Ministry of Health

Medical Service Lead Executive Office

Hospital Service Performance Monitoring for Improvement Indicators (HSPMI)

March , 2024
Addis Ababa, Ethiopia

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 FOREWORD

Medical Service Lead Executive Office emphasizes the ongoing commitment to enhancing the quality
of healthcare services in Ethiopian hospitals. Despite considerable strides in expanding health services,
there's a recognized necessity to improve the overall quality and equitable access to healthcare across
the country.

With the goal of providing quality and equitable access to all segments of Ethiopian Hospitals, the
Hospital Performance and Monitoring Improvement (HPMI) manual was first published in 2011 G.C.
Then revised in 2017 G.C and is presently being revised in 2023 G.C. Hospitals are at the heart of these
reform efforts, with a number of recent measures aimed explicitly at improving hospital performance
and health-care quality.

The Health Sector Transformation Plan (HSTP) has significantly contributed to expanding health
services, but the current focus is on elevating the quality of healthcare provision. The recently revised
Hospital Service Performance Monitoring Improvement (HSPMI) manual in 2023 stands as a crucial
tool in this endeavor. It meticulously details 28 Medical Service HMIS Indicators, 32 Hospital Key
Performance Indicators (KPI) and additional of 22 pool indicators for Hospitals internal consumption.

Moreover, these guidelines, along with initiatives like EHSTG, NQSS, SaLTs and HMIS, are
foundational tools for performance improvement of clinical and administrative aspects hospitals. The
Ministry of Health aims to implement these guidelines aligned with revised EHSIG guideline with a
focus on swift and time-bound activities aligned with the roadmap outlined in the HSPMI guideline.

Expressing gratitude to the professionals, partners, and the ministry's Medical Service Lead Executive
Office staff who contributed to the development and finalization of these crucial manuals, the message
highlights the collective effort and commitment toward implementing these guidelines for the
enhancement of healthcare services across Ethiopian hospitals.

Dr. Elubabor Buno

Medical Service Lead Executive Officer

Ethiopia Ministry of Health

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ACKNOWLEDGMENTS

The Ministry of Health's Medical Service Lead Executive Office (MSLEO) spear headed the
development of the Hospital Service Performance Monitoring for Improvement (HSPMI) manuals in
the Health Sector, which is the result of the efforts of all key stakeholders in the health sector. Ministry
established a national taskforce through the HSPMI technical working group to monitor and coordinate
the technical and consultative procedures in the development of the manual. The data elements and
indicators outlined in this manual are designed to operationalize the Hospital's Service Performance
Monitoring framework and establish a minimum bar for performing monitoring and improvement
efforts at healthcare facilities across the country.

I extend my sincere gratitude to the members of the national HSPMI technical working groups and key
stakeholders and partners for their invaluable input and oversight throughout this entire process. Their
constructive contributions, expertise, and active involvement played a critical role in shaping and
finalizing of this document.

FMOH Led Core Team

We appreciate and thank the MOH-led core team members for their contributions to the preparation,
coordination, and facilitation of HSPMI guidelines development workshop briefs, consultation
documents, review of drafts and stakeholder contributions, and response to comments and
recommendations, as well as the enrichment of the manuals.

Core Team Member Organization

Dr. Elubabor Buno MoH/Medical Service Lead Executive Officer

Biniyam Kemal MoH/MSLEO – Hospital & Diagnostic Desk Coordinator

Sem Daniel (PhD fellow) MoH – Medical Service LEO – HSPMI Initiative National focal

Desalegn Bayissa MoH – Medical Service LEO – HSPMI Initiative National focal

Dr Hailemicheal Fikre MoH – Eka Kotebe Hospital

Yalemzewoud Ayalew MoH – Medical Service LEO

Kasu Tola (PhD fellow) MoH – Medical Service LEO

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Biruk Kefelegn MoH – Medical Service LEO

Etaferahu Alamaw MoH – Medical Service LEO

Abebaw Derso MoH – Medical Service LEO

Gobena Godana (PhD fellow) MoH – Medical Service LEO

Emebet Tarekegne MoH – Medical Service LEO

Tiruwork Akile MoH – Medical Service LEO

Abiy Dawit (PhD fellow) MoH – Medical Service LEO

Sara Paulos AAHB

Dr. Dawit Daniel Central Ethiopia Regional Health Bureau

Dr. Yoseph Workneh Hawela Tula General Hospital

Dr. Alemayehu Gareno Sidama Regional Health Bureau

Alem Wassie Yekatit 12 Hospital – Medical College

Ibrahim Heyredin St. Peter Specialized Hospital

Habtamu Milkiyase (PhD fellow) MoH – Quality and Innovation LEO

Edessa Deriba MoH- Pharmaceutical and medical device LEO

Addisu Taso MoH- Pharmaceutical and medical device LEO

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Contents
ABBREVIATIONS/ACRONYMS.........................................................................................................1

CHAPTER 1: INTRODUCTION...........................................................................................................1

1.1 Background............................................................................................................................................................... 1
1.2 Justification for HSPMI Manual Revision..................................................................................................2
1.3 Purpose of this Manual........................................................................................................................................ 2
1.4 Scope of HSPMI manual..................................................................................................................................... 4
1.5 Target Audience for the Manual..................................................................................................................... 4
CHAPTER 2: A FRAMEWORK FOR HOSPITAL SERVICE PERFORMANCE MONITORING
FOR IMPROVEMENT (HSPMI)...........................................................................................................5

Fig 1: Framework.......................................................................................................................................................... 9
CHAPTER 3: HOSPITAL KEY PERFORMANCE INDICATORS....................................................10

3.1. INDICATORS........................................................................................................................................................ 11
LIST OF HMIS INDICATORS..............................................................................................................................15
MODULE 1: HMIS INDICATORS......................................................................................................25

1.1. Out-Patient Attendance Per-Capita........................................................................................................25

1.2. Bed Occupancy Rate...................................................................................................................................... 27
1.3. Average Length of Stay (in days).............................................................................................................29
1.4. Hospital Bed Density.................................................................................................................................... 30
1.5. Assistive Technology Service Utilization.............................................................................................31
1.6. Essential laboratory test availability.....................................................................................................31
1.7. Referral-out Rate............................................................................................................................................ 33
1.8. Ambulance service utilization for referral service..........................................................................34
1.9. Ambulance service response rate...........................................................................................................35
1.10. Facility emergency department mortality rate............................................................................36
1.11. Emergency room attendances with length of stay > 24 hours..............................................38
1.12. Percentage of ventilator associated pneumonia..........................................................................38
1.13. Mortality rate in Intensive Care Unit................................................................................................40
1.14. Perioperative mortality rate.................................................................................................................41
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1.15. Average length of ICU stay.....................................................................................................................43
1.16. Mean duration of in-hospital pre-elective operative stay.......................................................43
1.17. Number of clients in the waiting list for elective surgical service.......................................44
1.18. Delay for elective surgical admission................................................................................................45
1.19. Inpatient mortality rate.......................................................................................................................... 46
1.20. Top 10 causes of morbidity...................................................................................................................47
1.21. Top ten causes of institutional mortality........................................................................................47
1.22. Supplier fill rate.......................................................................................................................................... 49
1.23. Essential Drugs Availability.................................................................................................................. 50
1.24. Percentage of encounters with an antibiotic prescribed.........................................................53
1.25. Percentage of client with 100% prescribed drug filled............................................................54
1.26. Percentage of medicines prescribed from the facility’s medicines list..............................55
1.27. Pharmaceuticals wastage rate............................................................................................................. 55
1.28. PMS_EQUIP: Functionality of medical equipment......................................................................57
2.1. Percentage of Good governance index score.....................................................................................59
2.2. Emergency room patients triaged within 5 minutes of arrival.................................................60
2.3. Outpatient waiting time to Consultation.......................................................................................61
2.4. Timely Outpatient service initiation..................................................................................................... 62
2.5. Outpatients not seen on the same day............................................................................................63
2.6. Percentage of hypoxemic patients treated with oxygen......................................................65
2.7. Medical oxygen stock out rate............................................................................................................. 66
2.8. Inpatient Medical Record Completeness.......................................................................................67
2.9. Percentage of acceptable EQA result...............................................................................................68
2.10. Percentage of laboratory tests completed within TAT.....................................................69
2.11. Elective Surgical case cancellation ratio due to blood unavailability for surgical
patients........................................................................................................................................................................... 70
2.12. Patients Receiving Rehabilitation Services.............................................................................71
2.13. Antimicrobial Stewardship Functionality Score.........................................................................72
2.14. Anesthesia adverse outcome........................................................................................................... 73
2.15. Elective Surgical Cases Treated within clinically recommended Time..................74
2.16. Major Elective Surgeries Performed...........................................................................................75
2.17. Safe Surgery Checklist Utilization.................................................................................................75

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 2.18. OR Table Efficiency................................................................................................................................ 76
2.19. Surgical Site Infection Rate.................................................................................................................. 77
2.20. Percentage of Reimbursed Costs........................................................................................................78
2.21. Percentage of Imaging Service Interruption Days.....................................................................81
2.22. Percentages of Pathology Service Interruption Days...............................................................81
2.23. Percentage of imaging service completed within TAT.............................................................82
2.24. Percentage of pathology tests completed within TAT..............................................................83
2.25. Percentage of Medical Devices Repaired........................................................................................84
2.26. IPC FLAT Score (IPC-FLAT)............................................................................................................ 84
2.27. Pressure sore incidence...........................................................................................................................86
2.28. Percentage of women who died from Post-Partum Hemorrhage........................................87
2.29. Births by instrumental or assisted vaginal deliveries...............................................................87
2.30. Patient satisfaction survey.....................................................................................................................88
2.31. Staff satisfaction survey..........................................................................................................................89
2.32. EHSIG Score............................................................................................................................................... 90
MODULE 3: POOL INDICATORS......................................................................................................92

3.1. Blood Product Wastage Rate....................................................................................................................92

3.2. Number of palliative Patients Seen........................................................................................................92
3.3. Pain Assessment Performed as 5th Vital Sign....................................................................................93
3.4. Pain Management per WHO Standards.............................................................................................94
3.5. Palliative Home-Based Care Linkage...................................................................................................95
3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service............................96
3.7. Functional improvement of rehabilitation clients...........................................................................97
3.8. Rehabilitation Service Utilization.......................................................................................................... 99
3.9. Percentage of SLIPTA standards met...............................................................................................99
3.10. Drug and Therapeutics Committee (DTC) Functionality....................................................100
3.11. Clinical Pharmacy Service Functionality................................................................................101
3.12. Percentage of Medicine Actually Dispensed...............................................................................102
3.13. Relative Share of Sources of Retained Revenue.................................................................104
3.14. Retained Revenue spending as a share of total operating budget spending....106
3.15. Proportion of Beneficiary Groups to total visits................................................................108

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 3.16. MEMIS implementation......................................................................................................................110
3.17. Mean time to respond to work order request for special healthcare setting...............110
3.18. Proportion of vacancies filled as per the standards of the approved positions..........111
3.19. Attrition rate of Healthcare workforce.........................................................................................111
3.20. Recipients of in-service and CPD training..................................................................................112
3.21. Grievances received and solved........................................................................................................113
3.22. Occupational injury incidence..........................................................................................................113
CHAPTER 4: HOSPITAL SUPPORTIVE SUPERVISION...............................................................116

CHAPTER 5: REVIEW MEETINGS.................................................................................................117

Reference.............................................................................................................................................119

Appendix.............................................................................................................................................120

Appendix 6 : Antimicrobial Stewardship program functionality Criteria..............................................134

Annex 4: Essential Palliative Care Medicines List.............................................................................135

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ABBREVIATIONS/ACRONYMS

ANC Antenatal Care

ART Antiretroviral Therapy

ALOS Average Length of Stay

BOR Bed Occupancy Rate

BPR Business Process Reengineering

CEO Chief Executive Officer

CHAI Clinton Health Access Initiative

DOTS Directly Observed Therapy (Short Course)

EHSIG Ethiopian Hospital Services Improvement Guidelines

HSPMI Hospital Service Performance Monitoring Improvements

EPI Expanded Program on Immunization

FMOH Federal Ministry of Health

FTE Full time equivalent

HMIS Health Management Information System

HCFR Healthcare Finance Reform

H-CAHPS Hospital Consumer Assessment of Health Providers and Systems

HR Human Resources

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I-PAHC Inpatient Assessment of Health Care

KPI Key Performance Indicator

MHA Masters in Hospital and Healthcare Administration

MCH Maternal and Child Health

NGO Non-Governmental Organization

OPD Outpatient Department

O-PAHC Outpatient Assessment of Health Care

PNC Post Natal Care

RHB Regional Health Bureau

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CHAPTER 1: INTRODUCTION

1.1 Background

The Ministry of Health envisions all of its citizens having quality and fair access to all forms of health
services under the Health Sector Transformation Plan (HSTP-II). In order to do this, the MOH and
RHBs are leading a sector-wide reform to enhance and improve the quality of Ethiopia's health
services. Hospitals are at the heart of these reform efforts, and a number of recent initiatives have
focused on improving hospital performance and service quality. Ethiopian Hospital Services
Improvement Guidelines (EHSIG), Saving Lives Through Safe Surgery (SaLTS-II), Diagnostic,
service, Emergency and critical care, and Infection Prevention and Control, as well as the revised
Health Management Information System (HMIS) and District Health Information System two
(DHIS2), are some of the examples of national health service initiatives.

Measurement is essential to the concept of quality improvement because it allows you to specify what
hospitals actually accomplish and compare it to the original goals in order to find areas where you can
improve. This is addressed by routine data collection, aggregation, and dissemination, performance
monitoring and quality improvement, integrated supporting supervision, inspection, and operational
research/evaluation components in the monitoring and evaluation of health sectors .In the HSTP's
M&E framework, a variety of data sources are used, including routine administrative sources (such as
the Health Management Information System), Service Provision Assessment (SPA) and the Service
Availability and Readiness Assessment (SARA), disease and behavioral surveillance, civil registration
and vital statistics, financial and management data, and disease and behavioral surveillance.

HSPMI designed to measure access, quality, and equity in healthcare provision, HSPMI plays a crucial
role in identifying performance gaps and disparities, enabling targeted resource allocation. This
approach enhances service delivery tailored to diverse populations, fostering a culture of continuous
improvement. It serves as a compass for progressing toward universal health coverage, advocating for
inclusive healthcare access. By promoting ongoing evaluation and evidence-based practices, HSPMI

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contributes to elevating patient outcomes, fostering equitable healthcare systems, and enhancing public
health on a national scale.

1.2 Justification for HSPMI Manual Revision

Hospital Services performance monitoring for improvement (HSPMI) can be defined as a process by
which hospitals practice strategic use of performance standards, measures, progress reports, and
ongoing quality improvement efforts to ensure their desired results are being achieved. The existing
HPMI (2017) was revised in 2023 due to a number of driving forces that have resulted in the need for
HPMI revision. Some of the driving forces for revision include:

1) The development of 3 years Health Sector Medium-Term Development and Investment Plan
(HSDIP) from 2023/24-2025/26.

2) The need to have more quality, access and equity indicators that will provide details required to
operationalize the monitoring and evaluation framework of the HSTP II.

3) The commitment to improve the access and transform the quality of health services provided at
hospitals with magnified efficiency, accountability and ownership at all level.

4) Developments of EHSIG, Infection Prevention and Control (IPC) Strategy, Health Ageing
Strategies, National Palliative Care Strategy, National Compressive Rehabilitative Assistive
Technology Service Strategy, National strategies for Safe life through Surgery (SaLTS),
Diagnostic strategy.

1.3 Purpose of this Manual

The purpose of this manual is to bring together processes and activities for hospital service
performance monitoring and improvement across the sector. Its mission is to provide data to hospital
senior management teams (SMTs), governing boards (GBs), health service providers, and higher health
sector offices in order to measure and monitor hospital performance using a core set of Key

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Performance Indicators, as well as conduct site visits and facilitate review meetings to ensure the
effectiveness, efficiency, and quality of services provided.

1. Data Provision for Performance Monitoring: Provide a structured approach to gather and
present data to hospital senior management teams (SMTs), governing boards (GBs), health
service providers, and higher health sector offices for monitoring and evaluating hospital
performance.
2. Utilization of Key Performance Indicators (KPIs): Ensure accurate collection and evaluation
of Key Performance Indicator (KPI) data, promoting evidence-based decision-making within
hospitals.
3. Instructions for Data Collection and Analysis: Offer clear instructions on collecting,
analyzing, evaluating, and utilizing performance data effectively.
4. Standardization of Performance Monitoring Definitions: Establish standardized definitions
for hospital performance monitoring and improvement, ensuring consistency and clarity in
measurements

There are additional particular instructions in the manual, such as:

1. Assuring that hospitals collect and evaluate accurate KPI data, as well as improving data
utilization for evidence-based decision-making.

2. Give instructions on how to collect, analyze, evaluate, and use performance data.

3. Establish a common standardized definition for hospital service performance monitoring and
improvement.

4. To identify areas inside hospitals where focused help from the community, government
agencies, and other partners is deemed important for further progress

5. Provide guidance on how to create and implement a comprehensive hospital performance

monitoring and improvement program

6. Create a learning culture that uses M&E data to inform management and governance decision-
making and accountability

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 7. It is necessary to identify and communicate best practices.

1.4 Scope of HSPMI manual

This Manual implemented in all tier of hospitals such as Primary hospitals, General hospitals, and
Compressive specialized hospitals.

1.5 Target Audience for the Manual

The goal of this manual is to help healthcare professionals obtain, synthesize, and analyze data to
improve hospital performance. The actors are:

1. National level: MOH agencies and directorates etc.

2. Regional level: RHB/Zonal departments etc.

3. Facility level: Hospital GB, SMT, Unit heads, service providers etc.

4. Community level: community forums, public wing members

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 CHAPTER 2: A FRAMEWORK FOR HOSPITAL SERVICE PERFORMANCE
MONITORING FOR IMPROVEMENT (HSPMI)

1. Introduction

The framework underlines the strategic approach to assess and improve hospital service
performance within Ethiopia's healthcare system. Aligned with the overarching objectives of the
Health Sector Transformation Plan (HSTP-II) from 2023/24-2025/26, this guideline aims to serve
as an essential tool in evaluating, enhancing, and aligning hospital-level healthcare delivery with
national health objectives.

2. Core Components

2.1 Access Assessment:

The assessment of hospital service performance encompasses critical dimensions such as

geographical accessibility, service availability, and equity indicators. Geographical accessibility
entails scrutinizing the proximity and ease of reaching healthcare facilities from population centers,
ensuring that individuals can readily access necessary care. Simultaneously, the evaluation of
service availability involves scrutinizing the comprehensive range and accessibility of essential
healthcare services provided by hospitals. Moreover, equity indicators play a pivotal role in
guaranteeing equal access to healthcare services for all segments of the population, regardless of
socioeconomic disparities or geographic disparities, thus striving towards an inclusive and fair
healthcare system that caters to diverse demographics.

2.2 Quality Improvement Indicators:

The comprehensive evaluation of hospital service performance includes critical aspects such as
clinical effectiveness, patient safety, and patient-centeredness. Clinical effectiveness involves
diligent monitoring of healthcare outcomes, adherence to established clinical protocols, and the
utilization of evidence-based practices to ensure optimal patient care. Additionally, patient safety
remains paramount, entailing the meticulous tracking of infection rates, safety incidents, and strict
adherence to safety protocols to safeguard patient well-being within healthcare settings. Moreover,

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focusing on patient-centeredness involves assessing patient satisfaction levels and their active
involvement in care processes, ensuring that healthcare services are tailored to meet individual
needs and preferences, fostering a more personalized and patient-centric approach to healthcare
delivery.

