DILCHORA REFERRAL HOSPITAL

EHAQ 4TH CYCLE

BASELINE ASSESSMENT REPORT

Evidence Based Care (EBC)

Prepared By: - Dr. Yosef Assefa

May 2022
Dire Dawa

1
No Focus area initiative CHANGE CONCEPT EXPECTED SCORE PERFORMED SCORE UNMET
SCORE
# % # %
1 Mechanism to Avail Scope Based Practice 33   20 29 50 17 4
High Quality Evidence 60
Standard based clinical services 27 21 6

2 Evidence Generation Evidence generation and utilization 28   28 24 63 21 4

and Utilization  
System redesign and EHSTG Boosters 30  84 23.5 6.5
Efficient use of healthcare resources 26 15.5 10.5
3 Focus Service Area Quality nursing care 26   34 20.5 75 25 5.5
Surgical service efficiency and safety  
26  
17.5 8.5
Improve neonatal intensive care  102
26 22 4
Improve Emergency, trauma and critical 24 15 9
care
4 Patient Preferences and Person centered care 30 10 17.5 5 12.5
Value

5 Cluster Activity (EHAQ Networking and engagement) 24 8 17 6 7

 

Grand Score 300 100   222.5 74% 77.5

 
300

Dilchora Referral Hospital EHAQ 4TH CYCLE Baseline Assessment REPORT

1
Hospital Information

Date of Audit

Hospital’s name Dilchora General Hospital

Hospital Address (Region, Zone/Sub city, Dire Dawa

District/Woreda)

Contact Information Hospital CEO/CED: Muna Ibrahim

Hospital Medical Director/CCD: Dr Alef Ahmed
Hospital Quality Unit Head: Mulat
Tel No. 0251525692 Fax: Email:

Level of the hospital

Tertiary General / Primary

Staff Profile Number

Specialist 23

General Practitioner 22

Nurse 138

Health Officer 6

Medical Laboratory Technologist/Technician 19

X-ray technician 7

Pharmacy 28

HIT 3

Midwives 23

Others 33

Name of Auditors Signature

1. Dr Yosef Assefa

2.Dr Micheal Akalu

3.Dr Dagmawi Eyob

4. Biyalf

5.Tariku

6. Mulat

7. Arsema

SECTION I: Hospital Information

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1
SECTION II: MECHANISM TO AVAIL HIGH-QUALITY EVIDENCE (20%)
Section II (a). Scope Based Practices Audit tool

Description: Scope of practice is a model which allows healthcare services provided by a physician or other healthcare
practitioner to be performed based on the level they are authorized to practice. Such scope for a health care practitioner
is defined based on the education, training, experience, and demonstrated clinical competencies.

Standard(S) and Criteria(C)

Yes/ No/NA Means of verification Remark
1. Hospital has implemented scope based clinical Score
practice
S 1.1 Define scope: based on levels of care for the 12
selected priority health conditions 12

C1. The hospital Has protocol defining facility-level/specific Yes  Check for the availability of the
scope of practice. 2
protocol/ guideline
C2. Scope of practice defined for Different levels of Yes  Check the personnel files of each  Intern and
physicians - 4 levels of care (Intern, G.P. and Junior category of a physician working in Resident-not
residents, Senior residents, Consultants) 2 the four focus areas (8-10 files) applicable for
 Interview at least two staff each from Primary
each focus area Hospital
C3. Scope of practice is defined for Specialists and sub- Yes  Check the personnel files of at least
specialists in order to prevent fragmentation of care. 2 2 Specialists and Sub-Specialists
working in the four focus areas.
C4. Scope of practice is defined for Different levels of Yes  Check the personnel files of at least
nurses, midwives, and anesthetists based on specialty and two professionals from each
years of experience. category of health professionals
3
working in the four focus areas
 Interview at least two staff from each
focus area
C5. Interdepartmental Consultations are requested by at Yes  Check for availability of the
least Senior residents/G.P. and above. If the required Interdepartmental Consultation
provider level is not available, the client should be seen by Protocol
the highest available scope and referred if required.  Randomly check five consultations
3
conducted for each focus area
during the last one year.
 Verify availability of monitoring
system for the implementation of

1
 Interdepartmental consultation
protocol.
S 1.2 Dispose patients to the appropriate scope level by 4
arranging an emergency and non-emergency triage system 4
based on the EHSTG Standards.
C1. Triage has to be done by at least G.P.s and above Yes  Check for availability of triage
Protocol
4  Check letter of assignment for the
G.P.
 Observation of Triage services
S1.3 Client evaluation at the initial point of contact should 4
8
be by physicians with the appropriate level of scope
C1. Patients referred from other facilities should be seen No  Check this in the scope of practice
protocol
by at least 1 step higher professional from referring
 Review charts of 10 randomly
4
clinician selected clients accepted by referral
and verify they were seen by higher
professional
C2. Referral clinics should be supervised and service given Yes  Observe the schedule of referral
Clinic
authenticated by the responsible specialist or subspecialist
 Review Charts of 10 randomly
4
selected clients seen at referral
Clinics authenticated by a senior
physician
S 1.4 All consultations are carried out by senior residents 9
9
and above
C1. Based on the hospital tier level, all consultation Yes  Verify that the interdepartmental
Consultation Protocol includes this.
responses should be made, at least by senior residents if
 Review charts of 5 clients for whom
not available, by consultants. In a setup where the above 3 Consultation responses were
aren’t available, the most senior clinician for the setup received

should respond to the consultation

C2. Consultation requests, request time, responses & Yes 3  Verify that the interdepartmental
Consultation Protocol includes this.
response time should be recorded appropriately

1
  Review charts of 5 clients for whom
Consultation responses were
received and verify the times were
recorded.
 Check for availability Monitoring
system for adherence to consultation
protocol
C3. All elective and emergency surgeries should be done in Yes  Check for availability of surgical
services protocol and verify that this
the presence of the senior physician
is included.
3  Review randomly selected charts of
10 clients (5 from elective & 5 from
emergency) for who elective surgery
was performed.
Sub-total score for Scope based clinical practice 29 /33

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Section II (b). Standard Based Clinical Service Audit tool

Description: A protocol states the course of action to be adopted by people working within a particular organization,
profession, or service. Clinical protocols are basic rules of how to proceed in certain situations. They provide health care
practitioners with parameters in which to operate.

