ETHIOPIAN HOSPITAL SERVICES

TRASFORMATION GUIDELINES
(EHSTG)

FMOH/CSD
 Outline

•Introduction
•Rational for revision of EHRIG
•What is new from EHRIG
•Overview of EHSTG
Introduction
A reform is a significant, purposeful effort to improve the
performance of a health care system
 History of Hospital Reform
4
2006-EHMI
2008-
Blue print of hospital Standards
2010-EHRIG

2011-HPMI

2012- EHAQ
 History of Hospital Reform…
6

• HAD 2013

• CASH 2014

• APTS 2015

• HSTP 2015/6

• ENQS 2016

• The HSTQ 2016

• EHSTG 2016

• SALT/EHAQ
Purpose of EHSTG
• To strengthen capacity of hospital management system

• To improve the quality of clinical care and patient satisfaction at

hospital level

• FMOH expectation is that over time, all public hospitals will attain the
Operational Standards Fully
 Rational for EHRIG revision
•Some standards are already met by most hospitals and a need to revise/upgrade them
• Laboratory service management
• Pharmacy service management

•Some standards were incomplete

• A need to harmonized academic activities with patient centered care

•Some services were not covered

• Radiologic service
• Rehabilitative and palliative care services
 Rational for EHRIG revision

•Did not include the context of teaching hospitals

•Has to be aligned with the HSTP transformation agendas
• New indicators

•Some services were packed in one chapter

• Patient flow chapter packing liaison, emergency, outpatient, inpatient services

•Incorporated learnings From New Reforms

• CASH, HDA, APTS etc.
What is new from EHRIG ???
ESHTG - 20 chapters in two volumes
•MNCH service management

•Radiology and imaging services

•Palliative and rehabilitative care

•Federal and Teaching hospitals’ Mx

•Patient flow = > 4 Chapters (OPD, IPD, Liaison and referral, Emergency)
•Implementation assessment hand book
 OVERVIEW

•2O chapters
•197 operational standards
• Minimum standards

•Assessment Hand book Prepared Separately

Volume -1 Volume - 2
•Chapter 1 HLGM •Chapter 11 Rad Imagi Service Management
•Chapter 2 LRS Services •Chapter 12 Pain Pal Rehab Care

•Chapter 3 Emergency Medical Ser. •Chapter 13 IPPS

•Chapter 4 Outpatient Services •Chapter 14 Federal and Teaching HMx

•Chapter 15 Medical Equipment Mx

•Chapter 5 Inpatient Services
•Chapter 16 Facility Management
•Chapter 6 M record Mx
•Chapter 17 Human Resource Mx
•Chapter 7 Nursing and Midwifery S.
•Chapter 18 Health Financing and Asset
•Chapter 8 MNCH Services
•Chapter 19 Clinical Governance & QIMx
•Chapter 9 Laboratory Services •Chapter 20 Monitoring and Reporting

•Chapter 10 Pharmacy Service 

 
   
How is each chapter set out?
• Table of Contents

• Section 1 Introduction

• Section 2 Operational Standards

• Section 3 Implementation Guidance

• Section 4 Assessment tool, Checklist and Indicators

• Source Documents/References

• Appendices
 LEADERSHIP, MANAGEMENT AND GOVERNANCE

•8 Standards
•Functional GB
o Annual work plan
o meets regularly with plan of agendas
o Community representative
o impact on the quality and efficiency
o maintaining a strong bond between the hospital and the community
o The board conducts self assessment of its performance
o Determine Vision, Mission and Values
o Set Short and Long term Plans
o Select and Evaluate CEO in regular basis
•Functional SMT
 TOR ,meets regularly, Support CEO ,Oversee daily work and different
committee performance
•Well-functioning HDA
 Identify local problem ,set solution and disseminate best practice
 regular hospital community ,Staff and other forum as per standard
 engage all Staff ( Senior clinicians)
 Citizen Charter
 key Vehicle to achieve HSTP Plan

•Implemented HCF
• Annual budget approved
• resource mobilization plan and implementation
• resources are utilized effectively and efficiently
• Review Audit reports
 LEADERSHIP, MANAGEMENT AND GOVERNANCE

•Performance measurement and evaluation in place

 BSc plan for hospital and each departments
 Feedback for each unit based on performance regularly
 System of recognition (case team/ workers)

•Promotes good ethical practice

 Ethics violation reporting and responding mechanism
 Assigns unit to timely submit violation, as well as takes proper action
 Suggestion boxes and logbooks are in place at each services area

•Regular for GB & SMT members capacity building Programme

 Board members/SMT participate in ongoing education
 Planned orientation Programme for new Board /SMT members
CEO/CED evaluation
 Every six months
 Result submitted to MOH/RHB/Zonal department
 FMOH or regional legislation
 If meeting operational and strategic plans
 The CEO has signed a job description that outlines his/her duties to lead the hospital.
 Membership of Senior Management Team
The SMT should be comprised of senior hospital leaders such as
department or case team heads, senior clinical staff and key
administrative personnel.

