EHSTG

Federal Ministry of Health of

Ethiopia
 OBJECTIVES

• Introduction
• Rational for revision of EHRIG
• What is new from EHRIG
• Overview of EHSTG
 INTRODUCTION

2010: The Ethiopian Hospitals Reform Implementation Guidelines

launched
2011-2012: Hospital Performance Monitoring Framework introduced
with KPI reports, site visits and review meetings
2012 The Ethiopian Hospital Alliance for Quality(EHAQ) launched.
2015 The CASH initiative lunched
 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 without
• 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 CASH, HDA, APTS etc
 OVERVIEW

• 2O chapters
• 197 operational standards
• Minimum standards for patient satisfaction
 LEADERSHIP, MANAGEMENT AND GOVERNANCE

• Functional GB
• Community representative
• meets regularly with plan of agendas
• impact on the quality and efficiency
• maintaining a strong bond between the hospital and
the community
• The board conducts self assessment of its
performance
• Functional SMT
• meets regularly
• Well-functioning HDA
• regular hospital community forum held at
least every month
• Implemented HCF
• resource mobilization plan
• resources are utilized effectively and efficiently
 LEADERSHIP, MANAGEMENT AND GOVERNANCE
• Performance measurement and evaluation in place (BSc)
• Promotes good ethical practice
• ethics violation reporting and responding mechanism
• Assigns unit to timely submit violation, as well as takes proper action
• 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
• 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.
• • Two Clinical Department Heads
Hospital CEO (Chairperson of
SMT) • Planning Head
• Chief Clinical Officer • Finance and Procurement Head
• Matron • Human Resources Head
• Laboratory Head • Audit Head
• Pharmacy Head • Staff Representative
• Clinical Governance and • General Services Head
Quality Improvement 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 • HDA 100%
medical equipment • GG index 80%
• Established 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

• a triage system established

• screening and classifying patients as per priority needs

• emergency medical service 24 hrs/7days

• diagnostic laboratory, radiology and pharmacy
services.
• emergency response plan
• both internal and external disasters
• system to alarm or communicate personnel and other stake holders.

• Presence and use of policies, protocols, flowcharts,

consultation and treatment guidelines
 EMERGENCY SERVICES MANAGEMENT

KPI National targets

• Emergency Services • Emergency service
• KPI 6: Emergency room patients • Triaged with in 5 min 100%
triaged within 5 minutes of arrival at • ER mortality 0%
ER
• KPI 7: Emergency room attendances
• ER stay > 24hrs 0%
with length of stay > 24 hours
• KPI 8: Emergency room mortality
• KPI 9: Emergency re-attendance rate
within 28 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
• Efficient flow of patients requires
• fulfillment of all the necessary HR, infrastructure and equipments 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 equipments, 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

• Established management structures and job

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

Medical records management - 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.
A strong medical records system is also equally important to make clinical and
public health evidence based practices as well as making informed decisions
Medical records may serve as a reliable source of information for medico-legal
issues and medical/ public health researchers.
 MEDICAL RECORD MANAGEMENT

• A well-organized medical recording system ensures the availability of

reliable healthcare data in the health system
• input for the implementation of national health sector transformation strategic
plan (HSTP), in particular to the information revolution agenda.
• All pertinent information regarding the patient and his/her course of
care at the hospital should be recorded in the MR
• The patient's name and MRN should appear on each page.

• All handwriting should be in permanent ink that is legible when photocopied. Pencil entries in
any part of the record are not be permitted.
• All entries should be dated and authenticated, including name, signature and title of the
author
 MEDICAL RECORD MANAGEMENT

• Unique medical record number

• Need to use paper based and computer based MPI
• 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.
 MEDICAL RECORD MANAGEMENT

• medical records auditing, data quality

checks, archiving/ culling procedures
• corrective actions accordingly on a regular basis.

• automate health information system

• implement integrated electronic medical record system.
• Only authorized personnel should have access to MRs, and
only on a “need to know basis”.
 MEDICAL RECORD MANAGEMENT

• Inactive files (i.e., MRs with no clinical activities for a pre-defined period of
time (i.e., 5 years) may be archived by MR staff in order to regain shelving
space
• A facility is required to retain a MR for up to 10 years after the
patient’s last episode of care at that facility.
• the MR should then be destroyed by burning, shredding or another method
• But, key information should be maintained permanently:
• MRs should be removed from the facility only upon an order from a
federal or regional jurisdiction.
• But, the original MR should never be transferred out of the hospital
 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

