPI focal person
within the hospital.

Regular monitoring, analysis, and action planning based on HKPIs are essential to drive continuous
improvement in hospital performance. It’s crucial for HKPI data owners to collaborate closely with the HKPI
focal person and other relevant stakeholders to ensure that data-driven decisions are made to enhance
hospital operations and achieve desired performance outcomes.

8 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.4.2. Key Performance Indicators (HKPIs) Focal Person

Assigning a dedicated HKPI focal person plays a critical role in ensuring the effective collection, validation,
and reporting of Hospital Key Performance Indicators (HKPIs). Here are the responsibilities and functions
of the HKPI focal person:

Responsibilities of the HKPI Focal Person:

1. Collection of HKPI Data: Gather HKPI data from each designated HKPI data owner at the end of
the reporting period. Ensure that all required data elements are collected accurately and on time
from respective data owners.

2. Data Accuracy Review: Verify the accuracy and completeness of HKPI/EHSIG data by conducting
spot checks and reviewing data sources provided by data owners. This involves validating the
integrity of the collected data to maintain data quality.

3. Data Entry and Database Management: Enter validated HKPI/EHSIG data into the computerized
Hospital HKPI Database or DHIS2 platform. Ensure accurate and timely input of data elements to
maintain an updated database.

4. HKPI Report Creation: Generate a comprehensive HKPI report from the HKPI Database, compiling
data items and outcomes to create a structured report for analysis and review.

5. Submission of HKPI Report: Submit the compiled HKPI report to relevant departments, such as
the Clinical Governance and Quality Management Unit (CG & QMU), and the Chief Executive Officer
(CEO) within the reporting period.

6. Training and Support: Provide training and support to HKPI data owners and relevant personnel
involved in data collection and reporting processes. Ensure they understand their roles and
responsibilities in contributing to accurate data collection.

7. Resource Management: Ensure that necessary equipment, software, stationery, and required
formats are available and accessible for the collection, input, and submission of HKPI data.

Additionally, the HKPI focal person’s role includes being a part of the hospital’s Quality Team and the
Performance Review Team, which emphasizes their involvement in strategic decision-making related to
hospital performance and quality improvement initiatives.

Moreover, in the absence of the HKPI focal person, trained members from the HMIS team can step in to
perform HKPI-related tasks to ensure continuity in data collection and reporting processes. Overall, the
HKPI focal person plays a central role in managing the entire process of HKPI data collection, validation,
reporting, and ensuring that the hospital’s performance is measured accurately against established
benchmarks and standards.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 9

LIST OF HMIS INDICATORS

HMIS CODE Name of HMIS Indicator

1.1. Out-Patient Attendance Per-Capita
1.2. Bed Occupancy Rate
1.3. Average Length of Stay (in days)
1.4. Hospital Bed Density
1.5. Assistive Technology Service Utilization
1.6. Essential laboratory test availability
1.7. Referral-out Rate
1.8. Ambulance service utilization for referral service
1.9. Ambulance service response rate
1.10. Facility emergency department mortality rate
1.11. Emergency room attendances with length of stay > 24 hours
1.12. Percentage of ventilator associated pneumonia
1.13. Mortality rate in Intensive Care Unit
1.14. Perioperative mortality rate
1.15. Average length of ICU stay
1.16. Mean duration of in-hospital pre-elective operative stay
1.17. Number of clients in the waiting list for elective surgical service
1.18. Delay for elective surgical admission
1.19. Inpatient mortality rate
1.20. Top 10 causes of morbidity
1.21. Top ten causes of institutional mortality
1.22. Supplier fill rate
1.23. Essential Drugs Availability
1.24. Percentage of encounters with an antibiotic prescribed
1.25. Percentage of client with 100% prescribed drug filled
1.26. Percentage of medicines prescribed from the facility’s medicines list
1.27. Pharmaceuticals wastage rate
1.28. PMS_EQUIP: Functionality of medical equipment
1.29. Percentage of Good governance index score
1.30. Proportion of reimbursed amount from the total spent
1.31. Major Elective Surgeries Performed

10 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

LIST OF HSPMI INDICATORS

HMIS CODE Name of HSPMI Indicator

2.1. Emergency room patients triaged within 5 minutes of arrival
2.2. Outpatient waiting time to Consultation
2.3. Timely Outpatient service initiation
2.4. Outpatients not seen on the same day
2.5. Percentage of hypoxemic patients treated with oxygen
2.6. Medical oxygen stock out rate
2.7. Inpatient Medical Record Completeness
02.8. Percentage of acceptable EQA result
2.9. Percentage of laboratory tests completed within TAT
2.10. Elective Surgical case cancellation ratio due to blood unavailability for surgical patients
2.11. Patients Receiving Rehabilitation Services
2.12. Antimicrobial stewardship functionality score
2.13. Anesthesia adverse outcome
2.14. Elective Surgical Cases Treated within clinically recommended Time
2.15. Safe Surgery Checklist Utilization
2.16. Major OR Table Efficiency
2.17. Percentage of Surgical Site Infection
2.18. Percentage of Imaging Service Interruption Days
2.19. Percentage of Pathology Service Interruption Days
2.20. Percentage of imaging service completed within TAT
2.21. Percentage of pathology tests completed within TAT
2. 22. Percentage of Medical Devices Repaired
2. 23. IPC FLAT Score
2.24. Pressure sore incidence
2.25. Percentage of women who died from Post-Partum Hemorrhage
2.26. Births by instrumental or assisted vaginal deliveries
2.27. Patient satisfaction Score
2.28. Staff satisfaction Score
2.29. EHSIG Score

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 11

List of Pool Indicators

Indicator number Name of Pool Indicator

3.1. Blood Product Wastage Rate

3.2. Number of Patients Seen

3.3. Pain Assessment Performed as 5th Vital Sign

3.4. Pain Management per WHO Standards

3.5. Palliative Home-Based Care Linkage

3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service

3.7. Functional improvement of rehabilitation clients

3.8. Rehabilitation Service Utilization

3.9. Percentage of SLIPTA standards met

3.10. Drug and Therapeutics Committee (DTC) Functionality

3.11. Clinical Pharmacy Service Functionality

3.12. Percentage of Medicine Actually Dispensed

3.13. Relative Share of Sources of Retained Revenue

3.14. Proportion of Beneficiary Groups to total visits

3.15. Retained Revenue spending as a share of total operating budget spending

3.16. MEMIS implementation

3.17. Mean time to respond to work order request for special healthcare setting

3.18. Proportion of vacancies filled as per the standards of the approved positions

3.19. Attrition rate of Healthcare workforce

3.20. Recipients of in-service and CPD training

3.21. Grievances received and solved

3.22. Occupational injury incidence

12 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.5. Analyze and report hospital HKPI data

Reporting period of public health facilities, 26th- 7th of next month. The PMT of the hospital is expected to
evaluate the data before submission. Hospital HKPIs data should be used to inform decision-making and
planning for performance improvement at all levels. Below are some specific considerations for hospital
administration, employees, Governing Boards, RHBs, and the MOH.

Each HKPI’s data owner is accountable for not just reporting the data, but also reflecting on it and
communicating with colleagues to enhance performance.

When examining HKPI data, consider the following questions:

• What is the difference between this HKPI’s result and the previous reporting period?
• Is there improvement or change?
• What caused the change in performance, and why did it happen?
• Has the goal been attained? What happened if the goal was not met, and why?
• Is there a need for this HKPI to be improved further?
• Is there any further information that needs to be gathered in order to learn more?

Is there anything else the RHB or other partners can do to help the hospital improve (e.g. training,
supervision)?

The HKPI data owner, in collaboration with the case team and other relevant colleagues, should assess
performance and suggest steps to enhance it. To handle performance monitoring and improvement
functions across the hospital, each hospital should have a performance review team or Quality Unit and
Quality Committee (QC). The quality committee should be multidisciplinary, with members drawn from the
hospital’s clinical, administrative, and support units. The chair of the committee or the head of the Quality
Unit should work full time and report to the CEO as a member of the hospital’s senior management team.
Roles of the Quality Unit include:

1. Develop and deliver a hospital performance and/or quality management strategy for approval to
the Senior Management Team.
2. To establish and monitor an implementation plan for improving hospital performance overall.
3. To ensure that performance management activities are in line with the hospital’s vision and goal, as
well as its strategic and yearly plans.
4. To coordinate all actions aimed at improving hospital performance.
5. To encourage and support all employees’ engagement in hospital performance improvement
efforts.
6. To collect and analyze input from patients, staff, and visitors.
7. Receiving clinical audit reports and keeping track of all clinical audit actions.
8. To review selected hospital deaths
9. To monitor HKPIs and HMIS indicator.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 13

 10. Conduct peer reviews in response to specific quality and safety concerns, and take necessary action
and follow-up when flaws are discovered.
11. Through cross-temporal comparisons, case team/department comparisons, and comparisons
with other health facilities, keep hospital staff informed about activities and discoveries linked to
hospital performance improvement.

3.6. Use of HKPIs by a Hospital Governing Board

The hospital CEO should present the Governing Board with hospital performance reports. The report,
together with the agenda and any other discussion materials for the Governing Board meeting, should be
circulated at least one week before the meeting. The Governing Board should discuss the report, identifying
areas of strength and weakness, and establishing a course of action with detailed follow-up steps.

If the Patient Satisfaction Score is low or declining, the Governing Board might ask the CEO to present the
full results of the Patient Satisfaction Survey to see if there are any particular areas of concern, as well as
to describe the actions that the hospital will take to improve patient satisfaction. Alternatively, if inpatient
mortality is high or rising, the Governing Board could ask the CEO if there are any factors that could explain
this (such as a communicable disease outbreak) or provide additional information on the mortality rate for
each ward or specialty (e.g. surgical mortality rate, pediatric mortality rate, etc.) to determine if there is a
specific problem area.

Questions that Governing Board members should consider while analyzing hospital HKPI data and
discussing with the CEO include:

1. How does each HKPI stack up against the previous reporting period?
 If there has been progress, how did it happen? Should any staff employees or case teams
who are responsible for the improvement be given special recognition?
 Why has this happened if performance has worsened?
 How does each HKPI compare to the reporting period’s target? Has the goal been attained?
Why not, if not?
2. In light of the HKPI findings, what actions should the CEO/hospital take?
3. What kind of support (e.g., training, supervision) is required by the RHB or other partners to assist
the hospital in improving?

3.7. Use of HKPIs by Regional Health Bureaus

RHBs should compare hospitals, monitor changes over time, and determine regional averages after
obtaining hospital KPI and EHSIG data and entering them into the Regional KPI and EHSIG/DHIS2
Databases. The RHB should provide comments on the KPI reports to each hospital, asking for clarification
or more information as needed. The RHB should also use hospital KPI data to highlight areas where the
RHB should take action. KPI reports, in particular, should be used as a source of information for hospital
site visits and regional review meetings. When examining individual hospital HKPI reports, the RHB should
think about the same questions that the Governing Boards should think about. In addition, the RHB should
compare hospital performance, particularly:

14 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 • Which hospitals are performing the best and/or worst?
• What are the region’s special strengths and/or weaknesses?

3.8. Use of HKPIs by MOH/Medical Service-LEO

The regional focal person selected by the Medical Service-LEO is responsible for receiving reports from all
RHBs, reviewing them, and providing timely feedback to the regions. Using the electronic national HKPI/
EHSIG database or DHIS2, regional reports should be used nationwide to track changes over time and
compute national averages. Medical Service-LEO should ask the same questions as RHBs when assessing
regional HKPI reports. Medical Service-LEO should also compare performance across regions, focusing on:

 Which regions are the most successful in terms of overall performance?

 Which ones aren’t performing as well as they should?
 Which areas are gaining ground? Which areas are improving slowly or not at all?
 What are the strengths and limitations that all areas have in common?

Medical Service-LEO should provide comments on the HKPI reports to each RHB, asking for clarification
or more information as needed. In response to HKPI reports, Medical Service-LEO should consult with
the RHB first, so that a combined response can be issued to the hospital and any follow-up action may
be decided upon jointly by MOH and the RHB. HKPI reports, in particular, should be used as a source of
information for hospital site visits and regional and national review meetings.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 15

 1
MODULE

HMIS INDICATORS
MODULE 1: HMIS INDICATORS
1.1. Out-Patient Attendance Per-Capita

Definition Number of outpatient department visits (days) per person per year.

Total number of outpatient visits

Formula
Total catchment population

Outpatient attendance shows the level of utilization of and access to outpatient

health care services. It reflects the interaction between demand and supply of
outpatient care. The use of outpatient services is inversely related to certain barriers
that may be physical, economic, cultural, (belief low awareness and health care
seeking behavior) or technical (poor quality of health care). It has been demonstrated
that OPD attendance visit goes-up when such barriers are removed through
bringing services closer to people and reducing user fees. It is used to examine
trends, variations, and use of service by type of facility and health care services,
geographic districts, and urban rural locations.

Every patient or client who visited any health facility including public, private,
non- governmental, and community-based health facilities for any service should
be included in OPD attendance report. Patients who attend the following services
Interpretation should be INCLUDED in the outpatient count and should be counted once a day:

General outpatient clinics

Specialty outpatient clinics (including Dental, Ophthalmic and Psychiatry)

TB clinics

ART clinics

VCT clinics

MCH clinics (EPI, IMCI, well baby clinics, ANC, PNC, family planning etc)

Private wing clinics

Patients attending the emergency department

Patients who attended services at dressing and injection room

Dis-aggregation Age, sex

Service delivery tally (for HP)/Central Card Room Register and patient attendance
Source
tally ,Central and Emergency Triage registers

Reporting level Health Post/Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 17

1.2. Bed Occupancy Rate

Definition Percentage of available beds that have been occupied over a given period
Sum-total of the length of stay (in days) in the reporting period
Formula X100
(Number of beds available)X(Number of days in the period)
Bed occupancy rate (BOR) is calculated as a percentage of the number of beds
effectively occupied (bed-days) for curative care divided by the number of beds
available for curative care multiplied by the number of days in the period. It is a
measure of the efficiency of inpatient services. Hospitals are most efficient at a
BOR of about 85%. If the BOR is lower, resources may be wasted. If the BOR is
higher than 85% there is a danger of staff burnout, over-crowding, and shortage of
beds during sudden increases in demand for in-patient services during epidemics or
emergency situations. Higher BOR is usually associated with reduced patient safety
and privacy and is associated with an increase in rates of in-hospital mortality. BOR
could be sharply increased during epidemics or emergency situations. In resource-
limited situations, hospitals may admit patients beyond their capacities and treat
them by keeping them on the floor, trolleys and stretchers and BOR could be
raised beyond 100%. Measuring BOR helps hospitals to determine inefficiencies or
stresses in service delivery to investigate and take action to address it, and also to
plan for the future staff or other resource requirements.

An operational (in-patient) bed includes beds for all components of curative

care of illnesses (including both physical and mental or psychiatric illnesses)
Interpretation or treatment of injury), diagnostic, therapeutic, and surgical procedures; and
obstetric services. It EXCLUDES beds in emergency room or emergency gynecology
departments, beds in day units or day surgery, temporary beds (stretchers or
trolleys, observation or recovery beds in the emergency department, operating
room or outpatient department, labor suite beds, delivery beds or couches,
examination beds for non-patients (e.g. beds for mothers accompanying children),
beds or cots for healthy babies who are born in the hospital or visiting the facility as
accompany. Beds for rehabilitative care, long term and palliative care should also be
excluded.

The length of stay should ONLY be counted for the actual reporting period. If a
patient was admitted during a previous reporting period, their length of stay during
that previous reporting period should not be counted for the current period. During
calculation, INCLUDE patients admitted to both public and private facilities.

Limitation: Comparing the performance of hospitals of the same level but with
different number of beds using BOR may be misleading. Hospitals with fewer beds
(fewer than the standard) can have higher BOR than hospital of the same level (in
the tier system) with higher number of hospitals
Dis-aggregation None
Source Inpatient admission/discharge (IPD) register
Reporting level Health center/Clinic/Hospital/
Reporting Frequency Monthly

18 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.3. Average Length of Stay (in days)

The average length of stay (in days) of patients in an inpatient facility during a given period
Definition
of time
Total length of stay (in days)
Formula
Number of in-patient discharges
Average length of stay is a measure of health service quality and efficiency. It
reflects the appropriate utilization of inpatient services. By monitoring length of
stay, hospitals can assess if patients remain in hospital for longer than what is
necessary, perhaps due to non-clinical reasons, and investigate further if required.
The longer the patient stays at hospital, the greater the risk of developing health
facility-acquired infection, lower patient capacity of hospitals and increased costs.
Decreased ALOS has been associated with decreased risks of nosocomial infections
and side effects of medication rates, reduced burden of medical fees and increase
the bed turnover rate and lowered social costs.
Interpretation
NB: If the patient is directly discharged or transferred to home or other facility from
ICU the length stay should be counted.