 Hospital CEO (Chairperson of SMT)  Two Clinical Department Heads

 Chief Clinical Officer  Planning Head

 Matron  Finance and Procurement Head

 Laboratory Head  Human Resources Head

 Pharmacy Head  Audit Head

 Clinical Governance and Quality  Staff Representative

Improvement Head
 General Services Head
 Medical Equipment Management Head
LEADERSHIP, MANAGEMENT AND GOVERNANCE

Monitoring Targets
•KPI 1: % of EHSTG operational
standards for hospital reform met •EHSTG 80%
•KPI 2: % of Functional medical •HDA 100%
equipment •GG index 80%
•Established and Functional quality
structure
 LIAISON, REFERRAL AND SOCIAL SERVICES

 Established management structures and job descriptions which detail roles and
responsibilities
 Reception service, liaison and referral service and social service
 Liaison service - 24/7 (weekends & holidays)
 Admission and discharge protocol
 Known, and adhered to, by all relevant staff.
 LIAISON, REFERRAL AND SOCIAL SERVICES

 Referral service
 referrals service directory - refer to or receive patients.
 Referral Criteria - standardized referral and feedback forms
 Referral management protocol - staff members are familiar
 promotes and publicizes the referral system in the community
 social service
LIAISON, REFERRAL AND SOCIAL SERVICES

Monitoring Targets
•Referral Services
•Emergency referral 0%
• KPI 30: Rate of referrals
• KPI 31: Emergency referrals as a
proportion of all referrals made
 EMERGENCY SERVICES management

 Emergency department
 led by an emergency director / case manager
 Emergency Triage
 infrastructure, trained personnel ,equipment, drugs and supplies
 Easily accessible with an ambulance parking area
 Established procedure for efficient flow of Patients
 EMERGENCY SERVICES management
o A triage system established
o screening and classifying patients as per priority needs
o Emergency medical service 24 hrs/7days
o Diagnostic, laboratory, radiology and pharmacy services.
o Emergency response plan
o both internal and external disasters
o system to alarm or communicate personnel and other stake holders.
o Presence and use of policies, protocols, flowcharts, consultation and treatment
guidelines
EMERGENCY SERVICES management

National targets
Emergency Services KPI
 KPI 6: Emergency room patients triaged within 5
minutes of arrival at ER •Emergency service
 KPI 7: Emergency room attendances with length of
• Triaged with in 5 min 100%
stay > 24 hours
 KPI 8: Emergency room mortality • ER mortality 0%
 KPI 9: Emergency re-attendance rate within 28
• ER stay > 24hrs 0%
days following ER attendance
 KPI 38: Patient day equivalents per doctor
 KPI 39: Patient day equivalents per nurse
 OUTPATIENT SERVICES management
 Outpatient services management refers to the processes and procedures needed to
ensure the efficient flow of patients in OPD
 Efficient flow of patients requires
 Fulfillment of all the necessary HR, infrastructure and equipment based on
the standard and addressing differently abled clients and there should be
established and facilitated patient flow procedures
 Properly designed and implemented patient flow will reduce patient waiting times,
increase provider efficiency and staff/client satisfaction
 OUTPATIENT SERVICES management
 Layout
 Outpatient services should be organized in a manner that reduces the length of time that it might
takes a patient to travel from one service area to another.
 clinical services should be organized as close to one another as possible

 Outpatient services includes

 Central triage and patient waiting area
 Medical Record Room
 Examination room, sample collection and treatment rooms
 Pharmacy dispensing unit and cashier
 Laboratory team, with cashier
 imaging diagnostic team, with cashier
 OUTPATIENT SERVICES management
Central Triage Pathway
 The first point of patient contact in outpatient services
 Client source can be from reception or Emergency Department
 Should be open one hour before regular working hours
 All the necessary HR, infrastructure, medical equipment's, drugs and supplies should be available based on
the standard
 Efficient patient flow should be designed to reduce patient crowding.
 Responsibilities includes
 Taking V/S, sorting and directing patients to the specific case team/examination room,
 Securing IV line for ER patient,
 Regular registering and reporting patients not seen on the same day and conducting all relevant
administrative procedures
 OUTPATIENT SERVICES management
7 Standards
 Established management structures and job descriptions
 led by full time outpatient director / case team manager with nurse coordinator
 accountable to the hospital’s CCO/MD
 Detailed roles and responsibilities of each discipline including reporting relationships should be
clearly defined
 Outpatient specific diagnostic laboratory, radiology, and pharmacy service units should be available
 Waiting area with adequate lightening, ventilation and multimedia facilities should be available
 OUTPATIENT SERVICES management
 Well-equipped service specific OPD rooms and staffed with adequate and appropriately trained
personnel as per hospital tier level
 HR - OPD service rooms - at least a GP, Specialty clinics - service specific specialist, and
Sub- specialty clinic - sub specialist
 Pertinent history, P/E findings, laboratory & imaging findings, procedure notes has to
documented on the patient chart
 All the necessary information has to be provided to all clients based on their understanding
and literacy level
 Clients involvement in the care has to be optimal
 Established appointment and queuing management systems.
OUTPATIENT SERVICES management

