Implementation /Operational Standards, Checklist and Indicators

Table1. Operational standards for leadership, governance and health care financing

met
=1
Sta. Yes √
Standard Method of evaluation not Remark
# No X
met
=0

Have community representatives.

Has staff representatives

The Health Centre
Governing Body is A focal person for HC-HP linkage
established using represented.
1 clear and
transparent The GB has at least two female
systems and members.
processes.
Members appointment letter issued

TOR is defined.

The Governing Testimony/ Appointment letter from

Body approves the WorHO/ Mayor/ Governing Body
Health Center
Head who is Signed a job description that
2 appointed/ outlines his/her duties to lead the
nominated by the HC
town, sub city or
Woreda Health Board approval minute
Office

The Governing Minutes of approval of strategic and

Body approves an annual plans
annual and
strategic plan for
3 the Health Center
to achieve its goal Signature of the GB members and
of improving its stamp of the HC on the documents.
community’s
health and welfare

4 The Governing The meetings are regularly

Body conducts conducted
 met
=1
Sta. Yes √
Standard Method of evaluation not Remark
# No X
met
=0

Minutes and agenda of meetings are

available(observe minutes of the
current year).

Meeting agendas distributed at least

one week in advance, and approved
by members’ signature

More than fifty percent of board

regular meetings members attend the meetings.
with written
Action plan with defined
minutes at least
responsibility developed
quarterly
Action plan implementation status
was monitored in subsequent
meetings.

GB visits the HC before the

meeting(check in the minute)

Is there an orientation session for

new GB members?

The health centre HC report reviewed

Head is evaluated biannually(check in the minute)
biannually,
consistent with
Regional
5 Legislation to
ensure he/she is Performance appraisal assessment
meeting result of the Health Centre Director
operational plan as
approved by the
board.

6 The health centre Members nomination is in

management accordance with the region’s HSDA
committee has legal framework
been established
and functioned as Has a staff representative
 met
=1
Sta. Yes √
Standard Method of evaluation not Remark
# No X
met
=0

issued appointment letter to each

member of the committee by the
HC head

TOR is defined

The committee meets a minimum

every week (or as per the region’s
HSDA legal framework)

Agenda of meetings and minutes

per the respective are available
regional health More than fifty percent members
service delivery attend the meetings
and administration
legal framework. Action plan with responsibility
developed

Action plan monitored during

subsequent meetings(Check in the
minute)

Check presence of posted fee and

exempted services
The health center Check all exempted services are
shall post service provided free of charge in the
fee and facility (take a sample of 5 eligible
exemptions using mothers and children and verify
7
local language(s) with interview)
in each department
and cash collection Poster that advises patients to obtain
premises. and keep receipts posted at cash
points for all Out Of Pockets

8 The Health Centre Existence of a plan that justifies

has a procurement
plan, approved by Approval of the plan by the
management committee & GB
 met
=1
Sta. Yes √
Standard Method of evaluation not Remark
# No X
met
=0

Approval minute from the board

Responsible person(s) for

governing board.
procurement activities

Take sample procurements and

check for bid/proforma
The health center
procurement Check supplier selection
9 process is process(purchase committee
according to selection minute)
regional HSAD.
Cross check procured items are in
line with approved plan

The HC prepares both monthly

financial and quarterly performance
reports

Completeness of the report (include

The health center revenue, expenditure, receivables,
finance team shall payables, transfers, cash count , trial
submit reports on balance & bank reconciliation)
10 monthly basis to
Monthly financial reports timely
the health center
reported to WoFED/ WorHO in
management
regular manner
committee
quarterly performance reports
timely reported to the governing
body and SMT management
committee on regular bases

The health center Check the audit feedback report

shall be audited
with third party on
11 Approval of the audit report by the
annual basis and
submit reports to GB
governing body..

12 The Health Centre Check memorandum of

has a understanding for the current year
 met
=1
Sta. Yes √
Standard Method of evaluation not Remark
# No X
met
=0

Memorandum of with CBHI.

Understanding
with Waiver Check memorandum of
Certificate understanding for fee waiver of the
Granting current year with Woreda council.
Authorities and
CBHI schemes
which provide
details on the type
of service and
mode of payment.
(CBHI agreement)

Presence of updated records of

services offered & costs incurred

The Health Centre Timely reporting and requesting of

shall facilitate the service expenses
13 reimbursement for
waived and credit A report that shows the current
services. status of amount claimed,
reimbursed & outstanding balance
for the three types of services
(waiver, credit)

There is a current
Observe and confirm presence of
Health Facility
the three types of documents at the
14 Financial
HC account manual of the regional
Management
or Federal
manual.