2.3 Equity Evaluation:

Assessing equitable healthcare provision encompasses two fundamental components: fair

distribution and accessibility for vulnerable populations. Fair distribution necessitates a
comprehensive evaluation of how healthcare services are equitably distributed among diverse social
and economic groups, ensuring that access to care is justly allocated across various demographics.
Simultaneously, ensuring accessibility for vulnerable populations is crucial, aiming to provide equal
opportunities and unhindered access to healthcare services for marginalized or vulnerable groups.
This facet emphasizes the importance of removing barriers and disparities, guaranteeing that those
in need, irrespective of their socioeconomic status or vulnerabilities, have equitable access to
essential healthcare services

2.4 Performance Improvement Strategies:

The section focusing on performance improvement strategies encompasses key elements vital for
enhancing hospital service delivery. Target setting plays a pivotal role, involving the establishment
of measurable targets aligned with objectives related to access, quality, and equity, providing a clear
direction for improvement efforts. Concurrently, the development of action plans forms a
cornerstone, delineating comprehensive strategies aimed at continually improving the quality of
healthcare services offered by hospitals. Moreover, the aspect of capacity building is crucial,
providing guidance for the training and skill development of healthcare professionals, ensuring they
meet set standards and are equipped with the necessary competencies to deliver high-quality care in
line with established objectives.

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2.5 Data Collection and Reporting Mechanisms:

Within the realm of data collection and reporting mechanisms, several critical components shape
the evaluation of hospital service performance. Firstly, defining standardized tools, sources, and
methodologies for data collection and analysis stands as a pivotal step, ensuring consistency and
reliability in acquiring pertinent information. Secondly, the establishment of measurement tools
plays a crucial role in evaluating performance indicators and establishing benchmarks for assessing
hospital service quality. Lastly, outlining robust reporting methods is essential, delineating
procedures for data reporting, comprehensive analysis, and efficient dissemination of findings,
thereby enabling stakeholders to make informed decisions and implement targeted improvements
based on the collected data.

2.6 Benchmarking and Comparisons:

The benchmarking and comparisons segment of hospital service evaluation involves pivotal steps
toward enhancing overall performance. Firstly, comparing hospital performance against established
national benchmarks and best practices serves as a crucial measure for assessing the effectiveness
of healthcare delivery. Secondly, fostering a culture of learning and sharing becomes imperative,
encouraging hospitals to share successful initiatives and best practices among one another. This
exchange of knowledge facilitates continuous improvement, allowing hospitals to learn from each
other's successes and adopt innovative approaches to further elevate the quality of healthcare
services provided

2.7 Governance and Leadership:

In the domain of governance and leadership, establishing clear guidelines and accountability
mechanisms is fundamental to the effective implementation of the HSPMI framework. Firstly,
defining explicit roles and responsibilities for stakeholders involved in implementing the HSPMI
framework is crucial, ensuring that each party comprehends their specific duties and
accountabilities within the framework. Secondly, embedding robust accountability mechanisms
becomes essential to monitor and achieve performance improvement objectives. By establishing

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clear lines of responsibility and accountability, this framework cultivates an environment of
transparency and ensures that all stakeholders are committed and responsible for driving the
improvements outlined within the HSPMI guideline.

2.8 Supportive Supervision and Review Meetings:

Supportive supervision and review meetings play a pivotal role in ensuring the successful
implementation of improvement initiatives within hospital settings. To facilitate this, providing
structured guidelines for conducting effective supportive supervision and review meetings becomes
imperative. These guidelines offer a framework for conducting sessions that are productive,
focused, and conducive to addressing performance-related issues and implementing necessary
improvements. Additionally, offering action plan templates is essential, providing hospitals with a
standardized format for developing action plans. These templates delineate clear objectives and
timelines for implementation, aiding in the systematic execution of improvement strategies and
ensuring that initiatives are well-defined, actionable, and trackable to achieve desired outcomes
within set timeframes.

3. Implementation Guidelines

The implementation phase of the HSPMI guideline necessitates practical application and proper
training for stakeholders involved in hospital service provision. Guidelines for practical application
and recommended training programs ensure the effective utilization of this framework to drive
meaningful and sustainable improvements in hospital service delivery.

In conclusion, the comprehensive framework detailed within the National Hospital Service
Performance Monitoring Improvement Indicator guideline presents a structured approach towards
assessing, monitoring, and enhancing hospital service performance. The guideline stands as a
beacon, guiding the healthcare system toward a data-driven approach to achieve equitable,
accessible, and quality healthcare delivery at a national level.

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Fig 1: Framework

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CHAPTER 3: HOSPITAL KEY PERFORMANCE INDICATORS

It's clear that Key Performance Indicators (KPIs) are crucial in assessing and improving hospital
performance. These indicators serve as benchmarks for tracking progress toward goals and
identifying areas needing improvement. Here are some common types of KPIs used in hospitals:

1. Clinical Quality Indicators: These KPIs measure the quality of care delivered by clinical
teams. They may include metrics related to patient outcomes (e.g., mortality rates,
infection rates, readmission rates), adherence to clinical guidelines, patient satisfaction
scores, etc.
2. Financial Performance Indicators: These indicators focus on the financial health of the
hospital. Metrics may include revenue, operating costs, profitability, cash flow, billing and
collection efficiency, etc.
3. Operational Efficiency Indicators: These KPIs assess the effectiveness of hospital
operations. They can cover metrics like bed occupancy rates, length of stay, emergency
department waiting times, surgery turnaround times, etc.
4. Patient Access and Throughput Indicators: These KPIs measure how easily patients can
access care and how efficiently they move through the system. Metrics might include
appointment wait times, admission rates, discharge rates, etc.
5. Staffing and Workforce Indicators: These indicators assess the hospital's workforce
management, including metrics on staff satisfaction, turnover rates, staffing levels
compared to patient demand, training and development metrics, etc.
6. Compliance and Regulatory Indicators: These KPIs ensure adherence to legal and
regulatory standards. They may include metrics related to compliance with healthcare
regulations, accreditation status, adherence to safety protocols, etc.
7. Patient Safety and Risk Management Indicators: These KPIs focus on reducing medical
errors, ensuring patient safety, and managing risks. Metrics may include incident reporting
rates, adverse event rates, near misses, etc.

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The selection of KPIs should be strategic and aligned with the hospital's objectives and priorities.
It's crucial to not overwhelm stakeholders with excessive data but to focus on a concise set of
indicators that provide a comprehensive view of hospital performance.

Regular monitoring and analysis of these indicators allow for early detection of issues,
benchmarking against industry standards or other hospitals, and enable proactive decision-making
to improve hospital performance and quality of care.

Furthermore, it's important for relevant authorities (such as the ZHD/RHB and FMOH) to
regularly review these KPIs, identify areas needing support or improvement, and provide timely
feedback and resources to ensure continuous enhancement of hospital services.

3.1. INDICATORS

1. HMIS Indicators: The HMIS is designed primarily to monitor and refine the
implementation of Health Sector Transformation Plans. It gathers data from routine
services and administrative records, aligning its indicators with broader national and
international goals like the Sustainable Development Goals (SDGs)
2. HSPMIs Indicators: The HSPMIs encompass a smaller collection of 32 indicators, with
each hospital conducting self-assessments and reporting to the Ministry of Health through
DHIS2. These indicators are specifically crafted to aid Hospital staff, Senior Management
Teams (SMTs), Governing Boards, Regional Health Boards (RHBs), and Ministry of
Health (MOH) in overseeing hospital operations. The primary goal of these specific KPIs
is to offer a concise yet comprehensive overview of hospital performance.
3. Pool Indicators: Individual hospitals have the option to use Pool indicators as needed
without the obligation and no need of report them through DHIS2 to the Ministry of
Health. This integration permits a comprehensive evaluation, enabling the assessment of
indicators customized to each hospital's specific needs while also considering those that
align with broader objectives in the healthcare sector.

This joint assessment could help in:

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  Identifying overlaps or gaps between the hospital-specific indicators and the broader health
sector goals tracked by the HMIS.
 Streamlining data collection processes to avoid duplication and ensure efficient use of
resources.
 Providing a comprehensive understanding of how hospital performance contributes to the
larger healthcare landscape and national health objectives.

Regular joint assessments can facilitate informed decision-making, strategic planning, and targeted
interventions aimed at improving both hospital operations and the overall health system
performance in alignment with national health priorities.

Data Collection

Establishing efficient data collection strategies is crucial for accurately monitoring Hospital Key
Performance Indicators (HKPIs). steps and considerations for effective data collection:

1. Clear Data Collection Procedures: Develop standardized and documented procedures for
data collection, ensuring clarity on what data needs to be collected, how it should be
gathered, and when it needs to be reported.
2. Data Validation and Quality Assurance: Implement measures to ensure data accuracy
and quality. This might involve data validation checks, verification processes, and regular
audits to identify and rectify errors or inconsistencies.
3. Designated Responsibilities: Assign a dedicated focal person for HKPIs and designate
specific data owners for each indicator. These individuals will be responsible for
overseeing data collection, analysis, and reporting, ensuring accountability and accuracy.
4. Training and Capacity Building: Provide necessary training and support to staff
responsible for data collection. This includes training on data collection methods, tools,
and the importance of accurate and timely reporting.
5. Use of Technology: Leverage technology where possible to streamline data collection
processes. Implementing electronic data collection systems or utilizing software solutions
can improve efficiency and reduce errors.

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 6. Regular Review and Analysis: Establish a schedule for regular review and analysis of
collected data. This enables identification of trends, performance evaluation against targets,
and timely corrective actions if discrepancies or issues are identified.
7. Documentation and Reporting: Ensure proper documentation of data collection
processes, analysis, and reporting. Develop clear and concise reports that highlight
performance against HKPIs and EHSIGs facilitating informed decision-making.
8. Feedback Loops: Create mechanisms for feedback and communication between data
collectors, focal persons, and stakeholders. This facilitates continuous improvement and
adjustments in data collection processes based on feedback and evolving needs.

By implementing these strategies and ensuring a systematic approach to data collection, hospitals
can enhance the reliability, accuracy, and relevance of the collected data. This, in turn, supports
effective decision-making, goal attainment, and overall improvement in hospital performance
aligned with EHSIGs.

3.4.1 Data Owners of KPIs

Specific data owners responsible for managing the primary data sources linked to Hospital Key
Performance Indicators (HKPIs) is crucial for maintaining data accuracy and integrity. Here's a
breakdown of the responsibilities for HKPI data owners:

Responsibilities of HKPI Data Owner:

1. Management of Primary Data Sources: The HKPI data owner is accountable for
ensuring that the primary data sources, such as registers, records, databases, or relevant
systems, are regularly updated, accurate, and complete. This involves overseeing data
collection, entry, and maintenance procedures.
2. Calculation of HKPIs: At the end of each reporting period, the data owner is responsible
for performing calculations based on the collected data to generate the HKPI values. This
involves applying the predefined formulas or methodologies to compute the specific
indicators accurately.

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 3. Timely Submission of Data: The data owner must submit the HKPI and EHSIG data to
the designated HKPI focal person within the stipulated time frame. Timely submission
ensures that the information is available for analysis and reporting purposes.
4. Analysis and Action Planning: The data owner, in collaboration with relevant
stakeholders, should examine the HKPIs and associated standards to evaluate performance
against targets or benchmarks. If performance falls below expectations, they should initiate
action plans or performance improvement initiatives to address identified gaps.

Example, the Chief of Human Resources (HR) department is designated as the HKPI data owner
for Employee satisfaction KPI. This individual would oversee employee satisfaction data sources,
ensure data accuracy, compute the HKPI value based on collected information, and submit it to the
HKPI focal person within the hospital.

Regular monitoring, analysis, and action planning based on HKPIs are essential to drive
continuous improvement in hospital performance. It's crucial for HKPI data owners to collaborate
closely with the HKPI focal person and other relevant stakeholders to ensure that data-driven
decisions are made to enhance hospital operations and achieve desired performance outcomes.

3.4.2. Key Performance Indicators (HKPIs) Focal Person

Assigning a dedicated HKPI focal person plays a critical role in ensuring the effective collection,
validation, and reporting of Hospital Key Performance Indicators (HKPIs). Here are the
responsibilities and functions of the HKPI focal person:

Responsibilities of the HKPI Focal Person:

1. Collection of HKPI Data: Gather HKPI data from each designated HKPI data owner at
the end of the reporting period. Ensure that all required data elements are collected
accurately and on time from respective data owners.
2. Data Accuracy Review: Verify the accuracy and completeness of HKPI/EHSIG data by
conducting spot checks and reviewing data sources provided by data owners. This involves
validating the integrity of the collected data to maintain data quality.

14
 3. Data Entry and Database Management: Enter validated HKPI/EHSIG data into the
computerized Hospital HKPI Database or DHIS2 platform. Ensure accurate and timely
input of data elements to maintain an updated database.
4. HKPI Report Creation: Generate a comprehensive HKPI report from the HKPI
Database, compiling data items and outcomes to create a structured report for analysis and
review.
5. Submission of HKPI Report: Submit the compiled HKPI report to relevant departments,
such as the Clinical Governance and Quality Management Unit (CG & QMU), and the
Chief Executive Officer (CEO) within the reporting period.
6. Training and Support: Provide training and support to HKPI data owners and relevant
personnel involved in data collection and reporting processes. Ensure they understand their
roles and responsibilities in contributing to accurate data collection.
7. Resource Management: Ensure that necessary equipment, software, stationery, and
required formats are available and accessible for the collection, input, and submission of
HKPI data.

Additionally, the HKPI focal person's role includes being a part of the hospital's Quality Team and
the Performance Review Team, which emphasizes their involvement in strategic decision-making
related to hospital performance and quality improvement initiatives.

Moreover, in the absence of the HKPI focal person, trained members from the HMIS team can
step in to perform HKPI-related tasks to ensure continuity in data collection and reporting
processes. Overall, the HKPI focal person plays a central role in managing the entire process of
HKPI data collection, validation, reporting, and ensuring that the hospital's performance is
measured accurately against established benchmarks and standards.

LIST OF HMIS INDICATORS

HMIS CODE Name of HMIS Indicator

1.1. Out-Patient Attendance Per-Capita
1.2. Bed Occupancy Rate

15
1.3. Average Length of Stay (in days)

1.4. Hospital Bed Density

1.5. Assistive Technology Service Utilization

1.6. Essential laboratory test availability

1.7. Referral-out Rate

1.8. Ambulance service utilization for referral service

1.9. Ambulance service response rate

1.10. Facility emergency department mortality rate

1.11. Emergency room attendances with length of stay > 24 hours

1.12. Percentage of ventilator associated pneumonia

1.13. Mortality rate in Intensive Care Unit

1.14. Perioperative mortality rate

1.15. Average length of ICU stay

1.16. Mean duration of in-hospital pre-elective operative stay

1.17. Number of clients in the waiting list for elective surgical service
1.18. Delay for elective surgical admission

1.19. Inpatient mortality rate

1.20. Top 10 causes of morbidity

1.21. Top ten causes of institutional mortality

1.22. Supplier fill rate

1.23. Essential Drugs Availability

1.24. Percentage of encounters with an antibiotic prescribed

16
1.25. Percentage of client with 100% prescribed drug filled

1.26. Percentage of medicines prescribed from the facility’s medicines list

1.27. Pharmaceuticals wastage rate

1.28. PMS_EQUIP: Functionality of medical equipment

LIST OF HSPMI INDICATORS

HMIS CODE Name of HSPMI Indicator

2.1. Percentage of Good governance index score

2.2. Emergency room patients triaged within 5 minutes of arrival

2.3. Outpatient waiting time to Consultation

2.4. Timely Outpatient service initiation

2.5. Outpatients not seen on the same day

2.6. Percentage of hypoxemic patients treated with oxygen

2.7. Medical oxygen stock out rate

2.8. Inpatient Medical Record Completeness

2.9. Percentage of acceptable EQA result

2.10. Percentage of laboratory tests completed within TAT

17
2.11. Elective Surgical case cancellation ratio due to blood unavailability for surgical
patients

2.12 . Patients Receiving Rehabilitation Services

2.13. Antimicrobial stewardship functionality score

2.14. Anesthesia adverse outcome

2.15. Elective Surgical Cases Treated within clinically recommended Time

2.16. Major Elective Surgeries Performed

2.17. Safe Surgery Checklist Utilization

2.18. Major OR Table Efficiency

2.19. Percentage of Surgical Site Infection

2.20. Percentage of Reimbursed Costs

2.21. Percentage of Imaging Service Interruption Days

2. 22. Percentage of Pathology Service Interruption Days

2. 23. Percentage of imaging service completed within TAT

2.24. Percentage of pathology tests completed within TAT

2.25. Percentage of Medical Devices Repaired

2.26. IPC FLAT Score

2.27. Pressure sore incidence

2.28. Percentage of women who died from Post-Partum Hemorrhage

2.29. Births by instrumental or assisted vaginal deliveries

18
2. 30. Patient satisfaction Score

2.31. Staff satisfaction Score

2. 32. EHSIG Score

List of Pool Indicators

Indicator Name of Pool Indicator

number
3.1. Blood Product Wastage Rate

3.2. Number of Patients Seen

3.3. Pain Assessment Performed as 5th Vital Sign

3.4. Pain Management per WHO Standards

3.5. Palliative Home-Based Care Linkage

3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service

3.7. Functional improvement of rehabilitation clients

3.8. Rehabilitation Service Utilization

3.9. Percentage of SLIPTA standards met

3.10. Drug and Therapeutics Committee (DTC) Functionality

3.11. Clinical Pharmacy Service Functionality

3.12. Percentage of Medicine Actually Dispensed

19
3.13. Relative Share of Sources of Retained Revenue

3.14. Proportion of Beneficiary Groups to total visits

3.15. Retained Revenue spending as a share of total operating budget spending

3.16. MEMIS implementation

3.17. Mean time to respond to work order request for special healthcare setting

3.18. Proportion of vacancies filled as per the standards of the approved positions

3.19. Attrition rate of Healthcare workforce

3.20. Recipients of in-service and CPD training

3.21. Grievances received and solved

3.22. Occupational injury incidence

20
3.5. Analyze and report hospital HKPI data

Reporting period of public health facilities, 26 th- 7th of next month. The PMT of the hospital is
expected to evaluate the data before submission. Hospital HKPIs data should be used to inform
decision-making and planning for performance improvement at all levels. Below are some specific
considerations for hospital administration, employees, Governing Boards, RHBs, and the MOH.

Each HKPI's data owner is accountable for not just reporting the data, but also reflecting on it and
communicating with colleagues to enhance performance.

When examining HKPI data, consider the following questions:

● What is the difference between this HKPI's result and the previous reporting period?

● Is there improvement or change?

● What caused the change in performance, and why did it happen?

● Has the goal been attained? What happened if the goal was not met, and why?

● Is there a need for this HKPI to be improved further?

● Is there any further information that needs to be gathered in order to learn more?

Is there anything else the RHB or other partners can do to help the hospital improve (e.g. training,
supervision)?

The HKPI data owner, in collaboration with the case team and other relevant colleagues, should
assess performance and suggest steps to enhance it. To handle performance monitoring and
improvement functions across the hospital, each hospital should have a performance review team
or Quality Unit and Quality Committee (QC). The quality committee should be multidisciplinary,
with members drawn from the hospital's clinical, administrative, and support units. The chair of
the committee or the head of the Quality Unit should work full time and report to the CEO as a
member of the hospital's senior management team. Roles of the Quality Unit include:

21
 1. Develop and deliver a hospital performance and/or quality management strategy for
approval to the Senior Management Team.

2. To establish and monitor an implementation plan for improving hospital performance

overall.

3. To ensure that performance management activities are in line with the hospital's vision and
goal, as well as its strategic and yearly plans.

4. To coordinate all actions aimed at improving hospital performance.

5. To encourage and support all employees' engagement in hospital performance

improvement efforts.

6. To collect and analyze input from patients, staff, and visitors.

7. Receiving clinical audit reports and keeping track of all clinical audit actions.

8. To review selected hospital deaths

9. To monitor HKPIs and HMIS indicator.

10. Conduct peer reviews in response to specific quality and safety concerns, and take
necessary action and follow-up when flaws are discovered.

