YaleSchool EthiopianFederalMinistry WilliamJ.Clinton ofPublicHealth ofHealth foundation

Ethiopia HospitalManagement Initiative

Blueprint Standardsfor Hospital Management in Ethiopia

CLINTONFOUNDATION

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Ethiopia

Hospital Management Initiative Blueprint Standards for Hospital Management in Ethiopia

Ethiopia Federal Ministry of Health Yale School of Public Health

William J. Clinton Foundation

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Published by Yale Reprographic and Image Services 155 Whitney Avenue New Haven CT 06511 USA Blueprint for Hospital Management in Ethiopia and the accompanying Standards for Hospital Management are subject to copyright © by Yale University and William J. Clinton Foundation. This document has been developed for use by the Ethiopia Hospital Management Initiative (EHMI). Printed in New Haven, CT, United States of America, 2007 Editors Josh Pashman, Erika Linnander and Martha Dale Correspondence Elizabeth H. Bradley, PhD Professor, Department of Public Health Yale School of Medicine 60 College Street New Haven CT 06520-8034 USA Tel. 203.785.2937 Fax. 203.785.6287 Email: Elizabeth.Bradley@yale.edu Yale School of Public Health William J. Clinton Foundation Yale University 55 West 125th Street 60 College Street New York, NY 10027 P.O. Box 208043 USA New Haven, Connecticut 06520-8034 USA publichealth.yale.edu www.clintonfoundation.org Federal Ministry of Health Federal Democratic Republic of Ethiopia Lideta Subcity, Sudan Street P.O. Box 1234 www.moh.gov.et

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Standards for Improved Hospital Management

Human Resource Management 4

Governing Boards 5

Patient Flow 5

Medical Records Management 6

Nursing Standards and Practice 6

Infection Prevention Policies 7

Pharmacy Inventory and Warehouse Management 8

Global Budgeting and Financial Management 8 Equipment Management 9 Facilities Management and Safety 9 Laboratories 10 Referrals between Facilities 11 Other Service Unit Standards 12

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EHMI Blueprint Standards for Hospital Management June 28, 2007

These Standards are consistent with the Blueprint Document for Hospital Management in Ethiopia, which provides greater detail on guidelines and approaches to meeting these Standards. In addition, several categories (equipment management, facility management and safety, laboratories, and referrals between facilities) have been added in order to provide a more comprehensive set of hospital operating Standards. Human Resource Management 1.1. The Hospital has a Human Resources Department that maintains a personnel file

for each hospital employee. 1.2. Human Resources Department provides services to employees to ensure

satisfactory productivity, motivation, and morale as evidenced by effective policies and procedures for personnel recruitment, retention, compensation, training, and employee relations.

1.3. A representative of the Hospital’s Human Resources Department is on the

Hospital’s senior management team/committee. 1.4. The Human Resources Department has an operations manual that includes all

personnel policies, including policies for work schedules, hiring procedures, new employee orientation, compensation, benefits and payroll information, workplace injuries, and performance review, evaluation, and management.

1.5. Based on the Human Resources operations manual, Hospital Management has

responsibility for recruiting, hiring and retaining staff, utilizing performance management to reinforce high performance or improve substandard performance. Corrective action and performance rewards will be undertaken using the performance review process, as specified in Human Resources operations manual.

1.6. Job descriptions are developed collaboratively with the Human Resources

Department and Hospital department directors for all positions. 1.7. The Hospital has a performance management process for its personnel in which

all employees are formally evaluated at least annually and action plans for improved performance are documented.

1.8. The Hospital has a new-hire orientation program and on-going training and

development programs for employees.

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Governing Boards 2.1. The Hospital Governing Board is developed using clear and transparent policies

and includes a representative sample of community members. 2.2. There is a qualified Board Chairperson that leads and manages the Board. 2.3. The Board has open communication via effective and regular meetings and

written minutes of meetings, which are reviewed and approved by vote of the Board members.

2.4. The Board selects the Chief Executive Officer (CEO), who leads all Hospital

operations and functions. All Hospital staff ultimately report to the CEO, who reports to the Board. Physician staff report to the Medical Director, or Chief Medical Officer, who reports to the CEO.

2.5. The Board approves an annual strategic plan for the Hospital to achieve its goal

of improving its community’s health and welfare. 2.6. In collaboration with the CEO, the Board has established performance indicators

for the Hospital, and the CEO and Board regularly monitor Hospital performance. 2.7. The Board evaluates the CEO annually to ensure he/she is meeting operational

and strategic plans as established by the Board and the CEO collectively. Patient Flow 3.1. Procedures are established to ensure efficient patient flow; such procedures are

specific to emergency, outpatient, and inpatient settings and seek to reduce patient crowding.

3.2. The Hospital has a centralized triage location in order to avoid patient crowding. 3.3. A clinical staff member is stationed in the triaging area near the emergency room

to readily determine patients’ clinical status. 3.4. Patient appointment systems are in place wherever possible. 3.5. The Hospital has criteria for surgical admissions, criteria for admission referral,

and criteria for discharge.