Table 2: Assessment tool for operational standards – Health Center and Health post
linkage
 met
Yes
=1
Description of the √ Remar
S.N Verification criteria not
standards No k
met
X
=0

HEP unit/ family health team

established and has a coordinator

Has a detail community

health/HEP implementation plan,
Health center established report, and performance
functional HEP monitoring at PHCU level
1
unit/family health team in
HEP/community health program is
urban
fully implemented at the kebele in
which the HC is located

The unit has a dedicated office

Use standard checklist

Performance improvement plan

The HC regularly
conducts multi- Schedule for the multi-disciplinary
2 disciplinary team-based team-based supportive supervision
supportive supervision to Use standard checklist
HPs on quarterly basis
Supervision finding Feedback

Baseline assessment conducted,

key constraints identified, and
prioritized for mentorship
Mentorship and coaching
is being implemented for Mentorship plan developed
3 HPs/urban HEps on key
prioritized health Mentorship guide and
interventions tools/checklist are available

Mentorship conducted (review

mentorship reports)

Health center prepares a Shared annual plan

joint annual plan with
4 Minutes/reports on PHCU plan
health extension
professionals as a unit. sensitization workshop
 met
Yes
=1
Description of the √ Remar
S.N Verification criteria not
standards No k
met
X
=0

The health center collects Plan-versus achievement reports

weekly plan and
performance report from
5
each HP/family health Report reviewed and feedback
team and then provided provided
feedback

The HC established Minute for learning and experience

learning and experience shared
sharing platform for HC
6
and HP staffs/urban HEps Documented best practices and
and being in use at least lessons learned
monthly

Monthly PHCU level performance

review meeting minute
Conduct monthly Root cause analysis conducted for
performance review key constraints and performance
7 meeting with health improvement plan developed
extension workers/urban
HEps at PHCU level. Performance improvement action
plan developed

Documented best practices

All the kebeles under the Records of community health

HC catchment established volunteers of all kebeles are kept
active and functional at the PHCU level
community health
8 volunteers(women group,
men group, village health Key performances of community
leaders, youth health health volunteers of all kebeles are
groups, and informal maintained at the PHCU level
social structures)

The health center establish Supervision program

linkage with the catchment
9
primary/general/specialize
d hospital Supervision feed back

10 The health center ensures All HPs/family health teams

sustainable supply and implement integrated
 met
Yes
=1
Description of the √ Remar
S.N Verification criteria not
standards No k
met
X
=0

pharmaceutical logistics system

(observe HPRRF sent from HPs)

Essential supplies, drugs, and

logistics management equipment are available and/or
system in all health functional in all HPs (observe
posts/family health team HP/family health team reports of
under its catchment. tracer drugs availability and
monthly PHCU level performance
review meeting minute)

Monitoring system in place

Table 3: Assessment tool for operational standards – Patient flow

Yes met =1 Remar
S.No Standard Method of evaluation √ not k
No met =0
1. The Health Check presence of standalone ER X
centre shall have Check whether the ER unit is labelled
an emergency properly, visible from the distance,
services led by and located near to the gate
General
practitioner or Check team lead is GP/HO
Health officer
24/7. Observe team leader assignment letter

Check team leader job description

Check whether emergency department

team are trained(interview)

Check presence of protocols and

guidelines

Check whether necessary equipment,

drugs and supplies are fulfilled based
on Ethiopian Emergency Service
Labelling Guideline Standard.

View triage registration sheet

 Yes met =1 Remar
S.No Standard Method of evaluation √ not k
No met =0
View emergency registration form X

Sample 5 charts and view whether

BEC ESC toolkit attached to patient
folder

The health Check the ambulance parking area and

2. Centre shall have confirm that it is accessible for
ambulance emergency service
parking area
The health Check whether the ER unit is labelled
Centre shall have properly & visible from distance,
easily accessible ER is located near to the gate
emergency room,
with necessary
infrastructure,
and with
3. Check whether necessary equipment,
necessary
drugs and supplies are fulfilled based
equipment, drugs
on Ethiopian Emergency Service
and supplies
Labelling Guideline Standard
needed to
standards.
provide quality
emergency
medical services.

The health centre Check availability of central triage

shall have a Check protocol for triaging and
central triage managing queue
room, with
necessary
infrastructure,
4. protocol, staffed
Check availability of basic medical
with
equipment for triage (BP apparatus,
appropriately
temperature measurement, weighing
trained personnel
scale, glucometer, pulse oximeter)
and queuing
management
systems

5. The health centre Check presence of focal

shall have a person(assignment letter)
liaison service. Check presence of updated protocol
 Yes met =1 Remar
S.No Standard Method of evaluation √ not k
No met =0
Check availability of revised referral X
directory

Check whether referrals are managed

according to the EPHCG (3 sample
patient charts)

Check the availability of a standard

referral sheet and register.

Check feedbacks received

Check the availability of at least:

 Adult OPD,
 Chronic disease OPD,
The health centre  assignment
Youth friendly
Check letterservice OPD
for team lead
shall have an Out
Patient Check team lead JD
Department
6.
(OPD) led by a Check presence of examination coach,
General BP apparatus and stethoscope
practitioner or
health officer. Check training on EPHCG of staff at
OPD

Check the registration book and

appointment logbook.