Standard and criteria Yes,/No/

Score Means of verification Remark
2. Standard Based Clinical Service N.A.
S2.1 Prepare adapt or adopt guidelines or protocols based 10
on hospital morbidity and mortality burden of priority 10
focus area
C1. Evidence-based Clinical Practice Protocols are Yes  Verify the availability of protocols at
prepared for at least surgical Services, OPD Clinics, service delivery points of the focus
Emergency Services, and Neonatal ICU. areas.
3  Observe the utilization of the protocols
at each service delivery unit of the
focus areas.
 Conduct random Chart review
C2. Protocols/policy/procedures are developed for Yes  Check for availability of
Rounds, Selected nursing procedures, Patient protocols/policy/procedures for:
transportation, Bad news breaking, Surgical scheduling, Patients rounds, including bedside teachings
Standard treatment guideline Nursing Procedures
3
Patient Transportation
Bad news breaking
Surgical Scheduling
STG
C3. Staff were trained on the protocols, and their Yes  Check minute for staff training on the
utilization monitored protocols
 Review Regular clinical audits were
4 conducted on selected diseases
condition, and an appropriate action
plan or improvement plan was
designed
S2.2 avail the established Protocol / STG to Clinical Staff 7 7

1
C1. Ensure orientation training is provided to the staff, Yes  Check minute for staff training on the
protocols
 Randomly interview staff working at
4
focus area services
 Observe the availability of the
protocols at service delivery units.
C2. Protocol is printed and given in booklet form to Yes  Clinician Interview (2 from each
clinical staff 3 selected focus area)
 Observation of the booklets availability
S2.3.Monitor the consistent utilization of the clinical 4
10
protocols
C1. The facility should conduct a regular clinical audit to Yes  Selected staff interviews (2 from each
ensure the implementation of STG and Clinical protocols, selected focus area)
at least in the aforementioned focus areas  Check for protocols utilization
4
monitoring mechanism
 Verify for findings of utilization
monitoring findings.
C2. The facility designed Improvement plans based on the No  Check the improvement plan
protocol utilization monitoring findings. 6  Check for the implementation of the
improvement plan
Sub-total score for Standard Based Clinical Service 21 /27

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Section III. Evidence Generation and Utilization (28%)
Section III (a). Evidence generation and utilization Audit tool
Description: In healthcare, decision-makers rely on high-quality data. The issue is not whether the quality information is
important but rather how it can be achieved. Establishing standard protocols for documentation of data comes prior to
measuring.

Standard and criteria

Yes/No Score Means of verification Remark
3. Evidence generation and utilization
S3.1 Implement an electronic medical record system – 7
7
fully automated
C1. Implementation of full automation of medical records Yes 4 Observation
C2. Regular capacity building for staff Yes  Check for staff capacity building
Plan/schedule
 Availability of standardized manual
3 for staff training
 Randomly selected staff interviews
for the user-friendliness of the
system
S3.2 - Established Chart audit system for completeness 2 5
C1. Established team for the chart audit team Yes 1  TOR for Chart audit team
C2. System established for charts audit to improve proper Yes  Review for the Chart audit reports,
1
documentation practice regularity, and recommendations
C3 The hospital established a system to check the No  Observe the procedures
completeness of medical records before returning to the 3  Conduct staff interviews at the four
medical record room focus service areas
S3.3. DHIS2 implementation completeness and timeliness 5 5
C1. Availability of adequate number of data collection Yes  Observe for the availability of
tools ( registers, tally sheet, and reporting format) registers, Tally sheets, and reporting
1 formats
 Conduct staff interviews for its
adequacy/interruption in availability.
C2. Mechanism established to check proper utilization and yes 1  Check for availability utilization
completeness of data monitoring mechanism
 Completeness assessment reports

1
 verification
C3. There is a timely and complete report of data to yes  Verify hospital-specific report
appropriate body 1 completeness and timeliness in
DHIS2
C4. The PMT Conducts analysis and discussion on data Yes  Review for PMT Minutes and check
2
prior to reporting its regularity
S3.4. There is a regular mechanism to ensure the quality 5
5
of data
C1. Regular LQAS/DQA conducted by the HMIS Team Yes  Review for LQAS/DQA
documentation and check for its
3
regularity
C2. Verified by PMT Yes  Review for PMT Minutes and check
2
its regularity
S3.5 Regular data driven decision making is practiced 5 6
C1. There is facility specific data analysis. Yes  Check for availability regular trend
1 analysis at each focus area
C2. Facility-based data utilization and institutional Q.I. No  Review for available or implemented
project devised based on data findings Q.I. Project
1  Verify that the Q.I. Projects are
linked to analysis facility-specific
data
C3. Data quality triangulation between units Yes  Availability of protocol for
triangulation of selected data
2
 Review for reports on data
triangulation reports
C4. Facility plan is based on in house generated data Yes  Check for annual plan linkage to
facility specific historical
0.5 performance data
 Facility has active strategic plan that
addressed its past performances
C5. The hospital has the mechanism to encourage Yes  Review document for budget
evidence generation (Gap oriented research) 1.5 allocation.
 Check research report
Sub-total score for Evidence Generation and Utilization 24/ 28

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Section III (b). System redesign and EHSTG Boosters Audit tool
Description: System redesign in a hospital setting involves making systematic changes to all segments of the hospital
service provision process in order to improve the quality, efficiency, and effectiveness of patient care. It requires thinking
through from the patient perspective, identifying where delays, unnecessary steps, or potential for error are built into the
process, and then redesigning the process to remove them and dramatically improve the quality of care.

Standard and criteria Yes,/

Score Means of verification Remark
4. System Redesign and EHSTG Boosters No/N.A.
S4.1 Establish a triage system which is well equipped 2  Check the triage area with all the available
and facilitates one-stop triage, registration, and equipment & supplies
cashier service, and accommodates the needs of  Check for the ETAT protocol availability and
2
highly infectious cases implementation
 Observe for screening and Source Control
 Observe cashier service availability
C1. Pre-triage set up screen for highly infectious cases Yes  Check for availability of pre-triage screening
and isolate them protocol
0.5
 Observe for pre-triage screening and isolation
services
C2. Diagnostic triage tool kit - B.P. apparatus, Yes  Observe the availability of those kits at the
stethoscope, pulse oximeter, glucometer, weighing 0.5 triage area
scale  Staff interview for its interruption
C3. Cough corner and cough clinic Yes  Check for availability protocol for patient
0.5 channeling to the cough clinic
 Observe the clinic
C4. Adhere to EHSTG guideline recommendation Yes  There is a central triage.
 There are personnel trained in triage processes
0.5 working in both the central triage
 Central triage is equipped with necessary
supplies and equipment.
S4.2 - OPD clinics meets all the minimum standards 1.75
2
required for an examination room
C1. Well designed with good lighting Yes Observe the OPDs with good premises &
0.25
lighting

