Suitable for: Hospital Administrators and Managers

Jan 2010

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Table of Content
Table of Content ................................................................................................................. 2
Introduction......................................................................................................................... 8
Session1: Overview .......................................................................................................... 10
What is Hospitals? ............................................................................................................ 10
History of Hospitals .......................................................................................................... 11
Role of Hospitals in Health System .................................................................................. 13
Changing Role of Hospitals .......................................................................................... 16
Reasons for changing role of hospitals ......................................................................... 16
Function of an Acute Care Hospital.................................................................................. 17
Hospital viewed as a System............................................................................................. 19
Peculiarities of a Hospital System ................................................................................ 20
Component or Structure of a Hospital .............................................................................. 22
A. Administration Services........................................................................................ 23
B. Informational Services .......................................................................................... 23
C. Therapeutic Services ............................................................................................. 23
D. Diagnostic Services............................................................................................... 25
E. Support Services ................................................................................................... 25
Organization of Hospitals in Afghanistan......................................................................... 27
The Future of Hospitals in Afghanistan............................................................................ 28
Group work and Facilitator Notes: ............................................................................... 29
Materials ................................................................................................................... 29
Process ...................................................................................................................... 29
Hospital Policies in Afghanistan....................................................................................... 30
Levels of Hospitals in the country ................................................................................ 31
District Hospital ........................................................................................................ 32
Provincial Hospital.................................................................................................... 32
Regional Hospital...................................................................................................... 32
Rationalization of Hospital Services (components)...................................................... 33
Aga Khan University Hospital Components and Activities ............................................. 34
Hospital and Challenges in Afghanistan........................................................................... 36
Hospital and Community .................................................................................................. 37
The provider, support group and community ............................................................... 39
Community and its Participation .................................................................................. 39
Hospital community relationship.................................................................................. 40
Session 2: Effective Management at Hospitals................................................................. 42
Medical profession and management................................................................................ 42
Principles of Management ................................................................................................ 42
Administration or management......................................................................................... 44
The governing board of hospitals ................................................................................. 45
Hospital Administrator.............................................................................................. 46
Choice of Hospital Director (Administrator)............................................................ 46
Role and functions of Hospital Administrator .......................................................... 47
Management Styles........................................................................................................... 48
Laissez-faire Management style : ............................................................................. 48
Democratic Management Style:................................................................................ 48

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 Autocratic Management Style: ................................................................................. 48
Group work: .................................................................................................................. 48
Skills of effective managers.............................................................................................. 51
Conceptual Skills .......................................................................................................... 51
Communication Skills................................................................................................... 52
Interpersonal Skills ....................................................................................................... 52
Importance of the managerial skills.................................................................................. 52
Ways to Improve Your Managerial Skills ........................................................................ 54
Coordination ..................................................................................................................... 58
Facilitation of coordination........................................................................................... 59
Characteristics of effective Hospital Manger ................................................................... 59
Efficiency versus Effectiveness ........................................................................................ 60
What is Efficiency?....................................................................................................... 60
What is Effectiveness?.................................................................................................. 60
Comparison of effectiveness and efficiency ................................................................. 61
Session 3: Hospital Planning and Design ......................................................................... 63
Guiding principles in Planning ......................................................................................... 63
Patient care of high quality ........................................................................................... 63
Effective community orientation .................................................................................. 64
Economic Viability ....................................................................................................... 64
Orderly Planning........................................................................................................... 65
A sound architectural plan ................................................................................................ 65
Hospital Utilization and planning ..................................................................................... 66
Bed Planning in Hospitals................................................................................................. 67
Planning for equipment in hospitals ................................................................................. 69
Session 4: Basics of Strategic Planning in Hospitals........................................................ 72
Importance of Strategic Planning...................................................................................... 72
Roles and Responsibilities in planning process ................................................................ 73
Strategic Planning Committee ...................................................................................... 73
The General Director/Chief Executive Officer............................................................. 74
Medical Staff................................................................................................................. 74
Patients and Community............................................................................................... 74
Planner and consultants................................................................................................. 75
The Steps of the Strategic Planning .................................................................................. 75
Get Organized ............................................................................................................... 76
Analysis of the Situations ............................................................................................. 77
Develop a Vision........................................................................................................... 78
Development or Review the Mission Statement........................................................... 78
Value statement............................................................................................................. 79
Develop Strategies ........................................................................................................ 79
Goal approach ........................................................................................................... 80
Critical Issues Approach ........................................................................................... 81
SMART Objectives................................................................................................... 82
Scenario Approach.................................................................................................... 82
Strategic Plan preparation ................................................................................................. 83
Taking Approval of the Plan......................................................................................... 84

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 Implementation of the Plan........................................................................................... 84
Monitoring and Updating the Strategic Plan ................................................................ 84
Operational Planning and Activity Scheduling................................................................. 85
What is Operational Plan? ............................................................................................ 88
Importance of Operational Plan .................................................................................... 89
Steps in developing Operational Planning.................................................................... 89
Step 1 – List Main Activities .................................................................................... 89
Session 5: Hospital Costing and Budgeting...................................................................... 93
Budget Principles .............................................................................................................. 93
What is cost? ..................................................................................................................... 94
Classification of Costs ...................................................................................................... 95
Classification by type.................................................................................................... 95
Classification by behavior............................................................................................. 95
Classification by function/activity ................................................................................ 97
Classification by level................................................................................................... 98
Layout of Methodology of Framework............................................................................. 99
Goals summary ............................................................................................................. 99
Resources (Inputs) ........................................................................................................ 99
Converting the costing to a budget ................................................................................. 100
Steps for creating a budget.............................................................................................. 100
Hospital Budgeting ......................................................................................................... 104
Preparing to draw up a Budget.................................................................................... 105
STEP 1: list the inputs............................................................................................. 105
STEP 2: cost of inputs............................................................................................. 105
STEP 3: Combine the costs..................................................................................... 106
Budgeting for Revenue: .............................................................................................. 106
Cost consciousness.......................................................................................................... 107
Cost containment and improving profitability............................................................ 107
A checklist for cost containment................................................................................. 108
Cost Effectiveness........................................................................................................... 109
Program Budgeting In Afghanistan ................................................................................ 111
Implementing Program Budgeting.............................................................................. 112
Group work: ................................................................................................................ 114
Session 6: Hospital Monitoring and Evaluation ............................................................. 116
Justifications for Monitoring Hospitals ...................................................................... 117
Monitoring Framework................................................................................................... 117
Evaluation Framework.................................................................................................... 118
Planning for Monitoring and Evaluation ........................................................................ 118
Hospital as a System for Monitoring .............................................................................. 119
Quality Monitoring Framework.................................................................................. 121
What is Quality Monitoring? ...................................................................................... 124
Criteria .................................................................................................................... 124
Standards................................................................................................................. 124
Hospital Monitoring Indicators....................................................................................... 126
Length of Stay (LS...................................................................................................... 127
Occupancy Rate (OR):................................................................................................ 127

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 Proportion of all Births in the Hospital:...................................................................... 128
Cesarean Sections as a Proportion of all Births:......................................................... 128
Case Fatality Rate (CFR):........................................................................................... 129
Incidence rate (IR) (6 EPI target diseases, diarrhea, ARI): ........................................ 130
Mortality rate under age 5 (U5MR):........................................................................... 130
Post Operative Infection proportion: .......................................................................... 130
External and Internal Monitoring.................................................................................... 131
Hospital Monitoring of Adverse Drug Reactions ........................................................... 131
Monitoring of Absenteeism in Hospitals ........................................................................ 133
Why absenteeism ........................................................................................................ 133
Management issues: .................................................................................................... 133
Staff issues: ................................................................................................................. 133
How to deal with absenteeism .................................................................................... 134
Session 7: SWOT Analysis of Hospital .......................................................................... 136
Strengths: .................................................................................................................... 136
Weaknesses:................................................................................................................ 136
Opportunities: ............................................................................................................. 136
Threats: ....................................................................................................................... 137
Group work: ................................................................................................................ 137
Session 8: Medical Audit and Quality Assurance........................................................... 139
Definitions....................................................................................................................... 139
History of medical audit.................................................................................................. 140
Types of audit ................................................................................................................. 141
Standards-based audit ................................................................................................. 141
Adverse occurrence screening and critical incident monitoring................................. 141
Peers review ................................................................................................................ 141
Patient surveys and focus groups ................................................................................ 141
Protocol for medical audit............................................................................................... 141
Process of clinical audit .............................................................................................. 143
Stage 1: Identify the problem or issue ........................................................................ 144
Stage 2: Define criteria & standards ........................................................................... 144
Stage 3: Data collection .............................................................................................. 144
Stage 4: Compare performance with criteria and standards ....................................... 145
Stage 5: Implementing change.................................................................................... 145
Re-audit: Sustaining Improvements............................................................................ 146
Evaluation, Research, Medical and Clinical Audit......................................................... 147
How to Write an Audit Report.................................................................................... 148
Hospital Standards in Afghanistan.................................................................................. 149
Section 1: Governance ................................................................................................ 149
Section 2: Clinical Care .............................................................................................. 150
Section 3: Nursing Services ........................................................................................ 151
Section 4: Ancillary and Support Services ................................................................. 151
Section 5: Administration and Management............................................................... 152
Standards and Performance at Hospitals..................................................................... 152
Importance of Clinical Audit ...................................................................................... 158
Areas and Time of clinical audit................................................................................. 160

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Quality Care in Hospitals................................................................................................ 161
Choice of Quality Healthcare...................................................................................... 162
Checklist for choice of Quality Healthcare............................................................. 163
The way forward ............................................................................................................. 164
Session 9: Financial Management in Hospitals .............................................................. 166
Health Providers in Hospital System .............................................................................. 166
Payers in Hospital System .............................................................................................. 168
Hospital Revenues: How Hospitals are earning money? ................................................ 169
Hospital Expenses: How Hospitals are spending money? .............................................. 172
Financial Information in the Hospitals ........................................................................... 173
The Income Statement .................................................................................................... 174
What Is Profit? ............................................................................................................ 175
The Balance Sheet........................................................................................................... 176
The Cash Flow Statement ............................................................................................... 179
Evaluation of Hospital Financials conditions ................................................................. 181
Ratio Analysis............................................................................................................. 181
Cash Flow Analysis .................................................................................................... 183
Affiliate Charts................................................................................................................ 183
Financial report and information system ........................................................................ 183
Session 10: Grievance and complaint Management in Hospitals................................... 185
Importance of facing complaints as challenge................................................................ 186
Follow-up actions taken by the hospital ..................................................................... 190
Six rules for pursuing hospital complaints through patient’s perspective .................. 191
Patients’ rights ................................................................................................................ 191
Session 11: Hospital Information System....................................................................... 194
Working principles for revising the HMIS ................................................................. 195
Criteria for Health Indicator selection ........................................................................ 195
Importance of Health Information System ................................................................. 196
Hospital Information System Forms in MoPH ............................................................... 198
Monthly Integrated Activity Report – Facilities OPD (MIAR).................................. 198
Hospital Monthly Inpatient Report (HMIR) ............................................................... 204
Hospital Status Report Form (HSR) ........................................................................... 211
Session 12: Waste Management in Hospitals ................................................................. 218
Types of wastes........................................................................................................... 218
Characteristics of a good waste disposal system ........................................................ 220
Collection and Removal of wastes.............................................................................. 220
Disposal of waste ........................................................................................................ 221
Classification of waste ................................................................................................ 221
1. Type 0 wastes: Trash ...................................................................................... 221
2. Type 1 waste: Rubbish:................................................................................... 222
3. Type 2 Waste: Refuge..................................................................................... 222
4. Type 3 Waste: Garbage................................................................................... 222
5. Type 4 Waste: Pathological ............................................................................ 222
6. Type 5 and 6 Waste: Industrial Operations..................................................... 222
Methods of disposal .................................................................................................... 222
Infection Prevention and Waste Management in Hospitals............................................ 223

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 Policy: ......................................................................................................................... 223
Waste Segregation ...................................................................................................... 223
Color coding: Clinical Waste Segregation.................................................................. 229
Session 13: Report writing.............................................................................................. 231
Why report writing?.................................................................................................... 231
Structure of Report Writing ........................................................................................ 232
Annexes: ......................................................................................................................... 237
Annex A: Quiz on Organizational Structure of Hospitals .......................................... 237
Annex B: Sample of strategic plan (partially) ............................................................ 238
Annex C: Patients’ Rights and Responsibilities at Aga Khan University Hospital.... 244
Annex D: HMIS form (Monthly Integrated Activity Report- MIAR)........................ 248
Annex E: HMIS form (Hospital Monthly Inpatient Report- HMIR).......................... 250
Annex F: HMIS form (Hospital Status Report- HSR)................................................ 252
Annexé G: Waste Colour Coding ............................................................................... 256
References:...................................................................................................................... 258

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Introduction
Hospitals are an important component of the health care system and are central
to the process of reform, and yet, as institutions, they have received remarkably
little attention from government and stakeholders. They are important within the
health care system for several reasons. Although donors are less interested to
support tertiary healthcare system in Afghanistan, however they account for a
substantial proportion of the health care budget through ministry of public health
(MoPH). Second, their position at the apex of the health care system means that
the policies they adopt, which determine access to specialist services, have a
major impact on overall health care. Third, the specialists who work in hospitals
provide professional leadership. Finally, technological and pharmaceutical
developments, as well as more attention to evidence-based health care, mean
that the services that hospitals provide can potentially contribute significantly to
population health. If hospitals are ineffectively organized, however, their
potentially positive impact on health will be reduced or even be negative.
In Afghanistan the hospitals are at the stage growing and rapidly changing
pressures in public and private sector. These include the impact of changes in
populations, patterns of disease, opportunities for medical intervention with new
knowledge and technology, and public and political expectations. As we are
faced with double burden of diseases and there is a need to focus on primary,
secondary and tertiary care at the same time, therefore new types of hospitals,
new configurations of buildings, qualified people with different skills and new
ways of working are required. There is the need to shift the boundary between
hospital and primary care, where hospitals are thought to provide just advance
medical healthcare. Hospitals increasingly focus on acute care, only admitting
people with conditions requiring relatively intensive medical or nursing care or
sophisticated diagnosis or treatment. Hospitals must adapt internally to these
new circumstances.
There is now considerable information on what does and what does not work,
although this is not always easy to locate and evaluate. Using experiences of
developing countries and WHO recommendation we should proceed. In this

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regard we can use the Essential Package of Hospital Services (EPHS) and
Hospital Policy in Afghanistan which is developed and available. In this training
module it is tried to discuss the reasonable and modern ways of managing
hospitals in country context. This is not, however, a textbook on how to manage
a hospital. The module is focusing on the role of hospitals as part of a wider
health care system, in improving health and responding to the legitimate needs of
people who use hospitals.

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Session1: Overview
What is Hospitals?
At the outset, it is necessary to be clear about the subject of this module. What,
precisely, is a hospital? One definition is that it is ‘an institution which provides
beds, meals, and constant nursing care for its patients while they undergo
medical therapy at the hands of professional physicians. In carrying out these
services, the hospital is striving to restore its patients to health. Although this
captures its essence, a hospital can cover very diverse structures.
There are definitions of medical care and hospital which is published by WHO in
1959.
Medical care is a programme of services that should make available to the
individual, and thereby to the community, all facilities of medical and allied
services necessary to promote and maintain health of mind and body. The
programme should take into account the physical, social and family environment,
with a view to prevention of diseases, the restoration of health and the alleviation
of disability. (WHO, 1959)
A Hospital is an integral part of a Social and Medical organization, the function of
which is to provide for the population complete healthcare, both curative and
preventive, and whose outpatients services reach out to the family and its home
environment; the hospital is also a center for the training of health workers and
bio-social research. (WHO definition of Hospital)
Thus, Hospital is a health facility where patients receive treatment. It is a medical
institution where sick or injured people are given medical or surgical care. A
hospital today is an institution for professional health care provided in part by
physicians and nurses.
A hospital might be a ten-bed building without running water in a district or a
large specialist centre equipped with the most advanced technology in a capital
of the country. This diversity is not surprising, given that some countries in
Europe spend less than a 50 euro per head of population per year on hospitals,
whereas others spend almost a14, 000. Second, the type of hospital can be
difficult to classify. For example, how does one classify a facility that links a small

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acute care service to a larger long term care facility? What is the difference
between a small private hospital offering mainly nursing care and an examination
home visited daily by a physician? How about public hospitals that are semi
closed afternoons and how about private hospitals that are semi closed in the
morning? Does the definition of a hospital cover only the activities undertaken
within its walls? Hospitals in the United States have embarked on vertical
mergers that incorporate other service types such as rehabilitation and post-
discharge care. “Hospital without walls’ or ‘hospital at home’ links the hospital to
a wide range of outreach services.

History of Hospitals
During the middle Ages the hospital could serve other functions, such as
almshouse for the poor, or hostel for pilgrims. The name comes from Latin
hospes (host), which is also the root for the English words hotel, hostel, and
hospitality. The modern word hotel derives from the French word hostel, which
featured a silent s, which was eventually removed from the word; French for
hospital is hôpital. Some patients just come for diagnosis and/or therapy and
then leave (outpatients); while others are admitted and stay overnight or for
several weeks or months (inpatients). Hospitals are usually distinguished from
other types of medical facilities by their ability to admit and care for inpatients.
In ancient cultures, religion and medicine were linked. The earliest documented
institutions aiming to provide cures were Egyptian temples. Classical Greek
temples dedicated to the healer-god Asclepius might admit the sick, who would
wait for guidance from the deity in a dream. The Romans adopted his worship.
Under his Roman name Æsculapius, he was provided with a temple (291 BC) on
an island in the Tiber in Rome, where similar rites were performed. The
Sinhalese (Sri Lankans) may have been responsible for introducing the concept
of dedicated hospitals to the rest of the world. According to the Mahavamsa, the
ancient chronicle of Sinhalese royalty, written in the sixth century A.D., King
Pandukabhaya (fourth century B.C.) had lying-in-homes and hospitals
(Sivikasotthi-Sala) built in various parts of the country. This is the earliest
documentary evidence we have of institutions specifically dedicated to the care

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of the sick anywhere in the world. Institutions created specifically to care for the ill
also appeared early in India. King Ashoka is said to have founded at least
eighteen hospitals 230 B.C., with physicians and nursing staff, the expense being
borne by the royal treasury. Stanley Finger (2001) in his book, Origins of
Neuroscience: A History of Explorations Into Brain Function, cites an Ashokan
edict translated as: "Everywhere King Piyadasi (Asoka) erected two kinds of
hospitals, hospitals for people and hospitals for animals. Where there were no
healing herbs for people and animals, he ordered that they be bought and
planted. The first teaching hospital where students were authorized to practice
methodically on patients under the supervision of physicians as part of their
education was the Academy of Gundishapur in the Persian Empire. One expert
has argued that "to a very large extent, the credit for the whole hospital system
must be given to Persia. The Romans created valetudinaria for the care of sick
slaves, gladiators, and soldiers around 100 B.C., and many were identified by
later archeology. The adoption of Christianity as the state religion of the Roman
Empire drove an expansion of the provision of care. The First Council of Nicaea
in 325 A.D. urged the church to provide for the poor, sick, widows, and strangers.
It ordered the construction of a hospital in every cathedral town. Among the
earliest were those built by the physician Saint Sampson in Constantinople and
by Basil, bishop of Caesarea. The earliest recorded hospital in the medieval
Islamic world was that of al-Walid ibn 'Abdul Malik (ruled 705-715 CE) which he
built in 86 AH (706-707 CE). It somewhat resembled the Persian bimaristan and
Byzantine nosocomia, but was more general, as it extended its services to
lepers, invalid, and destitute people. All treatment and care was free of charge
and there was more than one physician employed in this hospital. In the
medieval Islamic world, the word "bimaristan" was used to indicate an
establishment where the ill were welcomed and cared for by qualified staff. In this
way Muslim physicians distinguished between a hospital and a hospice, asylum,
lazaret, or leper-house, all of which were more concerned with isolating the sick
and the mad (insane) from society than offering them a cure. Some thus consider

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the medieval Bimaristan hospitals as "the first hospitals" in the modern sense of
the word.
The first hospital in Egypt was opened in 872 A.D. and thereafter public hospitals
sprang up all over the empire from Spain and the Maghrib to Persia. As the
system developed, physicians and surgeons were appointed who gave lectures
to medical students and issued diplomas to those who were considered qualified
to practice - an early parallel to modern medical schools. Between the eighth and
twelfth centuries CE Muslim hospitals developed a high standard of care.
Hospitals in Baghdad in the ninth and tenth centuries employed up to twenty-five
staff physicians and had separate wards for different conditions.

Role of Hospitals in Health System

Basically there are various roles and functions that a hospital might be expected
to perform. A hospital may undertake several functions, depending on the type of
hospital, its role in the health care system and its relationship with other health
care services. Hospitals should and may offer a range of health care services
covering a simple medical check up to specified tertiary care at competitive
process. They should develop services as per the needs of the different
consumers with provision of good quality services that can compete in the
market. Hospitals can be classified into four basic categories - the private,
income generating hospitals; the hospitals run by NGOs; the military hospitals
and finally, the public hospitals, both large and small. Traditionally, hospitals
have been regarded as big institutions, rather than just as a place for cure and a
place for disease. For health professionals they are centers of technical
excellence for both learning and practice. However, hospitals now need to re-
think their traditional roles and look at aspects that they did not consider as part
of health care. The reason for this is the growing trend of globalization.
Globalization is a modern phenomenon, a development of the last few decades
of the 20th Century. Globalization is inevitable and desirable. However, it poses
considerable challenges and uncertainties in the provision of health care. If we
are not prepared for these changes, they could lead to policy mistakes, which
could prove to be costly. For Afghanistan government it is required to move away

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from the monopolies that currently exist in this country and introducing
competitiveness. There is a need to encourage foreign companies to invest
comprehensive tertiary hospital in zones. Time consuming and lengthy
procedures are needed to be removed and facilitated. In addition, it is necessary
that the basic services for the poor and under served are not forgotten and
continued.
In last years, in Afghanistan, another area of trade is foreign direct investment in
the private hospitals. With no control on their standards and quality of services,
for sure there will be poor impact on health system of the country. Some feel that
this would enhance investment opportunities, increase competition for quality
health care and remove the burden on the public sector. Others feel that the
foreign facilities would attract the best medical professionals from the public
sector and thus lead to internal brain drain.
Another component which is newly added to some private and public hospitals in
the country is Telemedicine. Using such advanced technology will facilitate
diagnostic, curative, preventive and building the capacity of health professionals
at the hospital sector. In fact this is a new area of investment the country which
still requires growing and development. This could improve the quality of care
and improve skills and knowledge of the professionals but would also need
substantial investment. By establishment of such mechanism, that is possible to
provide advice for medical professionals at provinces through on-line services on
the internet, thus affecting the quality of healthcare delivery. Production of more
medical doctors as compare to nurses and paramedical has affected the quality
of hospital services in big cities. It seems the country is flooded with service
providers in terms of medical doctors whereas there is dire need for nursing
activities. Certainly hospitals are the only hope for poor people of the country for
receiving health. There are some issues such as qualification of health
professionals, standards of hospitals, observation of policy and their accreditation
procedures need to be discussed, debated and settled by the health authorities
in collaboration with other sectors and professional organizations.

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If we claim and say that health care is a “right” not a “privilege” then we should
work for accessibility of everyone to health. Now the government should, based
on bazaar economy, believe that there should be competition in health care and
that the market should prevail. Nowadays despite advanced technology in private
and public hospitals, most expensive hospital technology is the physician’s pen.
As part supplier induced demand, the physicians order more tests and demand
more technology, hospitals scramble to provide the needed facilities and
equipment. In Afghanistan the hospitals are owned by public and private
organizations with different facilities and charges. Some are public and owned by
government while others are private for profit and are owned by individuals and
may even be publicly traded.
With low capacity public or private hospital in the country, the sick people travel
to neighboring countries in order to receive care. The government is always
criticized by public and member of assemblies due to low attention to tertiary
care hospitals. Though in post conflict situations there is a need to focus on
access of population of basic package of health services, however now it is time
to focus partially the secondary and tertiary services by the government. If you
evaluate the current status of the country more progress has been made in terms
of communications (mobile phones), banks, roads, agriculture, electricity and so
on, therefore Are banks and mobile companies more important than essential
hospitals to our nation’s well being? Thus hospitals should be part of health care
reform.
Hospitals, usually looked up to for leadership in the total health care effort,
cannot do the job alone but ideally can contribute to the comprehensive plan.
Primary Health Care (PHC) is a strategy now internationally accepted as the
most important means of meeting the health needs of people in communities
around the world. Therefore by involvement of PHC in we will have a good
answer to the mounting crisis in health care today. We are suffering from double
burden of health problems. It means beside communicable diseases people have
started to over-eat, over-smoke, over- drink, over-drive, and over-stress.

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Hospitals can and must play an important role in helping to overcome these
challenges.

Changing Role of Hospitals

From its gradual evolution through the 18th and 19th centuries, the hospital both in
the eastern and western- has come of age only recently during the past 50 years
or so, the concept of today’ hospital contrasting fundamentally from the old idea
of a hospital as no more than a place for the treatment of the sick. With the wide
coverage of every aspect of human welfare as part of healthcare versus physical,
mental and social wellbeing, a reach-out to the community, training of health
workers, biosocial research, etc— the healthcare services have undergone a
steady metamorphosis, and the role of hospital has changed, with the emphasis
shifting from:
# From To
1 Acute Chronic illness
2 Curative Preventive medicine
3 Restorative Comprehensive medicine
4 Inpatient care Outpatient and home care
5 Individual orientations Community orientations
6 Isolated functions Area-wise or regional functions
7 Tertiary and secondary Primary Health Care
8 Episodic care Total care

Reasons for changing role of hospitals

The important factors which have led to the changing role and functions of the
hospitals are as follows.
• Expansion of the clientele from the dying, the destitute, the poor and
needy to all classes of people
• Improved economic and social status of the community
• Control of communicable diseases and increase in chronic degenerative
diseases
• Progress in the means of communications and transportation

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 • Political obligation of the governments to provide comprehensive care
• Increasing health awareness
• Rising standards of living especially in urban areas and sociopolitical
awareness especially in semi urban and rural areas with the result that
expect better services and facilities in healthcare institutions
• Control and promotion of quality of care by government and professional
associations
• Rapid advances in medical sciences and technology
• Increase in population requiring more number of hospital beds
• Sophisticated instrumentations, equipment and better diagnostic and
therapeutic tools
• Advances in administrative procedures and management technique
• Reorientation of health care delivery system with emphasis on delivery of
primary health care.
• Awareness of the community
If the role of hospital is to restore health and not merely to cure a disease entity,
the role and responsibility of hospitals assumes great significance. It goes for
beyond the diseased organ or individual. The modern hospital is a modern a
social universe with a multiplicity of goals, profusion of personnel and extremely
fine division of labor.

Function of an Acute Care Hospital

The questions commonly asked by policy-makers include: What size population
should the hospital serve? How many patients, beds and specialties should it
contain? Where should the boundary lie between the hospital and other health
services? The answers will depend on the values and objectives of the individual
or organization asking the questions. In many cases, competing objectives must
be balanced. For example, surgeons may want large hospitals that can support
large clinical teams and complex equipment, whereas the public may want ‘their’
hospital close to where they live.

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The core function of a hospital is to treat patients who are ill, but an analysis
confined to this function would be misleading. The hospital may also be an
important setting for teaching and research and may actively support its
surrounding health care system. Furthermore, the hospital may be an important
source of local employment and may play several societal roles. The
expectations that accompany each of these roles have important implications for
the organization of the hospital and its relationship with its wider environment.
Following is the main functions and sub functions which is needed to be
performed in ideal hospitals.
• Patient care
o Inpatient, outpatient and day patient
o Emergency and elective
o Rehabilitation
• Teaching
o Vocational
o Undergraduate
o Postgraduate
o Continuing education
• Research
o Basic research
o Clinical research
o Health services research
o Educational research
• Health system support
o Source for referrals
o Professional leadership
o Base for outreach activities
o Management of primary care
• Employment
o Inside hospital:

Health professionals

18

Other health care workers
o Outside hospital:

Suppliers

Transport services
• Societal
o State legitimacy
o Political symbol
o Provider of social care
o Base for medical power
o Civic pride
In the course of last six years (2004-2010) the Basic Package of Health Services
(BPHS) is being expanded (85%) throughout Afghanistan. The BPHS is an
important element in the redevelopment of the health system because it deals
with the priority health problems of the country. Hospitals have an important role
in this PHC-focused strategy because district, provincial, and regional hospitals
are required to form an integrated referral system providing a range of needed
services: from health promotion to disease prevention to basic treatment to
disability care to specialized inpatient care. This policy establishes the guidelines
for the redevelopment of hospitals as a key element of the Afghan health system.

Hospital viewed as a System

A hospital can be variously described as a factory, and office building, a hotel,
and eating establishment, a medical care agency, a social service institution and
a business institution. In fact it is all of these in one, and more. Sometimes it is
run by business means but not necessarily for business ends. This complex
character of hospital has fascinated social scientists as well as lay people.
Management sciences define a system as “a collection of components
subsystem which, operating together, perform a set of operations in
accomplishment of defined objectives.” A system is views as anything formed of
parts placed together or adjusted into a cohesive whole. Every system is
therefore a part of a large system and has its own subsystems. A system is

19
construed as having inputs which undergo certain processing and get
transformed into output, the output itself in turn sending feedback to the input and
the process, which can be altered to achieve still better output. A system is
therefore a continuous and dynamic phenomenon.

Figure: conceptual representation of a system

FEEDBACK

INPUT PROCESS OUTPT

(TRANSFORMATION)

Peculiarities of a Hospital System

In spite of simple definition of a system, a hospital system is more than the sum
of its parts. The peculiarities hospital systems are as follows.
• A hospital is an open system which interacts with its environemtn
• Although a system generally has boundary, the boundaries separating the
hospital system from other social systems are not clear but rather fuzzy
• A system must produce enough outputs through use of inputs. But the
output of a hospital system is not clearly measureable
• A hospital has to be in a dynamic equilibrium with the wider social system
• A hospital system is not an end it itself. it must function, as a part of larger
health care system.
• A hospital like other open social systems tends towards elaboration and
differentiation i.e. as it grows, the hospital system tends to become more
specialized in its elements and elaborate in structure, manifesting in the
creation of more and more specialized departments, acquisition of new
technology, expansion of the “product lines” and scope of services.

20
In considering the hospital as a system for the delivery of personal services,
which is the more important of its functions Anand (1984) views the system from
four different perspectives which are as follows.
1. Client oriented perspective: which is that of access to service, use
of services, and quality of care, maintenance of client autonomy
and dignity, responsiveness to client needs, wishes and freedom of
choice.
2. Provider oriented perspective: that of the physicians, nurses and
other professionals working for the hospital, and include freedom of
professional judgment and activities, maintenance of proficiency
and quality of care, adequate compensations, control over
traditions and terms of practice and maintenance of professional
norms.
3. Organization oriented perspective: which covers cost control,
control of quality, efficiency, ability to attract clients, ability to attract
employees and staff, and mobilization of community support.
4. Collective orientation perspective: that includes proper allocation of
resources among competing needs, political representation,
representation of interests affected by the organization, and
collaboration with other agencies.

21
 Component or Structure of a Hospital
The hospital is more the sum of its parts. The major components of a hospital
system are depicted in the flowing figure.
Figure: components of a hospital system

Hospital System

Care
Cure
Subsystem
Subsystem

Diagnostic Therapeutic Nursing Supportive

Subsystem Subsystem Subsystem Subsystem

Minor
Subsystem

Administrative Circulation Environmental Technical Social, etc

It is easily understandable to see the organ gram of the hospital and know what
its components are because every hospital, large or small, has an organizational
structure that allows for the efficient management of departments. Basically
grouping of Hospital Departments within the Organizational Structure is done.
Although each hospital department performs specific functions, departments are
generally grouped according to similarity of duties and promotion of efficiency of
the healthcare facility. Anyway common organizational categories might include:
Administration Services, Informational Services, Therapeutic Services,
Diagnostic Services and Support Services (sometimes referred to as

22
“Environmental Services”). For more information following each service is
outlined in more detail.
A. Administration Services—business people who “run” the hospital
o Hospital Administrators
o manage and oversee the operation of departments

oversee budgeting and finance

establish hospital policies and procedures

perform public relation duties
o generally include: Hospital President, Vice Presidents, Executive
Assistants, Department Heads
B. Informational Services—documents and process information
o Admissions-often the public’s first contact with hospital personnel
o checks patients into hospital

responsibilities include: obtaining vital information (patient’s
full name, address, phone number, admitting doctor,
admitting diagnosis, social security number, date of birth, all
insurance information)

frequently, admissions will assign in-house patients their
hospital room
o Billing and Collection Departments - responsible for billing patients for
services rendered
o Medical Records - responsible for maintaining copies of all patient records
o Information Systems - responsible for computers and hospital network
o Health Education - responsible for staff and patient health-related
education
o Human Resources - responsible for recruiting/ hiring employees and
employee benefits
C. Therapeutic Services – provides treatment to patients
o includes the following departments:
a. Medical Therapy (including adults, children and infants)
b. Surgical Therapy (including adults, children and infants)

23
c. Physical Therapy (PT)
i. provide treatment to improve large-muscle mobility and
prevent or limit permanent disability
ii. treatments may include: exercise, massage, hydrotherapy,
ultrasound, electrical stimulation, heat application
d. Occupational Therapy (OT)
i. goal of treatment is to help patient regain fine motor skills so
that they can function independently at home and work
ii. treatments might include: arts and crafts that help with hand-
eye coordination, games and recreation to help patients
develop balance and coordination, social activities to assist
patient’s with emotional health
e. Speech/Language Pathology
i. identify, evaluate, and treat patients with speech and
language disorders
ii. also help patients cope with problems created by speech
impairments
f. Respiratory Therapy (RT)
i. treat patient’s with heart and lung diseases
ii. treatment might include: oxygen, medications, breathing
exercises
g. Medical Psychology
i. concerned with mental well-being of patients
ii. treatments might include: talk therapy, behavior modification,
muscle relaxation, medications, group therapy, recreational
therapies (art, music, dance)
h. Social Services
i. aid patients by referring them to community resources for
living assistance (housing, medical, mental, financial)
ii. social worker specialties include: child welfare, geriatrics,
family, correctional

24
 i. Pharmacy
i. Dispense medications per written orders of physician,
dentists, etc.
ii. provide information on drugs and correct ways to use them
iii. ensure drug compatibility
j. Dietary - responsible for helping patients maintain nutritionally
sound diets
k. Sports Medicine
i. provide rehabilitative services to athletes
ii. teaches proper nutrition
iii. prescribe exercises to increase strength and flexibility or
correct weaknesses
iv. apply tape or padding to protect body parts
v. administer first aid for sports injuries
l. Nursing (RN, LVN, LPN)
i. provide care for patients as directed by physicians
ii. many nursing specialties include: nurse practitioner, labor
and delivery nurse, neonatal nurse, emergency room nurse,
nurse midwife, surgical nurse, nurse anesthetist
iii. In some facilities, Nursing is a service in and of itself.
D. Diagnostic Services – determines cause(s) of illness or injury
o includes the following departments:
a. Medical Laboratory (MT) - studies body tissues to determine
abnormalities
b. Imaging
i. image body parts to determine lesions and abnormalities
ii. includes the following: Diagnostic Radiology, MRI, CT, Ultra
Sound
c. Emergency Medicine - provides emergency diagnoses and
treatment
E. Support Services—provides support to entire hospital

25
 o includes the following departments:
a. Central Supply
i. in charge of ordering, receiving, stocking and distributing all
equipment and supplies used by healthcare facility
ii. sterilize instruments or supplies
iii. clean and maintain hospital linen and patient gowns
b. Biomedical Technology
i. design and build biomedical equipment (engineers)
ii. diagnose and repair defective equipment (biomedical
technicians)
iii. provide preventative maintenance to all hospital equipment
(biomedical technicians)
iv. pilot use of medical equipment to other hospital employees
(biomedical technicians)
c. Housekeeping and Maintenance
i. maintain safe clean environment
ii. cleaners, electricians, carpenters, gardeners
The above structure could be depicted easily in a chart that is the organ gram of
the hospitals.
Board of the
Hospitals

Administration

Information Therapeutic Diagnostic Supportive

Services Services Services Services

26
Organization of Hospitals in Afghanistan
The way in which the general administration of hospitals in Afghanistan should
be organized is illustrated in following Figure. The figure shows the staff
positions, the relationship among the various hospital departments, and the
necessary reporting relationships. As noted in the following section, hospital
boards will be introduced to make sure that hospitals are overseen by community
members who can identify the true needs of the community and ensure the
accountability of the hospital administration.
While the Hospital Director is responsible for the hospital’s operation and the
day-today management of the facility and its services, the Director is also
expected to develop a management team of key staff. Team members should
meet on a weekly basis to discuss and resolve the hospital’s major plans,
problems, and budgets. By promoting participatory management and teamwork,
the Hospital Director will be able to improve the quality of care, performance,
operation, and management of the hospital.
Figure: organization of hospitals in Afghanistan

27
The Future of Hospitals in Afghanistan
According to EPHS, the top three priorities of the hospital sector in the coming
years are to increase access to hospital services, improve the quality of patient
care, and to increase the efficiency of hospital operation. Bringing about these
improvements will require several initiatives.
The following three initiatives can be expected to be operational within the next
five to 10 years.
First, standards must be established. Hospitals require standards for both clinical
and administrative operations in order to improve clinical and managerial
performance and to attain an acceptable level of patient care and hospital
operation. Standards establish what is expected of hospitals and their staff at all
levels of operation; standards permit the monitoring of operations and the
measurement of performance. The national hospital policy outlines the six areas
for which basic standards need to be developed. Specific elements of each
standard must be developed and specified in greater detail by the Ministry of
Public Health.
Second, to strengthen community involvement and support, hospital boards must
be established. Community support for hospitals is often poor; communities using
a hospital tend to regard it as the “government’s hospital” or the “NGO’s hospital”
rather than “their” hospital. A hospital board will provide general direction and
guidance for the management and operation of the hospital, as well as serving as
a link between the community and hospital. Hospital community boards will be
made up of volunteers with diverse skills and experiences who will be
responsible for the long-term viability of the hospital and ensure that it meets the
real and felt needs of the community. Their responsibilities will include:
ensuring that high quality services are provided;
maintaining community and government relations and generating
community support for the hospital;
serving as the policy and strategy-setting body of the hospital;
supporting the leadership of the hospital;
providing financial oversight;

28
 Helping develop the hospital’s strategic plan.
Third, as the number of hospitals operated by government, NGOs and private
entities increases, hospital certification or accreditation will be needed to ensure
that all hospitals provide a basic standard of care. Accreditation is the process of
assessing health institutions against a commonly accepted set of standards in
order to ensure and improve the quality of health services. The goal of
accreditation is to ensure that providers, both the hospital as an institution and its
physicians and nurses, provide high quality care to patients. Table 5 lists the
elements of quality of care that would be considered in an accreditation process.

Group work and Facilitator Notes:

Purpose: The main goal of the exercise is to draw the organizational chart of a
hospital. By this group work despite of promoting teamwork you will encourage
participants to execute logic and problem solving skills and make use of creativity
and innovative thoughts.
Materials: colored markers or colored pencils, white butcher paper (3 x 2’) or
poster board
Process:
1. Divide participants into groups of 4 to 5.
2. Using the Organizational Structure, show the students how a hospital’s
organizational structure can be demonstrated in a non-traditional way.
3. Discuss the hierarchy of the structure and its relationship
4. Each group gets a piece of butcher paper and colored markers.
5. Instruct the students to think of a symbolic way in which to represent the
organizational structure of the hospital. Here is a simplistic example to get
them thinking: (tree in a field)
i. ground represents support services
ii. trunk of tree represents administration services
iii. sun in sky represents information services
iv. main branches represent diagnostic services

29
 v. leaves represent various therapeutic services
6. Each department and service should be labeled.
7. Tell participants that they must be able to explain why they think their
drawing symbolically represents each service.
8. To strengthen their understanding the facilitator may use the quiz
regarding structure of the hospital which is attached in as annex A. at the
end of module

Hospital Policies in Afghanistan

According to Hospital Policy in Afghanistan Health System the hospitals of
country will provide a comprehensive referral network of secondary and tertiary
health facilities. The policies guiding the hospital sector are:
1. Hospitals, as part of a unified national health system, will provide
necessary curative and emergency services, which complement the Basic
Package of Health Services that includes disability care, offered at basic
and comprehensive health centers.
2. Hospitals must be rationally distributed so their services are accessible on
an equitable basis for the entire population.
3. The MoPH will carefully plan the number of hospitals, their location,
hospital beds, and types of hospital beds to ensure that the resources
committed to hospitals result in the maximum impact on the population’s
health status. Because Afghanistan does not have unlimited resources to
finance hospitals, so health planning, resource allocation and financial
management of hospitals will be undertaken by MOH for the entire
hospital sector as a means for maximizing the impact and effectiveness of
hospitals on the country’s health status.
4. Provision of hospital care must be based on need for hospital care and not
on ability to pay.
5. Hospitals must be managed in an efficient manner that adheres to basic
clinical and managerial standards that ensure the provision of quality care
to all patients, including patients with disabilities.