11. Through cross-temporal comparisons, case team/department comparisons, and

comparisons with other health facilities, keep hospital staff informed about activities and
discoveries linked to hospital performance improvement.

3.6. Use of HKPIs by a Hospital Governing Board

The hospital CEO should present the Governing Board with hospital performance reports. The
report, together with the agenda and any other discussion materials for the Governing Board
meeting, should be circulated at least one week before the meeting. The Governing Board should
discuss the report, identifying areas of strength and weakness, and establishing a course of action
with detailed follow-up steps.

22
If the Patient Satisfaction Score is low or declining, the Governing Board might ask the CEO to
present the full results of the Patient Satisfaction Survey to see if there are any particular areas of
concern, as well as to describe the actions that the hospital will take to improve patient
satisfaction. Alternatively, if inpatient mortality is high or rising, the Governing Board could ask
the CEO if there are any factors that could explain this (such as a communicable disease outbreak)
or provide additional information on the mortality rate for each ward or specialty (e.g. surgical
mortality rate, pediatric mortality rate, etc.) to determine if there is a specific problem area.

Questions that Governing Board members should consider while analyzing hospital HKPI data
and discussing with the CEO include:

1. How does each HKPI stack up against the previous reporting period?

 If there has been progress, how did it happen? Should any staff employees or case
teams who are responsible for the improvement be given special recognition?

 Why has this happened if performance has worsened?

 How does each HKPI compare to the reporting period's target? Has the goal been
attained? Why not, if not?

2. In light of the HKPI findings, what actions should the CEO/hospital take?

3. What kind of support (e.g., training, supervision) is required by the RHB or other partners
to assist the hospital in improving?

3.7. Use of HKPIs by Regional Health Bureaus

RHBs should compare hospitals, monitor changes over time, and determine regional averages after
obtaining hospital KPI and EHSIG data and entering them into the Regional KPI and
EHSIG/DHIS2 Databases. The RHB should provide comments on the KPI reports to each
hospital, asking for clarification or more information as needed. The RHB should also use hospital
KPI data to highlight areas where the RHB should take action. KPI reports, in particular, should be
used as a source of information for hospital site visits and regional review meetings. When
examining individual hospital HKPI reports, the RHB should think about the same questions that

23
the Governing Boards should think about. In addition, the RHB should compare hospital
performance, particularly:

● Which hospitals are performing the best and/or worst?

● What are the region's special strengths and/or weaknesses?

3.8. Use of HKPIs by MOH/Medical Service-LEO

The regional focal person selected by the Medical Service-LEO is responsible for receiving reports
from all RHBs, reviewing them, and providing timely feedback to the regions. Using the electronic
national HKPI/EHSIG database or DHIS2, regional reports should be used nationwide to track
changes over time and compute national averages. Medical Service-LEO should ask the same
questions as RHBs when assessing regional HKPI reports. Medical Service-LEO should also
compare performance across regions, focusing on:

 Which regions are the most successful in terms of overall performance?

 Which ones aren't performing as well as they should?

 Which areas are gaining ground? Which areas are improving slowly or not at all?

 What are the strengths and limitations that all areas have in common?

Medical Service-LEO should provide comments on the HKPI reports to each RHB, asking for
clarification or more information as needed. In response to HKPI reports, Medical Service-LEO
should consult with the RHB first, so that a combined response can be issued to the hospital and
any follow-up action may be decided upon jointly by MOH and the RHB. HKPI reports, in
particular, should be used as a source of information for hospital site visits and regional and
national review meetings.

24
MODULE 1: HMIS INDICATORS

1.1. Out-Patient Attendance Per-Capita

Definition Number of outpatient department visits (days) per person per year.

Total number of outpatient visits

Formula
Total catchment population

Outpatient attendance shows the level of utilization of and access to outpatient

health care services. It reflects the interaction between demand and supply of
outpatient care. The use of outpatient services is inversely related to certain
barriers that may be physical, economic, cultural, (belief low awareness and
health care seeking behavior) or technical (poor quality of health care). It has
been demonstrated that OPD attendance visit goes-up when such barriers are
removed through bringing services closer to people and reducing user fees. It is
used to examine trends, variations, and use of service by type of facility and
health care services, geographic districts, and urban rural locations.

Every patient or client who visited any health facility including public, private,
non- governmental, and community-based health facilities for any service should
be included in OPD attendance report. Patients who attend the following services
should be INCLUDED in the outpatient count and should be counted once a day:
Interpretation
General outpatient clinics

Specialty outpatient clinics (including Dental, Ophthalmic and Psychiatry)

TB clinics

ART clinics

VCT clinics

MCH clinics (EPI, IMCI, well baby clinics, ANC, PNC, family planning etc)

Private wing clinics

Patients attending the emergency department

25
 Patients who attended services at dressing and injection room

Dis-aggregation Age, sex

Source Service delivery tally (for HP)/Central Card Room Register and patient
attendance tally ,Central and Emergency Triage registers

Reporting level Health Post/Health center/Clinic/Hospital/

Reporting Monthly
Frequency

26
1.2. Bed Occupancy Rate

Definition Percentage of available beds that have been occupied over a given period

Sum-total of the length of stay (in days) in the reporting period

Formula X100
(Number of beds available)X(Number of days in the period)

Bed occupancy rate (BOR) is calculated as a percentage of the number of beds

effectively occupied (bed-days) for curative care divided by the number of beds
available for curative care multiplied by the number of days in the period. It is a
measure of the efficiency of inpatient services. Hospitals are most efficient at a
BOR of about 85%. If the BOR is lower, resources may be wasted. If the BOR is
higher than 85% there is a danger of staff burnout, over-crowding, and shortage
of beds during sudden increases in demand for in-patient services during
epidemics or emergency situations. Higher BOR is usually associated with
reduced patient safety and privacy and is associated with an increase in rates of
in-hospital mortality. BOR could be sharply increased during epidemics or
emergency situations. In resource-limited situations, hospitals may admit patients
beyond their capacities and treat them by keeping them on the floor, trolleys and
stretchers and BOR could be raised beyond 100%. Measuring BOR helps
hospitals to determine inefficiencies or stresses in service delivery to investigate
and take action to address it, and also to plan for the future staff or other resource
requirements.

An operational (in-patient) bed includes beds for all components of curative care
of illnesses (including both physical and mental or psychiatric illnesses) or
treatment of injury), diagnostic, therapeutic, and surgical procedures; and
Interpretation obstetric services. It EXCLUDES beds in emergency room or emergency
gynecology departments, beds in day units or day surgery, temporary beds
(stretchers or trolleys, observation or recovery beds in the emergency
department, operating room or outpatient department, labor suite beds, delivery
beds or couches, examination beds for non-patients (e.g. beds for mothers
accompanying children), beds or cots for healthy babies who are born in the

27
 hospital or visiting the facility as accompany. Beds for rehabilitative care, long
term and palliative care should also be excluded.

The length of stay should ONLY be counted for the actual reporting period. If
a patient was admitted during a previous reporting period, their length of stay
during that previous reporting period should not be counted for the current
period. During calculation, INCLUDE patients admitted to both public and
private facilities.

Limitation: Comparing the performance of hospitals of the same level but with
different number of beds using BOR may be misleading. Hospitals with fewer
beds (fewer than the standard) can have higher BOR than hospital of the same
level (in the tier system) with higher number of hospitals

Dis-aggregation None

Source Inpatient admission/discharge (IPD) register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

28
1.3. Average Length of Stay (in days)

Definition The average length of stay (in days) of patients in an inpatient facility during a
given period of time

Total length of stay (in days)

Formula
Number of in-patient discharges

Average length of stay is a measure of health service quality and efficiency. It

reflects the appropriate utilization of inpatient services. By monitoring length of
stay, hospitals can assess if patients remain in hospital for longer than what is
necessary, perhaps due to non-clinical reasons, and investigate further if required.
The longer the patient stays at hospital, the greater the risk of developing health
facility-acquired infection, lower patient capacity of hospitals and increased
costs. Decreased ALOS has been associated with decreased risks of nosocomial
infections and side effects of medication rates, reduced burden of medical fees
Interpretation and increase the bed turnover rate and lowered social costs.

NB: If the patient is directly discharged or transferred to home or other facility

from ICU the length stay should be counted.

During calculation, discharge includes discharge due to any possible reasons

including death, referral, terminal, absconded, or death. Analysis by type of ward
is more informative for facility level analysis and pinpoint area of improvement.

Limitations: Regional or national level aggregation of ALOS may be less

informative to identify types of disease and wards with increased or lower
ALOS.

Dis-aggregation None

Source Inpatient admission/discharge register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly

29
 Fre quency

1.4. Hospital Bed Density

Definition Total number of hospital beds per 10, 000 population

Total number of functional beds in the hospital

Formula X 10,000
Total number of population

The indicator contributes to the measurement of facility infrastructure

management, such as physical availability and accessibility of health services. It
is a measure of access to hospital service, equity in access and inform plan for
possible expansion of hospital service. It excludes labor and delivery beds. The
Interpretation total population should consider all population that need to have access to
hospital service.

Limitations: the indicator shows access at a point in time. Because of catchment

population overlap at the lower level, the indicator could be exaggerated and
misleading at the lower level of health system.

Dis-aggregation None

Source Tally sheet/register at liaison/ward to capture the number of beds

Reporting level Hospital

Reporting Annually
Frequency

30
1.5. Assistive Technology Service Utilization

Definition Proportion of clients received AT service among those who sought AT service

Total number of clients received AT service

Formula X100
Total number of clients registered to receive AT service

This indicator measures the demand satisfied for AT by people with different

Interpretation types of dis- ability. It shows the inclusiveness of the health service to provide
technology services to the disabled to improve their quality of life.

Category of disabilities (Physical, mobility, hearing, others)

Dis-aggregation Age, sex

Source AT service register (New)

Reporting level Hospital

Reporting Quarterly
Frequency

1.6. Essential laboratory test availability

Definition The number of days in which all health center or hospital specific essential
laboratory tests

were available in the reporting period

Total number of days each essential laboratory tests are available in the
facility during the reporting period
Formula X100

(Total number of facility specific essential tests) X (Total number of

days in the

reporting period)

31
 Hospitals and health centers are required to avail the minimum laboratory tests
recommended by Food and Drug Administration standards at all times. The
availability of health facility specific essential laboratory tests is a measure of
service availability. Essential tests should ALWAYS be available at the health
Interpretation facility. If one of these tests is unavailable at any time, the health facility should
take action to identify and address the cause. For the RHB, knowledge of the
availability of health facility specific essential laboratory tests in hospitals helps
to assess the adequacy of access to laboratory tests and helps to address issues of
good governance. The list of essential laboratory tests at each level is annexed.

Dis-aggregation None

Source Excel based tally sheet(electronic)

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

32
1.7. Referral-out Rate

Definition Proportion of patients who are referred to another health facility

Number of referred patients (emergency + non- emergency)

Formula X100
Total number of OPD visits(emergency and regular OPDs)

A referral is the process in which a health worker at one level of the health
system, having insufficient resources (drugs, equipment, skills) to manage a
clinical condition, seeks the assistance of a better or differently resourced facility
at the same or higher level to assist in, or take over the management of the case.
An effective referral system ensures a close relationship between all levels of the
health system and helps to ensure people to receive the best possible care closest
to home.

Referral rate is an indicator of quality of health care. Referrals are systems that
are important for clients to receive the proper care they need in another health
facility. A high number and proportion of referrals made from a health facility to
another health facility may indicate that the health facility is not providing all
services required, whereas a low number and proportion of referrals might
Interpretation
indicate that the health facility is not following referral guidelines and is treating
patients beyond their capacity. Knowing the rate of referrals helps to plan for
future service provision.

A referral rate of a facility ranges from 10-20% and it should be interpreted

cautiously by taking expert’s suggestion into consideration. When referral rate is
below 10%, it indicates the need to conduct audit on professional scope of
practice to discern if the health facility is practicing health care delivery beyond
its scope. If the referral rate is above 20%, it signifies the need to identify the top-
five reasons for referral and consider expanding service.

Limitation: The indicator is more informative at the facility level and doesn’t
indicate reasons for referral-out.

Dis-aggregation Emergency and non- emergency

33
 Source Referral register/Liaison register, OPD tally sheet

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

1.8. Ambulance service utilization for referral service

Definition Percentage of referral-in with ambulance among the emergency referral-ins

Formula Total number of emergency referral-in with ambulance

X100
Total number of all emergency referral-in the reporting period

Interpretation This indicator shows the percentage of emergency referrals that used ambulance
to travel to the health facility and roughly measures the utilization of ambulance
service. Because this indicator doesn’t show the service quality, it should be
interpreted along with ambulance response rate, which shows the use of EMT or
nurse accompanying the emergency case. When calculating this indicator, all
referrals including referral-ins should be included in the denominator.

Referral In is defined as referrals coming from other facilities and those from the

Community

Dis-aggregation Pre-facility, between facility

Source Emergency register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

34
1.9. Ambulance service response rate

Definition Percentage of community ambulance requests for whom ambulance was

dispatched

Number of ambulance requests for whom ambulance was dispatched

Formula X100
Total number of community requests made for ambulance service

Pre-facility emergency care and ambulances service is an emergency care

outside of a health facility or at the scene and continuing care during
transportation with ambulance and ends with proper hand over of patient or
victim to respective health facility. When it is accessible to the community, it
contributes for reduction of deaths and disability due to acute illness and severe
injuries. A high response rate indicates the services the system’s
responsiveness and availability of services, and adequacy of the number of
ambulances. Low response shows demand and capacity gap. The target is more
than 90% of actual emergency call has to get ambulance dispatch for the
Interpretation service. The dispatch center where the register will be put could be different
and it should be placed in all centers where there are call and dispatching of
ambulances.

Limitation: This indicator doesn’t show the community demand for

ambulance service, as the community members who have awareness about the
service and who have the capability to make a call request ambulance services.

N.B. The number of Ambulance Requests includes all requests that are made
within the facilities and from the community. Data should be collected from
centralized call & dispatch centers, facilities, and/or woreda.

Dis-aggregation Labor & Obstetrics Emergency, Neonatal Emergency, RTA, Trauma, Non-
traumatic emergency, Burn & Poisoning

Source Ambulance service register

Reporting level Health center/Clinic/Hospital/ Woreda

Reporting Monthly
Frequency

1.10. Facility emergency department mortality rate

Definition Percentage of patients died at the emergency department within 24 hours

among all emergency attendances

Total number of deaths in emergency unit within 24 hours

Formula X100
Total number of emergency room attendances

The emergency department mortality is a measure of the quality of care

provided by the emergency department of the health facility within 24 hours of
arrival at the emergency room. A high mortality could indicate that the facility
is providing poor quality emergency care with unnecessary patient deaths
against national target. Nationally emergency room mortality should be less
than 0.6 %. The number of deaths within the facility in places other than
emergency room should be captured as absolute number can be used to see the
trend.
Interpretation
N.B. A Patient who is already dead on arrival should be excluded in the
indicator.

Dead on arrival means when the patient arrives to the triage area and
confirmed dead

by the physician.

Note that the crude number of death >24 hours is collected at all OPDs & IPDs
but not included in the calculation of this indicator. Crude data will be used to
assess the overall emergency care throughout the facility.

Sex: Male/Female

Dis-aggregation Age <15 years, 15+ years

< 24 hours, >=24 hrs

Source Emergency register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.11. Emergency room attendances with length of stay > 24 hours

Definition The proportion of all emergency room admissions who remain in the emergency
room for > 24 hours

Total number of admissions who remain in emergency room for more

than 24 hours
Formula X100

Total number of emergency room discharges (disposed)

Hospitals have emergency room beds where patients can stay for a short period
of time to receive emergency treatment. However, the length of stay (starting
from the 1st minute of triage) in the emergency room should always be less than
24 hours. If a patient requires treatment for longer than 24 hours, the patient
should be transferred to a ward. If emergency room beds are occupied by patients
Interpretation for more than 24 hours, then the emergency room will become congested and
there is a danger that the emergency room will not have the capacity to receive
any NEW emergency attendances.

The indicator includes all patients registered in the emergency room (of both
sexes and all ages) and excludes patients who were already dead (i.e. no vital
signs present) on arrival.

Dis-aggregation None

Source Emergency register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

1.12. Percentage of ventilator associated pneumonia

Definition The percentage of ICU clients who have developed ventilator associated
 pneumonia among those who were intubated for mechanical ventilation

Total number of clients developed ventilator associated pneumonia

Formula X100
Total number of ICU clients on ventilator

Ventilator associated pneumonia is one of the common complications that affects

the clients in the ICU. The probability of developing VAP of a patient in the ICU
Interpretation
depends on the skills of ICU staff to provide mechanical ventilation to patients
and it measures the quality of ICU service and determines the outcome of the
patient.

Dis-aggregation None

Source ICU register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.13. Mortality rate in Intensive Care Unit

Definition Percentage of patients who died in the ICU among those admitted to ICU

Number of deaths in ICU

Formula X100
Total number of discharges from ICU

Intensive Care Unit (ICU) service is an initiative to enhance critical care in

the Ethiopian health care delivery system. The ICU has to have at least 4-6
bed, along with cardiac monitors for each of the beds, and mechanical
ventilators. The ICU mortality rate helps to monitor the quality of care in the
ICU. Even though the number of beds in ICU of hospitals is few, it consumes
8% to 20% of the hospital’s budget.

The mechanical ventilator machine, without appropriate monitoring and

evaluation, has its own side effects including machine related baro-trauma,
infections, machine failure which is associated with serious effect to the
Interpretation patient. Death with mechanical ventilation means death of a patient after
mechanical ventilation was provided with endotracheal intubation. Death
without mechanical ventilation is death of a patient without being provided
with a mechanical ventilation using endo-tracheal intubation.

Though there is no known data about specific death related to conditions

associated with use of mechanical ventilator, according to WHO
recommendation, total mortality rate in ICU for developing countries lie
between 30% and 35%. If the general mortality rate is more than 35 %, it
needs investigation.

NB. This indicator doesn’t include Neonatal ICU death. In addition, discharge
should include the deaths as denominator. It should also exclude death at high
dependency units.

Limitation: the indicator could underestimate the mortality in the ICU as

patients who are not actually eligible for ICU may be admitted to the ICU

Dis-aggregation With vent, without vent,

 <24 hours, >=24 hours

Source ICU register

Reporting level Hospital

Reporting Frequency Monthly

1.14. Perioperative mortality rate

Definition All-cause death rate prior to discharge among patients having one or more
procedures for

a major surgery in an operating theatre during relevant admission for a major

surgery

Number of deaths among patients having one or more procedures in an

operating theatre admitted for major surgery
Formula X 100

Total number of patients for whom major surgery has been conducted

This indicator is rough measure of quality and safety of surgical service in the
facility. It includes all death that happen after anesthesia was provided to the
patient until discharge. The denominator for this indicator, which is the
number of major surgical procedures done per year is an indicator of met need
for surgical services. Ethiopia had the least surgical volume in the world [9].
With the high surgical need of the population, this indicator will show
progress across time towards meeting demand for surgical care services. It
informs policy and planning regarding met and unmet need for surgical
Interpretation service. It is a rough indicator of access to service [2]. Hospital procedure
volume is assumed to be a proxy measure of experience of doing surgeries
repeatedly over long period of time. There is a relation between volume and
outcome of surgeries, when the surgical volume of a hospital is very high and
surgeries are concentrated in high volume centers, it has been associated with
better outcomes. [10]. WHO estimates about 6495 operations per 100,000
populations per year are required in sub-Saharan Africa in which 95% of those
requiring surgical care do not have access to the service [11, 12].
 NB: Major surgery is defined as a procedure performed under general
anesthesia, regional

anesthesia or profound sedation in an operation theatre.