1
C2. Well ventilated and ensures privacy Yes
C3. - Well furnished - a table with at least two chairs Yes
C4. Well equipped - at least B.P. apparatus, Yes
stethoscope, reflex hammer (weighing scare and
glucometer at least for department pools)
C5. Hand washing/hygiene facility No
C6. Adhere to EHSTG guideline recommendation Yes
C7. Adequate OPD waiting area for patients, Yes
proportional to the number of OPDs and number of
patients seen per day
S4.3. Early Initiation of Outpatient Clinics and block- 2
based Appointment System
C1. Protocolize - start time, service, and academic Yes
activities to be conducted in parallel, lunch time
service
C2. Block-based appointment system is in place No
C3. Make Clinics functional during lunch/break hour Yes
 Observe the OPDs premises for having
adequate yeswindows and doors to be opened
0.25  Review the airborne and droplet precaution
protocols
 Observe the OPDs with needy furniture
0.25
having at least one table and two chairs
 Observe for the availability of those equipment
0.25  Review list of the medical equipment available
at the OPDs level
 Observe the functionality of hand washing
basins with water & soap
 Observe the availability of 70% of ABHR
0.25
solution at each of the OPDs
 Review the CASH audit reports in the hand
hygiene section
 Outpatient department is managed by at least a
G.P. and specialty clinics by a service-specific
specialist/sub-specialty clinic by a sub-specialist
0.5
per hospital tier level of care.
 Review for the Human resources assignment list
& the BPR staffing standard is met
 Observe the OPD Waiting Areas
0.25
3
 Check for availability of OPD Services Protocol
0.5  Observe for services initiation time
 Conduct client interview
 Check for appointment schedule
0.5  Conduct client interview
 Review for the appointment register
 Observe for continuity of services at lunchtime
 Conduct five client interviews
1
 Review for staff assignment schedule
1
C4. Divide Clinic work hours based, For specialty Yes  Observe clinic services
Service to morning and afternoon hours (for general &  Review Clinic service hours arrangement
0.5
specialized Hospitals) schedule
Conduct Client in-depth interview
C5. Regularly assess patients not seen on the same No  Check for availability of assessment mechanism
day (checklist) (refer to the appointment register)
0.5 Interview clients not seen on the same day

S4.4. Hospital has separate Pediatric Wards 2

composed of separate critical, general, SAM, isolation,
and procedure rooms.
C1. Established pediatric ward with at least a
Therapeutic feeding room for children with
complicated SAM, Pediatric ICU or at least HDU for
critically ill children next to the nursing station,
Isolation room, procedure room
C2. All ward room paintings are child friendly
C3. National guidelines and job aids should be readily
available
C4. Protocol for rounds and clinical care
2
Yes  Check that the pediatric ward is composed of
the following rooms:
- Therapeutic feeding room for children with
complicated SAM
 Pediatric ICU or at least HDU for critically ill
children next to the nursing station
0.25
 Isolation room for children with communicable
diseases (in primary hospitals, this may be
shared with a procedure room for adults)
Clean, ventilated procedure room with good light
source (in primary hospitals, this may be shared with
procedure room for adults)
Yes  Check that the hospital has a pediatric ward
separate from the adult ward and painted in a
child-friendly manner Therapeutic feeding room
0.25 for children with complicated Isolation room for
children with communicable diseases (in
primary hospitals, this may be shared with a
procedure room for adult
Yes  Observe for the availability of guidelines and job
0.25 aids
Conduct staff interview
Yes  Check for the availability of the protocol
 Observe that rounds are conducted based on
0.25
the protocol
 Conduct staff interview

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C5. Vital signs are measured with the stated protocol Yes  Check for vital signs protocol
0.25  Observe its measured as per the protocol
 Conduct staff interview
C6. Growth monitoring is performed for all U5 Yes  Review 5 Charts of admitted Patients
children admitted to the ward 0.25  Observe growth monitoring performed at
admission
C7. Pain management accordingly practiced Yes  Pain management, at least for those with burn,
0.25
surgery, cancer
C8. Adhere to EHSTG guideline recommendation Yes  Children admitted to the wards should be
evaluated by physicians (preferably
pediatricians) on a daily basis ( twice per day for
0.25
critical children)
 Critically sick children should be evaluated by
registered clinical nurses every 4 hours
S4.5 The Hospital has a rehabilitation and palliative 0
1
care service with the necessary equipment
C1. Integrated or separate rehabilitation and No  Observe for Palliative and rehabilitative clinic
0.5
palliative service Check for Rehabilitative and palliative care protocol
C2. Established physiotherapy service No  Observe for Physiotherapy services unit/clinic
0.5
 Check Protocol above
S4.6 The Hospital has a general maintenance center 2
2
with adequate resources.
C1. Technical personnel, sufficient space, and Yes  Observe the general maintenance workshop
adequate ventilation to conduct maintenance and  Check for availability of general maintenance
repair (e.g., electrical, water, sanitation, sewerage, and 0.25 equipment maintenance protocol
ventilation) and equipment.  Adequacy of H.R. as per the standard
 Staff Interview
C2. Appropriate tools and testing equipment to Yes  Staff Interview
perform repairs, as well as procedures to ensure the  Observe for the availability of the tools
0.25
routine calibration of the testing equipment is Review for the calibration procedure
performed as required
C3. Conducts regular preventive maintenance for all Yes  Observe the preventative maintenance schedule
facilities and operating systems (e.g., electrical, water, for major equipment
1
sanitation, sewerage, and ventilation) to ensure Check for availability of Preventive maintenance
patient and staff safety and comfort. protocol
C4. There is a notification and work order system for Yes  Check for the availability notification protocol
facility and operating system (e.g., electrical, water, 0.5  Observe the requested services
sanitation, sewerage, and ventilation) repairs. Conduct user interview

1
S4.7 The Hospital establishes and institutionalizes 1
Human Resources Information Management Systems 1
(HRIS) that enhance the H.R. management functions.
C1. The hospital HRIS in place Yes  Check for availability and functionality of HRIS
1 Review the randomly selected personnel file

S4.8 The Hospital has a human resource 1.75 Check for the HRIS at the human resource
development plan that addresses staff numbers, skill 2 department and refer to the BPR staffing criteria
mix, and staff training and development.
C1. Check Plan address skill mix for short term training YES Review the HRDP and check for those contents
(offsite and onsite), long term training
0.25

C2. Ensure that the plan by H.R. department addresses YES  Check for availability of need assessment
staff numbers, necessary budget, and training Verify that the need assessment findings were used
1
schedule on the basis of need assessment with for the HRDP
departments
C3. Check the plan approved by G.B. and SMT YES Review the plan and verify that it was approved by
0.25
both G.B. & SMT
C4 Check whether the plan implemented was NO  Review the performance review
evaluated or not decrement/report
0.25
 Check for the availability of a performance
review plan/schedule
C5. H.R. Management Manual yes 0.25 Verify that the hospital has HR Manual
S4.9 Standardize food and beverage service 2 2
C1. Establish facility-specific menu Yes  Review the facility-specific menu
0.25  Observe that one meal is served as per the
menu
C2. Monitoring mechanism is established to assuring Yes  Observe the cleanliness of the kitchen
the quality of catering services  Review the quality monitoring
0.5 protocol/checklist
 Observe the quality monitoring schedule
 Review quality monitoring report
C3. Establish patient feedback and monitoring Yes  Review the patient feedback monitoring
mechanism mechanism/tool
1
 Observe the findings of patient feedback
analyzed
C4. Hospital has a food and beverage service manual Yes 0.25  Review the Manual

1
  Observe that the services are delivered as per
the manual.
 Conduct staff interview
S4.10 Standardize duty room service provision 1.5 2
C1. Duty rooms should be gender-based, not No  Observe the duty rooms for both genders
profession-based  Conduct staff interview
0.5  Check the duty rooms are near to the stated
service units.