The health centre Check availability of the EPHCG in

shall provide the all OPD rooms
clinical service Check 5 sample patient charts on
based on the adherence to EPHCG algorithmic
7. Ethiopian approach
primary health
care clinical Check minute on bi monthly clinical
guideline forum conduction
(EPHCG). Check training records for new staffs

The health center

emergency unit Check the availability at least annually
8. should have updated documented disaster
updated disaster preparedness and response plan.
preparedness and
response plan.
 Yes met =1 Remar
S.No Standard Method of evaluation √ not k
No met =0
X
The health center
shall have Check presence of signage which
9. direction clearly directs customers to the service
pointers and they want very easily.
signage.

Table 4: Assessment Tool for Operational Standards – MNCH services

Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

Check rooms for

o ANC,

o FP,
The health
centre shall o L & D,
avail amenities o under five OPD,
1
and resources
for MNCH o EPI.
service.
Check team lead assigned is
MW/GP/HO

View job description of the MNCH

team lead

2 The health Check availability of :

center avails
resources for o Dedicated personnel for ANC
comprehensive
o Dedicated personnel for
ANC and
PMTCT
PMTCT
services. o BP apparatus

o Weighing scale
 Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

o Fetoscope

o Stadiometer

o MUAC meter

o basic laboratory tests (VDRL,

Blood Group &Rh, Hgb & HIV, urine
dipstick, RBS…)done

o Supply of Iron folate

o ART for HIV positive mothers

o Supply of TT vaccine
o Treatments for HIV exposed
baby
Check availability of separate
maternal waiting homes with at least:

o Safe water supply

The health
centre shall o Food
establish
maternal o Kitchen
waiting Homes
3 o Separate shower and latrine
with necessary
facilities and o Adequate electricity
services
(optional for o Availability of pairs linen
urban HCs).
o Audio visual tools

Check pregnant mother’s chart for

daily clinical check up

4 The Health Trained personnel

Centre should
ensure Separate L & D room
provision of
New-born corner as per standard
Basic
Emergency Basic supplies
Maternal and
 Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

o Parenteral Antibiotics

o Parenteral Anticonvulsant

o Uterotonics

New born Care o MVA kit

(BEmONC)
services for o Vacuum extractor
24/7.

 Fully functional operating theatre

(one table dedicated for caesarean
section)and it should be adjacent
to the labour and delivery room.

If the HC have  Appropriate and adequate

OR block, The caesarean sectionteam members
Health Centre should be available 24/7
should ensure
provision of (OBY/GYN or IESO,
Comphrensive anaesthetist, scrub nurses)
5 Emergency
obstetrics and  Allessential drugs for caesarean
New born Care section and functional essential
(CEmONC)
equipment should be available.
services for
24/7.  Check documented Safe surgery
check list for all completed
surgeries

 Check Clinical audit done every 3

month toassess completeness of
documentation
 Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

The Health Ensure that the health centre have

Centre shall separate room for PNC
provide
comprehensive
6
postnatal care
in the facility Trained personnel
as per national
standards

The health  National Technical and

center should procedural guideline for abortion
provide care
comprehensive
abortion care  MVA
service (Safe
7  Misoprostol
abortion and
Post abortion  Pain management for CAC
care) as per the
national
guideline and  Trained personnel
protocol.

8 The Health Ensure that the EPI room is separate

Centre should and child friendly:
provide static
EPI and GMP o Comfortable
services. chairs

o Well ventilated
room

o Attractive for
children

Check availability of trained focal

person

Check availability of functional

refrigerator, cold box, vaccine carrier,
and ice packs

Temperature monitored twice

including weekends(check
temperature monitoring chart)
 Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

Check regular availability of all

routine vaccines, diluents, AD
syringe and needles, and safety boxes

Check EPI guidelines and job aids are

readily available and in use

Ensure availability of GMP

assessment tools (weight scale,
MUAC meter, Meter/Stadiometer,
WHOI standard curve)

 Check availability NACS room

 Supply of Supplements (plumpy,

BP100..)

Check the presence of separate under

5 OPD

ORT corner is established within

Health centres under 5 OPD
shall have
established Check IMNCI implementation:
9 separate under
o Check diagnostic facilities
5 OPD, with
(weighing scale, measuring tape)
necessary
facilities o IMNCI booklet chart

o IMNCI registration book

Trained personnel

10 The Health Trained health professional

Centres shall
ensure Supply of contraceptive methods,
provision of including IUDs, implants, injectable,
family oral Contraceptives & emergency
planning contraceptives
services.
EPHCG guide
 Yes
met =1
S.N √
Standard Method of evaluation not Remark
o No
met =0
X

MVA

Misoprostol

Table 5: Operational standards for pharmaceutical services

Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

Presence of official letter of

assignment for members

Presence of terms of
reference (TOR)

The Health Center has a

functional Drug and Presence of DTC annual
1 Therapeutics Committee plan for the fiscal year
(DTC).