30
 6. The proportion of the government’s annual operational budget for
hospitals will not exceed 40% of the total health budget.
7. To ensure budgetary accountability and transparency, the MOH will
develop the appropriate financial systems and develop proper
mechanisms, such as empowering financial management of hospitals to
their board of directors.
8. Equitable cost-sharing strategies which are appropriate for Afghanistan
will be developed to he lp make the operation of hospitals more financially
sustainable.
9. Hospitals also have a role within the health system to provide supervision
of lower level health facilities, a place for professional training of
physicians, nurses, midwives and other health providers as well as
supporting necessary national medical and health systems research.
10. Private hospitals are permitted and are part of the health system and must
comply with all standards for providing good quality care, be accredited
and adhere to all MOH policies.

Levels of Hospitals in the country

There are three levels of hospitals: district (as a part of the BPHS), provincial,
and regional, including specialized hospitals. Differentiation of hospital levels is
based on the patient services offered. Five core clinical functions will exist in
each level of hospital: medicine, surgery, pediatrics, obstetrics and gynecology,
and mental health. An escalating level of sophistication will exist from district to
urban hospitals. The health post, basic health center and comprehensive health
center will offer basic curative and preventative services.
Hospitals in conjunction with the Provincial Coordination Committees (PCC) will
ensure the enforcement of a well-functioning referral system. A two-way referral
mechanism will be established maintaining a functional link between hospitals
and primary health care facilities. First line referrals will stem from health centers
to district hospital outpatient departments from where consultation will define
whether patients need to be further referred to higher levels or treated at that
level. Similarly patients are referred back to primary health care facilities for

31
follow-up. The following general specification of services for various hospital
levels will be supplemented by the Basic Package of Hospital Services, to be
developed by MoPH, will identify, in detail, the clinical services provided at each
level, the equipment and supplies required and the minimum staffing required.

District Hospital
Each district hospital will have from 30 to 75 beds and serve a population of
100,000 to 300,000, covering from one to four districts. The basic services
offered at a district hospital are:
• Surgery,
• Medicine,
• Pediatrics;
• Obstetrics and gynecology;
• Mental health;
• Dental services;
The district hospital will also have nutrition, physical therapy, laboratory,
radiology, blood bank, and pharmacy services.

Provincial Hospital
A provincial hospital serves a province and will have from 100 to 200 beds. In
addition to the services offered at a district hospital, the provincial hospital has:
• Physical therapy and rehabilitation services
• Nutrition services
• Infectious disease medicine;

Regional Hospital
A regional hospital serves several provinces and will have from 200 to 400 beds.
In addition to the services offered at a provincial hospital, the regional hospital
has:
• Surgery with ENT, urology, neurosurgery, orthopedics, plastic surgery and
physiotherapy
• Medicine with cardiovascular, pulmonary, endocrinology, and dermatology

32
 • Oncology
• Forensic medicine
Diagnostic services include:
• Laboratory: hematology, parasitology, bacteriology, virology, allergy and
immunology, biochemistry, toxicology, cytology, and pathology.
• Blood Bank/Transfusion Services: Provides for the taking, preserving, and
distributing blood to patients and the diagnosis of blood related diseases
(hemophilia, thalassemia, and leukemia, and viral diseases— hepatitis,
HIV/AIDS).
• Imaging: routine and specialized radiography, ultra-sonography.

Rationalization of Hospital Services (components)

There will be rationalization of services, such as polyclinics, where specialized
diagnostic and curative services are provided on an outpatient basis. These
facilities will be linked to regional and specialized hospitals for referral of
complicated cases requiring inpatient care in order to reduce the burden on these
hospitals and to give quality services at an outpatient level. They will not have
beds as this duplicates what exists in hospitals and is expensive for the health
system.
While there may be a need for some additional specialized diagnostic services
for the country, these services are too expensive and for too few patients to be
available at every regional hospitals. Further rationalization of services will occur
at the urban level where clinical and diagnostic services specialized and
equipment will be centralized. These include: pathology and forensic medicine,
histology, bio-technical support, centralized statistic s center, and research.
Equipment and services such as CT-scan and radiotherapy will be located at
only one hospital in the country to provide the services for the entire the country
rather than being provided at each regional hospital. Specialized hospitals will be
combined into regional hospitals with multiple specialties, as much as possible.
As current specialized hospitals are rehabilitated and new facilities planned, the
MOH will seek to combine them with other major hospitals in order to rationalize

33
the number and type of hospitals. The current specialized hospitals include eye,
mental health, disabilities, tuberculosis, chest, oncology, orthopedic and
prosthesis, maternity, pediatrics, and emergency hospitals.

Aga Khan University Hospital Components and

Activities
Aga Khan University Hospital, Karachi, (AKUH, K) started operations is an
integrated, health care delivery component of Aga Khan University (AKU). It is a
multidisciplinary approach to diagnosis and care ensures a continuum of safe
and high-quality care for patients – all services under one roof. This University
Hospital has 563 beds in operation and provides services to over 50,000
hospitalized patients and to over 600,000 outpatients annually with the help of
professional staff and facilities that are among the best in the region. Care is
available to all patients in need. Those who are unable to pay for treatment,
receive assistance through a variety of subsidies and through Hospital’s Patient
Welfare Program. AKUH is the first hospital in Pakistan and among the first few
teaching hospitals in the world to be awarded the prestigious Joint Commission
International Accreditation (JCIA) for practicing the highest internationally
recognized quality standards in health care. Similarly, the Hospital also holds ISO
9001:2008 certification for practicing consistent international standards of quality
services.
The Hospital is equipped to diagnose and treat Medical (including Cardiology,
Endocrinology, Gastroenterology, Hematology, Nephrology, Neurology and
Pulmonology), Surgical (Dental, General, Neurosurgery, Ophthalmology,
Orthopedics, Otolaryngology, Urology and Plastic), Obstetrics and Gynecology,
Pediatrics and Psychiatry patients. The Hospital also provides comprehensive
Oncology Services including: Medical and Surgical Management, Radiation
Therapy, Chemotherapy, Brach therapy and Bone Marrow Transplant.
Enough critical care beds are available in the Intensive Care Unit (ICU),
Coronary Care Unit (CCU), Coronary Intensive Care Unit (CICU) and Neonatal
Intensive Care Unit (NICU). The Hospital has 11 main operating theaters. There
are an additional 3 operating theaters in Surgical Day Care, 2 in the Community

34
Health Centre, 1 in Obstetrics and Gynecology and 2 mini-theatres in Section of
Emergency. State-of-the-art Pharmacy, Radiology (including nuclear medicine),
Laboratory, Cardiopulmonary, Neurophysiology, and Rehabilitation services are
available at AKUH. A fully equipped Emergency Room is open 24 hours a day
with a Triage desk and Fast Track System to ensure prompt medical attention for
all patients. AKUH Laboratory operates over 180 phlebotomy or specimen
collection centers in Karachi and all major cities of Pakistan and Afghanistan.
The Hospital also operates nine off-site medical centers (Integrated Medical
Service Units) in various parts of Karachi. Home Physiotherapy and Home
Nursing and Health Care Services are also available in almost all areas of the
city. These off-site services are a part of AKUH's outreach program to facilitate
public accessibility to quality health care. The Hospital draws a large number of
referrals from outside Karachi and Pakistan and operates Patient Information and
Referral Desks in Hyderabad and Quetta and a Representative Office in Dubai,
U.A.E. These offices provide assistance by coordinating all necessary
arrangements, including review of medical history by consultants prior to the
patient's arrival at the Hospital. Aga Khan University Hospital, Karachi provides a
broad range of latest and technically advanced diagnostics and therapeutic
services.
• Inpatient services
• Consulting services
• Emergency
• Radiology
• Cardiopulmonary services
• Neurophysiology
• Executive clinic
• Pharmacy services
• Physiotherapy and Rehabilitation services
• Home Health Services
• Clifton Medical Services
• Other Off-sit Medical Services

35
 • Corporate Services
• Support Services
• Special Services

Hospital and Challenges in Afghanistan

In Essential Package of Hospital Services (EPHS) it is enshrined that hospitals
play a critical role in the Afghan health sector: they are part of the referral
system, which aims to reduce high maternal and early childhood mortality rates.
In addition, hospitals utilize many of the most skilled health workers and much of
the financial resources available in the health system. Hospital management
must dramatically improve to ensure that these scarce resources are used in an
effective and efficient manner and to enable hospitals to function more effectively
as part of the health system. Serious need for improvement exists at all hospital
levels—district, provincial and regional hospitals—as well as at Kabul’s tertiary
and specialty hospitals.
The Hospital Management Task Force determined that the key issues facing
hospitals could be summarized by six problems and the resulting consequences.
The mentioned problems and consequences are arranged in the following table.

Table: problems and consequences with respect to Hospitals

# Problem
1 Poor distribution of hospitals
and hospital beds throughout
the Country
2 Lack of standards for clinical
patient care
3 Lack of management skills for
Consequences
Lack of equitable access to hospital care
throughout the country: people in urban
areas have access, but semi-urban and
rural populations have only limited access.
Kabul has 1.28 beds per 1000 people,
while provinces have only 20% of that
amount (0.22 beds per 1000 population).
Poor quality of care
Inefficiently run hospitals, poorly managed

36
 operation of hospitals
4 A fragmented and
uncoordinated hospital system
that is not integrated into the
health system
5 Limited financial resources for
hospitals, and sustainability
staff, lack of supplies, and unusable
equipment due to lack of maintenance
A referral system that does not work—
people from rural areas and basic health
centers are not referred to hospitals for
problems such as problem pregnancies.
Support for a BPHS-based system for
secondary and tertiary services is lacking;
the roles of hospitals in a BPHS-based
health system have not been spelled out.
Virtually all hospitals in Afghanistan lack
adequate financial resources. A user fee
system must be developed to help finance
hospitals while at the same time ensuring
that exemption mechanisms allow the poor
continued access to care.

6 Lack of qualified personnel, Difficulty in guaranteeing 24-hour

especially female, in remote coverage, problems with quality of care
areas provided to female patients.

Hospital and Community

Sociologists have considered hospital as a social system based on bureaucracy,
hierarchy and super ordination- subordination. A hospital manifests
characteristics of a bureaucratic organization with dual lines of authority which
are administrative and professional. In teaching hospitals and in some others,
many professionals at the lower and middle level are transitory, while as in
others, all medical professionals are permanent with tenured positions and
nontransferable jobs. In order to continue in a orderly fashion, every socials

37
system has to fulfill the functional needs of that system versus the need for
pattern maintenance, the need for adaptation, for goal attainment and integration.
In a hospital system, the patients’ need determine the interactions within the
system. When a patient is cured and discharged, in his or her place a new patent
is admitted. This new patient also demands all the attentation and skills of
doctors, nurses and others, forcing the essential and separative components into
immediate action, repeatedly as each patient is admitted. Free upward and
lateral communication is an important characteristic of any system.
Anyway the ultimate purpose of health services is to meet the total health needs
of the community. There are a lot of factors which determine the health needs of
the community and solutions to them. Some of the important factors are listed
here in the following table.
Table: factors determine the health needs of community
# Main factors Contributing factors
1 Demographic factors • Age
• Sex
• Marital status
• Family compositions
• educations
2 Enabling factors • family financial resources
• family relationship in the households
• availability and accessibility of
services
• Health insurance
• Attitude to health and disease
3 Internal or Health system • Manpower availability
factors • Physical facilities
• Organization and structure
• Interface with users
4 External factors • Political

38
 • Social
• Administrative

A good hospital would build its services on the knowledge and understanding of
the community it is to serve, its success will depend upon the involvement of
many groups, both professionals, within and outside the hospitals.

The provider, support group and community

The hospitals being a distinct, albeit integral, part of the health services, is
influenced by all the above mentioned factors and the health services in turn
influence those factors. It has to deal with three different groups which form the
larger community.
1. Providers: the first group is the providers of medical care, viz. the doctors,
nurses, technicians and paramedical personnel.
2. Management: the second group is management, administrative and
support group comprising of personnel dealing with non clinical functions
of the hospital, such as diet, supplies, maintenance, accounts,
housekeeping, water and ward, etc.
3. Community: the third group is the most important one for whose benefit
the first two groups exists in the first place, is that of the patients who seek
hospital services and their attendants, relatives, and associates who,
along with patient come in close contact of the hospital. This group is
broadly termed as community.

Community and its Participation

Community is a unit of society and each community is a microcosm of a nation.
It may be consist of educational and professional groups, members of fraternal
organizations, women's and garden clubs. It is business and industry, civic
leaders, youth, media, labor and church leaders and the elderly. So Community
is people, and they need to participate in hospital activities. Community
participation is a social process where by specific groups with shared needs
living in defined geographic area actively participates in identifying their needs,

39
take decisions and establish mechanisms to meet these needs. The hospital is
responsive to the community’s (health) needs and its services are accessible to
the community. It should be ensured that patient are treated with dignity and
have a right to be treated in a respectful manner. They want quick and efficient
service and good quality care. They expect satisfaction with care, food and
cleanliness of the hospital.
There are some benefits as a result of community participation such as
decentralization of the process of decision making, participation of the people in
setting the goals and their prioritization, generation of resources from within the
community to take remedial steps, sharing of benefits by the masses,
development of mechanism of control for assessing the outcome, involvement in
the efforts to evaluate the program, involvement /self help for sustaining the
program without -external help and involvement in implementation.

Hospital community relationship

In a complex juxtaposition between the providers of care and immediate support
group on the one hand and the patient and community on the other, it will not be
unusual to expect conflicts between the two groups. The nature of the
relationship between the two group influences community relationship, and on its
relationship depends the image of the hospital. To better this image, hospitals
have to re-orientate themselves to the expectations of the community. Following
figure shows the relationship.
Figure: Hospital Community Relationship

H C
PROFESSINAL GROPS

O U H C
FAMILY GROUP

S L O P O
P T S A M
I U P T M
INTERACTION
T R I I U
A E T E N
L A N I
L T T
Y

40
Relevant communication and information must reach the user community in
order to promote their participation and involvement. A community that is well
informed and aware of its social responsibilities can become an effective
instrument of cooperation and support. People go to hospitals with high
expectations believing that every disease is fully and quickly curable. The
average health consumer regards contemporary hospitals as the panacea to his
health problems. They can not appreciate the limitations of the hospital. There is
an increasing demand for better care and quick cure. Despite of giving care to
every patient public expects sympathetic understanding of the behavior of the
patient and his or her attendants and relatives. This shift has necessitated a new
approach to doctor-patient and hospital community relationship. Respect of the
dignity of the patient is one of the most basic rights and needs of the patient.
Concern for care of the human being as a whole requires contribution from
everyone working in the hospital. Therefore there has to be a growing interest in
the importance of human well-being, in the integration of health services
provided.

41
Session 2: Effective Management at Hospitals
Management has been defined in many ways by many authorities, but the
original definition by Henri Foyal, considered the father of modern management,
over seventy years ago still holds good. “ tom manage is to forecast and plan, to
organize, to command, to co-ordinate and to control”. The task of the
management of each enterprise incorporates:
• Determining the goals and objectives
• Acquisition and utilization of resources
• Instituting communication system
• Determining control procedures, and
• Evaluating the performance of the enterprise

Medical profession and management

In the not very distant past, hospitals were run by Medical Superintendents,
directors, secretaries, but rarely by “hospital administrators”. The initiative for
development of hospitals has come from the medical and nursing professions
themselves. Primarily being dedicated professionals; to them the administrator
function naturally became secondary, necessary to practice of healing but
definitely subordinate to it. Many learnt It along the way during their careers. But
generally doctors were traditionally uninterested in ways and means, often
seeing medical administration and management as an escape for those who
have no taste for, or were not particularly successful in, the practice of medicine.
Therefore , most doctors have very little idea of what administration and
management really is.

Principles of Management
Fourteen Principles of Management were developed by Henri Fayol (1841-1925)
and have been considered as one of the classical organization theory that is
universally applicable to every type of organization. Classical organization theory
was the traditional theory and remains to be the foundation upon which other
schools of organization theory have built. Therefore many subsequent analyses

42
presume an understanding of it. Influenced by the industrial revolution in the
1700s and related to the professions of mechanical and industrial engineering,
the principles were developed under fundamental assumptions as follows:
Organization and individuals behave in conformity with rational economic
principles.
Fayol proposed that management was a common activity to all human beings
who involve in organization. His principles consist of the elements as follows:
1. Division of work. Output can be increased by specialization, making
employees more efficient.
2. Authority. The right or power to give orders to subordinates is authority.
Wherever authority exists, responsibility arises.
3. Discipline. Employees must obey the organizational rules. Good
discipline must result from an agreement between firm and employees
with fairness and clear understanding of both sides. Penalties can be
applied to violations of rule.
4. Unity of Command. Each subordinate should receive orders from one
superior.
5. Unity of Direction. Organizational activities that have the same objective
should be guided by one manager, using one plan.
6. Subordination of individual Interests to the General Interest. The
interests of one employee (or group of employees) should not precede
over the interests of the organization as a whole.
7. Remuneration. Employees must be paid a fair wage. Rewards should be
used as a tool of encouragement.
8. Centralization. The degree to which subordinates are involved in
decision-making. Whether the decision is centralized or decentralized is a
question of proportion.
9. Scalar Chain. The line of authority from top to the lowest ranks of
management. Communication should go along this chain. To avoid
delays, cross communications can be allowed if agreed by all involved
parties.

43
 10. Order. Materials and people should be in right place at right time.
11. Equity. Managers should be kind and fair to their subordinates
12. Stability of Tenure of Personnel. High employee turnover causes
inefficiency. Managers should ensure replacements at hand when
vacancies arise.
13. Initiative. The power of thinking out, proposing and executing.
Management should encourage employees to originate and carry out
plans. This urging tends to boost levels of effort.
14. Esprit de Corps. Fostering team spirit is the way to construct harmony
and unity among employees.

Administration or management
The terms of management and administration have interchangeably been used.
Some people have tried to define management and administration as two distinct
entities. To them administrations seems to connote some higher and broader
function than management. They continue to distinguish them without agreeing
clearly on what the distinction is about. But management is not an academic
discipline alone. It is get ting job done through people and by people. It is a
practical art and a science, calling for development of knowledge, skills and
attitudes. Managing and administration make use of organized knowledge i.e. the
best use of the enterprise. The science and art of management is not are not
mutually exclusive, but complementary.
Managerial activities of a hospital
The following activities are common to the management of all hospitals.
• Determination of goals and objectives
• Facility and programme planning
• Financial management
• Personnel management
• Coordinating departmental operations
• Programme review and evaluations
• Public and community activities

44
 • Health industry activities
• Government related activities
• Educational development

The governing board of hospitals

There are a number of important people in the hospital to whom a person asking
to see the chief in a hospital maybe led to. He could be led to the chief physician,
or the office superintendent, or the medical superintendent, or the secretary of
governing board, to mention a few. Most organizations have a chief, who is in
charge on every thing goes on there. But who controls the hospitals’ activities
services?
There appear to be several people and several groups who all have something to
do with controlling the above activities, but no single person or group appears to
be in charge of the whole set up. The administrator on the other hand, if asked as
to what goes on his office, might go so far as to say that it is the placed form
where the hospital is run.
Except in single proprietorship hospital, there has to be a body of person
statutorily responsible for running the hospital. This body is variously called the
board of directors, governing board, and board of trustees, governing body, or
management board. A governing board, as a body of persons, can make and
guide policy but cannot, by its vary compositions, run a hospital. The task is
carried out by the hospital administrator. As the board chief executive officer he
has overall charge of the affairs of the hospital. However, the extent of his control
depends upon the following factors.
1. how he perceives his job
2. how the board perceives the job
3. how much freedom he is allowed in doing the job
a typical hospital management board is scarcely different from many other
dissimilar organizations. Some boards may interpret their role as of running the
hospitals day-to-day affairs. On the other hand, the administrator could be
inhibited from showing his initiative.

45
Hospital Administrator
Thus at the hospital level the function of administration rests with the hospital
administrator, variously called the chief executive officer (CEO), medical
superintendent, director (administrator), hospital manager, hospital director etc.
Nevertheless managing a hospital always involves partnership with medical and
nursing staff. Therefore, the hospital administrator can never have quite the
same degree of autonomy as his industrial counterpart. In many situations, it may
be the medical staff that will be making of many of vital decision on operational
policy, but they will have to exercise this authority in conjunction with the hospital
administrator, giving him or her in the difficult job of providing efficient services.
One of the principles of organization is that responsibility must be given and
matched with authority. Therefore, it is natural to suppose that the administrator,
charged with this responsibility would have the full authority to act on its behalf.
The job of the administrator is to plan, to organize, to direct and to control—
functions which are inherent to the job of each administrator. As a general
manger he represents the hospital to higher authorities and outside organization.
He is responsible for policy and procedures, the overall administrative structure,
financial management, personnel management, reporting to the board, relations
with the medical staff, overseeing medical care, maintaining physical facilities,
legal matters and maintaining good public relations.
Having a deal with multiple groups with conflicting interests, the demands on a
top hospital administrator are almost unending. He must be a generalist and
specialists combined in one, capable of understanding and interpreting medical,
financial, economic, functional and logistic matters, and he must excel at
personnel management.

Choice of Hospital Director (Administrator)

Opinion is divided whether a hospital administrator should be a person with
medical background or a non-medical person. For too long, all types of hospitals
were headed and administered by highly qualified medical professionals who had
hardly any time, let alone the background, to devote to administrative functions.
Even though in some western countries non medical persons trained in medical

46
administration are heading hospitals, there is now an increasing realization that
medical professionals with training in hospital administration would be more
qualified to head all types of hospitals without being burdened with clinical
functions.
Hospital chief executive should spend almost 100% of their time on non medical
functions and activities, far removed from direct patient care. This precludes
appointing senior practicing doctors as chief executives. Medical doctors trained
in medical and hospital administration, who are alive to the medical needs of the
patients also understand the needs of the hospital and professionals working in
them, and are thus more suitable to head hospitals. Following table shows time
distribution.
Table: time distribution on administrative functions
# Activity Percentage of time
1 Planning 25
2 Directing and controlling the hospitals 48
3 Personal meeting people 11
4 Controlling 12
5 Organizing 4

Role and functions of Hospital Administrator

The following is the main roles and functions the hospital administrator.
• Working with people
• The enabling role
• Staff motivation
• Facilitating decision making
• Management of resources
• Negotiating
• Containing costs
• Dealing with new technology
• Establishing managerial climate

47
 • Management development
• Evaluation
• Social commitment

Management Styles
Laissez-faire Management style :
The laissez-faire management style gives people almost complete freedom to
organize and carry out their work: It is only limited if a task has to be completed
by a certain date or - if flexible working hours are agreed on - to make sure that
during certain hours of the day all employees are present. There is no formal
structure of decision making.

Democratic Management Style:

This style makes use of the fact that people are more motivated if their non-
monetary needs are met: job satisfaction and a feeling of belonging. Employees
are involved in taking decisions: They are either consulted directly or through
their representatives. This is particularly important if an organisation plans to
change the product design or working conditions, methods and practices.

Autocratic Management Style:

The manager of the organisation takes complete responsibility for decisions that
are made in his firm. He sets the objectives for the firm and allocates the tasks
the employees. He expects his subordinates to carry out exactly what he has told
them to do in the way that he has decided on. Employees are told exactly how
and when work has to be started and to be finished. Non-monetary needs of the
employees are not taken into account. The employees are not consulted and do
not take part in decision making.

Group work:
Read the sentences below the box. Decide which management style is advisable
(or not advisable respectively) under the conditions that are described in the
sentences.

48
Mark the respective box with an “A” if the management style is advisable; mark it
with an “N” if the management style is not advisable.

Laissez démocratique autocratic

faire
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q

A. There are very serious risks to health and safety when total control is
lacking.

B. Employees are more satisfied with their jobs and more motivated because
they feel that their opinions are valued and they take part in decision
making. Their team spirit also improves.

49
C. In the markets that are served by the firm changes are so rapid and
unpredictable that it takes too much time to ask employees.
D. The kind of business requires the development of individual talents,
initiatives and creative thinking.
E. An employee may build up his own area of work, which may prevent the
organization as a whole from reaching its objectives.
F. An organization can take fuller advantage of its human resources by
tapping their skills, knowledge and experience.
G. It is more difficult to identify an employee who misuses the greater
freedom and puts too little effort into his job.
H. Consultation needs time and slows down decision making. During the time
that is lost problems may become more serious and chances may be lost.
I. Employees work away from their offices in their own homes.
J. The workforce consists of unskilled people with little motivation beyond
their pay.
K. People who represent the other employees in meetings with management
put their interests before those of the members of the staff that they
represent.
L. If a manager is not able to explain the role of employees who take part in
decision making the employees may think the manager only pretends or
he might look condescending.
M. Employees feel that they are in charge of their working lives. That is how
stress can be reduced.
N. Employees want to have a greater chance to choose the people they work
with. They will only choose those people with whom they feel they will
form a harmonious and efficient working team.
O. Employees do not like that every aspect of their work is controlled by a
leader and might seek every chance to relax in their efforts when they are
not supervised.

50
 P. More personal contact between management and other employees is
needed– they get to know each other as individuals and understand more
fully the stress under which each of them works.
Q. In small organizations the leader is in a position to get involved in even
day-to-day decisions.

Skills of effective managers

After a lot of research, it has now been established that successful management
rests on three basic skills— technical, human and conceptual, these three skills
are not absolute and mutually exclusive, but interrelated. Technical skills include
knowledge of and proficiency in a certain specialized field, such as engineering,
computers, financial and managerial accounting, or manufacturing. These are
more important at lower levels of management since these managers are dealing
directly with employees doing the organization's work. Human skills involve the
ability to work well with other people both individually and in a group. Because
managers deal directly with people, this is crucial! Managers with good human
skills are able to get the best out of their people. They know how to
communicate, motivate, lead, and inspire enthusiasm and trust. These are
equally important at all levels of management. Finally conceptual skills are those
managers must have to think and conceptualize about abstract and complex
situations. Using these skills managers must be able to see the organization as a
whole, understand the relationship among various subunits, and visualize how
the organization fits into its broader environment. These are most important at
top level management.
A professional association of practicing managers, the American Management
Association, has identified important skills for managers that encompass
conceptual, communication, effectiveness, and interpersonal aspects. These are
briefly described below:
Conceptual Skills: Ability to use information to solve business problems,
identification of opportunities for innovation, recognizing problem areas and
implementing solutions, selecting critical information from masses of data,

51
understanding the business uses of technology, understanding the organization's
business model.
Communication Skills: Ability to transform ideas into words and actions,
credibility among colleagues, peers, and subordinates, listening and asking
questions, presentation skills and spoken format, presentation skills; written and
graphic formats
Effectiveness Skills: Contributing to corporate mission/departmental objectives,
customer focus, multitasking; working at multiple tasks at parallel, negotiating
skills, project management, reviewing operations and implementing
improvements, setting and maintaining performance standards internally and
externally, setting priorities for attention and activity, time management.
Interpersonal Skills: Coaching and mentoring, diversity ; working with
diverse people and culture, networking within the organization, networking
outside the organization, working in teams; cooperation and commitment.

Importance of the managerial skills

The mix of these skills varies as an individual advances in management form
supervisory to top management positions. At the lower levels of each
organization, technical skills are very important. As manger movers from lower to
higher levels less technical skills tends to be needed. Although it is important at
all levels, human skills assumes paramount important at the middle management
level. At the higher levels conceptual skills assumes more important in policy
decisions, strategy formulations and planning actions. Following figure shows the
importance of each skill and levels of management.

52
 Figure: importance of managerial skills and level of management
Technical skill Human skill Conceptual skills

TOP LEVEL

MID LEVEL

LOW LEVEL

In today's demanding and dynamic workplace, employees who are invaluable to

an organization must be willing to constantly upgrade their skills and take on
extra work outside their own specific job areas. There is no doubt that skills will
continue to be an important way of describing what a manager does.
The managerial skills are the quality of the manager which is found in the
managers. The work need of the different organization and business requires the
different skills in the managers in order to handle the business environment and
to make it successful in the market. So there are different types of skills which
the managers need in order to exercise the skills in the person in the different
people. So managers have to deal with the lot of problem which requires special
skills of the mangers in order to solve them. So when the manager counters a
problem then they require some special skills in order to deal with the specific
problems.
So there are many different organizations which require different skills in the
people in order to get the proper job done. So the demand jobs skills of today
managers are intuitiveness, work under pressure, manage the people, conflict
management, crises management and motivate the people under their
supervision so these are the skills which are needed in order to carry the different
operations of the business. So this is the reason the manager use their skills in
order to counter the problems. So this is all about the manager skills.

53
Ways to Improve Your Managerial Skills
Robert W. Bly has listed some ways to improve the managerial skills. Here are
his eight tips that will help you to manage and to guide your people more
effectively.
The Human Touch
The most valuable qualities you can develop within yourself are patience,
kindness, and consideration for other people. Although machines and chemicals
don't care whether you scream and curse at them, people do. Your subordinates
are not just engineers, scientists, administrators, clerks, and programmers they're
people, first and foremost. Respect them as people and you'll get their respect
and loyalty in return. But treat them coldly and impersonally and they will lose
motivation to perform for you.
Corny as it sounds, the Golden Rule "Do unto others as you would have others
do unto you'' -is a sound, proven management principle. The next time you're
about to discipline a worker or voice your displeasure, ask yourself, "Would I like
to be spoken to the way I'm thinking of speaking to him or her?'' Give your people
the same kindness and consideration that you would want to receive if you were
in their place.
Don’t Be Overly Critical
As a manager, it's part of your job to keep your people on the right track. And that
involves pointing out errors and telling them where they've gone wrong.
But some managers are overly critical. They're not happy unless they are
criticizing. They rarely accomplish much or take on anything new themselves, but
they are only too happy to tell others where they went wrong, why they're doing it
incorrectly, and why they could do the job better. Don't be this type of person.
Chances are, you have more knowledge and experience in your field than a good
many of the people you supervise. But that's why the company made you the
boss! Your job is to guide and teach these people not to yell or nit-pick or show
them how dumb they are compared to you.
Mary Kay Ash, founder and director of Mary Kay Cosmetics, says that successful
managers encourage their people instead of criticizing them. “Forget their

54
mistakes," she advises, "and zero in on one small thing they do right. Praise
them and they'll do more things right and discover talents and abilities they never
realized they had."
Let Them Fail
Of course, to follow through on Mary Kay's advice, you've got to let your people
make some mistakes. Does this shock you? I'm not surprised. Most workers
expect to be punished for every mistake. Most managers think it's a "black eye"
on their record when an employee goofs.
But successful managers know that the best way for their people to learn and
grow is through experience and that means taking chances and making errors.
Give your people the chance to try new skills or tasks without a supervisor
looking over their shoulders but only on smaller, less crucial projects. That way,
mistakes won't hurt the company and can quickly and easily be corrected. On
major projects, where performance is critical, you'll want to give as much
supervision as is needed to ensure successful completion of the task.
Be Available
Have you ever been enthusiastic about a project, only to find yourself stuck,
unable to continue, while you waited for someone higher up to check your work
before giving the go ahead for the next phase? Few things dampen employee
motivation more than management inattention. As a manager, you have a million
things to worry about besides the report sitting in your mailbox, waiting for your
approval. But to the person who wrote that report, each day's delay causes
frustration, anger, worry, and insecurity.
So, although you've got a lot to do, give your first attention to approving,
reviewing, and okaying projects in progress. If employees stop by to ask a
question or discuss a project, invite them to sit down for a few minutes. If you're
pressed for time, set up an appointment for later that day, and keep it. This will
let your people know you are genuinely interested in them. And that's something
they'll really appreciate.
Improve the Workplace

55
People are most productive when they have the right tools and work in pleasant,
comfortable surroundings. According to a study by the Buffalo Organization, a
comfortable office environment creates an extra $1600 of productivity annually
for professionals and managers.
Be aware that you may not be the best judge of what your employees need to do
their jobs effectively. Even if you've done the job yourself, someone else may
work best with a different set of tools, or in a different setup because each person
is different.
If your people complain about work conditions, listen. These complaints are
usually not made for self gain, but stem from each worker's desire to do the best
job possible. And by providing the right equipment or work space, you can
achieve enormous increases in output . . . open with a minimal investment.
A Personal Interest in People
When is the last time you asked your secretary how her son was doing in Little
League or how she enjoyed her vacation?
Good salespeople know that relating to the customer on a person-to-person level
is the fastest way to win friends and sales. Yet many technical managers remain
aloof and avoid conversation that does not relate directly to business. Why?
Perhaps it's because engineers are more comfortable with equations and
inanimate objects than with people, and feel uncomfortable in social situations.
But just as a salesperson wants to get to know his customer, you can benefit by
showing a little personal interest in your people their problems, family life, health,
and hobbies. This doesn't have to be insincere or overdone just the type of
routine conversation that should naturally pass between people who work
closely.
If you've been ignoring your employees, get into the habit of taking a few minutes
every week (or every day) to say "hello" and chat for a minute or two If an
employee has a personal problem affecting his mood or performance, try to find
out what it is and how you might help. Send a card or small gift on important
occasions and holidays, such as a 10th anniversary with the firm or a birthday.
Often, it is the little things we do for people (such as letting workers with long

56
commutes leave early on a snowy day, or springing for dinner when overtime is
required) that determine their loyally to you.
Be Open to Ideas
You may think the sign of a good manager is to have a department where
everybody is busy at work on their assigned tasks. But if your people are merely
"doing their jobs," they're only working at about half their potential. A truly
productive department is one in which every employee is actively thinking of
better, more efficient methods of working ways in which to produce a higher
quality product. In less time, at lower cost
To get this kind of innovation from your people, you have to be receptive to new
ideas; what's more, you have to encourage your people to produce new ideas.
Incentives are one way you can offer a cash bonus, time off, a gift. But a more
potent form of motivation is simply the employee's knowing that management
does listen and does put employee suggestions and ideas to work. Quality
Circles, used by Westinghouse and other major firms, are one way of putting this
into action. The old standby, the suggestion box - Is another time tested method.
And when you listen to new ideas, be open minded. Don't shoot down a
suggestion before you've heard it in full. Many of us are too quick, too eager, to
show off our own experience and knowledge and say that something won't work
because “we've tried it before” or “we don't do it that way.” Well, maybe you did
try it before, but that doesn't mean it won't work now. And having done things a
certain way in the past doesn't mean you've necessarily been doing them the
best way. A good manager is open-minded and receptive to new ideas.
Give Your People a Place to Go
If a worker doesn't have a place to go a position to aspire to, a promotion to work
toward then his job is a dead end. And dead-end workers are usually bored,
unhappy, and unproductive. Organize your department so that everyone has
opportunity for advancement, so that there is a logical progression up the ladder
in terms of title, responsibility, status, and pay. If this isn't possible because your
department is too small, perhaps that progression must inevitably lead to jobs
outside the department. If so, don't hold people back; instead, encourage them to

57
aim for these goals so that they will put forth their best efforts during all the years
they are with you?

Coordination
Every individual and group in the organization contributes to the realization of the
organizations’ goals, but none is able to realize them alone without working with
others. Because of division of the labors and specialization of functions, the
hospital can achieve its objectives only if its part is coordinated into a cohesive
whole. Thus coordination is basic to practice of management at all levels and
pervades all functions in hospital administration. The role of the hospital
administrator in this regard becomes that of coordinator. The work of the
hospitals is characterized by the following.
• Heterogeneous group workers
• Specialization
• Complex interrelationship
• Group work
• Crisis orientation
• Round the clock functioning
• Objectives not clear, results not quantifiable
• Exhibits both authoritative and participative pattern of leadership
• Patients cannot their needs
The above conditions are prevailed and optimum performance in the hospitals
can not be achieved by each unit carrying out its activities in isolation. Good
aggregate results and outcomes are a product of a number of independent
decisions.
Coordination is facilitating different groups in an organization and orchestrates
their efforts to achieve the common goal of good patient care and efficient
hospital operations. The three basic considerations in coordination are as
following.
1. it must start early
2. all interrelated factors in a situation ultimately decide outcome

58
 3. interpersonal relationship play a major role in coordination
Coordination depends on cooperation improvisations by staff at all levels, and on
the understanding which different individuals have of each others’ roles.

Facilitation of coordination
Administrators at all levels achieve coordination through many actions and
methods. In fact, there may be as many method and styles of coordination as
there are administrators. However certain common actions are evident. These
are as follows.
• Horizontal contact
• Vertical contact
• Motivations
• Participations
• Communication
• Cooperation

Characteristics of effective Hospital Manger

Many factors are attributed towards success or failure in administration.
Situation, circumstances, social environment and social connections have all
been put forward as factors affecting success, failure and effectiveness. There
are very large number of variables with determines the effectiveness of
administrators. However, after studying the characteristics of a great many
successful careers, certain common qualities, traits and characteristics of
successful and effective administrator emerge.
• Clear and Realistic Goals
• Professional Par-Excellence
• Perceptual and Cognitive Flexibility
• Professional Growth
• Commitment to chosen field
• Attitudes and Confidence
• Communication

59
 • Diversity
• Creative Orientation
• Motivation
• Satisfaction
• Self-Esteem

Efficiency versus Effectiveness

What is Efficiency?
“Judgements of efficiency are based on some idea of ‘wastage’. A relatively
efficient process either requires fewer inputs or produces more outputs compared
to a similar process, to achieve the objectives of the process. The authors refer
to this as technical efficiency, which in equation form is:
Technical efficiency = Output quality / Input quantity
Different business units performing the same process can be compared by
calculating the efficiency of each unit (giving a set of measures of absolute
efficiency) and comparing the results [the relative efficiency].
An important variant of efficiency is Allocative efficiency. This involves weighting
the inputs and outputs by their monetary values. Thus:
Allocative efficiency = Value of outputs/Cost of inputs

What is Effectiveness?
Effectiveness is very similar to efficiency, but the measure is related to some
enterprise objective rather than the technical quality of output. For example, one
common indicator of effectiveness is related to customer satisfaction rather than
output. Therefore the effectiveness measure of a business process can be
indicated by the resource inputs needed to produce a level of an enterprise
objective. Being effective means producing powerful effects. Being efficient
means producing results with little wasted effort. It is the ability to carry out
actions quickly. However, by so doing, you may not be achieving effectiveness.
Effectiveness involves achieving your worthwhile goals that support your vision
and mission.

60
For instance, you may be very efficient at working through and completing your
to-do list. However, when you shift your focus to being effective, you may choose
to delegate part of your list, stop doing some of it, and focus on one or two things
that enable you to achieve your goals. Perhaps you're efficient at sending follow
up letters to potential clients, but being effective may mean only following up
more comprehensively on certain key ones

Comparison of effectiveness and efficiency

The words efficiency and effectiveness are often considered synonyms, along
with terms like competency, productivity, and proficiency. However, in more
formal management discussions, the words efficiency and effectiveness take on
very different meanings. Another way to look at it is this: efficiency is doing things
right, and effectiveness is doing the right things. Let's consider a surgery
example. A surgeon is very skilled, perhaps the best in the country. The
impending job is to operate on the patient's left knee. However, the surgeon
doesn't perform all the steps of the process leading up to the surgery. Someone
else marks the right knee for surgery. However skilled this surgeon is, however
fast he performs the surgery (i.e., however efficient he is), this process will not be
effective. When the patient awakens from the surgery, he will not be a happy
camper.

Some process efficiency measures are:

• cycle time per unit, transaction, or labor cost;

• queue time per unit, transaction, or process step;
• resources (dollars, labor) expended per unit of output;
• cost of poor quality per unit of output;
• percent of time items were out of stock when needed;
• percent on-time delivery; and
• Inventory turns.

Some effectiveness measures are:

61
 • how well the output of the process meets the requirements of the end user
or customer;
• how well the output of the sub process meets the requirements of the next
phase in the process (internal customers); and
• how well the inputs from the external suppliers meet the requirements of
the process.

By contrast, measures of ineffectiveness include:

• defective products;
• customer complaints;
• high warranty costs;
• decreased market share; and
• percent of activities that customers perceive to be non-value-added.

Efficiency and effectiveness are often considered synonyms, but they mean
different things when applied to process management. Efficiency is doing things
right, while effectiveness is doing the right things.

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Session 3: Hospital Planning and Design
The picture regarding medical care services in developing countries including
Afghanistan is can be described as chaotic. Standard hospitals are lacking,
hospital beds are inadequate, the hospitals are located far away from where
community lives, most crowded in towns and cities, and heavily biased in favor of
urban population. There are many reasons for the current state of affairs.
Absences of a realistic national health policy, haphazard medical care planning,
more than two decades of conflict, more attention towards primary health care,
lack of willingness of donors to invest in hospitals, and inadequate availability of
funds for the health sector are amongst the main reasons. Experience from many
countries having advanced medical care system has shown that hospitals are
very expensive to build. The initial capital costs are high, and the construction
and equipment consumes tremendous capital investment. But what is more
important is they are also very expensive to operate, with their running cost
amounting to approximately one third of the initial construction costs for each
year of operation. Haphazard planning at initial stages by inexperienced and
uncommitted technical personnel results in changes at constructional stage
resulting in avoidable drainage of funds.

Guiding principles in Planning

A hospital is responsible to render an essential service. In fulfilling this
responsibility, hospital planning should be guided by certain universally
acknowledged principles. The principles are useful irrespective of level of
planning, i.e. Weather at the national level, provincial level or individual hospital
level. These principles were developed in the context of American system of
hospitals but have relevance and usefulness to hospital planning in the country.