C2. Duty bed should be available to half duty team Yes  Observe for number of beds and compare it
0.5 with the number of person on duty on average
 Conduct staff Interview
C3. There should be at least a desktop computer with No  Observe the availability of Computers with
a connection to internet or reference books loaded on connectivity
0.5
the computer and T.V.  Observe the availability of functional T.V.
 Staff Interview
C4. There should be a water boiler Yes  Observe that the water boiler (Functionality of
0.5 Boilers)
 Conduct staff interview
S4.11 Improve functionality of medical equipment 3
by establishing a Medical Equipment maintenance
3
center and Implementation of Medical equipment
Management information system.
C1. Protocol - Prioritized medical equipment list with Yes  Check for the availability of MEMIS
an inspection and preventive maintenance plan  Review for the availability of prioritized
0.5
equipment list
 Conduct staff interview
C2. There is a notification and work order system for Yes  Review the format
0.5
medical equipment maintenance requests.  Observe for documented formats
C3. Regular calibration and quality assurance Yes  Refer above
programs for prioritized medical equipment 1  Interview the MEM personnel for having a
history file for MEM
C4. Regular inventory is conducted for medical Yes  Review inventory report
equipment and history file for each medical 0.5  Conduct staff interview
equipment
C5. Technical personnel, sufficient space, and Yes  Observe the maintenance workshop
adequate ventilation to conduct maintenance and  Review personnel for technical staff availability
0.5
repair of Medical equipment(e.g., electrical, water,  Conduct Biomedical staff interview
sanitation, sewerage, and ventilation)

1
S4.12 Develop a mechanism/system which 1.25
encourages the rational use of medications and
2
stipulates a mitigation strategy for irrational use
of medications.
C1. The strategy addresses prioritized drug lists for Yes  Review the strategy for rational use of drugs
monitoring, problem identification and the need for and review its content
action, identification of underlying causes and 0.25  Conduct staff interview
motivating factors, list out and implement possible
interventions
C2. Adapt/adopt recommended management guides Yes  Check the availability of management guideline
with a focus on the selected prioritized health 0.25 Conduct staff interview
conditions and prioritized drug lists
C3. Prioritized drug list should include 2nd/ 3rd line Yes  Review the prioritized drug list for its content
antibiotics, narcotic drugs, other expensive drugs 0.25  Conduct staff interview

C4. Problem-based training on pharmacotherapy is No  Review training documents

0.25
undertaken when indicated/needed  Conduct staff interview
C5. A system to prescribe, dispense and monitor No  Check for the availability of protocol
appropriate and rational use of the selected and 0.5  Conduct staff interview
prioritized drugs is established
C6. Adhere to Rational use of Antibiotics and Yes  Random review of prescription paper
Antibiotics Stewardship Principles 0.5  Staff interview for awareness of rational use &
AMR principles
S4.13 The hospital Conducts regular clinical 2
audits and links improvement opportunities to 3
CQI.
C1. The hospital has a clinical audit team. Yes  Review the TOR of the clinical Audit team &
availability of quality projects on the audit
topics
 Established department-based audit team for
0.5 general and above, Hospital-based audit team
for primary hospitals
 Conduct staff interview
 Observe patient charts discussed for clinical
audit
C2. Regular clinical audit is conducted, and the finding Yes  Review the findings of Clinical audit and check
was presented. for regularity as per the TOR
1.5  Conduct staff interview
 Review all charts presented for clinical audit for

1
 the past three months
C3. Improvement opportunities identified by audits No  Check for improvement plans, Q.I. projects
are linked with CQI. 1 linked to clinical audit findings
S4.14 Senior physicians are consistently 1.25
engaged in all clinical care activities and decisions 3
which necessitate their involvement.
C1. Daily senior led multi-disciplinary round that Yes  Check for availability of multi-disciplinary round
addresses nursing care, IPC, client education, clinical (Grand round) protocol
pharmacy, and client satisfaction is made possible 0.5  Observe at least one multi-disciplinary round
Conduct staff interviews on the conducted
major rounds and grand rounds
C2. Senior physicians are assigned on duty, including Yes  Observe the duty schedule for weekends and
weekends and holidays. holydays
0.25  Conduct staff interview
 Review patient charts seen by senior physicians
on weekends and holidays
C3. All new admissions are audited and co-signed by No  Check for availability of such protocol
day time and duty time assigned senior physicians 0.5  Conduct chart review
 Conduct staff interview
C4. Duty senior physician should make handover from No  Check for the availability of handover protocol
day time senior physician 0.25  Conduct chart review
 Conduct staff interview
C5. Weekly senior chart round practice is No  Review weekly chart review schedule
implemented, and identified gaps are linked with CQI.  Check for the status of Q.I. linked to Chart
0.5
review finding
 Conduct staff interview
C6. Chart round should address clinical evaluation and Yes  Review for the availability chart round checklist
decision process, use of an appropriate and justified and verify that it includes those contents
work up, rational use of drugs, nursing care  Conduct staff interview
0.25  Review for the clinical pharmacy medication
care plan within the patient chart

C7. Quality improvement projects led by senior No  Review Q.I. Project documents and identify role
physicians are undertaken of senior physicians
0.5  Check for those patient charts suggested for Q.I
project review with senior physicians

1
C8. Engagement of senior physicians in clinical audit Yes  Review documents for clinical audit training
report
0.25
Conduct staff interviews assigned focal on the
clinical audit
Sub-total score for System redesign and EHSTG Boosters 23.5/30

1
Section III (c). Efficient use of healthcare resources Audit tool
Description: Efficiency is one of the healthcare quality dimensions related to avoiding waste, including waste of
equipment, supplies, ideas, and energy. The Health Sector Transformation Plan has prioritized three main causes of
inefficiencies: procurement, supply chain management, and human health resource.

Standard and criteria Yes/No Means of verification Remark

Score
5. Efficient utilization of healthcare resources
S5.1 Explore options to strengthen and outsource clinical and 2.5
5
non-clinical services (including the supply chain management)
C1. Outsourced Non-clinical Services Yes  Review outsourcing documents and visit
the unit
2.5  Interview at least one staff from each
focus area and at least two Senior
management members
C2. Explore options for outsourcing clinical services (Eyecare, No  Review documents/Minute for
ENT, Pathology, Radiology, dialysis, etc.) based on needs outsourcing clinical services/efforts
2.5  Interview at least one staff from each
focus area and at least two Senior
management members
S5.2 - Implement different staff incentives and recognition 6
10
mechanisms for enhancing efficiency and effectiveness
C1. Transparent staff incentive and recognition system is in Yes  Review the staff incentive and
place recognition procedure/guide
6
 Interview at least one staff from each
focus area
C2. Benchmarking of staff incentive mechanisms are undertaken No  Review the source documents for staff
incentive guide
 Review implementing guide, minute
4
 Interview at least 1 staff from each focus
area and all Senior management
members