Dis-aggregation Elective, emergency

Source OR register, IPD register, Surgical ward register

Reporting level Hospital

Reporting Monthly
Frequency
1.15. Average length of ICU stay

Definition The average length of stay (in days) of patients in the ICU during a given period
of time

Sum total length of stay in ICU (in days)

Formula
Number of ICU discharges

The duration of ICU stays for clients that received care at ICU indicates the
quality of care at the ICU. Bed rest is considered as part the treatment for
admitted patients with critical illnesses. An average of 3.3 days of stay in an ICU
Interpretation
bed is considered adequate to provide adequate rest and treatment for critical
patients. A critical patient is expected to spend an additional 1.5 days in non-IUC
bed.

Dis-aggregation None

Source ICU register

Reporting level Hospital

Reporting Monthly
Frequency

1.16. Mean duration of in-hospital pre-elective operative stay

Definition The mean duration of in-hospital pre-elective operative stay in days

Total number of in-hospital pre-elective operative stay in days

Formula
Total number of elective surgeries conducted in the period

The mean duration of in-hospital pre-elective operative stay shows the length of
duration a patient spends in the hospital from admission to operation. It shows
the readiness of the surgical team and the facility within the acceptable duration.
Interpretation
 It is a proxy measure of cancellation of surgeries in that if there a higher
cancelation rate, the mean duration of in- hospital pre-elective operative stay will
be higher.

Dis-aggregation None

Source Surgical ward register

Reporting level Hospital

Reporting Monthly
Frequency

1.17. Number of clients in the waiting list for elective surgical service

Definition The number of clients in the waiting list for elective surgery

Formula The absolute number of clients in the waiting list for elective surgery

In countries where the access to surgical services is limited, hospitals usually

tend to have long list of clients waiting for surgical procedures. The number of
clients in the waiting list for surgery roughly measures access to surgical services
Interpretation
and can help to inform allocation of resources and finalize the plan. It shows the
backlog, demand for elective surgeries and the need for expanding surgical
services.

Age, <15 years, >=15 years

Dis-aggregation Service (General surgery, Urology , Neurology , Orthopedics, Plastic, Pediatrics,

Gynecology, Ophthalmology, ENT, Others

Source Register at liaison to capture

Reporting level Hospital

Reporting Monthly
Frequency
1.18. Delay for elective surgical admission

Definition The average number of days that patients who underwent elective surgery during
the reporting period waited for admission

Sum total of number of days between date added to surgical waiting list to date of
admission for surgery
Formula

Number of patients who were admitted for elective surgery

It is the average number of days between the dates each patient was added to the
waiting list to their date of admission for surgery. Delays in surgery for different
conditions are associated with a significant increase in morbidity and mortality.
The Government has set a stretch objective that any outpatient who requires a
bed should receive the service within 2 weeks. By monitoring the waiting time
for surgical admission, hospitals can assess the adequacy of surgical capacity and
identify the need for improved efficiency in systems and processes, and/or the
need for additional surgical staff and/or resources
Interpretation
EXCLUDE:

Elective Caesarean Sections

Emergency Surgery

Ophthalmic Surgery

NB: If a cold case patient is admitted on the same day (the same calendar date)
that the decision for surgery is made, then their number of days on the waiting list
should be counted as zero.

Dis-aggregation None

Source Surgical ward register, liaison register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.19. Inpatient mortality rate

Definition Inpatient deaths before discharge per 100 patients discharged

Number of inpatient deaths

Formula X100
Total number of discharges

Provides rough evidence regarding quality of care when compared with other
facilities. Care should be exercised, however. The level and location of a facility
may affect its case mix. The inpatient mortality rate is calculated as the number
Interpretation
of IPD deaths divided by the number of IPD discharges in the facility during a
given time period. The number of deaths can be known from the monthly totals
of IPD deaths reported. The inpatient mortality rate can be estimated at all levels
except Health Post.

Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66

Dis-aggregation Sex: Male, Female

Service Area

Source In-patient registers.

Reporting level HC/Clinic, Hospital

Reporting Monthly
Frequency
1.20. Top 10 causes of morbidity

Definition The ten leading causes of morbidity per 1000 population

Number of new OPD + IPD Cases from specific diseases

Formula X1000
Total population in the catchment area

Provides evidence regarding priorities for planning and resource allocation. The
top ten causes should be listed, from highest to lowest. The total number of cases
seen at OPD and IPD and the cases per 1,000 should also be included for
Interpretation comparison. This indicator may show the burden of specify diseases in the
community.

Note:-The numerator should include only those who are new cases so that a
person will not be counted more than once for the same illness/disease.

Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66

Dis-aggregation
Sex: Male, Female

Source Outpatient (OPD) registers, Inpatient register, Emergency register; Disease

information tally (HP)

Reporting level Not to be reported but to be analyzed

Reporting Annual but can be done at anytime

Frequency

1.21. Top ten causes of institutional mortality

Definition The ten leading causes of mortality

Number of deaths in a health facility from specific disease

Formula X100
Total number of discharge
 The top ten causes can be known from the annual totals of monthly IPD deaths
reported. Provides evidence regarding priorities for planning and resource
allocation. The top ten causes should be listed, from highest to lowest. The total
number of IPD deaths and the case fatality rate should also be included for
Interpretation comparison with other locations. While deaths are reported monthly, the top ten are
calculated annually, based on the sum of monthly totals. IPD death is death of a
patient who was alive when he/she came to the health facility and died afterwards.
Note that patients who died at arrival before admission/at emergency should not be
counted and include deaths from OPD, emergency, IPD, ICU and NICU.

Age: 0-4, 5-10, 11-19, 20-29, 30-45, 46-65, >=66

Dis-aggregation Sex: Male, Female

Source Outpatient (OPD) registers, Inpatient register, Emergency register; Disease

information tally (HP)

Reporting level Not to be reported but to be analyzed

Reporting Analysis Frequency (Any time)

Frequency
1.22. Supplier fill rate

Definition Supplier fill rate is the percentage of correctly filled items (at least 80%) by
quantity by supplier (EPSA, or other private supplier who have agreement to
supply) of total order made by a health facility over a given period.

Number of line item delivered at least 80% of the requested amount

Formula Total number of line item requested X100

This indicator measures supplier’s ability to fill orders completely in terms of

items and quantity during a definite period of time.

An item in an order is considered completely filled if at least 80% of the request

is filled in
Interpretation
the correct quantities with the correct products.

This indicator also helps health facilities to identify which items are causing the
most prob-

lems and find another mechanism for obtaining those items

By type of supplier: (EPSA, others), By category: RDF, Program

Disaggregation

Sources RRF report, Receiving voucher of HF, approved procurement request by DTC or
HF head

Reporting level Health center/Hospital/

Reporting
Frequency Quarterly
1.23. Essential Drugs Availability

Definition The number of months in which a tracer drug was available averaged over all
tracer drugs during the month

Number of tracer drugs available in all days of the

reporting month
Formula X 100
Total number of tracer drug specific for facility level

Essential drugs should always be available. Essential drug availability is the

proportion of months in the time period under consideration for which a given
tracer drug was available when needed. The availability can be averaged over
several tracer drugs to give a general picture of availability. The type of
essential drug that needs to be avail- able differs by type of health facility. The
following drugs are those essential drugs that are selected as tracers for
essential drug availability:

For Health Posts:

Amoxicillin dispersible tablet

Oral Rehydration Salts

Zinc dispersible tablet

Gentamycin Sulphate injection

Medroxyprogesterone Injection

Arthmeter + Lumfanthrine (Coartem) tablet (any packing)

Ferrous sulphate + folic acid

Albendazole tablet/suspension

For health centers and hospitals:

Medroxyprogesterone Injection

Pentavalent vaccine

Magnesium Sulphate injection

Oxytocine inj
Interpretation Gentamycin injection

ORS+/- Zinc sulphate

Amoxcillin dispersable/suspension/capsule

Iron + folic acid

Albendazole/Mebendazole tablet/suspension

TTC eye ointment

RHZE/RH

TDF/3TC/DTG

Co-trimoxazole 240mg/5ml suspension

Arthmeter + Lumfanthrine tablet

Amlodipine tablet

Frusamide tablets

Metformin tablet

Normal Saline 0.9%

40% glucose

Adrenaline injection

Tetanus Anti Toxin (TAT) injection

Omeprazole capsule

Metronidazole capsule

Ciprofloxcaxillin tablet

Hydralizine injection

Any month in which a drug unavailability is experienced, even for only 1 day,
is reported as a month in which the drug was unavailable when needed

Disaggregation No disaggregation

Sources This information is available from records kept at the facility drug dispensary

Reporting level Health post /Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.24. Percentage of encounters with an antibiotic prescribed

Definition The percentage of encounters with one or more antibiotics prescribed per
individual patient

Total number of encounter with one or more antibiotics

Formula X 100
Total number of encounter

This indicator measures the overall level of antibiotics use. Imprudent use of
antibiotics leads to antimicrobial resistance. The emergence and spread of
Antimicrobial resistance (AMR) continues to threaten the ability to treat
common infections and is becoming ever-growing concern in the healthcare
community. AMR can lead to treatments becoming ineffective and accelerate
the spread of infections. The cost of AMR to national economies and their
health systems is significant as it affects productivity of patients or their
caretakers through prolonged hospital stays and the need for more expensive
and intensive care.
Interpretation One of the major preventive intervention to curb antimicrobial resistance is
proper antibiotic prescription and utilization. Globally, only 20-30% of the
prescription for patient encounter should have antibiotic.

Encounter refers to every patient’s or client’s visit to the health facility.

Whether a patient is given one or more prescription papers per visit, all is
considered as one encounter.

Limitation: Those clients that are sent home with counseling and advice i.e.
without a prescription are missed

Disaggregation No disaggregation

Data Sources Drug dispensing Register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.25. Percentage of client with 100% prescribed drug filled

Percentage of clients who get all the prescribed medicines (100%) from the
health facility dispensary among all the clients who received prescriptions in a
Definition
given time period.

Number of client who received all prescribed drug

Formula X 100
Total number of client who received prescription

This indicator measures proportion of clients who get all the prescribed drugs
within the facility. It is one of the indicators that tell about continuous
availability of medicines. Getting prescribed drugs within the facility pharmacy
improves patient satisfaction and overall trust and confidence in the health
Interpretation sector.

It is expected that all clients should get all the prescribed drugs (100%) from the
health facility dispensary.

Disaggregation No disaggregation

Sources Drug dispensing Register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency
1.26. Percentage of medicines prescribed from the facility’s medicines list

Definition The percentage of medicines that are prescribed from the health facility
medicine list out of the total number of medicines prescribed

Total number of medicines prescribed from Health facility medicine

Formula list X100

Total number of medicine prescribed

Every health facility is expected to have a medicine list specific to the facility
based on its history of disease burden. This facility medicine list is revised
periodically to address emergence of new needs and change in disease pattern
in the facility.

Accordingly, health care workers are expected to prescribe medicine that are
Interpretation listed in the health facility. The more health care workers prescribe medicines
from the health facility list, the better chance that patients /clients get the
medicine and the more likely that patients get them for cheaper price. It also
prevents clients from frustration and improves satisfaction.

Monitoring this indicator regularly and taking corrective actions for any gap
identified

should be a major activity of health facilities

Disaggregation No disaggregation

Sources Drug dispensing Register

Reporting level Health center/Clinic/Hospital/

Reporting Monthly
Frequency

1.27. Pharmaceuticals wastage rate

 The percentage of the stock of products, in value, that are unusable because of
expiration or damage during a period to the total value of the products
Definition
received during the same period plus the quantity of the products found during
the beginning of the period

Unusable stock of products during a period in monetary value

Formula X100
Beginning stock+ received stock during the same period in monetary
value

This indicator can be calculated for any facility that manages pharmaceutical
of interest. It can be measured over any period but it is preferable to be
calculated for unusable stock with in a quarter. It is usually calculated after a
physical inventory is taken. Unusable stock that has been accumulated for
long period and were not disposed previously (expired and damaged items that

Interpretation were transferred from previous quarter) should not be included during
calculation of this indicator. In addition, items that were unusable during the
quarter reviewed but were disposed with in the quarter should be taken in to
consideration during calculation. This indicator is one of the performance
indicators to have efficiency gain, which is one of the HSTP priorities. The
target in HSTP is to reduce wastage of pharmaceuticals to less than 2%.

Disaggregation By: RDF, Program

Sources Bin cards/stock cards

Reporting level Health center/Clinic/Hospital

Reporting Quarterly
Frequency
1.28. PMS_EQUIP: Functionality of medical equipment

Percentage of functional medical equipment from the health facility’s

updated medical equipment inventory list
Definition

Number of functional medical equipment in the health facility

Total number of available medical equipment in the health facility

Formula from updated medical equipment inventory list X 100

This indicator measures percentage of functional medical equipment in the

health facility at the time of reporting. Functional medical equipment are
instruments which are giving the expected services. To monitor and evaluate
this indicator, the health facility should establish computer based or manual
medical equipment inventory system and also should update the inventory
whenever additions or omissions of medical equipment occur to the health
facility. Health facilities should use the Medical Equipment Inventory Form to
Interpretation
register medical equipment that is available in the health facility.

Medical equipment refers to a capital medical device used for specific purpose
of diagnosis and treatment of disease or rehabilitation following disease or
injury it can be used alone or in combination with any accessory consumable
or other devices requiring professional installation, user training,
commissioning, maintenance, calibration, decommissioning.

Disaggregation No disaggregation

Sources Facility medical equipment inventory

Reporting level Health center/Clinic/Hospital/

Reporting Annual
Frequency
MODULE 2: HSPMI INDICATORS

2.1. Percentage of Good governance index score

Definition Percentage of Good governance index

Formula Good Governance Index Assessment Score

The Good Governance Index is an important tool for measuring the extent to
which hospitals adhere to principles of good governance. It measures the status
of good governance of the hospital by reviewing those standards against the
good governance principles. The tool contains three thematic areas

1) Response to public grievance

2) Service Delivery and

3) Health Systems.

It is essential for building trust and ensuring the effective functioning of

institutions. Implementing GGI on the hospital changes the service quality in
remarkable way through creating accountability and engaging all health care
service stakeholders and actors.
Note: Good Governance Index (GGI) score > 80% is met and <80% is un met.
Interpretation GGI Score that did not conduct the assessment will be considered as having a
GGI value of less than 80%.
Dis-aggregation None
Data Source Good governance index measurement checklist, Annex 1
Unit of Percentage
measurement
Reporting Quarterly
Frequency
 2.2. Emergency room patients triaged within 5 minutes of arrival

Definition Percentage of all patients presenting to the emergency room who were
triaged within 5 minutes of arrival. It is a time from arrival to ER gate to
ER triage initiation. When we say EOPD it includes Pediatric, Adult,
Gynecology /Obstetrics, Emergency OPDs.

Number of surveyed patients who undergo triage within 5

Formula minutes of arrival in emergency room
X 100
Number of patients included in emergency room triage time
survey
Triage is a process of sorting patients into priority groups according to their
need and available resources. The aim of triage is to give priority treatment
to those with the most critical conditions, thus minimizing delay, saving
lives, and making the most efficient use of available resources. The first
five minutes of arrival in the emergency room (ER) is the most critical time
to save lives. If assessment and treatment is not initiated during this time
then lives will be lost unnecessarily.
By monitoring the % of patients triaged within 5 minutes the hospital can
assess whether ER services are sufficient and identify the need for
Interpretation
additional staff and/or resources and/or service redesign to reduce waiting
times in ER.
Protocol for survey to measure % of patients triaged within 5 minutes of
arrival in ER attached in Annex 2.
The survey should be conducted at 3 different time periods on the first
week of the final month of each reporting period as follows:
 Monday: 8am to 12 noon
 Wednesday: 12 noon to 5pm
 Sunday: 5pm to 8am
Dis-aggregation None
Data Source Survey – see Annex 2
Unit of Percentage
measurement
Reporting Quarterly
Frequency

2.3. Outpatient waiting time to Consultation

Definition Outpatient waiting time to consultation is an average time from arrival at

triage to physician first contact.

∑ total of outpatient waiting time(¿ minutes)

Formula
Number of outpatient “ waiting time cards ”completed

The time that a patient waits from arrival to treatment is a measure of

access to health care services. Long waiting times indicate that there is
insufficient staff and/or resources to handle the patient load or the available
resources are being used inefficiently. By measuring waiting time a hospital
can assess if there is a need for extra personnel, service unit expansion or
Interpretation
other resources in the outpatient department. It also helps to identify need
to review patient flow processes to increase the efficiency of service
provision.

The survey should be conducted on Monday and Thursday of the first week
of the last month of each quarter. The time can be further sub-divided in to
different service point (Triage to MRU, MRU to waiting area, &
waiting area to OPD) include in interpretation part. All OPDs like Medical,
Surgical ANC,FP, NCD etc should be included in survey.
EXCLUDE:
 Patients not seen on the same day

 Patients who have an appointment and who go immediately to the OPD

waiting area without attending registration or triage
Dis-aggregation Regular OPDs, Specialty Clinic
Data Source Survey – see the protocol in Annex 3
 Unit of Minutes
measurement
Frequency of Quarterly
Reporting

2.4. Timely Outpatient service initiation

Definition The percentage of outpatient rooms that initiated service exactly at the time
of government work starting time.

Number of outpatient examination rooms

Formula that started service timely
¿ X 100
Total Number of outpatient examination rooms

All outpatient examination rooms should start service to patients at the

government opening time. Timely initiation of services will contribute to,
reducing outpatient waiting time, and improving outpatient satisfaction. By
measuring timely outpatient service initiation, the hospital can assess if
Importance there are modifiable factors contributing to untimely initiation of services.
/Interpretation/
Note: The survey should be conducted on Monday and Thursday

OR market/ busy day and a less likely free day of a certain week of each
month. Responsible survey coordinator is an OPD director in collaboration
with Quality Unit officer.All OPDs like Medical, Surgical ANC, FP, NCD
etc should be included in survey.
Dis-aggregation Regular OPD, Specialty Clinic

Data Source Survey tool and tally sheet- See Annex 4

Unit of Percentage
measurement
Frequency of Monthly
Reporting
 2.5. Outpatients not seen on the same day
Definition Number of all outpatients were not seen on the same day of visit after
triage to the outpatient department
Sum total of outpatients were not seen on the same day with in the

Formula reporting period

Importance
All patients should be seen in the OPD on the same day that they register
/Interpretation/ for treatment. By measuring the number of patients that were not seen on
the same day. The hospital can assess if there is a need for extra
personnel and/or other resources in the outpatient department and/or to
review patient flow processes to increase the efficiency of service
provision.
Dis-aggregation Regular OPDs, Specialty Clinics
Data Source OPD Register, MR Register, Central Triage Register

Unit of Number
measurement
Frequency of Monthly
Reporting

2.6. Percentage of hypoxemic patients treated with oxygen

 Definition The percentage of hypoxemic patients who have treated with oxygen for any
disease

resulting hypoxemia as per the standard prescription.

 Standard prescription describes rational use of oxygen through

 Prescribed O2 at any time including at Dx and during stay (emergency,

IPD).

 State mode of delivery (Nasal prong, Nasal Catheter, Ventury Mask or

Face Mask)

 State flow rate, target saturation and mention frequency of monitoring

 Received O2 therapy and SPO2 monitored as prescribed

 O2 therapy stopped after at least two records of SPO2 >90%.

Number of survey patients with hypoxemia

who received oxygen treatment
Formula as per the standard X 100
Number of
All eligible patients for oxygen T reatment

Importance Oxygen is vital to combat any respiratory system related morbidity and
/Interpretation/ mortality. It is also useful in the treatment of many obstetric emergencies,
cardiac arrest, acute blood loss, shock, dyspnea, pulmonary edema,
unconsciousness, convulsions, and fetal distress.