During calculation, discharge includes discharge due to any possible reasons

including death, referral, terminal, absconded, or death. Analysis by type of ward is
more informative for facility level analysis and pinpoint area of improvement.

Limitations: Regional or national level aggregation of ALOS may be less informative to

identify types of disease and wards with increased or lower ALOS.
Dis-aggregation None
Source Inpatient admission/discharge register
Reporting level Health center/Clinic/Hospital/
Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 19

1.4. Hospital Bed Density

Definition Total number of hospital beds per 10, 000 population

Total number of functional beds in the hospital

Formula X 10,000
Total number of population

The indicator contributes to the measurement of facility infrastructure

management, such as physical availability and accessibility of health services. It is a
measure of access to hospital service, equity in access and inform plan for possible
expansion of hospital service. It excludes labor and delivery beds. The total population
Interpretation should consider all population that need to have access to hospital service.

Limitations: the indicator shows access at a point in time. Because of catchment

population overlap at the lower level, the indicator could be exaggerated and
misleading at the lower level of health system.

Dis-aggregation None

Source Tally sheet/register at liaison/ward to capture the number of beds

Reporting level Hospital

Reporting
Annually
Frequency

1.5. Assistive Technology Service Utilization

Definition Proportion of clients received AT service among those who sought AT service

Total number of clients received AT service

Formula X100
Total number of clients registered to receive AT service

This indicator measures the demand satisfied for AT by people with different types
Interpretation of dis- ability. It shows the inclusiveness of the health service to provide technology
services to the disabled to improve their quality of life.

Category of disabilities (Physical, mobility, hearing, others)

Dis-aggregation
Age, sex

Source AT service register (New)

Reporting level Hospital

Reporting
Quarterly
Frequency

20 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.6. Essential laboratory test availability

The number of days in which all health center or hospital specific essential laboratory
Definition
tests were available in the reporting period

Total number of days each essential laboratory tests are available in the facility
during the reporting period
Formula X100
(Total number of facility specific essential tests) X (Total number of days in the
reporting period)

Hospitals and health centers are required to avail the minimum laboratory tests
recommended by Food and Drug Administration standards at all times. The
availability of health facility specific essential laboratory tests is a measure of service
availability. Essential tests should ALWAYS be available at the health facility. If one of
Interpretation
these tests is unavailable at any time, the health facility should take action to identify
and address the cause. For the RHB, knowledge of the availability of health facility
specific essential laboratory tests in hospitals helps to assess the adequacy of
access to laboratory tests and helps to address issues of good governance.

Dis-aggregation None

Source Excel based tally sheet(electronic)

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 21

1.7. Referral-out Rate

Definition Proportion of patients who are referred to another health facility

Number of referred patients (emergency + non- emergency)

Formula X100
Total number of OPD visits(emergency and regular OPDs)

A referral is the process in which a health worker at one level of the health system,
having insufficient resources (drugs, equipment, skills) to manage a clinical condition,
seeks the assistance of a better or differently resourced facility at the same or
higher level to assist in, or take over the management of the case. An effective
referral system ensures a close relationship between all levels of the health system
and helps to ensure people to receive the best possible care closest to home.

Referral rate is an indicator of quality of health care. Referrals are systems that are
important for clients to receive the proper care they need in another health facility.
A high number and proportion of referrals made from a health facility to another
health facility may indicate that the health facility is not providing all services
required, whereas a low number and proportion of referrals might indicate that the
Interpretation
health facility is not following referral guidelines and is treating patients beyond their
capacity. Knowing the rate of referrals helps to plan for future service provision.

A referral rate of a facility ranges from 10-20% and it should be interpreted

cautiously by taking expert’s suggestion into consideration. When referral rate is
below 10%, it indicates the need to conduct audit on professional scope of practice
to discern if the health facility is practicing health care delivery beyond its scope. If
the referral rate is above 20%, it signifies the need to identify the top-five reasons for
referral and consider expanding service.

Limitation: The indicator is more informative at the facility level and doesn’t indicate
reasons for referral-out.

Dis-aggregation Emergency and non- emergency

Source Referral register/Liaison register, OPD tally sheet

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

22 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.8. Ambulance service utilization for referral service

Definition Percentage of referral-in with ambulance among the emergency referral-ins

Total number of emergency referral-in with ambulance

Formula X100
Total number of all emergency referral-in the reporting period

This indicator shows the percentage of emergency referrals that used ambulance
to travel to the health facility and roughly measures the utilization of ambulance
service. Because this indicator doesn’t show the service quality, it should be
interpreted along with ambulance response rate, which shows the use of EMT
Interpretation or nurse accompanying the emergency case. When calculating this indicator, all
referrals including referral-ins should be included in the denominator.

Referral In is defined as referrals coming from other facilities and those from the

Community

Dis-aggregation Pre-facility, between facility

Source Emergency register

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 23

1.9. Ambulance service response rate

Definition Percentage of community ambulance requests for whom ambulance was dispatched

Number of ambulance requests for whom ambulance was dispatched

Formula X100
Total number of community requests made for ambulance service

Pre-facility emergency care and ambulances service is an emergency care outside

of a health facility or at the scene and continuing care during transportation with
ambulance and ends with proper hand over of patient or victim to respective
health facility. When it is accessible to the community, it contributes for reduction
of deaths and disability due to acute illness and severe injuries. A high response
rate indicates the services the system’s responsiveness and availability of services,
and adequacy of the number of ambulances. Low response shows demand and
capacity gap. The target is more than 90% of actual emergency call has to get
ambulance dispatch for the service. The dispatch center where the register will be
Interpretation put could be different and it should be placed in all centers where there are call
and dispatching of ambulances.

Limitation: This indicator doesn’t show the community demand for ambulance
service, as the community members who have awareness about the service and
who have the capability to make a call request ambulance services.

N.B. The number of Ambulance Requests includes all requests that are made
within the facilities and from the community. Data should be collected from
centralized call & dispatch centers, facilities, and/or woreda.

Labor & Obstetrics Emergency, Neonatal Emergency, RTA, Trauma, Non-traumatic

Dis-aggregation
emergency, Burn & Poisoning

Source Ambulance service register

Reporting level Health center/Clinic/Hospital/ Woreda

Reporting
Monthly
Frequency

24 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.10. Facility emergency department mortality rate

Percentage of patients died at the emergency department within 24 hours among all
Definition
emergency attendances

Total number of deaths in emergency unit within 24 hours

Formula X100
Total number of emergency room attendances

The emergency department mortality is a measure of the quality of care provided

by the emergency department of the health facility within 24 hours of arrival at
the emergency room. A high mortality could indicate that the facility is providing
poor quality emergency care with unnecessary patient deaths against national
target. Nationally emergency room mortality should be less than 0.6 %. The
number of deaths within the facility in places other than emergency room should
be captured as absolute number can be used to see the trend.

Interpretation N.B. A Patient who is already dead on arrival should be excluded in the indicator.

Dead on arrival means when the patient arrives to the triage area and confirmed
dead

by the physician.

Note that the crude number of death >24 hours is collected at all OPDs & IPDs
but not included in the calculation of this indicator. Crude data will be used to
assess the overall emergency care throughout the facility.

Sex: Male/Female

Dis-aggregation Age <15 years, 15+ years

< 24 hours, >=24 hrs

Source Emergency register

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 25

1.11. Emergency room attendances with length of stay > 24 hours
The proportion of all emergency room admissions who remain in the emergency room for
Definition
> 24 hours
Total number of admissions who remain in emergency room for more than 24
Formula hours X100
Total number of emergency room discharges (disposed)
Hospitals have emergency room beds where patients can stay for a short period of
time to receive emergency treatment. However, the length of stay (starting from
the 1st minute of triage) in the emergency room should always be less than 24
hours. If a patient requires treatment for longer than 24 hours, the patient should
be transferred to a ward. If emergency room beds are occupied by patients for
more than 24 hours, then the emergency room will become congested and there is
Interpretation
a danger that the emergency room will not have the capacity to receive any NEW
emergency attendances.

The indicator includes all patients registered in the emergency room (of both sexes
and all ages) and excludes patients who were already dead (i.e. no vital signs present)
on arrival.
Dis-aggregation None
Source Emergency register
Reporting level Health center/Clinic/Hospital/
Reporting
Monthly
Frequency

1.12. Percentage of ventilator associated pneumonia

The percentage of ICU clients who have developed ventilator associated pneumonia
Definition
among those who were intubated for mechanical ventilation

Total number of clients developed ventilator associated pneumonia

Formula X100
Total number of ICU clients on ventilator

Ventilator associated pneumonia is one of the common complications that affects

the clients in the ICU. The probability of developing VAP of a patient in the ICU
Interpretation
depends on the skills of ICU staff to provide mechanical ventilation to patients and it
measures the quality of ICU service and determines the outcome of the patient.

Dis-aggregation None

Source ICU register

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

26 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.13. Mortality rate in Intensive Care Unit

Definition Percentage of patients who died in the ICU among those admitted to ICU

Number of deaths in ICU

Formula X100
Total number of discharges from ICU

Intensive Care Unit (ICU) service is an initiative to enhance critical care in the
Ethiopian health care delivery system. The ICU has to have at least 4-6 bed, along
with cardiac monitors for each of the beds, and mechanical ventilators. The
ICU mortality rate helps to monitor the quality of care in the ICU. Even though
the number of beds in ICU of hospitals is few, it consumes 8% to 20% of the
hospital’s budget.

The mechanical ventilator machine, without appropriate monitoring and

evaluation, has its own side effects including machine related baro-trauma,
infections, machine failure which is associated with serious effect to the
patient. Death with mechanical ventilation means death of a patient after
mechanical ventilation was provided with endotracheal intubation. Death
without mechanical ventilation is death of a patient without being provided with
Interpretation a mechanical ventilation using endo-tracheal intubation.

Though there is no known data about specific death related to conditions

associated with use of mechanical ventilator, according to WHO
recommendation, total mortality rate in ICU for developing countries lie
between 30% and 35%. If the general mortality rate is more than 35 %, it needs
investigation.

NB. This indicator doesn’t include Neonatal ICU death. In addition, discharge
should include the deaths as denominator. It should also exclude death at high
dependency units.

Limitation: the indicator could underestimate the mortality in the ICU as patients
who are not actually eligible for ICU may be admitted to the ICU

Dis-aggregation With vent, without vent, <24 hours, >=24 hours

Source ICU register

Reporting level Hospital

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 27

1.14. Perioperative mortality rate

All-cause death rate prior to discharge among patients having one or more procedures
Definition
for a major surgery in an operating theatre during relevant admission for a major surgery

Number of deaths among patients having one or more procedures in an

operating theatre admitted for major surgery
Formula X 100
Total number of patients for whom major surgery has been conducted

This indicator is rough measure of quality and safety of surgical service in the
facility. It includes all death that happen after anesthesia was provided to the
patient until discharge. The denominator for this indicator, which is the number of
major surgical procedures done per year is an indicator of met need for surgical
services. Ethiopia had the least surgical volume in the world [9]. With the high
surgical need of the population, this indicator will show progress across time
towards meeting demand for surgical care services. It informs policy and planning
regarding met and unmet need for surgical service. It is a rough indicator of access
to service [2]. Hospital procedure volume is assumed to be a proxy measure
Interpretation of experience of doing surgeries repeatedly over long period of time. There is a
relation between volume and outcome of surgeries, when the surgical volume
of a hospital is very high and surgeries are concentrated in high volume centers,
it has been associated with better outcomes. [10]. WHO estimates about 6495
operations per 100,000 populations per year are required in sub-Saharan Africa
in which 95% of those requiring surgical care do not have access to the service [11,
12].

NB: Major surgery is defined as a procedure performed under general anesthesia,

regional anesthesia or profound sedation in an operation theatre.

Dis-aggregation Elective, emergency

Source OR register, IPD register, Surgical ward register

Reporting level Hospital

Reporting
Monthly
Frequency

28 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.15. Average length of ICU stay

Definition The average length of stay (in days) of patients in the ICU during a given period of time
Sum total length of stay in ICU (in days)
Formula
Number of ICU discharges
The duration of ICU stays for clients that received care at ICU indicates the quality of
care at the ICU. Bed rest is considered as part the treatment for admitted patients
Interpretation with critical illnesses. An average of 3.3 days of stay in an ICU bed is considered
adequate to provide adequate rest and treatment for critical patients. A critical
patient is expected to spend an additional 1.5 days in non-IUC bed.
Dis-aggregation None
Source ICU register
Reporting level Hospital
Reporting
Monthly
Frequency

1.16. Mean duration of in-hospital pre-elective operative stay

Definition The mean duration of in-hospital pre-elective operative stay in days

Total number of in-hospital pre-elective operative stay in days

Formula
Total number of elective surgeries conducted in the period

The mean duration of in-hospital pre-elective operative stay shows the length of
duration a patient spends in the hospital from admission to operation. It shows
Interpretation the readiness of the surgical team and the facility within the acceptable duration. It
is a proxy measure of cancellation of surgeries in that if there a higher cancelation
rate, the mean duration of in- hospital pre-elective operative stay will be higher.

Dis-aggregation None

Source Surgical ward register

Reporting level Hospital

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 29

1.17. Number of clients in the waiting list for elective surgical service

Definition The number of clients in the waiting list for elective surgery

Formula The absolute number of clients in the waiting list for elective surgery

In countries where the access to surgical services is limited, hospitals usually tend to
have long list of clients waiting for surgical procedures. The number of clients in the
Interpretation waiting list for surgery roughly measures access to surgical services and can help to
inform allocation of resources and finalize the plan. It shows the backlog, demand for
elective surgeries and the need for expanding surgical services.

Age, <15 years, >=15 years

Dis-aggregation
Service (General surgery, Urology , Neurology , Orthopedics, Plastic, Pediatrics,
Gynecology, Ophthalmology, ENT, Others

Source Register at liaison to capture

Reporting level Hospital

Reporting
Monthly
Frequency

30 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.18. Delay for elective surgical admission

The average number of days that patients who underwent elective surgery during the
Definition
reporting period waited for admission

Sum total of number of days between date added to surgical waiting list to date of
Formula admission for surgery

Number of patients who were admitted for elective surgery

It is the average number of days between the dates each patient was added to the
waiting list to their date of admission for surgery. Delays in surgery for different
conditions are associated with a significant increase in morbidity and mortality.
The Government has set a stretch objective that any outpatient who requires a
bed should receive the service within 2 weeks. By monitoring the waiting time for
surgical admission, hospitals can assess the adequacy of surgical capacity and
identify the need for improved efficiency in systems and processes, and/or the need
for additional surgical staff and/or resources

Interpretation EXCLUDE:

Elective Caesarean Sections

Emergency Surgery

Ophthalmic Surgery

NB: If a cold case patient is admitted on the same day (the same calendar date) that
the decision for surgery is made, then their number of days on the waiting list should
be counted as zero.

Dis-aggregation None

Source Surgical ward register, liaison register

Reporting level Health center/Clinic/Hospital/

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 31

1.19. Inpatient mortality rate

Definition Inpatient deaths before discharge per 100 patients discharged

Number of inpatient deaths

Formula X100
Total number of discharges

Provides rough evidence regarding quality of care when compared with other
facilities. Care should be exercised, however. The level and location of a facility may
affect its case mix. The inpatient mortality rate is calculated as the number of IPD
Interpretation deaths divided by the number of IPD discharges in the facility during a given time
period. The number of deaths can be known from the monthly totals of IPD deaths
reported. The inpatient mortality rate can be estimated at all levels except Health
Post.

Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66

Dis-aggregation Sex: Male, Female

Service Area

Source In-patient registers.