Monitoring National Targets

•Outpatient Services
 KPI 3: Outpatient waiting time to treatment
 KPI 4: Outpatients not seen on same day
•Waiting time less than 60 minutes
 KPI 5: Number of OPD visits per practitioner per
day •Outpatients not seen the same day 0%
 KPI 38: Patient day equivalents per doctor
 KPI 39: Patient day equivalents per nurse
 MEDICAL RECORD MANAGEMENT

Medical records management (MRs) - is one of the components of health

information system that documents information related to a patient generated
during patient-to-health care provider encounters at a health care facility.
 MEDICAL RECORD MANAGEMENT

 A well-managed medical records system is critical to:

 Improve the provision of quality health care services
 Serve as a reliable source of information for medico-legal issues and
medical/ public health researchers.
 Ensures the availability of reliable healthcare data which is key for
implementation information revolution agenda.
 MEDICAL RECORD MANAGEMENT
8 Standards
•Unique medical record number
• Need to use paper based (MPI)and computer based
• ONE MRN: ONE PATIENT
•There should only be a single unified medical registration unit
• All patients – regardless of which service they will access – should be registered at one central
registration site.
•There should be a paper and computer-based systems to register and retrieve medical records.
• A hospital-approved folder should be assigned to each patient
• MRN number → MPI box → computer search
 MEDICAL RECORD MANAGEMENT
 Use of tracer card and patient’s medical records return from different service units at the end of
each service day
 When a MR is removed, one should put in its place, a tracer card.
 Standard set of formats should be used
 facilitate the entry, review, and retrieval of information.
 All forms should be of the same size, usually A4.
 Implement and comply with national guidelines to manage and access patient’s medical records.
 Only authorized personnel should have access to MRs
 MRs should be removed from facility only upon an order from a federal or regional
jurisdiction.
 But, the original MR should never be transferred out of the hospital
 MEDICAL RECORD MANAGEMENT
•Medical records auditing, data quality checks, archiving/ culling procedures
• corrective actions accordingly on a regular basis.
• shelve for Inactive files( 5 years)
• retain a MR for up to 10 years
•Automate health information system
• implement integrated electronic medical record system.
POORLY HANDLED PATIENT CARDS WELL HANDLED PATIENT CARDS
 INPATIENT SERVICE MANAGEMENT

 Patients enter care in to the inpatient service comes mainly from

 Previous ambulatory care such as referral from outpatients or emergency
outpatient department (OPD),
 Home (with an appointment),
 Transferred from inter-department or referred from another facility
 Main purpose:
 To provide high quality inpatient service through integrated, respectful and
compassionate team approach.
 INPATIENT SERVICE MANAGEMENT

 Established management structures and job descriptions that

detail the roles and responsibilities including reporting
relationships
 Inpatient director or case manager oversee the inpatient activities and is
accountable to CCO or medical director
 Case teams should comprised of specialists, general practitioners, health officers,
nurses, pharmacists, lab. technologists, runners, and cleaners.
 INPATIENT SERVICE MANAGEMENT
Layout of wards
 in close proximity to the emergency and outpatient departments, and easily accessible from elevators,
ramps or stairways
 adequate number of well-ventilated rooms with a separate dining corner, functioning set of adequate
number of toilets, sinks and showers.
 Privacy of patient maintained at all times (mixed wards, P/E, during sample collection etc)
 Laboratory and pharmacy dispensary & counseling services readily accessible to the inpatient wards
Specific Inpatient facilities and services
 Operating theatre
 Intensive Care Unit (ICU) mixed
 Mental Health Care Service
 Separate or Isolation rooms for MDR-TB, Tetanus and others as per the recommendation
 INPATIENT SERVICE MANAGEMENT
IPD specific admission services
 24/ 7 admission service, including holidays and weekends
 Assessment on arrival
• On arrival by the receiving nurse and informs the on-duty physician
• On duty physician - immediately for critically ill patients and within 2 hours for patients with
stable conditions
 Nursing/midwifery process completed for all patients within 8 hours after admission and implemented
 multidisciplinary team patient rounds conducted minimum daily
 Regular re-evaluation
• Physicians - at least once a day for stable patients and two or more times for critically ill patients
• Nurses - four hourly for stable patients and more often for critically ill-patients
 INPATIENT SERVICE MANAGEMENT
IPD specific discharge services
o 24/ 7 discharge service, including holidays and weekends
o Procedures in place to reduce the unnecessary inpatient length of stay which includes pre surgical
admission protocol
o Decision for discharge should be made by the treating physician who should complete a
discharge summary where the first copy of the discharge summary should be given to the patient
and the second copy retained in the patient’s Medical Record
o Counseling on discharge by the attending physician, nurse in charge and clinical pharmacist
o discharge process should be complete in no more than 2 hours (including administrative process)
 INPATIENT SERVICE MANAGEMENT
Policy or a protocol that states the procedure to be followed for dead body care
 Death confirmation by the attending duty physician and death summary
completed
 a separate room to provide post mortem care and immediate transfer to morgue
 If a need for pathologic examination to confirm of cause of death, a post mortem
examination form should be completed and the body should be transferred to the
pathology case team.
 If the deceased does not have a next of kin, the local authority is responsible for
funeral service.
 INPATIENT SERVICE MANAGEMENT
 HR, Equipment, drugs and supplies as per the recommendation
 verbal and written communication protocols to ensure continuity of care
 patient handover
 Guideline for working relationship within the same profession, different profession
 Communicating with patients and care givers
 inter-professional and departmental consultation
 intra and inter disciplines transfer of patients’