1
S5.3. Assess sources of inefficiency in procurement, human 2
6
resource for health and supply chain.
C1. Prioritized mitigation measures are developed and the Yes  Review the document of efficiency
progress is continuously monitored. assessment
2  Review efficiency monitoring system
 Interview at least 1 staff from each focus
area
C2. Identified gaps are linked to CQI. No  Check the status of Q.I. Project linked to
4
improving efficiency
S5.4. Enhance transparent, accountable, and sound resource 5
5
utilization and financial tracking management system
C1. Harmonization of planning, budgeting, and budget Yes  Review the plan document for
execution processes, including producing and disseminating the harmonization
required financial and audit reports 5  Review response actions on financial
audits
 Interview at least 1 staff from each focus
area
Sub-total score for Efficient use of healthcare resources 15.5/26

1
Section IV Focus Service Areas (34%)

Section IV (a). Quality Nursing Care Audit tool

Description: Quality nursing care is an integration of research evidence, clinical expertise, and a patient’s preference. This
problem-solving approach to clinical practice encourages nurse to provide individualized patient care, and this leads to a
better patient outcome which can decrease demand for healthcare resources.

Standard and criteria

Yes/No Score Means of verification Remark
6. Improved Quality of Nursing Care
S6.1 Nursing care protocol and procedure prepared for 1
2
prioritized health conditions
C1. Have a nursing care protocol known and adhered to by the Yes  Check for availability of nursing care
nursing staff protocol
1  Selected staff interview
 Check for availability of adherence
monitoring mechanism and its findings
C2. Key Nursing Procedures (IV line securing, NG-Tube insertion, No  See protocol above
Catheterization, etc.) and do bi-annual KAP assessment 1  Review for KAP assessments conducted
and actions taken.
S6.2 Regular nursing care audit and identified gaps linked with 3
the Q.I. project 5

C1. Establish nursing care round and audit team with TOR Yes  Check for availability of nursing round
0.5 protocol
 Check for the nursing audit team TOR
C2. Audit should address the implementation and quality of a Yes  Verify that the Nursing Audit Protocol
nursing process, patient monitoring, pain management, addresses these topics
medication administration, and client education 0.5  Review the findings of the nursing audit
for these contents
C3. Regular performance report review (Every month) involving Yes  Check for monthly performance report
key stakeholders 2  Check for monthly performance review
minutes
C4. Data driven Q.I. projects conducted based on identified gaps No 2  Check for Q.I. Projects linked to gaps
identified during Performance reviews

1
  Verify the status of the Q.I. Projects
S6.3. Conduct daily nursing rounds (prepare round packages - 5
Emergency preparedness, shift handover, attendance, dressing 5
code adherence, cleanliness etc.)
C1. Daily nursing round is conducted (1 hour vs. 3 hrs. nursing Yes  Inclusion of these in nursing round
round for 4P‟s,) protocol
 Conduct chart audit on randomly
1.5 selected clients at IPD, Emergency

C2. Shift handover is properly executed and documented to Yes  Check for availability of shift handover
assure a continuum of care protocol
1.5  Verify handover documentation in the
four focus areas.

C3. The nursing staff adheres to the code of conduct, including Yes  Check for the availability of the nursing
dress code, cleanness, and IPC practices. code of conduct
1  Observation for cleanliness
 Staff interview
 Client interview
C4. Nurses prepared daily round tables and emergency tables Yes  Observe for daily round table package
 Observe for prepared emergency tables
1 in the ward
 Check for availability of round table
package and emergency table
S6.4. Implement ICU nursing care packages as per the standard 3 3 preparedness protocol.
C1. Protocolize - ICU nursing care package with their indications Yes  Check for availability of ICU nursing
and implementation requirements 0.5 care package/protocol
 Conduct Client Chart audit
C2. The package should at least address V/S and fluid balance 0.5  Review the package/protocol for these
monitoring requirements, enteral nutrition, G.I. prophylaxis, DVT contents.
prophylaxis, and medication administration  Conduct client Chart audit
C3. ICU nursing care packages Implementation evidence - client Yes  Review Clients’ charts for inclusion of
chart formats should be adopted/adapted for documenting all the charts as per the package
nursing care services provided to the client 2  Conduct selected staff interviews for
their awareness of the formats
S6.5 Established a skill Lab and regular need-based capacity 3 5

1
building for nursing staff
C1. Established a skill Lab Yes  Observe for availability of clinical skill
lab
2  Check for the schedule for the
utilization of the skill lab.
 Review the skill lab register
C2. Conducted Regular capacity building based on identified No  Check for availability of skill gap
gaps assessment
2  Need based capacity building plan
 Documentation of capacity building
Performance
C3. Participating in MDT meeting, round, audit, and research yes  Capacity building protocol/ guide
(protocol and document) 1  Attendance verification mechanism
 Review Meeting minutes
S6.6 Standardizing nursing stations 2.5 3
C1. Availability of Nursing station Yes 0.5 Observation
C2. Location of the nursing station easily accessible for patients Yes 1 Observation
C3. There should be a reception service available at nursing Yes Observation
0.5
station
C4. There should at least be 1 desktop available at nursing No  Observe for the functionality of the
station with important information on patient admission and 0.5 desktop computer
status in the wards
C5. There should be a T.V., health education material and Yes  Observe for functionality of the T.V.
different protocols available at the nursing station  Observe for availability of the
0.5
aforementioned protocols
 Conduct staff interview
S6.7 Patient preference included in decision making 3 3
C1. Patient clearly understand the diseases process Yes  Check for the availability of patient
orientation protocol
 Review clients’ chart for Documentation
1
of patient orientation in their chart
review
 Conduct Patient interviews
C2. Involvement in care plan, intervention, expected discharge Yes  Verify that these are included in the
planning, estimated cost, and expected outcome 2 patient orientation protocol
 Conduct Patient interviews
Sub-total score for Cleanliness of ca Quality Nursing Care 20.5/ 26

1
Section IV (b). Surgical service efficiency and safety Audit tool
Description: Access to Emergency and essential surgical care (EESC) is one of the prioritized global initiatives with the aim
of improving access to safe, affordable, and timely care for the population.