NB. Assessing level of O2 saturation for all patients in central triage and
Emergency also regular checkup when V/S taken
Dis-aggregation Patient outcome, Department

Data Source For the survey use 50 hypoxic patients’ charts from different service areas (ER,
IPD, ICU, OR), If <50 all hypoxic patients charts should be audited . In
addition to this, patient chart should be triangulated with the following
formats : Triage forms, Order Sheet ,Vital sign sheet, Medication
 Administration sheet
Unit of Percentage
measurement
Frequency of Monthly
Reporting

2.7. Medical oxygen stock out rate

Definition Medical oxygen stock out rate is the percentage of oxygen stock out days at
facility among total days in reporting period.

Number of days with oxygen stock out .

X 100
Total number of days∈reporting period
Formula

Access to safe oxygen is essential for saving life. However, oxygen remains
under supplied In Ethiopia; alike many low- and middle-income countries
and often, patients who require oxygen for survival do not receive it.

The biggest challenge for health care supply chains is to manage inventory
of oxygen supply efficiently and keep up the satisfactory service level at the
Interpretation same time. As oxygen is essential supplies in medical industry, proper stock
management system will help to ensure the quality health service.

Oxygen is a drug registered in WHO list of emergency essential drugs, so

that it should be prescribed as per the standard prescription to secure its
rational use too.

Note: All hospitals should secure continuous and reliable oxygen source
and avail at selected treatment units throughout the year. Secure hospitals
with functional oxygen devices at selected across all health service delivery
units (Emergency, ICU, OR, Medical wards, Pedi ward)
Dis-aggregation None
Data Source Consumption record registration
Unit of Percentage
measurement
Frequency of Monthly
Reporting

2.8. Inpatient Medical Record Completeness

Definition Percentage of elements completed of the minimum elements of an
inpatient medical record.

The MINIMUM elements are*:

1. Patient Card (Physician notes) – present and all entries

signed

2. Vital sign Sheet – including BP, PR, RR, To, pain score and
Spo2

3. Progress note – documented at least once a day throughout

the hospital stay

4. Order Sheet – Present and revised daily

5. Nursing Care Plan – Present, revised at least daily; V/S taken

at least QID for all admitted patients

6. Medication Administration Record – present and all

medications given are signed

7. Discharge planning and Summary – present and signed

8. Clinical pharmacist recording charts present and signed

Formula
¿
∑ total of medical records checklist scores Yes
Number of discharged inpatient medicalrecords surveyed x 8 X 100 ¿
¿

Importance Complete and accurate medical records are essential to maintain

/Interpretation/ the continuity of patient care and ensure that the health provider
has full information about the patient when providing healthcare.
Through HMIS a standardized medical record has been
introduced nationwide. The completeness of this medical record is
a measure of the quality of care provided at the hospital.

Note: The checklist describes the MINIMUM set of documents

that should be present in the medical record of EVERY
discharged patient. Some inpatient records will contain additional
documents and forms (E.g., referral forms, laboratory report
forms etc) WHO Safe Surgery Check list (for major Surgeries …
etc)

However, for standardization of this indicator, 50 medical

records should be audited and only the items that are listed in the
checklist should be included in the survey.
Dis-aggregation None
Data Source Survey - See Annex 5
Unit of measurement Percentage

Frequency of Reporting Quarterly

2.9. Percentage of acceptable EQA result

Definition External Quality Assurance (EQA) acceptance involves comparing
the results generated by a laboratory to a known standard and
determining whether the laboratory's results fall within an
acceptable range. If a laboratory's results fall outside of the
 acceptable range, corrective action may be necessary to improve the
accuracy and reliability of the laboratory's testing process.

Total number of laboratory tests with

Formula
acceptable EQA results X100

Total number of EQA participated laboratory tests

EQA, or External Quality Assessment, is important because it helps

to ensure that medical laboratories are producing accurate and
reliable results. EQA programs involve sending samples to
participating laboratories and comparing the results generated by
Importance each laboratory to a known standard. This helps to identify any
/Interpretation/ potential errors or discrepancies in the testing process, allowing for
corrective action to be taken. Ultimately, EQA helps to improve the
quality of laboratory testing and ensure that patients receive
accurate diagnoses and appropriate treatment.

Dis-aggregation None

Data Source EQA program feedback report

Unit of measurement Percentage

Frequency of Reporting Quarterly

2.10. Percentage of laboratory tests completed within TAT

Definition TAT refers to the time it takes from when a patient's specimen is collected to
 when the laboratory test results are reported to the clinician.

Formula

Number of tests reported within TAT

× 100
Total number of Laboratory tests performed

Importance Monitoring TAT is essential for ensuring that patients receive timely and
/Interpretation accurate test results, improving laboratory efficiency, and meeting regulatory
and accreditation requirements.

NB: for patients requiring multiple tests at a time, TAT should be established
for each laboratory tests.

Disaggregation None

Data sources Daily laboratory TAT monitoring sheet.

Unit of Percent
measurement
Frequency of Monthly
reporting

2.11. Elective Surgical case cancellation ratio due to blood unavailability for
surgical patients

Definition The ratio of elective surgical cases which are referred or cancelled
because of unavailability of blood to major surgical procedures in
the reporting period.

Formula Total number of major surgical procedures

canceled or referred due to lack of blood

 Total number of elective procedures scheduled

Importance/Interpretation Timely access to blood is a factor in surgical morbidity and

mortality especially in obstetric and trauma care where hemorrhage
is a major cause of mortality.

Disaggregation None

Data source OR Register, Ward cancellation register

Unit of measurement Ratio

Frequency of reporting Monthly

2.12. Patients Receiving Rehabilitation Services

Definition Rehabilitation service is a specialized team focused on helping

patients recover lost function and regain independence after illness,
injury, or surgery. Using therapies like physical, occupational, and
speech therapy, the interdisciplinary rehab team works to restore a
patient's mobility, self-care abilities, communication skills, and
overall quality of life. The goal is to facilitate the patient's effective
transition from hospital back to their highest level of functioning.

Formula Total number of clients receiving rehabilitation services

Importance/Interpretation Provides information on the health condition groups and number of

cases receiving rehabilitation. This can be used for short- to
medium-term service planning (e.g. for personnel requirements).
Measuring rehabilitation service utilization is important for
improving the quality and efficiency of rehabilitation services and
ensuring that individuals in need receive appropriate care.
Disaggregation age group (<15 years; 15-65 years, >=65years)

Data sources Medical rehabilitation center/ hospital rehabilitation service register

Unit of measurement Number

Frequency of reporting monthly

2.13. Antimicrobial Stewardship Functionality Score

Definition Percentage of criteria fulfilled in the functionality of ASP in the health

facility

Formula Antimicrobial Stewardship Program (ASP) Functionality criteria

score

Interpretation This indicator measures the functionality of ASP within the health
facility. The main objectives of antimicrobial stewardship include
optimize the use of antimicrobials, promote behavior change in
antimicrobial prescribing and dispensing practices, improve quality of
care and patient outcomes, and save on unnecessary health care costs.

The facility is considered to have functional ASP if it meets ≥75% of

the criteria. Annex 6

Disaggregation None
Data Sources ASP functionality Assessment tool

Unit of measurement Percent

Frequency of Quarterly
collection/Reporting
 2.14. Anesthesia adverse outcome
Definition Percentage of surgical patients who experienced any of the following
during major surgeries:
1. Cardiac arrest
2. High spinal anesthesia
3. Inability to secure airway

- Cardiac arrest, defined as cessation of heart activity shown by: Chest

compressions being performed, Loss of femoral, carotid and apical pulse
accompanied by ECG changes

- High spinal anesthesia, defined as: Within 15 minutes after spinal

anesthesia is given, the patient loses sensation in their shoulders AND
needs positive pressure breathing assistance because the spinal
anesthesia reached above T4 level

- Inability to secure airway, defined as: Having to wake up the patient

due to failed intubation attempt OR cardiac arrest resulting from failed
intubation

NB: Major surgery refers to invasive operative procedures that involve a

significant incision, excision, manipulation, or suturing of tissue, usually
requiring systemic anesthesia, regional anesthesia or profound sedation
to allow the patient to tolerate the procedure.

Formula Number of surgical cases with anesthetic adverse outcome

during the reporting period
¿ X 100
Total number of major surgical procedures performed
¿∨duringthe reporting period

Interpretation A large component of the difference in mortality after surgery between

developed and LMIC is caused by differences in anesthesia mortality.
The rate of anesthetic adverse outcomes assesses the safety and quality
of anesthesia service and drive continuous improvement in surgical
practices and patient care.
 Disaggregation None

Data sources Anesthesia Register/ OR log book

Unit of measurement Percent

Frequency of Monthly
reporting

2.15. Elective Surgical Cases Treated within clinically recommended Time

Definition The proportion of patients who received elective surgery and were
treated within the clinically recommended time for their urgency
category. Elective surgery patients treated are those who were registered
on a surgical waiting list as a category 1, 2 or 3, with a surgical
specialty, and were removed because they received their surgery as an
elective or emergency patient. The waiting time is calculated as the
difference between the date the patient was placed on the waiting list
and the date the patient was removed from the waiting list, excluding
any periods the patient was not ready for surgery and any periods that
the patient was waiting at a less urgent category than their category at
Removal

Category 1: Procedures that are clinically indicated within 30 days.

Category 2: Procedures that are clinically indicated within 90 days.

Category 3: Procedures that are clinically indicated within 365 days

(check elective surgical waiting list management guideline of Ethiopia,
2023)

Formula number of patients who received elective surgery at

recomended time
( Category 1+Category 2+Category 3 )
¿ X 100
Total number of patients who received elective surgery

Importance/ This indicator will help to assess if patients are being treated based on
interpretation their urgency level. It will help to know if there is a delay in treatment of
 patients while they are in need of surgery

Disaggregation Category1, Category2, Category3

Data sources Liaison register and OR register

Unit of measurement Percent

Frequency of Monthly
reporting

2.16. Major Elective Surgeries Performed

Definition Percentage of major elective surgeries performed out of those who are
on waiting list

Formula Total number of major elective surgeries performed

×100
Number of patients on waiting list

Importance/interpretation This indicator will help to measure how many surgeries are being
performed out of those who are waiting for surgery. It will show if the
surgical service is meeting the demand of clients. Clearance rate of the
waiting list.

Disaggregation Across all departments providing major elective surgical services

exclude all ophthalmic surgeries and C/S

Data source Liaison and OR registers

Unit of measurement Percent

Frequency of reporting Monthly

 2.17. Safe Surgery Checklist Utilization

Definition Percentage of surgical cases where the WHO safe surgery check list was fully
implemented

Formula Number of surgical patient charts∈ which the

WHO Surgical Safety
Checklist was completed
¿ X 100
Total number of patient charts reviewed

Importance/ Safe surgery checklist a safety checks that could be performed in any operating
interpretation room. It is designed to reinforce accepted safety practices and foster better
communication and teamwork between clinical disciplines. The Checklist is
intended as a tool for use by clinicians interested in improving the safety of
their operations and reducing unnecessary surgical deaths and complications.
This is an important aid to ensure patient safety.

Disaggregation Elective and Emergency surgeries

Data source Survey 50 patient charts across all departments; if less from 50 use all charts
within the reporting period

Unit of Percent
measurement

Frequency of Monthly
reporting

2.18. Major OR Table Efficiency

Definition Number of surgeries performed in every surgical table per day.

A minimum of 3 major surgeries per table per day is expected.

Formula ∑ total number of major elective surgical
procedures conducted
¿
Total number of major elective∨tables∗Total number of days∈the
reporting period

Importance/ This indicator plays a critical role in maximizing resource usage through
interpretation monitoring OR table efficiency; it facilitates enhanced scheduling and
surgical planning, fostering improved procedural coordination and a
more efficient workflow. This contributes to better patient care through
decreased wait times, effective cost management, and an evaluation of
the surgical suite's overall performance.

Disaggregation Each available OR tables for facility level except emergency OR tables &
minor OR tables

Data sources OR Registry

Unit of measurement Ratio

Frequency of reporting Monthly

2.19. Percentage of Surgical Site Infection

Definition Surgical site infection is defined as an infection that occurs in site of

surgical wound after 48 hours of surgery, within 30 days after the
operation or within 1 year if implant left during operation. It involves
the skin and subcutaneous tissue (superficial), and/or fascia/ muscle
(deep), and/or organs or spaces other than the incision that was opened.
(HAI Surveillance guideline, 2023)

Formula Number of Surgical Site Infections

X 100
Total Number of Surgical Procedures performed

Importance/interpretation The importance of measuring surgical site infection (SSI) rate is to

 monitor and evaluate the effectiveness of infection control measures
in healthcare facilities. The SSI rate is an important indicator of the
quality of surgical care and helps healthcare professionals monitor
and identify areas for improvement in infection prevention and
control practices

Disaggregation Departments providing surgical services

Data sources OPD register, IPD register, emergency register, ICU register, NICU
register

Unit of measurement Rate

Frequency of reporting Monthly

2.20. Percentage of Reimbursed Costs

Definition This refers to the proportion of money paid back (reimbursed) to the
hospital out of the total costs incurred in providing health services
on post payment basis such as services for health insurance
beneficiaries, other credit services and exempted health services out
of the total expenditure the hospital incurred to provide these
services.

Reimbursed costs are expenses incurred by an individual or

organization that are later compensated or repaid by another party.
Reimbursement typically occurs when a party incurs expenses on
behalf of another party, such as an employee making a business
expense or a healthcare provider conducting a medical procedure.
The individual or organization that incurs the expense can then
submit a claim for reimbursement to the other party, who will pay
 back the incurred costs.

Formula Reimbursed amount of spending ¿ t he hospital ¿

Total amount of spending requested ¿

Importance/interpretation There is no health care service provided for free. In one way or another
amount of money that the health facility spent should be reimbursed.
Costs incurred for exempted health services should be covered by the
government or by the development partners; costs for insurance
beneficiaries by health insurance schemes, and costs of credit services
must be covered by the third party.

Currently health insurance programs are expanding and out of pocket

payment is being replaced by post-payment. Furthermore, hospitals
are covering cost of exempted health services from internal revenue
as adequate budget is not allocated and/or there is no adequate donor
funding to cover costs of these services. Therefore, hospitals should
improve their data capturing system to record accurate service and
cost data; conclude strong agreement with the concerned paying
bodies, make timely reimbursement requests, and closely follow up
actual reimbursements. Thus, this indicator helps hospitals to improve
their data capturing system, to device mechanisms for new payment
arrangements, and take timely corrective action. It also provides
information to formulate alternative policy options.

Disaggregation CBHI, SHI, Free, exempted, 3rd party payment (Road Traffic Accident

Data sources Financial statements, audit reports

Unit of measurement Percent

Frequency of reporting Quarterly

 2.21. Percentage of Imaging Service Interruption Days
Definition Percentage of imaging services interrupted out of all existing imaging services in
the hospital during the reporting period.
Total number of days each imaging service is interrupted in the
facility during the reporting period
Formula x 100
(Total number of existing imaging services in the facility x Total
number of days in the reporting period)
When imaging service interruptions occur for various reasons, they can lead to
Interpretation
delays in patient care, increased costs, and potential harm to patients if crucial
diagnostic information is missed. Healthcare facilities can identify patterns and
trends and prioritize action points or repairs by measuring the percentage of
imaging service unavailability due to equipment failure, professional
unavailability, etc.
A high percentage of unavailable days may indicate equipment maintenance
needs, staffing shortages, or operational inefficiencies. Conversely, a low
percentage suggests a well-functioning imaging service.
Expected Imaging Services:
 Ultrasound, X-ray, MRI, CT scan, and mammography (based on hospital
tire level standard).
Existing service means:
 Those hospital imaging services that were announced to the public
Dis-aggregation Type of imaging service
Unit of
Percentage
measurement
Source Imaging service interruption record format (Annex XX)
Reporting Monthly
Frequency

2.22. Percentages of Pathology Service Interruption Days

Definition Percentage of pathology tests interrupted out of all existing pathology services in
the hospital during the reporting period.
Total number of days each tests service is interrupted in the facility
during the reporting period
Formula x 100
Total number of existing pathology services in the facility x Total
number of service days in the reporting period
Pathological service interruptions occur for different reasons, leading to delays in
Interpretation
 patient care, increased costs, and potential harm to patients if crucial diagnostic
information is missed. By measuring the percentage of pathology service
interruptions due to equipment failure, professional unavailability, etc, healthcare
facilities can identify patterns and trends and prioritize action points or repairs as
necessary.
A high percentage of unavailable days may indicate equipment maintenance,
staffing shortages, or operational inefficiencies. Conversely, a low percentage
suggests a well-functioning imaging service.
Expected Pathology services like:
 FNAC, Cytology, PAP Smear, Biopsy, etc. (based on hospital tire level
standard).
Existing service means:
 Those hospital pathology services that were announced to the public
Dis-aggregation Type of pathology tests
Unit of
Percentage
measurement
Source Pathology test interruption record format (Annex xxx)
Reporting
Frequency Monthly

2.23. Percentage of imaging service completed within TAT

Definition Percentage of imaging services completed and reported within a pre-established

specified time frame.
Number of imaging services completed within TAT
Total number of imaging services given during the reporting period x 100
Formula
Turnaround Time (TAT) is the duration between when an image is taken in the
Interpretation
service unit and when the result is reported to the ordering healthcare provider or
the patient. Meeting TAT is crucial because it ensures timely diagnosis and
treatment of patients. Delays in obtaining test results can increase morbidity,
mortality, and healthcare costs. This measure assesses the efficiency and
 effectiveness of the imaging service unit and its ability to provide high-quality
patient care. If the proportion of imaging services completed within TAT is low, it
may indicate a need to identify and address bottlenecks and inefficiencies in the
service unit workflow to improve TAT and patient care.
Dis-aggregation Type of imaging services
Unit of
Percentage
measurement
Source Imaging TAT registration book/form
Reporting
Frequency Monthly

2.24. Percentage of pathology tests completed within TAT

Definition Percentage of pathology tests completed and reported within a pre-established
specified time frame.
Number of pathology tests completed within TAT
Total number of pathology tests performed during the reporting x 100
Formula
period
TAT is the time it takes from receiving the specimen in the laboratory to reporting
Interpretation
the test result to the ordering healthcare provider or the patient. Meeting TAT is
important because it helps ensure timely diagnosis and treatment of patients.
Delays in obtaining test results can increase morbidity, mortality, and healthcare
costs. This measure can be used to assess the efficiency and effectiveness of the
pathology laboratory and its ability to provide high-quality patient care. If the
proportion of imaging services completed within TAT is low, it may indicate a
need to identify and address bottlenecks and inefficiencies in the service unit
workflow to improve TAT and patient care.
NB: this KPI is expected only for those who have pathology service in their
hospital
Dis-aggregation Type of pathology tests
Unit of Percentage
measurement
Source Pathology TAT registration book/form
Reporting Monthly
Frequency

2.25. Percentage of Medical Devices Repaired

Definition The percentage of medical devices repaired in the healthcare facility based on
maintenance request work order.
Percentage of medical devices repaired in the healthcare facility based on
maintenance request work order is a KPI that measures the proportion of medical
devices that have been successfully repaired in the healthcare facility, as per the
maintenance request work order.
Total number of medical devices repaired in the reporting period
Total number of MD maintenance Request in the reporting period 100%
Formula
This indicator measures the health facility’s capacity and responsiveness in
Interpretation
repairing medical devices. Both maintenance requests and activities performed
should be recorded. The HTMU expected to respond immediately.
Dis-aggregation None
Unit of Percentage
measurement
Source Maintenance report sheet, work order request, MEMIS
Reporting Quarterly
Frequency

2.26. IPC FLAT Score (IPC-FLAT)

Definition The IPC-FLAT Score serves as a comprehensive assessment tool for hospitals to
evaluate and improve their Infection Prevention and Control (IPC) practices,
ensuring safe healthcare services for patients and staff.
Total sum of each domain percentage
Formula Total number IPC-FLAT domains
Importance The IPC FLAT Score (IPC-FLAT) is an important indicator for hospitals to
/Interpretation/ assess their overall Infection Prevention and Control (IPC) practice
continuously and periodically every three months at the facility level. The IPC
assessment tool is designed for use in hospital settings to evaluate the system
and capacity of IPC for safe healthcare services, assess the compliance of
healthcare workers to IPC standards and practices, aid in the development of
work plans for improvement, and monitor the progress of IPC quality
improvement activities over time
The tool has 22 domains, which can be divided into two main categories:
1. 1. Section I Facility IPC Capacity and System (Domains 1-8): This section
 addresses high-level IPC systems and capacities within the hospital.
2. Section II IPC Practices and Compliances to IPC standards by healthcare
workers (Domains 1-14): This section includes routine IPC practices of
healthcare workers, considering the IPC standards and priorities.
To interpret the IPC-FLAT Score, hospitals can categorize the scores into four
distinct levels
 Inadequate (0-25%): Indicates a lack of basic IPC practices and
infrastructure.
 Basic (26-50% points): Indicates a basic level of IPC practices and
infrastructure, but with some gaps and areas for improvement.
 Intermediate (51-75% points): Indicates a more developed IPC program
with improved practices and infrastructure, but still with some gaps and
areas for improvement.
Advanced (76-100% points): Indicates a comprehensive and well-structured
IPC program with high-quality practices and infrastructure, with minimal gaps
and areas for improvement.
Dis-aggregation EACH domain score (IPC Program, IPC guidelines or standard operating
procedures (SOPs), IPC education and training, Health care-associated
infection (HAI) surveillance, Multimodal Strategies, Monitoring/audit of IPC
practices and feedback, Workload, staffing and bed occupancy, Built
environment, materials and equipment for IPC, Appropriate Personal
Protective Equipment (PPE) Use, Hand Hygiene (HH) Practice Compliance,
Transmission-based Precautions Adherence, Instrument Reprocessing,
Environmental Cleaning, Adherence with Injection Safety Practices, Facility
Design and Patient Flow Management, Processing reusable textiles and
laundry services, Food and Water Safety, Waste Management and Sharps
Disposal, Healthcare Workers Safety, IPC in Mortuary, Outbreak Preparedness
and Response, Environmental cleanliness and safety)
Unit of Percentage
measurement
Source Survey/Assessment tool
Reporting Quarterly
Frequency

2.27. Pressure sore incidence

Definition Proportion of inpatients that develop a pressure ulcer during their hospital stay.