Presence of at least 6
signed meeting minutes in
the last 12 months

Presence of performance
report of DTC activities of
the last fiscal year

2 The Health Center has a Presence of pharmacy

separate pharmacy services nearby outpatient,
department comprising inpatient (optional) and
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

emergency departments

Presence of pharmaceutical
supply management unit
(DSM officer)

Presence of drug
information service unit

dispensaries and medical

store directed by a
registered Pharmacist Presence of store for
and medical supplies, lab
Pharmacist/Pharmacy reagents, and medical
technician respectively. equipment

Check the dispensary is

guided by a
pharmacist/druggist

Check store is led by a

druggist/pharmacist(check
assignment letter)

Availability of 24/7 hours

pharmacy services

3 The Health Center Availability of annually

develops, utilizes and updated pharmaceutical list
annually updates a as per EPHCG drug list
comprehensive list of
pharmaceuticals
prioritized by VEN
The list is prioritized by
VEN
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

The list is updated in line

with EPHCG drug list.

Workflow organized as:

Evaluator
BillerCasher
Counsellor (Entrance and
Exit)

Presence of properly
recorded and filed
vouchers1 at store

Presence of properly
recorded and filed
The health center prescriptions, sales tickets
implements auditable, and registers at dispensaries
transparent and
4 accountable
pharmaceutical Adequate human resource
transactions and services is deployed in each
(APTS). (if applicable) pharmacy services
units2(hint: based on
workload
analysis:numberof
prescriptions and bed size)

Pharmacy premises are

arranged so as to keep
patient safety and privacy

Implementation of coding
to uniquely identify
1
Vouchers include: model 19/health and 22/health
2
Human resource: pharmacists at OPD pharmacy, Inpatient pharmacy, emergency pharmacy, drug information services, and
Pharmaceutical Supply Mgmt. unit; Pharmacy accountants, cashiers, porters, admin assistant and cleaners
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

medicines

Bin ownership is
implemented

Presence of monthly
reports for products,
finance and services

Presence of audit report

(internal)

Presence of annual report

on ABC and VEN analyses

Presence of survey report

on patient satisfaction of
overall pharmacy services

The health center has

patient medication profile
card in use for recording of
medications for chronic
disease such as ART

5 The Health Center Presence of dedicated room

provides access to drug for drug information
information to both services
health care providers and
the public

Dedicated assigned
pharmacy professional for
DIC
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

Presence of properly filled

query receiving and
answering forms (see the
previous month records

Presence of recently
prepared sample drug
alert/newsletter, therapy
update, drug monograph

Presence of updates on
stock availability, new
arrivals to the hospital
community (ask health
care team or see records or
posts)

Presence of medicine use

education for patients (ask
the appropriate unit and
Presence of yearly and
weekly plans (see theplan)

The Health Center has The health center has ADR

policies and standard reporting form.
operating procedures for
Presence of semi-annual
identifying and
managing drug use prescription monitoring
6 problems, including: report
Identifying and reporting
adverse drug reactions, Presence of annual DUE
and prescription Report
monitoring. (if
applicable) The health center clinical
staffs knows where/how to
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

report ADR(ask clinical

unit)

Presence of WHO drug use

indicator study report

Presence of procurement
policy

Presence of annual
pharmaceutical
quantification and supply
plan (check with DTC)

Report that shows

percentage of procured
items from the health
The Health Centre has a center list.
pharmaceutical supply
7 and inventory Presence of updated bin
management system for card (check randomly
drugs, medical supplies
selected 10 bin cards)
and equipment.
Availability of IFRR to
distribute pharmaceuticals
(ask other units ways of
distribution)

Availability of paper based

or electronic inventory
management tool

The facility has done

regularly (monthly) stock
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

status analysis

Availability of vital drugs

of the health facility at any
time.

Conducts physical
inventory minimum once a
year for dispensaries and
store (check report)

Good storage practice is

being followed 3(refer table
5.4)

Check for cold chains are

stored in refrigerators/cold
room

The health center uses the

report of physical count of
drugs for financial
reconciliations/auditing and
decisions.

8 The Health Center List of disposable drugs

ensures proper and safe
disposal of Committee approval for
pharmaceutical wastes disposal
and expired drugs in line
Check presence of
with national guidance.
guideline

3
See storage areas for cleanliness, proper arrangement, use of pallets, adequate shelves, ventilation and presence of thermometer
on the wall and in the refrigerator
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

The health centre disposes

expired and unusable drugs
in accordance with
FMHACA guideline(check
report).