Patient care of high quality

Patient care of high quality should be achieved by the hospital through adopting
following measures.
• Provision of appropriate technical equipment and facilities necessary to
support the hospital objectives

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 • And organizational structure that assigns responsibility appropriately and
requires accountability for the various functions within the institutions
• A continuous review of the adequacy of care provided by physicians,
nursing and paramedical personnel and the adequacy with which it is
supported by other hospital activities.

Effective community orientation

Effective community orientation should be achieved by the hospital through
adopting following measures.
• A governing board made up of persons who have demonstrated concern
for the community and leadership ability.
• Policies that assure availability of services to all the people in the hospitals
service area.
• Participation of hospital in community programmes to provide preventive
care
• A public information program that keeps the community identified with the
hospitals goals, objectives and plans.

Economic Viability
Economic viability should be achieved by the hospital through taking these
measures.
• A corporate organization that accepts responsibility for sound financial
management in keeping with desirable quality of care
• Patient care objective that are consistent with projected service demands,
availability of operating finances and adequate personnel and equipment.
• A planned program of expansion based solely on demonstrated
community need.
• A specific program of funding that will assure replacement, improvement
and expansion of facilities and equipment without imposing too much cost
burden on patient charges.
• An annul budget plan that will permit the hospital to keep pace with times.

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Orderly Planning
Orderly planning should be achieved by the hospital through the following.
• Acceptance by the hospital administrators of the primary responsibility for
short and long range planning, with support and assistance from
competent financial organizational, functional and architectural advisors.
• Establishment of short and long range planning objectives with a list of
priorities and target dates on which such objectives maybe achieved.
• Preparation of a functional program that describes the short range
objectives and the facilities equipment and staffing necessary to achieve
them.

A sound architectural plan

A sound architectural plan should be achieved by the hospital through the
following.
• Engaging an architectural experienced in hospital design and construction
• Selection of site large enough to provide for future expansion and
accessibility of population.
• Recognition of the need of uncluttered traffic patterns within and without
the hospital for movement of physicians, hospital staff, patients, and
visitors and for efficient transportation of supplies.
• An architectural design that permit efficient use of personnel,
interchangeably of rooms and provide for flexibility.
• Adequate attention to important concepts such as infection control and
disaster planning.
Medical technology and planning
Development in medical technology is taking place so rapidly that now the use of
sophisticated technology determines professional status. The diffusion of medical
technology vis-à-vis shortage of resources constantly plays on the minds of
planners. Even in western countries rational planning for medical technology is
an evasive subject.

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Hospital Utilization and planning
Social, economic, educational and cultural characteristics of the people and the
attitude of medical professionals influence both the manner in which the existing
hospital facilities are utilized and the extent of utilization. However where hospital
facilities fall woefully short of the bare minimum requirements, utilization statistics
doesn’t depict the correct picture. The following factors affect the manner and
extent of hospital bed utilization, a knowledge of which will be of help during the
planning process.
• Hospital bed availability: as opposed to developed countries where
utilization is high because of large availability of hospital beds, in
developing countries because of low bed population ratio. A high available
bed complement may lead to low bed occupancy rate.
• Population coverage and bed distribution: since full coverage of
population depends upon equitable regional distribution rather than on
total number of beds, an even distribution increases hospital utilization by
wider coverage of population. People from scarcely populated areas
generally find it necessary to travel to provincial and regional hospitals or
metropolitan towns for more sophisticate type of medical care.
• Age profile of population: a population with high life expectancy tends to
raise the volume of hospitalization.
• Availability of medical services: availability of well- organized
dispensaries, outpatient clinics, mobile clinics, and competent general
practitioners reduce the load on hospital beds in an area.
• Customs on attitude of medical profession: doctors order admissions
primarily for medical reasons. On the other hand, people themselves
influence the decisions for admission if strong hospital habit is developed
in them, or against admission because of fear of the hospital and
unwillingness for separation from family.
• Methods for payment for hospital services: hospital services can be
free, on payment by patient directly to the hospital, or indirect payment

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 through other channels. Hospital utilization is greatly influenced in the last
case.
• Availability of qualified medical manpower: in areas with very small
number of qualified doctors, much illness remains undetected, and
therefore admission rates are low. However the costumes and attitudes of
medical profession and pattern of services available influence hospital
utilization more than number of doctors.
• Housing: break up of the joint family system and a trend for nuclear
families living in independent houses result in increasing hospital
admission because of inconveniences encountered in caring for the sick
person at home.
• Mobility pattern: acute communicable diseases result in a demand for
short stay hospitals, while as chronic infective and degenerative diseases
creates demands for long stay institutions
• Hospital bottlenecks: the efficiency with which supportive services
support and reinforce the total hospital organization has direct effect on
hospital utilization.
• Internal organization: a high degree of specialization where specialists
departments functions as watertight compartments result in segmentation
within a hospital resulting in lesser degree of utilization due to tight
compartmentalization of beds.
• Public attitudes: these are certain factors which are of considerable
importance in determining where people will go to receive medical care,
these are public attitudes. The category includes social and religious
attitudes, local customs and traditions, beliefs and mores, and group
preferences.

Bed Planning in Hospitals

It is unlikely that elaborate calculation to determine number of beds will be
required in starting a new hospital anywhere because no where has the bed:

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population ratio reached adequate levels. Even in cities where it has achieved
such figures, more beds are required because of increasing urbanization.
Here it should be realized that the hospital facilities in an area are not only
utilized primarily population in the vicinity of the hospital— the direct population,
but also by people who will constitute the indirect population in the larger
catchment area. When these population factors are worked out, the calculation
for total bed requirements can proceed as per guidelines of WHO.
Indices of direct and indirect admissions give the coverage hoped to be attained,
the assumed average length of stay and the occupancy rate indicate efficiency in
the use of services. About 85% bed occupancy is considered optimum.
Example:
Data
Direct population (DP) 600000
Indirect population (IP) 800000
Admission per year per 1000 (DP) 165
Admission per year per 1000 (IP) 55
Average length of stay in days (ALS) 10
Occupancy rate desired (BOR) 85%
Procedures
Admission per year (DP) 600000X165/1000= 99000
Admission per year (I1P) 800000X55/1000=44000
Total admission per year 143000
Total bed days per year 143000X10=1430000
(Total admissions X ALS)
Total beds required with 100% BOR 1430000/365= 3918
(Total beds required per day/365)
Total beds required with 85% BOR 3918X100/85= 4610
Deduction the number of already available beds in the region from the figures
arrived at will give shortfall of beds and therefore beds to be planned for that
region.

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Planning for equipment in hospitals
The mechanical and electrical installations and the plant and equipment
component in a modern general hospital has been estimated to cost about 40%
of the entire hospital project out of which about half (20%) is required for medical
equipments. Hospital equipment covers a broad range of items necessary for
functioning of all the services. Various ways of classifying the equipment in the
hospital can be used. However for universal applications the equipment in
hospital can be classified as:
1. hospital plant
2. hospital furniture and appliances
3. general purpose furniture and appliances, and
4. therapeutic and diagnostic equipment
For more detailed information a broad range of the plant and equipment that is
required in t he general hospital is given in the following table.
Table: plants and equipment required in a general hospital.
1 Physical plant • lifts
• refrigeration and air
conditioning
• fixed sterilizers
• incinerators
• boilers
• pumps
• kitchen equipment
• mechanical laundry
• central oxygen
• suction
• generator
2 Hospital furniture and appliances • beds
• stretchers
• trolleys

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 • wheelchairs
• bedside lockers
• dressing drums
• kitchen utensils
• bedside lamps
• moveable screens
• hand wash stands
• operation tables
• instrument trolleys
• bedpans
• waste bins
• hospital Lenin
3 General purpose furniture and appliances • intercom sets
1. office machines • typewriters
• calculators
• cash registers
• filling system
• electronic exchange
• computers
4 2. office furniture
5 3. crockery and cutlery
6 Diagnostic and therapeutic equipment • surgical instruments
1. equipment for general use • BP instrument
• Suction machines
• Rehabilitation
department equipment
• Physiotherapy
department equipment
• Sterilizers
• Equipment for clinical

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 laboratory
• Glassware washers
• Voltage stabilizers
• Refrigerators
• Chemical analyzers
• microscopes
7 2. equipment interfacing with patients during • short way diathermy
Diagnostic and therapeutic procedures machines
• electric cautery
machines
• defibrillators
• X— Ray machines
• Monitoring equipment
• Respirators
• Incubators
• ECG machines
• USG machines

During the last decades, there has been an explosive growth of sophisticated
electronic biomedical equipment in the hospital field. However a rapid
introduction of electronic equipment without thorough assessment may pose
problems of economy, safety and unsuitable system. Apart from selection of the
equipment, it is equally important that procurement, installation and maintenance
of each item of major equipment is planned accordingly.

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Session 4: Basics of Strategic Planning in Hospitals
Prior to development and implementation of operational plan there is necessary
to have strategic framework as strategic planning. Positioning the hospital for the
future is the purpose of strategic planning. The strategic planning process
provides a hospital/health system with the ability to determine its future and
achieve it. A strategic planning process must be established to position the
hospital in a rapidly changing environment.
Strategic planning is the process of determining what an organization wants to be
in the future and how it will get there. Hospitals that develop and implement
strategic plans tend to be more successful than those that don’t. Strategic
planning is different from short-term or operational planning. Operational
planning usually focuses on an annual cycle and requires the development of
yearly objectives and plans. This becomes part of the annual budgeting process.
Operational plans lay out how the hospital will move toward its future during that
year. The future is described in the hospital’s strategic plan. Strategic planning
requires that choices be made about your hospital’s future. These choices
concern your vision and mission, the goals to be pursued, what services will be
offered and to whom, the resources that will be needed (people, facilities,
technology, money and knowledge) and how they will be acquired.

Importance of Strategic Planning

Strategic planning is widely practiced by successful hospitals and health
systems. Strategic planning can have a positive effect on a hospital, but it is not
the answer in all situations or to all problems. A hospital should plan for its future
to:
• Improve the hospital’s performance
• Determine the hospital’s future direction
• Provide high quality health care services
• Optimize resource allocation
• Meet accreditation and regulatory requirements
• Meet the hospital’s vision and mission statement

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 • Maximize its chances for success
Although it is said failing to plan is planning to fail and either you are not planning
that is plan to not plan. Nevertheless prior to engaging in strategic planning, the
Hospital Board needs to:
• Understand what strategic planning is and how to do it
• Determine if the hospital is stable
• Identify whether a need for change exists
• Be committed to the planning process and include the participation of the
hospital administration, community, physicians and staff
• Decide if the hospital has the capability, resources and commitment
needed for the planning process
Planning takes time and money. Both must be allotted to the process. It is
important to make sure that the necessary resources, including Board and staff
time, are available to plan for the future and keep operating in the present.

Roles and Responsibilities in planning process

The Executive/ Governing Board have the principal responsibility for strategic
planning. The Board guides the development of the plan consistent with the
hospital’s mission, philosophy and values. The role of the Governing Board in
strategic planning process includes:
• Approval of the hospital’s vision, mission statement and goals
• Suggestion and considerations of strategies
• Approval of the strategic plan and its implementation
• Monitoring and updating the plan and its implementation

Strategic Planning Committee

The chair of the Governing Board appoints the Strategic Planning Committee and
the Committee is responsible for:
• Organizing the planning process
• Scheduling and conducting meetings
• Focusing the planning process

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 • Ensuring that Board and community values are reflected in the plan
• Developing the strategic plan
• Periodically reviewing the hospital’s mission and vision statement
• Monitoring trends, demographics, technology and community needs
• Reviewing and approving annual strategic planning goals and objectives
• Monitoring progress toward objectives

The General Director/Chief Executive Officer

Although the position of hospital’s chief executive officer (CEO) is usual in private
as compare to public sector in the country, however, there is a resemble position
for it in public hospitals as well. He or she is involved in the planning process as
a strategist, organizer, tactician and facilitator. The CEO is responsible for
carrying out the strategic plan after it is approved by the Board.

Medical Staff
Involvement of the medical staff in strategic planning is fundamental to ensuring
the development and implementation of the strategic plan. This involvement can
take several forms. Representatives of the medical staff should serve on the
Strategic Planning Committee. The medical staff may have its own planning
responsibilities and, upon completion of those responsibilities, report the results
to the Strategic Planning Committee. Hospital department heads make an
extremely valuable contribution to the strategic planning process. Their internal,
functional planning serves a major role in developing objectives, weighing
alternatives and implementing the Board-approved plan.

Patients and Community

The role of patients and the community in the strategic planning process merits
special consideration, for these groups provide information which nourishes two
vital steps in the hospital’s planning: analysis of the internal and external
environments, and development of the hospital’s mission. While actual
participation by these groups in the process may be limited, community and

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patient use of and attitudes about the hospital are reflected in all steps of the
planning process.

Planner and consultants

The hospital planner and / or manager are involved in staffing all aspects of the
planning process. The planner performs feasibility and planning studies,
develops the environmental assessment for the Strategic Planning Committee’s
consideration and provides assistance in developing the plan’s format, timetables
and evaluation procedures. In hospitals without a planner, these functions are
the responsibility of the chief executive officer and/or administrative staff.
Consultants are helpful in the strategic planning process to prepare the
Governing Board for the planning process through education or retreats and give
an objective assessment of the hospital’s strengths and weaknesses. In addition
they can steer the Board and Strategic Planning Committee through the process
and keep the planning process on track. A consultant cannot substitute for the
Board’s unique knowledge of the hospital and its mission. The consultant is not
the planner and, for sure, he is just a facilitator and technical advisor.

The Steps of the Strategic Planning

The Governing Board should design a process that is realistic and that works for
its hospital. In order to develop technical and functional strategic plans for
hospitals there is a need to follow a predetermined process. The steps of the
strategic planning process usually include:
• Get organized
• Perform an environmental assessment
• Develop a vision
• Develop the mission statement
• Develop Value Statement
• Develop strategies
• Prepare the strategic plan
• Approve the plan
• Implement the plan

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 • Monitor and update the plan
Mostly the steps are not linear and they can be combined and completed at the
same time. They may be completed in a different order depending on the
planning process. Planning should focus on the critical issues that will determine
the hospital’s future success or failure. As you design your strategic planning
process, answer questions such as what is the Governing Board’s experience
with planning? What is the Board’s commitment to strategic planning? How much
time and resources are needed from the Board, administration and staff? Does
the Board or hospital have a knowledgeable person to guide the planning
process? What technical or political issues may arise? After making adjustment
for these issues the avenue will be opened to commence the process.
Strategic plans have been completed in a one-day retreat. However, it is more
likely to take minimally 40 to 120 hours of actual Strategic Planning Committee
meeting time. The length of time depends on the availability of needed
information, the expertise of the Strategic Planning Committee and the staff and
resources allocated to the process.
With the recent rapid changes in the health care environment, hospitals may
want to develop a two- to three-year (maximum five year) strategic plan with an
annual update and review. Let’s have a look of above mentioned processes a bit
in detail.

Get Organized
Everyone needs to be committed to the planning process. Don’t begin without
the commitment of members and the medical staff. Learn about strategic
planning and how your hospital can use it. Discuss what strategic planning can
accomplish, any concerns Board members have and what problems may occur.
Decide if outside help is needed. Outline the planning steps your hospital will
take. It is important not to design a planning process that takes more time than
can realistically be expected from staff or the Board. Form a planning team of
five to ten people. The larger the team, the more structure will be needed at
strategic planning team meetings. The team could include: Board
representatives, the CEO, medical and technical staff representatives, staff

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members who have patient care responsibilities, community representatives,
consultants or other resource people. The planning team members need to be
able to work together, have different viewpoints, be creative and understand
health care trends and the hospital.

Analysis of the Situations

One step in strategic planning is a thorough, objective environmental
assessment. This includes a realistic assessment of the hospital’s history and
present situation, its strengths, weaknesses, opportunities and threats (SWOT).
The result of this analysis is a list of critical issues for the future. The hospital
functions in two environments – external and internal.
For assessment of internal environment review your hospital’s history including
its beginning, original mission and services, any significant events, major
changes, successes or failures and values or traditions. In addition review the
hospital’s present environment including services, products, programs, staffing,
financial position and current plans. Historical and projected utilization statistics,
patient origin data and financial reports, as well as medical staff profiles and
patient opinion polls, are instructive and should be gathered. This information,
prepared by consultants or administrative staff, provides a sense of how the
hospital has evolved. This assessment of strengths and weaknesses may be
difficult or even unpleasant. A truthful and candid evaluation performed at this
stage is necessary to position the hospital for a strong future.
In order to perform external assessment we should know that every hospital
functions within a larger setting, and is affected by surrounding forces. The
external assessment focuses on demographic data, political trends, social
change, the economic climate, community perceptions and competitive
providers. Painting scenarios of how the hospital might be affected is helpful in
exploring threats, opportunities and potential strategies. Certainly this portion will
incorporate the assessment of opportunities and threats which is in place and
affect the activities of the hospital positive or negatively.

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Develop a Vision
Strategic planning is about creating your hospital’s future and being ready for the
future. The vision statement describes the way you want the hospital to be in the
future. For development or review of the visions of the hospital we should focus
on some factors such as: clarification of the organization’s values; agreement on
the basic beliefs that guide the hospital; exploring what ideas and trends could
change the way the hospital is doing business; identifying what needs are
emerging as a result of demographic, technological, economical, political and
regulatory trends and identifying who is needed to make the vision possible. The
hospital should make efforts to make the visions shared one. According to Dr
Islam Saeed the head of training department at MoPH the vision should be like of
SIMCARD with everyone which are stands for:
• S-Stimulating
• I-Inspiring
• M-Motivating
• C-Cooperating
• A-Aspiring
• R-Reorienting
• D-Devoting
So that the vision is dreams with action and dreams without action is just
imaginations. A vision is a description of how you want the practice to operate in
the future and how your patients will benefit. Answer the question: What do you
want your practice to look like?
Sample Vision Statement: To be known as the most caring practice and the most
effective in diagnosing and treating every patient through better communication
and understanding. We will lower the critical effects of specific diseases, such as
cardio vascular diseases, diabetes and liver diseases.

Development or Review the Mission Statement

The mission should answer the question why you exist and what is your
business. The mission statement provides the purpose or reasons for the

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hospital’s existence. It expresses philosophy, community service, research or
educational commitments, affiliations and major functions or services offered by
the hospital. The mission statement should be a specific, succinct articulation of
what the Board wishes the hospital to be. Although the mission statement
defines what a hospital is, it also sets forth any limits or restrictions on a
hospital’s activities. The hospital’s policy, charter, enabling legislation, Board
minutes and annual reports are valuable sources for the review and development
of the mission statement. The mission statement establishes the guiding
principles from which the strategic planning process flows. Your mission
statement is unique to your hospital. Mission statements include a brief
description of your practice’s purpose. It should be posted in a prominent location
in your office. The mission should answer the question: what are you involved in?
Whom do you focus? And, how do you wish to render value to your patients?
Sample Mission Statement: To deliver the highest possible quality of care to
each patient, with respect and special attention to each person’s racial, ethnic
and socio-cultural background and needs.

Value statement
Whatever you believe you should practice and promote in your hospital. List how
you want the practice to operate, including moral values such as integrity,
honesty and respect, as well as operational values such as increased efficiency,
timeliness and communication.
Sample Values Statement: All patients are to be treated equally, regardless of
race, ethnicity or socio-economic background and give the best possible
available care and consideration. These values are the responsibility of each
individual within our organization.

Develop Strategies
Strategies tell “how to get there.” Many methods are for developing strategies.
Once the Board has approved vision and mission statements, development and
prioritization of goals becomes the next challenge. Here are three methods which
are used for developing strategies for the future.

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Goal approach: In Goal Approach a goal identifies an end to which the
organization aspires, what is hoped to be achieved. For purposes of clarification,
this is distinguished from an objective, which is an activity necessary to reach the
goal. Understanding the differences between a goal and an objective can be
confusing. Goals are broad, brief statements of intent that provide focus or vision
for planning. Goals are warm and fuzzy. They are non-specific, non-measurable,
and usually cannot be attained. For instance afghan children will be healthy.
Objectives are meant to be realistic targets for the program or project. Objectives
are written in an active tense and use strong verbs like plan, write, conduct,
produce, etc. rather than learn, understand, feel. Objectives can help you focus
your program on what matters. They will always answer the following question:
WHO is going to do WHAT, WHEN, WHY, and TO WHAT STANDARD?
Each proposed goal should be examined against community need and
acceptability, relation to the mission, feasibility and effectiveness in addressing a
problem or concern. Obtaining a consensus on goal priorities may be difficult, for
it calls into play a complex set of value judgments, biases and differences in
degree of relative urgency or importance. Recognizing that resources are limited
is a key consideration. Here, creativity is a welcome skill for discovering
innovative strategies or solutions. The Strategic Planning Committee generates
several possible approaches to accomplish goals. Each alternative is then
subjected to an evaluation of costs, equipment and personnel resources, benefits
and constraints. Consultants and the experiences of other hospitals may prove
helpful in assembling the information needed to assess each option. Upon
completion of this research, the Committee focuses on selecting the most
appropriate specific course(s) of action. If numerous steps or objectives are
necessary to achieve each goal, develop a breakdown of those goals which
would require two to five years, as well as short-term actions. In this way, goals
are less overwhelming, and organizational achievement of each goal is another
step toward the desired end. To develop a goal outline the specific issues you
want your practice to address over the next year and the results you desire.

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Goals should be quantifiable, consistent, realistic and achievable. You may want
to limit your goals to two or three.
Sample Goals: Reduce the incidence of post surgical infection rate among our
operated patients by 75 % till end of coming two years. Or improve
communication with rural patients to provide better diagnosis, treatment and
positive outcomes. Or Increase proper usage of inhalers by asthmatic patients.
Objectives include how you will achieve your goals. For example: to increase
tetanus immunization rates for selective surgery patients or send staff members
to medical capacity building or develop or access treatment protocols in multiple
local languages. Determine the actions, methods and/or steps needed to achieve
each goal and objective. Consider any budget that might need to be developed
for training or special services. For example if we consider the last objective of
improving inhaler usage the action plan will include the following activities:
• Take into account language barriers and/or cultural considerations
• Let the patient show how he/she thinks the inhaler should be used
• Demonstrate how to properly use the inhaler
• Provide materials explaining the use of an inhaler in the patient’s language
• For patients who need additional help, arrange for a nurse to visit their
home and practice with them
• Have staff follow up with patients to determine their ongoing level of
understanding/ compliance
• Ensure the patients is using the inhaler properly

Critical Issues Approach: After assessment of the environmental there would

be a list of critical issues. Take this list and focus on the four to eight issues most
critical to your hospital’s future. Each issue should be stated in question form.
Put the critical issues in a logical order. Each issue should be discussed,
possible solutions/options identified and the best solutions selected. The
hospital’s strategy for the future becomes clear after all of the critical issues
questions are answered. That strategy needs to be reviewed for clarity and
coherence. The strategic plan is then developed and presented for approval.

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Even when we are choosing some critical issues and strategies are developed to
overcome them, still there is a need to put it in the framework of strategic
directions. Some of the most common errors in writing objectives include: writing
an objective like an activity, writing an objective like a vision; or writing too many
objectives.
SMART Objectives” refers to an acronym built around the five leading
measures of a strong program. This acronym can be very helpful in writing
objects that can be employed to evaluate the quality of Hospital Services
proposed and carried out.
Specific – What exactly are we going to do, with or for whom? The Hospital
states a specific outcome, or a precise objective to be accomplished. The
outcome is stated in numbers, percentages, frequency, reach, scientific outcome,
etc. The objective is clearly defined.
Measurable – Is it measurable & can WE measure it? This means that the
objective can be measured and the measurement source is identified.
If the objective cannot be measured, the question of funding non-measurable
activities is discussed and considered relative to the size of the investment. All
activities should be measurable at some level.
Achievable – Can we get it done in the proposed timeframe/in this political
climate/ for this amount of money? The objective or expectation of what will be
accomplished must be realistic given the market conditions, time period,
resources allocated, etc.
Relevant – Will this objective lead to the desired results? This means that the
outcome or results of the program directly supports the outcomes of the agency
or funder’s long range plan or goal, e.g., the selected MOD priority area.
Time-framed – When will be accomplishing this objective? This means stating
clearly when the objective will be achieved.
Scenario Approach: The scenario approach requires the development of
several pictures (scenarios) of what your hospital might be in one, two, five or
more years. Scenarios should be evaluated in terms of your hospital’s vision and
mission, community needs and financial feasibility. Identify the advantages and

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disadvantages of each scenario and select one. The chosen scenario may be a
combination of more than one original scenario. Determine if the scenario is
feasible, and then translate it into a strategic plan. The scenario approach is
particularly useful when dealing with major changes in health care delivery, its
emphasis or direction. It produces “big picture” thinking, is fairly quick and
people find it interesting. The scenario and critical issues approaches can be
used with the goal approach. After the strategy for your hospital’s future has
been identified using the scenario or critical issues approach, specific goals can
be determined using the goal approach.

Strategic Plan preparation

Whatever is discussed and decided during meetings is documented and makes
the basis for preparation of the strategic plan. Focusing on goals, strategies and
objectives, the Strategic Planning Committee assigns responsibility for achieving
these objectives, specifies the timetable by which each is to be accomplished
and determines what resources are required to accomplish each objective. The
plan should serve as a guide for all activity and direct the hospital toward a
preferred future. A simple, brief plan with short- and long-term objectives
encourages the hospital to move ahead and specifically identifies the path for
doing so. Decide on the format for your written strategic plan and outline what it
will look like, based on the needs of your hospital. The plan might include:
• Executive Summary of the strategic planning process
• History of the hospital
• Vision and Mission statement
• Target population
• Catchment area or Community served by the hospital
• Future issues facing the hospital
• Analysis of strengths and weaknesses, opportunities and threats
• Programs and services, medical staff, operations and finances
• Assumptions upon which the plan is based
• Goals and objectives

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 • Implementation strategies
• Organizational structure planned for the future
• Plans for buildings, technology or renovation
• Marketing plans
• Key relationships and how they will be maintained, improved or developed
• Organizational polices for the future
• Contingency plans
Draft your strategic plan. It is easier if one to two members of the Strategic
Planning Committee put together the draft of the plan.

Taking Approval of the Plan

Despite of review of draft by Strategic Planning it should also be reviewed by
others, such as staff members, interested community leaders and people who
have a stake in the hospital’s future. Then make needed revisions. It is
important to develop a plan that can be understood and carried out. The
Committee submits the plan for Board approval.

Implementation of the Plan

Now it is time to put it in practice. The Board authorizes the CEO to initiate the
implementation process through policy modifications, hiring staff or purchasing
equipment, appointing special task forces or allocating and budgeting funds. The
Board, the community and the medical and hospital staff should be aware of and
understand the plan. The plan should be communicated to all.

Monitoring and Updating the Strategic Plan

Strategic plans should be monitored continually and updated annually. Given the
rapidly changing health care environment, quarterly reviews of processes may be
needed. Updating of the strategic plan should occur before budget development.
Updating requires reviewing the hospital’s performance, the plan’s objectives,
changes in opportunities, threats, strengths and weaknesses and critical issues.
Revisions to the plan are then made and included in the budget. The strategic

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plan needs to be adjusted when conditions change, when new information
becomes available or when the health care delivery system changes.

Operational Planning and Activity Scheduling

Nowadays the business of running a hospital is increasingly complicated.
Hospitals are in need of best practices and sources of competitive advantage.
Hospitals should brings the experience and expertise in the development of new
and redesigned operational processes to allow the institution to maximize their
full potential and achieve their goals of program, superior customer service,
impeccable quality, improved efficiency and effective asset utilization. Hospitals
integrate skills in clinical program planning, technology and facility planning to
deliver innovative solutions that are practical, implementable and infused with the
organizational understanding and support for needed change.
The vision sets the direction for operations by highlighting the key drivers of
change and provides line of sight for reaching a higher level of performance. It is
required to translate the strategic framework into small activities and task to be
manageable and applicable. Before going into detail of operational planning your
attention is requested to pay to concise operation plan of a hospital in the
following table in which the strategic planning and operational planning its related
to each other.
Table: strategic framework and operational planning in a hospital
Mission: “To Heal, Comfort and Serve our Community with Compassion.”
Vision: To Provide each Patient Superior Service & Safety, Exceptional by Any
Standard.”
Values: Reverence ~ Integrity ~ Compassion ~ Excellence
Pillars Strategy Measurements
PEOPLE • Create a culture that • <15% Turnover
Always hire, retain, and inspires. • 75% Employee
inspire the best. • Provide a safe work Satisfaction
environment • 16 Hours Training per
• Engage employees to Employee

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 achieve new levels of • 0 Needle Sticks
effectiveness • <51 L & I Claims
• Reduce Patient
Handling Injuries 50%
SERVICE • Provide an exceptional • 75% Patient
Always provide service service experience Satisfaction
that exceeds customer • Create loyalty and • 80% HCAHPS
expectation. sense of ownership • Baseline Physician
• Create the easiest Satisfaction
access to services • Baseline Internal
Customer Satisfaction
• Baseline Wait Times
(E.D. & Imaging)
QUALITY • Ensure safety of all • Quality/Safety/PI
Always achieve patients Indicators
organizational • Leverage technologies ⇒ 100% CMS
excellence & patient to attain “best in class” Compliance
Safety. outcomes ⇒ All Green “Board
• Embrace award winning quality”
health care criteria for Dashboard
performance excellence • State Quality Program
• Quality standards are Submission 10/08
known & practiced by all
FINANCE • Control Expenses •100 Days Cash
Always sustain • Manage capital • 4.0% Operating Profit
Robust financial expenses responsibly Margin
health. • Staff to Budget • 60% Medicare
• Negotiate Payer /Medicaid/Healthy
Contracts Options
• Maximize public/private • 4.06 Employees Per
contributions & grants Occupied Bed

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 • $150K in Grants &
Donations
GROWTH • Develop and grow new • 1.5% Market Share
Always optimize & existing services Growth
Responsible growth to • Recruit well-trained • 1.5% Increase in
achieve our mission & physicians who exemplify Operating Revenue
vision. our Values & Standards • 5,999 Admissions
• Invest strategically in • New services meet
existing facilities. projected results

When you are developing operational planning it is very necessary to follow the
strategic frameworks. The main areas for which there is a place in strategic
planning in a hospital are the following:
• Clinical services
• Training & education
• Research
• Human resources management
• Financial management
• Administrative support services
• Facilities management
• Quality and safety
• Information systems and communication technology
• General management & corporate governance
To implement all above goals and strategies we need the develop operation
planning in which the following issues will be included.
• Costing Approach: it is possible to include the costs within operational
planning or develop a financial planning as a separated document.
• Assumptions: it will shows the conditions in which the plan will be applied
smoothly and they should be met for implementation.
• Medical equipments: to provide services there is a need to develop a plan
for all equipments which is needed now and in future

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 • Non-Medical equipment
• Facilities: facilities may include power, gas, communication,
transportations and so on
• Information and Communication Technology
• Staffing : it may include all staff including technical, administrative and
supportive
• Professional training: if you are providing training to your professional
staff, therefore, training requires a separate operational plan including its
cost is needed.

What is Operational Plan?

The Operational Plan defines how you will operate in practice to implement your
action and monitoring plans – what your capacity needs are, how you will engage
resources, how you will deal with risks, and how you will ensure sustainability of
the Hospital’s achievements.
An Operational Plan does not normally exist as one single standalone plan;
rather the key components are integrated with the other parts of the overall
Strategic Plan. The key components of a complete Operational Plan include
analyses or discussions of:
• Human and Other Capacity Requirements – The human capacity and
skills required to implement your plan, and your current and potential
sources of these resources. Also, other capacity needs required to
implement your plan
• Financial Requirements – The funding required implementing your plan,
your current and potential sources of these funds, and your most critical
resource and funding gaps.
• Risk Assessment and Mitigation Strategy – What risks exist and how
they can be addressed.
• Estimate of Plan Lifespan, Sustainability, and Exit Strategy – How
long your plan will last, when and how you will exit your plan (if feasible to
do so), and how you will ensure sustainability of your plan achievements.

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As the plan moves into Implementation, several of these components are then
defined in more detail and tested in reality. Thus the Operational Plan provides a
critical bridge between strategic plan and Implementation of those plans.
The level of detail and formality of your Operational Plan will vary depending on
the size and complexity of your plan. Small plans may only briefly touch on each
of these topics before moving on to implementation.

Importance of Operational Plan

An Operational Plan ensures you can successfully implement your Action and by
getting your team to prepare your project to raise funds, being clear about how
you will get the resources and arming you with a convincing plan to review with
existing and potential donors. In addition it will help you to use resources
efficiently, to help allocate scarce resources to the most critical gaps and needs.
It helps to clearly define your capacity gaps and most critical resource
requirements and reduce risks where possible, and prepare contingency plans
where necessary. By operational plan we think about the long term future of the
project, including how you will ensure sustainability of your project’s targets and
impacts.

Steps in developing Operational Planning

Operational planning is short-range planning that focuses on particular course of
actions or operational planning provides a detailed statement of the activities and
related budgets that will be undertaken to implement the strategic plan.

Step 1 – List Main Activities

The main activities in the log frame are a summary of what the project must do in
order to achieve project objectives. These can now be used as the basis for
preparation of the activity schedule that will specify activities in operational detail.

Step 2 – Break Activities down into Manageable Tasks

The purpose of breaking activities down into sub-activities or tasks is to make
them sufficiently simple to be organized and managed easily. The technique is to

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break an activity down into its component sub-activities, and then to take each
sub-activity and break it down into its component tasks. Each task can then be
assigned to an individual, and becomes their short-term goal.

The main skill is in getting the level of detail right. The most common mistake is
to break the activities down into too much detail. The breakdown should stop as
soon as the planner has sufficient detail to estimate the time and resources
required, and the person responsible for actually doing the work has sufficient
instructions on what has to be done.

Step 3 – Clarify Sequence and Dependencies

Once the activities have been broken down into sufficient detail, they must be
related to each other to determine their: sequence - in what order should
related activities be undertaken? Dependencies - is the activity dependent on
the start-up or completion of any other activity?
This can best be described with an example. Building a house consists of a
number of separate, but inter-related activities: digging and laying the
foundations; building the walls; installing the doors and windows; plastering the
walls; constructing the roof; installing the plumbing. The sequence dictates that
digging the foundations comes before building the walls; while dependencies
include the fact that you cannot start installing doors and windows until the walls
have reached a certain height; or you cannot finish plastering until the plumbing
has been fully installed. Dependencies may also occur between otherwise
unrelated activities that will be undertaken by the same person.
Step 4 – Estimate Start-up, Duration and Completion of Activities
Specify timing means making a realistic estimate of the duration of each task,
and then building it into the activity schedule to establish likely start-up and
completion dates. Sometimes it is difficult to estimate the probable completion
time. To ensure that the estimates are at least realistic, those who have the
necessary technical knowledge or experience should be consulted. Inaccuracy is
a common mistake, usually resulting in an underestimate of the time required,
and can arise for a number of reasons: omission of essential activities and

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tasks failure to allow sufficiently for interdependence of activities failure to
allow for resource competition (i.e. scheduling the same person or piece of
equipment to do two or more things at once) a desire to impress with the
promise of rapid results

Step 5 – Summarize Scheduling of Main Activities

Having specified the timing of the individual tasks that make up the main
activities, it is useful to provide an overall summary of the startup, duration and
completion of the main activity itself.

Step 6 – Define Milestones

Milestones provide the basis by which project implementation is monitored and
managed. They are key events that provide a measure of progress and a target
for the project team to aim at. The simplest milestones are the dates estimated
for completion of each activity - e.g. Training needs assessment completed by
January 1998.

Step 7 – Define Expertise

When the tasks are known, it is possible to specify the type of expertise required.
Often the available expertise is known in advance. Nonetheless, this provides a
good opportunity to check whether the action plan is feasible given the human
resources available.

Step 8 – Allocate Tasks among Team

This involves more than just saying who does what. With task allocation comes
responsibility for achievement of milestones. In other words, it is a means of
defining each team member’s accountability - to the project manager and to other
team members. Task allocation must therefore take into account the capability,
skills and experience of each member of the team. When delegating tasks to
team members, it is important to ensure that they understand what is required of
them. If not, the level of detail with which the relevant tasks are specified may
have to be increased.

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The easy and important format for operational planning is Gantt chart in which all
steps mentioned above can be accommodated with specification of time and
resources along with activities and tasks.

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Session 5: Hospital Costing and Budgeting
The budget is a financial plan that summarizes the forecasted revenues and
expenditures for an organization/project for a given period of time. Revenue is
the total amount of money received by an organization/company for output,
goods sold or services provided during a certain period of time. Expense is the
money spent by an organization/company to continue its ongoing operations

Budget Principles
During budget preparation, some rules and procedures are strictly followed and
these are known as budget principles. Before preparation of budget the
legislative body formulates these principles and distributes it to all line ministries.
An organization can also have its own principles but some main principles to
assess soundness of budget are the following.
• Compliance: all expenditures must comply with all relevant policies and
regulations
• Comprehensiveness : the budget should encompass all operations (off-
budget expenditure and revenue are prohibited)
• Legitimacy: Policy makers, that can change policies during the
implementation , must take part in and agree on
• Predictability: there must be stability in strategic policy and in the funding
of this policy
• Transparency of budgetary process and information: decision makers
should have all relevant issues and information before them when they
take decisions and these decisions and their basis should be widely
communicated
• Accountability: decision-makers are responsible for the actions they take
• Equity: resources are directed according to real needs to all people and
areas of the provinces.
• Flexibility: budget should be enough flexible to fund overseen
circumstances and take advantage of opportunities.

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 • Honesty: budget should be delivered from unbiased projections of
revenue and expenditure
• Be realistic, attainable and reasonable: Realistic: should be formulated
to avoid underestimated or overestimated program/project cost.
Attainable: can be performed successfully, possible to do and reasonable:
showing reason and sound judgment

What is cost?
Hospitals as a business are conducted by exchanging liquid assets for fixed
assets and vice-versa. A first type of payment occurs when we exchange cash or
another liquid asset for such things as property, machinery and vehicles. These
are material assets that enable us to make things. A second type of payment
occurs when we purchase such things as raw materials, and employ people to
operate the machines, answer telephones and the like. Rent is an example of
this second type of payment. We may decide to hire rather than buy a
photocopier. The rent on the photocopier must be paid for, and we pay rent for
the use of the photocopier. The first type of payment is called an investment, and
the second type of payment is called a cost.
Investments increase the material that is, fixed assets, of the person buying
them. The owner has an item that can be used as a means of production.
Investment in such items is called capital expenditure
We should understand the distinction between fixed and liquid assets. The most
liquid asset is cash. A liquid asset can be used to pay a bill. The more liquid an
asset the more readily it can be exchanged for cash. Fixed assets are those that
take time to be sold. They cannot be exchanged immediately for goods and
services. Factories and vans are examples of fixed assets.
Money is in itself unproductive. It does not make anything. So cash (the
ultimately liquid asset) must be used to by other assets that can be productive,
such as machinery. These fixed assets are used in conjunction with other inputs
– labor and raw materials – so make goods and services that can be sold for

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cash. Hence liquid assets are exchanged for fixed assets, which produce goods
and/or services that result in sales, bringing in further liquid assets.
A capital item is used to make things – in the sense of providing the facilities for
production – a factory, a machine – these are examples of capital items. But the
making of goods requires other factor inputs as well – raw materials and labor.
Every time a good is produced these are consumed. These inputs are called
costs in accounting terms.

Classification of Costs
Costs are payments incurred in day-to-day production. It is possible to analyze
costs in two separate ways.

Classification by type
Costs are classified as either arising directly or indirectly. Direct costs are ones
that can be specifically related to the production of a particular good. Indirect
costs are those that are not so specifically related. For example, suppose a
company manufactures chairs. The cost of the labor and raw materials that goes
into the manufacture of the chairs is direct costs. The production overheads
include the factory rent and heat, light and power, and depreciation on plant and
machinery. Indirect costs are also frequently called overheads.