Number of inpatients who develop a new pressure

Formula ulcer during the reporting period
100%
Number of patients discharged (alive, transfers out
and deaths) in the reporting period
Importance A pressure ulcer is localized damage to the skin and/or underlying tissue,
/Interpretation/ usually over a bony prominence. It arises in areas of unrelieved pressure
(commonly sacrum, elbows, knees or ankles). Either of the following criteria
should be met:
 A superficial break in the skin (abrasion or blister) in an area of
pressure OR
 An ulcer that involves the full thickness of the skin and may even
extend into the subcutaneous tissue, cartilage or bone
Pressure ulcer is a health problem worldwide that is common among
inpatients and elderly people with physical-motor limitations. To deliver
nursing care and prevent the development of pressure ulcers, it is essential to
follow the incidence regularly. This indicator aims to conduct timely pressure
ulcer incidence, to evaluating and continuous improving nursing care quality.
INCLUDE:
 New pressure ulcers that arise during the patient’s admission, during
the reporting period
EXCLUDE:
 Pressure ulcers that were already present at the time of admission
 Pressure ulcers that developed in a previous reporting period
Dis-aggregation Inpatient departments, ICU
Unit of
Percentage
measurement
Source Inpatient & ICU Register
Reporting Monthly
Frequency

2.28. Percentage of women who died from Post-Partum Hemorrhage

Definition Women who developed PPH and died

Number of women who died from PPH

Formula
Total number of women who gave birth in the facility 100%
referred-in or on arrival who developed
PPH in the reporting period
Importance Post-Partum Hemorrhage (PPH) is commonly defined as blood loss exceeding
500 milliliters (ml) following vaginal birth and 1000ml for Cesarean Section.
/Interpretation/
Patients with PPH require aggressive measures to restore and maintain the
circulating blood volume (and thereby perfusion pressure) to vital structures. All
medical units involved in the care of pregnant women must have a protocol for the
management of severe obstetric hemorrhage.
Dis-aggregation Spontaneous Vaginal Deliveries, instrumental & assisted deliveries, Cesarean
section
Unit of Percentage
measurement
Source Delivery, Postnatal ward, ICU, OR, Emergency registration book
Reporting Monthly
Frequency

2.29. Births by instrumental or assisted vaginal deliveries

Definition Number of births by instrumental or assisted vaginal deliveries per 100 deliveries
attended in the hospital.
 Number of instrumental or assisted vaginal deliveries

Formula Total deliveries (number of live births, 100%

still births attended in the hospital

Interpretation The instrumental delivery rate is a percentage that indicates the proportion of
births requiring the use of instruments or assistance during vaginal delivery,
such as forceps or vacuum extraction. A higher instrumental delivery rate may
suggest a higher frequency of assisted deliveries in comparison to the total
number of deliveries attended, highlighting potential areas for further
examination of maternal health practices during childbirth. This indicator
provides insights into the prevalence of assisted deliveries and contributes to
assessing maternal health outcomes during childbirth.
Exclusion:- Vaginal tear and Episiotomy.
Dis-aggregation Type of instruments
Unit of Percentage
measurement
Source Delivery registration book
Reporting Monthly
Frequency

2.30. Patient satisfaction score

Definition Proportion of “neutral and satisfied” client responses among all clients surveyed
in the specified period.
[Total number of "Neutral" response + Total number of "Satisfied"

Formula response]
X 100%
[Total number of patient satisfaction survey completed ×
Total number of patient satisfaction criteria's evaluated]
Importance Patient satisfaction with the health care they receive at the hospital is a measure of
/Interpretation/ the quality of care provided. By monitoring patient satisfaction hospitals can
identify areas for improvement and ensure that hospital care meets the
expectations of the patients served. Patient satisfaction survey tool have been
 developed for use in Ethiopian health facilities. These survey tool measure the
patient experience related to service availability, cleanliness, communication,
respect, medication (prescription, availability and patient information) and cost in
OPD, IPD, maternity and emergency departments. See Annex 7

Dis-aggregation Outpatients, MCH, Emergency, Inpatients

Unit of Percentage
measurement
Source Survey – protocol for the patient satisfaction survey is presented in Appendix xxx.
A minimum of 120 patient (30 from each of departments; OPD, IPD, maternity
and ED). Data entry and analysis can be undertaken using the electronic Access
database and Excel pre-programmed analytical tool through which summary
tables, charts and the average satisfaction rating can be calculated.
Reporting Quarterly
Frequency

2.31. Staff satisfaction score

Definition Proportion of “neutral and satisfied” staff responses among all staffs surveyed
in the specified period.
[Total number of "Neutral" response + Total number of

Formula "Satisfied" response]

100%
[Total number of staff satisfaction survey completed × Total
number of staff satisfaction criteria evaluated]
Importance There is a definite link between employee attitudes and patient satisfaction. If
/Interpretation/ employees are unhappy or dissatisfied, despite their best efforts, it is difficult
for them to conceal this factor when interacting with patients and other staff
members. Not only is it important in terms of quality of patient care, assessing
employee satisfaction is a critical component in retaining qualified health
professionals. Many health care providers feel frustrated and disillusioned in
 jobs they expected to find fulfilling. They have less time to do a quality job of
caring for patients; they are continually expected to cut corners, but see waste
and feel unable to change the situation; they feel unappreciated and they feel
their skills are underused. This leads to low morale, staff turnover, and overall
disenchantment with job opportunities in health care.
One of the primary reasons for evaluating employee satisfaction is to identify
problems and try to resolve them before they impact on patient care and
treatment. See Annex 8
Dis-aggregation By profession
Unit of Percentage
measurement
Source Survey
Reporting Quarterly
Frequency

2.32. EHSIG Score

Definition Ethiopian Hospitals Service Improvement guideline (EHSIG) implementation

status score
Total sum of each chapter percentage

Formula Total number of EHSIG Chapters(23)

Importance All hospitals are expected to implement the Ethiopian Hospitals Service

/Interpretation/ Improvement Guideline (EHSIG). It offers significant benefits to hospitals by

providing a national framework for quality improvement in healthcare,
fostering a culture of continuous improvement, and being responsive to the
evolving needs of public hospitals in the country. It has 23 chapters, and all
tier-level hospitals are expected to comply with all of it and report the
implementation status percentage of each chapter.

Dis-aggregation HLMG, LRS, Emergency, Medical RMx, Outpatient service, Inpatient,

Nursing care, Pediatrics and child health, Maternal newborn RH and
Midwifery service, Surgical and anesthesia, Specialty and subspeciality,
Rehab, palliative care, Pharmacy, Laboratory, IPC, Teaching and Affiliated,
 Health care technology, Hospital infrastructure and asset, Human resource,
Health financing, Health Services quality, Hospital performance M&E

Unit of Percentage
measurement
Source EHSIG database

Reporting Quarterly
Frequency
MODULE 3: POOL INDICATORS

3.1. Blood Product Wastage Rate

Definition Blood wastage is the proportion of blood and blood products

disposed before used due to different reasons; such us Expired
blood, improper storage, improper transportation, wrong handling,
pediatrics transfusion of adult sized blood packs, etc.

Formula

¿ Total wasted amount of blood∧blood products

¿¿

Importance/ Helps to manage blood products carefully and ensure that they are
interpretation used before their expiration date. By reducing the blood wastage
rate, we can ensure that more patients receive the blood
transfusions they need.

Disaggregation By blood type

Data sources Mini blood bank record

Unit of measurement Percent

3.2. Number of palliative Patients Seen

Definition Total palliative care patients seen at the facility's hub/unit, supporting patient
care until end of life
 Formula Total number of patient seen on palliative service wing

Importance/ Tracking access to palliative care at this facility supports internal

Interpretatio improvement efforts and care delivery.
n

Disaggregation None

Data sources Palliative care registration book

Unit of Number/ Count

measurement

3.3. Pain Assessment Performed as 5th Vital Sign

Definition Pain assessment is a critical first step in managing pain effectively. It measures the
presence, location, intensity, quality, onset/duration and factors that relieve or exacerbate
pain. Assessing pain thoroughly informs treatment plans tailored to individuals. Key
components include:

- Using validated scales like the 0-10 numerical rating for patient self-reported intensity

- Identifying pain type - acute or chronic;

- Determining disease/injury related factors versus independent pain

- Monitoring effects of analgesia and side effects

- Documenting at appropriate intervals as 5th vital sign

Standard techniques should be utilized consistently across patient encounters.

 Formula Patient Charts with completed pain assessments
¿ X 100
Total Surveyed patient charts

Importance/ Pain assessment represents a vital sign for ethical, patient-centered care. Inadequacy
Interpretation often stems from attitudinal barriers rather than resource limitations. Patients cannot
receive appropriate treatment without thorough evaluation of their pain experience
across physical, psychological and situational domains. Undertreated pain creates
immense burdens through reduced function, mental health issues and extended
hospital stays or readmissions.

This indicator tracks facility-wide integration of evidence-based pain assessment

principles. It helps determine the percentage of patients whose pain is managed per
best practices through comprehensive analysis guiding targeted relief. Higher scores
indicate appropriate priority placed on alleviating suffering for all. Progress over time
and comparisons to benchmarks can reveal areas needing improvement regarding
assessment standards, consistency, documentation or ineffective assessment-analgesia
gaps.

Disaggregation Departments

Data sources Survey (take 50 random patient cards from all service delivery areas)

Unit of Percent
measurement

3.4. Pain Management per WHO Standards

Definition Percentage of facility's pain patients managed using WHO analgesic ladder, which
provides standards for pain relief.

Formula Number of patientsmanaged pain by WHO analgesic ladder

¿ X 100
Total number of patients those who have pain scored ∈reporting period
 Importance/ Ensures pain relief available at the facility per best practices. Allows identifying
Interpretation areas for improvement. Studies have shown that following the WHO analgesic
ladder can improve patient outcomes, reduce hospital stays, and improve quality
of life.

Its three steps are: Step 1 Non-opioid plus optional adjuvant analgesics for mild
pain; Step 2 Weak opioid plus non-opioid and adjuvant analgesics for mild to
moderate pain; Step 3 Strong opioid plus non-opioid and adjuvant analgesics for
moderate to severe pain.

Annex 7: WHO analgesic ladder

Disaggregat Departments
ion

Data sources Survey (take 50 random patient cards from all service delivery areas)

Unit of Percent
measurement

3.5. Palliative Home-Based Care Linkage

Definition Home-based care refers to continued palliative care services provided in a patient's
home after discharge from the hospital. This includes symptom control,
psychosocial support, health communication, and coordination of care to improve
quality of life for patients and families facing serious chronic or terminal illnesses.

Specifically, a multidisciplinary team works with the patient at home to provide

pain and symptom management, counseling, nutrition advice, wound care,
education, and other services - allowing the patient to remain comfortable and
 retain independence in familiar surroundings for as long as possible

Formula ¿ Number of patientslinked ¿ HBC after discharge ¿

Total Number of discharged patients illi

Importance/ This indicator tracks the percentage of palliative patients successfully referred to
Interpretation structured home-based care programs after discharge. Seamless care continuity
between hospital and home is essential for this vulnerable population.
Compassionate support maximizes function and minimizes crises prompting
repeat hospitalizations.

Home-based services allow patients to preserve dignity and relationships at the

end of life while receiving specialized medical care. They significantly reduce
symptoms, caregiver burden and costs for those with complex needs. Monitoring
linkages informs efforts to expand community capacity and reach more patients
with sustainable solutions.

Disaggregation None

Data sources Patient Cards/Registration book

Unit of measurement Percent

3.6. Availability of Drugs and Supplies for Pain and Palliative Care Service

Definition The percentage of essential pain and palliative care drugs and supplies that are
available out of the identified list required for pain and palliative service
provision.

Number of essential pain∧palliative care drugs / supplies available

¿ X 100
Total Number of essential pain∧palliative care drugs / supplies
Formula

Importance/ Availability of essential pain and palliative care medications and supplies is critical
 Interpretation for effective pain management and palliative care service provision. Tracking
availability helps identify gaps and take measures to improve access to these
essential items. Annex 8 Pain and palliative list of supplies

Disaggregation None

Data sources Supply chain management

Unit of measurement Percent

3.7. Functional improvement of rehabilitation clients

Definition This indicator measures the proportion of clients who achieved

functional improvement after receiving rehabilitation services.
Functional improvement refers to an increase in a client's ability to
perform daily activities or tasks related to their work or social roles,
such as dressing, grooming, bathing, cooking, or driving. Functional
improvement can be influenced by various factors, such as injury,
illness, aging, or disability. Functional improvement can be assessed
using standardized tools that evaluate an individual's performance of
specific activities. The aim of rehabilitation services is often to enhance
functional improvement and enable an individual to carry out daily
activities and participate fully in their social roles.

Formula Number of clients who achieved functional improvement after

receiving rehabilitation services among discharged /referred clients
¿
Total number of rehabilitation clients discharged∨¿ referred other facilities∈the reporti
¿

Importance/ This indicator is important for evaluating the quality and effectiveness of
Interpretation rehabilitation services and ensuring that clients receive suitable,
individualized care that meets their needs and goals.

Disaggregation None

Data sources Medical rehabilitation center/ hospital rehabilitation service register

Unit of measurement percent

3.8. Rehabilitation Service Utilization

Definition This indicator measures the percentage of cases accessing

rehabilitation services categorized by health condition group (i.e.
musculoskeletal, neurological, sensory, and others) among registered
clients who come with inter- and intra-referrals.

Formula Number of clients that receive rehabilitation services in the

facility

within the reporting period X100

Number of new registered clients and clients came with

appointment during reporting period

Importance/Interpretation Provides information on the health condition groups and number of

cases receiving rehabilitation. This can be used for short- to medium-
term service planning (e.g. for personnel requirements). Measuring
rehabilitation service utilization is important for improving the quality
and efficiency of rehabilitation services and ensuring that individuals
in need receive appropriate care.

Disaggregation age group (<15 years; 15-65 years, >=65years)

Data sources Medical rehabilitation center/ hospital rehabilitation service register

Unit of measurement Percent

3.9. Percentage of SLIPTA standards met

 Definition The percentage of SLIPTA audit scored met from total
number of SLIPTA audit standards

Formula SLIPTA audit standards Met

X100
Total number of SLIPTA audit standards

Importance/ The Stepwise Laboratory (Quality) Improvement Process

Interpretation Towards Accreditation (SLIPTA) is a framework for improving
quality of Hospital laboratories to achieve ISO 15189 standards. It
is a five- star tiered approach, audit of laboratory operating
procedures, practices, and performance. There are a total of 275
points across 12 sections: Laboratory quality management
implementation is an effective means to;

1) determine if a laboratory is providing accurate and

reliable results;

2) determine if the laboratory is well-managed and is

adhering to good laboratory practices; and

3) Identify areas for improvement.

Currently Ethiopian national accreditation Service is providing

scope based accreditation certificate for qualified laboratories
according to ISO15189:2012 or 2022.

Disaggregation None

Unit of measurement Percent

Data sources Assessment tool for Stepwise Laboratory (Quality) Improvement

Process Towards Accreditation (SLIPTA)

3.10. Drug and Therapeutics Committee (DTC) Functionality

Definition Percentage of criteria fulfilled by the facility on the functionality of drug and
 therapeutic committee (DTC)

Formula Sum of weight of fulfilled criteria

Total weight of functionality criteria X 100

Importance This indicator measures the functionality of DTC in the health facility. DTC
develops and implements interventions, promoting the rational and cost-
/Interpretation
effective use of medicines. DTC functionality serves as a proxy indicator of
ability of a health facility to avail pharmaceuticals and ensures rational use.
The facility is considered to have functional DTC if it meets 75% of the
criteria. Data is collected by observation of the document sources mentioned
above using structured checklist provided on the annex. Annex 9: DTC
functionality Criteria

Disaggregation By type of health facility

Sources Documents from DTC secretary (DTC minutes, official assignment letters,
approved tor, action plan facility specific medicine list, policy & procedures, action
letter or notice of DTC decisions, DTC performance reports, medicine use
study/evaluation reports)

Unit of Percent
measurement

3.11. Clinical Pharmacy Service Functionality

Definition Percentage of functionality criteria fulfilled by hospitals in the provision of

clinical pharmacy service (CPS)

Formula Sum of weight of fulfilled CPS functionality criteria

X 100
Total weight of CPS functionality criteria

Importance This indicator measures the extent of the provision of pharmaceutical care in
inpatient wards by pharmacists to maximize therapeutic benefits and minimize
/Interpretation
risk of medicines. A functional clinical pharmacy service requires the provision
of pharmaceutical care from admission to discharge. The service should be
 provided at all times at all major inpatient wards. A hospital is considered to
have functional CPS when 75 % of the criteria is fulfills.

Disaggregation None

Sources Clinical pharmacy records, performance report, assignment letter, bedside round
book, duty program, patient chart, MDT morning session book, observation,
interview of ward nurse, minutes of pharmacy only morning session, daily CPS
summary, and observation.

The data is collected by survey from the various source documents indicated
above including interviews with ward nurses/physicians and observation of
actual performance.

Unit of Percent
measurement

3.12. Percentage of Medicine Actually Dispensed

Definition The percentage of medicines dispensed to clients from all prescribed medicines in
in a reporting period

Formula Total number of medicines actually dispensed

X 100
Total number of medicines prescribed

Importance The indicator measures the degree to which the health facilities fulfill prescribed
medicine. It is used as supplementing indicator for HMIS indicator “ Clients With
/Interpretation
100% Prescribed Drugs Filled ” It shows the effectiveness of pharmaceutical supply
chain in availing medicines in the health facility. The target for this indicator is
100%.