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Medical Records Management 4.1. The Hospital utilizes a single, unified registration system for all patients, including

both in-patients and out-patients. 4.2. The Hospital utilizes a Master Patient Index with a single, unique Medical Record

Number for each patient. 4.3. The Hospital utilizes a paper-based or computer-based medical record tracking

system, or both, to facilitate the generation, completion, and filing of medical records. This system is the central tool for the patient registration process.

4.4. The Hospital utilizes a uniform set of forms that comprise a complete medical

record for the duration of a patient’s care. The documents include at least the following: front sheet, observation sheets (vital signs record), physicians’ orders, medication administration record, inpatient admission form, progress notes with lab results and daily progress of care, and discharge summary.

4.5. The proper handling and confidentiality of medical records is ensured. Nursing Standards and Practice 5.1. The Hospital has established management structures and job descriptions that

detail the roles and responsibilities of each nursing staff member. 5.2. Nurses complete a nursing admission assessment for each new inpatient. 5.3. The Hospital has established guidelines for verbal and written communication

about patient care that involves nurses. Written communication includes the use of clinical forms, nursing Kardex, progress notes, and/or nursing care plan for each patient and discharge instructions. Verbal communication includes reporting to physicians, nurse-to-nurse reporting, communication with other clinical staff, and patient and family education.

5.4. The Hospital has streamlined procedures for standardized, safe, and proper

administration of medications by nurses or designated clinical staff, including regular checks of patients’ medications and proper documentation of administered medications.

5.5. There is a clear organizational structure for all staff in the nursing department;

delineating that health assistants report to staff nurses or a nurse manager, staff nurses report to a nurse manager, and nurse managers report to the nursing director (also called Matron or Chief Nursing Officer), who in turn reports to the CEO.

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Infection Prevention 6.1. The Hospital develops clearly defined policies, procedures, and financial

mechanisms to ensure supply of all necessary materials for proper infection prevention including all personal protective equipment, waste management and cleaning supplies.

6.2. Senior Hospital Management supports improvement efforts in infection

prevention (IP) and ensures that operational and technical capacity required to adhere to IP guidelines is available.

6.3. Capital investment is made to ensure that sinks and running water are available

at all times in all patient care areas, that washers and dryers are in working order 100% of the time, towels and linens are regularly laundered and essential supplies such as gloves, disinfectant and soap are available in all patient care areas.

6.4. The Hospital has access necessary to an incinerator that is in working order. 6.5. The Hospital has an Infection Prevention Committee charged with annual review

of operating standards for IP. 6.6. The Hospital has established a Hospital Acquired Infection (HAI) Committee and

HAI surveillance system. 6.7. Hospital staff members are trained in and adhere to IP and HAI guidelines,

including proper hand hygiene, environmental cleanliness, and waste management.

6.8. There are clearly defined policies and procedures as well as surveillance of staff

adherence to policies and procedures to ensure patient and visitor crowd control. 6.9. The Hospital implements universal precautions and conducts surveillance to

assess adherence to policies and procedures for implementing universal precautions.

6.10. The Hospital is working towards developing and implementing adequate

transmission-based precautions for patients with specific diseases. 6.11. There are clearly defined policies and procedures as well as surveillance of staff

adherence to policies and procedures to ensure that there is adequate use of post-exposure prophylaxis, which is consistent with the documented Hospital policy on post-exposure prophylaxis.

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6.12. There are clearly defined policies and procedures as well as surveillance of staff adherence to policies and procedures to ensure adequate environmental infection prevention is in place.

6.13. There are clearly defined policies and procedures as well as surveillance of staff

adherence to policies and procedures to ensure proper waste management. 6.14. The Hospital has necessary personal protective equipment and infection

prevention materials to implement existing IP policies and procedures. Pharmacy Inventory and Warehouse Management 7.1. The Hospital has a Drugs and Therapeutics Committee that includes

representation from physicians, nurses, management, and pharmacists. This Drug and Therapeutics Committee works in an open and transparent manner to establish and implement clear guidelines for cost effective and clinically effective medication evaluation, selection, quantification and procurement.

7.2. The Hospital has a formulary that details the medications that a physician can

prescribe and that are routinely stocked by the hospital pharmacy. 7.3. The Hospital has and implements a plan for training pharmacy staff on

appropriate pharmacy management techniques including ordering, storing, dosing, and distributing drugs as well as inventory management skills.

7.4. The Hospital has a paper-based or computer-based inventory management

system to reduce the frequency of stock-outs, oversupply, and drug expiry. 7.5. There is proper and safe disposal of all expired drugs. Global Budgeting and Financial Management 8.1. The Hospital collaborates with Regional or City Health Bureaus to implement

performance-based global budgeting, with agreed upon indicators for performance.

8.2. The Hospital tracks patient volume (in-patient and out-patient) as well as

expense and revenue budget variances on a monthly basis. Hospital senior management presents these reports to the Governing Board at least quarterly. These reports are provided to the relevant Health Bureau at least twice per year.

8.3. The Hospital reviews operating cash flow regularly to ensure financial liquidity.

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8.4. The Hospital reports operating costs per quarter to the relevant Health Bureau so that Health Bureaus can ensure sufficient budget is allocated for Hospital sustainability.