• 24/ 7 discharge service, including holidays and weekends
• Procedures in place to reduce the unnecessary inpatient length of
stay which includes pre surgical admission protocol
• 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
• Counselling on discharge by the attending physician, nurse in charge
and clinical pharmacist
• 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

• Inpatient Mortality < 5%
surgical admission
• Delay for elective surgical
• KPI 17: Inpatient mortality
admission less than 30 days
• KPI 18: Delay for elective
• BOR 80%
surgical 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
 Monitoring Targets
• KPI 23: Completeness of • Completeness of inpatient
inpatient medical records medical records more than 95%
• KPI 24: Healthcare acquired • Cancellation rate for elective
infection rate surgery less than 5%
• KPI 25: Cancelation rate for • Major surgery per surgeon
elective Surgery shows efficiency
• KPI 41: Major surgeries
conducted in the private wing
• KPI 38: Patient day equivalents
per doctor
• 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 • Completeness of inpatient
• KPI 39: Patient day medical records more than
equivalents per 95%
nurse/midwife
• 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 • ANC 4 more than 70%
• KPI 26: Proportion of mothers with
• Institutional MMR less than
all 4 ANC visits
• KPI 27: Births by surgical, 0.5%
instrumental or assisted vaginal • Institutional NMR less than
delivery
• KPI 28: Institutional maternal
3%
mortality
• KPI 29: Institutional neonatal death
within 24 hours of birth
• KPI 38: Patient day
equivalents per 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 • Essential test availability

95%
diagnostic Services • Proportion of tests that
• KPI 36: Essential tests were referred to another
availability facility less than 5%
• KPI 37: Proportion of
laboratory tests that were
referred to another
facility
 PHARMACY SERVICE MANAGEMENT

• Functional DTC
• Develops and implements interventions promoting the rational and cost-effective use of medicines

• 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
• Annual update

• Good dispensing practices at all dispensing outlets.

• APTS implemented
 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.
• Regular monitoring and evaluation of performance
 PHARMACY SERVICE MANAGEMENT

• Pharmacy Services • Established APTS

• KPI 32: Stock out of • Stock out of tracer drugs
tracer drugs 0%
• KPI 33: Expired drug • Documented inpatient
stock value pharmaceutical care more
than 80%
• KPI 34: Consumption to
Stock Ratio
• KPI 35: Documented
inpatient Pharmaceutical
care given.
 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 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
• Clinical governance • Maternal 80%
• KPI 47: Number of never events • Pediatric 80%
• KPI 48: % of Clinical Audit standards met • Communicable disease 80%
• KPI 49: % of Maternity services audit score
• KPI 50: % of Child health service audit score • NCD 80%
• KPI 51: % of Communicable diseases audit • STG adherence 100%
score
• KPI 52: % of Non-communicable diseases
• Nursing/midwifery 60%
audit score • Surgical service
• KPI 53: % of Nutrition services audit score
• KPI 54: % of Nursing/midwifery standards
• PCC and CRC
audit score • Patient safety 100%
• KPI 55: % of Surgical services audit score
• Data quality
• KPI 56: % of STG adherence audit score
• KPI 57: % of Data quality score • Patient satisfaction 9/10
• KPI 58: Patient satisfaction
• Staff satisfaction 9/10
• TB and HIV Services • Non Communicable
• KPI 10: Survival rate on Diseases
• KPI 14: Proportion of patients with
ART chronic diabetes complications
• KPI 11: Proportion of • KPI 15: Proportion of patients with
patients with good ARV chronic hypertension
complications
treatment adherence
• Malnutrition
• KPI12: Proportion of LTFU • KPI 16: Treatment outcome for
for Chronic HIV care management of severe acute
• KPI 13: TB cure rate 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
• 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

• 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
• 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.
• Staff training
• fire safety, security, hazardous materials, and emergencies.
 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
• 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 • 0%
• KPI : Attrition rate -
physicians • Staff satisfaction 9/10
• KPI : Staff satisfaction
 FINANCE AND ASSET MANAGEMENT

• Established finance, procurement • Provides exempted services

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

• Finance KPI Targets

• KPI 41: Reimbursement ratio • >85%
• KPI 42: Share of revenue
collected from out-of-pocket
(OOP) payment as a proportion • <20%
of retained revenue • improve trend of raised
• KPI 43: Raised revenue revenue as a proportion
spending as a proportion of of total operating
total operating spending spending
• KPI 44: proportion of patient • >80%
attendances for insurance
beneficiaries
• 100%
• KPI 45: budget utilization
 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!!