Reporting level HC/Clinic, Hospital

Reporting
Monthly
Frequency

32 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.20. Top 10 causes of morbidity

Definition The ten leading causes of morbidity per 1000 population

Number of new OPD + IPD Cases from specific diseases
Formula X1000
Total population in the catchment area
Provides evidence regarding priorities for planning and resource allocation. The top
ten causes should be listed, from highest to lowest. The total number of cases seen
at OPD and IPD and the cases per 1,000 should also be included for comparison.
Interpretation This indicator may show the burden of specify diseases in the community.

Note:-The numerator should include only those who are new cases so that a person
will not be counted more than once for the same illness/disease.
Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66
Dis-aggregation
Sex: Male, Female
Outpatient (OPD) registers, Inpatient register, Emergency register; Disease
Source
information tally (HP)
Reporting level Not to be reported but to be analyzed
Reporting
Annual but can be done at anytime
Frequency

1.21. Top ten causes of institutional mortality

Definition The ten leading causes of mortality

Number of deaths in a health facility from specific disease

Formula X100
Total number of discharge
The top ten causes can be known from the annual totals of monthly IPD deaths
reported. Provides evidence regarding priorities for planning and resource allocation.
The top ten causes should be listed, from highest to lowest. The total number of IPD
deaths and the case fatality rate should also be included for comparison with other
Interpretation locations. While deaths are reported monthly, the top ten are calculated annually,
based on the sum of monthly totals. IPD death is death of a patient who was alive
when he/she came to the health facility and died afterwards. Note that patients who
died at arrival before admission/at emergency should not be counted and include
deaths from OPD, emergency, IPD, ICU and NICU.
Dis- Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66
aggregation Sex: Male, Female
Outpatient (OPD) registers, Inpatient register, Emergency register; Disease information
Source
tally (HP)
Reporting level Not to be reported but to be analyzed
Reporting
Analysis Frequency (Any time)
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 33

1.22. Supplier fill rate
Supplier fill rate is the percentage of correctly filled items (at least 80%) by quantity by
Definition supplier (EPSA, or other private supplier who have agreement to supply) of total order made
by a health facility over a given period.
Number of line item delivered at least 80% of the requested amount
Formula X100
Total number of line item requested
This indicator measures supplier’s ability to fill orders completely in terms of items
and quantity during a definite period of time.

An item in an order is considered completely filled if at least 80% of the request is

filled in
Interpretation
the correct quantities with the correct products.

This indicator also helps health facilities to identify which items are causing the most
prob-

lems and find another mechanism for obtaining those items

Disaggregation By type of supplier: (EPSA, others), By category: RDF, Program

RRF report, Receiving voucher of HF, approved procurement request by DTC or HF

Sources
head
Reporting level Health center/Hospital/
Reporting
Quarterly
Frequency

34 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.23. Essential Drugs Availability

The number of months in which a tracer drug was available averaged over all tracer
Definition
drugs during the month
Number of tracer drugs available in all days of the reporting month X 100
Formula
Total number of tracer drug specific for facility level

Essential drugs should always be available. Essential drug availability is the

proportion of months in the time period under consideration for which a given
tracer drug was available when needed. The availability can be averaged over
several tracer drugs to give a general picture of availability. The type of essential
drug that needs to be avail- able differs by type of health facility. The following
drugs are those essential drugs that are selected as tracers for essential drug
availability:
For Health Posts:
Amoxicillin dispersible tablet
Oral Rehydration Salts
Zinc dispersible tablet
Gentamycin Sulphate injection
Interpretation Medroxyprogesterone Injection
Arthmeter + Lumfanthrine (Coartem) tablet (any packing)
Ferrous sulphate + folic acid
Albendazole tablet/suspension
For health centers and hospitals:
Medroxyprogesterone Injection
Pentavalent vaccine
Magnesium Sulphate injection
Oxytocine inj
Gentamycin injection
ORS+/- Zinc sulphate
Amoxcillin dispersable/suspension/capsule

Disaggregation No disaggregation
Sources This information is available from records kept at the facility drug dispensary
Reporting level Health post /Health center/Clinic/Hospital/
Reporting Frequency Monthly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 35

 Iron + folic acid
Albendazole/Mebendazole tablet/suspension
TTC eye ointment
RHZE/RH
TDF/3TC/DTG
Co-trimoxazole 240mg/5ml suspension
Arthmeter + Lumfanthrine tablet
Amlodipine tablet
Frusamide tablets
Metformin tablet
Normal Saline 0.9%
40% glucose
Adrenaline injection
Tetanus Anti Toxin (TAT) injection
Omeprazole capsule
Metronidazole capsule
Ciprofloxcaxillin tablet
Hydralizine injection
Any month in which a drug unavailability is experienced, even for only 1 day, is
reported as a month in which the drug was unavailable when needed

Disaggregation No disaggregation

Sources This information is available from records kept at the facility drug dispensary

Reporting level Health post /Health center/Clinic/Hospital/

Reporting Frequency Monthly

36 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.24. Percentage of encounters with an antibiotic prescribed

The percentage of encounters with one or more antibiotics prescribed per

Definition
individual patient
Total number of encounter with one or more antibiotics
Formula X 100
Total number of encounter
This indicator measures the overall level of antibiotics use. Imprudent use
of antibiotics leads to antimicrobial resistance. The emergence and spread
of Antimicrobial resistance (AMR) continues to threaten the ability to treat
common infections and is becoming ever-growing concern in the healthcare
community. AMR can lead to treatments becoming ineffective and
accelerate the spread of infections. The cost of AMR to national economies
and their health systems is significant as it affects productivity of patients
or their caretakers through prolonged hospital stays and the need for more
expensive and intensive care.
Interpretation
One of the major preventive intervention to curb antimicrobial resistance is
proper antibiotic prescription and utilization. Globally, only 20-30% of the
prescription for patient encounter should have antibiotic.

Encounter refers to every patient’s or client’s visit to the health facility.

Whether a patient is given one or more prescription papers per visit, all is
considered as one encounter.

Limitation: Those clients that are sent home with counseling and advice i.e.
without a prescription are missed
Disaggregation No disaggregation
Data Sources Drug dispensing Register
Reporting level Health center/Clinic/Hospital/
Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 37

1.25. Percentage of client with 100% prescribed drug filled

Percentage of clients who get all the prescribed medicines (100%) from the health
Definition facility dispensary among all the clients who received prescriptions in a given time
period.

Number of client who received all prescribed drug

Formula X 100
Total number of client who received prescription

This indicator measures proportion of clients who get all the prescribed
drugs within the facility. It is one of the indicators that tell about continuous
availabilityof medicines. Getting prescribed drugs within the facility pharmacy
improves patient satisfaction and overall trust and confidence in the health
Interpretation
sector.

It is expected that all clients should get all the prescribed drugs (100%) from the
health facility dispensary.

Disaggregation No disaggregation

Sources Drug dispensing Register

Reporting level Health center/Clinic/Hospital/

Reporting Frequency Monthly

38 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.26. Percentage of medicines prescribed from the facility’s medicines list

The percentage of medicines that are prescribed from the health facility medicine
Definition
list out of the total number of medicines prescribed

Total number of medicines prescribed from Health facility medicine list

Formula X100
Total number of medicine prescribed

Every health facility is expected to have a medicine list specific to the facility
based on its history of disease burden. This facility medicine list is revised
periodically to address emergence of new needs and change in disease pattern
in the facility.

Accordingly, health care workers are expected to prescribe medicine that are
Interpretation listed in the health facility. The more health care workers prescribe medicines
from the health facility list, the better chance that patients /clients get the
medicine and the more likely that patients get them for cheaper price. It also
prevents clients from frustration and improves satisfaction.

Monitoring this indicator regularly and taking corrective actions for any gap
identified should be a major activity of health facilities

Disaggregation No disaggregation

Sources Drug dispensing Register

Reporting level Health center/Clinic/Hospital/

Reporting Frequency Monthly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 39

1.27. Pharmaceuticals wastage rate

The percentage of the stock of products, in value, that are unusable because of
expiration or damage during a period to the total value of the products received during
Definition
the same period plus the quantity of the products found during the beginning of the
period

Unusable stock of products during a period in monetary value

Formula X100
Beginning stock+ received stock during the same period in monetary value

This indicator can be calculated for any facility that manages pharmaceutical of
interest. It can be measured over any period but it is preferable to be calculated for
unusable stock with in a quarter. It is usually calculated after a physical inventory
is taken. Unusable stock that has been accumulated for long period and were
not disposed previously (expired and damaged items that were transferred from
Interpretation previous quarter) should not be included during calculation of this indicator.
In addition, items that were unusable during the quarter reviewed but were
disposed with in the quarter should be taken in to consideration during calculation.
This indicator is one of the performance indicators to have efficiency gain,
which is one of the HSTP priorities. The target in HSTP is to reduce wastage of
pharmaceuticals to less than 2%.

Disaggregation By: RDF, Program

Sources Bin cards/stock cards

Reporting level Health center/Clinic/Hospital

Reporting
Quarterly
Frequency

40 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.28. PMS_EQUIP: Functionality of medical equipment

Percentage of functional medical equipment from the health facility’s updated

Definition
medical equipment inventory list

Number of functional medical equipment in the health facility

Formula X 100
Total number of available medical equipment in the health facility from
updated medical equipment inventory list
This indicator measures percentage of functional medical equipment in the health
facility at the time of reporting. Functional medical equipment are instruments
which are giving the expected services. To monitor and evaluate this indicator, the
health facility should establish computer based or manual medical equipment
inventory system and also should update the inventory whenever additions or
omissions of medical equipment occur to the health facility. Health facilities should
use the Medical Equipment Inventory Form to register medical equipment that is
Interpretation
available in the health facility.

Medical equipment refers to a capital medical device used for specific purpose
of diagnosis and treatment of disease or rehabilitation following disease or
injury it can be used alone or in combination with any accessory consumable or
other devices requiring professional installation, user training, commissioning,
maintenance, calibration, decommissioning.

Disaggregation No disaggregation

Sources Facility medical equipment inventory

Reporting level Health center/Clinic/Hospital/

Reporting
Annual
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 41

1.29. Percentage of Good governance index score

Definition Percentage of Good governance index

Formula Good Governance Index Assessment Score

The Good Governance Index is an important tool for measuring the extent to
which hospitals adhere to principles of good governance. It measures the status
of good governance of the hospital by reviewing those standards against the
good governance principles. The tool contains three thematic areas

1) Response to public grievance

2) Service Delivery and

Interpretation 3) Health Systems.

It is essential for building trust and ensuring the effective functioning of

institutions. Implementing GGI on the hospital changes the service quality in
remarkable way through creating accountability and engaging all health care
service stakeholders and actors.

Note: Good Governance Index (GGI) score > 80% is met and <80% is un met. GGI
Score that did not conduct the assessment will be considered as having a GGI
value of less than 80%.

Dis-aggregation None

Data Source Good governance index measurement checklist, Annex 1

Unit of
Percentage
measurement

Reporting
Quarterly
Frequency

42 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

1.30. Proportion of reimbursed amount from the total spent
This refers to the proportion of money paid back (reimbursed) to the
hospital out of the total costs incurred in providing health services on
post payment basis such as services for health insurance beneficiaries,
other credit services and exempted health services out of the total
expenditure the hospital incurred to provide these services.

Reimbursed costs are expenses incurred by an individual or organization

Definition
that are later compensated or repaid by another party. Reimbursement
typically occurs when a party incurs expenses on behalf of another
party, such as an employee making a business expense or a healthcare
provider conducting a medical procedure. The individual or organization
that incurs the expense can then submit a claim for reimbursement to
the other party, who will pay back the incurred costs.

Reimbursed amount of spending to the hospital

Formula X 100
Total amount of spending requested to be reimbursed

There is no health care service provided for free. In one way or another
amount of money that the health facility spent should be reimbursed.
Costs incurred for exempted health services should be covered by
the government or by the development partners; costs for insurance
beneficiaries by health insurance schemes, and costs of credit services
must be covered by the third party.

Currently health insurance programs are expanding and out of pocket

payment is being replaced by post-payment. Furthermore, hospitals
Importance/interpretation are covering cost of exempted health services from internal revenue
as adequate budget is not allocated and/or there is no adequate donor
funding to cover costs of these services. Therefore, hospitals should
improve their data capturing system to record accurate service and cost
data; conclude strong agreement with the concerned paying bodies,
make timely reimbursement requests, and closely follow up actual
reimbursements. Thus, this indicator helps hospitals to improve their data
capturing system, to device mechanisms for new payment arrangements,
and take timely corrective action. It also provides information to formulate
alternative policy options.
Disaggregation CBHI, SHI, Free, exempted, 3rd party payment (Road Traffic Accident
Data sources Financial statements, audit reports
Unit of measurement Percent
Frequency of reporting Quarterly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 43

1.31. Major Elective Surgeries Performed

Percentage of major elective surgeries performed out of those who are on

Definition
waiting list

Total number of major elective surgeries performed

Formula X 100
Number of patients on waiting list

This indicator will help to measure how many surgeries are being
Importance/ performed out of those who are waiting for surgery. It will show if the
interpretation surgical service is meeting the demand of clients. Clearance rate of the
waiting list.

Across all departments providing major elective surgical services exclude

Disaggregation
all ophthalmic surgeries and C/S

Data source Liaison and OR registers

Unit of measurement Percent

Frequency of reporting Monthly

44 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 2
MODULE

HSPMI INDICATORS
MODULE 2: HSPMI INDICATORS
2.1. Emergency room patients triaged within 5 minutes of arrival

Percentage of all patients presenting to the emergency room who were

triaged within 5 minutes of arrival. It is a time from arrival to ER gate to ER
Definition
triage initiation. When we say EOPD it includes Pediatric, Adult, Gynecology /
Obstetrics, Emergency OPDs.

Number of surveyed patients who undergo triage within 5

minutes of arrival at emergency room gate
Formula X 100
Number of patients included in emergency room triage time
survey
Triage is a process of sorting patients into priority groups according to their
need and available resources. The aim of triage is to give priority treatment
to those with the most critical conditions, thus minimizing delay, saving lives,
and making the most efficient use of available resources. The first five minutes
of arrival in the emergency room (ER) is the most critical time to save lives. If
assessment and treatment is not initiated during this time then lives will be
lost unnecessarily.

By monitoring the % of patients triaged within 5 minutes the hospital can

assess whether ER services are sufficient and identify the need for additional
Interpretation
staff and/or resources and/or service redesign to reduce waiting times in ER.

Protocol for survey to measure % of patients triaged within 5 minutes of arrival

in ER attached in Annex 2.

The survey should be conducted at 3 different time periods on the first week of
the final month of each reporting period as follows:

• Monday: 8am to 12 noon

• Wednesday: 12 noon to 5pm
• Sunday: 5pm to 8am
Dis-aggregation None
Data Source Survey – see Annex 2
Unit of
Percentage
measurement
Reporting
Quarterly
Frequency

46 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.2. Outpatient waiting time to Consultation

Outpatient waiting time to consultation is an average time from arrival at triage

Definition
to physician first contact.

Sum total of outpatient waiting time (in minutes)

Formula
Number of outpatient “waiting time cards” completed

The time that a patient waits from arrival to treatment is a measure of access
to health care services. Long waiting times indicate that there is insufficient
staff and/or resources to handle the patient load or the available resources
are being used inefficiently. By measuring waiting time a hospital can assess if
there is a need for extra personnel, service unit expansion or other resources in
the outpatient department. It also helps to identify need to review patient flow
processes to increase the efficiency of service provision.

The survey should be conducted on Monday and Thursday of the first week of
Interpretation
the last month of each quarter. The time can be further sub-divided in to different
service point (Triage to MRU, MRU to waiting area, & waiting area to OPD) include
in interpretation part. All OPDs like Medical, Surgical ANC,FP, NCD etc should be
included in survey.

EXCLUDE:
Patients not seen on the same day
• Patients who have an appointment and who go immediately to the OPD
waiting area without attending registration or triage
Dis-aggregation Regular OPDs, Specialty Clinic

Data Source Survey – see the protocol in Annex 3

Unit of
Minutes
measurement
Frequency of
Quarterly
Reporting

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 47

2.3. Timely Outpatient service initiation

The percentage of outpatient rooms that initiated service exactly at the

Definition
time of government work starting time.