Classification by behavior
This is concerned with the way an impact of a change in output causes a change
in costs. Costs are classified in this way as either fixed or variable. Fixed costs
do not change as the quantity of output changes. Increasing output does not
increase these costs. Variable costs do change. Variable costs increase as
output increases. It is a mistake to confuse indirect costs with fixed costs. Both
direct and indirect costs can and do vary with output, and both can, and do,
contain elements of fixed costs. For example, the amount of energy used by a
company (an overhead) does increase with the number of goods produced.
The usual example of a direct cost that is also fixed is depreciation on machinery.
Depreciation is the loss of value of an asset owing to ageing. Machinery just
wears out, and so loses value. Depreciation on dedicated machinery means

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depreciation on machinery that is used for only one purpose in the production
cycle, and so can be regarded as a direct cost.
Economists classify costs as either fixed or variable. At present we are
concerned with how costs vary with output in the short run. The short run is
defined as a period of time in which at least one factor of production is fixed –
usually capital. That is, a firm as a fixed size of plant. In the long run the firm can
move to larger or smaller premises.
In the short run, because the capital (and hence size of production unit) is fixed,
the fixed costs remain constant. That is, fixed costs are those costs that remain
constant regardless of the quantity produced in the short run.
An example of a fixed cost would be rent on a building. The rent remains
constant regardless of how much business is done in it. Variable costs are those
cost that change as output increases.
Total costs are the sum of fixed costs and variable costs.
Total costs = Fixed costs + Variable costs
TC = FC + VC
To estimate a hospital costs, it is necessary to classify its components. Cost
elements can be broken down in several ways, as illustrated below. A good
classification scheme depends on the needs of the particular situation or
problem, but there are three essential elements:
• It must be relevant to the particular situation.
• The classes (categories) must not overlap.
• The classes chosen must cover all possibilities.
Economists define cost as the value of resources used to produce something,
including a specific health service or a set of services. Resources used for
hospitals can be described in many different ways. For example, a infection
control in hospitals might be described as using the following resources:
personnel, administration and management, anti infections, anti septic,
equipment, trainings and so on. These categories are well defined and their
meaning is clear. However, they do not constitute a very useful way of thinking
about the resources used in the hospital. The main problem is that the categories

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overlap; money from staff can be used to pay administration, and personnel are
likely to be involved disinfection operations. If we add up the value of these three
categories, they may well come to more than the total cost of the programme.
Obviously, several different classification schemes are involved here. These and
others need to be looked at separately, starting with the most basic resource
inputs. Examples of resource inputs include personnel, supplies and equipment.
Describing the resources used in terms of physical inputs, as we have done
above, is one way of dividing them up. However, it is not the only way.
Resources have other characteristics that are important. There are four other
characteristics that you might find helpful in describing and assessing the costs
of your programme. They are usually less important than the inputs scheme, and
are explained briefly below.

Classification by function/activity
The first of the secondary classifications involves the kind of activity or function
for which the resources are used. A maternal health department in the hospital
encompasses a wide range of activities, such as tetanus toxoid vaccinations for
pregnant women, prenatal care, supervision of deliveries, and immunization and
weighing of children. For each of these activities, groups of physical inputs are
required. For example, infant weighing requires personnel to do the weighing and
record the results, scales, tables, charts, building space and possibly vehicles.
The activities mentioned above for MCH are a limited set. They include only the
service provision activities. We should include in our list the essential activities
that support and complement them. Examples that you are likely to find in most
health programmes include: training, supervision, management, monitoring and
evaluation, logistics and transport.
There is one other thing to be careful about when estimating the costs of
multiple-activity programmes. You will have to allocate resources that are shared
among the activities so that each is charged only for its proper share. This is
especially important for personnel in some cases.

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Classification by level
Another way of dividing up resources is according to the level at which they are
used. For most hospitals there is an obvious hierarchy of operations. For
example medical level, administration and supportive level are some levels in the
hospitals.
Planning, costing and budgeting is interlinked to each other at any project
including health service delivery such as hospitals. There is dire need for
effective planning, costing and budgeting tools and methodologies when one is
running the hospitals. Significant amounts of funding have been made available
to help countries combat major health crises and yet the funding is often not
accessed because of weaknesses in the plans and budgets submitted.
Specific weaknesses often encountered include:
• The absence of quantified, time-bound measurable goals and objectives.
• The incorrect quantification of activities and resources
• The inaccurate calculation of resource costs.
An overall and critical weakness in many cases is the lack of clear linkages
between activities, strategies, objectives and goals. In such cases it is not clear
how much the completion of a set of activities will contribute to the achievement
of an objective, or how much the achievement of an objective will contribute to
the achievement of a goal.
The framework we are discussing here, it shows the principles of planning,
costing and budgeting in a practical and easy-to-follow way.
The framework provides a method for:
• Setting out quantified, time-bound measurable goals and objectives.
• Describing and quantifying the activities needed to achieve the goals and
objectives.
• Showing the resources required to carry out the activities.
• Calculating the costs of the resources,
• Showing the sources of funding and estimating financing gaps, and
• Producing a budget.

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The budget should accurately reflect the resources required to achieve the goals
and objectives. The process is best followed by planners, program managers and
financial analysts as a team, since this should help to improve their planning and
budgeting skills and their understanding of the relationship between the
programmatic and financial elements. The resulting plan should be more logical
and realistic and more likely to be funded and successfully implemented.

Layout of Methodology of Framework

The Planning, Costing and Budgeting Framework are laid out in a logical, step-
by-step format, which:
• Encourages the user to move from each goal down through the planning
levels to the activities and inputs level, which accentuates the need to
quantify each level and to link each level to the preceding level.
• Encourages the identification and quantification of the critical inputs
needed for each activity and putting a cost to each of these inputs, thereby
arriving at an informed cost of each activity, strategy and objective.
• Shows the funding commitments for the plan and provides estimates of
the funding gap.
The Planning and budgeting document that you develop should contains all the
elements of the plan – the descriptions, targets, inputs, unit costs, total costs and
financing. We should take into account the following framework.

Goals summary
In order to cost and budget easily the Plan should have a Goals Summary which
is used to show an overview of the goals contained in the plan, together with the
target for each goal. Each goal is entered on a separate paragraph. Vertically the
form should explain each goal, each objective under a goal, each strategy under
an objective.

Resources (Inputs)
All goals, strategies and activities are in need of resources to perform the
activities and achieve the results. For examples the inputs maybe staff,

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equipment, supplies and so on. We should develop a table to show the total
numbers of outputs and inputs in quantities, to be easily converted in monetary
values. The total costs for each activity, strategy and objective are what we can
obtain if we follow the steps accordingly. The total for each strategy is the sum of
the figures for all the activities under the strategy.

Converting the costing to a budget

If the amount of funding available is less than the total cost, then either the costs
or the activities have to be reduced for the costing to become a budget. The first
step is to review the activities, inputs and costs to see if there are cheaper ways
to carry them out without reducing the quality of the results. If that possibility has
been eliminated then the goals, objectives, strategies and activities may need to
be reduced and some of them may need to be eliminated completely. Removal of
activities, strategies or objectives should be carried out with care since they
generally form parts of packages required to achieve the goals and removing one
or more may result in the goals not being achieved. Reducing the number of
units per output is not recommended since it is likely to reduce quality, for
example, less training for a nurse. Reductions should, therefore, generally be
made by changing the target population, providing the target and numbers of
activities have been linked to the target population. After the plan is adjusted to
match the available funding it effectively becomes a budget.

Goals Description Unit of Cost Quantity Total Cost

Objective
Strategy
Activities
Inputs

Steps for creating a budget

Step 1:

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You should have already been determined hospital revenue. Revenue can come
from patient payments, tax dollars, donations, and other sources. Be sure to
deduct a percentage of the patient bills that will remain uncollected, the charity
work expected by the hospital and the pro bono work it does. Probably the
hospital would have identified how much is going as average on welfare services.
Step 2:
How is your figure out expenses in the hospital? Start with the physical facility.
How much does it cost to keep up the building? What is the maintenance cost of
each department, engineering, air-conditioning, heat, water, other utilities? Know
what equipment costs, how much must be replaced per patient day, and if any
can be recycled. Include the non-medical cost of each bed in the hospital. You
should include advertising and marketing cost as well.
Step 3:
Certainly the manager should understand and know the cost of personnel, all
employees and ancillary staff, including consultants, outsourced contracts,
perhaps laundry or nurse staffing services. For all employees of the hospital,
from janitorial to hospitalists, figure the fringe benefits the hospital must pay for
each.
Step 4:
Add all medical equipment costs, ongoing and expected expansion or
replacement of new diagnostic equipment. In addition there are some
accessories for equipment as well and should be indentified and forecasted.
Step 5:
Based on the number of beds you may know the medical costs of each bed. How
many staff hours are spent on each bed, occupied or not. Use this figure as an
average to get a cost per patient year. Add to that the non medical costs per bed.
Include every possible cost that keeps that bed in the hospital. Don't forget
replacement costs per annum for any and all patient needs.
Step 6:
Nowadays the hospitals are not meeting the requirement of society. What about
expansion? Are you planning a new wing, or the renovation of an old one? Are

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you expanding into a new specialty that could bring in extra revenue? Estimate
that revenue when planning your budget.
Step 7:
You may need in your hospital waiting room for attendants and gift shop and
some canteen. Don't forget parking garages, lots, landscaping, rehabilitation
center, grounds keeping or window washing.
Step 8:
If you have the facility of insurance in the country then you should include all
insurance for the facility and personnel. It may be deducted from their monthly
salary after putting in the budget or some other mechanism could be used.
Step 9:
Contingency financial plan is helping in unforeseen situation. Write in an
emergency expense fund. Disasters occur and the hospital must be prepared for
them when they arrive. That is very necessary for disaster particularly flood and
earthquake prone areas.
Step 10:
Finally when all data is available and all activities and their inputs are listed, then
you can do the budget, use a spreadsheet. Enter all categories and the cost of
each. Add all taxable items and the percentage of each. You probably get
reduced rates on utilities, or least a break on the taxes on them. Enter all
formulas for those. It is possible your hospital system has one already available.
If the spreadsheet exists, use it or modify it for your own needs. If it does not,
make one, so making next year's budget is simply a matter of entering numbers
and letting the computer do the work.
When we are costing and making budget for hospitals it is very necessary to to
categorize the components into separate heads and then put all other sub
categories under them. For example in a hospital the following major heads
would be needed to run the departments.
• Capital
o Vehicles
o Equipments

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 o Buildings
o Training which is not recurrent
• Recurrent
o Personnel
o Supplies
o Vehicle operation and maintenance
o Building Operation and Maintenance
o Training recurrent
o Other operating inputs
• Overhead
o Space
o Electricity
o Gas
o Other utilities
o Institution charging

Input Budget Expenditure

(currency...) (currency...)
Capital
Vehicles
Equipment
Buildings, space
Training, non-recurrent
Social mobilization, non-recurrent
Subtotal, capital
Recurrent
Personnel
Supplies
Vehicles, operation & maintenance
Buildings, operation &
maintenance
Training, recurrent
Social mobilization, recurrent

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Other operating inputs
Subtotal, recurrent
Total

Hospital Budgeting
A budget reflects the service priorities. It is the framework for spending money
and for assessing financial performance. A budget does the following:
• Shows how much it costs.
• Reflects policy choices.
• Sets in motion implementation.
• Reflects what monies will be collected (revenue) and what monies will be
spent (expenditure).
• Provides the framework.
The budget is made up of line items covering all the input needs to render a
service. These are called line items. For each of the cost centers the budget is
structured according to line items such as:
• Personnel - costs for all the staff requirements, such as salaries,
overtime, bonuses and employer contributions for medical schemes.
• Administration - administration costs such as telephones, postage, travel
and subsistence, study expenses and transport costs.
• Stores and Livestock - costs related to the purchase of consumable
items such as stationery, drugs, protective clothing and fuel.
• Equipment - costs to purchase or hire equipment and items such as
furniture and hospital equipment.
• Land and Buildings - costs to hire office space.
• Professional and Specialized Services - payments for professional type
of services such as medical services, laboratory services and consultancy
services.

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 • Transfer Payments - payments transferred to people outside government
who render goods and services per special agreement as well as
subsidies.
These line items are further unpacked as minor items. Each minor item also has
an identity code that is used for purposes of budgeting and recording
transactions. A minor item in personnel, for example, is medical aid or housing
schemes. Minor items for operational costs such as stores will include cleaning
materials or drugs.

Preparing to draw up a Budget

Budgeting for inputs:
Budgeting for inputs follows some important steps. The inputs required flow from
unpacking the Service.

STEP 1: list the inputs

List the amount and type of inputs required and prepare the list according to all
the applicable line and minor items. Differentiate between current inputs that
require continuation and new inputs that are required.

STEP 2: cost of inputs

The costing process could follow different approaches, as demonstrated below.
Personnel
• Make sure that all the staff working in the cost centre appears on the
personnel list.
• Make sure that staff numbers and staff mix is appropriate for the service
activity.
• Identify key posts that need to be filled if there are any vacant.
• Make sure at the end that the added cost will fit your expenditure
framework.
• Determine all costs related to personnel
Administration
Determine the administration costs for the cost centre. These include costs for
telephone calls, hiring of telephones and post boxes and transport costs. A

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critical evaluation of previous expenditure history will assist. If a manager knows
that s/he has to attend monthly meetings requiring subsistence and travelling,
these can be calculated.
Equipments
Prepare a list of new equipment required. Number the list. This will ensure that
purchases during the financial year are made according to an approved list.
Estimate the cost of each piece of equipment.
Other items
Follow similar processes for each of the other items and minor items of your
financial system. It is important to remember that any capital spending such as
building a new clinic has financial implications for running the facility in the future.

STEP 3: Combine the costs.

Once every cost centre has compiled a budget, the budget team needs to
examine and verify the budget before incorporating all the cost centers’ budgets
into a single district budget.
The final hospital budget needs to reflect priorities and ensure that more
resources are distributed to entities in more need. Not all funds should be locked
in fixed costs such as staff, but there should be sufficient funds for operation.

Budgeting for Revenue:

Hospitals need to budget for the revenue they will collect. The revenue could
come from subsidies, from other sources such as donor and patient fees or from
own revenue, such as from the hospital revenue system.
The following measures would indicate a good budgeting process:
• Having a picture and understanding of financial performance for the
previous year and using this information for financial planning in the
forthcoming year.
• Clearly identifying input items, prioritizing them and listing them.
• Having available equipment inventories to support decisions on
maintenance and replacement.
• Having estimates for each applicable minor and line item.

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 • Setting revenue targets.
• Completing an estimated expenditure and revenue report which is
accompanied by supporting documentation.

Cost consciousness
It is a behavior of healthcare provider at service delivery points including
hospitals which is affected by their attitude and beliefs. Because most health care
expenditures are the results of doctors' decisions, whether doctors are cost-
conscious is an important matter. Many decisions regarding medical tests and
treatments are influenced by factors other than the expected benefit to the
patient, including the doctor's demographic characteristics, training, work context,
financial incentives and information about costs. Medical decisions are also
influenced by subjective considerations, including risk aversion, tolerance for
uncertainty, and concerns about cost and income. Cost-consciousness is
associated with lower self-reported estimates of resource use. However, whether
cost-consciousness leads to less costly medical care is not known. Therefore the
Predictors of cost-consciousness or the determinants of cost-consciousness
include socio-demographic characteristics (age, sex), time since graduation from
medical school, type of practice (public versus private), medical specialty,
workload characteristics (number of patients per week, time spent with a new
patient), stress from uncertainty, and work-related satisfaction.

Cost containment and improving profitability

As in other field, there has been a steady increase in the cost of medical care,
but the raise in costs has been very rapid during the last one decade. Every type
of hospital and healthcare institution is concerned over the rising cost of patient
care. There are three elements in a cost containment process.
• Cost awareness: Inculcate the awareness amongst all the hospital
personnel, and the process of available to contain them.
• Cost monitoring: provide a mechanism for identify report, and analyze
actual expenditure against budget and standards.

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 • Cost management: establish a responsibility and accountability system for
attainment of plans
On analysis generally three causes for differences between budgeted and actual
costs emerge. They are as follows.
• Prices paid for inputs were different than budgeted prices
• Outputs level were lower than budgeted
• Actual quantities of inputs used were different from budgeted levels.
It is generally accepted that hospital costs could be contained with approaches
such as reduction the cost of input resources, improving efficiency and reduction
of volumes.

A checklist for cost containment

Any cost containment programme should be viewed as a continuing program and
one which should maintain the critical balance between quality and cost of
services.
Certain costs of hospitals are seen as being controlled more by the physicians
than administration. Case-mix, admissions, scope of service, intensity and length
of stay fall in this class. The bases for cost containment is by self-discipline
(humanism, efficiency and morale) and financial discipline ( capital control,
utilization control, and budget control ), by intensifying the organizational
awareness by everyone— from the class four employees to the chief of various
services— of the processes available to contain them. The following is a
checklist for cost containment to achieve improved efficiency with limited
resources.
• Reduction in staff by eliminating redundant positions
• Budget control. Instituting a department wise quarterly budget variance
report to review actual to budget comparisons and pinpoint problem areas.
• Computerization of patient accounting and administrative records
• Computerization of inventory management
• Streamlining paperwork
• Reducing dependence on outside services by creating them in-house

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 • Participation in shared services with other neighborhood hospitals
• Developing in-house servicing and maintenance facility
• Control on stationery, forms, duplicating and printing
• Shutting down electricity when not in use
• Shutting down AC plant at night where possible
• Market surveys for less expensive product
• Plan ahead purchasing
• Eliminating wastage and pilferage
• Good security and vigilance
• Standardization
• Economy in supplies and expenditure
• Motivational trainings for staff
The list is not exhaustive and you can add some other strategies which is
working in your own setting.

Cost Effectiveness
Cost-effectiveness analysis is the primary tool for comparing the cost of a health
intervention with the expected health gains. An intervention can be understood to
be any activity, using human, financial, and other inputs, that aims to improve
health. The health gain might be reducing the risk of a health problem, reducing
the severity or duration of an illness or disability, or preventing death. If the health
outcome is the same, say preventing death from measles either by immunizing a
child or by treating the disease, then analysts need only compare the costs of
different interventions that can achieve that outcome. The result is a cost-
effectiveness ratio, expressed as cost per outcome, which can be compared
across various types of services or various service locations that perform the
same function. The ratio is always discussed in relative terms, as there is no
“best” or absolute level of cost-effectiveness.
Basically cost effective analysis is the technique for choosing, form alternative
courses of actions, a preferred choice when objectives are not very clear in such

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areas as sales, costs or profits. In cost effective analysis, decision criteria may
include:
• Achieving a given objectives at least cost,
• Attaining it with reasonable resources, or
• Providing a trade-off cost for effectiveness
Therefore cost effective analysis is not an analysis for cost reduction— it is an
approach to specific set of goals.
The cost-effectiveness of an intervention can vary greatly depending on a
program’s size and scope. Typically, as program coverage expands and more
people are served, the cost per outcome drops. For example, if more children
can be immunized with the same fixed costs like nurses and clinics, then each
additional immunization will be cheaper until the service approaches full capacity.
Using child immunizations as an example, the incremental cost of adding mobile
vaccination teams might be lower than expanding fixed clinic services,
particularly if the unvaccinated children are dispersed and hard to reach. As
shown in the following figure, several alternatives might be available for
expanding the coverage of a current intervention (the status quo shown at point
“X”). If an alternative is more effective and less costly, decision makers should
usually opt in favor of adopting it, while they should abandon options that are
more costly and less effective. The trade-offs are less clear in the unmarked
quadrants, requiring decision makers to weigh whether the benefits that might be
gained merit a change in strategy.

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 Cost More

Alternative
is worse in
both
respects

Less
Effective

More
Alternative Effective
is better in
both
respects
Cost More

Program Budgeting In Afghanistan

Program Budget Documents are meant for Line ministries to present their
budgets in a program format i.e. in terms of resources allocated to each program
and the expected results to be achieved from those resources. It enables
Ministers, Government, Parliament and the Public to measure the performance of
the program in terms of benefits it produces for the country and costs of those
benefits and whether a program is providing “value for money”. The Program
Budget Document consists of two major parts:
Narrative Justification of the Ministry’s programs and services it delivers are
represented in components (1) (2) and (3) in the illustration below, and;
Financial Justification of the Ministry’s programs and services are represented
in component (4) in the below illustration.

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There are four categories of information in the program budget structure:
Program structure: Ministry Programs Sub-Programs Activities
Objectives: Strategic Objectives Program Objectives Operational
Objectives
Performance Indicators: Outcomes Outputs
Expenditures: Summary Costs Expense Summary and Line Item Expenses
In the Program Budget Documents, these elements are structured in the
following way. Each succeeding classification presents a greater level of detail.
This means that each Ministry comprises the sum of its programs, where each of
these programs comprises the sum of its sub-programs, and each sub-program
comprises the sum of its activities. In the same way, strategic objectives are
broken down into more specific program objectives that collectively contribute to
achieving strategic objectives; further, each program objective contains several
operational objectives specifically designed to cumulatively help achieve the
program objective.

Implementing Program Budgeting

Many countries have implemented program or results-based budgeting in one
form or another. Most countries have found that it takes a number of years to
fully implement program budgeting processes and to get the full benefits of
decision making based on expected results.
Program budgeting requires a “mind-set” shift and not just among budget
planners and program managers. Line Ministries and Line ministries and work of
their managers will be more and more assessed and judged on the performance
of Government programs and services in meeting the needs of its citizens.
Particularly in the early stages of program budgeting, the quality of information
provided may be less than is desirable or necessary to assist Governments make
informed budget decisions. This generally reflects either a lack of understanding
or an inability to shift the mindset from the “old ways” of doing things – e.g.
budgeting for salaries and operational expenses, to budgeting for results.
Patience is therefore required as program budgeting will take a number of years
to bed down.

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Some of the more common problems that have been observed with the quality of
program documentation within other countries that have adopted program or
results based approaches include:
Strategic or operational objectives that are not clearly defined;
Programs that are defined based on inputs (eg purchases, transfers or specific
activities) rather than the strategic or operational objectives and expected results
(outputs and outcomes);
Operating and development budget failed to be integrated, and future recurrent
cost not taken into account when planning investment projects;
Resource allocation requests continue to be based on unrealistic and unfunded
legal mandates rather than resources available with the inevitable result of
unrealistic budget expectations never likely to be fulfilled;
Performance measures that are not specified, inappropriate, or submitted without
comparative or time-based benchmarks making assessment by the Government,
Parliament and the public difficult;
Policy priorities are not properly established - ie Line ministries and the Ministry
of Finance do not know which (sub-)programs within Line ministries are the most
important and how do they fit within the Government’s overall economic and
social development strategy, and policy objectives stated in the ANDS;
The link between policy priorities and to budget allocation decisions is unclear –
why do low priority, poor performing programs continue to be funded;
There is often a lack of accountability among Government and Line ministries’
officials for results of Government programs and services (who is or should be
responsible for poor performance or good performance);
There is a lack of fiscal transparency i.e. little public or parliamentary debate
about budget development – the priorities, strategies, and performance of
Government programs. For example, why is the program not achieving its
objectives; is this the most efficient way of delivering this program etc.
Afghanistan is not unique in experiencing “teething” problems. Many countries
implementing program or results-based budgeting have encountered similar
problems. Implementing program budgeting is a long-term commitment and it

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generally takes a number of years for the full benefits of program budgeting to be
realized.
While some of the problems may be the result of a lack of understanding and
even lack of commitment to embracing the new processes, encouraging greater
fiscal transparency through providing program information to parliament and the
public (through publication) can be the catalyst for expediting reform. Greater
scrutiny on the results of Government activity is one of the best means of holding
Government and program managers accountable for the resources they
consume.

Group work:
• Divide the participants into group of four to five individuals
• Request them to discuss the costs concepts at hospitals and classification
of cost among them
• Then distribute the following table to them to work on it and fill the blanks
with appropriate types of cost
• They will present their finding in plenary
• All class will have discussion over important points
• The facilitator will close the exercise with his own feedback

Major and minor heads Types behavior

Staff
Managers Fixed Overhead
Nurses
Doctors
Allied Health
Professionals
Technicians
Supplies
Drugs Variable Direct

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X-ray film
Transport
Utilities
Depreciations
Training and Educations
Property TAX

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Session 6: Hospital Monitoring and Evaluation
Usually the term “monitoring and evaluation” tends to get run together as if it is
only one thing, monitoring and evaluation are, in fact, two distinct sets of
organizational activities, related but not identical.
Monitoring is the systematic collection and analysis of information as a project
progresses. It is aimed at improving the efficiency and effectiveness of a project
or organization. It is based on targets set and activities planned during the
planning phases of work. It helps to keep the work on track, and can let
management know when things are going wrong. If done properly, it is an
invaluable tool for good management, and it provides a useful base for
evaluation. It enables you to determine whether the resources you have available
are sufficient and are being well used, whether the capacity you have is sufficient
and appropriate, and whether you are doing what you planned to do.
Evaluation is the comparison of actual project impacts against the agreed
strategic plans. It looks at what you set out to do, at what you have
accomplished, and how you accomplished it.
What monitoring and evaluation have in common is that they are geared towards
learning from what you are doing and how you are doing it, by focusing on
efficiency, effectiveness and impact. Efficiency tells you that the input into the
work is appropriate in terms of the output. This could be input in terms of money,
time, staff, equipment and so on. When you run a project and are concerned
about its replicability or about going to scale then it is very important to get the
efficiency element right. Effectiveness is a measure of the extent to which a
development program or project achieves the specific objectives it set. If, for
example, we set out to improve the qualifications of all the high school teachers
in a particular area, did we succeed? Impact tells you whether or not what you
did made a difference to the problem situation you were trying to address. In
other words, was your strategy useful?

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Justifications for Monitoring Hospitals
Monitoring and assessment enable you to check the “bottom line” of
development work: Not “are we making a profit?” but “are we making a
difference?” Through monitoring and evaluation, you can review progress,
identify problems in planning and/or implementation and make adjustments so
that you are more likely to “make a difference”. It is important to recognize that
assessment, monitoring and evaluation are not magic wands that can be waved
to make problems disappear, or to cure them or to miraculously make changes
without a lot of hard work being put in by the project or organization. In
themselves, they are not a solution, but they are valuable tools. Monitoring and
evaluation can:

• Help you identify problems and their causes;

• Suggest possible solutions to problems;
• Raise questions about assumptions and strategy;
• Push you to reflect on where you are going and how you are getting there;
• Provide you with information and insight;
• Encourage you to act on the information and insight;
• Increase the likelihood that you will make a positive development
difference

Monitoring Framework
In order to perform monitoring effectively and efficiently we should follow the
following steps.
• Establishing indicators) of efficiency, effectiveness and
• impact;
• Setting up systems to collect information relating to these indicators;
• Collecting and recording the information;
• Analyzing the information;
• Using the information to inform day-to-day management.
• Monitoring is an internal function in any project or organization.

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Evaluation Framework
In order to perform monitoring effectively and efficiently we should follow the
following steps.
• Looking at what the project or organization intended to achieve – what
difference did it want to make? What impact did it want to make?
• Assessing its progress towards what it wanted to achieve, its impact
targets.
• Looking at the strategy of the project or organization. Did it have a
strategy? Was it effective in following its strategy? Did the strategy work?
If not, why not?
• Looking at how it worked. Was there an efficient use of resources? What
were the opportunity costs (see Glossary of Terms) of the way it chose to
work? How sustainable is the way in which the project or organization
works? What are the implications for the various stakeholders in the way
the organization works?

Planning for Monitoring and Evaluation

Monitoring and evaluation should be part of your planning process. It is very
difficult to go back and set up monitoring and evaluation systems once things
have begun to happen. You need to begin gathering information about
performance and in relation to targets from the word go.
When you do your planning process, you will set indicators. These indicators
provide the framework for your monitoring and evaluation system. They tell you
what you want to know and the kinds of information it will be useful to collect. In
this section we look at:
• What do we want to know? This includes looking at indicators for both
internal issues and external issues
• Different kinds of information.
• How will we get information?
• Who should be involved?

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We can measure the status and progress of all our activities through
development of indicators and collection of information about them.

Hospital as a System for Monitoring

A system may be defined as an alignment of interdependent parts and processes
that, in turn, deliver an outcome. Too frequently, however, the focus is on only a
specific aspect of healthcare or service being provided, overlooking the
interrelationship between the services and departments that make up a hospital
system. Nothing functions in isolation, and a systems view provides a way to look
at a system as a whole, thus allowing professionals to see how the care or
service provided in one area relates to another. A systems view includes
consideration of the resources—called “inputs”— needed to provide healthcare.
Equally important are the activities, or processes, involved in providing care and
services. These inputs and processes result in an outcome. Table 1 presents a
systems view of some hospital services.
Hospitals are complex systems. Many services, such as rendering emergency
care and providing meals, not only must be kept in operation over two or more
shifts, but also must be implemented across departments. A systems view, for
example, can reveal the process involved in transporting a patient treated in the
emergency department to another part of the hospital for surgery. What is the
process for letting the operating staff know the kind of care that was provided in
the emergency department and the expected outcome of that care? When one
part of the system fails, how does the failure affect the other parts? For example,
if a gurney is not available, it will be difficult to quickly deliver the patient to the
operating room. If there is not a process to inform other caregivers about the
patient’s medical history, the surgical staff may not receive the information they
need to select the most appropriate kind of anesthesia and do so as quickly as
possible. Please review the following table for more understanding of hospital as
a system.
Table: System views of Hospital Services
Aspects of care Inputs Process Outcomes

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management Lab tests

Management of Hospital staff Use of protocols Diarrhea is

Diarrhea Medications Medication resolved
Rehydration administrations Dehydration is
Lab tests Rehydration resolved
protocols administration Patient and family
Testing can describe
procedures preventive
Health education measures
Medication Medications Stock Medications are
availability Pharmacist management available in the
Nurse Medication pharmacy
Medication distribution Medications are
storage cart delivered to the
unit/ department in
a timely manner
Normal delivery/ New mothers Communication Midwife had
discharge Physicians between providers information
planning Nurses Education of regarding the
Family patients and mothers condition
Midwives family and follow-up care
Teaching They
materials patient/family has
home instructions
Infection control All healthcare Hand washing Patients don’t
(post operative workers Sterilization of acquire infections
cesarean Cleaning staff equipment while hospitalized
section) Soap Wound care
Sterile equipment Cleaning
Sterilizers procedures

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 Materials for
sterile dressing
changes

We should understand that Inputs are the resources needed to provide a

service, while processes are the activities that use these inputs to produce out
puts and outcomes. Similarly the outcomes are the results of the processes. If
we are thinking of immediate results in that case we are using outputs. Or if we
are using change in social condition and health status then we are using the
impact as a proxy to show the results.

Quality Monitoring Framework

As it was discussed above the hospital is like a system in which the input is used
by performing some activities and outcome is produces as a result of these
expenses and activities. Therefore hospital processes is easily understood for
reviewing the following chart.
Hospital Process

Admissions Diagnostic Medical

Patients exams, tests, treatment
enter procedures
hospital

Complementar Counseling Follow-up /

y services and patient discharge plans Patient
education outcomes

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The framework presented above is based on the systems model. As the diagram
shows, a patient who enters the hospital becomes involved in a variety of
processes that will lead to an outcome. Most patients will experience all or most
of these processes during an inpatient stay. Some of the processes can be
defined as “supportive” inasmuch as they are not direct care. For example, the
admission process and medical record systems are needed to support patient
care and treatment. During the admission process, the patient or family provides
biographical information, and the staff creates a medical record (the information
system). The physician, laboratory, and radiology staff carry out various
diagnostic exams, tests, and procedures. Nursing care is an integral process to
the hospital system as are other complementary services such as nutrition, social
services, and physical therapy. Counseling and patient education take place all
along the continuum of care as physicians, nurses, and others explain what can
be expected during the tests, procedures, and treatment processes as well as
the diagnosis and follow-up/ discharge plan. Following chart demonstrates the
systems view and shows how the various hospital processes interrelate.

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Chart: Hospital System Model

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What is Quality Monitoring?
Most hospitals have a health information system to collect data. The data often
include the number and types of diseases treated, surgeries performed, and
patients seen per day. Typically, the data are tabulated in the Medical Records
Department, which submits a report to the hospital director. However, the
information may not be sufficient or may be presented in a way that would not
help healthcare providers draw conclusions on the quality of care and make
sound decisions to improve it. A monitoring system should enable healthcare
providers to set priorities, establish quality indicators, and assess the hospital’s
systems performance to ensure that desired outcomes are achieved.
The foundation of a monitoring system is standards. Standards are the guidepost
for achieving quality in care. The data collected through monitoring provide a way
to compare performance with standards, both at a specific point in time and over
a period of time, and also with the performance of other hospitals. The results
provide a way to determine causes for variance and identify areas for
improvement.

Criteria
An effective monitoring system meets the following criteria:
• Data are collected regularly and over a significant period of time so that
the hospital can monitor the trends in the indicators
• Data collection is a routine activity integrated into daily tasks
• Data are used to identify the presence and causes of system problems
that can result in poor performance
• Data are used to guide management decisions

Standards
A standard is an expectation of quality that is explicit (written) or implicit
(understood). “Implicit” healthcare standards derive from the expertise of
professionals who work in a specific environment. For example, professionals
who work on the pediatric ward may know the treatment that a dehydrated child
needs, but differ on ideas about the most appropriate way to provide the

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treatment (e.g., dosage, duration, and frequency). Converting implicit standards
to explicit standards provides uniformity in the way to provide quality care and
allows a baseline measure for monitoring quality. “Explicit” healthcare standards
appear in a variety of forms, such as specifications, procedures, or protocols.
These standards may be developed by a Ministry of Public Health, professional
organizations, international organizations (e.g., the World Health Organization:
standards for the treatment of malaria), accrediting organizations (e.g., Joint
Commission Resources), or by a hospital itself. Applied standards should be
based on the most up-to-date research and should be:
• Realistic: The standard can be followed or achieved with existing
resources
• Reliable: Following the standards for a specific intervention results in the
same outcome (all factors being equal)
• Valid: The standard is based on scientific evidence or other acceptable
experience
• Clear: The standard is understood in the same way by everyone
concerned and is not subject to distortion or misinterpretation
• Measurable: The standard is amenable to assessment and quantification

Indicators are measurable or tangible signs that something has been done or that
something has been achieved. In some studies, for example, an increased
number of year’s people live in a community have been used as an indicator that
the standard of living in that community has improved. Higher bed occupancy
rate shows more consultations and clients in the hospital. Common indicators for
something like overall health in a community are the infant/child/maternal
mortality rate, the birth rate, and nutritional status and birth weights.
Indicators are an essential part of a monitoring and evaluation system because
they are what you measure and/or monitor. Through the indicators you can ask
and answer questions such as: Who? How many? How often? How much?
But you need to decide early on what your indicators are going to be so that you
can begin collecting the information immediately.

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To measure indicators there is need for data and/or Information. Information
used in monitoring and evaluation can be classified as: quantitative; or
qualitative. Quantitative measurement tells you “how much or how many”. How
many people consulted the hospital, how many people took lab examinations,
how much a publication cost, how many people were infected with HIV? and so
on. Quantitative measurement can be expressed in absolute numbers,
percentage, rates and ratios. Qualitative measurement tells you how people feel
about a situation or about how things are done or how people behave. So, for
example, although you might discover that 50% of the medical doctors at hospital
are unhappy about the assessment criteria used, this is still qualitative
information, not quantitative information. You get qualitative information by
asking, observing, interpreting.
The monitoring and evaluation process requires a combination of quantitative
and qualitative information in order to be comprehensive. For example, we need
to know what the hospital enrolment figures for females are, as well as why
women do or do not come to hospitals. For data collection there are many
methods and tools. Some are mentioned here.
• Case studies
• Recorded observation
• Observations
• Checklists
• Forms
• Structured questionnaires
• One-on-one interviews
• Focus groups
• Sample surveys
• Systematic review of relevant official statistics.

Hospital Monitoring Indicators

An indicator of quality is a measure that is used to determine the degree of
adherence to a standard. Indicators translate a qualitative statement (as

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expressed by a standard) into a quantitative one. For example, “the proportion of
healthcare providers who greet their patients by name” measures the extent to
which the standard for a quality reception is being met. Indicators can be
expressed as a number (a count), an average, or a ratio (a proportion or rate). An
indicator presented as a ratio consists of a numerator (the number of times an
event occurs) and a denominator (the total number of times the event should
have occurred). An example of a ratio is the proportion of post-surgical patients
whose temperature was taken by the healthcare worker according to protocol.
It is useful to select indicators that measure inputs, processes, and outcomes.
The basis for selecting an indicator is its importance or potential impact on the
quality of care. Be aware that outcome indicators measure the level of
achievement of the intervention and, therefore, can serve as indirect measures of
the quality of care and services. However, a good outcome does not necessarily
mean that the process was managed correctly; neither does a poor outcome
mean that the process was managed incorrectly. Therefore, the measurement of
input, process, and outcome indicators is warranted.
Some quality experts believe that organizations should strive for zero defects.
They suggest that setting a level of expected quality limits the highest level of
quality that might otherwise be achieved. The belief is that once the quality
level—e.g., targeted infection control rates—is attained; the staff will be satisfied
with this level rather than continuing to strive to decrease infection control rates
to zero infections. Keeping this view in mind, establishing indicators remains an
established means of setting the bar at a reasonable level of achievement and
the bar can (and should be) raised/lowered as the targets are achieved. As an
example we see some examples below:
Length of Stay (LS): It is the mean number of days that patients remain at
the hospital whereas HD (Hospital Days) is the sum of inpatient days in a specific
period of time. D (Discharge) is the number of discharged patients in the same
period of time.
Occupancy Rate (OR): It is a relative number that expresses the percentage
of beds occupied in relation to the total number of available beds during a

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specific period of time whereas BD (Bed days) is the sum of daily available beds
multiply by the number of days in the same period of time.
Proportion of all Births in the Hospital: The proportion of births that is
delivered in Hospital is calculated as: Number of births delivered in Hospital
facilities in a specified time period divided by estimated number of live births in a
specified time period in the geographical area served by the Hospital. Sources
for numerator is hospital or facility records while the source of data for
denominator is demographic surveys for crude birth rates; census for total
populations.
The proportion of all births that take place in a Hospital serves as a crude
indicator of the utilization of hospital. This indicator is useful because the data are
readily available. Furthermore, it is useful in conjunction with other indicators
such as ‘met need’ to gauge internal consistency. For example, if this indicator
does not change, but ‘met need’ increased substantially, a deeper look at the
facility and the community it serves would be warranted.

The ultimate goal is to increase utilization of Hospital among women with

obstetric complications to 100 per cent. This indicator is not intended to promote
the delivery of all births in facilities. Many countries could not meet this
theoretical demand. Thus, women with normal deliveries may be better off
delivering at home or at facilities with fewer services.
Cesarean Sections as a Proportion of all Births: the proportion of
pregnant women who have a cesarean section in a specific geographical area
and time period. This is calculated as: Number of cesarean sections performed in
a specified time period and area divided by the number of live births in the same
specified time period and area. Data requirements are numerator: the number of
cesarean sections performed in a defined population during a specified time
period. Denominator: the total number of live births in the same area and time
period. Sources of data for numerator would be facility records, surgery log
books and for denominator: demographic surveys for crude birth rates; census

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for total populations. Household demographic surveys often produce national and
disaggregated estimates of the C-section rate.
This indicator demonstrates the extent to which a particular life-saving obstetric
service is being performed in emergency obstetric unit of hospital. It reflects the
availability, accessibility and utilization of services as well as the functioning of
the health service system. The appropriate use of a cesarean section leads to a
decrease in maternal mortality and morbidity, as well as decreasing prenatal
morbidity and mortality. While cesarean sections may be performed solely for the
health of the fetus or newborn, in developing countries the vast majority will be
done for maternal indications.
Case Fatality Rate (CFR): it is usually due to all complications. That is
good to take the example of obstetric complications which is defined as the
proportion of women with major obstetric complications who die in a facility. This
is calculated as: Number of deaths from specified obstetric complications in a
facility during a specified time period divided by number of women with specified
obstetric complications attended in the facility during the same time period.
Where deaths from the following complications are included:

• hemorrhage: ante partum, intra-partum or postpartum;

• prolonged/obstructed labor;
• postpartum sepsis;
• complications of abortion;
• pre-eclampsia / eclampsia;
• ectopic pregnancy; and
• Ruptured uterus.
All cases in the numerator also appear in the denominator and all complications
specified in the list above are included in both the numerator and denominator.
By definition, a CFR is cause-specific, but in this case a single facility may not
see but a small number of women with any one complication. Data requirements
are numerator: a count of the deaths from the specified complications in the
facility during the specified time period. Denominator: a count of women

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diagnosed with one or more of these complications attended at the emergency
obstetric unit of hospital during the specified time period. All data for numerator
and denominator would be received from facility records.
This indicator is used to measure facility performance, in particular quality and
promptness of care. It is most useful when comparisons are made over time for
the same facility. It is not useful for comparisons across facilities of different
types because of the different services they offer. Women with more severe
complications are more likely to present at referral hospitals while women with
less severe complications may access district hospitals or health centers. Even
comparisons among ‘same level’ or ‘like’ facilities may be difficult to interpret as
the population profile can vary dramatically due to socio-cultural factors or other
circumstances outside the control of the health sector, like transportation and
road systems.
Incidence rate (IR) (6 EPI target diseases, diarrhea, ARI): The
number of new cases of EPI targeted diseases in a specified time that occurs in
a population at risk of the disease in the same time period.
Rate of treatment or psychosocial intervention for symptoms of mental illness
It is the proportion of all people with symptoms of mental illness who requested
treatment. Numerator: Number of people requesting treatment or psychosocial
intervention for symptoms of mental illness during the past two weeks
Dominator: Number of people with symptoms of mental illness during the past
two weeks
Mortality rate under age 5 (U5MR): The ratio between the number of
deaths in children under 5 in a given year and the number of live births in that
year.
Numerator: Number of children who die before reaching 5 years of age
Denominator: Total number of live births in the given 1-year period

Post Operative Infection proportion: it is the proportion of infection

which is seen in patients after being operated. The numerator would be all those

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who have some sorts of infection related to their cases divided by the number of
cases that have been operated in a hospital in specific period of time.

