ETHIOPIAN HOSPITAL SERVICE IMPROVEMENT

GUIDELINES
ETHIOPIAN HOSPITAL MANAGEMENT INTIATIVES

FOR IMPROVEMENT OF HIGH QUALITY HEALTH CARE

ASSESSMENT HAND BOOK

MEDICAL SERVICE LEAD EXCUTIVE OFFICE

September/2023
ETHIOPIAN HOSPITALS’
SERVICE IMPROVEMENT
GUIDELINE
ASSESSMENT HANDBOOK

REVISED
September
2023 MOH
Ethiopia
 About the Revision

Considering that alignment of standards with implementation guide and assessment hand book verifications, MOH – Medical service
Lead Executive Office together with relevant partners and all the RHBs’ tried to revise the assessment hand book. The hand book helps
hospitals to provide better quality services by crosschecking their performance regularly against the set standards. To make this
effective, Hospitals should create regular awareness program for the staffs to oversee their respective service areas progress against
the standards and take actions based on findings.

The main revision is made on verification criteria that help to improve service quality as most criteria need to be verified by audits of
the whole chapters & prepared documents with adherence, observations, triangulation of data and possibly interview of staffs. And also
some chapters split and stand independently. Some standards set as ‘optional’ for primary hospitals, but expected to full fill gradually
focusing mainly on the implementation guide so as to give better quality of services.
 CHAPTER-6 INPATIENT SERVICE MANAGEMENT ASSESSMENT TOOL
S/N Operational standards Verification criteria Scoring
weight Score
1 Review organization chart (organogram) and verify 1
The inpatient department has a management structure, annual plan preparation and dissemination to front
annual and monthly services plan, with line staff.
departments/units/case teams
Confirm development of annual QI plan aligned with 2
Quality department based on gap analysis and graduated
initiative planning.

Ensure appointment of inpatient department focal persons 1

for infection prevention, pain, oxygen and data
management.

Validate existence of data verification system prior to 2

external reporting.

Score 6
2 The Hospital provides inpatient services as per Ensure porters/runners are trained on safe sample 2
regulatory standards and request transport, patient transfer, and
maintaining confidentiality.
Confirm appropriate skill mix assignment in each 2
service unit including phlebotomists, clinical
pharmacists, nurses etc.
Verify service provision adheres to SOP's and 2
guidelines.
 Assess bed spacing and room ventilation meet 3
regulatory standards
Score 9
3 Inpatient staff regularly follow and implement the Check preparedness and patient awareness of 2
hospital's admission and discharge protocols proactive discharge planning
Randomly select 10 staff from different units of IPD and 3
assess sample of staff knowledge on hospital
admission and discharge protocols.
Randomly select 10 patient charts and evaluate 3
completeness of admission and discharge
documentation in sample of charts and registers.
Confirm patient appointment and referral linkage 3
with liaison office at discharge.
Validate post-discharge outpatient follow-up with 2
senior physician through sample chart review. (check
5 patient charts)

Score 13
4 All inpatient records contain completed medical record Randomly audit 10 sample charts for complete and 4
formats revised admission, progress, discharge and death
summaries.
Audit 10 sample charts for compliant supplemental 3
oxygen therapy orders covering flow rate, delivery
mode, monitoring frequency, reporting time, device
change, weaning plan.
 Score 7
5 The Hospital should implement multidisciplinary team Ensure availability of MDT protocols/guidance 2
rounds twice per day and chart audit by senior for
newly admitted patient
Check MDT rounds conducted twice/day using 2
format

Ensure availability of chart audit system for newly 2

admitted patient by senior physician

Verify existence of twice multidisciplinary team 2

rounding schedule.

Observe rounding on site visit day for compliance 1

and review rounding team composition meets
requirements.
Confirm availability and regularity of signed 2
rounding format.
Ensure joint rounds by senior physicians from 1
different specialties for complicated cases.
Score 12
6 The inpatient department is staffed with adequate Verify medical devices and supplies are stored and 3
personnel appropriately trained and equipped for handled appropriately.
inpatient care as per regulatory standards
Confirm professionals are acting within defined 3
scope of practice.
 6
7 The department has guidelines for verbal and written Verify the availability of communication guideline. 2
communication on patient care including handovers
within and between disciplines Check if shift hand over protocol is in place 2
Interview 10 staff members and assess their 2
knowledge and adherence to the handover protocol
and communication guideline.
6
8 Established procedures exist for inter-professional and Validate existence of interdepartmental consultation 2
inter-departmental consultations and patient transfers to protocols.
ensure continuity of care
Audit timeliness and completeness of consultation 2
documentation.

Confirm consultations adhere to established 2

turnaround times.
Score 6
9 A policy requires accompanying all patients by Observe patient transportation practices. 2
appropriately trained staff during diagnostic services
outside the department and for inter-ward/department Review transportation protocol content. 2
transfers
Interview 10 sample of admitted patients on 2
experience.
Score 6
10 Nutrition guidelines and services are in place for Verify existence of hospital nutrition guidelines. 2
inpatients
 Confirm availability of patient dietary menus. 2
Check provision of standard daily meals for admitted 2
patients. (3 times a day)
Review availability of patient-tailored nutritional 3
interventions. (DM, HTN, CLD, etc.)
Score 9
11 Informed consent is provided to all patients admitted Confirm existence of informed consent protocol and 2
standardized form.
Verify informed consent obtained for admitted 2
patients before provision of care (client interview)
Audit consent form signing and documentation prior 3
to invasive procedures through sample of charts.
(audit 10 charts)
Score 7
12 Continuous oxygen supply and appropriate utilization Assess oxygen supply availability and stock back-up 2
are ensured and monitored mechanisms.
Ensure a designated focal person coordinates oxygen 2
management with relevant stakeholders.
Audit sample of all admission charts for pulse 2
oximetry records.(from Emergency, IPD and ICU, 10
cards each)
Verify functionality and availability of oxygen 2
delivery devices and interfaces. (Concentrators, pulse
 oximeters, consumables or interfaces like nasal
prong, face mask with/out reservoir, nasal catheter,
etc.)
Review budget allocation for oxygen supplies and 2
consumables.
Confirm centralized piped oxygen system with digital 2
monitoring and cylinder protocols.
Score 12
13 Regular audits are conducted and quality improvement Ensure an assigned focal person to conduct regular 2
projects implemented service audit
Confirm clinical audit is conducted regularly 3
Observe QI projects are ongoing 3

Score 8
100