The health center pharmacy

section:

Gives continuous supplies

The health centres to the catchment area
pharmacy assists and health posts(Check
9 monitors pharmaceutical HPMRR))
management activities at
the health posts. Provides technical support
on drug use to the
catchment area health post
team(checklist and Support
feedback)

TheHealth Centre
conducts audits of all
drugs, medical supplies
and consumable
Presence of audit report of
equipment in the store drugs, medical supplies and
and in each dispensing consumable equipment that
10
are audited at least once a
unit at a minimum bi year by internal and
annually by internal external auditors
auditor and once a year
by external auditor.

11 The health center has Presence of official letter

functional antimicrobial of assignment for members
stewardship program of ASP
 Yes
met =1
√
S.No Standard Method of evaluation not met Remark
No
=0
X

Check for availability of

AMR training trained
personnel

Presence of terms of
reference TOR

Presence of meeting minute

Presence of latest action

plan (check for the plan)

Table 6: Assessment toll for operational standards - Laboratory services

Yes
met =1
Std. √
Standard Method of evaluation not met Remark
# No
=0
X

Laboratory has adequate

The health centre space as per standard
provides laboratory
Staffed according to
1 service with optimal
standard
infrastructure and
resources. Has equipment as per
EPHCG

Check lab register

The health centre has
functional laboratory Lab request forms
2
management information
system. Annual plan and
performance

3 The health centre Check posted list of

laboratory posted updated laboratories tests in OPD,
list of laboratory tests as ER, MNCH
 Yes
met =1
Std. √
Standard Method of evaluation not met Remark
# No
=0
X

per EPHCG Verify laboratory list is as

recommendation. per EPHCG

Collected survey data

The Health center
monitors laboratory Check report of client
4 service satisfaction satisfaction survey
biannually(client and
providers). Check report of providers
satisfaction on survey

The Health centre has a Check bin card

functional laboratory
5 Check storage area
supplies management
system. Check RRF

Check SOP for:

o Sample
collection, acceptance,
transport, storing and
disposal

The Health centre o Lab testing SOPs

6 laboratory has standard o Safety and
operating procedures. medical waste disposal

o Lab equipment
maintenance and follow-up
SOP

o Quality assurance
SOP

Presence of water
The laboratory has Fire extinguisher
7 established safety
facilities. Safety kit

Waste segregation

8 The laboratory shall Check backup plan

 Yes
met =1
Std. √
Standard Method of evaluation not met Remark
# No
=0
X

Check MOU for lab backup

design a backup service
laboratory service.

IQA plan

The health centre IQA report

laboratory shall
9 IQA sample
implement quality control
activities. EQA plan

EQA report/feedback

The health centre

Laboratory participates in
the National As well as Check recognition
10
international certificate
accreditation body
(ENAO/SLIMTA/ISO.

Table 7: Assessment Tool for Operational Standards - IPC/CASH

met
Yes √ =1
Remar
Std # Standard Method of Evaluation No not
k
X met
=0

Check member assignment letter

Focal person assignment letter

Health center
established Check IPC committee TOR
1. functional
IPC/CASH Current annual plan
committee.
Minutes of regular IPC meetings

Used IPC/CASH audit tool in

 met
Yes √ =1
Remar
Std # Standard Method of Evaluation No not
k
X met
=0

ensuring IPC/CASH activities

regularly

Check presence of audit plan

The health
center Check assessment checklist/audit
conducts tool
2.
quarterly
CASH/IPC Action plan based on audit result
audit
Implementation of action plan

Check availability of:

The health
center shall disinfectant
avail the detergents supplies
necessary
3.
equipment, PPE,
supplies
necessary for Sweeping & mopping tools,
IPC/CASH.
trollies for waste transport

The Health Training plan

center shall
ensure that all Training Attendance, minute and
staff are photos
trained using
4. Interview 5 sampled staff(3
standard
infection providers & 2 support) on training
prevention and
control training
manual.

The health Adequate cleaners as per standard

center ensures
5.
housekeeping Observe visibly cleanliness of
activities. sampled rooms(eg delivery, toilet
 met
Yes √ =1
Remar
Std # Standard Method of Evaluation No not
k
X met
=0

Compound cleanliness(inside and

around)

Check rooms are well ventilated

Observe presence and functionality of

hand hygiene stations in all service
The health outlets
center ensures
hand hygiene
6. Hand hygiene job aids posted at all
facilities are
stations
available at all
service points.
Check presence of sanitizers in all
service outlets

Check presence of designated laundry

room
The health Check presence and functionality of
center has a laundry machine
7. functional
laundry
service. Presence of water at all times

Use of PPE during laundry machine

operation

Presence of SOPs based on revised IPC

The health manual(2019)
center ensures
standardized Presence of sterilizer/high level
8.
instrument disinfection setup
processing
practice. Separate Storage area for
sterilized and cleaned supplies

9. The health Annual plan HBV/COVID

center ensures vaccinations for staff
 met
Yes √ =1
Remar
Std # Standard Method of Evaluation No not
k
X met
=0