This indicator is measured by survey methods based on available prescribing and

dispensing data in the health facility. Where dispensing registers are available, all
data registered in the reporting period should be used for calculating the indicator.
 Alternatively, a sample of 100 prescribing encounters can be selected from all
prescriptions dispensed during the reporting period. Systematic random sampling
can be used to properly select representative sample of prescriptions (Refer Drug
Use Study Guide or DTC training manual) This indicator should be calculated by
the pharmacy unit on bi-annual basis use the information to improve availability of
medicines

Disaggregation None

Sources APTS registers (APTS implementing HFs), prescription paper,DHIS2 dispensing

register,

Unit of Percent
measurement
3.13. Relative Share of Sources of Retained Revenue

Definition Relative Share of sources of retained revenue refers to the proportion or percentage of
internal revenue collected from or attributable to a specific program or reform, such
as health insurance or private wing, implemented in the hospital as a percent of total
revenue generated.

Formula Retained Revenue collected ¿ a repective reform ¿ X 100

Total retained revenue collected

Importance/ Hospitals are expected to effectively implement components of health financing

Interpretation reforms designed to improve financial protection, equity, efficiency, effectiveness, and
financial sustainability of the health sector for the ultimate attainment of improve
health outcomes. In implementing the reforms/programs hospitals are expected not
only track the change of number of beneficiaries but also change of retained revenue
generated from beneficiaries of different reforms. Tracking proportion of the revenue
from different reform programs helps, among other things, to generate data to make an
informed decision. For example, if hospitals generate less retained revenue from the
expanding programs of health insurance over time, the issue needs to be assessed to
come up with the root cause(s) of the problem and appropriate corrective actions have
to be taken based on the findings and recommendations of the assessment.

This is, therefore, important to make financial analysis and performance tracking to
monitor changes over time and identify trends or areas of concern.

Disaggregatio CBHI, SHI, Private Wing, Credit service , other

n

Data sources Financial records at hospitals

Unit of
measurement Percent
3.14. Proportion of Beneficiary Groups to total visits

Definition The proportion of visits of a beneficiary group to total visits of a hospital refers to
the proportion of visits of beneficiaries of major health financing reforms or
components as a percentage of total hospital visits. it is the percentage of visits
made by a specific group of beneficiaries, such as CBHI beneficiaries out of the
total number of visits made to a hospital. This indicator can be used to assess the
utilization patterns of a hospital's services by specific patient populations and can
help identify areas where targeted interventions may be needed to improve health
outcomes and reduce costs.

Formula Number vist of respective beneficiary group

¿ ∗100
Total hospital visit

Importance/ The proportion of visits of a beneficiary group to the total visits to a hospital is an
Interpretation important measure because it can help identify disparities in healthcare utilization by
specific patient populations. For example, if a particular group of beneficiaries is
found to have a lower proportion of visits to a hospital compared to other groups, it
may indicate barriers to access to care for that group. On the other hand, if a group
of beneficiaries is found to have a higher proportion of visits to a hospital, it may
indicate a higher burden of disease for that group. Understanding the proportion of
visits of beneficiary groups can inform targeted interventions to improve healthcare
access and outcomes for those groups, as well as help identify areas where targeted
interventions may be needed to improve health outcomes and adjust costs.

 Proportion of CBHI beneficiaries visit to total hospital visit

Disaggregation
 Proportion of SHI beneficiaries visit to total hospital visit
 Proportion of exempted service beneficiaries visit to total hospital visit
 Proportion of credit service clients visit to total hospital visit

Data sources Registry for CBH, SHI, EHS and Credit Service registry.
Unit of Percent
measurement
3.15. Retained Revenue spending as a share of total operating budget spending
Internal revenue expended as a proportion of total operating expenditure (i.e.,
Definition
expended raised revenue and treasury operating) for the reporting period)
*Operating budget spending from treasury for reporting period means budget
spent for the general running of a hospital (including, consumables and
supplies etc.). Staff salaries, allowance for personnel and capital budget
allocation should be EXCLUDED.

Retained revenue expended during reporting period

Formula ¿ X 100
Total operating expenditures
(¿ treasury+ ¿ retainrevenue)during reporting period
Retained revenue spending as a proportion of total operating budget spending
Importance
refers to the portion of a hospital’s retained revenue spending as a percentage
of total budgets that is being used to fund ongoing operations. The proportion
of retained revenue spending as a portion of total operating budget spending is
a metric used to assess how effectively an organization is using its resources
and reinvesting in its own growth and sustainability.

Disaggregation None

Data sources Hospital financial statement /records

Unit of Percent
measurement
3.16. MEMIS implementation

Definition Percentage of MEMIS functionality criteria met by hospital

Formula Sum of weight of scored criteria

X100%
Total weight of standard criteria

Importance/ This indicator measures the functionality of MEMIS in a healthcare facility

interpretation that used for registering, requesting and analyzing report of installation,
inventory, maintenance, disposal and other related information of medical
equipment in the healthcare facility. It is considered as functional, if the
healthcare facility meets 80% of the criteria:

Disaggregation None

Sources MEMIS review, survey (MEMIS, history file, inventory records, documented
reports)
Unit of Percent
measurement

3.17. Mean time to respond to work order request for special healthcare setting

Definition Mean time taken to respond to the total work order request for special
healthcare setting

Formula Sum of the total time taken to respond a work order request

Total number of work order request

Importance/ This indicator measures the meantime taken to respond a work order request
interpretation from the special service settings such as ICU, emergency, OR, imaging and
laboratory. This indicator helps us to take quick intervention to save lives and
enhance service efficiency.

Disaggregation ICU, emergency, OR, laboratory, imaging and maternity service

Data Sources Work order request & maintenance report sheet, maintenance logbook

Unit of Minute/Hour
measurement

3.18. Proportion of vacancies filled as per the standards of the approved positions

Definition Percentage of employee vacancies fulfilled in the hospital as per

approved positions of the hospital according to the national/regional
structure

Formula Number of vacancies filled

100
Total number of posts/vacancies as per standard

Interpretation Fulfilling the gaps in HR vacancies helps in the improvement of quality

services delivery, reduce work load and staff burnout and also increases
patients satisfaction

Disaggregation Administrative, Health professionals

Data sources HRIS

Unit of measurement Percent

3.19. Attrition rate of Healthcare workforce

Definition Attrition rate of healthcare workforce is a percentage of healthcare

workforces who leave the hospital due to different reasons in the
reporting period.

Formula Number of healthcare workforce who left the hospital during

the reporting period 100

Total number of healthcare workforce at the beginning of the

reporting period
 Interpretation This indicator is used to assess and follow the number of healthcare
workforce who left the hospital during the reporting period and attrition
cause in the hospital.

Disaggregation Administrative staff, Health Professionals

Data sources HRIS

Unit of measurement Percent

3.20. Recipients of in-service and CPD training

Definition An in-service training is a professional training or staff development

efforts, where professionals are trained and discussed their work with
others in their peer group.

Formula Total number of staff who received in-service training/total number of

staff at beginning of period *100

Importance/ Proper medical staff training is an essential for insuring employees are
Interpretation confident in their ability to provide quality care. it can increase staff
motivation, improve productivity, staff commitment and the quality of
work.

Disaggregation Administrative staff, Health professionals

Data sources Registration sheet, HR report,

Unit of measurement Percent

3.21. Grievances received and solved

Definition A grievance is an expression of dissatisfaction with any aspect of the

operations, activities, or behavior of a Hospital’s, or its providers, regardless
 of whether remedial action is requested

Formula Total number of grievances received and solved by the HR department

Interpretation As an employer, it is best to handle grievances in an amicable and supportive

way to avoid unnecessary escalation and negative feelings. Grievance
handling procedures also allow you to identify and address unacceptable or
unlawful practices quickly.

Disaggregation All staffs

Data sources Grievance Register

Unit of Number
measurement

3.22. Occupational injury incidence

Definition An occupational injury is defined as any personal injury, disease or death
resulting from an occupational accident. An occupational injury is
therefore distinct from an occupational disease, which is a disease
contracted as a result of an exposure over a period of time to risk factors
arising from work activity.
Formula Total number of occupational injuries occurred
Total number of Hospital staff

Interpretation Reduced risk or accidents or injuries by identifying and mitigating

hazards. Improved efficiency and productivity due to fewer employees
 missing work from illness or injury. Improved employee relations and
morale (a safer work environment is a less stressful work environment)
Disaggregation Health professionals, Administrative staffs
Data sources Register
Unit of measurement Number
CHAPTER 4: HOSPITAL SUPPORTIVE SUPERVISION

Fundamental Goal of Hospital Onsite Supportive Supervision: Supportive supervision aims to

guide hospitals by providing direction and technical assistance to enhance performance. It ensures the
accuracy of hospital performance data submitted to Regional Health Boards (RHBs), identifies good
practices for sharing among hospitals, highlights areas needing improvement, and identifies where
additional support from RHBs or other partners is necessary.

Steps to Conduct Supportive Supervision:

Step 1: Selection of the Site

 The RHB coordinates the site visit team, comprising at least three individuals, including the
team leader. The team leader's responsibilities include team coordination, preparation of the
site visit briefing document, communication with the hospital CEO, and reporting.

Step 2: Pre-visit Preparation:

 The site visit team gathers relevant evidence regarding the hospital's performance and analyzes
it to create a briefing document outlining hospital performance, strengths, weaknesses, areas
for investigation, and key focus areas during the site visit.

Step 3: Conducting the Site Visit:

 The site visit typically spans one to two days and involves an opening meeting, information
gathering through departmental visits, and a closing meeting to discuss preliminary findings
with the hospital's Senior Management Team (SMT).

Step 4: Post-visit Follow-up:

 After the site visit, the team leader writes a detailed report summarizing the findings and
recommendations. The report undergoes review and refinement by the site visit team. The
hospital CEO then responds with an action plan addressing the report's recommendations.

The entire process involves thorough preparation, data collection, discussion, and follow-up, ensuring
that hospitals receive the necessary guidance and support to improve their performance and contribute
to the overall enhancement of healthcare services.
CHAPTER 5: REVIEW MEETINGS

Purpose of MOH and RHB Meetings: The purpose of the Ministry of Health (MOH) and
Regional Health Boards (RHBs) meetings is multifaceted, serving as a vital platform for
various collaborative endeavors. These gatherings facilitate the presentation and thorough
discussion of regional performance reports, enabling comprehensive insights into healthcare
achievements and challenges across different regions. They foster benchmarking exercises,
allowing comparisons between regions to identify best practices, areas of improvement, and
innovations. Moreover, these meetings aim to recognize and reward exemplary practices,
encouraging the dissemination of successful healthcare delivery methods. Participants utilize
this forum to openly share both successes and challenges encountered within healthcare
services, promoting a collective learning environment. Additionally, these sessions provide
opportunities for the dissemination and discussion of recent research reports pertinent to
hospitals, as well as addressing relevant topics crucial for enhancing the overall quality and
efficacy of healthcare delivery systems.

Frequency and Duration:

 Meetings should occur biannually.

 Each meeting is typically three days long, but it can be extended if necessary.

Participants:

 MOH Staff: selected MOH members should attend relevant meetings.

 RHB Staff: Ideally, all members of each Clinical, Regulatory, all RHBs Medical
Service Directorate should attend. At a minimum, the core process owner and hospital
lead should be present.
 Hospital Staff: A selected number of hospital CEOs, governing board chairs, or senior
administrators should be invited based on the agenda items.
 Other Partners: Additional partners relevant to the agenda topics may be requested to
attend based on their expertise.
Pre-Meeting Preparation:

 MOH should select a location, prepare the agenda, identify attendees, and send
invitation letters along with the agenda at least two weeks before the meeting.
 Follow-up emails or phone calls should be made one week before the meeting to
confirm attendance.
 MOH should analyze regional HKPI reports beforehand to identify successes and
challenges, informing the meeting preparation.
 Individual RHBs scheduled to present or share experiences should be notified in
advance to prepare necessary information.

During the Meeting:

 MOH chairs the meeting, potentially with facilitators for specific sessions or topics.
 Minutes of the meeting should be taken by designated personnel from MOH or
partners.
 MOH presents HKPI and EHSIG assessment reports from each region and offers
recommendations based on the findings.
 The agenda items will vary for each meeting.

Post-Meeting Procedures:

 MOH must produce meeting minutes and distribute them to all attendees within two
weeks.
 Relevant minutes may also be forwarded to others, such as RHB heads, and other MOH
directors or Ministers.

These structured meetings serve as an opportunity for collaborative learning, sharing best
practices, addressing challenges, and aligning efforts towards improving healthcare services
across regions in the country.
Reference
Appendix

Appendix 1: Outpatient Waiting Time to Treatment

Purpose of survey:

The average OPD wait time is one of the Key Performance Indicators that should be reported by
hospitals to their Governing Board and to the RHB has a measure of hospital performance.

Period of survey:

The survey should be conducted on Monday and Thursday of the first week of the last month of
each quarter.

Role of KPI Owner:

The hospital should assign an „owner‟ for the KPI „Outpatient Waiting Time to consultation”.
He/she is responsible to oversee the survey , to select and train surveyors, to issue „Waiting Time
Cards‟ to each surveyor, to receive completed „Waiting Time Cards‟ from the surveyors at the
end of the survey period, and to calculate the average wait time at the end of the survey period.

Additionally, at the start of each survey period the KPI Owner should inform all OPD staff that the
survey is taking place and should instruct OPD Case Teams to complete the relevant section on the
„Waiting Time Card‟ for every patient seen and ensure that all Waiting Time Cards are returned to
the surveyor at the end of the survey day.

Selection and role of surveyors:

The KPI Owner should assign individuals to act as surveyors. The number of surveyors required
will depend on the patient load. However, there should be sufficient surveyors to ensure that the
waiting time of at least100 outpatient is measured during the survey. In those facilities where the
outpatient load is very high (>200), every 3rd patient may be taken to a total of at least 100
patients. As an approximation, the number of surveyors required will be approximately the same
as the number of individuals conducting patient registration.

Ideally, the surveyors should be individuals who DO NOT WORK regularly in the outpatient
department in order to avoid bias. Surveyors could be volunteers from the community, students or
hospital staff assigned from other departments. If necessary, the hospital should provide payment
to surveyors according to the number of hours worked.

The surveyors should follow the methodology outlined below to conduct the survey and should
submit all completed „Waiting Time Cards‟ to the KPI Owner at the end of the survey period.

Role of OPD Case Teams:

A member of each clinical case team should receive the Waiting Time Card from each and every
patient seen during the survey period. He/she should record on the Card the time at which the
clinical consultation begins, and the name of the case team. Instructions should be given to each
case team to provide all completed cards to the surveyor at the end of the survey day. Case teams
should ensure that no Waiting Time Cards are lost or misplaced.

Methodology of Survey:

Assign surveyors to the areas where patients arrive at the outpatient department as follows:

If outpatients undergo registration before triage à assign surveyors to patient registration area

If outpatients undergo triage before registration à assign surveyors to triage area

If the hospital has an appointment system and patients go immediately to the OPD waiting area
(without passing through registration or triage) à assign surveyors to OPD waiting areas

Issue „Waiting Time Card‟

Each surveyor should have a batch of „Waiting Time Cards‟ as below:

OPD Waiting Time Card Card Number: ________

Patient name: ___________________________________ ___ (completed by surveyor)

Time of patient arrival: ________________________________ (completed by surveyor)

Time clinical consultation begins: ________________________ (completed by clinical case

team member)

Name of case team: ___________________________________ (completed by clinical case team

OPD Waiting Time Card Card Number: ________

ታካሚውስም: ___________________________________ ___ (ትሪያጅከፍሉይሞላል) ታካሚውየደረሰበትጊዜ:
________________________________ (ትሪያጅክፍሉይሞላል)

የህክምናአገልግሎትየጀምረበትጊዜ): _______________________(የኬስቲምአባል

ይሞላል)

የኬስቲሙስም: ___________________________________ (የኬስቲምአባልይሞላል)

(የተመላላሽተካሚህክምናለማግኘትየወሰደበትጊዜ(በደቂቃ): __________________ (የመረጃ)

Before any of the Waiting Time Cards are given out, Card Numbers should be written on every
card to that they can be easily tracked by the surveyor and the clinical case teams. As soon as a
patient arrives at OPD the surveyor should enter the patient’s name and time of arrival on a
Waiting Time Card and then hand the Card to the patient. The surveyor should instruct the patient
to give the card to a member of the clinical case team.

The Surveyor should keep track of the number of cards issued and the number of cards completed.
To do this he/sh e should keep a tally of the number of Waiting Time Cards issued and follow up
any that are missing at the end of the day.

c) Clinical Case Teams receive „Waiting Time Card‟

On arrival in the consultation room, the patient should hand over the Waiting Time Card to a
member of the case team. If the patient does not automatically hand this over then a member of
the team should request the Card from the patient.

The case team member should record on the Card the time at which the consultation begins. The
case team should keep all Cards received from patients.

Surveyor collects completed „Waiting Time Cards‟.

At the end of the day (or close of clinic) the surveyor(s) should collect all Cards from each and
every Case Team and should compare this with the list of Cards issued. If any cards are missing
the surveyor(s) should follow up with the relevant Case Team and determine whether the patient
was seen that day.

Every effort should be made to ensure that no Cards are missing or lost because this could lead to
an inaccurate survey result.

Surveyor calculates waiting time for each patient

After receiving the Waiting Time Cards from each clinical case team, the surveyor should
calculate the wait time for that patient (in minutes) and should enter it onto the Card.

KPI Owner calculates average waiting time

A t the end of the survey period the KPI owner should collect all Waiting Time Cards from each
surveyor. The KPI Owner should tally the total wait times and divide by the total number of
completed Cards in order to calculate the average wait time during the survey period. In cases
where the patient was seen on the same day but the Waiting Time Cards were lost or incomplete,
the Waiting Time Cards should be excluded from the survey count.

KPI Owner reports to KPI focal person

After calculating Outpatient Waiting Time the KPI owner should report all data elements and KPI
result to the KPI focal person. The KPI focal person will then check the calculations and enter
them into the KPI report form.

Optional, supplementary data analysis

If the average wait time is very long (especially if some patients are not seen on the same day)
then the surveyor may also want to record the range (shortest and longest) of wait times.