Standard and criteria

Yes/No Score Means of verification Remark
7. Surgical service efficiency and safety
S7.1 Standardize OR efficiency and the minimum 6
6
productivity per table
C1. The hospital has the minimum number of the Yes  Observation
table is as per the requirement of hospital tier level  2 for primary Hospital
0.5
 4 for general Hospital
 7 for specialized Hospital
C2. The hospital conducts a Minimum of 3 cases Yes  Document review OR register review
per table per day 1  Triangulate the table output with the
hospital backlog
C3. The hospital starts the first case incision Yes  OR schedule
before 8:00 am for elective surgeries.  Observe the time of surgery initiation for
1
elective cases from the patient chart/
anesthesia sheet.
C4. The hospital Turn around time b/n cases 20 Yes  Review Elective surgery Protocol
minutes and has a mechanism to monitor  Randomly select two consecutive elective
adherence to the time 0.5 surgery scheduled; check the first case
end time and second case start time from
the patient charts.
C5. 2-3 shift implementation - Morning, afternoon, Yes  Observe OR Schedule
0.5
and private wing
C6. The hospital has a customized Format and Yes  Document review OR register review Schedule
schedule notification system for head nurse and communicatio
scrub nurses (prior preparedness for adequate 1 n formats
drape and required instruments and suturing
materials)
C7. Regular monitoring mechanism linked with Yes  Check the status of Q.I. Project on
quality improvement project improving OR efficiency
1
 Verify that the Q.I. Projects are derived
from regular performance Monitoring

1
C8. Elective surgical service productivity - >90% of Yes  Compare plan versus performance for
0.5
the initial performance plan the last two years
S7.2 - Establish OR patient preparation unit 0 1
C1. Established OR patient preparation room No  Observe floors, walls, and overall physical
structure of the OR patient preparation
1
room for cleanliness

S7..3. Implement measures to reduce cancellation 2 4

C1. Establish a multi-disciplinary pre-admission Yes  Check for availability of the Pre-
evaluation clinic ( including anesthetic evaluation ) admission evaluation protocol
 Check pre-operative format is attached
and recorded before admission
(5patients
 Check all investigations are done at list a
day before elective surgery admission
1
 Check consent form is signed before
surgery day
 Check all pre-operative preparation is
done (Abdominal preparation,
Prophylactic drugs, and counseling)
before surgery done
 Interview 5 patients
C2. The hospital has to Standardize pre-operative Yes  Check for availability of pre-operative
evaluations and work-ups work-up protocol
 Randomly check for ten patient charts
0.5
 Check for availability and utilization of
peri-operative checklist for nurses
 Interview 5 Patients
C3. Regular monitoring mechanism linked with  Check the status of Q.I. Project on
quality improvement project yes reducing cancellation
 Verify that the Q.I. Projects are derived
1.5
from regular performance monitoring

C4. The hospital conducts a multi-disciplinary per- No 1  Verify the schedule for Peri-operative
operative conference a day before surgery to Conference
finalize the patient preparation plan before  Conduct surgical staff interview
scheduling

1
S7..4. Standardize and monitor pre-elective and 0
1
post-operative hospital stay
C1. Protocolize - Pre-operative and post- No  Check for availability of Protocol on Pre-
operative hospital stay and Post-operative hospital stay
0.5

C2. Regular monitoring mechanisms linked with No  Review for hospital stay monitoring
improvement and/or accountability mechanisms mechanism
0.5
for the identified gaps. Check for actions linked to monitoring
findings
S7..5 Establish surgical governance and 0.5
3
management structure that ensures team functions
C1. OR led by a director No 0.5  Observe for a letter of assignment
C2. Department-specific teams - for multi-specialty Yes  Check for department-specific team
0.5
hospitals  Conduct staff interview
C3. The hospital has a daily team briefing and No  See briefing and debriefing protocol
debriefing at the beginning and end of the OR day. 1  See the documentation of feedback and
action plans
C4. Daily OR director and coordinators No  Check for trend analysis linked to
monitoring mechanism linked with quality improvement actions
1
improvement project and/or accountability  Conduct staff interview
mechanisms for the identified gaps
S7..6 Establish a Daycare surgery unit and ensure 0
2
its active functioning
C1. Protocolize - define daycare surgery clinical No  Check for availability of daycare surgery
conditions for each department and ensure the protocol
necessary infrastructure  Observe infrastructure for daycare
surgery (define)
2
 Conduct staff interview
 Register review for the number of
patients who get access to daycare
surgery
S7.7 Regular performance audit and identified 4
gaps linked with Q.I. and/or accountability 4
mechanisms
C1. Regular performance review (at least every Yes 2  Document review  Check for
two weeks) involving key stakeholders  Minutes performan

1
  Action plan ce review
 Implementation reports, minutes
 Project documents and its
regularity(
SaLTS
committee
)
 Review
every two
weeks'
performan
ce report
document
 Improvem
ent Plan
liked to
performan
ce review
C2. Data-driven Q.I. projects conducted based on Yes  Document review  Status of
the identified gap  Minutes Q.I.
 Action plan Projects
 Implementation reports,  Minutes on
2  Project documents Q.I. Project
decision
 Review Q.I.
Project
document
S7..8 The Hospital Regularly follows 2
adherence to WHO SSC and identified gaps
2
linked with Q.I. and/or accountability
mechanisms
C1. Regular audit conducted for the completeness Yes  Check for SSC Audit protocol
of SSC 1 Check for availability of SSC audit report and
its regularity
C2. Regular mechanism of implementing a direct Yes Randomly review 10 Client charts for
observation in the Operating theater for adherence 1 completeness of SSC
to the SSC
S7.9 Established system of SSI tracking and 3
3
intervention to reduce SSI

1
C1. Institution integrated the SSI registers in service Yes  Check for availability of SSI Register at
areas and monitor utilization surgical, Obs-Gyn, and postnatal wards
0.5  Randomly review client charts and
triangulate with registers
 Conduct staff interview
C2. Establish a system of close follow-up for sign Yes  Check for availability of SSI Protocol
and symptoms of SSI for each patient (WHO SSI  Conduct staff interview
checklist, wound assessment and documentation  Chart review(utilization of WHO SSI
1
on charts for every patient) surveillance tool in the charts, check
documentation of surgical wound
condition in each chart
C3. Mechanism established for SSI tracking After Yes  Verify that these are included in the SSI
discharge protocol
1.5  Check documentation for outpatient
follow-up for SSI
 Conduct for staff interview
Sub-total score for Surgical service efficiency and safety 17.5/ 26

1
Section IV (C). Improve neonatal intensive care Audit tool
Description: Improving the Neonatal ICU service is one of the critical areas that will reduce morbidity and mortality of
neonates in a hospital setting and beyond. Additionally, NICU care in a hospital setting shows the quality of care, and it is
by far the known litmus of better organizational function.

Standard and criteria

Yes/No Score Means of verification Remark
8. Improved Neonatal Intensive Care
S8.1 Provide a standard NICU service based on the level 10 10
of the Hospital
C1. Fulfill Standard requirements for Level I, II, and III Yes 2  Check the level of service for
NICU service establishment based on hospital’s tier level Infrastructure, Human resources, and
Primary, General, and Comprehensive specialized medical equipment as defined by NICU
Hospitals, respectively National level document
 Review protocol for NICU service
 Interview 5 NICU staff for the service level
C2. Check services provided in the hospital are aligned Yes 2  Check ten charts for the services provided
with the scope of the level N.B- (Level I- basic Neonatal care, Level II-
General Neonatal care, Level III- Advanced
neonatal care)
 Staff interview at least 3 for the service
level alignment
C3. All Health professionals (Physicians and Nurses) are Yes 2  Documentation of training provided
trained on NICU service provision based on the levels  Staff interview at least 3
(Level I, II, and III)
C4. All the needed rooms are available and providing the Yes 2  Observation for the functionality of the
intended services for the given level of NICU rooms
C5. All equipment needed are functional and provides Yes 2  Check availability and functionality of lists
service for the given level of equipment for the given level of
service
S8.2 - Avail all needed protocols and guidelines for 5 5
evidence-based neonatal care and adhere to protocols of
services
C1. Avail Neonatal care guidelines, protocols updated Yes 1  Check availability of Documents Review
versions  Staff Interview
C2. – Adherence to guidelines and protocols by all Yes 2  Randomly check five charts for adherence
service providers to protocols