Number of outpatient examination rooms

Formula that started service timely on both survey days
= X 100
Total Number of outpatient examination rooms

All outpatient examination rooms should start service to patients at the

government opening time. Timely initiation of services will contribute
to, reducing outpatient waiting time, and improving outpatient
satisfaction. By measuring timely outpatient service initiation, the
hospital can assess if there are modifiable factors contributing to
untimely initiation of services.
Importance
/Interpretation/ Note: The survey should be conducted on Monday and Thursday

OR market/ busy day and a less likely free day of a certain week of each
month. OPD’s which started late in one of the survey days shouldn’t
be counted as early initiators. Responsible survey coordinator is an
OPD director in collaboration with Quality Unit. All OPDs like Medical,
Surgical ANC, FP, NCD etc should be included in survey.

Dis-aggregation Regular OPD, Specialty Clinic

Data Source Survey tool and tally sheet- See Annex 4

Unit of
Percentage
measurement

Frequency of
Monthly
Reporting

48 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.4. Outpatients not seen on the same day

Number of all outpatients were not seen on the same day of visit after triage
Definition
to the outpatient department

Sum total of outpatients were not seen on the same day with in the reporting
Formula
period

All patients should be seen in the OPD on the same day that they register for
Importance treatment. By measuring the number of patients that were not seen on the
same day. The hospital can assess if there is a need for extra personnel and/
/Interpretation/ or other resources in the outpatient department and/or to review patient flow
processes to increase the efficiency of service provision.

Dis-aggregation Regular OPDs, Specialty Clinics

Data Source OPD Register, MR Register, Central Triage Register

Unit of
Number
measurement

Frequency of
Monthly
Reporting

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 49

2.5. Percentage of hypoxemic patients treated with oxygen
The percentage of hypoxemic patients who have treated with oxygen for any
disease

resulting hypoxemia as per the standard prescription.

• Standard prescription describes rational use of oxygen through

» Prescribed O2 at any time including at Dx and during stay (emergency,

IPD).
Definition
» State mode of delivery (Nasal prong, Nasal Catheter, Ventury Mask or
Face Mask)

» State flow rate, target saturation and mention frequency of monitoring

» Received O2 therapy and SPO2 monitored as prescribed

» O2 therapy stopped after at least two records of improvement.

Number of patients with hypoxemia

who received oxygen treatment
Formula as per the standard
X 100
Number of
All eligible patients for oxygen Treatment
Oxygen is vital to combat any respiratory system related morbidity and
mortality. It is also useful in the treatment of many obstetric emergencies,
Importance cardiac arrest, acute blood loss, shock, dyspnea, pulmonary edema,
unconsciousness, convulsions, and fetal distress.
/Interpretation/
NB. Assessing level of O2 saturation for all patients in central triage and
Emergency also regular checkup when V/S taken
Dis-aggregation Patient outcome, Department
For the survey use 50 hypoxic patients’ charts from different service
areas (ER, IPD, ICU, OR), If <50 all hypoxic patients charts should be
Data Source audited . In addition to this, patient chart should be triangulated with the
following formats : Triage forms, Order Sheet ,Vital sign sheet, Medication
Administration sheet
Unit of
Percentage
measurement
Frequency of
Monthly
Reporting

50 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.6. Medical oxygen stock out rate

Medical oxygen stock out rate is the percentage of oxygen stock out days at
Definition
facility among total days in reporting period.

Number of days with oxygen stock out

Formula X 100
Total number of days in reporting period

Access to safe oxygen is essential for saving life. However, oxygen remains
under supplied In Ethiopia; alike many low- and middle-income countries
and often, patients who require oxygen for survival do not receive it.

The biggest challenge for health care supply chains is to manage inventory
of oxygen supply efficiently and keep up the satisfactory service level at the
same time. As oxygen is essential supplies in medical industry, proper stock
management system will help to ensure the quality health service.
Interpretation
Oxygen is a drug registered in WHO list of emergency essential drugs, so
that it should be prescribed as per the standard prescription to secure its
rational use too.

Note: All hospitals should secure continuous and reliable oxygen source
and avail at selected treatment units throughout the year. Secure hospitals
with functional oxygen devices at selected across all health service delivery
units (Emergency, ICU, OR, Medical wards, Pedi ward)

Dis-aggregation None

Data Source Consumption record registration

Unit of
Percentage
measurement
Frequency of
Monthly
Reporting

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 51

2.7. Inpatient Medical Record Completeness

Percentage of elements completed of the minimum elements of an

inpatient medical record.

The MINIMUM elements are*:

1. Patient Card (Physician notes) – present and all entries signed

2. Vital sign Sheet – including BP, PR, RR, To, pain score and Spo2
3. Progress note – documented at least once a day throughout the
hospital stay
Definition
4. Order Sheet – Present and revised daily
5. Nursing Care Plan – Present, revised at least daily; V/S taken at least
QID for all admitted patients
6. Medication Administration Record – present and all medications given
are signed
7. Discharge planning and Summary – present and signed
8. Clinical pharmacist recording charts present and signed

Sum total of medical records checklist scored Yes

Formula = X 100
Number of discharged inpatient medical records surveyed x 8

Complete and accurate medical records are essential to maintain the

continuity of patient care and ensure that the health provider has full
information about the patient when providing healthcare. Through HMIS
a standardized medical record has been introduced nationwide. The
completeness of this medical record is a measure of the quality of care
provided at the hospital.
Importance Note: The checklist describes the MINIMUM set of documents that
/Interpretation/ should be present in the medical record of EVERY discharged patient.
Some inpatient records will contain additional documents and forms
(E.g., referral forms, laboratory report forms etc) WHO Safe Surgery
Check list (for major Surgeries …etc)

However, for standardization of this indicator, 50 medical records should

be audited and only the items that are listed in the checklist should be
included in the survey.
Dis-aggregation None
Data Source Survey - See Annex 5
Unit of measurement Percentage
Frequency of
Quarterly
Reporting

52 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.8. Percentage of acceptable EQA result

External Quality Assurance (EQA) acceptance involves comparing

the results generated by a laboratory to a known standard and
determining whether the laboratory’s results fall within an acceptable
Definition
range. If a laboratory’s results fall outside of the acceptable range,
corrective action may be necessary to improve the accuracy and
reliability of the laboratory’s testing process.

Total number of laboratory tests with acceptable EQA

results
Formula X100
Total number of EQA participated laboratory tests

EQA, or External Quality Assessment, is important because it helps to

ensure that medical laboratories are producing accurate and reliable
results. EQA programs involve sending samples to participating
laboratories and comparing the results generated by each laboratory
Importance
to a known standard. This helps to identify any potential errors or
/Interpretation/
discrepancies in the testing process, allowing for corrective action to
be taken. Ultimately, EQA helps to improve the quality of laboratory
testing and ensure that patients receive accurate diagnoses and
appropriate treatment.

Dis-aggregation None

Data Source EQA program feedback report

Unit of measurement Percentage

Frequency of Reporting Quarterly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 53

2.9.Percentage of laboratory tests completed within TAT
TAT refers to the time it takes from when a patient’s specimen is collected to when
Definition
the laboratory test results are reported to the clinician.

Number of tests reported within TAT

Formula × 100
Total number of Laboratory tests performed

Monitoring TAT is essential for ensuring that patients receive timely and accurate
test results, improving laboratory efficiency, and meeting regulatory and
Importance
accreditation requirements.
/Interpretation
NB: for patients requiring multiple tests at a time, TAT should be established for
each laboratory tests.
Disaggregation None
Data sources Daily laboratory TAT monitoring sheet.
Unit of
Percent
measurement
Frequency of
Monthly
reporting

2.10. Elective Surgical procedure cancellation ratio due to blood unavailability

The ratio of elective surgical cases which are referred out or cancelled
Definition because of unavailability of blood to major surgical procedures in the
reporting period.

Total number of major elective surgical procedures

Formula canceled or referred out due to lack of blood

Total number of elective procedures scheduled

Timely access to blood is a factor in surgical morbidity and mortality

Importance/
especially in obstetric and trauma care where hemorrhage is a major
Interpretation
cause of mortality.

Disaggregation None

Data source OR Register, Ward cancellation register

Unit of measurement Ratio

Frequency of reporting Monthly

54 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.11. Clients Receiving Rehabilitation Services

Rehabilitation service is a specialized team focused on helping patients

recover lost function and regain independence after illness, injury, or
surgery. Using therapies like physical, occupational, and speech therapy,
Definition the interdisciplinary rehab team works to restore a patient’s mobility,
self-care abilities, communication skills, and overall quality of life. The
goal is to facilitate the patient’s effective transition from hospital back
to their highest level of functioning.

Formula Total number of clients receiving rehabilitation services

Provides information on the health condition groups and number of

cases receiving rehabilitation. This can be used for short- to medium-
term service planning (e.g. for personnel requirements). Measuring
Importance/Interpretation
rehabilitation service utilization is important for improving the quality
and efficiency of rehabilitation services and ensuring that individuals in
need receive appropriate care.
Disaggregation age group (<15 years; 15-65 years, >=65years)
Data sources Medical rehabilitation center/ hospital rehabilitation service register
Unit of measurement Number

Frequency of reporting monthly

2.12. Antimicrobial Stewardship Functionality Score

Percentage of criteria fulfilled in the functionality of ASP in the health

Definition
facility
Formula Antimicrobial Stewardship Program (ASP) Functionality criteria score
This indicator measures the functionality of ASP within the health facility.
The main objectives of antimicrobial stewardship include optimize the use
of antimicrobials, promote behavior change in antimicrobial prescribing and
dispensing practices, improve quality of care and patient outcomes, and
Interpretation
save on unnecessary health care costs.

The facility is considered to have functional ASP if it meets 75% of the

criteria. Annex 6
Disaggregation None
Data Sources ASP functionality Assessment tool

Unit of measurement Percent

Frequency of
Quarterly
collection/Reporting

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 55

2.13. Anesthesia adverse outcome
Percentage of surgical patients who experienced any of the following during
major surgeries:
1. Cardiac arrest
2. High spinal anesthesia
3. Inability to secure airway

- Cardiac arrest, defined as cessation of heart activity shown by: Chest

compressions being performed, Loss of femoral, carotid and apical pulse
accompanied by ECG changes

Definition - High spinal anesthesia, defined as: Within 15 minutes after spinal
anesthesia is given, the patient loses sensation in their shoulders AND needs
positive pressure breathing assistance because the spinal anesthesia reached
above T4 level

- Inability to secure airway, defined as: Having to wake up the patient due to
failed intubation attempt OR cardiac arrest resulting from failed intubation

NB: Major surgery refers to invasive operative procedures that involve a

significant incision, excision, manipulation, or suturing of tissue, usually
requiring systemic anesthesia, regional anesthesia or profound sedation to
allow the patient to tolerate the procedure.

Number of major surgical procedures performed with anesthetic adverse outcome

during the reporting period
Formula = X 100
Total number of major surgical procedures done
during the reporting period

A large component of the difference in mortality after surgery between

developed and LMIC is caused by differences in anesthesia mortality. The
Interpretation rate of anesthetic adverse outcomes assesses the safety and quality of
anesthesia service and drive continuous improvement in surgical practices
and patient care.
Disaggregation None
Data sources Anesthesia Register/ OR log book
Unit of measurement Percent
Frequency of reporting Monthly

56 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.14. Elective Surgical Cases Treated within clinically recommended Time

The proportion of patients who received elective surgery and were treated
within the clinically recommended time for their urgency category. Elective
surgery patients treated are those who were registered on a surgical waiting
list as a category 1, 2 or 3, with a surgical specialty, and were removed
because they received their surgery as an elective or emergency patient. The
waiting time is calculated as the difference between the date the patient was
placed on the waiting list and the date the patient was removed from the
Definition waiting list, excluding any periods the patient was not ready for surgery and
any periods that the patient was waiting at a less urgent category than their
category at Removal

Category 1: Procedures that are clinically indicated within 30 days.

Category 2: Procedures that are clinically indicated within 90 days.

Category 3: Procedures that are clinically indicated within 365 days (check
elective surgical waiting list management guideline of Ethiopia, 2023)

Number of patients who received elective surgery at recomended time

(Category1+Category2+Category3)
Formula
= X 100
Total number of patients who received elective surgery

This indicator will help to assess if patients are being treated based on their
Importance/
urgency level. It will help to know if there is a delay in treatment of patients
interpretation
while they are in need of surgery

Disaggregation Category1, Category2, Category3

Data sources Liaison register and OR register

Unit of measurement Percent

Frequency of reporting Monthly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 57

2.15. Safe Surgery Checklist Utilization

Percentage of surgical cases where the WHO safe surgery check list was fully
Definition
implemented

Number of surgical patient charts in which the

WHO Surgical Safety
Formula Checklist was completed
= X 100
Total number of patient charts reviewed

Safe surgery checklist a safety checks that could be performed in any operating room.
It is designed to reinforce accepted safety practices and foster better communication
Importance/ and teamwork between clinical disciplines. The Checklist is intended as a tool for
interpretation use by clinicians interested in improving the safety of their operations and reducing
unnecessary surgical deaths and complications. This is an important aid to ensure
patient safety.
Disaggregation Elective and Emergency surgeries
Survey 50 patient charts across all departments; if less from 50 use all charts
Data source
within the reporting period. Annex 7
Unit of
Percent
measurement
Frequency of
Monthly
reporting

58 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.16. Major OR Table Efficiency

Number of surgeries performed in every surgical table per day.

Definition
A minimum of 3 major surgeries per table per day is expected.
Sum total number of major elective surgical
procedures conducted
Formula =
Total number of major elective OR tables * Total number of days in the
reporting period

This indicator plays a critical role in maximizing resource usage through

monitoring OR table efficiency; it facilitates enhanced scheduling and surgical
Importance/ planning, fostering improved procedural coordination and a more efficient
interpretation workflow. This contributes to better patient care through decreased wait
times, effective cost management, and an evaluation of the surgical suite’s
overall performance.
Each available OR tables for facility level except emergency OR tables & minor
Disaggregation
OR tables
Data sources OR Registry
Unit of measurement Ratio
Frequency of reporting Monthly

2.17. Surgical Site Infection Rate

Surgical site infection is defined as an infection that occurs in site of surgical
wound after 48 hours of surgery, within 30 days after the operation or within
Definition 1 year if implant left during operation. It involves the skin and subcutaneous
tissue (superficial), and/or fascia/ muscle (deep), and/or organs or spaces
other than the incision that was opened. (HAI Surveillance guideline, 2023).

Number of Surgical Site Infections

X 100
Formula
Total Number of major Surgical Procedures performed

The importance of measuring surgical site infection (SSI) rate is to monitor

and evaluate the effectiveness of infection control measures in healthcare
Importance/
facilities. The SSI rate is an important indicator of the quality of surgical
interpretation
care and helps healthcare professionals monitor and identify areas for
improvement in infection prevention and control practices
Disaggregation Departments providing surgical services
OPD register, IPD register, emergency register, ICU register, NICU register
Data sources
(Annex 8)
Unit of measurement Rate
Frequency of reporting Monthly

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 59

2.18. Percentage of Imaging Service Interruption Days

Percentage of imaging services interrupted out of all existing imaging services in the
Definition
hospital during the reporting period.
Total number of days each imaging service is interrupted in the facility
during the reporting period
Formula x 100
(Total number of existing imaging services in the facility x Total number of
days in the reporting period)

When imaging service interruptions occur for various reasons, they can lead to delays
in patient care, increased costs, and potential harm to patients if crucial diagnostic
information is missed. Healthcare facilities can identify patterns and trends and
prioritize action points or repairs by measuring the percentage of imaging service
unavailability due to equipment failure, professional unavailability, etc.

A high percentage of unavailable days may indicate equipment maintenance needs,

staffing shortages, or operational inefficiencies. Conversely, a low percentage
Interpretation suggests a well-functioning imaging service.

Expected Imaging Services:

• Ultrasound, X-ray, MRI, CT scan, and mammography (based on hospital tire level
standard).

Existing service means:

• Those hospital imaging services that were announced to the public

Dis-aggregation Type of imaging service

Unit of
Percentage
measurement
Source Imaging service interruption record format
Reporting
Monthly
Frequency

60 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.19. Percentages of Pathology Service Interruption Days

Percentage of pathology tests interrupted out of all existing pathology services in the
Definition
hospital during the reporting period.

Total number of days each tests service is interrupted in the facility during
the reporting period
Formula x 100
Total number of existing pathology services in the facility x Total number
of service days in the reporting period

Pathological service interruptions occur for different reasons, leading to delays in

patient care, increased costs, and potential harm to patients if crucial diagnostic
information is missed. By measuring the percentage of pathology service interruptions
due to equipment failure, professional unavailability, etc, healthcare facilities can
identify patterns and trends and prioritize action points or repairs as necessary.