External and Internal Monitoring

“External monitoring” is monitoring conducted by someone from outside the
hospital. The monitor may be a representative of the Ministry of Health, a
neighborhood health committee, or an agency contracted to measure compliance
with specific standards; these standards are often established by the external
entity doing the measuring. Accreditation of the hospital, as conducted by Joint
Commission International Accreditation, is an example of an external monitoring
system. A discussion of external monitoring is not within the scope of this
module. “Internal monitoring” is a system set up by the hospital staffs who adopts
standards written by another credible group (e.g., the World Health Organization)
or by the hospital itself; the hospital can conduct a self-assessment to measure
the degree of compliance. An approach to developing an internal monitoring
system follows. Ongoing monitoring involves regularly measuring quality
indicators. Some indicators may be important enough (e.g., maternal mortality or
infection rates) to measure frequently and regularly (e.g., monthly): This concept
is often referred to as “trending.” However, because it is not feasible to measure
the hundreds of standards that are in existence, spot checks may be conducted
to measure specific standards during a specific period of time. A spot check may
be done on a one-time basis, or, as an example, the quality team may decide to
monitor the effectiveness of a new patient education program for six months.

Hospital Monitoring of Adverse Drug Reactions

Adverse reaction to drugs poses as serious health hazards and has been
observed as long as the drugs have been used. There are some adverse
reactions of drugs which are related to ignorance of patients themselves and
health personnel in hospital or out of hospital. According to a survey which was
conducted in Singapore over dosage, intolerance, drug side effects,
hypersensitivity, idiosyncrasy was seen among patients admitted to hospitals.

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Due to low awareness concerning adverse reactions to drugs few attempts have
been made to measure the incidence of such reactions or their relationship to the
use of individual drugs. Since drug is any substance given as therapy or for
investigational purposes, thus, adverse Reaction to a Drug is any adverse
response to medication undesired or unintended by the physician.
Severity of Adverse Reactions is classified in three grades
• Severe: fatal or life threatening.
• Moderate: required treatment, admission to hospital, or prolonged the stay
in hospital by at least one day.
• Mild: incidental, required no treatment, and did not necessarily call for
withdrawal of any treatment.
A classification of the type of drug reaction which takes account of the dose and
the possible mechanism of the reaction was used.
• Overdosage. Excess intake of drug causing excess predictable
pharmacological action
• Excessive effect. Therapeutic dose but excess pharmacological action;
this might be: (a) a toxic extension of the action of the drug, or (b)
conditioned intolerance
• Side-effect. Unwanted predictable pharmacological action unrelated to the
therapeutic effect and not due to Overdosage.
• Hypersensitivity. Allergic sensitization to a drug by previous exposure to
the same drug or a chemically related substance, mediated by antigen-
antibody reactions
• Idiosyncrasy. Unrelated to known pharmacological actions of the drug and
not due to immunological mechanism; possibly genetically determined.
Taking into consider the reaction should keep close eye on drug reactions and
monitor it by some surveys and documental and prescriptions reviews from time
to time and develop some techniques for its mitigation.

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Monitoring of Absenteeism in Hospitals
Absenteeism is defined as staff taking time off that has not been scheduled or
staff taking more leave than is necessary or reasonable. Many health service
managers are familiar with the problem of absenteeism in district hospitals. It
affects the running of the hospital and can seriously compromise the quality of
care which patients receive. Clearly there are many legitimate reasons for taking
sick or other types of leave. It is often debatable how much leave is “reasonable”.
It often depends on the pattern and circumstances, rather than the actual total
amount of leave that an individual takes. Managers have a responsibility to
balance the rights and needs of individual staff members, with the needs of the
hospital. High levels of absenteeism, both on the part of individuals or in the
whole hospital, are often symptomatic of underlying problems. Addressing these
issues can result in lower absenteeism levels that benefits staff, managers and
patients.

Why absenteeism
There are many causes why people are absent from work. They range from
unhappiness with management, to being bored with the work to a child-minder
being ill. The causes can be broadly divided into two groups – management
issues and staff issues.

Management issues:
• lack of coherent leadership in some hospitals
• lack of systems and processes in the workplace
• staff problems are not being dealt with quickly and appropriately
• low staff morale
• managers are not trained to manage staff and problems such as
absenteeism

Staff issues:
• unpleasant work environment – the work may be boring or staff may not
get on with other staff members

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 • personal problems such as problems at home, substance abuse or
depression
• practical issues such as problems with childcare or caring for other family
members
• economic pressures – some staff may be holding down additional jobs to
supplement their income
Good hospital and human resource management practices will not necessarily
eliminate the problem, but can be expected to reduce the severity of the problem

How to deal with absenteeism

Step One: Establish the size and pattern of the problem. It means establish the
absenteeism patterns at your hospital over a period of time (e.g. three months)
by monitoring all the different kinds of leave taken by ALL staff.
Step Two: Make sure that everyone is aware of their rights and responsibilities.
Make sure that all staff members understand their rights and responsibilities
regarding leave and the consequences of breaking the regulations. It may be
useful to hold group workshops with ALL staff in the hospital on issues. Staff
should be aware what leave is legally allowed and what is not. They should know
the procedures required to have authorized leave. Each hospital should have
grievance and disciplinary policies and procedures that have been discussed
with staff and union representatives. Make sure that the hospital policies about
leave and employment, which are pertinent to absenteeism, are put into files
which are accessible to all staff.
Step Three: Address the problem as a whole. Improvements in the overall
management of the hospital with staff being more involved in decision-making
and feeling that their concerns are addressed is probably the best way to reduce
high levels of absenteeism. Agree on performance, provide sufficient support and
reward achievements. The hospital managers believe that this is due to the fact
that they have put a lot of effort into ensuring that issues affecting staff are
discussed with them and efforts made to accommodate their circumstances.

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Step Four: Dealing with individuals. In cases where one or more individuals
contribute substantially to the absenteeism rates, the approach needed may be
different.
• If it is a first offence, the staff member has an absence record no worse
than the average for the hospital, there are no other previous offences and
the explanation for unscheduled leave is feasible, then counseling should
be used.
• Counsel the staff member individually to ascertain their side of the story
regarding their leave patterns.
• Deal with personal/substance abuse problems in an individual capacity.
• Seek a second opinion from a hospital doctor regarding perceived abuse
of sick leave i.e. unreasonably long sick leave or frequent sick leave.
Some staff may be referred to social support or other agencies where they
can find help for their problems.
• Document the counseling and support offered
• Follow up.
• If it is not the first offence and the absence record is unsatisfactory or
previous warnings are on file, then the disciplinary process should be
used.
Step Five: Ongoing monitoring. The continuation of monthly monitoring will assist
managers to know if the absenteeism is being adequately addressed. Have
report-back sessions with your staff to applaud their efforts and carry on being
firm on the legal side of absenteeism, while remaining fair to the personal
problems which staff may have. Make efforts to have weekly sessions where the
unit meets as a team to share information, experiences and concerns.
Remember that in fulfilling the vision of the hospital, the rights of staff, the rights
of the hospital as employer and the patients’ rights to a quality service have to be
ensured.

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Session 7: SWOT Analysis of Hospital
In general SWOT (strengths, weaknesses, opportunities, and threats) analysis is
a management tool for assessment an organization including hospitals and its
environment. It is the first stage of planning and helps the organization to focus
on key issues. Below is the S.W.O.T. analysis on a hospital which helps you very
much to think strategically in this regard.

Strengths:
Despite of having primary care services, our hospital is well known for its
provision of quality medical care. During the year the hospital has strived to
attract more members of staff especially nursing staff. The nursing staffing levels
have indeed been better this year than in recent years. The coming of young
Medical Doctors will further strengthen the clinical department of the hospital. We
are equipped with high technology services.

Weaknesses:
We are faced, as like other hospitals, a high nurse turnover of staff and it has
continued to affect nursing services at the institution. Due to inadequate funds
some planned activities especially in the Primary Health Care department have
not been undertaken. Although we have continued to receive support from our
partners for which we are very thankful, we are conscious that we have not made
any real progress in becoming fewer donors dependent. The hospital has been
discussing possibilities of embarking on income generating activities; however,
the poor prevailing economic situation makes such ventures risky. We are
working in a competitive environment.

Opportunities:
Our consumers are growing and the hospital continues to excel in its various
endeavors because of committed staff and a supportive working environment.
These factors offer opportunities for expansion of hospital services especially in

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Primary Health Care department. The hospital with financial, material and human
resources available would go a long way in strengthening community-based
interventions. The government is paying due attention to quality tertiary services.

Threats:
Hospital consultation is declining as compare to last quarter. Financial position of
the hospital has not been well during the year. Additionally while staff are
committed to working in the hospital, the rising costs of food and school fees
combined with more lucrative offers from external non-profit organizations for
highly skilled staff, often requires the hospital to pay top-ups to retain staff. The
hospital therefore struggles to meet the salary requirements. There is a real need
for the hospital to explore other means of sustaining the running of their
institutions through income generating activities and other donors especially for
community based activities.

Group work:
Process:
• Distribute participants into groups of 4- 6
• Invite them to assess their institution using the SWOT analysis
• The should report their finings in the plenary
• Collect comments of whole participant
• Close preventions by constructive feedback
Following table maybe used for group work.

SWOT analysis matrix to evaluate the institutions

Strengths Weaknesses
• Quality lab services • Infrastructure
• Committed employees • Workforce force
• Advanced technology • Low resources

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 • Availability of nursing staff
• Availability of job descriptions
• Compliance code of ethics
• In-service education
• Good discipline
• Communications within
departments at the hospital
Opportunities
• Vaccinations
• Surveillance
• Strategic plans
• Good relationship with
government
• Easy of the public transportation
to the hospitals
• Ability to expand the hospital
departments
• Opportunity to create training
programs
• Few specialists and registered
nurses
• No competition among staff
themselves
• Lack of work innovations and
creativity
• Understaffed departments
• High work load
Threats
• Re-emerging disease
• Inflation
• Security
• Low staff income
• Lack of updated services
• Recruitment of staff through
MOH
• Lack of external fund resources
• Nursing shortage
• Lack of information technology
system
• Lack of internet resources
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Session 8: Medical Audit and Quality Assurance
Definitions
The volume of literature on medical audit and the broader field of quality
assurance are expanding rapidly. Medical audit is now a requirement for all
medical practitioners; therefore, to perform it, they need to know something about
it.
Since audit was introduced in 1989 there have been many different definitions of
clinical audit. “Clinical audit is a quality improvement process that seeks to
improve patient care and outcomes through systematic review of care against
explicit criteria and the review of change. Aspects of the structure, process and
outcome of care are selected and systematically evaluated against explicit
criteria. Where indicated changes are implemented at an individual, team, or
service level and further monitoring is used to confirm improvement in healthcare
delivery”. Although this is an excellent technical definition of clinical audit it is also
68 words long and unlikely to inspire healthcare professionals to take part in
clinical audit work. Ironically, the 1989 White Paper Working for Patients provided
a far shorter and simpler definition of audit: “audit involves improving the quality
of patient care by looking at current practice and modifying it where necessary”.
Clinical audit is essentially all about checking whether best practice is being
followed and making improvements if there are shortfalls in the delivery of care.
A good clinical audit will identify (or confirm) problems and lead to effective
changes that result in improved patient care.
Basically clinical audit is a quality improvement process that involves reviewing
the delivery of healthcare to ensure that best practice is being carried out. In
recent times there has been a move away from “optional” clinical audit activity to
a more “obligatory” approach. It means that after development of medical audit
guidelines for all medical institutions including hospitals, they should be closely
monitored by MoPH to make sure that clinical audit work is being carried out.
The key component of clinical audit is that performance is reviewed or audited to
ensure that what should be done is being done, and if not it provides a
framework to enable improvements to be made.

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History of medical audit
One of first ever clinical audits was undertaken by Florence Nightingale during
the Crimean of 1853-1855. On arrival at the medical barracks hospitals in 1854,
Florence was appalled by the unsanitary conditions and high mortality rates
among injured or ill soldiers. She and her team of 38 nurses applied strict
sanitary routines and standards of hygiene to the hospital and equipment.
Following this change the mortality rates fell from 40% to 2. Her methodical
approach, as well as the emphasis on uniformity and comparability of the results
of health care, is recognized as one of the earliest programs of outcomes
management. Another famous figure who advocated clinical audit was Ernest
Codman (1869-1940). Codman became known as the first true medical auditor
following his work in 1912 on monitoring surgical outcomes. Codman's "end
result idea" was to follow every patient's case history after surgery to identify
individual his / her errors on specific patients. Whilst Codman's 'clinical'
approach is in contrast with Nightingale's more ' epidemiological ' audits, these
two methods serve to highlight the different methodologies that can be used in
the process of improvement to patient outcome.
In 1989, the White Paper, Working for patients, saw the first move in the UK to
standardize clinical audit as part of professional healthcare. The paper defined
medical audit (as it was called then) as "the systematic critical analysis of the
quality of medical care including the procedures used for diagnosis and
treatment, the use of resources and the resulting outcome and quality of life for
the patient." Medical audit later evolved into clinical audit and a revised definition
was announced by the NHS Executive: "Clinical audit is the systematic analysis
of the quality of healthcare, including the procedures used for diagnosis,
treatment and care, the use of resources and the resulting outcome and quality
of life for the patient." The National Institute for Health and Clinical Practice
(NICE) published the paper Principles for Best Practice in Clinical Audit, which
defines clinical audit as "a quality improvement process that seeks to improve
patient care and outcomes through systematic review of care against explicit
criteria and the implementation of change. Aspects of the structure, processes,

140
and outcomes of care are selected and systematically evaluated against explicit
criteria. Where indicated, changes are implemented at an individual, team, or
service level and further monitoring is used to confirm improvement in healthcare
delivery. "

Types of audit
Standards-based audit - A cycle which involves defining standards,
collecting data to measure current practice against those standards, and
implementing any changes deemed necessary.
Adverse occurrence screening and critical incident monitoring -
This is often used to peer review cases which have caused concern or from
which there was an unexpected outcome. The multidisciplinary team discusses
individual anonymous cases to reflect upon the way the team functioned and to
learn for the future. In the primary care setting, this is described as a 'significant
event audit'.
Peers review - An assessment of the quality of care provided by a clinical
team with a view to improving clinical care. Individual cases are discussed by
peers to determine, with the benefit of hindsight, whether the best care was
given. This is similar to the method described above, but might include
'interesting' or 'unusual' cases rather than problematic ones. Unfortunately,
recommendations made from these reviews are often not pursued as there is no
systematic method to follow.
Patient surveys and focus groups - These are methods used to obtain
users' views about the quality of care they have received. Surveys carried out for
their own sake are often meaningless, but when they are undertaken to collect
data they can be extremely productive.

Protocol for medical audit

Health care is one of the most important issues facing our nation, yet the
standard of care received in private practices, hospitals and long-term care

141
facilities can often be substandard. This is why medical audits are so important.
They play a pivotal role in meeting and exceeding health care standards by
evaluating the current level of care and setting goals that will help to improve it.
Step 1: Determine the reason for the audit. The determination process involves
gathering input from workers, patients and patients' families. Before
concentrating on a specific area that needs improvement, you must first know
what areas your hospital is weak in. Once you have this information, you can
concentrate on the most important areas of care that require improvement.
Step 2: Collect available data and evidence to support the problems mentioned.
Go through health records, nurses' notes and care plans for the patients. This will
give you a better idea of where you are currently at and help you better focus on
specific problems needing immediate attention.
Step 3: Focus on specific problem. If you are writing an audit for a private
practice, one problem might be the amount of time a patient has to wait to be
seen. If you are working for a hospital, you might focus on the amount of time it
takes to answer a call light (the light above the door indicating a patient needs
assistance). If the standards set for this is within 2 minutes and patients say it
takes the staff 5 minutes to reach them, then you need to concentrate on ways
for the staff to get to the patient quicker. If you work in a nursing home and find
that incontinent patients are not being changed promptly, causing rashes or skin
breakdown, you will focus on what can be done to avoid these unnecessary
health problems.
Step 4: Set your desired standards. Ask the staff members what they think are
acceptable standards. If it's the private practice, the staff may suggest spacing
appointments out so that the patients are seen in a more reasonable time frame.
For the hospital, the staff may suggest improving teamwork so that they are all
working together to meet the patients' needs. Many times in health care, the main
reason for patient neglect is the unwillingness of the staff to care for patients they
are not assigned to. In the nursing home, a suggestion may be to begin the
patient on a toileting schedule to cut down on the amount of accidents they have.

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Unfortunately in nursing homes, many patients are incontinent when they are
capable of being toileted, even through the use of bedpans.
Step 5: Write the plan for improvement. After you have discussed the problems
and possible solutions with your staff, write out a plan describing which
improvements need to be made and a reasonable resolution for the problems
identified. It helps to take into consideration the input of the direct care staff and
incorporate some of their ideas into the plan of action. This will put them on the
offense and motivate them to make the necessary changes by feeling as though
their opinions count.
Step 6: Reveal the plan and discuss it with your workers. Begin to set goals to
improve the standards of care. Discuss short-term and long-term solutions you
have decided upon. The short term will have a definite effect on the long term, so
set your goals within a reasonable time frame. If anyone feels a goal is
unobtainable, they will not reach for it at all. Also set a time for re-evaluation. This
will help in determining if the changes made have been effective and beneficial
for the patients.
Step 7: Write your conclusion--a short and concise closing that summarizes the
findings and the solutions that have been decided upon. Once you have
completed this, save the audit so you can compare your next audit to it. It will
help in determining which improvements have taken place and which areas still
require attention from the health care team.

Process of clinical audit

The clinical audit process seeks to identify areas for service improvement,
develop & carry out action plans to rectify or improve service provision and then
to re-audit to ensure that these changes have an effect.
Clinical audit can be described as a cycle or a spiral, see figure. Within the cycle
there are stages that follow the systematic process of: establishing best practice;
measuring against criteria; taking action to improve care; and monitoring to
sustain improvement. As the process continues, each cycle aspires to a higher
level of quality.

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Stage 1: Identify the problem or issue
This stage involves the selection of a topic or issue to be audited, and is likely to
involve measuring adherence to healthcare processes that have been shown to
produce best outcomes for patients. Selection of an audit topic is influenced by
factors including:

Stage 2: Define criteria & standards

Decisions regarding the overall purpose of the audit, either as what should
happen as a result of the audit, or what question you want the audit to answer,
should be written as a series of statements or tasks that the audit will focus on.
Collectively, these form the audit criteria. These criteria are explicit statements
that define what is being measured and represent elements of care that can be
measured objectively. The standards define the aspect of care to be measured,
and should always be based on the best available evidence.
A criterion is a measurable outcome of care, aspect of practice or capacity. For
example, ‘parents are involved in negotiating or planning their child’s care’.
A standard is the threshold of the expected compliance for each criterion (these
are usually expressed as a percentage). For the above example an appropriate
standard would be: ‘There is evidence of parent in care planning in 90% of
cases’.

Stage 3: Data collection

To ensure that the data collected are precise, and that only essential information
is collected, certain details of what is to be audited must be established from the
outset. These include: the user group to be included, with any exceptions noted;
the healthcare professionals involved in the users' care; and the period over
which the criteria apply. Data to be collected may be available in a computerized
information system, or in other cases it may be appropriate to collect data
manually depending on the outcome being measured. In either case,
considerations need to be given to what data will be collected, where the data will
be found, and who will do the data collection. Ethical issues must also be
considered; the data collected must relate only to the objectives of the audit, and

144
staff and patient confidentiality must be respected - identifiable information must
not be used. Any potentially sensitive topics should be discussed with the local
authorized committee (Institutional Review Board at APHI).

Stage 4: Compare performance with criteria and standards

This is the analysis stage, whereby the results of the data collection are
compared with criteria and standards. The end stage of analysis is concluding
how well the standards were met and, if applicable, identifying reasons why the
standards weren't met in all cases. These reasons might be agreed to be
acceptable, i.e. could be added to the exception criteria for the standard in future,
or will suggest a focus for improvement measures. In theory, any case where the
standard (criteria or exceptions) was not met in 100% of cases suggests a
potential for improvement in care. In practice, where standard results were close
to 100%, it might be agreed that any further improvement will be difficult to obtain
and that other standards, with results further away from 100%, are the priority
targets for action. This decision will depend on the topic area – in some ‘life or
death’ type cases, it will be important to achieve 100%, in other areas a much
lower result might still be considered acceptable.

Stage 5: Implementing change

Once the results of the audit have been published and discussed, an agreement
must be reached about the recommendations for change. Using an action plan to
record these recommendations is good practice; this should include who has
agreed to do what and by when. Each point needs to be well defined, with an
individual named as responsible for it, and an agreed timescale for its
completion. Action plan development may involve refinement of the audit tool
particularly if measures used are found to be inappropriate or incorrectly
assessed. In other instances new process or outcome measures may be needed
or involve linkages to other departments or individuals. Too often audit results in
criticism of other organizations, departments or individuals without their
knowledge or involvement. Joint audit is far more profitable in this situation and
should be encouraged by the Clinical Audit lead and manager.

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Re-audit: Sustaining Improvements
After an agreed period, the audit should be repeated. The same strategies for
identifying the sample, methods and data analysis should be used to ensure
comparability with the original audit. The re-audit should demonstrate that the
changes have been implemented and that improvements have been made.
Further changes may then be required, leading to additional re-audits.
This stage is critical to the successful outcome of an audit process - as it verifies
whether the changes implemented have had an effect and to see if further
improvements are required to achieve the standards of healthcare delivery
identified in stage 2. Results of good audit should be disseminated widely.
While clinical audit makes great sense, there can be an issue around persuading
hospitals and clinicians to undertake and apply clinical audit to their everyday
work. All the process which is described above is sometimes expanded to more
steps to be elaborated effectively. Such a detail is brought to your attention by
following chart.

8. Re-audit 1. Selected
Topic

7. 2. Agree
Implement Standards
Change of best
practice
Action
Planning
Audit
6. Make 3. Define
recommend Methodolog
ations y

5. Analysis 4. Pilot
and and data
Reporting Collection

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Evaluation, Research, Medical and Clinical Audit
Some times there is a confusion regarding the above terminology. It is better to
clarify them a bit for your understanding. Clinical audit’ tends to be used as an
umbrella term for any audit conducted by professionals in health care. Audits
conducted by doctors are often referred to as medical audits, although the term
‘Clinical audits’ could also be used. It is important to stress that very few health
care procedures involve just one professional discipline and that non-clinical staff
such as receptionists, secretaries, porters, managers, etc. play a vital role in the
quality of the service provided. Clinical audit, therefore, is usually a multi-
disciplinary activity. Many clinical audits are also ‘multi-sectoral’, that is, they may
involve health and social services, primary and acute care providers, education
and health.
Service evaluation may be defined as: “A set of procedures to judge a service’s
merit by providing a systematic assessment of its aims, objectives, activities,
outputs, outcomes and costs” (NHS Executive, 1997). There are many different
approaches to service evaluation. Whichever method is used, the process should
provide practical information which helps to inform the future development of a
service. Clinical audit may be one activity which takes place during a service
evaluation, alongside other activities such as routine data gathering, incident
reporting, and interviews with staff and service users. In order to conduct an
evaluation, services need to consider their aims, objectives and then identify their
key evaluation questions. Further texts to assist in service evaluation are listed at
the end of this book.
Clinical audit is not research, but it does make use of research methodology in
order to assess practice Key differences between clinical audit and research is
outlined in the coming table. Although research and clinical audit are two distinct
activities with different purposes, they are interrelated in several ways, as
described by Black (1992):
• Research provides a basis for defining good-quality care for clnical audit
purposes.

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 • Clinical audit can provide high-quality data for non-experimental evaluative
research.
• Research into the effectiveness and cost-effectiveness of clinical audit is
needed.
• Research needs to be audited to ensure that high-quality work is
performed.
Differences between research and clinical audit - Adapted from Madden (1991)
and Firth-Cozens (1993)
Research Evaluation
• Aims to establish what is best • Aims to evaluate how close
practice practice is to best practice and
to identify ways of improving the
quality of health care provided
• Is designed so that it can be • Is specific and local to one
replicated and so generalized to particular patient group – that its
other results are not transferable results can be
to other settings similar groups
• Aims to generate new • Aims to improve services
knowledge/increase the sum of
knowledge
• Is usually initiated by • Is practice-based
researchers Is usually led by
service providers
• Is theory driven • Is an ongoing process
• Is often a one-off study
• May involve allocating service • Never involves allocating
users randomly to different patients randomly to different
treatment groups treatment groups
• May involve administration of a • Never involves a placebo
placebo treatment
• May involve a completely new • Never involves a completely
treatment new treatment

How to Write an Audit Report

Writing the report often makes up the most difficult portion of the audit process;
while you want a comprehensive report, you also want to make it user-friendly so

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management and others looking at your audit can make the best decisions based
on its findings.
Step 1: Include a front page with the name of the organization, project title, audit
lead and date. For reports longer than 5 pages, include a table of contents.
Step 2: Start with an executive summary relating your findings with a brief
abstract of the issues, state of the findings and conclusions.
Step 3: Include a background summary. This should provide the background for
why you conducted the audit. Discuss how your organization assembled audit
team and why it made the audit a priority.
Step 4: Provide objectives and standards. The objectives detail the project's
goals, and standards inform the reader what format you used to conduct the
audit. If you conducted the audit with the goal of setting standards, state this
here.
Step 5: Include a section on methodology. This should provide the reader with
the population for the sample, rationale for how you chose the sample, the size of
the audit and the time period in which you conducted it.
Step 6: End with results and conclusions. Use charts and percentages to help
readers to visualize your findings. Put the conclusion in terms anyone in the
organization can understand, and make sure the conclusion directly ties back to
audit objectives.

Hospital Standards in Afghanistan

The MOPH National Hospital Standards Policy for Afghanistan which is
developed and revised in June 2006. It consist the following main headings,
subheadings and standards which are not possible to mention all in this module.
For each standards there are criteria for verification and there level of ordinal
scores .Anyway I would like to just outline them with the number of standards in
each one. If needed reader is requested to refer to the original document at
MoPH.

Section 1: Governance
1.1 Community Hospital Board (9 standards)

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Section 2: Clinical Care
2.1 Pediatric Care
• Acute Febrile Illness in a Child 2 Months to 5 Years of Age (8 standards)
• Acute Respiratory Distress in a Child 2 Months to 5 Years of Age (9 standards)
• Diarrhea and Dehydration in Children (6 standards)
• Malnutrition—Severe in a Child 0 to 5 Years of Age (7standards)
• Facilities and Equipment for Pediatric Department and Ward (4 standards)

2.2 Surgical Care

• Management of Abdominal Pain Patients (9 standards)
• Burn Patients—Initial Management (4 standards)
• Operating Room/Theater Practices (5 standards)
• Fluids and Electrolytes in Surgical Care (4 standards)
• Organization of Surgical Department (4 standards)

2.3 Surgical Emergencies

• Management of Trauma Patients (8 standards)
• Management of Shock (3 standards)
• Management of Brain Injured Patients (8 standards)

2.4 Anesthesia and Post-Anesthesia Care

• Anesthesia and Trauma Care (6 standards)
• Anesthesia and Post-Anesthesia Care Unit Practices (10 standards)
• Anesthesia Care Documentation (6 standards)
• Patient Information and Education (3 standards)
• Facilities and Physical Environment for Anesthesia and Post-Anesthesia Care
Unit (4 standards)

2.5 Obstetric Care

• Management of Complications during Pregnancy (20 standards)
• Care During Normal Labor, Delivery, Postpartum and Newborn (27 standards)

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• Drugs for Obstetrics (2 standards)
• Information, Education, and Communication (5 standards)
• Human, Physical, and Material Resources (18 standards)
• Management Systems (13 standards)

Note: Standards in italics have not been developed as of June 2006

2.6 Infection Prevention
• Central Sterilization and Supply Department (14 standards)
• Surgical Unit (23 standards)
• Isolation Systems (10 standards)
• Labor and Delivery (19 standards)
• Casualty, Surgical, and Medical Wards (33 standards)
• Maternal and Child Health and Family Planning Clinics (24 standards)
• Dental Department (13 standards)
• Laboratory (17 standards)
• Blood Bank (20 standards)
• Post-Mortem Care (6 standards)
• Administrative Functions (8 standards)
• Patient/Client Education (4 standards)
• Food Service and catering (8 standards)
• Laundry (5 standards)
• Waste Management (9 standards)

2.7 Internal Medicine (No standard available now)

Section 3: Nursing Services

3.1 Patient Wards (No standard available now)
3.2 Operating Theater/Room (No standard available now)
3.3 Central Service and Sterilization (No standard available now)

Section 4: Ancillary and Support Services

4.1 Laboratory (12 standards)

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4.2 Blood Bank (19 standards)
4.3 Hospital Pharmacy Management (8 standards)
4.4 Radiology/X-Ray (No standard available now)

Section 5: Administration and Management

5.1 Hospital Maintenance of Facilities and Equipment (11 standards)
5.2 Human Resource Management in Hospitals (13 standards)
5.3 Medical Records (No standard available now)
5.4 Housekeeping (No standard available now)
5.5 Catering/Food Service (No standard available now)
5.6 Laundry (No standard available now)
5.7 Purchasing/Medical Stores (No standard available now)
5.8 Business Office and Administration (No standard available now)

Standards and Performance at Hospitals

According to hospital policy in Afghanistan and EPHS the following standards
have developed and promoted. It is mentioned there that standards are required
to improve the clinical and managerial performance to attain an acceptable level
of operations for hospitals. Standards establish what is expected of hospitals and
their staff at all levels of operation. It is the establishment of such reasonable
standards which permits the monitoring of hospital operations against which
hospital performance can be measured. This is required to improve the standard
of care and management of hospitals in
Afghanistan. The following provide the framework of the basic standards.
Specific details, elements and components of each standard must be developed
and specified in greater detail by the MOH. The following provides a structure
and direction for development of detailed standards for hospitals, which will be
used for accreditation, ultimately.
1. Responsibilities to the Community
1.1. The hospital is responsive to the community’s needs
1.2. Hospital services will be accessible to the community.

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1.3. Hospitals will have a proper disaster preparedness plan so it can properly
respond in the event of natural or man-made disasters.
2. Patient Care
2.1. Patients will be treated with dignity and have a right to be treated in a
respectful manner.
2.2. Quality of clinical care to the patient that the hospital serves is high and
appropriate for Afghanistan, including the proper staffing, equipment and
supplies.
2.3. Quality of care will be monitored and measured by agreed indicators (e.g.
wound infections, length of hospital stay, operations per patient, mortality rates
etc).
2.4. Women and children will receive the basic package of health services at
hospitals, including immunization, outpatient care for conditions, such as
pneumonia and diarrhea, as well as appropriate assistance at the time of
delivery.
2.5. Hospitals will be “mother and baby friendly” and encourage “rooming-in” and
immediate, exclusive breast feeding.
2.6. Care delivery is monitored by the hospital’s health care team to ensure that
care meets the needs of patients and to assist in the improvement of care.
2.7. Medical records are maintained for each patient and are kept confidential
and secure.
3. Leadership and Management
3.1. The hospital is effectively and efficiently governed, organized, supervised
and managed to ensure the highest quality of care possible for patients.
3.2. To ensure the responsiveness of hospitals to the community, a hospital
board of directors or board of management will be established at each hospital to
govern and oversee the proper operation and management of the hospital.
4. Human Resource Management
4.1. Staff planning ensures a properly trained hospital staff and the appropriate
number of staff.

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4.2. Staff is appointed through a recruitment, selection and appointment
procedure that is consistent with the MOH human resources policy.
4.3. In performing their duties, staff adheres to high ethical standards and a code
of conduct.
4.4. A comprehensive program of staff development and in-service training
meets individual and hospital needs.
4.5. Effective workplace relations are developed through use of teams
5. Management Systems
5.1. Financial management policies and procedures are developed and adhered
to in order to ensure accountability of the hospital’s finances from all sources.
5.2. Management information systems meet the hospital’s internal and external
needs
5.3. Patient care, management of services, education and research are facilitated
by the timely collection and analysis of data
5.4. Information technology enhances the hospital’s ability to gather, store and
analyze information and to communicate.
5.5. Appropriate logistics and purchasing systems are maintained to ensure
clinicians have the proper equipment, supplies and pharmaceuticals to provide
patient care.
5.6. Buildings and grounds are maintained to ensure a safe patient care and
work environment for patients, staff and visitors.
6. Hospital Environment
6.1. Infection is effectively controlled throughout the hospital
6.2. The physical environment of the hospital and its equipment are properly
maintained to ensure patient and staff safety and that there are no physical
barriers for those with disabilities.
6.3. The hospital is accessible to all patients with including those with physical
disabilities.
6.4. Buildings, grounds, plant and equipment are regularly maintained to ensure
a safe environment for all persons in the hospital.
6.5. Waste from the hospital is handled, contained and disposed of safely and

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Efficiently
6.6. Occupational health measures are adopted to ensure the safety of staff,
especially those dealing with direct patient care.
6.7. Clean water of sufficient quantity and quality is available for patients and
staff and for proper hospital functioning.
6.8. Toilets in the hospital are kept clean for use by patients, staff, and visitors.

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 Hospital Standards for Accreditation for Afghanistan:
Assessment of Progress in Achieving the Standards
Hospital Department or Area: Infection Prevention:
Patient/Client Education
Hospital Facility: _____________
Assessor: __________________ Date of assessment: ____________________

Infection Prévention: Patient/Client / Education

Standa Standard Criteria for Compliance in Bases for
rd # Verification of meeting standard evaluation
meeting (score) Grads/Comme
standard Full Partial non nts/Action Plan
e
1 There are Observe if:
educational • There are
posters for posters or
patients/ stickers visible
clients about and in good
infection condition about
prevention hand washing
(IP) and hygiene
measures. located in:
• Corridors
• Waiting
areas
• Toilets
• wards
There are signs
saying “no
littering” to
encourage
patients/clients
and relatives to
avoid littering on
the grounds

There are
posters or
stickers visible
and in good

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 condition about
visiting hours
and number and
age of visitors

There are
posters or
stickers visible
and in good
condition about
“cough
etiquette”

2 There are Observe if there

informational are posters
posters visible and in
about good condition
patients’/clie informing
nts’ rights patients/clients
concerning about the critical
IP during the IP practices
provision of (e.g., hand
care. washing,
injection safety,
use of gloves
during invasive
procedures) that
should be
followed by
providers during
the provision of
care, located in:
• Outpatient
facilities

• Wards
• Causality
areas
• Laborator
ies
• Dental
Departm

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 ents
3 There are Observe if there
signs to alert are signs in
patients/clie these areas:
nts about • Laboratory
restricted or Isolation areas
risky areas.
Central supply
and Sterilization
Department and
operating room
Lab and delivery
areas
Nursery
Mortuary
Waste storage
areas
4 The hospital Verify with the
works with hospital
community director/manage
organization r if:
s on IP • There is a
education. written plan to
conduct
educational
activities on IP
for the
community and
for the relatives
who accompany
patients/clients

There is a
record of
activities
implemented

Importance of Clinical Audit

If we come once more to definition, them “clinical audit involves systematically
looking at the procedures used for diagnosis, care and treatment, examining how

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associated resources are used and investigating the effect care has on the
outcome and quality of life for the patient” (Department of Health, 1993).
‘Audit’ is a word which has acquired different meanings over time in relation to
health care quality. The above definition, provided by the Department of Health,
emphasizes the fact that clinical audit can be used to examine all aspects of
patient care from assessment through to outcomes. In brief, clinical audit
provides a method for systematically reflecting on and reviewing practice
In the literature about clinical audit methods, the following terms are often
mentioned: criteria based audits; adverse occurrence screening; critical incident
audits; peer reviews; and case note analysis. These are used inconsistently by
different authors and tend to add to the general confusion about the clinical audit
process. We would recommend ignoring this labyrinth of terminology since there
is only one clinical audit method – the clinical audit cycle. This method involves
completing a number of stages and activities as described.
The overarching aim of clinical audit is to improve service user outcomes by
improving professional practice and the general quality of services delivered
There are a number of reasons why clinical audit is an important activity. The
main reason is that it helps to improve the quality of the service being offered to
users. Without some form of clinical audit, it is very difficult to know whether you
are practicing effectively and even more difficult to demonstrate this to others.
The benefits of clinical audit are that it:
• identifies and promotes good practice and can lead to improvements in
service delivery and outcomes for users
• can provide the information you need to show others that your service is
effective (and cost-effective) and thus ensure its development
• provides opportunities for training and education
• helps to ensure better use of resources and, therefore, increased
efficiency
• Can improve working relationships, communication and liaison between
staff, staff and service users, and between agencies.

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Areas and Time of clinical audit
There are numerous topics which are suitable and relevant for clinical audit.
Several ways of subdividing clinical audit topic areas have been devised. A
useful framework has been provided by Donabedian (1966) who classified topics
under three headings:
Structure: The availability and organization of resources and personnel.
Process: The activities undertaken, that is, what is done with the service’s
resources?
Outcome: The effect of the activities on the ‘health/well-being’ of the service
user, that is, changes for the individual which can be attributed to the clinical
intervention they received.
For some clinical audit projects, data collection, analysis and action plans can be
carried out in an hour or two. Similarly these audit stages can take one or more
years to complete. What is important is to design a clinical audit project which will
produce meaningful data and which can be finished within the budget and time
available. The most time-consuming element of any clinical audit project is the
implementation of required changes. It is suggested that projects be kept simple
and cover areas in which changes can be achieved. Clinical audit can be both
simple and quick
A clinical audit project is more likely to be successful and beneficial to service
users if all of the key stakeholders are involved from the outset. These may
include: clinical and non-clinical staff providing the service, service users and
people whose support may be required to implement resulting changes in
practice (e.g. managers, referrers, and trust board members).
As many of the above groups as possible should be represented on the clinical
audit project team. If individuals are unable to attend team meetings, then they
will need to be consulted and kept informed about the clinical audit project
throughout the process. Key stakeholders should be involved in the clinical audit
project from the start.

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Quality Care in Hospitals
Quality assurance and medical audit are processes which seek to improve the
quality of care by addressing differences between accepted good care and actual
practice. Nowadays more or less hospitals are very much concerned of quality in
their services. A revolution is taking place in the field of healthcare. The concept
of “quality of care,” is now speeded by the advent of healthcare reform in many
countries. Providing quality healthcare within the constraints of available
resources is a challenging undertaking. Nonetheless, even in an environment
with limited resources, methods are available to regularly monitor the quality of
care by collecting and analyzing a core set of health indicators, and thereby
laying the groundwork for improvement.
Main approaches for quality improvement in hospitals are quality monitoring,
providing feedback to healthcare workers, training and supporting staff to
undertake improvements leading to quality care, and designing solutions for
closing identified quality gaps. It means that there is no shortage of evidence to
support the argument for the introduction of quality assurance into clinical
practice. Many published studies, which have assessed the quality of care with
measurable criteria, have shown wide gaps between actual care and accepted
good practice. For example, in a large proportion of deaths from asthma there is
evidence of lack of appropriate medication or referral or physiological
measurement, similar findings were reported in studies of routine care given to
patients admitted to hospital with acute severe asthma.' Underuse of a blockers
and aspirin for patients who have had myocardial infarction and of streptokinase
for those admitted with myocardial infarction has been described.
Variation in use of procedures and demonstration of inappropriate use of invasive
investigations such as coronary angiography and of prescribed drugs such as
antibiotics" indicate a degree of uncertainty in clinical decision making - a factor
which may at least partly explain some of the differences between actual and
accepted practice.

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Choice of Quality Healthcare
Quality health care means doing the right thing, at the right time, in the right way,
for the right person—and having the best possible results. Although people would
like to think that every health plan, doctor, hospital, and other provider gives high
quality care, this is not always so. Quality varies, for many reasons. Fortunately,
there are scientific ways to measure health care quality. These tools, called
measures, have mostly been used by health professionals. They use measures
to check up on and improve the quality of care they provide. But there is some
quality information that can be used to help you compare the health care choices
for consumers. And more and more is becoming available all the time. Many
public and private groups are working to improve and expand health care quality
measures. The goal is to make these measures more reliable, uniform, and
helpful to consumers in making health care choices.
There are two main types of quality measures that can help you choose quality
health care are consumer ratings and clinical performance measures. Both types
are based on "outcomes research." Outcomes research measures the end
results of health care practices and treatments. For example, after treatment, is
the pain gone? Can the patient carry out his or her daily activities? Is he/she
satisfied with his or her care?
Consumer Ratings (or "consumer satisfaction" information): These look at health
care from the consumer's point of view. For example, do doctors in the plan
communicate well? Do members get the health services they need? Many
consumer ratings of health plans are based on a survey called the Consumer
Assessment.
Clinical Performance Measures (also sometimes called "technical quality"
measures): These measures look at how well a health care organization prevents
and treats illness. For example, one clinical performance measure looks at
whether children get the immunizations (shots) they need when they need them.
Research shows that people want and value quality health care. And that's a
good thing. Because when you make health care choices that offer the best
possible care, you are most likely to get the best possible results. So when it

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comes to making major health care decisions—about health plans, doctors,
treatments, hospitals, and long-term care—how can you tell which choices offer
quality health care, and which do not? Fortunately, more and more public and
private groups are working on ways to measure and report on the quality of
health care. This means there is more and more information to help one make
choices that improve the quality of his or her own care.
Here are some important things which make individuals to choose hospital care
and make such choices:
• Quality matters. It can be measured, and it can be improved.
• Patient and doctor should see each other as a team. You need to work
together to get the best care.
• The patients should ask questions, and make they understand the
answers. The only "bad" question is the one you wish you had asked.
• Remember that "more" is not always "better." It is always a good idea to
find out why a test or treatment is needed and how it can help you.
• Customers want to find and use reliable health care information. They will
ask the doctor or nurse, to library, and explore the internet

Checklist for choice of Quality Healthcare

The following checklists summarize the major ways you can check for quality in
health care. The information in it comes from research about the information
people want and need when making decisions about health plans, doctors,
treatments, hospitals, and long-term care.
• The hospital has been rated highly by its members on the things that are
important to you.
• The hospitals do a good job of helping people stay well and get better.
• It is accredited, if that is important to you.
• Ii has the doctors and hospitals you want or need.
• The center provides the benefits you need.
• The hospitals provides services where and when you need them.
• Meets your budget.