 a policy for accompanying all patients

 appropriately trained health provider/s during diagnostic services and transfer between wards/departments.
 Monitoring Targets
 KPI 14: delay for elective surgical
 Inpatient Mortality < 5%
admission
 Delay for elective surgical admission
 KPI 17: Inpatient mortality
 KPI 18: Delay for elective surgical less than 30 days
 BOR 80%
admission
 ALOS < 5days
 KPI 19: Bed occupancy
 Pressure ulcer 0%
 KPI 20: Average length of stay
 SSI 0%
 KPI 21: Pressure ulcer incidence
 KPI 22: Surgical site infection
 Targets
Monitoring

 Completeness of inpatient medical

 KPI 23: Completeness of inpatient medical records
records more than 95%
 KPI 24: Healthcare acquired infection rate
 KPI 25: Cancelation rate for elective Surgery  Cancellation rate for elective surgery less
 KPI 41: Major surgeries conducted in the private than 5%
wing  Major surgery per surgeon shows
 KPI 38: Patient day equivalents per doctor
efficiency
 KPI 39: Patient day equivalents per nurse
 NURSING/MIDWIFERY SERVICE MANAGEMENT

•Hospitals need to provide competent, safe and ethical nursing and

midwifery care
•An essential part of the hospital system in improving the health outcomes
of individuals, families and communities
 NURSING/MIDWIFERY SERVICE MANAGEMENT

Nursing/midwifery service management structures should be in place

 Nursing/Midwife Director who is a member of SMT
 Head nurses/midwives in each ward who are accountable to the Nursing/Midwifery Director
 Supervisor Nurses who are accountable to the Nursing/Midwifery Director

Nursing and midwifery workforce plan practiced considering

 severity of the clinical condition
 intensity of nursing/midwifery care needed
 NURSING/MIDWIFERY SERVICE MANAGEMENT

Verbal and written communication protocol

 Written communication which includes the written documentation of all findings, progress, care
and treatment provided to the client by the multidisciplinary team.
 Verbal communication which entails the act of reporting and conversing with other members of
the health care team regarding the client’s progress and status. Verbal orders will only accepted in
emergencies
 NURSING/MIDWIFERY SERVICE MANAGEMENT

Holistic nursing/midwifery care plan for all admitted patients

• nurse gathers and examines both Subjective and Objective data.
• most commonly selected nursing/midwifery diagnoses compiled and categorized by
NANDA.
• An individualized care plan that addresses and prioritize identified problems
• Implement the plan
• Evaluate the plan
 NURSING/MIDWIFERY SERVICE MANAGEMENT

 Nursing practice requires teamwork

• Need to collaborate with patients, caregivers and other health professionals
•Procedures for supervision and delegation
• Senior nurses lead the clinical supervision activities like nursing shift rounds, nursing case
discussion program, nursing service audit program and etc
• Nurses/midwives may delegate tasks and responsibilities to junior nurses/midwives, student
nurses/midwives or parallel position
 NURSING/MIDWIFERY SERVICE MANAGEMENT

 safe and proper administration of medications

 Different types of orders well communicated and implemented
 nursing/midwifery care practice audit programme and QI programmes are in place
 regular nursing/midwifery eight hours’ shift rounds and room/central cabinet
medication store are practiced
 centralized nursing/midwifery station is in place based on the recommended package
 adequate space, equipment and consumables
 Monitoring Targets

 KPI 21: Pressure ulcer incidence

 KPI 39: Patient day equivalents per •Completeness of inpatient medical
nurse/midwife
records more than 95%
 KPI 39: Patient day equivalents per nurse
 IPPS/CASH

•Health care facilities should provide safe, effective, patient-centered, timely, efficient
and equitable quality of service.
•HCAI is the most frequent harmful event in health-care delivery and occurs worldwide
in both developed and developing countries
•The prevalence of infectious diseases such as TB, HIV, HBV and HCV etc in Ethiopia
enhance the urgency for health facilities to CASH/IPPS program
 IPPS/CASH