A high percentage of unavailable days may indicate equipment maintenance, staffing

Interpretation shortages, or operational inefficiencies. Conversely, a low percentage suggests a
well-functioning imaging service.

Expected Pathology services like:

• FNAC, Cytology, PAP Smear, Biopsy, etc. (based on hospital tire level standard).

Existing service means:

• Those hospital pathology services that were announced to the public

Dis-aggregation Type of pathology tests

Unit of
Percentage
measurement

Source Pathology test interruption record format

Reporting
Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 61

2.20. Percentage of imaging service completed within TAT

Percentage of imaging services completed and reported within a pre-established specified

Definition
time frame.
Number of imaging services completed within TAT
Formula x 100
Total number of imaging services given during the reporting period
Turnaround Time (TAT) is the duration between when an image is taken in the service
unit and when the result is reported to the ordering healthcare provider or the patient.
Meeting TAT is crucial because it ensures timely diagnosis and treatment of patients.
Delays in obtaining test results can increase morbidity, mortality, and healthcare
Interpretation costs. This measure assesses the efficiency and effectiveness of the imaging service
unit and its ability to provide high-quality patient care. If the proportion of imaging
services completed within TAT is low, it may indicate a need to identify and address
bottlenecks and inefficiencies in the service unit workflow to improve TAT and patient
care.
Dis-aggregation Type of imaging services
Unit of
Percentage
measurement
Source Imaging TAT registration book/form
Reporting Monthly
Frequency

2.21. Percentage of pathology tests completed within TAT

Definition Percentage of pathology tests completed and reported within a pre-established specified
time frame.
Formula Number of pathology tests completed within TAT
x 100
Total number of pathology tests performed during the reporting period
Interpretation TAT is the time it takes from receiving the specimen in the laboratory to reporting
the test result to the ordering healthcare provider or the patient. Meeting TAT is
important because it helps ensure timely diagnosis and treatment of patients.
Delays in obtaining test results can increase morbidity, mortality, and healthcare
costs. This measure can be used to assess the efficiency and effectiveness of
the pathology laboratory and its ability to provide high-quality patient care. If the
proportion of imaging services completed within TAT is low, it may indicate a need
to identify and address bottlenecks and inefficiencies in the service unit workflow
to improve TAT and patient care.
NB: this KPI is expected only for those who have pathology service in their hospital

Dis-aggregation Type of pathology tests

Unit of
Percentage
measurement
Source Pathology TAT registration book/form
Reporting Monthly
Frequency

62 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.22. Percentage of Medical Devices Repaired

The percentage of medical devices repaired in the healthcare facility based on maintenance
request work order.

Definition Percentage of medical devices repaired in the healthcare facility based on maintenance
request work order is a KPI that measures the proportion of medical devices that have
been successfully repaired in the healthcare facility, as per the maintenance request work
order.

Total number of medical devices repaired in the reporting period

Formula 100%
Total number of MD maintenance Request in the reporting period

This indicator measures the health facility’s capacity and responsiveness in repairing
Interpretation medical devices. Both maintenance requests and activities performed should be
recorded. The HTMU expected to respond immediately.

Dis-aggregation None

Unit of
Percentage
measurement

Source Maintenance report sheet, work order request, MEMIS

Reporting Quarterly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 63

2.23. IPC FLAT Score (IPC-FLAT)
The IPC-FLAT Score serves as a comprehensive assessment tool for hospitals to
Definition evaluate and improve their Infection Prevention and Control (IPC) practices, ensuring safe
healthcare services for patients and staff.
Total sum of each domain percentage
Formula
Total number IPC-FLAT domains
The IPC FLAT Score (IPC-FLAT) is an important indicator for hospitals to assess
their overall Infection Prevention and Control (IPC) practice continuously and
periodically every three months at the facility level. The IPC assessment tool is
designed for use in hospital settings to evaluate the system and capacity of IPC
for safe healthcare services, assess the compliance of healthcare workers to IPC
standards and practices, aid in the development of work plans for improvement,
and monitor the progress of IPC quality improvement activities over time

The tool has 22 domains, which can be divided into two main categories:

1. Section I Facility IPC Capacity and System (Domains 1-8): This section
addresses high-level IPC systems and capacities within the hospital.

2. Section II IPC Practices and Compliances to IPC standards by healthcare

workers (Domains 1-14): This section includes routine IPC practices of
Importance healthcare workers, considering the IPC standards and priorities.
/Interpretation/
To interpret the IPC-FLAT Score, hospitals can categorize the scores into four
distinct levels

• Inadequate (0-25%): Indicates a lack of basic IPC practices and

infrastructure.

• Basic (26-50% points): Indicates a basic level of IPC practices and

infrastructure, but with some gaps and areas for improvement.

• Intermediate (51-75% points): Indicates a more developed IPC program

with improved practices and infrastructure, but still with some gaps and
areas for improvement.

Advanced (76-100% points): Indicates a comprehensive and well-structured IPC

program with high-quality practices and infrastructure, with minimal gaps and
areas for improvement.

64 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 EACH domain score (IPC Program, IPC guidelines or standard operating
procedures (SOPs), IPC education and training, Health care-associated infection
(HAI) surveillance, Multimodal Strategies, Monitoring/audit of IPC practices and
feedback, Workload, staffing and bed occupancy, Built environment, materials
and equipment for IPC, Appropriate Personal Protective Equipment (PPE) Use,
Dis-aggregation Hand Hygiene (HH) Practice Compliance, Transmission-based Precautions
Adherence, Instrument Reprocessing, Environmental Cleaning, Adherence
with Injection Safety Practices, Facility Design and Patient Flow Management,
Processing reusable textiles and laundry services, Food and Water Safety, Waste
Management and Sharps Disposal, Healthcare Workers Safety, IPC in Mortuary,
Outbreak Preparedness and Response, Environmental cleanliness and safety)
Unit of
Percentage
measurement

Source Survey/Assessment tool

Reporting Quarterly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 65

2.24. Pressure sore incidence

Definition Proportion of inpatients that develop a pressure ulcer during their hospital stay.

Number of inpatients who develop a new pressure

ulcer during the reporting period

Formula 100%
Number of patients discharged (alive, transfers out

and deaths) within the reporting period

A pressure ulcer is localized damage to the skin and/or underlying tissue, usually
over a bony prominence. It arises in areas of unrelieved pressure (commonly
sacrum, elbows, knees or ankles). Either of the following criteria should be met:

• A superficial break in the skin (abrasion or blister) in an area of pressure

OR

• An ulcer that involves the full thickness of the skin and may even extend
into the subcutaneous tissue, cartilage or bone

Pressure ulcer is a health problem worldwide that is common among inpatients

Importance and elderly people with physical-motor limitations. To deliver nursing care and
prevent the development of pressure ulcers, it is essential to follow the incidence
/Interpretation/
regularly. This indicator aims to conduct timely pressure ulcer incidence, to
evaluating and continuous improving nursing care quality.

INCLUDE:

• New pressure ulcers that arise during the patient’s admission, during
the reporting period

EXCLUDE:

• Pressure ulcers that were already present at the time of admission

• Pressure ulcers that developed in a previous reporting period

Dis-aggregation Inpatient departments, ICU
Unit of
Percentage
measurement
Source Inpatient & ICU Register (annex 9)
Reporting Monthly
Frequency

66 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.25. Percentage of women who died from Post-Partum Hemorrhage
Definition Women who developed PPH and died

Number of women who died from PPH

Formula Total number of women who gave birth in the facility, 100%
referred-in and on arrival who developed
PPH in the reporting period
Post-Partum Hemorrhage (PPH) is commonly defined as blood loss exceeding 500
milliliters (ml) following vaginal birth and 1000ml for Cesarean Section. Patients
Importance with PPH require aggressive measures to restore and maintain the circulating blood
/Interpretation/ volume (and thereby perfusion pressure) to vital structures. All medical units involved
in the care of pregnant women must have a protocol for the management of severe
obstetric hemorrhage.
Spontaneous Vaginal Deliveries, instrumental & assisted deliveries, Cesarean
Dis-aggregation
section
Unit of
Percentage
measurement
Source Delivery, Postnatal ward, ICU, OR, Emergency registration book
Reporting
Monthly
Frequency

2.26. Births by instrumental or assisted vaginal deliveries

Number of births by instrumental or assisted vaginal deliveries per 100 deliveries
Definition
attended in the hospital.
Number of instrumental or assisted vaginal deliveries
Formula Total deliveries (number of live births, 100%
still births attended in the hospital
The instrumental delivery rate is a percentage that indicates the proportion of
births requiring the use of instruments or assistance during vaginal delivery,
such as forceps or vacuum extraction. A higher instrumental delivery rate
may suggest a higher frequency of assisted deliveries in comparison to the
Interpretation total number of deliveries attended, highlighting potential areas for further
examination of maternal health practices during childbirth. This indicator
provides insights into the prevalence of assisted deliveries and contributes to
assessing maternal health outcomes during childbirth.
Exclusion:- Vaginal tear and Episiotomy.
Dis-aggregation Type of instruments
Unit of
Percentage
measurement
Source Delivery registration book
Reporting Monthly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 67

2.27. Patient satisfaction score

Proportion of “neutral and satisfied” client responses among all clients surveyed in the
Definition
specified period.
[Total number of “Neutral” response + Total number of “Satisfied”
response]
Formula X 100%
[Total number of patient satisfaction survey completed ×

Total number of patient satisfaction criteria’s evaluated]

Patient satisfaction with the health care they receive at the hospital is a measure
of the quality of care provided. By monitoring patient satisfaction hospitals
can identify areas for improvement and ensure that hospital care meets the
Importance expectations of the patients served. Patient satisfaction survey tool have been
/Interpretation/ developed for use in Ethiopian health facilities. These survey tool measure the
patient experience related to service availability, cleanliness, communication,
respect, medication (prescription, availability and patient information) and cost in
OPD, IPD, maternity and emergency departments. See Annex 10
Dis-aggregation Outpatients, MCH, Emergency, Inpatients
Unit of
Percentage
measurement
Survey – protocol for the patient satisfaction survey is presented in Annex 10.

A minimum of 120 patient (30 from each of departments; OPD, IPD, maternity
Source and ED). Data entry and analysis can be undertaken using the electronic Access
database and Excel pre-programmed analytical tool through which summary
tables, charts and the average satisfaction rating can be calculated.
Reporting Quarterly
Frequency

68 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

2.28. Staff satisfaction score
Proportion of “neutral and satisfied” staff responses among all staffs surveyed
Definition
in the specified period.
[Total number of “Neutral” response + Total number of

Formula “Satisfied” response] 100%

[Total number of staff satisfaction survey completed × Total
number of staff satisfaction criteria evaluated]
There is a definite link between employee attitudes and patient satisfaction. If
employees are unhappy or dissatisfied, despite their best efforts, it is difficult
for them to conceal this factor when interacting with patients and other staff
members. Not only is it important in terms of quality of patient care, assessing
employee satisfaction is a critical component in retaining qualified health
professionals. Many health care providers feel frustrated and disillusioned in
Importance jobs they expected to find fulfilling. They have less time to do a quality job of
caring for patients; they are continually expected to cut corners, but see waste
/Interpretation/
and feel unable to change the situation; they feel unappreciated and they feel
their skills are underused. This leads to low morale, staff turnover, and overall
disenchantment with job opportunities in health care.

One of the primary reasons for evaluating employee satisfaction is to identify

problems and try to resolve them before they impact on patient care and
treatment. See Annex 11
Dis-aggregation By profession
Unit of
Percentage
measurement
Source Survey
Reporting Quarterly
Frequency

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 69

2.29. EHSIG Score

Definition Ethiopian Hospitals Service Improvement guideline (EHSIG) implementation status score

Total sum of each chapter percentage

Formula
Total number of EHSIG Chapters

All hospitals are expected to implement the Ethiopian Hospitals Service

Improvement Guideline (EHSIG). It offers significant benefits to hospitals by
Importance providing a national framework for quality improvement in healthcare, fostering
a culture of continuous improvement, and being responsive to the evolving
/Interpretation/ needs of public hospitals in the country. It has 23 chapters, and all tier-level
hospitals are expected to comply with all of it and report the implementation
status percentage of each chapter.

HLMG, LRS, Emergency, Medical RMx, Outpatient service, Inpatient, Nursing

care, Pediatrics and child health, Maternal newborn RH and Midwifery service,
Dis- Surgical and anesthesia, Specialty and subspeciality, Rehab, palliative care,
aggregation Pharmacy, Laboratory, IPC, Teaching and Affiliated, Health care technology,
Hospital infrastructure and asset, Human resource, Health financing, Health
Services quality, Hospital performance M&E

Unit of
Percentage
measurement

Source EHSIG database

Reporting
Quarterly
Frequency

70 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 3
MODULE

POOL INDICATORS
MODULE 3: POOL INDICATORS
3.1. Blood Product Wastage Rate
Blood wastage is the proportion of blood and blood products disposed
before used due to different reasons; such us Expired blood, improper
Definition
storage, improper transportation, wrong handling, pediatrics transfusion
of adult sized blood packs, etc.

Total wasted amount of blood and blood products

Formula = X 100
Sum total of received amount of blood and blood products

Helps to manage blood products carefully and ensure that they are used
Importance/
before their expiration date. By reducing the blood wastage rate, we can
interpretation
ensure that more patients receive the blood transfusions they need.

Disaggregation By blood type

Data sources Mini blood bank record

Unit of measurement Percent

3.2. Number of palliative Patients Seen

Total palliative care patients seen at the facility’s hub/unit, supporting patient care
Definition
until end of life

Formula Total number of patient seen on palliative service wing

Importance/ Tracking access to palliative care at this facility supports internal improvement
Interpretation efforts and care delivery.

Disaggregation None

Data sources Palliative care registration book

Unit of
Number/ Count
measurement

72 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.3. Pain Assessment Performed as 5th Vital Sign

Pain assessment is a critical first step in managing pain effectively. It measures

the presence, location, intensity, quality, onset/duration and factors that relieve
or exacerbate pain. Assessing pain thoroughly informs treatment plans tailored to
individuals. Key components include:

- Using validated scales like the 0-10 numerical rating for patient self-reported
intensity
Definition
- Identifying pain type - acute or chronic;

- Determining disease/injury related factors versus independent pain

- Monitoring effects of analgesia and side effects

- Documenting at appropriate intervals as 5th vital sign

Standard techniques should be utilized consistently across patient encounters.

Patient Charts with completed pain assessments

Formula = X 100
Total Surveyed patient charts

Pain assessment represents a vital sign for ethical, patient-centered care.

Inadequacy often stems from attitudinal barriers rather than resource limitations.
Patients cannot receive appropriate treatment without thorough evaluation of
their pain experience across physical, psychological and situational domains.
Undertreated pain creates immense burdens through reduced function, mental
health issues and extended hospital stays or readmissions.
Importance/
Interpretation This indicator tracks facility-wide integration of evidence-based pain assessment
principles. It helps determine the percentage of patients whose pain is managed
per best practices through comprehensive analysis guiding targeted relief. Higher
scores indicate appropriate priority placed on alleviating suffering for all. Progress
over time and comparisons to benchmarks can reveal areas needing improvement
regarding assessment standards, consistency, documentation or ineffective
assessment-analgesia gaps.
Disaggregation Departments

Data sources Survey (take 50 random patient cards from all service delivery areas)

Unit of
Percent
measurement

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 73

3.4. Pain Management per WHO Standards

Percentage of facility’s pain patients managed using WHO analgesic ladder, which
Definition
provides standards for pain relief.

Number of patients managed pain by WHO analgesic ladder

Formula = X 100
Total number of patients those who have pain scored in reporting period

Ensures pain relief available at the facility per best practices. Allows identifying
areas for improvement. Studies have shown that following the WHO analgesic
ladder can improve patient outcomes, reduce hospital stays, and improve quality of
life.
Importance/
Its three steps are: Step 1 Non-opioid plus optional adjuvant analgesics for mild
Interpretation
pain; Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to
moderate pain; Step 3 Strong opioid plus non-opioid and adjuvant analgesics for
moderate to severe pain.