Presence of PEP for HIV & HBV

all the post PPE including:

exposure and
preventive o Mask
interventions
and procedures o Face shield
are in place in o Boots
case of
occurrence of o Heavy duty gloves
occupational
risks. o Head cover

o Goggles

Annual plan
The health Posted monthly schedule
center provides
health HE Logbook/report
10. education to
patients/clients EPHCG included in all HE
, caregivers sessions
and visitors.
IPC HE topics included in
monthly schedules

Check segregation of wastes

The health
center shall
Fenced Placenta pit, Incinerator
ensure proper
11. and Burning pit
health care
waste
Disposal is proper(no waste
management.
around spaces mentioned above)

12. The Health Annual plan for support

center provides
IPC/CASH Support checklist and feedback
support to its
satellite health Training report
 met
Yes √ =1
Remar
Std # Standard Method of Evaluation No not
k
X met
=0

IPC/CASH supplies provided

posts

Table 8: Assessment Tool for Operational Standards– Health Centre Infrastructure and
Facility Management

s.no met
Yes
=1
√
Standard Verification not Remark
No
met
X
=0

1 The health center has blue print

documents verifying
ownership of land. ownership certificate

2 Employment letter
Designated Health center
maintenance officer is hired Job description
for facility maintenance
functions. Annual plan

3 The health center floors are

inspected on weekly bases,
maintained and when
Reports of weekly
appropriate improved to ensure
inspections
cleanliness of grounds and
safety of patients, visitors and
staff.

4 Check the availability of

Potable water is available 24/7 water [inspect and
through regular or alternate interview]
sources to meet essential
patient care. water quality test report
s.no met
Yes
=1
√
Standard Verification not Remark
No
met
X
=0

5 Electrical services are

Check the availability of
available 24/7 through a
electiric power [ inspect and
regular or alternate sources to
interview]
meet essential patient care.

6
The health center conducts [inspect ]
quarterly preventive and
corrective maintenance for all
facilities and operating
systems (e.g. electrical, water,
sanitation, sewerage and
maintenance reports
ventilation) to ensure patient
and staff safety and comfort

7 Notification form
There is a notification and
work order system for facility Maintenance request form
and operating system(e.g.
electrical, water, sanitation,
sewerage and ventilation)
repairs. Maintenance report form

8 The health center has a

transport policy for the use of
Observe policy
and access to health center
vehicles.

9 Observe policy
The health center has a policy
addressing access to health Availability of guards
center premises and traffic
flow. Observe traffic flow
management

10 The health center has a fire Observe plan

safety plan that addresses both
the prevention and response to Updated Fire extinguisher /
Sand
s.no met
Yes
=1
√
Standard Verification not Remark
No
met
X
=0

Report on Fire safety drill

fires. exercise during last year

11 The health center has a plan Assigned surveillance

for responding to likely officer
community or health center
emergencies, epidemics and
Observe plan
natural disasters.

12 Health center staff members

are trained and knowledgeable
about their roles in the plans Observe training report
for fire safety, security, and/or list
hazardous materials and
emergencies.

13 Observe

o toilets
The health center ensures the (labelled for men and
availability of functional women) as per standard
toilets, hand washing sinks and
showers. o
handwashing stations

o showers

14 Observe compound for

cleanliness
The Health centre compound Separate entrance gates and
are regularly inspected, exit for cars as well as
maintained, and, when people
appropriate, improved to
ensure cleanliness and safety Observe functional fence
of compound.
Dedicated green areas

Inspection reports
Table 9: Standards checklist for medical equipment

Yes
met =1
Std Description of the √
Verification Criteria not met Remark
.# standard No
=0
X

Verify DTC TOR address medical

The Drug and equipment
Therapeutic
Committee o
(DTC) should be Commissioning
1 responsible to
oversee the entire o
Medical Maintenance and history file
Equipment documentation
Management.
o Disposal

The health centre MOU with ZHD/primary hospital

has an active workshop
medical
equipment Maintenance request form
maintenance
work order
system and
2 ensure functional
work relationship
with workshops
Maintenance report form
available within
zone health
department or
nearby Primary
Hospital.

3 The health centre Users guide attached in file

 Yes
met =1
Std Description of the √
Verification Criteria not met Remark
.# standard No
=0
X

Verify paper/computer based

has a paper-based documentation is current
or computer-
Preventive maintenance reports
based current
equipment history Electronic/paper based medical
file equipment history update form-
documentation. containing maintenance requests,
reports and other documentations

All new
equipment’s are Acceptance testing report
installed and
commissioned in
accordance with
the
manufacturer’s
specifications and
undergoes
acceptance
4
testing prior to its
initial use to Installation report in line with
ensure the manufacturer’s guide
equipment is in
good operating
condition(evaluat
e this standard if
there is new
equipment
procured).

All equipment Training plan

operators and
personnel are
trained on proper
5 application,
safety, and Training report
maintenance of
medical
equipment.
 Yes
met =1
Std Description of the √
Verification Criteria not met Remark
.# standard No
=0
X

The health centre Decommissioning plan

ensures
decommissioning
6 including
relocation, uses Decommissioning report
as spare, donation
or selling.