•Management system should be established

• designated person or persons to oversee day to day CASH / IPPS activities
• Actively working Infection Prevention and patient safety Committee
• Senior level management should support the CASH and IPPS committee’s efforts
• successful implementation of IPPS program requires a strategy and an operational plan
•Compliance of Hand hygiene practice should be monitored
• Ensure adequate infrastructure and supplies
• Promotion and Best practices benchmarking
• culture of providing positive feedbacks
• culture of rewarding role models
 IPPS/CASH

•necessary commodities and supplies should be availed and compliance on use of

PPE should be strengthened
• PPE
• Consumables
•safe surgical procedures and practices in place
• 4 surgical zones need to be established
• Safety rules should be practiced
•Safe injection practices need to be implemented
 IPPS/CASH

•health care waste management should be in place

• Need of integrated, effective waste management system can minimize the risks both within and
outside healthcare facilities
• Implement multi-step process involving waste minimization, segregation, handling, collection,
storage, transportation and treatment and disposal
•cleanliness and housekeeping activities should be monitored
• Can be self managed or outsourced
•adequate and functional toilets, hand washing sinks and showers should be available
• assessment should be done periodically (at a minimum quarterly) to ensure that any new needs
are identified
 IPPS/CASH

•adequate and functional laundry service should be present

•Proper Instrumental processing should be practiced and monitored
•traffic flow regulation should be present in high risk areas
• a system should be designed to regulate the number of visitors and caregivers allotted for each
patient
•mechanism to minimize harm to clients and staff should be in place
 IPPS/CASH

•safety of food and water should be monitored

• Standardized kitchen
• Safety monitoring mechanisms implemented
•clients’ education system should be standardized and strengthened
• education materials contextualized to their settings and their clients
• Activities monitoring and evaluation mechanism should be in place
 IPPS/CASH

•post exposure and preventive interventions and procedures has to be implemented in

case of occurrence of occupational risks
• Need to monitor and evaluate the program on regular bases
• Maximize all preventive measures to minimize health risks associated with exposure to HBV and
HCV
•hospital acquired infections tracking and monitoring system should be present
• Risk assessment must be done on regular bases
• results of the research and surveillance studies should be compiled
 Monitoring

•CASH/IPPS 80%
 MNCH SERVICE MANAGEMENT
Standardization of MNCH services is vitally important
 An effective care to prevent and manage complications during ANC, labor and delivery, and
postnatal likely to have a significant impact on reducing maternal deaths, stillbirths and early
neonatal deaths.
 The high neonatal and U5 mortality should be also equivocally addressed.
 MNCH SERVICE MANAGEMENT

•ANC unit with individualized, client centered and evidence

based care provided on all working days
• Referral clinic for high risk mothers
•CEmONC services
• All the ten signal functions should be availed
•women and child friendly services including pain management
should be implemented
•all essential equipment, drugs, supplies and reference
materials should be available in all maternity and pediatric
units
 MNCH SERVICE MANAGEMENT
•intrapartum care should be given as per national protocols
•comprehensive postnatal care should be provided as per national
standards
•family planning service (with focus on long term methods) and
comprehensive abortion care services should be availed
•CQI activities should be in place (as per HSTQ recommendation)
•separate pediatric OPD, emergency and triage services should be
available
 MNCH SERVICE MANAGEMENT

•comprehensive neonatal care service should be provided

• NICU, KMC, mother’s room and isolation rooms.
•separate pediatric wards need to be prepared for the following
services
• separate critical, general, SAM, isolation and procedure rooms.
•midwifery process should be implemented for all admitted
patients
•Maternity waiting Homes-MWH should be prepared when in need
 MNCH SERVICE MANAGEMENT
•Maternity services
• KPI 26: Proportion of mothers with all 4 ANC
visits
• KPI 27: Births by surgical, instrumental or
assisted vaginal delivery
• KPI 28: Institutional maternal mortality
• KPI 29: Institutional neonatal death within 24 •ANC 4 more than 70%
hours of birth •Institutional MMR less than 0.5%
• KPI 38: Patient day equivalents per •Institutional NMR less than 3%
doctor
• KPI 39: Patient day equivalents per
midwife
 LABORATORY SERVICE MANAGEMENT

•Laboratory services play an essential role by providing clinicians with the necessary
information needed to make clinical decisions in relation to
• assessing status of a patient’s health
• Making accurate diagnoses
• Formulate treatment plans and monitoring the effects of treatment
• Management of diseases
 LABORATORY SERVICE MANAGEMENT

•Laboratory management structure should be in place

• Accountability arrangement with well-defined roles and responsibilities should be established
• Central, emergency and inpatient laboratory services should be established
• Communication systems – both internally and externally
• Organizational chart (organ gram) that describes the management and supervisory
•System for management of documents and records in place
• For use and maintenance of controlled, reviewed and approved to ensure the provision of quality
laboratory service
 LABORATORY SERVICE MANAGEMENT