Annex 12: WHO analgesic ladder

Disaggregation Departments

Data sources Survey (take 50 random patient cards from all service delivery areas)

Unit of
Percent
measurement

74 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.5. Palliative Home-Based Care Linkage

Home-based care refers to continued palliative care services provided in a

patient’s home after discharge from the hospital. This includes symptom
control, psychosocial support, health communication, and coordination of care
to improve quality of life for patients and families facing serious chronic or
terminal illnesses.
Definition
Specifically, a multidisciplinary team works with the patient at home to
provide pain and symptom management, counseling, nutrition advice,
wound care, education, and other services - allowing the patient to remain
comfortable and retain independence in familiar surroundings for as long as
possible

Number of patients linked to HBC after discharge

Formula = X 100
Total Number of discharged patients illigable for HBC

This indicator tracks the percentage of palliative patients successfully

referred to structured home-based care programs after discharge. Seamless
care continuity between hospital and home is essential for this vulnerable
population. Compassionate support maximizes function and minimizes crises
prompting repeat hospitalizations.
Importance/
Interpretation
Home-based services allow patients to preserve dignity and relationships
at the end of life while receiving specialized medical care. They significantly
reduce symptoms, caregiver burden and costs for those with complex needs.
Monitoring linkages informs efforts to expand community capacity and reach
more patients with sustainable solutions.

Disaggregation None

Data sources Patient Cards/Registration book

Unit of
Percent
measurement

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 75

3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service
The percentage of essential pain and palliative care drugs and supplies that
Definition are available out of the identified list required for pain and palliative service
provision.
Number of essential pain & palliative care drugs/supplies available
Formula = X 100
Total Number of essential pain & palliative care drugs/supplies

Availability of essential pain and palliative care medications and supplies is

Importance/ critical for effective pain management and palliative care service provision.
Interpretation Tracking availability helps identify gaps and take measures to improve access to
these essential items. Annex 13
Disaggregation None

Data sources Supply chain management

Unit of
Percent
measurement

3.7. Functional improvement of rehabilitation clients

This indicator measures the proportion of clients who achieved functional
improvement after receiving rehabilitation services. Functional improvement
refers to an increase in a client’s ability to perform daily activities or tasks
related to their work or social roles, such as dressing, grooming, bathing,
cooking, or driving. Functional improvement can be influenced by various
Definition
factors, such as injury, illness, aging, or disability. Functional improvement can
be assessed using standardized tools that evaluate an individual’s performance
of specific activities. The aim of rehabilitation services is often to enhance
functional improvement and enable an individual to carry out daily activities and
participate fully in their social roles.
Number of clients who achieved functional improvement after
receiving rehabilitation services among discharged/referred clients
Formula = X 100
Total number of rehabilitation clients discharged or
referred to other facilities in the reporting period
This indicator is important for evaluating the quality and effectiveness of
Importance/
rehabilitation services and ensuring that clients receive suitable, individualized
Interpretation
care that meets their needs and goals.
Disaggregation None

Data sources Medical rehabilitation center/ hospital rehabilitation service register

Unit of
percent
measurement

76 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.8. Rehabilitation Service Utilization

This indicator measures the percentage of cases accessing rehabilitation

services categorized by health condition group (i.e. musculoskeletal,
Definition
neurological, sensory, and others) among registered clients who come with
inter- and intra-referrals.

Number of clients that receive rehabilitation services in the

facility within the reporting period
Formula X100
Number of new registered clients and clients came with
appointment during reporting period

Provides information on the health condition groups and number of cases

receiving rehabilitation. This can be used for short- to medium-term
service planning (e.g. for personnel requirements). Measuring rehabilitation
Importance/Interpretation
service utilization is important for improving the quality and efficiency
of rehabilitation services and ensuring that individuals in need receive
appropriate care.

Disaggregation age group (<15 years; 15-65 years, >=65years)

Data sources Medical rehabilitation center/ hospital rehabilitation service register

Unit of measurement Percent

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 77

3.9. Percentage of SLIPTA standards met
The percentage of SLIPTA audit scored met from total
Definition
number of SLIPTA audit standards
SLIPTA audit standards Met
Formula X100
Total number of SLIPTA audit standards

The Stepwise Laboratory (Quality) Improvement Process Towards

Accreditation (SLIPTA) is a framework for improving quality of Hospital
laboratories to achieve ISO 15189 standards. It is a five- star tiered
approach, audit of laboratory operating procedures, practices, and
performance. There are a total of 275 points across 12 sections:
Laboratory quality management implementation is an effective means to;

1) determine if a laboratory is providing accurate and reliable

Importance/Interpretation results;

2) determine if the laboratory is well-managed and is adhering to

good laboratory practices; and

3) Identify areas for improvement.

Currently Ethiopian national accreditation Service is providing scope

based accreditation certificate for qualified laboratories according to
ISO15189:2012 or 2022.
Disaggregation None

Unit of measurement Percent

Assessment tool for Stepwise Laboratory (Quality) Improvement Process

Data sources
Towards Accreditation (SLIPTA)

78 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.10. Drug and Therapeutics Committee (DTC) Functionality
Percentage of criteria fulfilled by the facility on the functionality of drug and
Definition
therapeutic committee (DTC)
Sum of weight of fulfilled criteria
Formula X 100
Total weight of functionality criteria

This indicator measures the functionality of DTC in the health facility. DTC develops
and implements interventions, promoting the rational and cost-effective use of
Importance medicines. DTC functionality serves as a proxy indicator of ability of a health facility
to avail pharmaceuticals and ensures rational use. The facility is considered to have
/Interpretation functional DTC if it meets 75% of the criteria. Data is collected by observation of
the document sources mentioned above using structured checklist provided on the
annex. Annex 14: DTC functionality Criteria
Disaggregation By type of health facility
Documents from DTC secretary (DTC minutes, official assignment letters, approved
Sources tor, action plan facility specific medicine list, policy & procedures, action letter or notice of
DTC decisions, DTC performance reports, medicine use study/evaluation reports)
Unit of
Percent
measurement

3.11. Clinical Pharmacy Service Functionality

Percentage of functionality criteria fulfilled by hospitals in the provision of clinical
Definition
pharmacy service (CPS)
Sum of weight of fulfilled CPS functionality criteria
Formula X 100
Total weight of CPS functionality criteria

This indicator measures the extent of the provision of pharmaceutical care in

inpatient wards by pharmacists to maximize therapeutic benefits and minimize
Importance risk of medicines. A functional clinical pharmacy service requires the provision of
/Interpretation pharmaceutical care from admission to discharge. The service should be provided at
all times at all major inpatient wards. A hospital is considered to have functional CPS
when 75 % of the criteria is fulfills.
Disaggregation None
Clinical pharmacy records, performance report, assignment letter, bedside round
book, duty program, patient chart, MDT morning session book, observation, interview
of ward nurse, minutes of pharmacy only morning session, daily CPS summary, and
Sources observation.

The data is collected by survey from the various source documents indicated
above including interviews with ward nurses/physicians and observation of actual
performance.
Unit of
Percent
measurement

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 79

3.12. Percentage of Medicine Actually Dispensed
The percentage of medicines dispensed to clients from all prescribed medicines in a
Definition
reporting period
Total number of medicines actually dispensed
Formula X 100
Total number of medicines prescribed
The indicator measures the degree to which the health facilities fulfill prescribed
medicine. It is used as supplementing indicator for HMIS indicator “ Clients With
100% Prescribed Drugs Filled ” It shows the effectiveness of pharmaceutical supply
chain in availing medicines in the health facility. The target for this indicator is 100%.

This indicator is measured by survey methods based on available prescribing and

Importance dispensing data in the health facility. Where dispensing registers are available, all
data registered in the reporting period should be used for calculating the indicator.
/Interpretation
Alternatively, a sample of 100 prescribing encounters can be selected from all
prescriptions dispensed during the reporting period. Systematic random sampling
can be used to properly select representative sample of prescriptions (Refer Drug
Use Study Guide or DTC training manual) This indicator should be calculated by the
pharmacy unit on bi-annual basis use the information to improve availability of
medicines

Disaggregation None

APTS registers (APTS implementing HFs), prescription paper,DHIS2 dispensing

Sources
register,
Unit of
Percent
measurement

80 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.13. Relative Share of Sources of Retained Revenue

Relative Share of sources of retained revenue refers to the proportion or

percentage of internal revenue collected from or attributable to a specific program
Definition
or reform, such as health insurance or private wing, implemented in the hospital as
a percent of total revenue generated.

Retained Revenue collected from a repective reform

Formula X 100
Total retained revenue collected

Hospitals are expected to effectively implement components of health financing

reforms designed to improve financial protection, equity, efficiency, effectiveness,
and financial sustainability of the health sector for the ultimate attainment of
improve health outcomes. In implementing the reforms/programs hospitals are
expected not only track the change of number of beneficiaries but also change
of retained revenue generated from beneficiaries of different reforms. Tracking
proportion of the revenue from different reform programs helps, among other
Importance/
Interpretation things, to generate data to make an informed decision. For example, if hospitals
generate less retained revenue from the expanding programs of health insurance
over time, the issue needs to be assessed to come up with the root cause(s) of the
problem and appropriate corrective actions have to be taken based on the findings
and recommendations of the assessment.

This is, therefore, important to make financial analysis and performance tracking to
monitor changes over time and identify trends or areas of concern.
Disaggregation CBHI, SHI, Private Wing, Credit service , other

Data sources Financial records at hospitals

Unit of
Percent
measurement

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 81

3.14. Proportion of Beneficiary Groups to total visits

The proportion of visits of a beneficiary group to total visits of a hospital refers

to the proportion of visits of beneficiaries of major health financing reforms or
components as a percentage of total hospital visits. it is the percentage of visits
made by a specific group of beneficiaries, such as CBHI beneficiaries out of the
Definition
total number of visits made to a hospital. This indicator can be used to assess the
utilization patterns of a hospital’s services by specific patient populations and can
help identify areas where targeted interventions may be needed to improve health
outcomes and reduce costs.

Number visit of respective beneficiary group

Formula = *100
Total hospital visit

The proportion of visits of a beneficiary group to the total visits to a hospital is an

important measure because it can help identify disparities in healthcare utilization
by specific patient populations. For example, if a particular group of beneficiaries is
found to have a lower proportion of visits to a hospital compared to other groups, it
Importance/ may indicate barriers to access to care for that group. On the other hand, if a group
Interpretation of beneficiaries is found to have a higher proportion of visits to a hospital, it may
indicate a higher burden of disease for that group. Understanding the proportion of
visits of beneficiary groups can inform targeted interventions to improve healthcare
access and outcomes for those groups, as well as help identify areas where targeted
interventions may be needed to improve health outcomes and adjust costs.

• Proportion of CBHI beneficiaries visit to total hospital visit

• Proportion of SHI beneficiaries visit to total hospital visit
Disaggregation
• Proportion of exempted service beneficiaries visit to total hospital visit
• Proportion of credit service clients visit to total hospital visit

Data sources Registry for CBH, SHI, EHS and Credit Service registry.

Unit of
Percent
measurement

82 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.15. Retained Revenue spending as a share of total operating budget spending

Internal revenue expended as a proportion of total operating expenditure (i.e.,

expended raised revenue and treasury operating) for the reporting period)

Definition *Operating budget spending from treasury for reporting period means budget
spent for the general running of a hospital (including, consumables and supplies
etc.). Staff salaries, allowance for personnel and capital budget allocation should be
EXCLUDED.
Retained revenue expended during reporting period
= *100
Formula Total operating expenditures
(from treasury + from retain revenue) during reporting period

Retained revenue spending as a proportion of total operating budget spending

refers to the portion of a hospital’s retained revenue spending as a percentage
of total budgets that is being used to fund ongoing operations. The proportion of
Importance
retained revenue spending as a portion of total operating budget spending is a
metric used to assess how effectively an organization is using its resources and
reinvesting in its own growth and sustainability.

Disaggregation None

Data sources Hospital financial statement /records

Unit of
Percent
measurement

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 83

3.16. MEMIS implementation

Definition Percentage of MEMIS functionality criteria met by hospital

Sum of weight of scored criteria

Formula X100%
Total weight of standard criteria

This indicator measures the functionality of MEMIS in a healthcare facility that

used for registering, requesting and analyzing report of installation, inventory,
Importance/
maintenance, disposal and other related information of medical equipment in the
interpretation
healthcare facility. It is considered as functional, if the healthcare facility meets 80%
of the criteria:

Disaggregation None

Sources MEMIS review, survey (MEMIS, history file, inventory records, documented reports)

Unit of
Percent
measurement

3.17. Mean time to respond to work order request for special healthcare setting

Mean time taken to respond to the total work order request for special healthcare
Definition
setting

Sum of the total time taken to respond a work order request

Formula
Total number of work order request

This indicator measures the meantime taken to respond a work order request from
Importance/ the special service settings such as ICU, emergency, OR, imaging and laboratory.
interpretation This indicator helps us to take quick intervention to save lives and enhance service
efficiency.

Disaggregation ICU, emergency, OR, laboratory, imaging and maternity service

Data Sources Work order request & maintenance report sheet, maintenance logbook

Unit of
Minute/Hour
measurement

84 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

3.18. Proportion of vacancies filled as per the standards of the approved positions
Percentage of employee vacancies fulfilled in the hospital as per approved
Definition
positions of the hospital according to the national/regional structure
Number of vacancies filled
Formula 100
Total number of posts/vacancies as per standard
Fulfilling the gaps in HR vacancies helps in the improvement of quality services
Interpretation delivery, reduce work load and staff burnout and also increases patients
satisfaction
Disaggregation Administrative, Health professionals
Data sources HRIS
Unit of measurement Percent

3.19. Attrition rate of Healthcare workforce

Attrition rate of healthcare workforce is a percentage of healthcare workforces

Definition
who leave the hospital due to different reasons in the reporting period.
Number of healthcare workforce who left the hospital during the
reporting period
Formula 100
Total number of healthcare workforce at the beginning of the
reporting period
This indicator is used to assess and follow the number of healthcare
Interpretation workforce who left the hospital during the reporting period and attrition cause
in the hospital.
Disaggregation Administrative staff, Health Professionals
Data sources HRIS
Unit of measurement Percent

3.20. Recipients of in-service and CPD training

An in-service training is a professional training or staff development efforts,

Definition where professionals are trained and discussed their work with others in their
peer group.

Total number of staff who received in-service training/total number of staff at

Formula
beginning of period *100

Proper medical staff training is an essential for insuring employees are

Importance/
confident in their ability to provide quality care. it can increase staff
Interpretation
motivation, improve productivity, staff commitment and the quality of work.
Disaggregation Administrative staff, Health professionals
Data sources Registration sheet, HR report,
Unit of measurement Percent

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 85

3.21. Grievances received and solved

A grievance is an expression of dissatisfaction with any aspect of the

Definition operations, activities, or behavior of a Hospital’s, or its providers, regardless
of whether remedial action is requested

Formula Total number of grievances received and solved by the HR department

As an employer, it is best to handle grievances in an amicable and

supportive way to avoid unnecessary escalation and negative feelings.
Interpretation
Grievance handling procedures also allow you to identify and address
unacceptable or unlawful practices quickly.

Disaggregation All staffs

Data sources Grievance Register

Unit of measurement Number

3.22. Occupational injury incidence

An occupational injury is defined as any personal injury, disease or death

resulting from an occupational accident. An occupational injury is therefore
Definition distinct from an occupational disease, which is a disease contracted as a
result of an exposure over a period of time to risk factors arising from work
activity.

Total number of occupational injuries occurred

Formula
Total number of Hospital staff

Reduced risk or accidents or injuries by identifying and mitigating hazards.

Improved efficiency and productivity due to fewer employees missing work
Interpretation
from illness or injury. Improved employee relations and morale (a safer work
environment is a less stressful work environment)
Disaggregation Health professionals, Administrative staffs
Data sources Register
Unit of measurement Number

86 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

CHAPTER 4: HOSPITAL SUPPORTIVE SUPERVISION
Fundamental Goal of Hospital Onsite Supportive Supervision: Supportive supervision aims to guide
hospitals by providing direction and technical assistance to enhance performance. It ensures the accuracy
of hospital performance data submitted to Regional Health Boards (RHBs), identifies good practices for
sharing among hospitals, highlights areas needing improvement, and identifies where additional support
from RHBs or other partners is necessary.