Similarly, the waiting time for each clinical case team could be analyzed separately to see if there
are any differences between clinical teams. This information could help to assess the efficiency of
each case team and/or to determine the need for additional clinical staff in particular case teams
and/or the need for patient numbers assigned to a specific case team to be decreased or increased.
 Annex 1: የመልካም አስተዳደር ኢንዴክስ (Good Governance Index)

ተ.ቁ አመላካቾች የተሰጠ ክብደት

I የህዝብ ሮሮ አመላካቾች 40

1 የተገልጋይ እርካታ ደረጃ (Client Satisfaction Rate) 12

2 ስለ ህመማቸው እና ስለ ህክምና አገልግሎት በቂ መረጃ ያላቸው ህሙማን መጠን፣ 4

3 የታዘዘላቸዉን መድሃኒት ሙሉ በሙሉ ያገኙ ህሙማን ምጣኔ 5

4 የታዘዘላቸዉን ሙሉ የላቦራቶሪ ምርመራ አገልግሎት ያገኙ ህሙማን ምጣኔ 4

5 የታዘዘላቸዉን ሙሉ ኢሜጂንግ አገልግሎት ያገኙ ህሙማን ምጣኔ 4

6 መሰረታዊ የራዲዮሎጂ እና ኢሜጂንግ አገልግሎት በመቶኛ 3

7 የካርድ አወጣጥና ክፍያ አገልግሎት (ቅልጥፍና፣ፍትሀዊነት፣ካርድ መጥፋት) 4

8 የጤና መድህን ክፍያ ጥያቄ ሪፖርት ብዛት በመቶኛ 2

9 የጤና መድህን ተመላሽ የተደረገ ገንዘብ ብዛት በመቶኛ 2

II አገልግሎት አሰጣጥ አመላካቾች (Service Delivery) 28

10 በ 5 ደቂቃ ትሪያጅ የተደረጉ የድንገተኛ ህክምና ተጠቃሚዎች ምጣኔ 4

11 በ 24 ሰዓት ዉስጥ ከድንገተኛ ህክምና ክፍል ታክመዉ የወጡ ህሙማን ምጣኔ 4

12 ረዥሙ የቀዶ ጥገና ህክምና የቆይታ ጊዜ (ከአንድ ወር በታች (6 ነጥብ፣ ከ 1-3 ወር (3 ነጥብ)፣ ከ 3-6 ወር (1)፣ ከ 6 6
 ወር በላይ (0 ነጥብ)) ይሰጠዋል፡፡ መረጃ ከላይዝን ይገኛል፡፡

13 ከ 2፡30 አገልግሎት መስጠት የጀመሩ ተመላለሽ የህክምና ክፍሎች 6

14 በስታንዳርዱ መሰረት የተሰጠ የነርሲንግ አገልግሎት nurseing audit score (HSTQ) 4

15 አገልግሎት ሳያገኙ የተመለሱ ታካሚዎች ምጣኔ 4

III የጤና አሰራር ስርዓት ግብዓት አመላካቾች 32

16 በተቋሙ የመድኃኒት መዘርዝር መሰረት የመሰረታዊ የበጀት መድሃኒቶች አቅርቦት ምጣኔ 4

17 ባለፉት 6 ወራት ከአገልግሎት ዉጭ የሆኑ መድሃኒቶች ምጣኔ በመቶኛ (ተሰልቶ ይቀመጥ) 4

18 በጤና ሚኒስቴር ከሚጠበቀው 85% የላብራቶሪ ምርመራ አገልግሎት በመሰራት ላይ ያለ ሽፋን 4

19 አገልግሎት የሚሰጡ የህክምና መሳሪያዎች ምጣኔ (ከወቅታዊ ቆጠራ/ኢንዜንቴሪ ዝርዝር የሚወሰድ) 2

20 አንቡላን ምላሽ የመስጠት ምጣኔ 3

21 ትርፍ ሰዓት ክፍያ የተፈጸመላቸው ሰራተኞች በመቶኛ (በበጀት ዓመት ምልከታ ጊዜ የተፈጸመ ክፍያ ይሁን) 3

25 ተቋማዊ የሆነ የመልካም አስተዳደር እቅድ ማቀድና መገምገም በመቶኛ 2

26 የጤና ባለሙያ ና የሰራተኛ ደንብ ልብስ ግዢ በወቅቱና በቀረበው እስፔስፊኬሽን ግዢ በመቶኛ 3

27 የሰራተኛ ንጽህና መጠበቂያ ግዢ በወቅቱና በቀረበው እስፔሽፊኬሽን ግዢ በመቶኛ 2

መረጃ መሰረት አድርጎ የተካሄደ ወርሀዊ አፈጻጸም ግምገማ (Performance Review Team)ግብረመልስ
28 3
በመቶኛ

29 የለውጥ ስራዎችን የሚከታተል የስራ ክፍል መኖር 2

አጠቃላይ የመልካም አስተዳደር /ጭማቂ ውጤት (GG Index)

100

Annex 2: Emergency Patients Triaged Within 5 Minutes of Arrival

Purpose of survey:

Through BPR, the Ministry of Health has set a stretch objective that „any patient with the need for
emergency treatment should be provided with the service within 5 minutes of arrival at the
hospital”.

The proportion of emergency patients who undergo triage within 5 minutes is one of the Key
Performance Indicators that should be reported by hospitals to their Governing Board and to the
RHB has a measure of hospital performance.

Period of survey:

The survey should be conducted during the following time periods during the final week of the
reporting period:

Monday: 8am to 12 noon

Wednesday: 12 noon to 5pm

Saturday: 6pm to 8am

Role of KPI Owner:

The hospital should assign an „owner‟ for the KPI „% of patients triaged within 5 minutes of
arrival in ER”. He/she is responsible to oversee the survey, to select and train surveyors, and to
calculate the proportion seen within 5 minutes at the end of the survey period. Additionally, at the
start of each survey period the KPI Owner should inform all ER staff that the survey is taking
place.

Selection and role of surveyors:

The KPI Owner should assign individuals to act as surveyors. The number of surveyors required
will depend on the patient load. However, there should be sufficient surveyors to ensure that the
waiting time of each and every emergency patient is measured during the study period.

Ideally, the surveyors should be individuals who DO NOT WORK regularly in the emergency
department in order to avoid bias. Surveyors could be clinical or non clinical staff from other
hospital departments. If necessary, the hospital should provide payment to surveyors according to
the number of hours worked.

The surveyors should follow the methodology outlined below to conduct the survey and should
submit all completed „Triage Data Forms‟ to KPI Owner at the end of the survey period.
Methodology of Survey:

Assign surveyor(s)

One or more surveyors should be assigned to the ER Department for each study time period. The
surveyor(s) should be located at the entrance to ER. If the hospital does not have a separate ER
department the surveyors should be located in an area where they can identify easily identify
emergency cases versus outpatient cases.

Surveyors complete „Triage Data Forms‟

Each surveyor should have a batch of „Triage Data Forms‟ as below:

As soon as a patient arrives at ER the surveyor should enter the time of arrival on the Triage Data
Form. The surveyor should follow the patient until the time of triage (ie until assessment by a
clinical staff member). The surveyor should enter the time of triage on the Triage Data Form and
calculate the wait time in minutes. The surveyor should then complete the final column on the
Triage Data Form to state if the patient was triaged within 5 minutes of arrival (yes or no).

c) KPI Owner calculates % of patients triaged within 5 minutes (KPI 5)

At the end of the survey period the KPI Owner should collect all Triage Data Forms from each
surveyor. The KPI owner should calculated the % of patients triaged within 5 minutes as follows:
Number of surveyed patients who undergo triage within 5 minutes of arrival in emergency room ÷
Number of patients included in emergency room triage time survey x 100

d) KPI Owner reports to KPI focal person

After calculating % of patients triaged within 5 minutes the KPI owner should report all data
elements and KPI result to the KPI focal person. The KPI focal person will then check the
calculations and enter them into the KPI report form.
Annex 3 Outpatient waiting time to consultation

Annex 4 Timely Outpatient service initiation Survey Tool

Survey Days OPD1 OPD2 OPD 3 OPD4 OPD5 OPD 6 OPD7 OPD 8 OPD(N)

Start Start Start Start Start Start Start Start Start

Time Time Time
Time Time Time Time Time Time

Monday

Or Busy
Day

Thursday

Or Free Day
Annex 5 WHO Safe surgical check list
Appendix 6: Completeness of Inpatient Medical Records

Purpose of Audit:

The “% of medical records complete” is one of the Key Performance Indicators that the hospital should report every quarter
to the Governing Board and Regional Health Bureau.

Frequency of Audit:

The audit should be conducted quarterly.

Role of KPI Owner:

The hospital should assign an „owner‟ for this KPI. He/she is responsible to oversee the Medical Record Audit, to select
and train Medical Record staff who will conduct the audit, and to liaise with the Medical Records Department to select and
obtain the Medical Records which are included in the audit.

Selection and Role of Medical Record Reviewers:

The Medical Record Reviewers should be members of the Medical Records Department. Each should review the assigned
Medical Records following the checklist below and submit their completed Forms to the KPI Owner.

Methodology of Survey:

Select and obtain the medical records

Identify and list all patients who were discharged from an inpatient ward during the reporting period. This information can
be obtained from the Medical Records Database or Admission/Discharge Registers. The sample size of medical records to
be surveyed should be 50 or 5% (which ever number is higher) of the discharged patients. After identifying your sample
size randomly select patients from the discharged list. Obtain the Medical Records of these patients from the Medical
Records Department. If any Medical Record is missing, another patient /Medical Record should be selected as a
replacement.

b) Complete Medical Record Review Form

Annex 10: Medical Record Review Form

Medical Record Review Form

MR Number:

Date patient discharged from hospital:

Ward:

Inpatient Medical Record

Checklist
 Section Yes No
1. Patient Card (Physician Notes):
- Is this present?
- Are all entries dated and signed?

2. Vital sign Sheet – including BP, PR, RR, To,

pain score it may also include column for Spo2

3. Progress note – documented at least once a day

throughout the hospital stay
4. Physician Order sheet:
- Is this present?
- Are all entries dated and signed?
5. Nursing Care Plan
- Is this present?
- Are all entries dated and signed?
6. Medication Administration Record -
Is this present?
- Are all entries dated and signed?
7. Discharge Planning and Summary Sheet
- Is this present?
- Are all entries dated and signed?
8. Clinical Pharmacist Record
- Is this present?
- Are all entries dated and signed?

Total number of “Yes” and “No” Checks

MR Reviewed by:

Name of Reviewer:

Date of Review:

Appendix : New pressure ulcers reporting format

This form should be used to report new pressure ulcers arising in patients following admission to hospital.

Definition of Pressure Ulcer:

Pressure Ulcers arise in areas of unrelieved pressure (commonly sacrum, elbows, knees or ankles).
 Either of the following criteria should be met:

A superficial break in the skin (abrasion or blister) in an area of pressure or

An ulcer that involves the full thickness of the skin and may even extend into the subcutaneous tissue, cartilage
or bone

Ward (ዋርድ):

Name of patient:

Date of admission (በሽተኛውየተኙበትቀን):

Reason for admission/diagnosis (በሽተኛውየተኙበትምክንያት):

Date pressure ulcer detected (ቁስልየተገኘበትቀን):

Clinical signs of pressure ulcer (የአልጋቁስልክሊኒካልምልክቶች):

Action taken (የተወሰዯውእርምጃ):

Reported by :

Name : _______________________ Position : ___________________________

Outcome (to be completed at time of discharge) (ውጤት (በሽተኛውልወጣሲል):

Signed :______________________ Position : __________________________

 Appendix : Surgical Site Infection Report Form

This form should be used to report infection occurring at the site of surgery in patients who undergo major surgical
procedures (i.e. any procedure conducted under general, spinal or major regional anesthesia).

Definition of Surgical Site Infection (SSI):

One or more of the following criteria should be met:

Purulent drainage from the incision wound

Positive culture from a wound swab or aseptically aspirated fluid or tissue two of the following: wound pain or
tenderness,

Localized swelling, redness or heat

Spontaneous wound dehiscence or deliberate wound revision/opening by the surgeon in the presence of:

o pyrexia > 38C or

o localized pain or tenderness

An abscess or other evidence of infection involving the deep incision that is found by direct examination during re-operation
or by histopathological or radiological examination

Ward (ዋርዴ): Date SSI detected :

Name of patient : Date of surgery:

Type of surgical procedure :

Name of surgeon :

Clinical signs (የተወሰዯውእርምጃ):

Action taken (የተወሰነው እርምጃ):

Reported by :

Name :_____________________________ Position : ____________________________

Outcome (to be completed at time of discharge) :

Signed : _____________________________ Position:_________________________

Annex 6: Antimicrobial Stewardship program functionality Criteria

Category Functionality parameter

0  There no ASP team in the facility

 There is ASP team having approved ToR with list and responsibilities of
members,
1
 Availability of ASP plan addressing ASP guideline

 Availability of the national ASP practical guide in hard and soft copies.

 Availability of AMR trained professionals,

2  Availability of functioning diagnostic laboratory in the facility,

 Presence of institutional base line data.

3  Conduct regular review meeting with minutes documented,

 Availability of audit and feedback system, appropriate de-escalation

(Spectrum), appropriate switch from IV to oral (route de-escalation),

 Registration of antimicrobial consumption,

 Recording of HAIs in the institution

  Availability of DUE finding conducted on AMs in the past one year.

Appendix : WHO Analgesic Ladder

Essential Palliative Care Medicines List

Drug Name Properties Clinical Uses Alternative Drugs

Paracetamol Non opioid Fever

Analgesic Pain
Aspirin Non opioid Pain

Analgesic Antipyretic Fever

Ibuprofen NSAID Pain (esp. bone Diclofenac

pain) Fever Indomethacin

Tramadol Weak opioid Pain Low dose
morphine
Codeine Analgesic

Morphine liquid Strong opioid Pain Morphine slow

Analgesic Introduction release tablets

Breakthrough pain

Difficulty swallowing
Morphine (slow Strong opioid Pain Morphine

Dexamethasone Corticosteroid Painful swelling and Prednisolone

Anti- inflammatory inflammation

Amitriptyline Tricyclic Neuropathic pain Carbamazepine

Amitriptyline Tricyclic Depression Imipramine

Hyoscine Butyl Antimuscarinic Abdominal pain Propantheline

bromide Antispasmodic (Colic)

Diazepam Benzodiazepine Muscle spasm Lorazepam

Anticonvulsant Seizure
Phenobarbitone Anticonvulsant Seizure Diazepam
Metoclopramide Antiemetic Vomiting Haloperidol

Domperidone
Metoclopramide Pro-kinetic Abdominal Fullness
Chlorpromazine Antipsychotic Hiccups Metoclopromide
Drug Name Properties Clinical Uses Alternative Drugs

Magnesium Trislicate Antacid Indigestion

Gastro-esophageal
Loperamide Antidiarrheal Chronic diarrhea
Bisacodyl Stimulant Constipation

ORS Rehydration Diarrhea

Salt Rehydration
Chlorpheniramine Antihistamine Drug reactions

Flucloxacillin Antibiotic Chest infection

Skin infection

Cotrimoxazole Broad PCP treatment &

Spectrum prophylaxis

Antibiotic Infective diarrhea in

Metronidazole Antibacterial Foul smelling

for anaerobic infections wounds

Lumefantrine Anti- malarial Malarial treatment

artemether (LA)
Acyclovir Antiviral Herpes zoster
Chloramphenicol eye Antibacterial Eye infections
ointment/drops
Fluconazole Antifungal Oral & esophageal
candidiasis

Clotrimazole 1% Cream Topical Fungal Skin

Nystatin Antifungal Oral & vaginal

candidiasis Prophylaxis
Suspension and pessaries
for patients on steroids
Annex 7: Patient Satisfaction Survey Tool

Patient Satisfaction Survey Tool

Date in Ethiopian calendar: date…………………..…month……………..…

year………………………………
Service area …………………………………………………….
To tal
Characteristics Outpatien Emergency Inpatient Maternity
t department department service
departme
nt
1 2 3 1 2 3 1 2 3 1 2 3
1=Disagree 2=Neutral 3=Agree
Had positive
experience or felt
respected during
the first encounter
with the hospital
staffs (guards,
receptionists,
medical record
room, triage)
Hospital compound
was clean, attractive
and safe to patients,
patient assistants,
visitors and the
hospital workers
Easily identified the
service areas where
you want to get a
service (reception
service,
runner,signage)
Patient
registration
facilitated in a
reasonable time
Acceptable waiting
time to get evaluated
(seen by a doctor at
OPD/1st evaluation
by a HCW if admitted
either in the
IPD or labor ward)
knows who provided
their care, and what

the role is of each

provider on the care
team (introduced
during the encounter,
ID badge)
Able to identify who
are doctors, nurses,
and students
Client called by
name during
encounters
Privacy maintained
at all times of care
Expressed ideas
during provider
client interaction,
actively listened
without interruption
HCP showed respect
and tolerance at all
encounters
There was no
incidence of physical
or psychological
abuse including
insulting, shouting,
withholding services
Obtained consent
before examination
and procedures
Provided with
adequate time for
counselling and
informing about
client’s clinical
condition (type and
severity) and
his/her treatment
and care
plan
Information was
clear and explained
to their level of
understanding
Involved in
treatment options
and decision was
made taking their
say in to
consideration
Their wishes and
decisions were
respected even if
the
HCP disagrees
Get excused for
shortcomings
All requested
laboratory
items were
availed in the
facility
Get respected by
laboratory
workers
Adequate
information was
provided
regarding the
process of test
including
sample
collection
methods and
precautions,
TAT, when,
where and how
to collect
results etc
Laboratory
result was ready
in a reasonable
time (as per the
counselling
in the TAT)
All prescribed
drugs are availed
in the
facility
Get respected by
pharmacy workers
Adequate time
and information
was given
regarding the
drug usage
including
frequency, dose,
possible adverse
events, storage,
duration, what to
do in case of
doubts or adverse
events like using
DIS in the
hospital
Toilets and
bathrooms were
not
closed at any time
of
his/her experience
Toilets and
bathrooms
were clean
during all
times of
his/her
encounter
Toilets and
bathrooms were
not shared
between male
and female
Discharge
planning was
addressed during
admission which
at least includes
possible days of
hospital stay and
the cost it may
incur
Pain management
was adequate
Linen was being
changed
regularly and
during times of
gross
contamination
with body fluids
Adequate supply
of hospital
gowns and
pyjamas
Did not felt
abandoned for
long time without
care (failure of
provide to
monitor and
intervene when
needed)
The food service
was
satisfactory
Adequate water
supply during
the stay
Adequate
information
provided
regarding waste
segregation,
norms of the
ward,
infection
prevention
Auditory privacy
was maintained
during times of
hospital stay
All oral
medications
were kept in
cabinet and
supported to
take in the
presence of
assigned the
nurse/midwife
Not felt incidents
of breaks in
confidentiality
(no information
provided to the
client him/herself
while other family
member/visitor
was there and
whom he/she did
not want to be
shared with the
information)
Felt good
communication
and collaboration
with in
the health care
team
Providers
responded
promptly and
professionally
when
he/she asks for
help
Perceived that
providers are
skillful and
displayed
confidence while
providing care or
treatment
Felt served
equally
irrespective
his/her status
including gender,
age, economic
status, social
status, place of
living, presence of
a
relative/provider
he/she knows
working in the
hospital
No incidence
of detainment
in the
facility for
administrative
reasons
including
unable to pay
for
services
Allowed to labor in
preferred position
Allowed to deliver
in preferred
position
when applicable
Trust developed
on the overall
hospital and
recommend it to
others to be served
Total

Black shaded – not applicable to the departments at all times

 Annex 8 : STAFF SATISFACTION SURVEY TOOL
THANK YOU FOR YOUR COOPERATION!

Date in Ethiopian calendar: date…………………..…month……………..…year………………………………

Profession / responsibility in the hospital …………………………………………………….

Length of service in the hospital: years………………………….months………………………………….

Characteristics Doctors Nurses Laboratory Supportin

(GPs, / / g staffs
midwiv pharmacy/
specialist
s es radiology
) and other
health care
workers
1 2 3 1 2 3 1 2 3 1 2 3
1= Disagree 2=Neutral 3=Agree
The hospital clearly conveys
its mission to its employees.
I agree with Thehospital’s
overall mission.
I understand how my
job aligns with
thehospital
mission.
I feel like I am a part of the
hospital
There is good
communication
from employees to
managers in the hospital.
There is good
communication from
managers to employees
in the hospital.
My job gives me the
opportunity to learn
I have the tools and
resources
I need to do my job.
I have the training I need to
do my job.
I receive the right amount of
recognition for my work.
 I am aware of the
advancement
opportunities that exist
in the hospital for
me.
I feel underutilized in my job
The amount of work
expected
of me is reasonable.
It is easy to get along with
my colleagues.
The morale in my
department is high.
People in my department
communicate sufficiently
with one another
Get excused for
shortcomings
Overall, my supervisor does
a
good job.
My supervisor actively
listens
to my suggestions.
My supervisor enables me to
perform at my best.
My supervisor promotes an
atmosphere of teamwork.
It is clear to me what my
supervisor expects of me
regarding my job
performance
My supervisor evaluates my
work performance on a
regular basis.
My supervisor provides me
with actionable suggestions
on what I can do to improve.
When I have questions or
concerns, my supervisor is
able to address them.
I would recommend this
hospital as a good place to
work.
Total