•Established system should be present to monitor effectiveness of its customer service

programme
• Laboratory handbook, lab advisory service, information notification, customer satisfaction survey,
suggestion boxes, suggestion books
•Proper medical equipment management system should be in place
• Calibration, maintenance , inventory
•Supplies management system should be strengthened
•IQA & EQA system should be in place
• Pre analytical to post analytical phases of testing,
 LABORATORY SERVICE MANAGEMENT

•Established incident handling and reporting system including errors or near

errors (also called near misses)
•Established laboratory management information system.
•Design and organization for at least bio safety level 2 or above
• Work environment is clean and well maintained at all times.
•Backup laboratory service
• Back laboratory equipment or and through backup laboratory facility.
 LABORATORY SERVICE MANAGEMENT

•Blood and blood products service

• Appropriate blood use practice
• appropriate storage and stock management systems
• mobilization of blood donation strategy with regional blood banks through community awareness
programs.
• appropriate cold chain system until used by prescribers.
• report blood administration and patient safety information to respective regional blood banks.
 LABORATORY SERVICE MANAGEMENT

•Laboratory and diagnostic

Services
• KPI 36: Essential tests availability
• KPI 37: Proportion of laboratory
tests that were referred to another •Essential test availability 95%
facility •Proportion of tests that were referred to
another facility less than 5%
 PHARMACY SERVICE MANAGEMENT
12 Standards
•Functional DTC
• Develops and implements interventions promoting the rational and cost-effective use of medicines
• Multidisciplinary
•Availing quality pharmaceutical products and effective services
• Outpatient, inpatient, and emergency pharmacy service units.
•Efficient and effective pharmaceutical management practice.
•Drug formulary list
• Prioritized by VEN (local pattern of disease, STG, NDL, Services and Diagnostic)
• Annual update
•Good dispensing practices at all dispensing outlets.
• Receiving, validation, interpretation and checking, Billing and recording transactions, Packaging
,labeling and counseling
•APTS implemented
• Data driven, accountable and transparent Pharmacy practice
• Help optimize utilization of medicines budget, improve access to medicines, and decrease wastages.
 PHARMACY SERVICE MANAGEMENT

•Clinical pharmacy services available

• Inpatient, outpatient and emergency departments

•Drug information services

• To health care providers, patients and the public
•Functional compounding service
•Ensure uninterrupted supply of drugs and supplies
• Selects, quantifies, procures, stores and distributes safe, effective and quality pharmaceuticals consistently
•Regularly monitors medication use and safety.
•Continuous segregation, documentation and safe disposal of pharmaceutical wastes.
Pharmacy Service Organization and management

assistant
Administrative assistant
Outpatient Pharmacy
unit

Administrative
Emergency pharmacy
unit

Inpatient & Clinical

Pharmacy unit
Pharmacy Service
Head/Director
Pharmaceutical Supply
Management Unit

Drug Information Service

Unit

Compounding unit
Dispensing work flow should be organized as
 PHARMACY SERVICE MANAGEMENT

•Pharmacy Services
• KPI 32: Stock out of tracer drugs
• KPI 33: Expired drug stock value
• KPI 34: Consumption to Stock Ratio
•Established APTS
• KPI 35: Documented inpatient
•Stock out of tracer drugs 0%
Pharmaceutical care given.
•Documented inpatient pharmaceutical
care more than 80%
 RADIOLOGICAL & IMAGING SERVICES MANAGEMENT

•radiology unit
• oversees radiological and imaging services.
•layout and infrastructure, personnel and equipments
• as per FMHACA and ERPA standards.
•All users are appropriately trained on the operation and
maintenance
• standard operating procedures readily available
•established procedures for the maintenance, calibration, capability, quality control
testing and functionality of all radiological and imaging equipment.
•written policies, procedures, protocols and guidelines
• for the delivery of all radiological services, interpretations and timely reporting of results for all
patients.
•paper or computer based system
• recording and reporting of all radiological and imaging procedures
• archiving all patients’ results that are periodically audited for quality assurance, service
improvement and expansion.
 REHABILITATIVE & PALLIATIVE CARE SERVICES MANAGEMENT

• Rehabilitation of people with disabilities is

• a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual,
psychological and social functional levels.

• Palliative care is an approach that improves the quality of life of patients and their families
facing the problem associated with life-threatening illness, through the prevention and relief of
suffering.
• achieved by treating pain and its components, physical, psychosocial and spiritual.