Steps to Conduct Supportive Supervision:

Step 1: Selection of the Site

• The RHB coordinates the site visit team, comprising at least three individuals, including the team
leader. The team leader’s responsibilities include team coordination, preparation of the site visit
briefing document, communication with the hospital CEO, and reporting.

Step 2: Pre-visit Preparation:

• The site visit team gathers relevant evidence regarding the hospital’s performance and analyzes
it to create a briefing document outlining hospital performance, strengths, weaknesses, areas for
investigation, and key focus areas during the site visit.

Step 3: Conducting the Site Visit:

• The site visit typically spans one to two days and involves an opening meeting, information
gathering through departmental visits, and a closing meeting to discuss preliminary findings with
the hospital’s Senior Management Team (SMT).

Step 4: Post-visit Follow-up:

• After the site visit, the team leader writes a detailed report summarizing the findings and
recommendations. The report undergoes review and refinement by the site visit team. The hospital
CEO then responds with an action plan addressing the report’s recommendations.

The entire process involves thorough preparation, data collection, discussion, and follow-up, ensuring that
hospitals receive the necessary guidance and support to improve their performance and contribute to the
overall enhancement of healthcare services.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 87

CHAPTER 5: REVIEW MEETINGS
Purpose of MOH and RHB Meetings: The purpose of the Ministry of Health (MOH) and Regional Health
Boards (RHBs) meetings is multifaceted, serving as a vital platform for various collaborative endeavors.
These gatherings facilitate the presentation and thorough discussion of regional performance reports,
enabling comprehensive insights into healthcare achievements and challenges across different regions.
They foster benchmarking exercises, allowing comparisons between regions to identify best practices,
areas of improvement, and innovations. Moreover, these meetings aim to recognize and reward exemplary
practices, encouraging the dissemination of successful healthcare delivery methods. Participants utilize this
forum to openly share both successes and challenges encountered within healthcare services, promoting
a collective learning environment. Additionally, these sessions provide opportunities for the dissemination
and discussion of recent research reports pertinent to hospitals, as well as addressing relevant topics
crucial for enhancing the overall quality and efficacy of healthcare delivery systems.

Frequency and Duration:

• Meetings should occur biannually.

• Each meeting is typically three days long, but it can be extended if necessary.

Participants:

• MOH Staff: selected MOH members should attend relevant meetings.

• RHB Staff: Ideally, all members of each Clinical, Regulatory, all RHBs Medical Service Directorate
should attend. At a minimum, the core process owner and hospital lead should be present.
• Hospital Staff: A selected number of hospital CEOs, governing board chairs, or senior administrators
should be invited based on the agenda items.
• Other Partners: Additional partners relevant to the agenda topics may be requested to attend
based on their expertise.

Pre-Meeting Preparation:

• MOH should select a location, prepare the agenda, identify attendees, and send invitation letters
along with the agenda at least two weeks before the meeting.
• Follow-up emails or phone calls should be made one week before the meeting to confirm
attendance.
• MOH should analyze regional HKPI reports beforehand to identify successes and challenges,
informing the meeting preparation.
• Individual RHBs scheduled to present or share experiences should be notified in advance to prepare
necessary information.

88 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

During the Meeting:

• MOH chairs the meeting, potentially with facilitators for specific sessions or topics.
• Minutes of the meeting should be taken by designated personnel from MOH or partners.
• MOH presents HKPI and EHSIG assessment reports from each region and offers recommendations
based on the findings.
• The agenda items will vary for each meeting.

Post-Meeting Procedures:

• MOH must produce meeting minutes and distribute them to all attendees within two weeks.
• Relevant minutes may also be forwarded to others, such as RHB heads, and other MOH directors
or Ministers.

These structured meetings serve as an opportunity for collaborative learning, sharing best practices,
addressing challenges, and aligning efforts towards improving healthcare services across regions in the
country.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 89

Appendix
Annex 1: የመልካም አስተዳደር ኢንዴክስ (Good Governance Index)

የተሰጠ
ተ.ቁ አመላካቾች
ክብደት
I የህዝብ ሮሮ አመላካቾች 40
1 የተገልጋይ እርካታ ደረጃ (Client Satisfaction Rate) 12
2 ስለ ህመማቸው እና ስለ ህክምና አገልግሎት በቂ መረጃ ያላቸው ህሙማን መጠን፣ 4
3 የታዘዘላቸዉን መድሃኒት ሙሉ በሙሉ ያገኙ ህሙማን ምጣኔ 5
4 የታዘዘላቸዉን ሙሉ የላቦራቶሪ ምርመራ አገልግሎት ያገኙ ህሙማን ምጣኔ 4
5 የታዘዘላቸዉን ሙሉ ኢሜጂንግ አገልግሎት ያገኙ ህሙማን ምጣኔ 4

6 መሰረታዊ የራዲዮሎጂ እና ኢሜጂንግ አገልግሎት በመቶኛ 3

7 የካርድ አወጣጥና ክፍያ አገልግሎት (ቅልጥፍና፣ፍትሀዊነት፣ካርድ መጥፋት) 4
8 የጤና መድህን ክፍያ ጥያቄ ሪፖርት ብዛት በመቶኛ 2
9 የጤና መድህን ተመላሽ የተደረገ ገንዘብ ብዛት በመቶኛ 2

II አገልግሎት አሰጣጥ አመላካቾች (Service Delivery) 28

10 በ5 ደቂቃ ትሪያጅ የተደረጉ የድንገተኛ ህክምና ተጠቃሚዎች ምጣኔ 4

11 በ24 ሰዓት ዉስጥ ከድንገተኛ ህክምና ክፍል ታክመዉ የወጡ ህሙማን ምጣኔ 4
ረዥሙ የቀዶ ጥገና ህክምና የቆይታ ጊዜ (ከአንድ ወር በታች (6 ነጥብ፣ ከ1-3 ወር (3 ነጥብ)፣ ከ3-6 ወር
12 6
(1)፣ ከ6 ወር በላይ (0 ነጥብ)) ይሰጠዋል፡፡ መረጃ ከላይዝን ይገኛል፡፡
13 ከ2፡30 አገልግሎት መስጠት የጀመሩ ተመላለሽ የህክምና ክፍሎች 6

14 በስታንዳርዱ መሰረት የተሰጠ የነርሲንግ አገልግሎት nurseing audit score (HSTQ) 4

15 አገልግሎት ሳያገኙ የተመለሱ ታካሚዎች ምጣኔ 4

III የጤና አሰራር ስርዓት ግብዓት አመላካቾች 32

16 በተቋሙ የመድኃኒት መዘርዝር መሰረት የመሰረታዊ የበጀት መድሃኒቶች አቅርቦት ምጣኔ 4
17 ባለፉት 6 ወራት ከአገልግሎት ዉጭ የሆኑ መድሃኒቶች ምጣኔ በመቶኛ (ተሰልቶ ይቀመጥ) 4
18 በጤና ሚኒስቴር ከሚጠበቀው 85% የላብራቶሪ ምርመራ አገልግሎት በመሰራት ላይ ያለ ሽፋን 4
19 አገልግሎት የሚሰጡ የህክምና መሳሪያዎች ምጣኔ (ከወቅታዊ ቆጠራ/ኢንዜንቴሪ ዝርዝር የሚወሰድ) 2
20 አንቡላን ምላሽ የመስጠት ምጣኔ 3
21 ትርፍ ሰዓት ክፍያ የተፈጸመላቸው ሰራተኞች በመቶኛ (በበጀት ዓመት ምልከታ ጊዜ የተፈጸመ ክፍያ ይሁን) 3

25 ተቋማዊ የሆነ የመልካም አስተዳደር እቅድ ማቀድና መገምገም በመቶኛ 2

26 የጤና ባለሙያ ና የሰራተኛ ደንብ ልብስ ግዢ በወቅቱና በቀረበው እስፔስፊኬሽን ግዢ በመቶኛ 3

27 የሰራተኛ ንጽህና መጠበቂያ ግዢ በወቅቱና በቀረበው እስፔሽፊኬሽን ግዢ በመቶኛ 2
መረጃ መሰረት አድርጎ የተካሄደ ወርሀዊ አፈጻጸም ግምገማ (Performance Review Team)ግብረመልስ
28 3
በመቶኛ
29 የለውጥ ስራዎችን የሚከታተል የስራ ክፍል መኖር 2
አጠቃላይ የመልካም አስተዳደር /ጭማቂ ውጤት (GG Index) 100

90 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 2: Emergency Patients Triaged Within 5 Minutes of Arrival

Purpose of survey:

Through BPR, the Ministry of Health has set a stretch objective that „any patient with the need for
emergency treatment should be provided with the service within 5 minutes of arrival at the hospital”.

The proportion of emergency patients who undergo triage within 5 minutes is one of the Key Performance
Indicators that should be reported by hospitals to their Governing Board and to the RHB has a measure of
hospital performance.

Period of survey:

The survey should be conducted during the following time periods during the final week of the reporting
period:

Monday: 8am to 12 noon

Wednesday: 12 noon to 5pm

Saturday: 6pm to 8am

Role of KPI Owner:

The hospital should assign an „owner‟ for the KPI „% of patients triaged within 5 minutes of arrival in ER”.
He/she is responsible to oversee the survey, to select and train surveyors, and to calculate the proportion
seen within 5 minutes at the end of the survey period. Additionally, at the start of each survey period the
KPI Owner should inform all ER staff that the survey is taking place.

Selection and role of surveyors:

The KPI Owner should assign individuals to act as surveyors. The number of surveyors required will depend
on the patient load. However, there should be sufficient surveyors to ensure that the waiting time of each
and every emergency patient is measured during the study period.

Ideally, the surveyors should be individuals who DO NOT WORK regularly in the emergency department
in order to avoid bias. Surveyors could be clinical or non clinical staff from other hospital departments. If
necessary, the hospital should provide payment to surveyors according to the number of hours worked.

The surveyors should follow the methodology outlined below to conduct the survey and should submit all
completed „Triage Data Forms‟ to KPI Owner at the end of the survey period.

Methodology of Survey:

Assign surveyor(s)

One or more surveyors should be assigned to the ER Department for each study time period. The
surveyor(s) should be located at the entrance to ER. If the hospital does not have a separate ER department
the surveyors should be located in an area where they can identify easily identify emergency cases versus
outpatient cases.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 91

Surveyors complete „Triage Data Forms‟

Each surveyor should have a batch of „Triage Data Forms‟ as below:

As soon as a patient arrives at ER the surveyor should enter the time of arrival on the Triage Data Form. The
surveyor should follow the patient until the time of triage (ie until assessment by a clinical staff member).
The surveyor should enter the time of triage on the Triage Data Form and calculate the wait time in minutes.
The surveyor should then complete the final column on the Triage Data Form to state if the patient was
triaged within 5 minutes of arrival (yes or no).

c) KPI Owner calculates % of patients triaged within 5 minutes (KPI 5)

At the end of the survey period the KPI Owner should collect all Triage Data Forms from each surveyor. The
KPI owner should calculated the % of patients triaged within 5 minutes as follows: Number of surveyed
patients who undergo triage within 5 minutes of arrival in emergency room ÷ Number of patients included
in emergency room triage time survey x 100

d) KPI Owner reports to KPI focal person

After calculating % of patients triaged within 5 minutes the KPI owner should report all data elements and
KPI result to the KPI focal person. The KPI focal person will then check the calculations and enter them into
the KPI report form.

92 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 3 Outpatient waiting time to consultation

Purpose of survey:

The average OPD wait time is one of the Key Performance Indicators that should be reported by hospitals
to their Governing Board and to the RHB has a measure of hospital performance.

Period of survey:

The survey should be conducted on Monday and Thursday of the first week of the last month of each
quarter.

Role of KPI Owner:

The hospital should assign an „owner‟ for the KPI „Outpatient Waiting Time to consultation”. He/she is
responsible to oversee the survey, to select and train surveyors, to issue „Waiting Time Cards‟ to each
surveyor, to receive completed „Waiting Time Cards‟ from the surveyors at the end of the survey period,
and to calculate the average wait time at the end of the survey period.

Additionally, at the start of each survey period the KPI Owner should inform all OPD staff that the survey
is taking place and should instruct OPD Case Teams to complete the relevant section on the „Waiting Time
Card‟ for every patient seen and ensure that all Waiting Time Cards are returned to the surveyor at the end
of the survey day.

Selection and role of surveyors:

The KPI Owner should assign individuals to act as surveyors. The number of surveyors required will depend
on the patient load. However, there should be sufficient surveyors to ensure that the waiting time of at
least100 outpatient is measured during the survey. In those facilities where the outpatient load is very
high (>200), every 3rd patient may be taken to a total of at least 100 patients. As an approximation, the
number of surveyors required will be approximately the same as the number of individuals conducting
patient registration.

Ideally, the surveyors should be individuals who DO NOT WORK regularly in the outpatient department in
order to avoid bias. Surveyors could be volunteers from the community, students or hospital staff assigned
from other departments. If necessary, the hospital should provide payment to surveyors according to the
number of hours worked.

The surveyors should follow the methodology outlined below to conduct the survey and should submit all
completed „Waiting Time Cards‟ to the KPI Owner at the end of the survey period.

Role of OPD Case Teams:

A member of each clinical case team should receive the Waiting Time Card from each and every patient
seen during the survey period. He/she should record on the Card the time at which the clinical consultation
begins, and the name of the case team. Instructions should be given to each case team to provide all
completed cards to the surveyor at the end of the survey day. Case teams should ensure that no Waiting
Time Cards are lost or misplaced.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 93

Methodology of Survey:

Assign surveyors to the areas where patients arrive at the outpatient department as follows:

• If outpatients undergo registration before triage à assign surveyors to patient registration area
• If outpatients undergo triage before registration à assign surveyors to triage area
• If the hospital has an appointment system and patients go immediately to the OPD waiting area
(without passing through registration or triage) à assign surveyors to OPD waiting areas

Issue „Waiting Time Card‟

Each surveyor should have a batch of „Waiting Time Cards‟ as below:

OPD Waiting Time Card Card Number: ________

Patient name: ___________________________________ __ (completed by surveyor)

Time of patient arrival: _______________________________ (completed by surveyor)

Time clinical consultation begins: _____________________(completed by clinical case team member)

Name of case team: _____________________________(completed by clinical case team

OPD Waiting Time Card Card Number: ________

ታካሚውስም: ___________________________________ ___ (ትሪያጅከፍሉይሞላል)

ታካሚው ትሪያጅ የደረሰበትጊዜ: __________________________ (ትሪያጅክፍሉይሞላል)

ታካሚውካርደ ክፍል የደረሰበትጊዜ: ________________________ (ካርደ ክፍሉ ይሞላል)

የህክምናአገልግሎትየጀምረበትጊዜ): _______________________(የኬስቲምአባል ይሞላል)

የኬስቲሙስም: ___________________________________ (የኬስቲምአባልይሞላል)

(የተመላላሽተካሚህክምናለማግኘትየወሰደበትጊዜ(በደቂቃ): __________________ (የመረጃ)

94 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Before any of the Waiting Time Cards are given out, Card Numbers should be written on every card to that
they can be easily tracked by the surveyor and the clinical case teams. As soon as a patient arrives at OPD
the surveyor should enter the patient’s name and time of arrival on a Waiting Time Card and then hand the
Card to the patient. The surveyor should instruct the patient to give the card to a member of the clinical
case team.

The Surveyor should keep track of the number of cards issued and the number of cards completed. To do
this he/sh e should keep a tally of the number of Waiting Time Cards issued and follow up any that are
missing at the end of the day.

c) Clinical Case Teams receive „Waiting Time Card‟

On arrival in the consultation room, the patient should hand over the Waiting Time Card to a member of the
case team. If the patient does not automatically hand this over then a member of the team should request
the Card from the patient.

The case team member should record on the Card the time at which the consultation begins. The case
team should keep all Cards received from patients.

Surveyor collects completed „Waiting Time Cards.

At the end of the day (or close of clinic) the surveyor(s) should collect all Cards from each and every Case
Team and should compare this with the list of Cards issued. If any cards are missing the surveyor(s) should
follow up with the relevant Case Team and determine whether the patient was seen that day.

Every effort should be made to ensure that no Cards are missing or lost because this could lead to an
inaccurate survey result.

Surveyor calculates waiting time for each patient

After receiving the Waiting Time Cards from each clinical case team, the surveyor should calculate the wait
time for that patient (in minutes) and should enter it onto the Card.