1
  Staff Interview
C3 - Regular monitoring of services provided on Yes 2  Check minutes for Regular performance
protocols adherence review meetings (3 months)
 Staff Interview for the presence of regular
meeting
S8.3. Perform continuous clinical audits for NICU care 3 7
services and link with Q.I. for the findings
C1. Perform clinical audits on NICU services YES 3  Check Documents for performed clinical Expected at
audits in NICU in the last 6 months least 2 audits
C2. Perform Quality improvement projects for NICU care NO 2  Check approved Q.I. in NICU service Expected at
services improvements in the last 6 months least 1 Q.I.
C3. Documented or Published Q.I. in NICU service NO 2  Check for availability of documented or
published Q.I. in NICU services
S8.4. Implement Neonate and Family centered care 4 4
C1. Establish a family counseling corner Yes 1.5  Observe if the facility assigned a corner or
room for neonatal family counseling
 Neonates parent Interview for practice of
counseling
C2. Monitor family participation in decisions making Yes 2.5  Check 5 random charts for presence of
starting from evaluation to discharge process parent engagement in the decision
making
 Parent interview
 Staff Interview on their practice of
engaging parents
Sub-total score for Improved neonatal intensive care 22/ 26

1
Section IV (d). Improve emergency, trauma, and critical care Audit tool
Description: Emergency, injury, and critical care system is a spectrum of activities including prehospital care and
transportation; initial evaluation, diagnosis, and resuscitation; in-hospital care (emergency units and Intensive care units
(ICU)) as well as a referral system to deliver time-sensitive health care services for acute illness and injury across the life
course.

Standard and criteria

Yes/No Score Means of verification Remark
9. Improved emergency, trauma, and critical care
S9.1 Provide a standard emergency service based on the national 3
5
leveling document.
C1. Level emergency departments/ rooms according to the No  Check if the facility conducts regular
national emergency leveling document assessments based on the national
1 emergency leveling document checklist.
 Documentation of the assessment finding
report
C2. Conduct Regular capacity building based on identified gaps No  Check for availability of gap assessment
during the assessment  Check the plan for capacity building
2  Documentation of capacity building activity
and performance
 Staff interviews
C3. Upgrade emergency departments to meet standards Yes  Check for plans of upgrading E.D.s to meet
national standards
 Observe emergency unit arrangement and
service process flow
1
 Check if Material resources for E.D.s are
available
 Check for availability of emergency Drugs
and crash cart medication.
C4. Expand the use of WHO BEC toolkit in facilities Yes  Documentation of BEC training performance
1  Check availability of medical formats at
E.D.s
S9.2 - Provide a standard critical care service based on the 6
6
national leveling document
C1. - Level ICUs according to the national ICU leveling document Yes 1  Check if the facility conducts regular

1
 assessments based on the national ICU
leveling document checklist.
 Documentation of the assessment finding
report
C2. Upgrade facilities to meet ICU standards Yes  Check for plans of upgrading ICUs to meet
national standards
 Check equipment availability and
2
functionality in ICUs.
 Staff Interview on capacity building
conducted
C3 Ensure adherence to ICU admission, treatment, and discharge Yes  Observation: Check for availability of ICU
protocols protocols
 Check clinical rounds adhere to the protocol
3
 Document review: review charts to check
adherence.
 Staff interview
S9.3. Avail protocols and guidelines for evidence-based 4
emergency, injury, and critical care and adhere to protocols of 4
services
C1. Ensure availability of standard Protocols and guidelines for Yes  Documents Review: Check for the
referral, triage, burn, poisoning, trauma ED ICU services 1 availability of protocols and guidelines.
 Staff Interview
C2. Ensure adherence to guidelines and protocols Yes  Check charts to Verify the use of guidelines
and protocols in Clinical practice at services
3 delivery points
 Observe the utilization of the protocols in
E.D.s and ICUs.
S9.4. Use of standardized registries to capture a reliable data for 2
4
evidence-based decisions
C1. Implementation of the WHO trauma registry No  Documents Review: Check for availability of
trauma registry
 Chart review: Review charts of randomly
2 selected patients to verify the trauma
registry is filled
 Staff Interview
C2. Availability of the revised ICU, Emergency, Liaison referral, Yes  Documents Review: Check for availability of
and ambulance service registers. 2 registries
 Staff Interview

1
  Chart review: Review charts of randomly
selected patients to verify that the registries
were filled properly
S9.5 Perform clinical audit for selected conditions, used to
5
inform Q.I. projects 0
C1. Continuous quality improvement for EICC services No  Staff interview: Check if clinical audits are
conducted
 Documents: Check the clinical audit findings
5
 Documents: Check if a Q.I. project on EICC
has been designed, Review Q.I. project plan
 Observation: Check status of Q.I. project
Sub-total score for Improved Emergency, trauma and critical care 15/ 24

1
Section V. Patient Preferences and Value Audit tool
Description: Improving healthcare safety, quality, and coordination, as well as the quality of life, are important aims of
caring for persons of all age groups. Person-centered care is an approach to meet these aims in such a way that assures
the privacy of individuals’ health and life goals in their care planning and their actual care.

Standard and criteria

Yes/No Score Means of verification Remark
10. Person-centered care
S10.1 Establish a health literacy unit/desk with full 3
4
time working health care provider/s
C1. The unit should be established and be accounted Yes  Visit the office/the unit
for Medical Director  Interview the assigned staff
1
 Obtain the letter of assignment and check
the job description
C2. The unit should have trained HCP, and the HCP Yes  Interview the assigned staff
can rotate in fixed term (Nurse, HO or Physician) 1  Review the letter of assignment and check
the assignment period.
C3. The facility will assign a coordinator/ focal Yes  Review letter of assignment of the
coordinator.
1
 Interview the coordinator/ focal and ask
about his role.
C4. The health literacy unit should have a register No  Review the client/patient register
entailing the patient's full name, address, DX, the 1  Check all the necessary data is
information provided, contact number, and at least captured/documented
S10.2 - Clinical information standardization - 2
prepare education materials (for the selected 4
prioritized health conditions)
C1. Leaflets and/posters for clients and health care Yes  Observe sample leaflets and posters.
providers  Leaflets and posters are prepared at least in
one local language.
1
 Randomly select the contact number of 3
clients/patients from the register, and then
call and ask if they received a leaflet.
C2. Local language use is advised Yes  Observe and check the presence of active
1
mini media for health education.
C3. Audio visual Health education material is No 2  Randomly select the contact number of 2