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 REHABILITATIVE & PALLIATIVE CARE SERVICES MANAGEMENT

•rehabilitation and palliative care service

• necessary equipment, aids and human resources.
•physical therapy/physiotherapy service
• if possible, occupational, speech and Prosthetics Osthotic Technology.
•good pain and symptom control
•written SOP and patient record management for all
rehabilitative and palliative care services.
•established mechanism for referral and transfer of
rehabilitation and palliative care services
• through in-patient and outpatient
• palliative care - linkage to home-based care
 CLINICAL GOVERNANCE AND QUALITY MANGEMENT

•Clinical Governance and Quality Improvement Unit that is led

by an assigned Senior Physician or GP.
•CG&QI strategy and an operational plan
•monitor clinical practices and standards through services
specific process and outcome measures
•regular clinical audit program in each service area.
•Risk assessment and minimization procedures in place
• system in place for reporting and analyzing incidents, errors and near misses.
•adopts a statement of patient rights and responsibilities
• posted in public places
•Continuous and systematic review of patient safety related
activities
• apply best practice to assess & manage risks to patients, staff & others.
•monitors patients’ experiences with care
• patient satisfaction surveys - quarterly.
•patients and public involvement strategy
•Patient centered care and CRC strategy
•participation in benchmarking activities to learn from and share good
practices.
•Quality score
• Maternal 80%
• Pediatric 80%
• Communicable disease 80%
• NCD 80%
• STG adherence 100%
• Nursing/midwifery 60%
• Surgical service
• PCC and CRC
• Patient safety 100%
• Data quality
•Patient satisfaction 9/10
•Staff satisfaction 9/10
•TB and HIV Services
• KPI 10: Survival rate on ART
• KPI 11: Proportion of patients with
good ARV treatment adherence
• KPI12: Proportion of LTFU for
Chronic HIV care
• KPI 13: TB cure rate
•Non Communicable Diseases
• KPI 14: Proportion of patients with
chronic diabetes complications
• KPI 15: Proportion of patients with
chronic hypertension complications
•Malnutrition
• KPI 16: Treatment outcome for
management of severe acute
malnutrition in Children 6-59
months
•All other KPIs
 Medical Equipment management

•Medical Equipment Management unit /MEMU/with an

operational plan
• Appropriate staff & led by a Biomedical Engineer/HTM/Clinical Engineer/Senior Biomedical
Technician personnel.
•Medical Equipment Committee
•medical equipment maintenance workshop – well equipped
•inventory management system
• paper-based and computer-based or automated
• all equipment and spare parts
•An Equipment History File
•policies and procedures in place for
• acquisition of new medical equipment
• Commissioning
• decommissioning and disposal of equipment
• the receipt of donations,
• outsourcing technical services for medical equipment repair and maintenance.
•acceptance testing prior to its initial use
• ensure the equipment is in good operating condition, and are installed and commissioned in
accordance with the manufacturer’s specifications.
• All new equipment should be received with all the necessary documentation like user’s manual,
service manual, and contractual agreement
•Training for All equipment operators and personnel
• proper operation, safety, maintenance with SOP readily available
•schedule for calibration, inspection, testing and preventive
maintenance for each piece of equipment
• guided by manufacturer’s recommendations
• schedule is appropriately implemented.
•notification and work order system
• for corrective maintenance and calibration
•KPI 2: % of Functional medical
equipment
 Facilities Management
Purpose of Facilities Management

• To ensure the facility (buildings, grounds, utilities) is kept in good

working order
 safe environment for patients, visitors & staff
uninterrupted clinical services

• To ensure hospital is adequately prepared to deal with internal and

external emergencies
 Facilities Management

Maintenance
Buildings
Landscape & renovation
& Garden
Utilities &
Facilities Sewerage
Management
Vehicle & Function
Transport
Services Major
Incidents
Safety
Security
 Facilities Management

14 Standards
•Complies with relevant laws, regulations, and facility inspection
requirements.
•Hospital staff members are assigned for facility maintenance functions. 
•Hospital grounds are regularly inspected, maintained
• ensure cleanliness of grounds and safety of patients, visitors and staff.
•Potable water - 24hrs/7days
• regular or alternate sources
• Regular checks to ensure water is potable
•Electrical services 24hrs/7days
• regular or alternate sources
•Maintenance center
• technical personnel, sufficient space and adequate ventilation
• electrical, water, sanitation, sewerage and ventilation
• proper hand washing facilities, proper disinfection and cleaning of equipment facilities, a storage
area, and a library.
• appropriate tools and testing equipment to repair , routine calibration
•Regular preventive and corrective maintenance
• Schedule or plan
• (electrical, water, sanitation, sewerage and ventilation) to
ensure patient and staff safety and comfort.
•Notification and work order system
•Transport policy for use and access of hospital vehicles.
•Policy addressing access to hospital premises
•Fire safety plan
• both the prevention and response to fires.
• A ‘Fire and Evacuation Drill’ is conducted at least annually.
•Plan to respond to community or hospital emergencies,
epidemics and natural or other disasters.
• A major incident is any event whose impact can’t be
handled within routine service arrangements.
• MIC,MIP, implement the MIP through training

•Staff training
• fire safety, security, hazardous materials, and emergencies.
Untidy Environment
 FEDERAL HOSPITALS MANAGEMENT

•established functional management and governance structure

• integrates patient care, medical education and research.
•orientation programme for students/interns/residents on hospital
policies and procedures prior to clinical attachments.
•established system to ensure care provided and students’ practice
maintains patients’ confidentiality and privacy at all times.
•established protocols/policies and procedures for ward rounds and
bedside students’ teaching to maximize patients’ benefit.
•ensures students/interns/residents’ patient care provided is supervised by their
respective teachers/hospital based instructors at all times.