Health center
conducts proper Disposal plan
disposal of
medical
7 equipment
according to
national and Disposal report
regional
legislations.

Table:10 Assessment Tool for Operational Standards - Human Resources Management

met
Yes √ =1
Std. Description of the
Verification Criteria No not Remark
# standard
X met
=0

Employment or assignment
The Health Center (HC) letter
1 has a HRM personnel
staffed as per standard. Letter assignment to
Management committee
 met
Yes √ =1
Std. Description of the
Verification Criteria No not Remark
# standard
X met
=0

Randomly select five files and

The HRM case team check the following points.
maintains a personnel file
2 Employment or assignment
for each and every HC
letter
employee.
Job description

Electronic/paper based
employee profile including:

The health centre - Socio-

establishes and demography
institutionalizes Human
3 Resources Information - Employment
Management System history
(HRIS) that enhance the - Trainings & CPD
HR management function.
- Family

- Profession

The HC has annual plan Current annual plan

that also addresses Human
Resource Development
4
(HRD), staff numbers,
skill mix and staff training Reports on HRD
and development.

The Health Center

Motivation plan
adopted and implemented
5 benefits and motivation
packages to ensure Identification and recognition
satisfactory productivity. of best performers

The HC has a
performance management
process in which all Select 5 files and check BSC
6
employees are formally based performance appraisal
evaluated at least two
times per annum.
 met
Yes √ =1
Std. Description of the
Verification Criteria No not Remark
# standard
X met
=0

Check presence of policy

The HC has an HR policy Interview 3 staff on knowledge
and procedure related to of policy
human resource
7
management and code of All staff wear
conduct that is known,
and adhered to, by staff. o ID badges

o gown

Survey checklist
The HC regularly
conducts a staff job Survey report
satisfaction survey and
8 Filled Exit interview tool in
exit interview to assess
staff opinions about their files of employees left the HC
workplace.
Action plan based on results

Employees safety need

Health centre established assessment
occupational health and
9 safety system to identify Employees safety plan
and address health and
safety risks to staff. Employees safety
implementation report

Grievance management
committee
Health center has
Grievance collection forms,
10 grievance management
registration, box
system
Weeklygrievance management
action plan/reports/minute

Table11: Assessment Tool for Operational Standards - Clinical governance, safety and
quality
 met
Yes
=1
√
No Standards Verification criteria not Remark
No
met
X
=0

Members from each case team

assigned with official letter
The health center has a Review TOR and list of Team
functional QI established comprise of different
committee that leads case team
1
clinical governance,
quality and safety Regular meeting minute
initiatives. documented

Health center have assigned QI

focal person with official letter

The health center has Check quality and safety plan

operational plan
disaggregated by
2 Check quality and safety plan is
quarter for clinical
governance, quality integrated with annual health
and safety center plan

The patient right and

responsibility developed with
local language and posted

check updated charter is posted

check standardized TAT from

The health center registration book
implement citizen Check needed pre conditions are
3
charter for the services posted when patients come to
they render health center.

Measure services are performed

according to the standard

Check action plan after

performance review of the
charter

4 The health center Review EPHCG training records

ensured adherence to
Primary Health Care availability EPHCG in all OPD
 met
Yes
=1
√
No Standards Verification criteria not Remark
No
met
X
=0

rooms

review continued forum minutes

check advocacy of EPHCG in

the HE sessions/public forums

observe EPHCG is included in

the HC plan

check EPHCG mentoring docs

Clinical Guideline
(EPHCG) to provide observe 2 HW-patient
standardized clinical interactions
care and ensure quality
take randomly 3 charts from d/t
and patient safety.
departments and audit

pick randomly 3 referrals and

compare referral reason with
EPHCG

The health center review conducted audit docs

implemented quarterly
clinical audit (using Review identified problems
EPHCG, health center
5
clinical audit) and use review if audit findings are used
the findings for quality for quality improvement
improvement and interventions(QI projects)
assurance

The health center review problem priority doc

identified priority
problems on quality review QI project docs
services and
6
implemented quality review run charts
improvement projects
(Kaizen, Models for observe /check changes after
improvement) project implementation

The health center review quarterly CSC reports

7 conducted quarterly
review town hall meeting minute
community score card
 met
Yes
=1
√
No Standards Verification criteria not Remark
No
met
X
=0

check if key quality indicators

are discussed /presented

Check community concerns are

addressed (number of raised
and town hall meetings
concerns against number of
with the community to
addressed) in narration form
monitor service quality
(chapter 2)
and ensure
accountability.
The health center check if the HC is member/lead
participates quarterly in the cluster
in collaborative
learning and check minute/photos/video of
8 experience sharing EPAQ participation in the last
platform of Ethiopian quarter
Primary Health Care
Alliance for Quality Action plans based on EPAQ
(EPAQ). participation

check bi annual survey docs

Patient satisfaction
check analysis of survey docs
should be done bi -
9
annually and use it for check action plan based on
improvement survey findings for performance
improvement