KPI Owner calculates average waiting time

A t the end of the survey period the KPI owner should collect all Waiting Time Cards from each surveyor.
The KPI Owner should tally the total wait times and divide by the total number of completed Cards in order
to calculate the average wait time during the survey period. In cases where the patient was seen on the
same day but the Waiting Time Cards were lost or incomplete, the Waiting Time Cards should be excluded
from the survey count.

KPI Owner reports to KPI focal person

After calculating Outpatient Waiting Time the KPI owner should report all data elements and KPI result
to the KPI focal person. The KPI focal person will then check the calculations and enter them into the KPI
report form.

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 95

Optional, supplementary data analysis

If the average wait time is very long (especially if some patients are not seen on the same day) then the
surveyor may also want to record the range (shortest and longest) of wait times.

Similarly, the waiting time for each clinical case team could be analyzed separately to see if there are any
differences between clinical teams. This information could help to assess the efficiency of each case team
and/or to determine the need for additional clinical staff in particular case teams and/or the need for patient
numbers assigned to a specific case team to be decreased or increased.

96 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 4 Timely Outpatient service initiation Survey Tool

OPD1 OPD2 OPD 3 OPD4 OPD5 OPD 6 OPD7 OPD 8 OPD(N)

Survey Days
Start Start Start Start Start Start Start Start Start
Time Time Time Time Time Time Time Time Time

Monday

Or Busy Day

Thursday

Or Free Day

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 97

Annex 5: Completeness of Inpatient Medical Records

Purpose of Audit:

The “% of medical records complete” is one of the Key Performance Indicators that the hospital
should report every quarter to the Governing Board and Regional Health Bureau.

Frequency of Audit:

The audit should be conducted quarterly.

Role of KPI Owner:

The hospital should assign an „owner‟ for this KPI. He/she is responsible to oversee the Medical
Record Audit, to select and train Medical Record staff who will conduct the audit, and to liaise
with the Medical Records Department to select and obtain the Medical Records which are
included in the audit.

Selection and Role of Medical Record Reviewers:

The Medical Record Reviewers should be members of the Medical Records Department. Each
should review the assigned Medical Records following the checklist below and submit their
completed Forms to the KPI Owner.

Methodology of Survey:

Select and obtain the medical records

Identify and list all patients who were discharged from an inpatient ward during the reporting
period. This information can be obtained from the Medical Records Database or Admission/
Discharge Registers. The sample size of medical records to be surveyed should be 50 or 5%
(which ever number is higher) of the discharged patients. After identifying your sample size
randomly select patients from the discharged list. Obtain the Medical Records of these patients
from the Medical Records Department. If any Medical Record is missing, another patient /
Medical Record should be selected as a replacement.

b) Complete Medical Record Review Form

Medical Record Review Form

98 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 Medical Record Review Form

MR Number:

Date patient discharged from hospital:

Ward:

Inpatient Medical Record Checklist

Section Yes No
1. Patient Card (Physician Notes):
- Is this present?
- Are all entries dated and signed?
2. Vital sign Sheet – including BP, PR, RR, To, pain score it
may also include column for Spo2

3. Progress note – documented at least once a day

throughout the hospital stay
4. Physician Order sheet:
- Is this present?
- Are all entries dated and signed?
5. Nursing Care Plan
- Is this present?
- Are all entries dated and signed?
6. Medication Administration Record -
Is this present?
- Are all entries dated and signed?
7. Discharge Planning and Summary Sheet
- Is this present?
- Are all entries dated and signed?
8. Clinical Pharmacist Record
- Is this present?
- Are all entries dated and signed?

Total number of “Yes” and “No” Checks _____________ _____________

MR Reviewed by:

Name of Reviewer:

Date of Review:

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 99

Annex 6: Antimicrobial Stewardship program functionality Criteria

Category Functionality parameter

0 There no ASP team in the facility

There is ASP team having approved ToR with list and responsibilities of members,

1 Availability of ASP plan addressing ASP guideline

Availability of the national ASP practical guide in hard and soft copies.

Availability of AMR trained professionals,

2 Availability of functioning diagnostic laboratory in the facility,

Presence of institutional base line data.

Conduct regular review meeting with minutes documented,

Availability of audit and feedback system, appropriate de-escalation (Spectrum), appropriate

switch from IV to oral (route de-escalation),

3 Registration of antimicrobial consumption,

Recording of HAIs in the institution

Availability of DUE finding conducted on AMs in the past one year.

100 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 7: WHO Safe surgical check list

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 101

Annex 8: Surgical Site Infection Report Form

This form should be used to report infection occurring at the site of surgery in patients who
undergo major surgical procedures (i.e. any procedure conducted under general, spinal or major
regional anesthesia).

Definition of Surgical Site Infection (SSI):

One or more of the following criteria should be met:

• Purulent drainage from the incision wound

• Positive culture from a wound swab or aseptically aspirated fluid or tissue two of the
following: wound pain or tenderness,

Localized swelling, redness or heat

• Spontaneous wound dehiscence or deliberate wound revision/opening by the surgeon in the

presence of:

o pyrexia > 380C or

o localized pain or tenderness

An abscess or other evidence of infection involving the deep incision that is found by direct
examination during re-operation, or by histopathological or radiological examination

Ward (ዋርዴ): Date SSI detected :

Name of patient : Date of surgery:

Type of surgical procedure :

Name of surgeon :

Clinical signs (የተወሰዯውእርምጃ):

Action taken (የተወሰነው እርምጃ):

Reported by :

Name :_______________________Position : ___________________________

Outcome (to be completed at time of discharge) :

Signed : ________________________Position:_________________________

102 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 9: New pressure ulcers reporting format

This form should be used to report new pressure ulcers arising in patients following
admission to hospital.
Definition of Pressure Ulcer:
Pressure Ulcers arise in areas of unrelieved pressure (commonly sacrum, elbows, knees or
ankles).

Either of the following criteria should be met:

• A superficial break in the skin (abrasion or blister) in an area of pressure or

• An ulcer that involves the full thickness of the skin and may even extend into the
subcutaneous tissue, cartilage or bone

Ward (ዋርድ):

Name of patient:

Date of admission (በሽተኛውየተኙበትቀን):

Reason for admission/diagnosis (በሽተኛውየተኙበትምክንያት):

Date pressure ulcer detected (ቁስልየተገኘበትቀን):

Clinical signs of pressure ulcer (የአልጋቁስልክሊኒካልምልክቶች):

Action taken (የተወሰዯውእርምጃ):

Reported by :

Name : _______________________ Position : ___________________________

Outcome (to be completed at time of discharge) (ውጤት (በሽተኛውልወጣሲል):

Signed :______________________ Position : __________________________

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 103

Annex 10: Patient Satisfaction Survey Tool

Patient Satisfaction Survey Tool

Date in Ethiopian calendar: date…………………..…month……………..…year………………………………
Service area …………………………………………………….

Outpatient Emergency Inpatient Maternity

Total
department department department service
Characteristics

1 2 3 1 2 3 1 2 3 1 2 3
1=Disagree 2=Neutral 3=Agree
Had positive experience or
felt respected during thefirst
encounter with the hospital
staffs (guards, receptionists,
medical record room, triage)

Hospital compound was clean,

attractiveand safe to patients,
patient assistants, visitors and
the hospital workers

Easily identified theservice

areas whereyou want to get
a service (reception service,
runner,signage)

Patient registrationfacilitated in
a reasonable time

Acceptable waiting time to get

evaluated(seen by a doctor at
OPD/1st evaluation by a HCW
if admitted either in the IPD or
labor ward) knows who provided
their care, and what the role is of
each provider on the care team
(introduced during the encounter,

ID badge)

Able to identify whoare doctors,

nurses, and students

Client called byname during

encounters

Privacy maintained at all times of

care

Expressed ideas during

provider client interaction,
actively listened without
interruption

104 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 HCP showed respectand
tolerance at all encounters
There was no incidence of physical
or psychological abuse including
insulting, shouting, withholding
services
Obtained consent before
examination and procedures

Provided with adequate time

for counselling and informing
about client’s clinical condition
(type and severity) and his/her
treatment and care plan

Information was clear and

explainedto their level of
understanding
Involved in treatment options
and decision was made taking
their say in to consideration

Their wishes and decisions

were respected even if the HCP
disagrees
Get excused for shortcomings
All requested laboratory items
were availed in the facility
Get respected by laboratory
workers
Adequate information was
provided regardingthe process
of test including sample
collection methodsand
precautions, TAT, when, where
and how to collect results etc
Laboratory result was ready in
a reasonable time (asper the
counselling in the TAT)
All prescribed drugsare availed in
the facility
Get respected by pharmacy
workers
Adequate time and information
was given regarding the drug
usage includingfrequency, dose,
possible adverse events, storage,
duration, what to do in case of
doubts or adverse events like
using DIS in the hospital
Toilets and bathrooms were not
closed at any time of his/her
experience

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 105

Toilets and bathrooms
wereclean during
alltimes of his/her
encounter
Toilets and bathrooms
were not shared between
male and female
Discharge planning
was addressed during
admission which at least
includes possible days of
hospital stayand the cost it
may incur
Pain management was
adequate

Linen was being changed

regularly and during times
of gross contamination
with body fluids

Adequate supply of
hospital gowns and
pyjamas
Did not felt abandoned
for long time without
care (failure of provide to
monitor and intervene
when needed)
The food service was
satisfactory
Adequate water supply
during thestay
Adequate information
providedregarding waste
segregation, norms of the
ward, infection prevention
Auditory privacy was
maintained during times of
hospital stay

106 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 All oral medications
were kept in cabinetand
supported to take in the
presenceof assigned the
nurse/midwife
Not felt incidents of
breaks in confidentiality
(no information provided
to the client him/herself
while other family member/
visitor was there and
whom he/she did not
want to be shared with the
information)
Felt good communication
and collaboration with in
the health care team
Providers responded
promptly and
professionally when he/
she asks for help

Perceived that providers

are skillfuland displayed
confidence while providing
care or treatment

Felt served equally

irrespective his/her status
including gender, age,
economic status, social
status, place of living,
presence ofa relative/
provider he/she knows
working in the hospital
No incidence of
detainment in
the facility for
administrative reasons
includingunable to pay
for services

Allowed to labor in preferred

position

Allowed to deliver in
preferred position when
applicable
Trust developed on the
overall hospital and
recommend it to others to
be served

Total

Black shaded – not applicable to the departments at all time

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 107

Annex 11 : STAFF SATISFACTION SURVEY TOOL

THANK YOU FOR YOUR COOPERATION!

Date in Ethiopian calendar: date…………………..…month……………..…year………………………………

Profession / responsibility in the hospital …………………………………………………….

Length of service in the hospital: years………………………….months………………………………….

Laboratory/
pharmacy/
Doctors (GPs, Nurses / radiology and Supporting
specialists) midwives other health care staffs
Characteristics workers

1 2 3 1 2 3 1 2 3 1 2 3
1= Disagree 2=Neutral 3=Agree
The hospital clearly conveys its
mission to its employees.
I agree with Thehospital’s
overall mission.
I understand how my job
aligns with thehospital
mission.
I feel like I am a part of the
Hospital
There is good communication
from employees to managersin
the hospital.
There is good communication
from managers to employees
in the hospital.
My job gives me the
opportunity to learn
I have the tools and resources
I need to do my job.
I have the training I need to do
my job.
I receive the right amount of
recognition for my work.
I am aware of
the advancement
opportunitiesthat exist in
the hospital for me.

I feel underutilized in my job

108 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

 The amount of work expected
of me is reasonable.
It is easy to get along with my
colleagues.
The morale in my department
is high.
People in my department
communicate sufficiently with
one another
Get excused for shortcomings
Overall, my supervisor does a
good job.
My supervisor actively listens
to my suggestions.
My supervisor enables me to
perform at my best.
My supervisor promotes an
atmosphere of teamwork.
It is clear to me what my
supervisor expects of me
regarding my job Performance
My supervisor evaluates my
work performance on a regular
basis.
My supervisor provides me
with actionable suggestions on
what I can do to improve.
When I have questions or
concerns, my supervisor is able
to address them.
I would recommend this
hospital as a good place to
work.
Total

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 109

Annex 12 : WHO Analgesic Ladder

110 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 13: Essential Palliative Care Medicines List

Drug Name Properties Clinical Uses Alternative Drugs

Non opioid
Fever
Paracetamol Analgesic
Pain
Antipyretic
Non opioid Pain
Aspirin Analgesic Antipyretic Fever
Anti- inflammatory Sore mouth
Pain (esp. bone pain)
Diclofenac
Ibuprofen NSAID Fever
Indomethacin
Anti-inflammatory

Tramadol Weak opioid

Pain Low dose morphine
Codeine Analgesic

Pain
Introduction
Breakthrough pain
Strong opioid Morphine slow
Morphine liquid Difficulty swallowing
Analgesic release tablets
children
Breathlessness Severe
Diarrhea
Pain Morphine
Morphine (slow release tablets) Strong opioid
Severe diarrhea Liquid
Painful swelling and
Corticosteroid
Dexamethasone inflammation Prednisolone
Anti- inflammatory
Poor appetite
Tricyclic Neuropathic pain Carbamazepine
Amitriptyline
Antidepressant (nerve pain) Phenytoin
Tricyclic
Amitriptyline Depression Imipramine
Antidepressant

Hyoscine Butyl bromide Antimuscarinic Abdominal pain

Propantheline
(Buscopan) Antispasmodic (Colic)

Muscle spasm
Benzodiazepine
Diazepam Seizure Lorazepam
Anticonvulsant
Anxiety, sedation
Phenobarbitone Anticonvulsant Seizure Diazepam
Haloperidol
Metoclopramide Antiemetic Vomiting Domperidone
Promethazine

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 111

Drug Name Properties Clinical Uses Alternative Drugs

Metoclopramide Pro-kinetic Abdominal Fullness

Metoclopromide
Chlorpromazine Antipsychotic Hiccups
Nifedipine
Indigestion
Magnesium Trislicate Antacid Gastro-esophageal reflux
Gastritis
Loperamide Antidiarrheal Chronic diarrhea

Bisacodyl Stimulant laxative Constipation

Rehydration Diarrhea
ORS
Salt Rehydration

Chlorpheniramine Antihistamine Drug reactions

Chest infection
Flucloxacillin Antibiotic
Skin infection

PCP treatment &

Broad prophylaxis
Cotrimoxazole Spectrum Infective diarrhea in HIV/
Antibiotic AIDS
Urinary Tract Infection

Foul smelling wounds

Antibacterial for
Metronidazole gingivitis dysentery
anaerobic infections
Vaginal discharge

Lumefantrine
Anti- malarial Malarial treatment
artemether (LA)

Acyclovir Antiviral Herpes zoster

Chloramphenicol eye ointment/
Antibacterial Eye infections
drops
Oral & esophageal
Fluconazole Antifungal candidiasis
Cryptococcal meningitis
Topical Fungal Skin
Clotrimazole 1% Cream
antifungal Infection
Oral & vaginal candidiasis
Nystatin
Antifungal Prophylaxis for patients
Suspension and pessaries
on steroids

112 Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

Annex 14: Criteria for functional DTC

S.N Criteria Weight Score

Official letter of assigned DTC members (2.5) and updated and approved
1 5
TOR are available (2.5)
2 Annual action plan is approved 5

Documented minute that shows regular meetings, at least every two

3 10
months

Updated (annually) health facility specific pharmaceutical list prioritized by

4 10
VEN
Availability of medicine management policy and procedures (at least
three policies) (Example: procurement policy, formulary management
5 10
policy, prescription management policy, stock transfer policy, inventory
management and storage policy. disposal policy)

Conduct pharmaceutical supply studies (at least one assessment report

6 10
semi-annually) (ABC/VEN reconciliation, stock status analysis, etc.)

Conduct medicine use studies using indicator study method (at least
7 10
annually)

Conduct in-depth medicine use studies using medicine use evaluation (at
8 10
least one study annually)

Take actions hased on the supply and medicine use study findings with
9 20
report, minutes, letter of action and any related document

ADE/AEFI reports are generated, monitored regularly and take actions on

10 5
the finding

11 Report its performance activities to the management 5

Total score (%)

Functionality of DTC if ≥75%, Yes, If< 75%, No

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI) 113

Hospital Service Performance
Monitoring for Improvement
Indicators (HSPMI)