•established guidelines, memoranda of understanding and procedures for affiliation

with other teaching institutions, communities and field activities.
MEASURES
•Established governing structure
•Defined and institutionalized roles and responsibilities of all role players
•Harmonized academic – health service activities
 HUMAN RESOURCE SERVICE MANAGEMENT
14 Standards

•HRM directorate / Department/ Support Process staffed by Qualified experts

•Comprehensive HRM plan Including HR Development plan
• HR Head an active member of SMT
•Institutionalization of HRIS
•National Human Resource Policy Implementation
•Employee handbook
•Availability of Job descriptions signed by staffs
 HUMAN RESOURCE SERVICE MANAGEMENT
•Fully Functional Performance Management system
•Personnel file organization and updating System
•Code of Conduct and Professional Ethics
• Implementation of occupational health and safety policies and procedures
•ID badges and appropriate uniforms are wear by employees at all times
•Regularity of staff satisfaction survey & results shared with SMT
 HUMAN RESOURCE SERVICE MANAGEMENT

•Monitoring •Targets
•Human resources KPI
• KPI : Attrition rate - physicians
• KPI : Staff satisfaction
•Attrition 0%
•Staff satisfaction 9/10
• FINANCE AND ASSET MANAGEMENT
 FINANCE AND ASSET MANAGEMENT

•Established finance, procurement and asset

management structure
• operational plan , approved by SMT that details:
• The process of submitting procurement requests
• The responsible body/person for approval of procurement
requests
• The means of procuring
• Responsible person(s) for procurement activities
A five year plan for major capital purchases
•Bilingual service fee schedule posters
• each departmental reception desk, all waiting areas, all cash
points.
• shows fees and advises patients to obtain and keep receipts for
all payments.
•Provides exempted services
• in accordance with the relevant
Federal/Regional Legislation
• displays at appropriate locations
•All services indicated in health insurance benefit
package in accordance with the agreement
• displayed at appropriate locations
•Submits timely payment requests/claims
/reimbursements for services to the Health
Insurance Agency and fee waiver beneficiaries
 FINANCE AND ASSET MANAGEMENT
•Records of services provided to eligible health insurance agency, fee
waiver and exempted service beneficiaries
• related financial information as appropriate and, reported to the
relevant body.

•Private wing service is established in accordance with the required federal /regional
directives

•Services are outsourced, procedures are in place to monitor

•Multi-year budgeting and expenditure which link to programs and priorities of

each department
Fiscal information is channeled
 FINANCE AND ASSET MANAGEMENT

•stock management
• ranging from identifying the need for a property to materials and supplies
• disaggregated by each department.
•The accounting system should produce and access periodic
reports to the relevant bodies at all levels.
•Internal audit on quarterly basis and external audit at least
once in a year
• reports are reviewed by the SMT and Governing Board.
 Public Private Partnership in Hospitals
PPP is an arrangement between public sector and private sector which aims at
joining forces together to meet public needs through the most appropriate
allocation of resources, risks and rewards. Public Private Partnership in Health (PPPH)
particularly:
 provision of secondary and tertiary level health services ;
 Priority Public Health Programs;
 alleviation of human resource constraints.
 Pharmaceutical Products

To encourage the private sector for a high end diagnostic services (laboratory and imaging
services), high end clinical services such as Hemo-dialysis, radiotherapy, neurosurgery and
rehabilitation medical services and others unmet need driven PPPH projects in the premises
of the public health facilities. 109
 FINANCE AND ASSET MANAGEMENT
•Finance KPI
• KPI 41: Reimbursement ratio
Targets
• KPI 42: Share of revenue collected
• >85%
from out-of-pocket (OOP) payment as a
proportion of retained revenue • <20%
• KPI 43: Raised revenue spending as a • improve trend of raised revenue as
proportion of total operating spending a proportion of total operating
• KPI 44: proportion of patient spending
attendances for insurance beneficiaries • >80%
• KPI 45: budget utilization
• 100%
 Monitoring & reporting

•HMIS Monitoring Team (or equivalent)

• collaborates with the CG&QIU in reviewing the HMIS indicators and takes action to address any
areas of concern.
•self-assessment of its own performance at a minimum every
quarter
• using HMIS indicators and any additional local indicators
•submits monthly, quarterly and annual HMIS reports to the
relevant higher office within the agreed timelines.
•Data Quality Assurance (DQA) and Lot Quality Assurance
Sample (LQAS) is ≥85%.
• correspondence between data reported on HMIS forms and data recorded in registers and
patient / client records
•with GB , CG/QIU have established performance indicators
• described in hospital performance reports as a minimum every quarter.
• Indicators included are a combination of national/regional indicators and other local indicators
•staff receive orientation on all performance indicators
• case teams/departments/Directorates monitor their own performance
Thanks!!