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 • Medical personnel Is rated to give quality care.
• They have the training and background that meet your needs.
• They try to takes steps to prevent illnesses for example, talks to you about
quitting smoking.
• It is part of your health plan, unless you can you afford to pay extra.
• The staff encourages you to ask questions.
• They are listening to you.
• They are explaining things clearly.
• Treats you with respect.
• The hospital makes it clear what your diagnosis is.
• It will predict whether treatment is really needed at this time.
• Suggestion will be given what your treatment options are.
• Whether the treatment options are based on the latest scientific evidence.
• The benefits and risks of each treatment is clearly explained
• It is affordable for you to incur the cost of each treatment.
• It is accredited by the Joint Commission on Accreditation of Healthcare
Organizations.
• The hospital is rated highly by government or consumer or other groups.
• It is one where your doctor has privileges, if that is important to you.
• The hospital has experience with your condition.
• Checks and works to improve its own quality of care.
• Its quality has been approved by other institutions
• It provides the services you need.
• It has qualified staff that meets your needs.

The way forward

Apparently the quality assurance activities are not well documented or well
developed and are seen as the purview of the medical staff. Although some sorts
of standards are developed for QA which is usually partially applied in lower
public health facilities which are controlled by MoPH and implemented by NGOs.
If you review them and evaluate quality control processes, it is not widespread.

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We can conclude that few formal QA function exists, and little attention is given
to these activities.
Quality assurance activities should become a higher priority at the hospitals and
the process of accreditation and QA capacity-building should be implemented
and should include hospital line administrative managers as well as the medical
staff. It is time to begin such activities with some alleged quality private hospitals.
> QA standards should be developed and implemented. Possible Technical
Assistance is capacity-building and developing and implementing accreditation
standards. Technical assistance is recommended in the education, training, and
implementation of the accreditation process for hospitals under the Hospital
Reform Project. One hospital department, possibly OB/GYN, could be selected to
work with HSR as a model for the development of standards and for
implementation of the accreditation process for QA capacity-building.

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Session 9: Financial Management in Hospitals
Assessment of hospital financial performance starts with some basic questions
such as how does a hospital get and spend its money? Is the hospital in good
financial health (able to cover its basic financial requirements and)? What types
of government policies and regulations affect the hospital’s financial health?
What are the market trends and how are these forces shaping the decisions of
the hospital leadership? These are just a few of the questions that are needed to
be answered when one is evaluation the financial status of the hospital.
The health services industry includes many providers of service. To understand
the flow of funds, or how money flows through a hospital, it is important to know
the key players in the hospital industry. These include physicians and ancillary
providers, skilled nursing facilities, long-term care providers, home health care,
and pharmacies, as well as hospitals.

Health Providers in Hospital System

Hospitals are registered with different health system maybe seen as general,
special ones. General Hospitals provide patient services, diagnostic and
therapeutic, for a variety of medical conditions while in specialty related ones
they provide diagnostic and treatment services for patients who have specified
medical conditions, both surgical and nonsurgical. In addition hospitals are
organized as public, private and not-for-profit entities. In general, public hospitals
provide substantial services to patients living in poverty. There are some public
hospitals such as those run by the military. Public Hospitals are often funded by
local and central government through taxes which is collected from people.
Private, not-for-profit hospitals are nongovernment entities organized for the sole
purpose of providing health care. Non for profit hospitals are exempt of paying
taxes to government. Their number is very low in Afghanistan. We can name the
French Medical Institute for Children (FMIC) one of such hospital which is
running by Aga Khan University in Kabul. There are some health centers and
hospitals which are controlled by government but not through channel of MoPH.
They are also included in public Hospitals.

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Other Providers are physicians may practice general medicine or specialize in a
particular area. We call them medical examination room which is very common
in the country. Some physicians are employed by private hospitals while others
may have private practices in the community. Home care services are, as the
name implies, provided in the patient’s home usually by a home health aide.
These services may include nursing, nutritional and therapeutic aid, and the
rental and sale of medical equipment. As patients are discharged to their homes
sooner—due to hospitals’ economizing strategies— home care plays an
increasingly more important role in the health services industry. This is less
common in a country like Afghanistan but mostly it is seen in developed countries
and even in it has been started in developing countries. Pharmacies are found in
hospitals as integrated portion and they are working in private pharmacies which
are partially controlled by the MoPH as well in the community. They are providing
pharmaceuticals to that patient who request for and have become more
important in the health care delivery sector as they may supplant treatments.
If we assess the types of hospital ownership they can bye classified to groups of
hospitals of public and private sectors. Public hospitals are further classified into
hospitals under the MOPH, under the Universities, and under various Ministries.
The determined categories of private hospitals are not-for-profit hospitals, for-
profit hospitals and other types of private hospitals. The public hospitals are
providing more wide ranges of services concerning comprehensive care
including curative, promotive, preventive and rehabilitative care. The private
hospitals are emphasizing mostly on curative care and they are less likely
providing promotive and preventive care from which they were able to make
profits. They show low interest in provision of those services which include the
public goods.
Based on constitution public hospitals in Afghanistan are bound to provide free of
cost services which is hindering the modern and state of art technology. Payment
system in the private hospitals is market salary based or it is related to staff’s
work productivity in terms of quantity and quality while the public system is
basically a salary system in which promotion is likely to link with work years.

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However, training and development for public hospital staff is more formalized
than the private hospitals. Public Hospitals consider information system as a key
element to enhance evidence-based decision making while the culture is less
supported in private hospitals. More number of qualified employees with specialty
of current and modern financing and accounting are employed in the private
hospitals. Their roles are relevant for providing inputs to make decisions while
the public hospitals do have limited qualified staff leading to limited inputs-based
decisions. They are mostly based on traditional lengthy procedures. Auditing
system is performed in the public hospitals as obliged to the law of Ministry of
Finance while there is no approved auditing system for private hospitals. As an
autonomous hospital is increasingly considered as an alternative to improve
efficient use of health resources in public hospitals, some recommendations of
general management for transforming the public hospital into the autonomous
hospital are made as follows:
• Comprehensive care should be provided,
• three levels of management composed of the hospital board, the hospital
management team and functional units should be established,
• Internal and external auditing system should be carried out to improve
management transparency,
• incentives system should be designed to encourage health workers to
work more productively,
• Qualified people whose backgrounds are accounting and financing should
be more recruited,
As a fundamental structure of the hospital management, the information system
should be developed to produce beneficial inputs for decision making,
The accounting system should be based on the accrual system, used for auditing
and estimating care costs to facilitate more equity of resource allocation.

Payers in Hospital System

To understand how hospitals generate revenue for patient services, it is
important to understand the “payers” in the healthcare industry. Public payers

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include government which fund hospitals in MoPH and other public institutions.
Private payers are insurance companies which is not common in the country.
Both public and private payers are often referred to as third-party payers. We can
allege that all population in the country is not insured just in some very rare
cases. The efforts have been started lately. There are some payment which is
done by external donors and the channels maybe indirectly through involvement
of government and or directly by non governmental organizations.
Out of pocket payment is by consumers themselves pay the costs of medical
expenses out of their own pocket. Typically, hospitals “charge” these patients a
higher fee than what they actually expect to collect from the organized payers
described above. If an individual does not have adequate resources to pay the
bill, providers will not deliver the services to them. Nevertheless the welfare
system and exemption schemes are there in some hospitals. Hospital policies
are required to put the issue in attention of private hospitals.

Hospital Revenues: How Hospitals are earning money?

Typically, hospitals get their revenue in a variety of ways: by providing medical
services; by providing nonmedical services; through donations and grants from
individuals, foundations, or the government; through investments and so on.
There are various sources of revenue for hospital in different countries. Some of
them are discussed here.
Operating revenue is the income earned by delivering patient care and it is the
first and primary way that hospitals make money. This revenue is further
categorized in hospital finance terms as gross and net: Gross Patient Service
Revenue (GPSR). The amount of money that hospitals would make if they were
paid in full (that is, the non-discounted rate) for the care they deliver (total
inpatient and outpatient revenues before deductions). However, hospitals provide
most patient care at less than full charge and never actually collect their gross
patient service revenue. Net Patient Service Revenue (NPSR) is the total amount
of money the hospital actually collects after deducting charity care and
contractual adjustments.

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We should understand here the difference among charge, payment and cost. A
charge is the amount the hospital lists as the price for services. Only self-payers
and some private insurers pay this “sticker price.” Payment is the amount the
hospital actually receives in cash for its services. Private insurers, public
insurers, and the uninsured all pay different amounts for the same services.
Payment can be either more or less than what it costs the hospital to provide a
given service. Cost is what it actually costs the hospital to provide the services.
Costs are reported in aggregate, so you will not be able to find cost for individual
Procedures on financial statements. The payment-to-cost ratio illustrates the
amount of revenue a hospital receives relative to its costs. A payment-to-cost
ratio of 1 means that the hospital is receiving payment that exactly covers its
costs. A ratio greater than 1 means that the hospital is receiving more money
than the cost of the service it is providing.
Table: Payment methodology and incentives created in Hospitals

Payment method Definition Incentives

Fee for Service (FFS)
Discounted FFS
Providers are paid a fee The FFS method rewards
for every service hospitals for providing
performed. more care. The more
they provide, the more
they are paid. Under this
method, there is concern
that FFS payments
will lead to additional and
unnecessary services
which is called supplier
induced demand
Providers are paid a fee This method offers
for every service incentives similar to
performed, but at a those described above.
discounted rate. Although hospitals are
not paid as much per
service, there are still
incentives to provide
additional services in
order to get additional
payments. There is also
an incentive for providers
to mark-up charges to
offset the discount.

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Capitations Providers are paid a Hospitals receive the
certain amount per same monthly fee
patient for a whether they treat a
predetermined set of patient or not. The
services. capitation method of
payment leads to a
common concern that
hospitals and other
providers will not provide
necessary services,
since providing additional
services will not increase
the amount of money
they receive.
Per diem Providers receive fixed Since a hospital is paid
daily payments that do by the day and not by
not vary with the level of individual case, the
services used by the hospital can make more
patient. money by keeping a
patient in the hospital for
more days than are
necessary.
Diagnostic Related Providers are paid a lump DRG payments will
Grouped (DRG sum to cover inpatient create an incentive for
acute care operating hospitals to provide
costs. Patients are sorted services at lower cost
into groups according to and to shorten lengths of
principal diagnosis, type stay. They will also
of surgical procedure, benefit from an increase
presence or absence of in the volume of
significant co-morbidities admissions.
complications, and other
relevant criteria.
Charges Hospital’s posted price In most states there are
for services. no limits (other than
“market forces”) as to
what a hospital can
charge. The incentive
is to establish charges as
high as possible to get
the most from the
indemnity.

Other operating revenues in Hospitals also make money by providing services

that are ongoing business activities, but that are not directly related to the

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hospital main mission of delivering patient care. While these activities bring in
significant and continuous streams of funds, the money resulting from these
services and activities is called other operating revenue. Some typical categories
that make up other operating revenue include:
• Cafeteria sales
• Gift shop sales
• Parking garage fees
• Space or equipment rentals
• Research grants
While it is probably obvious how a hospital benefits financially from rentals,
cafeteria, gift shop, and parking garage fees, funding from research grants
deserves a little more explanation. Hospitals are a valuable arena for researching
new drugs, treatments, and procedures, and outside agencies fund hospitals to
perform such research. Such a fund was provided to Maiwand Teaching
Hospital for cohort (clinical trial) of affecting vitamin D in occurrence of
pneumonia in children. It was supported and conducted by London School of
Hygiene and Tropical Medicine. Hospitals also receive funding from
pharmaceutical companies to test new drugs and products. Money from research
grants can be a significant source of funds for a hospital, particularly if it is a
teaching hospital.

Hospital Expenses: How Hospitals are spending money?

Hospitals must spend money to function and provide patient care. The main
categories of expenses include salaries, supplies, depreciation, amortization,
interest, and bad debt expenses.
Wages and salaries paid to employees are usually the largest category of
expenses for hospitals. In many hospitals, salaries make up about 60 percent of
total expenses. Only physicians who are employees of the hospital are included
in the category. Most community hospitals do not employ physicians except in
the emergency department, the radiology department, the laboratory, and often
in the anesthesiology department.

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Supplies usually make up the second largest category of hospital expense and
typically account for 30 percent of a hospital’s expenses. “Other” includes a
range of expenses, but often represents contract labor and lease expenses.
When any entity (including hospitals) buys equipment, buildings, or other fixed
assets, it does not expense, or write off, the entire cost of purchasing that fixed
asset in one accounting period. Instead, it recognizes the cost over the estimated
life of the good, and records the appropriate portion as an expense during the
current accounting period. The process of expensing a fixed asset for its
expected length of use is called depreciation. For example, if a hospital bought
an x-ray machine for $100,000 and expected it to last 10 years, using the
straight-line depreciation method the hospital would record the expense of the
machine at $10,000 per year for 10 years. Similarly, when a hospital purchases
an intangible asset the process of expensing its cost over the expected length of
its life is called amortization. Intangible assets consist of the nonphysical assets
of a business, such as goodwill, copyrights, and patents. The entire cost is
spread over the anticipated life of the asset instead of recognizing it all at once in
the first year.
Hospitals often borrow money for mortgages and other large purchases. Interest
expense is the amount a hospital must pay in the current accounting period for
borrowing funds.
Bad debt represents service charges for which a hospital expected to collect but
does not receive payment. Bad debt is valued at charges. For example, a patient
is billed $1,000 for a procedure. If the patient is only able to pay half of the cost
($500), the hospital must write off the other $500 as bad debt and record it as an
expense.

Financial Information in the Hospitals

After knowing how a hospital makes and spends money, now you need to learn
where you can find this information. All hospitals must have complete financial
statements.
Hospitals, like other businesses or organizations, issue financial statements.

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Financial statements are reports that show the type of financial actions an
organization has taken and the impact of these actions. For example, statements
show where and when a hospital’s money has been spent and whether the
hospital is financially successful. They answer questions such as: What is the
financial picture of the organization in any given year? How well did the hospital
do during a given period of years?
There are three major financial statements: the income statement; the balance
sheet; and the cash flow statement. Each statement has a distinct focus and use.

The Income Statement

The income statement (also referred to as the Profit and Loss Statement or
Comparative Statement of Operations) focuses on performance over a
designated period of time, usually one year. This statement provides important
information about the profitability of a hospital, including information on how the
hospital gets its money and how the hospital spends its money. Here is an
example of income statement.
Table: income statement in 1000
OPERATING REVENUES 1998 1998
Gross Patient Service Revenue $258,125 $263,469
Free Care 5,800 6,024
Contractual 69,320 67,985
Net Patient Service Revenue 183,005 189,460
Other Operating Revenue 14,600 14,843
Total Operating Revenue $197,605 $204,303

OPERATING EXPENSES
Depreciation 13,152 13,805
Interest 3,222 5,026
Bad Debt 5,163 6,866
Other Operating Expenses 168,585 173,634
Total Operating Expenses $190,122 $199,331
Net Operating Income $7,486 $4,972

NONOPERATING REVENUE
Investment Income $2,530 $ 3,328
Gains/Losses 159 0
Other Income (Expenses) 470 1,112
Total Non-operating Revenue $3,159 $4,440
Excess Revenues over Expenses $10,645 $9,412

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OTHER GAINS (LOSSES) DUE TO:
Extraordinary Gains (Losses) 0 –748
Total Surplus/Deficit $10,645 $8,664

The purpose of the income statement is to provide information on hospital

performance, including how much profit the hospital makes. So that it is
necessary to know what does profit means.

What Is Profit?
Profit is the difference between revenue and expenses in addition to non-
operating gains and losses. Profit is sometimes referred to as the hospital’s
“bottom line,” because the bottom line of the income statement shows the excess
revenues remaining once expenses have been subtracted. Profit may also be
called “total margin.” For example, a 2 percent total margin means that the
hospital keeps as profit 2¢ for each dollar of revenue. In addition to looking at the
bottom line to gauge profit, financial analysts also measure the difference
between operating revenue and operating expenses without non-operating gains
and losses. This measure of profit is referred to as net operating income and is
used to measure how much profit comes from a hospital’s central mission of
delivering patient care. A “not-for-profit” designation does not mean a hospital
can’t make money. A nonprofit may make a “profit,” but it does not distribute its
profit to individuals or shareholders as a for-profit organization might.
A hospital may be conservative in its estimate of how much money it will earn
from patient revenues. Because these numbers usually require a certain amount
of estimation, bad debt and contractual settlements might be much less (or more)
than the hospital’s reported figures. For example, a hospital may not recognize
all Medicare patient revenue because of the uncertainly regarding whether the
hospital will be permitted to keep this revenue. When a hospital “settles” with an
insurer at the end of the financial reporting period and it is found that the insurer
overpaid the hospital, the hospital may have to give back some of the money to
the insurer.

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The Balance Sheet
The balance sheet gives a snapshot of the organization’s financial health at a
particular point in time, for example, as of June 30, 2000. It is also known as the
statement of financial position or statement of financial condition. In general, the
organization’s total assets should be greater than its total liabilities, or it cannot
survive for long. The kinds of assets and liabilities an organization has also affect
its financial health. For instance, current assets (such as cash, receivables, and
securities) should cover current liabilities (such as payables, deferred revenue,
and current-year loan and note payments). Otherwise, the organization may face
immediate solvency problems. On the other hand, if an organization's cash and
equivalents greatly exceed its current liabilities, the organization may not be
putting its resources to the best use.
There are several major elements on a balance sheet.
• Assets are economic resources that are expected to provide future
benefits by helping to increase cash inflows or reduce cash outflows.
Property, plant, and equipment (PPE) are considered assets.
• Liabilities are economic obligations of the organization to outsiders, or
claims against its assets by outsiders. Accounts payable is as example of
a hospital liability.
• Net assets, fund balance, or owners’ equity are all different names for
the same thing: they all refer to the residual interest in, or remaining
claims against, the organization’s assets after all liabilities have been
deducted. This may be expressed as: assets – liabilities = net assets.
Balance Sheet Equation shows that the balance sheet has two counterbalancing
sections which form the balance sheet equation:

Assets = Liabilities + Equity (or Net Assets)

The Liabilities + Equity portion of the balance sheet equation represents outsider
and owner “claims against” the total assets shown on the assets portion of the
equation.
Hospital Balance Sheet

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Assets Liabilities and Net Assets
Current Assets A list of resources Current Short-term
which will most Liabilities obligations to
likely be used outside
within the year parties who have
Cash and Cash, cash provided
Investments– equivalents, and resources
Unrestricted short-term (liabilities)
investments on Current Portion Principal
which no special of Long-term payments due this
restrictions are Obligations fiscal year on
imposed on how long-term
they may be spent obligations
Cash and Cash, cash Accounts Includes accounts
Investments– equivalents, and Payable and payable, accrued
Board short-term Accrued salaries payable,
Designated investments Expenses wages, payroll
internally taxes, interest,
designated vacation (earned
for use by the time) and other
board of trustees accrued liabilities
Cash and Cash, cash Current Portion Current portion of
Investments– equivalents, and of Accrual for amounts received
Trustee Held short-term Settlements from third-party
investments with payers which the
designated as Third-Party hospital expects to
trustee-held to be Payers be due back to
used to repay third parties in the
specific current year
obligations Due to Affiliates Current amounts
(usually long-term owed to related
debt) entities
Net Patient Payments due Total Current Sum total value of
Accounts from patients Liabilities all of the current
Receivable minus amounts liabilities listed
subtracted for above
estimated Noncurrent Long-term
uncollectible Liabilities obligations which
accounts and Long-Term are not
“discounts” Obligations, due within one
to large Less year
purchasers Current Portion Noncurrent portion
Due from Contractual of long-term
Affiliates obligations of debt, capital
affiliates leases, and
due this year mortgage

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Third-Party Estimates of notes payable
Settlements settlements to be Other All other
Receivable received this fiscal Noncurrent noncurrent
year Liabilities liabilities,
Other Accounts Includes other including reserves
Receivable receivables not for self-insurance,
related accrued pension
to patient and post-retiree
services, third- health benefits,
party receivables noncurrent
or amounts due amounts
from affiliates due to affiliates,
Inventories Goods being held amounts due to
for sale, and restricted funds,
material notes payable,
and partially deferred gift
finished products annuities,
that will be sold construction
upon completion and retain age
Prepaid Intangible assets payable, etc
Expenses that will become Net Assets Net assets
expenses in future represent the
periods when the difference
services they between assets
represent are and the claim to
used up those assets by
Total Current Sum total value of third parties or
Assets all the current liabilities;
assets listed increases in this
above account balance
Noncurrent Assets that are occur from either
Assets expected to be of contributions or
use earnings
to the hospital for Unrestricted Includes all net
longer than one assets that are
year not temporarily or
Long-Term Long-term permanently
Investments resources restricted by donor
or grant
Pledges A promise to give Temporarily Includes funds
Receivable (pledge) by a Restricted temporarily
Over a Period donor which has restricted
Greater not yet been by donor or
Than One Year received and will grantor
not be received stipulations.
within one year’s Permanently Includes funds

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 time Restricted called for a
Net Property and Value of land, specific
Equipment buildings, purpose; property,
equipment, plant and
construction in replacement; or
progress, and endowment funds
capitalized Total Net Assets Includes funds
leases permanently
Other All other restricted
Noncurrent noncurrent assets by donor or
Assets not listed grantor
above, including stipulations
amounts due from TOTAL Sum total value of
restricted funds; LIABILITIES all net assets
deposits; other AND NET Sum total value of
noncurrent all liabilities and
ASSETS
unrestricted net assets raised
receivables;
by issuing stock
deferred financing
costs and deferred
charges; pension
and insurance
obligations
or retirement
programs;
Organization
costs, etc.
The sum total
TOTAL ASSETS
value of all current
and
noncurrent assets

The Cash Flow Statement

The cash flow statement shows the cash that has come into and gone out of an
organization, after operating expenses have been met, during the accounting
period. Cash flow analysis provides a reliable, valuable perspective on hospital
financial performance. Because cash is not estimated, it cannot be hidden or
misleadingly labeled. Over the long term, multi-year cash flow analysis provides
an accurate and objective perspective of hospital financial performance.
Statement of Cash Flow
CASH FROM OPERATING ACTIVITIES

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Net Income $10,645
Noncash Expenses (Depreciation & Amortization) 13,152
Working Capital Changes:
Increase Accounts Receivable 6,480
Increase Accounts Payable –4,295
Total Cash from Operating Activities $25,982
CASH USED FOR INVESTING ACTIVITIES
Property, Plant, and Equipment Purchases –7,854
Increases or Decreases in Marketable Securities 2,702
CASH FROM FINANCING ACTIVITIES
Issuance or Repayment of Long-Term Debt –7,087
Transfers to and from Affiliates –4,300
NET CHANGE IN CASH $9,443

This sample shows the standard items listed on the cash flow statement. One
piece of valuable information that can be gleaned from the statement is transfers
to and from affiliates. Hospitals that are affiliated with other hospitals or entities
often transfer funds to and from one another. For example, many hospitals are
now merging or creating alliances with other hospitals. Suppose Hospital A
created an alliance with Hospital B and created a parent company called Parent,
Inc., to handle certain operations and other business ventures. In this typical
situation, Hospital A might transfer funds to Parent, Inc., to run business
operations for them. CCESS PROJECT
Hospital A would then record this transaction as a transfer to an affiliated entity
and record it as a negative change in net assets (equity), separate from the
hospital’s bottom line on the income statement. The hospital would also record
the transfer of funds on the cash flow statement. It is important to understand this
flow of funds between entities, as a hospital’s profitability can be affected if the
hospital is transferring resources to affiliates instead of investing in its own
operations.

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Evaluation of Hospital Financials conditions
Three types of performance indicators are used to measure a hospital’s financial
condition: Ratio analysis, Multi-year cash flow analysis, Affiliate charts

Ratio Analysis
The purpose of a ratio is to relate several pieces of information through one
summary measure that is more meaningful. Ratios can be looked at across time,
called a trend analysis, and can be compared to other hospitals or industry
standards. Ratios should be used together to understand the full story of a
hospital. Ratios address three aspects of financial performance: profitability,
liquidity, and solvency.
Profitability: how much profit has a company made? Is the hospital rolling in
dough or just breaking even and covering its costs?
Liquidity: A company’s ability to meet its short-term obligations. Does the
hospital have enough cash to pay its bills?
Solvency: A company’s ability to meet its long-term obligations. For example,
can the hospital pay back its mortgage? The following table shows a list of
common ratios used to evaluate financial performance.
Ratio Definition What it shows?
Profitability
Total Margin Revenues in excess Shows the percentage of revenues
of expenses / collected from central and peripheral
Total Revenues activities that is kept as profit.
For example, a 5% Total Margin means
Net Operating that for every $1.00 collected as revenue,
Operating Income/ $0.05 is kept as profit.
Margin Total Operating Shows the percentage of revenues
Revenue collected from central activities that is kept
(Gross Patient as profit. For example, a 3% Operating
Service Revenue + Margin means that for every $1.00
Markup Other Operating collected of patient revenues, the hospital
Ratio Revenue)/ keeps $0.03 as profit.
Total Operating Measures the percentage by which
Expense charges are increased above cost. For
Contractual example, if the hospital’s cost for
Allowance/ providing a particular service was $10,000
Gross Patient and they charged $15,000 for the service,
Deductible Service Revenue they would have a markup of 1.5.

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Ratio

Measures the percentage discount that

third-party payers get, on average, from
listed charges. For example, a 25% ratio
would mean that the average third-party
payer received a 25% discount off listed
charges.
Liquidity
Current Current Assets/ Measures how many times the hospital is
Ratio Current Liabilities able to meet its short-term obligations with
short-term resources.
Current Cash and A ratio of two would show that the hospital
Days Cash Investments/ could pay its current liabilities twice over.
on Hand, (Other Operating Illustrates the number of days the hospital
Short-Term Expenses/365) could continue to operate without
Sources collecting any additional cash. For
Only example, a ratio of 150 would mean that
the hospital could stop collecting
revenues today and be able to continue
operations for an additional 150 days
Days Cash (Current Cash and before running out of cash.
on Hand, Investments + Considering all sources of unrestricted
with Board- Board-Designated cash available for operations, this ratio
Designated Investments)/ illustrated the number of days the
Investments (Other Operating hospital could continue to operate without
Expenses/365) collecting any additional cash.
Solvency
Equity Unrestricted Net Shows how much of the hospital’s assets
Financing Assets were paid for using equity, and how much
Total Unrestricted of its assets were paid for using debt.
Assets For example, a ratio of 60% would
indicate that the hospital financed 60% of
its assets with equity, which means the
remaining 40% were paid for by debt.

Cash Flow to (Revenues in Illustrates financial risk: Given the firm’s

Total excess of source of total funds for the current year,
Debt Expenses + how much of their total debt could they
Depreciation) pay off this year? For example, a ratio of
(Total Current + 30% means that a hospital would be
Total Noncurrent able to repay a third of their total debt in
Liabilities) the current year, if they used all of their
available funds.

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Cash Flow Analysis
A cash flow analysis aggregates cash inflows and outflows over time to illustrate
a pattern of cash sources and uses. Hospitals can provide services (operating
activity), borrow (financing activity), or buy and sell assets (investing activity). A
healthy hospital generates cash mainly from operating activities, especially
operating income, non-operating income, and depreciation. An unhealthy hospital
uses debt financing as a large source of cash and uses cash for unprofitable
operations. Depreciation expense is the largest source of operating cash for
many hospitals.

Affiliate Charts
Affiliate charts help to explain the organizational structure of the system to which
the hospital belongs. The chart may illustrate if the hospital supports other
entities or is supported by the other entities. The charts may help interpret trends
in ratios and explain impacts on cash flows. The tax status of the affiliates is also
important to assess.

Financial report and information system

A hospital administrator must be conversant with the financial status on a week
to week and month to month to basis and in a long perspective. It is the duty of
the finance officer to provide reports on financial performance and explain the
situation on regular basis to the administrator.
The assessment end result can not be possible without accurate data provided
on timely basis. Information about actual outcomes should be available through
the management information system in standardized format.
Daily Reports:
• Inpatient census, admissions, discharge
• Outpatients visits— new and repeat
• Tests carried out in laboratory, X-Ray, etc.
• Daily bank and cash positions

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Monthly Reports:
• Monthly statement of income and expenditure with department wise
break-p
• Budget versus actual cash positions— detailed comparison of actual to
budget sources and the application of the cashes
• Free and concessional care
• Operating indicators
Quarterly Reports:
Budget performance of all departments
Yearly Report:
• Balance sheet
• Income and expenditure statement
• Departmental income and expenditure statement
• Cost analysis

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Session 10: Grievance and complaint Management in
Hospitals
Complaint is an expression of grievance or resentment. It is a pleading
describing some wrong or offense; "he was arrested on a charge of larceny"
In general use, a complaint is an expression of displeasure, such as poor service
at a hospital, or from a local government, etc. in addition complaint is he first
step taken by an employee who believes he or she has been discriminated
against. A complaint is an allegation of illegal discrimination that is handled
through an administrative procedure or the document which, when filed with the
court, initiates a lawsuit. It sets forth the plaintiff's claims against the defendant.
Therefore a complaint is the legal document that is filed in court to begin a
lawsuit. (Web definitions)
Over the years, the hospitals faces thousands of complaint cases, derived from
all areas of hospital activities. However, attention has to be focused mainly on
the handling of individual complaint cases—some of which could be very
complex, involving more than one hospital or department, and encompassing
comments relating to varied aspects of hospital care. Whilst the satisfactory
resolution of individual cases is important, it is also important, particularly from
the viewpoint of a hospital authority to try to discern whether there are particular
trends, or systemic problems. Focusing only on dealing with individual complaints
also means that the chance is lost to prospectively and systematically learn from
circumstances that have led to complaints in the past, in the hope that proactive
action or precautions may be taken to minimize the chances of similar complaints
arising again in the future. The Hospital management should be, therefore,
aiming to enhance proactive mining of the complaint cache that exists in the
Hospital authority, so as to develop a system to more sensitively monitor system
failures and to achieve organization-wide enhancements.
As most medical colleagues are aware, the term ‘clinical iceberg’ is used to
describe the phenomenon whereby the visible part of a disease—that which is
detected or diagnosed— is only the ‘tip of the iceberg’. What may matter even
more is that there might be a significantly greater part which has not yet been

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uncovered. We may perhaps use the same analogy to consider what may be
usefully gained from the complaints process. It may be that what we can see
from the complaints received is only the tip of the ‘complaints iceberg’.
Nonetheless, just as it is useful to work from what is visible to try to discern
pointers as to what is happening in the greater, unearthed portion, so there may
perhaps be useful ‘lessons to learn’ from a sampling of the cases which have
been received over the years.

Importance of facing complaints as challenge

Better management of grievance and complaints in the hospital improves the
quality of care. As a hospital you should be a customer focused organization and
highly value patient and family rights. The Hospital is supposed to establish a
complaint handling process that fully assists its valuable customers in reporting,
investigating and responding to their raised concerns. You should encourage our
patients and their family members to freely raise and discuss their concerns with
the concerned health care team members of doctors, nurses, and service
coordinators in the wards, who always try to address and resolve these issues on
the spot. In case the ward staff is unable to resolve such issues, the patients and
families have the right to make a formal written complaint. The prescribed forms
and drop boxes should be available in all patient care areas.
The staff in the Health Complaints Office (HCO) should be available from in
working hours for a personalized complaint reporting mechanism and assistance
in resolving the raised concerns. If desired, representatives from senior medical,
nursing, and administrative leadership should be always more than willing to
meet the complainants in order to explore timely resolution of raised issues. The
hospital should be a learning and quality driven organization, and always
welcomes its valuable customers to freely raise their concerns or complaints and
views these as opportunities for improvement. Some hospitals are fearful of
grievance and complaints and try to conceal or resolve it without awareness of
other staff and costumers.
The potential value of clinical complaints as a means of improving quality of care
is accepted in overseas health care systems. In the United States, the Joint

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Commission on Accreditation of Health Care Organizations, in its publication
Using Quality Improvement Tools in a Health Care Setting, sets out a ten-step
model for monitoring and evaluation of health care quality including the collation
of patient complaints as an important step in carrying out a full evaluation of
health care quality standards. In the quality process as set out, it was also noted
that while the collation of complaints as an initial step was important, just as
important was the communication of results of the evaluation back to the source
of the feedback and/or complaint, thereby ensuring that the loop was closed and
that there was a genuine continuous quality ‘cycle’ at work. This is particularly
relevant to a health care organization. It is one of the most complexes of
professional organizations as professionals have a large degree of control over
such an organization a result, the ability of managers to influence decision-
making is more constrained than in other organisations5 and ways have to be
found to generate change from the bottom up, not just the top down. Hospital
doctors are unwilling to make changes unless they see benefits for their own
practices and patients. Similar recognition of the value of complaints can be
found from various studies in the United Kingdom, for example, the study by Bark
et al7 where 1007 complaints in 24 hospitals in the North West Thames region of
England were surveyed and various aspects of each of the complaints were
examined, including the nature of the complaint, the reasons for making a
complaint, and factors that could have prevented complaints. The authors
concluded that a better response to complaints at the clinical level by the staff
involved in the original incident was needed, staff training in responding to
complaints was essential, and monitoring complaints must form part of a more
general risk management programme. As a further recognition of the value of
complaints Good medical records and thorough documentation are very
important.
So that there is a dire need to establish procedure and envisage that there would
be a full investigation for each complaint case. So that individual complaints
could be satisfactorily responded to, and hospitals must vigorously investigate
and learn effectively from complaints and that investigation of complaints and

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incidents should be coordinated under a single senior manager. It would be
better to establish and strengthen the office and Health Complaint Office which is
mentioned in Human Resource Policy for Health in Afghanistan. The quality
officer or any other appointed one can follow and take action in this regard in
hospitals. Following please review the complaints, investigation and
recommended action to strengthen your learning in this regard.
Complaint case 1: Informed consent for teaching purposes
In a patient complaint which happened at a teaching and clinical session of the
gynecology clinic of a public hospital, the complainant was dissatisfied with the
hospital’s arrangement whereby she had to undergo vaginal examination 3 times
(one by the specialist and the others by two medical students). She alleged that
no prior consent for the vaginal examination for teaching purposes was sought
from her.
Observations and conclusion
The case was subsequently submitted to the Hospital Authority (HA) Public
Complaints Committee (PCC)—the final appeal body for patient complaints
within the HA— which ruled that:
• the specialist did not clearly inform the patient that the vaginal examination
by the medical students was for teaching purposes;
• no prior consent was sought from the patient for the vaginal examinations
by the medical students; and
• the medical students were not clear about the concept of patient informed
consent as reflected in their statements submitted during the complaint
investigation
Recommendations and follow-up actions
Following the PCC’s recommendations, a review was conducted by the HA on
the issue of patient consent for physical examination by medical students for
teaching purposes as part of the Authority’s risk management initiatives. Since
the review, the concerned medical staff has been reminded that prior patient
consent must be obtained. The case was also shared by all frontline staff through
the Risk Management Release (a corporate electronic publication on risk

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management) to prevent recurrence of similar problems. The PCC Secretariat
has also formally written to the deans of the medical schools drawing their
attention to the case and suggesting that they alert medical students of the
importance of patient consent for physical examination.
Complaint case 2: The importance of good medical records keeping
In a complaint against a public hospital for inappropriately discharging a patient
who was suspected to be suffering from peritonitis, the PCC noted that the
patient had had a history of Sjogren’s syndrome complicated by
thrombocytopenia and hyper viscosity for 8 years. She also suffered from
nephritis and was maintained on immunosuppressive therapy. She was admitted
to hospital A for fever and abdominal distension and was discharged 2 days later
upon stabilization. Six days later, the patient was admitted to hospital B through
the Accident and Emergency Department for a similar complaint and it was
treated as peritonitis. She was subsequently transferred back to hospital A for
further treatment.
Observation and conclusion
The complaint was received 2 years after the incident. During the course of
investigation, the patient’s medical records during the first episode of
hospitalization at hospital A were found to be missing. This had posed great
problems for the PCC in reconstructing the chronology of events and what
transpired when the patient was hospitalized. The hospital had made tremendous
efforts to retrieve other available evidence, including medical information in the
computerized laboratory results report, the prescription records during her
hospital stay, and the discharge summary. These records revealed that
abdominal parencentesis was not indicated during the patient’s hospitalization,
that her condition at the time of discharge was stable, that she was not on
antibiotics during her hospital stay nor upon discharge and that a follow-up
appointment was only scheduled for 3 weeks’ time. Based on expert advice, the
available medical information and circumstantial evidence during the patient’s 2-
day stay in hospital A, the PCC concluded that it was unlikely that the patient was

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suffering from peritonitis at the time. The allegation of inappropriate discharge of
the patient was unsubstantiated.
Recommendations
Good medical records and thorough documentation are essential in responding
to complaints and claims. They provide an objective record of treatment of a
patient. Arising from this case, the PCC had made a general recommendation to
remind management and staff of all HA hospitals on the importance of proper
record management.
Complaint case 3: Use of less flammable disinfectant
In a complaint against a public hospital for causing a burn injury to the patient
during an emergency appendectomy operation, the PCC noted that the patient
was suffering from acute appendicitis. Emergency appendectomy under general
anaesthesia was arranged. After induction and intubation, Hibitane, a
disinfectant, was used to prepare the patient for operation. Bleeding was noted
during the operation. To stop the bleeding, coagulation diathermy was applied.
When diathermy was applied for the second time, smoke was noted coming out
beneath the drapes covering the patient. A longitudinal burn was subsequently
found on the patient’s right loin and upper part of the right buttock.
Observations and conclusion
Although the blue flame generated by fire involving Hibitane would normally not
be visible under operating theatre lighting, the Committee considered that the
patient’s injury was caused by accidental diathermy burns as a result of
inadvertent collection of excessive Hibitane beneath the drapes covering the
patient.
Recommendations
Since Hibitane is an inflammable disinfectant used to prepare patients for
operation, the Committee recommended that extra care should be exercised
when applying the disinfectant and diathermy in any operative procedure.

Follow-up actions taken by the hospital

Following the Committee’s recommendation, the hospital reviewed and
considered the use of an alternative and less flammable disinfectant other than

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Hibitane for preoperative preparation of patients to prevent future recurrence of
similar incidents.

Six rules for pursuing hospital complaints through patient’s

perspective
Rule 1: Know your patient rights - before you file your complaint. It is believed
that you should familiarize yourself with your hospital's patient rights policy before
you file your complaint. You can then cite the patient right that applies to your
particular complaint, should you choose to do so.
Rule 2: Be pro-active and persistent when pursuing hospital complaints. Many
patients are reluctant to complain because they fear "retaliation" by hospital
employees. This is unfortunate. Hospitals want to maintain a positive reputation,
and avoid potential negative publicity. More importantly, it is your health that's at
stake - far better to be pro-active and persistent as a means of getting action for
you or your loved one, than it is to be passive and never get the complaint
properly addressed.
Rule 3: Act quickly - don't delay. Delaying the filing of your complaint is a
mistake. File the complaint when the information is still fresh in your mind.
Rule 4: Be thorough, and clearly state the facts. Be tactful. Explain your
complaint thoroughly - what exactly is the complaint, who was involved, what are
the time frames. Whether you are writing or speaking, state the facts in clear,
understandable terms. Also, be tactful.
Rule 5: Start your complaint process directly with the hospital. Patients are
encouraged to first file their complaints directly with the hospital. It’s believed that
it is best to resolve your complaint locally, if possible.
Rule 6: File your complaint with external organizations, if necessary. If you get no
resolution after filing your complaint directly with the hospital, we suggest
promptly filing your complaint with one or more external organizations.

Patients’ rights
It is very necessary for hospital staff to familiarize themselves with hospital's
patient rights. You should develop the patient’s rights base on your setting and

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just paste it in public area to be visible by all your costumers. Costumers can
then cite the patient right that applies to their particular complaint.
The Joint Commission, which is the national accrediting organization for most
hospitals in many countries, adopted patient rights standards many years ago.
All hospitals accredited by the Joint Commission are required to adopt their own
patient rights policies based on the Joint Commission's standards, and to provide
a copy to each patient. These patient rights policies are routinely provided by the
hospital to patients and their families during the pre-admission or admission
process. Here are the Joint Commission's patient rights standards.
• The hospital respects the rights of patients.
• Patients receive information about their rights.
• Patients are involved in decisions about care, treatment and services
provided.
• Informed consent is obtained.
• Consent is obtained for recording or filming made for purposes other than
the identification, diagnosis or treatment of the patients.
• Patients receive adequate information about the person(s) responsible for
the delivery of their care, treatment, and services.
• Patients have the right to refuse care, treatment, and services in
accordance with law and regulation.
• The hospital addresses the wishes of the patient relating to end-of-life
decisions.
• Patients and, when appropriate, their families are informed about the
outcomes of care, treatment, and services that have been provided,
including unanticipated outcomes.
• The hospital respects the patient's right to and need for effective
communication.
• The hospital addresses the resolution of complaints from patients and
their families.
• The hospital respects the needs of patients for confidentiality, privacy, and
security.