1
recommended
S10.3. Comprehensive Information provision is
delivered entirely and consistently
C1. Information provision should address clinical
diagnosis, treatment options, and plan; subsequent
follow up scheme and parameters, expected lifestyle
modifications
C2. Patient preference was heard in treatment
options
C3. Mechanism established to address patient and
family concern
S10.4. Practice patient discharge planning
C1. Hospital established a protocol for discharge
planning
C2. Create and standardize discharge plan format for
selected diseases based on hospital morbidity and
mortality
C3. Attach discharge plan on every patient admitted
C4. Regular monitoring mechanism in place to assess
the practice
clients/patients from the register of the four
focus areas, and then call and ask if they
received all the necessary information
4
4
Yes  Client interview
 Phone call interview
1
Yes  Randomly select the contact number of 2
clients/patients from the register of the four
1
focus areas, and then call and ask if their
preferences were heard during their care
Yes  Randomly select the contact number of 2
clients/patients from the register of the four
2 focus areas, and then call and ask if all their
and their concerns were addressed.
4 4
Yes  Check the presence of a protocol detailing
the discharge planning.
 Randomly ask two ward nurses from the four
0.5 focus areas and ask them about the
discharge planning protocol
Yes
 Observe the discharge planning format.
0.5
 Check the presence of the format, at least in
the wards of the four focus areas
Yes  Randomly select 2 (from each of the focus
areas) medical record numbers of patients
1 that have already been discharged from the
admission and discharge register and check
the presence of the copy of the discharge
plan.
Yes 2  Interview head nurses in the four focus areas
and how they monitor the implementation of
1
 discharge planning.
 Review self-assessment documents/reports
S10.5 Regular Client awareness and knowledge audit 0
5
and identified gaps linked with Q.I. projects
C1. Design mechanism to assess the awareness and No  Check for availability of mechanism to
knowledge audit. assess awareness and knowledge of the client
1.5 on their specific case
 Conduct random Client interviews in the four
focus areas
C2. Regular performance report review (at least every No  Review bi-weekly performance report
two weeks) involving key stakeholders document
1.5  Improvement Plan liked to performance
review
Check for two weeks performance review minutes
C3. Data driven Q.I. projects conducted based on No  Check for Q.I. Projects linked to gaps
identified gaps 2 identified during Performance reviews
 Verify the status of the Q.I. Projects
S10.6 Control pain for all emergency, outpatient, and 2.5
3
admitted patients
C1. Establish a pain clinic or integrate the existing all Yes  Verify the availability of pain Clinic/Practice
the service delivery points at all service delivery points of the focus
0.25 areas.
 Observe the pain clinic
 Client interview
C2. Prepare/adapt pain management protocol Yes  Check for the availability of pain
management protocol
0.25
 Conduct staff interview on the utilization of
the pain protocol
C3. Pain assessed in a regularly as 5th V/S; integrate Yes  Observe for the availability of pain
documentation with the existing V/S sheet assessment regularity, Tally sheets, and
reporting formats
0.5
 Review Clients’ charts for inclusion of the
charts as per the package
 Conduct random Client interview
C4. Pain managed accordingly (According to prepared Yes  Conduct Chart review and verify the
protocol) 1 management was as per the protocol
 Conduct Staff interview
C5. Advocate pain management through the use of Yes 0.25  Check the availability of pain management
different methods -“Zero tolerance for pain” posters in posters at wards and rooms

1
all wards and rooms,  Client interview.
 Conduct Staff Interview
C6. Address clients with chronic pain and those No  Observe for chronic pain and Palliative care
requiring palliative care clinic
0.5
 Check for chronic pain and Palliative care
clinic guidelines/protocol
C7. Assign a focal person for pain management Yes  Check the letter of assignment for the pain
management focal person
0.25
 Review the Job description of the focal
person
S10.7 Regular audit for adequacy of pain control 0
2
and identified gaps linked with Q.I. projects
C1. Regular performance report review (at least every No  Review every two weeks' performance report
two weeks) involving key stakeholders document
 Improvement Plan linked to performance
1
review
 Check for two weeks performance review
minutes
C2. Data driven Q.I. projects conducted based on No  Check the status of Q.I. Project linked to
1
identified gaps improving efficiency
S10.8 The hospital has established a hospital based 2
social service which addresses the psycho-social care 4
needs of clients
C1. Establish or strengthen a social service unit Yes  Check for the availability of social service
1
unit
C2. Has a guideline/ protocol for the functions Yes  Check for the availability and utilization of
1
social service protocol
C3. Regular audit conducted and improvements made No  Review for the social services audit reports
and its recommendations
2
 Review the actions taken based on the Audit
findings
Sub-total score for Person- centered care 17.5/ 30

1
 Section VI: CLUSTER ACTIVITY (EHAQ Networking and engagement) Audit tool

Description: The Ethiopian Hospital Alliance for Quality (EHAQ) is a system for promoting learning and collaboration
based on a model that involves hospitals exchanging knowledge with each other and empowering the hospital industry to
self-improve.

CLUSTER ACTIVITY (8%)

Note: all standards will apply for all hospitals except standards 1& 2, which will be used only for Coordinator
Hospital Audit.
11. AUDIT TOOL FOR CLUSTER ACTIVITY AND COMMUNITY ENGAGEMENT- Total score -8%
Yes /No Score Means of verification Remark
S11.1. Clusters have regular meeting 5 8
C1. There is approved TOR and shared with all members of the Yes  Check approved TOR document
1
cluster
C2. There is an agreed activity plan and performance report Yes  Check approved plan activity
1
for the cluster.  Performance report
C3. Cluster regular meeting is conducted, recorded and a No  Check the meeting minute at least
follow-up action plan is developed 3 three every three months
 Interview technical expert
C4. Best practices are documented and shared among Yes  Check availability of documented best
member hospitals 3 practices
 Interview member hospitals
S11.2. Cluster conducts regular mentorship and 7
supportive supervision 7

C1. Coordinator hospital conducted regular mentorship or Yes  Document review

3
supervision to member hospitals.  Interview member hospital
C2. Regular feedback is given to member hospitals Yes  Check availability of written and
2 received feedback
 Interview member hospital

1
C3. Coordinator hospital regularly monitored member Yes  Check performance report
2
hospitals cluster performance  Interview member hospital
S11.3. Community discussion panel 5 5
C1. Quarterly community forum is conducted Yes  Check the minutes
2
 Interview community representative
C2. Community forum action plan developed, communicated, Yes  Check the action plan and
and implemented 3 performance report
 Interview community representative
S11.4. Hospital to health centers support 0 4 
C1. Hospital conducted regular mentorship or supervision to No  Check performance report
1
catchment Coordinator health centers.  Interview coordinator health centers
C2. Hospital regularly monitored the performances of No  Check performance report
1
Coordinator health centers  Interview coordinator health centers
C3. Hospital regularly supported coordinator health centers No  Any evidence of support (e.g., Letter,
with human resources, medical equipment, and supply 2 model invoice)
 Interview Coordinator health centers
Total score for cluster activity 17/24