Check risk assessment of ER,

delivery, laboratory ,injection
room and OR if available (annex
tools)
Procedures are Check risk assessment was
established to asses performed last 6 month and
10 and minimize risk to reviewed
patients during health
care service. Action plan based assessment
findings

Check incident reports collected

and investigated analysed and
monitored for improvement
 met
Yes
=1
√
No Standards Verification criteria not Remark
No
met
X
=0

Neonate identification system

should be in place (arm band
card number)

Emergency care Clinical Skill

drill annually

Safety protocols posted in

emergency care settings(ER, L
&D, Laboratory, Pharmacy) etc

Filled GGI assessment of last

quarter
Health center conducts
quarterly good Analysis of GGI assessment
11
governance index Action plan based on assessment
assessment
Intervention report of action
pplan

Table 12: Assessment Tool for Operational Standards - HIS

met
Yes
=1
√ Remar
S.No Standard Verification criteria not
No k
met
X
=0

Availability of Card room

The Health Center shall Have MR registration Officers

have a single unified including runners
1
health information system Have HIT Units/HIT experts
department.
Have data managers for
electronic data entry.

2 The Health Center shall Total of 5-10 shelves for

have a single standardized storing medical records.
 met
Yes
=1
√ Remar
S.No Standard Verification criteria not
No k
met
X
=0

Each shelves should be labelled

Have MPI boxes

Have Computers and UPSs for

medical record room electronic patient registration.

Have adequate furniture’s (1

table, 1 chair, and accessories)
and office materials

Card room: patient Individual

Folder, Patient ID, Tracer
cards, MPI card, patent history
sheets,

The Health Center should OPD Room: OPD Abstract,

avail and utilizes standard Tally sheet, Progress Notes,
3
set of formats for medical Lab orders, referral,
record registration prescription, etc

HIT Room: Reporting formats

(OPD, IPD and Service),
updated version of DHIS2 app,
NCOD, etc

Audit bi-annually to identify

passive and active cards.

Consistency check b/n

electronic and manual system
though auditing [Check
The Health Center should redundant cards, duplication,
have medical records incomplete, etc) by selecting 10
4 individual patient cards from
management auditing
system. MPI check consistency]

Review utilization of formats

(Randomly sample 10
individual patient cards seen in
the previous quarters, and
confirm that each has a
minimum, data elements
 met
Yes
=1
√ Remar
S.No Standard Verification criteria not
No k
met
X
=0

(demographic data, clinical and

administrative information)

Have assigned focal person for

medico-legal issues at card
room.
The Health Center has Identify medico legal cards
ensure proper handling
5 and confidentiality of Prepare lockable box for
medico legal patient- medico-legal cards
medica records.
Ensure Medico legal cards
should register when they
submitted and returned to
medico-legal box

Regular gap identification on

data management

Have regular bi-monthly

The Health Center have a meeting b/n HIT and medical
capacity building platform record.
6
to improve health
information system. Provide training for all staffs
working in medical record
management

Have trained HIT professionals

Have a PMT team comprise of

different case teams.
The health center should
Have regular monthly meeting
7 establish a functional PMT
with documented minute
team
Have avail and utilize standard
PMT and data quality Logbook

The health center needs to Have documented five years

prepare strategic plan, strategic plan
8
annual quarterly and
monthly plan Have documented annually
plan that is disaggregated
 met
Yes
=1
√ Remar
S.No Standard Verification criteria not
No k
met
X
=0

quarterly and monthly,

Cascaded plan up to each

unit/case team of the health
center which is agreed and
signed by each unit leader

Availability of copy of the

report /monthly, quarterly, bi-
annually, and annually/

Prepared improvement plan of

The health center needs to action based on the identified
collect report and utilize gaps
9 findings for internal Perform plan vs achievements
service quality (by chart, table, graphs, map,
improvement etc)

Display performance both

internally and external to the
community (by chart, table,
graphs, map, etc)

Self-assessments of health
center performance conducted
using LQAS
The health center needs to Have functional DHIS 2
implement Data quality application with updated data
10
audit selected priority
problems Major indicators selected for
follow up where the health
center has poor performance

Developed action plan

11 The health center should Have plan to improve the

have fulfilled all the implementation of Connected
requirements of Woreda strategy (CWS).
Information Revolution.
Assign enough budget for HIS
activity
 met
Yes
=1
√ Remar
S.No Standard Verification criteria not
No k
met
X
=0

regularly monitor the

implementation of Connected
Woreda strategy (CWS).

Quality improvement project is

developed for identified gaps
during data evaluation by the
The health center performs PMT and Quality unit
12 QI projects to improve
identified data quality gaps Action plans are implemented

Charts are plotted to measure

progresses