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 • Patients have a right to an environment that preserves dignity and
contributes to a positive self image.
• Patients have the right to be free from mental, physical, sexual, and verbal
abuse, neglect, and exploitation.
• Patients have the right to pain management.
• Patients have a right to access protective and advocacy services.
• The hospital protects research subjects and respects their rights during
research, investigation, and clinical trials involving human subjects.
• In hospitals that provide opportunities for work, a defined policy addresses
situations in which patients work.
Right to billing information: Under Organization Ethics, there is an "element of
performance" which states: "Patients receive information about charges for which
they will be responsible."

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Session 11: Hospital Information System
The HMIS is a system based on qualitative and quantitative indicators where
data is collected, processed, analyzed, interpreted, disseminated, and used to
improve the provision of health services according and ultimately to improve the
health of the population. In addition, the information generated can be used for
research and training purposes.
A hospital information system (HIS), variously also called clinical information
system (CIS) is a comprehensive, integrated information system designed to
manage the administrative, financial and clinical aspects of a hospital. This
encompasses paper-based information processing as well as data processing
machines.
It can be composed of one or a few software components with specialty-specific
extensions as well as of a large variety of sub-systems in medical specialties.
CIS are sometimes separated from HIS in that the former concentrate on patient-
related and clinical-state-related data whereas the latter keeps track of
administrative issues. The distinction is not always clear and there is
contradictory evidence against a consistent use of both terms.
The advance Hospital management system is a web based software system
which regulates each and every function of Hospital with 50-1000 beds. The
software registers a patient, recommends him the required treatment, and gets
admitted. That means right from Patient Registration, OPD, Ward Management,
Radiology, Pathology, Pharmacy, Store, Inventory, HR & Payroll, Finance &
Accounts, Help Desk, kitchen & Laundry, MRD, Dash board, MIS Reports you
have all the modules integrated and functional with our package. A person who
enters the cycle by getting registered and till the time he gets out of the cycle by
finally settling his/her bills and getting discharged from the hospital is all the
automated. All the process during his entry to exit is also performed by different
modules deployed at different locations which is all integrated and made
functional.

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Working principles for revising the HMIS
The working principles which is developed and applied are worth of mentioning
here and it should be taken into account when the hospital is collecting data or
health information.
1. Any data to be recorded at a service level must have a use (action) in
terms of case or community management by staff or community members
at that level.
2. Proposed changes should simplify the existing system.
3. Any changes or developments to data recording and reporting should be
made only to improve the provision of care at the patient and community
level, particularly for those populations most in need.
4. Great prudence should be applied when making changes to components of
health information systems that are working fairly well. If it is working well
now, don't fix it.
5. Efforts should be made to make better use of existing data at all levels
through practical analysis and improved presentation of data.
6. Modest use of computerization should be encouraged and supported for
data base maintenance and report generation.
7. Improvement in health data generation and use at the various service
levels should be undertaken in support of efforts to improve service task
performance and be seen as a by-product of such performance
improvement.

Criteria for Health Indicator selection

Health Indicators, in particular those obtained through routine reporting systems,
should be chosen for national use with the following criteria in mind:
1. Useful for action at the recording level - The data needed for the indicator
is useful for the person doing the recording (manager, staff, community
leader or patient) and the recorded data contributes to necessary action
being take with regard to the case, family, community or district being
served

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 2. Valid, consistent, reliable and sensitive - The indicators should have been
proven capable of being recorded across the service with the necessary
degree of validity, consistency and reliability, and be sensitive to short
term changes in the variable of interest.
3. Ease of Generation and Measurement.
4. Understandable - The indicator should deal with a single clear idea which
everyone will see as an important measure.
5. Representative - Indicators should be selected that can be a measure of
health status or service performance beyond the immediate event or task
being reported.
6. Relevant for National and Program Monitoring
7. Ethical - Data collection, including the choice of the data source,
computation of the indicator and its use should not conflict with accepted
ethical values, and follow the values of the MOPH.

Importance of Health Information System

By increasing the population of the country and rising hospital management
costs, a shortage of healthcare workers, challenges in accessing services, timely
availability of information, issues of safety and quality, and rising consumerism
are some of the facts of today’s healthcare system. The critical questions facing
the hospitals and other healthcare institutions today include: how can we
effectively manage hospitals and provide enhanced services without placing
additional burden on a system already pushed to its limits; how can we provide
care in a cost-efficient manner at a time when healthcare spending is rising; and
how do we most efficiently use our resources and support front-line staff in order
to reduce medical errors and enhance quality of care.
These are just a few questions facing the hospitals systems. The answers is
developing the new generation of Hospital Information System (HIS) or Hospital
& Information Management System (HIMS) that would be powerful, flexible and
easy to use and would have been designed & developed to deliver real
conceivable benefits to hospitals. The Health Management Information System
(HMIS) in Afghanistan has been conceived by a group of technical and

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professionals with rich and relevant experience in healthcare system. The system
incorporates the healthcare practices which is relevant to BPHS and EPHS and
is designed to deliver key tangible benefits to clients across the heath system
including governmental and non-governmental organizations.
Offering HIMS is comprehensively a revolutionary solution with end-to-end
features for simplifying hospital management. Access to the right information and
the automation of complex tasks & workflow is the key focus of the HMIS and
HMIS, enabling freeing the staff to spend more time on caring for patients and
extending the reach of services.
An HMIS for a hospital would require being very precise and must result in
operational cost reduction, process improvement and efficient management. We
should develop a HIMS solution which would be very accurate in its approach
and suits all environments including large, medium or small hospitals. That is a
need to be taken into account and accomplished by MoPH as an initiative. The
support maybe solicited from private sectors and donors. The new generation of
HIMS should be designed in such a way to cover a wide range of hospital
administration and management processes. It should be integrated to other
databases and with great stability and flexibility. It should be easily customized to
suit the requirements and reflect the priorities of a hospital management team.
By enabling a smooth flow of patient information, the HIMS will enable hospitals
and doctors to better serve their patients. Additionally, the HMIS provides a host
of direct benefits such as easier patient record management, reduced paperwork,
faster information flow between various departments, enhanced availability of
timely and accurate information, reduced length of stay, reduced test requests,
greater organizational flexibility, reliable and timely information, easier resource
management, minimal inventory levels, reduced wastage, reduced waiting time
at the counters for patients and reduced registration time for patients. The
indirect benefit would be an improved image of the hospital and increased
competitive advantage. The HIMS optimizes the resources to be deployed and
helps in prioritizing the developmental activities of the hospital. The system not
only provides an opportunity to the hospital to enhance their patient care but can

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also increase the profitability of the organization. The Return on Investment
coupled with an enhanced image of the hospital act as drivers for healthcare
providers to invest in the HIMS that will keep their patients satisfied. Based on
view points of scholars the patient satisfaction is quality.

Hospital Information System Forms in MoPH

After development of HMIS in 2003, efforts have continuing to include secondary
and tertiary service delivery units in the system. Fortunate the second version of
HMIS manual has presented some forms for collection of data from Hospitals.
They are briefly described here. Following forms are used for data collection from
hospitals. For more detail please refer to actual forms at the annex of this
module.
• Monthly Integrated Activity Report (MIAR)
• Hospital Monthly Inpatient Report
• Hospital Status Report
Monthly Integrated Activity Report – Facilities OPD (MIAR)
Services Report 1. Purpose of the Form
This reporting form has been designed to consolidate into one document most of
the data about health services offered at the BHC/CHC level and the out patient
hospital level. This form is used by BHCs, CHCs, and Hospital outpatient
departments and emergency rooms.
2. Lay-out of the Form
This document is a 2-page form printed on A-4 paper, so that the different
sections are not separated. The form consists of the following main sections:
A. Morbidity of Priority Health Problems
B. Nutrition status
C. Maternal & Neonatal health
D. Stock-outs of Essential drugs and commodities
E. Immunizations
F. Laboratory Exams
G. Tuberculosis

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H. Community Health
I. Report Transmitted
J. Report received/Aggregated
K. Comments
3. Data Sources
The data for this report comes from 9 principal sources:
1. OPD Tally sheet
2. The Antenatal Care Register
3. The Maternity Register
4. EPI register
5. Nutrition Surveillance Register/Child Clinic Register
6. Stock Register
7. Family Planning Register
8. Lab Register
9. TB Register
Some organizations use different registers for each of these data sources; others
combine some of the data sources into one form. Use the form in your facility
which corresponds with the listed data source. The MOPH is testing a tally sheet
in conjunction with a patient card for the sections A, B and C of this report. If the
tally sheet is used, write totals in the corresponding boxes of the MIAR.
4. Person who prepares
Staffs responsible for the various services contribute the data related to their own
activities (e.g., the midwife for data on obstetric care, the Lab technician for
laboratory data, etc.). The senior staff member of the team reviews the report for
accuracy and completeness before signing it and sending it to the PPHO. OPD
attached to Hospitals should also complete a BHC/CHC Monthly activity report in
addition to the Monthly Inpatient Report. Hospital maternity wards (district,
provincial, regional) should use the MIAR for all obstetric services, except for
caesarean and other obstetric surgery services.
5. Definitions

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This form is the key data collection instrument to collect most data required to
calculate HMIS indicators for the BHC/CHC and outpatient hospital level. At the
provincial health office level, data from the forms of all facilities is aggregated to
calculate the indicators at the provincial level.
6. Instructions
This form has a total of 11 sections (A to K).
General information
Province name & code: Write the name and the Geocode of the province where
the facility is located. Use official reference lists to find the name and Geocode.
District name & code: Write the name and the Geocode of the district where the
facility is located. Use official reference lists to find the name and Geocode.
Facility name: Write the full name of the health facility reporting
Facility code: Write the ID code assigned by the MOPH to this facility
Month: Write the number of the month for which the data is being reported
(usually this will be the month prior to the current month)
Year: Write the 4 digit year (shamsi calendar) for which the data is being
reported.
Facility Type: Circle the type of facility, for hospitals, circle the type of hospital:
H1 for regional/national hospitals, H2 for provincial hospitals, H3 for district
hospitals.
Patients/clients: Totals for the corresponding row and column in the MIAR Tally
Sheet are written in each cell. Write the sum of the four preceding columns under
the column labeled “Total new.”
A. OPD Morbidity
In this section, record information about morbidity and visits to your facility during
the month. This information is gathered from the OPD tally sheet. Totals for the
corresponding row and column in the Tally sheet are written in each cell. Write
the sum of the four preceding columns under the column labeled “Total new.”
Use the comments section to highlight any unusual cases that you treated or to
explain any disease trends that you have noticed in the catchment area of your
facility.

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B. Nutrition Status
Write the totals of the corresponding cells of the tally sheet in each cell.
C. Maternal Health
Write the totals of the corresponding cells of the tally sheet in each cell.
D. Status of Stock of Essential Drugs
Go through the stock register (and check shelves where you may keep drugs for
day to day distribution) and place a cross (X) in the box to the left of any of the
indicator drugs (listed below) which was not present for one or more days during
the month. Situations, in which a couple of tablets of a drug remain, but not a
number sufficient to serve patients, should also be considered as the drug not
being present. If the drug was present every single day of the month, a tick-off
( ) should be placed in the box to the left of name of the drug name:
X = during the last month, this drug was not present one day or more
= during the last month this drug was present every single day
Although the stock position of all drugs should be monitored regularly, the
following is the list of essential drugs for which the stock status should be
reported monthly:

Oral contraceptive
Injectable contraceptive Acetyl Salicylic Acid/Paracetamol , Mebendazole
Amoxicillin/Ampicillin, INH, Rifampicin, Amp. Diazepam, Inj. Lidocaine
Metronidazole ,Co-trimoxazole, Anti-hypertensives, Condoms, IUD, TT vaccine
DPT vaccine, ORS, Vitamin A, Chloroquine, Sulfadoxine + Pyrimethamin
Ferrous Suplhate + folic acid, Oxytocin, Gloves, D2.
Comments about stock situation: Use this space to note any special drug stock
problems – this could include overstocks, understocks, expiring drugs that have
been destroyed, drugs that were received in bad condition.
E. Immunizations
E1. Childhood Immunizations: Record in the boxes the total number of doses of
DPT3 administered by age group. “Total” is the sum of all children who received
DPT3: 0-11 + 12- 23 + children two years and older. This information can be

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found in the EPI Monthly Vaccination Activity Report. Similarly, from the same
report note for each age group, the doses of vitamin A administered. “Total” is
the sum of all children:0-11 + 12-23 + older children who received vitamin A.
E2. TT Immunizations
Record the total number of Tetanus Toxoïd immunizations given to pregnant
women. In the column TT2, list the number of TT2 doses given. In the column
>TT2, list the sum of all TT shots given after the second shot (TT3,TT4, c) This
information should be calculated from the EPI monthly tally sheet.
F. Laboratory Exams:
Although many facilities conduct a number of other lab tests that should be
recorded in the laboratory register, only the following tests and test results should
be reported because they confirm diagnoses of priority health problems. If
necessary, use a tally sheet to abstract the data from the laboratory register.
F1. Blood
Total malaria slides examined: total blood slides examined from for
malaria
Total PF positive: slides positive for Plasmodium Falciparum
Total other Positive: slides positive for Plasmodium Vivax or other
plasmodia, but not for Plasmodium Falciparum
Total HIV examined: total blood specimen examined for HIV
Total HIV positive: number of blood specimen positive for HIV
F2. Sputum
Total AFB slides examined: all sputum slides examined for AFB
Total AFB positive: number of slides found AFB +
G. Tuberculosis
This section is only filled out if the facility is involved in tuberculosis diagnosis
and treatment.
G1. Case detection
Number of new smear (+) cases: from the Monthly Report on Tuberculosis
Case- Finding: Sum of male and female pulmonary smear (+) cases.

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 Number that started treatment: from TB Treatment register: all smear (+)
patients with a treatment start date within the past month and a pre-
treatment positive lab result.
G2. Treatment success
Number of cases completed treatment and smear (-): from the TB treatment
register: all initially smear (+) patients that completed their treatment and tested
negative after they completed the treatment.
H. Community Health
1. No. of community meetings held with the community health committee:
number of meetings held in which the facility staff went to the village to meet with
the health committee
2. Number CHWs visited for supervision: obtained from the CHW supervisory
log.
I. Report Submitted
These details should be completed to trace the submission of the report. The
boxes should be filled by the health worker in charge of the facility who prepared
the report or checked the report for completeness before sending it to the PPHO.
Name: Enter the name of the health worker who was in charge of the facility at
the time the report was submitted,
Designation: Enter the designation of the person submitting the report.
Date: Write the date that the completed report was submitted (i.e., mailed or
dispatched by courier).
Signature: Sign the report.
J. Report received/aggregated
Date Received: The in-charge in the Provincial Health Directorate who receives
the report should note the date that the report was received at the office. This
should be recorded in the dispatch/receipt register.
Date aggregated: The person who completes the aggregation of the data on
paper or the entry of the data onto the computer should enter the date that the
report was aggregated / entered.
K. Comments

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Use this space to note special activities or problems in the BHC/CHC or
community during the reporting period or to explain significant trends or
anomalies in morbidity or service delivery. Add an extra sheet, if required. This is
an important mechanism to communicate important issues to your supervisor
and to explain your analyses of health problem and service trends.
7. Submission Guidelines:
This report is to be prepared by the staff member responsible for each of the key
service areas included: Ante-Natal Clinic, Maternity, Nutrition/Child Clinic,
Reproductive Health service, Laboratory, and Pharmacy. The data are reported
from all OPDs: Hospitals, BHC and CHCs. For hospitals, the emergency room
also fills out this form; the in-charge of the hospital combines the data of the OPD
and the emergency room into one MIAR. The in-charge of the health facility must
review the report for missing data and other anomalies, note any comments
about important trends or problems in the catchment area and dispatch it to the
PPHO within 7 days of the end of each month. A copy of each report should be
kept in a chronological file within the facility.

Hospital Monthly Inpatient Report (HMIR)

1. Purpose of the Form
The purpose of this form is to report about inpatient activities, services, morbidity
and mortality at district, provincial and regional hospitals. The primary focus is on
indoor patients and referral services.
The hospitals report maternity care, outpatient services, and laboratory services
using the same Monthly Integrated Activity Report (MIAR) that is completed by
Basic Health Centers (BHCs) and comprehensive Health Centers (CHCs.)
2. Lay-out of the Form
The form contains nine sections:
A. Indoor patients
B. Nutrition of under fives
C. Imaging services
D. Other Surgical services
E. Stock out of hospital drugs

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F. Cases and deaths of priority diseases
G. Comments
H. New inpatient cases
I. Report submission
3. Data Sources
The data for the form comes from:
• Indoor Patient Registers of each departments (including nutrition)
• Daily Indoor Patient Census of each departments
• Operating Theatre Registers
• X-ray and Ultrasound Register
• Pharmacy
4. Who prepares
This form is mainly used to report information about referral services provided at
district, provincial and regional hospitals. The document is prepared by the staff
of the various departments and then compiled under the supervision of the
Hospital Director. The report is sent to the PPHO by the 7th day of each month.
The PPHO enters all hospital data into the HMIS database and sends a quarterly
electronic copy to MOPH/HMIS
5. Definitions
Most of the terms on this form are self-explanatory. There are two calculated
entries:
Number of Patient Days: This number is an indicator of the volume of indoor
patients who are treated during a given month. An example for the calculation of
this indicator is included below in the Detailed Instructions.
Average length of stay: This number is an indicator of the efficiency of
hospitalization. To calculate this indicator, take the sum of the duration of
hospitalization for all patients who were discharged during the month and divide it
by the total number of patients discharged during that month. An example for the
calculation of this indicator is included below in the Detailed Instructions.
6. Detailed Instructions
General information

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Province Code & Name: Write the Geocode and the name of the province
where the hospital is located
District Code & Name: Write the Geocode and the name of the district where
the hospital is located
Hospital Name: Write the name of the hospital
Facility Code: Write the MOPH ID code that identifies the Hospital
Type of hospital: Tick H1 (National or specialized hospital), H2 (Regional or
provincial hospital, H3 (District hospital)
A. Indoor Patients
Using the Indoor Patient Register, provide a summary of patient movements
during the month in the categories listed below. For each of the listed categories,
write the total number of children under five, females over five and males over
five.
1. Admissions: all patients admitted as inpatients. Note that maternal and
neonatal data related to deliveries performed at the hospital are noted on the
MIAR. However, those hospitalized are included in the general admission
register and counted here.
2. Referred-in: count those who have been referred-in from other health
facilities, including those who originated in your hospital’s outpatient
departments.
3. Deaths: all inpatients who died in the hospital before being discharged
4. Number of Patient days: Add together the number of patients who stayed
each night during the month. See the box below or an example.

6 7 8 4 4 8 8 5 5 6 7 9 10 7 8 5 3 4 4 6 7 7 7 7 8 5 8 8 8 5 x total =191

For example, if there were 6 people on the 1st, 7 on the 2nd, 8 on the 3rd, etc.,
the number of patient days would be 6+7+8+etcc or at total of 191. In the
example, the month has only 30 days, so day 31 is not counted. The number of
daily inpatients should be obtained from the census conducted each morning.
The number of patient days per month when combined with the number of

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available beds during the same period allows calculation of the bed occupancy
rate.
Average length of stay: sum of the duration of hospitalization for all patients
who were discharged during the month divided by the total number of patients
who were discharged or died during that month. In the example given, 23
patients were discharged or died during the month and they stayed in the
hospital for a total of 191 days: an average length of stay of 8.3 days.
Average length of stay
Number of patients Number of days for stays Average days
discharged or died hospitalized
23 Total =191 ALS=191/23=8.3

5. Discharged: Note the total number of inpatients discharged. For the

discharged patients, write the total that corresponds to each category:
a. Recovered/improved: inpatients that were discharged because their status
improved, including those who need some further ambulatory care
b. Absconded/defaulted: patients that are no longer hospitalized, but whose
whereabouts are unknown. Ideally, this number should be zero.
c. Not Improved: patients who were discharged without improvement in status.
This includes patients whose status did not improve, for whom no further
treatment is useful.
d. Referred-out: those patients who have been referred to other medical
facilities for more specialized care.
B. Nutrition of under fives
Only malnourished children who need hospitalization are taken into account.
Ambulatory screening and treatment of the nutritional status of children under
five is noted in the MIAR.
1. Admitted: Number of malnourished children admitted into the hospital
2. Improved: Number discharged with improvement
3. Defaulter: dropped out, left the hospital before being discharged

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4. Referred out: Number of hospitalized malnourished children referred to other
facilities for more specialized care
5. Deaths: number of malnourished children who died
C. Imaging services
Using the imaging department records, report the number of images taken during
the month according to the following categories:
1. Chest x-ray
2. Abdomen x-ray
3. Skeletal x-ray
4. Other x-ray
5. Ultrasound
D. Other Surgical interventions
Using the operation theatre (OT) register, you record the total number of surgical
interventions of the following types that were performed during the month. Be
sure to sort them out by Major (under general anesthesia) and minor (under local
or regional anesthesia) interventions.
1. Gynecological: all gynecological interventions, except obstetric interventions,
which are already captured in the MIAR. This includes all interventions on the
female genital tract and breast.
2. ENT
3. Eye
4. Orthopedic: all orthopedic and traumatic surgery not pertaining to any of
those listed under 1, 2, 3.
5. Others: any surgical intervention, not listed under F1, F2, F3, F4.
6. Total: total of the above
7. Post operative deaths: number of patients who die within 10 days of surgery
8. Post operative complications: number of patients who have complications of
the surgical intervention: local or general infection; bleeding; re-intervention.
9. Blood transfusions: the number of patients who received a blood transfusion.
This also includes patients who undergo cesarean sections and other obstetric
surgery.

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10. Blood transfusion reactions: number patients with adverse reactions
following blood transfusion. This also includes patients who undergo cesarean
sections and other obstetric surgery.
E. Stock status of hospital drugs
Go through the stock register (and check the shelves where you may keep some
drugs for day to day distribution) and place a cross (X) in the box to the right of
any of the following indicator drugs that was not present for one or more days
during the month. Situations, in which a couple of tablets of a drug remain, but
not a number sufficient to serve patients, should also be considered as the drug
not being present. If the drug was present every single day of the month, a tick-
off X) should be placed in the box to the left of the name of the drug:
X = during the last month, this drug was not present one day or more
= during the last month this drug was present every single day
Although the stock position of all drugs should be monitored regularly, the
following is the list of essential drugs whose stock status should be reported
monthly:
Arthesunate inj
Atropine inj
Benzathine Penicilline inj
Digoxine
Ergometrine inj
Furosemide inj
Gentamycine inj
Iodine poluvidone
Ketamine inj
Lidocaine 5% spinal inj
Magnesium Sulphate
Morphine inj
Naloxone inj
Hydralazine inj
Oxygen

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 Pethidine inj
Phenobarbital inj
Quinine inj
Ranitidine inj
Ringer lactate IV
Salbutamol inj
Sodium chloride IV
F. Cases and Fatalities for Priority Diseases
Using the indoor patients register, note the total number of admissions and
deaths for the following priority diseases/health problems. To simplify calculation,
record only the total deaths and total admissions during the month – even if
some of the deaths may have been from admissions during previous months. Be
sure to focus on admissions and death in <5 children for Diarrhoea, ARI with
pneumonia, Measles.
G. Comments
Note any particular issues or trends that you wish to highlight at the central level
H. New Indoor Cases of Morbidity
Using the indoor patient register, tally up the number of patients admitted during
the month for each of the priority health problems/diseases listed. Include only
inpatients, do not include outpatients. Cases definitions are given in Annex 3.
I. Report Submission
This section should be filled out by the person responsible for submitting and
receiving the report.
Report Submitted
These details should be completed to trace the submission of the report. The
boxes should be filled by the hospital in-charge who prepared the report or
checked the report for completeness before sending it to the PPHO.
Name: Enter the name of the hospital in-charge at the time the report was
submitted,
Designation: Enter the designation of the person submitting the report.

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Date: Write the date that the completed report was submitted (i.e., mailed or
dispatched by courier).
Signature: Sign the report.
Report received/aggregated
Received by: Initials of the person at the PPHO who receives the report
Date Received: The in-charge in the Provincial Public Health Office who
receives the report should note the date that the report was received at the office.
This should be recorded in the dispatch/receipt register.
Aggregated/computerized by: Initials of the person(s) who aggregates /
computerizes the report
Date aggregated: The person who completes the aggregation of the data on
paper or the entry of the data onto the computer should enter the date that the
report was aggregated / entered.
7. Submission Guidelines:
This report is to be prepared by the staff member responsible for each of the key
service areas included. The data are reported from all Inpatient departments. The
in-charge of the hospital must review the report for missing data and other
anomalies, note any comments about important trends or problems in the
catchment area and dispatch it to the PPHO within 7 days of the end of each
month. A copy of each report should be kept in a chronological file within the
hospital.
Hospital Status Report Form (HSR) R-2)
1. Purpose of the Form
The purpose of this form is to report on the physical facility and human resources
available at the Hospital. This form also captures some hospital activities that are
not directly clinical activities. The hospital staff and provincial level health
authorities use this information to assess the adequacy of physical facilities and
human resources to ensure uninterrupted health services at the hospital. While
usually required on an annual basis, during periods of rapid expansion of or a
change in the level of health services, the MoPH may require the report on a six-
monthly or quarterly basis.

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2. Lay-out
The form is an A4 two page (four sides) form, printed in landscape mode.
The report contains 7 sections:
A. General Hospital Information
B. Human Resources
C. Supervision
D. Equipment list
E. Services provided
F. Remarks and observations
G. Report submission
3. Data Sources
The data for the form comes from
1. Inventory Register
2. Visitor’s Book
3. Facility inspection
4. Various activity records (e.g. Health Education)
5. Staff records
6. Diary or register of IEC and other activities
If records are not available or are incomplete, the in-charge of the facility will
personally check the accuracy of the required information and complete the
information. If data is ultimately not available for a reporting period, the in-charge
will note “NA” in the corresponding entry.
4. Who Prepares
The in-charge of the hospital prepares two copies of this form. When reporting
annually, one copy is submitted to the PPHO by the 15th of Hamal each year, or,
when reporting six monthly or quarterly, submitted by the 15th of the month after
the last month in the reporting period. Another copy is filed at the hospital for
future reference.
5. Definitions
MD medical doctor
CHW community health worker

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6. Instructions
A. General Facility Information
1. Province Code & Name: Write the Geocode and the name of the province
where the hospital is located
2. District Code & Name: Write the Geocode and the name of the district where
the hospital is located
3. Hospital Code & Name: Write the MoPH ID code and the name of the
hospital
4. Type of hospital: circle H1 (National or specialized hospital), H2 (Regional or
provincial hospital, H3 (District hospital)
5. Period: Write the months (fromc to c.) and the year (ofcc) for which the
report is being prepared. Dates should reflect the Afghan Shamsi calendar.
When the report is prepared annually, note that this year is not the same as the
year you are preparing the report. When you are reporting more frequently, the
same is true for the first reporting period of the year. For example, if you are
preparing the report in the month of Hamal of 1381, write 1380 here because the
report you are preparing is for year 1380.
6. Building: A building is considered temporary if the building’s original and
permanent future intended use was/is use for something other than a health
facility.
Examples of temporary buildings are tents and prefab structures used while the
hospital building is being renovated or enlarged, schools or other public buildings
used as health facilities, rented houses, shops, or other buildings. A building is
considered permanent if the original or permanent future use is as a health
facility.
7. Main construction material: circle concrete or other. “Concrete” means
having at least a concrete base and concrete supporting beams for walls and
roof (in theory, earthquake proof. The “concrete” reflects the Dari term “ ‫ ” پخته‬and
the “other” reflects the Dari term “ .”‫خام‬
8. Main source of drinking water: this refers to the usual source of drinking
water. If a facility normally uses a water tap, except for the dry months, when it

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uses a well, the main source of drinking water is the water tap. Safe means water
obtained from a covered deep well, a tube well with a covered base, piped water,
and/or chlorinated water from closed containers. Other means all other sources.
9. Main source available: Write the number of months the main source of
drinking water is available; write “12” if the source is available throughout the
year.
10 Electricity: circle YES if available, even only a few hours a day, and NO if not
available at all.
11. If Electricity is YES, indicate the main source of electricity by ticking any
one of the options. If the facility relies usually on line electricity, and has
generator backup, only line should be ticked.
12. Indicate the Average hours per 24 hours that electricity from the main
source is available, e.g., if line electricity is available six hours a day and a
generator is used two hours a day on average, write “six”
13. On drivable road: Circle YES or NO to indicate whether or not the facility is
located on a drivable road.
14. If not, walking time from road: If the answer is “No,” write the number of
hours and minutes needed to walk to the nearest drivable road, e.g., 90 minutes,
note as 1 hour 30 minutes. A “drivable road” is any road regularly used by
motorized vehicles, regardless of its shape or condition.
15. Referral facility name & code: write the name and the MOPH ID code of the
most frequently used referral facility--the general facility (hospital) that is most
often used for complicated cases. Many facilities can use a specialized hospital
(e.g., eye hospital) for specific cases – do not write the name of this hospital.
16. Latrine for use by patients: circle YES if there are latrines for patients, NO
if not. If the facility has latrines for use by staff of the facility only, the answer
should be NO.
17. If Yes, type: If YES is circled, mark the type of latrine. Open means that flies
and other animals have access to the waste, e.g., the traditional Afghan latrines.
Closed means flies and other animals have no access to the waste, e.g., VIP
latrines, flush latrines, etc.

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18. Separate latrine for male and female: circle YES if there are separate
latrines for men and women, circle NO if there are not.
19. No. of Beds: Write the number of patient beds currently available at the
hospital for each of the wards. This includes both occupied and unoccupied
beds.
20. Waste disposal: Circle YES or NO as to whether the facility has a special
area for medical waste.
21 If YES, type: mark the type of waste disposal. Incinerator means a special
device to completely burn the medical waste. Burn and bury means a place
where waste is accumulated, then burned and buried at regular intervals.
(Beware that an oven-like construction is often referred to as “incinerator” in
Afghanistan when it really is a “burn and bury.” ) Other means any other than the
afore-mentioned or none.
24. Main source of support: write the name of the agency that delivers the
greatest regular support to the facilities’ activities. This can be the MOPH, a
specific UN agency, an NGO, a donor. If it is a UN agency, NGO or donor, write
the specific name.
25. Other sources of support: write the specific name of all other agencies that
support the facility in one way or another.
B. Human Resources
The staff categories listed is those listed in the BPHS for hospitals. Note that a
DH has staff required for BPHS and additional staff for the EPHS. Write down the
number of female and male staff of each category. Write the number of staff in
each category who are certified according to the new MOPH certification rules
and the number of staff who attended at least one refresher training during the
last reporting period.
B2. Physicians
11. Medical Specialist: any MD specialist who is not a Surgeon, Anesthetist,
Pediatrician or Dentist.
B5. Support Staff

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34. Administrative staff: any clerks, computer operators, accountants, etc. The
in charge of the administration of the hospital is listed under management: 4.
Administrator
C. Supervision
Write the number of supervisory visits to this facility performed during the last
reporting period by the PPHO and by others (NGO, UN agency, and donor).
Count only supervisory visits, not monitoring or evaluation visits.
D. Equipment list
For each of the listed types of equipments, mark the number that are present in
the facility. The actual number is useful for the in-charge of the hospital. For
several items, the actual number becomes less useful for provincial and national
analysis. For larger facilities, the in-charge will have to sum reports from different
departments.
Usable: The equipment is new and complete, or some parts or accessories may
be missing but the equipment can still be used for its basic functions, e.g., some
clamp or forceps of the Minor Surgery Kit may be missing, but the kit can still be
used; however, if only a scalpel and needle holder are left, the kit is no longer
usable.
Not usable: pieces are missing or broken to the extent that the equipment
cannot be used for its basic function.
E. Services provided
Mark for each of the listed services whether or not they were provided on a
regular basis during the past reporting period.
E1. General Curative
2. IMCI implemented means that all modules of the IMCI are being
implemented: ARI, Diarrheal, Fever & malaria case management, EPI, growth
monitoring. All of the separately mentioned modules need to tick off as well. If
IMCI is not completely implemented, IMCI should not be ticked off, but the
specific services (ARI, DD, malaria, EPI, Growth monitoring) that are provided
need to be ticked off.
E2. Child Health

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4. Management of severely ill child means the treatment of referred, severely
ill children (IMCI classification).
E10. Community services
1. CHWs supervised once: write the number of CHWs who were supervised at
least once this quarter.
2. Health Post Active: write the number of Health Posts active and reporting to
this facility
3. Health Posts Supervised once: write the number of Health Posts supervised
at least once this quarter
F. Remarks and observations
Write all notable achievements, observations or experiences regarding the
functioning of the facility during the last reporting period in this space. For
example, if the facility was closed for a period of time, mention this as well as the
reason for the closure, or, if a particular service was not delivered during the
reporting period, provide the reason it was not delivered and suggest a remedy.
G. Report submission
Finally, the person that filled out the report should provide his/her name and
designation, as well as the date of the report, and sign.
7. Submission guidelines
The in-charge of the hospital fills out two copies of this report. When reporting
annually, one copy is sent to the PPHO by the 15th of Hamal of each year; the
other copy is filed and kept in the facility. When reporting more frequently, the
report is sent by the 15th of the month after the last month of the reporting
period.

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Session 12: Waste Management in Hospitals
Hospitals produce many types of waste material, housekeeping activity
generates considerable amount of trash, and visitors and others bring with them
food and other materials which must in some way be disposed of. In addition to
the waste that is produced in many residential buildings, hospital generates
pathological waste— blood soaked dressings, carcasses and similar waste.
These waste material must be suitably disposed of immediately lest they putrefy,
emit foul smells, and as a source of infection and diseases, and become a public
health hazard. While in developing countries many of the public health problems
are also related to defective sewage and waste disposal.
Many of our hospitals neither have a satisfactory waste disposal system nor a
waste management policy and disposal policy. The disposal of waste in
exclusively entrusted to the junior most staff from the housekeeping department
without any supervision, and even pathological waste are observed to be
disposed off in the available open ground around hospitals with scant regard to
aesthetic and hygiene considerations.
Waste can be defined as any discarded, unwanted residual matter arising from
the hospital or activities related to the hospital. Disposal covers the total process
of collecting, handling, packing, storage, transportations and final treatment of
wastes. On an average, the volume of total solid waste in hospitals in India is
estimated to range between 1- 3 kg per day on per bed basis. While the quantum
of waste in advanced countries is six to ten times more. The average refuge in
hospitals in Denmark and Germany is 14kg per bed per day. Unfortunately in
Afghanistan it is still not studied and low attention is given to this critical issue in
hospitals.

Types of wastes
Hospital waste can be divided into two major groups. The first group comprises
of mainly solid waste, and the second group mainly liquid waste. Waste covered
under group I include the following.

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Table: solid waste of hospitals
# Main category
1 Dry garbage
2 Wet garbage
3 We tissues and bones
4 Plaster casts
5 Packing materials
6 Surgical wastes
7 Metal wastes
8 Glass
9 Disposable plastic items
Descriptions
Ordinary floor refuse, papers, flowers, trash
Waste from kitchen ( fruit peels, left over food,
etc)
From operational theatres labor rooms,
mortuary, laboratory
From plaster rooms
Cardboard cartons, paper packets, etc
Dressings, cotton pads
The cans, bottle caps. Needles
Broken bottles, syringes
From all areas in hospitals

The group II of hospital waste covers sullage and sewage which emanates from
bathrooms, lavatories, toilets, kitchen, pantries, operations theatre, dressing
rooms, laboratory and laundry. To this must be added the waste from radiology
department comprising of chemical developers and fixers solutions. The quantity
of total liquid waste is estimated at 300 to 400 liter s per bed per day.
A third group of hospital waste is the radioactive waste from radiotherapy and
nuclear department (if available), usually in large teaching hospitals. The
quantum of such waste per se is very little, but requires and understanding of
principles of disposal of such wastes produced in the department itself and also
that excreted by the patients.
Then hospital waste disposal covers solid waste— whether biological or non
biological— that is discharged and not intended for further use, including
materials generated as a result of direct patient care activities— such waste can
be termed medical waste, and includes infection waste that can transmit the
disease (e.g. microbiological waste, discarded laboratory glassware and
materials, intravenous tubes, syringes, needles and dressings).

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Characteristics of a good waste disposal system
Incidents of inappropriate waste disposal and the fear of AIDS and Hepatitis have
drawn medical attentions to hospital waste management practices. Any good
waste disposal system should be planned for:
• Good appearance
• Safety
• Pest control
• Odor control
• Public health safety
The system should also be sanitary, economical and convenient. During the
planning stage attention should have been given to the routes by which garbage
and infected material are to be removed. In principle firstly the garbage and
infected materials should be removed from this point of origin by direct (and
shortest) routes without using hospital corridors. In tall building a lift for garbage
is necessary.
Secondly the movement of dirty and infected material should be restricted to the
minimum. Thirdly, handling and transportation of the waste within the hospital
premises should also be minimized.

Collection and Removal of wastes

Whatever the final method of disposal, collection is an important aspect. The
method of collection will depend upon the method of disposal. Collection can be
done in waste baskets, wheel barrows or in trash carts. Waste baskets made of
metal are preferable to wicker or wood for ease of cleaning. Trash carts should
have two sets of containers wherein after collection of dirty filled container, and
empty clean container is replaced in its place. Timing of collection and removal
should be convenient to all departments. It should be avoided during normal
hospital routine or while the patients are resting. Collection of removal should be
free of noise to avoid disturbing the patients. Trash removed in cans should be in
covered containers to avoid and unsightly appearance.

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Disposal of waste
Waste disposal is a problem that is rapidly assuming alarming proportions.
There is no epidemiological evidence to suggest that most hospital waste is any
more infective than residential waste. There is no also epidemiological evidence
that hospital waste has caused disease in the community as a result of improper
disposal. Therefore, identifying wastes for which special precautions are
indicated is largely a matter of judgment about the relative risk of disease
transmission.
However, hospital wastes, for which special precautions appear prudent, include
microbiology and laboratory waste, pathology wastes and blood specimens or
blood products. Infected wastes in general should better incinerate or should be
autoclaved before disposal in a sanitary land fill. All blood, suction fluid, excretion
and secretions of infective cause maybe carefully pour down in a drain
connected to a sanitary sewer. Sanitary sewers maybe also used to dispose of
other infectious waste capable of hospital of being group and flushed in the
sewer.
Disposal of hospital waste has public health implications as compared to such
material from the community because of the potentially dangerous nature of such
waste as mentioned earlier. Whatever the method of disposal it has to be
carefully chosen and regularly supervised. The principle in the mode of disposal
of waste is to treat the waste appropriately at the source itself and then ensuring
its hygiene transportation to the site of final treatment, and that during the internal
transportation of the waste within the hospital, it should not come in close vicinity
of patients.

Classification of waste
From the final disposal point of view, based on their combustibility and moisture
content, waste has been classified into sic types.
1. Type 0 wastes: Trash: type 0 wastes is a mixture of highly combustible
waste such as papers, cardboard, cartons, wooden boxes, and
combustible floor seeping from commercial, industrial and housekeeping

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 activities. These types of waste contain 10% moisture, 5% incombustible
solids and have a heating value of 8500 BTU/lb as fired.
2. Type 1 waste: Rubbish: rubbish consists of combustible waste such
as paper, cartons, rags, wood scraps, saw-dist, foliage, and floor
sweeping from domestic commercial and industrial activities. This type of
waste contains up to 25% moisture, up to 10% incombustible solids, and
has a heating value of 6500 BT/lb as fired.
3. Type 2 Waste: Refuge: refuge consists of an approximately even
mixture of rubbish and garbage by weight. This type of waste is common
to residential blocks, and contains up to 50% moisture ,7% incombustible
solids, and has a heating value of 4300 BTU/lb as fired
4. Type 3 Waste: Garbage: gar b age consists of animal and vegetable
wastes from restaurants, cafeterias, hotels, hospitals, markets and similar
establishments. This type of waste contains up to 70% moisture, up to 5%
incombustible solids and has a heating value of 2500 BT/lb as fired.
5. Type 4 Waste: Pathological: it is human and animal remains
consisting of carcasses, organs, and solid organic wastes from hospitals,
laboratories, abattoirs, animal pounds and similar source, containing up to
85% moisture , 5% incombustible solids and having the heating value of
1000 BTU/lb as fired.
6. Type 5 and 6 Waste: Industrial Operations: these types of waste
are byproduct waste, gaseous, liquid of semi liquid and solid from
industrial operations. Calorific values must be determined individually to
be destroyed.

Methods of disposal
In general, the methods available for disposal of refuge are as follows:
1. Storage at a central point in the hospital from where it is removed by the
local municipal authority. In most public hospital this method is being
followed. Needless to say, this is the most unsatisfactory method posing
public health problems.