Equipment Management 9.1. The Hospital maintains an inventory of existing equipment. The Hospital has a

plan for equipment maintenance, to include replacements, upgrades, and new equipment.

9.2. The Hospital has a Biomedical Technology Department that manages medical

equipment at the Hospital. The Biomedical Technology Department, as directed by Hospital senior management, procures equipment, performs equipment inventory management functions, evaluates and coordinates equipment donations to the Hospital, and manages equipment maintenance and disposal.

9.3. The Hospital Biomedical Technology Department staff are trained by a

biomedical technician training program and supported by the Equipment Maintenance Center in the country.

9.4. There are Hospital policies (which are consistent with existing government

policies) that direct staff on discarding equipment that cannot be repaired. Safe disposal procedures are in place so that the disposal of items does not create a hazard or unsafe environment.

9.5. An effective tracking system is used to monitor equipment maintenance activity. 9.6. The Hospital has a monitoring method that ensures laboratory equipment

operates with predicted specificity and sensitivity. Facility Management and Safety 10.1. There is a monitoring and improvement plan for important systems in the

following areas: safety (fire safety and the safety of staff, patients and visitors), security, control and disposal of hazardous materials, medical equipment, facilities and physical plant management.

10.2. The Hospital regularly inspects its facilities and physical plant and has a plan to

reduce risks and to provide a safe physical environment for patients, families, staff and visitors.

10.3. Potable water and electrical services are available 24 hours a day, seven days a

week through regular or alternate sources to meet essential patient care.

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10.4. The Hospital has a disaster plan for responding to likely community or Hospital emergencies, epidemics and natural or other disasters. The Hospital conducts staff trainings in each department at least annually on this plan.

10.5. The Hospital conducts regular preventative maintenance for all facilities and

operating systems (e.g., electrical, water, ventilation) to ensure patient and staff safety and comfort.

10.6. There is a notification and work order system for facility and operating system

repairs. 10.7. There is a planning and budgeting system for facility refurbishments and

upgrades that is incorporated into the overall Hospital budget and strategic plan. 10.8. Dedicated Hospital staff members are assigned to all facility maintenance and

safety functions.

Laboratories

11.1. Hospital management ensures that the Hospital laboratory has the necessary space, working environment, reagents, consumables, analyzers and associated equipment needed to conduct the required repertoire of tests.

11.2. The Hospital has available and follows standard operating procedures and conducts routine quality assessments to ensure reliable patient specimens.

11.3. The laboratory provides and adheres to defined turn-around times for each laboratory test.

11.4. Laboratory staff members are trained in all required procedures and are assessed periodically to review current competence in laboratory procedures.

11.5 . The laboratory work environment is organized and clean, with safety procedures for handling of specimens and waste material to ensure patient and staff protection from unnecessary risks at all times.

11.6 . Laboratory equipment is calibrated regularly and routine preventive maintenance is performed by Hospital staff to prevent errors and breakdowns.

11.7 . Laboratory staff members monitor stocks of testing reagents and other consumables so that supplies are ordered early and in sufficient quantity to prevent stock-outs or oversupply.

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11.8 . Patient samples are stored only as long as necessary to conduct the designated tests (or other permitted procedure) according to fixed storage times, and are destroyed safely and confidentially immediately after storage.

11.9. Patient information and laboratory data are handled according to defined procedures and archived securely for fixed periods of time to ensure minimal errors or loss of patient test results.

11.10. There are laboratory ordering and reporting systems that ensures accurate and timely processing of patient laboratory tests and timely reporting of results as needed for patient care.

11.11. The Hospital has policies and procedures in place for sample collection and transport.

Referrals Among Facilities 12.1. Standards and criteria for the referral of patients from the Hospital to other health

facilities are established, including standardized referral forms and necessary clinical documents to accompany referred patients.

12.2 Hospital staff members are familiar with the referral systems including relevant

standards, criteria, and forms. 12.3. There is a designated referral person(s) at the Hospital in order to monitor and

manage the referral systems. This person(s) will work with staff to create and maintain effective linkages between the Hospital and other health facilities.

12.4. The Hospital has a listing of facilities to which the Hospital may refer patients,

categorized by the type of clinical services they provide. 12.5. The Hospital conducts periodic meetings with health facilities used as referral

centers and facilities from which the Hospital receives referrals in order to effectively manage and trouble-shoot gaps that may exist in the referral systems.

12.6. There is a standardized method for tracking and monitoring referrals. 12.7. A two-way referral system is established that allows the Hospital to both refer

and receive patients from other facilities as appropriate. 12.8. The Hospital promotes and publicizes the referral system throughout the

community in order to ensure all constituents are aware of the applicable service pathway.

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Other Service Unit Standards 13.1 Treatment Guidelines for service area (e.g., pediatrics, medical, maternal,

surgical, emergency services) will be established and implemented as established by the Hospital to ensure the best patient care possible.

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New Haven, Connecticut 06520-8034USA

publichealth.yale.edu

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www.clintonfoundation.org