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 2. Refrigerated storage in cans in a walk-in-type of refrigerated facility has
the advantage of minimizing unpleasant odors.
3. Food scrap can also by flushed out
4. Sanitary land fill is a method is suitable for small hospitals where all types
of garbage is filled in pits, each filling being covered with layers of loose
earth.
5. Burning in conventional incinerators or electrical or oil-fired incinerators.

Infection Prevention and Waste Management in

Hospitals
MoPH in has developed the Procedures Manual for Infection Prevention and
Control in Hospitals and Health Centers with the aims to ensure a safe and clean
environment to protect people who handle waste items from accidental injury, to
prevent the spread of infection to healthcare workers who handle the waste, to
prevent the spread of infection to the local community, and safely dispose of
hazardous materials (toxic chemicals and radioactive compounds).

Policy:

Waste Segregation
• The doctor, nurse or any other person generating waste shall separate
hazardous waste from non-hazardous waste at source that is at the
ward bedside, operation theatre, laboratory or any other room in the
hospital where waste is generated.
• Disposable medical equipment and supplies like syringes, needles,
plastic bottles, drips, etc shall be disposed of at the point of use by the
person using them.
• Sharps including syringes and needles shall be placed in safety boxes
resistant to penetration and leakage and these containers shall be
designed in such a way that the items can be dropped in using one
hand.

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 • All HCW shall be classified, colored and labeled appropriately
according to WHO standards.
• A Board of Survey shall be constituted to monitor treatment and
disposal of pharmaceutical waste.
• The pharmaceutical companies shall provide treatment and disposal
methods for their products.
• Distributed pharmaceutical products with shelf life less than six months
shall be returned to the supplier.
• Chemical waste and waste with high content of mercury or cadmin
shall not be incinerated but shall be placed in chemical resistant
containers and sent to specialized treatment facilities.
2. Waste Storage
• A separate central storage facility shall be provided for hazardous waste
at each health facility and be inaccessible to unauthorized persons and
animals.
• A hazardous waste central storage area shall have a sign clearly
mentioning that the facility stores hazardous waste.
• Hazardous waste shall be put in an appropriately color coded container
• The storage facility shall be located within the health facility premises
close to the incinerator (if available) and should be away from food
storage or food preparation areas.
• No waste shall be stored at the central storage facility for more than 1 day
(24 hrs) failing which the waste shall be refrigerated at a temperature of
3oC to 8oC.
• The central storage facility shall be thoroughly cleaned.
• Containers with chemical waste that are to be treated at a specialized
treatment facility shall be stored in a separate room.
• Waste should be stored in closed waste containers
3. Waste Collection

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 • Ground staff, ward/patient attendants when handling HCW shall wear
protective clothing at all times including face masks, industrial aprons,
industrial boots and disposable or heavy duty gloves
• Ground staff, ward/patient attendants shall ensure that:
• Waste shall be collected daily.
• All bags shall be labeled before removal indicating the point of production,
time of production at the health facility and contents.
• Bags and containers that are removed are immediately replaced with new
ones of the same type.
• Where a waste bag is removed from a container, the container is
thoroughly cleaned before a new bag is filled therein.
4. Waste Transportation
• In the case where waste is transported on site (within the health facility
premises), the waste collection equipment (trolley, wheelbarrow) shall be
free of sharp edges, easy to load, unload and clean
• Hazardous waste shall be collected using separate trolleys, wheelbarrows
that shall be solely used for that purpose.
• The collection route shall be the most direct one from the final collection
point to the designated central storage area.
• Transportation off-site shall be the responsibility of the local authority or
legally permitted private agencies that shall follow the stipulated guideline.
5. Waste Treatment and Disposal
• Risk waste shall be inactivated or rendered safe before final disposal by
thermal, chemical, irradiation, incineration or filtration.
• Hazardous waste shall be disposed of by burning in an incinerator or by
burial in a landfill
• Radioactive waste shall be disposed by encapsulation
• Sharps containers not placed in yellow bags for incineration shall be
disposed of by encapsulation or any other method approved by
Afghanistan Bureau of standards.

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 • Disposal methods (burning or incineration, burial in landfill) shall be
operated by a hospital after approval of its Environmental Impact
Assessment
• All hazardous waste delivered to an incinerator shall be burned within 24
hrs.
• Ash and residues from incineration and other methods shall be placed in
non-combustible containers and be disposed off appropriately according
to guidelines
• Landfills for HCW treatment shall be located at sites with minimum risk of
pollution of groundwater and rivers. Access to the site shall also be
restricted to authorized personnel only.
• Each HC shall have functional treatment and disposal facility in operation
at all times.
• Vehicles of the local authorities or permitted private agencies shall take
daily collection of hazardous waste from the health facilities immediately to
the designated landfill or incinerator.
• All liquid hazardous waste shall be discharged into a sewerage system
only after being properly treated and disinfected.
• In case of gaseous radioactive waste, portable filter assemblies shall be
used to extract iodine and xenon.
6. Accidents and Spillages
• In case of accidents or spillage, the following actions shall be taken
• The contaminated area shall be immediately evacuated.
• The contaminated area shall be cleared or disinfected.
• Exposure of the staff shall be limited to the extent possible during the
clean up operation and appropriate immunization carried out
• Any emergency equipment used shall be immediately replaced in the
same location from which it was taken.
• All health staff members shall be properly trained and prepared for
emergency response including procedures for treatment of injuries

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 cleaning up of the contaminated area and all incidents of accidental
spillage reported appropriately.
• The responsible waste management officer shall immediately investigate,
record and review all such incidents to establish causes.
7. Health Care Waste Minimization and Re-Use
• To minimize health care waste, each health facility shall introduce
• Purchase and stock controls, involving current management of the
ordering process to avoid over- stocking.
• Waste recycling programs. This shall involve proper pre-packaging before
sending of un-used health care products or HCW to recycling unit for
reprocessing.
• Waste reduction practices in health facility departments.
8. Training and Capacity Building
• All health-training institutions shall in conjunction with the MOHP,
regulatory bodies and other stakeholders develop and strengthen their
curriculum on HCWM.
• All health – training institutions shall incorporate HCWM into their curricula
by introducing it or strengthening already existing related fields.
• All medical, paramedical, nursing and environmental health students shall
be trained in HCWM principles.
• Evaluation of the implementation of the training program in all health-
related training institution shall be carried out.
• The MOHP in collaboration with regulatory bodies and other stakeholders
shall develop a national training package for HCWM targeting all health
staff (including municipal and private staff working in solid waste
management) so as to enforce HCWM measures, knowledge and good
practices.
• The training package shall be adapted to various professional categories.
• Advocacy on risk awareness and their responsibilities related to HCW to
policy makers and health care facility managers shall be strengthened.

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 • On going training in HCWM shall be ensured by the infection
prevention/HCWM team for each category of medical and non-medical
staff dealing with waste.
• An orientation shall be conducted to each new staff member working in
the health facility. It shall include a comprehensive briefing on HCW
segregation and handling as well as emergency measures to be taken in
case of accident or injury.
9. Community Awareness
• The MOHP (Health Education unit) in collaboration with stakeholders shall
outline requirements for HCWM messages for the community.
• The MOHP in collaboration with other stakeholders shall develop IEC
materials for the community
• The IEC materials on HCWM shall target all Afghans irrespective of their
gender, ethnic background and age.
• The IEC on HCWM materials shall respect cultural norms without limiting
the intended message
Some institutions have put color code for wastes in order to dispose are safely
and appropriately.

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 Color coding: Clinical Waste Segregation

Hospital Waste Stream

Setting Examples
Colour Code
of
Description and Method of
Containers
Disposal
Examples

General waste.
Personal Protective Equipment not
Household Waste
contaminated with body fluids.
Paper towels, disposable cups,
Can go to
newspapers, rinsed medicine tots,
packaging from medication and
Landfill
uncontaminated dressings, bandages
etc

Offensive Waste
Incontinence pads, colostomy bags,
urine bags dressings and PPE
contaminated with body fluids NOT Can go to deep
known to be infectious.
Tiger Bag
Order Code
Landfill MVN 030

This waste must be tagged before disposal – and tag usage recorded in book
Items KNOWN to be contaminated
with infectious pathogens
Infectious Waste
E.g. Dressings from known infected
wounds, and other items that have
Can go to alternative
been in contact with infectious body
fluids
treatments such as
During confirmed outbreaks of
autoclaving then Landfill
infection dispose of incontinence
pads, bedpans, PPE etc
This waste must be tagged before disposal – and tag usage recorded in book

229
 Sharps Waste
Sharps
Needles, syringes, scalpels, stitch, Must go for
cutters, razors, empty ampoules etc.
Incineration

This waste must be tagged before disposal – and tag usage recorded in book

Full clinical waste containers must be placed into the corresponding colour
wheelie bins for collection by the waste contractor

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Session 13: Report writing
Report writing needs good writing skills. A good report can help the decision
makers to take a sound decision; on the other hand, poor reports lead to poor
decisions. So, developing writing skills and knowing the methodologies of writing
a good and systematic report are much desired skills, which the organizations
look for in its employees.
There are reports, which are highly formal both in writing style and in physical
appearance. Again, there are reports, which display a very high degree of
informality. The objective quality of a report is its unbiased approach to the
problem. The basic ingredients of report, is factual information. Information is
based on events, records, data, and like. The report must serve the purpose for
which it is written.
This handout will provide a basic knowledge on report writing. The development
workers at all levels, who are involved in reporting, will be benefited from this
paper. The paper discusses the definition, rationale, Purpose and structure of a
standard report.
There are definitions of both extremities amongst the scholars of the subject.
Some define reports as ‘every written presentation, which contain information or
data’. The other extreme defines it as ‘only the most formal presentations’. The
middle ground definition is the definition, which has been widely accepted: ‘A
report is an orderly and objective communication of factual information that
serves a purpose.

Why report writing?

Report writing work is universal and used by all organizations for different
purposes. Sometimes reports are written by individuals or in collaboration with
others. All branches and departments have their own reporting systems and
such reporting is vital to the organization. Reports supply the decision makers
with the very vital ingredients of decision making i.e. information. Reports are
written for various reasons as following:

• If there is any discrepancy within the organization

231
 • If there is any problem, where identifying the causes are necessary for
decision making
• For routine reporting within the organization
• Following up previous issues
• Introduction / adoption of any new concept or idea
Written reports are useful and we also derive following benefits from written
reports:
• Written reports make permanent records.
• Those who need information can study at their convenience.
• Can reach a number of readers with minimum efforts.
• Maintains uniformity of contents throughout.
• Be used as reference at any later time.

Structure of Report Writing

Reports can be as simple as the standard memo format or as complex as a
formal report. The inclusion of all the items of the formats may not be necessary
or similar in all types of reports, as it will vary depending on the situation. A
formal report might have following parts:
• Cover
• Title page
• Letter / Memo of Transmittal
• Acknowledgement
• Table of Content
• List of Illustration
• List of abbreviations and acronyms
• Executive Summary
• Introduction
• Main body of the report
• Conclusions
• Recommendations
• Appendices

232
 • References / Bibliography
Now let us look at each of the parts in detail and see how to present them so that
we have an effective report:
a. Cover
The cover is the first encounter with the reporter and has to be eye catching.
The cover also serves to further the corporate image of the organization. In case
of reports prepared by the students the cover page and the title page is usually
the same.
b. Title page
The title page should contain the following information:
• Subject
• Recipient /prepared for
• Writer / Prepared by
• Date
The title should be precise and convey the main objective of the study or the
project. This page could also include subtitles, which gives more information
about the projects.
c. Letter / Memo of Transmittal
This is the memo through which the report is forwarded to the recipients.
d. Acknowledgement
The persons, organizations or institutions who contributed in the process of
preparation by information, data or other resource material, should be
acknowledged in this section. Authors own establishment and staffs need not be
included here.
e. Table of Content
This section gives the broad contents of the report and the flow of information in
the report. The arrangement of topics and the flow of information should be as
logical as possible and ideas should naturally follow each other.
Do not include ‘Table of Content’ in the list
Use lower case Roman numerals for all documents that precede the introduction

233
f. List of Illustration
If the report includes only figures, title this section ‘List of Figures’
If the report includes only Tables, title this section ‘List of Tables’
If the report includes Both, title this section ‘List of Illustration’

g. List of abbreviations and acronyms

The definitions of unfamiliar words, abbreviations and acronyms used in the
paper must be provided. Common and universally used ones may not be
included.
h. Executive Summary
This is the most important part of the report. The summary should contain the
gist of the report. The entire information carried in the report must be conveyed
in its essence. This is going to be the section, based on which a reader will
decide whether to read the whole report or not.
The summary must convey the results. One must inform the readers what they
want to know immediately. Ideally, the first paragraph must itself satisfy their
curiosity.
The summary must be precise and one must use as much non-technical
language as possible. This is especially relevant in case of organizations, as the
users of the reports in other departments may base their decision on the
summary. For e.g. finance manager may take a decision on the technical
feasibility report based on the summary as he may not be well versed with the
technicalities and it could be difficult for him.
• The executive summary summarizes the report, and it is also called
Synopsis, abstract, epitome, précis, digest etc.
• This is primarily prepared for the busy executives, but other readers can
also use it as the preview of the report.
• It includes highlights of the facts, analyses, conclusions and
recommendations in proportion.
• As a general rule, the executive summary is one eighth of the original
report.

234
 • No unnecessary details should be incorporated in the executive summary.
• Follow indirect-order or direct-order executive summaries. Any one is all
right but to put more emphasis on the conclusions / recommendations the
direct-order executive summaries are popularly used.

i. Introduction
(a) The ‘Introduction’ Paragraph should include following:
• Purpose/objective
• Rationale
• Scope
• Preview / Background
• Introduce the major topics of the report.
• Limitations / Constraints / Assumptions
• Methodologies

(b) Finally, the introduction must lead the writer to the main report and prepare
him for the information he is about to receive.
j. Main Body (Report Proper):
• Data / Information / Analysis
• Summarize the data with major findings
• Cause / Reason against rationale (if any)
In case of data, the following should be noted: In case the data is less and
manageable then the data can be included in the main body of the report.
However, if the data is large, it can be included as appendices.
Similarly, any reference material, which is to be quoted, or any concept is to be
explained, it can be attached as appendices if it is too large
k. Conclusions
• Reports that seek an answer end with a conclusion to the question.
• Structure of the conclusion might vary on problem.
• Suggestions and recommendations may also be included here if not
specifically asked to provide a recommendation.

235
This section must give the results of the report. This should be very objective
section. This section must contain only the conclusions.
l. Recommendations
• When the goal is not to draw a conclusion but to recommend a / set of
solutions.
• In some report, it may be a part of conclusion, but if the objective is to
provide recommendation then it should be a separate section following the
conclusion.

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Annexes:
Annex A: Quiz on Organizational Structure of Hospitals
Select the best answer and write the corresponding letter on line beside numeral.
______ 1. Understanding the organizational structure of a hospital is important to
because it lets the hospital personnel know who is responsible for each area of
the hospital.
a. True b. False
______ 2. Policies and procedural activities would be in which hospital service?
a. administrative services c. therapeutic services b. informational services
d. diagnostic services e. support services
______3. Diagnostic Radiology is a part of what service?
a. administrative services c. therapeutic services b. informational services
d. diagnostic services e. support services
______ 4. Therapeutic Services functions to:
a. diagnose patients c. treat patients b. admit patients d. maintain patient record
______ 5. The department that often assigns patient rooms is:
a. information services c. transportation b. administration d. admissions
______ 6. In some facilities, Nursing is a service by itself.
a. True b. False
______ 7. A patient’s first contact with a hospital is generally with:
a. nursing c. medical records c. admissions d. billing
______ 8. Central Supply is part of which service?
a. administrative services c. therapeutic services b. informational services
d. diagnostic services e. support services
______ 9. Support Services is sometimes referred to as:
a. accommodation services c. environ mental services b. organizational services
d. foundation services
______ 10. This service determines the causes of illness or injury.
a. administrative services c. therapeutic services b. informational services
d. diagnostic services e. support services
Key: 1. a ,2. a ,3. d ,4. c ,5. d ,6. a ,7. c ,8. e ,9. c ,10. d

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Annex B: Sample of strategic plan (partially)
King Faisal Hospital, Kigali Strategic Plan 2006-2010
The strategic directions:
Vision Statement: “King Faisal Hospital, Kigali will be a centre of excellence in
health services provision and clinical education in Africa”.
Mission statement: “We, King Faisal Hospital, Kigali, are committed to providing
cost-effective, self-sustaining, high quality and specialized health services in
collaboration with our clients. We do this with an empowered workforce in an
environment that values professionalism respects patients’ rights and upholds
human dignity at all times. With our partners and within available resources, we
contribute to the development of health services, research and education in
Rwanda”.
Value statement: All employees must relate to these values and they will be
instilled to each and every employee and we all shall always LIVE by them.
These values are: Quality Care, Compassion and Accountability
Key Success Factors: Key Success Factors (KSF) was agreed upon as central
to the achievement of this vision and mission and these are as follows:
a) Effective leadership
b) Financial sustainability
c) High involvement & commitment of all stakeholders in the change process
d) Quality systems that promote best practices in everything we do
e) Optimal utilization of available resources
f) Superior marketing and public relations
g) Effective capacity building
h) Shared vision and values
SWOT Analysis: An analysis of the Hospital Strengths, Weaknesses,
Opportunities and Threats at both organizational and departmental levels and
these were identified as follows:
Strengths
1. Endowment of resources: Strong physical facility, committed staff
2. Clear vision, mission and values for the hospital

238
3. Stakeholders commitment to quality improvement
4. Demonstrated ability to provide training
5. Availability of substantial capital funding
Weaknesses
1. Obsolete and ill-functioning equipment, with a history of poor maintenance
2. Inadequate management systems
3. Financial un-sustainability
4. Insufficient specialized and trained staff
5. High dependency on external resources
Opportunities
1. Strong commitment of GoR
2. Teaching hospital and higher level of care status
3. Not for profit status
4. Emerging healthcare financing schemes
5. Land available for expansion
Threats
1. Erratic power and water supply
2. A degree of skepticism towards the hospital services held by certain segments
of the public
3. Potential loss of Government subsidy
4. Insufficient local suppliers of goods & services
5. Insufficient specialized skills in Rwanda
KEY STRATEGIC ISSUES: These include ten strategic areas around which
Strategic Goals have been developed and include the following:
1) Clinical services
2) Training & education
3) Research
4) Human resources management
5) Financial management
6) Administrative support management services
7) Facilities management

239
8) Quality and safety
9) Information and communication technology
10) General management & Corporate Governance
Key Operational Areas (existing and new services) in line with Strategic
Issues identified and guided by the strategic issues identified above, a process of
identifying services that will require to be consolidated (existing services) and
those that require to be developed (new services) was undertaken. See the
following table for clinical services.
Services Current Planned
Surgery Surgery General Paediatric
Surgery Cardio-Thoracic
Orthopedics Vascular
Ophthalmology Maxillo-Facial
Neurosurgery Urology
Dentistry Plastic Surgery & Burns Unit
Ear Nose & Throat
Internal Medicine General Medicine Gastroenterology
Dermatology Neurology
Cardiology Endocrinology
Pulmonology Oncology
Nephrology Rheumatology
Hematology
Infectious diseases
Peadiartices General Paediatrics Nephrology
Neonatology Haematology/Oncology
Cardiology Endocrinology
Neurology
Infectious Diseases
Neonatal ICU (independent)
Obstetrics and Obstetrics and Fertility Services
Gynecology Gynaecology Services Oncology

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 Utrasonography Obstetrics theatre
Ante Natal Care Midwifery post natal services
Baby friendly hospital initiative
Well women clinic
High dependency Ante- Natal
Care
Accident & Reception and triage Poison management services
Emergency Host the Ambulance Services
base
Anesthesia General Pain Management services
Regional
Recovery
Intensive Care Unit Non –Invasive Invasive monitoring
monitoring High Dependency Care
Radiology CT Scanning Mammography
Ultrasonography Angiography
Fluoroscopy Dental Panoramic X-Ray
General radiography
Pathology Haematology Histology
Chemistry Immunology
Parasitology Blood Transfusion Unit
Microbiology Drug Monitoring Assays
Serology Molecular Biology
Cytology

STRATEGIC GOALS AND OBJECTIVES: There exists a logical link between all
strategic components. Information from one component provides input into the
next level, the logic cascading down to lower level components in a hierarchical
fashion. In CLINICAL SERVICES we have following goal and objectives:
To strengthen existing and develop new clinical services that are responsive to
the needs of the people of Rwanda and beyond

241
To have:
• Implemented a vibrant clinical governance program by end of 2009 and
maintain it thereafter.
• improved existing medical services in line with accreditation standards by
August 2010
• consolidated and developed clinical support services that are responsive
to the needs of clinical care and that are able to meet international
standards by the end of 2009
• developed non-existing medical services while sustaining the achieved
quality level by 2009, resulting in a at least 50% decrease of 2004 number
of patients referred abroad
• strengthened the quality of nursing care for all existing clinical services
within two years and corresponding emerging services by 2010
STRATEGY IMPLEMENTATION: Inherent to this strategy are numerous
departmental operational plans. They contain more detailed and specific
information to guide implementation at each operational level. Each departmental
plan contains objectives, activities with time lines, the responsible person,
performance indicators and expected results. All these are aligned to the hospital
implementation plan.
FUNDING REQUIREMENTS: The implementation of this strategy will by any
means not be possible unless the necessary funding is secured in time. It is
indeed crucial for its successful implementation.
Descriptions Year 1 Year 2 Year 3 Year 4 Year 5 total
Medical equipment
Non medical equipment
Facilities
HIS&ICT
Training
Grand total funded required
Funded available
Fund needed

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PERFORMANCE MONITORING AND EVALUATION: The monitoring and
evaluation framework is an important aspect of this strategic plan. It provides the
mechanisms for monitoring, reviewing, and evaluating progress towards
attainment of the strategic objectives and goals.
CONCLUSION: We hold the strong view that this strategic plan is a road map
that will guide King Faisal Hospital, Kigali achieve an internationally recognized
status. The plan crystallizes the numerous thoughts and aspiration of the
members of the King Faisal Hospital, Kigali’s community.

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Annex C: Patients’ Rights and Responsibilities at Aga Khan
University Hospital
Patient Rights and Responsibilities
Dear Patient,
Welcome to Aga Khan University Hospital (AKUH) and thank you for selecting
our Hospital for your healthcare needs. We are grateful to you for the level of
confidence you have placed in us.
At this academic medical centre, we are all committed to providing the highest
standards of quality care and are striving to not only meeting but exceeding your
expectations. The facility personnel who care for the patient are qualified through
education and experience to perform the services for which they are responsible
as per set standard and policies. The patient's bill of rights and responsibilities is
another pioneering initiative to ensure high-quality patient care services. It is
expected that observance of these rights will contribute to more effective patient
care and greater satisfaction for you, your family and our staff and the facility as
a whole caring for you.
Your Rights:
1.0 Accessibility to Care:
You will be provided with the best possible care available, regardless of age,
gender, nationality, ethnic background, religious origin or financial means. The
care will be respectful of your culture, religion and beliefs.
2.0 Guidance:
You will be provided with proper guidance in seeking financial assistance if you
are in need of such help in connection with your care and treatment at AKUH.
Such financial assistance is subject to the availability of resources in the
institution.
3.0 Communication:
You will be informed of your rights in a manner that you can understand. In
addition, other relevant information such as services available in the faculty, the
mechanism to lodge a complaint, making a suggestion, accessibility to ethics
consults, etc. will be provided to you and/or to your family.

244
4.0 Patient education:
You and/or your family will be provided with education about our disease process
after assessing your learning needs. Upon discharge, you will be provided with a
discharge summary. On your request, a clinical summary under the signature of
the treating physician will be provided.
5.0 Privacy and confidentiality:
Care will be provided with full recognition of the individual need for privacy in
treatment and care along with protection of confidentiality of your health
information. Disclosure of information will be made as per the Hospital's policy
and Government regulations.
6.0 Involvement:
Depending on your ability or that of your next of kin, you and/or your immediate
family will be involved in decisions regarding admission, treatment, referral
and/or transfer and discharge. You and your next of kin have a right to be
informed about the benefits and risks of the proposed investigative and treatment
procedures.
7.0 Informed consent:
An informed consent will be administered to you/your next of kin prior to
undergoing treatment procedure according to the Hospital policy. The
organization will follow the established process, within the context of existing law
and culture, when persons other than you grant consent.
8.0 Refusing treatment:
You and/or your family have a right to refuse treatment and to seek discharge.
We will advise you/your family regarding the medical consequences of such a
decision. However the Hospital will not be held responsible for any
consequences resulting from such a decision made by you/your family.
9.0 Seeking second medical opinion:
We will respect your right to seek a second medical opinion, which in most
instances will be provided by an AKUH credentialed specialist. A request for
consultation from an outside non-credentialed physician will be honored with the
concurrence and approval of the treating physician and of the Medical Director of

245
AKUH. In case of genuine dissatisfaction with treatment, you are entitled to
request a change in your treating physician. The concerned chair/section head
will assist you in this regard
10.0 Transfer
A critical care patient being considered for transfer to an alternate treatment
facility will be provided with all possible support and facilities.
11.0 Participation in research:
You have the right to be informed, to agree to or to refuse to participate in any
research/educational projects affecting your care or treatment. Your refusal will
not in any way affect the quality of care available to you. An informed consent
must be obtained from you and/or from your next of kin prior to your being
enrolled in a research project. This should include explanation of benefits and
risks or discomfort from participating in the project. All research project involving
patients and/or review of their medical records should be undertaken after
approval of the research protocol by the Ethical Review Committee of Aga Khan
University (AKU).
12.0 The Hospital Ethics Committee:
In case of conflict or ethical concern arising from care and treatment given to
you, consults from The Hospital Ethics committee can be sought by you/your
family through the physician/nurse in charge of your care.
13.0 Patient’s Complaints/Suggestions:
The Hospital will provide for and welcome the expression of grievances or
complaints and suggestions by you at all times either by speaking directly to the
team leader, supervisor, service coordinator or manager assigned to your care.
You may file a formal complaint in writing by filling the “Complaint/Suggestion
Form”, which is available at all service counters, and depositing it in the
complain/suggestion boxes available at several locations throughout the
Hospital. Our staff on each floor will be happy to assist you in this regard.
Your and / Or Your Family Responsibilities
1. You and/or your family members are responsible for:

246
 • Providing complete and accurate information necessary for your medical
treatment.
• Abiding by Hospital rules and regulations regarding admission, treatment,
safety, privacy and visiting etc.
• Refraining from the use of violent and disruptive behaviors or language
abuse. In case of any dispute, query or grievance, you are requested to
bring the matter directly to the attention of team leader, supervisor, service
coordinator or manager assigned to your care.
• Seeking complete and accurate information and/or explanation regarding
Hospital services and charges and for ensuring payment of Hospital bills
in full and in a timely manner.
• Exercising care and caution in using Hospital facilities and equipment.
• Complying with all discharge instructions and keeping follow-up
appointments.
• Being considerate towards the rights of other patients and of Hospital
staff.
2. Smoking is not allowed anywhere in the Hospital premises except designated
areas.
3. You are advised not to bring valuable personal belongings to the Hospital.
4. It is expected that you and your family will cooperate with nursing staff,
consultants, housekeeping staff, trainees/residents and students in carrying out
assessment, investigations and treatment procedures.
5. In case of gross misbehavior by the patient and his/her family and friends,
AKUH reserves the rights of admission to its facility, transfer out of the Hospital
and further action.
We wish you a complete and speedy recovery.

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 Annex D: HMIS form (Monthly Integrated Activity Report- MIAR)
Monthly Integrated Activity Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN
MIAR – Facilities, Page 1 MINISTRY OF PUBLIC HEALTH
District Name & Code Province Name & Code
Year Month Facility Code Facility Name
Referred Out Referred Reatten- New BHC Facility Type
In dance Total >= 5 <5 CHC
New F M F M H1 H2 H3 OPD

Patients/Clients

A1. OPD Morbidity

1. COUGH &
COLD
ARI
2. ENT
3. PNEUMONIA
4. ACUTE
WATERY
5. ACUTE
DIARRHEA
BLOODY
6. W
DEHYDRATION
7. SEVERELY ILL CHILD
8. VIRAL HEPATITIS
9. MEASLES
10. PERTUSSIS
11. DIPHTHERIA
12. NEONATAL TETANUS
13. TETANUS
14. ACUTE FLACCID PARALYSIS
15. MALARIA
16. URINARY TRACT INFECTIONS
17. PSYCHIATRIC DISORDERS
18. TRAUMA
19. TB SUSPECTED CASE
99. OTHERS/UNLISTED DIAGNOSES
A2. Remarks

B. Nutrition

Monthly Integrated Activity Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

MIAR – Facilities, Page 2 MINISTRY OF PUBLIC HEALTH
D. Stock status Essential Referred Referred Reatten- New C. Maternal & Neonatal Care
Drugs/commodities Out In dance Cases
Acetyl Salicylic Acid/Paracetamol ## C1. Family planning
Mebendazole 1. Oral
Amoxicillin/Ampicillin 2. Injectable
INH 3. IUD
Rifampicin 4. Condoms
Amp. Diazepam 5. Permanent

248
 Inj. Lidocaine C2. Pre- and Post-Natal
Metronidazole 1. First Antenatal Visit
Co-trimoxazole 2. Other Antenatal Visit
Anti-hypertensives 3. Postnatal Visit
Oral contraceptive C3. Obstetric Care
Injectable contraceptive 1. Normal Delivery
Condoms 2. Assisted Delivery
IUD 3. Major complication
TT vaccine 4. Other Complication
DPT vaccine 5.Maternal Death due to Major
ORS 6. Maternal Death due to Other
Vitamin A 7. Cesarean section
Chloroquine 8. Other obstetric surgery
Sulfadoxine + Pyrimethamin C4. Neonatal Care
Ferrous Suplhate + folic acid 1. Newborn Alive
Oxytocin 2. Low Birth Weight
Gloves 3. Neonatal Complication
D2. Comments about stock 4. Neonatal Death
5. Stillbirth
E. Immunizations G. Tuberculosis
Total 12-23 months 0-11Months E1. Childhood G1. Case detection
1. DPT3 1. Number of new smear (+) cases
2. Vitamin A 2. Number that started treatment
G2. Treatment success
>TT2 TT2 E2. TT Immunization 1. Number of cases completed and smear (-)
1. Pregnant Women H. Community Health
F. Laboratory Exams 1. Number of meetings with
F1. Blood community health committee
1. Total malaria slides examined 2. Number of CHWs seen for supervision
2. Total PF positive I. Report Transmitted
3. Total other positive Name
4. Total HIV examined Designation
5. Total HIV positive Date
F2. Sputum Signature
1. Total AFB slides examined J. Report Received/Aggregated
2. Total AFB positive Date Received
Data aggregated/computerized
Any special activities or problems, significant anomalies or trends in morbidity and service delivery K. Comments:

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 Annex E: HMIS form (Hospital Monthly Inpatient Report- HMIR)
Hospital Monthly Inpatient Report GOVERNMENTOF THE ISLAMIC REPUBLIC OF AFGHANISTAN
HMIR - Page 1 of 2 MINISTRY OF PUBLIC HEALTH
District Name & Code Province Name & Code
Year Month Facility Code Hospital Name
 Regional (H1)  Provincial (H2)  District (H3) Hospital Type

B. Nutrition of under fives A. Indoor patients

1. Admitted =>5M =>5 F <5
2. Improved 1. Admissions
3. Defaulted 2. Referred-in
4. Referred out 3. Deaths
5. Deaths 4. Number of patient days
C. Imaging services 5. Average length of stay
1. Chest x-ray 6. Total Discharged
2. Abdomen x-ray a. Recovered/Improved
3. Skeletal x-ray b. Absconded/defaulted
4. Ultrasound d. Not improved
5.Other e. Referred-out
E. Stock of essential hospital drugs D. Other surgical interventions
Arthesunate inj Total Minor Major
Atropine inj 1. Gynecological
Benzathine Penicilline inj 2. Orthopedic/trauma
Digoxine 3. ENT
Ergometrine inj 4. Eye
Furosemide inj 5. Others
Gentamycine inj 6. Total
Iodine poluvidone 7. Post operative deaths
Ketamine inj 8. Post operative complication
Lidocaine 5% spinal inj 9. Blood Transfusions
Magnesium Sulphate 10. Blood transfusion reactions
Morphine inj F. Cases and deaths of priority diseases
Naloxone inj Deaths Admissions Health Problem
Hydralazine inj 1. Diarrhea <5
Oxygen 2. Pneumonia <5
Pethidine inj 3. Measles <5
Phenobarbital inj
Quinine inj
Ranitidine inj
Ringer lactate IV
Salbutamol inj
Sodium chloride IV
G. Comments (any particular observations or issues that you want to highlight to the central level)

Hospital Monthly Inpatient Report GOVERNMENTOF THE ISLAMIC REPUBLIC OF AFGHANISTAN

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 HMIR - Page 2 of 2 MINISTRY OF PUBLIC HEALTH
Year Month Facility Code Hospital Name
H. New Inpatient Cases
Death Referr. Referr. In >= 5 <5
Total Priority health problem/disease
Out F M F M
Injuries and trauma
1. Weapon wounded
2. Road traffic accidents
3. Occupational injuries
4. Burns and scalds
5. Other injuries
Cardiovascular
6. Cerebro-vascular accidents
7. Rheumatic heart disease
Nervous system
8. Meningitis/encephalitis
9. Epilepsy
Endocrine & metabolic
10. Diabetes
11. Micronutrient deficiencies
Gastro-intestinal
12. Acute appendicitis
13. Peptic ulcer syndrome
14. Inflammatory bowel syndrome
15. Liver & gall bladder disease
Gynecology
16. Urinary tract infections(no STD)
17. Pelvic inflammatory disease
Infections (other than Notifiable)
18. Dysentery (all types)
19. Diarrhea (except dysentery)
20. Malaria
21. Tuberculosis
22. Hepatitis
23. Typhoid
Mental diseases
24. Depression
25. Psychosis
Respiratory
26. Pneumonia
27. Asthmatic disease
28. All other new inpatient cases
I. Report submission
Report Received/aggregated Report Submitted
5. Received by 1. Name
6. Date received 2. Function
7. Aggregated/computerized by 3. Date
8. Date aggregated/computerized 4. Signature

251
Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN
HSR - Page 1 of 4 MINISTRY OF PUBLIC HEALTH

A. General Facility Information

2. District Code & Name 1. Province Code & Name

3. Hospital Code &Name

……..To…….From 5. Period H1 National/specialist H2 Provincial/regional H3 District 4. Type of Hospital

……………Of

Annex F: HMIS form (Hospital Status Report- HSR)

Stone Mud Concrete 7. Main construction material Temporary Permanent 6. Building

9. Main source available ….….. months per year Other Safe 8. Main source of drinking water

……..12. Average hours/day Wind Solar Generator Line 11. Main sources of electricity Yes No 10. Electricity

15. Referral facility name & code …..Hrs ……..Min 14. If not, walking time from road Yes No 13. On drivable road

No Yes 18. Separate latrine for male and female Open Closed 17. If Yes, type: Yes No 16. Latrine for use by patients

19e. Other 19d. Surgery 19c. Adult Internal 19b. Ob&Gyn 19a.Pediatric 19. No of beds

Other Burn and Bury Incinerator 21. If yes, type No Yes 20. Medical waste disposal

22. Other sources of support 21. Main source of support

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 2 of 4 MINISTRY OF PUBLIC HEALTH
B. Human Resources
Refresh Cert Female Male Type Refresh Cert Female Male Type
B4. Technical staff B1. Management
23. Psychologist 1. Hospital Director
24. Physiotherapist 2. Medical Director
25. Pharmacist 3. Chief nurse
26. X-ray technician 4. Administrator
27. Lab Technician B2. Physicians

252
 28. Blood bank technician 5. Surgeon
29. Dental Technician 6. Ophthalmologist
30. Vaccinator 7. ENT
31. Nutritionist/cook 8. Anethesiologist
32. Technical assistants 9. ObGyn
33. Community Health Supervisor 10. Pediatrician
B5. Support Staff 11.Radiologist
34. Administrative Staff 12. Medical Specialist
35. Storekeeper 13. General MD
36. Technical maintenance 14. Dentist
37. Cleaners, waste & grounds B3. Nurses & Midwives
38. Laundry 15. Midwifes
39. Cook 16. Nurse operating theatre
40. Drivers 17. Nurse surgical ward
41. Guards and porters 18. Nurse internal ward
42. Tailor 19. Nurse pediatric ward
43. Mullah 20. Nurse anesthetic
B6. Community Health 21. Nurse ER and OPD
44. CHWs ever trained 22. Assistant Nurse
45. Trained CHWs active
C. Supervision
1. Number of supervisory visits received from MOPH
2. Number of supervisory visits from grantee agency

Hospital Status Report GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN

HSR - Page 3 of 4 MINISTRY OF PUBLIC HEALTH
D. Equipment list
Not Usable Usable Type Not Usable Usable Type
27. Autoclave 1. Computer
28. Ob/gyn table 2. Printer
29. D&C set 3. Stabilizer
30. Wound set 4. Radio
31. Minor surgical set 5. Telephone
32. Laparatomy set 6. Water purification
33. Caesarean/hysterectomy set 7. Fire extinguishers
34. Obstructed labour set 8. Vehicle, 4 wheel drive
35. Episiotomy set 9. Ambulance, 4 wheel drive
36. Suture set 10. Vaccine Refrigerator
37. Amputation set 11. Blood refrigerator
38. Laryngoscope set 12. Food refrigerator

253
 39. Endo-tracheal introducer
40. Vacuum extractor (childbirth)
41. Neonatal incubator, van Hemel
42. X-Ray machine
43. Ultrasound machine
44. Brown frame
45. Microscope
46. HB meter
47. Urine sticks
48. Blood transfusion set
49.Cross match test
50. Blood HIV test
51. Blood Hepatitis B&C test
52. VDRL test
Hospital Status Report
HSR - Page 4 of 4
E7.Surgery
1. Closed fractures and dislocations (minor)
2. Lacerations and soft tissue injury
3. Acute osteomyelitis
4. Rheumatoid arthritis
5. Amputation
6. Burns
7. Superficial abscesses, cysts and tumors
E8. Mental health
1. Acute confusion
2. Depression
E9. IEC Actvities
1. Obstetric complications & birth preparedness
2. Family Planning
3. Nutrition
4. Child health
5. Injection Safety
E10. Community Health Worker Supervision
1. CHWs supervised once
2. Health Posts active
3. Health Posts supervised once
GOVERNMENT OF THE ISLAMIC REPUBLIC OF AFGHANISTAN
MINISTRY OF PUBLIC HEALTH
E4. Maternal Health
1. Antenatal care
2. TT immunization
3. Basic EmOC
4. Comprehensive EmOC
5. Blood transfusion
6. Blood storage
7. Neonatal resuscitation
E5.Family planning
1. Oral contraceptives
2. Injectable contraceptives
3. IUD
4. Condoms
5. Tubal ligation
6. Vasectomy
E6. Radiology
1. Thorax x-ray
2. Abdomen x-ray
3. Extremities x-ray
4. Ultrasound
13. Cooking stove
14. Water heater
15. Sphygmomanometer
16. Stethoscope
17.Vision Chart
18. Thermometer
19. Child scale
20. Height measuring scale
21. Suction machine
22. ECG machine
23. Fetal stethoscope
24. Ambubag & Guedel
25. Operating table & accessories
26. Mayo Stand
E. Services provided
E1. General Curative
1. Curative OPD
2. IMCI implemented
3. ARI Case Management
4. DD Case Management
5. Malaria Case Management
6. Minor surgery (I&D, suture)
7. Major surgery
E2. Child Health
1. Routine Growth Monitoring
2. Nutritional rehabilitation
3. Child Immunization
4. Management of severely ill child (IMCI)
E3. Infectious Diseases
1. TB detection & referral
2. TB labdiagnosis
3. TB treatment (excl. DOTS)
4. DOTS
5. Malaria lab diagnosis
6. ITN distribution
7. HIV/AIDS diagnosis
254
 F. Remarks and observations

G. Report submission
Designation Signature
Date Name

255
Annexé G: Waste Colour Coding

Waste Description Example Contents

Receptacle

Infectious waste
contaminated with
Dressings / tubing from cytotoxic and/or
cytotoxic and /or
cytostatic treatment
cytostatic medicinal
Yellow with products
purple stripe

Sharps contaminated Sharps used to administer cytotoxic products.

with cytotoxic and /or
cytostatic medicinal
products
Yellow purple lid
CONTAINER
WHITE

Amalgam waste Dental amalgam waste

T

Infectious waste, Soiled dressings from infected wounds and

other items contaminated with infectious body
category A – yellow fluids

category B – orange
Yellow/orange
see section 4.1.2

Non- medicinally Sharps from phlebotomy

contaminated sharps minor surgery instruments
scalpel blades, razor blades
Orange top

Medicinally Ampoules, vaccine syringes and needles

contaminated sharps Local anaesthetic syringes and needles

Yellow top

256
 Human hygiene waste
Offensive waste
and
non-infectious disposable equipment, bedding
plaster casts, etc

Yellow/black
stripe
Domestic waste General refuse, including, flowers, etc

Black bag or
clear bag is
acceptable
Mixed recycling Paper, cardboard, tins, cans, plastic,
Glass

Green/clear

257
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